[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON: DRAFT LEGISLATION, THE VETERANS AFFAIRS MEDICAL
SCRIBE PILOT ACT OF 2017; H.R. 91; H.R. 95; H.R. 467; H.R. 907; H.R.
918; H.R. 1005; H.R. 1162; H.R. 1545; AND H.R. 1662
=======================================================================
HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
FIRST SESSION
__________
WEDNESDAY, MARCH 29, 2017
__________
Serial No. 115-8
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.fdsys.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
29-404 WASHINGTON : 2018
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COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BRAD R. WENSTRUP, Ohio JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida KILILI SABLAN, Northern Mariana
JODEY ARRINGTON, Texas Islands
JOHN RUTHERFORD, Florida ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
BRAD WENSTRUP, Ohio, Chairman
GUS BILIRAKIS, Florida JULIA BROWNLEY, California,
AMATA RADEWAGEN, American Samoa Ranking Member
NEAL DUNN, Florida MARK TAKANO, California
JOHN RUTHERFORD, Florida ANN MCLANE KUSTER, New Hampshire
CLAY HIGGINS, Louisiana BETO O'ROURKE, Texas
JENNIFER GONZALEZ-COLON, Puerto LUIS CORREA, California
Rico
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
----------
Wednesday, March 29, 2017
Page
Legislative Hearing On: Draft Legislation, The Veterans Affairs
Medical Scribe Pilot Act of 2017; H.R. 91; H.R. 95; H.R. 467;
H.R. 907; H.R. 918; H.R. 1005; H.R. 1162; H.R. 1545; AND H.R.
1662........................................................... 1
OPENING STATEMENTS
Honorable Brad Wenstrup, Chairman................................ 1
Honorable Julia Brownley, Ranking Member......................... 2
WITNESSES
Honorable Jackie Walorski, U.S. House of Representatives, 2nd
Congressional District, Indiana................................ 4
Prepared Statement........................................... 29
Honorable Doug Collins, U.S. House of Representatives, 9th
Congressional District, Georgia................................
Prepared Statement........................................... 31
Honorable Mike Coffman, U.S. House of Representatives, 6th
Congressional District, Colorado............................... 7
Prepared Statement........................................... 32
Honorable Stephen Knight, U.S. House of Representatives, 25th
Congressional District, California............................. 8
Prepared Statement........................................... 33
Honorable Ann M. Kuster, U.S. House of Representatives, 2nd
Congressional District, New Hampshire.......................... 10
Prepared Statement........................................... 34
Honorable Roe, U.S. House of Representatives, 1st District,
Tennessee...................................................... 21
Prepared Statement........................................... 34
Jennifer S. Lee, M.D., Deputy Under Secretary for Health for
Policy and Services, Veterans Health Administration, U.S.
Department of Veterans Affairs................................. 11
Prepared Statement........................................... 35
Accompanied by:
Susan Blauert, Chief Counsel for the Health Care Law Group,
Office of the General Counsel , U.S. Department of
Veterans Affairs
Kayda Keleher, Legislative Associate, National Legislative
Service, Veterans of Foreign Wars of the United States......... 12
Prepared Statement........................................... 40
Shurhonda Y. Love, Assistant National Legislative Director,
Disabled American Veterans..................................... 14
Prepared Statement........................................... 45
Sarah S. Dean, Associate Legislative Director, Paralyzed Veterans
of America..................................................... 16
Prepared Statement........................................... 49
STATEMENTS FOR THE RECORD
The Honorable Lee Zeldin, U.S House of Representatives,1st
Congressional District; New York............................... 53
The American Legion.............................................. 59
National Association of State Veteans Homes...................... 60
Swords to Plowshares............................................. 62
Wounded Warrior Project (WWP).................................... 71
American Federation of Government Employees, Afl-CIO (AFGE)...... 72
Vietnam Veterans of Ameria (VVA)................................. 73
LEGISLATIVE HEARING ON: DRAFT LEGISLATION, THE VETERANS AFFAIRS MEDICAL
SCRIBE PILOT ACT OF 2017; H.R. 91; H.R. 95; H.R. 467; H.R. 907; H.R.
918; H.R. 1005; H.R. 1162; H.R. 1545; AND H.R. 1662
----------
Wednesday, March 29, 2017
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Disability Assistance
and Memorial Affairs,
Washington, D.C.
The Subcommittee met, pursuant to notice, at 8:01 a.m., in
Room 334, Cannon House Office Building, Hon. Brad Wenstrup
[Chairman of the Subcommittee] presiding.
Present: Representatives Bilirakis, Radewagen, Dunn,
Rutherford, Higgins, Gonzales-Colon, Brownley, Takano, Kuster,
O'Rourke, and Correa.
OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN
Mr. Wenstrup. The Subcommittee will come to order. Good
morning and thank you all for joining us early this morning for
today's Subcommittee legislative hearing. Before I begin I
would like to ask unanimous consent for our colleague and
fellow Committee Member, Representative Coffman from Colorado,
to sit on the dais and participate in today's proceedings.
Without objection, so ordered.
This morning we will discuss ten bills that will address a
number of issues impacting America's veterans and the health
care services that they receive from the Department of Veterans
Affairs. These proposals are sponsored by our colleagues both
on and off the Committee and from both sides of the aisle,
demonstrating the commitment that all of us feel towards
improving the lives and well-being of those who have served our
Nation in uniform.
I look forward to a thorough discussion of the merits and
challenges of each of the bills on our agenda this morning and
I am grateful to the bill sponsors, as well as the witnesses
from VA and from our veteran service organization partners for
being with us today to present their views, which are so
critical to informing how we move forward.
Given our ambitious agenda and the early morning hour, I
will refrain from commenting on all of the bills that we will
discuss today. However, I do want to briefly discuss the bill
that I am proud to sponsor, H.R. 1662. H.R. 1662 would prohibit
smoking inside any Veterans Health Administration facility
immediately, and prohibit smoking outside of any VHA facility
over the next five years. Legislation enacted in 1992 requires
VHA to provide smoking areas for patients and visitors. This is
contrary to common practice in private sector hospitals and
clinics, most of which adopted 100 percent smoke free policies
for their facilities, grounds, and buildings many years ago in
recognition of how harmful smoking and secondhand smoke
exposure can be for patients, visitors, and employees alike.
I recognize that some veterans and VA employees are smokers
and that quitting can be a challenging uphill battle. That is
why H.R. 1662 would allow smoking outside of VHA's facilities
to be phased out over a five-year period rather than right
away. And VA offers a variety of programs and interventions to
support those who are trying to kick their smoking habit. And I
am hopeful that those who are struggling to quit smoking will
take full advantage of those resources.
However, as a doctor and as a veteran I feel strongly that
we cannot continue to allow a practice as toxic and damaging as
smoking to continue taking place on VA medical facility
campuses where our most vulnerable patients are trying to heal
and our hardest working employees are trying to work.
H.R. 1662 would ensure that VA is in line with industry
standards with regard to smoke free polices, while also
ensuring that the money that VA currently spends to maintain
designated smoking areas, estimated at more than 1.2 million
annually, and the space the VA designates to smoking both
inside and outside of VA medical facilities across the country,
which VA told me in January couldn't be estimated, can be
reallocated to efforts and improve the health of our veterans
and employees, rather than an outdated requirement that we know
that will continue to harm them.
This is a common sense legislation I hope we will have the
support of everyone here today. I would ask unanimous consent
to include a letter of support for H.R. 1662 from the
Commissioned Officers Association of the U.S. Public Health
Service into the record.
Without objection so ordered.
Mr. Wenstrup. I now yield to Ranking Member Brownley for
any opening statements she may have.
OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER
Ms. Brownley. Thank you, Mr. Chairman. And thank you for
holding this hearing. We have some great legislation that we
are considering today. And your expertise and input, the VA's,
and our VSO organizations, their expertise and input is going
to be very valuable to us as we consider what changes might
need to be made to be of the most benefit to our veterans.
As we near the end of Women's History Month I am pleased
that two of my bills that will help our women veterans are
being considered today: H.R. 91, the Building Supportive
Networks for Women Veterans Act, and H.R. 95, the Veterans
Access to Child Care Act. I introduce these two bills because I
believe that we should be doing more to ensure our women
veterans are able to access the care they need and work to
break down barriers that may be preventing women veterans from
receiving VA care.
The Building Supportive Networks for Women Veterans Act
will permanently authorize a VA pilot program that offers
counseling at a retreat for women veterans who are recently
separated from the military. VA's data shows that for the 272
women who have participated in the retreat since 2011, many saw
a decrease in symptoms associated with post-traumatic stress
disorder, had better coping mechanisms, and scored higher on
psychological well-being tests after completion of the retreat.
In fact, two months later 84 percent showed a decrease in
stress symptoms. Due to the success of this program, I am also
interested to hear from the VA and from our VSOs about how this
program might be expanded to help other groups of veterans.
I am also glad to see the Subcommittee consider the
Veterans Access to Child Care Act, which I introduced with my
colleague, Congressman Higgins. This bill will help ensure that
veterans do not have to choose between caring for their
children and getting the health care they need.
Just yesterday I was able to attend a roundtable with our
VSOs, including many of you here today to discuss supporting
women veterans, and we discussed this very issue. I heard from
many of you about what a challenge the lack of affordable child
care can be, especially for women veterans. Since women
veterans are more often responsible for caring for their
children, lack of convenient and affordable child care can be a
barrier for women who need reoccurring mental health care or
even intensive care services. That is why I introduced the bill
to allow the VA to provide child care services at VA
facilities, provide veterans with a stipend for child care, or
make direct payments to child care providers for veterans in
need of intensive care or mental health treatments.
I hope that VA can provide a better estimate of the
necessary resources for his program and some better data on
whether lack of child care is creating a barrier for woman
veterans to access care at VA facilities. I am also interested
to hear more about VFW's idea to include child care services
for homeless veterans attending employment training programs.
For our homeless veterans or veterans at risk of being
homeless, lack of child care can--lack of child care access may
pose an even greater challenge to accessing care and receiving
additional services and assistance. I hope to work with the VA,
the VSOs testifying here today, and our other stakeholders to
ensure child care is available to those veterans who need to
access VA health care.
Finally, I want to thank my colleagues here today who have
introduced legislation intended to improve the lives of
veterans and their families. I welcome the input of the VA and
our VSOs so that we can continue to work together to develop
the best legislation that will achieve this purpose. Thank you,
Mr. Chairman, and I yield back.
Mr. Wenstrup. Thank you, Ms. Brownley. I am honored to be
joined this morning by several of my colleagues who are going
to be testifying about the bills on our agenda that they have
sponsored. I appreciate you all taking time out of your morning
to be here with us and for sponsoring legislation to help our
veterans.
With us this morning are Representative Jackie Walorski
from Indiana, Representative Doug Collins from Georgia,
Representative Mike Coffman from Colorado, Representative
Steven Knight from California and Representative Ann Kuster
from New Hampshire. Chairman Roe, who is sponsoring the draft
bill on our agenda, will be joining us shortly and I will
recognize him upon arrival.
Representative Walorski, we will begin with you. You're now
recognized for five minutes.
OPENING STATEMENT OF HONORABLE JACKIE WALORSKI
Ms. Walorski. Thank you. Good morning, Chairman Wenstrup,
Ranking Member Brownley. I can say it is an honor to be here. I
miss working with you on the official committee, but thanks for
hearing this bill today.
This is H.R. 467, the VA Scheduling Accountability Act.
First I would like to thank Chairman Wenstrup and Ranking
Member Brownley for holding this hearing allowing me to testify
on the reintroduction of this bill that we passed last year.
In 2014 news reports uncovering gross mismanagement and
scheduling manipulation at a Department of Veteran Affairs
Hospital in Phoenix shook us to the core. Through hearings held
in this Committee and investigations by the VA Office of
Inspector General and Government Accountability Office we
substantiated many of the allegations of manipulated scheduling
and falsified wait time data at the Phoenix facility.
The manipulation of appointment schedules and data in
Phoenix led to at least 40 veterans dying while they were
waiting for care. However, three years after this tragedy VA is
still plagued with facilities unable to get their act together
when it comes to scheduling appointments. Earlier this month
the OIG released yet another report that identified flaws in
the scheduling system still used by VA facilities nationwide.
Instead of owning up to the problems that continue to prevent
veterans from getting timely care they need, the new secretary
disputed the findings of inaccurate wait times.
We need to let the VA know that we will never give up in
holding their feet to the fire. That is why I reintroduced the
VA Scheduling Accountability Act. VA Directive 2010-027 is VA's
implementation processes and procedures policy for scheduling
at their facilities and contains 19 different items on the
checklist. The directive requires an annual certification of
full compliance with all items on the list. For instance,
facilities are required to conduct an annual audit of the
timeliness and appropriateness of scheduling actions and the
accuracy of desired dates. They are also required to ensure
that deficiencies of competency or performance that are
identified by the audit are effectively addressed.
In August 2014 OIG report uncovered that in May of 2013 the
then Deputy Undersecretary for Health and Operations Management
waived the fiscal year 2013 annual requirement for facility
directors to certify compliance with the VHA scheduling
directive. Allowing facilities to only self-certify reduced
oversight over wait time data integrity and compliance with
appropriate scheduling practices. This in turn allowed VA's
data to be easily manipulated contributing to the wait time
scandal. While the VA has reinstated the certification
requirement, there's nothing stopping them from waiving it
again.
The VA Scheduling Accountability Act would codify into law
that each facility director is required to annually certify
compliance with the scheduling directive or any successor
directive that replaces it, and would prohibit any waivers in
the future.
Should a director be unable to to certify compliance,
either because a facility is not in compliance or the director
refuses to sign the certification for some other reason, the
director must submit a report to the Secretary explaining why
the facility is out of compliance. The Secretary will then
report yearly to the House and Senate VA Committees with the
list of facilities in compliance and those that are not, with
an accompanying explanation as to why they were not in
compliance. To incentivize a facility's compliance there is a
provision that allows the VA Secretary to revoke an award or
bonus for non-compliance.
Lastly, the legislation requires that any time VA waives or
allows non-compliance with requirements in any other directive
or policy beyond scheduling, VA must provide a written
explanation for the decision to the House and Senate Veteran
Affairs Committee. This will provide more oversight of the
department and ensure Congress is aware when VA is waiving
these policies. We need this legislation in order to end the
reckless practice of avoiding compliance.
I look forward to working with the Members of this
Committee, veterans' service organizations in addressing this
critical issue. I thank you again today for this opportunity to
testify. Thank you, Mr. Chairman.
[The prepared statement of Representative Jackie Walorski
appears in the Appendix]
Mr. Chairman. Thank you very much.
Representative Collins you are now recognized for five
minutes.
OPENING STATEMENT OF HONORABLE DOUG COLLINS
Mr. Collins. Thank you, General Wenstrup. Thank you
Ranking Member Brownley and the Members of the
Subcommittee.
It is my opportunity to introduce this legalization H.R.
907, the Newborn Care and Improvement Act. This bill is--we
have come before this Committee before and testified. We are
bringing it back again as we go forward. This bill improves the
care provided by the Department of Veterans' Affairs to the
newborn children of female veterans. And I appreciate your
consideration.
In the second inaugural address President Lincoln derived
his idea for the VA from scripture stating ``The challenge for
us is to care for him who shall have borne the battle and for
his widow and his orphan.'' In the 21st century we must apply
Lincoln's statement more broadly to ``She who hath borne the
battle.'' And the way--one way we can do that is to provide
better maternity and newborn care to our female services
members.
Historically much of the VA health care system was designed
to meet the needs of men. An increasing number of female serve
in our military. It is essentially that the VA to expand its
services for the care of female veterans and their families
effectively. Our female veterans often need maternity care. And
I believe that the Newborn Care Improvement Act is one
important way to support these services while honoring their
contributions to society.
When the Care Givers and Veterans Omnibus Health Savings--
Services Act was signed into law in 2010 it provided short-term
newborn care for female veterans who receive maternity care
through the VA. Under this law newborns became eligible for up
to seven days of care at hospitals covered by the VA. Since
then we have learned significantly more about the health care
challenges facing female veterans and about the levels of
neonatal care that their newborns may require.
According to a 2008/2012 study in one women's health
journal, for example, the overall delivery rate of female
veterans using VA maternity benefits increased by 44 percent.
And a majority of these women had disabilities connected to
their military service. A recent December 2016 GAO report found
that the maternity care was significantly delayed at
approximately 27 percent of VA facilities, according to the
facilities' own reports, and that all veterans, including
women, face consistent challenges in receiving timely access to
care.
We know that we must take action to address access to care
issues at the VA, including maternity and newborn medical
services. Without congressional action to achieve parity
between the number of days new mothers and newborns can receive
care covered by the VA, female veterans may be forced to now
get complex insurance options and financial decisions even as
their child's life is in danger.
I introduce H.R. 907, the Newborn Care Improvement Act to
ensure that newborns have access to the care they need,
particularly if they are born prematurely or face complications
from birth.
As some of you may remember, this was a legislative
initiative that I introduced in the 114th Congress. And last
Congress this legislation extended the covered VA care for
newborns from seven to fourteen days and provided an annual
report on the number of newborns who received such care during
each fiscal year.
This Congress the bill provides an important improvement to
the length of neonatal care that newborns can receive in
extending infant's access to medical care from 14 to 42 days. I
appreciate the Chairman Roe's influence in this and others of
the Committee on this vital addition. This 42-day standard
corrects a disparity in the length of the time the VA covers
care for mothers and for their newborn children by
incorporating an amendment offered by Chairman Roe that was
included when the House passed this legislation last year.
I hope that the Committee will once again place the Newborn
Care Improvement Act on its markup calendar on behalf of
newborns and their mothers. Many of our female veterans have
served us at great risk and great personal cost, and these
heroes deserve the highest standard of care we can offer. Our
responsibility to the women of our armed services do not end
because they complete their time of active duty. Any female
veteran who chooses to receive maternity or neonatal care at
the VA should be confident in the quality of those services.
It is therefore important for us to understand that
research has indicated that some female veterans may have
unique maternity needs as a result of their military service.
One recent study illustrated a link between veterans having
PTSD in the year prior to giving birth and a 35 percent
increase in the risk of spontaneous premature delivery. This
study indicates that PTSD could represent a significant
epidemiological risk factor for pre-term delivery.
And this is only one of the health issues that our female
veterans may face as a result of their sacrifices they have
made as part of the military. Tragically PTSD impacts a
substantial number of our female veterans. More than 20 percent
of the female veterans in recent conflicts of Iraq and
Afghanistan have been diagnosed with PTSD. These diagnoses are
not limited to women serving in combat role.
As a father who has a special needs daughter who just turns
25 on Saturday, I know the effect of having that first few
weeks or even months being found in a neonatal facility. I know
what it is like to have a daughter who went through multiple
surgeries and the impact it takes. It should not be an issue
for our VA, for our females who have served, and the babies
that they bring into this work.
I thank this Committee and I ask for your favorable
consideration in markup in moving this bill forward.
And with that, Mr. Chairman, I yield back.
[The prepared statement of Representative Doug Collins
appears in the Appendix]
Mr. Chairman. Thank you, Mr. Collins.
Representative Coffman, you're now recognized for five
minutes.
OPENING STATEMENT OF HONORABLE MIKE COFFMAN
Mr. Coffman. Thank you, Mr. Chairman.
Thank you for having me at this hearing for H.R. 918,
Veterans Urgent Access to Mental Health Care Act. Mr. Chairman,
I would like to begin by obviously thanking you for today's
legislative hearing. To our witnesses, thank you for your
testimony and for ensuring Congress and the American public a
better understanding of the challenges facing our veterans
today.
As a Marine Corp combat veteran, I would like to live by
the rule that we never leave anyone behind. And the Veteran
Urgent Access to Mental Health Care Act makes sure that we do
not forget those who bravely served our country in their time
of need.
Here is what we know for a fact. An average of 20 veterans
take their lives daily. Likewise, VA evidence suggests a
decrease in suicide risk among those who have received VA
health care services, and since 2009 a decrease in those who
have had mental health services. And since 2009 the Army has
separated approximately 22,000 combat veterans diagnosed with
mental health disabilities or TBI for alleged misconduct,
leaving them without access to VA's critical mental health care
services.
While the correlation between their illness and minor
misconduct could be linked, this made no difference to the
character of the discharge. Historically a veteran with other
than honorable--with an other than honorable discharge, has
been able to seek VA care for a service-connected disability.
However, due to the way these veterans were discharged and the
failure to connect the dots between the other than honorable
discharge and mental health services, this precedent has failed
to recognize this problem. My bill will stay with tradition and
correct this disconnect by authorizing urgent mental health
care to these veterans. And to note, it would not limit VA's
existing authority should the VA choose to provide services
beyond what is covered in my legislation.
My bill also calls for a third-party study to review the
effect of combat service on veteran suicide rates, as well as
the rate and method of suicide among veterans who have received
health care from the VA and those who have not. Before the rate
of veteran suicides increases anymore, we have to make sure
that these servicemembers get the critical mental health care
they need and that the Nation has a better understanding of why
veterans think that taking their own lives is the only way out
to end their pain and suffering. This is something that we need
to get to the bottom of as quickly and as accurately as
possible. My legislation would do that.
Over the years Congress has been looking into
inefficiencies and mission disconnect at the VA. And I believe
this has been a key disconnect at the VA. It is time to right
this wrong and permanently authorize the Secretary to provide
initial mental health assessments and urgent mental health care
services to veterans at a risk of suicide or harming others
regardless of their discharge status. When someone puts on the
uniform, they take an oath to defend our freedoms. We, in turn,
promise to make sure they receive the care and services they
need upon returning from their mission.
Mr. Chairman, thank you for allowing me to testify today on
behalf of my legislation. I look forward to continue working
with the Committee, as well as our Nation's VSOs to make sure
that the men and women in uniform are never left behind. I
yield back.
[The prepared statement of Representative Mike Coffman
appears in the Appendix]
Mr. Wenstrup. Thank you, Mr. Coffman.
Mr. Knight, you're now recognized for five minutes.
OPENING STATEMENT OF HONORABLE STEPHEN KNIGHT
Mr. Knight. Thank you, Chairman Wenstrup and Ranking Member
Brownley. Members of the Committee, thank you for the
opportunity to testify today on my legislation H.R. 1162, the
No Hero Left Untreated Act. We are working to get our military
the most advanced weapons, vehicles and equipment in the world
in order to defeat any enemy. We owe it to those who selflessly
serve to match this commitment to innovation when it comes to
their medical treatment when they need it most. Our fighting
men and women will always face incredible danger and put their
lives on the line in service to our Nation.
PTS and TBI are some of the most prevalent and
misunderstood injuries our troops face upon returning home from
answering the call to duty. A recent study and many studies
have shown that about 20 veterans commit suicide every day.
This is unacceptable and the VA must adopt new ideas to help
prevent and decrease veteran suicide rates.
An emerging technology is achieving compelling results in
restoring veteran's mental health and shows promising potential
to prevent more suicides from needlessly occurring, magnetic
EEG/EKG guidance resonance therapy. This reliable effective
protocol uses a suite of FDA approved medical innovations to
uniquely image the brain, identify areas that may need repair,
and most importantly treat sub-optimal regions of the brain
with the goal of restoring optimal neurological function using
non-invasive neuromodulation. This protocol is an
individualized non-pharmaceutical, non-invasive procedure to
prevent patient specific application of repetitive magnetic
stimulation to help restore proper brain function.
Over the course of several treatments, patients experienced
improved quality of sleep, increased motivation and ability to
manage stress, improved mood and better concentration and
focus. With veteran patients, magnetic EEG/EKG guided resonance
therapy has achieved excellence in success rates in both open-
label trials and randomized placebo-controlled double-blind
studies. In fact, to date 98 percent of veterans in recent
trials have experienced at least a 10-point change in their PTS
checklist military PCLM score and averaged a 61 percent
reduction in symptom severity after four weeks of treatment
based on PCLM.
Veterans who depend on the VA can benefit from this
treatment, which why I introduced H.R. 1162, the No Hero Left
Untreated Act. This bill would establish a pilot program for
two VA medical centers to treat 50 veterans using magnetic EEG/
EKG guided resonance therapy. It's interesting to note when I
bring up the 98 percent and the 61 percent that they have done
this on 500 veterans already. So they have seen the therapy
work to this date.
The VA is currently behind and unequipped to deal with this
growing problem and must take advantage of innovative
treatments that can help veterans who struggle with mental
health issues. I urge my colleagues to support this vitally
important piece of legislation and get our veterans the best
treatment possible. Innovation is the key to effectively treat
these conditions. And Congress does--can bring this new therapy
services like magnetic EEG/EKG guided resonance therapy into
the 21st century.
I know that the American Legion has come out with a letter
that they said they have not supported this bill yet. I am an
American--or a member of the American Legion and we will be
working with them closely. And I thank you for this opportunity
to testify and I look forward to working with you and providing
innovative solutions to treat our brave men and women in
uniform.
[The prepared statement of Representative Stephen Knight
appears in the Appendix]
Mr. Wenstrup. Thank you, Mr. Knight, I appreciate that and
I appreciate the statistics, and might ask that you submit any
study results for the record within five days.
Mr. Knight. Yes, sir.
Mr. Wenstrup. Thank you.
Representative Kuster, you are now recognized for five
minutes.
OPENING STATEMENT OF HONORABLE ANN M. KUSTER
Ms. Kuster. Thank you, Mr. Chairman and distinguished
colleagues of the Subcommittee on Health. And thank you for
inviting me to speak on behalf of my proposed bill, H.R. 1545,
the VA Prescription Data Accountability Act. My bill would
resolve a peculiar problem with the VA's initiative to connect
VA medical facilities to state prescription drug monitoring
programs.
As you know, in 2012 the VA was authorized by Congress to
provide state PDMPs, the prescription data of VA beneficiaries.
As a Member of the House Veterans' Affairs Committee and as the
Co-Founder and Co-Chair of the bipartisan heroin task force, I
recognize that PDMPs are an important tool to prevent the
spread of prescription opioids in our communities.
The VA has provided prescription opioids at a rate nearly
twice that of the general population. Many veterans utilize
both the VA and private providers to meet their health care
needs. Additionally, many drugs, excuse me, including opioids
can be dangerously and lethally combined with other drugs.
Often these lethal combinations are accidental and could have
been resolved with better available information. These are the
reasons why it is critical to ensure that the VA is fully
connected to our state PDMPs.
Thankfully the VA has taken action to connect all its
medical facilities to available PDMPs, and all indications are
that the VA is on schedule to connect all VA medical facilities
with PDMPs. However, the VA has reported that they cannot
provide non-veteran data to state PDMPs. This problem is
twofold: VA's authority is currently confined to veterans and
their dependents, and VA's IT systems cannot distinguish
between dependents and non-dependent users of the VA.
Consequently, hundreds of thousands of non-veterans do not have
their data reported. That would include the largest population
of non-veterans, beneficiaries of CHAMP VA, as well as some
active servicemembers.
My bill would expand VA's authority to include all VA
beneficiaries that are prescribed a drug at the VA. This will
close the gap without requiring the VA to update its electronic
health records, a process that is neither quick nor
inexpensive. Consequently, the VA and the CBO have preliminary
reported that my bill would have little to no cost. And thank
you for this opportunity to speak on behalf of the legislation.
[The prepared statement of Representative Ann M. Kuster
appears in the Appendix]
Mr. Wenstrup. Thank you, Ms. Kuster. At this time I have
reviewed these bills have no questions at this time. And I
yield to Ranking Member Brownley.
Ms. Brownley. I have no questions either.
Mr. Wenstrup. All right. Are there any other Committee
Members that have questions at this time? If there are none,
then the first panel is now excused.
And I now welcome our second panel to the witness table.
Joining us is Dr. Jennifer Lee, VA's Deputy Under Secretary for
Health for Policy and Services, who is accompanied by Susan
Blauert, the Chief Counsel for the Healthcare Law Group; Kayda
Keleher, Legislative Associate for the Veterans of Foreign Wars
of the United States; Shurhonda Love, the Assistant National
Legislative Director for the Disabled American Veterans; and
Sarah Dean, the Associate Legislative Director for the
Paralyzed Veterans of America.
And I apologize if I butchered any of those names, but I
thank you all for being here today and for your advocacy on
behalf of our veterans today and every day. And I look forward
to hearing the views of your Members.
We will begin with Dr. Lee. You are now recognized for five
minutes.
STATEMENT OF JENNIFER LEE, M.D.
Dr. Lee. Good morning, Chairman Wenstrup, Ranking Member
Brownley, and Members of the Subcommittee. Thank you for
inviting us here today to present our views on a number of
bills that affect VA's programs and services. Joining me today
is Susan Blauert, Chief Counsel for the Healthcare Law Group
and our Office of General Counsel.
First I want to thank the Members of this Committee and our
colleagues from the VSOs for their tremendous support on behalf
of our Nation's veterans, especially on a special day like
today, which is National Vietnam War Veterans Day. I know that
we all share the same goal, to ensure VA provides the best
possible care and services that they have so nobly earned.
I would like to focus on several bills on today's agenda
that VA supports because they provide us with authorities and
flexibilities to better meet the needs of veterans and their
families. We would like to note that there are some bills that
we do not support because we lack the necessary resources
needed to implement them as drafted, have determined that they
could lead to potential duplication with existing programs, or
have concerns about technical aspects of the bills even as we
support their intent.
First, VA strongly supports H.R. 1662, Dr. Wenstrup's bill
to prohibit smoking in any VHA facility. VA has proposed
legislation for many years to reverse the requirement for
smoking areas at VHA facilities and appreciates the Chairman
and the Committee's interest in working to accomplish this. We
believe veterans and employees should be protected from
secondhand smoke exposure at VA health care facilities, as they
would be in thousands of other hospitals currently smoke free
across the country. While the rate of smoking among veterans is
at an all-time low, less than 20 percent of enrolled veterans
are smokers, VA supports implementation of this bill in a
veteran-centric and compassionate way.
