    [Senate Hearing 114-201]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 114-201

                   HEARING ON PENDING HEALTH CARE LEGISLATION

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED FOURTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                  JUNE 3, 2015

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

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                         COMMITTEE ON VETERANS' AFFAIRS

                       Johnny Isakson, Georgia, Chairman
    Jerry Moran, Kansas                  Richard Blumenthal, Connecticut,
    John Boozman, Arkansas                   Ranking Member
    Dean Heller, Nevada                  Patty Murray, Washington
    Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
    Mike Rounds, South Dakota            Sherrod Brown, Ohio
    Thom Tillis, North Carolina          Jon Tester, Montana
    Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                         Joe Manchin III, West Virginia
                           Tom Bowman, Staff Director
                     John Kruse, Democratic Staff Director

                                C O N T E N T S

                                  ----------

                                  June 3, 2015

                                    SENATORS

                                                                       Page
    Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
    Blumenthal, Hon. Richard, Ranking Member, U.S. Senator from
      Connecticut....................................................     2
    Moran, Hon. Jerry, U.S. Senator from Kansas......................    19
    Tester, Hon. Jon, U.S. Senator from Montana......................    19
    Rounds, Hon. Mike, U.S. Senator from South Dakota................    21
    Manchin, Hon. Joe, U.S. Senator from West Virginia...............    23
    Boozman, Hon. John, U.S. Senator from Arkansas...................    26
    Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......    27

                                   WITNESSES

    Kirk, Hon. Mark, U.S. Senator from Illinois......................     2
    Lynch, Thomas, Assistant Deputy Under Secretary for Health
      Clinical Operations, Veterans Health Administration, U.S.
      Department of Veterans Affairs; accompanied by Maureen
      McCarthy, Deputy Chief, Patient Care Services Office, Veterans
      Health Administration, Susan Blauert, Deputy Assistant General
      Counsel, Office of General Counsel.............................     3
        Prepared statement...........................................     5
        Additional views.............................................    10
        Response to request arising during the hearing by:
          Hon. Jon Tester............................................    20
          Hon. Joe Manchin

          Hon. Patty Murray..........................................    28
          Hon. Johnny Isakson........................................    48
    Atizado, Adrian, Assistant National Legislative Director,
      Disabled American Veterans.....................................    31
        Prepared statement...........................................    32
    Benjamin, Fred, Vice President and Chief Operating Officer,
      Medicalodges, Inc..............................................    37
        Prepared statement...........................................    39
    Snee, Thomas J., National Executive Director, Fleet Reserve
      Association....................................................    41
        Prepared statement...........................................    43
    Medina, Sergeant First Class Victor, U.S. Army, Retired..........    45
        Prepared statement...........................................    47

                                    APPENDIX

    Zumatto, Diane M., National Legislative Director, AMVETS;
      prepared statement.............................................    51
    Concerned Veterans for America (CVA); prepared statement.........    54
    Tomek, Jamie, Chair, Government Relations Committee, Gold Star
      Wives of America, Inc. (GSW); prepared statement...............    55
    Military Officers Association of America (MOA); prepared
      statement......................................................    56
    Chiarelli, General Peter W., USA (Ret.), Chief Executive Officer,
      One Mind; prepared statement...................................    61
    Paralyzed Veterans of America (PVA); prepared statement..........    61
    The American Legion (TAL); prepared statement....................    64
    Fuentes, Carlos, Senior Legislative Associate, National
      Legislative Service, Veterans of Foreign Wars of the United
      States (VFW); prepared statement...............................    68
    Berger, Thomas J., Ph.D., Executive Director, Veterans Health
      Council, Vietnam Veterans of America (VVA); prepared statement.    72

                        PENDING HEALTH CARE LEGISLATION

                                  ----------

                            WEDNESDAY, JUNE 3, 2015

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 2:30 p.m., in
    room 418, Russell Senate Office Building, Hon. Johnny Isakson,
    Chairman of the Committee, presiding.
        Present: Senators Isakson, Moran, Boozman, Rounds,
    Sullivan, Blumenthal, Murray, Brown, Tester, and Manchin.

               OPENING STATEMENT OF HON. JOHNNY ISAKSON,
                  CHAIRMAN, U.S. SENATOR FROM GEORGIA

        Chairman Isakson. The Committee on Senate Veterans Affairs
    will come to order. Welcome everybody. We look forward to an
    active afternoon, and look forward to your testimony, and
    appreciate Senator Kirk and the others who are going to testify
    here today.
        We will be discussing health care bills currently pending
    before the Committee. Two draft bills on the agenda are very
    important. They are all very important, obviously, to the
    authors, but two I want to point out. One is a bill to allow VA
    to enter into provider agreements for delivering care to non-VA
    providers. This is an issue that has been before the VA for
    some time we are moving forward on and I am happy that we are.
        A draft bill to direct VA and DOD to develop a joint
    formulary for pain and psychiatric drugs. Both the Armed
    Services Committee and the Veterans' Affairs Committee are very
    interested in this being a seamless process in terms of
    formularies and I am glad we are working on that.
        Another bill seeks to improve the provision for health care
    for women veterans and as a Georgian with 50,000 women veterans
    in my State, and with the issues that are arising with women's
    participation in our military, I think it is very important
    that this Committee focus on benefits to our women.
        There are also two bills on the agenda that seek to address
    issues related to veterans' homelessness and the
    reauthorization of certain veterans' homelessness programs. I
    look forward to dealing with those and look forward to all the
    other issues that come before the Committee today. I want to
    thank the Members that are present for their attendance and I
    will call on the Ranking Member, Richard Blumenthal.

                 STATEMENT OF HON. RICHARD BLUMENTHAL,
             RANKING MEMBER, U.S. SENATOR FROM CONNECTICUT

        Senator Blumenthal. Thank you, Mr. Chairman. Thanks for
    holding this hearing. I, too, very much welcome this profoundly
    significant discussion of health care issues that challenge our
    Veterans Administration today and challenge our Nation to do
    better. I am going to ask, if there is no objection, that I be
    joined as cosponsor to 207, 297, 425, 471, and 684, all
    representing a very comprehensive approach to problems relating
    to women's health care, formularies, veterans reintegration,
    and access to quality care.
        These are a very important step forward. I am going to cut
    short my remarks because we are here really to hear from the
    witnesses and I welcome them here today. Thank you, and
    particularly our colleague, Senator Kirk, whose commitment to
    our veterans is unquestionable and so very impressive. Thank
    you, Senator Kirk, for being here.
        Chairman Isakson. As is the practice here, all of the
    Members will be able to submit statements for the record at the
    conclusion of our hearing. We will go in order of questioning
    based on the attendance of the Members. It is also our
    tradition to make sure any visiting Senator who is present to
    speak is recognized first, so, Senator Kirk, we are glad to
    welcome you.

                     STATEMENT OF HON. MARK KIRK,
                       U.S. SENATOR FROM ILLINOIS

        Senator Kirk. Thank you, Mr. Chairman. I would like to
    recognize the presence of the world's best ranking member, Mr.
    Tester, on the VA MILCON Subcommittee of Appropriations. I just
    want to say that it has been a real joy to work with Jon. We
    are going to make sure that the Red Horse Squadron in Malmstrom
    is really taken care of.
        I am here to testify on behalf of my bill which is S. 297,
    the Frontlines to Lifelines Act of 2015 legislation. Let me
    show you a graphic that really explains what is going on. We
    now have about 10,000 active-duty corpsmen leaving the active-
    duty force that creates a need for about 28,000 health care
    assistants in the VA.
        The goal of this legislation is to make sure that the
    transition between active duty to VA is as seamless as possible
    knowing that veterans are going to care for veterans better
    than anybody else.
        When you hang around VA, if you talk to somebody and ask,
    ``Where did you serve,'' and they say, ``Hey, I served in this
    war and this place,'' you are going to have a lot more
    confidence in that person that is taking care of you if they
    are former active-duty.
        To make sure we recoup all the training that has come to
    those corpsmen and the 10,000 that are coming out of the
    active-duty force. I would say that I have bipartisan support
    for this legislation, including Mr. Blount, Manchin, Scott, and
    now Mr. Blumenthal. Thank you for the support. I would say that
    we want to get this through and that would conclude my
    statement, Mr. Chairman.
        Chairman Isakson. Thanks, Senator Kirk. Same here. Thank
    you for your service to the country and to the U.S. Senate. I
    noticed Senator Tester is a cosponsor on this, 425. Did you
    have any comments you wanted to enter about that?
        Senator Tester. We will make some comments later, but I
    just want to thank Chairman Kirk for his kind remarks. It has
    been fun working with you on MILCON VA. The problem has been--
    and I know you do not do this to Senator Blumenthal, but
    Senator Kirk has side comments that he makes about different
    issues that come up, and their importance.
        Chairman Isakson. I have been known to issue an editorial
    or two.
        Senator Tester. Thank you for being here.
        Senator Kirk. Thank you, Mr. Chairman.
        Chairman Isakson. Thank you very much, Senator Kirk. We
    will be taking the bill up in a markup later on this month and
    we appreciate your testimony. I think we are going to go to the
    first panel now.
        Our first panel is Thomas Lynch, Assistant Deputy Under
    Secretary for Health Clinical Operations, Veterans Health
    Administration, U.S. Department of Veterans Affairs,
    accompanied by Deputy Chief, Patient Care Services Officer,
    Veterans Health Administration, U.S. Department of Veterans
    Affairs, Maureen McCarthy, and Deputy Assistant General
    Counsel, Office of the General Counsel, the Department of
    Veterans Affairs, Susan--is that Blauert?
        Ms. Blauert. Blauert.
        Chairman Isakson. Thank you. I am sorry I could not get
    that. Dr. Lynch, thank you very much for being here today. We
    appreciate your time and we will give you as much time as you
    need as long as you do not run too long. We normally like to
    keep it down to 5 minutes, but we know we are commenting on
    legislation that is before the VA, so what time you need,
    please take. We are glad to have you.

        STATEMENT OF THOMAS LYNCH, M.D., ASSISTANT DEPUTY UNDER
       SECRETARY FOR HEALTH CLINICAL OPERATIONS, VETERANS HEALTH
         ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS;
     ACCOMPANIED BY MAUREEN McCARTHY, M.D., DEPUTY CHIEF, PATIENT
      CARE SERVICES OFFICE, VETERANS HEALTH ADMINISTRATION, U.S.
       DEPARTMENT OF VETERANS AFFAIRS; AND SUSAN BLAUERT, DEPUTY
          ASSISTANT GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL

        Dr. Lynch. Thank you, Mr. Chairman. I will try to keep my
    comments to 5 minutes. Mr. Chairman, Ranking Member, thank you
    for inviting us here today to present the Department's views on
    several bills that would affect VA programs and services.
        As you mentioned, I am joined today by Dr. Maureen McCarthy
    on my right and Mrs. Susan Blauert on my left. Mr. Chairman, we
    appreciate the Committee's attention to those subjects
    important to veterans and we support many of the provisions you
    are considering today.
        There are several bills for which we have not been able to
    prepare views due to time constraints. We will submit those
    opinions as soon as we can and we will follow up with your
    staff in the meantime to address any technical concerns.
        In beginning, I would like to express VA's appreciation for
    the recent enactment of Public Law 114-19, which will give VA
    new flexibility to use the Veterans Choice program--when a
    veteran may live within 40 miles of a VA facility, but still
    face an unusual or excessive burden in getting to that
    facility. It will expand the different individual circumstances
    VA can consider in determining eligibility for Veterans Choice
    beyond simply geography, to include environmental factors and
    the veteran's medical condition.
        This will allow VA to be more responsive to the special
    challenges faced by individual veterans. Let me add that we
    also sincerely appreciate placement of the draft purchased care
    reform bill on the agenda today. We strongly support enactment
    of the bill which is similar to legislation requested by the
    Administration to reform VA's authorities for purchasing
    hospital care, medical services, and extended care. This is a
    well-crafted measure that is critical to address deficiencies
    in current law, as well as provide a comprehensive framework
    for the purchase of non-VA care.
        We know this is important as well to a great number of
    providers with whom VA partners and on whom we depend for the
    delivery of care to veterans in the community. Mr. Chairman,
    this measure is absolutely critical to assure timely access to
    care for veterans. Again, we greatly appreciate your strong
    support.
        Mr. Chairman, you will see VA's detailed discussion on
    other bills under consideration today in our written testimony,
    but I would like to take this opportunity to highlight some of
    our views. S. 297 would, in part, direct the Department to
    transfer available credentialing data from health care
    providers to VA when we hire those providers. Credentialing is
    required to ensure a health care provider has the necessary
    clinical competence and professional experience.
        Consultation with the Department of Defense is necessary
    before VA can present a position on this provision. We look
    forward to working with the Department and the Committee on
    this bill.
        S. 425 would provide additional employment services for
    homeless and at-risk veterans. Employment is a key factor in
    achieving and maintaining stability and permanent housing. VA
    believes this bill would be helpful in our efforts to combat
    homelessness, but we defer to the Department of Labor for their
    views and cost estimate.
        S. 684 has multiple provisions addressing support for
    homeless veterans. We appreciate the attention to so many
    aspects of homelessness and the VA's homeless program. As you
    can see detailed in our written statement, we support many of
    those provisions. Other provisions we support in concept, but
    would like to engage with the Committee on technical aspects as
    well as funding issues.
        Mr. Chairman, although we do not present views today on the
    draft bill that would establish a joint VA/DOD formulary, we
    understand the importance of the continuity of medical care
    when a servicemember transitions his or her health care to VA.
        Over the past decade, VA has taken concrete steps to ensure
    medication continuity is a departmental priority. Most
    recently, VA issued guidance to VA prescribers and pharmacists,
    reiterating our long-standing practice of continuing mental
    health and pain medications for transitioning servicemembers.
        VA, in fact, analyzed mental health and pain medication use
    for 2,000 transitioning servicemembers. Of those 2,000, only 21
    veterans had medication switched solely due to differences
    between the VA and DOD drug formularies. While not acceptable,
    we believe even these few incidents can be addressed.
        A GAO analysis had similar results with a finding that 90
    percent of mental health medications and 96 percent of pain
    medications dispensed by DOD are listed on the VA national
    formulary. Although the report did not mention it, VA routinely
    dispenses DOD formulary medications even though they are not
    listed on the VA national formulary.
        We look forward to working with the Committee to ensure
    there is confidence in the continuity of care for transitioning
    servicemembers. Thank you, Mr. Chairman, for the opportunity to
    testify today. My colleagues and I would be pleased to respond
    to any questions that you or the Members of the Committee may
    have at this time.
        [The prepared statement of Dr. Lynch follows:]
       Prepared Statement of Thomas Lynch, M.D., Assistant Deputy Under
           Secretary for Health Clinical Operations, Veterans Health
           Administration (VHA), U.S. Department of Veterans Affairs
        Good morning Chairman Isakson, Ranking Member Blumenthal, and
    Members of the Committee. Thank you for inviting us here today to
    present our views on several bills that would affect VA benefits
    programs and services. Joining us today is Maureen McCarthy, M.D.,
    VHA's Deputy Chief Patient Care Services Officer and Susan Blauert,
    Deputy Assistant General Counsel in VA's Office of General Counsel.
        We do not yet have cleared views on sections 2 and 4 of S. 297,
    S. 471, the draft bill on Joint VA/DOD formulary for pain and
    psychiatric medications, and the draft bill Veterans Health Act of
    2015. We will forward the views to the Committee as soon as they are
    available.
             s. 207--veterans access to community care act of 2015
        S. 207, the Veterans Access to Community Care Act of 2015, would
    require VA to use specified authorities to purchase non-VA hospital
    care and medical services for Veterans who reside more than 40 miles
    driving distance from the closest VA medical facility that can furnish
    the care sought by the Veteran. The specified authorities are section
    1703 of title 38, United States Code (U.S.C.), the authority in section
    101 of the recently enacted Veterans Access, Choice, and Accountability
    Act of 2014 (VACAA) (Public Law 113-146), and any other authority under
    the laws administered by VA relating to the purchase of hospital care
    and medical services at non-VA facilities.
        We believe the intent of S. 207 is to expand eligibility for the
    Choice Program to Veterans who meet the threshold eligibility
    requirements for Choice and reside more than 40 miles driving distance
    from the closest VA medical facility that can furnish the care sought
    by the Veteran. However, it is not clear whether the bill as drafted
    would accomplish this objective. The language of section 2(b)(2),
    ``relating to the furnishing of hospital care and medical services * *
    * if the veteran is unable to schedule an appointment * * * within the
    wait-time goals of the Veterans Health Administration,'' appears to
    limit the application of the bill's reference to VACAA to Veterans
    eligible for Choice based on section 101(b)(2)(A) of VACAA, i.e., only
    those Veterans unable to schedule an appointment within wait time
    goals.
        We also note that S. 207 would not amend section 101 of VACAA.
    Consequently, it is not clear how the requirements of section 101 would
    apply to care provided under the authority in section 2(b)(2) of the
    bill. If enacted as drafted, we would interpret S. 207 in conjunction
    with section 101 by, for example, applying the provider eligibility
    requirements and payment rates set forth in VACAA. Similarly, sections
    2(b)(1) and (3) do not amend section 1703 or VA's sharing agreement
    authorities, but we would apply the requirements of those existing
    authorities to care provided under S. 207. Because the bill does not
    actually alter distance-based eligibility under the Veterans Choice
    Program, it creates significant ambiguities, funding questions and
    legal issues which we would be glad to discuss with Committee staff.
        When VA analyzed the cost impact of providing care under the
    Veterans Choice Program based on the distance between a Veteran's
    residence and the closest VA medical facility that provides the needed
    care, we concluded that this change would have a significant budgetary
    impact, leading to total Choice Program costs for those eligible
    Veterans more than 40 driving miles that could range from $5 billion to
    $34 billion annually; this estimate assumes that participation in the
    Veterans Choice Program is not limited to only those Veterans enrolled
    as of August 1, 2014, as is required under the current law. We have
    briefed your staff, as well as representatives from the Congressional
    Budget Office, on that range of estimates, including their underlying
    assumptions. VA cannot reconcile the resource requirements that would
    be posed by S. 207 with any realistic view regarding the resources that
    will be available to VA under the framework reached in the budget
    resolution recently approved by both the Senate and House. Therefore,
    VA does not support S. 207.
        As VA testified on May 12 before this Committee, VA has taken steps
    to improve the Veterans Choice Program, including expanding access by
    publishing a second interim final rule changing the way we measure
    distance for purposes of determining eligibility based on residence
    from a straight-line measure to a driving distance measure. VA was glad
    to see this change also carried out in legislation, H.R. 2496, the
    Construction, Authorization and Choice Improvement Act, just signed
    into law by President Obama on May 22nd. This change has approximately
    doubled the number of Veterans eligible for the Veterans Choice Program
    based on the distance criteria, and we are glad to have eliminated one
    significant source of frustration and confusion for Veterans. H.R. 2496
    also will provide VA greater flexibility within VACAA to consider
    factors unrelated to geographic challenges that impact a Veteran's
    ability to travel to access care. Enactment of this change allows us to
    mitigate the impact of distance and other hardships, including the
    Veteran's medical condition, for many Veterans, and enable more
    Veterans to receive health care closer to home.
        VA is committed to continuing to work with the Committee to improve
    Veterans' timely access to care, within the Veterans Choice Program and
    outside of it.
                  s. 297--frontlines to lifelines act of 2015
        Section 3(a) of the Frontlines to Lifelines Act of 2015 would
    direct the Secretary of Defense to transfer to the Secretary of
    Veterans Affairs the credentialing data of a covered health care
    provider who has been hired by VA, upon receiving a request from VA for
    the Department of Defense's (DOD) credentialing data related to such
    health care provider.
        Section 3(b) would define a ``covered health care provider'' as a
    health care provider who is or was employed by the Secretary of
    Defense, provides or provided health care related services as part of
    such employment, and was credentialed by the Secretary of Defense.
        Section 3(c) would require the Secretaries of Veterans Affairs and
    Defense to establish policies and promulgate regulations as may be
    necessary to carry out this section.
        Section 3(d) would define the term ``credentialing'' to mean the
    systematic process of screening and evaluating qualifications and other
    credentials, including licensure, required education, relevant training
    and experience, and current competence and health status.
        Credentialing is required to ensure a health care provider has the
    necessary clinical competence, professional experience, health status,
    education, training and licensure to provide specified medical or other
    patient care services. VA understands the goals of section 3, and the
    sharing of credentialing data between departments would facilitate VA's
    credentialing process and the appointment of only qualified, covered
    health care providers to the VA facility's medical staff. However, as
    this provision places requirements upon DOD, consultation with DOD is
    necessary before VA can present a position on this provision.
     s. 425--homeless veterans' reintegration programs reauthorization act
                                    of 2015
        S. 425 would extend the authorization of appropriations for the
    Department of Labor's Homeless Veteran Reintegration Programs (HVRP)
    and the Homeless Women Veterans and Homeless Veterans with Children
    Reintegration Grant Program from 2015 to 2020. The bill would further
    expand the population eligible to receive services under HVRP to
    include not only homeless Veterans but also Veterans who are
    participating in the Department of Housing and Urban Development-VA
    Supportive Housing (HUD-VASH) program, receiving assistance under the
    Native American Housing Assistance and Self-Determination Act of 1996,
    or transitioning from incarceration.
        VA defers to the Department of Labor for views and costs on S. 425;
    however, we offer that this bill would provide additional services for
    homeless and at-risk Veterans in the critical area of employment, which
    is a key factor in achieving and maintaining stability in permanent
    housing. Veterans transitioning from incarceration often face multiple
    barriers to successful reentry, and expanding HVRP eligibility to this
    population would help address the employment-related needs of a
    population of Veterans who are often at high risk of becoming homeless.
    It would also be especially helpful for Veterans transitioning from
    incarceration who may not be eligible for VA services.
                s. 684--homeless veterans prevention act of 2015
        Section 2 of S. 684 would amend 38 U.S.C. Sec. 2012(a)(2) to
    increase the per diem payments for Veterans who are participating in
    the VA's Homeless Provider Grant and Per Diem (GPD) Program through a
    ``transition in place'' (TIP) grant. The per diem payments under GPD
    TIP would be increased to 150 percent of the VA State Home rate for
    domiciliary care, compared to the current payment which is the lesser
    of 100 percent of the VA State Home rate for domiciliary care or the
    daily cost of care minus other sources of payments to the per diem
    recipient for furnishing services to homeless veterans.
        VA supports section 2. This new provision would facilitate and
    provide support for Veterans moving from transitional to permanent
    housing. Supporting Veterans' transition from homelessness to permanent
    housing is a strategy VA believes will be effective in our efforts to
    end homelessness among Veterans. By allowing Veterans to ``transition
    in place'' to permanent housing, the Department would provide a
    valuable alternative for Veterans who may not need or be interested in
    participating in the HUD-VASH program.
        Section 3 would amend 38 U.S.C. Sec. 2012(a) to permit a grantee
    receiving per diem payments under the GPD Program to use part of these
    payments for the care of a dependent of a homeless Veteran who is
    receiving services covered by the GPD grant. This authority would be
    limited to the time period during which the Veteran is receiving
    services under the grant.
        VA supports the intent of section 3, conditioned on the
    availability of additional resources to implement this provision. We
    feel that this authority is needed to fully reach the entire homeless
    population. However, full implementation of the legislation would
    require additional funding to avoid diminished services in VA's full
    complement of programs for homeless Veterans.
        Section 4 would authorize the Secretary to enter into partnerships
    with public or private entities to provide general legal services to
    Veterans who are homeless or at risk of homelessness. The language
    further specifies that VA is only authorized to fund a portion of the
    cost of legal services.
        VA supports section 4 as legal services remain a crucial but
    largely unmet need for homeless and at-risk Veterans, but respectfully
    recommends technical amendments to the bill language. The Supportive
    Services for Veteran Families Program currently allows for grantees to
    enter into partnerships with legal service providers to address legal
    needs that pose barriers to housing stability. However, this is not a
    required service under the SSVF regulations and, therefore, is not
    provided to Veterans through all SSVF programs. Rather than authorizing
    VA to enter into ``partnerships,'' section 4 should authorize VA to
    provide grants to ensure the language reflects a funding mechanism that
    VA could use to execute it. Furthermore, VA recommends removing the
    phrase ``a portion of'' from the proposed section 2022A(a). This change
    would allow VA to fund a portion or the entirety of the legal services
    provided under the partnership, thereby providing VA greater
    flexibility to support these efforts. Finally, VA would like to work
    with the Committee to make additional minor improvements to section 4.
        Section 5 would extend dental benefits under 38 U.S.C. Sec. 2062 to
    a Veteran enrolled in the VA health care system who is also receiving
    for a period of 60 consecutive days assistance under the HUD-VASH
    program, or care under title 38 authority in one of the following
    settings: a domiciliary, therapeutic residence, community residential
    care, or a GPD program. For purposes of the 60-day requirement, it
    would permit breaks in the continuity of assistance or care for which
    the Veteran is not responsible.
        VA appreciates the intent of section 5 to expand eligibility for VA
    dental care, but cannot support it under a realistic assumption of
    future funding availability. VA believes these services would be
    especially valuable for this group of Veterans, and we welcome further
    discussion with the Committee.
        VA supports section 6, which would provide permanent authority for
    VA's Veterans Justice Outreach (VJO) and Healthcare for Reentry
    Veterans (HCRV) Programs. VJO's goal is to avoid the unnecessary
    criminalization of mental illness and extended incarceration among
    Veterans by ensuring that eligible Veterans involved with the criminal
    justice system have timely access to VA's mental health and substance
    use services when clinically indicated, and other VA services and
    benefits as appropriate. Similarly, designed to address the community
    reentry needs of incarcerated Veterans, HCRV's goals are to prevent
    homelessness, reduce the impact of medical, psychiatric, and substance
    abuse problems upon community readjustment, and decrease the likelihood
    of re-incarceration for those leaving prison. This permanent authority
    would recognize the crucial role these programs play in preventing and
    ending Veteran homelessness.
        Section 7 would amend 38 U.S.C. Sec. 2044(e) to authorize the use
    of $500 million from VA's FY 2016 Medical Services appropriation for
    the Supportive Services for Veteran Families (SSVF) Program, and to
    extend the existing $1 million appropriation authority for training and
    technical assistance to SSVF grantees through FY 2015.
        While the $500 million level of this authorization is above the
    level proposed in VA's budget, we nevertheless support an authorization
    level that provides flexibility should VA determine that additional
    funding is necessary and the Department is in a position to dedicate
    higher amounts to the program. VA thus supports the intent of section
    7, but believes that in order to ensure the provision of quality
    services to Veteran families and the efficient execution of such
    additional funds; this increased flexibility should be accompanied by
    an increased proportional authorization in technical assistance for
    SSVF providers.
        Section 8 would require the Secretary to assess and measure the
    capacity of programs receiving grants under 38 U.S.C. Sec. 2011, or per
    diem payments under 38 U.S.C. Sec. 2012 or 2061.
        VA believes the intent of section 8 is satisfied by existing VA's
    Homeless Providers Grant and Per Diem Program monitoring practices.
    VA's GPD Program regularly monitors capacity and performance in
    grantees' programs, so section 8 would impose a new and potentially
    duplicative reporting requirement. Although VA expects that compliance
    with section 8 would require time and effort from VA employees, the
    reporting requirements are not unduly burdensome and would result in
    minimal costs to VA. Therefore, VA does not object to section 8.
        Section 9 would require the U.S. Comptroller General to conduct an
    assessment of VA programs serving homeless Veterans to determine
    whether these programs are meeting Veterans' needs, and recent efforts
    to improve the privacy, safety, and security of female Veterans
    receiving assistance under these programs. VA supports the intent of
    section 9, but believes its goals have been accomplished by recent
    reviews of VA homeless programs conducted by the Government
    Accountability Office and by VA's annual assessment of homeless
    Veterans' service needs and the availability of responsive VA and
    community services. Since its inception in 1994, VA's Project CHALENG
    (Community Homelessness Assessment, Local Education and Networking
    Groups) has surveyed participants (homeless and formerly homeless
    Veterans, as well as VA and community service providers) on the needs
    of homeless Veterans in their local communities, and the extent to
    which these are addressed by existing VA and community services. The
    results not only drive the development of new local partnerships, but
    also generate a national picture of male and female homeless Veterans'
    met and unmet service needs, as identified by homeless Veterans
    themselves and the service providers who work with them directly.
        Section 10 would remove the requirement that VA report to the
    Senate and House of Representatives Committees on Veterans' Affairs on
    the activities of the Department during the calendar year preceding the
    report under programs of the Department for the provision of assistance
    to homeless veterans.
        VA supports section 10. Removing this time consuming reporting
    function would free up VA resources that could be better used to
    internally asses the programs and implement changes to enhance the
    benefits and services provided to homeless Veterans. Furthermore, VA
    remains committed to providing timely data reporting to the Committees
    upon request. Removing this annual reporting requirement would
    recognize that VA, on its own initiative, conducts ongoing data
    analysis of VA homeless programs.
        draft bill--department of veteran affairs purchased health care
                       streamlining and modernization act
        This draft bill is similar to legislation requested by the
    Administration to reform the authorities VA uses to purchase hospital
    care, medical services, and extended care when that care is not
    feasibly available at a VA facility, or through contracts or sharing
    agreements entered into under other authorities. We sincerely
    appreciate the Committee placing it on the agenda today, and look
    forward to working with you on this critical aspect of ensuring
    Veterans' timely access to health care.
        Section 2 would amend chapter 17 of title 38, U.S.C., by adding a
    new section, ``1703A. Veterans Care Agreements with certain health care
    providers.''
        Subsection (a) of 1703A would provide that if VA is not feasibly
    able to furnish hospital care, medical services, or extended care
    within the Department or through the exercise of other authority to
    enter into contracts or sharing agreements, VA may enter into
    ``Veterans Care Agreements'' (VCA) with eligible providers who are
    certified under subsection (c) of the new 1703A. Eligibility for care
    would be determined in the same manner as if the care or services were
    furnished directly by a VA facility.
        Subsection (b) would define eligible providers to include Medicare
    and Medicaid providers; an Aging or Disability Resource Center, an area
    agency on aging, or a State agency as defined in section 102 of the
    Older Americans Act; a center for independent living as defined in
    section 702 of the Rehabilitation Act; and other providers the
    Secretary determines to be appropriate.
        Subsection (c) would require the Secretary to establish a process
    for the certification and re-certification of eligible providers. This
    process must include procedures for screening providers according the
    risk of fraud, waste, and abuse and must require the denial of
    applications from providers excluded from certain Federal programs. VA
    notes that this provision would require VA to certify all eligible
    providers, including those participating in Medicare or Medicaid. In
    VA's legislative proposal, VA would establish a separate certification
    process for those eligible providers that are not under the
    certification regimes of Medicare and Medicaid. VA suggests this
    approach to avoid subjecting providers to duplicative certification
    processes, which could dissuade providers from entering VCAs.
        Subsection (d) would require the inclusion of specific terms in
    VCAs, including payment rates that are, to the extent practicable, in
    accordance with the rates paid by the United States in the Medicare
    program. Other requirements of VCAs would include restricting care to
    that authorized by VA, prohibiting third-party billing by providers,
    and submitting medical records to the Department.
        Subsection (e) would specify the terms and conditions under which
    VA or the provider may terminate a VCA.
        Subsection (f) would require the Secretary to review VCAs of
    material size every two years to determine whether it is feasible or
    advisable to provide the necessary care at facilities of the Department
    or through contract or sharing agreements entered into under other
    authorities.
        Subsection (g) would specify that VCAs under section 1703A are
    exempt from certain provisions of law governing Federal contracting.
    Specifically, VCAs would be awarded without regard to competitive
    procedures and would not subject an eligible provider to certain laws
    that providers and suppliers of health care services through the
    Medicare program are not subject to. Providers entering into VCAs would
    be subject to all laws regarding integrity, ethics, fraud, or that
    subject a person to civil or criminal penalties, as well as all laws
    prohibiting employment discrimination on the basis of race, color,
    national origin, religion, gender, sexual orientation, gender identity,
    disability, or status as a Veteran.
        Subsection (h) would require the Secretary to establish a system or
    systems to monitor the quality of care and services provided to
    Veterans under section 1703A and to assess the quality of care and
    services for purposes determining whether to renew a VCA.
        Subsection (i) would require the Secretary to establish
    administrative procedures for providers to present disputes arising
    under or related to VCAs. It would further require that providers
    exhaust these administrative procedures before seeking judicial review
    under the Contract Disputes Act.
        Subsection (j) would direct the Secretary to prescribe regulations
    to carry out section 1703A.
        Section 3 of the draft bill would amend 38 U.S.C. Sec. 1745 to
    permit VA to enter into agreements with State Veterans Homes that are
    exempt from certain provisions of law governing Federal contracting.
    Specifically, an agreement could be awarded without regard to
    competitive procedures and would not subject a State Home to certain
    laws that providers and suppliers of health care services through the
    Medicare program are not subject to. An agreement would be subject to
    all laws regarding integrity, ethics, fraud, or that subject a person
    to civil or criminal penalties, as well as all laws prohibiting
    employment discrimination on the basis of race, color, national origin,
    religion, gender, sexual orientation, gender identity, disability, or
    status as a Veteran. In addition, subsection (c) would establish a
    separate effective date for the amendments made by section 3 based on
    the effective date of implementing VA regulations.
        Although section 3 would eliminate the word ``contract'' in section
    1745, it would authorize VA to enter into ``agreements'' which VA
    believes would include contracts based on the Federal Acquisition
    Regulation (FAR) contracts. VA thus does not interpret this amendment
    to prohibit VA from using FAR-based contracts if a State home requests
    it.
        Similar to the legislation proposed by the Administration, the
    draft bill would not result in additional costs and thus would be
    budget neutral.
        This bill is a critical reform that will address deficiencies in
    current law, as well as provide a comprehensive framework and
    foundation for the purchase of non-VA care in those circumstances where
    it is not feasibly available from VA or through contracts or sharing
    agreements. We strongly support its enactment, which we believe is
    essential to maintaining Veterans' access to care in every part of the
    country.

