[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]



 
 LEGISLATIVE HEARING ON H.R. 93; H.R. 501; H.R. 1063; H.R. 1066; H.R. 
1943; H.R. 1972; H.R. 2147; H.R. 2225; H.R. 2327; AND, A DRAFT BILL TO 
  MAKE CERTAIN IMPROVEMENTS IN VA'S HEALTH PROFESSIONALS EDUCATIONAL 
                           ASSISTANCE PROGRAM

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

                                HEARING

                               before the

                         SUBCOMMITTEE ON HEALTH

                                 of the

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

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                      TUESDAY, SEPTEMBER 26, 2017

                               __________

                           Serial No. 115-31

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
       
       
 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]    


        Available via the World Wide Web: http://www.govinfo.gov
        
        
        
                                _________ 

                  U.S. GOVERNMENT PUBLISHING OFFICE
                   
 31-339                    WASHINGTON : 2018             
        
        
        
                     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

                              ----------                              

                      Tuesday, September 26, 2017

                                                                   Page

Legislative Hearing On H.R. 93; H.R. 501; H.R. 1063; H.R. 1066; 
  H.R. 1943; H.R. 1972; H.R. 2147; H.R. 2225; H.R. 2327; And, A 
  Draft Bill To Make Certain Improvements In Va's Health 
  Professionals Educational Assistance Program...................     1

                           OPENING STATEMENTS

Honorable Brad Wenstrup, Chairman................................     1
Honorable Julia Brownley, Ranking Member.........................     2

                               WITNESSES

Honorable Debbie Dingell, U.S. House of Representatives, 12th 
  District; Michigan.............................................     3
    Prepared Statement...........................................    30
Honorable Beto O'Rourke, U.S. House of Representatives, 16th 
  Congressional District; Texas..................................     5
    Prepared Statement...........................................    31
Honorable Derek Kilmer, U.S. House of Representatives, 6th 
  Congressional District; Washington.............................     5
    Prepared Statement...........................................    32
Honorable Steve King, U.S. House of Representatives, 4th 
  Congressional District; Iowa...................................     7
    Prepared Statement...........................................    33
Honorable Lloyd Smucker, U.S. House of Representatives, 16th 
  Congressional District; Pennsylvania...........................     9
    Prepared Statement...........................................    34
Honorable Steve Stivers, U.S. House of Representatives, 15th 
  Congressional District; Ohio...................................    10
    Prepared Statement...........................................    35
Honorable Ron DeSantis, U.S. House of Representatives, 6th 
  Congressional District; Florida................................    12
    Prepared Statement...........................................    36
Honorable Mike Coffman, U.S. House of Representatives, 6th 
  Congressional District; Colorado...............................    13
    Prepared Statement...........................................    36
Honorable John Rutherford, U.S. House of Representatives, 4th 
  Congressional District; Florida................................    14
    Prepared Statement...........................................    37
Keronica Richardson, Assistant Director of Women and Minority 
  Veterans Outreach, National Security Division, The American 
  Legion.........................................................    16
    Prepared Statement...........................................    38
Amy Webb, National Legislative Policy Advisor, AMVETS............    17
    Prepared Statement...........................................    44
Harold Kudler M.D., Acting Assistant Deputy Under Secretary for 
  Health for Patient Care Services, Veterans Health 
  Administration, U.S. Department of Veterans Affairs............    19
    Prepared Statement...........................................    48

        Accompanied by:

    Catherine Biggs-Silvers, Executive Director for Mission, 
        Planning, and Analysis, Human Resources and 
        Administration, U.S. Department of Veterans Affairs

Rick Weidman, Executive Director for Policy & Government Affairs, 
  Vietnam Veterans of America, Prepared Statement only...........    56

                       STATEMENTS FOR THE RECORD

David J. Shulkin, M.D............................................    58
Blinded Veterans Association (BVA)...............................    59
Disabled American Veterans (DAV).................................    62
Justice For Vets.................................................    69
Make A Difference America........................................    72
Paralyzed Veterans of America (PVA)..............................    73
Veterans of Foreign Wars of The United States (VFW)..............    77


 LEGISLATIVE HEARING ON H.R. 93; H.R. 501; H.R. 1063; H.R. 1066; H.R. 
1943; H.R. 1972; H.R. 2147; H.R. 2225; H.R. 2327; AND, A DRAFT BILL TO 
  MAKE CERTAIN IMPROVEMENTS IN VA'S HEALTH PROFESSIONALS EDUCATIONAL 
                           ASSISTANCE PROGRAM

                              ----------                              


                      Tuesday, September 26, 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 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. Brad Wenstrup, 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Wenstrup, Bilirakis, Radewagen, 
Dunn, Rutherford, Higgins, Brownley, Takano, Kuster, O'Rourke, 
and Correa.
    Also present: Representative Coffman.

          OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN

    Mr. Wenstrup. Good morning and thank you all for joining us 
today.
    Before we begin, I would like to ask unanimous consent for 
our colleague and fellow Member Representative Coffman from 
Colorado to sit on the dais and participate in today's 
proceedings.
    Without objection, so ordered.
    It is a pleasure to be here this morning with all of you to 
discuss ten pieces of pending legislation that would impact our 
Nation's veterans and the care provided to them by the 
Department of Veterans Affairs.
    I am grateful to my colleagues who sponsor the bills on our 
agenda for their hard work and leadership and for being here 
this morning to testify about their proposals. I am also 
grateful to our witnesses from VA and from the veterans' 
service organization community, as well as those stakeholders 
and advocates who provide statements for the record, for their 
insightful comments, thoughtful recommendations, and ongoing 
efforts on behalf of veterans and their families.
    The agenda for today's hearing includes bills that would 
help the VA health care system become a more transparent, 
streamlined, well-staffed, patient-centered, accountable, and 
innovative organization. While I look forward to examining all 
the legislation we are considering this morning, I am 
particularly interested in Representative Rutherford's draft 
bill to strengthen VA's recruitment and retention programs.
    Previous legislation of mine to improve VA's ability to 
hire high-quality employees was signed into law as part of a 
larger VA bill in August. However, VA's staffing shortages and 
workforce retention issues are complex and will not be fully 
overcome without strong efforts to improve VA's ability to 
identify talented clinicians early in their medical careers, 
recruit them during or straight out of residency, and bring 
them quickly on board to begin serving veteran patients and 
bolstering the strength of the VA health care system. 
Representative Rutherford's bill would do that and I look 
forward to discussing it, and the many other bills before us 
this morning.
    I now yield to Ranking Member Brownley for any opening 
statement that she may have.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Mr. Chairman.
    And thank you to all of today's witnesses for participating 
in our legislative hearing, and particularly to all of the 
Members who are here representing very, very good bills. So 
thank you for that.
    I will say right up front that unfortunately I will be 
unable to remain for the entire hearing. I have a constituent 
testifying at the T&I Committee and I need to be there for my 
constituent. I sit on the T&I Committee. Mr. Takano has kindly 
agreed to sit in for me to finish out today's hearing.
    We have a number of important bills on the agenda for today 
and I want to thank my colleagues for offering their 
legislation to improve the care and services we provide to 
veterans.
    After reading the witnesses' prepared statements ahead of 
today's hearing, I would also like to extend a special thank 
you to each of the VSOs for supporting my legislation, H.R. 93, 
that will ensure women veterans have access to gender-specific 
services at VA facilities.
    The Women Veteran Equal Access to Quality Care Act will 
increase access to health care for the every-growing population 
of women veterans enrolled in VA care by requiring the 
Department to offer gender-specific services at each of its 
medical facilities. This legislation is critical to ensure that 
women veterans receive the equal access to health care that 
they have earned.
    Almost 10 percent of the total veteran population, over 2 
million veterans are women, and the VA projects that this 
percentage will continue to rise. In the years since 9/11, more 
American women have served our country in uniform than ever 
before. Nearly 280,000 women have served in Iraq and 
Afghanistan and through their service have earned the full 
range of health care services provided by the VA. We must 
ensure that our Nation's women veterans have access to the full 
range of health care services that they need, including 
dedicated women's health providers and gender-specific care.
    I am also eager to hear from our witnesses about the two 
pieces of legislation related to service dog therapy on the 
agenda today. Both the PAWS Act and the Veteran Dog Training 
Therapy Act serve as important discussion points in ensuring VA 
is exploring the efficacy of alternative forms of treatment, 
especially treatments that have seemingly obvious benefits. I 
have yet to meet a veteran assigned a service dog that did not 
appreciate the assistance and therapy offered by the dog.
    We must continue to look at these complementary and 
alternative treatments that help veterans cope with the 
invisible wounds of war. 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.
    Mr. Chairman, thank you for the opportunity to discuss the 
legislation in front of the Committee today 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 your 
work to help our veterans.
    With us this morning is Congresswoman Debbie Dingell from 
Michigan; Congressman Beto O'Rourke from Texas; Congressman 
Derek Kilmer from Washington; Congressman Steve King from Iowa; 
Congressman Lloyd Smucker from Pennsylvania; Congressman Mike 
Coffman from Colorado; Congressman Steve Stivers from Ohio; 
Congressman Ron DeSantis from Florida; and Congressman John 
Rutherford from Florida as well.
    Congresswoman Dingell, we will begin with you. You are now 
recognized for 5 minutes.

         OPENING STATEMENT OF HONORABLE DEBBIE DINGELL

    Mrs. Dingell. Thank you, Mr. Chairman.
    Chairman Wenstrup, Ranking Member Brownley, thank you for 
your tireless dedication--and all the Members of this 
Subcommittee and Full Committee, thank you for your tireless 
dedication to our veterans and allowing me to testify in 
support of my legislation, H.R. 501, the VA Transparency 
Enhancement Act.
    This bipartisan legislation, which I introduced with my 
colleague Congressman Tim Walberg from Michigan, is a 
commonsense measure we can take to improve transparency and the 
quality of care for our veterans, and I urge the Committee to 
consider this bill as soon as possible.
    The bill would simply require the director of each VA 
medical center to send quarterly reports to the Secretary on 
the number of surgical infections at each facility and the 
number of surgeries which were cancelled or transferred to 
another hospital. The Secretary would then transmit these 
reports to Congress and publish them on the Department's Web 
site to help improve transparency.
    This legislation is a direct response to an unfortunate 
incident at a VA hospital in my district, which actually lasted 
over a period of almost two years. The VA and our health care 
system had a reoccurring problem with particulate matter 
appearing on trays of surgical equipment that are supposed to 
be sterile. In addition to raising the risk of infections, many 
veterans had their surgeries cancelled or moved to a different 
location. Cancelling or delaying a surgery could result in 
adverse health for our veterans and we must know as soon as 
possible if this is happening at VA facilities.
    This is not the only instance of cancelled surgeries at a 
VA hospital. In September 2015, the Star Tribune reported that 
the Minneapolis Veteran Affairs Medical Center was forced to 
postpone and reschedule dozens of surgical procedures after an 
unidentified substance was found in sterilizing equipment.
    As I dug into the issue, I learned that VA hospitals are 
not required to publicly report on surgical infections and 
cancellation rates as other hospitals do. The VA Transparency 
Enhancement Act will help Congress and the veterans themselves 
understand when, where, and why infections are happening or if 
surgeries are being cancelled, so the VA and Congress can 
effectively address the problem.
    We should know as soon as possible if surgical infections 
or cancellations are increasing at any VA hospital.
    Other hospitals throughout the country are required to make 
this data available and it is a transparent metric for all of 
us to ensure our veterans are receiving quality health care. 
Surgical infection rates are an important measurement and all 
patients in any hospital have the right to know. This should be 
critical for our veterans.
    Improving transparency at the VA by requiring these 
quarterly reports will help ensure we are doing everything we 
can to give our veterans the care they deserve, and will help 
policymakers and the VA staff craft an appropriate response to 
help fix the problem.
    The number-one priority for all of us is to ensure that 
veterans receive the highest quality health care. We do not 
want to see any more surgeries cancelled or delayed because of 
unsterile equipment, but if it does happen again we must know 
right away. We also need to know when people are having an 
increased infection rate; that is a simple measurement of 
quality of care.
    The VA Transparency Enhancement Act is a good government 
bill that represents a modest step to help improve confidence 
in our VA health care system. By increasing transparency, we 
can prevent bad outcomes for our veterans and identify problems 
at the VA hospital sooner. Our responsibility as Members of 
Congress is to be a voice and an advocate for veterans across 
this country and serve our veterans as they have served us.
    Thank you again for inviting me to testify and allowing me 
to testify on this critical legislation. I thank the Chairman 
and Ranking Member for holding this important hearing and do 
hope that this bill will get marked up soon and moved to the 
House floor for consideration.
    Thank you, Mr. Chairman.

    [The prepared statement of Debbie Dingell appears in the 
Appendix]

    Mr. Wenstrup. Well, thank you very much. I think those are 
key components to quality assurance that exist in virtually 
every hospital setting and it is the tool to manage adverse 
trends and be able to nip those in the bud. So I appreciate you 
bringing that forward.
    Congressman O'Rourke, you are now recognized for 5 minutes.

          OPENING STATEMENT OF HONORABLE BETO O'ROURKE

    Mr. O'Rourke. Thank you, Chairman Wenstrup. I will be brief 
in describing H.R. 1063, the Veteran Prescription Continuity 
Act.
    Essentially, what this does is it harmonizes the formulary 
between DoD and the VA, so that if a servicemember is receiving 
a prescription for their hypertension, pain control, sleep 
disorder, or a psychiatric issue to include post-traumatic 
stress disorder, that they can continue to receive that same 
medication in the VA. Today, unfortunately, that is not the 
case.
    And if we want to make that transition from active service 
to civilian life as a veteran as seamless and successful as 
possible, then we need to make sure that those two formularies 
are really one. This bill would do that. It has the support of 
many veteran service organizations, for which I am grateful, 
and is cosponsored by Representative Mike Coffman of Colorado, 
to whom I am grateful as well.
    So that's it. Thanks.

    [The prepared statement of Beto O'Rourke appears in the 
Appendix]

    Mr. Wenstrup. I appreciate that as well, especially if 
their medications are working that they don't have to change.
    Congressman Kilmer, you are now recognized for 5 minutes.

          OPENING STATEMENT OF HONORABLE DEREK KILMER

    Mr. Kilmer. Thank you, Chairman and Ranking Member, and 
Members of the Subcommittee. I appreciate the opportunity to 
join you today to discuss how we can improve the operations of 
the Veterans Administration, so that those who have served our 
Nation actually get the care that they have earned.
    I have the honor of representing more than 82,000 military 
veterans, more than almost any other Member of my party, and 
one of the largest concentrations in the House of 
Representatives. In my region, we know that those who have 
served and their families have made tremendous sacrifices for 
us, and we know they have had our backs and part of our job is 
to have theirs too.
    And that means, if you fight for your country, you 
shouldn't have to fight for a job when you come home. It means, 
in the land of the free and the home of the brave, every brave 
servicemember should have a home. And it means that anywhere in 
this country, if you are a veteran, you should have access to 
the benefits that you have earned.
    That last point is what brings me here today. It is a 
conversation we have been having for far too long. I have heard 
in VA halls and the grocery store and from members of my 
Veterans Advisory Council, why can't we fix the VA once and for 
all? Why does it take so long to see a practitioner? Why do 
folks in smaller towns have to travel so far to get served? 
These questions have arisen because of the inability of 
veterans to schedule appointments, the difficulty to build a 
community-based outpatient clinic in my district, and other 
issues. And they are symptoms of a larger problem: systemic 
management challenges at the VA.
    I appreciate all that this Committee and this Congress have 
done to deliver answers to veterans like those that I 
represent. I am glad that we have passed legislation seeking 
information, providing enhanced authorities and funding, and 
calling for accountability, but we also know that there is more 
to do.
    In 2013, I partnered with then Ranking Member Brown and 
eventually Chairman Miller to request the Government 
Accountability Office to conduct a management review of the 
Veterans Health Administration. In our minds, this would help 
us get to the root of the problem. And the GAO team dove in and 
what started with three reports on our organizational 
structure, human capital, and information technology has 
doubled. These findings have begun to see the light of day and 
are accompanied by specific solutions to fix the problems that 
the GAO found.
    One of the key findings that stood out is that, after a 
number of reviews from both within and outside the VA, there 
was a clear menu of recommendations to fix things for the 
better. These specific recommendations included clarifying 
different responsibilities between local and national 
facilities, evaluating if core duties were being met, and 
improving services, planning, and communications, but the GAO 
found that these recommendations were never implemented. That 
is not fair to veterans, it is not fair to the staff that 
conducted these reviews, and, frankly, it is not fair to 
taxpayers who paid for them.
    On top of that, the Veterans Health Administration 
struggles to implement new policies and procedures due to a 
severe lack of clarity regarding the roles, missions, and 
accountability of senior leaders and organizations within the 
agency. The scale of the VA is so large that we need to go 
beyond position descriptions and office missions. There has to 
be clear, transparent, and enforced relationships between the 
leaders and the layers of the VA.
    How can we expect leaders and staff at more local levels to 
seek opportunities for collaboration and efficiency if there is 
not a clear understanding of how they are supposed to work 
together to care for veterans? We need all of the oars in the 
water rowing in the same direction, rather than the oars out of 
the water, beating each other over the head.
    And that is why I introduced the VA Management Alignment 
Act, to make sure that we follow through on the GAO 
recommendations. This bill simply requests that the Secretary 
of the VA provide a report to Congress within 180 days on the 
organizational structure of the VA. Specifically, the bill 
would require the Secretary to outline the roles, 
responsibilities, and accountability measures of senior leaders 
and branches of the VA informed by existing recommendations on 
the matter, and to provide Congress with a series of 
legislative options to assist the Secretary in realizing 
positive change.
    Before coming to Congress, I worked as a management 
consultant for McKinsey & Company and then worked in economic 
development, and my experience in both roles led me to 
understand that good management requires clarity from the top. 
To do that, we need to better measure outcomes, we need to work 
collaboratively with the administration to set an environment 
for success, and this bipartisan bill, which was drafted in 
consultation with the GAO and consistent with their 
recommendations, meets both of those tests.
    It is also important to note that the VA Management 
Alignment Act is supported by the American Legion and the 
American Federation of Government Employees. I am grateful that 
the largest veterans service organization and the Federal 
employees union has joined me in this effort.
    I know this is a legislative hearing and not a markup, and 
I would just request that we continue to work together to move 
this policy forward. I am with you in the effort to improve the 
VA and to turn words into deeds. And, again, I appreciate the 
opportunity to join you today and look forward to working with 
you to honor the service and sacrifices of our Nation's 
veterans.
    Thank you.

    [The prepared statement of Derek Kilmer appears in the 
Appendix]

    Mr. Wenstrup. Thank you very much. I appreciate your deep 
dive into some of the issues with GAO and seeking solutions. 
Thanks again.
    Mr. Kilmer. Thank you.
    Mr. Wenstrup. Congressman King, you are now recognized for 
5 minutes.

           OPENING STATEMENT OF HONORABLE STEVE KING

    Mr. King. Thank you, Mr. Chairman, and good morning, and 
Ranking Member and Members of the Committee.
    I am Steve King from Iowa and I represent the 4th District, 
and I am honored to testify before you today in support of my 
bill, H.R. 1943. The designated title is Restoring Maximum 
Mobility to Our Nation's Veterans Act of 2017.
    This critical legislation aims to ensure that our Nation's 
veterans with service-connected disabilities are not simply 
afforded a wheelchair, but are instead equipped with the very 
best wheelchair, one that affords maximum achievability of 
mobility and in the activities of daily life.
    The ability to pursue life to the fullest possible degree, 
even in the face of disability, is critical to ensuring that 
our Nation's veterans are as healthy as possible in body, in 
mind, emotions, and spirit. And the statistics prove the truth 
of that statement. An average of 20 veterans die each day due 
to suicide and six of them have been receiving VA service, the 
veterans and VHA services, I should say, in the two preceding 
years leading up to the tragic decision to commit suicide. In 
my home state of Iowa, there were 75 veteran suicides in 2014 
alone. We mourn these lives and they were lost unnecessarily 
many of them, and we find it unthinkable that these trends 
should continue.
    But according to current practice, when determining which 
wheelchair is best equipped for a particular veteran, a VA 
clinician will take into account medical diagnosis, prognosis, 
functional abilities, limitations, goals, and ambitions. 
Evaluation of those mobility accesses include a number of 
medical evaluations, but these capacities in response are to 
effort, quality, speed and mobility, and overall function. That 
really gives them enough latitude, except the VA 
recommendations clarify in addition that, quote, ``motorized 
and power equipment or equipment for personal mobility intended 
solely for recreational leisure activity should not be 
provided. Motorized and power equipment designed for 
recreational leisure activities do not typically support a 
rehabilitative goal.''
    That is their opinion and I think this Congress has an 
opportunity now to weigh in on how we really want to take care 
of our veterans. And in view of the suicide rates and a number 
of other observations, how can motorized and power equipment 
designed for recreational leisure activities not support a 
rehabilitative goal?
    According to a study made available by the National Center 
for Biotechnical Information, which operates under the NIH, 
quote, ``Leisure activities are defined as preferred and 
enjoyable activities participated in during one's free time, 
and characterized as representing freedom and providing 
intrinsic satisfaction. Individuals can recover from stress, 
restore social and physical resources through leisure 
activities. Leisure activities with others may provide social 
support and in turn mediate the stress-health relationship, 
enrich meaning of life, recovery from stress, and restoration 
of social and physical resources,'' close quote.
    This description will sound accurate to anyone who has 
found this kind of rest and solace.
    And I think that I will allow the rest of my prepared text 
into the record or ask that it be included into the record, but 
I want to tell a couple narratives into this on how this came 
together for me. And each year for a number of years, a decade 
or more, I have hosted the Bud Day Pheasant Hunt. Bud Day at 
the time of his passing about three or four years ago was the 
most decorated living American hero. He had 70-some Federal 
medals, including the Medal of Honor, which he received as a 
POW in North Vietnam. He was my hunting buddy and my friend.
    In that hunt, we would welcome Jack Zimmerman, a double 
amputee who had lost his legs at the hip and the use of most of 
his right arm and some of the use of his left arm. He hunted in 
a track chair with us. He had to shoot left-handed because his 
left hand was the only one that could operate the trigger and 
his right forearm he used to hold up the gun. But as he is 
tracking down through the field, I noticed that he only could 
shoot between 12 o'clock and 3 o'clock, because he has to shoot 
left-handed and he can't turn. I have hunted ducks from a 
canoe, I know what that's like. I'm 9 o'clock to 12 o'clock 
from a canoe.
    And so I started watching Jack. And he was limited and he 
couldn't rotate the chair, he couldn't rotate the seat in the 
chair, and you've got one second to get turned when a bird gets 
up. He loves to hunt and fish and outdoors. So I wanted him to 
have a rotating table that could turn in one second. I saw him 
going down the hill and that chair would push down to where he 
had to fight to keep from falling out of the chair. And I sit 
on dozers and equipment on side hills that now automatically 
level the seat. When you sit on the side, it will turn it this 
way; when you're going downhill, it turns you back to level; 
when you're going uphill, it sets you level. Jack can have that 
and every veteran that wants to hunt should have something like 
that.
    And so we need to remember that these wheelchairs are 
archaic and there is a lot of progress that will be made, let's 
make sure we provide that for our veterans.
    Thank you, Mr. Chairman, and I yield back the balance of my 
time.

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

    Mr. Wenstrup. Thank you. I appreciate your interest in 
getting the best care for our patients and the decision-making 
process being between the physician and the patient.
    Congressman Smucker, you are now recognized for 5 minutes.

          OPENING STATEMENT OF HONORABLE LLOYD SMUCKER

    Mr. Smucker. Thank you, Chairman Wenstrup, for the 
invitation to participate today. I would like to thank you, 
Ranking Member Brownley, and Members of the Subcommittee for 
the opportunity to testify before the Committee on legislation 
entitled the VA Billing Accountability Act.
    In August of this year, the Veterans Affairs Office of 
Inspector General reported that in the fiscal year 2015, of 
roughly 15.4 million bills that the Veterans Health 
Administration issued during 2015, approximate 1.7 million of 
those were improper bills for the treatment of service-
connected conditions.
    To put this in perspective, the Veterans Health 
Administration collected a staggering 13.9 million from our 
Nation's veterans inappropriately. That is simply unacceptable. 
Our servicemen and women should not be responsible to pay when 
there are errors or delays by the Department of Veterans 
Affairs.
    For more than a decade, the Department has failed to 
address its broken medical billing system that leaves our 
Nation's veterans to pick up an inaccurate or expensive bill. 
That is why I introduced the bipartisan VA Billing 
Accountability Act to relieve veterans of financial burdens 
caused by delays at the VA.
    My congressional district is home to more than 38,000 
veterans, all of them deserve the highest quality medical care 
and the assurance from the VA that they will not be forced to 
foot the bill for the mistakes made by the VA bureaucrats.
    To address this ongoing issue, my bill authorizes the VA to 
waive veterans' copayments if a veteran received a copayment 
bill more than 120 days after they received care at the VA or 
if they have received care at a non-VA facility after 18 
months.
    The VA Billing Accountability Act also holds the VA 
accountable by giving the Secretary of the VA the authority to 
get rid of the requirement that veterans make a copayment if 
the VA does not abide by the billing timing mandates.
    To ensure accountability, my bill requires the Secretary of 
Veterans Affairs to review the agency's copayment billing 
controls and notification systems to see if there are better 
solutions that can monitor and prevent erroneous bills within 
180 days after enactment of this legislation. It is imperative 
that the Department of Veterans Affairs prioritizes improving 
its internal billing procedures.
    Our Nation's veterans and their families have sacrificed so 
much in defense of our Nation, we should be making it easier, 
not harder, for them to transition to post-military life. That 
starts with making sure that the VA not only delivers quality 
health care, but also timely bills that our veterans can count 
on.
    Thank you again for the opportunity to testify before the 
Committee today and for all the work that the Members of this 
Committee do to ensure quality and affordable care for our 
Nation's veterans.
    I yield back.

    [The prepared statement of Lloyd Smucker appears in the 
Appendix]

    Mr. Wenstrup. Well, thank you very much. There is no doubt 
that the billing process in the VA is in need of some help as 
we move forward.
    Congressman Stivers, you are now recognized for 5 minutes.

          OPENING STATEMENT OF HONORABLE STEVE STIVERS

    Mr. Stivers. Thank you, Chairman Wenstrup and Ranking 
Member Brownley for holding this very important hearing and 
giving me the opportunity to testify on the Veteran Dog 
Training Therapy Act.
    I want to thank my cosponsor, Tim Walz from Minnesota, for 
his support on this important bill. It is a bipartisan bill 
that can help us with the devastating mental health crisis 
facing many of our veterans.
    You know, when veterans return home, many of them are 
struggling with visible, physical wounds; however, it is the 
invisible wounds that our veterans suffer that are sometimes 
overlooked. This includes post-traumatic stress, depression, 
and other mental health-related issues.
    Today, I want to discuss a few of the ways that this 
bipartisan bill can help our Nation's veterans in a unique way 
and build on the already-proven benefits of therapy dogs. First 
and foremost, therapy dogs work. Anybody who has ever had a pet 
understands the calming presence that they can be. We have a 
bunch of therapy dogs in the room today and, you know, it just 
kind of warms your heart just to look around and see what they 
are doing for our veterans.
    We have so many veterans who are struggling with service-
connected mental health issues and having the presence of the 
service dog can make all the difference in the world for them, 
and there is scientific evidence to back it up. A Kaiser 
Permanente study showed that veterans who have service dogs 
have fewer symptoms of post-traumatic stress, depression, 
anxiety, have better interpersonal relationships, and lowered 
risk of substance abuse and overall better mental health.
    Dog training therapy can clearly make a difference and we 
are losing too many veterans every day to suicide, I believe 
this is something that can really make a difference. The pilot 
program that this bill establishes would have the Department of 
Veterans Affairs Secretary contract with local therapeutic dog 
training organizations to help veterans who are seeking 
treatment learn the art and science of dog training. So they 
get to bond with the dog, they get to actually train with the 
dog, there is real therapeutic benefit there. Upon completion, 
the dog would be provided to a disabled veteran. And, you know, 
obviously, hopefully it would be those veterans who trained 
them, but we want to work with the Committee to make sure that 
that is something that we can have happen.
    The Compassionate Innovation Office at the Veterans Health 
Administration would be responsible for managing the program, 
ensuring only the best organizations who are certified and 
specialize in service dog training receive contracts. The bill 
establishes a Director of Therapeutic Service Dog Training, who 
would have a background in social services, experience in 
teaching and experience with service dogs, and at least one 
year of experience working with veterans dealing with post-
traumatic stress.
    The unique part of this legislation will help veterans work 
with other veterans who are struggling. We know the value of 
veteran-on-veteran engagement in assisting our servicemen and 
women. This legislation adds preference to the pilot dogs for 
contracting with the veterans who have graduated from post-
traumatic stress treatment programs and service dog training 
certification to conduct the training.
    This is just another way that we can help engage other 
veterans and help work on post-traumatic stress, make 
connections between veterans.
    We are working and want to continue to work with the staff 
to put a pay-for in the bill. The pay-for that we had last year 
got taken away and used in another bill that the Committee did, 
which we appreciate and it was a good pay-for. We want to make 
sure that we work with the Committee with this year's pay-for 
and make it appropriate. Right now the bill does not have a 
pay-for in it, but we want to work with you to find a pay-for 
that you think is appropriate and the right thing to do.
    The Veteran Dog Training Therapy Act is bipartisan, it 
establishes a pilot program to measure real outcomes of 
connecting veterans to therapeutic training and interaction 
with service dogs, and gives veterans the opportunity to help 
other veterans. I hope that you can support this bill. It is 
supported by numerous organizations: The Paralyzed Veterans of 
America, Iraq and Afghanistan Veterans of America, the VFW.
    More ever, this legislation was passed last year out of 
this Committee, included in a bigger bill, and unfortunately 
the Senate didn't get this portion of the bill done. So we are 
looking forward to working with you to bringing the benefit of 
therapy dogs to our veterans and to help our mental health 
issues.
    Thank you for allowing me to testify and I hope you will 
all consider this legislation.
    I yield back the balance of my time.

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

    Mr. Wenstrup. Well, thank you. Thank you, General Stivers, 
for your firsthand insights on the issues that our troops face.
    Congressman DeSantis, you are now recognized for 5 minutes.

           OPENIG STATEMENT OF HONORABLE RON DESANTIS

    Mr. DeSantis. Well, thank you, Chairman. Thank you, Ranking 
Member Brownley.
    I will submit my statement for the record, the prepared 
remarks. You know, I would just say that we have I think a wide 
acknowledgment that the suicide rate among veterans is 
appallingly high. There are obviously a number of factors that 
go into that. I think there is a broad agreement that post-
traumatic stress for veterans and all of our veterans, but 
particularly some of the post-9/11 veterans who have done 
multiple deployments in very difficult circumstances, you know, 
that that is a problem that we need to address and that the 
VA's prescription for that typically is counseling and 
prescribing drugs, which can be helpful, but doesn't really 
answer the call for all the veterans. So you have a lot of 
veterans who go through the VA suffering from really 
significant post-traumatic stress; they do some counseling, 
they do drugs, and then they are still symptomatic and 
sometimes they're even worse off.
    And so how can you deal with that problem? And what you 
have seen throughout our country is a number of organizations 
that have taken it up upon themselves to harness the use of 
service dogs. And these are not just dogs that are just pulled 
off the street and given new veterans. I mean, they go through 
training programs so that the dogs understand the symptoms of 
PTS when the veterans are in circumstances where this is 
triggered, whether it is in public or whether it is having 
nightmares. The service dog understands that and can respond 
accordingly. And so what that ends up doing is that allows 
these veterans to get back into society and function.
    So we have a number of people who have endorsed, you know, 
our bill who have some great stories to tell. I mean, what our 
bill would basically do is have the VA recognize this as a 
possibility, write grants to some of the organizations that are 
accredited and that have been proven to do a good job. And if 
you look at the cost of, you know, the service dog, the 
training, the veterinary care, even traveling the veteran to go 
and pick up the dog, if you end having a veteran where that 
works well and they stop using some of the prescription drugs, 
that is actually going to save a lot of money. I mean, we are 
doing it to save lives, but it really will, it is a bargain in 
many respects.
    And so we have got almost 200 cosponsors on this. It is 
definitely a bipartisan bill, been endorsed by the major 
veterans organizations. But I have just had a number of 
veterans come up to me who, you know, had gone through the VA 
treatment and were not doing well. And I have had a number tell 
me, look, I was lucky enough to get a service dog through this 
organization or through a family friend, or however they got 
referred, and if I didn't have that, you know, I don't think I 
would be here today, because they were suicidal.
    I have in the crowd here one of the guy who has really 
pushed for this named Cole Lyle, who is a Marine, former 
Marine, and he, you know, can tell you about he was in the 
dumps, he had a service dog and, you know, went to school. He 
is now up here, he has worked on the Hill, he is doing all 
kinds of things.
    So the results are there for us to see. There is more 
medical research now coming out that is showing that this is a 
positive effect, declining use of drugs, and a lot of the good 
indicators. So I appreciate the Committee's interest in this 
issue.
    I think that this bill, the pilot program, it is only five 
years, it is not a lot of money overall, but I think you will 
see real results. And I think the VA then--and I give Secretary 
Shulkin credit, he said, look, we can't wait, if this can work, 
we've got to do it. So I think what will happen is that will 
really open up even more possibilities so that we can get that 
suicide rate down, so that we can get veterans who are 
suffering from post-traumatic stress back on their feet and 
back to being productive members of society because, when they 
are, they do an awful lot of good in society too even after 
their military service.
    So I appreciate you giving me the time to say a few words 
about this bill and I yield back the balance of my time.