VA appreciates the intent of H.R. 91, which directs VA to
provide readjustment counseling services in a retreat setting
to women veterans who are separated from military service.
Studies show these retreats to be quite successful with
participants having improvement in overall psychological well-
being and a decrease in PTSD symptoms. We believe the bill
could be improved by expanding access to these services to even
more veterans and would be happy to provide assistance to that
end.
VA also supports H.R. 1545, which directs the Secretary to
disclose information about not just veterans, but all covered
individuals to state controlled substance monitoring programs.
This bill would help ensure VA has authority to be able to
fulfill its public health role in sharing vital clinical
information and guiding treatment decisions.
Regarding the draft bill, the VA Medical Scribe Pilot Act
of 2017, VA does not support the bill as written because we are
currently expanding the use of medical scribes in over a dozen
VA facilities and would like the opportunity to evaluate this
project for its impact on productivity and patient
satisfaction. VA is utilizing a dual role, the health advocate,
to service both a health coach and a medical scribe in the
primary care setting. And we have obtained early positive
results from implementation of this model.
VA supports H.R. 907, expanding access to newborn care in
part. VA is particular supportive of the extension of newborn
coverage from today's eight through fourteen, as a newborn
needing care for a medical condition may require treatment
extending beyond the current seven days authorized by law.
However, we cannot responsibly support the full extension of
newborn services through day 42 without additional
appropriations for this specific care. The resources necessary
to implement this bill must be carefully considered alongside
considerations for resources needed to fund other core direct
to veteran services.
H.R. 467 would require each VA medical facility to comply
with requirements related to scheduling veterans for health
care appointments and to ensure the uniform application of VA
directives. VA supports the intent of this bill in terms of
ensuring veterans are appropriately scheduled for the care that
they need and that scheduling processes are reliable and
timely. However, VA needs the flexibility to set scheduling
standards that can change and improve over time in step with
other changes in the way that transacts as health care.
With regard to H.R. 918, VA definitely supports the
principles in this bill and appreciates the leadership of
Congressman Coffman and other Members of this Committee in this
proposal. Secretary Shulkin, in fact, announced several weeks
ago his own intent to expand access administratively to mental
health services for former servicemembers with other than
honorable discharges. Before finalizing the plan in the summer,
VA will continue to seek input from Congress, VSOs, and DoD
officials to determine the best way to connect these former
servicemembers with the care they need.
My written statement provides the Department's views on the
remaining bills. Thank you, Mr. Chairman and Ranking Member for
the opportunity to testify before you today. My colleague and I
would be pleased to respond to questions you or other Members
may have. Thank you.
[The prepared statement of Jennifer Lee, M.D. appears in
the Appendix]
Mr. Wenstrup. Thank you, Dr. Lee.
Ms. Keleher, you are now recognized for five minutes.
STATEMENT OF KAYDA KELEHER
Ms. Keleher. Chairman Wenstrup, Ranking Member Brownley,
and Members of the Subcommittee, on behalf of the men and women
of the VFW and our auxiliary I would like to thank you for the
opportunity to present our legislation pending before the
Subcommittee. The VFW supports and thanks the Subcommittee for
their consideration of Building Supportive Networks for Women
Veterans Act and the Newborn Improvement Act. These two pieces
of legislation have long been a priority of the VFW in our
efforts to improve care and services to women and homeless
veterans.
Since the implementation of the original retreat counseling
programs, women veterans have reported it as invaluable in
their seamless transitions into civilian life. By making this
important program permanent, it will have a positive impact on
the fastest growing sub-population of veterans. Yet for those
who are not so fortunate to have a successful transition from
the military, the Veterans Access to Childcare Act can also
prove invaluable.
In 2016 the VFW conducted a survey of nearly 2,000 female
veterans. In our study, 38 percent of homeless female veterans
reported having children. These women face unique challenges
with accessing not only medical care, but services to assist
them in finding meaningful employment. Currently, VA has three
successful pilot programs which offer childcare services to
veterans attending health care appointments. The VFW believes
expanding this legislation to include homeless veterans in need
of employment services would assist some efforts to reduce
veteran homelessness.
The VFW supports the intent of the Veteran Urgent Access to
Mental Healthcare Act, but believes it must be expanded before
it is passed. VA does not and should not provide sporadic care
to veterans, but rather it provides a full continuum of high
quality care which regularly outperforms the private sector.
For this reason, the Veteran Urgent Access to Mental Healthcare
Act must be expanded to provide more than just urgent mental
health care to veterans with bad paper discharges.
At this time it is no longer a secret that DoD failed to
comply with its own regulations intended to protect injured and
ill servicemembers before issuing bad paper discharges to many
who experienced trauma as a result of their service. These
veterans deserve the care they earned, prior to the wrongful
discharges, as a direct result from the traumas of service,
war, or sexual assault.
Veterans with other than honorable discharges are currently
three times more likely to die by suicide. Suicide prevention
cannot be addressed in a fragmented nature; it must be done
holistically.
The VFW opposes the No Hero Left Untreated Act. VA is a
primary contributor of mental health research and has been
leading the way in finding effective treatments to address
PTSD, TBI, and other disorders associated with trauma.
Implementing the No Hero Left Untreated Act would, in fact,
leave heroes untreated.
MeRT would be an unfounded mandate for VA to conduct
unproven research, which is not FDA approved. MeRT derives from
transcranial magnetic stimulation, or TMS, which is empirically
proven to be effective for mental health issues from trauma and
is also FDA approved, though MeRT is not TMS.
VA has been conducting repetitive TMS research at more than
25 sites and has received positive outcomes, as well as
feedback from the veterans undergoing this treatment.
By passing mandates such as this, Congress would be forcing
VA to ration an estimated $2 million in appropriation, which is
already going toward effective proven research.
The VFW believes VA should be leaders in innovative
research and therapies, but they must have empirical data
showing they are effective, as well as paid for.
The VFW cannot support the VA's Scheduling Accountability
Act. The VFW agrees with the intent of this legislation, but
Congress and VA must address the underlying issues with
scheduling, instead of requiring compliance with archaic and
flawed metrics that are susceptible to data manipulation.
One solution to this could be to provide VA the authority
to hire and retain medical support assistance. The VFW also has
serious concerns about withholding bonuses from VA Medical
Center directors who fail to comply with scheduling standards
as the Choice Act prohibits this from determination of
performance awards. This was done due to the VA, OIG, and
congressional oversight findings that VA employees were
manipulating data to receive awards and bonuses.
VA must move away from arbitrary standards of wait-time
measurement and adopt industry best practices before enacting
compliance requirements that very well could lead to another
culture of cover-ups.
Mr. Chairman, Ranking Member, this concludes my testimony.
I am happy to answer any questions you or the other Members of
the Subcommittee may have.
[The prepared statement of Kavda Keleher appears in the
Appendix]
Mr. Wenstrup. Thank you very much.
Ms. Love, you are now recognized for five minutes.
STATEMENT OF SHURHONDA Y. LOVE
Ms. Love. Chairman Wenstrup, Ranking Member Brownley, and
Members of the Subcommittee, thank you for inviting DAV to
testify at this legislative hearing. We appreciate the
opportunity to share our comments on several bills before the
Subcommittee.
H.R. 91 would make permanent, the pilot program on
counseling in a retreat setting for women veterans, following a
wartime deployment. During a wartime deployment, many women
cope with being away from their families and their normal
everyday lives by replacing their feelings and thoughts of home
with survival in their immediate roles and duties during the
deployment.
This coping mechanism, coupled with constant serious risk
factors during deployment can result in difficulty
reintegrating into their familial and everyday roles; a process
that is further complicated when those roles include parenting
and marriage.
Women attending the retreat are able to connect with each
other and rebuild many of the life skills that were lost during
or damaged during the deployment in an atmosphere that is
created for them. Counseling in the setting allows women
veterans to freely relate to each other, while rebuilding
supporting networks which were useful in completion of the
retreat and when they return home. Women report access to the
new networks as critical in their recovery months after the
retreat. It is for these reasons DAV supports this bill and
urges its enactment.
H.R. 95 would provide child care assistance to an eligible
veteran during any period that the veteran is receiving a
mental health or intensive health care services at a VA
facility. All veterans deserve to have access to specialized
mental health care offered by the VA. The need for child care
should not be a barrier for receiving that treatment.
A high percentage of women veterans who serve in Iraq and
Afghanistan are within child-bearing years and many are the
sole-care providers for young children. We also note that these
women have been diagnosed with service-related mental health
conditions.
For many women, the need for child care is not just a
convenience, but a necessity for them to take advantage of the
specialized services that VA offers for their recovery. For
these reasons, we are pleased to support this measure.
H.R. 907 would provide up to 42 days of health care to
newborn children of women veterans who are enrolled in VA
health care and receiving maternity care authorized by VA. DAV
has no specific resolution on this particular measure; however,
we feel it important to note that women use mental health
services at higher rates than their male peers.
Having service-related psychological disorders, like post-
traumatic stress, places women at a higher risk for a pre-term
delivery or other birth-related complications. Data from the
Chief Business Office estimates that 11 percent, roughly 2,200
births occurring each year are complicated births, requiring
neonatal care beyond seven days. It is for these reasons DAV
would not oppose this legislation.
H.R. 918 would allow VA to furnish initial mental health
assessment and urgent mental health care treatment to a veteran
of the Armed Forces, with an other-than-honorable discharge. As
we know, many veterans with these types of discharges may have
suffered a head or combat trauma, sexual trauma, or an other
event that went undiagnosed, leading to behavioral issues and a
less-than-honorable discharge. DAV is pleased to support H.R.
918 in accordance with DAV Resolution 226, calling for a more
liberal review of the discharges for the purposes of access to
VA care and mental health services.
H.R. 1005 authorizes the secretary to enter into agreements
with state veteran homes to provide adult day health care to
veterans whom are not in nursing homes, but require a skilled
level of care, due to a service-connected disability. Veterans
want to be independent for as long as they can be without being
burdensome to their families. In addition, they still want to
remain an active part of the family unit.
Adult day health care helps to accomplish this goal by
allowing the caregiver, respite to take care of their personal
needs while the veteran has an opportunity to interact with
their peers and obtain the services that they need. For these
reasons, we are pleased to support H.R. 1005.
Mr. Chairman, DAV appreciates the opportunity to provide
testimony. I would be pleased to address any questions you or
the Subcommittee may have on these bills.
[The prepared statement of Shurhonda Y. Love appears in the
Appendix]
Mr. Wenstrup. Thank you, Ms. Love.
Ms. Dean, you are now recognized for five minutes.
STATEMENT OF SARAH S. DEAN
Ms. Dean. Chairman Wenstrup, Ranking Member Brownley, and
Members of the Subcommittee, on behalf of Paralyzed Veterans of
America, I would like to thank you for the opportunity to
present our views on the legislation before you today.
PVA supports H.R. 95, the Veterans' Access to Child Care
Act; this legislation would make permanent, the provision of
child care services for a veteran receiving covered health
services at VA. PVA believes child care is critical to
expanding access to care for veterans. There is no denying that
when a primary care provider had reliable child care, their
participation in their own health and well-being increases.
Women veterans, in particular, have reported time and,
again, that one of the greatest barriers to VA is the inability
to obtain child care. A permanent program will help to prevent
no-shows, cancellations, or a veteran having to choose between
the needs of their family and their health.
While providing child care is the right thing to do, it is
also the economic one. If veterans have timely access to care,
we decrease the compounding costs that come with treating an
injury or mental illness later down the line.
A trustworthy child care option alleviates stress for the
veteran and encourages they maintain their contact and
treatment plan with their VA provider.
The extended pilot program is set to expire on December
31st of this year. PVA encourages Congress to make this program
permanent in order to care for veterans who would otherwise not
be able to access VA.
PVA supports H.R. 907, the Newborn Care Improvement Act, to
amend Title 38 to authorize hospital stays of up to 42 days for
newborns under VA care. The current provision allows for the
maximum coverage of seven days, and as the average hospital
stay for a healthy newborn is two days, any newborn needing
additional coverage is likely to be facing serious
complications. Women veterans with VA maternity care must bear
the total cost after the seven days.
We know, well, that the welfare of the infant impacts the
recovery and well-being of the veteran and their families, and
the stress of an impending medical bill for the care of an ill
newborn is an unnecessary burden.
PVA is particularly concerned about those veterans with
catastrophic injuries or mental illnesses that can cause high-
risk pregnancies or pre-term deliveries. A seven-day limit
arguably impacts veterans with disabilities at a greater rate
than other veterans. Extending newborn coverage is the right
thing to do.
PVA supports H.R. 1545, the Prescription Data
Accountability Act of 2017. VA now shares prescription
information of veterans and their dependents with the state's
Prescription Database Monitoring Program or PDMP, however, due
to a technical oversight in the law, the information of non-
dependent, non-veteran VA beneficiaries is not shared and H.R.
1545 would require the prescription data of everyone by VA--
covered by VHA, be submitted to the appropriate PDMP.
And while PVA strongly supports the H.R. 1545, we are
concerned that PDMPs may not be capturing another group:
veterans who travel to different states to receive their
specialized care. It is our understanding that VA medical
centers only share prescription day with the state PDMP in
which the medical center is located. Some states have
established regional memoranda of understanding, sharing--
communicating information with neighboring states.
But there are veterans, particularly veterans with spinal
cord injury or disease, who regularly travel across multiple
state lines to receive care from one of the 24 SCI centers
across the country. There is yet to be any assurance that the
prescription data of an SCI veteran who receives care in
Minnesota but lives in Wyoming will be shared. We urge the
Subcommittee to make sure these specialized patient populations
are benefitting from the opioid safety initiatives in the same
way as non-traveling veterans.
Mr. Chairman, PVA thanks the Subcommittee for the
opportunity to submit our views and I am happy to take any
questions you may have.
[The prepared statement of Sarah S. Dean appears in the
Appendix]
Mr. Wenstrup. I want to thank you all for your testimonies
here this morning. At this time, will yield myself five minutes
for questions and I want to start with you, Dr. Lee, if you
don't mind, if you could help me understand the difference
between the Health Advocate Pilot Program and the Medical
Scribe Pilot Program that would be created by Chairman Roe's
bill.
What we are looking at, right, is to increase productivity
of the provider, really, in this situation. And so as a follow-
up question to that, when you are doing any of this and you are
studying the results, are you looking at the physical
environment that the provider is operating in so that we are
comparing apples-to-apples; in other words, if you have one
provider who has three treatment rooms to work with and you are
comparing to a provider with one treatment room, it is really
not a fair comparison as far as productivity, because it is
hard to produce if you only have one treatment room, which
those are the types of things that we see in some of the
clinics.
So, if you could help me with that, I would appreciate it.
Dr. Lee. So, our Health Advocate Pilot Program is now
rolling out in 14 different VA facilities, but really came from
the field, this idea. The site that is probably the most
advanced is White River Junction and we have some data from
implementation of this program there.
So, rather than the health--just having a medical scribe,
the health advocate has a dual role. So, they scribe, helping
the provider physician to document the clinical encounter, but
they also are trained as a health coach, so, as they spend time
with that patient during that visit, they help educate the
patient, help the patient to clarify healthy behaviors and
things they can do at home and really advocate for that
patient.
We have heard good results, feedback from the program so
far in terms of productivity, in particular. So, at this site,
some providers are saying that they typically could only see 12
patients a day, but now with the help of the health advocate,
they are able to see anywhere from 16 to 20 patients per day.
And we have also heard good feedback from patients who like
having that advocate there, so they don't have to retell their
clinical history over and over and they can also help interpret
what the providers are telling to the patients.
Mr. Wenstrup. So, if I can, with that component of it, what
is the licensure, what is the background of the health coach
that allows them to operate in that capacity?
Dr. Lee. Right. Most of our health advocates are either
licensed practical nurses or licensed vocational nurses and
they are directly employed by the VA. And we looked at both,
the model of employing the scribe advocates or contracting with
them and our sites chose, in most cases, to directly hire them
because they might--they had difficulty finding contractors or,
again, having a licensed individual, allowed them to use that
role for more than just scribing.
Mr. Wenstrup. What would you anticipate, if you took this
VA-wide, what would you anticipate the ability to recruit and
retain people in that role, as opposed to just a scribe,
because obviously you are talking about a higher level of
education to have the authority to act in that role. So, what
do you think the field is like for hiring for that?
Dr. Lee. I think it would vary from location to location,
but we are hopeful. What we would really like to do is finish
out this project and get some good data on the broader impact
at all of these 14 different sites, since we have just the data
from the one site so far. So, I think we will have a better
idea as we get more data from our program.
Mr. Wenstrup. Yeah, fair enough. I guess what I am saying
is I think we need to keep in mind that there might not be a
pool out there to fill that role across the country if it is a
good program, so we might want to consider scribes as, although
they may not be able to operate at as high a level, but still
could increase productivity. So, what is ideal may not be real
as far as being able to provide that across the country, but I
appreciate the input on that.
And I do have another question, Dr. Lee: Does VA partner
with nonprofit groups to provide the retreats for the pilot
program?
Dr. Lee. So, for the--in the case of this particular pilot
program, we have actually contracted with entities to provide
the retreat services, but we would definitely be open to
looking at ways to partner with nonprofits as well.
Mr. Wenstrup. Currently, what type of monitoring or
oversight is there on the retreats to gain information from the
effectiveness?
Dr. Lee. So, we have a full report that we would be happy
to share, evaluating the effectiveness and outcomes from our--
the retreats in the pilot program, overall, really great
results; a good satisfaction from the women veterans who
participated, and as I mentioned, positive results, in terms of
clinical symptoms and coping mechanisms that have actually
sustained over time.
Mr. Wenstrup. Well, thank you.
And I yield back, and Ms. Brownley, you are now recognized
for five minutes.
Ms. Brownley. Thank you, Mr. Chairman.
I just want to comment that it is very nice to see all
women testifying here today; that is an unusual occurrence in
this hearing room. So, thank you very much to all of you for
being here.
I wanted to also follow up on the Supportive Networks for
Women Veterans Act. Dr. Lee, you had advocated in your
testimony to allow for more veterans in this kind of setting,
so, to clarify, are you advocating for inclusion of other
veteran cohorts in the women's retreat or are you advocating
for separate retreats for different cohorts that might find it
beneficial?
Dr. Lee. I think the results were so positive from the
pilot program that we just saw it as a great opportunity to
extend those positive results to other veterans. And I think
the flexibility to be able to design the program in a way that
makes sense for veterans is what would be great here. So,
clearly--
Ms. Brownley. So, you may have young men, let's say, as a
cohort, right?
Dr. Lee [continued]. Exactly. Other veterans, and in
particular, those who go to the vet centers, who are combat
veterans, or may have been victims of sexual trauma or even
families, potentially.
Ms. Brownley. Thank you. And in terms of the Child Care
Act, I noticed that you did not testify today regarding your
position on it, but you stated in your written testimony that
the inability to find child care was not shown to be a
significant factor, whether veterans choose to utilize VA care.
And so, what data do you have to support that statement?
Dr. Lee. So, this--the data comes from a study we did in
2015 titled, ``The Study of Barriers to Care for Women
Veterans.'' And from a statistical analysis of the study
results, the study showed that the lack of child care was not a
significant factor in whether the women veterans chose to
utilize VA care; however, more than three out of five women did
indicate that on-site child care would be helpful. So, those
are the results from our survey.
Ms. Brownley. So, I'm sorry, the three out of five said
yes, but the first part of your statement was what?
Dr. Lee. So, from a statistical analysis--
Ms. Brownley. Uh-huh.
Dr. Lee [continued]. --the surveyed respondents said having
ability of child care would not be a significant factor in
deciding whether they chose to go to VA--
Ms. Brownley. Uh-huh.
Dr. Lee [continued]. --chose to use VA services or not;
however, a majority of them said they would find it helpful.
Ms. Brownley. And so, did you ask those veterans if they
were having treatment that was going to be two months, three
months long and had to go to the VA frequently for this,
whether it is mental health therapy or cancer treatments, or
whatever; if that wouldn't be beneficial in making sure that
they got the treatment that they needed?
Dr. Lee. I don't think the question specifically asked
about the frequency of the visits, but we did survey a wide
range, over 8500 women veterans, to get these general results.
Ms. Brownley. So, if the VSS could weigh in, I know that
many of you have also done your own surveys in terms of the
need for child care, if you could make a comment. I know you
did already in your statements, but I think if you have some
data-driven analysis to indicate the need, that would be, I
think, helpful for countering this argument.
Ms. Keleher. So, last year, as I said earlier, VFW did a
survey of women veterans. In our survey, we had 72 women
identify as being homeless or on the verge of homelessness and
I believe it was 58 of them requested assistance from us. Of
those 72 women, 38 percent of them responded as having
children--and I cannot remember the number off the top of my
head; I'd be happy to get that to you--but the majority of them
did specify that access to, particularly, employment services
was difficult for them, due to them having children.
I think it would be common sense that if somebody is
homeless and living on the street with their children, they are
not going to be able to afford access to child care. We had one
particular--one of our members who actually said they attempted
taking their child to access the employment training and was
told they had to leave because the child was, I believe the
terminology was something along the lines of ``it was dangerous
to have the child there.''
Ms. Brownley. Thank you.
Ms. Love?
Ms. Love. Congresswoman Brownley, this morning during the
process of preparing for the testimony, I Googled the cost of
child care and I found that it was about $11,666 a year,
breaking down to $972 a month. So, when you take that into
perspective of the cost that it takes to take care of children,
this is surely a factor when you have veterans that will need
long-term care.
These veterans are having a hard time and it could lead to
them choosing not to receive the care that they need if--as
they experience these high costs.
Ms. Brownley. Thank you.
And Ms. Dean?
Ms. Dean. Following up on what they have already shared, I
think the other consideration is the children of
catastrophically disabled veterans who have to have their
caregiver go along with them to appointments, for whom staying
behind with the child is not perhaps an option. This then
allows the caregiver to be with the veteran in the appointment,
which isn't included, I don't think, in the survey for--the
women veterans survey--but certainly is a significant factor
for our population.
Ms. Brownley. And I appreciate, also, your economic
argument in your testimony by virtue of saying that by
providing the service, it could be an economic plus or saver,
if you will, in terms of just resources, if people are not
getting the appropriate care that they need and preventing
other issues that may arise. So, thank you very much for that,
and I will yield back.
Mr. Wenstrup. At this time, if I may indulge the Committee
and the panel for five minutes to allow Chairman Roe, who just
joined us, to discuss his bill.
Dr. Roe, you are recognized for five minutes.
OPENING STATEMENT OF HONORABLE DAVID P. ROE
Mr. Roe. Thank you, Mr. Chairman and Ranking Member
Brownley.
It is a pleasure to join the Subcommittee on Health today
to talk about my draft legislation to require VA to implement a
pilot program for medical scribes within the VA medical
centers.
As a physician in practice, years ago, I took on the
arduous task of converting from paper medical records to a
million-dollar-plus electronic health records system. For me,
it took time, lots of time to get used to using a new
electronic system. And as we all know, electronic health
records are extremely helpful tools in organizing and analyzing
a patient's medical data, but you would be hard-pressed to find
a doctor's office or hospital today that doesn't use some form
of EHR; it is about 80 percent now, I believe.
And after my practice converted to an EHR, I finally
familiarized myself with it and it became a normal part of my
practice. I say this as a joke, but it was an electronic health
record that made me congressman; however, I also learned that
in order to fully utilize a new EHR, I had to divert my
attention away from patients and toward the computer screen.
That never did set well with me and it is--but it is what I had
to do and what every practice was doing to accommodate the new
her technology.
Today, medical scribes are often used to assist clinicians
by navigating and entering data into the patient's her,
allowing the clinician to focus on the patient and not
paperwork. Medical scribes can improve efficiency in areas with
a high demand of appointments, but a low supply of providers
and can be especially helpful in a high-paced area of practice
like an emergency department where every moment that is focused
away from the patient could potentially lead to a tragic
outcome.
Medical scribes are often recruited as undergraduates or
recent graduates, having an interest in entering into a medical
career. For them, scribing provides an opportunity to glimpse
firsthand at what life in medicine is really like and gain
valuable experience for future careers. I wholeheartedly
believe that veteran patients and VA providers, alike, could
benefit from embracing medical scribes within the VA medical
facilities.
My draft bill would require the secretary to implement a
two-year pilot practice to establish positions for 40 scribes
across ten VA medical centers within areas of emergency
medicine and specialty care. This pilot seeks to improve both,
efficiency and more importantly, the patient-doctor experience,
by allowing physicians to focus on their personal interactions
with patients.
Under this draft legislation, VA would submit a report on
the efficiency of the pilot every 180 days following its
commencement and the GAO would submit an independent report
within 90 days of the conclusion of the pilot to include a
comparison of the pilot program with similar private-sector
programs. The next in my legislation would prohibit any
additional appropriations, with which to carry out this pilot.
And I am disappointed that the VA's testimony is not
supportive of my draft legislation. I would note that VA's
current Health Advocate Pilot Program is largely incongruent
with the intent and scope of my draft legislation. Not only is
VA's current program lended to primary care, while my draft is
exclusively to emergency and specialty care, but it also
requires the scribe take on the clinical role of health coach
which brings a litany of licensure issues into the equation.
Nonetheless, I look forward to working with the Department
and the Members of this Subcommittee to address any outstanding
concerns and move this legislation to regular order very
quickly.
With that, I appreciate very much you allowing me to be
here, and I know Dr. Wenstrup and other physicians, one of the
things that being a data-entry person took a lot of the joy out
of the practice and took your attention away from the patient.
Me, personally, I never took the computer in the room with me;
I walked in with a piece of paper, put the information down,
looked at the patient and took care of them. And one of the
problems were--and then went out later and entered the data, so
it didn't interfere with that relationship.
One of the things that we are having is a shortage of
providers and if you can make the provider more efficient by
having a person enter that data, when they could spend their
time with the patient, I think that does improve the care. And,
certainly, I don't want the scribe to be a health coordinator;
I want them to enter the data so that the health care people
that are there are able to focus on that purpose, which is to
provide health care for patients.
With that, I yield back.
[The prepared statement of Representative Daivd P. Roe
appears in the Appendix]
Mr. Wenstrup. Thank you, Dr. Roe.
Yes, I will concur that that transition to becoming a data-
entry person, away from being a physician the whole time was
very challenging, decreased our productivity, and made your
days a little bit longer. So, there is definitely some benefit
to having assistance in that regard, and I thank you for your
testimony.
At this time, we will resume our questions to the panel, if
we may, and Ms. Radewagen, you are now recognized for five
minutes.
Ms. Radewagen. Thank you, Mr. Chairman.
I want to welcome the panel. Thank you for being here
today. And I want to thank Chairman Wenstrup and Ranking Member
Brownley for holding this hearing today.
And good morning, Chairman Roe.
There are some very good bills on our agenda today and I am
happy to be a Member of a Subcommittee that is committed to
addressing veteran accessibility to care, especially in the
area of mental health and PTSD treatment.
Regarding that topic, I also want to thank Congressman
Coffman and Congressman Knight for introducing H.R. 918 and
1162, respectively, and I am proud to be a co-sponsor of both
bills.
Dr. Lee, would you please provide for the record, a list of
the recent or ongoing research regarding the effective combat
surveys on suicide and serious mental illness that your
testimony notes the study required by 918 would be largely
duplicative of.
Dr. Lee. Sure. Congresswoman, there is one study--there are
several studies ongoing now, but there is one study in
particular that involved OEF and OAF veterans who had been
deployed and their risk for suicide and that study actually did
not find a direct relationship between the deployment to combat
situations and the suicide risk, but we do have some studies
ongoing right now.
Ms. Radewagen. Dr. Lee, a statement for the record from The
American Legion alleges that VA has recently implemented a
pilot program in 23 medical centers to provide electromagnetic
therapy via a repetitive transcranial magnetic stimulation. Is
that true, and if so, how is that ongoing pilot different from
the pilot that H.R. 1162 would create?
Dr. Lee. Yes. So, VA is supportive of a repetitive
transcranial magnetic stimulation, or RTMS, which as you said,
Congresswoman, is now being used in approximately 25 VAs. We
are hoping to see that expand to other VA facilities, because
there has been evidence to show it helps with conditions like
PTSD.
This bill speaks specifically to a proprietary treatment
that is different from RTMS or a variation on it, that doesn't
have specific evidence that shows a benefit for the conditions
listed in the bill. So, we would--and for that reason, we are
not supportive of this and, instead, would like to advance
expansion of access to RTMS in our facilities.
Ms. Radewagen. Thank you, Mr. Chairman. I yield back.
Mr. Wenstrup. Mr. Takano, you are now recognized for five
minutes.
Mr. Takano. Thank you, Mr. Chairman.
I still want to congratulate my colleague, Ranking Member
Brownley for her legislation on access to care--on child care,
in light of the roundtable we had yesterday.
I want to ask Ms. Keleher to expand on the barriers to the
training issues, because I think you cited in the roundtable,
an example, of how that not only impedes--lack of child care
impedes access to health care, but also maybe employment
training.
Ms. Keleher. Yes. Thank you, Congressman.
So, as I said before, when you have a homeless woman who
has primary custody of her children and they are sleeping on
the streets, homeless under a bridge, as my colleague Shurhonda
said, the average cost of child care in the United States is
just over $11,000, I believe. I know, particularly, here in
D.C., it is over $20,000 at this point.
So, if you have a homeless female veteran sleeping on the
streets with her children and she needs to access VA for
employment training, whether it be VRE or one of the other
programs, and they can't afford the child care, much less to
seek housing, then that is a barrier for them in trying to find
the meaningful employment that is required for them to put a
roof over their children's heads and make sure that they are
able to go to school and get an education, so on, and so forth.
Mr. Takano. Well, thank you. I appreciate that. Thank you
for that.