        Mr. Chairman, thank for the opportunity to present the Department's
    views on these bills and we will be glad to respond to the Committee's
    questions.
                                     ______

             Additional Views from Robert A. McDonald, Secretary,
                      U.S. Department of Veterans Affairs

                                Department of Veterans Affairs,
                                         Washington, DC, July 15, 2015.
    Hon. Johnny Isakson,
    Chairman,
    Senate Committee on Veterans' Affairs
    U.S. Senate, Washington, DC.

        Dear Mr. Chairman: The agenda for the Senate Committee on Veterans'
    Affairs' June 3, 2015, and June 24, 2015, legislative hearings included
    a number of bills that the Department of Veterans Affairs (VA) was
    unable to address in our testimony. We are aware of the Committee's
    interest in receiving our views and cost estimates for those bills.
        By this letter, we are providing the following remaining views and
    cost estimates for the following bills from the June 3, 2015,
    legislative hearing: S. 471, the Women Veterans Access to Quality Care
    Act of 2015; and sections 4(b)-(c) and 5 of the draft Veterans Health
    Act of 2015.
        We are also providing views and costs on the following bills from
    the June 24, 2015, legislative hearing: the Draft Biological Implant
    Tracking and Veteran Safety Act of 2015; on S. 1117, the Ensuring
    Veteran Safety Through Accountability Act of 2015; sections 203, 205,
    208, and 209(b) of S. 469, the Women Veterans and Families Health
    Services Act of 2015; sections 3 through 8 of S. 1085, the Military and
    Veteran Caregiver Services Improvement Act of 2015; section 2 of the
    draft bill referred to on the agenda as ``Discussion Draft;'' and
    sections 101-106, 204, 205, 403 and 501 of the draft Jason Simcakoski
    Memorial Opioid Safety Act.
        In the time requested for transmittal of follow up views, VA was
    not able to include in this letter the following views: sections 2 and
    4 of S. 297, the Frontlines to Lifelines Act of 2015; the draft bill on
    establishing a joint VA-Department of Defense (DOD) formulary for
    systemic pain and psychiatric medications; sections 2, 3, and 5 of the
    draft Veterans Health Act of 2015, sections 203, 208, and 209(b) of
    S. 469, the Women Veterans and Families Health Services Act of 2015;
    sections 4(b) and 8 of S. 1085, the Military and Veteran Caregiver
    Services Improvement Act of 2015; and sections 105, 205, 403, and 501
    of the Jason Simcakoski Memorial Opioid Safety Act. The remaining views
    can be forwarded in a separate and final follow-up views letter.
        We appreciate this opportunity to comment on this legislation and
    look forward to working with you and the other Committee Members on
    these important legislative issues.
                Sincerely,
                                            Robert A. McDonald,
                                                             Secretary.

      Enclosure.

                              June 3, 2015 Agenda
           s. 471, women veterans access to quality care act of 2015
        Section 2 of S. 471 would require VA to establish standards to
    ensure that all VA medical facilities have the structural
    characteristics necessary to adequately meet the gender-specific health
    care needs, including privacy, safety, and dignity, of Veterans at
    these facilities. VA would be required to promulgate regulations within
    180 days of the date of enactment to carry out this section. Within 270
    days of the date of the enactment of the Act, VA would be required to
    integrate these standards into the prioritization methodology used by
    VA with respect to requests for funding of major medical facility
    projects and major medical facility leases. Not later than 450 days
    after the date of the enactment of the Act, VA would be required to
    report to the Committees on Veterans' Affairs of the House and Senate
    on the standards established under this section, including a list of VA
    medical facilities that fail to meet the standards; the minimum total
    cost to ensure that all VA medical facilities meet such standards; the
    number of projects or leases that qualify as a major medical facility
    project or major medical facility lease; and where each such project or
    lease is located in VA's current project prioritization.
        VA appreciates the intent of section 2 of S. 471, but we do not
    believe it is necessary given other actions we are already taking. For
    example, in 2012, VA developed and published a Space Planning Criteria
    Chapter for Women Veterans Clinical Service, which provides standards
    for Women Veterans Clinical services within VA. A standard examination
    room plan for Women Veterans Clinics was developed including access to
    bathroom facilities directly connected to the examination room. VA's
    Medical/Surgical Inpatient Units and Intensive Care Nursing Units
    Design Guide, developed in 2011 and 2012, addresses the gender-specific
    needs of women Veterans. These standards are available online at:
    www.cfm.va.gov/TIL. Moreover, it is unclear why VA would need to
    promulgate regulations for this section. Absent the requirement in the
    bill, VA would not need to promulgate regulations. VA's construction
    standards have been established through policy for years, and revising
    our standards through this process is less resource intensive and
    faster than formal regulations.
        Section 3 of S. 471 would require the Secretary to use health
    outcomes for women Veterans furnished hospital care, medical services,
    and other health care by VA in evaluating the performance of VA medical
    center directors. It would also require VA to publish on an Internet
    Web site information on the performance of directors of medical centers
    with respect to health outcomes for women Veterans, including data on
    health outcomes pursuant to key health outcome metrics, a comparison of
    how such data compares to data on health outcomes for male Veterans,
    and explanations of this data to help the public understand this
    information.
        We do not support section 3 of S. 471. Many important health
    outcomes, such as mortality and readmission, are normally not reported
    by gender in hospitals. The inherent problem relates to the difficulty
    of measurement at individual facilities where numbers of outcome events
    for women Veterans may be few, which would mean that any findings would
    not be statistically significant or reliable. VA could report
    outpatient experience by gender, but to obtain valid results at the
    facility level, we would need to implement over-sampling of women
    Veterans for the Survey of Healthcare Experiences of Patients (SHEP).
    This would be costly and is likely to be perceived as burdensome on
    women Veterans.
        Furthermore, the Institute of Medicine (IOM), in its report ``Vital
    Signs: Core Metrics for Health and Health Care Progress'' (2015), has
    raised concerns about the increasing burden on providers posed by the
    proliferation of performance measures. Valid and actionable metrics are
    difficult and costly to develop and implement. Flawed measures, however
    well-intentioned, can produce programmatic distortions such as an
    overly narrow focus on measured activities rather than what is most
    important to the patient (IOM, p 19). VA already monitors gender-
    specific performance system wide and has other mechanisms in place,
    such as site surveys, to ensure equitable provision of care. For these
    reasons, we do not support inclusion of gender-based outcome measures
    for evaluating the performance of medical center directors.
        Section 4 of S. 471 would seek to increase the number of
    obstetricians and gynecologists employed by VA. Paragraph (a) of this
    section would require, not later than 540 days after the date of the
    enactment of this Act, that VA ensure that every VA medical center have
    a full-time obstetrician or gynecologist.
        VA supports the intent of section 4(a) and is already taking steps
    to expand access to gynecological care throughout VA. Currently,
    approximately 78 percent of VA medical centers have a gynecologist on
    staff, and we plan to add this service at roughly another 20
    facilities. This will ensure that all facilities with a surgical
    complexity of intermediate or complex will have a gynecologist on
    staff. At facilities with a surgical complexity designation of standard
    or less, we do not believe that there is sufficient patient demand to
    support a full-time gynecologist or obstetrician. For Veterans needing
    these services at these facilities, VA uses its authorities for care in
    the community to ensure these Veterans are able to access care.
    Moreover, in some areas of the country, particularly in smaller or more
    rural areas, VA faces recruitment challenges in hiring new staff, and
    we anticipate we would face similar challenges if this legislation were
    enacted.
        Paragraph (b) of section 4 of S. 471 would require VA, within 2
    years of the enactment of this Act, to carry out a pilot program in not
    less than three Veterans Integrated Service Networks (VISN) to increase
    the number of residency program positions and graduate medical
    education positions for obstetricians and gynecologists (OB-GYN) at VA
    medical facilities.
        VA supports the intent of paragraph (b) of section 4, and is
    already using authority Congress has previously provided to recruit
    residents in these fields. Currently, VA funds over 25 OB-GYN residency
    positions across 32 sites. While gynecologic services are widely
    available throughout VA, the limited patient population and scope of
    services at some sites makes broad-based national increases in these
    residency positions difficult. Additionally, section 301(b) of the
    Veterans Access, Choice, and Accountability Act of 2014 (``the Choice
    Act,'' Public Law 113-146) allows the Secretary to support primary
    care, mental health, and other specialty residency positions as
    appropriate. VA is using the authority and resources from the Choice
    Act to increase OB-GYN residency positions in locations demonstrating
    significant access issues for Women Veterans, as long as these sites
    can also demonstrate sufficient educational infrastructure such as
    faculty supervision and space, and willing educational program
    partners. We do not have costs at this time.
        Section 5 of S. 471 would require VA to develop procedures to share
    electronically certain information with State Veterans agencies to
    facilitate the furnishing of assistance and benefits to Veterans. The
    information would include military service and separation data, a
    personal email address, a personal telephone number, and a mailing
    address. Veterans would be able to prevent their information from being
    shared with State Veterans agencies by using an opt-out process
    developed by VA. VA would be required to ensure that the information
    shared with State Veterans agencies is only shared by such agencies
    with county government Veterans service offices for such purposes as VA
    would determine for the administration and delivery of assistance and
    benefits.
        We believe strong relationships with State Veterans agencies, as
    well as outreach to Veterans, are critical. However, VA does have
    concerns with this section. The information required, we believe, would
    have Privacy Act implications. Also, managing opt-out requests would
    require additional resources, although the amount cannot be projected
    with specificity. We would be glad to discuss with the Committee VA's
    collaborative efforts with State Veterans agencies on outreach, and how
    the goals of section 5 could be fulfilled while avoiding the concerns
    expressed above.
        Finally, section 6 of S. 471 would direct the Comptroller General
    to carry out an examination of whether VA medical centers are able to
    meet the health care needs of women Veterans. The examination would
    include the wait times for women Veterans for appointments; whether the
    medical centers have a clinic that specializes in the treatment of
    women Veterans; the number of full-time obstetricians or gynecologists;
    the number of health professionals trained in women's health; the
    extent to which the medical center conducts regular training on issues
    specific to women's health and sensitivity training; the differences in
    health outcomes between men and women Veterans; the security and
    privacy measures used in registration, clinical, and diagnostic areas;
    the availability of gender-specific equipment or procedures; the extent
    to which VA's Center for Women Veterans advises and engages with
    medical centers in providing health care to women Veterans; the extent
    to which the medical centers implement directives from the Center for
    Women Veterans; the outreach conducted by VA to women Veterans in the
    community; the collaboration between VA medical centers and providers
    in the community to meet the health care needs of women Veterans; and
    the effectiveness of the Patient Aligned Care Teams in meeting the
    health care needs of women Veterans. The Comptroller General would be
    required, within 270 days of the date of the enactment of this Act, to
    submit to the Committees on Veterans' Affairs of the Senate and the
    House of Representatives a report on this examination.
        We defer to the U.S. Government Accountability Office (GAO) on this
    provision.
                    draft bill, veterans health act of 2015
        Section 4 would extend by one year, until December 31, 2016, VA's
    authority to transport persons to and from VA facilities and other
    places in connection with vocational rehabilitation, counseling
    required under chapter 34 or 35 of title 38, or for the purpose of
    examination, treatment, or care. Section 4(b) would authorize
    appropriations of $4 million for FY 2016 and 2017, and section 4(c)
    would require a report to Congress within 1 year of the date of the
    enactment of this Act on VA's transportation program, the use of the
    program by Veterans, and the feasibility and advisability of continuing
    the program beyond December 31, 2016.
        VA has no objection to the reporting requirement under section
    4(c).
        Section 5 would require VA to make available on an Internet Web
    site data files that contain information on research of the Department,
    a data dictionary on each data file, and instructions for how to obtain
    access to each data file for use in research. It would also require,
    within 18 months of the date of the enactment of this Act, that any
    final, peer-reviewed manuscript prepared for publication that uses data
    gathered or formulated from research funded by the Department be
    submitted to the Secretary for deposit in a digital archive. VA would
    be required to establish this archive within 18 months of the date of
    the enactment of the Act or to partner with another executive agency to
    compile such manuscripts in a digital archive. The digital archive
    would have to be publicly available on an Internet Web site, and each
    manuscript would have to be available through the archive within 1 year
    of the official date on which the manuscript is published. VA would
    also be required, within 1 year of making manuscripts available and
    annually thereafter, to report to Congress on the implementation of
    this section. Finally, within 1 year of the date of the enactment of
    this Act, the VA-Department of Defense (DOD) Joint Executive Committee
    would be required to submit to the VA and DOD Secretaries options and
    recommendations for the establishment of a program for long-term
    cooperation and data sharing between the two Departments.
        VA is still analyzing this section and would be glad to provide
    views at a later time.
              * * * * * * *
                                     ______

                                Department of Veterans Affairs,
                                     Washington, DC, September 4, 2015.
    Hon. Johnny Isakson,
    Chairman,
    Committee on Veterans' Affairs,
    U.S. Senate, Washington, DC.

        Dear Mr. Chairman: The agenda for the Senate Committee on Veterans'
    Affairs' June 3, 2015, and June 24, 2015, legislative hearings included
    a number of bills that the Department of Veterans Affairs (VA) was
    unable to address in our testimony or in our prior correspondence with
    you on July 15, 2015. By this letter, we are providing the final
    remaining views and cost estimates on the following bills from the June
    3, 2015, legislative hearing: sections 2 and 4 of S. 297, the
    Frontlines to Lifelines Act of 2015; the draft bill on establishing a
    joint VA-Department of Defense (DOD) formulary for systemic pain and
    psychiatric medications; and sections 2, 3, and 5 of the draft bill,
    Veterans Health Act of 2015.
        We are also providing the final remaining views and cost estimates
    on the following bills from the June 24, 2015, legislative hearing:
    sections 203, 208, and 209(b) of S. 469, Women Veterans and Families
    Health Services Act of 2015; sections 4(b) and 8 of S. 1085, Military
    and Veteran Caregiver Services Improvement Act of 2015; and sections
    105, 205, 403, and 501 of the Jason Simcakoski Memorial Opioid Safety
    Act.
        We appreciate this opportunity to comment on this legislation and
    look forward to working with you and the other Committee Members on
    these important legislative issues.
                Sincerely,
                                            Robert A. McDonald,
                                                             Secretary.

      Enclosure.

                                  June 3, 2015
                  s. 297--frontlines to lifelines act of 2015
        Section 2 of S. 297 would require VA to revive the Intermediate
    Care Technician Pilot Program of the Department of Veterans Affairs
    (VA) that was carried out between January 2013 and February 2014. VA
    would be required to expand the pilot program to include not less than
    250 intermediate care technicians in the pilot program. It would also
    permit VA to assign any intermediate care technician hired under this
    program to a VA medical facility, with the Secretary giving priority to
    facilities at which Veterans have the longest wait times for
    appointments for the receipt of hospital care or medical services. The
    pilot would be authorized during the 3-year period beginning on the
    date of the enactment of this Act.
        As we explained in a response to a question from Senator Rounds at
    the hearing, we are currently working to expand the program beyond
    emergency services, most notably to increase support in podiatry and
    surgical clinics given the qualifications of those participating in the
    earlier pilot program. We do not require additional legislation for
    this expansion of the program, and consequently, VA does not support
    section 2 of this bill because we are already moving ahead with a
    permanent program, rather than a pilot program.
        Section 4(a) of S. 297 would give discretion to the Secretary to
    authorize ``covered nurses'' to practice independently, without
    supervision or direction of others, under a set of privileges approved
    by the Secretary. Such authority would be notwithstanding any provision
    of state law and regardless of the state in which the covered nurse
    would be employed by VA. Section 4(b) would define a ``covered nurse''
    as an advanced practice registered nurse (APRN) who is employed by VA
    in any of the following specializations: Nurse Midwife, Clinical Nurse
    Specialist (with respect to the provision of mental health care), and
    Nurse Practitioner.
        VA supports the intent of section 4, but we offer four
    recommendations for technical revisions to the legislation. First, we
    recommend adding a reference to state of licensure in section 4(a).
    This would enable the Secretary to standardize the practice of APRNs
    throughout VA's health care system, regardless of the state(s) in which
    they are licensed and/or employed by VA. This technical revision would
    facilitate the provision of additional health care services in
    medically-underserved areas, thereby increasing access to high quality
    health care for all Veterans.
        Second, we recommend that the phrase ``under a set of privileges
    approved by the Secretary'' be deleted from section 4(a), as
    unnecessary. To practice professionally, all health care providers must
    be granted a scope of practice or clinical privileges by the medical
    facility where they work.
        Third, we recommend that the word ``Licensed Certified'' be added
    to the titles of Nurse Midwife, Clinical Nurse Specialist, and Nurse
    Practitioner.
        Fourth, we recommend that Section 4 contain a new subsection (c) to
    clarify that covered nurses may prescribe controlled substances
    provided they are authorized by their state licensure to do so and
    comply with the limitations and restrictions on that prescribing
    authority.
     draft bill--establishing a joint uniform formulary for systemic pain
                             and psychiatric drugs
        The draft bill establishing a joint uniform formulary for systemic
    pain and psychiatric drugs, would require the Secretaries of Defense
    and Veteran Affairs to establish (and periodically update) a joint
    strategic, evidence-based, uniform formulary for systemic pain and
    psychiatric drugs that are critical for individuals receiving health
    care services furnished by DOD who are transitioning to health care
    services furnished by VA.
        While this draft bill is narrower in scope than other legislation
    being considered by the Congress, VA still believes the proposed
    legislation is unnecessary and has the potential to undermine VA's
    formulary process. First, as documented by a U.S. Government
    Accountability Office (GAO) report, DOD and VA Health Care: Medication
    Needs during Transitions May Not Be Managed for All Servicemembers
    (November 2012), VA's formulary already lists 90 percent of mental
    health and 96 percent of pain medication DOD currently dispenses
    (p. 17-18). Second, VA and DOD already collaborate to conduct extensive
    reviews of medications available to transitioning Servicemembers on
    their respective formularies. Furthermore, VA has a longstanding policy
    of promoting continuity of care between DOD and VA and existing
    policies to manage Servicemember transition from DOD to VA. For
    example, an Information Letter (IL 10-2014-15) from the Under Secretary
    for Health in July 2014 stated, ``The medication therapy needs of
    recently discharged Veterans who choose VA for their medical care
    should also be carefully evaluated by VA health care providers and
    unless medical conditions warrant a change, existing medication
    therapies should be continued.'' Additionally, in August 2014, as part
    of the President's executive actions to address the mental health needs
    of Servicemembers and Veterans, VA announced a new policy to ensure
    that transitioning Servicemembers can maintain access to mental health
    medication absent specific safety or clinical reasons to make a change.
    VA has implemented this policy through Veterans Health Administration
    (VHA) Directive 2014-02, Continuation of Mental Health Medications
    Initiated by Department of Defense Authorized Providers, which states
    that it is VHA policy not to discontinue mental health medications
    initiated by a DOD authorized provider solely because of differences
    between the VA and DOD drug formularies.
        VA's formulary process is evidence-based and not automatic or based
    on prescriber preferences. This process involves VA clinical subject
    matter experts, who perform clinical reviews and provide recommended
    guidelines, and recommendations and decisions by VA's Medical Advisory
    Panel and the Veterans Integrated Service Network Pharmacy Executive
    Committee. VA's current formulary methodology enables clinical staff to
    use discretion to exclude drugs from VA's formulary when there is the
    belief that certain pharmaceuticals pose safety risks or have unknown
    safety risks and/or offer no clinical benefit over existing formulary
    drugs. For example, between 1997 and 2011, 31 FDA-approved drugs were
    removed from the U.S. market, primarily for safety reasons, yet only 2
    of these drugs were on VA's formulary. Despite the language in the
    proposed legislation aimed at preserving DOD and VA's authority to
    maintain their own unique formularies, VA does not see how the proposed
    legislation reconciles the differences between DOD and VA's formulary
    processes for purposes of a joint formulary, even of limited scope, and
    believes the current proposal may actually undermine VA's formulary
    process. Finally, VA believes implementing such a proposal could result
    in increased cost to VA with no corresponding clinical benefit for
    Veterans.
        Of note, DOD has similarly noted concerns regarding establishment
    of a joint formulary in response to recent recommendations of the
    Military Compensation and Retirement Modernization Commission. DOD
    noted that it works with VA to ensure that medications can be
    maintained for transitioning Servicemembers but believes that
    sufficient authorities exist today to do so.
        VA is unable to estimate the cost of this bill because it cannot be
    known, at this time, what medications would be included in the
    formulary.
                    draft bill--veterans health act of 2015
        Section 2 of the draft bill, ``Veterans Health Act of 2015,'' would
    amend the definition of ``preventive health services'' in 38 United
    States Code (U.S.C.) 1701(9) to include immunizations against
    infectious diseases, including each immunization on the recommended
    adult immunization schedule at the time such immunization is indicated
    by the Advisory Committee on Immunization Practices established by the
    Secretary of Health and Human Services and delegated to the Centers for
    Disease Control and Prevention. It would also modify the requirements
    of the annual report to Congress on preventive health services by
    including a requirement to report on VA's programs to provide Veterans
    each immunization on the recommended adult immunization schedule at the
    time such immunization is indicated. Finally, section 2 would require
    VA, within 2 years of enactment of the Act, to submit to Congress a
    report on the development and implementation of quality measures and
    metrics, including targets for compliance, to ensure Veterans receiving
    medical services receive each immunization on the recommended adult
    immunization schedule at the time such immunization is indicated.
        VA strongly supports preventive care measures, including making a
    wide range of immunizations available at VA medical facilities.
    However, because we believe VA is already satisfying the purpose of
    this bill, we do not support this legislation. Under current policy, VA
    already provides preventive immunizations at no cost to the Veteran. In
    addition, VHA is represented as an ex-officio member of the Advisory
    Committee on Immunization Practices (ACIP), and VA develops clinical
    preventive services guidance statements on immunizations in accordance
    with ACIP recommendations. All ACIP-recommended vaccines are available
    to Veterans at VA medical facilities. These vaccines currently include:
    hepatitis A, hepatitis B, human papillomavirus, influenza, measles/
    mumps/rubella, meningococcal, pneumococcal, tetanus/diphtheria/
    pertussis, tetanus/diphtheria, varicella, and zoster. As the ACIP
    recommendations change, VHA policy reflects those changes.
        The delivery of preventive care, including vaccinations, has been
    well established in the VHA Performance Measurement system for more
    than 10 years with targets that are appropriate for the type of
    preventive service or vaccine. VA updates the performance measures to
    reflect changes in medical practice over time.
        Section 3 would require VA to carry out a program to provide
    chiropractic care and services to Veterans through VA medical
    facilities at not fewer than two VA medical centers in each VISN by not
    later than 2 years after the date of the enactment of this Act, and at
    not fewer than 50 percent of all VA medical centers in each VISN by not
    later than 3 years after the date of the enactment of this Act. It
    would also modify 38 U.S.C. 1701 to amend the definition of ``medical
    services'' to include chiropractic care and would amend the definition
    of ``preventive health services'' to include periodic and preventive
    chiropractic examinations and services.
        VA supports the intent of section 3 of this bill, conditioned on
    the availability of additional resources to implement this provision.
    Expanding the number of VA medical facilities providing on-station
    chiropractic care would serve the needs of Veterans in expanding the
    availability of evidence-based treatment for musculoskeletal pain
    conditions that are highly prevalent in Veterans. Chiropractic
    treatment has been shown to be clinically effective, cost effective,
    and in high demand by Veterans. Patients who have access to
    chiropractic care are less likely to receive opiate medications and
    spinal surgeries. Just this year, The Joint Commission added
    chiropractic care to its pain management standards.
        Additionally, VA has already been expanding access to chiropractic
    services for Veterans. In fiscal year (FY) 2014, VA provided on-station
    chiropractic care to 26,395 Veterans, an increase of 14 percent from FY
    2013. As of May 2015, 52 VA medical centers have chiropractic clinics,
    up from 47 in FY 2014. Nevertheless, VA continues to face significant
    variation in access to chiropractic care across the country. Therefore,
    expanding the minimum number of chiropractic clinics per VISN will
    facilitate providing these services to Veterans in a more equitable
    manner.
        We offer two recommendations for technical revisions to the
    legislation. First, we recommend removing the reference to clinics in
    the proposed amendment to section 204(c) of Public Law 107-135. This
    change would focus the language on VA medical centers and would not
    result in confusion over whether clinic referred to a service at a
    medical center or an independent clinic at another location. Second, we
    recommend the legislation not amend the definition of preventive health
    services in section 1701(9). Chiropractic services are provided as part
    of the medical benefits package and are administered based on clinical
    need, similar to all other medical care. It would be inconsistent with
    the professional standards for other medical disciplines and
    inappropriate to provide ``periodic and preventative chiropractic
    examination and services'' when there are no clinical indications that
    such care is needed.
        We estimate that VA would need to add chiropractic services at five
    facilities to meet the requirement to operate the program at not fewer
    than two VA medical centers in each VISN within 2 years of the date of
    the enactment of this Act, and at another 23 facilities to meet the
    requirement that these services be available at not fewer than 50
    percent of all VA medical centers in each VISN within 3 years of the
    date of the enactment of this Act. We estimate that the cost to hire
    these additional staff would be $3.67 million per year after the
    requirements of section 3 are fully phased in.
        Section 5 would require VA to make available on an Internet Web
    site data files that contain information on research of the Department,
    a data dictionary on each data file, and instructions for how to obtain
    access to each data file for use in research. It would also require,
    within 18 months of the date of the enactment of this Act, that any
    final, peer-reviewed manuscript prepared for publication that uses data
    gathered or formulated from research funded by the Department be
    submitted to the Secretary for deposit in a digital archive. VA would
    be required to establish this archive within 18 months of the date of
    the enactment of the Act or to partner with another executive agency to
    compile such manuscripts in a digital archive. The digital archive
    would have to be publicly available on an Internet Web site, and each
    manuscript would have to be available through the archive within 1 year
    of the official date on which the manuscript is published. VA would
    also be required, within 1 year of making manuscripts available and
    annually thereafter, to report to Congress on the implementation of
    this section. Finally, within 1 year of the date of the enactment of
    this Act, the VA/DOD Joint Executive Committee would be required to
    submit to the VA and DOD Secretaries options and recommendations for
    the establishment of a program for long-term cooperation and data
    sharing between the two Departments.
        VA supports the goal of this bill and is already taking action to
    achieve its objectives. Public access to research has been an
    increasingly important topic among Federal research agencies over the
    past several years. As a result, most of what is required in this bill
    has already been accomplished or is in process. On February 22, 2013,
    the White House Office of Science and Technology Policy (OSTP) directed
    each Federal agency with over $100 million in annual expenditures for
    the conduct of research and development to develop a plan to support
    increased public access to the results of research funded by the
    Federal Government, including any results published in peer-reviewed
    scholarly publications that are based on research that directly arises
    from Federal funds. The bill's requirement to make information on VA
    research publicly available on an Internet Web site is nearly identical
    to requirements established by OSTP. Similarly, VA has already taken
    steps to satisfy the bill's requirement that VA ensure public access to
    manuscripts on VA-funded research. All VA-funded investigators are
    required to place their published manuscripts on the National
    Institutes of Health (NIH) PubMed, which provides manuscripts free to
    the public. Use of PubMed ensures that texts and their associated
    content will be stored in non-proprietary and/or widely-distributed
    archival, machine readable formats; provide access to persons with
    disabilities in accordance with Section 508 of the Rehabilitation Act
    of 1973; enable interoperability with other Federal public access
    archival solutions and other appropriate archives; and ensure that
    attribution to authors, journals, and original publishers will be
    maintained. VA also currently requires, and will continue to require,
    that the results of applicable VA-funded clinical trials must be
    provided to the public through the ClinicalTrials.gov archive, which
    provides access to the results of clinical trials involving products
    regulated by the Food and Drug Administration. Additionally, VA is
    working with DOD to develop data sharing agreements, and several such
    agreements are already in place.
        We are concerned that the bill, as written, would greatly increase
    costs to the Department and may inadvertently limit the public
    availability of manuscripts. As stated, VA is currently making much of
    this information public, but through other mechanisms, such as PubMed
    or ClinicalTrials.gov. Requiring VA to develop its own Web site would
    require additional expenses with no net benefit in terms of the
    availability of information. Additionally, creating a separate
    repository for this information from PubMed or ClinicalTrials.gov would
    spread information among several Federal Web sites, making it more
    difficult for users to find information. VA is unable to offer a cost
    estimate at this time because we cannot determine the information
    technology (IT) costs associated with these requirements.
              * * * * * * *