    [The prepared statement of Ron DeSantis appears in the 
Appendix]

    Mr. Wenstrup. Well, thank you, and I appreciate that you as 
a veteran are continuing to advocate on behalf of our veterans.
    Mr. Coffman, you are now recognized for 5 minutes.

          OPENING STATEMENT OF HONORABLE MIKE COFFMAN

    Mr. Coffman. Thank you, Mr. Chairman.
    My bill, H.R. 2147, the Veterans Treatment Court 
Improvement Act, builds upon an existing and successful program 
that connects veterans who go into the criminal justice system 
with a VA representative in these Veterans Treatment Courts, 
and they are Veterans Justice Outreach Specialists. This is to 
keep veterans who may have substance abuse issues, may have 
mental health issues oftentimes related to their military 
service, to keep them out of jail. And so I was very suspicious 
of whether or not these programs actually work and so I went to 
one of the Veterans Courts, Treatment Courts to actually 
witness it. And what was amazing to me was that what it did was 
it touched on something in their lives where they were 
successful, something in their lives where they held something 
in common, and that was they all were successful at one point 
in time in the military. They got through basic combat training 
in the Army, they got through boot camp in the Army, basic in 
the Air Force and the Navy. And the judge in the court that I 
went to in Adams County, Colorado, the prosecutor was a Marine 
Corps combat veteran from Vietnam, and I think that to see the 
pride in these veterans come out in the court.
    And it is amazing, in the 18th Judicial District in the 
State of Colorado, they have a 74-percent success rate, which 
is much higher; the rate of recidivism normally is the vast 
majority re-offend.
    So you have a representative from the VA who is there to 
make appointments, make mental health appointments, substance 
abuse appointments right on the spot for these veterans who are 
periodically required to show up for these court proceedings. 
And so in effect what this bill asks is an additional 50 VIO 
Specialists.
    And so I just want to say how impressed I am with this 
program, how it keeps our veterans out of the criminal justice 
system in terms of being incarcerated, gets them back into 
being contributing members of society, and I just think this is 
a very important program and would urge the passage of the 
bill.
    And with that, Mr. Chairman, I yield back.

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

    Mr. Wenstrup. Thank you. I know that in my home county the 
Veterans Treatment Court has been very successful and includes 
mentoring from a veteran of similar background, and we have 
seen very good results with that and I appreciate that.
    Mr. Coffman. Mr. Chairman, if I could for one second?
    Mr. Wenstrup. Yes.
    Mr. Coffman. That is another point is that there are 
mentors that are associated with the program and I did fail to 
mention that. I think they are not generally with the VA, they 
are volunteers that do that. There is again one VA employee 
associated with the court that we discussed here. And, you 
know, to be able to where they don't have to navigate the 
bureaucracy of the VA, to have somebody right there that will 
set up that mental health appointment, that will set up that 
substance abuse appointment for that veteran is so important.
    This is such a tremendous savings to the taxpayers of the 
United States by keeping these veterans from being incarcerated 
and keeping them on as taxpayers.
    I yield back, Mr. Chairman.
    Mr. Wenstrup. Thank you.
    Mr. Rutherford, you are now recognized for 5 minutes.

           OPENING STATEMENT OF HON. JOHN RUTHERFORD

    Mr. Rutherford. Chairman Wenstrup, Ranking Member Takano, 
and fellow Members of the Subcommittee, I want to thank you for 
this opportunity to speak on behalf of this draft legislation 
that would improve the Health Professional Education Assistance 
Program at the VA.
    This Subcommittee has frequently heard testimony regarding 
the high number of physician vacancies at the VA and the 
negative impact that this has on the care of our Nation's 
veterans. And currently the VA has several programs to address 
recruitment in their profession ranks, including the Education 
Debt Repayment Program and the Health Professions Scholarship 
Program. And while these programs have improved recruitment, 
physician remains at the top of VA's critical mission shortage 
with the current estimate of physician vacancies to be 3500.
    One way to ensure that the VA is long-termed staffed with 
qualified providers is to recruit those who are currently in 
medical school or in residency and assist in their educational 
expenses in exchange for their service within the VA system.
    As we as a Congress work with our partners in the 
Administration and in our communities to improve care and 
decrease wait times, I believe it is critical that the VA has
    the tools to recruit and retain providers in areas that are 
desperately needed throughout the system.
    This draft legislation really makes three primary 
improvements to the program.
    First, it requires the VA to provide a minimum total of 50 
2-to-4-year scholarships annually for students studying to 
become physicians or dentists any time the shortage of these 
professions is 500 or greater. These students will then be 
obligated to provide clinical service at a VA facility for 18 
months for each year of scholarship support.
    Second, the legislation requires the VA to create a pilot 
program to fund two scholarships at each of the five Teague-
Cranston Act medical schools for veterans who qualify for 
admission to those medical schools. The schools that 
participate in this program will each receive two seats in each 
class for the veteran recipients of those scholarships. The 
veterans are obligated to provide clinical service at a VA 
facility for a minimum of 4 years in exchange for the 
scholarship.
    Third, and finally, it standardizes and increases the VA 
Loan Repayment Program for newly graduated medical students or 
those currently in residency who will be training in 
specialties deemed as shortages in VHA. The loan payments will 
be a maximum of $40,000 per year with a maximum total of 
$160,000.
    Following completion of residency training, the loan 
recipients would be obligated to provide clinical service at a 
VA facility for 1 year for each $40,000 of loan repayment, but 
in no case fewer than 2 years. The current program varies among 
the various VISNs and is not actually adequately competitive, 
quite frankly.
    So the VA has made many impactful changes in recent years, 
but it is important that we consider ways, alternative ways 
that the VA can attract talent on the front end to improve the 
system long term. A key part of this is attracting young talent 
and getting that to come into the system and compete. To do 
that, we are going to have to compete with the private sector.
    In closing, I would like to thank the Chairman, the Ranking 
Member, my colleagues on the Committee, and the Subcommittee 
staff for their commitment to this and other pieces of 
legislation that are under consideration today that would 
continue to improve our VA health care system.
    Thank you. I yield back.

    [The prepared statement of Honorable Rutherford appears in 
the Appendix]

    Mr. Wenstrup. Thank you, and I appreciate that premise. It 
is something that has been very successful within the military 
as far as recruitment and gaining good medical providers, I 
appreciate that.
    If there are no questions of our two remaining panelists, 
then we will move on to the second panel, and I will now 
welcome our second panel to the witness table.
    Joining is Dr. Harold Kudler, the Acting Assistant Deputy 
Under Secretary for Health for Patient Care Services for the 
Department of Veterans Affairs, who is accompanied by Catherine 
Biggs-Silver, the Executive Director for Mission, Planning, and 
Analysis for Human Resources and Administration; Keronica 
Richardson, the Assistant Director of Women and Minority 
Veterans Outreach for the National Security Division of The 
American Legion; and Amy Webb, the National Legislative Policy 
Advisor for AMVETS.
    Thank you all for being here and for your advocacy on 
behalf of our veterans, today and each and every day.
    As soon as you get settled, we will begin with Mrs. 
Richardson, and you are now recognized for 5 minutes.

                STATEMENT OF KERONICA RICHARDSON

    Ms. Richardson. Good morning, Chairman Wenstrup, Ranking 
Member Brownley, and distinguished Members of the Subcommittee 
on Health. On behalf of the National Commander Denise H. Rohan 
and The American Legion family, we thank you for the 
opportunity to testify on behalf of The American Legion.
    The American Legion is the country's largest patriotic 
wartime service organization to veterans, with over 2 million 
members and serving every man and woman who have worn the 
uniform for this country, we welcome the opportunity to speak 
on behalf of our constituents.
    I am Keronica Richardson, the Assistant Director of the 
Women and Minority Veterans Outreach, and it is my duty and 
honor to present The American Legion's position and we 
appreciate this opportunity to testify and expand on these 
important issues.
    Since the American Revolution, women have volunteered to 
serve in the U.S. military. In fact, according to the 
Department of Veterans Affairs, the female veteran population 
accounts for 10 percent of U.S. veterans and that number is 
expected to grow to 15 percent by 2030.
    Women veterans are significantly different than their male 
counterparts; as such, the care that women veterans receive at 
medical centers and community out-patient clinics should be 
gender-specified. Although the VA has made some progress in 
providing gender-specific services, more work needs to be done. 
H.R. 93, Medical Services for Women Veterans, would amend Title 
38 to provide increased access to care for women veterans at 
the Department of Veterans Affairs.
    To understand the need for this bill, some of the important 
issues that female veterans encounter are obstacles in 
receiving gender-specific health care in rural areas; the lack 
of female providers for military sexual trauma, treatment, and 
therapies; a full-time gynecologist on staff, the lack of a 
full-time gynecologist on staff; and female veterans are more 
likely than their male counterparts to be referred to an 
outside VA system for specialty care.
    If enacted, H.R. 93 will require the VA to meet the health 
care needs of women veterans across the VA health care system. 
When the VA is unable to meet their needs, the Secretary may 
enter into contracts with third-party organizations to provide 
the necessary services. The American Legion supports this bill 
and stands ready to assist in however we can help expand the 
health care needs of women veterans.
    Shifting focus to H.R. 2327, the PAWS Act of 2017, we feel 
that it is important to make service dogs accessible to 
veterans wanting an alternative post-traumatic stress disorder 
treatment. Currently, the Department of Veterans Affairs does 
not fund service dogs or recognize the use of service therapy 
dogs as a possible method for veterans suffering from PTSD.
    There have been multiple studies proving that service dogs 
can provide many different forms of mental healing to veterans 
suffering from the invisible wounds of war. Service dogs can 
act as an effective complementary therapy treatment, especially 
for those veterans who suffer on a daily basis from the 
physical and psychological wounds of war.
    PTSD has become an epidemic and the VA has estimated that 
between 11 and 20 percent of veterans who served in Afghanistan 
or Iraq have PTSD. While the VA continues to stall on their 
dog-based therapy studies, veterans are being denied 
alternative forms of treatment.
    The American Legion supports H.R. 2327 because it allows 
for an alternative treatment to injured veterans suffering from 
traumatic brain injury or post-traumatic stress disorder.
    Lastly, I would like to shift my focus to H.R. 1063, the 
Veteran Prescription Continuity Act. This legislation will 
require the VA to continue serving medications, supplying 
medications prescribed to DoD health care providers while the 
DoD health care provider determines that such pharmaceutical 
agent is critical for transition out of the military. The 
American Legion feels that this legislation serves in the best 
interest of transitioning servicemembers and veterans by 
allowing them the comfort in knowing that their medical 
treatment will continue even after their military discharge. 
The American Legion supports H.R. 1063.
    Again, I would like to thank you for this opportunity to 
testify and I welcome your questions.

    [The prepared statement of Ms. Keronica Richardson appears 
in the Appendix]

    Mr. Wenstrup. Thank you.
    Ms. Webb, you are now recognized for 5 minutes.

                     STATEMENT OF AMY WEBB

    Ms. Webb. Good morning, Chairman Wenstrup, Ranking Member 
Brownley, and Members of the Subcommittee. AMVETS is truly 
pleased to be invited to testify today.
    While AMVETS is on the record in support of all of the 
bills and the discussion draft under consideration, I would 
like to start by talking about the concerns or the cautionary 
way in which we offer support for H.R. 2327, the PAWS Act.
    AMVETS has long advocated for the pairing of well-trained 
service dogs with veterans to assist the veteran with a myriad 
of physical and emotional health issues. On its face, we 
wholeheartedly support the PAWS Act, but, as mentioned in our 
written statement, there are several stipulations to this 
support.
    First, it is vital that organizations that train the 
service dogs are well vetted, and it seems that great care has 
been taken in writing the bill to ensure this. We appreciate 
the quality measures put in place, such as requiring that any 
eligible organization is Assistance Dog International or ADI 
accredited, and that it meets the Association of Service Dog 
Providers for Military Veterans Service Dog Agency standards.
    Per the ADI Web site, there are currently 65 accredited 
programs in the country and of those just nine mention PTSD or 
veterans. And in extrapolating the funding request for the 
bill, it looks like the intention is to place about 80 dogs 
with veterans per year for five years. Our hope is that the 
limited number of accredited programs can meet the demand for 
this wonderful pilot.
    Second, it is also vital that veterans chosen to 
participate in the pilot are very closely monitored, especially 
in the first year of the pairing, which should be implemented 
into the contact plan outlined in the bill. There should also 
be some type of recourse for the veteran if they are not 
getting a response to their questions or requests for follow-up 
training, and recourse for the organization if the veteran does 
not respond or keep their part of the contact agreement.
    Veterans chosen for this pilot remain diagnosed with PTSD 
after completing evidence-based treatment with no improvement. 
It is well known that PTSD can manifest in sleep issues, losing 
interest in activities that you used to enjoy, along with 
depression. This can be as simple as losing interest in taking 
a shower, going to the store to buy food, or going out with 
family and friends. Having a service dog requires consistency 
and work on the handler's part.
    Our reasoning for suggesting very close follow-up stems 
from the alarming issues that occurred in the first part of 
VA's study on PTSD service dogs and the fact that AMVETS has 
paired with an ADI accredited service dog organization for 
nearly 30 years and they will not train PTSD service dogs.
    AMVETS and this particular organization does believe that 
dogs can be trained to perform concrete tasks to help a person 
with PTSD in a heightened state of anxiety or in the midst of a 
nightmare, but they do not employ a full-time psychiatrist and 
therefore they do not feel they have the insight needed to 
properly pair dogs or provide the follow-up. AMVETS wants to 
ensure that all measures are proactively put in place to set 
this pilot up to have as much of a positive impact that we know 
that it can and we look forward to passage of this bill.
    On a separate note, as an organization we have to mention 
H.R. 2147, the Veterans Treatment Court Act. This bill goes 
straight to the heart of our organization.
    In 2008, our then National Commander J.P. Brown worked in 
Buffalo, New York with Judge Russell on the country's first 
Veterans Treatment Court. To this day, Commander Brown stays 
highly involved with the Veterans Treatment Court he helped 
found in his home state of Ohio. These courts reach out and 
hold the proverbial hand of justice-involved veterans and guide 
them down a better path. The results and percentages of 
veterans that complete the 2-year program is quite incredible 
and we wholeheartedly support this bill.
    Lastly, AMVETS would like to comment on H.R. 501, the VA 
Transparency Enhancement Act. This straightforward, bipartisan 
bill requires VA to publicly report on post-surgical infections 
and cancelled or transferred surgeries. The origin of this 
bill, as we heard earlier, stems from an ongoing issue at the 
Ann Arbor VA, and the intent is simply to provide veterans 
knowledge and safe health care. The reporting requirement would 
also alert Congress if something more needs to be done.
    AMVETS members strongly support VA accountability and we 
believe that transparency is part of being accountable. AMVETS 
supports this bill and urges its passage.
    Thank you again for the opportunity to speak on behalf of 
AMVETS and I welcome any questions.

    [The prepared statement of Amy Webb appears in the 
Appendix]

    Mr. Wenstrup. Thank you.
    Dr. Kudler, you are now recognized for 5 minutes.

                STATEMENT OF HAROLD KUDLER, M.D.

    Dr. Kudler. Thank you and good morning, Chairman Wenstrup, 
Ranking Member Brownley, and Members of the Subcommittee. Thank 
you for inviting us to present our views on several bills that 
would affect the Department of Veterans Affairs programs and 
services.
    Joining me today is Catherine Biggs-Silvers, Executive 
Director of Management, Planning, and Analysis for VA's Human 
Resources and Administration.
    VA and Congress are closely aligned in what we want to 
accomplish for veterans, their families and the Nation. In the 
few instances where we're not in concurrences, it's generally a 
matter of details. We see these bills as opportunities to 
collaborate with you to work these details out.
    We share Congress' concern about services for women 
veterans, but because the language of H.R. 93 doesn't specify 
what is meant by gender-specific, it may require more than you 
intend.
    The percentage of women veterans increases yearly across VA 
and we have primary care services for all women in all our 
medical centers, as well as women veterans comprehensive care 
centers in more than half of our VA medical centers, 81 of 
these in total. But we want to work with Congress to best meet 
this growing need.
    H.R. 501 would impose new reporting requirements regarding 
surgical infections and cancelled or transferred surgeries. 
Currently, each facility collects data on surgical infections, 
but this information is not rolled up nationally. The VA 
Surgical Quality Improvement Program, VASQIP, examines a 
statistically significant sample, approximately 30 percent of 
all complex surgeries completed across VA, to study surgical 
infections. Nationally, 1.5 percent of VASQIP-assessed 
surgeries are associated with infection.
    There are no good comparators in the community because no 
other system of our size and scale keeps such records, nor does 
the Joint Commission require them to do so.
    We do not support this bill because the VASQIP system 
already addresses surgical infections and examining all 
surgeries would siphon resources away from clinical care 
without any appreciable improvement in quality. Furthermore, we 
are concerned that the summaries called for could expose 
veterans' protected personal information.
    We would therefore like to discuss this bill further with 
you to see if our current systems could satisfy your 
objectives.
    VA does not support H.R. 1063 because of unintended risks 
and requirements. While continuity between DoD and VA care is 
critically important, we are concerned that this bill as 
currently written would tie clinician's hands and create the 
potential for serious harm.
    VA looks forward to working with Congress to ensure that 
before any change in medication is made patients get an 
individualized assessment, and have an opportunity to discuss 
their needs and their concerns with VA clinical staff.
    The VA supports H.R. 1066, which requires a report on VA's 
organizational structure. We are already working to ensure that 
we in VA are held accountable.
    Regarding H.R. 1943, VA already provides whatever a veteran 
needs for biking, driving, or other mobility issues, including 
adaptive equipment. Access to this level of support is not 
currently limited to service-connected injuries, as this bill 
would require. But it depends only on medical necessity and on 
the veteran's individual rehabilitation plan.
    We agree with Congress that veterans have a right to know 
whether they are going to be charged a copay in a timely 
manner. Unfortunately, H.R. 1972 does not take into account the 
multiple steps and stakeholders required to generate an 
accurate bill. We place priority on giving the veteran an 
accurate statement as quickly as possible and look forward to 
working with Congress to align our timeframes in accomplishing 
this.
    Congress' support for VA's Veterans Justice Outreach 
Program has had a major impact on homelessness and mental 
health problems among veterans. H.R. 2147 would require VJO 
Specialist hiring without providing the additional funds 
needed. But VA is already working to hire and train more than 
50 new VJO Specialists using funds prioritized for exactly this 
purpose rather than to require new offsets, which would harm 
other programs.
    H.R. 2225 proposes a five-year pilot for veteran training 
of service dogs. However, both DoD and VA are already piloting 
similar programs. We do not believe that creating yet another 
program would add significant value.
    VA is already helping veterans obtain service dogs when 
that best supports their recovery. However, H.R. 2327 specifies 
a funding strategy which would predictably undermine 
statutorily required VA functions.
    Mr. Chairman, this concludes my prepared statement.
    We look forward to working with the Subcommittee to achieve 
our shared goals. My colleague and I would be pleased to answer 
any questions which you or other Members of the Subcommittee 
may have.
    Thank you.

    [The prepared statement of Dr. Harold Kudler appears in the 
Appendix]

    Mr. Wenstrup. Thank you.
    I am going to yield myself some time for questions before 
we go to the others.
    Dr. Kudler, I would say that I think the more data you have 
on infection and infection control is important. You know, our 
troops when they come from all parts of the country, they come 
together and they go to common places, but then when they come 
back as veterans they are all over the country. And if you want 
to follow trends and where that infection maybe came from, you 
have to look at it nationally, because now our troops are all 
across the country.
    So I think we can take a look at that. I understand some of 
your concerns, but I think that is important data to collect 
and try and find the origin and cause of certain infections, if 
indeed it came from their military service especially and where 
the common origin is. They don't all come back to the same VA 
hospital when they leave. So I think that is important.
    But I do have a question for you on women's health 
especially. But, you know, a VA medical facility may not have a 
large enough female population to be able to recruit and retain 
a woman's health provider or OB/GYN because of the low volume, 
so how do you plan to engage in that and be able to provide 
that opportunity for our women?
    Dr. Kudler. Well, we have been training 500 clinicians a 
year in women's health in order to try to meet that need. We 
have been, as you say, looking to work with communities and 
under Choice we can do a great deal more of that. And under 
Choice as we imagine in the future even more, not just to meet 
the needs that we identify, but to meet the convenience and the 
desires of women veterans in their own communities.
    We need to scale this. We are growing at about 6 percent 
per year in women veterans, and women veterans do have 
different needs and different ways they would like to use 
services. One thing that is really interesting about women 
veterans and VA is when they do use VA, they tend to use more 
of our services than the men do, and I think that reflects back 
to women are smarter and speak up for their own health better 
than men do.
    The bottom line is, we need to work together with you to 
figure out how to scale this and also how to pay for it.
    Mr. Wenstrup. Thank you.
    And in the same vein, Ms. Richardson and Ms. Webb, what are 
your feelings today at the current state of VA services for 
women?
    Ms. Richardson. Keronica from The American Legion. At this 
current moment, I feel that the VA has made improvements. There 
are some gender-specific services available; however, there is 
still a lot of work that needs to be done. As I mentioned, 
there are still not any on-site gynecologists, there are still 
issues in rural areas about not being able to have the gender-
specific services available. Even on a smaller scale not having 
sanitary items in the restrooms or not having the privacy 
curtains at the VA utilized when female veterans are present.
    So I think there is still room for growth.
    Mr. Wenstrup. Thank you.
    Ms. Webb?
    Ms. Webb. Yes, I agree that over the years a lot of 
progress has been made in each facility, the development of the 
Women Veteran Program managers at every facility, but there is 
a lot of work to be done. You know, each woman needs to be able 
to go in and feel not only welcome, recognized, but have 
someone that knows her specific health care needs. It is a 
priority.
    Mr. Wenstrup. Thank you.
    Mr. Takano, you are now recognized for 5 minutes.
    Mr. Takano. Thank you, Mr. Chairman.
    I have long said that we need to improve the human 
resources function of the VA and the co-chairs of the 
Commission on Care testified before this Committee that they 
agreed that we needed to improve the human resource function.
    I support Representative Kilmer's work to improve 
accountability at the VA with H.R. 1066, the VA Management 
Alignment Act of 2017. The VA has said that they are working to 
improve accountability, but I think Mr. Kilmer's legislation 
helps expedite the process.
    Now, can any of the VSOs who are present today expound on 
how you see Representative Kilmer's legislation helping to 
improve accountability at the VA?
    Ms. Webb. Well, I believe that it is, you know, very 
important to have each department take a really good look at 
what they are doing and streamline functions and make sure that 
every role, you know, is working at its full capacity. And that 
if there are cost-saving measures and downsizing, or if they 
need to bring in more staff on the other side of it, it is just 
always a good business practice to do such things and it does 
speak to them being accountable for what each department is 
doing and you can't be accountable if you don't know what's 
going on.
    Mr. Takano. Great.
    The American Legion, anything to add?
    Ms. Richardson. I don't have anything to add to that. I 
think she covered exactly how The American Legion feels on that 
stance as well. We just feel like being accountable would allow 
them to have the service provider or the veteran more informed 
and make more informed decisions about whichever VA that they 
decide to choose from.
    Mr. Takano. Wonderful.
    Ms. Richardson. Other than that, we don't have any more 
stance.
    Mr. Takano. Well, moving on to a different topic, having 
reviewed the written testimony from the VSOs, I noted there was 
broad support for the Veterans Treatment Court Improvement Act 
of 2017, and based on what you have heard from your members, 
why is this legislation so important?
    Ms. Webb. Well, a lot of people have post-deployment 
readjustment issues and the whole point is that, you know, 
sometimes they misbehave or sometimes there are undiagnosed 
mental health issues, or perhaps they have gotten into drugs, 
and instead of just throwing someone away into the jail system 
or into the criminal justice system, you know, these courts, 
the mentorship is a really big part of it, working with them. 
They have to make a commitment to get through this program so 
their charges can be dropped, and we hear time and time again, 
that the ones that get through these programs, they lead 
better, fuller lives, they don't know what they would have done 
without that mentorship, and then many of them proceed to give 
back.
    Ms. Richardson. The American Legion's stance on that is 
when you look at an overview of the Veterans Treatment Court, 
it is a hybrid of veterans with drugs and mental illnesses that 
relates back to PTSD.
    So we definitely fully support the Veterans Treatment Court 
because we feel it would give the veteran another opportunity 
to readjust to society, so we support that bill.
    Mr. Takano. Great. Thank you.
    Dr. Kudler, accountability remains a key focus of this 
Committee and as I just asked the VSOs about and their 
testimony about 1066, you in your written testimony noted that 
the VA is not waiting for legislation to improve the 
Department's organizational structure and internal management, 
and the VA has already taken aggressive steps to address these 
areas. Can you provide some insight into these efforts?
    Dr. Kudler. Yes. VA has taken on a modernization program 
that exceeds the rest of the Federal agencies. We have been 
working on it before it was ordered down from the White House 
to be done by all agencies. And I think the real principle is 
increasing accountability and transparency, and moving the 
fulcrum of control from Washington closer to the point of 
service. So that local facilities will have more 
responsibility, but also more flexibility in how do you provide 
service in Beckley, West Virginia versus New York City in 
Manhattan or the Bronx.
    It makes sense to answer veterans' needs in community 
terms. But we also want the networks, which are large enough to 
have more buying power and more centralized control and more 
data to pull together, but also small enough to know regional 
issues to then be able to roll that up and coordinate with 
them. And we in central office will be there to offer support, 
but not try to use a 3,000-mile screwdriver to adjust 
everything that happens everywhere around the country. And this 
I think is a key principle of where we are trying to go.
    Mr. Takano. Thank you very much, Dr. Kudler.
    And thank you, Mr. Chairman, my time is up.
    Mr. Wenstrup. Mrs. Radewagen, you are now recognized for 5 
minutes.
    Mrs. Radewagen. Thank you, Mr. Chairman. And I want to 
thank the panel for appearing today, thank you for your 
service.
    As everyone here is acutely aware, VA still has a 
significant shortage of health care professionals despite 
existing educational assistance programs. For example, in my 
home district of American Samoa, we are currently facing 
difficulties in finding physical therapists and other health 
care specialists for our small VA clinic.
    American Samoa is a remote area with no VA hospital of our 
own and because of staffing problems we cannot even make use of 
the limited facilities we do have.
    So, Dr. Kudler, what can VA do to address staffing 
shortfalls in remote areas like the U.S. Territories and how 
can we ensure that once we have an adequate supply of trained 
professionals they end up where they are needed most?
    Dr. Kudler. Yes, thank you.
    The citizens of American Samoa serve at a higher rate than 
most other groups in the United States and they do have not the 
3,000-mile screwdriver, but I am going to say probably more 
like a 10,000-mile screwdriver of us trying to get in there and 
fix things directly. But there are different ways that we can 
work together.
    For example, you mentioned physical therapy and I work with 
the Physical Medicine Department in Durham, North Carolina to 
help promote a rural physical therapy program that used a 
point-to-point telehealth to actually do physical therapy. You 
can provide equipment to help somebody increase their range of 
motion and measure it within a micron of movement to work with 
a physical therapist who isn't even on the same island where 
you are. So it is just one of many possibilities.
    Obviously, we need to hire more people, we need to make 
transportation more available, we need to think about how do we 
project our strength and our talent, and how do we also bring 
people in when it meets their needs and it is their wish to be 
brought in. I know not everybody wants to get on a plane and 
fly to a remote location either for their care. So we have a 
long way to go, but fortunately new tools are being developed 
and we have to keep using innovation to apply them properly.
    Mrs. Radewagen. Thank you.
    Mr. Chairman, I yield back the balance of my time.
    Mr. Wenstrup. Dr. Dunn, you are now recognized for 5 
minutes.
    Mr. Dunn. Thank you very much, Mr. Chairman.
    Let me start out by saying to Ms. Webb, I am a life member 
of AMVETS and I invite you to come see your chapter in Panama 
City. Maybe when it is cold and nasty up here you will find the 
time to do that.
    Dr. Kudler, I want to turn my attention to the Health 
Professionals Educational Assistance Program. I know you are 
working on providing a formal view on the cost estimates of 
this bill, when do you think that will be available?
    Dr. Kudler. Well, we did get that bill a little bit later 
and too late to prepare, but let me say as quickly as possible 
and we are looking forward to responding, because--
    Mr. Dunn. I am just looking for a timeframe.
    Dr. Kudler. I would have to get that for you, sir; I don't 
have it.
    Mr. Dunn. Okay. We are anxious to have your thoughts on it, 
because we think it may help.
    Do you agree on the estimate of the shortage in the VA of 
medical professionals that Congressman Rutherford mentioned, 
3500?
    Dr. Kudler. There is a national medical shortage--
    Mr. Dunn. There is.
    Dr. Kudler [continued]. --and we are not gearing up to meet 
it. And the VA as the largest employer of physicians, and 
especially of psychiatrists and psychologists in America, is 
really in need of any help we can get.
    Mr. Dunn. I am just trying to quantify it. Is it about 
3,500 in the VA nationwide?
    Dr. Kudler. Oh, I would have to get that for you, sir.
    Mr. Dunn. Okay. So we need a lot of data, it sounds like. 
We can't fix a problem without data.
    What is the attrition rate for medical professionals in the 
VA annually?
    Dr. Kudler. Once again, I would have to get that for you.
    Mr. Dunn. Okay. So you get a sense of the data things we 
are looking for. Do you know how many people, how many medical 
professionals you hire in a year?
    Dr. Kudler. I know that we are--
    Mr. Dunn. Just roughly.
    Dr. Kudler. In mental health, which is the area I work in, 
I think we are now up in the last year about almost 900.
    Mr. Dunn. Nine hundred in a year?
    Dr. Kudler. Professionals, yes.
    Mr. Dunn. Good, that is an important area.
    Dr. Kudler. Psychologists, psychiatrists, licensed 
professional counselors, social workers, all of whom are 
employed in the mental health field in VA.
    Mr. Dunn. How about the--do you know how many you 
anticipate resigning or retiring in the next year?
    Dr. Kudler. I really hesitate. I have got some numbers 
kicking in my head, but I am not sure they are accurate, sir.
    Mr. Dunn. How about how many of your scholarship programs 
have been granted to physicians in the last X amount of time, 
year, 2 years, whatever, anything you are familiar with?
    Dr. Kudler. I am not aware of VA having a scholarship 
program for physicians at this time. We do have under the Clay 
Hunt Act medical debt reduction for psychiatrists and we are 
fully engaging that, and we are spending every dollar that is 
in there, we are matching every person that is in there.
    Mr. Dunn. Yeah, I'm sure.
    Dr. Kudler. That has been very effective.
    Mr. Dunn. Let's turn our attention to H.R. 501, the 
Transparency Enhancement Act. Do you have a feeling for the 
number of surgeries performed in your system, systemwide in a 
year?
    Dr. Kudler. Sir, I wish I did, I do not.
    Mr. Dunn. Okay. So that would be a really important number 
for us to have when we are talking about infection rates.
    I want to echo the Chairman's comments on tracking 
infections that have started, you know, we picked up in some 
other country and brought back with all the other problems we 
bring back from those countries. So we need to have--I will say 
I have built and operated at least a half a dozen surgery 
centers in my career and worked at a number of hospitals too, 
we had 100-percent surveillance on infection rates in all of 
our hospitals and in our surgery centers, and I actually was 
surprised to hear that the VA doesn't have 100-percent 
tracking. Everybody else that I am aware of on the civilian 
side is doing this already and they are doing it with far fewer 
resources, honestly, per surgical case than the VA has. So, I 
mean, we never considered or occurred to us that we were going 
to be in the situation where we weren't reporting all of our 
surgical infections.
    And I think that the fact the VA, as you said, it is 
burdensome to implement, it is just the cost of doing business. 
Everybody else in the country is doing it. So I would urge you 
to reconsider that and get on board with the, you know, 100-
percent surveillance rate and the reporting nationally. You are 
a hospital system that takes people from all over the world and 
treats them all over the country.
    So I just want to turn my attention now in my diminishing 
seconds here and applaud my friend and fellow Floridian 
Representative Rutherford for his educational enhancement bill 
that he has advanced. We really feel like this has worked for 
the military. I went through the military on a health 
professional scholarship and I think that this kind of program 
for the VA is a jolly good thing.
    Thank you. I yield back my time, Mr. Chairman.
    Mr. Wenstrup. If I may add to the point that you made, Dr. 
Dunn, is even our outpatient facilities we assured that we 
followed up with the surgeon to say were there any adverse 
problems with the patient's care. Was there a post-operative 
infection? Was there any type of complication? Which is more 
challenging when they are not in the hospital where you can 
collect that data as they are sort of a captive audience, but 
we made sure that we captured all that information because it 
is imperative to the quality and to follow trends?
    So I think we really need to consider that and I hope the 
VA would change their position on where we are going with that 
data that I think is very valuable and needed.
    Did you want to make a comment, sir?
    Dr. Kudler. May I clarify that every hospital in the VA 
system does track its own data on infection, but rolling it up 
using the VASQIP system, we look nationally, we use a 30-
percent sample of incision infections within 30 days, which is 
different than bio surveillance if people bring communicable 
diseases home, which I absolutely agree is a vital national 
issue.
    Mr. Wenstrup. And that is why I think we need the data 
nationwide and not just a sample. Thirty percent seems like a 
pretty small sample for the opportunity to miss something 
important that may exist. But we will talk more about that, I 
am sure.
    Mr. Higgins, you are now recognized for 5 minutes.
    Mr. Higgins. Thank you, Mr. Chairman. And I thank the panel 
for appearing, your service to your country, and I recognize 
and appreciate the presence of the many VSOs represented in the 
audience and the concerned citizens.
    Dr. Kudler, you stated that the VA is already working to 
hire more than 50 additional Veterans Justice Outreach 
Specialists to provide Treatment Court services to justice- 
involved veterans or VA courts. As a police officer for 14 
years, I understand the importance of addressing the root 
causes of misbehavior and crime, and I appreciate the VA's 
commitment to our veterans in this area.
    How many of the 50 new VJO Specialists has the VA hired 
thus far, sir, are you aware?
    Dr. Kudler. I am not sure how many have been hired so far, 
but I can assure you we have no problem hiring and training 
this staff; we will hire them expeditiously.
    Mr. Higgins. Thank you.
    Additionally, you had highlighted concerns regarding 
funding that other bills may result in a reduction of funding 
for other programs. How is the VA funding the 50 new positions?
    Dr. Kudler. We prioritized this as critically important for 
our mission and therefore found that money in other funds. And 
what concerns us about the bill as currently written is it 
would have a similar number, but it is a zero-sum game, we 
would have taken funds from still another program and it does 
come to a lot. We believe that other veterans would suffer.
    The current new 50, 51 actually will bring us to 312 
Veterans Justice Outreach Specialists in VA, which we feel 
right now would match the available Veterans Courts around the 
country. We would continue to scale as those numbers grew.
    Mr. Higgins. Thank you, sir. That brings me to my real 
question.
    Within my own district, I represent the 3rd District of 
Louisiana, we have the highest density of population of 
veterans in the State of Louisiana. I am humbled and honored to 
represent 133,000 veterans in my district. We are attempting to 
set up VA courts in our district, jurisdictional authorities 
across the district, and it is quite difficult, it is quite 
difficult. Where a VA court, a diversion court does not exist 
in this manner, it is quite challenging to establish within the 
judicial system, at least those that we are encountering within 
my own district.
    Would we as representatives of the citizens that we serve 
in an effort to set up a VA diversion court within the judicial 
systems to help our veterans navigate criminal issues as they 
encounter them, is there a process, sir, within the VA where 
you can help us set this up? I would certainly, you know, 
humbly raise my hand and ask for that assistance.
    Dr. Kudler. We would be very glad to work with you. I have 
helped set up Veterans Courts and worked with law enforcement 
Mecklenburg County, that's Charlotte, North Carolina, I know it 
is a challenge. You need a judge who is ready and willing to 
take this up, prosecutors, defense. You need local law 
enforcement to sign on, because they play a critical role in 
this. We would be glad to work with you. And also SAMHSA, in 
the past at least, has provided grants for communities to 
develop this capacity.
    So we would be glad to work with you on doing this 
together.
    Mr. Higgins. Would I be able to communicate with you 
directly, sir, about that? I represent ten parishes of 
Louisiana. We don't have counties, because we are Louisiana. 
But that is ten jurisdictional districts and you are talking 
about ten seated judges and it is quite challenging. And I 
would like to communicate with you after this event, sir, so 
perhaps you can give me a hand.
    Dr. Kudler. It would be a pleasure. We have been involved 
in many communities of all sizes and shapes and I am sure that 
we could be of help. I look forward to it.
    Mr. Higgins. And I look forward to that ongoing 
conversation.
    Mr. Chairman, thank you. I yield the balance of my time.
    Mr. Wenstrup. Mr. Rutherford, you are now recognized for 5 
minutes.
    Mr. Rutherford. Thank you, Mr. Chairman.
    Dr. Kudler, I would like to talk a little bit about the 
Veterans Prescription Continuity Act. And I was glad to hear 
your testimony when you asserted that medical necessity, not 
formulary status, drives prescription decisions. Do you have an 
idea how many requests for off-formulary prescriptions were 
filed last year and what percentage were actually approved?
    Dr. Kudler. You know, as a VA clinician who many times did 
ask for non-formulary prescriptions, I was pretty lucky in 
mine. I couldn't tell you nationally where that stands now, but 
when it comes to people transferring from DoD, we always give 
the benefit of the doubt to that this might be exactly the 
regimen this person needs.
    When it comes to mental health, some time ago working with 
Congress we have established that we will continue these 
medications. For example, if someone came to us on Lexapro 
Escitalopram, which is more expensive and was non-formulary at 
that time, it is now generic, we were going to continue to 
provide that and not change to say Citalopram, one of the other 
medicines that can be used. But in mental health, we have not 
only decided we are going with what DoD did, we have been 
measuring the outcomes, and we found generally very good 
outcomes in these groups.
    What we worry about and one specific thing is opiates and 
perhaps opiates plus a benzodiazepine. And if a patient came to 
me from DoD and was on a medicine for pain, and unfortunately 
military service often generates chronic pain, but was also 
getting a benzodiazepine and they said, well, Doctor, aren't 
you going to sign off on this script, I would say, well, within 
my practice that would be a very bad idea, but let's sit and 
talk about it. So I think what is critical and you captured it, 
sir, is we would figure out what is clinically appropriate, not 
have our hands bound and not have the veteran's hands bound. I 
could make somebody happy saying I am not going to touch 
anything, sir, but I would be endangering them and I don't 
think it would be ethically and certainly not medically 
appropriate.
    Mr. Rutherford. And I presume the VSOs all agree with the 
concept that it needs to be medical necessity, not formulary, 
or what is on the formulary.
    But, Dr. Kudler, you also in your statement said that this 
act would usurp a prescriber's professional responsibility and 
that would carry for the patient-provider relationship and also 
for the overall strength of the VA health care system some 
implications. Can you talk a little more about that, because 
I--make me understand that part?
    Dr. Kudler. Well, what I mean by that, you know, I learned 
how to drive in New York City and I learned how to practice 
medicine in Brooklyn, and the rule of thumb was the same, you 
practice, you drive like everyone else was crazy. You are 
responsible, you are this person's doctor, you cannot take for 
granted what another doctor writes, even if you like and 
respect that person. And you have a professional responsibility 
to make your own clinical decision and stand by it. This does 
not mean be high-handed with the patient. Part of being a 
doctor is collaborating with a patient, because you don't get 
any compliance and they may not take any medicine you write 
unless you and the patient have a rapport, an understanding, a 
trust.
    So what I was trying to get at there is simply, when I say 
this is my patient, I have a responsibility to make my own 
assessment, make my own decisions, but then collaborate with 
the patient to see if we can agree on this.
    And by the way, if the patient says no way on earth am I 
doing that, I am not going to settle for simply being right, I 
am going to work out something we can both agree on.
    Mr. Rutherford. But, Doctor, I think the issue that is 
trying to be captured here is exactly what you were--I don't 
think the sponsor of this bill would disagree with what you 
just said. The challenge, though, is as they transferred from 
DoD to VA there is that time that it takes you to evaluate, to 
determine what the medical necessity needs are of that 
particular patient. Because, as you said, I'm not just going to 
take somebody else's word for it, I am actually going to, you 
know, do my job and make those decisions for myself, formulary 
and otherwise, but surely you must understand that that is 
going to take some time.
    So there is a delay between coming from DoD over to VA, you 
know, and I don't think that that continuity of care until you 
as the doctor make an informed decision--look, even the doctor 
that was treating them in DoD may at some point change the 
formulary because their needs change. Can you address that?
    Dr. Kudler. You know, I think that gets at the core issue, 
which is the continuity of care between DoD and VA, and we have 
to address that as a critical area where people fall between 
the cracks, that might be one day or it might be five years, 
and we have to create a warm handoff between our agencies which 
would include this. We developed that for traumatic brain 
injury years ago where if you were coming say out of the 
Richmond VA for our polytrauma program, I would actually sit in 
Richmond and talk over a telehealth hookup with your doctors in 
Landstuhl and we would work this out together.
    Mr. Rutherford. Right.
    Dr. Kudler. We need to create that continuity and I think 
that is a missing element in this bill. But I have got to tell 
you this, we are working--and this was the Secretary's demand 
and he is absolutely right--same-day assessment in primary care 
and mental health. And I don't see a reason why if you have a 
mental health issue say, you shouldn't be able to walk into a 
VA and get a clinical assessment on that spot, on that day, and 
review your medicines and confront issues.
    Mr. Rutherford. Thank you, Mr. Chairman. I yield back.
    Mr. Wenstrup. Thank you. I appreciate that was a good 
conversation, and the handoff is important and how we can 
facilitate that. No one wants there to be a gap, no one wants 
there to be someone who falls through the cracks, but how do we 
assure that there isn't that situation.
    I want to thank you all once again for being here today, 
and if there are no further questions, the second panel is now 
excused.
    And 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 again thank you all, our witnesses and the 
audience members for joining us here this morning.
    This hearing is now adjourned.