In the statements for the record, the Vietnam Veterans of
America and Swords to Plowshares expressed concerns over the
scope of the bill that relates to other-than-honorable
discharges. And I want to know if Ms. Keleher, Ms. Love, and
Ms. Dean, whether your organizations support the scope of this
legislation, if you can be brief, yeah.
Ms. Keleher. The VFW supports the intent of the
legislation, but we strongly believe it needs to be expanded.
No matter what form of health care you are looking at, you
can't look at it from a small level; it has to be done
holistically.
Mr. Takano. Okay. Ms. Love?
Ms. Love. DAV supports the legislation. We want to make
sure that the veterans have ever opportunity to access VA
health care. As this bill would do, is allow them the
opportunity to now receive the care, I think it is important
for DoD to get it right the first time, but this bill would
help for those veterans that are not receiving the care, to get
the care that they need.
Mr. Takano. Okay. Ms. Dean?
Ms. Dean. Thank you. We do find the scope appropriate, if
only, because we are concerned about the potential pressure
that it would put on the existing system, having a wave of new
patients in the system and making sure that VA is staffed and
able to care for those coming in.
Mr. Takano. What do you think about expanding access to
these veterans for care that is more than mental health care
and can we really separate the impact of physical health on
mental health?
Ms. Keleher. Congressman, physical health most definitely
has an impact on mental health and vice versa and the way Title
38 is currently stated--I don't have it off the top of my
head--but they do define the way they look at dishonorable
differently than DoD does. So, the VFW believes that VA should
already be providing this care to those who have paper
discharges.
One example of that we talk about in our office would be
Desmond Doss, who is a Medal of Honor recipient. He was a
conscientious objector--sorry, I slaughtered that word--and
under current definition, VA could deny them access to VA
because of his conscientious objection, even though he has a
Medal of Honor recipient.
Ms. Love. The objective of the bill is to take care of
those veterans that suffer from these conditions that are
stemming from experiences that they had in the military. And
the mission of the VA would be to take care of the whole
veteran, so whether it is mental health or other intensive
needs, we think the intent of the bill is to provide care to
those veterans that need it.
Ms. Dean. Absolutely, you can't separate mental health care
from physical care, however, I think the aim of this bill is to
address imminent mental health crisis, something that is
occurring right away. But it is our understanding that VA is
already able to, as they said, to care for these other-than-
honorable discharges, so if those could be linked or if
Congress can encourage VA to have a less-strict interpretation,
then by all means.
Mr. Takano. All right. Mr. Chairman, my time is up.
Mr. Wenstrup. Mr. Rutherford, you are now recognized for
five minutes.
Mr. Rutherford. Thank you, Mr. Chairman.
And I want to thank all the panel Members this morning.
Dr. Lee, I am going to follow up where Mr. Takano was at.
In light of the secretary's announcement before a Full
Committee here last month, that they were actually going to
begin accepting and treating at the VA, those with less-than-
honorable discharges, can you explain how 918, does that
compliment or complicate what the secretary is already
intending to do at VA?
Dr. Lee. Congressman, I think it is very aligned with our
intent and our work now at VA. We are focusing on those
veterans. We are using--flexing our current administrative
authority to ensure we are meeting those urgent mental health
needs for veterans, even if they have an other-than-honorable
discharge.
And we are working now to get input and to see how we can
specifically roll out this program, what services should be
covered or not over the course of the next few months.
Mr. Rutherford. And I think it is important to point out,
as well, as Mr. Coffman said earlier, that this does not
preclude the VA from expanding into other than mental health
care; that is correct, Ms. Lee?
Dr. Lee. That would--that is our understanding. I think the
focus, though, is on mental health care.
Mr. Rutherford. Yeah, Mr. Coffman, do you want to comment?
Mr. Coffman. Sure, if I could? The--what this does is it
has essentially a prioritized mandate, so where the Department
has discretion, they would not have discretion on this
particular population that is in the bill right now.
Mr. Rutherford. Okay. And for Ms. Lee, particularly, but
all of you in general, a statement from the record from the
Wounded Warrior Project notes that many veterans suffering from
PTSD, TBI have received bad-paper discharges. Is there any data
that shows how many veterans there are with other than--because
I agree with Ms. Dean, there are some issues about if you open
this up to everyone with bad paper for all treatment, mental
health and other, is there any idea what numbers we are talking
about that currently suffer PTSD and have a bad paper
discharge?
Dr. Lee. I am not sure of the specific numbers. We can
certainly take that for the record and come back to you with
that. But I know that there are, in total, approximately
500,000 individuals with other-than-honorable discharges from
the military.
Mr. Rutherford. And, Ms. Dean, do you know of any numbers
out there?
Ms. Dean. Sorry, no, I don't. But I do--the only number we
are--I am aware of is the 500,000.
Mr. Rutherford. Okay. And I will yield back, Mr. Chairman.
Thank you.
Mr. Wenstrup. Mr. Higgins, you are now recognized for five
minutes.
Mr. Higgins. Thank you, Mr. Chairman.
Ms. Keleher, you stated in your testimony that veterans
with bad-paper discharges are three times more likely to die by
suicide. Where did you get that information from and can you
share that with us?
Ms. Keleher. I have that data in my office and I would be
more than happy to get it to your office as quickly as
possible, but I can't remember it off the top of my head.
Mr. Higgins. But you feel confident that those are accurate
numbers based on some--of course I trust your testimony, ma'am,
I just hadn't seen that data myself and I would be very
interested. I am quite sure my colleagues on the Committee
would like to see that research.
Ms. Keleher. Yes, sir.
Mr. Higgins. Thank you very much.
Dr. Lee, I understand your assertion in your written
testimony that the VA cannot responsibly support the creation
of a new child care assistance program for veterans without a,
what you refer to a ``realistic consideration of the resources
necessary.'' That being said, your testimony didn't include a
cost estimate and the pilot program has been in place, very
new, since 2010, and we are looking for a permanent renewal.
Can you share with us, when can we expect to receive that
information regarding the cost?
Dr. Lee. We will be happy to get it--we are working on it
actively and we will be happy to try to get that back to you as
soon as possible.
The--I would like to point out that we have seen favorable
responses from veterans who have used the child care pilot
programs and we would like to see that continue. We like the
discretionary--the permanent, but discretionary authority to
see the child care programs continue.
Mr. Rutherford. My experience, ma'am, as a veteran and a
police officer, seems there are a lot of cops who are veterans
and historically, my personal observation has been that there
is a double-standard, somewhat of a societal double-standard
divided by gender between guys that are veterans and their
female counterparts. There seems to be an assumption that
female veterans would just, at their--when they end their time
of service, would just right back into their roles as mothers
and wives, et cetera; whereas, the comradery and esprit de
corps for my male veteran counterparts seems to continue, and
that level of support seems to continue, whereas, for my
female, veterans, it does not.
So, I am very encouraged by my colleague's--Gentlewoman
Brownley's legislation of H.R. 91. And I would like you to, if
you don't mind, please, expand upon your feelings about that
legislation that I have very much in support of.
Dr. Lee. VA is also support I have of the bill to make
permanent the retreat centers, the retreat programs for women
veterans. Again, we have done--we have run the retreat programs
for a small number of women veterans for the past several years
in multiple sites, including California, San Bernardino, and
other states, and we found good results in evaluation from
women veterans who have engaged in the program.
So, they have, as you said, Congressman, they have
benefitted from that comradery of being with other women
veterans. They have learned better coping skills and mechanisms
and actually have had a decrease in their clinical symptoms
from PTSD as a result and those improvements have sustained
over time at the end of the retreat program.
Mr. Rutherford. And some of the research indicates that 75
or 80 or 85 percent of the female veterans that have
participated in retreat programs, even months after the retreat
itself, have shown a significant increase in coping and
reintegrating into civilian society.
Dr. Lee. That is correct.
Mr. Rutherford. Is that correct?
Dr. Lee. That is correct.
Mr. Rutherford. Thank you, ma'am.
Mr. Chairman, I yield back.
Mr. Wenstrup. Dr. Dunn, you are now recognized for five
minutes.
Mr. Dunn. Thank you very much, Mr. Chairman.
I am interested in the number also, 500,000 bad-paper
discharges; over what period of time is that? Anybody can
answer--500,000, I have heard multiple people say that--bad-
paper discharges.
Dr. Lee. At least, sir, that represents a snapshot of
currently how many?
Mr. Dunn. Five hundred thousand veterans currently in the
country with bad-paper discharges?
Dr. Lee. Correct.
Mr. Dunn. How do they get that? What--how does--what
administrative--we aren't talking about dishonorable
discharges, or are we, dishonorable and general discharges?
Dr. Lee. Well, the discharges--so, not being a veteran
myself, and I may defer to other Members of the panel up here--
I will share that my understanding of the discharge--the
character of the discharge is basically determined by the
Department of Defense during the military--
Mr. Dunn. Yeah, I was just--
Mr. Wenstrup. Let's defer.
Yes, sir?
Mr. Coffman. Thank you, Mr. Chairman, and I thank the
gentleman for yielding.
The other-than-honorable discharges are certainly below
honorable and above a bad-conduct discharge or a dishonorable
discharge, and so, you know, often sometimes and currently are
given for really--could be given for non-judicial punishment
under a--
Mr. Dunn. Sort of like an AR-15?
Mr. Coffman [continued]. An Article 15.
Mr. Dunn. Article 15.
Mr. Coffman. Right. Uh-huh.
And so, just to give you a metric, in 2009, the Army
separated approximately 22,000 combat veterans diagnosed with
mental health disabilities, or TBI, for misconduct in the
category of other-than-honorable discharge in that one year.
Mr. Dunn. So, if I can opine--if you will yield back, thank
you.
Mr. Coffman. Go.
Mr. Dunn. I opine, I think that is pretty harsh.
But, let me--Dr. Lee, regarding H.R. 467, you said that the
VA national policies already apply uniformly across the
Department, however, the Committee continues to receive, daily,
examples of VA directives that are only partly followed or not
at all followed or complied in the field.
What is the mechanism for ensuring compliance out in the
field throughout the VA when we have these directives?
Dr. Lee. In general, sir, or specifically in regard to the
scheduling directives?
Mr. Dunn. Well, scheduling, yes.
Dr. Lee. So, with regard to the scheduling directive, there
are two mechanisms of oversight that we are really pushing on
right now. One is called--an actual tool, an IT tool, called
the ``scheduling trigger tool'' that allows us to see across
the system if there are any unusual aberrations in scheduling
that might indicate a problem. So, that is one.
The second is that we have increased the frequency of our
scheduling audits. So, this used to be done only once per year;
now, it is at least twice per year.
Mr. Dunn. Are those announced or unannounced, those audits?
So, they are surprise or not surprise?
Dr. Lee. Those--the way those audits work are at each
facility, the supervisors for the schedulers pull a random
sampling of appointments that are scheduled and look to see if
the--our policies have been followed in scheduling those.
Mr. Dunn. And that software system you mentioned there
where you could see across the system, that is what was
subverted by those lists that we all have read about in the
papers; is that what I understand?
Dr. Lee. I think some of the concerns from the scheduling,
the behaviors before, led to the trigger--this tool that allows
us to monitor.
Mr. Dunn. And I would like to change the subject to H.R.
91. We are talking about retreats for the female veterans. Is
that something that doesn't apply to the male retreats for
their PTSD?
Dr. Lee. Well, we actually think, Congressman, that other
veterans would also benefit from those types of programs. We
know there are many out there in the community.
Mr. Dunn. And do you partner with those community programs?
Dr. Lee. We would be interested in exploring how to do
that.
Mr. Dunn. But right now, we are not reaching out and
partnering with the numerous community-based VA programs; is
that fair?
Dr. Lee. We are referring veterans to programs like that
across the system, and there may very well be facilities that
have more robust and direct partnerships, but there--we do
support access for veterans to programs like this.
Mr. Dunn. Thank you very much.
Mr. Chairman, I yield back.
Mr. Wenstrup. Thank you. Mr. Coffman, you are now
recognized.
Mr. Coffman. Chairman, I have no questions.
Mr. Wenstrup. Are there any further questions?
Mr. Rutherford. Mr. Chairman?
Mr. Wenstrup. Yes, Mr. Rutherford?
Mr. Rutherford. If I could just point out one thing about
Mr. Coffman's bill, H.R. 918, I think the important element in
this bill is the fact that these men and women were actually
discharged because of behavior that was not, at that time, tied
to PTSD or TBI, which later, we find out that they suffer that
consequence and that that behavior was, in fact, the result of
their combat service.
And that is why I support this, whatever the cost might be,
because we owe that to those combat veterans. I just wanted to
add that in. Thank you.
Mr. Wenstrup. Well, I think if there are no further
questions, the--I am sorry.
Mr. Higgins, you are recognized.
Mr. Higgins. I would just like to state that regarding
Chairman Roe's draft bill, any measure, any measure that we can
take as a body, as a citizenry, to allow veterans, doctors to
have increased facetime, one-on-one relationship with their
patients, rather than typing on a keyboard of a computer, we
should all, and I urge all my colleagues, to be in full support
of any measure that allows a doctor to have a real relationship
with a veteran. It is a problem in the system and I believe
this draft improves that.
Thank you, Mr. Chairman.
Mr. Wenstrup. I want to thank you all once again. And
seeing no further questions, the second panel is now excused.
I ask unanimous consent that all Members have five
legislative days to revise and extend their remarks and include
extraneous material.
Without objection, so ordered.
I would like to, once again, thank all of our witnesses and
audience members for joining us here this morning, and the
hearing is now adjourned.
[Whereupon, at 9:31 a.m. the Subcommittee was adjourned.
A P P E N D I X
----------
Prepared Statement of Honorable Jackie Walorski
Good morning Chairman Wenstrup, Ranking Member Brownley and members
of the Committee. I appreciate being given the opportunity to discuss
the VA Scheduling Accountability Act.
First, I would like to thank Chairman Wenstrup and Ranking Member
Brownley for holding this hearing and allowing me to testify on the
reintroduction of this important legislation. In 2014, news reports
uncovering gross mismanagement and scheduling manipulation at a
Department of Veterans Affairs (VA) hospital in Phoenix shook us to the
core. Through hearings held in this committee and investigations by the
VA Office of Inspector General (OIG) and Government Accountability
Office (GAO), we substantiated many of the allegations of manipulated
schedules and falsified wait-time data at the Phoenix facility. The
manipulation of appointment schedules and data in Phoenix led to at
least 40 veterans dying while they were waiting for care. However,
three years after this tragedy VA is still plagued with facilities
unable to get their act together when it comes to scheduling
appointments. Earlier this month the OIG released yet another report
that identified flaws in the scheduling system still used by VA
facilities nationwide. Instead of owning up to the problems that
continue to prevent veterans from getting timely care they need, the
new Secretary disputed the findings of inaccurate wait times. We need
to let the VA know that we will never give up in holding their feet to
the fire. That is why I reintroduced the VA Scheduling Accountability
Act.
VA Directive 2010-027 is VA's implementation processes and
procedures policy for scheduling at their facilities and contains 19
different items on the checklist. The directive requires an annual
certification of full compliance with all items on the list. For
instance, facilities are required to conduct an annual audit of the
timeliness and appropriateness of scheduling actions and the accuracy
of desired dates. They are also required to ensure that deficiencies of
competency or performance that are identified by the audit are
effectively addressed.
An August 2014 OIG report uncovered that in May 2013, the then-
Deputy Under Secretary for Health for Operations Management waived the
FY 2013 annual requirement for facility directors to certify compliance
with the VHA scheduling directive. Allowing facilities to only self-
certify reduced oversight over wait time data integrity and compliance
with appropriate scheduling practices. This, in turn, allowed VA's data
to be easily manipulated, contributing to the wait time scandal. While
the VA has reinstated the certification requirement, there is nothing
stopping them from waiving it again.
The VA Scheduling Accountability Act would codify into law that
each facility director is required to annually certify compliance with
the scheduling directive, or any successor directive that replaces it,
and would prohibit any waivers in the future. Should a director be
unable to certify compliance, either because the facility is not in
compliance or the director refuses to sign the certification for some
other reason, the director must submit a report to the Secretary
explaining why the facility is out of compliance. The Secretary will
then report yearly to the House and Senate VA Committees with a list of
facilities in compliance and those that are not, with an accompanying
explanation as to why they were not in compliance. To incentivize a
facility's compliance, there is a provision that allows the VA
Secretary to revoke an award or bonus for not complying. Lastly, the
legislation requires that any time VA waives or allows noncompliance
with requirements in any other directive or policy beyond scheduling,
VA must provide a written explanation for the decision to the House and
Senate Veterans' Affairs Committees. This will provide more oversight
of the Department and ensure Congress is aware when VA is waiving these
policies.
We need this legislation in order end the reckless practice of
avoiding compliance. I look forward to working with the members of this
Committee, and Veteran Services Organizations in addressing this
critical issue. I thank you again for this opportunity to testify
today.
Prepared Statement of Honorable Doug Collins
Chairman Wenstrup and Members of the Subcommittee, thank you for
the opportunity to testify on legislation that I introduced, H.R. 907,
the Newborn Care Improvement Act. This bill improves the care provided
by the Department of Veterans Affairs to the newborn children of female
veterans, and I appreciate the Subcommittee's consideration of this
legislation.
In his Second Inaugural Address, President Lincoln derived his idea
for the VA from Scripture stating, ``.the challenge for us is to care
for him who shall have borne the battle and for his widow and his
orphan.'' In the 21st Century, we must apply Lincoln's statement more
broadly to ``she who hath borne the battle,'' and one way we can do
that is to provide better maternity and newborn care.
Historically, much of the VA healthcare system was created and
designed to meet the needs of men. As an increasing number of females
serve in our military, it is essential for the VA to update and expand
its care and services to meet the needs of female veterans and their
families.
Maternity care is often among the needs of our female veterans, and
I believe the Newborn Care Improvement Act is one important way to
help. In 2010 when the Caregivers and Veterans Omnibus Health Services
Act was signed into law, it provided short-term newborn care for female
veterans who receive maternity care through the VA. Under this law,
newborns were provided with up to seven days of care at hospitals
covered by the VA.
In January 2012, the Department of Veteran's Affairs issued a rule
to officially implement the law. The rule was retroactively applied to
newborn care provided to eligible female veterans on or after May 5,
2011.
Since the law's implementation, we have learned significantly more
about the challenges impacting female veterans and the evolving needs
of veterans seeking care for their newborns from the VA. According to a
2008-2012 study in one women's health journal, for example, the overall
delivery rate of female veterans using VA maternity benefits increased
by 44 percent, and a majority of these women had service-connected
disabilities.
However, a recent December 2016 Government Accountability Office
(GAO) report illustrated that there is still a long way to go to meet
the care needs of our female veterans and their newborns. The GAO found
that approximately 27 percent of VA facilities reported maternity care
was ``significantly delayed'' and that all veterans, including women,
face consistent challenges in receiving timely access to care.
We know we must take action to address access to care issues at the
VA, including maternity and newborn care.
Absent Congressional action to achieve parity between the number of
days new mothers and newborns can receive care covered by the VA,
female veterans may be forced to navigate complex insurance options and
face challenging financial decisions - even as their child's life is in
danger.
I introduced H.R. 907, the Newborn Care Improvement Act, to ensure
that newborns are better able to receive the care they need,
particularly if they are born prematurely or face birth complications.
As some of you may remember, I introduced similar legislation in
the 114th Congress, and it was favorably reported by this Committee.
Last Congress, my legislation extended the length of covered VA care
for newborns from 7 to 14 days and provided an annual report on the
number of newborns who receive such care during each Fiscal Year.
The 115th Congress' version provides an important update to the
length of covered care for newborns by extending it from 14 to 42 days.
This 42 day standard creates parity for newborns with the length of
time the VA covers care for mothers, incorporating an amendment offered
by Chairman Roe that was included when the House passed this
legislation last year. I hope that the Committee will once again place
the Newborn Care Improvement Act on its markup calendar to move forward
this legislation for newborns and their mothers.
Many of our female veterans have paid the ultimate price, and those
who have risked their lives to serve our nation deserve the highest
standard of care. Our duties to the women in our Armed Services do not
end because they are no longer serving on active duty, and should they
choose to receive maternity care at the VA, they should be confident it
will be quality care.
In fact, research has indicated that some female veterans may have
unique maternity needs as a result of their service. One recent study
illustrated a link between a veteran having PTSD in the year prior to
giving birth and a 35 percent increase in risk of spontaneous premature
delivery. This study indicates that PTSD could be a significant
epidemiological risk factor for pre-term delivery, and it is only one
of the service-connected issues that our female veterans, who have
bravely sacrificed for us, may face.
Tragically, PTSD impacts a substantial number of our female
veterans. Over 20 percent of female veterans in the recent conflicts in
Iraq and Afghanistan have been diagnosed with PTSD. These diagnoses are
not limited to women serving in combat roles.
Female veterans who may have higher-risk pregnancies should feel
confident they will receive appropriate and necessary maternity care
and care for their newborns. This care becomes even more critical for
premature babies who may face greater complications than full-term
infants and potential long-term developmental problems absent proper
care.
From a personal perspective, I understand the fear and heartache of
parents when their beautiful new baby needs intensive medical care. My
daughter, Jordan, was born with spina bifida and was over 10 days old
before I could hold her.When a parent is in this situation, they
shouldn't be worried that their insurance will no longer cover the
child or that the facility where the baby was born can't or won't
provide necessary care. As a parent, I know the only thing you're
thinking about is the safety, health, and well-being of your child.
That's why I introduced this legislation-in those situations where
longer care is necessary, it should be available for the newborns of
our female veterans.
Our goal should be to ensure that mothers receive the best pre-
natal and maternity care possible, so that newborns can have the best
chance of a healthy delivery and a long life. Our female veterans have
served our country with honor and distinction, and this is one small
step we can take to show our gratitude.
The Newborn Care Improvement Act is a commonsense measure to
support the changing needs of women in the Armed Services. H.R. 907
represents a significant step forward for maternity and newborn care at
the VA that builds on research and existing programs.
Thank you again for the opportunity to testify before you today,
and for all that you do to improve care for our nation's veterans.
I yield back.
Prepared Statement of Honorable Mike Coffman
Mr. Chairman, I would like to begin by thanking you for including
my bill in today's legislative hearing. To our witnesses, thank you for
your testimony, and for ensuring Congress and the American public
better understand the challenges facing our Veterans today.
As a Marine Combat Veteran, I like to live by the rule that we
never leave anyone behind, and the Veteran Urgent Access to Mental
Healthcare Act makes sure that we do not forget those who bravely
served our county in their time of need.
Here is what we know for a fact - an average of 20 veterans take
their lives daily. Likewise, VA evidence suggests a decrease in suicide
risk among those who have received VA healthcare services. And since
2009, the Army has separated approximately 22,000 combat veterans
diagnosed with mental health disabilities or TBI for alleged
misconduct--leaving them without access to VA's critical mental
healthcare services.
While the correlation between their illness and minor misconduct
could be linked, this made no difference to their character of
discharge. Historically, a veteran with an other than honorable
discharge has been able to seek VA care for a service-connected
disability. However, due to the way these veterans were discharged and
this failure to connect the dots between an other than honorable
discharge and mental health services, this precedence has failed to
recognize this problem.
My bill will stay with tradition and correct this disconnect by
authorizing urgent mental healthcare to these veterans. And to note, it
would not limit VA's existing authority, should the VA choose to
provide services beyond what is covered in my legislation.
My bill also calls for a third-party study to review the effect of
combat service on veteran suicide rates, as well as the rate and method
of suicide among veterans who have received healthcare from the VA and
those who have not.
Before the rate of veteran suicides increases anymore, we have to
make sure that these service members get the critical mental healthcare
they need and that the nation has a better understanding of why
veterans think that taking their own lives is the only way out to end
their pain and suffering. This is something that we need to get to the
bottom of, as quickly and as accurately as possible. My legislation
will do just that.
Over the years, Congress has been looking into inefficiency's and
mission disconnect at the VA and I believe this has been a key
disconnect at the VA. It is time to right this wrong and permanently
authorize the Secretary to provide initial mental health assessments
and urgent mental healthcare services to veterans at risk of suicide or
harming others, regardless of their discharge status.
When someone puts on the uniform, they take an oath to defend our
freedoms. We in turn promise to make sure they receive the care and
services they need upon returning from their mission.
Mr. Chairman, thank you for allowing me to testify today on behalf
of my legislation I look forward to continue working with the
committee, as well as our nation's VSOs, to make sure the men and women
in uniform are never left behind.
Prepared Statement of Honorable Stephen Knight
Chairman Wenstrup, Ranking Member Brownley and Members of the
Committee, thank you for the opportunity to testify today on my
legislation H.R. 1162 No Hero Left Untreated Act.
We are working to get our military the most advanced weapons,
vehicles, and equipment in the world in order to defeat any enemy. We
owe it to those who selflessly serve to match this commitment to
innovation when it comes to their medical treatment when they need it
most.
Our fighting men and women will always face incredible danger and
put their lives on the line in service to our nation. Post-Traumatic
Stress (PTS) and Traumatic Brain Injury (TBI) are some of the most
prevalent and misunderstood injuries our troops face upon returning
home from answering the call of duty. A recent study found that 20
veterans commit suicide EVERY DAY. This is unacceptable and the VA must
adopt new ideas to help prevent and decrease veteran suicide rates. An
emerging technology is achieving compelling results in restoring
veterans' mental health and shows promising potential to prevent more
suicides from needlessly occurring: Magnetic EEG/EKG-guided resonance
therapy.
This reliable, effective protocol uses a suite of FDA approved
medical innovations to uniquely image the brain, identify areas that
may need repair, and, most importantly, treat suboptimal regions of the
brain with the goal of restoring optimal neurological function using
non-invasive neuromodulation.
This protocol is an individualized, non-pharmaceutical, non-
invasive procedure, to provide patient specific application of
repetitive magnetic stimulation to help restore proper brain function.
Over the course of several treatments, patients experienced improved
quality of sleep, increased motivation and ability to manage stress,
improved mood, and better concentration and focus.
With veteran patients, magnetic EEG/EKG-guided resonance therapy
has achieved excellent success rates in both open-label trials and
randomized, placebo-controlled, double-blind studies. In fact, to date,
98% of veterans in recent trials have experienced at least a 10 point
change in their PTSD Check List Military (PCL-M) score, and averaged a
61% reduction in symptom severity after four weeks of treatment based
on PCL-M.
Veterans who depend on the VA can benefit from this treatment,
which is why I introduced H.R. 1162, the No Hero Left Untreated Act,
earlier this year. This bill would establish a pilot program for two VA
medical centers to treat 50 veterans using magnetic EEG/EKG-guided
resonance therapy.
The Department of Defense has already begun clinical trials on EEG/
EKG at Tinker Air Force Base and the U.S. Special Operations Command is
also about to launch a larger two-site trial study to treat a cohort of
military personnel as well.
The VA is currently behind and unequipped to deal with this growing
problem, and must take advantage of innovative treatments that can help
veterans who struggle with mental health issues. I urge my colleagues
to support this vitally important piece of legislation and get our
veterans the best treatment possible. Innovation is the key to
effectively treat these conditions and it's time Congress does
something to bring new treatment services like the magnetic EEG/EKG-
guided resonance therapy into the 21st century.
Thank you for this opportunity to testify and I look forward to
working with you on providing innovative solutions to treat our brave
men and women.
Prepared Statement of Honorable Ann M. Kuster
Written Testimony on H.R. 1545, VA Prescription Data Accountability Act
Mr. Chairman and distinguished colleagues of the Subcommittee of
Health, thank you for inviting me to speak on behalf of my proposed
bill - H.R. 1545, the VA Prescription Data Accountability Act.
My bill would resolve a peculiar problem with the VA's initiative
to connect VA medical facilities to state Prescription Drug Monitoring
Programs. As you know, in 2012, the VA was authorized by Congress to
provide state PDMPs the prescription data of VA beneficiaries. As a
member of the House Veterans Affairs Committee and as the co-founder
and co-chair of the Bipartisan Heroin Task Force, I recognize PDMPs as
an important tool to prevent the spread of prescription opioids to our
communities.
The VA has provided prescription opioids at a rate nearly twice
that of the general population. Many veterans utilize both the VA and
private providers to meet their healthcare needs. Additionally, many
drugs - including opioids - can be dangerously and lethally combined
with other drugs. Often, these lethal combinations are accidental and
could have been resolved with better available information. These are
reasons why it is critical to ensure the VA is fully connected to state
PDMPs.
Thankfully, the VA has taken action to connect all its medical
facilities to available PDMPs. All indications are that the VA is on
schedule to connect all VA medical facilities with PDMPs.
However, the VA has reported that they cannot provide non-Veteran
data to these state PDMPs. This problem is two-fold: VA's authority is
currently confined to ``Veterans and their dependents,'' and VA's IT
systems cannot adequately discriminate between ``dependents'' and
``non-dependent'' users of the VA. Consequently, hundreds of thousands
of non-Veterans do not have their data reported. That would include the
largest population of non-Veterans - beneficiaries of CHAMPVA - as well
as some active service members.
My bill would expand VA's authority to include all VA beneficiaries
that are prescribed a drug. This will close the gap without requiring
VA to update its electronic health records, a process that is neither
quick nor inexpensive. Consequently, the VA and the CBO have
preliminarily reported that my bill would have little to no cost.
Thank you for the opportunity to speak on behalf of my legislation.
Prepared Statement of Honorable David P. Roe
It's a pleasure to join the Subcommittee on Health today to talk
about my draft legislation to require VA to implement a pilot program
for medical scribes within VA medical centers (VAMCs).
As a physician in private practice years ago, I took on the arduous
task of converting from paper medical records to a million-dollar
electronic health record system (EHR).
For me, it took time - lots of time - to get used to using the new
electronic system.
As we all know, EHRs are extremely helpful tools for organizing and
analyzing a patient's medical data and you would be hard-pressed to
find a doctor's office or hospital today that doesn't use some form of
EHR.