        Chairman Isakson. Thank you, Dr. Lynch. I have a comment
    and a question. You made favorable statements about the
    language providing for provider agreements, is that correct?
        Dr. Lynch. Yes, Senator.
        Chairman Isakson. VA has had input into that language in
    terms of non-VA health care, is that correct?
        Dr. Lynch. Yes, Senator.
        Chairman Isakson. And those provisions are merged with
    another provision that Senator Hoeven introduced to allow VA
    nursing home vouchers be accepted by private providers, is that
    correct?
        Dr. Lynch. Senator, I would have to defer to Ms. Blauert on
    that.
        Ms. Blauert. Yes, the veterans care agreements would be
    available to be used for extended care services, so purchasing
    nursing home care from community providers.
        Chairman Isakson. And there is no objection from the VA on
    any of those provisions, is that correct?
        Ms. Blauert. Specifically, we are in favor of being able to
    purchase extended care services through a mechanism like a
    veterans care agreement.
        Chairman Isakson. For the benefit of the Members, one of
    the burdens of chairmanship is from time to time you are asked
    to make commitments on the floor of the Senate that you wish
    you had waited to make. I committed to Senator Hoeven that we
    would not object to a UC (unanimous consent) on provider
    agreements in terms of nursing home facilities. Subsequently,
    that information was merged, as I understand it, with provider
    language for all non-VA provider contracts, both
    hospitalization as well as physicians, is that correct?
        Ms. Blauert. Yes. The Administration bill that was
    presented on May 1st included hospital care medical services
    and extended care services.
        Chairman Isakson. So, the Members are fully appraised, if a
    UC is offered on the floor prior to us doing a markup on that
    bill, I am not going to object to that UC. I wanted you all to
    all hear from the VA that they have no objection to the
    provider agreement language, which is, I think, what the lawyer
    said.
        Chairman Isakson. Am I right, Tom?
        Dr. Lynch. Yes, sir.
        Chairman Isakson. Senator Blumenthal, is that right?
        Senator Blumenthal. That is absolutely correct, Mr.
    Chairman, and I want to thank you personally for your
    understanding on behalf of myself, and I think I speak for
    Senator Hoeven. Our staffs have worked very closely and well on
    merging these two pieces of legislation that essentially deal
    with providing alternative opportunities for care to our
    veterans, and I want to thank the VA for being cooperative as
    well.
        Chairman Isakson. Thank you, Senator Blumenthal. Senator
    Blumenthal, do you have a question?
        Senator Blumenthal. I just want to ask you, Dr. Lynch, very
    quickly about the formulary issue. I do not know whether you
    have had a chance to read Mr. Medina's written testimony
    telling of his struggle to obtain medication that his doctor
    previously found to work well for him and to manage chronic
    symptoms from his Traumatic Brain Injury. It is a very powerful
    and compelling story.
        I understand that after learning of Mr. Medina's attempt to
    testify today, the VA reached out to him offering to cover the
    medication that was originally prescribed by DOD, but, in
    effect, denied by the VA.
        I am very pleased and thankful that the VA seems to be
    taking action to remedy the problems of a prior policy, and my
    feeling is that the VA, or perhaps more directly veterans
    treatment options, should not be determined by whether or not
    they have an opportunity to speak in front of Congress.
        Earlier this year, the VA issued a directive meant to
    prevent transitioning soldiers like Mr. Medina from having to
    stop treatment that has proven effective simply because it is
    not in the VA's formulary. I welcome that directive or policy
    change.
        Can you discuss whether you have seen any other
    improvements? Obviously Mr. Medina's situation has improved
    since the implementation of this policy.
        Dr. Lynch. The only reference I would have, Senator, is
    that when we did look at a series of 2,000 veterans, we saw a
    small percentage who did have a problem as they related to the
    VA/DOD formulary issue. We have been very aggressive in getting
    communications to the field. VA feels strongly that there needs
    to be an appropriate transfer of medications.
        The single qualification would be that there is a certain
    clinical judgment that has to occur at the time of transfer and
    there may be some changes under those circumstances. But
    otherwise, I think it is important, as the veteran transitions,
    that we do not change medications if clinically appropriate.
        Senator Blumenthal. And that the approach be, in effect,
    evidence-based and that it be consistent with patient safety?
        Dr. Lynch. That has been the VA's approach to our formulary
    as we have developed the formulary. It has been evidence-based,
    it has been focused on patient safety, it has used the best
    available information to determine what drugs to place on that
    formulary, absolutely.
        Senator Blumenthal. Thank you. Thanks, Mr. Chairman.
        Chairman Isakson. Senator Moran.

               HON. JERRY MORAN, U.S. SENATOR FROM KANSAS

        Senator Moran. No questions.
        Chairman Isakson. Senator Tester.

               HON. JON TESTER, U.S. SENATOR FROM MONTANA

        Senator Tester. Well, thank you, Mr. Chairman, and I want
    to say thank you for holding this hearing. We have focused
    mainly on oversight of this Committee, which is very, very
    important, so it is good to get some good policies out, too.
    So, I thank you for that, Mr. Chairman and Ranking Member
    Blumenthal.
        Just a question for you, Mr. Lynch--Dr. Lynch, I am sorry.
    The VA----
        Dr. Lynch. It is only important to my mother.
        Senator Tester [continuing]. Launched a veterans
    transportation service initiative which began providing funds
    to local VA facilities to help them better meet the
    transportation needs of our veterans out there. Since that
    time, this funding has been used in Montana and elsewhere to
    hire staff, transportation staff, and purchase vehicles.
        I think the program is working and there is a
    reauthorization proposal here today. I think it is in the fifth
    group down, which is a compilation of bills that is Number 172,
    but I think a long-term authority is important. I just want to
    get your perspective on the transportation bill and
    transportation perspective.
        Does this program so far do what it was intended to do and
    that is connect veterans with rehab counseling and medical care
    that they need?
        Dr. Lynch. Absolutely. This has been a tremendous program.
    It has helped us get veterans to services that they need in a
    convenient fashion. It is being expanded. Interestingly, one of
    my responsibilities is spinal cord injury. Our spinal cord
    injury physicians are beginning to explore the use of this
    service to move those veterans to care as well. I think it is
    very well formed. I think it is a good program. I think it
    needs to continue.
        Senator Tester. Now, the VA has estimated that a longer-
    term authorization could potentially save the taxpayers about
    $206 million, a little over that, almost $207 million over 5
    years.
        Dr. Lynch. Yes, sir.
        Senator Tester. Would you agree with that estimate? I
    assume that is because of additional travel costs, staying
    overnight, all that kind of stuff.
        Dr. Lynch. That would be my assumption, sir.
        Senator Tester. OK, good. So, there are some areas where it
    has been tough to find drivers, to be quite frank with you, and
    I will just give you an example. Like Fort Peck Indian
    Reservation where we have a high number of veterans, yet, tough
    to get qualified drivers for a number of reasons, and they are
    all real.
        Is there some way--do you have the ability now in cases
    like that--and this is not with this bill particularly, just
    overall--to be able to contract with other transportation
    services out there that already exist?
        Dr. Lynch. Senator, I cannot answer that question
    specifically. I would like to get back to you with an answer
    that I am confident with, if that would be permissible.
        Senator Tester. That would be very good because I think it
    may serve some purpose down the line, so if you could do that,
    that would be great.
     Response to Request Arising During the Hearing by Hon. Jon Tester to
            Thomas Lynch, M.D., U.S. Department of Veterans Affairs
        Response. For the purpose of delivering healthcare, the VA may
    contract transportation services for certain eligible Veterans, other
    persons traveling with an eligible Veteran or in certain circumstances
    when transport is required to provide a complete hospital or medical
    services.
        Title 38 U.S.C. 111 provides authority to make payment to or for
    certain persons for travel in relation to VA examination, treatment or
    care. This authority is limited to the eligibility criteria of the
    authority and determined under the regulations prescribed at 38 CFR
    Part 70.
        Title 38 U.S.C. 7301(b) has been interpreted to provide the
    transportation for the transfer of a patient between VA facilities and/
    or Non-VA facility at VA expense when; the initial transferring VA
    facility is incapable of providing the necessary treatment, care or
    examination, The transfer is necessary for the continuation of
    services, A VA facility has accepted for admission a patient receiving
    emergency care at a non-VA facility at VA expense under 38 U.S.C. 1728
    or who is otherwise eligible for travel benefits under 38 U.S.C. 111.
        The majority of our transportation contracts consists of ambulance
    and wheelchair transport services, but may include such services as
    taxi when appropriate. VA facilities typically do not have these types
    of vehicles and the staff needed to provide transport or those that do
    cannot meet the volume of service required. Although not always
    possible, the VA attempts to enter into Transportation service
    contracts to reduce costs to the government when the facility has
    insufficient assets to meet the demand for transporting our Veterans to
    ensure they have access to care.
        When VA must utilize a contract for transportation services the
    role of the contracting officer is to ensure that a contract is
    appropriate and complies with all terms of both Federal and VA
    Acquisition Regulations prior to and upon award.
        Realizing these services are very costly to the government the
    Veteran Transportation Program continues to look for ways to offset the
    cost. One such program is our Veteran Transportation Service that works
    with facilities to implement their own transportation services. Other
    initiatives involve developing transportation partnerships within the
    local community.
        Regardless of the methods used, transportation contracts, VA owned
    and operated services or community transportation services, all efforts
    are focused on providing our Veterans timely access to care.

        Senator Tester. Immunizations are kind of the low-hanging
    fruit out there from my perspective. I think it is very, very
    fast and effective for prevention of disease and health and
    death.
        As many as 70,000, according to CDC, adults deaths are from
    vaccine preventable diseases. Dr. Lynch, as you may know, many
    of our veterans are in a high-risk category of contracting such
    diseases. To what extent does the VA--if you want to defer this
    you certainly can. To what extent does the VA place a priority
    on immunizations?
        Dr. Lynch. Number 1, VA places a high priority. I am not
    going to defer it. I am going to pass it off to Dr. McCarthy
    who actually has been looking at this very carefully over the
    past couple days in preparation.
        Dr. McCarthy. Thanks for this question. VA takes the need
    for immunization extremely seriously and we have one of our
    chief consultants, actually an ex officio member on the
    national committee about immunizations.
        Senator Tester. OK.
        Dr. McCarthy. We take what is the from the Committee and
    have a very proactive approach.
        Senator Tester. Now, the CDC has recommended that adult
    immunization schedules be periodically reviewed and revised. Do
    you do that?
        Dr. McCarthy. Yes, we do.
        Senator Tester. OK. To what extent does the VA follow
    immunization recommendations of the CDC?
        Dr. McCarthy. We follow the recommendations to the letter
    of the law in terms of what we recommend to veterans in terms
    of the immunizations that we would expect them to take. There
    are choices involved from the veteran perspective.
        Senator Tester. As you look at the protocol that is out
    there for administering vaccinations to veterans, do you see
    any improvements that could be made?
        Dr. McCarthy. We look at this often. What is it that we are
    doing right, what could we do better. When we think, in
    particular--let us take flu vaccine, for instance. We seized
    the moment in terms of the Ebola crisis for people to have a
    lot of education about it, you know, in this country. There was
    a very significantly increased risk of death from influenza,
    and how important it was for our veterans to be vaccinated with
    influenza.
        We had a very large education campaign about that. Some of
    our facilities set up drive-in clinics for flu shots and
    everything else. You know, what we could to better, perhaps, is
    make it even more convenient for veterans. That is where our
    focus has been.
        Senator Tester. Thank you. Thank you all for being here
    today and I may have some questions for the record on
    homelessness. Thank you, Mr. Chairman.
        Chairman Isakson. Senator Rounds.

            HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA

        Senator Rounds. Thank you, Mr. Chairman, I would also like
    to echo the comments earlier. It is good to see the Committee
    taking up discussions on these different pieces of legislation.
    I have appreciated the evaluation which you have expressed on
    the legislation which is before us today.
        I guess my first question would be, if there was an order
    of importance with regard to the items found within it and that
    we are looking at today, could you give me the most important
    bill or the most important piece of legislation that would help
    you deliver health care to our veterans?
        Dr. Lynch. I think from VA's standpoint, it would be the
    development of a non-FAR model for obtaining purchased care in
    the community for our veterans.
        Senator Rounds. Specifically, to one of the pieces of
    legislation here today?
        Dr. Lynch. Specifically, it is the draft legislation. Let
    me make sure I have the name correct here.
        Ms. Blauert. It is the draft version of the Department of
    Veterans Affairs Purchased Health Care Streamlining and
    Modernization Act.
        Senator Rounds. As I have said, I appreciate your review of
    the other legislation involved. If I could, just on S. 297, I
    did have just a question with regard to Section 3 and Section 4
    of that and your analysis. How do you lay out, in terms of the
    health care provider, how broad were you looking at or
    anticipating your review of who would be included as a health
    care provider for the pilot project?
        Dr. Lynch. VA has already had a pilot project with respect
    to intermediate care technicians. It concluded recently. It
    involved about 15 different sites. It included 45 individuals.
    Services were predominantly in the emergency department. It was
    wildly successful. VA is moving forward actively to expand the
    program and to expand it beyond emergency services.
        Senator Rounds. Do you include the other allied health
    professions? I am just curious as to how broad the project is
    or how broad you could look at it in terms of the different
    professional services being provided.
        Dr. Lynch. Dr. McCarthy.
        Dr. McCarthy. I can say that the initial thought was
    perhaps the best fit would be in emergency departments, but as
    time evolved, it seemed to support in podiatry and surgical
    clinics were a very good fit for the people that were part of
    the pilot for the transition. We are looking in the health care
    arena and what might be a good fit and it is a win-win.
        Senator Rounds. You would be open to expanding the pilot
    project to other allied health professions that may not be
    involved in your pilot project today? What I am thinking about
    is, in South Dakota, we do not necessarily have--in a lot of
    our rural areas, we are served by allied health professionals.
    I just want to make sure that if we are looking at a pilot
    project like this, that we be as broad as possible. If there is
    a concern with regard to one profession versus another, I am
    just curious if you could share any concerns like that you
    might have.
        Dr. McCarthy. I can say a little bit about the development
    of the pilot and the people in the different kinds of
    professions that were represented.
        Senator Rounds. Please.
        Dr. McCarthy. It included physicians, physician assistants,
    nursing staff of various professional degrees, in particular. I
    do not know that we had any representative from lab, but that
    is the kind of thing that we would embrace, yes.
        Dr. Lynch. I think we would be interested in exploring with
    your office any opportunities to expand that program and work
    with you to make a more effective program.
        Senator Rounds. Very good.
        Dr. Lynch. It has been very successful. I think it is a
    great opportunity. It is win-win for the veteran and it is win-
    win for the VA.
        Senator Rounds. Thank you. Mr. Chairman, I yield back.
        Chairman Isakson. Thank you, Senator Rounds.
        Senator Manchin.

           HON. JOE MANCHIN, U.S. SENATOR FROM WEST VIRGINIA

        Senator Manchin. Thank you, Mr. Chairman, and thank all of
    you. I am going to switch topics to something that is really
    devastating to my State. It is the opioids, prescription of
    these opioids, painkillers, and I am sure you all are very much
    aware of it. We are being devastated in my State. It is the
    number 1 killer. We have a mortality rate and it is because of
    prescription drug abuse.
        I am finding that the VA does not always have or offer good
    alternatives. For example, just in the Beckley VA medical
    center, there are zero alternative treatments available, and at
    Clarksburg we only have one.
        So, my question would be, how do you plan on using funds
    provided under the Choice Act to establish alternative
    treatment methods at facilities like these?
        Dr. Lynch. Dr. McCarthy.
        Dr. McCarthy. Sure, I will be happy to start. I used to be
    chief of staff at the Salem, Virginia, VA medical center and we
    treated many veterans from Beckley and we had a pain program in
    which some of the veterans from Beckley actually came and
    received some non-pharmacologic interventions for their pain.
        They may not be provided right at Beckley, but there was
    access to those veterans, for instance, at Salem.
        Senator Manchin. Yes.
        Dr. McCarthy. Not perfect, I know,
        Senator Manchin. Well, let me ask, for areas where we do
    not have the proper treatment, with the Choice Act, are you all
    allowing them to find different providers, private providers,
    that might be able to provide the services they need which
    would help them versus trying to find something within the VA
    system that is not even practical for them to go to?
        Dr. McCarthy. Let us just talk about providers in general
    if we could, for a minute. We could talk about chiropractors.
    We could talk about pain specialists. We could talk about
    acupuncture. OK. Under the Choice program, indeed,
    chiropractors are included and pain specialists are included in
    terms of those that people are referred to.
        I am not aware of the integrative complementary and
    alternative medicine specialties like, for instance,
    acupuncture. I would have to take that one for the record and
    get back to you.
     Response to Request Arising During the Hearing by Hon. Joe Manchin to
          Maureen McCarthy, M.D., U.S. Department of Veterans Affairs
        Response. Many Complementary and Integrative Health (CIH) practices
    are in use within VHA and CIH practices that are offered by licensed
    practitioners could be offered by non-VA providers through the Choice
    program. Two common CIH practices offered by licensed CIH practitioners
    are acupuncture and massage therapy. Recently Congress amended the
    Original Choice Act to include these providers in their provider
    network so that these resources may be available to Veterans if they
    are needed and cannot be provided by their local facilities. The VA
    Community Care office is working on contract modifications to include
    integrative health services in the current contracts VA has for non-VA
    care.

        Dr. Lynch. Senator, I would just add that the VA has
    established, over the last 12 to 18 months, a very aggressive
    opioid safety initiative program which is looking at our use of
    opioids. Part of that program, as we are looking at the use of
    opioids and the prescriptions for opioids across the system, is
    also looking at how we can incorporate complementary and
    alternative therapies into more VA medical centers, realizing
    this is going to be a critical part of treating veterans with
    chronic pain.
        Senator Manchin. Well, let me just tell you what is hard.
    In my little State of West Virginia, from 2007 to 2012, over
    200 million pills, opioids, have been shipped to my State; 200
    million. Our veterans are being affected by this. We have
    double the mortality rate as far as opioid overdoses in
    military VA than the national average. So, we know we have a
    problem with the VA.
        We have got, basically, people who are not trained at
    dispensing or taking time to educate a veteran who is needing
    this--PTSD or whatever it may be--that are getting a
    concoction. They are taking things that are just lethal.
        Dr. McCarthy. Yes. We could talk to you a little bit about
    the opioid safety initiative that we have going on.
        Senator Manchin. How are you tracking your doctors who are
    over-prescribing?
        Dr. McCarthy. We have tracking of prescriptions. We are
    tracking all of the opioids in terms of the morphine equivalent
    doses. We are actually expecting trends downward. We are
    tracking people that are on opiates as well as benzodiazepines,
    which is not a great----
        Senator Manchin. Are we trying any alternatives? The reason
    I am saying that, if we as a Nation--you know, 5 percent of the
    population of the world is what we have in the United States of
    America, yet, we use 80 percent of the opioids that are
    produced in the world. Five percent of the world population
    consuming 80 percent of painkillers. Something is wrong.
        Dr. McCarthy. Yes.
        Senator Manchin. Now, you tell me that is not a big money
    scheme from pharma that is basically putting out pills that we
    do not need and putting out more of them than we ever could
    consume or should consume. Something is wrong there. So, I am
    saying, we have got to go to alternative pain methods. Are you
    all trying anything different?
        Dr. McCarthy. Go ahead, Dr. Lynch.
        Dr. Lynch. I think we are. I mean, I would need to get back
    to you with the specifics, but as part of our opioid safety
    initiative, we are beginning to engage complementary and
    alternative therapies as part of the program. We do, in fact,
    give veterans informed consent before we provide opioids at
    this point.
        We give them a discussion of what the risks and what the
    benefits of the treatment are. And we are making active efforts
    to get people off of high doses of opioids and on to
    alternative medications and therapies.
        Senator Manchin. I am just saying, if we, as in the sense
    of the Senate, the sense of Congress, basically said, We
    believe that our Medicare, Medicaid, and VA, which is probably
    the largest group of medical providers in the world, if we
    could do that which we have influence over, it could basically
    change the direction of how we treat chronic pain or pain
    relief, if you will, and not just going to the opioids
    immediately, but going to alternative uses. Would it be
    something accepted by the VA?
        Dr. McCarthy. I think it is a multifactorial approach. I
    think we need to not start people as much on them and we need
    to be very careful about the use of them and the mixing of
    them. Could I just add one other statement?
        Senator Manchin. I am sorry, Mr. Chairman.
        Dr. McCarthy. We are now dispensing opiate safety kits,
    which are the Naloxone kits, that reverse over-doses. I know
    that a lot of people are carrying them like first responders,
    police, and fire departments, but I did want you to know that
    we are actually dispensing them to veterans, and we have had
    over 55 people's lives saved by the veterans or their loved
    ones using it.
        Senator Manchin. How many times do you dispense it to the
    same user?
        Dr. McCarthy. I do not have the numbers on that.
        Senator Manchin. If you could get numbers for me, I would
    like to know. Because there is another problem coming with
    that.
        Dr. McCarthy. OK.
        Senator Manchin. Two, three, four, five, six, seven, eight?
    Life support?
        Dr. McCarthy. Right. I have not heard, but I would not be
    able to definitively say anything about the number of repeats.
    What I will say is we have veterans that are reaching out to
    their communities and saving those that are not veterans.
        Senator Manchin. I am sorry, Mr. Chairman. I have used up
    my time, but this is such an important----
        Dr. McCarthy. Yes, I would agree.
        Senator Manchin [continuing]. Such an important topic.
     Response to Request Arising During the Hearing by Hon. Joe Manchin to
          Maureen McCarthy, M.D., U.S. Department of Veterans Affairs
        Response. From June 19, 2014 to June 5, 2015, VA has received 72
    reported reversals from the use of the opioid safety kits. Eleven
    Veterans have reported more than 1 reversal.
        Providing another naloxone kit to a Veteran ensures the Veteran
    continues to have a means for their life to be saved should another
    overdose occur. This is similar to prescribing practices for other
    medications used in emergency situations, such as glucagon for
    hypoglycemia in diabetics and epi-pens for patients with severe
    allergies. It is recommended to use a naloxone prescription renewal
    request as an opportunity to determine the circumstances and base
    decisions to renew any prescriptions for opioids upon reassessment of
    the risks and benefits for that patient. It also presents the
    opportunity to engage the patient, provide re-education about
    overdoses, consider opioid risk mitigation strategies, and modify
    treatment plans.

        Dr. McCarthy. Thank you.
        Senator Manchin. Thank you.
        Chairman Isakson. It is a welcome topic and your focus is
    welcome. You are talking about statistics in terms of 200
    million pills to West Virginia?
        Senator Manchin. Just in my State. In a 5-year period--I
    only have 1.85 million people in my State.
        Chairman Isakson. A recent report turned out that there
    were enough opioids prescribed last year in the United States
    to provide 15 percent of the American population with a pill a
    day for the entire year. It is obviously an epidemic, not just
    in the military.
        Senator Manchin. This did not happen when we were youth.
    OK?
        Chairman Isakson. No.
        Senator Manchin. It has just changed. It has changed within
    the last two to three decades, that some of these doctors are
    putting them out for severe pain, and this never happened
    unless you came off of a very severe operation, but we are
    giving them out. If you have got a toothache, you can get a
    month or 2 months supply. This is something, but we can control
    this and we can help the veterans and it might change the whole
    trend of what we are doing in the country.
        Chairman Isakson. You are right on track.
        Senator Manchin. We are working on it.
        Dr. Lynch. Senator, we would be happy to work with your
    office providing some technical support for legislation.
        Senator Manchin. Thank you.
        Chairman Isakson. Senator Boozman.

