[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 [email protected]
                                 ______
                                 
  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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