After my practice converted to an EHR, I eventually familiarized
myself with it and it became a normal part of my practice.
However, I also learned that in order to fully utilize the new EHR,
I had to divert my attention away from the patient and towards the
computer screen.
That never sat well with me, but it was what was needed - and what
every practice was doing - to accommodate the new EHR technology.
Today, medical scribes are often used to assist clinicians by
navigating and entering data into a patient's EHR, allowing the
clinician to focus on the patient and not on the paperwork.
Medical scribes can improve efficiency in areas with a high demand
of appointments but a low supply of providers -and can be especially
helpful in high-paced areas of practice like an emergency department
(ED) where every moment focused away from the patient could potentially
lead to a tragic outcome.
Medical scribes are often recruited as undergraduates or recent
graduates having an interest in entering into a medical career.
For them, scribing provides an opportunity to glimpse first-hand
what life in medicine is like and gain valuable experience for their
future careers.
I wholeheartedly believe that veteran patients and VA providers
alike could benefit from embracing medical scribes within VA medical
facilities.
My draft bill would require the Secretary to implement a 2-year
pilot program to establish positions for 40 scribes across 10 VAMCs,
within the areas of emergency and specialty care.
This pilot seeks to improve both efficiency and, more importantly,
the patient-doctor experience by allowing physicians to focus on their
personal interactions with patients.
Under this draft legislation, VA would submit a report on the
efficacy of the pilot every 180 days following its commencement and the
Government Accountability Office would submit an independent report
within 90 days of the conclusion of the pilot, to include a comparison
of the pilot program with similar private sector programs.
The text of my legislation would prohibit any additional
appropriations with which to carry out this pilot.
I am disappointed to see that VA's testimony is not supportive of
my draft legislation and would note that VA's current Health Advocate
pilot program is largely incongruent with the intent and scope of my
draft legislation. Not only is VA's current program limited to primary
care while my draft is exclusively for emergency and specialty care,
but it also requires the scribe to take on the clinical role of
``health coach'', which brings a litany of licensure issues into
question.
Nonetheless, I look forward to working with the Department and with
the members of this Subcommittee to address any outstanding concerns
and move this legislation through regular order very quickly.
With that, I thank you for allowing me to be here today and yield
back the balance of my time.
Prepared Statement of Jennifer S. Lee
Good morning, Chairman Wenstrup, Ranking Member Brownley, and
Members of the Subcommittee. Thank you for inviting us here today to
present our views on several bills that would affect the Department of
Veterans Affairs' (VA) programs and services. Joining me today is Susan
Blauert, Chief Counsel for the Health Care Law Group, Office of General
Counsel.
H.R. 91 Building Supportive Networks for Women Veterans Act
H.R. 91 would direct VA to provide reintegration and readjustment
counseling services, in a retreat setting, to women veterans who are
recently separated from service in the Armed Forces after prolonged
deployments.
VA currently is in the final year of a pilot program, authorized by
Public Law 111-163 and reauthorized through several extensions of this
authority, to determine the feasibility and advisability of such
retreats. Under this program, a total of 12 retreats were provided to
272 women veterans between 2011 and 2016. Three more retreats are
planned for calendar year 2017. These retreats focus on building trust
and developing peer support for the participants in a therapeutic
environment. Data have shown that those who participated in these
retreats were able to increase their coping abilities and decrease
their symptoms associated with posttraumatic stress disorder. Eighty-
seven percent of participants are scoring higher on the Ryff Scale of
Psychological Well Being immediately post-retreat, and 78 percent had
higher scores two months later. Eighty-four percent showed a decrease
in stress symptoms at two months post-retreat. VA is expecting similar
results for those who participate in the 2017 retreats.
VA agrees that providing these retreats is beneficial to women
veterans, other veteran and Service member cohorts could also benefit
from this treatment modality. While VA appreciates the intent of this
bill, we would request that the bill language be amended to allow VA
the ability to conduct these retreats for all veteran or Service member
cohorts eligible for Vet Center services. Examples include those who
have experienced military sexual trauma, veterans and their families,
and families that experience the death of a loved one while on active
duty. Also, rather than creating a separate biennial report, as would
be required by the bill, VA recommends that this bill amend 38 U.S.C.
Sec. 7309 to include a report on this program as part of the annual
report to Congress on the activities of the Readjustment Counseling
Service.
VA estimates that this legislation would cost $467,347 to conduct
six retreats in Fiscal Year (FY) 2018, $2.5 million over five years,
and $5.6 million over 10 years. There retreats would serve an average
of 138 woman veterans annually, for a total cost of $3,400 per person.
H.R. 95 Veterans' Access to Child Care Act
H.R. 95 would require VA to carry out a program to provide
assistance to qualified Veterans to obtain child care so that the
veterans can receive covered health care services. Such assistance may
include stipends for payment of child care by licensed centers, direct
provision of child care at VA facilities, payment to private child care
agencies, and collaboration with other Federal facilities or programs.
Covered health care services would include regular and intensive mental
health care services and other intensive health care services access to
which could be improved by provision of child care assistance. While VA
is aware of the challenges faced by veterans with children in regard to
access to medical appointments and other medical care, counseling, and
care giving services, VA does not support this bill as written. In a
2015 Study of Barriers to Care for Women Veterans, when queried about
the possibility of on-site child care, more than three out of five
women (62 percent overall) indicated that they would find on-site child
care very helpful. However, this was not shown to be a significant
factor in whether they chose to utilize VA care.
VA believes it would be better to have permanent but discretionary
authority to provide child care assistance for the children of eligible
veterans while those veterans are accessing health care services at
facilities. In addition, VA cannot responsibly support the creation of
a new child care assistance program for veterans without a realistic
consideration of the resources necessary, including an analysis of the
future resources that must be available to fund other core direct-to-
veteran health care services.
VA does not have cost estimates at this time but will be happy to
follow up shortly with the Committee.
H.R. 467 VA Scheduling Accountability Act
H.R. 467 would require each VA medical facility to comply with
requirements relating to scheduling veterans for health care
appointments and to ensure the uniform application of VA directives.
Section 2(a) would require the director of each VA medical facility
to annually certify to the Secretary that the medical facility is in
full compliance with all provisions of law, regulations, and VA
directives relating to scheduling appointments for Veterans to receive
hospital care and medical services. If the director did not make a
certification, section 2(b) would require the director to submit a
report explaining why the director was unable to make such a
certification and a description of the actions the director is taking
to ensure full compliance. Section 2(c) of the bill would prohibit VA
from awarding any award or bonus to certain covered officials if the
director of a medical facility did not make a certification under
subsection (a)(1) for any year. Section 3 of the bill would require VA
to ensure that its policies apply uniformly to each office or facility
of the Department.
VA supports the intent of this bill in terms of ensuring veterans
are appropriately scheduled for the care they need and that scheduling
processes are reliable and timely. Existing Departmental policies
require VA directors to certify compliance with the scheduling
directive and explain gaps in compliance based on scheduling data
collected at the facility level.
In addition, VA national policies already apply uniformly across
the Department. At the same time, these policies provide some
flexibility so that facilities may develop and pilot innovative ideas
or implement policies and procedures that are specific to the needs of
the local Veteran community, while remaining consistent with the
principles and procedures established in national policy. Codifying
activities that VA already does administratively could potentially
limit VA facilities' ability to implement policies and procedures
needed to tackle local challenges, adapt to changing conditions, and
address veterans' needs in real time.
Finally, VA is actively working with Members of Congress on a
consolidated-care-in-the-community program and other efforts to improve
access to health care. In this dynamic environment, particularly with
the increased use of community care, VA needs the flexibility to set
scheduling standards that are clinically appropriate and that can
change and improve over time in step with other changes in the way
Veterans access health care.
VA estimates that there would be no costs associated with
implementing the requirements in this bill.
H.R. 907 Newborn Care Improvement Act
H.R. 907 would amend section 1786 of title 38, United States Code,
to increase from 7 to 42 the number of days after the birth of a child
for which VA may furnish covered health care services to the newborn
child of a woman veteran who is receiving maternity care furnished by
the Department and who delivered the child in a facility of the
Department or another facility pursuant to a Department contract for
services related to such delivery. Not later than October 31 of each
year, VA would be required to submit a report to the Committees on
Veterans' Affairs of the House of Representatives and the Senate on
such services provided during the preceding fiscal year, including the
number of newborn children who received such services during that
fiscal year.
VA supports extending, from seven to 14 days, coverage of newborns
of a woman veteran receiving delivery care. A newborn needing care for
a medical condition may require treatment extending beyond the current
7 days that are authorized by law. Additionally, the standard of care
is to have further evaluations during the first two weeks of life to
check infant weight, feeding, and newborn screening results. Pending
these results, there may be a need for additional testing and follow-
up. There are also important psychosocial needs that may apply,
including monitoring stability of the home environment or providing
clinical and other support if the newborn requires monitoring for a
medical condition. Extending care to 14 days would provide time for
further evaluations appropriate for the standard of care, as well as
sufficient time to identify other health care coverage for the newborn.
VA also notes the bill would not address travel benefits associated
with the newborn's care. VA would support authorizing the provision of
travel benefits under 38 U.S.C. Sec. 1786.
VA estimates this bill would cost $25.9 million in FY 2018, $136.8
million over 5 years, and $293.6 million over 10 years.
H.R. 918Veteran Urgent Access to Mental Healthcare Act
H.R. 918 would create a new section 1720I in title 38 that would
direct VA to furnish to certain former members of the Armed Forces an
initial mental health assessment and the mental health care services
the Secretary determines are required to treat the urgent mental health
needs of the former members, including risk of suicide or harming
others. To be eligible for this care, an individual must be a former
member of the Armed Forces, including the reserve components, who
served in the active military, naval, or air service and was discharged
or released therefrom under a condition that is not honorable but who
did not receive a dishonorable or bad conduct discharge. The member
would also have to have applied for a character of service
determination that is still pending and otherwise be ineligible to
enroll in the VA health care system established by section 1705 by
reason of such discharge or otherwise not meeting the requirements for
``veteran'' status under section 101(2) of title 38. Furthermore, the
former Servicemember must have been deployed in a theater of combat
operations or an area at a time during which hostilities occurred in
that area, participated in or experienced such combat operations or
hostilities, or was the victim of a physical assault of a sexual
nature, battery of a sexual nature, or sexual harassment.
VA would be authorized to furnish such mental health care in a non-
Department facility if treating the person in a VA facility would be
clinically inadvisable or if VA facilities are not capable of
furnishing such care economically because of geographic
inaccessibility. The Secretary would be required to ensure that mental
health services are furnished in a setting that is therapeutically
appropriate and provide referral services to assist former Service
members who are not eligible for services under this chapter to obtain
services from outside VA. VA would also be required to provide
information on the availability of services and to coordinate with the
Secretary of Defense to ensure that Service members who are being
separated from active service are provided appropriate information
about such services. VA would be required to submit an annual report on
the provision of services under this authority and would be required,
in consultation with the Secretary of Defense, to seek to enter into a
contract with an independent nongovernmental entity to carry out a
study on the effect combat service has had on suicide rates and serious
mental health issues among veterans. VA would be required, within one
year of enactment, to submit a report to Congress on this study.
VA supports this bill in principle. Veterans who were discharged or
released with an other-than-honorable (OTH) administrative discharge or
a punitive bad conduct discharge issued by a special court-martial may
or may not be eligible for VA benefits. The determination is made based
on the character of discharge standards in 38 C.F.R. Sec. 3.12. An
individual with an OTH administrative discharge that VA has determined
to be disqualifying under 38 C.F.R. Sec. 3.12 is eligible to receive
health care for service-incurred or service-aggravated disabilities
unless he or she is otherwise subject to one of the statutory bars to
benefits set forth in 38 U.S.C. Sec. 5303(a).
We note that requiring a study on the effect combat service has had
on suicide rates and serious mental health issues would be largely
duplicative of a number of recent research efforts in this area.
In addition, Secretary Shulkin recently announced his intention to
expand access to mental health services for former Service members with
OTH administrative discharges. It is estimated that there are slightly
more than 500,000 former service members with OTH administrative
discharges. As part of Secretary Shulkin's plan, former Service members
with OTH administrative discharges would be able to seek treatment at a
VA emergency department, Vet Center or contact the Veterans Crisis
Line. Before finalizing the plan in early summer, Secretary Shulkin
plans to meet with Congress, Veterans Service Organizations, and
Department of Defense officials to determine the best way forward to
get these former Service members the care they need.
H.R. 1005 Improving the Provision of Adult Day Health Care Services for
Veterans
H.R. 1005 would amend 38 U.S.C. Sec. 1745 to require the Secretary
to enter into an agreement under 38 U.S.C. Sec. 1720(c)(1) or a
contract with each State Veterans Home (SVH) for payment by VA for
adult day health care (ADHC) provided to an eligible Veteran. Eligible
veterans would be those in need of nursing home care for a service-
connected disability or who have a service-connected disability rated
at 70 percent or more and are in need of nursing home care. Payments
would be made at a rate that is 65 percent of the payment VA would make
if the veteran received nursing home care, and payment by VA would
constitute payment in full for such care. Currently, under a grant
mechanism, VA pays States not more than half the cost of providing
ADHC. States may currently obtain reimbursement for this care from
other sources in addition to VA's per diem payments.
VA supports growing ADHC programs in general as they are a part of
VA's home- and community-based programs that have been demonstrated to
benefit the health and well-being of older veterans. However, VA does
not support this bill as written for several reasons.
First, VA notes that the bill would base payment rates for ADHC on
nursing home care rates, though these are two distinctly different
levels of care and are furnished for different periods of time. Nursing
home residents live at the facility and receive 24-hour skilled nursing
care, including services after normal business hours with registered
nurses involved in care at all times. ADHC is a distinctly different
level of care that provides health maintenance and rehabilitative
services to eligible Veterans in a group setting during daytime hours
only. The nursing home rates that would be used to compute the ADHC
rates under this bill are based on a formula that was developed in
partnership with VA's State home partners and is specific to nursing
home care. VA would like the opportunity to thoroughly review the cost
of providing ADHC and, as was accomplished for nursing home care,
establish a mutually agreeable ADHC rate with our SVH partners. VA
believes revising the language to allow for VA to propose a formula for
computing ADHC rates and for SVHs to provide comments on the formula
would be consistent with the way the nursing home care rates were
developed under 38 U.S.C. Sec. 1745.
Second, VA has technical concerns with the legislation. We note
that the bill directs VA to ``enter into an agreement under section
1720(c)(1) of this title or a contract'' with each SVH. VA does not
have the authority to enter into individual agreements, and thus this
provision would need to be implemented through contracts. VA has
requested this specific authority.
Third, this legislation would impact VA's anticipated
implementation of a proposed regulation that would allow SVHs to offer
ADHC using either a medical supervision model or a socialized model.
Currently, VA requires states to operate ADHC programs exclusively
using a medical supervision model. In June 2015, VA published a
proposed rule, ``Per Diem Paid to States for Care of Eligible Veterans
in State Homes,'' RIN 2900-AO88. VA proposed these regulations in part
so that states may also establish ADHC programs using only a socialized
model. A medical supervision model would include physician services,
dental services, and administration of drugs, whereas these would not
be required for a socialized model. Although the intent of the
legislation may be to limit a higher per diem to medical supervision
model programs, VA is concerned that H.R. 1005 does not make this
distinction, which would result in VA being required to pay the same
rate for a socialized model as for a medical supervision model.
Additionally, VA expects the numbers of both socialized and medical
supervision model ADHCs to increase after publication of the proposed
regulation. VA is not able to predict how many SVHs will adopt the new
socialized model, nor how the new model's use will affect costs. Until
VA has such information, VA recommends against codifying a payment
rate, as such a limitation could result in VA overpaying or underpaying
States in the future.
VA estimates H.R. 1005 would cost an additional $492,972 in FY
2018, $3.8 million over 5 years, and $11.6 million over 10 years.
H.R. 1162 No Hero Left Untreated Act
H.R. 1162 would require VA, within 90 days of enactment, to begin a
one-year pilot program in no more than two VA facilities by providing
access to magnetic EEG/EKG-guided resonance therapy (Magnetic
eResonance Therapy or MeRT) to treat veterans suffering from post-
traumatic stress disorder (PTSD), traumatic brain injury (TBI),
military sexual trauma (MST), chronic pain, or opiate addiction. The
bill would not authorize additional amounts to be appropriated to carry
out the requirements of this bill.
While preliminary experience with this technology is promising, a
study by the Newport Brain Research Laboratory to establish the
efficacy of MeRT in treating PTSD in veterans is still in progress. VA
offers repetitive transcranial magnetic stimulation (rTMS), which is a
treatment related to MeRT that has FDA approval for treatment-resistant
depression, a common comorbid condition in PTSD, TBI, MST, and chronic
pain and opioid addiction. There is no existing evidence that MeRT is
superior to rTMS for treating any disorder. To date, no medical device
using MeRT technology has been cleared or approved by the Food and Drug
Administration for the uses described in the legislation. While VA
research continuously examines new treatment methods and modalities,
independently collected evidence of the safety and efficacy of this
technology has yet to be obtained. The additional pilot data that would
be obtained under the proposed legislation would not address the
critical issues of determining MerT's efficacy against a placebo or
against rTMS. For these reasons, VA does not support the legislation.
VA estimates the bill have a one-time $1.83 million cost to
implement.
H.R. 1545 Disclosure of Patient Information to State Controlled
Substance Monitoring Programs
H.R. 1545 would amend 38 U.S.C. Sec. 5701(l) to direct the
Secretary to disclose information about covered individuals to a State
controlled substance monitoring program, including a program approved
by the Secretary of Health and Human Services under section 399O of the
Public Health Service Act (42 U.S.C. 280g-3), to the extent necessary
to prevent misuse and diversion of prescription medications. Covered
individuals would include an individual who is dispensed medication
prescribed by a VA employee or a non-Department provider authorized to
provide such medication by VA.
VA supports this bill. Currently, VA is required to provide
information on veterans and their dependents, but this bill would
expand that authority to include any person who is dispensed medication
prescribed by a VA employee or a non-VA provider authorized to
prescribe such medication by the Department. Under our current
authority, VA does not disclose information for other persons who
receive care, such as in humanitarian cases or family members or
caregivers who are eligible to receive care. This bill would provide an
important authority to ensure that VA is able to fulfill its public
health role in sharing vital clinical information to help guide
treatment decisions. However, we note that there are information
technology challenges relating to variations in State prescription drug
monitoring program requirements that would prevent immediate
implementation of this provision.
We estimate there would be negligible costs associated with this
bill.
H.R. 1662 To Prohibit Smoking in Any Veterans Health Administration
(VHA) Facility
H.R. 1662 would repeal section 526 of Public Law (P.L.) 102-585 and
amend section 1715 of title 38, United States Code, to prohibit any
person from smoking indoors in any VHA facility. It would also
prohibit, beginning October 1, 2022, any person from smoking outdoors
at any VHA facility. The bill would prohibit the use of cigarettes, e-
cigarettes, cigars, pipes, and any other combustion of tobacco. The
prohibition would apply to any land or building that is under VA's
jurisdiction, under the control of VHA, and not under the control of
the General Services Administration. The amendments made by the bill
would take effect 90 days after the date of enactment.
VA strongly supports H.R. 1662. For several years, VA has proposed
legislation to reverse the requirement in P.L. 102-585, section 526 for
designated smoking areas at VA facilities. Currently P.L. 102-585,
section 526, enacted in 1992, requires VHA to provide suitable smoking
areas, either an indoor area or detached building, for patients or
residents who desire to smoke tobacco products. As of January 2, 2017,
there were over 4,000 local and/or state/territory/commonwealth
hospitals, health care systems and clinics, and four national health
care systems (Kaiser Permanente, Mayo Clinic, SSM Health Care, and
CIGNA Corporation) in the United States that have adopted 100 percent
smoke-free policies that extend to all their facilities, grounds, and
office buildings. Numerous Department of Defense (DoD) medical
treatment facilities have become tobacco free as well. VHA health care
providers and visitors do not have the same level of protection from
the hazardous effects of second-hand smoke exposure as do patients and
employees in these other systems. Currently, approximately 20 percent
of veterans enrolled in VA health care are smokers. Many of the non-
smokers are also older veterans who may be at higher risk for cardiac
or other conditions that may make them even more vulnerable to the
cardiovascular events associated with secondhand smoke. As with
patients of other health care systems, VA believes veteran patients
have a right to be protected from secondhand smoke exposure when
seeking health care at a VA facility. For veteran smokers who are
inpatients, nicotine replacement therapy is available.
VA estimates that it would see no savings in FY 2018, as the
substantive changes made by this bill would not become effective until
the beginning of FY 2023. VA estimates it would save approximately $8.2
million in FY 2023.
Draft Bill Veterans Affairs Medical Scribe Pilot Act of 2017
Section 2 of the draft bill would require VA to carry out a 2-year
pilot program under which VA would increase the use of medical scribes
at VA medical centers (VAMCs). The pilot program would be carried out
at 10 VAMCs, with four located in rural areas, four in urban areas, and
two in areas with need for increased access or efficiency. Under the
pilot program, VA would hire 20 new medical scribes and would seek to
enter into contracts with appropriate entities for the employment of 20
additional medical scribes. Two scribes would be assigned to each of
two physicians, 30 percent of the scribes would be employed in the
provision of emergency care, and the rest would be employed in the
provision of specialty care. Every 180 days, VA would be required to
report on the pilot program, and 90 days after completion, the
Comptroller General would submit a report to Congress on the pilot
program. No additional funding would be authorized to be appropriated
to carry out the program.
While VA is exploring the use of medical scribes, VA does not
support this draft bill as written. In the first quarter of FY 2017, VA
began a demonstration project that includes the use of scribes
(contracted or hired) and transcription, as well as a health advocate.
There are eight sites in varying implementation stages, and VA has
developed an evaluation plan for all methods of provider documentation
support. VA also has an Enterprise Wide Front End Speech Recognition
contract that includes unlimited licenses for clinical end users for
the Nuance Dragon Medical 360 Network Edition (DMNE) Version 2.3, which
is the current version. DMNE provides advanced, secure, speech
recognition solutions that allow clinicians to document the complete
patient story using voice while allowing healthcare organizations to
deploy and administer medical speech recognition across the enterprise.
VA does not have a cost estimate for this bill at this time, but will
continue to work to provide this to the Committee shortly.
Members of the Committee, this concludes my statement. I would be
happy to answer any questions you may have.
Prepared Statement of Kayda Keleher
Chairman Wenstrup, Ranking Member Brownley and members of the
Subcommittee, on behalf of the men and women of the Veterans of Foreign
Wars of the United States (VFW) and its Auxiliary, I want to thank you
for the opportunity to present the VFW's views on today's pending
legislation.
H.R. 91, Building Supportive Networks for Women Veterans Act
The VFW strongly supports this legislation, which would make
permanent VA's counseling in retreat setting program for women
veterans. VA's retreat counseling program has served as an invaluable
tool to help newly discharged women veterans seamlessly transition back
into civilian life. The VFW supported the original program established
by the Caregivers and Veterans Omnibus Health Services Act of 2010 and
subsequent year-long extensions. The VFW believes it is time to make
this important program permanent.
H.R. 95, Veterans' Access to Child Care Act
This legislation would extend and expand the VA child care pilot
program, which helps veterans attend their health care appointments and
complete their treatment plans by providing necessary child care
services. The VFW supports this legislation and has a recommendation to
improve it which we urge this subcommittee to consider.
Veterans with dependent children face diverse barriers when
obtaining their earned care and benefits. A barrier specific to parents
is finding child care so they can attend medical appointments.
Currently, VA has three pilot programs which offer child care services
to enable veterans to attend medical appointments. Veterans who have
used this program tell the VFW they would not have completed their
treatment plans if it were not for the VA child care program.
The lack of child care is particularly difficult for homeless
veterans who may forgo needed inpatient treatments for fear of losing
custody of their children. The VFW firmly believes child care service
would also improve access to employment training and counseling
services that homeless veterans need to obtain meaningful employment
that will allow them keep their homes and stay off the streets. That is
why the VFW urges this subcommittee to expand eligibility for this
important program by giving homeless veterans the opportunity to
receive child care services while they attend employment training
programs.
H.R. 467, VA Scheduling Accountability Act
The VFW believes all VA medical facilities must comply with
scheduling laws and directives. However, the VFW cannot support this
legislation because it would not resolve the underlying issue with
scheduling at VA medical facilities.
Before requiring compliance, Congress and VA must first improve
VA's wait time metric and scheduling directives. In the VFW's most
recent VA health care report, only 67 percent of veterans indicated
they obtained a VA appointment within 30 days, which is significantly
less than the 93 percent of appointments VA reported were scheduled
within 30 days during the same timeframe. This is because the way VA
measures wait times is not aligned with the realities of scheduling a
health care appointment.
VA also uses a wait time metric called the ``preferred date'' to
measure whether a veteran is given an appointment within 30 days from
the date a veteran would like to be seen or is told it is clinically
necessary, which fails to account for the full length of time a veteran
waits for care. The VFW is also concerned that VA's preferred date
metric remains susceptive to data manipulation. For example, when
veterans call to schedule appointments, they are asked when they prefer
to be seen. The first question a veteran logically asks is, ``When is
the next available appointment?'' Schedulers have the ability to input
the medical facility's next available appointment as the veteran's
preferred date--essentially zeroing out the wait time. VA must correct
its wait time metric to more accurately reflect how long veterans wait
for their care.
VA has established an arbitrary wait time goal of scheduling
appointments within 30 days of a veteran's preferred date. This not
only ignores whether a veteran should be seen earlier, but it is not
aligned with how the health care industry measures wait times. In a
recent report, the RAND Corporation found the best practices in the
private sector for measuring timeliness of appointments are generally
based on the clinical need of the health care requested and in
consultation with the patient requesting the care. That is why the VFW
has urged VA and Congress to move away from using arbitrary standards
to measure whether an appointment was delivered in a timely manner, and
adopt industry best practices by basing the timeliness of appointment
scheduling on a clinical decision made by health care providers and
their patients.
The VFW does not believe this legislation can be successful if VA's
wait time metric remains flawed and susceptible to data manipulation.
Compliance with flawed metrics does not lead to better health care
outcomes for veterans.
The VFW also has serious concerns with the requirement to withhold
bonuses from VA medical center directors who fail to comply with
scheduling standards. Section 205 of Public Law 113-146, the ``Veterans
Access, Choice, and Accountability Act of 2014'' prohibited the use of
scheduling and wait time metrics in determination of performance
awards. Congress did so because the VA Office of the Inspector General
and congressional oversight found VA employees were manipulating
scheduling and wait time data to receive bonuses or appease management.
The VFW fears this legislation would reinstate a culture of cover ups
to receive awards.
Instead of linking bonuses to compliance with scheduling
requirements, which will not result in veterans receiving more timely
care, Congress must focus on evaluating and addressing the underlying
reasons for high wait times. The VFW has highlighted many of these
issues in the past. VA's medical support assistance (MSA) positions,
who handle scheduling for the veterans, face the highest rate of
turnover in the VA health care system. Due to the cumbersome hiring
process and the low compensation levels for MSAs, it takes an average
of six months to fill an MSA vacancy. The VFW urges Congress to expand
VA's direct hire authority for this critical position.
VA's scheduling system is also archaic and hard to use. VA is in
the process of implementing a modification to its scheduling system and
is pursuing a commercial off the shelf (COTS) scheduling system. The
VFW supports a COTS solution to VA's scheduling system and urges
Congress to make certain VA has the resources needed to finally update
its outdated scheduling system with a state-of-the-art COTS system.
H.R. 907, Newborn Care Improvement Act
The VFW supports this legislation, which would expand VA's
authority to provide health care to a newborn child, whose delivery is
furnished by VA, from seven to 42 days post-birth.
According to the Centers for Disease Control and Prevention,
newborn screenings are vital to diagnosing and preventing certain
health conditions that can affect a child's livelihood and long-term
health. The VFW understands the importance of high quality newborn
health care and its long term impact on the lives of veterans and their
families. Congress must ensure newborn children receive the proper
post-natal health care they need.
H.R. 918, Veteran Urgent Access to Mental Health Care Act
This legislation would ensure veterans with other than honorable
discharges, also known as ``bad paper'' discharges, have the
opportunity to receive urgent mental health care from VA. The VFW
supports the intent of this legislation, but believes it should be
expanded before it is passed.
Under current law, eligibility for VA health care and benefits is
based on many different factors. Most benefits, including VA health
care and disability compensation, require veterans to have obtained a
discharge that is other than dishonorable to be eligible. This means
veterans who receive bad paper discharges and meet other eligibility
requirements are eligible for VA health care and most benefits.
However, VA has implemented a stringent interpretation of current law.
In a recent report entitled Underserved: How the VA Wrongfully Excludes
Veterans with Bad Paper, Swords to Plowshares found VA's process for
determining health care and benefits eligibility is not consistent with
the law, and results in 90 percent of veterans with bad paper
discharges being denied eligibility to much needed health care and
benefits.
When veterans go to a VA medical center for non-emergent care as a
new patient, they are required to undergo an eligibility determination
before they can receive care. Veterans who have an honorable discharge
and meet other criteria--such as having service-connected disabilities,
combat service, low income, or certain earned service medals--are
allowed to receive care immediately or schedule an appointment. When
veterans with bad paper discharges present to a VA medical facility for
the first time, they are told they must undergo a VA character of
discharge determination before they can receive care, which takes an
average of 1,200 days according to Swords to Plowshares' report.
It is also important to clarify that the term ``dishonorable'' has
different legal definitions for the Department of Defense (DOD) and VA.