             HON. JOHN BOOZMAN, U.S. SENATOR FROM ARKANSAS

        Senator Boozman. Thank you, Mr. Chairman, and again, I
    appreciate the Senator from West Virginia bringing this up. The
    other problem we have is that as people get onto this, because
    of cost, the next step is heroin. It is epidemic right now and
    it is increasing all of the time, again, in the sense that it
    is the same, but it is much cheaper.
        All of this stuff really does go together and we do
    appreciate your work on trying to get it under control. It is a
    situation that is not just a problem with the VA, but a problem
    across the board through society right now because of over-
    prescribing in the past.
        I really do not have any questions. Senator, I would like
    to thank you for including the S. 425, the Boozman-Tester,
    Homeless Veterans Reintegration program. What we are trying to
    do there is get this reauthorized. Then again, you know, you
    get in a situation where you have benefits based on being
    homeless and then you get into housing and things like that and
    you start losing benefits, which makes no sense at all.
        I mean, that is really where we need to double down. These
    are people that have admitted that they need help and we are
    doing the right thing. But the idea of providing them some help
    and then all of a sudden you start cutting benefits, which puts
    them in these Catch-22 situations. So, we are trying to get all
    of that sorted out and we do appreciate your help.
        Thank you. I yield back, Mr. Chairman.
        Chairman Isakson. And for your benefit, Senator Boozman, as
    well as the others on the Committee, we unfortunately had to
    move the June 24 markup to July 14, so that markup will take
    place on the bills we are hearing today and we will be bringing
    up at subsequent meetings.
        Senator Murray.

            HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON

        Senator Murray. Mr. Chairman, first let me start by
    thanking you for the commitment to list a number of really
    critical bills at your next legislative hearing later this
    month. Those bills are sponsored and supported by a number of
    Members on this Committee, and I know it includes my Women's
    Veterans and Fertility Treatment bill which is extremely
    important, my legislation to help family caregivers, and I
    understand Senator Baldwin's legislation to improve opioid
    safety that Senator Manchin was just referring to as well.
        I really appreciate that. You and I have worked on a lot of
    critical legislation over many years and I look forward to
    working with you on getting those bills done. Thank you.
        To this panel, Dr. Lynch, I wanted to ask you about the
    Women Veterans Access to Quality Care Act. I was really pleased
    to work with Senator Heller on this legislation, and as I am
    sure you all know, the population of women veterans is
    increasing dramatically. It has actually doubled since 2001.
    This bill will require all VA medical centers to have at least
    one full-time OB/GYN. I wanted to ask you today, how long will
    it take the VA to meet that standard and does the Department
    usually struggle to recruit OB/GYNs?
        Dr. Lynch. Right now VA has GYN specialists in 78 percent
    of our facilities, about 118. There are plans to add additional
    GYN providers by directive to, I think, around 20 more
    facilities as part of our operative complexity model. The VA
    has a model of operative complexity that looks at a certain
    infrastructure required to support surgical services at
    facilities.
        The mandate would be that all of our complex and
    intermediate facilities would have a GYN provider. Some of the
    smaller facilities, and unfortunately, Senator, I do not have
    the exact count for you, would have difficulty supporting a
    full-time GYN provider, and in some of those cases, care is
    provided through community contract.
        Senator Murray. If you do not have an OB/GYN, do you
    contract out to a community OB/GYN?
        Dr. Lynch. The expectation would be yes, that we would
    provide those services in the community if we could not provide
    them at the VA.
        Senator Murray. So, you can meet the needs of this bill?
        Dr. Lynch. Dr. McCarthy, would you like to----
        Dr. McCarthy. I believe that we could meet the intent,
    which is to do what Dr. Lynch said in terms of based on the
    surgical complexity, that there would be a plan to hire for all
    the facilities at a certain level of complexity and higher. But
    for the facilities, the smaller facilities, there is the
    expectation that there would be access to care either in the
    community by contract or by having someone actually come into
    the facility.
        Senator Murray. Do you have a timeline on how long that
    would take?
        Dr. McCarthy. No, ma'am, I do not. Some of our facilities
    are in areas where it may be a challenge to recruit, and so I
    could not give you an absolute timeline. I am sorry.
        Senator Murray. OK. Well, if you could give me an estimate,
    I would really appreciate it.
        Dr. McCarthy. Would you be OK if I took that for the
    record?
        Senator Murray. Yes, you may do it for the record.
        Dr. McCarthy. OK.
    Response to Request Arising During the Hearing by Hon. Patty Murray to
          Maureen McCarthy, M.D., U.S. Department of Veterans Affairs
        Response. Obstetrician-Gynecologist (Ob/Gyn) providers play a
    critical role in the VA health care system by providing reproductive
    specialty care. Currently not all VA health care systems have an Ob/Gyn
    on-site. However, all VA health care systems have access to basic
    gynecology on-site through Designated Women's Health Primary Care
    Providers and all sites have access to specialty gynecology care by an
    Ob/Gyn through non-VA care if not available on-site. VA is committed to
    having Ob/Gyn care on site at each health care system and the
    recruitment of these specialists will be affected by availability in
    surrounding areas. We are working with onsite facility leadership to
    address Ob/Gyn availability at sites with no Ob/Gyn. To allow time for
    recruitment and hiring, this requirement can be met by the end of
    Fiscal Year 17.

        Senator Murray. Dr. Lynch, one provision of the Homeless
    Veterans Prevention Act would allow the grant and per diem
    program to provide payments for dependents who are accompanying
    homeless veterans. This is an important change to consider as
    the number of veterans with dependents, especially women, is
    rising.
        Now, VA has stated that they support the intent of this
    part of the legislation, but it raised concerns about the need
    for additional resources to meet the needs of the veterans that
    would be served. If this unmet need is still there, why did the
    VA ask for cuts to the grant and per diem program in the budget
    request?
        Dr. Lynch. Senator, I would have to get back to you with
    the specifics on that. I cannot answer it. I know that we
    certainly do support the Homeless Veterans Prevention Act. We
    do support the increase in per diem for veterans participating
    in the grant and per diem program and the transition in place.
    I cannot comment specifically on the budget issues that you
    were speaking to right now.
        Senator Murray. OK. Well, if you could get an answer back
    to me that is really an important question.
        Dr. Lynch. We will do that.
    Response to Request Arising During the Hearing by Hon. Patty Murray to
            Thomas Lynch, M.D., U.S. Department of Veterans Affairs
        Response. VA acknowledges the unique needs of Veterans with
    dependent children. The Grant and Per Diem (GPD) program is not
    currently authorized to provide services or per diem payments for
    dependents who may accompany homeless Veterans.
        In FY 2016, in order to work within its prescribe budgetary
    parameters VA made the strategic decision to reduce the FY 2016 funding
    request for the Grant and Per Diem (GPD) program. This funding
    adjustment was necessary to preserve VA's full continuum of
    comprehensive care for homeless Veterans within the budget constraints.
    It also allowed for the continue support of programs with the greatest
    capability of providing services to families of homeless Veterans
    including HUD-VA Supportive Housing and Supportive Services for Veteran
    Families (SSVF). GPD was able to carefully manage this funding
    reduction without adversely impacting services to homeless Veterans by
    fully utilizing its FY 2015 funds to initiate grant agreements that
    fund a portion of FY 2016 per diem expenditures. The FY 2017 budget
    request for the GPD program restores program funding at the fully
    authorized level.
         VA continues its commitment to serve homeless Veterans
    with dependents and women Veterans. Although HUD-VASH does not track
    dependent children in the program, during FY 2015, 12 percent of the
    persons served by HUD-VASH were women. Additionally, in FY 2015, of the
    157,416 served by SSVF, 34,636 (15 percent) were dependent children.
    The proportion of children served in prevention services within SSVF is
    even higher at 29 percent.

        Senator Murray. Finally, Dr. Lynch, it is really essential
    that we make sure our veterans have seamless transition from
    DOD to VA's health care system, but there are still a lot of
    barriers out there for our servicemembers and veterans. One
    frequent problem for new veterans is having to switch
    medications when they leave the military and come into the VA
    because the Departments do not carry the same medications. What
    are the differences in how the VA and DOD decide which
    medications to carry?
        Dr. Lynch. Do you want to take that, Dr. McCarthy?
        Dr. McCarthy. Yes. Thanks for that question, Senator
    Murray. The VA formulary is one that is based on published
    evidence of drug safety and effectiveness. There is a process
    of consideration once a drug is approved by the Food and Drug
    Administration, whether it be included in the pharmacy.
        The DOD formulary is one that is statutory, that anything
    approved by the FDA is part of the DOD formulary. The VA's
    formulary is one that has a second-level review for evidence-
    bases, efficacy, safety and so forth. Our formulary process has
    been reviewed by Inspector General, Institute of Medicine,
    multiple people, and what they say is our formulary process is
    actually a model for the Federal Government.
        Senator Murray. So, how come the DOD has not done that? You
    are probably the wrong people to ask, but you are here.
        Dr. McCarthy. You are exactly right about that. We feel
    very strongly that we want to work with DOD and we want to ease
    those transitions very much, but I do not know that the answer
    is to have exactly the same formularies given that theirs is
    this statutory formulary by regulation and it is everything
    that is approved.
        For us, it makes sense. I believe Senator Blumenthal's
    proposed legislation talks about the medications related to
    psychiatric conditions as well as pain. I think that is an
    important place to start.
        In particular, his legislation talks about systemic drugs,
    not topical meds, which have caused some problems in the past.
    Some oral meds that we prescribe for psychiatric conditions and
    pain would be a very important place to start for blending.
        Dr. Lynch. If I could, Senator, I would just repeat from my
    opening statement, right now 90 percent of mental health
    medications and 96 percent of pain medications dispensed by DOD
    are also on the VA formulary. We also mentioned that there was
    a specific directive sent to the field that veterans will be
    maintained on their discharge medications from the military
    when they transfer to the VA if that is clinically appropriate.
        I would add that qualification. But we would not take
    veterans off of medications that they had been receiving from
    the military if it was felt to be appropriate to continue those
    medications.
        Senator Murray. OK.
        Dr. Lynch. I realize there are still, as you will probably
    hear in the second panel, there are still areas where we have
    failed. We can do better and we need to do better to make sure
    that that transition occurs.
        Senator Murray. OK. We want to make sure there are no
    barriers, but we also want to make sure people are taking the
    right medications. I understand the balance, but some attention
    needs to be really focused on this.
        Chairman Isakson. Thanks, Senator Murray, for raising that
    question and I will just make an observation. I am not a
    pharmacist or a physician, but it does not make a lot of sense
    to me for the formularies to be different between DOD and the
    Veterans Administration. I know Senator McCain is working on
    that same issue and we have expressed our desire to see if we
    cannot get that worked out. I appreciate you focusing on that
    issue today.
        Dr. Lynch, thank you.
        I am sorry. Senator Moran wanted to follow up.
        Senator Moran. Mr. Chairman, thank you very much. In part,
    I appreciate you recognizing me now so I can thank you for your
    help. You and Senator Blumenthal were very instrumental in the
    Senate passing a fix to the 40-mile rule, if we talk about
    community and fee-based services, as we did now nearly a week
    ago, and I wanted to express my gratitude to you.
        That bill was scheduled for consideration today and I asked
    that it be withdrawn from the calendar based upon its unanimous
    passage by the U.S. Senate. I met today with Chairman Miller
    and am working to see that the House consider this issue. In
    case I am talking in riddles, this is the issue of the
    inability for those who live more than--within 40 miles of a
    facility, even though that facility does not provide the
    services the veteran needs, they are being excluded from
    participation in the Choice Act. So, this legislation makes
    clear that that is not the intention or it is not the law.
        So, Mr. Chairman, Senator Blumenthal, thank you very much
    for your assistance in accomplishing the passage of that bill
    and thank you to my colleagues for voting for it.
        Chairman Isakson. Well, you were heavy, but we got you
    across the finish line.
        Senator Moran. I appreciate you carrying that load.
        Senator Blumenthal. It took two of us to do it.
        Senator Moran. We are not done yet, and we say the finish
    line, unfortunately, is not the U.S. Senate, but the finish
    line is the President of the United States.
        Senator Blumenthal. I am in total agreement.
        Senator Moran. Thank you both. Dr. Lynch, let me just raise
    a topic with you. I visited with Deputy Secretary Sloan Gibson
    yesterday. On your desk is an application for issue that we
    have been working on in regard to the Department of Emergency
    Medicine at the Colmery-O'Neil VA Hospital in Topeka, and my
    understanding is that there is a plan in place to get approval
    for that emergency room to be reopened.
        For my colleagues' understanding, we have been 400 days
    without an emergency room at one of our VA hospitals because of
    lack of necessary physician professional providers. The
    Colmery-O'Neil Hospital has employed five emergency room
    physicians, a sixth one arriving in July, and it now awaits the
    approval of Dr. Lynch and the VA at the central office here.
        Dr. Lynch, I understand there is a process in place by
    which that approval could be granted in the near future, and I
    just wanted to make certain that you were committed to make
    certain that once those requirements are met, that the approval
    is given.
        Dr. Lynch. Absolutely, Senator.
        Senator Moran. Thank you very much.
        Chairman Isakson. Thank you, Senator Moran. Thank you to
    our panel for being here today and we will pause to reset the
    table and have our second panel come forward.
        I would like to welcome our second panel and appreciate
    your being here to testify today. We have four distinguished
    people testifying. Adrian Atizado--is that the correct
    pronunciation?
        Mr. Atizado. Yes.
        Chairman Isakson. Assistant National Legislative Director,
    Disabled American Veterans; Fred Benjamin, Vice President and
    Chief Operating Officer, Medicalodges, Inc; Thomas Snee,
    National Director of the Fleet Reserve Association; and
    Sergeant First Class Victor Medina, U.S. Army, Retired. We
    welcome all of you and we will start with Mr. Atizado.

       ADRIAN ATIZADO, ASSISTANT NATIONAL LEGISLATIVE DIRECTOR,
                       DISABLED AMERICAN VETERANS

        Mr. Atizado. Chairman Isakson, Mr. Moran, Mr. Rounds,
    Senator Manchin, thank you for inviting DAV to testify at this
    legislative hearing and present our views on the bills under
    consideration. As many of you know, DAV is a nonprofit veterans
    service organization. We are comprised of 1.2 million wartime
    service-disabled veterans and we are dedicated to imparting
    veterans to lead high-quality lives with respect and dignity.
        While my written testimony discusses DAV's position on all
    seven measures on today's agenda, for the sake of brevity, my
    oral statement will only focus on just two. DAV would like to
    thank Senator Heller and Senator Murray, as well as their
    dedicated staff, for working with us on S. 471, the Women
    Veterans Access to Quality Care Act of 2015.
        This bill seeks to improve VA health care facilities to
    better accommodate the needs of women veterans. It would start
    by setting infrastructure standards to meet gender-specific
    needs for privacy, safety and dignity, and report those
    facilities that do not meet those standards.
        Section 3 of the bill would require VA to evaluate the
    performance of VA medical center directors based on the health
    outcomes for women veterans who use VA medical services.
        Section 4 would require a VA medical center to employ a
    full-time obstetrician or gynecologist. Section 5 would address
    the need to share veterans' contact information with State
    veterans agencies in order to facilitate assistance, services,
    as well as benefits. Veterans would, of course, retain the
    option of not participating in this information exchange.
        Finally, section 6 would instruct the Government
    Accountability Office to examine whether VA medical centers are
    able to meet the health care needs of women veterans across a
    number of specific domains of care. This bill is consistent
    with DAV Resolution 040 and with key recommendations in DAV's
    2014 report, Women Veterans, A Long Journey Home. Thus, the
    bill carries DAV's full support.
        On the draft measure titled, The Department of Veterans
    Affairs Purchased Healthcare Streamlining and Modernization
    Act, DAV thanks Senator Blumenthal for introducing this
    critical measure and for your Committee staff for working with
    us in its development. This measure would allow VA to use
    Medicare procedures to enter into provider agreements, to buy
    care from private sector providers.
        Now, these agreements are quite familiar to many community
    providers and we believe will make VA more appealing to work
    with in providing medical care and services closer to where
    veterans live. As you are aware, VA currently buys a broad
    spectrum of health care and services under specific but
    fragmented authorities. These authorities have, in some cases,
    created confusion and uncertainty among injured veterans as
    well as private providers in the community.
        Moreover, VA's current provider agreement authority is
    quite limited and, unfortunately, broken. And even with current
    workarounds, the situation continues to disrupt the continuity
    of services for many severely ill and injured veterans. It
    requires arduous work, not only in front line VA personnel, but
    as well as community providers.
        We understand this proposal is not intended to supplant
    long-standing regional and national contractual and sharing
    agreements; but rather, to play a supporting role in specific
    situations when, for a variety of legitimate reasons, needed
    care services cannot be purchased through existing contracts or
    sharing agreements. DAV fully supports this measure based on
    our Resolution Number 163.
        We do, however, urge the Committee to improve on the bill's
    provision for care coordination. It is a key component to
    delivering integrated health care, which is important to
    produce positive health outcomes among severely ill and injured
    veterans and aging veterans with chronic and debilitating
    conditions.
        Mr. Chairman, this concludes my testimony. I would be happy
    to answer any questions you or other Senators may have.
        [The prepared statement of Mr. Atizado follows:]
    Prepared Statement of Adrian M. Atizado, Assistant National Legislative
                      Director, Disabled American Veterans
        Chairman Isakson, Ranking Member Blumenthal and Members of the
    Committee: Thank you for inviting DAV (Disabled American Veterans) to
    testify at this legislative hearing, and to present our views on the
    bills under consideration. As you know, DAV is a non-profit veterans
    service organization comprised of 1.2 million wartime service-disabled
    veterans that is dedicated to a single purpose: empowering veterans to
    lead high-quality lives with respect and dignity.
                s. 297, the frontlines to lifelines act of 2015
        This bill would revive and expand a prior Department of Veterans
    Affairs (VA) pilot program of employing Intermediate Care Technicians
    in VA facilities; authorize and require Department of Defense (DOD) to
    transfer credentialing information on health care providers who
    relocate from DOD to employment in the VA; and, authorize independent
    practice privileges for certain advance practice nurses in VA.
        DAV has no resolution from our membership dealing specifically with
    these human resource issues. Nevertheless, on the assumption that that
    these matters if enacted would improve and protect VA care for enrolled
    veterans, they would be consistent with DAV National Resolution No.
    220, to support the provision of comprehensive VA health care services
    to all enrolled veterans. DAV would offer no objection to their
    enactment.
    s. 425, homeless veterans reintegration programs reauthorization act of
                                      2015
        This bill would extend authority for the VA Homeless Veterans
    Reintegration Programs (HVRP) and the Homeless Women Veterans and
    Homeless Veterans with Children Reintegration Grant Program through
    Fiscal Year 2020. The bill also would clarify eligibility for services
    under the HVRP to include veterans participating in the VA supported
    housing program for which rental assistance is provided under the
    United States Housing Act of 1937; Indians who are veterans receiving
    assistance under the Native American Housing Assistance and Self
    Determination Act of 1996; and veterans transitioning from being
    incarcerated.
        DAV is pleased to support S. 425, the Homeless Veterans
    Reintegration Programs Reauthorization Act of 2015, which is in line
    with DAV Resolution No. 203, which calls for sustained support and
    sufficient funding for VA's initiative to eliminate homelessness among
    veterans and improve its existing supportive programs.
           s. 471, women veterans access to quality care act of 2015
        This bill would seek to improve VA health care facilities to better
    accommodate the needs of women veterans. Section 2 of the measure would
    direct the VA Secretary to establish standards to ensure that all
    medical facilities have the structural features necessary to
    sufficiently meet the gender-specific health care needs of veterans,
    including those for privacy, safety, and dignity. The bill would
    require a report to the House and Senate Veterans' Affairs Committees
    with a list a facilities that fail to meet such standards and the cost
    for renovations or repairs necessary to meet them.
        Section 3 would require the Secretary to evaluate the performance
    of VA medical center directors by using health outcomes for women
    veterans who use VA medical services. The VA would be required to
    publish health outcomes for women veterans on a publicly available Web
    site including comparisons of the data to male health outcomes, and
    explanatory information for members of the public to easily understand
    the differences.
        Section 4 would ensure that every VA medical center employs a full-
    time obstetrician or gynecologist, and mandates a pilot program to
    increase the number of residency program positions and graduate medical
    education positions for obstetricians and gynecologists at VA medical
    facilities, in at least three Veterans Integrated Service Networks.
        Section 5 would require the development of procedures to
    electronically share veterans' military service and separation data;
    email address; telephone number; and mailing address with State
    veterans' agencies in order to facilitate the assistance of benefits
    veterans may need. Under the bill, veterans would retain the option of
    not participating in this information exchange.
        Section 6 would instruct the Government Accountability Office to
    examine whether VA medical centers are able to meet the health care
    needs of women veterans across a number of specific dimensions of care,
    including access, specialization, outcome differences, outreach and
    other key elements.
        The intent of this bill is consistent with DAV's 2014 Report, Women
    Veterans: The Long Journey Home; thus, the bill carries DAV's full
    support. The bill is also consistent with DAV Resolution No. 040 to
    support enhanced medical services and benefits for women veterans,
    passed by the delegates to our most recent National Convention.
                s. 684, homeless veterans prevention act of 2015
        This is a comprehensive bill that would seek to improve services
    for homeless veterans.
        Section 2 would increase per diem payments for transitional housing
    assistance that becomes permanent for veterans.
        Section 3 would authorize per diem payments for furnishing care for
    a dependent of a homeless veteran while the veteran receives services
    from a VA grant and per diem recipient.
        Section 4 would instruct VA to partner with public and private
    entities to provide legal services to homeless veterans and veterans at
    risk of homelessness in an equitably distributed geographic pattern to
    include rural areas and tribal lands; subject to available funding. The
    legal services would include those related to housing, including
    eviction defense and landlord-tenant cases; family law, including
    assistance with court proceedings for child support, divorce and estate
    planning; income support, including assistance in obtaining public
    benefits; criminal defense, including outstanding warrants, fines and
    driver's license revocation, and to reduce the recidivism rate while
    overcoming reentry obstacles in employment or housing. The Secretary
    would require entities that have partnered with VA and provided legal
    services to homeless veterans to submit periodic reports.
        Section 5 would expand the authority of VA to provide dental care
    to eligible homeless veterans who are enrolled for care, and who are
    receiving housing assistance under so-called ``section 8'' for a period
    of 60 consecutive days; or receiving care (directly or by contract) in
    a domiciliary; therapeutic residence; community residential care
    coordinated by the Secretary; or a setting for which the Secretary
    provides funds for a grant and per diem provider.
        Section 6 would make permanent the authority in section 2033, title
    38, United States Code, for VA to carry out a program of referral and
    counseling services for veterans at risk for homelessness who are
    transitioning from certain institutions.
        Section 7 would extend the authority for financial assistance for
    supportive services for very low-income veteran families in permanent
    housing.
        Section 8 of this bill would require VA to assess and measure the
    capacity of national and local programs for which entities receive
    grants under section 2011 of title 38, United States Code, or per diem
    payments under section 2012 or 2061 of such title. The following would
    be assessed:

         Whether sufficient capacity exists to meet the needs of
    homeless veterans in each geographic area.
         Whether existing capacity meets the needs of the
    subpopulations of homeless veterans located in each geographic area.
         The amount of capacity that recipients of grants under
    sections 2011 and 2061 and per diem payments under section 2012 of such
    title have to provide services for which the recipients are eligible to
    receive per diem under section 2012(a)(2)(B)(ii) of title 38, United
    States Code, as added by section 3(5)(B) of this bill.
        The Secretary would be required to use the information collected
    under this section to set specific goals to ensure that VA programs are
    effectively serving the needs of homeless veterans; assess whether
    these programs are meeting goals; inform funding allocations for
    programs described, and improve the referral of homeless veterans to
    such programs.
        The Secretary would be mandated to submit a report to Congress
    regarding the assessment and recommendations for legislative and
    administrative action to improve the programs.
        Section 9 would require the GAO to complete a study of VA programs
    that provide assistance to homeless veterans including whether programs
    are meeting the needs of veterans who are eligible for assistance and a
    review of recent efforts of the Secretary to improve the privacy,
    safety, and security of women veterans receiving assistance from such
    programs.
        Section 10 would repeal the requirement for annual reports on
    assistance to homeless veterans.
        DAV is pleased to support this bill, in accordance with DAV
    Resolution No. 203, which calls for continued support and sustained and
    sufficient funding for VA's initiative to eliminate homelessness and
    improve supportive programs. Our resolution also urges Congress to
    strengthen the capacity of VA's programs to end homelessness by
    increasing capacity for health care, specialized services for mental
    health, substance-use disorders as well as vision and dental care.
                draft bill, the veterans health care act of 2015
        If enacted, this bill would improve veterans' access to
    immunizations by including immunizations in the statutory definition of
    ``medical services;'' expand the availability of chiropractic care in
    VA facilities; extend the sunset date of certain VA transportation
    programs enabling veterans to access VA health care; and open public
    access to the results of VA research, including research data sharing
    for specific purposes between VA and the DOD.
        VA already conducts a rigorous program of immunizations for
    influenza, pneumonia, shingles and other disorders prevalent in
    enrolled veterans. This bill would broaden and regulate immunizations
    in accordance with Centers for Disease Control and Prevention (CDC)
    guidelines, and would require VA to provide a one-time report of its
    conformance to these CDC guidelines within two years of enactment of
    the legislation. Our DAV members have approved Resolution No. 220, to
    support the provision of comprehensive VA health care services to all
    enrolled veterans. We believe a more rigorous national immunization
    program as contemplated by this bill, and governed by CDC guidelines,
    would be consistent with DAV's resolution; therefore, DAV supports this
    provision.
        Resolution No. 220 also addresses the topic of chiropractic care,
    urging its broad availability for appropriate patients enrolled in VA
    health care. Therefore, DAV also supports the expansion of the existing
    program of chiropractic care that would be authorized by this bill.
        This bill would extend for one year the existing sunset date of
    December 31, 2015, of the Veterans Transportation Service (VTS) program
    and authorize $4 million to carry out the purposes of the
    transportation program, and would require a VA report on the program
    within one year of enactment.
        As this Committee is aware, the DAV National Transportation Network
    continues to show tremendous growth as an indispensable resource for
    veterans. Across the Nation, DAV Hospital Service Coordinators operate
    200 active programs and have recruited more than 9,000 volunteer
    drivers. Since we began our free Transportation Network program in
    1987, DAV has purchased and donated 2,856 vehicles to the VA, at a cost
    of 61.8 million dollars. The Ford Motor Company has also donated 192
    vehicles at a cost of 4.4 million dollars. So far our vans have carried
    veterans more than 589 million miles to and from their medical
    appointments.
        DAV believes VTS serves the transportation needs of a special
    subset of the veteran patient population that the DAV National
    Transportation Network is unable to serve--veterans in need of special
    modes of transportation due to certain severe disabilities. We believe
    that with a truly collaborative relationship, the DAV National
    Transportation Network and VTS will meet the growing transportation
    needs of ill and injured veterans in a cost-effective manner.
        Currently, DAV supports this provision; however, our support is
    based on the progress gained through our collaborative working
    relationship with VA to resolve weaknesses we have observed in the VTS
    program. As you may be aware, VTS operates with resources that would
    otherwise go to direct medical care and services for veterans. These
    resources should be used carefully for all extraneous programs to
    ensure veterans are not denied care when they most need it.
        This bill would require VA to create a Web site documenting VA
    research data, providing data dictionaries, and including instructions
    for users on gaining access to all published VA research data. The bill
    would also require VA to make publicly available through a digital
    archive the published manuscripts of all VA-funded research, and would
    establish a required annual report to Congress detailing implementation
    of the provision. At our most recent national convention, DAV delegates
    adopted Resolution No. 206, supporting the VA's medical and prosthetic
    research programs. This resolution is justified because VA research is
    one of the strongest underpinnings of VA health care and cements VA's
    relationships with its affiliated schools of health sciences and
    academic health centers.
        The bill would also require the VA/DOD Joint Executive Committee to
    submit a report to the respective Secretaries recommending methods to
    facilitate greater sharing of research between the departments dealing
    with outcomes of military service on servicemembers, veterans, family
    members and others. This provision is consistent with our statement of
    policy, in that its enactment would be helpful to ensure that wounded,
    injured and ill veterans and their families are better cared for, and
    their needs are better understood, by both departments. Therefore, we
    support this provision of the bill.
          draft--department of veterans affairs purchased health care
                       streamlining and modernization act
        VA purchases a broad spectrum of health care services from private
    sector providers for veterans, their families and survivors under
    specific but fragmented authorities. These authorities have in some
    cases created confusion and uncertainty among ill and injured veterans
    and private providers in their community.
        One example stems from a February 13, 2013 proposed rule in
    response to Section 105 of the Veterans Health Care, Capital Asset, and
    Business Improvement Act of 2003 (Public Law 108-170). The rule
    proposes to amend VA's medical regulations to allow the Department to
    use Medicare or State procedures to enter into provider agreements to
    obtain extended care services from non-VA providers. In addition, it
    proposes to include home health care, palliative care, and non-
    institutional hospice care services as extended care services, when
    provided as an alternative to nursing home care. Under this proposed
    rule, VA would be able to obtain extended care services for veterans
    from providers who are closer to veterans' homes and communities.
        The proposed rule has been stalled with no clear sign if and when a
    final rule will be made. Because regulations have not been made final,
    no new provider agreements are being issued by VA and existing provider
    agreements set to expire are not being renewed, effectively disrupting
    the continuity of extended care services for many service-connected
    disabled veterans.
        This measure would allow VA to use provider agreements for the
    purchase of non-VA medical care and services in certain circumstances.
    The bill appears to preserve key protections found in the contracts
    based on the Federal and VA Acquisition Regulations including
    protections against waste, fraud and abuse. It intends to streamline
    and speed the business process for purchasing care for an individual
    veteran that is not easily accomplished through a more complex contract
    with a community provider, and thus be more appealing to solo
    practitioners and small group practices.
        We understand this proposal is not intended to supplant long-
    standing regional and national contractual and sharing agreements such
    as those used for VA's Patient-Centered Community Care (PC3) program,
    which is helping to build VA's Extended Network of community providers.
    Rather, this authority it intended to play a supporting role in
    specific situations when, for a variety of legitimate reasons, needed
    care cannot be purchased through existing contracts or sharing
    agreements.
        We support favorable consideration of this measure based on DAV
    Resolution No. 163, which calls on VA to establish a non-VA purchased
    care coordination program that complements the capabilities and
    capacities of each VA medical facility and includes care and case
    management, quality of care, and patient safety standards equal to or
    better than VA, timely claims processing, adequate reimbursement rates,
    health records management and centralized appointment scheduling.
        VA must fully integrate the care it buys from the community into
    its health care delivery model by using care coordination to realize
    the best health outcomes and achieve veterans' health goals. VA also
    must improve administrative functions and business practices and employ
    data analytics to ensure the purchases are cost effective, preserve
    agency interests, and enhance the level of service VA directly provides
    veterans.
        We believe this bill will help VA achieve most of these attributes
    in community care; however, the bill's provision on care coordination
    could be improved. Care coordination for severely ill and injured
    veterans and for aging veterans with chronic conditions is essential
    when VA buys care from private providers. For example, the contracts
    used for the PC3 program include numerous provisions outlining VA's
    responsibility in coordinating outpatient care, inpatient admission/
    discharges, post-discharge care, and medications. The same intent is
    outlined in Section 101(a)(3) of the Choice Act: ``The Secretary shall
    coordinate through the Non-VA Care Coordination Program of the
    Department of Veterans Affairs the furnishing of necessary hospital
    care, medical services, or extended care under this section to eligible
    veterans, including by ensuring that an eligible veteran receives an
    appointment for such care and services within the wait-time goals of
    the Veterans Health Administration for the furnishing of hospital care,
    medical services, and extended care.''
        We ask the Committee to consider including similar requirements to
    facilitate the integration of care purchased under this authority with
    the VA health care system, which would produce a positive outcome on
    the quality of care a veteran receives.
        Draft Bill, to require the Secretary of Defense and the Secretary
    of Veterans Affairs to establish a joint uniform formulary with respect
    to systemic pain and psychiatric drugs that are critical for the
    transition of an individual from receiving health care services
    furnished by the Secretary of Defense to health care services furnished
    by the Secretary of Veterans Affairs, and for other purposes.
        The bill would require the two agencies concerned to establish a
    process to make available to veterans in transition from DOD to VA
    health care the same ``systemic pain'' and ``psychiatric'' drugs that
    are appropriate and effective in caring for such individuals in
    transition. The bill would exempt this joint process for transitioning
    servicemembers from the standing requirements of DOD's pharmacy
    benefits program, and would not interfere with each agency's
    maintenance of its own formulary for other purposes. The bill would
    require a joint report by DOD and VA to Congress on the establishment
    of the new process.
        While DAV has not received an approved national resolution from our
    membership on the specific topic addressed by this bill (a joint
    formulary), this bill is fully consistent with the intent of Public Law
    97-174, the Veterans Administration and Department of Defense Health
    Resources Sharing and Emergency Operations Act, enacted in 1982, as
    well Subtitle C of Title VII of the Bob Stump National Defense
    Authorization Act for Fiscal Year 2003, enacted in 2002. Among many
    other purposes, these acts intend for DOD and VA to work more closely
    together in joint projects of mutual benefit to beneficiaries of both
    agencies, and in particular health resources sharing that benefits
    active duty servicemembers and veterans. Therefore, we support the
    purposes of this bill.
        Given the recent controversy concerning the practice of over-
    prescribing of opioids both within VA and in private health care, we
    recommend the definitions of ``systemic pain'' and the word
    ``psychiatric'' be defined in the bill, but that the word
    ``psychotropic'' be substituted for ``psychiatric'' in creating such
    definitions.