    [Whereupon, at 11:31 a.m., the Subcommittee was adjourned.]




                            A P P E N D I X

                              ----------                              

             Prepared Statement of Honorable Debbie Dingell
    Chairman Wenstrup, Ranking Member Brownley, thank you for inviting 
me to appear before you today. The important work of this committee is 
invaluable to bettering the lives of all those who have served and the 
families at their sides. Thank you for your tireless dedication to 
serving our veterans.
    As you know, today's hearing includes bipartisan legislation 
introduced by Congressman Tim Walberg (R-MI) and I that aims to add 
enhanced transparency requirements at VA hospitals nationwide. Our 
bill, H.R. 501, the VA Transparency Enhancement Act, is a commonsense 
measure we can take to improve overall quality of care for veterans.
    The bill simply requires the Department of Veterans Affairs to 
report quarterly to Congress on the number of patients who contracted 
an infection as a result of a surgery and report the number of 
surgeries cancelled or transferred by the VA. It would also require the 
VA to publish these reports on the Department's website for all our 
veterans, their families, and the public to have and understand.
    While the VA currently provides completed and pending appointment 
data from local VA medical facilities to the public monthly, the VA 
does not publically release data on rates of surgical infection or 
cancelled or transferred surgeries. Patients have a right to see 
surgical infection rates and other issues impacting quality of care at 
VA hospitals. Improving transparency at the VA will help ensure we are 
meeting the quality standards we owe our veterans.
    The VA Transparency Enhancement Act will also help Congress 
understand when, where, and why infections are happening or surgeries 
are cancelled so we can respond to changing conditions more 
effectively. Should surgical infection or cancellation rates rise at 
any VA hospital, Congress and the public need to know about it as soon 
as possible. As policymakers we need to understand whether cancelled 
surgeries are affecting the health of a veteran. Ensuring our veterans 
have access to timely, quality health care is a critical responsibility 
of the Congress, and this is one more important step to ensure they do.
    In late 2015, my office and Congressman Walberg became aware of a 
contamination issue at the VA Ann Arbor Healthcare System after 
particulate matter was observed on sterile surgical equipment. This led 
to surgeries for veterans being intermittently cancelled or moved to 
different hospitals. For many months the issue persisted putting great 
stress and uncertainty on our veterans who were scheduled for 
operations.
    The staff at the Ann Arbor VA is a dedicated group of individuals. 
This issue came to light because they were doing their job inspecting 
surgical instruments and discovered the problem. To be clear, it does 
not appear that the contamination issue caused any infections or harm 
to a patient-but, for us, this remains a concern for any future cases.
    Throughout this problem we remained in constant communication with 
Ann Arbor VA leadership. In the process, we learned that VA hospitals 
are not required to report on surgical infection and cancellation rates 
as other hospitals do.
    This is not the only instance of cancelled surgeries at a VA 
hospital. In September 2015, the Star Tribune reported that the 
Minneapolis Veterans Affairs Medical Center was forced to postpone and 
reschedule dozens of surgical procedures after an ``an unidentified 
substance'' was found in sterilizing equipment. \1\
---------------------------------------------------------------------------
    \1\ Brunswick, Mark, ``Minneapolis VA shuts down surgeries over 
unidentified substance,'' Star Tribune, September 23, 2015, http://
www.startribune.com /minneapolis-va-hospital-shuts-down-surgeries-
after-a-substance-is-found-in-sterilization-equipment /328878601/
---------------------------------------------------------------------------
    We do not want to see this happen again in Michigan or any state, 
which is why we took action and introduced this bill. We believe it is 
important that, like other hospitals, the VA be open and transparent 
and report the number of patients that have acquired surgical 
infections while receiving care at the VA, and the number of surgeries 
that have been canceled or moved to another hospital.
    The number one priority for all of us is to ensure that veterans 
receive the highest quality health care. By increasing transparency we 
can prevent the worst scenarios for our veterans and identify 
problematic VA hospitals sooner. Our responsibility as Members of 
Congress is to be a voice and advocate for veterans all across this 
country, and serve our veterans as well as they have served us.
    Thank you again for inviting me to testify before this committee on 
legislation that will improve VA transparency and patient care for all 
our veterans. We urge every member of the committee to support this 
legislation and we stand ready to work with you in any way to move this 
bipartisan bill out of this committee for consideration on the House 
floor. At this time, I look forward to answering any questions the 
committee may have.

                                 
             Prepared Statement of Honorable Beto O'Rourke
                               CONCERNING

           H.R. 1063, THE VETERAN PRESCRIPTION CONTINUITY ACT
    Than you Chairman Wenstrup, Ranking Member Brownley, and members of 
the Subcommittee. I appreciate the opportunity to join you today to 
discuss how we can improve care for our veterans as they transition out 
of the military.
    Our nation asks much of its service members. We ask them to uproot 
their families, put themselves in harm's way, and endure pain and 
suffering. As members of the Veterans' Affairs Committee, we have an 
obligation to ensure that our service members and their families 
receive the best care possible when they leave the service. With as 
many as 20 veterans committing suicide a day, we are failing to fulfill 
that obligation.
    We may not be able to solve all of the Department of Veteran 
Affair's problems today, but we can take meaningful steps towards 
improving the care our veterans receive. One common sense measure to 
achieve this is my legislation before the Committee today, the Veterans 
Prescription Continuity Act. In the past, the pharmaceutical agent 
formularies used by the Department of Defense (DoD) and Veterans Health 
Administration (VHA) had numerous differences. This meant that a 
service member may not have been able to receive the same DoD 
prescribed medication when he or she enters the VHA system.
    Section 715 of the FY2016 National Defense Authorization Act (NDAA; 
Public Law 114-92) included a provision that attempted to improve 
prescription medication continuity when service members left the DoD 
health care system and entered the VHA system. This section required 
the Secretary of Defense and Secretary of Veterans Affairs to establish 
a joint formulary for prescription medications, with the intended goal 
to ensure veterans would receive the same medication under the VHA as 
they were prescribed during their service.
    Unfortunately, this section has shortcomings. It only accounts for 
certain medications. It did not cover some common, widely used drugs 
available to the DoD but not the VA as well as new or emergent 
medications for pain control, sleep disorders, and psychiatric 
conditions (including post-traumatic stress). Additionally, it did not 
require the DoD and VHA to regularly update their formularies to ensure 
they matched in the future.
    My legislation, the Veteran Prescription Continuity Act, will fix 
these shortcomings. It will allow transitioning service members the 
ability to retain their current regimen of pharmaceutical agents under 
their VA health care provider, even if it is not on the VA's formulary. 
It will require regular updates between the DoD and VA formularies and 
allow the VA to prescribe medications not on their formulary between 
these updates.
    Transitioning out of the military is a challenging task. Doing so 
while being forced to change medications increases the stress and 
burden on our service members and does not represent the best possible 
care we can give them. I thank my colleague, Mr. Coffman of Colorado, 
for his partnership with me to enact this common sense legislation. 
Together, we are taking steps towards improving our nation's care for 
its veterans.
    It is also important to note that the Veterans Prescription 
Continuity Act is supported by fourteen veteran service organizations 
that are a part of the National Military and Veterans Alliance. We have 
worked hand in hand with these organizations to create this common 
sense legislation.
    I appreciate the opportunity to speak before you today and look 
forward to continuing this committee's work in improving the care for 
our veterans.

                                 
              Prepared Statement of Honorable Derek Kilmer
                               CONCERNING
               H.R. 1066, THE VA MANAGEMENT ALIGNMENT ACT
    Than you Chairman Wenstrup, Ranking Member Brownley, and members of 
the Subcommittee. I appreciate the opportunity to join you today to 
discuss how we can improve the operations of the Veterans 
Administration so those who have served our nation actually get the 
care they have earned.
    I have the honor of representing more than 82,000 veterans, more 
than most any other member of my party and one of the largest 
concentrations in the House of Representatives. In my region we know 
that those who have served, and their families, have made tremendous 
sacrifices for us. We know they have had our backs. And we understand 
we should have theirs too. That means if you fight for your country you 
shouldn't have to fight for a job. In the land of the free and the home 
of the brave, every veteran should have a home. And anywhere in our 
country if you are a veteran, you should have access to the benefits 
you've earned.
    That last point is what brings me here today. It's a conversation 
we've been having for far too long. I've heard it in VA halls, in the 
grocery story, and from members of my Veterans Advisory Council - why 
can't we fix the VA once and for all? Why does it take so long to see a 
practitioner, why do folks in smaller towns have to travel so far to 
get served? These questions have arisen because of the inability of 
veterans to schedule appointments, the difficulty to build a new 
Community Based Outpatient Clinic (CBOC) in my district, and other 
issues. And they are symptoms of a larger problem - systemic management 
challenges at the VA.
    I appreciate all this committee and Congress has done to deliver 
answers to veterans like those I represent. I'm glad we've passed 
legislation seeking information, providing enhanced authorities, 
funding, and calling for accountability. But we all know there is more 
work to do.
    In 2013, I partnered with then Ranking Member Brown and eventually 
Chairman Miller to request the Government Accountability Office (GAO) 
conduct a management review of the Veterans Health Administration. In 
our minds, this would help us get to the root of the problem.
    The GAO team dove in, and what started with three reports on 
organizational structure, human capital, and information technology has 
expanded to more than six. These findings have begun to see the light 
of day and are accompanied by specific solutions to fix the problems 
GAO found.
    One of the key findings that stood out is that - after a number of 
reviews from both within and outside the VA - there was a clear menu of 
recommendations to fix things for the better. These specific 
recommendations included clarifying different responsibilities between 
local and national facilities, evaluating if core duties were being 
met, and improving services, planning, and communications. But the GAO 
found these recommendations were never implemented.
    That is not fair to veterans, the staff that conducted the reviews, 
or the taxpayers who paid for them.
    Moreover, the VHA struggles to implement new policies and 
procedures due to a severe lack of clarity regarding the roles, 
missions, and accountability of senior leaders and organizations within 
the agency. The scale of the VA is so large that we need to go beyond 
position descriptions and office missions. There has to be a clear, 
transparent, and enforced relationship between the leaders and layers 
of the VA. How can we expect leaders and staff at more local levels to 
seek opportunities for collaboration and efficiency if there is not a 
clear understanding of how they are supposed to work together to care 
for veterans? We need all the rowers in the boat paddling in the same 
direction - not beating each other over the heads.
    I introduced the VA Management Alignment Act to make sure we follow 
through on the GAO findings. This bill simply requests the Secretary of 
VA to provide a report to Congress within 180 days on the 
organizational structure of the VA. Specifically, the bill would 
require the Secretary to outline the roles, responsibilities, and 
accountability measures of senior leaders and branches of the VA 
informed by existing recommendations on the matter, and to provide 
Congress with a series of legislative options to assist the Secretary 
in realizing positive change.
    Before coming to Congress, I worked as a management consultant to 
large private sector companies and for a county wide economic 
development agency. My experience in both roles led me to understand 
that good management requires clarity from the top. To do that we need 
to better measure outcomes. We need to work collaboratively with the 
administration to set an environment for success. This bipartisan bill, 
which was drafted in consultation with GAO, meets both of those tests.
    It is also important to note that the VA Management Alignment Act 
is supported by the American Legion and the American Federation of 
Government Employees. I am grateful that the largest veterans' service 
organization and the federal employee union have joined me in this 
effort.
    As this is a legislative hearing and not a markup, I request that 
we continue to work together to move this policy forward. I am with you 
in the effort to improve the VA and turn our words into deeds.
    Again, I appreciate the opportunity to join you here today and look 
forward to working with you honor the service and sacrifices of our 
nation's veterans.

                                 
               Prepared Statement of Honorable Steve King
    Good Morning Chairman Wenstrup, Ranking Member Brownley, and 
Members of the Committee. I am Congressman Steve King. I represent the 
Fourth District of Iowa, and I am truly honored to testify before you 
today in support of my bill, H.R. 1943, the Restoring Maximum Mobility 
to Our Nation's Veterans Act of 2017. This critical legislation aims to 
ensure that our nation's veterans with service-connected disabilities 
are not simply afforded a wheelchair, but are equipped with the very 
best wheelchair-one that affords maximum achievable mobility and 
function in the activities of daily life.
    The ability to pursue life to the fullest possible degree, even in 
the face of disability, is critical to ensuring that our nation's 
veterans are as healthy as possible-in body, mind, emotions and spirit. 
And the statistics prove the truth of that statement. Statistics 
demonstrate that an average of 20 veterans die by suicide each day in 
our nation. Six of each 20 are recent users of Veterans Health 
Administration (VHA) services in the two preceding years leading up to 
the tragic decision to commit suicide. In my home state of Iowa, there 
were 75 veteran suicides in 2014 alone. We mourn these precious lives 
that were lost unnecessarily, and find it unthinkable that these trends 
should continue. We must do more, and we must provide better services, 
care and support that our nation's veterans need and deserve.
    According to current practice, when determining which wheelchair is 
best equipped for a particular veteran, a VA clinician will take into 
account medical diagnoses, prognosis, functional abilities, 
limitations, goals, and ambitions. Evaluation of mobility assesses 
musculoskeletal, neuromuscular, pulmonary, and cardiovascular 
capacities and response, effort, quality and speed of mobility, and 
overall function. However, the VHA recommendations clarify that 
``Motorized and power equipment or equipment for personal mobility 
intended solely for a recreational leisure activity should not be 
provided.Motorized and power equipment designed for recreational 
leisure activities do not typically support a rehabilitative goal.''
    In view of suicide rates among our nation's veterans, how can 
motorized and power equipment designed for recreational leisure 
activities not support a rehabilitative goal? According to a study made 
available by the National Center for Biotechnology Information, which 
operates under the National Institutes of Health (NIH), ``.leisure 
activities are defined as preferred and enjoyable activities 
participated in during one's free time, and characterized as 
representing freedom and providing intrinsic satisfaction. Individuals 
can recover from stress; restore social and physical resources through 
leisure activities. Leisure activities with others may provide social 
support and, in turn, mediate the stress-health relationship, enrich 
meaning of life, recovery from stress, and restoration of social and 
physical resources.''
    This description will sound accurate to anyone who has found rest, 
solace and rejuvenation in a preferred recreational activity. As 
someone who enjoys the outdoors, hunting, fishing and travel, I 
certainly can appreciate the importance of recreation to a healthy 
life. And as this reality affects our nation's disabled veterans, I 
have seen first-hand the benefit of recreation to their health. I have 
had the honor of hunting with my friend, Army Specialist Jack 
Zimmerman. Jack is a remarkable man and decorated veteran who lost both 
of his legs as a result of life-altering injuries caused by an 
improvised explosive device. After his injury, Jack had a long 
rehabilitation in front him. And he had to deal with trials that he 
simply should not have had to during that time, including the VA 
issuing multiple inadequate wheelchairs to him. As an outdoorsman, Jack 
needed a chair that could navigate uneven terrain without the risk of 
tipping over. Jack was made aware of an off-road powered-track 
wheelchair that could offer a heightened level of normalcy and 
enjoyment to his life. He contacted the VA to acquire one and waited 
months without success.
    Jack's wife ultimately was able to procure a powered-track 
wheelchair from an outside organization called the Independence Fund, 
which provides resources and tools that enable veterans to work through 
their physical, mental and emotional wounds and regain their 
independence. I am grateful for the Independence Fund and other 
organizations that make it their mission to provide for our veterans. 
But our veterans should not have to rely on such groups to do for them 
what their nation should. They fought for this nation and they should 
be cared for by this nation.
    In the aftermath of Iraq and Afghanistan, we have strived in 
Congress to halt veteran suicide. We have worked to ensure that every 
veteran has access to the health care and services they need. Sadly, 
the somber statistics demonstrate that we have far to go to adequately 
take care of our veterans. That's why I champion H.R. 1943, which 
amends Section 1701 of Title 38 of the United Code to ensure 
wheelchairs provided to our veterans include ``enhanced power 
wheelchairs, multi-environmental wheelchairs, track wheelchairs, stair-
climbing wheelchairs, and other power-driven mobility devices.'' This 
legislation ensures that the Secretary of Veterans Affairs may provide 
a wheelchair to a veteran because the wheelchair restores an ability 
that relates exclusively to participation in a recreational activity.

                                 
             Prepared Statement of Honorable Lloyd Smucker
    Chairman Wenstrup, Ranking Member Brownley, and Members of the 
Subcommittee, I thank you for the opportunity to testify before the 
committee on my legislation, the VA Billing Accountability Act.
    On August 9, 2017, the Veterans Affairs Office of Inspector General 
reported that in Fiscal Year 2015, of roughly 15.4 million bills the 
Veterans Health Administration issued during 2015 approximately 1.7 
million were improper bills for the treatment of service-connected 
conditions. To put this into perspective, the Veterans Health 
Administration collected a staggering $13.9 million from our nation's 
veterans inappropriately. This is simply unacceptable.
    Our service men and women should not have to pay for errors or 
delays by the Department of Veterans Affairs (VA). For more than a 
decade, the Department of Veterans Affairs has failed to address its 
broken medical-billing system that leaves our nation's veterans to pick 
up an inaccurate and expensive bill. That is why I introduced the 
bipartisan VA Billing Accountability Act to relieve veterans of 
financial burdens caused by delays at the VA.
    My congressional district is home to more than 38,000 veterans--all 
of them deserve the highest quality medical care and the assurance from 
the VA that they will not be forced to foot the bill for the mistakes 
made by VA bureaucrats.
    To address this ongoing issue, my bill authorizes the VA to waive 
veterans' co-payments if a veteran received a co-payment bill more than 
120 days after they received care at the VA or 18 months after they 
received care at a non-VA facility.
    The VA Billing Accountability Act also holds the VA accountable by 
giving the Secretary of the VA the authority to get rid of the 
requirement that veterans make a co-payment if the VA does not abide by 
the billing timing mandates.
    To ensure accountability my bill requires the Secretary of Veterans 
Affairs to review the agency's copayment billing controls and 
notification systems to see if there are solutions that can better 
monitor and prevent erroneous bills within 180 days after enactment of 
this legislation. It is imperative that the Department of Veterans 
Affairs prioritizes improving its internal billing procedures.
    Our nation's veterans and their families have sacrificed so much in 
defense of our nation. We should be making it easier, not harder, for 
them to transition to post-military life. That starts with making sure 
that the VA not only delivers quality health care, but also timely 
bills that our veterans can count on.
    Thank you again for the opportunity to testify before the committee 
today, and for all the work that the members of this committee do to 
ensure quality and affordable care for our nation's veterans.
    I yield back.

                                 
             Prepared Statement of Honorable Steve Stivers
    Testimony Before the House Committee on Veterans' Affairs, 
Subcommittee on Health: Veterans Dog Training Therapy Act
    Thank you Chairman Wenstrup and Ranking Member Brownley for holding 
this hearing today, and for giving me the opportunity to testify on 
behalf of my bill, the Veterans Dog Training Therapy Act. I also want 
to thank the co-sponsor of this bill, Congressman Tim Walz (D-MN), for 
his support.
    We face a devastating mental health crisis in this country - one 
that has particularly affected our veterans' community. When veterans 
return home, many struggle with visible, physical wounds. However, the 
invisible wounds our veterans suffer with are often overlooked. This is 
includes Posttraumatic Stress Disorder (PTSD), depression, and other 
mental health related issues from their service. It is just as 
important that we find ways to help veterans address mental health 
related issues, as it is their physical wounds.
    Today, I want to discuss a few of the ways that this bipartisan 
bill can help our nation's veterans in a unique way, and build on the 
already proven benefits therapy dogs can be to veterans.

Therapy Dogs Work

    First and foremost, therapy dogs work. Anyone who has a dog as a 
pet knows how much of a calming presence they can be. For veterans 
struggling with service-connected mental health issues, having this 
presence can make all of the difference.
    In fact, research by Kaiser Permanente has shown that veterans who 
have these companion dogs show fewer symptoms of PTSD, depression, 
anxiety, have better interpersonal relationships, a lowered risk of 
substance abuse, and better overall mental health. Therapy dogs can 
clearly make a difference, and as we are losing veterans every day to 
suicide, it is critical we pursue any strategy to help more veterans 
receive the help they need and deserve.

The Pilot Program

    The Veterans Dog Therapy Training Act would establish a pilot 
program at the Department of Veterans Affairs (VA) in which the 
Secretary will contract with local therapeutic dog training 
organizations, and help veterans seeking treatment to learn the art and 
science of dog training. Upon completion, the program will graduate the 
animal to go home with their veteran.
    The Compassionate Innovation office at the Veterans Health 
Administration will be responsible for managing the program and 
ensuring that only the best organizations who are certified and 
specialize in companion animal training receive contracts. This bill 
also establishes a director of therapeutic service dog training who has 
a background in social services, experience in teaching others to train 
companion dogs, and at least one year of experience working with 
veterans or service members dealing with PTSD.
    Additionally, this legislation will receive oversight from 
Congress. The Secretary of the VA will be required to collect data on 
the program to determine the effectiveness for those participating and 
their mental health outcomes and report back to Congress.

Veterans Helping Veterans

    A unique part of this legislation is it will help facilitate 
veterans to help other veterans who are struggling. We know how 
valuable, veteran on veteran engagement is to assisting our service men 
and women and, my legislation adds a preference to the pilot program 
for contracting with veterans who have graduated from PTSD treatment 
programs and companion dog training certifications to conduct the 
training. Only other veterans truly understand the struggles of 
returning home, and the benefits a companion dog can provide. This is 
just one more way we can help veterans coping with PTSD make 
connections to other veterans who are in need.
    I believe therapy dogs can make a real difference in the lives of 
veterans struggling with service-related mental health issues. The 
Veterans Dog Training Therapy Act is bipartisan, establishes a program 
to measure the real outcomes of connecting veterans to therapy dogs, 
and gives veterans the opportunity to help other veterans. This bill 
has the support of organizations such as the Paralyzed Veterans of 
America, Iraq and Afghanistan Veterans of America (IAVA), Veterans of 
Foreign Wars (VFW), and Disabled American Veterans (DAV). Moreover, 
this legislation is proven to have support - the Veterans Dog Training 
Therapy Act passed the House of Representatives during the 114th 
Congress.
    I want to thank the Committee again for inviting me to testify 
today, and I encourage all of the Members of the Committee to consider 
this legislation.