Whereas DOD only issues dishonorable discharges to service members who
have been convicted of major offenses in a general court martial, title
38, United States Code (U.S.C.) specifies that veterans can be
characterized as ``dishonorable'' when they are discharged for specific
offenses, conscientious objector status, desertion, or for being AWOL
for more than 180 days, regardless of whether or not such veterans
received a dishonorable discharge from DOD. For that reason, VA created
a character of discharge evaluation process to evaluate whether a
veteran received a discharge that is considered dishonorable under
title 38 U.S.C., but not by DOD standards. The VFW believes that this
review process has been misapplied to all bad paper discharges absent
the specific disqualifying criteria, which has resulted in VA depriving
certain veterans with bad paper discharges of benefits they not only
earned, but in many cases need.
Veterans who served honorably in combat, but were administratively
discharged upon returning home due to relatively small infractions,
like missing formations or self-medicating undiagnosed conditions,
should not have to wait years before they can receive VA health care
and benefits. Currently, veterans with bad paper discharges are three
times more likely to die by suicide. Without access to VA health care,
those suffering from service-related mental health injuries are left on
their own to deal with their mental health symptoms, making recovery
nearly impossible
The VFW is pleased that Secretary of Veterans Affairs David J.
Shulkin has announced he will expand access to urgent mental health
care to veterans who have received bad paper discharges. However, the
VFW firmly believes VA does not and should not provide sporadic care.
VA provides veterans a full continuum of high quality care that has
been found to outperform the private sector and leads to a lower
likelihood of attempts or death by suicide. That is why the VFW has
urged VA to expand its proposed regulations to ensure veterans with bad
paper discharges receive full eligibility to VA health care, rather
than simply receiving access to sporadic urgent mental health care.
If VA fails to act, the VFW urges Congress to amend relevant
sections of title 38, U.S.C., to make clear these veterans are eligible
for full VA health care, not just urgent mental health care. The VFW
recognizes that doing so would significantly increase VA's patient load
and could exacerbate access issues. That is why the VFW urges Congress
to make certain VA receives the resources it needs to care for these
vulnerable veterans.
H.R. 1005, to improve the provision of adult day health care services
for veterans
The VFW supports this legislation, which would expand adult day
health care benefits for veterans who are eligible for long-term
inpatient care.
Currently, veterans who are at least 70 percent service-connected
are eligible to receive cost free nursing home or domiciliary care at
any of the more than 120 state veterans' homes throughout the country.
While nursing home care is a necessity for veterans who can no longer
live in the comfort of their home, the VFW strongly believes veterans
should remain in their homes as long as possible before turning to
inpatient and long-term care options. This legislation would ensure
veterans have the opportunity to receive adult day care so they can
remain in their homes as long as possible.
H.R. 1162, No Hero Left Untreated Act
The VFW opposes this legislation, which would require VA to carry
out a pilot program to provide veterans Magnetic eResonance Therapy
(MeRT) to treat post-traumatic stress disorder (PTSD) and other mental
health conditions.
The VFW supports expanding access to integrated and complementary
therapies that have proven to effectively treat veterans who have not
responded to conventional or evidence-based mental health care.
However, MeRT is not approved by the U.S. Food and Drug Administration
(FDA) and has shown little to no evidence of effectiveness in treating
PTSD. VA already offers similar treatments that have been proven to
work, cost less, and are FDA approved.
Additionally, this legislation would not provide VA additional
funding to test the efficacy of MeRT. The VFW believes that VA must
spend its already scarce health care resources on therapies which have
shown promise or have a proven track record.
H.R. 1545, VA Prescription Data Accountability Act 2017
The VFW supports this legislation, which would expand VA's
requirement to report prescription data to state prescription drug
monitoring programs (PDMP).
Current law requires VA to report certain data on prescription of
opioids and other narcotics to state PDMPs. The requirement is for VA
to share the data of veterans and dependents. However, VA systems
cannot differentiate between dependents and other non-veterans who have
received care through the VA health care system. While the vast
majority of non-veterans receive VA care through the Civilian Health
and Medical Program of the VA (CHAMPVA) outside of VA medical
facilities, VA does provide care to some non-veterans in its medical
facilities, particularly in the emergency room. The VFW supports the
sharing of prescription data with state agencies and agrees VA should
share data for non-veterans as well.
H.R. 1662, to prohibit smoking in any facility of the Veterans Health
Administration
The VFW does not have a position on this legislation that would
prohibit smoking in and around VA medical facilities. We do have some
points to consider, however.
According to the Centers for Disease Control and Prevention,
smoking is the leading cause of preventive death in the United States.
The VFW is aware of the health hazards associated with smoking and
understands that the overwhelming majority of America's health care
systems and facilities have moved to smoke-free campuses. On the other
hand, VA is required by Public Law 102-585, the ``Veterans Health Care
Act of 1992,'' to establish and maintain ``a suitable indoor area in
which patients or residents may smoke.''
As a result, 120 VA community living centers (nursing homes) have
co-located smoking facilities for veteran residents. Recent news
reports also indicate that VA operates nearly 1,000 outdoor and 15
other designated smoking areas. While the VFW understands the reasons
for shifting VA medical facilities to smoke-free campuses, we are
concerned that this legislation would force VA to comply with arbitrary
implementation dates that would require a significant lifestyle change
for veterans who rely on VA for their health care without enough time
to adjust to new requirements, particularly for veterans who reside in
VA nursing homes.
This legislation would require VA to prohibit indoor smoking within
90 days of enactment, and outdoors by October 2022. This means that
veterans who reside in the 120 VA nursing homes with co-located smoking
areas, most of which are ventilated indoor smoking rooms, would only be
given three months to adjust to a smoke-free environment. Approximately
9,225 veterans currently reside in VA community living centers. This
legislation would force approximately 20 percent of veterans estimated
to be smokers (2,000 average daily census) to either leave or quit
smoking within 90 days--neither of which are easy decisions. If this
subcommittee advances this legislation, the VFW urges it to consider
extending the effective date to allow veterans more time to adjust to a
new lifestyle.
If VA medical facilities are to become smoke-free campuses, VA must
strengthen and expand its smoking cessation programs. This includes
nicotine replacement therapy for veterans residing in VA nursing homes
who tend to be older with severe service-connected disabilities, and
who may not be able to easily travel off campus to smoke, as well as
veterans using VA rehabilitation therapies for substance abuse of
illicit drugs and alcohol. Treatment must be provided to veterans, not
forced upon them. By forcing veterans to not smoke, unintended
consequences of veterans' not seeking care and treatment they need will
be inevitable. VA must also find ways to mitigate the loss of non-
clinical benefits veterans identify with smoking, such as socializing
with other veterans in smoking rooms.
Draft legislation, Veterans Affairs Medical Scribe Pilot Act of 2017
This legislation would require VA to carry out a pilot program to
evaluate the efficacy of using medical scribes. The VFW supports this
bill and has a recommendation to improve it.
A recent VA study evaluating common challenges faced by clinicians
in their day-to-day environments, conducted by VA's Emerging Health
Technology Service, concluded that burdensome non-clinician-centered
electronic health care systems have a significant impact on morale and
retention of VA physicians and veterans' experiences due to reduced
facetime with providers. This legislation would reduce the time
physicians spend on the keyboard and maximize face-to-face time with
their patients.
The Emerging Health Technology Service assessment determined that
searching and navigating disparate data systems consumes vast amounts
of time VA clinicians can spend interacting with their patients. That
is why the VFW is glad this legislation would require medical scribes
to help providers navigate a veteran's electronic medical record and
respond to messages, such as secure messages, in addition to serving as
a scribe during appointments.
VA currently operates a Health Advocate Program in six VA medical
facilities that is very similar to the medical scribe pilot programs
this legislation would establish. However, the majority of VA's Health
Advocate Program uses nurses instead of medical scribes to assist VA
physicians. In addition to serving as a scribe during medical
appointments and helping physicians navigate a veteran's electronic
health care record, health advocates ensure veterans understand their
treatment plans when the appointment has concluded. They also have
appointments with veterans to evaluate whether they are making progress
with their treatment. While the VFW does not believe scribing is the
most effective use of nurses, we do urge this subcommittee to base the
medical scribe pilot programs on VA's health advocate program. Medical
scribes should be trained to help veterans understand their treatment
plan and ensure veterans are on track to successfully complete their
treatments.
Prepared Statement of Shurhonda Y. Love
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting DAV (Disabled American Veterans) to testify
at this legislative hearing of the Subcommittee on Health. As you know,
DAV is a non-profit veterans service organization comprised of 1.3
million wartime service-disabled veterans that is dedicated to a single
purpose: empowering veterans to lead high-quality lives with respect
and dignity. DAV is pleased to be here to present our views on the
bills under consideration by the Subcommittee, and we appreciate your
invitation.
H.R. 91-Building Supportive Networks for Women Veterans Act
If enacted, beginning January 1, 2018, this bill seeks to make
permanent the pilot program to provide reintegration and readjustment
counseling in a retreat setting for women veterans newly separated from
service in the Armed Forces, after a prolonged combat theater
deployment. Participation in this program is voluntary, and done
through an application and screening process, which requires active
participation in counseling through a VA Vet Center, or Medical Center.
This bill would provide: information and assistance on reintegration
into family, employment, and community; financial and occupational
counseling; information and counseling on stress reduction and conflict
resolution; and any other counseling VA considers appropriate to assist
participants in reintegrating back into their families and communities.
This measure also requires VA to provide a biennial report on the
program.
Based on information taken from the biennial reports of the
program, nearly all participants identified some element of the
curriculum that was useful to their readjustment. One report indicates,
as a group, 85 percent of the participants showed significant
improvement in psychological well-being based on pre-treatment and
post- treatment testing. 75 percent of participants maintained
significant improvement in psychological well-being at two months post
retreat. After the retreat, participants were administered a Stress
Symptoms and Stress Coping Skills survey; more than 80 percent of
participants showed a decrease in stress symptoms, and improvement in
positive coping skills during the two-month period after the retreat.
Participants expressed high satisfaction with the results of the
retreat. The positive statistics of the program coupled with
satisfaction of women veterans serve as testament to the success of the
program. It is for this reason, we support making the program
permanent.
We thank the Subcommittee for its continued efforts to improve
women veterans' programs and services and are pleased to support the
Building Supportive Networks for Women Veterans Act, which is in line
with DAV Resolution No. 129, which calls for enhanced medical services
and benefits for women veterans.
H.R. 95-Veterans' Access to Child Care Act
The Veterans' Access to Child Care Act would provide child care
assistance to an eligible veteran during any period that the veteran is
receiving mental health or intensive health care or mental health
services at a VA facility. Child care assistance payments may be
provided to an onsite facility of the Department, directly to a private
child care agency, in collaboration with a facility or program of
another federal department or agency, or in the form of a stipend paid
to a licensed child care provider. This bill requires that, to the
extent practicable, the program should be modeled after the VA's Child
Care Subsidy Program.
All veterans deserve to have access to the high quality health care
offered by the VA. The need for child care should not be a bar to
receiving such care. The VA's April 2015 study, Barriers for Women
Veterans to VA Health Care Final Report, indicates 42 percent of VA
health care users report finding child care to attend medical
appointments is somewhat difficult. This is especially true for women
who are not married, and are the primary care takers of young children.
As the number of women enlisting into military service continues to
grow, so too will the number of women veterans seeking care at VA. VA
must ensure all veterans have every opportunity to access the services
they have earned and need to fully readjust following military service.
For many veterans, the provision of child care assistance by VA is not
a convenience, it is a necessity.
DAV is pleased to support H.R. 95. Our report, Women Veterans, The
Long Journey Home, recommends child care services to support better
access to VA health care. DAV resolution 129 calls for support of
legislation to enhance medical service and benefits for women veterans,
and is consistent with the intent of this bill.
H.R. 467-VA Scheduling Accountability Act
This bill would mandate a report be provided to both chambers of
Congress to indicate whether or not the VA medical centers have been
annually certified to be in compliance with all VA regulations,
policies, and directives relative to veteran patient appointment
scheduling for health care and medical services. This bill requires
directors of each medical facility to submit an annual report to the
Secretary indicating the status of their compliance with appointment
scheduling requirements. If the medical center is in full compliance
with said policies, regulations and directives, they are to certify
compliance to the Secretary. In the event a facility is unable to
certify full compliance, the director is to provide the Secretary with
an explanation of the failure, and corrective measures being taken to
bring the facility into full compliance. The bill mandates that the
Secretary is barred from providing a waiver to medical centers failing
to certify, and must report the status of each medical facility along
with reports received from the directors of these facilities to
Congress. The bonuses for officials responsible for the uncertified
medical facility would be withheld the following year of non-
certification.
Although DAV has no specific resolution, we support the intent of
this bill and the requirement for VA to be in full compliance with all
regulations, policies, and directives related to scheduling; however,
if a lack of resources or antiquated technology or other items outside
the control of local directors, are the underlying reasons for
noncompliance, these factors should be taken into consideration before
withholding bonuses to otherwise well performing medical center
directors.
H.R. 907-Newborn Care Improvement Act
If enacted, this bill would provide up to 42 days of health care to
newborn children of women veterans who are receiving maternity care
through the Department of Veterans Affairs (VA). Current law authorizes
VA to cover the cost of newborn care for up to seven days. This bill
not only expands post-natal care, but also requires VA to provide an
annual report to Congress no later than October 31 of each year that
includes the number of newborn children who received services during
each fiscal year.
Of great concern to DAV are those women whose service-connected
disabilities contribute to high risk pregnancies, or pre-term
deliveries. According to VA, in an analysis of VHA utilization of
health care by Operations Enduring and Iraqi Freedom and New Dawn (OEF)
(OIF) (OND) veterans, spanning from October 1, 2001 to June 30, 2015;
of the 1.2 million veterans who have obtained VA health care, almost 12
percent of these veterans are women. A significant number of women
veterans from this group have a mental health diagnosis and it is
important to take into consideration the effect these potential
service-related conditions have on their pregnancies.
According to the estimate provided by VA's Chief Business Office
report dated November 19, 2015, 11 percent of the 2,200 births to women
veterans occurring each year are complicated births requiring neonatal
care beyond seven days. Likewise, the juxtaposition of pregnancy and
mental health related issues is to be noted since pregnancy itself can
precipitate or exacerbate mental health conditions, and maternal
anxiety during pregnancy can give rise to pre-term deliveries and lower
birth weights.
DAV has no specific resolution on this particular measure; however,
we have no objection to its passage, based on the above-noted findings.
H.R. 918-Veteran Urgent Access to Mental Healthcare Act
This legislation would allow VA to furnish an initial mental health
assessment and urgent mental health care treatment to a veteran of the
Armed Forces having an ``other than dishonorable'' or ``bad conduct''
discharge. This treatment includes an initial mental health assessment
and the treatment of an urgent health care need, to include suicide
prevention efforts. The veteran must have participated in or
experienced combat operations or hostilities, including the use of
unmanned aerial vehicles; or was a victim of a physical assault,
battery of a sexual nature or suffered military sexual trauma and must
not be eligible for VA care under any other provision in statute and
has applied for a character of service determination and such
determination has not been made.
In the event that VA care is clinically inadvisable, or if
facilities are not located in a place that would allow reasonable
access to a VA medical campus capable of providing the required
assessment or treatment, non-Department care would be authorized. To
fulfil the obligations of this bill, the Secretary is authorized to
enter into contracts or agreements with non-Department facilities to
furnish hospital care and medical services to veterans at said
facilities. In furnishing health care services to veterans under this
section, the Secretary shall seek to ensure that health care services
are furnished in a therapeutically appropriate setting, and provide
referral service to assist former service members who are not eligible
for services under this chapter to obtain services from sources outside
of the Department.
The Secretary shall provide information regarding this program in
coordination with the Secretary of Defense to members separating from
the Armed Forces and to veterans to ensure awareness of the program,
and the process by which to utilize services. The Secretary would be
required to establish an 800 number, and keep updated information
regarding the services offered, ensure information is posted in VA
facilities where it is highly visible, and also make information
regarding this program available through public information services.
No later than one year after the date of enactment, the Secretary is to
submit an annual report to Congress detailing the number of individuals
receiving care under this program to include gender and any additional
information the Secretary deems necessary. In conjunction with this
program, a suicide study is to be conducted that compares the rate and
method of suicide among veterans receiving heath care from VA and those
who have not. An additional comparison is to be done on the rate of
veterans committing suicide, and the incidence of serious mental health
issues among combat and non-combat veterans.
DAV is pleased to support H. R. 918, which is in line with DAV
Resolution No. 226, calling for support of a more liberal review of
other than honorable discharges in cases of posttraumatic stress
disorder, traumatic brain injury, mental health conditions related to
military sexual trauma, and other trauma for the purpose of eligibility
for VA benefits and services.
H.R. 1005-to improve the provision of adult day health care services
for veterans
H.R. 1005, if enacted, would authorize the Secretary to enter into
agreements with state veterans homes to provide adult day health care
for veterans who are eligible for, but do not receive, skilled nursing
home care under section 1745(a) of title 38, United States Code.
Eligible veterans are those who require such care due to a service-
connected disability, or who have a VA disability rating of 70 percent
or greater and are in need of such care. The payment to a state home
under this program would be at the rate of 65 percent of the amount
payable to the state home if the veteran were an inpatient for skilled
nursing care and payment by VA would be considered payment in full to
the state home.
Adult day health care is an alternative to traditional skilled
nursing care that can allow some veterans requiring long-term service
and support to remain in their homes near family and friends, rather
than be institutionalized in nursing homes. This program is designed to
promote socialization, stimulation, and to maximize independence while
enhancing quality of life as well as providing comprehensive medical,
nursing, and personal care services for veterans.
DAV is pleased to support H.R. 1005, which is in line with DAV
Resolution No. 127, calling for support for the state veteran home
program, recognizing state home care as the most cost-effective care
available for sick and disabled veterans with long-term care needs
outside the VA health care system.
H.R. 1162-No Hero Left Untreated Act
This bill seeks to implement a one-year pilot program using
Magnetic EEG/EKG-guided resonance therapy (MeRT) to veterans in no more
than two VA Facilities, with no more than 50 veteran participants
suffering from posttraumatic stress, traumatic brain injury, conditions
related to military sexual trauma, chronic pain, or opiate addiction.
Not later than 90 days after the termination of the program, the
Secretary is to submit a report to the House Committee on Veterans'
Affairs on the pilot. The pilot is to be funded through existing funds
already appropriated to VA.
The measure notes that 400 veterans with post-traumatic stress
disorder, traumatic brain injury, military sexual trauma, chronic pain,
and opiate addiction have successfully been treated with MeRT.
Likewise, recent clinical trials and randomized, placebo-controlled,
double-blind studies, have produced promising measurable outcomes.
According to VA, Repetitive transcranial magnetic stimulation (rTMS), a
similar treatment option is currently available to veterans. rTMS has
been FDA approved in the treatment of resistant depression, and opioid
addiction. It is unknown if one method of treatment is better than the
other.
DAV has no resolution on this issue and generally does not oppose
or support a specific therapeutic intervention; however, we do support
the use of complementary and alternative medicine and research to
confirm new therapies as beneficial to veterans.
H.R. 1545-VA Prescription Data Accountability Act
This bill would amend title 38, Unites States Code, to clarify the
authority of the Secretary to disclose patient information to state-
controlled substance monitoring programs when controlled drugs are
dispensed by VA. Current law authorizes the Secretary to disclose said
information for veterans and their dependents when VA prescribes a
state-controlled substance. This bill would expand the Secretary's
authority to report all individuals who receive these drugs from VA.
DAV has received no national resolution from our membership that
addresses this particular legislation; therefore, we take no official
position.
H.R. 1662-to prohibit smoking in any facility of the Veterans Health
Administration
This bill seeks to amend title 38, United States Code, to prohibit
smoking by all persons in all facilities of the Veterans Health
Administration (VHA). Persons may continue to smoke outdoors at VHA
facilities until October 1, 2022; after which date, smoking will be
prohibited. The term smoking is to include all forms of combustion of
tobacco, including e-cigarettes, cigars, and pipes. The term facility
includes any medical center, nursing home, domiciliary facility,
outpatient clinic, or center that provides readjustment counseling that
is under the jurisdiction of the VA, under the control of the Veterans
Heath Administration.
DAV has no resolution on this issue; however, the prevalence of
smoking among people with mental illnesses is startling. According to
the Substance Abuse and Mental Health Services Administration, 36-80
percent patients with major depression use tobacco; 45-60 percent with
Post-traumatic stress disorder; 51-70 percent with bipolar mood
disorder; 62-90 percent with schizophrenia, and; 32-60 percent with
anxiety disorders. VA has a high percentage of veterans receiving
mental health services. In fiscal year 2015, more than 1.6 million
veterans received specialized mental health treatment from VA.
Individuals with mental health concerns are disproportionately
affected by, and suffer from the negative consequences of, tobacco use
disorder; perhaps because they are not receiving adequate information
and cessation services or that smoking has historically been part of
psychiatry's culture. While research has shown high levels of patient
support for indoor smoking bans in psychiatric settings, even among
current smokers, patients have a unique perspective on their experience
in psychiatric inpatient facilities, and every effort should be made to
include their voices in policy decision-making at a national level and
at individual facilities.
While we know the health benefits that come with smoking cessation,
we hope the implementation of this measure takes a compassionate
approach to eliminating tobacco use in VA facilities, as it is a
substance misuse disorder particularly impacting patients with mental
illness. While VA is a leader in treatment of substance use disorder
and focuses significant resources on tobacco cessation, many veterans
do not avail themselves of counseling and medication options to quit
smoking. If this bill is enacted, we suggest the measure require VA to
conduct a comprehensive tobacco cessation outreach program targeting
all veteran patients that smoke to raise awareness about options for
quitting. The policy must recognize that nicotine dependence is a
chronic, relapsing disorder; with most tobacco users in the general
population requiring multiple attempts before they are finally able to
quit for good.
Draft bill-to carry out a pilot program on the use of medical scribes
in VA medical centers
If enacted, this bill seeks to implement a two-year pilot program
to employ a total of 40 scribes at 10 different medical centers, where
a minimum of four medical centers are located in rural areas, and four
located in urban areas. Medical scribes would be assigned at a ratio of
two scribes to each of two physicians with 30 percent deployed in the
provision of emergency care, 70 percent in the provisions of specialty
care having the longest patient wait times, or lowest efficiency
ratings as determined by the Secretary.
These scribes would assist the physician or practitioner in
navigating the electronic health record, responding to messages as
directed by the provider, and entering information into the electronic
health record as directed by the provider. Reports on the pilot program
are to be provided to Congress beginning six months after enactment,
and every six months for the duration of the pilot. These reports are
to include an analysis of each of the scribes in the areas of provider
efficiency, patient satisfaction, average wait time, the number of
patients seen per day by each physician or practitioner and the amount
of time required to hire and train the scribe.
Upon termination of the scribe pilot program, the Comptroller
General shall submit a report to Congress that includes a comparison of
the pilot program with similar programs carried out in the private
sector. Funding for the program is to come from existing funding
appropriated to the Department.
In response to the growing complexity of health care and the
electronic medical record, medical scribes have been used in the
private sector to improve productivity, clinical documentation,
completion of medical records, as well as provider satisfaction.
We recommend the flexible deployment of scribes to areas in which
they are not only needed, but can be the most effective. We caution
about the restrictive deployment of scribes as directed by this bill,
as this could lead to not enough resources in one area, and too many in
another. VHA should reserve the ability to place the scribes in the
areas of the greatest need, and in accordance with performance measures
as well as accessibility.
DAV Resolution No. 244 adopted at our most recent National
Convention calls for quality care for veterans to be achieved when
health care providers are given the freedom and resources to provide
the most effective and evidence-based care available. We believe the
use of medical scribes could help to accomplish this goal, and,
therefore, we support the intent of this bill.
This concludes my testimony, Mr. Chairman. DAV would be pleased to
respond for the record to any questions from you or the Subcommittee
Members concerning our views on these bills.
Prepared Statement of Sarah S. Dean
Chairman Wenstrup, Ranking Member Brownley, and members of the
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank
you for the opportunity to present our views on the broad array of
pending legislation impacting the Department of Veterans Affairs (VA)
that is before the Subcommittee. No group of veterans understand the
full scope of care provided by the VA better than PVA's members-
veterans who have incurred a spinal cord injury or disease. Most PVA
members depend on VA for 100 percent of their care and are the most
vulnerable when access to health care, and other challenges, impact
quality of care. These important bills will help ensure that veterans
receive timely, quality health care and benefits services.
H.R. 91, the ``Building Supportive Networks for Women Veterans Act''
PVA supports H.R. 91, the ``Building Supportive Networks for Women
Veterans Act,'' a bill to make permanent the pilot program on
counseling in retreat settings for women veterans newly separated from
service in the Armed Forces. The bill would provide VA with the
authority to extend the program using the same measurements and
eligibility requirements. PVA supported the original program
established by the ``Caregivers and Veterans Omnibus Health Services
Act of 2010'' and has been pleased to see it continue.
In surveys conducted after the program, participants consistently
showed better understanding of how to develop support systems and to
access resources at VA and in their communities.
The OEF/OIF women veterans at these retreats are most often coping
with effects of severe Post-Traumatic Stress and Military Sexual
Trauma. They work with counselors and peers, building on existing
support. If needed there is financial and occupational counseling. To
be eligible, women veterans must have been deployed in OEF/OIF, and
have completed at least three sessions of counseling in the past six
months.
The program, managed by the Readjustment Counseling Service, has
been a marked success since its inception in 2011. The results have
been overwhelmingly positive for women veterans, who experience
consistent reductions in stress symptoms as a result of their
participation. Other long lasting improvements included increased
coping skills. It is essential for women veterans that Congress make
this program permanent. We believe the value and efficacy is
undeniable.
H.R. 95, the ``Veterans' Access to Child Care Act''
PVA supports H.R. 95 the ``Veterans' Access to Child Care Act.''
This legislation would make permanent the provision of child care
assistance to veterans receiving certain medical services from the
Department of Veterans Affairs.
PVA believes child-care is a critical avenue for veterans to access
health care, vocational rehabilitation, education, and employment
services. There is no denying that when heads of households have access
to reliable child care their participation in their own health care and
wellbeing increases.
A VA report from 2015, Barriers for Women Veterans to VA Health
Care, discussed nine primary barriers, one of which was child care.
Forty-two percent of women surveyed for the report said they had
difficultly securing child care in order to seek VA health care
services and would find on-site child care to be useful. PVA urges
Congress to make this program permanent in order to care for veterans
who would otherwise not be able to access VA.
Similarly, for veterans seeking mental health care, GAO has
identified several barriers that deter veterans, including stigma, lack
of understanding of the potential for improvement, lack of child care
or transportation, and work or family commitments. Timely access to
mental health care is imperative to preventing suicide, obviating long-
term health consequences, and minimizing the disabling effects of
mental illness.
While the permanent presence of child care services is the right
thing to do, it is also economic. Ensuring veterans have timely access
to health care decreases the compounding costs that come with treating
an injury or mental illness later down the line. A trustworthy child
care option alleviates stressors for the veteran, and encourages they
maintain their contact and treatment plan with their VA providers. The
extended pilot program is set to expire on December 31, 2017. PVA urges
Congress to continue this vital service.
H.R. 467, the ``VA Scheduling Accountability Act of 2017"
PVA supports the ``VA Scheduling Accountability Act of 2017,''
requiring all VA medical facilities to certify compliance with
scheduling laws and directives. This legislation would require each
facility director to annually certify compliance with VHA Directive
2010-027, or any successor directive that replaces it. The aim is to
increase transparency of scheduling practices at VA. In May 2013, VA
waived the annual certification requirement. This legislation makes
permanent the requirement for each VA medical center report its
scheduling compliance certification. If a facility director is unable
to certify compliance the director will then submit a report to the
Secretary of VA explaining why the facility is out of compliance and
what steps are being taken to achieve compliance. In turn, the
Secretary will report to the House and Senate Committees on Veterans'
Affairs a full list of the facilities that have or have not certified
compliance. Lastly, if a facility does not make a certification, their
leadership would then be prohibited from receiving any award or bonus
during the following year the certification was not made.
While PVA supports this bill it is unclear how this legislation
will resolve the underlying problems with scheduling at VA medical
facilities. Preferred date metrics do not properly measure how long a
veteran waits for an appointment. A GAO report from April of 2016,
``Actions Needed to Improve Newly Enrolled Veterans' Access to Primary
Care'' highlighted inaccurate recording of appointment request and wait
times for that appointment in the scheduling system. Using the request
date as the starting point is flawed because VA uses an arbitrary time
goal of 30 days for all appointments, a standard used by no other
health care system. The overwhelming best practices for measuring
timeliness is clinical need of the requested care, and in consultation
with the patient. The usefulness of this legislation is unclear as long
as VA's wait time metrics remain flawed and vulnerable to manipulation.
Compliance with the certification does not guarantee better scheduling
practices and improved health care access for veterans.
H.R. 907, the ``Newborn Improvement Act''
PVA supports H.R 907, the ``Newborn Improvement Act.'' This bill
would amend Section 1786 of title 38, United States Code, to authorize
hospital stays of up to 42 days for newborns under VA care. The current
provision allows a maximum stay of seven days. As the average stay for
a healthy newborn is two days, any newborn needing additional coverage
is likely to be facing complications immediate after birth or a severe
infant illness.
The current seven day coverage is in a non-department facility for
eligible women veterans who are receiving VA maternity care. Beyond the
seven days, the cost of care is the responsibility of the veteran and
not VA, even if complications require continued care beyond the
coverage period. Post-natal health is critical to newborn health which
directly impacts the lives and wellbeing of veterans and their
families.
H.R. 918, the ``Veterans Urgent Access to Mental Health Care Act''
PVA supports H.R. 918, which would provide urgent mental health
care to former members of the military who are not otherwise eligible
to receive care in the VA due to having an other-than-honorable
discharge status. The Secretary's recent announcement that VA will be
pro-actively offering mental health care services in urgent situations
demonstrates the importance of the issue and passage of supporting
legislation.