        Mr. Chairman, this concludes my testimony. DAV appreciates your
    request for this statement. I would be pleased to answer any questions
    from you or Members of the Committee dealing with this testimony.

        Chairman Isakson. Thank you very much. Mr. Benjamin.

    STATEMENT OF FRED BENJAMIN, VICE PRESIDENT AND CHIEF OPERATING
                      OFFICER, MEDICALODGES, INC.

        Mr. Benjamin. Good afternoon, Chairman Isakson. I better
    turn this on. Good afternoon, Chairman Isakson, Ranking Member
    Blumenthal, and distinguished Members of the Committee. I would
    like to thank you for holding this hearing to discuss, among
    other veterans related health care issues, the discussion draft
    on VA provider agreements language. I especially appreciate the
    opportunity to appear before you here today.
        I would also like to take a moment of personal privilege
    and extend a special hello to Senator Moran from my home State
    of Kansas. My name is Fred Benjamin and I am the Chief
    Operating Officer of Medicalodges, a company that offers a
    continuum of health care options, including independent living,
    skilled nursing home care, rehabilitation, assisted living, in-
    home services, and services for those with developmental
    disabilities.
        Medicalodges was launched in 1961 when its first nursing
    home, Golden Age Lodge, was opened in Coffeyville, KS. The
    company steadily grew and in 1998, the employees acquired the
    company from its founders becoming the first 100 percent
    employee owned nursing home company in the U.S.
        Today we own and operate over 30 facilities in Kansas,
    Missouri, and Oklahoma, and employ over 2,500 people. I have
    served as the company's Chief Operating Officer since 2009. I
    am honored to have worked in health care for 30 years,
    including senior management roles in skilled and sub-acute care
    hospitals and other for-profit and not-for-profit ventures. I
    currently serve also as the Chairman of the Kansas Health Care
    Association, the leading provider advocacy group for seniors in
    Kansas.
        Medicalodges is a member of the American Health Care
    Association, the Nation's largest association of long-term and
    post-acute care, providing essential services to approximately
    1 million individuals and more than 12,000 not-for-profit and
    proprietary member facilities.
        Today I submit a statement on behalf of American Health
    Care Association (AHCA), in strong support of provider
    agreements for veterans extended care services. AHCA has been
    working on the issue of VA provider agreements for over two
    decades and was supportive of the VA releasing its proposed
    rule in February 2013.
        This important rule, among other things, increases the
    opportunity for veterans to obtain non-VA extended care
    services from local providers and is an example of how the
    Government and the private sector can effectively work together
    for the benefit of veterans.
        Last Congress, through the advocacy efforts of AHCA's
    members, close to half of the U.S. Senate chamber and 109 U.S.
    House members signed onto a letter to the VA encouraging the
    release of the final VA provider agreement rule. Soon after, it
    was determined that the VA needed the legislative authority to
    enter into these agreements.
        The Senate and House Veterans' Affairs Committees are
    currently working on this issue through the VA provider
    agreement discussion draft that we are here to focus on today.
        We have worked very closely with the VA and Chairman
    Isakson, Ranking Member Blumenthal, Senator Manchin, along with
    House Chair Representative Miller and Representatives Walorski
    and Gabbard. It is long-standing policy that Medicare and
    Medicaid providers are not considered to be Federal
    contractors. However, if a provider currently serves VA-
    referred patients, they are considered to be a Federal
    contractor.
        The draft legislation being considered today would cover
    the gamut of care that VA provides, including primary care and
    other areas outside of extended care. Across that spectrum of
    health care, VA purchases through both the Federal Acquisition
    Regulation, so called FAR, and non-FAR-based agreements and
    that would continue under this proposal.
        I speak specifically from my experience leading
    Medicalodges and also from my fellow extended care providers
    across the country when I tell you that FAR-based agreements
    are simply not workable for many extended care providers. A
    streamlined approach that still protects veterans, taxpayers,
    and preserves oversight is desperately needed.
        What we like about the draft legislation is that it makes
    sure that the non-FAR-based option is still available so that
    we can continue in partnership with the VA to provide veterans
    quality health care close to their homes.
        By way of illustration, FAR-based Federal contracts come
    with extensive reporting requirements to the Department of
    Labor on the demographics of contractor, employees and
    applicants which have deterred providers, particularly smaller
    ones, and I particularly appreciated the comments that were
    made earlier about the rural aspect of the problems presented
    therein with VA participation.
        The use of provider agreements would promote provision of
    services from providers who are closer to veterans' homes and
    community support structures under terms and oversight similar
    to those used by Medicare. AHCA fully endorses the VA provider
    agreements draft legislation.
        As a provider myself managing VA contracts at nine
    locations, I can tell you that it is vital that extended care
    providers have the provider agreement option. My written
    testimony further outlines some of the day-to-day issues from
    the experience of our company and many other extended care
    providers.
        In closing, we must ensure that those veterans who have
    served our country so bravely have access to quality health
    care, and the legislative draft being worked on by Senators
    Hoeven and Blumenthal will ensure this to be the case. We are
    looking forward to continuing to work with both the Senate and
    House VA committees and members on the VA provider agreement
    and hoping to get it across the finish line and signed into
    law.
        Thank you for the opportunity to comment and I am happy to
    answer any questions.
        [The prepared statement of Mr. Benjamin follows:]
    Prepared Statement of Fred Benjamin, Vice President and Chief Operating
                         Officer of Medicalodges, Inc.
        Good afternoon, Chairman Isakson, Ranking Member Blumenthal, and
    distinguished Members of the Committee. I'd like to thank you for
    holding this hearing to discuss, among other veterans related health
    care issues, the discussion draft on VA provider agreements language. I
    especially appreciate the opportunity to appear before you here today.
    My name is Fred Benjamin, and I am the Vice President and Chief
    Operating Officer of Medicalodges, Inc., a company that offers a
    continuum of health care options which include independent living,
    skilled nursing home care, rehabilitation, assisted living, specialized
    care, outpatient therapies, adult day care, in-home services, as well
    as services and living assistance to those with developmental
    disabilities.
        Medicalodges was launched in 1961 when its first nursing home,
    Golden Age Lodge, was opened in Coffeyville, Kansas by founding owners
    Mr. and Mrs. S.A. Hann. The company grew through the 1960's with the
    addition of eight nursing facilities. In 1969, Golden Age Lodges was
    renamed Medicalodges, Inc. As new care centers were built or purchased,
    the company expanded its products and services to include a continuum
    of health care. In February, 1998 the employees of Medicalodges
    acquired the company from its previous owners in a 100% Employee Stock
    Ownership Trust transaction. Today, the company owns and operates over
    30 facilities with operations in Kansas, Missouri and Oklahoma and
    employs over 2500 people in the communities it serves.
        I have served as the Company's Chief Operating Officer since
    May 2009. I am honored to have worked 30-years in this industry that
    includes senior management roles in skilled and sub-acute care,
    hospitals and other for-profit and not-for-profit ventures. I am also
    currently serving as Chairman of the Board of the Kansas Health Care
    Association, the leading provider advocacy group for seniors in Kansas.
        I would like to note that Medicalodges is a member of the American
    Health Care Association (AHCA), which is Nation's largest association
    of long term and post-acute care providers. The Association's members
    provide essential care to approximately one million individuals in more
    than 12,000 not-for-profit and proprietary member facilities.
        AHCA, its affiliates, and member providers advocate for quality
    care and services for frail, elderly, and disabled Americans--including
    our Nation's veterans--and for the continuing vitality of the long term
    care provider community. The Association is committed to developing and
    advocating for public policies which balance economic and regulatory
    principles to support quality of care and quality of life. Therefore, I
    appreciate the opportunity today to submit a statement on behalf of
    AHCA in strong support of the concept of veteran's provider agreements
    for extended care services in particular.
        AHCA has been working on the issue of VA provider agreements for
    over two decades, and was supportive of the VA releasing its proposed
    rule, RIN 2900-A015, on this issue in February 2013. This important
    rule, among other things, increases the opportunity for veterans to
    obtain non-VA extended care services from local providers that furnish
    vital and often life-sustaining medical services. This rule is an
    example of how government and the private sector can effectively work
    together for the benefit of veterans who depend on long term and post-
    acute care.
        Last Congress, and through the advocacy efforts of AHCA's members,
    close to half of the U.S. Senate chamber and 109 U.S. House members
    signed onto a letter to the VA encouraging the release of the final VA
    provider agreement rule. Shortly after these letters were sent to the
    VA, it was determined that the VA needed the legislative authority to
    enter into these agreements. The U.S. Senate and House Veteran's
    Affairs Committees are currently working on this issue through the VA
    provider agreement discussion draft we are here to focus in on today.
        As I mentioned earlier, AHCA started work with the VA and Capitol
    Hill on the provider agreement issue for extended care services several
    years ago. In this current Congress, AHCA has worked very closely with
    Congressional members like Senators John Hoeven (R-ND), Chairman Johnny
    Isakson (R-GA), Committee members Richard Blumenthal (D-CT) and Joe
    Manchin (D-WV), along with House VA Committee Chairman Jeff Miller (R-
    FL-1st), Representatives Jackie Walorski (R-IN-
    2nd) and Tulsi Gabbard (D-HI-2nd) on ensuring
    that the VA has the legislative authority to enter into provider
    agreements. It is long-standing policy that Medicare (Parts A and B) or
    Medicaid providers are not considered to be Federal contractors.
    However, if a provider currently has VA patients, they are considered
    to be a Federal contractor. The discussion draft legislation being
    considered today, and worked on under the leadership of Senators Hoeven
    and Blumenthal, would cover the gamut of care VA provides, including
    primary care and other areas outside of extended care. Across that
    spectrum of health care, VA purchases care through both the Federal
    Acquisition Regulation (FAR) and non-FAR based agreements, and that
    would continue under this proposal.
        I speak specifically from my experience leading Medicalodges and
    also for my fellow extended care providers across the country whom the
    AHCA represents. For our company, and many extended care providers,
    FAR-based agreements are simply not workable, and a streamlined
    approach that still protects Veterans, taxpayers, and preserves
    oversight is desperately needed. What we like about the draft
    legislation is that it makes sure the non-FAR based option is available
    so that we can continue in partnership with the VA to provide veterans
    quality health care as close to home as possible.
        To illustrate the details, FAR-based Federal contracts come with
    extensive reporting requirements to the Department of Labor (DOL) on
    the demographics of contractor employees and applicants, which have
    deterred providers, particularly smaller ones, from VA participation.
    The use of provider agreements for extended care services would
    facilitate services from providers who are closer to veterans' homes
    and community support structures, under terms and oversight similar to
    those used by Medicare. Once providers can enter into provider
    agreements, the number of providers serving veterans will increase in
    most markets, expanding the options among veterans for nursing center
    care and home and community-based services. Services covered as
    extended care under the proposed rule include: nursing center care,
    geriatric evaluation, domiciliary services, adult day health care,
    respite care, and palliative care, hospice care, and home health care.
        After years and years of work on this issue by many, we are
    delighted to be at the point we are now of discussing a comprehensive
    provider agreement proposal. AHCA fully endorses the VA provider
    agreements draft legislation being worked on by Senators Hoeven and
    Blumenthal. As a provider myself and with a total of 9 VA contracts
    currently, I can tell you why it is so vital that extended care
    providers have the provider agreement option. I'll outline some of the
    day to day issues from the experience of our company and other extended
    care providers:

              Issue: Additional administrative workload. Additional
            administrative responsibilities under the Contractor
            Performance Assessment Reports System (CPARS) as compared to
            Medicaid or Medicare. Please note that aside from designated
            State Veterans Homes, most facilities have less than 5 Veterans
            in house at a time. Each of our contracts with the VA has 68
            pages of terms and responsibilities with rates that are updated
            quarterly. Beyond this, with the new CPARS program, I receive
            multiple emails daily from this automated system requesting
            approval or acknowledgement of payment in full when full
            payment has not yet been received. This alone has added to our
            administrative workload to deal with this correspondence.
              Issue: Lack of Clarity in Approval processes. Separate
            reporting structures for those writing and administering
            contracts results in lack of clarity in approval of needed
            supplies and services. Contracting personnel are not at the
            same location as those referring Veterans for care and managing
            contracts on a day to day basis. These include durable medical
            equipment such as wheelchairs, specialty equipment such as
            Clinitron beds, drugs and non-emergent dental services.
              Issue: Lack of consistency in contract administration. This
            includes different procedures at each location for getting
            approval for items such as durable medical equipment, oral
            medications whose cost exceed 8.5% of the approved daily rate.
            Another example is differing administration of daily rates and
            the requirement for pre-approval of services when personnel are
            not available to answer questions or provide approval. This
            sometimes leaves providers in the position of having to provide
            equipment or services because of State or Federal Centers for
            Medicare and Medicaid Service (CMS) requirements without
            guarantee of payment.
              Issue: Duplication of Regulatory Supervision. In addition to
            State and CMS performance reviews, the VA conducts its own
            annual reviews inspections that are largely duplicative of
            those in other governmental health programs.
              Issue: Additional DOL supervision and review. While we
            understand the need to be under DOL regulations for wage and
            hour/overtime rules and the like, there are additional
            requirements for those providing services under FAR. These
            include identification of direct care workers and documentation
            benefit premiums of 40% of base pay and exactly which workers
            this covers. This proposal strikes a good balance.

        To close, we must ensure that those veterans who have served our
    Nation so bravely have access to quality health care--and the
    legislative discussion draft being worked on by Senators Hoeven and
    Blumenthal will ensure this will be the case. We are looking forward to
    continuing to work with both the Senate and House VA Committees and
    Members of Congress on getting the VA provider agreement proposal
    across the finish line, and signed into law. Thank you again for the
    opportunity to comment on this important matter. I am happy to answer
    any questions that you may have.

        Chairman Isakson. Thank you, Mr. Benjamin.
        Mr. Snee.

    STATEMENT OF THOMAS J. SNEE, NATIONAL EXECUTIVE DIRECTOR, FLEET
                          RESERVE ASSOCIATION

        Mr. Snee. Chairman Isakson, Ranking Member Blumenthal, and
    Committee Members, good afternoon, and thank you. I am Tom
    Snee, the National Executive Director for the Fleet Reserve
    Association, FRA. We are the oldest enlisted sea service
    association for over 90 years representing members of our
    families in the U.S. Navy, Marine Corps, and the Coast Guard.
        I wish to thank you, Mr. Chairman, and the Ranking Member
    and the Committee for your support for our veterans of past,
    present and future. Your acknowledgments of our service are
    sincerely appreciated, not just in words, but in actions that
    we have come to know from all of you.
        If I may quote from a distinguished Member of this
    particular Committee, Senator Bernie Sanders, ``Taking care of
    our veterans is a cost of war itself. If you can spend $6
    trillion sending people to war, you can spend a few billion
    dollars taking care of them when they come home.''
        The FRA strongly supports and urges passage of S. 425 and
    S. 684. Mr. Chairman, some of my thoughts are reflective from
    both a personal account and from an already published VA
    Inspector General's report of May, 2012. Homelessness in the
    United States is a social concern for both local and State
    jurisdictions. We may never solve the national problem, but
    perhaps we can establish a template of aggressive and positive
    actions for our veterans to be the model for the rest of the
    country.
        Homeless veterans are not new to this country. The first
    sighting of homeless veterans is mentioned as early as the 1812
    War and continued on through the Civil War. World War II
    veterans returned home only to face economic depression.
        World War II veterans returned, however, with the relief
    that the G.I. Bill upscaled their quality-of-life. 20th century
    sociologists began to identify certain demographic factors
    associated with the homeless phenomenon, including benefits,
    education, medical, and other associated services.
        The economics and politics of poverty gained nationwide
    attention during the 1960s, especially when thousands of
    returning Vietnam veterans were visibly homeless after military
    separation due to physical, emotional, and mental health
    issues. Most of these veterans were young junior enlisted
    personnel.
        Today, some returning veterans are faced with the climate
    of unemployment, economic uncertainty, and nowhere to turn for
    the credible assistance due to trends or attitudes toward
    helping them or receiving the services they are so entitled to.
    Some, however, do have a very strong network of family and
    friends to back them on. For others, the lack of help has
    placed a hardship due to the waiting times, emotional and
    financial uncertainties leading to alternative choices to be
    given to the homeless.
        Former Secretary of the VA Shinseki established a 5-year
    plan of six strategies. The cause and effect factor focused on
    strategies targeting risk factors for homelessness, promoting
    employment of veterans, better access to preventive mental
    care, and enlarging transitional and affordable permanent
    housing options for homeless veterans.
        It was discovered that some of these initiatives under HUD
    and VA eligibilities offered the veteran a way out of being
    homeless. Between 2009 to 2011, homelessness among veterans
    declined nearly 12 percent. I will not go into it any further,
    but we all understand the hierarchy of his concerns, of his
    needs: basic food, safety, communal feeling of belonging,
    achievement status, and of course self-actualization.
        As noted in our testimony, the female veteran population
    has grown and deep concerns in both social and medical areas.
    This year marks the 20th anniversary of the combat exclusionary
    law allowing female servicemembers to serve in combat roles. We
    must extend and reauthorize the VA reintegration program
    through 2020 for job training, counseling, and placement
    services to expedite entry into the labor force.
        All of these will give the veteran a better boost to the
    quality-of-life, to move forward making a positive and personal
    decision that will have an influence if not peace of mind. FRA
    believes that enhancing the basic services and benefits of
    training, counseling, and medical awareness will ensure those
    individuals alternatives rather than homelessness.
        We have got a lot of members that are going into PTSD, and
    I can say from a personal example of a former student who
    recently came to me for assistance, citing the fact that he did
    not have the faith in VA. But, Mr. Chairman and Members, after
    15 years from having him in school, this past Sunday this
    veteran is on his way and has the trust of the VA. The
    Committee's oversight will always be needed to ensure these
    actions are measured and successful.
        Mr. Chairman, how many other veterans feel the same despair
    of the system that should be assisting rather than adding more
    stress in administrative burdens? FRA applauds Secretary
    McDonald's new VA efforts of care. Passage of these two bills
    will endorse timely and needed momentum for the VA's position
    of serving the veteran.
        As for the homelessness, specifically, all veterans, let us
    give them assurances of relief in concrete and success to have
    a place they can call home of their own. If we care for the
    veteran, let us listen to their basic hierarchy of needs,
    provide for them and their families. Let us support and meet
    the VA's Secretary's goal of zero homelessness for vets.
        Again, I want to thank you and the Committee and especially
    for your dedication on behalf of veterans and their families
    and I wait for your questions.
        [The prepared statement of Mr. Snee follows:]
        Prepared Statement of Thomas J. Snee, M.Ed., National Executive
        Director, FORCM (SW), USN, (Ret), The Fleet Reserve Association
                                  introduction
        Distinguished Committee Chairman Johnny Isakson, Ranking Member
    Richard Blumenthal and other Members of the Committee; Thank you for
    the opportunity to present the Association's views on various pending
    legislative proposals.
                              homeless legislation
        Recently, Department of Veterans Affairs (VA) Secretary Robert
    McDonald addressed over 600 organizations at the annual National
    Coalition for Homeless Veterans (NCHV) conference held in Washington,
    DC. He urged attendees to keep the progressive momentum for VA's self-
    imposed deadline of ending veteran's homelessness for this year. In
    2009, then VA Secretary, Eric Shinseki, set the bold goal of ending
    veteran homelessness by the end of 2015. Secretary McDonald stated that
    the department's goal of ``zero homeless veterans'' by January 2016 is
    less important than ensuring that the number doesn't rise again in the
    out years to come. He said, ``The important thing is not just to get to
    zero, but to stay at zero.'' ``How do we build a system that is so
    capable, that as a homeless veteran moves from Chicago to Los Angeles
    in the winter, (that) we have the ability to touch them immediately?''
        According to VA, the number of homeless veterans from 2010-2013,
    fell by more than one-third to about 50,000 veterans. VA officials
    expect those numbers will decrease even further when the 2014 estimates
    are released later this summer. VA funding for homeless assistance and
    prevention programs have noticeably increased from $2.4 billion in FY
    2008 to nearly $7 billion for FY 2016. These funds, according to
    homeless activists, say were nonexistent over a decade ago. Despite the
    downward trend, the VA's effort to end veteran's homelessness by the
    end of 2015 is expected to fall short.
        FRA thanks Senators John Boozman (Ark.) and Jon Tester (Mt.) for
    introducing the ``Homeless Veterans Reintegration Programs
    Reauthorization Act'' (S. 425) that reauthorizes current programs for 5
    years and clarifies for the veterans who receive housing assistance
    under the Department of Housing and Urban Development's Veterans
    Affairs Supportive Housing (HUD-VASH) program. Native American veterans
    participating in the Native American Housing Assistance program are in
    fact eligible to receive valuable assistance such as job training under
    the Homeless Veteran Reintegration Program (HVRP).
        Currently, if a veteran qualifies for housing under one of these
    programs, the VA no longer considers them ``homeless,'' and does not
    allow them to participate in HVRP.
        The Association also thanks Senators Richard Burr (NC) and Joe
    Manchin (WV) for introducing the ``Homeless Veterans Prevention Act''
    (S. 684) that allows the VA to house the children of homeless veterans
    in transitional housing programs. This bill will allow the VA to
    partner with public and private entities to increase the availability
    of legal services for homeless veterans, and increases the amount of
    money available for supportive services to low-income veteran families
    in permanent housing.
        Approximately 33 percent of the homeless US population are
    veterans, and seven percent of homeless veterans are women. According
    to Veterans Inc., over 529,000 to 840,000 veterans are homeless at one
    time during the year. On any given night, more than 300,000 veterans
    are living on the streets or in shelters across America.\1\
    ---------------------------------------------------------------------------
        \1\ Veteransinc.org
    ---------------------------------------------------------------------------
        According to the National Alliance to End Homelessness, the veteran
    homeless populations are veterans who served or have served in past
    wars/conflicts, from World War II to the most recent conflicts. Though
    research indicates that veterans who served in the Vietnam and post-
    Vietnam era conflicts are at a greater risk of homelessness, veterans
    returning from recent conflicts in Afghanistan and Iraq often have
    severe disabilities, including Traumatic Brain Injuries (TBIs) and Post
    Traumatic Stress Disorder (PTSD), and have a closer connection with
    homelessness.
        Since then, the Obama Administration, VA Secretary Bob McDonald,
    and Congress have demonstrated their support of this goal by devoting
    substantial and approved funding to the homelessness problem, an
    increase from recent years.
        FRA supports the recommendations of the IB which was recently
    released by AMVETS, Disabled American Veterans (DAV), Paralyzed
    Veterans of America (PVA) and the Veterans of Foreign Wars (VFW). The
    IB provides detailed funding analysis of the proposed VA budget and is
    intended to be used as a guide for policymakers to make necessary
    adjustments to meet the challenges of serving America's veterans.
    According to the Independent Budget for FY 2016, ``VA's efforts to
    eliminate veterans' homelessness have been impressive and are showing
    significant success. However, female veterans still have a higher rate
    of homelessness than their nonveteran counterparts, and housing support
    for female veterans needs to be enhanced, particularly for veteran
    mothers with dependent children.''
                         veterans access to health care
        FRA also thanks Senator Jerry Moran (Kan.) for introducing the
    ``Veterans Access to Community Care Act'' (S. 207), legislation
    cosponsored by a bipartisan group of 18 Senators, that requires the VA
    to implement the ``Veterans Access, Choice and Accountability Act''
    (the Choice Act) as Congress intended. The bill requires the VA to
    provide veterans access to non-VA health care when the nearest VA
    medical facility within 40 miles drive time from a veteran's home is
    incapable of offering the care sought by the veteran. The FRA supported
    legislation that was passed in the wake of a nationwide audit of the VA
    that indicates that over 57,000 veterans waited more than 90 days for
    an appointment at a VA medical facility, and over 64,000 who requested
    medical care were not even put on a waiting list. The audit also found
    that 13 percent of schedulers were told to falsify appointment requests
    to make the wait time appear to be smaller than they actually were. The
    VA forced thousands of veterans to choose between their traveling time
    to a VA medical facility, to paying out of pocket, or go without any
    care altogether. Since the introduction of this pending legislation the
    VA has announced that it will change the geographic calculation used to
    determine the distance between a veteran's home and the nearest VA
    medical facility for the Veterans Access, Choice and Accountability Act
    (VACAA) that was enacted on November 5, 2014. The VA has made a
    regulatory change from straight line distance (as the crow flies) to an
    actual driving distance to ensure veterans have more access to needed
    care. Enacting this legislation made the regulatory change permanent
    and in the favor of the veteran.
        The Association would also like to thank Senator Mark Kirk (IL) for
    introducing the ``Frontlines to Lifelines Act'' (S. 297) that makes it
    easier for veterans with medical training to care for their fellow
    veterans. The legislation expands a pilot program to hire combat
    medics, medical technicians and hospital corpsmen straight from active
    duty service to care for their fellow veterans at VA hospitals. The
    Intermediate Care Technicians (ICT) pilot program facilitates the
    employment of these veterans straight from active duty without
    additional training or certifications. This common-sense measure
    authorizes the VA to quickly hire former Department of Defense (DOD)
    medical professionals by seamlessly transferring credentials between
    agencies. VA Secretary Bob McDonald recently identified the need for
    more than 26,000 new VA healthcare providers. This bill extends the
    pilot program for three more years and helps the VA meet its shortfall
    by increasing ICTs and speeding up the transfer of other healthcare
    providers into the VA system from DOD.
        FRA supports the ``Women's Veterans Access to Quality Care Act''
    (S. 471) sponsored by Senator Dean Heller (NV) that provides the
    following:

         Requires VA to establish standards in VA health care
    facilities to meet the specific needs of women veterans and integrate
    these standards into prioritization for construction projects.
         Analyzes women's health outcomes as a performance measure
    for VA medical center executives.
         Requires every VA medical center to have a full-time
    obstetrician and/or gynecologist.
         Improves outreach to veterans by requiring VA to provide
    state veterans agencies with contact information for veterans.
         Conducts GAO study of VA's ability to meet the needs of
    women veterans and their privacy and security in VA facilities.