                                 
              Prepared Statement of Honorable Ron DeSantis
    Chairman Wenstrup, Ranking Member Brownley, thank you for the 
opportunity to testify this morning. I request that my statement be 
accepted for the record.
    Addressing service-connected disabilities is a critical part of the 
United States' commitment to the men and women who risk their lives 
through military service. Honoring our commitment includes safeguarding 
mental health, yet far too often combat wounds that go beyond the 
physical go ignored.
    According to the most recent Department of Veterans Affairs (VA) 
analysis of veteran suicide, ``Suicide Among Veterans and Other 
Americans,'' an average of 20 veterans died by suicide each day.
    The VA must be more effective in its treatment of our soldiers who 
struggle with mental health disorders, including post-traumatic stress 
disorder (PTS), to reduce the veteran suicide rate.
    For this reason, I reintroduced HR 2327, the Puppies Assisting 
Wounded Servicemembers (PAWS) Act, to direct the Secretary of the VA to 
carry out a 5-year pilot program to provide grants to select 
organizations that pair veterans suffering from severe PTS with the 
service dogs critical to their recovery.
    In order to be eligible for a VA grant for a service dog pairing, 
the organization must either be an Assistance Dog International 
accredited organization that also meets specific criteria listed in the 
measure, or meet the Association of Service Dog Providers for Military 
Veterans Service Dog Agency Standards, which cater to the needs of 
veterans with PTS.
    To be eligible for participation in the pilot, the veteran must 
have completed traditional therapies for PTS and remain symptomatic. A 
VA medical provider or clinical team must determine that the veteran is 
an appropriate candidate for the program, and the veteran shall see the 
VA medical provider at least every 6 months to remain eligible.
    The pilot is capped at $10,000,000 for the 5-year period covering 
2018-2023 and entirely offset with funds from the VA Office of Human 
Resources and Administration, which has demonstrated inappropriate 
conference planning and spending in the past.
    Prior to reintroduction, my staff and I worked with House Committee 
on Veterans' Affairs Committee staff, as well as U.S. Department of 
Veterans Affairs personnel who would be involved with implementing the 
pilot once it launches and U.S. Government Accountability Office 
employees who would evaluate its success, to improve language from last 
Congress. We appreciate the Committee's willingness to work with us to 
revise language and the support from outside organizations to help move 
this measure.
    An ongoing study conducted by a Purdue University research team 
revealed in February 2017 that service dogs contribute significantly to 
emotional and psychosocial well-being. Furthermore, on March 7, 2017, 
Veterans Affairs Secretary David Shulkin testified at a House hearing 
on the use of service dogs for veterans who have PTS or other emotional 
disorders, stating, ``[I] think it's common sense that service dogs 
help.we hear it every day from veterans.I'm not willing to wait because 
there are people out there today suffering.''
    I am not willing to wait either. The urgency of veteran suicide 
rates demands that we immediately explore the option of pairing service 
dogs with veterans suffering from mental health disorders.
    I look forward to continuing to work with the Committee to 
accomplish this goal.
    Thank you again for the opportunity to testify. I welcome your 
questions.

                                 
              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.
    While many veterans successfully readjust and transition back to 
civilian life after their military service, unfortunately, some do not. 
Often due to undiagnosed or untreated issues related to their service, 
veterans find themselves involved in the criminal justice system.
    My bill, H.R. 2147 - the Veterans Treatment Court Improvement Act, 
builds upon an existing and successful program that works with criminal 
justice involved veterans and connects them with the services they 
need.
    Mr. Chairman, Veterans Treatment Courts (VTCs) were created to be 
dedicated to veteran offenders specifically. These specialty, 
diversionary courts take veterans out from the regular criminal justice 
process to address the underlying issues, such as post-traumatic stress 
disorder (PTSD) or substance abuse.
    The VA provides Veteran Justice Outreach (VJO) Specialists who are 
licensed social workers operating through VA Medical Centers as part of 
the VJO Program. These VJO Specialists link veterans to available VA 
services and treatment, and monitor the veteran's progress in the 
Veteran Treatment Courts.
    This successful model avoids the unnecessary incarceration of 
veterans with mental illness, assesses their health and social needs, 
and then helps develop a rehabilitation treatment program specific to 
the veteran's needs.
    In my district, the 18th Judicial Veterans Treatment Court has a 
74% success rate for those who have participated in their program. 
Clearly, this program works.
    Mr. Chairman, there are more than 260 VJO Specialists in 167 VA 
Medical Centers nationwide. However, the VA currently lacks a 
sufficient number of VJO Specialists to meet the demand for their 
services. This means numerous veterans cannot avail themselves of the 
opportunity to enter the Veteran Treatment Courts and succeed in 
rehabilitating themselves.
    My bill, H.R. 2147, will help the VA to better meet the demands of 
the program and to serve many more veterans by authorizing the VA 
Secretary to hire 50 additional VJO Specialists. H.R. 2147 also 
requires the VA Secretary to identify an offset, and requires the VA 
and GAO to report to Congress on the implementation of this bill.
    Mr. Chairman, our veterans have served us - now let us serve those 
veterans who need our help. As a Marine Combat Veteran, I like to live 
by the rule that we never leave anyone behind, and the Veterans 
Treatment Court Improvement Act makes sure that we do not forget those 
who bravely served our country in their time of need.
    Mr. Chairman, thank you for allowing me to testify today on behalf 
of my legislation and I yield back the remainder of my time.

                                 
            Prepared Statement of Honorable John Rutherford
 Draft legislation to improve the VA Health Professionals Educational 
                           Assistance Program
    Chairman Wenstrup, Ranking Member Brownley, fellow members of the 
Subcommittee - thank you for the opportunity to speak on behalf of this 
draft legislation that would improve the Health Professional 
Educational Assistance Program at the VA.
    This Subcommittee has frequently heard testimony regarding the high 
number of physician vacancies at the VA and the negative impact this 
has on the care of our nation's veterans. Currently, the VA has several 
programs to address recruitment in their profession ranks, including 
the Education Debt Repayment Program (RDRP) and the Health Professions 
Scholarship Program (HPSP). While these programs have improved 
recruitment, ``physician'' remains the top VA mission critical 
shortage, with the current estimate for physician vacancies to be 
3,500. One way to ensure that the VA is long term staffed with 
qualified providers is to recruit those who are currently in medical 
school or are in residency and assist in their education expenses in 
exchange for their service within the VA system.
    As we as a Congress work with our partners in the Administration 
and in our communities to improve care and decrease wait times, I 
believe it is critical that the VA has the tools to recruit and retain 
providers in areas that are desperately needed throughout the system.
    This draft legislation makes three primary improvements to these 
programs.
    First, it requires the VA to provide a minimum total of fifty 2 to 
4 year scholarships annually for students studying to become physicians 
or dentists while the shortage of these professions is 500 or greater. 
These students will then be obligated to provide clinical service at a 
VA facility for 18 months for each year of scholarship support.
    Second, this legislation requires the VA to create a pilot program 
to fund two scholarships at each of the five Teague-Cranston Act 
medical schools for veterans who qualify for admission to those medical 
schools. The schools that participate in this program will each reserve 
two seats in each class for the veteran recipients of these 
scholarships. The veterans are obligated to provide clinical service at 
a VA facility for a minimum of 4 years in exchange for the scholarship.
    Third, it standardizes and increases the VA loan repayment program 
for newly graduated medical students or those currently in residency 
who will be training in specialties deemed as shortages in VHA. The 
loan payments will be a maximum of $40,000 per year with a maximum 
total of $160,000. Following completion of residency training, the loan 
recipients will be obligated to provide clinical service at a VA 
facility for a year for each $40,000 of loan repayment, but in no case 
fewer than two years. The current program varies among the VISNs and is 
not adequately competitive.
    The VA has made many impactful changes in recent years, but it is 
important that we consider ways the VA can attract talent on the front 
end to improve the system long term. A key part of this is attracting 
young talent that will come into the system and compete with the 
private sector.
    In closing, I would like to thank the Chairman, the Ranking Member, 
my colleagues on the Committee, and the Subcommittee staff for their 
commitment to this and the other pieces of legislation under 
consideration today that would continue to improve the VA health 
system.
    Congressman John Rutherford represents the 4th Congressional 
district of Florida. Prior to being elected in 2016, Congressman 
Rutherford served as the Sheriff of Duval County for 12 years where he 
led initiatives to reduce crime in Jacksonville to a 40-year low. He 
serves on the House Committee on Homeland Security, the House Judiciary 
Committee, and the House Committee on Veterans' Affairs.

                                 
               Prepared Statement of Keronica Richardson

 
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      Section                               Title                                Page              Position
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          H.R. 93                     To amend title 38, United States Code, to provide                 Support
                         for increased access to Department of Veterans
                               Affairs medical care for women veterans.
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         H.R. 501               VA Transparency Enhancement Act of 2017                                 Support
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        H.R. 1063                                 Veteran Prescription Continuity Act                   Support
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        H.R. 1066                   VA Management Alignment Act of 2017                                 Support
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        H.R. 1972                         VA Billing Accountability Act                                 Support
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        H.R. 2147                                   Veterans Treatment Court Improvement   t of 2017    Support
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        H.R. 2225                     Veterans Dog Training Therapy Act                                 Support
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         H.R.2327                                      PAWS Act of 2017                                 Support
         DRAFT BILL                   To amend title 38, United States Code, to make                No Position
                       certain improvements in the Health Professionals
                    Educational Assistance Program of the Department of
                              Veterans Affairs, and for other purposes.
----------------------------------------------------------------------------------------------------------------

    Chairman Wenstrup, Ranking Member Brownley and distinguished 
members of the Subcommittee on Health; on behalf of National Commander 
Denise H. Rohan and The American Legion, the country's largest 
patriotic wartime service organization for veterans, comprising over 2 
million members and serving every man and woman who has worn the 
uniform for this country, we thank you for the opportunity to testify 
on behalf of The American Legion's positions on the following pending 
and draft legislation.

                                H.R. 93

    To amend title 38, United States Code, to provide for increased 
access to Department of Veterans Affairs medical care for women 
veterans.
    According to the Department of Veterans Affairs (VA), the female 
veteran population accounts for 10 percent of U.S. veterans, and that 
number is expected to grow to 15 percent by 2030. This population 
experiences distinctive challenges such as access to female-specific 
medical care, the greater likelihood for homelessness, and higher 
unemployment rates than male veterans. \1\
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    \1\ http://www.blogs.va.gov/VAntage/40134/
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    In 2013, The American Legion conducted fifteen ``System Worth 
Saving'' site visits focusing on women veterans healthcare. Based on 
these visits, the following key findings were identified: \2\
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    \2\ https:// www.legion.org/sites/ legion.org/files/legion/ 
publications/ 2013-SWS-Report-WEB.pdf

      Women veterans do not identify themselves as veterans 
and/or do not know what benefits they are eligible to receive;
      VA medical center facilities do not have a baseline, one-
year, two-year, or five-year plan to close the gap between the 
catchment area, enrollment numbers, and actual users among women 
veterans;
      Additional research is needed to determine the purpose, 
goals, and effectiveness of the three VA women models of care on 
overall outreach;
      Communication and coordination of women veterans health 
services are substandard;
      Women veterans do not receive their mammogram results in 
a timely manner;
      Many VA facilities do not offer inpatient/residential 
mental health programs for women veterans; and
      VA's legislative authority for the child care pilot 
program is due to expire by the end of September 2017.

    If enacted, H.R. 93 will require the VA to meet the healthcare 
needs of women veterans across the VA healthcare system. When the VA is 
unable to meet their needs, the Secretary may enter into contracts with 
third-party organizations to provide the services required.
    Using resolution 147, Women Veterans, The American Legion supports 
any legislation that provides full comprehensive health services for 
women veterans department-wide, including, but not limited to: 
increasing treatment areas and diagnostic capabilities for female 
veteran health issues, improved coordination of maternity care, and 
increase the availability of female therapists/female group therapy to 
better enable treatment of Post-Traumatic Stress Disorder from combat 
and MST in women veterans. \3\
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    \3\ The American Legion Resolution No. 147 (2016): Women Veterans

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The American Legion Supports H.R. 93

           H.R. 501 - VA Transparency Enhancement Act of 2017

    To require increased reporting regarding certain surgeries 
scheduled at medical facilities of the Department of Veterans Affairs, 
and for other purposes.
    During a study by the Environment of Care and Safety Review of the 
operating room at the Edward Hines Jr. VA Hospital in Hines, IL, the 
Department of Veterans Affairs (VA) Office of Inspector General (OIG) 
found that surgery infections are often caused by improper temperature 
and humidity control in the emergency room \4\suite. \5\
---------------------------------------------------------------------------
    \4\ https://www.va.gov/oig/pubs/VAOIG-13-02315-332.pdf
    \5\ https://www.va.gov/oig/pubs/VAOIG-13-02315-332.pdf
---------------------------------------------------------------------------
    The Association of periOperative Registered Nurses recommends a 
temperature range in an operating room between 68°F and 73°F. 
This is to prevent hyperthermia, surgical site infections, longer 
hospital stays, and other negative outcomes. Additionally, the 
recommended humidity range in an operating room is 20 percent to 60 
percent. This is to reduce infections and prevent the development of 
mold and mildew in anesthetizing locations.
    H.R. 501 would require the VA to track and submit findings 
regarding complications due to surgery infections to the Secretary of 
VA. The American Legion knows that it is pertinent to the safety of 
future veterans utilizing these hospitals for the VA to track specific 
outcomes regarding surgeries. This legislation would require these 
outcomes be made public so that individuals can make the best-informed 
decision regarding their medical treatments at different VA locations. 
These metrics will also help Congress and veteran service organizations 
understand which VA hospitals are having more problems with surgery 
infection complications and find ways to address these issues.
    Using resolution 377, Support Veterans Quality of life, The 
American Legion supports any legislation that will enhance, promote, 
restore or preserve benefits for veterans and their dependents, 
including, but not limited to the following: timely access to quality 
VA health care, timely decisions on claims and receipt of earned 
benefits, and final resting places in national shrines and with lasting 
tributes that commemorates their service. \6\
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    \6\ The American Legion Resolution No. 377 (2016): Support Veterans 
Quality of Life Resolution

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The American Legion Supports H.R. 501

            H.R. 1063 - Veteran Prescription Continuity Act

    To ensure that an individual who is transitioning from receiving 
medical treatment furnished by the Secretary of Defense to medical 
treatment furnished by the Secretary of Veterans Affairs receives the 
pharmaceutical agents required for such transition.
    In late 2014, the Department of Veterans Affairs (VA) conducted an 
evaluation of medical prescriptions for 2,000 Department of Defense 
(DoD) servicemembers entering the VA system for the first time. The 
study included individuals taking mental health or pain medication. The 
goal of the assessment was to evaluate the extent to which mental 
health medications and opioid analgesics active at the time of DoD 
separation were changed versus continued unchanged upon entering the VA 
system, as well as the reason for any changes (clinical vs. 
administrative). \7\
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    \7\ https://www.pbm.va.gov/vacenterformedicationsafety/ 
othervasafetyprojects/ DoD--VA--Medication--Continuation--Report.pdf
---------------------------------------------------------------------------
    The study found that some veterans had their medication switched 
due to differences between the VA and DoD drug formularies. The current 
prescription drug formularies used by the DoD and VA have several 
differences, meaning that certain prescription drugs are unavailable to 
transitioning servicemembers once they start receiving care from the 
VA. As a result, there are occasions when transitioning servicemembers 
are forced to abruptly change their prescription drug regimen during an 
already arduous transition period.
    This legislation would require the VA to continue supplying 
medications prescribed by a DoD healthcare provider when the DoD 
healthcare provider determines that such pharmaceutical agent is 
critical for such transition.
    Using Resolution 377, Support Veterans Quality of Life Resolution, 
The American Legion supports any legislation that will enhance, 
promote, restore or preserve benefits for veterans and their 
dependents, including, but not limited to, the following: timely access 
to quality VA health care, timely decisions on claims and receipt of 
earned benefits, and final resting places in national shrines and with 
lasting tributes that commemorates their service. \8\
---------------------------------------------------------------------------
    \8\ The American Legion Resolution No. 377 (2016): Support Veterans 
Quality of Life Resolution

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The American Legion Supports H.R. 1063

            H.R. 1066 - VA Management Alignment Act of 2017

    To direct the Secretary of Veterans Affairs to submit to the 
Committees on Veterans' Affairs of the Senate and the House of 
Representatives a report regarding the organizational structure of the 
Department of Veterans Affairs, and for other purposes.
    The American Legion has been at the forefront of efforts to both 
increase accountability at Department of Veterans Affairs and improve 
timely access to quality VA health care for veterans. We have been 
rightly critical of past management failures and recognize the need to 
assist VA, Congress, and other stakeholders to address these problems.
    In 2015, VA health care was added to the Government Accountability 
Office (GAO) high-risk list because of concerns about VA's ability to 
ensure the timeliness, cost-effectiveness, quality, and safety of 
veterans' health care. In testimony delivered to the Senate Veterans 
Affairs Committee on March 15, 2017, GAO stated that insufficient 
progress has been made to address the concerns that led to high-risk 
designation. \9\
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    \9\ https://www.gao.gov/assets/690/683381.pdf
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    In May 2017, VA Secretary Shulkin delivered his diagnosis of the 
department noting a long road toward recovery. He offered an assessment 
on the ``State of VA,'' outlining 13 areas where the department needs 
to improve and the legislative and administrative fixes it needs in 
order to see progress. Shulkin reiterated his belief that the 
department's central office is too large and unwieldy.
    Another GAO report released in September 2016 found that the VA has 
been slow to make changes after the 2014 wait-time scandal and that VA 
does not have a process for following through with the recommendations 
that it receives or to effectively make changes \10\. The report also 
states that without a process, there is ``little assurance'' the 
delivery of health care will improve. It goes on to say the VA cannot 
confirm that it is holding leaders accountable for making improvements. 
\11\
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    \10\ https://www.gao.gov/mobile/products/GAO-16-803
    \11\ http://www.gao.gov/assets/690/680054.pdf
---------------------------------------------------------------------------
    The VA Management Alignment Act was introduced in response to this 
report to help address the issue. The measure would require the VA 
secretary to submit plans to the House and Senate veterans committees 
within 180 days after the bill goes into effect, detailing the roles 
and responsibilities of VA executives and spelling out how they would 
improve veterans' access to treatment.
    The American Legion Resolution No. 3: Department of Veterans 
Affairs Accountability urges Congress to pass legislation to improve 
accountability at VA. \12\ The VA Management Alignment Act of 2017 
would provide the agency and Congress with a new perspective on how to 
address VA's management challenges and is consistent with ongoing 
efforts to improve VA's ability to ensure the timeliness, cost-
effectiveness, quality, and safety of veterans' health care.
---------------------------------------------------------------------------
    \12\ The American Legion Resolution No. 3 (2016): Department of 
Veterans Affairs Accountability

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The American Legion supports H.R. 1066

               H.R. 1972 - VA Billing Accountability Act

    To amend title 38, United States Code, to authorize the Secretary 
of Veterans Affairs to waive the requirement of certain veterans to 
make copayments for hospital care and medical services in the case of 
an error by the Department of Veterans Affairs, and for other purposes.
    While many veterans qualify for free healthcare services based on a 
Department of Veterans Affairs compensable service-connected condition 
or other special eligibilities, most veterans are required to complete 
a financial assessment or means test at the time of enrollment to 
determine if they qualify for free health care services. Veterans whose 
income exceeds VA income limits, as well as those who choose not to 
complete the financial assessment at the time of enrollment, must agree 
to pay required copays for health care services to become eligible for 
VA healthcare services. VA is also authorized to recover the reasonable 
cost of medical care furnished to a veteran for the treatment of a non-
service-connected (NSC) disability or condition when the veteran or VA 
is eligible to receive payment for such treatment from a third-party.
    After enrollment, if a veteran's medical care appears to qualify 
for billing under reimbursable insurance and co-payment, the charges 
for co-payments will be placed on hold for 90 days, pending payment 
from the third-party payer. If no payment is received within 90 days, 
the charges will automatically be released and a statement generated to 
the veteran. VA will provide sufficient information about first party 
copayment debts to veteran patients reminding them of their 
responsibilities to pay their share of debts created as a result of 
medical services rendered as inpatient, outpatient, extended care, or 
medication. VA will follow up with the debtor until the debt is 
resolved.
    VA currently has multiple options available to help make copay 
charges more affordable, or to eliminate them:

      Repayment Plan: A veteran has the right to establish a 
monthly repayment plan at any time during their enrollment in VA health 
care if they cannot pay their debt in full.
      Waiver Request: A veteran also has the right to request a 
waiver of part or all of the debt. If the waiver is granted the veteran 
is not required to pay the amount waived.
      Compromise: A veteran has the right to request a 
compromise. A compromise means a veteran proposes a lesser amount as 
full settlement of the debt.

    H.R. 1972 would authorize the VA to waive the requirement that a 
veteran makes copayments for medications, hospital care, nursing home 
care, and medical services if:

      An error committed by the VA or a VA employee was the 
cause of delaying copayment notification to the veteran, and
      The veteran received such notification later than 120 
days (18 months in the case of a non-VA facility) after the date on 
which the veteran received the care or services.

    In requiring a veteran to make a copayment for care or services 
provided at a VA or a non-VA medical facility, this bill would require 
VA to notify the veteran not later than 120 days (18 months in the case 
of a non-VA facility) after the date on which the veteran received the 
care or services. If the VA does not provide notification by such date, 
it may not collect the payment, including through a third-party entity, 
unless the veteran is provided with:

      information about applying for a waiver and establishing 
a payment plan with the VA, and
      an opportunity to make a waiver or establish a payment 
plan.

    Finally, H.R. 1972 would require the VA to review and improve its 
copayment billing internal controls and notification procedures.
    The VA Billing Accountability Act of 2017, by setting forth 
specific and immediate billing requirements, so our nation's veterans 
are not receiving unbilled co-payments for VA care in an untimely 
manner, sometimes from years past, will help bring more stability and 
financial security to their post-military lives.
    Through Resolution No. 377: Support for Veteran Quality of Life, 
The American Legion supports any legislative proposal that urges 
Congress and the Department of Veterans Affairs to enact legislation 
and programs within the VA that will enhance, promote, restore or 
preserve benefits for veterans and their dependents, including, but not 
limited to the following: timely access to quality VA health care; 
timely decisions on claims and receipt of earned benefits; and final 
resting places in national shrines and with lasting tributes that 
commemorate their service. \13\
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    \13\ The American Legion Resolution No. 377 (2016): Support for 
Veteran Quality of Life

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The American Legion supports H.R. 1972

      H.R. 2147 - Veterans Treatment Court Improvement Act of 2017

    To require the Secretary of Veterans Affairs to hire additional 
Veterans Justice Outreach Specialists to provide treatment court 
services to justice-involved veterans, and for other purposes.
    The Veterans Court Improvement Act of 2017 recognizes the 
importance of Veteran Justice Outreach Specialists providing services 
to veterans as well as the importance of Veteran Treatment Courts. This 
legislation would assure our nation's veterans, who are in the criminal 
justice system, have access to services and resources they need to be 
productive members of society. With this bill, Congress validates that 
this unique population will be best served within their communities by 
providing sufficient resources to these courts.
    When veterans return from combat, some turn to drugs or alcohol to 
cope with mental health issues related to Post Traumatic Stress 
Disorder (PTSD) and/or Traumatic Brain Injury (TBI). Thus, many 
returning veterans are entering the criminal justice system to face 
charges stemming from these issues. In 2008, a judge in Buffalo, NY, 
created the first Veterans Treatment Court after seeing an increase in 
veterans' hearings on his dockets. Veteran Treatment Courts are a 
hybrid of drug and mental health courts. They have evolved out of the 
growing need for a treatment court model designed specifically for 
justice-involved veterans to maximize efficiency and economize 
resources while making use of the distinct military culture consistent 
among veterans.
    Through Resolution No. 145: Veterans Treatment Courts, The American 
Legion supports any legislation that establishes a separate program 
office within Department of Veterans Affairs Central Office with an 
increased program budget and hiring of staff to expand the Veterans 
Justice Outreach program and policies. \14\ The resolution specifically 
calls for continuing to fund and expand Veterans Treatment Courts and 
hire more staff to expand the Veterans Justice Outreach program and 
policies.
---------------------------------------------------------------------------
    \14\ The American Legion Resolution No. 145 (2016): Veteran 
Treatment Courts

---------------------------------------------------------------------------
The American Legion supports H.R. 2147

             H.R. 2225 - Veterans Dog Training Therapy Act

    To direct the Secretary of Veterans Affairs to carry out a pilot 
program on dog training therapy.
    Since 1991, the United States has been at war, and as a result, 
thousands of soldiers have returned home with mental and physical 
injuries. In 2009, Congress amended Title 38, United States Code Sec.  
1714 by authorizing the Department of Veteran Affairs to extend 
benefits for the upkeep of service dogs used primarily for the aid of 
persons with physical disabilities and psychological wounds.
    This bill directs the VA to carry out a five-year pilot program to 
assess the effectiveness of addressing veterans' post-deployment mental 
health and post-traumatic stress disorder symptoms through the 
therapeutic medium of training service dogs for veterans with 
disabilities.
    Through Resolution No. 160: Complementary and Alternative Medicine, 
The American Legion supports any legislation that provides oversight 
and funding to the Department of Veterans Affairs for innovative, 
evidence-based, complementary and alternative medicine (CAM) in 
treating various illnesses and disabilities. \15\
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    \15\ The American Legion Resolution No. 160 (2016): Complementary 
and Alternative Medicine

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The American Legion supports H.R. 2225

                      H.R.2327 - PAWS Act of 2017

    To direct the Secretary of Veterans Affairs to make grants to 
eligible organizations to provide service dogs to veterans with severe 
post-traumatic stress disorder, and for other purposes.
    The Puppies Assisting Wounded Servicemembers Act of 2017 (PAWS Act) 
makes service dogs accessible to veterans wanting an alternative post-
traumatic stress disorder (PTSD) treatment option possible for veterans 
open to this type of treatment. Currently, the Department of Veterans 
Affairs does not fund service dogs or recognize the use of therapy 
service dogs as a possible method to treat veterans suffering from 
PTSD. There have been multiple studies proving that service dogs can 
provide many different forms of mental healing to veterans suffering 
from physically invisible wounds of war.
    H.R. 2327 would create a five-year $10 million pilot program that 
pairs veterans who served on active duty in the Armed Forces on or 
after September 11, 2001, with eligible therapy service dogs if they 
have been diagnosed with PTSD severe enough to warrant treatment. 
Eligible veterans must have also completed an evidence-based treatment 
program and remain significantly symptomatic by clinical standards.
    The American Legion supports this legislation because it allows for 
an alternative form of treatment to injured veterans returning home 
from war with Traumatic Brain Injury (TBI) and PTSD. Service dogs can 
act as an effective complementary therapy treatment component, 
especially for those veterans who suffer on a daily basis from the 
physical and psychological wounds of war. PTSD has become an epidemic, 
and the VA has estimated that between 11 and 20 percent of veterans who 
served in Afghanistan or Iraq have PTSD \16\. While the VA continues to 
stall with their dog-based therapy studies, veterans are being denied 
alternative forms of treatment. As the VA is continually accused of 
over-prescribing veterans, and as veteran continue to complain about 
overprescription, it is time that the VA, and the Federal government, 
look at alternative options. \17\
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    \16\ https://medlineplus.gov/magazine/issues/winter09/articles/
winter09pg10-14.html
    \17\ http://www.npr.org/sections/health-shots/2014/07/11/330178170/
veterans-kick-the-prescription-pill-habit-against-doctors-orders
---------------------------------------------------------------------------
    Through Resolution No. 160: Complementary and Alternative Medicine, 
The American Legion supports any legislation that provides oversight 
and funding to the Department of Veterans Affairs for innovative, 
evidence-based, complementary and alternative medicine (CAM) in 
treating various illnesses and disabilities. \18\
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    \18\ The American Legion Resolution No. 160 (2016): Complementary 
and Alternative Medicine

---------------------------------------------------------------------------
The American Legion supports H.R. 2327.

                               DRAFT BILL

    To amend title 38, United States Code, to make certain improvements 
in the Health Professionals Educational Assistance Program of the 
Department of Veterans Affairs, and for other purposes.
    The provisions of this draft bill fall outside the scope of 
established resolutions of The American Legion. As a large, grassroots 
organization, The American Legion takes positions on legislation based 
on resolutions passed by our membership. With no resolutions addressing 
the provisions of the legislation, The American Legion is researching 
the material and working with our membership to determine the course of 
action that best serves veterans.

The American Legion has no current position on this Draft Bill.

                               Conclusion

    As always, The American Legion thanks this subcommittee for the 
opportunity to elucidate the position of the over 2 million veteran 
members of this organization. For additional information regarding this 
testimony, please contact The American Legion Deputy Director of the 
Legislative Division, Derek Fronabarger, at (202) 861-2700 or 
[email protected]

                                 
                     Prepared Statement of Amy Webb
                                   On
                  ``Pending Health Care Legislation''

 
----------------------------------------------------------------------------------------------------------------
 
----------------------------------------------------------------------------------------------------------------
 H.R. 93 to Provide Increased Access to Department of                                                  Support
      Veterans Affairs Medical Care for Women Veterans
----------------------------------------------------------------------------------------------------------------
     H.R. 501 VA Transparency Enhancement Act of 2017                                                  Support
----------------------------------------------------------------------------------------------------------------
        H.R. 1063 Veteran Prescription Continuity Act                                                  Support
----------------------------------------------------------------------------------------------------------------
        H.R. 1066 VA Management Alignment Act of 2017                                                  Support
----------------------------------------------------------------------------------------------------------------
 H.R. 1943 Restoring Maximum Mobility to Our Nation's                                                  Support
                                  Veterans Act of 2017
----------------------------------------------------------------------------------------------------------------
              H.R. 1972 VA Billing Accountability Act                                                  Support
----------------------------------------------------------------------------------------------------------------
H.R. 2147 Veterans Treatment Court Improvement Act of                                                  Support
                                                  2017
----------------------------------------------------------------------------------------------------------------
          H.R. 2225 Veterans Dog Training Therapy Act                                                  Support
----------------------------------------------------------------------------------------------------------------
                           H.R. 2327 PAWS Act of 2017                                                  Support
----------------------------------------------------------------------------------------------------------------
     Draft to Make Certain Improvements to VA's HPEAP                                                  Support
----------------------------------------------------------------------------------------------------------------