The scope of this bill is appropriately limited to former military
members who are facing an imminent mental health care crisis and have
already begun the review process of their discharge status. Those
undergoing review have specifically alleged that the circumstances
leading to their other-than-honorable discharge were a direct or
indirect product of the physical or mental wounds of war. The scope is
also properly limited to those who deployed, participated in or
experienced combat operations or hostilities, or were the victims of
sexual assault, battery or harassment.
H.R. 1005, ``to improve the provision of adult day health care services
for veterans''
PVA supports H.R. 1005, a bill that would provide ``no cost''
medical model adult day health care (ADHC) services to veterans who are
70 percent or more service-connected disabled. By authorizing the
Secretary to enter into agreements with state veterans homes the bill
would provide ADHC to those veterans who are eligible for, but do not
receive, skilled nursing home care under section 1745(a) of title 38,
USC. Currently, VA pays State Homes a per diem for ADHC. The per diem
rate covers around one-third the cost of the program. H.R. 1005 is an
extension to the Veterans Benefits, Health Care, and Information
Technology Act of 2006 (Pub. L. 109-461), which provides ``no cost''
nursing home care at any State Veterans Home to veterans who are 70
percent or more service connected disabled. This means there are
veterans making a choice between 100 percent free nursing home care or
expensive, out of pocket ADHC. The payment to a state home under this
legislation would be 65 percent the amount payable to the state home if
the veteran were an inpatient for skilled nursing care.
Adult day health care is a crucial service that allows veterans to
remain in their homes and communities and delay entry into traditional
nursing care. While a veteran may need long-term services and supports,
it is not always necessary those services be received in an
institutional setting. Rather, a veteran can receive comprehensive
medical care and socialization without the disruption of permanently
leaving their home. The program is staffed by a team of multi-
disciplinary healthcare professionals who evaluate each participant and
customize an individualized plan of care specific to their health and
social needs. ADHC is designed to promote social stimulation and
maximize independence while also receiving quality of life nursing and
personal care services.
Additionally, we know the wellbeing of a caregiver directly impacts
the quality of care they provide to their veteran. ADHC gives
caregivers the ability to meet other professional and family
responsibilities. Especially for those caregivers whose veteran was
injured before 9/11 and is not eligible for the VA Comprehensive
Caregiver Program. ADHC offers critically needed support. Delayed
institutional care for the severely disabled is a rare jewel in health
care; it is the least costly care for the taxpayer while at the same
time, the highest quality care for certain populations. And perhaps the
most important benefit, ADHC for disabled veterans allows spouses,
children, parents, friends and communities more time together.
H.R. 1162, the ``No Hero Left Untreated Act''
PVA has no official position on H.R. 1162, the ``No Hero Left
Untreated Act.'' This legislation would establish a pilot program with
the Department of Veterans Affairs (VA) to use Magnetic eResonance
Therapy technology, or MeRT technology. This therapy, while not yet FDA
approved, is used to treat post-traumatic stress disorder (PTSD),
traumatic brain injury (TBI), military sexual trauma (MST), chronic
pain, and opiate addiction. The legislation would establish a one-year
pilot program on MeRT technology for fifty veterans at two VA medical
centers.
VA currently offers veterans access to repetitive transcranial
magnetic stimulation (rTMS). This treatment is FDA approved to address
treatment-resistant depression, a comorbid condition in PTSD, TBI, MST,
and chronic pain and opioid addiction. While it is functionally similar
to MeRT there is no existing evidence that MeRT is superior to rTMS for
treating any disorder.
H.R. 1545, the ``VA Prescription Data Accountability Act of 2017"
PVA supports H.R. 1545, the ``VA Prescription Data Accountability
Act of 2017.'' In 2016, the ``Comprehensive Addiction and Recovery
Act'' (CARA) required providers at the Veterans Health Administration
(VHA) to participate in their respective state's Prescription Drug
Monitoring Program (PDMP). Prescribers must check patient records in
the state databases before prescribing pain killers. The pharmacists
are responsible for recording when they fill those prescriptions.
However, data for hundreds of thousands of non-veteran patients
seen at VA is unable to be shared due to a technical oversight in the
law. Current statute authorizes VA to send prescription data for two
groups; veterans, and dependents of veterans. Yet there is a third
group of patients who receive prescriptions through VA; non-dependent,
non-veteran, VA beneficiaries. These patients include CHAMPVA
enrollees, descendants of veterans with birth defects from toxic
exposure, VA health employees, some active duty service members, and
those receiving care through sharing agreements with academic
affiliates. To complicate matters, VistA cannot differentiate between
dependents and other non-veterans. VHA is only sending data for veteran
and dependents. Approximately 10 percent of VHA's patient population
are dependents or non-veteran, non-dependents who receive prescriptions
from VHA. H.R. 1545 would rectify this oversight by stipulating the
prescription data of all those covered by VHA, regardless of patient
group, be submitted to the appropriate PDMP.
The United States is in the midst of an opioid epidemic. PDMPs are
critical to ensuring safe prescribing practices and prevent
inappropriate pushing of narcotics by providers. Forty-nine states and
the District of Columbia have PDMPs. VA has been authorized to share
prescription data with PDMPs since 2011 and last year, CARA required
VHA to participate. The effectiveness of Opioid Safety Initiatives is
dependent on the availability of all prescription data. This loophole
allows for these non-dependent, non-veterans, to access prescriptions
within VA and a community setting, with neither entity the wiser. VA's
2017 projection of non-veteran patients is 715,000. These patients must
have the same safety protections as anyone else. VA would be better
able to mitigate the potential consequences of opioid use.
While PVA strongly supports H.R. 1545, we are concerned that PDMPs
may not be capturing another group; veterans who travel to different
states to receive their specialized care. It is our understanding that
each VA Medical Center (VAMC) only shares prescription data to the
state PDMP in which the VAMC is located. There is little clarity at
this point if state PDMPs can share with other states. Some have
established regional Memoranda of Understanding, communicating
information with neighboring states. But there are veterans,
particularly veterans with a spinal cord injury or disease (SCI/D) who
regularly travel across multiple state lines to one of the 24 SCI
Centers across the country. There has yet to be any assurance that the
prescription data of an SCI/D veteran who receives care at an SCI/D
center in Minneapolis, but lives in Wyoming, will be shared. We urge
the committee to make sure these specialized patient populations are
benefiting from the opioid safety measures in the same way as non-
traveling veterans.
H.R. 1662
PVA has no official position on H.R. 1662, a bill that would ban
smoking at all VA facilities within five years. While we understand the
intent of this legislation and applaud its intent, we would offer one
note of caution. Many veterans smoke as a form of stress relief. It
also serves as a form of social interaction for veterans who are
inpatients for extended periods of time. We have seen this to be
particularly true with veterans who often spend many months as
inpatients in VA's spinal cord injury centers. Smoking serves as a form
of mental health treatment for some of these veterans, albeit not an
optimal one. While it makes perfect sense to eliminate all smoking
inside VA facilities, we believe that the legislation should consider
the impact this prohibition will have on the many veterans who cannot
simply give up the habit.
``Veterans Affairs Medical Scribe Pilot Act of 2017"
PVA supports the draft ``Veterans Affairs Medical Scribe Pilot Act
of 2017.'' This legislation would allow for a pilot program to increase
the use of medical scribes to maximize the efficiency of physicians at
medical facilities of the Department of Veterans Affairs. A medical
scribe helps to decrease the burden of data entry on the part of the
medical provider. They accompany a provider to document the physician-
patient interaction, and enter it into the Electronic Health Record
(EHR) at that time. The physician later reviews and approves the data
entry. This dynamic allows for the physician to spend more
uninterrupted time interacting with the patient, and less time
dictating notes. Multiple studies have indicated that medical scribes
increase physician-patient satisfaction. Further, because the physician
is relieved of data entry, they are able to see more patients, thus
impacting wait times. In a time when VHA is struggling to hire and
retain physicians, allowing for medical scribes to help existing
providers carry the patient volume is essential.
PVA would once again like to thank the Subcommittee for the
opportunity to submit our views on the legislation considered today.
Enactment of much of the proposed legislation will significantly
enhance the health care services available to veterans and their
families. I would be happy to answer any questions that you may have.
Statements For The Record
CONGRESSMAN LEE ZELDIN
Testimony on behalf of H.R. 1005, To Improve Provisions of Adult Day
Health Care Services for Veterans
Good Morning Chairman Wenstrup, and thank you for the opportunity
to testify on behalf of my bill, H.R. 1005, which provides no-cost
medical model adult day health care services for our 70% or more
service connected disabled veterans.
It must always be a top priority of Congress to ensure that all
veterans receive the proper treatment and care they deserve after
fighting for our country. While overseas, these brave men and women are
exposed to significant hardships and trauma, and when they come home,
many return with the physical and mental wounds of war. Despite various
care options for veterans, their choices are often limited, and can
come at a great expense. Service members who are 70% or more disabled
from a service connected injury often require significant assistance
from others in order to carry out basic everyday tasks. In many
instances, veterans must rely on family members for assistance,
creating many financial and emotional hardships for both the veteran
and his or her family. Alternatively, some veterans, without the proper
support system, may even be forced to rely on the assistance of trained
medical professionals and reside in institutionalized facilities for
daily assistance. Veterans in these facilities often spend significant
sums of money each day just to be enrolled, and these expenses can be
expected to span the remainder of the veteran's life in many cases.
While alternative options currently exist, accessing these
services, however, can often be very difficult. One such program that
is currently available is Medical Model Adult Day Health Care; a daily
program for disabled veterans who need extra assistance and special
attention in their day to day lives. Adult Day Health Care programs
provide disabled veterans and their families with a high quality
alternative to nursing home care, providing quality outpatient services
for those suffering from debilitating illnesses or disabilities. These
programs provide a range of services from daily activities, such as
bathing, to full medical services, like physical therapy. Adult Day
Health Care, however, is only offered currently at three facilities in
the United States. Long Island is fortunate to be one of the three
locations, with a facility right in the heart of my district in Stony
Brook, New York, the Long Island State Veterans Home. There are
however, 152 other State Veterans Homes across the country, and this
program could easily be offered at any of the 153 total State Veterans
Homes. Unfortunately, however, the Department of Veterans Affairs does
not currently cover the cost of participation in this program at state
veteran homes and the expense of the program is put directly on the
veteran and their family, which significantly limits the number of
veterans who can enroll.
In order to address this issue and expand access to care for our
heroes, I introduced bipartisan legislation in Congress, H.R. 1005,
which would ensure that 70% or more service connected disabled veterans
are able to receive Adult Day Health Care at no cost to the veteran and
their family by defining the program as a reimbursable treatment option
through the VA. My bill would guarantee that all severely disabled
veterans are able to access Adult Day Health Care. By providing
disabled veterans with access to Adult Day Health Care programs, we can
ensure that all veterans receive the best and most efficient outpatient
services to provide them with the assistance and special attention that
they need in their day to day lives, while still allowing them to
maintain their independence.
Adult Day Health Care also helps keep families together and strong.
With the inclusion of Adult Day Health Care services as a covered VA
expense, family members and caregivers can rest easier knowing that
their loved ones are receiving top notch care during the day, while
being treated with the same respect and dignity that they would receive
at home. Not only does the Adult day Health Care model care for the
medical needs of a veteran, but it also addresses their social and
emotional needs as well. Adult Day Health Care allows veterans to
interact and socialize with their peers and other individuals enrolled
in the program. Rather than sitting home alone all day, participants in
the adult day health care program receive one-on-one attention from
medical and support staff while also maintaining an active social
schedule through planned events and activities. Family members and
caregivers can go about their day without the worry that their loved
ones are unattended, and the veteran can continue to remain as active
members of their community.
This legislation passed the House with unanimous support in the
114th Congress and it is my hope that we can continue the progress that
was made last year. It is a top priority of mine to ensure that all
veterans on Long Island and across the country receive the proper
treatment and care they deserve, which is why I fully support the adult
day health care program. I will continue working every day to spread
awareness of this bill, so that we pass this bill as soon as possible
to expand Adult Day Health Care for our disabled veterans, and I thank
you for considering this essential piece of legislation.
THE AMERICAN LEGION
(19 FOOTNOTES)
Chairmen Wenstrup, Ranking Member Brownley and distinguished
members of the Subcommittee on Health, on behalf of National Commander
Charles E. Schmidt, the country's largest patriotic wartime service
organization for veterans, comprising over 2.2 million members and
serving every man and woman who has worn the uniform for this country,
we thank you for the opportunity to submit this statement of The
American Legion's positions on the following pending legislation.
H.R. 91: Building Supportive Networks for Women Veterans Act
To amend title 38, United States Code, to make permanent the pilot
program on counseling in retreat settings for women veterans newly
separated from service in the Armed Forces.
This bill makes permanent the Department of Veterans Affairs' (VA)
successful pilot program, established under the Caregivers and Veterans
Omnibus Health Services Act of 2010, to provide counseling and
reintegration services in retreat settings for women veterans coping
with Post-Traumatic Stress Disorder (PTSD) and other wounds of war who,
are recently separated from service after a prolonged deployment.
Women veterans are the fastest growing demographic serving in the
military, so we can expect the number of women veterans using VA care
to increase dramatically. Resolution No. 147: Women Veterans, passed
during our 2016 National Convention in Cincinnati, Ohio, calls on The
American Legion to work with Congress and the VA to ensure that the
needs of current and future women veteran populations are met. Just as
women veterans have dedicated themselves to service, so should a
grateful nation be dedicated to providing them with the specialized
services they require. \1\ The American Legion actively supported the
legislation that introduced this program two years ago, and we support
the continuation of the program now.
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\1\ American Legion Resolution No. 147 (Sept. 2016): Women Veterans
---------------------------------------------------------------------------
The American Legion supports H.R. 91.
H.R. 95: Veterans' Access to Child Care Act
To amend title 38, United States Code, to direct the Secretary of
Veterans Affairs to provide child care assistance to veterans receiving
certain medical services provided by the Department of Veterans
Affairs.
In 2010 Congress established a childcare pilot program as part of
the 2010 Caregivers and Veterans Omnibus Health Services Act, (Public
Law 111-163), which was signed into law in 2011. The program was
established so that veterans had access to child care while receiving
health care services at a Department facility.
Currently, the pilot program is only available to the primary
caretaker of a child or children receiving regular mental health care
services, intensive mental health care services, or such other
intensive health care services that the Secretary determines; that
provision of assistance to the veteran to obtain child care would
improve access to such health care services by the veteran; or in need
of regular or intensive mental health care services from the
Department, and but for lack of child care services, would receive such
health care services from the Department.
The pilot program has been extended several times and is due to
expire on December 31, 2017. This bill would make the VA's Child Care
Pilot Program permanent and expanded so that all veterans, who are
primary caretakers, have a safe, reliable, and cost-free option for
child care when they use the services of the VA.
During The American Legion's System Worth Saving visits, our
research tells us that failure to enact this legislation will
discourage women veterans who lack access to reliable childcare, from
maintaining and attending their healthcare appointments at VA. This is
an unacceptable outcome and disproportionately disenfranchises women
veterans who happen to be single parents, and women veteran spouses who
live in regions where cultural norms expect woman to care for the
dependent children absent paternal assistance during work hours.
The American Legion, by Resolution No. 43 (2016): Department of
Veterans Affairs Child Care Program, supports legislation to provide
child care services to veterans with children in order for the veteran
to receive access to the quality care they have earned. \2\
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\2\ American Legion Resolution No. 43 (Sept. 2016): Department of
Veterans Affairs Child Care Program
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The American Legion supports H.R. 95.
H.R. 467: VA Scheduling Accountability Act
To direct the Secretary of Veterans Affairs to ensure that each
medical facility of the Department of Veterans Affairs complies with
requirements relating to scheduling veterans for health care
appointments, to improve the uniform application of directives of the
Department, and for other purposes.
This bill would require the director of each VA health care
facility to annually certify to the VA Secretary that their medical
facility is in full compliance with VHA Scheduling Directive 2010-027,
VHA Outpatient Scheduling Processes and Procedures, or any successor
directive. It would also direct the VA Secretary on a yearly basis to
report to both Veterans Affairs' Committees a list of medical centers
that have certified compliance and a list that have not. VA would also
have to provide an explanation of why those facilities did not meet the
requirements set forth within the VHA directive.
A 2014 report issued by the VA Office of Inspector General found
that a senior VA official in May 2013 waived a requirement that medical
facility directors annually certify their compliance with the VA's
scheduling policies. Waiving this requirement reduces accountability
for facilities charged with caring for veterans and damages the
integrity of wait time data. \3\
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\3\ American Legion Resolution No. 3 (Sept. 2016): Department of
Veterans Affairs Accountability
---------------------------------------------------------------------------
While The American Legion does not oppose this provision, we find
it troublesome that Congress feels the need to pass a law to require VA
to adhere to VA regulations. The American Legion has long been a
supporter of VA accountability \4\ and if proper accountability
measures were in place, then there would be no need to this
legislation. We are also cognizant of the cost and employee burden
these additional requirements consume, and while advocating for reduced
middle management at VA in favor of committing more resources to
providing direct healthcare, The American Legion calls on Congress to
review the reams of reports required by statute in favor of a more
digestible and streamlined oversight plan. The American Legion has
called on Congress in the past and renews our call here to require VA
to provide a quadrennial plan to Congress outlining VA's strategic plan
for program implementation as well as program funding. \5\
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\4\ Ibid
\5\ American Legion Resolution No. 1 (Sept. 2016): Department of
Veterans Affairs Quadrennial Plan for Budget
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The American Legion Supports H.R. 467.
H.R. 907: Newborn Care Improvement Act
To amend title 38, United States Code, to improve the care provided
by the Secretary of Veterans Affairs to newborn children.
Currently, VA covers newborn care for the first seven days after
birth in a non-department facility for eligible women veterans who are
receiving VA maternity care. This bill would extend the time frame VA
would be responsible for costs, up to 42 days.
Newborn care includes routine post-delivery care and all other
medically necessary services according to generally accepted standards
of medical practice. VA does not provide child delivery care in VA
health care facilities, but rather refers women veterans outside the VA
through contracted care. Under current law, VA only provides care for
the first 7 days after birth, even if birth complications require
continued care beyond that period. \6\ Beyond 7 days, the cost of care
is the responsibility of the veteran and not VA.
---------------------------------------------------------------------------
\6\ VA Women's Health Care FAQ
---------------------------------------------------------------------------
In 2011, The American Legion conducted a Women Veterans Survey with
3,012 women veterans in order to better understand their healthcare
needs through VA. The survey found while there were improvements in the
delivery of VA healthcare to women veterans, challenges with service
quality in the following areas remained:
tangibles
reliability
responsiveness
competence
courtesy
communication
credibility
security
access
understanding
In 2012-2013, The American Legion's System Worth Saving Task Force
report focused on women veterans' health care. The objectives of the
report were to:
Understand what perceptions and barriers prevent women
veterans from enrolling in VA,
Determine what quality-of-care challenges women veterans
face with their VA health care, and to
Provide recommendations and steps VA can take to mitigate
access barriers and quality-of-care challenges.
While maternity and newborn care is primarily purchased outside VA,
the Task Force found several medical centers had challenges finding
hospitals in the area that would accept fee-basis for maternity care
services due to VA's required use of the Medicare reimbursement rate.
At other medical centers, fee-basis expenditures on women veterans'
gender-specific services were not even available. We bold this section
to highlight the disparity between the quality of care at VA, and
readily available care at Medicare rates, which is often the foundation
on which VA contracted care is based. Continued discussions surrounding
VA outsourcing and Choice need to account for the cost associated
without restrictions as established by Medicare rates. These
differences were highlighted by The Commission on Care's report on
estimating costs part 3 \7\, and 4 ( \8\& \9\) and CBO's report,
Comparing VA's cost with civilian care costs. \10\
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\7\ https://s3.amazonaws.com/sitesusa/wp-content/uploads/sites/912/
2016/04/Estimating-Costs-for-Veterans-Health-Part-3.pdf
\8\ https://s3.amazonaws.com/sitesusa/wp-content/uploads/sites/912/
2016/05/Estimating-Costs-for-Veterans-Health-Part-4-Day-1.pdf
\9\ https://s3.amazonaws.com/sitesusa/wp-content/uploads/sites/912/
2016/05/Estimating-Costs-for-Veterans-Health-Part-4-Day-2.pdf
\10\ https://www.cbo.gov/sites/default/files/113th-congress-2013-
2014/reports/49763-VA--Healthcare--Costs.pdf
---------------------------------------------------------------------------
The Task Force report recommended that Business Office managers be
required to track women veterans' gender-specific fee-basis
expenditures. \11\ Furthermore, it was also recommended that these
expenditures should be rolled up by VA Central Office and disseminated
to stakeholders and the public to better facilitate planning for future
needs within VA.
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\11\ The American Legion System Worth Saving Report: ``Women
Veterans Health Care''- 2013
---------------------------------------------------------------------------
The American Legion is committed to working with VA in order to
ensure that the needs of the current and future women veterans'
population are met and the VA should provide full comprehensive health
services for women veterans department wide. \12\
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\12\ American Legion Resolution No. 147: (Sept. 2016) Women
Veterans
---------------------------------------------------------------------------
The American Legion supports H.R. 907.
H.R. 918: Veteran Urgent Access to Mental Healthcare Act
To amend title 38, United States Code, to direct the Secretary of
Veterans Affairs to furnish mental health care to certain former
members of the Armed Forces who are not otherwise eligible to receive
such care and for other purposes.
Being dismissed involuntarily from the military can have profound
consequences for servicemembers, their families, and their future. The
American Legion places a premium value on an honorably discharged
status, but also recognizes that some veterans are wrongfully
discharged with characterizations that are less than Honorable due to
medical injuries incurred during their honorable military service.
Former Secretaries of Defense Chuck Hagel and Ash Carter, as well as
the President of the United States has called on the Department of
Defense (DoD) to ensure that they properly screen service members for
illness or injury, and especially PTSD before discharging them with
less than honorable discharges, and further called on DoD to enjoin
with veterans who have discharges characterized as less than honorable
for the purposes of a generous review to ensure these veterans were not
wrongly discharged due to medical complications that should have been
addressed by DoD prior to discharge. \13\
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\13\ http://archive.legion.org/bitstream/handle/123456789/2498/
2013S026.pdf?sequence=1&isAllowed=y
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This legislation seeks to minimize rewarding bad behavior by
narrowing the eligibility to those veterans who had a higher propensity
for being wrongfully discharged, because the story of former
servicemembers who don't get help when their combat injuries fuel
misconduct happens all too often when DoD fails to properly address
these sustaining mental and physical health issues. The unfair result
is that these veterans have been discarded with involuntary discharges
that prevent them from receiving military retirement, medical care,
disability and GI Bill benefits - all in the interest of speed and cost
savings. \14\
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\14\ Olsen, K. (2016, May). Booted after battle. American Legion
Magazine. Retrieved from https://www.legion.org/magazine/232778/booted-
after-battle
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Many of these veterans end up homeless and are at greater risk of
suicide when they have no access to health care, even though VA has the
discretion to provide medical benefits on a case-by-case basis.
Veterans who were kicked out of the military for misconduct related to
PTSD, TBI and other invisible wounds are also excluded from receiving
help from many nonprofits.
Involuntary discharges have become an issue during the wars in Iraq
and Afghanistan. A litany of negative media prompted Congress to order
the military to carefully review the combat experiences of
servicemembers before discharging them for misconduct. Yet another
22,000 soldiers have been involuntarily discharged since that 2008
legislation was passed, according to an investigation by National
Public Radio \15\, and involuntary discharges for misconduct are only
part of the problem. A significant number of U.S. servicemembers who
are discharged for personality disorders or adjustment disorders are
also diagnosed with combat-related mental health issues such as PTSD
during military medical exams.
---------------------------------------------------------------------------
\15\ http://www.npr.org/2016/12/01/498557687/army-contests-npr-
investigation-of-dismissed-soldiers-in-misleading-report
---------------------------------------------------------------------------
Two weeks ago, VA Secretary Dr. David Shulkin announced that VA
would begin providing ``urgent care'' mental health services for
veterans with bad paper discharges. But these services will be very
limited.
The American Legion is pleased to offer our support for H.R. 918,
the Veteran Urgent Access to Mental Healthcare Act. This important bill
would direct the VA to provide initial mental health assessment and
urgent mental healthcare services to certain veterans at risk of
suicide or harming others, even if they have an Other Than Honorable
(OTH) discharge. We believe this bill targets a specific group of
veterans that have possibly been wronged by DoD, and is in concert and
theme with our Resolution No. 26: Mischaracterization of Discharges for
Servicemembers with Traumatic Brain Injury. \16\
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\16\ Resolution No. 26 (2016): Mischaracterization of Discharges
for Servicemembers with Traumatic Brain Injury
---------------------------------------------------------------------------
The American Legion Supports H.R. 918.
H.R. 1005
To amend title 38, United States Code, to improve the provision of
adult day health care services for veterans.
State Veterans Homes are facilities that provide nursing home and
domiciliary care. They are owned, operated and managed by state
governments. They date back to the post-Civil War era when many states
created them to provide shelter to homeless and disabled veterans.
Currently, there are only two Adult Day Health Care programs at
State Veterans Homes in the United States. Both are located on Long
Island, New York. However, these programs could easily be offered at
the other 151 State Veterans Homes located throughout the country.
H.R. 1005 would provide no cost medical model Adult Day Health Care
to veterans at State Veterans Homes who are 70 percent or more service-
connected disabled. This bill is an extension of Public Law (P.L.) 109-
461: Section 211, Veterans Benefits Health Care, and Information
Technology Act of 2006, which currently provides no cost nursing home
care at any State Veterans Home to veterans who are 70 percent or more
for their service-connected disability and who require significant
assistance from others to carry out daily tasks.
Adult Day Health Care is a daily program for disabled veterans who
need extra assistance and special attention in their day to day lives.
Adult Day Health Care programs provide disabled veterans and their
families with a high quality alternative to nursing home care and
quality outpatient services for those suffering from debilitating
illnesses or disabilities. These programs provide a range of services,
from daily activities such as bathing, to full medical services, like
physical therapy. The focus of the program is on improving a disabled
veterans' quality of life, which is why we support expanding this great
option of care for our veterans. \17\
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\17\ American Legion Resolution No. 377 (Sept. 2016): Support for
Veteran Quality of Life
---------------------------------------------------------------------------
The American Legion Supports H.R. 1005.
H.R. 1162: No Hero Left Untreated Act
To direct the Secretary of Veterans Affairs (VA) to carry out a
pilot program to provide access to magnetic EEG/EKG-guided resonance
therapy to veterans.
In the wake of serious concerns about over prescription of
medications by VA physicians, The American Legion agrees that VA can do
more to ensure that veterans and servicemembers have the most
dependable and precise treatment available to treat their combat-
related illnesses and injuries with the least amount of negative side
effects. The American Legion, like the rest of the nation is desperate
to see the rate of suicide among our veteran population begin to
decrease, and hopes that efforts by VA will help guide the rest of the
nation in treating this epidemic.
The American Legion has recently learned that the Veterans Health
Administration (VHA) has implemented a pilot program at approximately
23 VA Medical Centers across the country using Electromagnetic Therapy
to treat veterans with depression. VHA is using Repetitive Transcranial
Magnetic Stimulation, or RTMS therapy, which involves up to 30 sessions
over a six-week period. The American Legion is following this pilot
closely and is hopeful that this non-pharmaceutical noninvasive therapy
will prove successful and provide VA with another tool to help deal
with depression and Post Traumatic Stress Disorder.
The American Legion has long advocated for complementary and
alternative medicines (CAM) to be further explored by VA and applaud
this pilot. Additionally, The American Legion's PTSD/TBI Committee has
reviewed several promising CAM treatments that include using EEG
technology to help better determine the efficacy of certain medications
on patients with correlating quantitative electroencephalogram (EEG)
neurometrics, treatment with lesser toxic and addictive substances such
as the drugs CBD and THC, both found in the cannabis plant, and
Hyperbaric Oxygen Therapy (CBOT). The American Legion urges Congress to
first review VA's current pilot program, monitor the strategic
objectives and plans for evaluating how RTMS therapy will benefit
veterans before embarking on a therapy that has not received FDA
approval for the purposes that it is being suggested VA use it for.
Once the therapy outlined in H.R. 1162 is evaluated and approved by
the FDA for this intended purpose, The American Legion will call on VA
to compare a Magnetic EEG/EKG-guided resonance therapy program to
determine which would be in the best interest of veterans and the most
cost effective to American tax payers. Until that time, The American
Legion is unable to support this bill
The American Legion opposes H.R. 1162.
H.R. 1545: VA Prescription Data Accountability Act of 2017
To amend title 38, United States Code, to clarify the authority of
the Secretary of Veterans Affairs to disclose certain patient
information to State controlled substance monitoring programs, and for
other purposes.
In 2016, over 80,000 people died from drug overdoses or accidental
drug toxicity caused by lethal combinations of opioids and
benzodiazepines and Prescription Drug Monitoring Programs (PDMPs) are
designed to combat these two public health epidemics. PDMPs ensure
health care providers do not accidently prescribe dangerous and
potentially lethal combinations of drugs to patients who also see other
healthcare providers. These state programs also have been proven to
curb ``doctor shopping'' whereby people visit multiple health care
providers to solicit more prescription medications than their original
doctor has agreed to prescribe.
This bill would amend Title 38, U.S.C. Section 5701 by clarifying
the authority of the Secretary of VA to disclose certain patient
information to state controlled PDMPs. This bill also expands that
group of individuals to anyone who is prescribed medication through the
VA to include descendants of veterans, staff at VA, and individuals
receiving disaster relief.
The American Legion supports the use of Electronic Health records
as a method of coordinating care provided to veterans outside VA
medical facilities and the controlled but widespread sharing of
electronic medical records so that veterans can receive the highest
possible quality healthcare available. \18\
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\18\ American Legion Resolution No. 83 (Sept. 2106): Virtual
Lifetime Electronic Record
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The American Legion Supports H.R. 1545.