        FRA strongly supports this legislation due to the fact that women
    are now the fastest growing segment of eligible VA health care users.
    Today, nearly 2.3 million women are veterans of military service, and
    that number is expected to increase as women comprise 15 percent of the
    U.S. military's active duty personnel and 18 percent of the National
    Guard and Reserve forces.
                               draft legislation
        FRA wants to express its appreciation for having the opportunity to
    comment on draft legislation that includes provisions from other bills.
    FRA will support this legislation. The draft bill includes provisions
    from the ``Veterans Affairs Research Transparency Act'' (S. 114)
    sponsored by Senator Dean Heller (NV) that among its other provisions
    requires the VA/DOD Joint Executive to submit options and
    recommendations for establishing a program of long-term cooperation and
    data-sharing between VA and DOD to facilitate research on outcomes of
    military service, readjustment after combat deployment, and other
    topics of importance to veterans, members of the Armed Forces
    (members), their families, and members of communities that have a
    significant population of veterans or members. FRA has long supported
    efforts to ensure adequate funding for DOD and VA health care resource
    sharing in delivering seamless, cost effective, quality services to
    personnel wounded in combat and other veterans, and their families.
        There is currently some acceptable cross sharing accomplishments
    now in place between DOD, VA and the private sector; however more is
    needed to meet the expectations for a wider expansion of data sharing
    and exchange agreements. VA, DOD and the private sector will still need
    to actively pursue a mutual technological advantage to serve the VA's
    ``Blue Button'' initiatives. This would permit veterans to have online
    access to medical history, appointments, wellness reminders and
    military service information, but only after permissible measures and
    accessible after in-person authentication.
        The draft legislation that contains the provisions of the ``Access
    to Appropriate Immunizations for Veterans Act'' (S. 172) sponsored by
    Senator Jon Tester (Mt.) promotes a timelier and appropriate
    vaccinations for veterans, placing a greater emphasis on preventive
    care. This legislation is a win-win for veterans and the VA. The bill
    should in the long-term save money for the VA by preventing veterans
    from getting diseases and seeking health care and help to avoid certain
    illnesses.
        The draft legislation containing provisions of the ``Chiropractic
    Care Available to All Veterans Act'' (S. 398), sponsored by Senator
    Jerry Moran (Kan.), requires the VA to have at least 75 of their
    medical centers offer chiropractic care by December 31, 2016 and in all
    VA medical centers by December 31, 2018.
        Finally the draft legislation that includes provisions of the
    ``Rural Veterans Travel Enhancement Act'' (S. 398), sponsored by
    Senator Jon Tester (Mt.) will authorize the Secretary of Veterans
    Affairs to transport individuals to and from facilities of the
    Department of Veterans Affairs in connection with rehabilitation,
    counseling, examination, treatment and care and for other purposes.
                             joint va/dod formulary
        The need for a joint VA/DOD prescription drug formulary is the part
    of the eighth recommendation of the Military Compensation and
    Retirement Modernization Commission (MCRMC). The Commission's
    recommendation is supported by FRA. The lack of seamless transition for
    prescription formulary has had an impact on the treatment of PTSI.
    Treatment for this condition is difficult and no specific drugs have
    been approved for treating this condition. Finding the right
    combination and dosage of drugs for an individual is difficult. Often
    when DOD doctors identify an effective treatment, the VA with a much
    more limited formulary, has no access to those drugs. A big step
    forward in treating PTSI with creating a seamless transition would be
    to allow VA and DOD to use the same prescription drug formulary.
                                   conclusion
        In closing, allow me again to express the sincere appreciation of
    the Association's membership for all that you and the Members of the
    Senate Veterans' Affairs Committees and your outstanding staff do for
    our Nation's veterans.
        Our leadership and Legislative Team stand ready to work with the
    Committees and their staffs to improve benefits for all veterans who
    have served this great Nation.

        Chairman Isakson. Thank you, Mr. Snee.
        Sergeant Medina.

           STATEMENT OF SERGEANT FIRST CLASS VICTOR MEDINA,
                           U.S. ARMY, RETIRED

        Sergeant Medina. Chairman Isakson, Ranking Member
    Blumenthal and Committee Members, thank you for having me today
    and allowing me to testify. Just a quick note before I start. I
    did develop, as a result from my combat injuries, a speech
    impairment, so if you do not understand, I do not have any
    issues in repeating myself.
        Second, my testimony today is not intended to criticize the
    El Paso VA. The level of care and access to care that I have
    received from my facility has exceeded any expectation. I
    proudly served in the U.S. Army from 1994 to 2012. After three
    combat tours, two in support of Operation Iraqi Freedom and one
    in support of Operation Enduring Freedom.
        On June 29, 2009, I was wounded in action while on patrol
    in Iraq when an explosive formed projectile struck my vehicle.
    I received the Purple Heart for injuries sustained during this
    event. I sustained a moderate Traumatic Brain Injury which
    affected me both physically and cognitively. According to my
    health care providers, the effects of my injuries are expected
    to worsen over time, and in fact they have.
        Since 2009, I received approximately 2 years of
    rehabilitation. Since the beginning of my injury, I was
    prescribed different medications to attempt to lessen the
    effects of the cognitive disorder and pain. After several
    attempts, doctors were able to find the correct medication to
    lessen the effects of the newly acquired cognitive disorder and
    the pain.
        To address the cognitive disorders, I was finally
    prescribed Vyvanse, which was medication that caused no
    secondary effects and helped me find a new normalcy. After 3
    years with a medication that was working very well, I was
    forced to change medications to a less effective formula. Why?
    Unfortunately, the original medication that was working
    tremendously with no secondary effects and included in the DOD
    formulary is not included in the VA formulary.
        This situation forced me to return to a medication that was
    already discontinued from my care due to experienced adverse
    side effects.
        My health care services are provided by El Paso VA Health
    Center. Particular to my health care facility in El Paso, TX,
    is that both the DOD pharmacy and the VA pharmacy are co-
    located. They are both in the same building. While Vyvanse
    physically exists inside the building, I cannot receive it
    because the VA does not carry it in its formulary.
        That means that while I could be receiving the medication
    with no side effects, I have to settle for a medication that
    has been no good to me only because of a limitation in the VA
    formulary.
        In my case the medication is not intended to help with
    attention and concentration. This medication was vital in my
    successful completion of graduate studies and in becoming a
    certified rehabilitation counselor. So, I am not the case of
    one veteran with a tantrum because of not being able to receive
    one random medication. I am the case of one veteran that wants
    to succeed in my life by having my playing field level. My past
    medication levels my playing field.
        Today I do not come to you as an isolated veteran. I come
    to as the voice of many. I support the joint formulary bill. It
    is a bill that is economically sound. This bill may result in
    the better utilization and allocation of our resources, which
    in turn may reflect an increased quality of services provided
    to veterans.
        I have come across veterans with situations similar to
    mine. These veterans asked me to be their voice today. The
    following veterans have similar stories. They have authorized
    me to mention their names here today. Fernando Esquivel from
    Texas, Mike Barbour from Illinois, Zen Cypher from Texas,
    DeWayne Mayer from Ohio.
        This afternoon I am saddened as I ask myself how many
    veteran suicides have been related to medication change for the
    lack of uniform formularies? We may never know the answer. I
    only know one thing. I wish I could go back to the medication
    that worked well enough to live for 2 years than daily adverse
    secondary effects of a medication given to me solely because it
    is only option available.
        Thank you very much for having me and for everything you do
    for the veterans.
        [The prepared statement of Sergeant Medina follows:]
      Prepared Statement of Sergeant First Class Victor Medina, U.S. Army
                                     (Ret.)
        I proudly served in the United States Army from 1994 to 2012. I
    have three combat tours: two in support of Operation Iraqi Freedom and
    one in support Operation Enduring Freedom. On June 29th, 2009 I was
    wounded while on patrol in Iraq when an Explosive Formed Projectile
    struck my vehicle. I received the Purple Heart for injuries sustained
    during this event. I sustained a moderate Traumatic Brain Injury, which
    affected me both, physically and cognitively. According to my
    healthcare providers, the effects of my injuries are expected to worsen
    over time, and in fact they have.
        Since 2009, I received approximately 2 years of rehabilitation.
    Since the beginning of my injury, I was prescribed different
    medications to attempt to lessen the effects of the cognitive disorder
    and pain. After several attempts, doctors were able to find the correct
    medication to lessen the effects of the newly acquired cognitive
    disorder and pain.
        To address the cognitive disorders I was finally prescribed
    Vyvanse, which was a medication that caused no secondary effects, and
    helped me find a new normalcy. After 3 years with a medication that was
    working very well, I was forced to changed medications to a less
    effective formula. Why? Unfortunately, the original medication that was
    working tremendously with no secondary effects and included in the DOD
    formulary is not included in the VA limited formulary. This situation
    forced me to return to a medication that was already discontinued from
    my care due to the experienced adverse side effects.
        My healthcare services are provided by El Paso VA Health Center.
    Particular to my health care facility in El Paso, Texas is that both,
    the DOD pharmacy and the VA Pharmacy are co-located, they are in the
    same building. While Vyvanse physically exists in the building, I
    cannot receive it because the VA does not carry it in its formulary.
    That means that while I could be receiving the medication with no side
    effects, I have to settle for a medication that it has been no good to
    me, only because of a limitation in the VA formulary.
        In my case the medication, Vyvanse, is intended to help with
    attention and concentration. This medication was vital in my successful
    completion of graduate studies and in becoming a Certified
    Rehabilitation Counselor. So, I am not the case of one a Veteran with a
    tantrum because of not being able to receive one random medication. I
    am the case of one Veteran that wants to succeed in life, by having the
    playing field leveled. My past medication leveled my playing field.
        Today, I do not come to you as one isolated Veteran. I come to you
    as the voice of many. I support this bill. It is a bill that is
    economically sound. This bill may result in the better utilization and
    allocation of resources, which in turn may reflect in an increased
    quality of services provided to Veterans.
        I have come across Veterans with situations similar to mine. These
    Veterans ask me to be their voice here today. The following Veterans
    had similar stories to mine; they authorized me to mention their name
    here today: Fernando Esquivel from Texas, Mike Barbour from Illinois,
    Zen Cypher from Texas, and, DeWayne Mayer from Ohio.
        This afternoon, I am saddened as I ask myself: how many Veteran
    suicides have been related to medications changed for the lack of
    uniformed formularies? We may never know the answer. I only know one
    thing: I wish I could go back to the medication that worked well and to
    not live for 2 years with daily adverse secondary effects of a
    medication given to me, solely because it is the only available option
    to me.
        Thank you.

        Chairman Isakson. Well, thank you for your service to the
    country and thank you for your testimony.
        Dr. Lynch and the members of the VA, I want to repeat what
    the sergeant said and make sure I understood it correctly.
    While on active duty after your TBI injury and the explosion,
    you were prescribed Vyvanse. Is that right?
        Sergeant Medina. Vyvanse.
        Chairman Isakson. You were on it for 3 years and it dealt
    well with your cognitive disability, is that correct?
        Sergeant Medina. Mr. Chairman, it was a long process. It
    was a lot of trial and error, and here when I was in Walter
    Reed about 3 years after the injury, they finally found the
    right medication, and then I continued to take it until 6
    months ago--I am sorry, 2 years ago when I got to the VA and
    then I got switched.
        Chairman Isakson. So, you were switched from active duty to
    VA about 2 years ago, is that right?
        Mr. Atizado. Correct, Mr. Chairman.
        Chairman Isakson. Dr. Lynch, when you testified on the
    formulary issue, I thought I heard you say that if there was an
    inconsistency between DOD formulary and VA formulary, you did
    not change a prescription for a veteran who became under VA
    health care. Is that right?
        Dr. Lynch. That should not have happened, Senator.
        Chairman Isakson. OK. What happened to the sergeant was he
    was on Vyvanse and when he went into VA health care in El Paso,
    whose pharmacy--the VA pharmacy and the DOD pharmacy are side-
    by-side, is that correct?
        Sergeant Medina. They are not physically side-by-side, Mr.
    Chairman.
        Chairman Isakson. But they are in the same area?
        Sergeant Medina. They are in the same building.
        Chairman Isakson. So, this soldier, when he went in under
    veterans health care, because that formulary for Vyvanse was
    not on your list, he was switched to a less effective drug. Is
    that correct?
        Sergeant Medina. Correct, Mr. Chairman.
        Chairman Isakson. Are you still on the less effective drug?
        Sergeant Medina. Yes, Mr. Chairman.
        Chairman Isakson. I would think his case merits a revisit
    in terms of the VA, first of all, in consult with his
    physician. If going back to Vyvanse is in his best interest, I
    think it ought to happen, and it is a good testimony as to why
    the formularies should have a parallel agreement in terms of VA
    and DOD. This is a perfect example case.
        When I read this last night--I was not an expert on the
    formulary issue, but I am an expert on taking pills at my age.
    I know when you get the wrong one it is not good and when you
    get one that was working and you do not get it anymore it is
    bad. So, I think the VA ought to investigate this case and I
    would appreciate your advising the Committee of what happens in
    that investigation.
        Dr. Lynch. Yes, sir. We will do that.

        [Responses were not received within the Committee's
    timeframe for publication.]

        Chairman Isakson. Thank you for your service and thank you
    for your testimony and thank you for your courage, not only to
    represent the country, but to speak out at this hearing today.
    We appreciate you very much.
        Sergeant Medina. Thank you, Mr. Chairman.
        Chairman Isakson. Mr. Benjamin, I think I understood you.
    You used a lot of acronyms, but I think you were in support of
    the legislation that allows--that is going to revise the
    contracting procedures at VA for private care providers, is
    that correct?
        Mr. Benjamin. Yes, sir, absolutely.
        Chairman Isakson. The way it is written, it does not have
    all the red tape that you used in terms that I was not familiar
    with, such as FAR, Federal Acquisition Regulations.
        Mr. Benjamin. In fairness, I was not familiar with them
    until a couple of days beforehand because I figured you would
    be asking me a lot of tough questions.
        Chairman Isakson. Well, I feel better. But you think the
    way the legislation is drafted is good?
        Mr. Benjamin. It is and we very much appreciate the
    openness that the VA has had and Senator Blumenthal and also
    Senator Hoeven and the staffs of the various people involved. I
    have been doing this for a long time and sometimes you try to
    tell people things that they might not agree with. This has
    been one where there has been a lot of agreement and we have
    appreciated the support that we have received.
        Chairman Isakson. Mr. Atizado--is that better?
        Mr. Atizado. That works just fine.
        Chairman Isakson. With the Isakson name, I am tough with
    last names anyway. I want to thank DAV for their outspoken
    support of women's issues in the military for our women
    veterans. Your organization is doing an outstanding job of
    illuminating and elevating the women's issues and this
    Committee is going to do everything we can to respond to the
    illumination and elevation to see to it that they are provided
    equal access to health care that is particular to women just
    like we provide to men today. I appreciate your organization's
    testimony and your advocacy for them.
        Mr. Atizado. We thank you for championing this cause,
    Chairman and Ranking Member Blumenthal. We really appreciate
    it, as well as all the work on your Committee staff and the
    Members of this Committee.
        Chairman Isakson. As my wife always reminds me, if there
    were not any women, there would not be any men. So, we want to
    make sure we take care of them.
        Ranking Member Blumenthal.
        Senator Blumenthal. I might just say about Senator Isakson
    and his wife Dianne, since he referred to her, that he and I
    share the good luck of having married above ourselves. So, I
    join in approving of her sentiment in that regard.
        I want to thank again Sergeant First Class Medina, for
    being here today, for your courage in serving our Nation and
    also speaking for so many veterans who have unfortunately
    been--I am going to use the word victims because I think that
    is the correct word of the failure of the two formularies,
    Department of Defense and Veterans Administration, to
    coordinate.
        I am appreciative particularly to you for responding to the
    invitation that we issued, that my staff issued to you, and we
    thought about other witnesses, so-called experts, but you were
    really the expert and the best expert on this problem, and I
    referred to your testimony earlier by saying how compelling and
    important it was, and I truly believe it has been very powerful
    and will have an effect today.
        My thanks to you and the other veterans whose names you
    mentioned and the others who are nameless on this occasion, but
    who also can attest to this problem. Thank you for being here.
        Mr. Benjamin, let me just say that in my view, talking
    about FAR, FAR actually is an acronym for about five or six
    different things in military, VA, HUD, world. In my view,
    acronyms are the great enemy in Washington. So, I try to avoid
    using them, but thanks for explaining what FAR means in this
    context.
        Mr. Benjamin. I brought a whole bunch of other paperwork if
    you would like it.
        Senator Blumenthal. I thank you, but no thank you.
        Mr. Benjamin. I thought you might say that.
        Senator Blumenthal. We see plenty of paperwork in our line
    of work. I just want to thank you for supporting this
    initiative because I think it is very important in broadening
    the opportunities that are available for health care for our
    veterans. I think all of our witnesses today have spoken very
    powerfully to the need for more opportunities and I thank all
    of you for being here.
        I want to join in thanking the DAV for its support for
    women's health care, one of the great challenges of our time,
    increasingly important as more women become veterans. That is a
    good thing. So, we need to be prepared for more women becoming
    veterans since they are contributing more and more to our armed
    services. I do not have any other questions, so thank you, Mr.
    Chairman, for having this hearing.
        Chairman Isakson. Thank you, Ranking Member Blumenthal. The
    Committee will stand adjourned and thank you for your testimony
    today. We appreciate it.
        [Whereupon, the hearing was adjourned at 3:50 p.m.]

                                A P P E N D I X

                                  ----------

                    Prepared Statement of Diane M. Zumatto,
                     National Legislative Director, AMVETS
      S. 207, Veterans Access to Community Care Act of 2015
      S. 297, Frontlines to Lifelines Act of 2015
      S. 425, Homeless Veterans Reintegration Programs
    Reauthorization Act of 2015
      S. 471, Women Veterans Access to Quality Care Act of 2015
      S. 684, Homeless Veterans Prevention Act of 2015
       S. ----, Discussion draft to include provisions from
    S. 114; S. 172; S. 398 & S. 603
      S. ----, Discussion draft on provider agreement language
      S. ----, Joint VA/DOD formulary for pain and psychiatric
    medications

        I would like to begin today's statement with the following
    introductory remarks prior to turning to each specific piece of
    legislation: As the United States absorbs the aftereffects of more than
    a decade of continuous war and in the face of the planned draw-down of
    military personnel, the physical and mental health of our military and
    veterans will continue to be priority issues for AMVETS, the veteran's
    community and hopefully Congress. Thanks to improvements in battlefield
    medicine, swift triage, aeromedical evacuations and trauma surgery,
    more combat-wounded than ever before are surviving horrific wounds and
    will be needing long-term rehabilitation, life-long specialized medical
    care, sophisticated prosthetics, etc. Your committee has a
    responsibility to ensure that the VA and our Nation live up to the
    obligations imposed by the sacrifices of our veterans.
        It is encouraging to acknowledge at this time that, despite the
    extraordinary sacrifices being asked of our men and women in uniform,
    the best and the brightest continue to step forward to answer the call
    of our Nation in its time of need. I know that each of you is aware of,
    and appreciates the numerous issues of importance facing our military
    members, veterans and retirees; therefore this testimony will be,
    following these introductory remarks limited to the specific
    legislation listed above.
        I would also like to first delineate several general issues that
    AMVETS would like the Committee to monitor and enforce as it goes about
    its work, followed by specific recommendations related to the VA.
    General Recommendations:
          ensure that the VA provides a continuity of health care
    for all individuals who were wounded or injured in the line of duty
    including those who were exposed to toxic chemicals;
          ensure that all eligible veterans not only have adequate
    access, but timely and appropriate treatment, for all of their physical
    and mental healthcare needs;
          continue to press the VA to work collaboratively with the
    DOD in creating and implementing a completely operational and fully
    integrated electronic medical records system;
          continue the strictest oversight to ensure the safety,
    physical and mental health and confidentiality of victims of military
    sexual trauma;
          ensure that the VA continues to provide competent,
    compassionate, high quality health care to all eligible veterans; and
          ensure that the VA continues to receive sufficient,
    timely and predictable funding for VA health care.
    Specific Recommendations:
          Ensure that both advanced appropriations and
    discretionary funding for VA keeps pace with medical care inflation and
    healthcare demand as recommended in the IB so that all veterans
    healthcare needs can be adequately met;
          Maximize the use of non-physician medical personnel as a
    way to mitigate physician shortages and reduce patient wait times
    especially while utilization of the VA system continues to rise;
          Ensure that VA makes more realistic third-party medical
    care collection estimates so that Congress doesn't end up under-
    appropriating funds based on false expectations which in turn
    negatively impact veteran care. Additionally, VA needs to redouble its
    efforts to increase its medical care collections efforts, because taken
    together, the cumulative effects of overestimating and under-collecting
    only degrade the care available to our veterans. Furthermore, VA needs
    to establish both first- and third-party copayment accuracy performance
    measures which would help minimize wasted collection efforts and
    veteran dissatisfaction;
          VA needs to incorporate civilian healthcare management
    best practices and include a pathway to VA hospital/clinic management
    for civilians as part of their succession plan requirements, so that VA
    will be able to attract the best and the brightest healthcare managers
    in the industry;
          VA could immediately increase its doctor/patient (d/p)
    ratio to a more realistic and productive levels in order to cut wait
    times for veterans needing treatment and/or referrals. While the
    current VA (d/p) ratio is only 1:1200, the (d/p) ratio for non-VA
    physicians is close to 1:4200. Instituting this one change would
    drastically improve our veterans access to needed healthcare;
          VA needs to improve its patient management system so that
    veterans have more appointment setting options available to them, which
    could reduce staffing errors and requirements. VA should also consider
    utilizing a hybrid system whereby half the day might consist of
    scheduled appointment and the other half would be for walk in or same-
    day appointment. The elimination of the need for non-specialty
    appointments would allow veterans quicker access to their primary care
    providers;
          The current VA healthcare system appears to be top-heavy
    with administrative staff and short-handed when it comes to patient-
    focused clinical staff. This imbalance can only lead to noticeable
    veteran wait times;
          The VA needs to thoroughly review its entire
    organizational structure in order to take advantage of system
    efficiencies and to maximize both human and financial resources, while
    also minimizing waste and redundancies;
          VA needs to collaborate with HHS (Health & Human
    Services) so that it can utilize/share the benefits of the UDS (Uniform
    Data System). The UDS is a core set of information appropriate for
    reviewing and evaluating the operation and performance of individual
    health centers. The ability to track, through the UDS system, a wide
    variety of information, including patient demographics, services
    provided, staffing, clinical indicators, utilization rates, costs, and
    revenues would be invaluable in improving the overall VA healthcare
    system;
          Rather than have veterans go unseen or untreated due to
    limited appointment or physician availability, veterans should be
    allowed to utilized the currently existing system of FQHCs (federally
    Qualified Health Centers). FQHCs include all organizations receiving
    grants under section 330 of the Public Health Service Act, certain
    tribal organizations, and they qualify for enhanced reimbursement from
    Medicare and Medicaid, as well as other benefits. FQHCs are required
    to: serve an underserved area or population; offer a sliding fee scale;
    provide comprehensive services; have an ongoing quality assurance
    program; and to have a governing board of directors. Allowing veterans
    to seek care, even on a temporary basis, until the VA appointment
    backlog is eliminated, would provide our veterans with immediate care
    and would relieve some of the pressure on the VA system;
          VA must immediately improve its recruitment, hiring and
    retention policies to ensure the timely delivery of high quality
    healthcare to our veterans. VA currently utilizes a cumbersome and
    overly-lengthy hiring process which reduces its ability to deliver
    critical services. VA need to consider adopting a more expedient
    hiring/approval process which could include some form of provisional
    employment;
          VA needs to have, and utilize, the option to terminate
    non-performing employees at all levels of the organization so that only
    dedicated, accurate, motivated employees will remain in service to our
    veterans; and
          Finally, VA needs to reform their incentive programs so
    that only high-performing employees receive appropriate bonuses for
    their excellence in serving our veterans.
                              pending legislation
        S. 207, Veterans Access to Community Care Act of 2015--AMVETS
    supports this legislation which directs the VA Secretary to use
    existing authority to provide health care to veterans at non-VA
    facilities to veterans living more than 40 miles driving distance from
    the closest VA facility that furnishes the care needed by the veteran.
        There is an additional problem that should be considered when
    making improvements to the Choice legislation which I have not heard
    any discussion about that I would like to bring to your attention--this
    problem involves the inability of veterans to cross VISN lines for
    medical treatment when they live closer to a facility in another VISN
    than one in their own VISN.
        The issue of ``Timely Access to High-Quality Health Care,'' which
    is directly related to underlying foundation of S. 207, is the number
    one ``Critical Issue'' outlined in the Independent Budget and is among
    the highest priorities of AMVETS. Hopefully this legislation gets
    veterans one step closer to `real' choice and easier health care
    access.

        S. 297, Frontlines to Lifelines Act of 2015--AMVETS supports this
    legislation which seeks to address the physician shortage within the VA
    by:

          reintroducing, for a three-year period, VA's Intermediate
    Care Technician Pilot Program;
          streamlining the transfer of medical credential data
    regarding DOD health care providers that move from DOD to VA;
          allows advanced practice nurses to practice independently
    under a set of VA-approved privileges, regardless of the state in which
    VA employs the covered nurse.

        S. 297 goes a long way toward meeting our recommendation to
    maximize the use of non-physician medical personnel as a way to
    mitigate physician shortages and reduce patient wait times.

        S. 425, Homeless Veterans Reintegration Programs Reauthorization
    Act of 2015--AMVETS supports this legislation which seeks to
    reauthorize, for five-years, the Homeless Veterans/Homeless Women
    Veterans/Homeless Veterans with Children Reintegration Programs and to
    provide clarification regarding eligibility for said services.
        AMVETS believes that S. 425 will help continue the trend of
    reducing the number of homeless veterans.

        S. 471, Women Veterans Access to Quality Care Act of 2015--AMVETS
    fully supports this legislation, which is one of the Independent
    Budget's ``Critical Issues'' for the 114th Congress. Women are a
    rapidly growing component of the Armed Forces, comprising
    approximately: 20% of new recruits; 14.5% of active duty members; and
    18% of the reserve component. Additionally, while the number of male
    veterans is expected to decline by 2020, the opposite is true for the
    number of women veterans.

        S. 684, Homeless Veterans Prevention Act of 2015--AMVETS supports
    this legislation which seeks to address the issue of homeless veterans
    by expanding a number of important services, including:

          increasing per diem payments for transitional housing
    assistance to veterans placed in housing that will become permanent;
          allows qualified veterans to receive diem payments for
    dependents;
          encourages public/private partnerships to provide legal
    services to homeless veterans and/or veterans at risk of homelessness;
          providing dental care to homeless veterans;
          repeals the sunset authority of the VA and DOL to carry
    out a referral and counseling program for veterans at risk of
    homelessness and/or those transitioning from certain institutions; and
          expands supportive services to very low-income veteran
    families in permanent housing.

        There has been marked progress over the last few years in reducing
    the number of homeless veterans and these services need to continue
    until there are no longer any veterans in need.