    Chairman Wenstrup, Ranking Member Brownley, and all members of the 
committee; thank you for the opportunity to testify on behalf of 
AMVETS' 250,000 members. We are particularly thankful for your efforts 
to address some of the most challenging and longstanding veteran health 
care issues. We appreciate the dedication of your staff members who are 
working diligently to formulate policies that ensure we are taking care 
of our Nation's veterans.
  H.R. 93: Provide Increased Access to Department of Veterans Affairs 
                    Medical Care for Women Veterans
                        AMVETS supports H.R. 93
    H.R. 93 ensures that gender specific services are continuously 
available at every VA medical center and community based outpatient 
clinic.
    This bill is strongly aligned with our National Resolution on Women 
Veterans Health care which states, in part, that AMVETS urges DoD and 
VA to enhance their programs to ensure that women veterans receive 
high-quality, comprehensive primary and mental health care services in 
a safe and sensitive environment at every VA health care facility.
            H.R. 501 VA Transparency Enhancement Act of 2017
                        AMVETS supports H.R. 501
    This bill increases reporting requirements from VA medical 
facilities regarding post-surgical infections, and cancelled or 
transferred surgeries.
    AMVETS has a National Resolution on VA Accountability, and we 
believe that transparency is equally important. Any measure which seeks 
to improve the health care and health outcomes of veterans is something 
that we not only support, but advocate for as part of our 
organizational mission.
             H.R. 1063 Veteran Prescription Continuity Act
                       AMVETS supports H.R. 1063
    H.R. 1063 improves the care of individuals transferring from 
receiving treatment from the Department of Defense to the Department of 
Veterans Affairs by ensuring that any pharmaceuticals the patient is 
taking at the time of transfer that are not listed on the Joint Uniform 
Formulary for Transition of Care would be able to still be prescribed 
until such point where it was deemed they were no longer needed.
    AMVETS believes it is imperative to offer servicemembers 
transitioning into veteran status the continuity of care that medical 
professionals believe is in their best interest. Allowing the 
continuation of needed medication, whether or not it is listed in the 
Joint Uniform Formulary, is something that is important and we urge 
passage of this bill.
             H.R. 1066 VA Management Alignment Act of 2017
                       AMVETS supports H.R. 1066
    H.R. 1066 increases the reporting requirements of the Department of 
Veterans Affairs related to the roles, responsibilities and 
accountability of the departments and its key leaders and staff.
    This bill falls well under our National Resolution on VA 
Accountability. As VA works to ensure that those in all levels of 
employment are upholding their commitments and dedication to serving 
veterans, we encourage this type of reporting so that the different 
roles of different departments can be adjusted and enhanced to better 
serve those who have stood up to serve this country. This is VA's 
purported mission and we support all levels of improved excellence.
 H.R. 1943 Restoring Maximum Mobility to Our Nation's Veterans Act of 
                                  2017
                       AMVETS supports H.R. 1943
    This bill ensures that veterans with a service-connected disability 
may be furnished a wheelchair to restore an ability to participate in 
recreational activities and clarifies that wheelchairs furnished to 
these veterans should be intended to help the veteran achieve mobility 
and function in the activities of daily life and employment in addition 
to recreation.
    AMVETS supports this bill as it falls in line with our National 
Resolution on Prosthetics and Sensory Aids, and we also support in the 
spirit of encouraging veterans of all abilities to be as active as they 
are able. From VA's sports clinics to its wheelchair games, it is quite 
evident that when veterans realize that they are capable of 
participation and involvement in actives they were not sure was 
possible after being injured or wounded, that it improves their 
physical and mental health.
                H.R. 1972 VA Billing Accountability Act
                       AMVETS supports H.R. 1972
    H.R. 1972 waives the requirement of certain veterans to make 
copayments for VA medical care, and prescriptions if the Department 
made errors in properly notifying the veteran that a payment was 
required, and if the notification was received more than three months 
after the date of service. It will be required that the veteran is 
given information on how to apply for a waiver, or to establish a 
payment plan. For medical care received outside of VA, the veteran must 
be notified of a payment due within 18 months of service.
    AMVETS supports this protective measure of veterans, who should not 
be held liable if VA is not properly billing its patients, whether they 
receive care within or outside of the VA health care system.
       H.R. 2147 Veterans Treatment Court Improvement Act of 2017
                       AMVETS supports H.R. 2147
    H.R. 2147 would require the Secretary of VA to hire additional 
Veterans Justice Outreach (VJO) Specialists, and AMVETS 
enthusiastically supports this bill. Many veterans have specific needs 
and challenges related to their military service. AMVETS has been 
involved with veteran treatment courts since their inception - starting 
with our then Commander J.P. Brown who worked with Judge Russell in 
Buffalo New York who in January of 2008 created and began presiding 
over the nation's first Veterans Treatment Court. Commander Brown took 
that knowledge and spearheaded the creation of a veteran treatment 
court in his home state of Ohio where about 100 veterans have since 
gone through the system. Of those, only four have had to leave due to 
noncompliance. The 96 others have completed two years of treatment 
which combines VA services, Social Services, veteran and family 
counseling, and four mental health agencies. The veteran is also paired 
with a mentor. The court itself acts just like a regular court, and if 
the veteran client pleads guilty and completes the 2-year program, then 
the charges are dropped. It is a key legislative priority of ours to 
see these courts expanded and we appreciate that the bill would add 
more VJO Specialists. There are many solid systems in place to help 
veterans, but they will not properly function without adequate 
staffing.
              H.R. 2225 Veterans Dog Training Therapy Act
                       AMVETS supports H.R. 2225
    H.R. 2225 creates a five-year pilot program to study the 
effectiveness of treating post-deployment mental health symptoms by 
having eligible veterans learn how to train service dogs through the 
VHA's Center for Compassionate Innovation's Recreation Therapy Service. 
VA would be required to establish and hire a director of therapeutic 
service dog training who has a background in social services; 
experience teaching others to train service dogs in a vocational 
setting; and a minimum of a year working in a clinical setting with 
veterans or those on active duty with PTSD. In choosing dog training 
instructors, there would be preference given to veterans who have 
graduated from PTSD or other residential treatment programs and who are 
certified in service dog training.
    Veterans participating in the pilot would do so in conjunction with 
VA's vocational rehabilitation Compensated Work Therapy program. Non-
governmental entities would be contracted to perform the assessments of 
the pilot which include how stigma is reduced, improvements to 
emotional regulation and patience, reintegrating into the community, 
improving sleep patterns and instilling a sense of purpose.
    The intent of this bill is in line with our National Resolution on 
VA mental health care that strongly recommends Congress appropriate 
more dedicated funding for mental health care and related programs and 
services. AMVETS is also a strong proponent of the benefits of service 
dogs, and believes that veterans in this pilot program would benefit by 
being in the leadership position to help train these canines that can 
change and better the lives of the fellow veterans they end up being 
paired with.
                       H.R. 2327 PAWS Act of 2017
                       AMVETS Supports H.R. 2327
    The Puppies Assisting Wounded Servicemembers Act creates a five-
year pilot program assessing the benefits of pairing a service dog with 
veterans suffering from severe PTSD, in an effort to reduce the 
concerning veteran suicide rate. The VA would provide $25,000 to 
eligible organizations for the procurement and training of each service 
dog paired with a veteran in addition to any necessary hardware, travel 
expenses for the veteran to obtain the service dog, or any potential 
replacement service dog, and a veterinary health insurance policy for 
the life of the dog.
    In order for a veteran to be eligible for the pilot they must be 
enrolled in VA healthcare and have completed an established evidence-
based treatment for PTSD without suitable improvement so as they still 
remain diagnosed under the PTSD checklist (PCL-5) and their mental 
health care provider determines that they may potentially benefit from 
a service dog. Once accepted into the pilot, in order to remain 
eligible the veteran needs to maintain their relationship with their 
mental health care provider, and have office visits at least every six 
months to determine whether the veteran is benefitting from being 
paired with a service dog. If it is determined that the veteran is not 
benefitting than the eligible organization that provided the dog will 
decide how best to ensure the safety of the dog and the veteran.
    While the VA does not compensate veterans for the care of service 
dogs that assist veterans with PTSD as they do for some other 
conditions, they remain in the midst of a $12-million-dollar study to 
measure the cost and mental health benefits of pairing well-trained 
service dogs with veterans diagnosed with PTSD. The study also aims to 
compare service dogs and emotional support dogs in how they assist 
veterans with PTSD. Unfortunately, the study has been beset by many 
setbacks, including improper pairing of poorly trained dogs with 
veterans, and for being slow in acquiring and pairing dogs with 
veterans. After undergoing a pause and reorganization, the VA study 
picked back up in 2015 and according to the VA's Office of Research and 
Development website, ``VA researchers are studying whether Veterans 
with PTSD can benefit from the use of service dogs or emotional support 
dogs. The study, being overseen by VA's Cooperative Studies Program, is 
enrolling 230 Veterans with PTSD from Atlanta, Iowa City, and Portland. 
To date, there is ample evidence on the benefits of service dogs for 
people with physical disabilities, but very little such evidence in the 
area of mental health.'' This particular study is set to be complete in 
2018.
    AMVETS has long seen the importance of well-trained and well-paired 
service dogs, and the impact this relationship has on individuals and 
veterans with physical and emotional illnesses or wounds. Service dogs 
can perform specific tasks to assist with the symptoms of PTSD such as 
learning commands to help secure space, turn on lights, sweep a room 
prior to a veteran entering and bark if anyone is present, to wake them 
up during a nightmare, remind them to take medication, and pick up on 
stress cues and offer calming support.
    The AMVETS Ladies Auxiliary has worked with ADI accredited ``Paws 
with a Cause'' as its National Community Service program for nearly 
thirty years in a consistent effort to help veterans with visible and 
invisible wounds obtain a service dog to enhance their daily 
functioning. Through this partnership, AMVETS has seen firsthand the 
marked benefits to a veteran's quality of life when paired with a well-
trained service dog.
    The intent of this bill is in line with our National Resolution on 
VA mental health care that strongly recommends Congress appropriate 
more dedicated funding for mental health care and related programs and 
services. While AMVETS supports passage of the PAWS Act, it is with the 
stipulation that great care, consult, and oversight occur when awarding 
a contract to an organization that trains the service dogs; in choosing 
veterans who are able to manage the continued care and training the dog 
will require; in closely following those who are part of the pilot 
program; and in setting expectations for how quickly the veteran can 
obtain a dog. Fully trained service dogs are quite rarely immediately 
available, but once paired with a receptive and willing owner, the 
benefits can be extraordinarily rewarding. AMVETS looks forward to 
providing any assistance needed to properly choose organizations that 
provide trained animals that can effectively support veterans with 
PTSD.
       Discussion Draft: Make Certain Improvements to VA's HPEAP
                  AMVETS supports the discussion draft
    This measure will improve the VA's Health Professionals Educational 
Assistance Program (HPEAP) by offering additional scholarships to those 
seeking to become a physician or dentist, and stipulates varying 
degrees of commitment to working full time at a VA medical facility in 
return for the scholarship, in addition to repayment parameters should 
the individual not meet the requirements of the scholarship.
    In addition this measure would create a VA Specialty Loan Repayment 
Program in order to repay the loans of certain VHA physicians who are 
eligible to be board certified in areas that are deemed to be most 
needed in the areas of recruitment and retention.
    Lastly, it would establish a veterans healing veterans pilot 
program to fund the educations of ten eligible veterans who have 
separated from the military within ten years, and who are not eligible 
for other educational assistance. They must apply for admission to one 
of five Teague-Cranston medical schools for 2019 and would be chosen 
for being veterans with the highest admissions rankings. If each of the 
five schools do not receive or award the two scholarships, then another 
school may award an additional scholarship in order for ten total 
scholarships to be awarded.
    Quality recruitment and retention of high performing physicians and 
dentists at VA has been a longstanding and complex challenge. We 
believe that this measures offers offer some excellent solutions to 
this issue, albeit rather short term with the repayment in the form of 
time committed to working in VA rather short-term. We hope that in the 
interim VA is able to strengthen its ability to retain physicians long-
term in the way of comparable compensation to the private sector, and 
internal organizational processes across the board that speak to VA's 
stated core values of: Integrity, Commitment, Advocacy, Respect, 
Excellence (``I CARE'').

                                 
               Prepared Statement of Harold Kudler, M.D.
    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 or Department) programs and services. Joining me 
today is Ms. Catherine Biggs-Silvers, Executive Director, for Mission, 
Planning, and Analysis, Human Resources and Administration. Due to the 
timing of the hearing, VA is unable to provide views on the draft bill, 
to make certain improvement in the Health Professionals Educational 
Assistance Program of the Department of Veterans Affairs. These views 
are currently being drafted and we will forward them to you as soon as 
they are available.

H.R 93 Medical Services for Women Veterans

    H.R. 93 would add section 1720H to Title 38, United States Code 
(U.S.C.), requiring the Secretary to ensure that gender specific 
services are continuously available at every VA medical center (VAMC) 
and community-based outpatient clinic (CBOC). It also would allow the 
Secretary to employ appropriate staff and enter into such contracts as 
may be needed to meet current and expected future demand for these 
services.
    We appreciate the intent of this proposal and would like to work 
with the Committee to further clarify the scope of this bill. We 
strongly believe that every Veteran should receive care specific to his 
or her needs, but we caution that the language as written could be 
broader than intended. For example, the term ``gender specific 
services'' is undefined, and could apply to both men and women 
Veterans. It is also unclear if this is intended to refer to gender-
specific primary care services for women or more advanced services such 
as obstetrics and gynecology (for women) or urology (for men). We also 
note that the bill as written would require these services be 
continuously available at every VAMC and CBOC. This could potentially 
have significant resource implications depending upon the intended 
effect. We would greatly appreciate the opportunity to meet with the 
Committee further to discuss these and other issues to improve this 
legislation.
    Given the unclear scope of the legislation, we are unable to 
provide a cost estimate for this bill at this time but note that it 
could have significant resource implications depending on the intended 
effect.

H.R 501 VA Transparency Enhancement Act of 2017

    H.R. 501 would impose new reporting requirements on medical center 
directors and the Secretary. It would require each VAMC Director to 
file a quarterly report to the Secretary providing specific data 
related to surgical infections and cancelled or transferred surgeries. 
Within 60 days of the end of each calendar quarter, the Secretary would 
be required to report to Congress and publish online the reports 
submitted by the VAMC Directors and a summary on those reports.
    We do not support this bill because portions of it are unnecessary 
and others would be burdensome to implement. Currently, each facility 
collects data on surgical infections locally, but this information is 
not gathered nationally. The VA Surgical Quality Improvement Program 
(VASQIP) examines a portion of all surgeries (approximately 30 percent) 
completed within VA to identify surgical infections, and nationally, 
approximately 1.5 percent of VASQIP assessed surgeries result in 
infections within 30 days of the procedure. Examining all surgeries 
could significantly increase our demand for resources without 
generating an appreciable improvement in quality.
    We are concerned about the intended result of the summaries of 
surgical infections, which could implicate patient privacy information. 
We would appreciate the opportunity to discuss this further with the 
Committee to resolve these concerns while ensuring the Committee has 
the information it needs to perform its oversight functions.
    We currently collect information on cancelled surgeries (including 
both the number and the reasons for such cancellations) and can provide 
this information as needed, both locally and nationally. It would be 
more difficult to gather information on transferred surgeries, as our 
systems do not collect this information now. We note that section 
2(a)(2)(C) directs VA to provide information on the number of 
additional days each such patient had to wait for surgery because of 
cancellation or transfer, but we caution that there are a number of 
reasons for cancellations and transfers, some of which are patient-
driven and others that may be clinically necessary, and that this 
information would therefore not necessarily be helpful. Some surgeries 
may be cancelled and never performed, either because they were elective 
or because of intervening circumstances. We would also like to discuss 
this provision further with the Committee to see if currently available 
information may satisfy the objective of this provision.
    VA estimates the cost of the legislation would be $18 million in 
fiscal year (FY) 2018, $97 million over five years, and $209 million 
over 10 years.

H.R 1063 Veteran Prescription Continuity Act

    H.R. 1063 would amend Section 715 of the National Defense 
Authorization Act for Fiscal Year 2016 (Public Law 114-92) by adding a 
new subsection (c). The Secretary would be required to provide any 
pharmaceutical agent not included in the joint uniform formulary for VA 
and the Department of Defense (DoD) to an individual who is 
transitioning from receiving treatment from DoD to receiving treatment 
from VA, if a DoD health care provider determines that such 
pharmaceutical agent is critical for such a transition. VA would be 
required to furnish these pharmaceutical agents beginning on the date 
on which the individual enrolls in the VA health care system and ending 
on the date on which a VA provider determines the agent is no longer 
required by the individual.
    We do not support this bill. When filling prescriptions, the 
Veteran's medical necessity drives the utilization of medications, not 
the formulary status of a medication. Fundamentally, we are concerned 
that the legislation would usurp a prescriber's professional 
responsibility to ensure a medication, whether a controlled substance 
or not, started by another provider continues to be safe and effective.
    We have a long-standing practice of continuing medications that are 
clinically needed for transitioning Servicemembers, and we have 
strengthened this further with a policy articulating this requirement 
in 2015 (VHA Directive 2014-02, issued January 20, 2015). Further, as 
required by Congress, VA and DoD have developed a process for annually 
reviewing the Continuity of Care Drug List, and we recently completed 
this review earlier this summer. VA's Center for Medication Safety has 
collaborated with DoD and performed two studies that have validated 
that our policies are working and that transitioning Servicemembers and 
new Veterans are receiving the medications they clinically need. The VA 
Center for Medication Safety is assessing the financial impact of the 
Continuity of Care Drug List, as required by Congress.
    DoD has no requirements in law to address the opioid crisis 
currently affecting the country. While section 715 required a joint 
formulary, there is no requirement for VA and DoD to adhere to the same 
protections and metrics for opioid prescriptions. We recommend that if 
Congress is interested in legislating in this area, this is an area 
that could produce significant improvements in the safety and well-
being of Veterans and Servicemembers alike. We would be happy to work 
with the Committee on this initiative. We also recommend that Congress 
enact legislation requiring DoD to notify VA immediately for any 
patients on high-risk medications who are transitioning out of military 
service. There currently is no mechanism for sharing this information, 
which introduces the potential for gaps in clinical care and patient 
safety.
    The bill is intended to ensure that patients maintain continuity of 
their prescription medications as they transition from DoD to VA, but 
as written, this legislation could obligate providers and pharmacists 
to furnish medications in ways that could violate other provisions of 
law or professional responsibility. For example, if a Servicemember 
received a prescription for a controlled substance, and such a 
prescription requires either routine monitoring or additional 
screening, a VA pharmacist or provider could be forced to decide which 
law to comply with and which to violate. As another example, if a 
Servicemember received a prescription for a controlled substance, then 
sought additional prescriptions for the same substance from several 
private providers, a VA pharmacist would know this by checking the 
Prescription Drug Monitoring Program; ordinarily, VA pharmacists would 
not fill that prescription, but this bill could require them to do so. 
VA providers and pharmacists are trained to review prescriptions 
carefully to ensure that patient safety is the top priority, and we are 
concerned that this legislation, while well-intended, could impede that 
objective.
    We note as a technical manner that, as written, proposed section 
715(c)(2)(B) would require a VA health care provider to determine that 
the Veteran does not require a pharmaceutical agent. This would 
preclude a non-Department provider authorized to furnish care and 
services to Veterans from making this determination. Given the 
continuing discussion regarding the future of Care in the Community, we 
note this language may affect some Veterans differently based upon who 
furnishes their care.
    We are unable to provide a cost estimate for this bill given the 
uncertainty regarding how many transitioning Servicemembers would be 
affected, which medications VA would have to provide, how much those 
medications would cost, and how long it would take for VA to make a 
clinical determination regarding the continued need for that 
medication.

H.R. 1066 VA Management Alignment Act of 2017

    H.R. 1066 would require, within 180 days of enactment of this Act, 
the Secretary to report to Congress on the roles, responsibility, and 
accountability of elements and individuals within VA. In creating the 
report, the Secretary would be required to utilize the results of the 
Independent Assessment of the Health Care Delivery Systems and 
Management Process established by section 201 of the Veterans Access, 
Choice, and Accountability Act of 2014 (Public Law 113-146), any study 
or report by the Commission on Care established by section 202 of 
Public Law 113-146, and other studies or reports. The Secretary's 
report to Congress would also have to specify clearly delineated roles 
and responsibilities to optimize the organizational effectiveness and 
accountability of each administration, staff office, or staff 
organization, their subordinate organizations, and key leaders of the 
Department.
    VA supports the intent of this bill. The Secretary has made 
improving accountability within VA, including ensuring that the 
Department is well-organized and well-functioning, one of his highest 
priorities, and our current efforts are achieving the intended results 
of this legislation. We are not waiting for legislation to improve VA's 
organizational structure and internal management-we are taking 
aggressive steps now to ensure that VA is responsive to Veterans' needs 
while being a good steward of taxpayer dollars.
    We do not expect this legislation would result in any appreciable 
costs.

H.R 1943 Restoring Maximum Mobility to Our Nation's Veterans Act of 
    2017

    H.R. 1943 would amend 38 U.S.C. Sec.  1701 by adding a new 
paragraph (11) defining the term ``wheelchair''. This term would 
include enhanced power wheelchairs, multi-environmental wheelchairs, 
track wheelchairs, stair-climbing wheelchairs, and other power-driven 
mobility devices. It would also add a new subparagraph (2) to 38 U.S.C. 
Sec.  1712(c) to require the Secretary to ensure that each wheelchair 
provided under this title to a Veteran because of a service-connected 
disability restores the maximum achievable mobility and function in the 
activities of daily life, employment, and recreation for the Veteran. 
The Secretary would be authorized to furnish a wheelchair in order to 
restore an ability that relates exclusively to participation in a 
recreational activity.
    We generally support the proposed changes to section 1701, but have 
concerns with a few of the types of wheelchairs identified. For 
example, track wheelchairs and stair-climbing wheelchairs are not 
currently cleared by the Food and Drug Administration (FDA) for use, 
and as a result, we do not believe it is appropriate to prescribe or 
furnish such equipment to Veterans. We currently furnish FDA-cleared 
wheelchairs, and in the event that other wheelchairs are cleared by FDA 
in the future, we would be able to furnish such wheelchairs at that 
time. Similarly, we are concerned about the breadth of the term ``other 
power-driven mobility devices'', which could include any number of 
items that have no valid medical necessity.
    Regarding the proposed changes to section 1712, we note that the 
language would limit eligibility to Veterans who are furnished a 
wheelchair because of a service-connected disability. VA currently 
provides wheelchairs to Veterans, regardless of their service-connected 
status, as long as they are enrolled in VA health care and the 
wheelchair is determined to be medically necessary. We do not 
distinguish between Veterans with service-connected disabilities and 
those without when making determinations regarding which prosthetic 
devices the Veteran needs; we only consider their medical necessity. In 
this context, we do not believe these amendments are needed because we 
already furnish these services. We recommend that the language 
requiring the Secretary to ensure that each wheelchair restores the 
maximum achievable mobility and function in the activities of 
``employment'' and ``recreation'' be removed, as this could potentially 
create an open-ended obligation. We believe it is sufficient for a 
Veteran's clinical needs that the wheelchair restore the maximum 
achievable mobility and function in the activities of daily life.
    We note there is some ambiguity in terms of the intent and effect 
of the second sentence in proposed 1712(c)(2), and we would appreciate 
the opportunity to discuss this further with the Committee to provide 
any technical assistance that may be required.
    Because the intended scope of the certain provisions of the bill is 
unclear, we cannot estimate the cost of this legislation to the 
Department but note that it could have significant resource 
implications.

H.R 1972 VA Billing Accountability Act

    H.R. 1972 would amend sections 1710(f)(3) and 1722A, and add a new 
section 1709C to title 38, U.S.C., that would require VA to notify 
Veterans of their copayment requirements no later than 120 days after 
the date of care or services provided at VA medical facilities, and no 
later than 18 months after the date of care or services provided at 
non-VA facilities. If VA does not provide such notice, VA could not 
collect the copayment, including through a third-party entity, unless 
VA provided the Veteran: (1) information on applying for a waiver and 
establishing a payment plan, and (2) an opportunity to make a waiver or 
establish a payment plan. The Secretary would be authorized to waive 
the copayment requirement in cases where notification to the Veteran 
was delayed because of an error committed by VA, a VA employee, or a 
non-VA facility (if applicable), and the Veteran received notification 
beyond the specified timeframes. H.R. 1972 would also require VA, no 
later than 180 days after enactment, to review and improve its 
copayment billing internal controls and notification procedures, 
including pursuant to the provisions of the bill.
    VA supports the intent of H.R. 1972 to prevent delays in the 
release of copayment charges due to operational error, avoid undue 
burden to Veterans, and improve VA's copayment billing procedures. 
However, we are concerned that the 120-day time period proposed in the 
bill could adversely affect some Veterans. Further, it is not clear 
what specific copayment billing issues the bill would address.
    We note that copayments are automatically generated by VA's 
integrated billing system. Moreover, VA ensures that every Veteran is 
given the notice of rights and the opportunity to request a waiver or 
compromise, and to establish a repayment plan for copayment charges. 
This information is included with every copayment billing statement 
that VA sends to a Veteran. As a service to Veterans, VA holds 
copayment bills until a Veteran's other health insurance (OHI) is 
billed and either pays or denies the claim. This allows VA potentially 
to offset the Veteran's copayment charges with payment received from 
the OHI, reducing the Veteran's liability. When a Veteran has OHI, the 
copayment charge is placed on hold for 90 days while the OHI is billed. 
If no payment is received within 90 days, the charges will 
automatically be released and a statement generated to the Veteran. If 
a balance remains after an OHI payment is applied to the copayment 
debt, the bill for the remaining balance is released to the Veteran and 
he or she receives it within a variable timeframe that ranges from 70 
to 150 days depending on when the OHI payment is made - a timeframe 
that can exceed the proposed 120-day standard in H.R. 1972. Requiring 
all copayment bills to be issued within 120 days could adversely affect 
some Veterans whose OHI payments are delayed, as they would be notified 
of a copayment and billed when they would ordinarily not incur any 
personal liability. We note that less than 10 percent of copayment 
bills currently are submitted more than 120 days from the date of 
service, but in these cases, requiring copayment bills be issued could 
produce confusion among Veterans, result in greater out-of-pocket costs 
for these Veterans, and increase VA's administrative burden in 
implementing this change. VA financial policy for medical care debts 
specifies that Veterans who do not have OHI should have the opportunity 
to satisfy copayment obligations at the Agent Cashier's office prior to 
leaving the medical facility. Otherwise, the record of service is 
prepared and the copayment is released for billing on the Veteran's 
next scheduled monthly billing statement, which is normally received 
anywhere from 14 to 42 days after the date of service. The timeliness 
of OHI payments to VA is one of the biggest factors affecting the 
timeliness of copayment bills issued by VA to Veterans.
    Copayment bills may also be generated following income verification 
under 38 U.S.C. Sec.  5317, which authorizes VA to validate certain 
Veterans' reported income with the Internal Revenue Service (IRS) and 
Social Security Administration information. This validation begins 18 
months after the calendar year in which that income is reported due to 
receipt of data, upon completion of tax processing, from the IRS. If VA 
identifies unreported income, VA has authority to generate copayment 
billings as a result of this verification process. VA also refunds 
copayments, when appropriate, as a result of this income verification 
process. The timeframe associated with this process exceeds the 120-day 
standard proposed in H.R. 1972. We also note that private sector 
billing industry standards allow for billing up to 12 to 18 months 
after services are rendered - also exceeding the proposed 120-day 
timeframe.
    H.R. 1972 does not specify what constitutes an error, what would 
justify a waiver, and whether the waivers and payment plans authorized 
under the bill would differ from those currently authorized in 
applicable statutes and regulations. VA has existing procedures under 
38 U.S.C. Sec.  5302 to waive collection in cases where the Secretary 
determines that recovery would be against equity and good conscience. 
In these instances, an application for relief must generally be made 
180 days from the date of notification of the indebtedness.
    We note that VA copayment requirements under 38 U.S.C. Sec.  
1710(f)-(g), 38 U.S.C. Sec.  1722A, and 38 U.S.C. Sec.  1710B (which is 
not referenced in H.R. 1972, but requires copayments of certain 
Veterans for extended care services) apply regardless of whether the 
care or services was provided in a VA facility or authorized by VA in a 
non-VA facility. Therefore, the 120-day timeframe that would be added 
in section 1710(f)(3)(G)(ii) and section 1722A(c)(2) by the bill may be 
read as applying to care or services in both VA and non-VA facilities.
    We note that the Department is close to submitting its plan for the 
future of community care, the Veteran Coordinated Access & Rewarding 
Experiences (CARE) Act, which will include proposed amendments to its 
practices concerning the recovery or collection of reasonable charges 
from other parties for certain care and services. We recommend the 
Subcommittee forbear further consideration of HR 1972 until VA has 
submitted the Veteran CARE Act and the Subcommittee can consider how 
this bill would be affected by the Department's proposal.
    If copayment billings delayed beyond 120 days from date of service 
are waived, VA estimates a 5-year revenue loss of $282 million and a 
10-year revenue loss of $562.8 million from the First Party Inpatient/
Outpatient and Pharmacy Medical Care Collection Fund.

H.R 2147 Veterans Treatment Court Improvement Act of 2017

    H.R. 2147 would require VA to hire additional Veterans Justice 
Outreach (VJO) Specialists to provide treatment court services to 
justice-involved Veterans. Specifically, H.R. 2147 would require that 
VA hire not less than 50 VJO Specialists and place each such VJO 
Specialist at an eligible VA medical center (VAMC). The bill would 
require that the total number of VJO Specialists employed by the 
Department not be less than the sum of (a) the VJO Specialists employed 
on the day before the enactment of this provision; and (b) the number 
of VJO Specialists to be hired under this bill. The bill would require 
that the Secretary prioritize placement of the VJO Specialists at 
facilities that will create an affiliation with a Veterans treatment 
court that is established on or after the date of enactment of the 
bill, or one that was established prior to enactment but is not fully 
staffed with VJO Specialists. The bill would require the Secretary to 
submit a report to Congress on the progress and effects of implementing 
these provisions within one year, with new reports submitted annually 
after that. The bill would also require the Comptroller General to 
submit to Congress a report on the implementation of this authority and 
the effectiveness of the VJO Program. The bill would authorize to be 
appropriated $5.5 million for each of fiscal years 2017 through 2027, 
and would require the Secretary to submit to Congress a report that 
identifies such legislative or administrative actions that would result 
in reduction in expenditures by the Department that are equal to or 
greater than the amounts authorized to be appropriated.
    VA supports the intent of this bill and is already working to hire 
more than the 50 additional VJO Specialists within the next year. 
However, the bill could ultimately result in a reduction of $5.5 
million in funding to other programs (including possibly programs for 
homeless Veterans). Because of this potential reduction in funding, VA 
does not support the legislation as drafted. Demand for VJO Specialists 
has grown considerably over the past several years, partly as a result 
of the adoption of the Veterans Treatment Court model in new 
jurisdictions. Limited VJO staff resources have affected VA's ability 
to partner effectively with Veterans Treatment Courts, especially those 
newly established.
    We note that provisions of section 2(e) of the bill concerning the 
authorization of appropriations may not accomplish the intended 
objective. We understand this provision is intended to ensure that the 
Secretary identifies offsets to fund the program required by this bill. 
However, this provision would violate the Recommendations Clause, U.S. 
Const. art. II, Sec.  3, by requiring the Secretary to recommend 
legislative actions regardless of whether the Secretary judges such 
legislation ``necessary and expedient.'' To comply with the 
Constitution, such recommendations should be discretionary rather than 
mandatory. Moreover, the bill only requires the Secretary to report to 
Congress on legislative or administrative actions that would result in 
a reduction of expenditures equal to or greater than $5.5 million. To 
the extent that the Secretary identifies legislative actions that would 
result in a reduction of expenditures, there is no guarantee that 
Congress would take such actions. We further note that the offsets 
would likely affect adversely VA's ability to implement and run other 
programs, which could result in delays in the provision of benefits, 
healthcare, and other critical services to Veterans and other 
beneficiaries. Ultimately, we do not believe this is an appropriate 
mechanism for funding the program required by this section.
    We also note that the definition of ``local criminal justice 
system'' in section 2(f)(3) of the bill would not include Federal 
courts. We understand there are some Federal district courts that have 
Veterans treatment courts, and these would not be supported under this 
bill.
    While we estimate the hiring of 50 additional VJO Specialists would 
cost $5.5 million in FY 2018, because the bill would require VA to 
identify offsets, we believe the ultimate cost would be $0 in FY 2018 
and over both 5 and 10 years, if these offsets, some of which may 
require legislation, can be implemented. We again caution that the 
costs for implementation would involve reductions to other VA programs.

H.R 2225 Veterans Dog Training Therapy Act

    H.R. 2225 would require the Secretary, within 120 days of 
enactment, to commence a 5-year pilot program under which the Secretary 
enters into a contract with one or more non-government entities for the 
purpose of assessing the effectiveness of addressing post-deployment 
mental health and post-traumatic stress disorder (PTSD) symptoms 
through a therapeutic medium of training service dogs for Veterans with 
disabilities. The bill would require the Secretary to enter into 
contracts with non-government entities located in close proximity to a 
minimum of three and not more than five VA medical centers. The bill 
requires that the non-government entities be certified in the training 
and handling of service dogs and have a training area that meets 
certain enumerated specifications.
    The bill would require each pilot program site to employ at least 
one person with clinical experience related to mental health, and to 
have certified service dog training instructors with preference given 
to Veterans who have graduated from a residential treatment program and 
are adequately certified in service dog training. In addition, the bill 
would require VA to collect data to determine how effectively the 
program assists Veterans in various areas such as reducing stigma 
associated with PTSD, improving emotional regulation, and improving 
patience. Not later than one year after the date of commencement of the 
pilot program and annually thereafter, VA would be required to submit 
to Congress a report regarding the number of participating Veterans, a 
description of the services carried out by the pilot program, the 
effects of pilot program participation in various areas relating to the 
participating Veterans' health and well-being, and recommendations with 
respect to extension or expansion of the pilot program.
    VA supports the identification of effective treatment modalities to 
address PTSD and other post-deployment mental health symptoms; however, 
VA does not support the specific provisions in H.R. 2225 because VA has 
significant concerns about the proposed legislation. Although anecdotal 
evidence has been offered to show the benefits of participating in such 
a dog training therapy program, there is no published scientific 
evidence to date that shows that such a program benefits PTSD patients 
specifically or that such a resource-intensive program is any better 
than other therapies known to be effective in alleviating PTSD 
symptoms. By propagating a yet unproven therapy, the bill may result in 
unintended and negative consequences for the Veterans who would be 
participating in this unsubstantiated treatment regime. Also, the pilot 
program would be duplicative of a DoD study of this same therapy 
program at the Uniformed Services University of Health Sciences. In 
addition, the service dog training therapy program currently in place 
at the Palo Alto VAMC is organized as part of an integrated set of 
services provided for their in-patient Trauma Recovery Program and is 
not offered as a stand-alone program or as an outpatient service. VA 
has no prior experience in offering or managing such a program as an 
outpatient program.
    We note the bill would require this program be carried out through 
the Center for Compassionate Innovation of the Veterans Health 
Administration (VHA) of the Department of Veterans Affairs. We 
recommend against including such specific language identifying a 
particular organization as the lead for implementation, particularly 
given the nature of this work and the involvement of multiple offices 
within VHA.
    The bill would require that each contract entered into under 
subsection (a) shall provide that the nongovernmental entity shall 
employ at least one person with clinical experience related to mental 
health. It is unclear what role this person is intended to fill.
    The bill would also make a number of restrictive stipulations 
regarding the structure and operation of the pilot program. For 
instance, contractor service dog trainers would be required to be 
certified, but there is currently no national certification program for 
service dog trainers. The bill would require the contractor to 
preferentially hire Veterans who have graduated from a PTSD or other 
residential treatment program and received ``adequate certification in 
service dog training.'' However, programs at the Palo Alto VAMC and DoD 
sites do not provide adequate training to qualify a Veteran as a dog 
trainer, and they focus on basic commands rather than the advance tasks 
required by service dogs. The legislation would also require 
establishing a VA director of therapeutic service dog training who is 
experienced in teaching others to train service dogs in a vocational 
setting, has a background in social services, and has at least one year 
of experience working with Veterans or active duty military members 
with PTSD in a clinical setting. These criteria would severely reduce 
the number of eligible candidates.
    VA also notes that, if any service dogs successfully trained 
through the program for Veterans with disabilities are to be eligible 
to participate in VA's service dog medical benefit program, the non-
government entities chosen would have to be accredited by Assistance 
Dog International. Thus, the number of potential non-government entity 
partners who could produce dogs eligible for VA's service dog medical 
benefit program would be relatively limited.
    VA estimates this bill would cost $3 million in FY 2018 and $14 
million over five years.