H.R.1662
To amend title 38, United States Code, to prohibit smoking in any
facility of the Veterans Health Administration, and for other purposes.
Over the years, many hospitals across the country have been
implementing smoke-free campuses in order to promote a healthy
environment and their commitment to a person's overall health. The
draft bill would prohibit any person from using tobacco products on the
grounds of any VA medical facility on or after October 1, 2022. The
American Legion is unable to determine whether this bill seeks to
provide a safe patient environment by protecting staff and patients
from second hand smoke, is a proposed law to eliminate a perceived
nuisance, or an overreach by government to legislate personal choices.
The American Legion is holding this bill for further review before we
offer any recommendation.
The American Legion currently has no position on this bill.
Draft Bill: Veterans Affairs Medical Scribe Pilot Act of 2017
To direct the Secretary of Veterans Affairs to carry out a pilot
program on the use of medical scribes in Department of Veterans Affairs
medical centers.
Veterans are experiencing long wait times for VA health care for a
variety of reasons, but in part due to high patient load and not enough
doctors to serve the population. This shortage is a nationwide problem
in both government and nongovernment medicine.
A medical scribe is a paraprofessional who specializes in charting
physician-patient encounters in real time, such as during medical
examinations. Depending on which area of practice the scribe works in,
the position may also be called clinical scribe, ER scribe or ED scribe
(in the emergency department), or just scribe (when the context is
implicit). A scribe is trained in health information management and the
use of health information technology to support it. A scribe can work
on-site (at a hospital or clinic) or remotely from a Health Insurance
Portability and Accountability Act (HIPAA) secure facility. Medical
scribes who work at an off-site location are known as virtual medical
scribes and normally work in clinical settings.
A medical scribe's primary duties are to follow a physician through
his or her work day and chart patient encounters in real-time using a
medical office's electronic health record (EHR) and existing templates.
Medical scribes also generate referral letters for physicians, manage
and sort medical documents within the EHR system, and assist with e-
prescribing. Medical scribes can be thought of as data care managers,
enabling physicians, medical assistants, and nurses to focus on patient
in-take and care during clinic hours. Medical scribes, by handling data
management tasks for physicians in real-time, free the physician to
increase patient contact time, give more thought to complex cases,
better manage patient flow through the department, increase
productivity to see more patients, help ease physician burnout, and can
help incentivize physicians to come to work for, or stay at VA.
The draft bill would require VA to carry out a 2 year pilot program
in no less than 10 VA medical centers located in rural areas, urban
areas, and areas in need of increased access or increased efficiency.
The draft bill would increase the use of medical scribes to assist VA
physicians with their workload and would ensure doctors have more time
to see patients rather than entering in medical data. By VA utilizing
medical scribes in health care settings, it will serve as a recruitment
tool for doctors who want an employment package comparable to the
private sector.
The American Legion supports any legislation and programs within
the VA that will enhance, promote, restore or preserve benefits for
veterans and their dependents, including timely access to quality VA
health care. \19\
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\19\ American Legion Resolution No. 377 (Sept. 2016): Support for
Veteran Quality of Life
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The American Legion supports the draft bill.
Conclusion
As always, The American Legion thanks this subcommittee for the
opportunity to explain the position of the over 2.2 million veteran
members of this organization. For additional information regarding this
testimony, please contact Mr. Warren J. Goldstein at The American
Legion's Legislative Division at (202) 861-2700 or
[email protected].
NATIONAL ASSOCIATION OF STATE VETERANS HOMES
TESTIMONY OF FRED S. SGANGA, LEGISLATIVE OFFICER
ON H.R. 1005 - LEGISLATION CONCERNING ADULT DAY HEALTH CARE AT STATE
VETERANS HOMES
Mr. Chairman and Members of the Subcommittee, thank you for this
opportunity to offer testimony regarding H.R. 1005, legislation
introduced by Congressman Lee Zeldin (R-NY) and Congresswomen Kathleen
Rice (D-NY) to provide severely disabled veterans with an enhanced
option to receive adult day health care services from State Veterans
Homes.
Last year, identical legislation (H.R. 2460) strengthening adult
day health care programs at State Veteran Homes was unanimously
approved by this Committee in the 114th Congress, and subsequently
passed the full House without any opposition. Both H.R. 2460 and a
Senate companion bill (S. 3198) were reviewed by the Congressional
Budget Office (CBO) last year and neither received a score that needed
to be offset. However, the Senate failed to take any action on either
bill prior to adjournment, necessitating reintroduction of the
legislation this year.
As you may know, the State Veterans Home program was established by
a Congressional Act on August 27, 1888, and for more than 125 years
State Homes have been in a partnership with the federal government to
provide long term care services to honorably discharged veterans; in
some states, widows and spouses as well as Gold Star Parents are also
eligible for admission. There are currently 153 State Veterans Homes
located in all 50 states and the Commonwealth of Puerto Rico. The
National Association of State Veterans Homes (NASVH) was conceived at a
New England organizational meeting in 1952 because of the mutual need
of State Homes to promote strong federal policies and to share
experience and knowledge among State Home administrators to address
common problems. NASVH is committed to caring for our nation's heroes
with the dignity and respect they deserve.
With over 30,000 beds, the State Veterans Home program is the
largest provider of long term care for our nation's veterans. Current
services provided by State Homes include skilled nursing care,
domiciliary care and adult day health care. The Department of Veterans
Affairs (VA) provides State Homes with construction grants to build,
renovate and maintain the Homes, with States required to provide at
least 35 percent of the cost for such projects in matching funds. State
Veterans Homes also receive per diem payments for basic skilled nursing
home care, domiciliary care and ADHC from the federal government which
covers about one third of the daily cost of care.
Mr. Chairman, a decade ago, NASVH led the effort on Capitol Hill to
assist our most disabled veterans by allowing them to receive skilled
nursing care in State Veterans Homes under a new program that would
provide the ``full cost of care'' to the State Home and thereby expand
the options available to these deserving veterans at no cost to them.
In 2006, Congress passed and the President signed Public Law 109-461
which guaranteed ``no cost'' skilled nursing care to any honorably
discharged veteran who has a 70% or higher service connected disabled
rating. Unfortunately, the bill did not extend the same ``no cost''
program to cover alternatives to traditional institutional care, such
as the medical model Adult Day Health Care currently provided at three
State Veterans Homes in Stony Brook, New York, Minneapolis, Minnesota
and Hilo, Hawaii. H.R. 1005 would fix that.
Adult Day Health Care at the LISVH is designed to promote wellness,
health maintenance, socialization, stimulation and maximize the
participant's independence while enhancing quality of life. A medical
model Adult Day Health Care program provides comprehensive medical,
nursing and personal care services combined with engaging social
activities for physically or cognitively impaired adults. These
programs are staffed by a caring and compassionate team of multi-
disciplinary healthcare professionals who evaluate each participant and
customize an individualized plan of care specific to their health and
social needs.
As a licensed nursing home administrator, I would like to thank
Representatives Zeldin and Rice for recognizing the need to offer non-
institutional alternatives to our veterans. Giving our veterans and
families choices in how they can receive care is just the right thing
to do. Making sure that there are no financial barriers to care is
important to our most medically compromised veterans.
It would be especially important to veterans like Jim Saladino and
his wife Noreen. Fifty years ago, Jim answered the call of his country
and served in the United States Army during the Vietnam War. Today, he
suffers from the ravages of Agent Orange exposure. Specifically, he
suffers from chronic illnesses including diabetes and Parkinson's
disease and he also recently suffered a stroke. Although the Saladino
family could have decided to put Jim into our State Veterans Home
because he is a 100% service connected veteran so it would have been
fully paid for by VA, but that is not their choice. They would like
their loved one to continue enjoying the comforts of his own home - for
as long as he can. By providing him the benefits of our medical model
Adult Day Health Care program, Jim is able to keep living at home.
Jim's wife, Noreen, serves as his primary caregiver. She has
publicly stated that the medical model Adult Day Health Care Program
has been a true blessing for her. Jim comes to the ADHC program three
days a week and we work closely with his personal physician to provide
services that will maintain his wellness and keep him out of the
emergency room. During his six hour day with us, Jim receives a
nutritious breakfast and lunch. He receives comprehensive nursing care.
He also receives physical therapy, occupational therapy and speech
therapy. He can get his eyes checked by an optometrist, his teeth
cleaned and examined by our dentist, and his hearing checked by an
audiologist. If required, he can get a blood test or an x-ray, have his
vital signs monitored and receive bathing and grooming services while
on site.
For Jim's wife, having him come to our program allows her the peace
of mind knowing that he is in a safe and comfortable environment. She
can then get a break as caregiver and tend to those issues that allow
her to run her household. However, because of the way the law is
currently structured, despite Jim's eligibility for ``no cost'' skilled
nursing care, they are required to pay out of pocket for a portion of
his Adult Day Health Care.
H.R. 1005 will fix this disparity that prevents some of the most
deserving and severely disabled veterans from taking advantage of this
valuable program to help keep living in their own homes. This
legislation would authorize VA to enter into agreements with State
Veterans Homes to provide Adult Day Health Care for veterans who are
eligible for, but do not receive, skilled nursing home care under
section 1745(a) of Title 38, the ``full cost of care'' program.
Veterans who have a VA disability rating of 70 percent or greater or
who require ADHC services due to a service-connected disability would
be eligible for this program. The payment to a State Home under this
program would be at the rate of 65 percent of the amount that would be
payable for skilled nursing home care under the same ``full cost of
care'' program. This legislation would not only offer a lower cost
alternative (ADHC) for severely disabled veterans who might otherwise
require full time skilled nursing care, but it would also allow them to
continue living in their own homes.
Mr. Chairman, in reviewing this legislation last year and in some
additional meetings since, the VA has argued that because a veteran
participating in the ADHC program is physically inside a State Home
facility for only about one-third of each day they are in the program,
therefore the per diem should be only about one-third of the skilled
nursing care per diem. However, this significantly misrepresents the
level of care and services provided to veterans in medical model ADHC
programs. First, it completely ignores the cost of transportation,
which alone accounts for a significant cost for transporting elderly,
frail, disabled veterans to and from their homes to State Homes.
Second, the overwhelming majority of services - particularly medical,
therapeutic and rehabilitation - are provided during the day shift, not
overnight when veterans residing in State Homes are sleeping. In fact,
the 65% ratio is identical to the ratio that Medicaid pays for adult
day health care in New York as compared to Medicaid per diems for
skilled nursing care. Finally, it is critical to note that allowing
veterans to use ADHC services two to three times a week is enormously
less expensive then placing them full-time into a skilled nursing
facility.
Moreover, the VA has been stressing the need to provide essential
long-term care services in non-institutional settings for our most
frail, elderly disabled veterans. Medical model Adult Day Health Care
is a tremendous solution to this challenge being faced by the VA, one
that can keep veterans living in their homes while allowing them to
receive skilled nursing services and supports. There are a number of
State Homes across the country interested in providing medical model
ADHC services, however the current basic ADHC per diem is not nearly
sufficient for most State Homes to be cover the costs of this program.
Enactment of H.R. 1005 would provide a higher ADHC per diem rate for
severely disabled veterans in medical model ADHC programs and thereby
allow additional State Homes across the country to offer this service.
For the Saladino family, receiving ``no cost'' medical model Adult
Day Health Care for their loved one would relieve a huge financial
burden that they currently incur. Even though Jim's service ended 50
years ago, he is still paying a price for his valor related to his
service in Vietnam. Passing H.R. 1005 would send a strong message to
all those who have worn the uniform to protect our freedoms that they
will never be forgotten.
H.R. 1005 has strong bipartisan support in the House, as does the
companion Senate bill, and has also been supported by major veterans
service organizations, including The American Legion, the Veterans of
Foreign Wars and Disabled American Veterans.
On behalf of the National Association of State Veterans Homes, I
urge you to favorably consider and pass H.R. 1005 for Jim and Noreen
Saladino, and for thousands of others across the country just like
them. Thank you for the opportunity to offer this testimony to the
Subcommittee.
SWORDS TO PLOWSHARES
Getting It Right:
``Bad Paper'' Legislation That Works
Submitted by
Swords to Plowshares, a Veteran Rights Organization
With the Assistance of Veterans Legal Clinic at Harvard Law School
I. The urgency of health services for ``bad paper'' veterans
Post-9/11 veterans are denied basic veteran services at a higher
rate than those of any previous era. Tens of thousands of
servicemembers who would have received Honorable or Honorable
Conditions discharges in prior eras today receive Other Than Honorable
(OTH) discharges. Our ``zero-tolerance,'' high op-tempo military has
little patience for even routine discipline and behavior issues. This
is true even when the behavior change is symptomatic of mental health
issues that arose in service. The statistics are alarming. Combat-
veteran Marines with PTSD diagnoses are 11 times more likely to get an
OTH discharge than others \1\; between 2009 and 2012, the Army gave
misconduct discharges to 20,000 servicemembers even after diagnosing
them with PTSD \2\; survivors of military sexual trauma are 50% more
likely to get misconduct discharges. \3\ Denying veterans basic
services for minor misconduct issues is unfair; denying them basic
services because they are disabled or traumatized is unconscionable. It
is happening now more than ever.
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\1\ https://www.ncbi.nlm.nih.gov/pubmed/20974004
\2\ NPR, ``Missed Treatment: Soldiers With Mental Health Issues
Dismissed For 'Misconduct''' (Oct. 28, 2015).
\3\ Gary Noling, ``What the Military Owes Rape Survivors Like My
Daughter,'' New York Times (Aug. 29, 2016) citing DOD Inspector
General, ``Evaluation of the Separation of Service Members Who Made a
Report of Sexual Assault'' (May 9, 2016).
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Exclusion from basic veteran services is not only unfair, it is
also deadly. Denying basic services means no health care for former
servicemembers who are disabled, and no income support if disabilities
prevent the servicemember from working. For veterans struggling with
mental health problems, this abandonment is life-threatening. The
suicide rate for veterans excluded from VA health care is twice the
suicide rate for VA-recognized veterans. \4\ For all of the issues
surrounding VA access, the fact is that VHA health care works. The
suicide rate for veterans under VHA care is decreasing, while the
suicide rate for those outside of VHA care is increasing. \5\
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\4\ https://www.ncbi.nlm.nih.gov/pubmed/25533155
\5\ http://www.mentalhealth.va.gov/docs/suicide--data--report--
update--january--2014.pdf
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We have created a suicide pipeline. Traumatic mental health
disabilities are one of the major contributors to misconduct
discharges. These veterans are some of those most at risk of suicide.
We have the tools at VHA to prevent people at a mental health risk from
committing suicide. However, we deny them many of them access to mental
health care because the behavior symptomatic of their condition in the
first place.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Effectively managing this problem requires more than short-term
mental health services. Most importantly, it requires access to primary
and preventative care. One of the reasons that VHA mental health care
is so effective is that it is integrated with somatic care. Many
people, including veterans, do not like to seek mental health care, so
we know that a great way to reach at-risk veterans is through referral
by primary care providers. We also know that pain management cannot
safely be separated from psychiatric care. In cases of TBI, which is a
significant precursor of behavioral health problems, somatic and
psychological conditions are inseparable. Effective mental health care
cannot be provided in isolation from overall health care.
Second, preventing mental health crises requires requires
management of life stressors beyond the hospital. Congress has recently
ended the shameful practice of turning away homeless veterans from
veteran shelters when they had bad paper discharges. However, that is
not enough. When a person's military disability prevents them from
earning a living, leaving them unemployable without income support is
short-sighted and unjust. Congress has designated certain services to
be rewards for exemplary service, notably the G.I. Bill; other benefits
are protective services to care for actual injuries that a person has
experienced, and withholding these basic veteran services on the basis
of minor behavior issues does not serve our nation's interests.
II. How not to do it: the lessons of P.L. 95-126
Congress faced this problem before. Like now, it faced a generation
of veterans returning home with mental and physical injuries, an
unprecedented percentage of whom were discharged less-than-honorably
and faced challenges accessing basic care and treatment. Tremendous
effort from Congress and advocates resulted in new legislation that was
similar to what is under consideration today. But it did not work.
In 1977, Congress saw that more than 260,000 Vietnam-era
servicemembers had received less-than-honorable discharges from the
armed forces, and that many struggled with unemployment, homelessness,
substance abuse, and mental illness. Congress held numerous hearings
investigating the issue and contemplating potential solutions. Its
solution was Public Law 95-126.
Section 2 of that bill granted to OTH veterans lifetime VA health
care for any disabilities that arose in military service, unless they
were otherwise barred by statute. This bill was broader than bills
currently under consideration, because it was not limited to mental
health care, it was not limited to temporary care, and it was not
limited to combat vets or MST survivors.
Although that provision is still on the books \6\, it does not do
the job it was intended to. If it had been successful, none of the
bills currently under consideration would be necessary: the
servicemembers, conditions, and services that the currently-proposed
bills describe are all encompassed by the already-existing provision
under P.L. 95-126. Yet, almost none of them are accessing the services
that Congress knows they need. In the 40 years since it was enacted,
the OTH health care provision created by P.L. 95-126 has reached only
9,450 servicemembers. \7\ This is only 1.3% of the OTH veterans
discharged during this period, and only 7% of the OTH veterans who
sought the help of VA for in-service disabilities.
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\6\ 38 C.F.R. Sec. 3.360.
\7\ Data provided VA Central Office analyst, details available on
request.
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P.L. 95-126 has not been effective because it was too targeted.
First, and most importantly, VBA has to adjudicate multiple complicated
questions before the veteran can get any care. The requirement of
adjudication slows everything down and renders a system unable to serve
veterans in moments of crisis. Second, VHA and VBA have difficulty
transferring information between them. The more times that a form or
notification has to be sent from one to the other, the more likely it
is that something will go astray. \8\ Third, the law has narrow
criteria that many find hard to remember and a complicated procedural
structure that is difficult to explain. The lack of simplicity makes it
difficult for VHA eligibility employees to consistently and reliably
implement the law, thus contributing to its ineffectiveness.
Furthermore, the referral process is invisible to the servicemembers:
there is no public VA form to request this, so there is no way for a
potentially-eligible person to start the process without the assistance
of an informed and willing VHA eligibility workers. \9\ In practice,
this simply does not happen.
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\8\ The following is a description of how the process technically
works. A veteran with an OTH discharge presents at a VA health facility
seeking care. VHA eligibility staff should ask the veteran to fill out
a health care application, and should then fill out an internal VA form
referring the veteran's application to the VBA Regional Office for
adjudication as to character of discharge. If the adjudication finds
the veteran's service was ``other than dishonorable,'' then the veteran
can receive full VA health care; if the adjudication finds the
veteran's service not ``other than dishonorable'' under VA regulatory
bars, then the veteran is advised that he or she may be eligible under
Public Law 95-126 for ``Chapter 17'' health care. Adjudication then
stops. There is no form or application to request ``Chapter 17'' health
care. However, the veteran--often assisted by an advocate--can send a
letter and health care application asking for ``Chapter 17'' health
care and requesting that VBA adjudicate service-connection for listed
conditions. VBA, now looking at the issue a second time, should then
make the determination and inform VHA as to its outcome. There are many
ways in which the procedures can and do fail.
\9\ Instructions to VHA eligibility staff were removed from the
latest edition of the VHA eligibility procedures manual. VHA Handbook
1601A.02 (2015). Incomplete and confusing instructions are provided in
a public Information Bulletin. VHA IB 10-448 ``Other than Honorable
Discharges - Impact on Eligibility for VA Health Care Benefits''
(2014). The VBA recently amended its Adjudication Procedures manual so
that an OTH veteran who applies for Compensation will automatically be
considered for the health care eligibility exception, if they receive a
negative Character of Discharge decision. M21-1 Part III.v.1.B.1.f.
Although promising, it creates a situation where the only pathway to
health care passes through a Compensation application, filed not at a
hospital but at a Regional Office, without any instruction to this
effect to service members. Implementation of this new procedure has
been uneven.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
The impact of these bureaucratic obstacles cannot be overstated. In
our experience, even the insistence of an attorney, carrying the
relevant regulations in hand, may not be sufficient to force the
internal adjudication referral process to happen. We are working with
one veteran where we succeeded in starting the process at the VA
hospital, but have now been waiting three years for a result. Another
client just received notice of health care eligibility five years after
beginning the process. Needless to say, it is unrealistic for a veteran
experiencing a mental health crises to navigate this system more
effectively.
As a practical matter, health care eligibility criteria must be
immediately discernible by the VHA eligibility clerk, or it will not
have its intended impact. VHA service databases (BIRLS) and DD214s do
not show whether disabilities arose in service, whether mental health
disabilities contributed to discharge, whether a person served in a
combat theater or in combat, or whether a person experienced Military
Sexaul Assault (MST). This can only be decided by having a VBA
adjudicator request and read a person's military service record. A
health care eligibility law that relies on any of these eligibility
factors will require an eligibility inquiry from the VHA to the VBA,
and experience shows that this cannot be operationalized. The 1.3%
reach of P.L. 95-126 after 40 years should be conclusive evidence that
this is not a local problem, and that it is not the fault of a certain
bureaucracy. The law, though well-intentioned, was not written to
operate within our veteran health care eligibility system.
Our lesson from P.L. 95-126 should be this: we cannot ensure health
care access to vulnerable populations by ``carving out'' services to
specific people or conditions. Each carve-out is a condition that a
different branch of the VA has to adjudicate, and veterans cannot be
expect to know how to navigate that. The eligibility criteria must be
simple and available on a DD214 or in BIRLS; this may require extending
to more than intended, however that is the cost of ensuring no
deserving veteran is abandoned.
III. H.R. 918 as currently drafted will not reach its target group
H.R. 918 proposes an approach similar to what P.L. 95-126
attempted. It identifies a specific target group and authorizes
services only to them: servicemembers with OTH discharges, but not
those barred by 38 U.S.C. 5303(a), who served a combat theater or in
combat, or who experienced MST. Like P.L. 95-126, VHA eligibility staff
will have to refer any claims to the VBA for adjudication of these
criteria, based on a review of military service records. As with P.L.
95-126, these conditions will almost certainly be too cumbersome for
service members to navigate effectively, particularly those facing
mental health crisis. And it will almost certainly be too difficult for
the VA to adjudicate rapidly.
H.R. 918 faces an additional obstacle that P.L. 95-126 did not
face. H.R. 918 only proposes to provide tentative health care: health
care while the VA decides permanent eligibility based on character of
discharge review. However, because H.R. 918 has its own eligibility
criteria that have to be adjudicated, servicemembers will never be able
to access immediate health care. Because the H.R. 918 eligibility
determination process will look very similar to the permanent
eligibility determination process, it is likely that H.R. 918 will not
create anything: the servicemember will learn their H.R. 918
eligibility at the same time as they learn their permanent eligibility,
so the H.R. 918 eligibility will be irrelevant.
IV. H.R. 918 may limit more effective regulatory and policy changes
already underway
The Department of Veterans Affairs is currently reviewing its
regulations that govern access to basic services for veterans with
less-than-honorable discharges, including tentative eligibility for
health care while a veteran's eligibility review is underway. It has
made this announcement publicly, in response to the Commission on
Care's recommendations to do so. It has told Congressional offices that
it plans to issue regulations on this during 2017.
Through this rulemaking, VA could propose regulations that would
fully accomplish the goals of H.R. 918. Using existing legal authority,
VA could amend its current tentative healthcare eligibility regulation
\10\ to extend care to veterans who served in or supported combat
operations or who experienced military sexual trauma.
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\10\ 38 C.F.R. Sec. 17.36.
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Furthermore, it is likely that the VA would propose a tentative
eligibility rule that exceeds what H.R. 918 proposes. The VA will
consider its internal systems and procedures, including the
capabilities of front-line eligibility staff and the availability of
information in existing databases. It will likely avoid criteria that,
like the criteria proposed with H.R. 918, require cumbersome intra-
agency adjudication referrals. Therefore a rule VA proposes may be
easier to implement and more likely to achieve the goal of ensuring
access to these at-risk veterans.
A more narrow rule enacted through legislation would be
unnecessary, and may potentially complicate the ongoing regulatory
action. It is unclear whether VA would still have regulatory discretion
to craft a workable standard, when Congress had just specified a
particular standard; this may be true even when the Congressionally-
mandated standard is less feasible.
Because adequate agency action is underway, it is imprudent to
issue legislation that may interfere with those outcomes. Where the
agency has the will and authority to take appropriate action, Congress
should provide guidance and oversight rather than micromanagement.
V. Better options: legislation with impact
Alternative options are available. Based on our direct experience
navigating the system from the veterans' perspective, we have developed
the following possible avenues to expanding access to mental health
care for vulnerable servicemembers, without exceeding the Committee's
intent to focus on combat-exposed veterans and MST survivors.
To the extent possible, the proposed solutions build on the
significant amount of authority that VA already has to provide mental
health care, as well as other treatment and services, to veterans with
bad-paper discharges. Eligibility for basic VA services--including
health care, disability compensation, and vocational rehabilitation--
require only that the veteran have been discharged under ``other than
dishonorable'' conditions and not be excluded under enumerated
statutory bars. \11\ Veterans with bad-paper discharges who served in a
combat theater or experienced military sexual trauma also can seek
counseling at a Vet Center. \12\ Therefore, under current law, veterans
with other-than-honorable or bad-conduct (by special court-martial)
discharges may be entitled to full or limited health care from VA. VA
only provides such care after it has conducted a lengthy eligibility
review process, known as a character of discharge determination. While
those reviews are pending, current VA regulations do not allow such
veterans to receive ``tentative'' eligibility for health care, \13\ but
VA could adopt new regulations that would allow as much. Despite the
VA's existing authority to offer care to veterans with bad-paper
discharges, both statistical and anecdotal evidence demonstrate that
many such veterans face challenges in accessing that care and that the
vast majority are presently excluded from VA. \14\ Encouraging and
supporting VA's utilization of existing statutory authority to provide
care to veterans with bad-paper discharges could allow for a quicker
roll-out of services, with greater certainty that the agency could
successfully operationalize Congress's goals.
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\11\ 38 U.S.C. Sec. Sec. 101(2), 5303(a); 38 C.F.R. Sec. 3.12.
\12\ 38 U.S.C. Sec. 1712A.
\13\ 38 C.F.R. Sec. 17.34.
\14\ See generally Veterans Legal Clinic, Underserved: How the VA
Wrongfully Excludes Veterans with Bad-Paper Discharges (March 2016),
available at https://www.swords-to-plowshares.org/sites/default/files/
Underserved.pdf.
Option 1. Amend H.R. 918 from U.S. Code provision to rulemaking
---------------------------------------------------------------------------
requirement
As described above, VA has considerable authority under existing
law to provide mental health care services to certain veterans with
bad-paper discharges, including veteran with other-than-honorable
discharges who served in combat or experienced military sexual trauma.
By enacting a law that directs VA to implement a policy that it already
had authority to implement, Congress could potentially narrow VA's
authority. For example, it is possible that VA would interpret the law
to prohibit it from providing tentative health care to veterans who are
having mental health crises but did not serve in combat or experience
MST, or to veterans who served in combat but are experiencing severe
physical injuries. To ensure that the Bill clearly communicates its
goal of expanding--rather than narrowing--access, one option is to
require that VA revise its tentative health care regulations to
include, at a minimum, access to mental health care services for combat
veterans and veterans who experienced MST.
REVISION OF REGULATIONS RELATING TO TENTATIVE HEALTH CARE.--No
later than one year after the date of enactment of this Act, the
Secretary shall issue a Final Rule amending its Regulations relating to
tentative eligibility for health care. Section 17.34, Title 38, Code of
Federal Regulations. The Final Rule shall address the ability of former
service members to receive tentative eligibility for health care when
their eligibility under Sections 101(2) and 5303, Title 38, United
States Code, must be determined. The Final Rule shall, at minimum,
require that VA provide mental health care services to any former
service members who served during a period of war (as defined in
section 1521 of this title) or, while serving in the Armed Forces,was
the victim of a physical assault of a sexual nature, battery of a
sexual nature, or sexual harassment (as defined in section 1720D(f) of
this title) and who has filed an application for hospital care or other
benefits administered by the Secretary that requires an adjudication as
to any eligibility prerequisite which cannot immediately be
established. This minimum requirement does not limit the Secretary from
establishing other provisions as allowed under existing authority.
Option 2. Authorize Vet Centers to provide psychiatric and
neurobehavioral services
The Vet Centers are community-based outpatient clinics that provide
counseling and readjustment services to veterans who served in a combat
theater, served in an unmanned aerial vehicle crew that support combat
operations, or experienced military sexual trauma. These services are
available to veterans with bad paper, and so target a similar veteran
cohort as H.R. 918. However, Vet Centers do not provide psychiatric
care or inpatient treatment programs, nor do they provide
neurobehavioral treatment for Traumatic Brain Injury. Some veterans
therefore will find that the Vet Centers cannot fully treat their
mental or neurological injuries. Rather than create an adjudication
process to carve out limited access to VA hospitals, Congress could
expand the authority and resources of Vet Centers, which are already
reaching the target population, so that they could provide or arrange
for improved mental health services directly or through community care.
IN GENERAL.--The Secretary shall use the existing assessment,
referral, and contracting authorities assigned to Vet Centers under
Sections 1712A(b)(1) and (e)(1), Title 38, United States Code, to
ensure that the mental health care services available to Vet Center
patients include psychiatric care for mental health disorders and
neurobehavioral care for patients who experienced Traumatic Brain
Injury. The Vet Centers are encouraged to use their contracting
authorities to refer patients to community care providers in cases
where Department facilities are unavailable. The Vet Centers shall
continue their existing practice of providing services on a tentative,
emergency, or reintegrative basis pending eligibility review in cases
where that is required.
SCOPE OF MENTAL HEALTH SERVICES.--Include the following paragraph
as Section 1712A(b)(3):
``(3) Mental health services furnished under paragraph (1) of this
subsection may, if determined to be essential to the effective
treatment and readjustment of the patient, include psychiatric care and
neurobehavioral care.''