        Discussion Draft, Veterans Health Act of 2015, to Include
    Provisions from S. 114; S. 172; S. 398; and S. 603--this legislation,
    which AMVETS supports, combines a variety of provisions aimed at
    improving veteran health, access to care and transparency, including:

          improved access to adult immunizations;
          expansion of chiropractic care including--rehabilitative
    & preventative services;
          extension of sunset date regarding transportation of
    individuals to/from VA facilities and the requirement of a report;
          access to VA research data and data sharing between VA
    and DOD

        Discussion Draft, Department of Veterans Affairs Purchased Health
    Care Streamlining and Modernization Act--this somewhat technical
    legislation, which AMVETS supports, expands veteran access to non-VA
    health care and sets conditions for: eligibility to participate in the
    program; establishment of a certification process for eligible non-VA
    providers; establishment of specific requirements under Terms of
    Agreement; the termination of Veterans Care Agreements; the periodic
    review of Veterans Care Agreements; the exclusion of certain Federal
    contracting provisions; the establishment of a monitoring system to
    measure the quality of care and services received by veterans; the
    establishment of equitable dispute resolution procedures; and modifies
    the authority to enter into agreements to provide nursing home care.

        Discussion Draft, Joint VA/DOD Formulary for Pain and Psychiatric
    Medications--This legislation, which AMVETS fully supports, calls for
    the establishment of a joint uniform formulary with respect to certain
    medications. Not only should this benefit servicemembers transitioning
    out of the DOD health care system into the VA system, it should also be
    more economical for both the DOD and VA, in that greater quantities
    generally equate to price reductions.
        This completes my statement at this time and I thank you again for
    the opportunity to offer our comments on pending legislation. I will be
    happy to answer any questions the Committee may have.
                                     ______

              Prepared Statement of Concerned Veterans for America
           s. 207: the veterans access to community care act of 2015
        To require the Secretary of Veterans Affairs to use existing
    authorities to furnish health care at non-Department of Veterans
    Affairs facilities to veterans who live more than 40 miles driving
    distance from the closest medical facility of the Department that
    furnishes the care sought by the veteran, and for other purposes.
        In August of last year, President Obama signed the Veterans Access,
    Choice and Accountability Act that established a temporary ``choice
    card'' program, which was intended to address an access problem at VA,
    by extending the possibility of private care to veterans who wait more
    than 30 days for an appointment and/or reside more than 40 miles from a
    VA facility--including a Community Based Outpatient Clinic (CBOC).
    However, rather than access and appointments getting easier, we have
    seen a process that is confusing, frustrating, and still unacceptably
    long. However, the primary implementation impediment has been VA's
    interpretation of the law; specifically their decision to restrict the
    use of the Choice program to those within 40 miles of a VA facility,
    even if that facility does not offer the care needed. The law states
    that veterans are eligible if they reside ``more than 40 miles from the
    medical facility of the Department, including a community-based
    outpatient clinic [CBOC], that is closest to their residence.'' VA has
    taken this quite literally--drawing 40 mile, ``as-the-crow-flies''
    circles around every single VA facility, regardless of whether that
    facility provides the services needed by the veteran seeking care.
        This legislation would clarify that language, requiring that
    determination of eligibility take into account whether the facility
    actually offers the needed care. This is a common-sense clarification,
    and one that is essential to choice card functioning as intended to
    improve the choices and access to care that veterans have earned by
    their service.
        Concerned Veterans for America SUPPORTS this legislation
                s. 297: the frontlines to lifelines act of 2015
        To revive and expand the Intermediate Care Technician Pilot Program
    of the Department of Veterans Affairs, and for other purposes.
        Concerned Veterans for American has no position on this
    legislation.
     s. 425: the homeless veterans reintegration programs reauthorization
                                  act of 2015
        To amend title 38, United States Code, to provide for a five-year
    extension to the homeless veterans reintegration programs and to
    provide clarification regarding eligibility for services under such
    programs.
        Concerned Veterans for American has no position on this
    legislation.
         s. 471: the women veterans access to quality care act of 2015
        To improve the provision of health care for women veterans by the
    Department of Veterans Affairs, and for other purposes.
        Concerned Veterans for American has no position on this
    legislation.
              s. 684: the homeless veterans prevention act of 2015
        To amend title 38, United States Code, to improve the provision of
    services for homeless veterans, and for other purposes.
        Concerned Veterans for American has no position on this
    legislation.
      discussion draft to include provision from s. 114 (heller); s. 172
                                   (tester);
                      s. 398 (moran); and s. 603 (tester)
        To amend title 38, United States Code, to improve the access of
    veterans to health care and related services from the Department of
    Veterans Affairs, and for other purposes.
        Concerned Veterans for American has no position on this
    legislation.
                discussion draft on provider agreements language
        To amend title 38, United States Code, to allow the Secretary of
    Veterans Affairs to enter into certain agreements with non-Department
    of Veterans Affairs health care providers if the Secretary is not
    feasibly able to provide health care in facilities of the Department or
    through contracts or sharing agreements, and for other purposes.
        Concerned Veterans for American has no position on this
    legislation.
          joint va/dod formulary for pain and psychiatric medications
        To require the Secretary of Defense and the Secretary of Veterans
    Affairs to establish a joint uniform formulary with respect to systemic
    pain and psychiatric drugs that are critical for the transition of an
    individual from receiving health care services furnished by the
    Secretary of Defense to health care services furnished by the Secretary
    of Veterans Affairs, and for other purposes.
        Concerned Veterans for American has no position on this
    legislation.
                                     ______

        Prepared Statement of Jamie Tomek, Chair, Government Relations
                  Committee, Gold Star Wives of America, Inc.
        Thank you for the opportunity to submit Testimony for the Record
    for the Senate Veterans Affairs' Committee hearing on Wednesday,
    June 3, 2015.
        Gold Star Wives of America, Inc. (GSW) was founded in 1945 and is a
    Congressionally Chartered Veterans Service Organization which serves
    the surviving spouses of military servicemembers and veterans who died
    in service or died of a service-connected cause.
        hey15526--department of veterans affairs purchased health care
                       streamlining and modernization act
        This bill would provide civilian medical care to veterans who
    cannot readily access VA medical care. This would substantially reduce
    the long wait for appointments at VA health care facilities.
        GSW recommends passage of this initiative.
                     hey15530--veterans health act of 2015
        This bill would provide adult immunizations against infectious
    diseases to veterans on the recommended adult schedule; expand
    chiropractic care and services to veterans; extend transportation to
    and from VA facilities for veterans; and provide a Web site to share VA
    research with the public.
        GSW concurs with these objectives and requests that surviving
    spouses entitled to CHAMPVA be included in the immunization initiative
    either directly from VA immunization clinics and/or through CHAMPVA
    without co-pay. GSW also requests that surviving spouses entitled to
    CHAMPVA be included in the extended chiropractic care and services
    initiative.
                                  hey 15532--
      va and dod drug formularies for systemic pain and psychiatric drugs
        This bill would ensure that military personnel who are being
    successfully treated for pain and/or psychiatric conditions would be
    able to continue receiving the same pain and psychiatric medications
    when they transition from DOD medical care to VA medical care.
        Care should be taken to ensure that patients entitled to or
    receiving both military medical care and VA medical care are not
    overmedicated, i.e., receiving medication from both the DOD medical
    facility and the VA medical facility.
        GSW recommends passage of this initiative.
                                     ______

         Prepared Statement of Military Officers Association of America

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

         Prepared Statement of General Peter W. Chiarelli, USA (Ret.),
                       Chief Executive Officer, One Mind
        Upon retirement from Military Service, last as the 32nd Vice Chief
    of Staff of the U.S. Army, I became the Chief Executive Officer of the
    non-profit, One Mind, which is dedicated to the treatment of brain
    diseases and injuries.
     draft bill--establishing a joint uniform formulary for systemic pain
                             and psychiatric drugs
        I fully support the proposed Legislation that will require the
    Secretary of Defense and Secretary of Veterans Affairs to establish a
    joint uniform drug formulary. Unfortunately today, systemic pain and
    psychiatric drugs that are critical for the health care of our military
    members suffering from what is commonly called ``the invisible wounds
    of war,'' specifically Traumatic Brain Injury, post-traumatic stress
    and other related mental injuries (e.g., depression), differ greatly
    from what is initially provided by the DOD health care system to what
    they receive when they transition to the VA system.
        Let me state that hindsight is the best teacher. Little did I know
    that such serious formulary differences existed, particularly for these
    injuries. The process of prescribing the right drug and dosage for an
    individual takes time to find the right combination for treatment of
    the invisible wounds described above. Due to genetic and other
    differences among individuals, patients react differently to varying
    drugs and dosages. Finding the right mix can be a frustrating saga of
    trial and error. The wrong drug or dose can, if not caught in time,
    become a factor to an individual's well being.
        It only makes sense that once DOD doctors identify an effective
    treatment for a servicemember, that same treatment should be available
    when the servicemember leaves active duty and moves to the VA for care.
    As stated before, more often than not, this is not the case.
        Why should a joint formulary be adopted? Rather than repeating the
    laborious process of finding another drug that works, many veterans
    have told me they sought out private providers to fill their
    prescriptions, usually paying for their medications out of pocket.
    Imagine how they feel about VA when their first experience with the
    system is a doctor telling them they cannot fill a prescription that
    has relieved their pain or psychiatric symptoms for months or even
    years? In some cases, the veteran is not even given enough of the
    recommended drug to safely discontinue its use.
        It is also important that medications be made available immediately
    upon a servicemember transitioning to VA care, not two to three weeks
    after. This is absolutely critical. The drugs need to be made available
    in the pharmacy and ready to distribute when the servicemember has
    their first appointment at the VA.
        The Legislation states that the Secretary of Defense and Secretary
    of Veterans Affairs have 180 days to submit a joint drug formularies
    report to Congress. I do not understand why it should take this long.
    The joint formulary needs to be initiated in the next 90 days. In the
    interim, DOD doctors should coordinate with VA doctors to support the
    facilitated transition of servicemembers. Every day that the joint
    uniform formulary is delayed is another day where servicemembers,
    veterans and their families are struggling and losing confidence in the
    ability of the VA to provide medical care.
        I believe The Legislation takes a huge step forward in ensuring a
    future where servicemembers experience a more seamless transition
    through the harmonization of the DOD and VA drug formularies. This bill
    focuses on formularies, but I urge the Committee to look into other
    areas or policies that will make the transition from DOD to VA seamless
    for servicemembers and their families.
                                     ______

              Prepared Statement of Paralyzed Veterans of America
              s. 297, the ``frontlines to lifelines act of 2015''
        PVA generally supports S. 297, the ``Frontlines to Lifelines Act of
    2015.'' This bill would revive and expand a pilot program that lapsed
    in February 2014. This bill would authorize VA to hire 250 intermediate
    care technicians at facilities with the longest wait times. It would
    transfer credentialing data of a health care provider who relocates
    from the Department of Defense to employment with the Department of
    Veterans Affairs. By rapidly absorbing qualified, experienced health
    care providers, this bill could ease some of the strains on VA's hiring
    process.
    s. 425, the ``homeless veterans reintegration programs reauthorization
                                 act of 2015''
        PVA supports S. 425, the ``Homeless Veterans Reintegration Programs
    Reauthorization Act of 2015.'' This bill would extend authority for the
    VA Homeless Veterans Reintegration Programs (HVRP) and the Homeless
    Women Veterans and Homeless Veterans with Children Reintegration Grant
    Program through Fiscal Year 2020. The HVRP program is one of the most
    cost-effective and cost-efficient programs in the Federal Government.
    Despite being authorized $50 million per year, it generally is
    appropriated less than half of that authorized level every year. And
    yet, it continues to serve a large number of veterans who are taking
    the necessary steps to overcome homelessness.
        This bill would also clarify eligibility to include homeless
    veterans participating in the Department of Housing and Urban
    Development--VA Supported Housing program (HUD-VASH), Native veterans
    receiving assistance under the Native American Housing Assistance and
    Self Determination Act of 1996, and those transitioning from
    incarceration.
       s. 471, the ``women veterans access to quality care act of 2015''
        PVA supports S. 471, the ``Women Veterans Access to Quality Care
    Act of 2015.'' This bill would establish structural standards in VA
    health care facilities that are necessary to meet the health care needs
    of women veterans. Implementation of this bill would generate a report
    to the House and Senate Veterans' Affairs Committees listing the
    facilities that fail to meet these standards and the projected cost to
    do so. VA would be required to publish the health outcomes of women in
    each facility, juxtaposed with the men that facility serves. VA would
    be required to hire a full-time obstetrician or gynecologist at every
    VA Medical Center, and pilot an OB-GYN graduate medical education
    program to increase the quality of and access to care for women
    veterans.
        The women veteran population who use VA health care doubled between
    2003 and 2012, from 200,631 to 362,014. By 2040, it will have doubled
    again. Given this projection, VA must increase their capacity to meet
    the needs of women veterans. This legislation is a crucial step in
    assessing the quality of care women veterans receive and the steps
    needed to improve it.
             s. 684, the ``homeless veterans prevention act of 2015
        PVA supports S. 684, the ``Homeless Veterans Prevention Act of
    2015'' to improve services for homeless veterans.
        Section 2 would increase per diem payments for transitional housing
    assistance that becomes permanent for veterans. Section 3 would
    authorize per diem payments to provide care for a dependent of a
    homeless veteran while the veteran receives services from a VA grant
    and per diem recipient.
        Section 4 would instruct VA to partner with public and private
    entities to provide legal services to homeless veterans and veterans at
    risk of homelessness. These services, subject to available funding,
    would be made available in an equitable geographic pattern to include
    rural populations and tribal land. The legal services would include
    those related to housing, including eviction defense and landlord-
    tenant cases; family law, including assistance with court proceedings
    for child support, divorce and estate planning; income support,
    including assistance in obtaining public benefits; criminal defense,
    including outstanding warrants, fines and driver's license revocation,
    and to reduce the recidivism rate while overcoming reentry obstacles in
    employment or housing.
        Section 5 would expand the authority of VA to provide dental care
    to eligible homeless veterans who are enrolled for care, and who are
    receiving housing assistance under ``section 8'' for a period of 60
    consecutive days. Those eligible also include veterans receiving care
    in a therapeutic residence; community residential care coordinated by
    the Secretary; or a setting for which the Secretary provides funds for
    a grant and per diem provider.
        Section 6 would repeal the sunset on authority to carry out the
    program of referral and counseling services for veterans at risk for
    homelessness who are transitioning from certain institutions. Section 7
    would extend the authority for financial assistance for supportive
    services for very low-income veteran families in permanent housing.
    Section 8 of this bill would require VA to assess and measure:

         Whether existing capacity meets the needs of the
    subpopulations of homeless veterans located in each geographic area.
         The amount of capacity that recipients of grants under
    sections 2011 and 2061 and per diem payments under section 2012 of such
    title have to provide services for which the recipients are eligible to
    receive per diem under section 2012(a)(2)(B)(ii) of title 38, United
    States Code, as added by section 3(5)(B) of this bill.

        Assessment and recommendations for improvements of the programs
    would be submitted to Congress by the Secretary.
        Section 9 would require the GAO to complete a study of VA programs
    that provide assistance to homeless veterans and a review of the
    privacy, safety, and security of women veterans receiving assistance
    from such programs. Section 10 would repeal the requirement for annual
    reports on assistance to homeless veterans.
                draft bill, the ``veterans health act of 2015''
        PVA supports the ``Veterans Health Act of 2015.'' This bill would
    include immunizations in the statutory definition of ``medical
    services,'' thereby improving access to immunizations. It would expand
    the availability of chiropractic care in VA facilities; extend the
    sunset date of VA transportation programs for veterans to access VA
    health care; and make publicly available the results of VA research.
        While VA already conducts an immunization program, this bill would
    broaden and regulate immunizations in accordance with the adult
    immunization schedule established by the Secretary of Health and Human
    Services.
        This bill would expand the provision of chiropractic care and
    services to veterans. It would require chiropractic services be made
    available in two VA medical centers in each VISN in two years from
    enactment, and in 50% of VA medical centers in each VISN in three
    years. It would also see that ``chiropractic services'' be included in
    title 38, United States Code, as a medical service, a rehabilitative
    service, and a preventative health service.
        The proposal would extend to December 31, 2016, VA's ability to
    directly transport certain veterans for the purpose accessing health
    care. The bill would also authorize $4 million to carry out the
    program, and would require a VA report on the program within one year
    of enactment. The extension of this program would allow veterans to
    maintain their ability to access VA health care.
        Further, it requires VA to create a Web site containing VA research
    data as well as a digital archive of published manuscripts of all VA-
    funded research.
        Last, it would also require the VA/DOD Joint Executive Committee to
    submit a report to the respective Secretaries recommending methods to
    facilitate greater sharing of research between the departments
    addressing the outcomes of military service on veterans, family members
    and their communities.
    draft bill, ``to require the secretary of defense and the secretary of
    veterans affairs to establish a joint uniform formulary with respect to
         systemic pain and psychiatric drugs that are critical for the
        transition of an individual from receiving health care services
    furnished by the secretary of defense to health care services furnished
        by the secretary of veterans affairs, and for other purposes.''
        The bill would exempt the established joint uniform formulary for
    transitioning servicemembers from the existing requirements of DOD's
    pharmacy benefits program. This bill would not interfere with each
    agency's maintenance of its own formulary for other purposes. The bill
    would require a joint report by DOD and VA to Congress on the
    establishment of the new process. This bill allows for DOD and VA to
    work more closely together in order to provide consistent, quality care
    to servicemembers transitioning.
          draft--department of veterans affairs purchased health care
                       streamlining and modernization act
        PVA supports the ``Department of Veterans Affairs Purchased Health
    Care Streamlining and Modernization Act.'' This bill is a necessary
    tool to allow the VA to meet the wide-ranging and unique health care
    needs of veterans, particularly veterans with spinal cord injury and
    dysfunction.
        Through various authorities VA purchases private sector health care
    services for veterans, their families and survivors. Among veterans and
    community providers, the multiple avenues for procuring care often
    creates more confusion than resources. Under this proposed rule, VA
    would be able to obtain extended care services for veterans from
    providers who are closer to veterans' homes and communities.
        The proposed legislation would protect VA's ability to continue to
    purchase private medical care when not otherwise available through VA,
    contracts, or sharing agreements. This allows VA to purchase care
    through agreements that are not subject to provisions of law governing
    Federal contracts, ensuring providers are treated similar to Medicare
    providers. This would enable VA to meet the needs of veterans in an
    effective manner.
        This measure preserves the protections against waste, fraud and
    abuse, based on the Federal and VA Acquisition Regulations. However,
    this legislation will also accelerate the purchasing process of a
    veteran's care by avoiding some of the complicated contracting rules
    governed by Federal Acquisition Regulations. This authority should
    prove extremely appealing to solo practitioners and small practices.

        This concludes PVA's statement for the record. We would be happy to
    answer any questions for the record that the Committee may have.
                                     ______

                   Prepared Statement of The American Legion
        Chairman Isakson, Ranking Member Blumenthal and distinguished
    Members of the Committee, on behalf of National Commander Michael D.
    Helm and the over 2 million members of The American Legion, we thank
    you and your colleagues for the work you do in support of
    servicemembers, veterans and their families.
                  s. 297: frontlines to lifeliness act of 2015
        To revive and expand the Intermediate Care Technician (ICT) Pilot
    Program of the Department of Veterans Affairs, and for other purposes.
        S. 297 would provide VA a good opportunity to expand patient care
    by employing veterans. This bill is beneficial for all parties
    involved, especially for the veteran. However, The American Legion has
    the following recommendations to improve the legislation:

    Section 3, subsection (b), (3)
        This section states ``was credentialed by the Secretary of
    Defense.'' The American Legion understands from the previous pilot
    program that Coast Guard corpsmen could also participate in the
    program. It is the recommendation of The American Legion that the Coast
    Guard not be excluded from this pilot program.
    Section 3, subsection (d), (3)
        This section states ``Credentialing Defined.'' In defining
    credentialing, the legislation lists ``health status'' as a part of the
    credentialing process. However, ``health status'' is not part of a
    credential unless the member does not have the ability to perform a
    task. Health status should not be construed as a requirement that the
    DOD supply VA the servicemembers medical records.
        The American Legion supports efforts to eliminate employment
    barriers that impede the timely and successful transfer of military job
    skills to the civilian labor market.\1\
    ---------------------------------------------------------------------------
        \1\ Resolution No. 313: Support Licensure and Certification of
    Servicemembers, Veterans, and Spouses--AUG 2014
    ---------------------------------------------------------------------------
        The American Legion could support this legislation with the above
    recommendations.
    s. 425: homeless veterans reintegration programs reauthorization act of
                                      2015
        To amend title 38, United States Code, to provide for a five-year
    extension to the homeless veterans reintegration programs and to
    provide clarification regarding eligibility for services under such
    programs.
        This legislation extends through FY 2020 the Department of Veterans
    Affairs (VA) homeless veterans reintegration programs. In addition, it
    makes eligible for participation in those programs:

        (1) Homeless veterans;
        (2) Veterans who are participating in the VA supported housing
    program for which rental assistance is provided under the United States
    Housing Act of 1937; and
        (3) Veterans who are transitioning from being incarcerated.

        Current estimates put the number of homeless veterans at
    approximately 50,000 on any given night, a decline of 33 percent (or
    24,837 people) since 2010.\2\ This includes a nearly 40 percent drop in
    the number of veterans sleeping on the street. The issues facing
    homeless veterans fall into three primary categories: health,
    financial, and access to affordable housing. A critical program in the
    fight to eliminate veteran homelessness is the Homeless Veterans
    Reintegration Program (HVRP) within the Department of Labor's Veterans'
    Employment and Training Services (DOL-VETS). HVRP is the only
    nationwide program focused on assisting homeless veterans to
    reintegrate into the workforce. This program is a highly successful
    grant program that needs to be fully funded at $50 million. Currently,
    HVRP is funded at $38 million.
    ---------------------------------------------------------------------------
        \2\ U.S. Department of Housing and Urban Development (HUD) press
    release HUD no. 14-103 AUG 2014
    ---------------------------------------------------------------------------
        Furthermore, there is long-term follow-up in HVRP--grantees must
    check in with and offer support to veteran participants for 270 days
    after completion--and a commitment to serve veterans transitioning out
    of incarceration, women veterans, and veterans with families. HVRP
    gives an opportunity for those who served in the Armed Forces and
    fallen into homelessness to build the skills necessary to become
    gainfully employed.
        The American Legion has taken a leadership role within local
    communities by volunteering, fundraising, and advocating for programs
    and funding for homeless veterans. Additionally, The American Legion
    provides housing for homeless veterans and their families (i.e.,
    Departments of Connecticut and Pennsylvania). One of the goals of The
    American Legion is to help bring Federal agencies, non-profit and
    faith-based organizations, and other stakeholders to the table to
    discuss best practices, along with funding opportunities, so homeless
    veterans and their families can obtain the necessary care and help in
    order for them to properly transition from the streets and/or shelters
    into gainful employment and/or independent living.\3\
    ---------------------------------------------------------------------------
        \3\ Resolution No. 306: Support Funding for Homeless Veterans--AUG
    2014
    ---------------------------------------------------------------------------
        The American Legion supports S. 425.
           s. 471: women veterans access to quality care act of 2015
        To improve the provision of health care for women veterans by the
    Department of Veterans Affairs, and for other purposes.
        S. 471 addresses the need for VA to provide the overall health care
    and services women veterans need in facilities that provide women
    veteran's the privacy, safety, and dignity they need and deserve. It is
    has been reported often that women veterans are the fastest growing
    demographic that is serving in the military \4\ and there needs to be a
    robust and comprehensive VA healthcare system to care for veterans when
    they transition from active duty to civilian life. Over the years, the
    Department of Veterans (VA) has made great strides in making health
    care services available for women veteran's to include providing women
    veterans with providers to meet their gender-specific health care
    needs. However, there is still much work to be done to meet the overall
    health care needs of women veterans. Even though the military has seen
    a significant increase in the number of women veterans joining the
    military, the number of women veterans enrolling in the VA health care
    system still remains relatively low when compared to their male
    counterparts.
    ---------------------------------------------------------------------------
        \4\ ``The number of women Veterans using VHA nearly doubled in the
    past decade, from 200,631 in FY 2003 to 362,014 in FY 2012 (an 80%
    increase)''--VHA Sourcebook Vol. 3 Women Veterans in the Veterans
    Health Administration, FEB 2014
    ---------------------------------------------------------------------------
        Despite the numerous improvements that VA has taken to improve
    their health-care programs and services for women veterans, there are
    still numerous challenges and barriers women veterans face with
    enrolling in the VA including:

         Women veterans often do not identify themselves as
    veterans,
         Women veterans are often not recognized by VA staff as
    being a veteran,
         Among women veterans, there can be a lack of awareness,
    knowledge, and understanding of their VA benefits,
         There is a stigma associated with the VA healthcare system
    as a being an ``all male'' healthcare system, and
         The VA does not provide all of the gender specific health
    care needs for their enrolled women veterans.
        As a result, The American Legion, through its Veterans Affairs and
    Rehabilitation Division, advocates ensuring women veterans are
    receiving the highest quality of VA health care, and the care is
    tailored to meet their gender specific health care needs.\5\
    ---------------------------------------------------------------------------
        \5\ Resolution No. 45: Women Veterans--OCT 2012
    ---------------------------------------------------------------------------
        The American Legion supports S. 471.
                s. 684: homeless veterans prevention act of 2015
        To amend title 38, United States Code, to improve the provision of
    services for homeless veterans, and for other purposes.
        This bill authorizes the Supportive Services for Veterans Families
    (SSVF) program at $500 million for Fiscal Year (FY) 2016. In addition,
    the bill allows the payment of per diem to support the dependents of
    homeless veterans in Grant and Per Diem (GPD) beds; allows up to 150%
    of the per diem rate be paid to support Transition-in-Place beds;
    expands dental care to homeless veterans living in Housing Urban
    Development-Veterans Affairs Supportive Housing (HUD/VASH) units,
    Domiciliary, or GPD programs; and creates an expansive corps of
    lawyers, through public-private partnerships, to attend to the legal
    services needs of homeless and at-risk veterans.
        Tremendous progress has been made in the fight to eliminate veteran
    homelessness; however, a great deal of work remains. S. 684 would
    continue to move the needle toward VA's goal of eliminating veteran
    homelessness by the end of 2015. The provisions in the bill would help
    VA's homeless veteran programs become more productive and efficient,
    while continuing to effectively partner with the community, national
    and local service providers, and other state and Federal agencies to
    provide comprehensive care to homeless veterans and veterans at-risk
    for homelessness. Due to our work with homeless veterans and their
    families, The American Legion understands that homeless veterans need a
    sustained coordinated effort that provides secure housing and
    nutritious meals; essential physical healthcare, substance abuse
    aftercare and mental health counseling; as well as personal development
    and empowerment. Veterans also need job assessment, training and
    placement assistance. The American Legion believes all programs to
    assist homeless veterans must focus on helping veterans reach their
    highest level of self-management.\6\
    ---------------------------------------------------------------------------
        \6\ Resolution No. 306: Support Funding for Homeless Veterans--AUG
    2014
    ---------------------------------------------------------------------------
        The American Legion strongly believes that Congress, VA and other
    stakeholders must continue to invest in the progress that has been made
    and remove any remaining barriers to housing for veterans. The VA's
    Five-Year Plan to eliminate veteran homelessness by 2015 is roughly 200
    plus days away. By helping to provide the necessary resources and
    changes to reach this obtainable, and worthy, goal, this Nation can
    finally end the scourge of veteran homelessness.
        The American Legion supports S. 684.
                 discussion draft: veterans health act of 2015
        To amend title 38, United States Code, to improve the access of
    veterans to health care and related services from the Department of
    Veterans Affairs, and for other purposes.
        This bill with multiple provisions would expand the immunizations
    available to veterans within the VA, establish a comprehensive policy
    to provide a full scope of chiropractic services to veterans, , and
    enhance public access to information on VA's research data files and
    publications based upon research funded by VA.
        The provisions of this bill fall outside the scope of established
    resolutions of The American Legion. As a large, grassroots
    organization, The American Legion takes positions on legislation based
    on resolutions passed by the membership in meetings of the National
    Executive Committee. With no resolutions addressing the provisions of
    the legislation, The American Legion is researching the material and
    working within our membership to determine the course of action which
    best serves veterans.
        The American Legion has no current position on this legislation.
    discussion draft: department of veterans affairs purchased health care
                       streamlining and modernization act
        To amend title 38, United States Code, to allow the Secretary of
    Veterans Affairs to enter into certain agreements with non-Department
    of Veterans Affairs health care providers if the secretary is not
    feasibly able to provide health care in facilities of the Department or
    through contracts or sharing agreements, and for other purposes.
        Under title 38 U.S.C. 1703, when Department facilities are not
    capable of furnishing economical hospital care or medical services
    because of geographical inaccessibility or are not capable of
    furnishing the care or services required, the Secretary, as authorized
    in section 1710 of this title, VA may contract with non-Department
    facilities. Contracts between VA and non-VA facilities are currently
    negotiated under Federal contract statutes and regulations (including
    the Federal Acquisition Regulation, which is set forth at 48 Code
    Federal Regulations (CFR) Chapter 1; and the Department of Veterans
    Affairs Acquisition Regulations, which are set forth at 48 CFR Chapter
    8).
        Federal contract laws and regulations are not always the best
    method for procuring individual services, which is why for many years
    VA issued individual authorizations to providers, without following
    contracting laws and regulations. VA General Counsel has informed VA
    that they must comply with contracting laws and regulations, which will
    make it more difficult for VA to procure individual services from non-
    VA providers. Provider agreements would allow the Veterans Health
    Administration (VHA) to procure non-VA health care services on an
    individual basis in accordance with the terms and agreements set forth
    in the law.
        The American Legion supports this discussion draft.
       discussion draft: joint va/dod formulary for pain and psychiatric
                                   conditions
        To require the Secretary of Defense and the Secretary of Veterans
    Affairs to establish a joint uniform formulary with respect to systemic
    pain and psychiatric drugs that are critical for the transition of an
    individual from receiving health care services furnished by the
    Secretary of Defense to health care services furnished by the Secretary
    of Veterans Affairs, and for other purposes.
        This bill would require the Secretary of Defense and the Secretary
    of Veterans Affairs to establish a joint uniform formulary with respect
    to systemic pain and psychiatric drugs that are critical for the
    transition of an individual from receiving health care services
    furnished by the Department of Defense to health care services
    furnished by the department Secretary of Veterans Affairs. One area of
    concerned is with the Veterans Administration's (VA) flawed formulary
    and policy which requires a servicemember to switch medications when
    they transfer from the Department of Defense (DOD) healthcare system to
    the VA healthcare system. The switch occurs when a new veteran's
    medication is not on the VA prescription drug formulary. When this
    occurs, the VA will for no clinical purpose, switch that veteran off of
    their successful medication treatment regiment to a drug that is on the
    VA formulary. Only when the veteran fails on the drug's course provided
    by the VA will that veteran be allowed to return the medication regimen
    that was successful for them in the DOD healthcare system.
        In order to eliminate this potential deadly bureaucratic hurdle,
    Congress introduced the Enhancing Veterans' Access to Treatment Act
    (EVAT Act). The EVAT Act mandates that the VA mental health drug
    formulary match the DOD's and requires that any veteran transferring
    from the DOD to the VA be kept on the same mental health medication for
    as long as medically necessary.
        In May 2015, The American Legion met with Michael Valentino, Chief
    Consultant, and Pharmacy Benefits Management Services at Department of
    Veterans Affairs. According to Mr. Valentino, on January 20, 2015, VHA
    issued VHA Directive 2014-02, Continuation of Mental Health Medications
    initiated by Department of Defense Authorized Providers.\7\ According
    to VHA's policy directive it is VHA policy that recently discharged DOD
    Servicemembers who transfer their care to a VA medical facility will be
    transitioned as follows:

        \7\ Veterans Health Administration Directive 2014-02 January 20,
    2015: Continuation of Mental Health Medications initiated by the
    Department of Defense Authorized Providers
    ---------------------------------------------------------------------------
        A VA provider must not discontinue mental health medications,
    initiated by a DOD authorized provider, solely because of differences
    between the VA and DOD drug formularies, VA Criteria-for-Use, or the
    cost of the drug. VA providers are not required to continue mental
    health medications started by a DOD provider if they determine such
    therapy is no longer safe, clinically appropriate, or effective based
    on a servicemembers current medical condition(s). In cases where a
    mental health medication initiated by a DOD provider is not continued
    by a VA provider, the rationale for the decision must be clearly
    documented in the progress note section of the medical record and the
    clinical rationale for this decision clearly explained to the patient.
        In the interest of Veteran-centered care principles, VA medical
    facilities must streamline local processes to ensure prompt access to
    DOD-prescribed VANF non-formulary or restricted mental health
    medications for recently discharged Servicemembers. When continuation
    of a DOD-initiated non-formulary or restricted mental health medication
    is determined to be safe, appropriate and effective by a VA provider,
    the only requirement to process the agent is a designation of
    ``Transitioning Veteran.''
        Standard non-formulary justifications (e.g., documentation of
    formulary medications that have already been tried, contraindication to
    a formulary medication, etc.) are not to be required; further ensuring
    that VA medical facilities will automatically process a ``Transitioning
    Veteran's'' prescription of the mental health medication for
    dispensing.
        In accordance with VHA policy, the policy states that VA providers
    should not discontinue mental health medications, initiated by a DOD
    authorized provider, solely because of differences between the VA and
    DOD drug formularies. Therefore, it appears VHA has already addressed
    these concerns and legislation at this point is not necessary. The
    American Legion is closely monitoring VA to ensure compliance with this
    directive at all levels, but if the directives are followed, this
    legislation may be superfluous and add an additional layer of confusion
    to the transition process as VA locations implementing the current
    directive are forced to determine how they would comply under a new
    change to the United States Code.
        The American Legion does not currently see the need for this
    legislation.
                                   conclusion
        As always, The American Legion thanks this Committee for the
    opportunity to explain the position of the over 2 million veteran
    members of this organization. Questions concerning this testimony can
    be directed to Warren Goldstein in The American Legion Legislative
    Division (202) 861-2700, or wgoldstein@legion.org
                                     ______

      Prepared Statement of Carlos Fuentes, Senior Legislative Associate,
     National Legislative Service, Veterans of Foreign Wars of the United
                                     States
        Chairman Isakson, Ranking Member Blumenthal and Members of the
    Committee, on behalf of the men and women of the Veterans of Foreign
    Wars of the United States (VFW) and our Auxiliaries, thank you for the
    opportunity to offer the VFW's views on legislation being considered by
    the Committee.
             s. 207, veterans access to community care act of 2015
        The VFW supports the intent of this legislation, which would
    require the Department of Veterans Affairs (VA) to provide veterans the
    option to receive non-VA health care when the health care they need is
    not available at a VA medical facility within 40 miles driving distance
    of their residence.
        The purpose of establishing standards for access to non-VA health
    care is to ensure veterans have timely access to high-quality care in
    their communities when VA health care is not readily available. The VFW
    believes that such standards should not require veterans to travel
    unreasonable distances to receive VA health care and that any travel-
    based standard should be based on travel to VA facilities that provide
    the care veterans need, not facilities that are unable to serve their
    specific needs.
        However, feedback the VFW has received regarding the Veterans
    Choice Program indicates that the 40-mile standard does not
    appropriately measure the travel burden veterans face when accessing VA
    health care. Before making any part of the Veterans Choice Program
    permanent, Congress and VA must properly evaluate the program and
    determine the most appropriate system-wide eligibility standards for
    health care furnished through non-VA health care providers. The
    Institute of Medicine is currently evaluating VA's wait-time standard
    to determine its efficacy. Yet, no one has been asked to evaluate
    whether the 40-mile standard is appropriate. The VFW urges Congress to
    commission a study of the 40-mile standard before making it permanent.
        Moreover, such a study must evaluate the impact a travel-based
    standard for non-VA health care eligibility would have on VA's ability
    to expand capacity to provide direct care to enrolled veterans. The VFW
    has conducted a number of surveys to gauge veterans' experiences with
    the Veterans Choice Program. These surveys have shown that about 50
    percent of veterans who are offered the choice to receive non-VA health
    care choose to continue receiving their care from VA, despite facing
    access challenges. While ensuring veterans have access to care in their
    communities is important, VA must have the ability to provide a full
    continuum of care for veterans who choose to receive their care from
    VA.
                  s. 297, frontlines to lifelines act of 2015
        This legislation would revive a successful VA program for
    transitioning servicemembers, improve the transition of health care
    providers between the Department of Defense (DOD) and VA, and expand
    the practice authority for certain health care providers. The VFW
    supports sections 2 and 3 and takes no position on section 4.
        Section 2 would revive the Intermediate Care Technician Pilot
    Program for three years. In December 2012, VA launched this program to
    recruit transitioning veterans who served as medics or corpsmen in the
    military to work in VA emergency departments as intermediate care
    technicians. The goal of this program was to employ transitioning
    medics and corpsmen who have extensive combat medicine experience and
    training to provide clinical support for VA health care providers,
    without requiring them to undergo additional academic preparation. The
    pilot program ended in December 2014, and resulted in 45 veterans being
    hired through the pilot program at 15 VA medical facilities. Veterans
    who participated in the pilot program and VA medical facilities that
    hired them were overwhelming satisfied with the program and would like
    it to continue. Other VA medical facilities have also noted the
    importance of employing experienced veterans as intermediate care
    technicians. Nearly 40 VA medical clinics have requested more than 250
    additional intermediate care technicians to fill staffing shortages
    throughout the country. With the end of the wars in Iraq and
    Afghanistan and the expected drawdown of military personnel, more
    medics and corpsmen will be leaving military service and transitioning
    into the civilian workforce. The VFW supports reviving this important
    program and supports making the intermediate care technician position a
    permanent health care specialty with the Department.
        Section 3 would streamline the hiring process for health care
    providers who transition from practicing medicine in the Military
    Health System to VA. This section would also require DOD to transfer
    the credentialing data of such individuals to VA. However, it does not
    require VA to accept the credentialing data it receives from DOD. The
    VFW urges the Committee to amend this legislation to require VA to
    exempt applicants who are transitioning from the Military Health System
    to VA from the VA credentialing process, when appropriate. Doing so
    would expedite the hiring process and ensure VA is able to more quickly
    address staffing shortages.
        Section 4 would grant independent practice authority for certain
    advanced practice registered nurses employed by the Department.
    Currently, VA advanced practice nurses are not authorized to practice
    at the full extent of their license in certain states. This legislation
    would ensure uniform and system-wide application of practice authority
    for VA nurses. The VFW does not take a position on scope of practice
    issues. The VFW defers to VA in determining what scope of practice
    authority enables its health care professional to provide timely access
    to high-quality health care to the veterans it serves.
     s. 425, homeless veterans' reintegration programs reauthorization act
                                    of 2015
        The VFW supports this legislation, which would expand and
    reauthorize a number of programs aimed at addressing the unacceptable
    problem of homelessness among veterans. The VFW firmly believes that no
    veteran who has honorably served this Nation should have to suffer the
    indignity of living on the streets. We praise the great progress that
    has been made in reducing veterans' homelessness in recent years as a
    direct result of coordinated efforts across multiple government
    agencies to provide transitional housing, rapid rehousing, and
    employment programs for veterans in need. The extensions and adequate
    funding provided by this legislation for these and other programs are
    vital to achieving the Secretary's goal of eradicating homelessness
    among veterans by 2015.
           s. 471, women veterans access to quality care act of 2015
        This legislation would improve the health care VA provides women
    veterans by establishing women health care standards, expanding access
    to gender-specific services and evaluating VA's ability to meet the
    health care needs of women veterans. The VFW supports this legislation
    and would like to offer suggestions to strengthen it.
        Recent years have seen unprecedented levels of women serving in the
    U.S. military. Today, over 1.3 million women wear our Nation's uniform,
    comprising over 15 percent of the total force. Likewise, the demand for
    VA services by women veterans has increased dramatically. According to
    VA data, the number of women using VA services grew from just over
    200,000 in 2003 to over 362,000 in 2012, an increase of more than 80
    percent. By 2014, that number had grown to over 400,000. In addition,
    recent VA data shows that approximately 19 percent of women using VA
    health care served in either Iraq or Afghanistan, compared to only 9
    percent of men. Accordingly, women veterans receiving VA care are
    younger than their male counterparts, with 42 percent of women under
    the age of 45, compared to only 13 percent of men. As a result, the
    number of women using VA services as a percentage of the total
    population will only continue to grow in the coming years, along with
    their need for health care.
        Although VA has made a concerted effort to increase capacity and
    quality of women's health care, gaps in services remain for women
    enrolled in VA, particularly in gender-specific specialty care. Today,
    only 52 VA facilities provide on-site mammography. According to VA
    testimony given on this April 21, 2015, to this Committee, 35 VAMCs
    still have no onsite gynecological services. Of those that do, many of
    the doctors work part-time. The VFW supports requiring all VA medical
    centers to have a full time obstetrician or gynecologist on staff.
        Regardless of what services are available, women veterans will not
    be afforded the opportunity to utilize them if they are unaware such
    services exist. This legislation seeks to improve outreach to women
    veterans by requiring VA to share veterans' information with state and
    county veterans agencies. The VFW supports sharing data between
    government agencies to ensure veterans are aware of the benefits and
    services they have earned and deserve. This legislation would afford
    veterans the opportunity to opt out of the data sharing mechanism VA is
    required to establish. The VFW urges Congress and VA to ensure veterans
    are fully informed that their personal information will be shared and
    are given clear notification of such action and granted an easily
    accessible and user friendly mechanism to opt out.
        In drafting testimony for women specific hearings, the VFW sought
    the input of women VFW members from across the country. A consistent
    issue identified by women VFW members was lack of child care at VA
    medical facilities. Without access to child care services veterans are
    often reluctant to take their small children to medical appointments
    with them. Veterans may even choose to forgo the care they need and
    deserve. The VFW strongly believes that veterans should not be forced
    to choose between their own wellbeing and that of their children. For
    this reason, we urge the Committee to amend this legislation to fully
    expand the VA child care pilot program to all facilities across the
    Department.
                s. 684, homeless veterans prevention act of 2015
        This legislation would improve benefits afforded to homeless
    veterans. As stated above, the VFW strongly supports efforts to end
    homelessness among veterans who have honorably served this Nation. The
    VFW supports this legislation and would like to offer a suggestion to
    strengthen section 4.
        The VFW generally supports section 4 of the bill which would allow
    the Secretary to enter into partnerships with public or private
    entities to fund a portion of certain legal services for homeless
    veterans. While the VFW recognizes that legal issues are often a
    significant barrier to homeless reintegration and must be addressed, we
    are concerned that some for-profit legal entities would view this
    program as an opportunity to exploit the availability of government
    resources in exchange for poor or inadequate services. For this reason,
    we suggest that the language in this section be changed to allow VA to
    enter into partnerships with only public or non-profit private legal
    entities that provide services to homeless veterans.
    draft legislation, department of veterans affairs purchased health care
                       streamlining and modernization act
        The VFW strongly supports this legislation, which would streamline
    VA's ability to purchase health care from private sector health care
    providers when VA health care is not readily available.
        VA must have the ability to quickly provide non-VA health care when
    it is unable to provide direct care to the veterans it serves. The VFW
    is glad to see this legislation includes best practices, such as
    requiring non-VA medical providers to return medical documentation, and
    quality and safety mechanisms to ensure veterans receive high quality
    care from non-VA providers. This legislation also required VA to
    exhaust all other avenues for furnishing non-VA health care before
    using veteran care agreements. The VFW believes it is important that VA
    medical facilities use other non-VA care programs such as the Patient-
    Centered Community Care Program (PC3), the Veterans Choice Program, or
    any future system wide non-VA health care program before using veteran
    care agreements. Doing so will ensure local medical facilities do not
    preclude administrators of system wide programs from expanding their
    networks to better serve veterans.
    draft legislation to require dod and va to establish a joint formulary
              with respect to systemic pain and psychiatric drugs
        This legislation would require DOD and VA to establish uniform
    systemic pain and psychiatric drugs and treatments for veterans
    transitioning from the Military Health System to the VA health care
    system. The VFW supports this legislation and would like to offer
    suggestions to strengthen it.
        The VFW has heard from veterans who were unable to continue their
    DOD prescribed pain treatment or mental health care therapies once
    transitioning to the VA health care system because their VA medical
    facilities refused to recognize their DOD prescriptions, or the drugs
    they needed were not on VA's formulary. This legislation would ensure
    veterans are not denied access to treatments that have worked for them
    due to the inconsistent formularies between DOD and VA. It does not,
    however, require VA to continue prescribing veterans medications that
    have proven to successfully address their pain or mental health
    conditions.
        Mental health medications require providers to work with patients
    to adjust medication treatments and dosages to obtain the optimal
    outcome. When transitioning from the Military Health System to the VA
    health care system, veterans must be allowed to continue the medication
    regiment that works best for them while they work with their VA
    providers to identify if continuing the same medication regiment is
    recommended or if they should begin a new regiment. The VFW suggests
    adding such a requirement to this legislation to ensure the treatments
    veterans receive from DOD are not disrupted when they transition to the
    VA health care system.
                 draft legislation, veterans health act of 2015
        The VFW support this legislation, which would improve VA health
    care by expanding access to immunizations and chiropractic care,
    extending VA's ability to provide transportation assistance, and making
    VA research available to the public.
        Section 2 would ensure that veterans receive the full complement of
    immunizations on the recommended adult immunization schedule
    established by the Centers for Disease Control (CDC) and Prevention
    Advisory Committee on Immunization Practices (ACIP). It would also
    mandate that VA develop and implement quality measures and metrics to
    ensure that veterans receiving VA medical services receive each
    immunization at the proper time according to the ACIP.
        The evidence is clear that vaccination is one of the safest, most
    cost effective ways to prevent disease and death from infectious
    diseases. Efforts to quantify and track vaccine utilizations in the
    past have clearly shown that prioritizing increased utilization and
    effectiveness of vaccination inoculations, in tandem with rigorous
    performance measures, generate monumental savings while improving
    patient health. When VA adopted performance measures for influenza and
    pneumococcal, significant improvement in vaccine utilization rates
    resulted--from 27 percent to 77 percent and 26 percent to 80 percent,
    respectively. Expanding performance measures to the entire list of VA
    and CDC recommended adult vaccinations would undoubtedly promote timely
    and appropriate vaccinations, while placing a greater emphasis on
    preventable care for veterans.
        Section 3 would require VA to provide chiropractic care in at least
    50 percent of VA medical centers within three years of enactment. This
    section would also include chiropractic services in the general health
    care package VA is required to provide enrolled veterans. It is well
    known that servicemembers who deploy to combat and participate in
    military training are subject to extraordinary physical demands, often
    resulting in the premature onset of painful spine and joint conditions.
    In its latest analysis of health care utilization among Operation
    Enduring Freedom (OEF), Operation Iraqi Freedom (OIF) and Operation New
    Dawn (OND) veterans, VA listed musculoskeletal ailments as the number
    one condition for which Iraq and Afghanistan veterans sought VA care.
    Chiropractic care can often be a successful alternative to drugs or
    invasive procedures for treating musculoskeletal disorders, while also
    offering suggestions for lifestyle modifications which promote overall
    wellness. The VFW believes that chiropractic care is a valuable option
    and should be made available to veterans at all VA medical centers.
        Section 4 would extend VA's authority to administer the Veterans
    Transportation Service (VTS). This program was commissioned by the
    Veterans Health Administration's Office of Rural Health in 2010, and
    greatly improved access to care for rural and seriously disabled
    veterans by allowing VA facilities to establish and coordinate networks
    of local transportation providers, including community and commercial
    transportation providers, and government transportation services. VTS
    augments veterans service organizations' volunteer-based transportation
    services, which are limited to transporting ambulatory veterans; the
    existing beneficiary travel programs of mileage reimbursement, which
    does not provide assistance with the coordination of transportation for
    those who need it; and special mode travel, for which few veterans
    medically qualify.
        VTS suffered a major setback in 2012 when it was temporarily
    suspended following a determination by the VA Office of General Counsel
    that VA lacked the statutory authority to hire paid drivers to
    transport veterans. Congress has passed one-year authorizations of the
    VTS program since January 2013, but a long term fix is still needed.
    The VFW believes that unnecessary hardships associated with accessing
    VA health care should be eliminated. The VFW urges the Committee to
    amend this section to make VTS permanent and expand it system wide to
    minimize the challenges veterans face in traveling to their VA
    appointments.
        Section 5 would make VA-funded medical research available to the
    public. The VFW believes that research furnished by VA benefits
    veterans who seek VA care and the health care community as a whole. VA
    health research has led to many medical breakthroughs and continues to
    lead the health care industry in many respects. Veterans service
    organizations and Congress depend on VA research to develop policy
    recommendations and advance legislative goals. Although VA's research
    is available to the public through peer reviewed journals, veteran
    advocates are at times precluded from obtaining VA research due to lack
    of access to such peer reviewed journals. The VFW supports making the
    benefits of VA research available to the public.

        Chairman Isakson, Ranking Member Blumenthal and Members of the
    Committee, this concludes my testimony.
                                     ______

      Prepared Statement of Thomas J. Berger, Ph.D., Executive Director,
              Veterans Health Council, Vietnam Veterans of America
        Good day, Chairman Isackson, Ranking Member Blumenthal and Members
    of the Senate Veterans' Affairs Committee. On behalf of Vietnam
    Veterans of America (VVA) National President John Rowan and all of our
    officers and members, we thank you for the opportunity for VVA to share
    our statement for the record regarding pending Veterans legislation
    before this Committee.

        S. 207, Veterans Access to Community Care Act of 2015 introduced by
    Senator Jerry Moran (KS). This legislation would direct the Secretary
    of Veterans Affairs (VA) to use the Secretary's existing authority to
    furnish health care to veterans at non-VA facilities for veterans who
    reside more than 40 miles driving distance from the closest VA medical
    facility providing the care they seek.
        VVA supports this legislation as it will provide veterans access to
    health care at non-VA facilities where a Choice Card-eligible veteran
    cannot receive health care at a VA facility within the 40-mile limit
    because the health care, particularly specialty care, is not available
    at the VA facility.

        S. 297, Frontlines to Lifelines Act of 2015, introduced by Senator
    Mark Steven (IL), this legislation directs the Secretary of Veterans
    Affairs (VA) to revive, for a three-year period, VA's Intermediate Care
    Technician Pilot Program that was carried out between January 2013 and
    February 2014. Requires VA to: (1) expand the pilot program to include
    at least 250 intermediate care technicians, and (2) give priority in
    assigning those technicians to VA facilities at which veterans have the
    longest wait times. Requires the Secretary of Defense (DOD) to transfer
    credentialing data regarding DOD health care providers that are hired
    by VA to VA.
        In general, VVA supports this legislation. However, VVA would like
    to see the pilot program expanded to include medics and Navy corpsmen.

        S. 425, Homeless Veterans' Reintegration Programs Reauthorization
    Act of 2015 introduced by Senator John Boozman (AR), Job readiness
    training and reeducation are a congressionally mandated function and
    responsibility of the US Department of Labor (DOL). The Homeless
    Veterans Reintegration Program (HVRP) has long suffered the
    consequences of limited funding. VVA is seeking to ensure that DOL
    request full authorized funding in its budget. This is not only a
    significant investment in the lives of veterans who are trying to make
    their way back * * *. It is an investment in our national economy. This
    training and employment program has proved over time to be extremely
    successful in retraining and reeducating our homeless veteran,
    providing a new start at life. It is a labor and training issue, and as
    such, it should be held accountable for program investment and
    performance in the same vein as all other agencies to include the U.S.
    Department of Veterans Affairs.
        VVA supports the expansion of the program as identified in this
    legislation and would also request that language be added to S. 425
    amending the eligibility criteria for veterans enrolled in the
    Department of Labor Homeless Veterans Reintegration Program (HVRP) so
    those veterans entering into ``housing first'' would be able to access
    this training for a period of up to 12 months after placement into
    housing.

        S. 471, Women Veterans Access to Quality Care Act of 2015
    introduced by Senator Dean Heller (NV), The Department of Veterans
    Affairs has become increasingly more sensitive and responsive to the
    needs of women veterans and many improvements have been made.
    Unfortunately, these changes and improvements have not been completely
    implemented throughout the entire system. In some locations, women
    veterans experience barriers to adequate health care and oversight with
    accountability is lacking. Primary care is fragmented for women
    veterans. What would be routine primary care in the community is
    referred out to specialty clinics in the VA. Over the last five years
    the per cent of women veterans using the VA has grown from 11% to 17%,
    with 56% of OEF/OIF women Veterans having enrolled in the VA. Their
    average age of women Veterans using the VA is 48.
        Further, we seek that the Secretary ensures:

         The competency of staff who work with women in providing
    gender-specific health care.
         That VA provides reproductive health care.
         That appropriate training regarding issues pertinent to
    women veterans is provided.
         That there is the creation of an environment in which
    staff are sensitive to the needs of women veterans; that this
    environment meets the women`s needs for privacy, safety, and emotional
    and physical comfort in all venues.
         Those privacy policy standards are met for all patients at
    all VHA locations and the security of all Veterans is ensured.
         That the anticipated growth of the number of women
    Veterans should be considered in all strategic plans, facility
    construction/utilization and human capital needs.
         That patient satisfaction assessments and all clinical
    performance measures and monitors that are not gender-specific, be
    examined and reported by gender to detect any differences in the
    quality of care.
         That the Assistant Deputy Under Secretary for Health for
    Quality, Safety, and Value report any significant differences and
    forward the findings to the Under Secretary for Health, Under Secretary
    for Operations and Management, the Regional Directors, facility
    directors and chiefs of staff, and the Women's Health Services Office.
         That every woman veteran has access to a VA primary care
    provider who meets all her primary care needs, including gender-
    specific and mental health care in the context of an ongoing patient-
    clinician relationship.
         That general mental health care providers are located
    within the women`s and primary care clinics in order to facilitate the
    delivery of mental health services.
         That sexual trauma care is readily available to all
    veterans who need it and that VA ensure those providing this care and
    treatment have appropriate qualifications obtained through course work,
    training and/or clinical experience specific to MST or sexual trauma.
         That an evaluation of all gender specific sexual trauma
    intensive treatment residential programs be made to determine if this
    level is adequate as related to level of need for each gender,
    admission wait times, and geographically responsive to the need.
         That Vet Centers are able to adequately provide services
    to women veterans.
         That a plan is developed for the identification,
    development and dissemination of evidence-based treatments for PTSD and
    other co-occurring conditions attributed to combat exposure or sexual
    trauma.
         That women veterans, upon their request, have access to
    female mental health professionals, and if necessary, use VA outsource
    to meet the women veteran`s needs.
         That all Community Based Outpatient Clinics (CBOC) which
    do not provide gender-specific care arrange for such care through VA
    outsource or contract in compliance with established access standards.
         Evidence-based holistic programs for women's health,
    mental health, and rehabilitation are available to ensure the full
    continuum of care.
         That the Women's Health Service aggressively seek to
    determine root causes for any differences in quality measures and
    report these to the Under Secretary for Health, Under Secretary for
    Operations and Management, the Regional Directors, facility directors
    and COS, and providers.

        Vietnam Veterans of America will continue its advocacy to secure
    appropriate facilities and resources for the diagnosis, care and
    treatment of women veterans at all DVA hospitals, clinics, and Vet
    Centers and we ask the Secretary of Veterans Affairs ensure senior
    leadership at all facilities and VISN Directors be held accountable for
    ensuring women veterans receive appropriate care in an appropriate
    environment and based on our recommendations above and language
    included in the bill. VVA supports S. 471 as written.

        S. 684, Homeless Veterans Prevention Act of 2015 introduced by
    Senator Richard Burr (NC), Homelessness continues to be a significant
    problem for veterans. The VA estimates about one-third of the adult
    homeless population have served their country in the Armed Services.
    Current population estimates suggest that about 49,000 veterans (male
    and female) are homeless on any given night and perhaps twice as many
    experience homelessness at some point during the course of a year.
    Federal efforts regarding homeless veterans must be particularly
    vigorous for women veterans with minor children in their care. And
    those Federal agencies that have responsibilities in addressing this
    situation, particularly the Departments of Veterans Affairs, Labor, and
    Housing and Urban Development, must work in concert and should be held
    accountable for achieving clearly defined results. VVA also believes
    the housing first model may work for some veterans; however, to take a
    homeless veteran off the streets and into permanent housing without
    first assessing their treatment needs is a mixture for disaster.
    Failure is not an option; please fix this now or we will see an
    increase in veteran homelessness, rather than ending veteran
    homelessness, by 2015. VVA supports S. 684 as written.
                       a. discussion draft that includes:

        (a) S. 172--Improved access to appropriate immunizations for
    veterans--VVA supports
        (b) S. 398 (and companion H.R. 1170)--Expansion of provision of
    chiropractic care and services to veterans--VVA supports, but believes
    that a needs assessment must be conducted in each VISN to determine the
    extent of expansion needed.
        (c) S. 603--Extension of sunset date regarding transportation of
    individuals to and from facilities of DVA and requirements of report--
    VVA supports
        (d) S. 114--Public access to DVA research and data sharing between
    departments--VVA supports
              b. discussion draft on provider agreements language
        VVA generally supports this draft, but believes stronger
    accountability measures must be added for both VA and non-VA providers.
    c. proposed joint va/dod formulary for pain and psychiatric medications
        VVA strongly supports the sharing of information with respect to
    systemic pain and psychiatric drugs that are critical for the
    transition of an individual from DOD healthcare to VA healthcare.
    However, at the present time, VVA also recommends the VA formulary
    system be overhauled to reflect transparency in the addition and
    removal of all pharmacological medications. VVA is willing to assist in
    this matter.

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