H.R 2327 PAWS Act of 2017

    H.R. 2327 would require the Secretary to carry out a pilot program 
under which the Secretary provides a $25,000 grant to an eligible 
organization for each Veteran referred to that organization for a 
service dog pairing. Grantees would be required to provide for each 
participating Veteran and service dog coverage of a commercially 
available veterinary health insurance policy; hardware, or repairs or 
replacements for hardware, that are clinically determined to be 
required by the dog to perform the tasks necessary to assist the 
Veteran with the diagnosed disorder of the Veteran; and payments for 
travel expenses for the Veteran to obtain the dog. If the Veteran is 
required to replace a service dog provided pursuant to a grant, the 
Secretary would be required to pay the travel expenses for the Veteran 
to obtain a new service dog, regardless of any other benefits the 
Veteran is receiving for the first service dog.
    To be eligible to receive a grant, an applicant would have to be a 
nonprofit organization certified by Assistance Dogs International 
(ADI), provide one-on-one training for each service dog and recipient 
for 30 hours or more over 90 days or more, provide wellness 
verifications from licensed veterinarians, ensure all service dogs pass 
the American Kennel Club Community Canine test and the ADI Public 
Access test prior to permanent placement, while also meeting other 
requirements. VA would review and approve Veterans to participate in 
this program based upon their application, and VA would have 90 days to 
make an approval determination. Veterans would have to: be enrolled in 
the VA health care system; have been treated and have completed an 
established evidence-based treatment for PTSD; receive the 
recommendation of a VA provider or team that the Veteran may 
potentially benefit from a service dog; and agree to successfully 
complete training provided by an eligible organization. Veterans would 
have to see their provider at least every six months to determine, 
based on a clinical evaluation of efficacy, whether they continue to 
benefit from a service dog. Any improvement in symptoms as a result of 
participation in the pilot program could not affect the eligibility of 
the Veteran for any other benefit under the laws administered by the 
Secretary.
    The Secretary would be required to develop metrics and other 
appropriate measurements to determine the efficacy of the program. 
Within one year of enactment, the Comptroller General would be required 
to brief Congress on the methodology established for the pilot program. 
Ten million dollars ($10,000,000) would be authorized to be 
appropriated for the period of FY 2018 through FY 2023 to carry out the 
pilot program, and the amounts otherwise authorized to be appropriated 
for VA's Office of Human Resources and Administration would be reduced 
by the same amount over the same time period. The pilot program would 
terminate on the date that is 5 years after the date of the enactment 
of this Act, and any eligible Veteran in possession of a service dog 
furnished under the pilot program as of the termination of the pilot 
program may keep the service dog after the termination of the program 
for the life of the dog.
    As we previously stated, VA supports the identification of 
effective treatment modalities to address PTSD and other post-
deployment mental health symptoms; however, we do not support the 
specific provisions in H.R. 2327 because VA has significant concerns 
about the proposed legislation. Again, there is no published scientific 
evidence to date that shows that such a program benefits PTSD patients 
specifically, or that such a resource-intensive program is any better 
than other therapies known to be effective in alleviating PTSD 
symptoms. By propagating a yet unproven therapy, the bill may result in 
unintended and negative consequences for the Veterans who would be 
participating in this unsubstantiated treatment regime. Also, the pilot 
program would be duplicative of an existing VA research study on the 
effectiveness of service dogs and emotional support dogs for Veterans 
with PTSD.
    We have several other concerns with this legislation. We note that 
the bill refers in certain places to ``severe'' PTSD, but there are no 
established diagnostic criteria to distinguish levels of severity of 
PTSD.
    In section 2 of the bill, Congressional findings are presented 
concerning Veteran suicide, mental health disorders, and substance use 
disorders. However, we note that there is no evidence to support that 
the presence or possession of a service dog would result in the 
reduction of any of these conditions or events. VA strongly agrees with 
the need to focus on reducing Veteran suicide and in treating Veteran's 
mental health conditions, but we do not believe the proposed bill would 
be the best use of resources to that end. VA is aggressively pursuing 
efforts to end Veteran suicide, but we cannot rely on the assumption 
that service dogs will ensure the well-being of Veterans.
    Under section 3(a) of the bill, grantees would receive $25,000 for 
each Veteran referred to that organization for a service dog pairing. 
We note that it is possible some organizations may be able to furnish 
these services for less than $25,000. We recommend the language be 
revised to state that grants may not exceed $25,000 to ensure that 
Federal resources are not wasted. We would appreciate the opportunity 
to conduct a cost analysis to ensure that we are the best stewards of 
taxpayer dollars and that we maximize the potential use of our 
resources.
    Section 3(c)(1)(A)(ii) of the bill would require an organization to 
provide, on average, one-on-one training for each service dog and 
recipient for 30 hours or more over 90 days or more. If this refers 
only to the pairing, this may be an appropriate amount of time, but if 
this is intended to cover all of the training of the dog, this would be 
inadequate.
    The 90-day approval period for VA to determine a Veteran's 
eligibility under section 3(d)(1) could present challenges in 
implementation given the number of consultations or clinical visits 
that may be required for some Veterans.
    We are concerned about section 3(d)(2)(A), which could provide an 
incentive for failing treatment and could interfere with other forms or 
guidelines for evidence-based mental health treatment. Regarding 
section 3(d)(2)(B), there is no clinical basis in existence for 
providers to make a determination about whether a Veteran may benefit 
from a service dog. This could make implementation more difficult and 
result in variation across the system. We have similar concerns about 
the requirement in section 3(d)(3) for the ongoing evaluation every 6 
months to determine the clinical efficacy of whether the Veteran 
continues to benefit from a service dog, as there are no recognized 
means for making such determinations. In section 3(d)(4), the bill 
clarifies what happens if the Veteran is no longer able or willing to 
care for the service dog, but does not address what would happen if the 
service dog were no longer able to fulfill its function.
    We strongly oppose section 3(i) of this bill, which would reduce 
the amounts authorized to be appropriated for VA's Office of Human 
Resources and Administration (HRA) by $10 million between FY 2018 and 
FY 2023. This reduction would have a devastating impact on our mission. 
HRA's budget funds missions that are statutorily driven. A reduction of 
this nature would have a cascading impact on all of the organizations 
in VA, including health care delivery. HRA's budget funds staff office 
rent for 10 buildings, security, U.S. mail, and other operational costs 
for VA's Central Office campus. These are non-negotiable fixed costs, 
and account for roughly half of the funds allocated to HRA as part of 
the General Administration appropriation. The remaining funds are 
allocated to payroll. Most of the services HRA provides to VA are 
provided through Federal employees. VA has already conducted a 
comprehensive review of HRA's organizational functions to reduce or 
eliminate activities not required by law, and as a result, there are no 
further programs that could be stopped based on a further reduction in 
funds.
    Under section 3(j), the authority to operate the program would end 
5 years from the date of enactment. This length of time would further 
limit the efficacy of this program. VA would be required to publish 
regulations for this program (see 38 U.S.C. Sec.  501(d)), and in 
addition, it takes on average approximately 18-24 months to train a 
service dog. This would result in very little time in which Veterans 
could receive service dogs and would likely not produce very many 
service dogs that could be provided to Veterans.
    We estimate the bill would cost $2 million in FY 2018 and $14 
million over 5 years, but note that certain provisions in this 
legislation could result in continuing costs beyond that time period.
    Mr. Chairman, this concludes my prepared statement. My colleagues 
and I would be pleased to answer any questions you or other members of 
the Subcommittee may have.

                                 
                   Prepared Statement of Rick Weidman
    Good morning, Chairman Wenstrup and other distinguished members of 
the subcommittee. Vietnam Veterans of America (VVA) is pleased to have 
the opportunity to appear here today to share our views concerning 
pending legislation before this subcommittee.

H.R.501 - VA Transparency Enhancement Act of 2017, introduced by 
    Congresswoman Debbie Dingell, (D-MI-12). This bill requires 
    increased reporting regarding certain surgeries scheduled at 
    medical facilities of the Department of Veterans Affairs.

    We have no objections to this bill.

H.R.93 - Introduced by Congresswoman Julia Brownley, (D-CA-26), would 
    provide for increased access to VA medical care for women veterans.

    VVA has always championed quality health care for women veterans. 
We continue our advocacy to secure appropriate facilities and resources 
for the diagnosis, care, and treatment of women veterans throughout the 
health care system. While the Department has made many improvements and 
advancements over the past several years, some concerns remain. 
Specifically, every woman veteran should have access to a VA primary 
care provider who meets all her primary care needs, including gender-
specific care.
    We support Ms. Brownley's bill as it addresses the need for such 
gender-specific services at every VA Medical Center and Community-Based 
Outpatient Clinic.

H.R.1063 - Veteran Prescription Continuity Act, introduced by 
    Congressman Beto O'Rourke (D-TX-16). This bill would ensure that an 
    individual who is transitioning from receiving medical treatment 
    furnished by the Department of Defense to medical treatment at a VA 
    facility receives a ``seamless transition'' of the pharmaceutical 
    agents provided by DoD yet may not be on the VA drug formulary.

    The transition process is not necessarily as robust as it should 
be. While VA and the DoD have collaborated for many years to improve 
the transitioning process, gaps still remain, and too many veterans 
still fall through the bureaucratic cracks. Oftentimes we hear of 
veterans who have transitioned from the military health care system to 
the VA health care system, not receiving the same medications, a 
situation very much the case with mental health drugs. We believe that 
every measure should be taken to ensure veterans have a safe, 
transparent, and hassle-free transition.

    VVA supports enactment of this bill.

H.R.1066 - VA Management Alignment Act of 2017, introduced by 
    Congressman Derek Kilmer (D-WA-6), which would direct the Secretary 
    of Veterans Affairs to submit to the Committees on Veterans' 
    Affairs of the Senate and the House of Representatives a report 
    regarding the organizational structure of the Department of 
    Veterans Affairs.

    VA's organizational structure seems to undergo changes whenever 
there is a change in leadership. This often leads to unnecessary 
confusion, as well as questions as to who has responsibility and 
accountability for a given task or program. Numerous studies and 
reports on what an effective organizational structure might look like 
have been developed, yet they wind up languishing on the shelf and 
forgotten. Mr. Kilmer's bill directs the VA to utilize the results of 
several recent reports to accomplish a restructuring and management 
realignment. We believe this process should be as transparent as 
possible.

    VVA supports this bill.

H.R.1943 - Restoring Maximum Mobility to Our Nation's Veterans Act of 
    2017, introduced by Congressman Steve King, (R-IA-4), would require 
    the Secretary of Veterans Affairs to ensure that each wheelchair 
    furnished to a veteran because of a service-connected disability 
    restores the maximum achievable mobility in the activities of daily 
    life, employment, and recreation.

    Restoring independence and mobility to a severely injured person 
speeds his/her recovery mentally as well as physically. The Department 
has many professional occupational and recreational therapists who 
assist veterans every day to bring them closer to achieving those 
goals. In fact, the Department has an adaptive sports program that is 
very popular with the veteran community. In 2017 there were six events 
for veterans to participate in. Similarly, DoD hosts the Wounded 
Warrior Games, and veterans can participate in the Invictus Games and 
Paralympics.
    This bill would authorize the Secretary to furnish a wheelchair to 
a veteran because the wheelchair restores an ability that relates 
exclusively to participation in a recreational activity.

    VVA supports this bill.

H.R.1972 - VA Billing Accountability Act, introduced by Congressman 
    Lloyd Smucker (R-PA-16), would authorize the VA Secretary to waive 
    the requirement that certain veterans make copayments for hospital 
    care and medical services in the case of an error by the 
    Department.

    The VA has a history of billing problems. Veterans should not be 
held responsible for making a payment due to the fault of the 
Department. VVA supports the opportunity for veterans to apply for a 
waiver or establish a payment plan for the purposes of paying 
copayments as laid out in the legislation.

    VVA has no objection to this bill.

H.R. 2147 - Veterans Treatment Court Improvement Act of 2017, 
    introduced by Congressman Mike Coffman (R-CO-6), would require the 
    Secretary of Veterans Affairs to hire 50 additional Veterans 
    Justice Outreach specialists to assist justice-involved veterans.

    Today there are more than 360 Veterans Treatment Courts in 
jurisdictions across the country, with scores more in various stages of 
planning and implementation. The role of VJOs is critical to the 
effective functioning of these courts. So, too, are VJOs key in 
assisting veterans incarcerated in jails as well as prisons, arranging 
for services and health care upon their release from confinement, 
providing invaluable aid in helping eligible veterans find housing and 
employment.
    While it is a chronic complaint among many in government that they 
are overworked, the reality is that the VA's VJOs are spread really 
thin, considering all the treatment courts and correctional facilities 
where their services are vitally needed. Considering that Mr. Coffman's 
bill would appropriate $5,500,000 to hire additional VJOs not only for 
FY'17 but for the next nine federal fiscal years as well, enactment of 
this bill is certainly a step in the proverbial right direction. It is 
also in essence companion legislation to Senator Jeff Flake's S. 946.

    VVA applauds Congressman Coffman for introducing this legislation.

H.R. 2225 - Veterans Dog Training Therapy Act, introduced by 
    Congressman Steve Stivers (R-OH-15), would direct the Secretary of 
    Veterans Affairs to carry out a pilot program on dog training 
    therapy.

    VVA has always recognized the importance of guide dogs trained to 
assist visually impaired veterans and service dogs trained to assist 
hearing impaired veterans or veterans with a spinal cord injury or 
dysfunction or other chronic impairment that substantially limits 
mobility.
    Recognizing the expansion of alternative treatments for mental 
health issues, Congress gave VA the authority in 2009 to provide 
service dogs for the aid of veterans with mental illness. However, we 
would like to emphasize that instead of a pilot program, or in 
conjunction with the pilot program, what is really needed for dog 
therapy and other alternative treatments is evidence-based 
epidemiological research studies that would determine the efficacy of a 
certain treatment. Currently, research is scarce on these types of 
treatments and a well-designed study conducted by professionals could 
be used to inform treatment protocols that are validated through such 
research.

    Still, VVA has no objection to the bill.

H.R. 2327 - PAWS Act of 2017, introduced by Congressman Ron DeSantis 
    (R-FL-6th). This bill would direct the VA Secretary to make grants 
    to eligible organizations to provide service dogs to veterans with 
    severe PTSD.

    While our comments regarding H.R. 2225 apply as well to this bill, 
we must object, however, to the offset in this bill that would take $10 
million from the Office of Human Resources and Administration. It is 
widely known that VA's HR office is understaffed and in need of 
training. They can hardly afford to have that funding taken away from 
them. It has been our long-standing argument that you do not take 
funding from one program for veterans to fund another: you do not rob 
Peter to pay Paul. If Congress cannot provide for the funding for PAWS, 
VVA cannot support its enactment.

Draft bill: introduced by Congressman John Rutherford (R-FL-4), to make 
    improvements in the VA's Health Professional Educational Assistance 
    Program (HPEAP).

    Section 2 of this bill would authorize the Secretary to award no 
less than 50 scholarships to individuals who are enrolled in a program 
to become a physician or dentist until the staffing shortage of 
physicians and dentists in the Department is less than 500. In return, 
the participant agrees to serve in the Veterans Health Administration 
as a full-time employee. It further extends HPEAP to December 31, 2033.

    Section 3 establishes the Specialty Education Loan Repayment 
Program. In general, to be eligible an individual must have recently 
graduated from an accredited medical or osteopathic school and matched 
to a residency program in a certain medical specialty described in 
title 38, owe money, and be a physician in training. In return, the 
participant incurs an obligation to serve for a specified number of 
years as a full-time clinical practice employee of VHA. The Secretary 
may give preference to veteran applicants.
    This legislation also authorizes the establishment of a pilot 
program in which the VA funds the medical education of 10 eligible 
veterans enrolled in the Teague-Cranston medical schools. The veterans 
must have been discharged under honorable conditions in order to be 
eligible for this program. In return, the veteran agrees to serve as a 
full-time clinical practice employee in the VHA for four years.
    VVA is well aware of the shortages in clinical staff throughout the 
VA health system. This is a good first step in trying to alleviate that 
shortage. However, this will take some time to implement and offers no 
immediate succor for an increasingly serious staffing situation.
    Also, we believe the VA would be well-served if they opened the 
doors of service to veterans with an administratively rendered OTH 
discharge. If a ``veteran'' is defined as one who is discharged under 
other than dishonorable conditions, then OTH vets should not be 
excluded from this program unless they were discharged for medical 
malpractice, crimes involving patients, or other reasons that call into 
question their integrity and hence, their ability to be the type of 
employee valued by the VA and the veterans it serves.
    The VHA - and Congress - must come to grips with the underlying 
causes of the so-called access scandal that rocked the VA in 2014 (even 
though the practice that was called into question had been going on for 
decades): the serious shortage of qualified medical personnel willing 
and able to work for the VA, and making less money than they might 
otherwise earn in private practice. If a veteran with ``bad paper'' 
goes on to a career in medicine and is otherwise qualified, s/he should 
be granted the opportunity to participate in this program.
    VVA thanks you for this opportunity to present our views here 
today. We will be pleased to respond to any questions you might care to 
put to us.

                                 
                       Statements For The Record

                         DAVID J. SHULKIN, M.D.
    The Honorable Brad Wenstrup
    Chairman
    House Committee on Veterans' Affairs
    Subcommittee on health
    United State House of Representatives

    Washington, DC 20510

    Dear Mr. Chairman:

    The agenda for the House Committee on Veterans' Affairs' 
Subcommittee on Health September 26, 2017, legislative hearing included 
the draft bill to make certain improvements in VA's Health 
Professionals Educational Assistance Act, for which the Department of 
Veterans Affairs (VA) was unable to provide views in our testimony. We 
are aware of the Committee's interest in receiving this information. 
The enclosure expresses VA's views on this legislative initiative.
    We appreciate the opportunity to comment on this legislation and 
look forward to working with you and the other Committee Members on 
these important legislative issues.

    Sincerely,

    David J. Shulkin, M.D.

    Enclosure

Draft Bill, to amend title 38, United States, Code, to make certain 
    improvements in the Health Professional Educational Assistance 
    Program of the Department of Veterans Affairs, and for other 
    purposes

    Section 2 of the draft bill, would require the VA to offer 50 
scholarships to physicians and dentists in return for a service 
obligation to practice at a VA facility.

    Section 3, would amend the Health Educational Assistance Programs 
to include the Specialty Education Loan Repayment Program (SLERP), an 
education loan repayment program to attract physicians who are eligible 
for board certification in medical specialties that are difficult for 
recruitment and retention for employment in the VA.

    Section 4, would require the VA to offer 10 additional scholarships 
to Veterans attending a Teague Cranston Medical School in return for a 
service obligation to practice at a VA facility.

    VA supports sections 2 and 4, subject to the availability of funds, 
as this is an excellent opportunity to recruit providers to fill 
critical vacancies throughout the VA. VA estimates the cost for 
sections 2 and 4 would be $45 million over five years and $98 million 
over ten years.
    VA supports the intent of section 3, but would like to work with 
the Committee to further clarify the scope to enhance existing programs 
and develop new programs to meet the hiring needs of VA. As written, 
the language infers that only recent medical school graduates or those 
in their initial year of residency who will not have declared a 
subspecialty would be eligible, limiting VA's ability to attract more 
experienced providers who would be eligible sooner. Furthermore, the 
maximum award amount exceeds the maximum award amount authorized under 
the Education Debt Reduction Program (EDRP), 38 U.S.C. Sec.  7683, 
which limits education debt reductions payments to$24,000/year, not to 
exceed $120,000). This creates disparity between physicians currently 
employed within the VA or those eligible for permanent appointment and 
recent medical school graduates or residents with less experience, 
giving those with fewer qualifications a larger reimbursement.
    VA is unclear regarding the eligibility requirement of ``[who are 
eligible to be board-certified]'' and the requirement that program 
candidates be ``.hired under section 7401.'' as individuals who have 
recently completed medical school or are in the first year of residency 
would not necessarily be a permanent VA employee.
    Given the existing loan repayment authority for the EDRP, VA 
recommends an alternative approach, such as a stipend program, to 
attract medical residents and fellows with declared specialties (i.e., 
those in the final two years of residency or fellowship) to better meet 
the recruitment and retention needs of VA.
    As written, VA is unable to estimate the costs of this section and 
would welcome the opportunity to discuss further. VA agrees with the 
intent of the draft legislation, however as written this will not 
fulfill the intent of the Committee. VA requests the opportunity to 
have a discussion with the Committee to develop a stipend or other 
program that will meet the intent of the legislation.
    VA appreciates, through the proposed legislation, the opportunity 
to recruit providers to fill critical vacancies throughout the VA.

                                 
                   BLINDED VETERANS ASSOCIATION (BVA)
    Introduction

    Thank you, Chairman Wenstrup, Ranking Member Brownley and members 
of the Health Subcommittee, for the opportunity to participate in this 
hearing. The comments that follow are submitted on behalf of the 
Blinded Veterans Association, (BVA) the only Congressionally chartered 
veteran service organization (VSO) exclusively dedicated to serving the 
needs of blinded veterans and their families. There are several 
significant pieces of legislation under consideration at this hearing, 
and we appreciate the opportunity to comment on them. Our comments will 
focus on three bills in particular: H.R.93; H.R.2225; and H.R.2327.

H.R. 93

    Approximately 400 of BVA's current members are female veterans. 
Most of these veterans are enrolled in the VA healthcare system. Many 
of them have reported experiencing significant hardships due to the 
lack of gender-specific medical services at the clinic where they 
receive their healthcare. These veterans sometimes face insurmountable 
barriers due to the lack of transportation options that would enable 
them to get to an alternate facility where gender-specific treatment is 
available. We, therefore, applaud the introduction of H.R. 93 and would 
welcome the assistance it could bring to some of our female members.

H.R.2225

    Many members and staff of the Blinded Veterans Association, 
including this writer, have experienced firsthand the benefits a well-
trained dog can provide to a person with a disability. Those benefits 
can be life changing. Therefore, we welcome efforts that will give 
veterans with other disabilities opportunities to experience similar 
benefits. Although we believe the sponsors of H.R.2225 intended to 
design a program that could provide such opportunities to veterans who 
struggle with PTSD, we are concerned that the effectiveness of the 
pilot it seeks to establish could be undermined by numerous 
shortcomings in the program's design. There are a number of questions 
crucial to the effectiveness of this program that this legislation 
leaves unanswered. First, although the bill directs the Secretary to 
enter into contracts with entities ``certified in the training and 
handling of service dogs,'' it does not specify what certification will 
be acceptable. We believe this is an important oversight that should be 
clarified. Working with quality training entities from the beginning 
will give this program a greater chance for success. Since other 
programs administered by the VA to support service dogs and their 
handlers require that the dogs be trained by entities with ADI or IGDF 
certification, we would be much more favorable to this legislation if 
it further specified that the entities participating in this program 
must be ADI certified. Alternatively, standards could be specified 
related to the training methodologies, facilities, and dog care 
practices expected of the contracting entities. This would give the VA 
some criteria by which to evaluate entities seeking to participate in 
the program, and determine whether they are likely to produce the 
desired results.
    Another key aspect of this pilot that this bill fails to consider 
adequately involves the dogs. It seems to us that one of the criteria 
contractors should be evaluated on is their ability to provide dogs 
that are likely to be successfully trained to assist veterans 
appropriately. The formal training is only one factor in determining 
that success. How will the dogs be prepared for participation in this 
program? For that matter, this legislation does not even discuss 
provision of the dogs. Is it assumed that contractors will provide dogs 
ready and available for training?
    With regard to the training itself, there is no mention of what 
tasks veterans will train dogs to do, or what tasks the dogs will be 
trained to perform, by participating veterans, as part of their 
therapy. This is a crucial omission, if the intended result is to have 
trained dogs that could be placed with other veterans as working 
service dogs. Activities that can provide veterans with high quality 
therapy may not necessarily also produce well-trained dogs that can be 
placed with other veterans and serve them as service dogs. We believe 
that all of these issues should be addressed in order to provide the VA 
with the greatest chance of designing a successful program. The 
training itself should be designed in a manner that minimizes obstacles 
and maximizes its chances of success. To do this, guidelines as to what 
the VA should look for in training entities should be provided. The VA 
is not currently involved in service dog training, so leaving such 
matters unspecified creates risk of unintended consequences, missteps 
by the VA and ultimately, design flaws that undermine the program's 
ability to achieve its goal of serving veterans. It also undermines the 
department's ability to assess the effectiveness of the program in 
mitigating the veterans' disabilities.
    It is also unclear whether this legislation anticipates that the 
veterans who receive training will then be utilized as trainers by the 
contracting entity during the pilot, or whether it anticipates an 
additional phase of the program, established in the future, to give 
these veterans an opportunity to utilize their newly-acquired skill. 
Further there are no criteria here for the placement of dogs with other 
veterans, and the nature and scope of follow-up services that will be 
provided to them in order to insure their long-term success after 
training.
    The premise behind this bill, that giving veterans a practical 
means of helping other veterans could restore the mental health of the 
helpers, while assisting additional veterans, is laudable. However, we 
are concerned that the program, as currently designed, is fraught with 
myriad opportunities for things to go wrong that could undermine the 
program's chances for success. It will also be difficult for VA to 
assess the effectiveness of this program. We applaud the intent to get 
help to veterans as quickly as possible in order to try to avert crises 
that could otherwise occur, and we acknowledge the possibility that 
this help could come in the form of a partnership with an animal begun 
through a program such as this, we worry that the concern for creating 
those partnerships as soon as possible could undermine the success of 
those partnerships long-term. That being said, we would welcome an 
opportunity to work with the offices of Rep. Stivers and Rep. Walz, and 
other co-sponsors of this legislation, to address these issues. It is 
our hope that the concerns that we believe currently undermine the 
effectiveness of this bill can be remedied, so that a program that 
gives additional veterans access to the benefits of partnership with 
service dogs will follow.

H.R. 2327

    There are many aspects of this bill that the Blinded Veterans 
Association both welcomes and supports. However, once again, we have 
several questions and serious concerns about the feasibility of the 
project, as set forth in this legislation.
    First, the general concern we have is with the offset being 
proposed to fund this pilot. It is our understanding that VA's Office 
of Human Resources is currently under staffed. Additionally, Secretary 
Shulkin has been talking about department-wide efforts to ramp up 
recruitment of personnel to deal with shortages of medical personnel 
throughout the VA healthcare system, particularly within the mental 
health field, whose professionals provide much-needed services to the 
same veterans the authors of this bill are trying to help. We wonder 
what impact reductions in funding for the VA Office of Human Resources 
will have on that office's ability to provide administrative support to 
VA's recruitment efforts.
    The design of the pilot program itself looks reasonable. It is our 
position that good training for both dogs and their users is essential 
to the success of their partnership. We are not certain how well 
developed the best practices are for training of dogs to assist people 
who have PTSD, but there are well established standards of dog behavior 
that should be included in any service dog training curriculum and we 
are pleased to see them included in the requirements for covered 
facilities here. The rush to get people paired with dogs as quickly as 
possible, in hopes of mitigating their disability's negative impact on 
quality of life is laudable and, we believe, generally well 
intentioned. But we hope this will not be done at the expense of 
careful and thorough training for both the dogs and their recipients. 
To compromise here could add significantly to, rather than relieve an 
individual's stress. It can and has also caused injuries to veterans, 
dogs, and members of the public who inadvertently get caught up in 
situations involving misbehaving, frightened or aggressive dogs.
    Finally, we have some concerns about whether VA has the capacity to 
administer a program of dog training and placement, such as the one 
called for in this legislation. We worry that the process of 
determining whether a facility and/or a veteran, is eligible to 
participate in this program might be more involved than this 
legislation appears to anticipate. It could easily require more than 
making sure all the boxes are checked and all the right documents are 
attached to the applications. Does the VA have staff with the expertise 
to make these determinations beginning in 2018? Do the bill's authors 
envision that some of the monies appropriated for this program would be 
used to hire additional staff with the expertise to process these 
applications? To make certain facilities are what and who they claim to 
be? If someone falls short and doesn't follow through, will VA have the 
capability of tracking and trying to redress the situation?
    I raise the questions above because VA is already having trouble 
communicating and consistently enforcing the policies they have in 
place with regard to service dog access. We have received numerous 
reports over the past couple of years of incidents involving apparently 
untrained, or poorly trained dogs on VA property who act aggressively 
toward VA employees, veterans who accidentally get too close to the 
dog, or the service dogs of veterans with disabilities. Several of our 
members have reported to us that they have been forced by repeated 
encounters with aggressive dogs at VA medical centers to leave their 
service dogs at home when they must go to those facilities for care. 
Unfortunately, many of these dogs are presented to VA personnel as 
service dogs who are needed by the person bringing them to the facility 
to mitigate PTSD. Frequently, front line personnel are not equipped to, 
or don't feel that they can, make a judgment as to whether an animal's 
behavior is sufficiently inappropriate to deny access. Security and law 
enforcement personnel who are called in response to incidents of dog 
misbehavior commonly ignore it or claim there's nothing they can do. 
Nobody wants to be the ``bad guy'' and risk wrongfully denying access 
to a service dog, even though both the VA policy and the ADA 
regulations clearly give agency and business operators the authority to 
remove out-of-control or disruptive animals from their premises. We met 
with Dr. Alaigh and other VHA leaders last month to discuss this 
growing trend and ask the under-secretary to initiate a review of both 
the current department policies and the means by which those policies 
are communicated to VA personnel. We hope this will encourage the VA to 
take action to clarify the access rights of service animal users, 
regardless of disability, as well as the enforcement tools available to 
security personnel who have reason to believe that a dog is being 
fraudulently presented as a service animal or who encounter a dog that 
is not under the control of its handler and poses a danger to other 
people on the premises. This should include the standards of good 
public behavior that the law allows the VA to expect as well as the 
enforcement options that can be exercised when animals, or their 
handlers, do not comply with those standards.
    In summary, while we appreciate the intent of this legislation, and 
we believe this program is a good one, we are not convinced that the VA 
has the capacity to carry out this program in the manner prescribed, or 
the funds to cover the cost of the program, within the time frame set 
forth in the bill.

Conclusion

    Each piece of legislation discussed above seeks to address critical 
issues faced by a significant number of veterans today. We appreciate 
the efforts of the bills' sponsors to address these critical issues, 
and we appreciate the opportunity to discuss these issues with the 
members of the Health Subcommittee. We hope this is the beginning of 
continuing dialogue on this legislation, and will look forward to 
working with committee members and staff to further address these 
issues and help the VA find innovative ways to provide critical 
assistance to veterans who have PTSD and post-deployment mental health 
conditions.

