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


 DRAFT LEGISLATION: To Establish A Permanent Veterans Choice Program; 
  Draft Legislation To Modify VA's Authority To Enter Into Agreements 
 With State Homes To Provide Nursing Home Care To Veterans, To Direct 
The Secretary To Carry Out A Program To Increase The Number Of Graduate 
 Medical Education Residency Positions, And For Other Purposes; DRAFT 
  LEGISLATION: To Direct VA To Conduct A Study Of The Veterans Crisis 
Line; DRAFT LEGISLATION: To Direct VA To Furnish Mental Health Care To 
      Veterans At Community Or Non	Profit Mental Health Providers 
    Participating In The Veterans Choice Program; The Department Of 
 Veterans Affairs (VA's) Legislative Proposal, The Veteran Coordinated 
Access And Rewarding Experiences (CARE) Act; H.R. 1133; H.R. 2123; H.R. 
                          2601; And, H.R. 3642

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

                                 HEARING

                               BEFORE THE

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

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION
                       TUESDAY, OCTOBER 24, 2017

                           Serial No. 115-35

       Printed for the use of the Committee on Veterans' Affairs
       
        Available via the World Wide Web: http://www.govinfo.gov     
              
                               __________
                               

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
31-343                       WASHINGTON : 2019                     
          
-----------------------------------------------------------------------------------
For sale by the Superintendent of Documents, U.S. Government Publishing Office, 
http://bookstore.gpo.gov. For more information, contact the GPO Customer Contact Center,
U.S. Government Publishing Office. Phone 202-512-1800, or 866-512-1800 (toll-free).E-mail, 
[email protected].                   
          
       
       
     
                     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

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, October 24, 2017

                                                                   Page

DRAFT LEGISLATION TO ESTABLISH A PERMANENT VETERANS CHOICE 
  PROGRAM; DRAFT LEGISLATION TO MODIFY VA'S AUTHORITY TO ENTER 
  INTO AGREEMENTS WITH STATE HOMES TO PROVIDE NURSING HOME CARE 
  TO VETERANS, TO DIRECT THE SECRETARY TO CARRY OUT A PROGRAM TO 
  INCREASE THE NUMBER OF GRADUATE MEDICAL EDUCATION RESIDENCY 
  POSITIONS, AND FOR OTHER PURPOSES; DRAFT LEGISLATION, TO DIRECT 
  VA TO CONDUCT A STUDY OF THE VETERANS CRISIS LINE; DRAFT 
  LEGISLATION, TO DIRECT VA TO FURNISH MENTAL HEALTH CARE TO 
  VETERANS AT COMMUNITY OR NON-PROFIT MENTAL HEALTH PROVIDERS 
  PARTICIPATING IN THE VETERANS CHOICE PROGRAM; THE DEPARTMENT OF 
  VETERANS AFFAIRS (VA'S) LEGISLATIVE PROPOSAL, THE VETERAN 
  COORDINATED ACCESS AND REWARDING EXPERIENCES (CARE) ACT; H.R.
  
  
  1133; H.R. 2123; H.R. 2601; AND, H.R. 3642.....................     1

                           OPENING STATEMENTS

Honorable David P. Roe, Chairman.................................     1
Honorable Tim Walz, Ranking Member...............................     3

                               WITNESSES

The Honorable Jim Banks, U.S. House of Representatives, 3rd 
  District; Indiana..............................................     6
    Prepared Statement...........................................    61
The Honorable Mike Gallagher, U.S. House of Representatives, 8th 
  District; Wisconsin............................................     7
    Prepared Statement...........................................    62
The Honorable John R. Carter, U.S. House of Representatives, 31st 
  District; Texas................................................     9
    Prepared Statement...........................................    63
The Honorable Glenn Thompson, U.S. House of Representatives, 5th 
  District; Pennsylvania.........................................    10
    Prepared Statement...........................................    64
The Honorable Neal P. Dunn, U.S. House of Representatives, 2nd 
  District; Florida..............................................    12
    Prepared Statement...........................................    65
The Honorable Andy Barr, U.S. House of Representatives, 6th 
  District; Kentucky.............................................    13
    Prepared Statement...........................................    66
The Honorable Julie Bronwley, U.S. House of Representatives, 26th 
  District; California...........................................    15
The Honorable David J. Shulkin, M.D., Secretary, U.S. Department 
  of Veterans Affairs............................................    16
    Prepared Statement...........................................    67
        Accompanied by:

    Carolyn Clancy M.D, Executive in Charge, Veterans Health 
        Administration, U.S. Department of Veterans Affairs
    Laurie Zephyrin M.D., MPH, MBA, Acting Deputy Under Secretary 
        for Health for Community Care, Veterans Health 
        Administration, U.S. Department of Veterans Affairs
Adrian M. Atizado, Deputy National Legislative Director, Disabled 
  American Veterans..............................................    47
    Prepared Statement...........................................    75
Roscoe G. Butler, Deputy Director for Health Care, Veterans 
  Affairs and Rehabilitation Division, The American Legion.......    49
    Prepared Statement...........................................    89
Kayda Keleher, Associate Director, National Legislative Service, 
  Veterans of Foreign Wars of the United States..................    50
    Prepared Statement...........................................    96