UTILISATION OF COMMUNITY CARE. Amend Section 1712A(b)(1), Title 38,
United States Code, as follows:
``(1) If, on the basis of the assessment furnished under subsection
(a) of this section, a licensed or certified mental health care
provider employed by the Department (or, in areas where no such
licensed or certified mental health care provider is available, a
licensed or certified mental health care provider carrying out such
function under a contract or fee arrangement with the Secretary)
determines that the provision of mental health care services to such
veteran is necessary to facilitate the successful readjustment of the
veteran to civilian life, such veteran shall, within the limits of
Department facilities, be furnished such services on an outpatient
basis. For the purposes of furnishing such mental health care services,
the counseling furnished under subsection (a) of this section shall be
considered to have been furnished by the Department as a part of
hospital care. Any hospital care and other medical services considered
necessary on the basis of the assessment furnished under subsection (a)
of this section shall be furnished only in accordance with the
eligibility criteria otherwise set forth in this chapter (including the
eligibility criteria set forth in section 1784 of this Title).''
Option 3. Create a ``Veteran'' eligibility determination process
Ninety percent of veterans with bad-paper discharges are ineligible
for basic VA services not because they applied and were denied but
because VA has never adjudicated their eligibility at all. \15\ These
veterans may never have applied, perhaps because they wrongly believed
that they were categorically ineligible, or they may have attempted to
apply but encountered barriers to doing so. Currently, there is no
method for a veteran with a bad-paper discharge simply to request that
VA determine whether he or she is eligible. That is, a veteran cannot
``appl[y] for a character of service determination,'' as H.R. 918
requires to be covered by its provisions. Instead, the veteran must
apply for a specific benefit, e.g., disability compensation, and VA
then initiates an eligibility review as its first step. VA's current
procedures for these reviews may not gather information critical to its
determination, such as from the veteran about the circumstances
surrounding his or her discharge or from medical professionals about
any in-service mental health conditions. These inadequate procedures
and low rate of applications could be remedied in part by requiring VA
to create a separate application by which a veteran with a bad-paper
discharge can ask for an eligibility review. Furthermore, veterans
might then know whether they are eligible for full VA services or not
before they are in crisis and seeking urgent mental care, rather than
having to grant temporary access to services while VA adjudicates their
eligibility.
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\15\ Veterans Legal Clinic, Underserved, supra note 15, at 10.
CHARACTER OF DISCHARGE ADJUDICATION.--
(1) FORM.--The Secretary shall create a form by which a former
service member may request that the Department determine whether the
member qualifies as a veteran under sections 101(2) and 5303, title 38,
United States Code. The form shall elicit information relevant to a
character of discharge determination, including any honorable or
meritorious service, any combat or hardship service, any physical or
mental health injuries or conditions that existed during the member's
service, any mitigating or extenuating circumstances that affected the
member's ability to serve, and any personal assaults or military sexual
trauma that the member experienced.
(2) PROCEDURES.--
(a) Upon receipt of a form referenced in subsection (1) from a
former member, the Secretary shall determine whether the former member
is a veteran under Sections 101(2) and 5303, Title 38, United States
Code.
(b) If the member is found to be a veteran under sections 101(2)
and 5303, Title 38, United States Code, and if the member submits an
application prior to or within one year after that determination that
the Secretary grants, then the effective date for that benefit shall be
the date that the Secretary received the subsection (1) form or the
application, whichever is earlier.
(c) If a former service member whose eligibility must be determined
under sections 101(2) and 5303, title 38, United States Code, submits
any other form that expresses a desire to apply for benefits
administered by the Secretary that is not the form referenced in
subsection (1), the Secretary shall send a subsection (1) form to the
veteran with instructions on how to complete and submit it. If the
member submits an application for a benefit but does not submit a
completed subsection (1) form, the Secretary shall make a character of
discharge determination and shall determine whether the member
qualifies for such benefit, notwithstanding the member's failure to
submit a completed subsection (1) form.
(d) In determining whether a former service member is a Veteran
under sections 101(2) and 5303, Title 38, United States Code, the
Secretary shall furnish all due assistance to the former member. If the
former member indicates that he or she may have experienced a mental
health disorder during his or her service, such assistance shall
include any physical or mental health evaluation necessary to determine
whether the former member meets the standards set forth in sections
101(2) and 5303(b), Title 38, United States Code.
Option 4. Express ``Sense of Congress'' concerning eligibility
regulations
The current eligibility standard for basic VA services dates back
to World War II, when Congress and the nation were preparing to welcome
home sixteen million service members. At that time, based on their
experiences after the First World War and prior conflicts, Congress
chose to help nearly all who served access VA's rehabilitation and
reintegration programs, barring only those who received or should have
received a ``dishonorable'' discharge. Congress recognized that many
service members returning from combat might be experiencing mental
distress, struggle with substance abuse, or have difficulty readjusting
and then engage in minor misconduct, but Congress determined that they
should nevertheless be eligible for VA services. At the time, that
meant that only 1.7% of WWII veterans were barred from VA, and that
generation of veterans, with support from the G.I. Bill, ushered in a
period of unprecedented growth and productivity. However, because of
imperfect regulations as well as shifting military practices, the
number of veterans excluded from VA has now more than tripled, to 6.5%
of Post-9/11 veterans. Congress would do well to reaffirm its
commitment to the 1944 eligibility standard, and thereby allow this
newest cohort of veterans to become our next Greatest Generation.
CONGRESSIONAL INTENT RELATING TO CHARACTER OF DISCHARGE.--Congress
hereby reaffirms its commitment to the existing statutory limitations
on access to veteran services based on in-service conduct, namely the
statutory provisions at Sections 101(2) and 5303, Title 38, United
States Code. These provisions were originally adopted as part of the
the Servicemen's Readjustment Act of 1944, better known as the G.I.
Bill of Rights. They were informed by this country's most broad-based
participation in military service. Congress did at that time, as now,
hold the two goals of rewarding faithful service and taking care of its
service members despite the hardships and inconsistent experiences
associated with military service, particularly in wartime. The
standards adopted in 1944 reflected Congress's best judgement on how to
reconcile those two goals. The transition to an All-Volunteer Force has
changed military retention practices significantly, but it has not
changed Congress's commitment to both of those goals. Congress has
adjusted its response since 1944 by limiting Education benefits to
those with fully Honorable discharges, with enactment of the 1981
Montgomery GI Bill. Congress tightened eligibility for that benefit in
order that it may best serve as an incentive to enlistment and reward
for faithful service. For veteran services that do not serve this
inducement function, Congress's judgement from 1944 remains prudent and
its statutory formulation is intact. In particular, Congress affirms
that the itemized bars in Section 5303(a), Title 38, United States
Code, are intended to indicate the types of disqualifying conduct
foreseen by the general provision in Section 101(2), Title 38, United
States Code. Furthermore, Congress affirms that the intent of the
statute is as much to promptly identify eligible service members as it
is to correctly identify those who are ineligible. The intent of the
statute is not achieved by undue delays or bureaucratic obstacles that
interfere with timely access to basic services. This is particularly
true with respect to mental health care services. Congress encourages
the Secretary to adopt regulations, policies, and procedures that
effectively implement our intent with respect to these limitations on
access to services.
Option 5. Ensure treatment eligibility for veterans who experienced MST
notwithstanding conditions of discharge
For a period of time, VHA facilities provided counseling and health
care services to treat conditions related to military sexual trauma,
including to veterans with bad-paper discharges, even if VA had not yet
adjudicated their character of discharge or questions of service
connection. \16\ Under that policy, victims and survivors of MST were
able to access critical mental health supports without undue delay or
excessive paperwork. However, currently, veterans with bad-paper
discharges cannot access such services until they have undergone a
lengthy character of discharge review process. \17\ Congress could
restore this salutary policy by amending the statute. It further could
expand the provision to include veterans who deployed or served in
support of combat operations.
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\16\ Department of Veterans Affairs, Directive 2010-033 (July 10,
2010); see 38 U.S.C. Sec. 1720D.
\17\ Department of Veterans Affairs, Memorandum, Eligibility for
Military Sexual Trauma-Related Counseling and Care and Services at the
Department of Veterans Affairs (VA) (July 26, 2016).
ACCESS TO CARE RELATED TO MILITARY SEXUAL TRAUMA (MST).--In order
to ensure timely access to essential care related to MST, the VA shall
not require prior adjudication of line-of-duty, minimum time in
service, or character of discharge prior to provision of counseling or
health care services due to MST.
Amend Section 1720D(a) as follows:
``(1) The Secretary shall operate a program under which the
Secretary provides counseling and appropriate care and services to
eligible persons whom the Secretary determines require such counseling
and care and services to overcome psychological trauma, which in the
judgment of a mental health professional employed by the Department,
resulted from a physical assault of a sexual nature, battery of a
sexual nature, or sexual harassment which occurred while the veteran
was serving on active duty, active duty for training, or inactive duty
training.
``(2) Eligible persons.
``(A) In operating the program required by paragraph (1), the
Secretary may, in consultation with the Secretary of Defense, provide
counseling and care and services to members of the Armed Forces
(including members of the National Guard and Reserves) on active duty
to overcome psychological trauma described in that paragraph.
``(B) A member described in subparagraph (A) shall not be required
to obtain a referral before receiving counseling and care and services
under this paragraph.
``(C) The services described in paragraph (1) may be provided to
prior and current service members without limitation on the basis of 38
U.S.C. 5303A (Minimum Active-Duty Service Requirement), 38 U.S.C. 5303
(Certain bars to benefits) or 38 U.S.C. 101(2) (Requirement for federal
active service under conditions other than dishonorable).''
Option 6. Implement mandatory training on eligibility for all front-
line VA staff
There is often confusion and misunderstanding about the eligibility
criteria for accessing VA services, particularly as relates to
character of discharge. To ensure that no veterans are wrongfully
turned away from access to care and support they deserve, Congress can
require that those who regularly interact with veterans who may not yet
be accessing VA services understand the eligibility criteria,
eligibility determination procedures, and their role in facilitating
eligibility processes.
TRAINING OF EMPLOYEES OF THE DEPARTMENT.--
(1) IN GENERAL.--Not later than one year after the date of the
enactment of this Act, the Secretary shall develop and implement a
comprehensive training curriculum for all employees whose duties
include regular interaction with former service members who are or may
be not enrolled in or receiving benefits administered by the Secretary
under Title 38, United States Code, and all employees who adjudicate
claims involving eligibility determinations for benefits administered
by the Secretary under Title 38, United States Code. The curriculum
shall address the basic eligibility criteria for benefits administered
by the Secretary, including eligibility for former service members who
were discharged or released under conditions that were not honorable.
(2) TRAINING.--
(A) IN GENERAL.--Each person for whom such training is required
shall undergo retraining at least once every five years during that
person's tenure at the Department.
(B) CURRENT EMPLOYEES.--Each person for whom training is required
under subsection (1) shall undergo training not later than 90 days
after the curriculum implementation date.
(C) NEW EMPLOYEES.--Each person who becomes a person for whom
training is required under subsection (1) shall undergo training not
later than 90 days after the date on which that person fills the
qualifying position.
Option 7. Study VA practices and procedures relating to health care
access
Many veterans with bad-paper discharges may be eligible for some
health care from VA, but for various reasons are not currently
utilizing that care. While policymakers, department staff, and
advocates can speculate as to the causes for that phenomenon, further
study is warranted to fully understand the causes and propose
recommendations for how it could remedied. Congress can direct the
Government Accountability Office to study and report back about this
question, which can then inform what policies Congress and VA adopt
going forward.
STUDY OF IMPLEMENTATION OF SECTIONS 101(2) AND 5303, TITLE 38,
UNITED STATES CODE.--The Comptroller General shall, no later than one
year after adoption of this provision, present a review of Department
of Veterans Affairs policies, activities, and performance that relate
to implementation of Sections 101(2) and 5303, Title 38, United States
Code. The purpose of the study shall be to determine whether
potentially eligible former service members receive timely access to
health care services and whether former service members barred under
statute are screened appropriately and efficiently. The study shall
include examinations of Veterans Benefits Administration adjudication
and performance of benefit applications where these provisions are
implicated; Veterans Health Administration staff performance in
receiving the applications and requests for care from former service
members where these provisions may be implicated; and coordination and
communication between the Veterans Benefits Administration and Veterans
Health Administration where these provisions may be implicated. The
study shall assess, to the extent possible, health care access
exclusion rates under existing policies and procedures and the reasons
therefor. The study shall assess whether information exchange or
coordination between the Department of Veterans Affairs and the
Department of Defense can affect the timely and effective access to
care for potentially eligible former service members.
Please address questions and comments to Bradford Adams (415) 252-
4788 x317 or [email protected].
For more information about access to VA for veterans with bad-paper
discharges, consult Underserved, a report by the Veterans Legal Clinic
at Harvard Law School published on behalf of Swords to Plowshares and
the National Veterans Legal Services Program, available online at
https://www.swords-to-plowshares.org/2016/03/30/Underserved.
WOUNDED WARRIOR PROJECT
RE: H.R. 918
Dear Chairman Wenstrup and Ranking Member Brownley,
Over the past several months, a groundswell of community support
has drawn attention to veterans with so-called ``bad paper discharge''
and reinvigorated discussion about what benefits should be available to
those whose service was determined to be less than honorable. In many
cases, access to educational assistance, disability compensation, and
other Department of Veterans Affairs (``VA'') benefits represents fair
and deserved reward for sacrifice. For those with mental health
challenges arising from service, access to mental health care must be
recognized as a pressing entitlement, regardless of discharge status.
Wounded Warrior Project appreciates and agrees with the intent of
H.R. 918, the Veterans Urgent Access to Mental Health Care Act, which
addresses access to mental health care for those with other than
honorable discharges. For too many veterans, trauma in service is the
nexus between yesterday's bad paper discharge and today's mental health
challenges. In our experience, many veterans suffering from post-
traumatic stress disorder, traumatic brain injury, or military sexual
trauma have received bad paper discharges for behavioral problems
rooted in the same circumstances that led to those diagnoses.
Regardless of cause, it remains that veterans with bad paper discharges
are at greater risk for homelessness, substance abuse, incarceration,
untreated physical and mental injuries, and suicide.
Given the gravity of this situation, WWP encourages this
Subcommittee to continue prioritizing this issue. We look forward to
working with the committee to ensure that H.R. 918, and other relevant
policy changes, appropriately and fully address the challenges at hand.
For instance, while we support H.R. 918's intent, we believe that it
can be improved. The legislation's eligibility criteria may place
administrative demands - such as the need to verify a veteran's combat
service - at odds with the need to provide urgent care. And although
H.R. 918 authorizes care for veterans who present with urgent mental
health care needs, VA should not be placed in a position where it must
turn individuals away until their problems worsen and their needs
become emergencies. A broader solution can more effectively address
needs and diminish the likelihood of bureaucratic hurdles to delivering
care.
On March 7th, before members of this Subcommittee, Secretary
Shulkin testified that VA would begin providing urgent mental health
care for veterans with other than honorable discharges, and indicated
that VA is poised start to providing such care under existing
authority. Although the implementation details remain to be seen,
Secretary Shulkin's signal of support should allow this Subcommittee
the extra time needed to ensure that any legislative solutions are
appropriately crafted, and that VA has more permanent capacity to
handle a surge of veterans seeking mental health care. Time is still of
the essence - VA has not announced plans to provide mental health care
for veterans with bad paper discharges in non-emergency situations -
but care must be taken to ensure that VA is prepared and able to
provide the care and support that these veterans need.
Earlier this March, Wounded Warrior Project reached a major
milestone in its service to our nation's wounded warriors, their
families, and their caregivers. Just weeks ago, Wounded Warrior Project
registered its 100,000th post-9/11 injured veteran, who will now have
access to our free, life-changing programs and services. This milestone
clearly demonstrates that the needs of our nation's veterans are great
and growing, and that it is more important than ever for us to stand
behind them in their recovery and rehabilitation. Thank you for the
opportunity to submit this statement for the record.
Sincerely,
Michael S. Linnington, LTG (ret), U.S. Army
Chief Executive Officer
Wounded Warrior Project
AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO (AFGE)
Chairman Wenstrup, Ranking Member Brownley and Members of the
Subcommittee:
The American Federation of Government Employees, AFL-CIO (AFGE),
appreciates the opportunity to submit a statement for the record on the
Medical Scribe Pilot Act of 2017. AFGE represents nearly 700,000
employees in the Department of Veterans Affairs (VA), including 230,000
employees at the Department of Veterans Affairs on the front lines
providing services for veterans.
AFGE opposes the draft legislation, the Veterans Affairs Medical
Scribe Pilot Act of 2017. This bill would direct the Secretary of
Veterans Affairs to carry out a pilot program on the use of medical
scribes in Department of Veterans Affairs medical center.
AFGE opposes this bill because it will not increase access or
reduce wait times, but is likely to have unintended adverse
consequences. Therefore, AFGE urges further study by the GAO (rather
than a private entity that could benefit from the increased use of
scribes) that looks at all options for freeing up provider time before
enacting this legislation.
Our physician and other provider members report that they already
have adequate technology through the Computerized Patient Record System
(CPRS) and dictation software to record their patient notes. They urge
lawmakers to consider other options for reducing pressures on
providers, most significantly, strengthening the ``PACT'' teams through
full staffing and better team training. Our providers also urge a
reduction in the number of computer view alerts to which they must
respond and management compliance with requirements to provide regular
``admin'' time slots during which they can address lab reports, call
backs and other non-appointment patient needs.
Such a study should include the views of front line providers and
their labor representatives. It is very disappointing that a recent
`physician engagement'' workgroup that was convened within the VA did
not include the views of front line providers. Similarly, we believe
that the view alert pilot project that was developed by that workgroup
was not fully implemented and did not adequately reduce the number of
view alerts placing undue pressures on providers.
This study should also examine the experiences of Kaiser Permanente
where medical assistants were used as scribes in some facilities; that
effort did not appear to increase the number of patients that could be
seen in a day.
Finally, we urge the GAO to consider the impact of scribes on the
provider-veteran relationship. The presence of a third party playing a
non-clinical role could interfere with the patient's ability to build
trust with the provider and share very personal information about his
or her veteran experience.
Thank you for considering the views of the American Federation of
Government Employees.
VIETNAM VETERANS OF AMERICA
Presented by
Kristofer Goldsmith, Assistant Director for Policy and Government
Affairs
Regarding
H, R, 918, H.R. 95, H.R. 91, H.R. 1162, H.R. 1545, H.R. 907, H.R. 1162,
H.R. 1005 and H.R. 467
Chairman Wenstrup, Ranking Member Brownley and distinguished
members of the House Veterans' Affairs - Subcommittee on Health, on
behalf of President John Rowan, our Board of Directors, and our
membership, Vietnam Veterans of America (VVA) thanks you for the
opportunity to present our statement for the record for today's
legislative hearing.
HR 918 - Veteran Urgent Access to Mental Healthcare Act - A bill to
amend title 38, United States Code, to direct the Secretary of Veterans
Affairs to furnish mental health care to certain former members of the
Armed Forces who are not otherwise eligible to receive such care, and
for other purposes.
Vietnam Veterans of America thanks Congressman Coffman and the
members who have joined him in fighting for veterans who have
experienced PTSD, TBI, or MST, who have been issued the lifetime
punishment of a less-than-honorable discharge without the due-process
rights of a court-martial. However, we must strongly oppose this bill
in its current form.
This legislation was inspired by reports revealing that veterans
with less-than-honorable discharges are more likely to be unemployed,
experience homelessness, suffer from substance abuse, be incarcerated,
and die by suicide. Furthermore, the bill responds to reports from the
Government Accountability Office that the Department of Defense has
failed to comply with its own regulations and Congress's directives
intended to protect veterans who have experienced post-traumatic stress
disorder, traumatic brain injury, military sexual trauma, and other
service-related illnesses and injuries from being discharged without
access to benefits.
Congress has attempted to fix this problem before. According to
Public Law 95-126, the Department of Veterans Affairs must provide
treatment to veterans with Other Than Honorable discharges for their
service-connected injuries and illnesses. Now, the Veteran Urgent
Access to Mental Healthcare Act seeks to build on that law so that
tentative access to mental healthcare is provided to veterans who have
experienced PTSD, TBI, or MST, until the Department of Veterans Affairs
makes a ``characterization of discharge determination''--which is
typically a lengthy process.
However, the bill may face challenges in implementation because,
under current VA policies, veterans cannot directly apply for a
character of discharge determination. Instead, the process is initiated
only after a veteran applies for some VA benefit. Because veterans
cannot simply request a character of discharge review, few veterans
with other-than-honorable discharges are aware of the fact that they
may be eligible for some benefits. Furthermore, most of those veterans
whose service is reviewed are eventually denied eligibility, because of
regulations that fail to give due credit to the meritorious and
valuable service of those veterans.
The bill may also have the unintended effect of limiting access to
VA, because it narrowly defines which veterans can get tentative
healthcare, where under existing law VA has the authority grant access
more broadly. VA could accomplish what the bill mandates under laws
already on the books.
The reason that VA could do that is because access to basic VA
benefits does not require an honorable discharge. According to 38
U.S.C. Sec. 101(2), a ``veteran'' is ``a person who served in the
active military, naval, or air service, and who was discharged or
released therefrom under conditions other than dishonorable'' (emphasis
added).
Under current law, the Department of Veterans Affairs has the
statutory authority to provide comprehensive healthcare to most
veterans who were not discharged by General Court-Martial (whether
Dishonorable or Bad Conduct) or who are otherwise barred by statute.
Indeed, VA can allow veterans with Other Than Honorable discharges to
get not only healthcare, but also disability compensation, pension,
vocational rehabilitation, and other supportive services intended to
rehabilitate and support former service members. For service members
who require an adjudication of eligibility on this issue--what the VA
calls a character of discharge determination--existing law already
allows the VA to provide tentative eligibility for comprehensive health
care, not limited to mental health care and not limited to combat
theater veterans. The VA chose not to extend the tentative health care
as a policy matter alone, it does not require legislation to do so now.
However, in recent decades, the Department of Veterans Affairs has
excessively employed its regulatory powers in determining eligibility
to deny care and benefits to hundreds of thousands of veterans,
including many who are suffering from wounds and illnesses caused by
their service.
The use of less-than-honorable administrative discharges has grown
significantly for recent generations of veterans. As a result of
Department of Veterans Affairs' self-imposed regulations, these
administratively issued less-than-honorable discharges are for many
veterans a lifetime ban on earned benefits. The Department of Veterans
Affairs' refusal to provide care to veterans who were discharged under
``other than dishonorable'' conditions is an absolute contradiction of
the congressional intent expressed by the 1944 G.I. Bill of Rights,
which sought to protect the due process rights of all veterans and
ensure that they could access the care that they needed.
In sum, laws already on the books should allow veterans with Other
Than Honorable discharges access to healthcare, at the very least for
service-connected injuries. Any delay in care to veterans due to a
lengthy characterization of discharge review is a failure of the
Department of Veterans Affairs to live by its motto ``to care for him
who shall have borne the battle and for his widow, and his orphan''.
Vietnam Veterans of America recommends that rather than risk
narrowing the scope of the VA's statutory authority to provide care to
veterans with OTH discharges, Congress instead exercise its
considerable oversight powers and encourage the Secretary of Veterans
Affairs to use his existing authority to review and replace the VA's
self-imposed regulatory restrictions with rules that provide timely,
fair, and patient-centered care for veterans with OTH discharges.
Congress must not limit healthcare to veterans impacted by PTSD,
TBI, or MST to those conditions alone, as care for the mind cannot be
successful without care for the body.
We would like to strongly support this well-intended legislation,
but it must be amended to replace sections which, as introduced, would
have the unintended effects of limiting the statutory authority of the
Department of Veterans Affairs to provide prompt and comprehensive
healthcare to the hundreds of thousands of veterans with less-than-
honorable discharges. Especially in light of the Secretary of Veterans
Affairs' March 7, 2017 announcement that he intends to expand and
improve VA's treatment of veterans with Other Than Honorable
discharges, we recommend that this bill be amended to support and
expedite those regulatory changes.
Specifically, the bill should require the VA to promptly issue a
Proposed Rule regarding eligibility and, at minimum, impose eligibility
standards as outlined in Recommendation # 17 of the Commission on Care
Report. The Commission on Care Report was required by the Veterans
Access, Choice, and Accountability Act of 2014. Recommendation #17 of
the Commission on Care Report was to ``Provide a streamlined path to
eligibility for healthcare for those with an other-than-honorable
discharge who have substantial honorable service.'' This recommendation
suggested VA regulatory changes rather than legislation. The Veteran
Ugent Access to Mental Healthcare Act could serve as an excellent
vehicle to expedite these long overdue amendments and ensure fair and
just treatment for all veterans. In line the the Report's
recommendations, we ask Congress to require that VA:
1.Amend 38 C.F.R. 17.34 to provide for tentative eligibility for
health care for individuals with Other Than Honorable discharges who
have had substantial honorable service, such as service in a combat
theater, service in support of combat operations, and other hardship
service.
2.Amend 38 C.F.R. 3.12(d) to require consideration of mitigating
and extenuating circumstances that show that service was ``other than
dishonorable.''
HR 95 - Veterans' Access to Child Care Act - A bill to amend title
38, United States Code, to direct the Secretary of Veterans Affairs to
provide child care assistance to veterans receiving certain medical
services provided by the Department of Veterans Affairs.
VVA strongly supports the Veterans' Access to Child Care Act. This
bill would expand the successful pilot program created in 2011 with the
passage of the Caregivers and Veterans Omnibus Health Services Act of
2010 (PL 111-163). In doing so, it would help the VA to fulfill its
mission to care for veterans and their families, and prevent veterans
from having to choose between the needs of their children and their own
health. The VA pilot program found in its first three years that nearly
half of its users were mothers or step-mothers, Access to childcare is
one of the top unmet needs for women and men Veterans, when enacted
into law H.R. 95, will improve patient satisfaction, prevent
appointment no-shows and cancellations, provide much-needed child care
services for veterans and veteran families especially those living in
rural areas.
HR 91 - Building Supportive Networks for Women Veterans Act - A
bill to amend title 38, United States Code, to make permanent the pilot
program on counseling in retreat settings for women veterans newly
separated from service in the Armed Forces.
VVA strongly supports the Building Supportive Networks for Women
Veterans Act. This bill makes permanent the requirement for the
Department of Veterans Affairs to carry out, through the Readjustment
Counseling Service of the Veterans Health Administration, a program to
provide reintegration and readjustment services in group retreat
settings to women veterans who are recently separated from service
after a prolonged deployment. Currently, such program is required as a
pilot program under the Caregivers and Veterans Omnibus Health Services
Act of 2010.
HR 1162 - No Hero Left Untreated Act - A bill to direct the
Secretary of Veterans Affairs to carry out a pilot program to provide
access to magnetic EEG/EKG-guided resonance therapy to veterans.
VVA supports the No Hero Left Untreated Act. This bill would
develop a pilot program at the VA to explore the effects of Magnetic
eResonance Therapy technology, or MeRT technology, to treat patients
suffering from PTSD, TBI, MST, opiate addiction, and chronic pain. This
non-surgical, non-pharmaceutical treatment has shown promising results
in limited studies.
HR 1545 - VA Prescription Data Accountability Act - A bill to amend
title 38, United States Code, to clarify the authority of the Secretary
of Veterans Affairs to disclose certain patient information to State
controlled substance monitoring programs, and for other purposes.
VVA strongly supports the VA Prescription Data Accountability Act.
This bipartisan bill would improve data sharing between the VA and
State controlled substance monitoring programs so that prescriptions
for non-veteran patients of VHA are tracked the same way that veterans'
prescriptions already are. This data sharing would help to combat the
opioid crisis.
HR 907 - Newborn Care Improvement Act - A bill to amend title 38,
United States Code, to improve the care provided by the Secretary of
Veterans Affairs to newborn children.
VVA strongly supports the Newborn Care Improvement Act. This bill
allows the Department of Veterans Affairs (VA) to provide the newborn
child of a woman veteran who is receiving VA maternity care with post-
delivery care services for 42 days after the child's birth if the
veteran delivered the child in a VA facility or another facility with
which VA has a contract for such services. Under current law, such care
may not be provided for more than 7 days. This bill will help the VA to
fulfill its mission, to improve its care for women veterans and their
families.
HR 1662 - A bill to amend title 38, United States Code, to prohibit
smoking in any facility of the Veterans Health Administration, and for
other purposes.
VVA must oppose this legislation, which is intended to protect
veterans and their families from the harmful effects of secondhand
smoke, but may have the unintended effect of discouraging veterans from
getting the care that they need. VVA is concerned that veterans
addicted to nicotine may face serious psychological and physiological
stress when denied access to cigarettes, especially if they require in-
patient care. For many veterans, the prospect of having to go ``cold-
turkey'' from cigarettes may dissuade them from getting care that they
need.
Furthermore, VVA members report value in the so-called ``smoke
pit'' where veterans often find camaraderie and build upon
relationships formed during group therapy.
VVA would support this legislation if it were amended so that
nicotine addicted veterans were guaranteed access to smoking areas in
weather-protected spaces that are outfitted with HEPA (high-efficiency
particulate air) filtration technology.
HR 1005 - A bill to amend title 38, United States Code, to improve
the provision of adult day health care services for veterans.
VVA strongly supports this legislation.
This bill directs the Department of Veterans Affairs (VA) to enter
into an agreement or a contract with each state home to pay for adult
day health care for a veteran eligible for, but not receiving, nursing
home care. The veteran must need such care specifically for a service-
connected disability or the veteran must have a service-connected
disability rated 70% or more. Payment under each agreement or contract
between the VA and a state home must equal 65% of the payment that the
VA would otherwise pay to the state home if the veteran were receiving
nursing home care.
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