                                 
                    DISABLED AMERICAN VETERANS (DAV)
                           SHURHONDA Y. LOVE
                ASSISTANT NATIONAL LEGISLATIVE DIRECTOR
    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 offer our views on the bills under 
consideration by the Subcommittee.
   H.R. 93, a bill to provide increased access to VA care for women 
                                veterans
    This bill seeks to improve access to Department of Veterans Affairs 
(VA) medical care for women veterans by ensuring that gender-specific 
health care services are available at every medical center and 
community-based outpatient clinic of the Department. It provides that 
the Secretary, in consideration of women veterans' increased demand for 
services and the projected growth in the population, may employ 
personnel, or enter into such contracts as necessary to ensure 
comprehensive gender-specific care is available to women veterans in 
accordance with Veterans Health Administration (VHA) quality standards.
    The number of women serving within the United States military 
continues to rapidly increase. Women now comprise 15.5 percent of 
active duty military, and 19.0 percent of the National Guard and 
Reserves. As more women serve within the military, the number of women 
seeking care from VHA will also grow. From 2005 to 2015, the number of 
women enrolled in VA health care increased by 83.9 percent, translating 
into more than 400,000 users of VHA care. With more than two million 
women represented within the total veteran population, and the women 
veterans' population projected to grow by 18,000 per year for the next 
10 years, it is vitally important that VA is prepared to meet their 
unique health care needs now and in the future.
    Currently women veterans between the ages of 18 and 44 make up 
approximately 42 percent of women users of VHA. This age group 
represents a population of women within child bearing years that may 
require maternity care. Women require routine breast care and 
gynecological services throughout their lives; therefore, it is 
important that VA is prepared to care for these women now and as they 
age. Yet, in a recent Government Accounting Office report (GAO-17-52), 
VHA data from fiscal year (FY) 2014 and 2015 shows about 27 percent of 
VA medical centers and health care systems lacked an onsite 
gynecologist.
    DAV understands that some facilities may not have enough women 
veterans seeking care to warrant a full time gynecologist onsite, but 
it must have policies and procedures in place to ensure women seeking 
care are able to receive the gender-specific services they need from a 
qualified health care provider either in VA or in the community.
    In addition to ensuring women veterans have access to gender-
specific care, like gynecology and other specialty services, women 
veterans must also have access to primary care physicians that have 
expertise in women's health. VHA Directive 1330.01, states that each VA 
medical facility must ensure eligible women veterans have access to 
high-quality, equitable, comprehensive medical care that includes but 
is not limited to primary care. However, GAO points out 18 percent of 
VA facilities are unable to provide women with a primary care provider 
who is specially trained in the care of women.
    In cases where VA is unable to provide health care services to 
women veterans, the Veterans Choice Program is used to purchase care in 
the community. Based on data contained in the GAO report, women 
veterans utilize more non-VA outpatient care than men, which is 
consistent with the inability to obtain basic gender-specific care, 
forcing them out of VA to receive care in the community. However, 
whenever possible we want women veterans to have the opportunity to get 
their care in VA so they are afforded access to VA's specialized 
services for veterans such as treatment for post-traumatic stress 
disorder (PTSD), sexual trauma, and war-related injuries. Veterans 
using VA care are frequently asked if they need supportive services for 
homelessness or post-deployment mental health challenges such as 
substance use disorder (SUD) or suicidal ideation. We want to ensure 
women veterans also have access to this unique and specialized care 
whenever possible. If care must be obtained from community providers, 
there must be a plan to provide a seamless transition for that care.
    DAV is pleased to support H.R. 93, which is consistent with DAV 
resolutions 128 and 225, adopted at our most recent National 
Convention. These resolutions call on VA to furnish quality primary 
health care and gender-specific services necessary to meet the needs of 
a growing population of women veterans, and to ensure that the 
provision of health care services and specialized programs are 
inclusive of gender-specific services. These services must be provided 
to the same degree and extent that services are provided to eligible 
male veterans.
           H.R. 501, VA Transparency Enhancement Act of 2017
    This measure would require increased reporting regarding certain 
surgeries scheduled at VA medical facilities.
    We note VA is not exempt from reporting hospital-acquired 
infections in VA hospitals in its annual Facility Quality and Safety 
Report. The first of such reports containing details at the VA facility 
level was issued in 2008. Moreover, subsequent to this bill's 
introduction, VA made available to the public through its website those 
measures, analysis and comparison on those aspects of health care 
quality and patient safety this bill requires and many other quality of 
care measures applicable for all its VA facilities.
    More specifically, the results of Healthcare Associated Infection 
measures and Surgical Complications based on Agency for Healthcare 
Research and Quality (AHRQ) Patient Safety Indicators (PSIs) for VA 
facilities can be found here: http://www.accesstocare.va.gov/
Healthcare/HospitalCompareData. As an example, information for Ann 
Arbor VA Medical Center is here: http://www.accesstocare.va.gov/
Healthcare/HospitalData/506
    While DAV has no resolution to support the particular approach 
proposed by this legislation, we urge the Subcommittee to consider 
focusing the resources and efforts that would otherwise be needed to 
meet these reporting requirements towards directly addressing veterans 
medical care needs as well as identifying and correcting known 
deficiencies at VA facilities.
             H.R. 1063, Veteran Prescription Continuity Act
    This measure would amend the FY 2016 National Defense Authorization 
Act (NDAA) to direct VA to furnish an individual, who is transitioning 
care settings from the Department of Defense (DoD) to VA, any 
pharmaceutical agent not included in the joint uniform formulary if a 
DoD health care provider determines that the pharmaceutical agent is 
critical for the transition.
    We urge the Subcommittee to strengthen this bill with regards to 
section (c)(2)(B). Specifically, the proposed language does not 
recognize or provide for consideration of a holistic, patient-centered 
approach for changing or discontinuing medications.
    DAV recognizes chronic and severe pain as one of the most prevalent 
reasons individuals, including wounded, injured and ill veterans, seek 
health care and that chronic pain is closely linked with depression and 
other mental health challenges, including suicidal ideation.
    The delegates to our most recent National Convention adopted 
Resolution No. 116, which highlights the failure of some VA providers 
to adhere to Department's own Pain Management Opioid Safety Guide. This 
guide calls for certain resources such as ``[i]ncreased options for 
monthly (or more) face to face and/or Telehealth visits, case 
management and a structured communication between primary care (or 
whoever is tapering the opioids) and mental health or SUD clinicians'' 
be in place when a VA clinician decides to taper or discontinue 
opioids.
    All too often we hear from veterans these supportive resources are 
not offered or provided to veteran patients when their pain medication 
is significantly reduced or abruptly discontinued. This paternalistic 
approach that harms severely ill and injured DAV members as well as the 
patient-provider relationship may be reinforced by section (c)(2)(B) of 
this bill or the lack of a provision requiring a patient-centered 
holistic approach.
    For example, in VA's Pain Management Opioid Safety Guide, 
healthcare providers are cautioned when ``[a] decision is [made] to 
taper opioids, the pace of opioid taper should be individualized with a 
risk benefit analysis.''
    Our resolution calls for, among other things, pain management that 
ensures severely disabled veterans with chronic pain who have used 
prescribed pain medications over long periods be managed in a patient-
centered environment, with balanced regard for both patient safety and 
humane alternatives to the use and reduction of controlled substances, 
and while under VA care receive their prescribed medications in a 
timely fashion.
    Mr. Chairman, DAV supports H.R. 1063 as it will be beneficial for 
veterans who have an effective, established medical regimen for 
treatment of psychiatric, pain or sleep issues and for transitioning 
service members whose medications are effective for them. We recommend 
the bill be amended to address medications such as benzodiazepines, 
stimulants and opioids that can be effective in the short-term, but 
detrimental if continued to be taken in the long-term. We believe VA 
providers should have the option of initiative tapers or changing these 
medications when appropriate but the bill should also propose a 
balanced decision-making process between the clinician and the patient 
when determining which pharmaceutical agent is deemed ``critical for 
such transition'' in a manner that mitigates harm at a vulnerable point 
in the patient's treatment-the space between care settings.
             H.R. 1066, VA Management Alignment Act of 2017
    This bill would require the VA to prepare and submit a report to 
the Senate and House Committees on Veterans' Affairs that details the 
roles, responsibilities and accountability requirements for key leaders 
and offices within the Department. In producing this report, VA would 
utilize the results of the Independent Assessment mandated by the 
Choice Act, the final report of the Commission on Care, and other 
relevant reports related to improving VA's organization and governance. 
The report should also include recommendations for any legislation VA 
considers necessary and appropriate to strengthen its organization, 
management and governance structure.
    DAV does not have a resolution from our membership specific to this 
bill but recognizing that better organization and management of VA 
could improve the delivery of benefits and services to veterans, we 
have no objection to its enactment.
 H.R. 1943, Restoring Maximum Mobility to Our Nation's Veterans Act of 
                                  2017
    This bill seeks to expand the term ``wheelchair'' to include 
enhanced power wheelchairs, multi-environmental wheelchairs, track 
wheelchairs, and other power-driven mobility devices. It further seeks 
to ensure that a veteran prescribed a wheelchair under the provisions 
of this bill due to a service connected disability receive any chair 
that restores the maximum achievable mobility and function in their 
activities of daily life, employment, and recreation.
    VHA provides care to thousands of veterans who require wheelchairs 
due to disabilities, age or infirmity. For these veterans, wheelchairs 
are an extension of the body that restore functionality, enhance 
independence, and even allow them to engage in preferred recreational 
activities. VA research and clinical experience show that physical 
activity is important to maintaining good health, speeding recovery and 
improving overall quality of life. Wheelchairs, for persons with 
disabilities who have lost the ability to ambulate on their own, allow 
many veterans to freely participate and engage actively with their 
families and in their communities, and are critical to overall 
wellbeing.
    Younger veterans, and veterans that are active in rehabilitative 
sports, or outdoor activities may require the use of more than one type 
of wheelchair to maintain or enhance their quality of life. These 
veterans should have every opportunity to receive the type of 
wheelchair appropriate for the activities in which they participate. 
Some veterans may require multiple chairs in order to navigate 
different terrain such as beaches or wooded areas, just as veterans 
with lower limb amputations may require different prosthetic devices to 
shower, swim or run. The preventive and therapeutic value of sports, 
fitness and recreation, are key factors in VA's extensive 
rehabilitation program. Participation in recreational activities is 
also beneficial to veterans helping many to overcome or mitigate the 
physical and emotional impact of severe disabilities.
    H.R. 1943 is in line with DAV Resolution No. 178, which calls for 
VA to deliver high quality cutting-edge prosthetic items to help 
injured, ill and wounded veterans recover, regain mobility and achieve 
maximum independence, to the extent possible, in all areas of their 
life. While assuring veterans of the highest quality wheelchairs and 
prosthetics in accord with their individual needs, VA must also access 
and assure veterans' safety. We believe that all specialized devices 
should meet appropriate and similar standards and criteria for FDA-
approved wheelchairs. There may be some instances in which a veteran 
requests a wheelchair that has not been FDA approved. The request for 
prescriptions for such wheelchairs should be determined on a case-by-
case basis.
                H.R. 1972, VA Billing Accountability Act
    This measure would require VA waive a veteran's copay requirement 
if, due to an error by the Department, its copayment notification was 
received by the veteran after 120 days from the date the veteran 
received VA medications, hospital care, nursing home care, or medical 
services.
    As the Subcommittee is aware, VA's antiquated systems supporting 
collections for first-party copayments and third-party reimbursements 
requires manual intervention making the process prone to human error. 
VA's Consolidated Patient Account Centers must rectify these mistakes 
and subsequently bill co-payments weeks to months after veterans 
receive care.
    We support the intent of this legislation based on DAV Resolution 
No. 115, which calls for legislation to eliminate or reduce VA health 
care out-of-pocket costs for service-connected disabled veterans.
    In addition, we urge the Subcommittee to further strengthen this 
important bill by including a provision to extend the waiver to VA-
furnished extended care services under title 38, United States Code, 
Section 1710B.
      H.R. 2147, Veterans Treatment Court Improvement Act of 2017
    This measure requires the VA to hire additional Veterans Justice 
Outreach (VJO) specialists to ensure veterans have greater access to 
effective and tailored treatment. VA created the VJO program to engage 
justice-involved veterans in specialty treatment courts and provide 
timely access to VA's specialized services. The veterans' treatment 
court model removes veterans from the regular criminal justice process 
and helps to address conditions that are prevalent among veterans, 
including traumatic brain injury, PTSD, and SUDs. In a veterans' 
treatment court, the presiding judge works alongside the veteran and 
the VJO specialist to establish a structured rehabilitation program 
that is tailored to the specific needs of that veteran.
    The bill would authorize $5.5 million for each fiscal year 
beginning in FY 2017 through 2027 to hire a minimum of 50 additional 
VJO Specialists. Funding priority would be given to VA facilities that 
work with newly established or existing but understaffed veterans' 
treatment courts. VA would be required to annually report on the 
implementation of the bill and its effect on the VJO program. The 
Government Accountability Office is also required to review and report 
on the implementation of the bill and the overall effectiveness of the 
VJO program for justice-involved veterans.
    DAV supports H.R. 2147 based on DAV Resolution No. 105, calling for 
the continued growth of veterans' treatment courts. We recognize the 
importance of this unique program as years of experience from the 
veterans' courts now in existence nationwide has produced a 
statistically significant reduction of recidivism rates among veterans 
compared to persons in other treatment courts and individuals not 
involved in any sort of alternative or diversionary treatment options. 
We also recognize that veterans in general deeply value their military 
experiences and share a unique bond with their peers. In our opinion, 
veterans' treatment courts build upon this bond by enabling veterans to 
proceed through the treatment court process with people who are 
similarly situated and by pairing veterans with veteran mentors. We are 
pleased to inform you that DAV members across the country strongly 
support this program and many volunteer to serve as mentors.
    We hope this measure receives favorable consideration, and ask the 
Subcommittee to further strengthen this bill. We join with other 
organizations who have voiced concern for section 2(e) of the bill that 
calls for the identification of offsets to fund the increase in VJOs. 
We believe that Congress should appropriate new funds rather than 
reallocate funds that may adversely affect other programs and/or 
benefits currently utilized by ill and injured veterans.
    Further, the DAV has concerns with section 2(f)(3) of the bill that 
defines the ``local criminal justice system'' as law enforcement, 
jails, and state and local courts. This limits the scope of the bill 
and precludes Federal Courts such as the Judicial District Veterans 
Courts. These Federal court cases make up 2.2 percent of the overall 
veteran cases in our justice system. Therefore, we ask that the bill be 
amended to include Federal courts so that all justice-involved veterans 
can be served by the program.
    Finally, we urge that a provision be added in section 2(d)(2)(B) of 
this bill, which currently directs the Government Accountability Office 
to submit to Congress a report on the implementation of this section 
and the effectiveness of the Veterans Justice Outreach Program. We 
suggest the report should include an evaluation of the sufficiency of 
VJO staffing levels in meeting current demand and the impact of 
existing staffing levels on the effectiveness of the program.
    DAV thanks the bill sponsor for his strong advocacy on behalf of 
justice-involved veterans and we are committed to working with all 
interested parties to enact this important measure.
              H.R. 2225, Veterans Dog Training Therapy Act
    This bill would require the Secretary of Veterans Affairs to 
establish a five-year dog training therapy pilot program, with one or 
more non-governmental entities certified in the training and handling 
of service dogs. The pilot would assess the effectiveness of addressing 
post-deployment mental health and PTSD symptoms through the training of 
service dogs for veterans with disabilities.
    The Center for Compassionate Innovation, in collaboration with 
Recreation Therapy Services of the Department, under the direction of a 
certified recreational therapist with sufficient administrative 
experience, would help oversee the program. It would also establish a 
new director of therapeutic service dog training.
    The measure mandates the pilot program be located in close 
proximity to at least three but not more than five medical centers of 
the Department. The Secretary would provide, to the one or more non-
government entities entering into contract, access to a training area 
in VA that is appropriate for educating veterans with mental health 
conditions, in-service dog training and handling through lecture and 
hands-on experience. Each contract awardee would be required to: employ 
at least one person with clinical experience related to mental health; 
ensure participating veterans receive training from certified service 
dog training instructors; include practical hands-on training and 
grooming of service dogs; and ensure that each service dog 
participating in the training pilot program is taught all essential 
commands for service dogs. In hiring dog trainers, awardees would give 
preference to veterans who have successfully completed PTSD treatment 
and who are certified in service dog training.
    Pilot program participants could include veterans who are enrolled 
in VA's Compensated Work Therapy (CWT) program and the Secretary would 
be required to determine if veterans would be selected or volunteer for 
participation in the dog training pilot program.
    Additionally, the Secretary would be required to collect data to 
determine the effectiveness of the program by assessing the reduction 
of stress associated with a veteran's PTSD, including the improvement 
of emotional regulation, and other standard measures. VA would also be 
required to submit a report to Congress not later than one year after 
the commencement of the pilot program, and each year thereafter, to 
include information about the number of veterans participating in the 
program; services provided in the program; and measures to demonstrate 
effectiveness of program in improving participants' PTSD 
symptomatology, family dynamics, pain management, and general 
wellbeing. In addition, the Secretary would be required to make a 
recommendation to Congress about extending or expanding the pilot 
program.
    Although DAV has no specific resolution approved by our membership 
relating to the training of service dogs that would authorize DAV to 
formally support this measure, we recognize that many veterans report 
that service animals have immensely improved their quality of life by 
promoting their recovery, helping them reestablish their independence 
and assisting them to better cope with stressful situations and 
facilitate reintegration into their communities. For these reasons, we 
have no objection to the passage of this bill.
    However, VA's Cooperative Studies Program is currently overseeing 
comprehensive multi-site research on the benefits of service dogs, to 
determine the efficacy of the types of therapy in improving activity 
and quality of life for veterans with PTSD. We understand this research 
is due to be completed in April of 2020. While we would like to ensure 
the effectiveness of trained therapy dogs for veterans with mental 
health conditions before VA makes significant investments in training 
or acquiring and maintaining service dogs for veterans, DAV is 
supportive of innovative non-traditional therapies and expanded mental 
health treatment options for veterans in accordance with DAV Resolution 
Nos. 019, 128 and 245.
 H.R. 2327, Puppies Assisting Wounded Servicemembers Act of 2017 (PAWS 
                              Act of 2017)
    If enacted, this bill would create a five-year pilot program and 
pair eligible veterans suffering from the most severe levels of PTSD 
with service dogs. Participants would be required to be enrolled in the 
VHA and have a medical determination by a Department health care 
provider, indicating that the veteran may benefit from having a service 
dog. Participants must have completed a course of evidence-based 
treatment for PTSD, yet remain significantly symptomatic prior to 
entering the program. Once approved for participation in the pilot, 
veterans would then be referred to an accredited dog assistance 
organization to be paired with a service dog.
    Service dogs must pass the American Kennel Club Community Canine 
Test and the Assistance Dogs International (ADI) Public Access Test 
prior to placement with the veteran. Follow-up support service for the 
life of the dog, to include a contact plan, should be offered to the 
veteran. If at any point the veteran is no longer able or willing to 
care for the service dog, the organization providing the dog, and the 
veteran shall determine the appropriate course of action.
    Organizations participating in the pilot must be nonprofit 
organizations that provide trained service dogs, certified by ADI. They 
must be able to provide one-on-one training, provide a wellness 
verification from a licensed veterinarian for each dog, and provide an 
in-house residential facility or other accommodations where the veteran 
may stay while receiving training with their new service dog. 
Participating organizations would be provided a grant in the amount of 
$25,000 for each veteran referred to that organization for service dog 
pairing. Offsets from the VA's office of Human Resources and 
Administration (HR), will be reduced for FY 2018 through 2023, by $10 
million per year in support of this pilot program.
    At the conclusion of the five-year program, the Comptroller of the 
United States shall provide Congress a briefing on the methodology 
established for the pilot program, and a report on the results of the 
pilot program.
    While DAV supports the intent of this bill, and recognizes that 
trained guide dogs and other trained service dogs can play a 
significant role in maintaining functionality and promoting maximal 
independence for individuals with disabilities, we are concerned with 
the $10 million proposed offset for FY 2018-2023 from VA's HR 
department. This department is already facing significant difficulties 
in filling critical employee vacancies, and this offset would likely 
impede VA's ability to attract, hire and retain high quality personnel 
necessary to fulfill VA's primary mission; the provision of high 
quality health care and benefits services to veterans.
    Furthermore, as noted above, such a significant investment of 
resources, and funds in a program that has not yet been shown to be an 
efficacious intervention in the treatment of veterans with PTSD may not 
prove to be an investment in the best interest of the veterans it seeks 
to aid. We understand that VA is currently conducting a legislatively 
mandated study at its Palo Alto facility, the Paws for Purple Hearts 
study to determine the efficacy of the use this nontraditional 
application of service dogs, acting as companions to veterans with 
PTSD. DAV encourages VA to complete its current research, and resolve 
the overarching question of whether service dogs are an efficacious 
therapy intervention for veterans with PTSD.
    Finally, DAV notes that only providing service dogs to veterans 
with PTSD, while excluding veterans with other severe mental health 
conditions raises questions of equity to this benefit. DAV's resolution 
019, adopted at our most recent National Convention, calls for VA to 
complete its plan to conduct research and expansion of ongoing model 
programs to determine the most efficacious use of guide and service 
dogs in defined populations; in particular, veterans with mental health 
conditions. While we support the intent of this bill, and have no 
objection to its passage, we do again note our concerns with the 
proposed offset in the legislation.
     Discussion Draft, to make certain improvements in the Health 
         Professionals Educational Assistance Program of the VA
    Mr. Chairman, we were also asked to make any comments on a draft 
bill to improve the Health Professionals Educational Assistance Program 
(HPEAP). DAV recently approved two resolutions that allow us to support 
this draft measure. DAV Resolution 177 specifically supports 
scholarships for mental health practitioners who practice in VHA 
facilities and DAV Resolution 228, which supports effective 
recruitment, retention and development of the VA health care system 
workforce.
    Section 2 of this bill would amend the HPEAP and require the 
Secretary to offer not less than 50 scholarships for physicians and 
dentists when VHA reports staff shortages of at least 500 positions. In 
years in which VHA reports fewer than 500 unfilled physician and 
dentist positions, the Secretary would offer scholarships representing 
at least 10 percent of the vacancies. Professionals awarded these 
scholarships would be required to serve in VHA for 18 months for each 
school year the scholarship was awarded. The Secretary would be 
authorized to give preference to veterans in awarding scholarships. In 
addition, the HPEAP would be extended from December 31, 2019 until 
December 31, 2033.
    Section 3 of the bill would create a new program under Chapter 76-
the Specialty Education Loan Repayment Program. This program would be 
specifically targeted at medical specialties that the Secretary 
determines VHA has difficulty recruiting or retaining providers and 
could be used alone or in tandem with the HPEAP or other tools. The 
program would authorize the Secretary to provide up to $40,000 
annually, for no more than four years, for a total of no more than 
$160,000 per provider to assist with tuition, educational expenses and 
reasonable living expenses. In return it would require the health 
professional to serve in VHA for 12 months for each $40,000 VHA 
provides under the program.
    Section 4 of the bill would establish a pilot program-Veterans 
Healing Veterans Medical Access and Scholarship Program. This program 
would require the Secretary to select two veterans to whom VA would 
award scholarships at each of the five Teague-Cranston medical schools. 
Veterans selected must have been honorably discharged from the military 
within the past decade and be able to meet the requirements for medical 
school admission.
    VA has identified staffing shortages for physicians for many years. 
DAV is aware that VHA requires new recruitment tools to meet increasing 
demand for care as well as quality and timeliness standards. Many VHA 
facilities serve in areas the Health Resources and Services 
Administration has designated as ``health professional shortage areas'' 
or medically underserved areas. VHA medical professional shortages will 
be exacerbated by the estimated 40 percent of the VHA workforce 
expected to retire in the next few years and the national shortage of 
physicians overall. In addition, the federal government has not been 
successful in recruiting younger employees. The recent Commission on 
Care noted that individuals younger than thirty years old accounted for 
only six percent of the federal government's employees as opposed to 23 
percent of the civilian workforce.
    The efficiency of talent management processes in VHA programs has 
also been called into question. VHA loses approximately 13 percent of 
its applicants in the hiring process, which many reports, including the 
Independent Assessment required under the Veterans Access Choice and 
Accountability Act of 2014, have found are slow and cumbersome compared 
to the processes used by many private health care organizations today. 
In addition, government pay rates are often not competitive with the 
private sector.
    There are many reasons VHA struggles with quickly filling critical 
health professional staff positions and all of these issues must be 
addressed if VA is to become the employer of choice. This draft bill 
would provide a way for the Department to attract professionals 
entering into medical careers at the beginning of the production 
pipeline, rather than the end when individuals with highly sought after 
skills have many more options. Use of these tools also requires the 
Secretary and VHA to determine and assess future workforce needs more 
systemically. DAV supports this draft measure, which we believe would 
assist VHA in becoming a more competitive employer of physicians and 
dentists, particularly for providers in scarce medical specialties 
ultimately leading to more timely care of our nation's ill and injured 
veterans.
    Mr. Chairman, this concludes my testimony. DAV would be pleased to 
respond to any questions from you or Subcommittee members concerning 
our views on the bills under consideration today.

                                 
                            JUSTICE FOR VETS
       H.R. 2147 Veterans Treatment Court Improvement Act of 2017
          Statement of Judge Robert Russell, Buffalo, New York
    To Chairman Wenstrup, Ranking Member Brownley, and distinguished 
Members of the Subcommittee, I am honored to have the opportunity to 
submit my testimony in support of H.R. 2147 Veterans Treatment Court 
Improvement Act of 2017 and respectfully request my statement be 
entered into the record.
    In 2007, while serving as presiding judge over the drug court and 
mental health court in Buffalo, New York, I began to see an increase in 
the number of veterans appearing on our dockets struggling with 
substance use disorders, mental health disorders and trauma. Drug court 
is the most successful justice intervention for offenders with a 
substance use disorder and is proven to significantly reduce drug abuse 
and crime while saving money. Mental health courts were established in 
the mid-nineties to apply the drug court model to cases involving 
individuals with an underlying mental health condition. Despite the 
proven success of these interventions, I became concerned that not 
enough was being done to connect veterans in crisis with the 
appropriate treatment and services.
    One day during our mental health court docket, I called the case of 
a Vietnam veteran who, to that point, had not been progressing in his 
treatment or with the help being offered by the court, and who 
struggled to communicate with the court team. In a moment of 
exasperation, I asked one member of my staff and a county employee, 
both Vietnam veterans, to go out in the hall and talk to him. The three 
Vietnam veterans met for over thirty minutes. The next time I called 
the case, the man walked up to the bench, stood at parade rest, and 
held his head high. I asked him if he had any comments, and he looked 
me in the eye and said yes, he would try harder and would work with the 
court and treatment.
    This profound experience became the inspiration for what would 
become the first veterans treatment court in the nation. It helped us 
recognize two things. First, the camaraderie that exists between men 
and women who served in the military can be motivational and 
therapeutic. Surrounding veterans with other veterans is crucial to 
breaking through the warrior mentality that can make accepting help 
difficult. Second, it is critical to link veterans with the specific 
resources they earned through their service and which are uniquely 
suited for their individual needs.
    Together, my staff and I decided that more must be done to serve 
our justice-involved veterans. I went to our local VA medical hospital 
and asked the director if they would allow a staff person to come to 
our court so they could immediately engage with veterans coming through 
the program. I told him our program could refer veterans to treatment 
at the hospital, and ensure compliance with said treatment through 
regular court appearances and supervision. He agreed. This became the 
impetus for the Veterans Justice Outreach (VJO) program.

Veterans Treatment Courts

    In January 2008, we launched the Buffalo Veterans Treatment Court. 
This veterans-only docket is an alternative to incarceration for 
veterans whose involvement in the justice system is rooted in a 
substance use or mental health disorder, often both. While maintaining 
the traditional partnerships and practices of our highly successful 
drug court - judge, prosecutor, defense, probation, law enforcement, 
case manager - the veterans treatment court interdisciplinary team 
includes representatives from the Department of Veterans Affairs - 
including the Veterans Health Administration and the Veterans Benefit 
Administration - as well as State Department/Commission of Veterans 
Affairs, Vet Centers, community mental health and substance use 
treatment providers, veterans service organizations, and volunteer 
veteran mentors.
    Veterans in the program receive structure, supervision, and 
treatment surrounded by other veterans and being connected to veteran 
specific local, state and federal resources.
    Almost immediately after launching our program, we became inundated 
with requests from other jurisdictions seeing the same increases of 
justice-involved veterans. This was the beginning of a movement that 
has grown to include today more than 350 operational veterans treatment 
court programs serving approximately 15,000 justice-involved veterans a 
year.
    Veterans treatment courts are now considered the most innovative 
and successful intervention for justice-involved veterans diagnosed 
with substance use and/or mental health disorders. Through a 
coordinated effort that promotes accountability, structure, and 
treatment, veterans treatment courts connect veterans in crisis with 
the benefits and services they earned. This approach saves money, 
reduces future crime, and ensures that veterans have the opportunity 
for freedom and recovery.

The Role of the VJO

    Veterans treatment courts simply could not exist without the VA's 
Veterans Justice Outreach program. Approximately 80 percent of veterans 
in the Buffalo Veterans Treatment Court qualify for VA benefits. This 
is consistent with other programs across the country. The VJO 
representative in court helps determine eligibility, assists with 
expediting or following up on the status of a VA Veteran Health 
Identification Card, provides necessary information for placement, 
educates enrolled participants about services that are available, 
provides ongoing support in connecting enrolled participants to 
treatment in the VA healthcare system and/or other community health 
systems and communicates directly with the court to ensure treatment 
referral and engagement - two of the most important indicators of 
treatment success.
    For example, a Marine combat veteran (one-tour Afghanistan/one-tour 
Iraq) enters veterans treatment court after becoming addicted to 
prescription drugs to cope with undiagnosed PTSD. The veteran is 
unemployed and sleeping on friends' couches because his wife has left 
him. He has only been out of the military for eight months and is not 
enrolled in the VA.
    During his first session in veterans treatment court, the VJO 
confirms his eligibility and enrolls the veteran in the VA. The VJO 
schedules the veteran to receive therapy for PTSD and coordinates with 
the court to secure inpatient treatment for his substance use disorder. 
While it ordinarily might take weeks or months for this veteran to 
receive treatment, he is getting help within days. The VJO monitors the 
veteran's progress in treatment and reports back to treatment court 
team weekly. The VJO helps the veteran explore other benefits offered 
through the VA. The veteran receives a service-connection disability 
rating from the VA that helps pay for living expenses. The veteran then 
applies and qualifies for VA's Vocational Rehabilitation and Employment 
(VR&E) and enrolls in college.
    This example is not unique, it is the type of success occurring in 
veterans treatment courts across the country; success that would not be 
possible without the presence of the VA in court.
    Since 2008, I have travelled the country as faculty for Justice For 
Vets, a division of the non-profit National Association of Drug Court 
Professionals dedicated to the training and expansion of veterans 
treatment courts. Justice For Vets has trained more than 227 of the 
more than 350 operational programs nationwide. The comprehensive 
Justice For Vets training brings together all stakeholders necessary to 
implement and sustain a veterans treatment court, including VJO and 
other VA personnel.
    The most common issue we encounter from jurisdictions seeking to 
establish a program is not knowing how to liaise with the VA. In my 
experience, the inability of a jurisdiction to coordinate directly with 
a VJO is the most significant mitigating factor in efforts to create a 
veterans treatment court.
    These concerns are alleviated by the presence of a VJO. 
Unfortunately, many communities do not have access to a VJO, or the VJO 
assigned to their region cannot fully engage with the court due to the 
large area they cover; one VJO in Upstate New York is responsible for 
eight counties alone. The VJO program has been crucial to the growth 
and success of veterans treatment courts and is also one of most 
effective programs at VA.
    The VJO program has one of the highest rates of treatment referral 
and engagement in the VA. A 2014 study of the program states, ``among 
veterans who had a mental health or substance use disorder, 97% entered 
mental health or substance use disorder outpatient or residential 
treatment or received pharmacotherapy for alcohol or opioid use 
disorders.[T]he rate of treatment engagement, defined as six or more 
mental health outpatient visits, or six or more substance use disorder 
outpatient visits, or any mental health or substance use disorder 
residential treatment, was 79%.''
    In 2016, the Government Accountability Office recommended the VA 
expand the VJO program to help keep up with demand, which is precisely 
what this bill aims to do.

Justice-Involved Veterans

    It is important to note veterans are incarcerated at significantly 
lower rates than non-veterans, and the number of veterans in jails and 
prisons decreased between 2004 and 2012 (Bureau of Justice Statistics 
[BJS], 2015). But there is a startling lack of data on the intersection 
of veterans and the justice system and too often veterans are not 
identified upon entry to the system or reentry to their community. What 
we do know suggests substance use disorders and mental health disorders 
are a significant factor in justice involvement.
    In March 2014, The Washington Post released a report finding that 
more than half of the 2.6 million American veterans of the wars in Iraq 
and Afghanistan struggle with physical or mental health problems 
stemming from their service, and feel disconnected from civilian life 
(Chandrasekaren, 2014). The RAND Center estimates about 1 in 5 veterans 
of the wars in Iraq and Afghanistan has post traumatic stress disorder 
(PTSD) or significant mental health needs (Tanielian & Jaycox, 2008). 
The Substance Abuse and Mental Health Services Administration (SAMHSA) 
estimates 1 in 15 veterans had a substance use disorder in 2014 
(SAMHSA, 2015).
    Left untreated, these issues put veterans at significant risk for 
involvement with the justice system. Historically, there is no 
comprehensive effort to ensure the justice system responds sufficiently 
to the unique clinical needs some veterans face. Justice-involved 
veterans are scattered throughout the justice system, making it 
difficult to coordinate effective treatment interventions. Until 
veterans treatment courts, the VA had little to no contact with 
justice-involved veterans.

Veterans Treatment Courts: Unprecedented Success

    Veterans treatment courts are now considered the most successful 
intervention for veterans in our justice system. In Buffalo, we have 
`graduated' 240 veterans, with less than 10 percent recidivism rate 
amongst these graduates.
    Nationally, the numbers are just as impressive. Recently, Community 
Mental Health Journal released the first published study on veterans 
treatment courts and concluded participating veterans experienced 
significant improvement with depression, PTSD, and substance use, as 
well as with critical social issues including housing, emotional well-
being, relationships, and overall functioning. The study further 
concluded that veterans who receive trauma-specific treatment and 
mentoring not only experienced better clinical outcomes, they reported 
feeling more socially connected (Knudsen & Wingenfeld, 2016). Much of 
this success can be attributed to the VJO program. A national study of 
more than 22,000 veterans in the VJO program found that veterans 
treatment court participants had better housing and employment outcomes 
as compared to other justice-involved veterans.
    These outcomes are crucial for ensuring long-term success.

