[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




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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.
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \2\ American Legion Resolution No. 43 (Sept. 2016): Department of 
Veterans Affairs Child Care Program
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \4\ Ibid
    \5\ American Legion Resolution No. 1 (Sept. 2016): Department of 
Veterans Affairs Quadrennial Plan for Budget
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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.
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \13\ http://archive.legion.org/bitstream/handle/123456789/2498/
2013S026.pdf?sequence=1&isAllowed=y
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \14\ Olsen, K. (2016, May). Booted after battle. American Legion 
Magazine. Retrieved from https://www.legion.org/magazine/232778/booted-
after-battle
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \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\
---------------------------------------------------------------------------
    \18\ American Legion Resolution No. 83 (Sept. 2106): Virtual 
Lifetime Electronic Record
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \19\ American Legion Resolution No. 377 (Sept. 2016): Support for 
Veteran Quality of Life
---------------------------------------------------------------------------
    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).

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    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.

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    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.

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    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.
---------------------------------------------------------------------------
    \10\ 38 C.F.R. Sec.  17.36.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \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.

                                 [all]