The Future

    Veterans treatment courts continue to be the fastest growing 
treatment court model in the United States. Thanks to the rise of 
veterans treatment courts and the role and engagement of VJOs in local 
justice systems, jurisdictions from coast to coast learned the 
importance of identifying veterans at the earliest possible contact 
with the justice system, assessing them for substance use or mental 
health disorders and diverting them to evidence-based treatment. The 
progress is monumental but in order to ensure existing programs remain 
faithful to the veterans treatment court model--and new programs are 
established with the proper policies and procedures in place--training 
and VJO involvement is absolutely necessary.
    Veterans treatment courts combine criminal justice and the VA in a 
way that has never been done. Programs that launch without proper 
training or coordination with the VA run the risk of doing more harm 
than good. Justice For Vets is doing all it can to meet the urgent and 
growing need for training but more support is needed.
    The men and women of the United States military safeguard our 
freedom. It is this nation's collective responsibility to treat the 
wounds-visible and invisible-of those who suffer as a result of their 
service.
    The Veterans Treatment Court Improvement Act of 2017 is a critical 
step in meeting the urgent and growing need, and ensuring out nation 
delivers its promise to our veterans. I want to thank Chairman Wenstrup 
and Ranking Member Brownley for conducting a hearing on this important 
piece of legislation, and urge the swift passage of the bill.

References

    Aos, S., Miller, M., & Drake, E. (2006). Evidence-based public 
policy options to reduce future prison construction, criminal justice 
costs, and crime rates. Olympia, WA: Washington State Institute for 
Public Policy; Carey, S. M., Finigan, M., Crumpton, D., & Waller, M. 
(2006). California drug courts: Outcomes, costs and promising 
practices: An overview of phase II in a statewide study. Journal of 
Psychoactive Drugs, SARC Supplement 3, 345-356; Finigan, M., Carey, S. 
M., & Cox, A. (2007). The impact of a The Bureau of Justice Statistics. 
(2015, December 7). Veterans in Prison and Jail, 2011-2012. Retrieved 
from http://www.bjs.gov/index.cfm?ty=pbdetail&iid=5479

    Aos et al. (2006). Evidence-based public policy options to reduce 
future prison construction, criminal justice costs, and crime rates. 
Olympia: Washington State Institute for Public Policy; Lattimer (2006). 
A meta-analytic examination of drug treatment courts: Do they reduce 
recidivism? Canada Dept. of Justice; Lowenkamp et al. (2005). Are drug 
courts effective: A meta-analytic review. Journal of Community 
Corrections, Fall, 5-28; Shaffer (2006). Reconsidering drug court 
effectiveness: A meta-analytic review. Las Vegas, NV: Dept. of Criminal 
Justice, University of Nevada; Wilson,et al. (2006). A systematic 
review of drug court effects on recidivism. Journal of Experimental 
Criminology, 2, 459-487.

    Chandrasekaren, R. (2014, March 29). Pain and Pride: A nationwide 
poll of Iraq and Afghanistan veterans reveals the profound and enduring 
effects of war on the 2.6 million who have served. The Washington Post. 
Retrieved from http://www.washingtonpost.com/sf/national/2014/03/29/a-
legacy-of-pride-and-pain/

    mature drug court over 10 years of operation: Recidivism and costs. 
Portland, OR: NPC

    Finlay, A. K., Rosenthal, J., Blue-Howells, J., Clark, S., Van 
Campen, J., & Harris, A. H. S. (2015). Veterans Justice Outreach 
Program: Connecting Veterans with Veterans Health Administration Mental 
Health and Substance Use Disorder Treatment [Fact Sheet 2015-000b]. 
Menlo Park, CA: Center for Innovation to Implementation.

    Finley, Andrea K., Smelson, David, Sawh, Leon, McGuire, Jim, 
Rosenthal, Joel, Blue-Howells, Jessica, Timko, Christine, Binswanger, 
Ingrid, Frayne, Susan M., Blodgett, Janet C., Bowe, Tom, Clark, Sean 
C., Harris, Alex H.S. (2014). U.S. Department of Veterans Affairs 
Veterans Justice Outreach Program: Connecting Justice-Involved Veterans 
With Mental Health and Substance Use Disorder Treatment. Criminal 
Justice Policy Review. DOI: 10.1177/0887403414562601.

    Knudsen, K.J. & Wingenfeld, S. (2016) A Specialized Treatment Court 
for Veterans with Trauma Exposure: Implications for the Field. 
Community Mental Health Journal, 52:127.

    Research; Loman, L. A. (2004). A cost-benefit analysis of the St. 
Louis City Adult Felony Drug Court. St. Louis, MO: Institute of Applied 
Research; Barnoski, R,. & Aos, S. (2003). Washington State's drug 
courts for adult defendants: Outcome evaluation and cost-benefit 
analysis. Olympia, WA: Washington State Institute for Public Policy; 
Logan, T. K., Hoyt, W., McCollister, K. E., French, M. T., Leukefeld, 
C., & Minton, L. (2004). Economic evaluation of drug court: 
Methodology, results, and policy implications. Evaluation & Program 
Planning, 27, 381-396.

    National Center for Veterans Analysis and Statistics. (n.d.). 
Veteran Population. Retrieved from http://www.va.gov/vetdata/veteran--
population.asp

    Substance Abuse and Mental Health Administration. (2015, May 7). 1 
in 15 veterans had a substance use disorder in the past year. Retrieved 
from http://www.samhsa.gov/data/sites/default/files/report--1969/
Spotlight-1969.pdf

    Tanielian, T. & Jaycox, L.H. (2008) Invisible Wounds of War: 
Psychological and Cognitive Injuries, Their Consequences, and Services 
to Assist Recovery. Retrieved from http://www.rand.org/pubs/monographs/
MG720.html

                                 
                       MAKE A DIFFERENCE AMERICA
    Wisdom, courage and compassion.

    These three words describe unique attributes of the men and women 
that are and have been members of the armed services of the United 
States of America.
    America's military is the greatest protective force in the world. 
There are many elements that contribute to making our military the best 
including leading edge technology, seasoned leadership and dedicated 
personnel. However, I believe that the overwhelming reason for our 
success is the manner in which we conduct ourselves.
    As American citizens and as Americans in the military, we care 
deeply about the people of the world. No matter what their country, 
origin, culture or tradition, we care. America will never be defeated 
with a military like ours that conducts itself with wisdom, courage and 
compassion. Our military also serves as an ambassador to the people of 
the world. Average citizens in foreign countries learn about America 
through their interaction with our service members. For this reason 
America and its citizens are respected around the world; whether or not 
their leaders agree.
    As citizens, knowing what our military does for us, we want to be 
confident that America is ensuring that our veterans are receiving the 
care that they have earned. Our men and women in the military have 
protected us and when necessary, sacrificed for us. It is our 
obligation to address their concerns even if they say they will ``tough 
it out and not complain''.
    HR1943 was initiated by an average citizen that asked the question, 
``Why are organizations like the Gary Sinise Foundation, Independence 
Fund and Wounded Warriors providing track wheelchairs to our veterans 
with private funds? Shouldn't the VA be providing them?''.
    After talking to members of the House and Senate, it was determined 
that Congress thought that the VA was providing the track wheelchairs 
to our veterans. That conclusion prompted us to commission a research 
project to determine if the VA actually had the authority to provide 
powered track wheelchairs to service-disabled veterans for recreational 
purposes. The research found a statement in the VHA Prosthetic Clinical 
Management Program (PCMP) which states that ``Motorized and power 
equipment or equipment for personal mobility intended solely for a 
recreational leisure activity should not be provided.''
    Now knowing the ``root cause'' for service-disabled veterans being 
denied powered mobility devices for recreational purposes by the VA, we 
had the credibility to approach members of Congress with the facts. 
Once we had the research information organized in a digestible form, it 
wasn't long before Congressman Steve King (IA), a long time veteran 
supporter, agreed that the regulations needed changing and offered to 
introduce our initiative as a bill.
    On April 05, 2017, HR 1943 was introduced by Congressman King. This 
was a great day for our country. HR1943 is not just a bill, it is a 
bill that came about the way our Founding Fathers intended, by citizens 
of our country using the legislative tools we were provided to make 
changes in the law.
    Of course, we are only at the beginning of the process; taking 
little steps at a time. However, it has been a pleasurable experience 
so far and has shown that one citizen can make a difference and 
together there is nothing we cannot change.
    I want to thank the Veterans Affairs Committee for selecting HR1943 
as one of the bills to be reviewed at the hearing scheduled for 
September 26, 2017. This will be one more important step in the process 
of providing changes to our laws that will make the lives of our 
disabled-veterans as whole as possible.

    Dave Meister

                                 
                  PARALYZED VETERANS OF AMERICA (PVA)
                               CONCERNING
                          PENDING LEGISLATION
    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. 93, ``to amend title 38, United States Code, to provide for 
  increased access to Department of Veterans Affairs medical care for 
                            women veterans''
    PVA supports H.R. 93, to amend title 38, United States Code, to 
provide for increased access to Department of Veterans Affairs (VA) 
medical care for women veterans. The bill would ensure gender specific 
services are continuously available at every VA medical center and 
community based outpatient clinic.
    As of 2016, women comprise nearly 10 percent of the total veteran 
population. That percentage is expected to rise. VA has made strides in 
recent years to meet the needs of women veterans, by providing basic 
reproductive health services, preventative screenings and provider 
training on women's health issues. However, nearly a third of VA 
medical centers still lack providers for gynecological services and 
refer women veterans to community providers.
    The great advantage for a patient of the VA health care system over 
other networks in the United States is the care coordination provided 
amongst its comprehensive services. For too many women veterans, their 
care is fractured between their VA medical center, and a bevy of 
community care providers. They have to worry about record sharing, 
prescription data, and if VA will pay the provider on time before 
receiving a bill themselves. For most male veterans at VA, these basic 
health services are quickly and readily available. All veterans deserve 
to benefit from the hallmark of the VA system. The number of women 
enrolling at VA continues to rise. VA must have systems and providers 
in place to address their unique needs. This legislation would require 
VA facilities hire or contract with the needed providers.
         H.R. 501, the VA Transparency Enhancement Act of 2017
    PVA generally supports H.R. 501, the ``VA Transparency Enhancement 
Act of 2017.'' The bill seeks to increase availability of information 
regarding the prevalence of surgical infections, cancellations, and 
transfers. The bill would require quarterly reports to the Committees 
on Veterans' Affairs of the House and Senate, and a public release on 
VA's website. Currently, VA provides the monthly completed and pending 
appointment data from local VA medical facilities. VA does not 
publically release data on rates of infection or cancelled or 
transferred surgeries. Hospitals that receive reimbursement from the 
Centers for Medicare and Medicaid Services (CMS) must report a variety 
of quality measures to the National Healthcare Safety Network, 
including surgical infections. This legislation will bring VA in line 
to be qualitatively compared to the private sector.
         H.R. 1063, the ``Veteran Prescription Continuity Act''
    PVA supports H.R. 1063, the ``Veteran Prescription Continuity 
Act.'' This bill would ensure a service member transitioning from 
Department of Defense to Department of Veterans Affairs while receiving 
medical treatment is able to maintain their prescription regimen if not 
included in the joint uniform formulary.
    Currently, there is no guarantee a patient transitioning to VA can 
be prescribed the same drug as prescribed by DOD. The only exception is 
medication for post-traumatic stress or chronic pain. This bill would 
have VA offer what DOD prescribed until the veteran's provider 
determines it is no longer necessary. This is a logical accommodation 
for a service member in transition. Ensuring there is a seamless 
handoff between systems is of the utmost importance.
         H.R. 1066, the ``VA Management Alignment Act of 2017"
    PVA supports H.R. 1066, the ``VA Management Alignment Act of 
2017.'' This legislation would direct VA to submit to Congress a report 
on the organizational structure of VA and the means to improve such 
structure to improve access to quality care. GAO reports have revealed 
VA has not implemented the recommendations for managerial and 
structural improvement. The report required by this bill would spell 
out the roles and responsibilities for senior staff and organizational 
units within VA and how they work together to promote efficiency and 
accountability, as well as any legislative recommendations to improve 
access to care.
 H.R. 1943, the ``Restoring Maximum Mobility to Our Nation's Veterans 
                              Act of 2017"
    PVA generally supports H.R. 1943, the ``Restoring Maximum Mobility 
to Our Nation's Veterans Act of 2017.'' The bill would amend title 38, 
USC, to require VA to ensure each wheelchair, furnished to a veteran 
with a service connected disability restores the maximum achievable 
mobility in activities of daily living, employment, and recreation. The 
bill would amend `wheelchair' to include `enhanced power wheelchairs, 
multi-environmental wheelchairs, track wheelchairs, stair-climbing 
wheelchairs, and other power-driven devices.' The bill would allow the 
Secretary to furnish a wheelchair to a veteran because the wheelchair 
restores an ability that relates exclusively to participation in a 
recreational activity.
    PVA supports this bill provided such wheelchairs meet all 
International Organization for Standardization (ISO) criteria and FDA 
requirements for wheelchairs. The existing regulations and standards 
will ensure the veteran is using equipment that has been rigidly tested 
to meet all safety, mechanical and software parameters. This is a 
difficult standard for many of the mentioned devices, such as tracked 
vehicles. Our primary concern is the veteran's safety and well-being. 
We would not encourage VA to furnish veterans with spinal cord injuries 
an off road ``wheelchair'' that could roll over. And there are general 
safety concerns for these recreational vehicles and the operation of 
gasoline motors.
            H.R. 1972, the ``VA Billing Accountability Act''
    PVA supports H.R. 1972, the ``VA Billing Accountability Act.'' This 
bill would authorize the Secretary of Veterans Affairs to waive the 
requirement of certain veterans to make copayments for hospital care 
and medical services in the case of an error by the VA. Many VA Medical 
Centers struggle to send billing statements for co-payments to veterans 
in a timely manner. For some veterans this means being sent a bill 
years after the service. H.R. 1972 would mandate that a veteran receive 
their bill within 120 days from receiving care at a VA Medical Center 
and within 18 months if seen at a non-VA facility. Further, the bill 
grants the Secretary the authority to waive the co-payment altogether 
if these billing timelines are not adhered to. If the bill is sent 
after the required time VA must notify the veteran of the option to 
receive a waiver or create a payment plan before the payment can be 
collected. Veterans and their families should not be burdened with 
unknown debts resulting from mistakes in VA's own processes.
   H.R. 2147, the ``Veterans Treatment Court Improvement Act of 2017"
    PVA firmly believes in the rule of law and that anyone convicted of 
a crime should be held accountable. Our criminal justice system, 
though, has long recognized the existence of aggravating and mitigating 
circumstances that play an important role in influencing the 
administration of penalties. While advocacy before a sentencing judge 
following conviction is critical, prosecutorial discretion is also 
vast. Veterans Justice Outreach Specialists can help veterans use their 
honorable service, as well as mitigating circumstances arising from 
that service, to ensure both the prosecutor and judge see more than 
just a rap sheet when making decisions.
    If the specialist demonstrates that the veteran is entitled to 
health care or disability benefits, the judge or prosecutor might be 
able to fashion a sentence or plea offer that incorporates utilization 
of these services in lieu of imposing solely punitive sanctions. It 
could also lead to an outright deferment of prosecution conditioned on 
the veteran exploring and obtaining all services available to him or 
her. This scenario is especially enticing to the judicial system given 
the constant struggle to find resources, particularly for in-patient 
substance abuse rehabilitation programs and mental health care.
    For some veterans, this path might help them avoid being 
permanently stigmatized with a criminal conviction. For others, it 
might be the ticket that lifts them out of homelessness and the 
corresponding criminal recidivism, specifically with petty and/or 
vagrancy crimes. It is no secret that some veterans go years before 
realizing they were entitled to certain benefits that might have helped 
them avoid poverty and dejection. A court order pointing the veteran to 
the Department of Veterans Affairs can sometimes turn into a life-
changing event. At the least, more veterans touched by this program 
will re-engage productively with society. That is a goal worth 
pursuing.
          H.R. 2225, the ``Veterans Dog Training Therapy Act''
    PVA supports H.R. 2225, the ``Veterans Dog Training Therapy Act.'' 
This legislation would require the Department of Veterans Affairs (VA) 
to contract with certified non-government entities to test the 
effectiveness of addressing veterans' post-deployment mental health and 
post-traumatic stress disorder (PTSD) symptoms through training service 
dogs for fellow veterans with disabilities.
    PVA knows that service animals provide tremendous benefits for many 
veterans living with disabilities. The benefits of service animals are 
multi-faceted. Service animals promote independence for veterans with 
disabilities and help them to break down barriers in their communities. 
Many PVA members have personally experienced these benefits.
    ``The Veterans Dog Training Therapy Act'' will allow VA to explore 
potential therapies for veterans with certain mental health issues to 
include training of service animals. Not only could this provide 
additional treatment options for veterans living with PTSD and other 
similar conditions but it will provide highly trained service animals 
for veterans living with disabilities. This pilot program would be 
located at VA medical centers and administered by VA's Center for 
Compassionate Innovation. We believe that this construct will provide 
the conditions that lead to effectively trained service animals for 
veterans with disabilities.
H.R. 2327, the ``Puppies Assisting Wounded Servicemembers (PAWS) Act of 
                                 2017"
    PVA generally supports H.R. 2327, the ``Puppies Assisting Wounded 
Servicemembers (PAWS) Act of 2017,'' to provide service animals to 
veterans who need them. If enacted, this legislation would direct the 
VA to carry out a pilot program to provide service dogs to certain 
veterans with severe post-traumatic stress disorder (PTSD). Service 
animals provide crucial assistance to many veterans living with 
catastrophic disabilities. The benefits of using a service animal are 
multi-faceted. Service animals promote independence and help to break 
down societal barriers. Many members of Paralyzed Veterans have 
personally experienced these benefits.
    Through the PAWS Act, VA will provide grants to service animal 
organizations to assist veterans referred by VA who have PTSD. This 
pilot program will provide service dogs to veterans with PTSD who have 
completed evidence-based treatment for PTSD but who continue to have a 
PTSD diagnosis. We support efforts to increase access to service 
animals for veterans with disabilities. It is our hope that this 
program will be funded. However, we strongly discourage it be done by 
offsetting resources for VA's Office of Human Resources and 
Administration, which could derail VA's efforts to hire and retain 
qualified personnel.
    Additionally, the bill as written does not appropriately reflect 
the fact that the VA currently does not provide service animals to any 
veteran directly. Service animals are provided to veterans by 
organizations responsible for the training and provision of service 
animals, not the VA. The VA currently bares no direct cost when it 
comes to providing service animals. As it is, we are not aware of a 
demonstrated need for VA to be the procurer of service animals. 
Additionally, this bill would have the VA provide service dogs only to 
veterans with PTSD, excluding veterans with other mental health 
conditions and physical disabilities who would also benefit.
    VA provides veterinary health insurance and other ancillary 
benefits to service animals used for veterans with physical 
disabilities. While this bill would make PTSD service dogs eligible for 
existing benefits, (something VA currently has the authority to do) it 
goes a step beyond by charging VA with procuring a trained, capable 
dog. We are concerned that creating a new process to place service dogs 
with veterans with PTSD confuses the process among veterans with other 
needs.
    Draft legislation to ``make certain improvements in VA's Health 
             Professionals Educational Assistance Program''
    PVA supports the draft legislation to make certain improvements in 
VA's Health Professionals Educational Assistance Program. The bill 
would designate at least fifty scholarships to medical or dental 
students. The goal is to award such scholarships until the Secretary 
determines the staffing shortage of these providers is less than 500. 
The recipient of the scholarship agrees to serve as a full-time 
employee in VHA for a period of obligated service of 18 months of each 
school year or part thereof that the scholarship was provided. The bill 
would also establish within VA a Specialty Education Loan Repayment 
Program. The purpose is to incentivize medical residents to work at 
VHA, particularly in specialties where recruitment and retention have 
proven difficult. This bill would allow for the Secretary to waive 
maximum loan repayment caps established under the Specialty Education 
Loan Repayment Program and pay the total amount of the principal and 
interest on a participant's loan. The participant's obligated service 
would be determined on a scale of the amounts repaid. Additionally, 
Section 4 of the bill would establish a pilot program to fund the 
medical education of ten eligible veterans throughout the Teague-
Cranston medical schools.
    Given the critical shortage of health care providers VA must be 
able to pursue the means to recruit and retain new residents. The 
majority of providers at VA and throughout the United States will soon 
retire and there are not enough poised to take their place. And with an 
aging patient population and uncertain healthcare landscape, these 
challenges require quick action
    That potential health care students are reluctant to commit to 
medical school, or new residents are hesitant to take a post in an 
underserved community, should come as no surprise. The cost burden of 
their education and training is an overwhelming prospect and debt is 
all but guaranteed. No matter how eager to serve, or desirous of giving 
back to veterans a new resident may be, a career at an understaffed VA 
may not be a tenable choice. By providing scholarships to cover the 
cost of medical school or paying off loans, in exchange for a period of 
service, VA would become an obvious choice. Removing the financial 
barriers encourages the best and the brightest to make their mark at 
VA. Additionally, such programs would cultivate a culture of commitment 
by those unburdened by debt and revive areas too long stressed by 
continuous shortages. VA must be given the resources to address this 
current and looming crisis. The health and wellbeing of our nation's 
veterans depend on it.

                                 
          VETERANS OF FOREIGN WARS OF THE UNITED STATES (VFW)
                   KAYDA KELEHER, ASSOCIATE DIRECTOR
                      NATIONAL LEGISLATIVE SERVICE
    Chairman Wenstrup, Ranking Member Brownley and members of the 
Subcommittee, on behalf of the women and men of the Veterans of Foreign 
Wars of the United States (VFW) and its Auxiliary, thank you for the 
opportunity to provide our remarks on legislation pending before this 
subcommittee.

H.R. 93, to provide for increased access to Department of Veterans 
    Affairs medical care for women veterans.

    The VFW supports this legislation which would ensure gender-
specific health care services maintain continuous availability within 
Department of Veterans Affairs (VA). It would also authorize VA to 
provide women veterans community care options when VA is unable to 
provide gender-specific care at its medical facilities.
    Estimated to grow to the size of the entire active duty military by 
the year 2030, women veterans are the fastest growing cohort of the 
veterans' community. It is absolutely imperative that VA provides 
necessary access and employ personnel trained to provide gender-
specific health care.

H.R. 501, VA Transparency Enhancement Act of 2017

    The VFW agrees with the intent of this legislation, but has 
concerns with some of its requirements. The VFW firmly believes VA must 
maintain agency transparency and be held accountable when necessary. 
Yet Congress must not put undue burdens on VA. The VFW does not believe 
it necessary to overstretch the already scarce resources it is given, 
which are intended for delivering health care and service to veterans, 
on superfluous reporting requirements.
    Health care associated infections are currently tracked by the 
Centers for Disease Control and Prevention (CDC) National Healthcare 
Safety Network (NHSN). More than 17,000 medical facilities within the 
United States currently submit surgical site infections data for public 
reporting to CDC NHSN for patients who are 18 years old or older. Most 
of this data is transferred by the medical facilities electronic health 
record systems directly to CDC.
    With this in mind, the VFW has concerns with this legislation that 
would require a quarterly report of surgical site infections, as well 
as cancelled or transferred surgeries. First, a quarterly report is 
unnecessarily frequent and unusual when compared to other health care 
systems. Aside from the logistics of preparing a quarterly report--
disseminating and analyzing it--any report made publicly available 
should be posted alongside similar reports of other non-VA facilities. 
This would help keep the information organized and easily comparable to 
the rest of America's health care sector. Also, a report strictly 
showcasing the number of surgical site infections without a comparison 
to the number of total surgeries per surgical site would be unusable, 
except for promoting unintended concern and distrust of VA.

H.R. 1063, Veteran Prescription Continuity Act

    The VFW supports this legislation which would ensure veterans 
transitioning from the Department of Defense (DOD) to VA have access to 
the same medical care and treatment, specifically pharmaceuticals, as 
they did before transitioning out of DOD. Making sure pharmaceuticals 
that are medically necessary and have a crucial effect on the quality 
of veterans' lives are available is an absolute must. Both DOD and VA 
must ensure their formularies match for medications of high prevalence 
and necessity for service members and veterans. This is particularly 
true for pharmaceuticals specific to both chronic pain and mental 
health.

H.R. 1066, VA Management Alignment Act of 2017

    The VFW agrees with the intent of this legislation, but does not 
support it. This bill would require the Secretary of VA to submit a 
report outlining the current organizational structure within VA, and 
how it should strive to work together between different offices and 
departments.
    VA has developed the Functional Organization Manual, which was 
updated this year. This manual covers VA's organizational structure, 
missions, functions, activities and authorities. This legislation would 
require the Secretary to use VA resources for an independent assessment 
striving for the same results, while also specifying how each office 
should work with other offices within VA. This legislation is also 
unclear as to whether it would require VA to evaluate all 300,000 
positions within VA or specifically VA's Central Office. While it is of 
utmost importance that VA continues striving to improve structural 
organization and working relationships within the department, it is 
increasingly redundant to continue demanding reports on already 
conducted studies.

H.R. 1943, Restoring Maximum Mobility to Our Nation's Veterans Act of 
    2017

    The VFW supports the intent of this legislation, but has concerns 
as currently written.
    Members of the VFW have vocalized concerns and barriers faced in 
trying to receive the prosthetics necessary to live functional, high 
quality lives. Whether they need an additional prosthetic limb for 
recreational activities or cultural purposes, veterans have earned 
them. While it may not be rampant, some members who have been fortunate 
enough not to lose a limb still need the assistance of a wheelchair.
    We believe all service-connected veterans in need of wheelchairs 
deserve one from VA. Mobility and functionality are crucial for the 
mental well-being of our nation's veterans. With this said, VA must 
work to ensure all veterans in need of a wheelchair have one which 
meets the requirements of both the International Organization for 
Standardization criteria, as well as the U.S. Food and Drug 
Administration. These regulations standardize requirements to ensure 
veterans are using wheelchairs that have been tested for safety, and 
mechanical and software perimeters.
    While technology keeps improving, it must also continue to meet 
industry standards for the safety of our veterans who are bound to 
wheelchairs. Many new models of wheelchairs do not meet these standards 
and can cost more than a car. Congress must ensure VA resources are 
spent smartly on safe medical equipment.

H.R. 1972, VA Billing Accountability Act

    The VFW supports this legislation to provide the Secretary of VA 
with the authority to waive certain veterans from copayment 
requirements for hospital care and medical services in the case of an 
error by VA.
    At this time, VA has the authority to waive copayment requirements 
for hospital and medical services both inside and outside VA. This 
legislation would codify that authority. While authorizing VA to waive 
debts if VA employees fail to provide timely notice to veterans is a 
step toward the right direction, the VFW would urge the subcommittee to 
require VA to waive debts for veterans when VA is unable to provide 
timely notice. Veterans must hot be held liable because VA sent them 
untimely bills that do not contain information for waivers or payment 
plans.

H.R. 2147, Veterans Treatment Court Improvement Act of 2017

    The VFW strongly supports this legislation which would require VA 
to hire more Veterans Justice Outreach Specialists to provide treatment 
court services to justice-involved veterans.
    According to the most recent data from the Bureau of Justice 
statistics, over 130,000 veterans are incarcerated in state and federal 
prisons, representing approximately eight percent of the total prison 
population. While the VFW realizes veterans who are convicted of crimes 
must suffer the consequences, we also recognize that having veteran 
advocates or individuals to represent them before sentencing and act in 
their best interests is invaluable.
    Increasing the amount of Veterans Justice Outreach Specialists will 
help our justice-involved veterans navigate the legal system, and 
hopefully attain outcomes that are best suited for each individual 
veteran. Also, by providing veterans struggling with legal issues, it 
allows VA and the justice system to more directly assist veterans 
struggling with substance abuse issues related to mental health 
conditions from their service.

H.R. 2225, Veterans Dog Training Therapy Act

    The VFW supports this legislation which would carry out a pilot 
program for dog training therapy at several VA facilities.
    With such a high ratio of veterans who have defended our nation 
being diagnosed with post-traumatic stress disorder (PTSD), VA must 
provide veterans mental health care options that work best for them. 
Recent studies show service dogs provide positive health care outcomes 
in veterans with PTSD. Such studies illustrate a reduction in symptoms 
from the PTSD Checklist, lowered effects of anxiety and depression 
disorders, as well as a reduced need for psychopharmaceutical 
prescriptions. Veterans who have service dogs also experience an 
increased participation in social settings, as well as overall 
satisfaction with life. The VFW supports continued efforts to evaluate 
the efficacy of using service dogs to treat PTSD and other mental 
health conditions. Currently, VA in Oregon has already developed the 
program on which this legislation is modeled. Basing legislation on a 
currently functioning program ensures an easy transition and proper 
implementation of the pilot program in more VA facilities.
    For more than a decade, research into the benefits of providing 
service dogs to veterans struggling with their mental health has 
garnered attention. Given promising research in both the private sector 
as well as VA, VFW members have consistently reported on the benefits 
they experienced from having a service dog.
    This legislation would ensure more veterans are provided the 
opportunity to receive a service dog for combat-related mental health 
conditions. This opportunity would be provided at a VA medical center, 
administered by VA's Center for Compassionate Innovation, with 
experienced and qualified staff training the dogs and veterans. 
Veterans would not need to travel for this benefit, and they would have 
access to VA's veterinary insurance. It would also have the potential 
to advance and positively affect ongoing studies of service dogs by 
collecting essential data. Many studies and anecdotal notes have found 
veterans with service dogs decrease their use of medications such as 
opioids for chronic pain linked to PTSD. This collection of data would 
be invaluable in knowing the likelihood of medication decreases, 
emotional well-being and improvements of service dog owners as well as 
sleep patterns.

H.R. 2327, Puppies Assisting Wounded Servicemembers Act of 2017

    The VFW supports the intent of this legislation. This legislation 
would provide grants to eligible private sector organizations to 
provide service dogs to veterans with severe PTSD.
    Studying the benefits of providing service dogs to veterans 
struggling with mental health disorders after the military is 
absolutely crucial. With that said, the VFW knows that not all combat 
veterans return home with PTSD. There is a wide range of behavioral 
health issues veterans may struggle with, from mental illness to 
psychosocial disorders. This pilot program would limit access to 
service dogs only for veterans with severe PTSD. These veterans would 
have to travel for their service dog training, which would be 
reimbursed by VA. While this is not always a barrier, travel outside VA 
may be a barrier to some veterans. Legislating that the pilot must be 
performed by private organizations outside VA adds a possible barrier 
to veterans in need. This legislation would also only require one 
report within nine months of the pilot program ending. This would limit 
the ability of VA and Congress to oversee the progress and benefits of 
the outcomes for participating veterans. Also, with more than 40,000 
employment vacancies within VA, the VFW is concerned this legislation's 
offset could have unintended consequences for VA's Human Resources 
trying to fill those much needed positions.
    The VFW strongly supports the continuance of care this legislation 
would require to maintain eligibility of canine health insurance. 
Continuance of care is crucial to successfully overcoming any illness, 
whether it is physical or mental. With VA only maintaining coverage of 
the service dogs if the veteran continues to see their physician or 
mental health care provider at least once a quarter--unlike other 
service dog bills--this legislation would ensure more consistent and 
open communication between the medical provider and veteran.

Draft Bill, to make certain improvements in VA's Health Professionals 
    Educational Assistance Program.

    The VFW Supports the draft legislation and has recommendations to 
improve it, which we hope the subcommittee considers before advancing 
it.
    This legislation would make improvements to scholarship and 
educational assistance programs provided by VA in an attempt to address 
provider shortages within the department. These position vacancies in 
VA must be properly addressed, and the VFW supports the idea of 
providing education incentives to attract more high quality VA 
employees. Section 2 of this draft bill is specific in designating 
scholarships specifically for physicians and dentists. There is zero 
doubt VA needs physicians and dentists, but this section must include 
scholarship opportunities for psychologists and students working toward 
their Master of Social Work. The entire country has a shortage of 
mental health care providers, and psychiatrists are not the ones 
providing talk therapy and the majority of mental health testing/
screening for patients. By not including psychologists and therapists 
in section 2, this legislation would be proving a disservice to VA in 
the form of not addressing veterans' mental health needs and access to 
care.
    The second alarming issue the VFW has concerns with is in Section 
4. This section would provide a full-ride scholarship to certain 
veterans who qualify and choose to attend a Teague-Cranston medical 
school. This scholarship is not tied to any other education benefit 
eligibility for title 38 or title 10 of the United States Code. Yet 
this legislation specifically shuns certain veterans with bad paper 
discharges. Eligible veterans would only include those discharged not 
more than 10 years before they apply, and only those with an honorable 
or a general discharge. The VFW firmly believes this criteria must be 
more open and inclusive.
    Mr. Chairman, Ranking Member, this concludes my testimony. The 
Veterans of Foreign Wars sincerely appreciates the opportunity to 
provide views on these important bills, and I am prepared to take any 
questions you or the subcommittee members may have.