                       STATEMENTS FOR THE RECORD

The American Congress of Obstretricians and Gynecologists (ACOG).   102
American Federation of Government Employees, AFL-CIO (AFGE)......   105
American Health Care Association (AHCA)..........................   108
American Medical Association (AMA)...............................   109
AMVETS...........................................................   110
The Association of VA Psychologist Leaders.......................   113
ASTS and AST.....................................................   118
Concerned Veterans of America (CVA)..............................   118
Fleet Reserve Association (FRA)..................................   120
Got Your 6.......................................................   122
Health IT Now....................................................   127
Iraq and Afghanistan Veterans of America (IAVA)..................   128
Military Officers Association of America (MOAA)..................   130
Military Order of the Purple Heart...............................   132
National Alliance on Mental Illness (NAMI).......................   135
National Guard Association of the United States (NGAUS)..........   138
Nurses Organization of Veterans Affairs/Association of VA 
  Psychologist Leaders/Association of VA Social Workers/Veterans 
  Healthcare Action Campaign.....................................   140
Paralyzed Veterans of America (PVA)..............................   141
Reserve Officers Association (ROA)...............................   148
University of California, Riverside..............................   148
University of Pittsburgh.........................................   150
Vietnam Veterans of America (VVA)................................   151
Wounded Warrior Project (WWP)....................................   155
National Indian Health Board (NIHB)..............................   158

                        QUESTIONS FOR THE RECORD

Post-Hearing Questions For Adrian M. Atizado, Dav Deputy National 
  Legislative Director...........................................   162

                   MATERIAL SUBMITTED FOR THE RECORD

JAVA Brochure....................................................   164

 
  DRAFT LEGISLATION To Establish A Permanent Veterans Choice Program; 
  DRAFT LEGISLATION To Modify VA's Authority To Enter Into Agreements 
 With State Homes To Provide Nursing Home Care To Veterans, To Direct 
The Secretary To Carry Out A Program To Increase The Number Of Graduate 
 Medical Education Residency Positions, And For Other Purposes; DRAFT 
  LEGISLATION, To Direct VA To Conduct A Study Of The Veterans Crisis 
Line; DRAFT LEGISLATION, To Direct VA To Furnish Mental Health Care To 
      Veterans At Community Or Non-Profit Mental Health Providers 
    Participating In The Veterans Choice Program; The Department Of 
 Veterans Affairs (VA's) Legislative Proposal, The Veteran Coordinated 
Access And Rewarding Experiences (Care) Act; H.R. 1133; H.R. 2123; H.R. 
                          2601; And, H.R. 3642

                              ----------                              


                       Tuesday, October 24, 2017

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 10:00 a.m., in 
Room 334, Cannon House Office Building, Hon. David P. Roe 
[Chairman of the Committee] presiding.
    Present: Representatives Roe, Bilirakis, Coffman, Wenstrup, 
Radewagen, Bost, Poliquin, Dunn, Arrington, Rutherford, 
Higgins, Bergman, Banks, Walz, Takano, Brownley, Kuster, 
O'Rourke, Rice, Correa, Esty, and Peters.

          OPENING STATEMENT OF DAVID P. ROE, CHAIRMAN

    The Chairman. Good morning. The Committee will come to 
order.
    Welcome and thank you for all joining us today, the Full 
Committee legislative hearing.
    Today we will begin discussing several pieces of important 
legislation, including draft legislation that I have been 
working on to establish a permanent, improved Department of 
Veterans Affairs Care in the Community Program, draft 
legislation that Ranking Member Walz has been working on to 
address VA's agreements with state veteran homes; graduate 
medical education residency positions, community care 
obligations, and telemedicine licensing issues; and a 
legislative proposal Secretary Shulkin has been working on, the 
Veteran Coordinated Access and Rewarding Experiences, or CARE 
Act.
    We will also consider legislation this morning that would 
affect how veterans are able to access life-saving transplant 
and mental health care, and how VA is able to use telemedicine 
to treat veterans in rural areas.
    Needless to say, we have a very full docket this morning. I 
am grateful to Ranking Member Walz, to Secretary Shulkin, and 
all the sponsors of the bills on today's agenda for being here 
this morning and for their hard work on behalf of our veterans.
    I look forward to hearing the testimony of my colleagues 
and of the Secretary on various proposals, and, for brevity's 
sake, will limit my comments to my draft bill addressing 
community care. So let's get started.
    Earlier this month, the Committee hosted a roundtable 
discussion with VA and numerous Veterans Service Organizations 
to discuss community care reform. At that roundtable, we had a 
robust discussion surrounding an earlier version of my 
community care reform bill. I am immensely grateful to all the 
VSOs, members, and other roundtable participants for their 
support of the earlier draft, their thoughtful suggestions for 
how it could be improved, and their willingness to meet with me 
and my staff over the last few weeks to discuss these issues 
and my language in depth.
    It is important to note that the written testimony that was 
submitted for today's hearing is based on an earlier draft of 
the bill that is before us today. On Friday, a revised version 
of the bill was circulated that incorporates the feedback that 
I have received over the last few weeks from VSOs, members, VA, 
and other stakeholders.
    Once again, I want to thank all of those who agreed to sit 
down with me and my staff, for being so generous with their 
time and for their commitment to ensuring that all viewpoints 
and concerns are heard and considered in the Committee's final 
work product. I made every effort, every step of the way, to be 
transparent and keep all stakeholders informed about our work 
and intentions with regard to this bill.
    To that end, I believe it is important to state yet again 
that this effort is in no way, shape, or form intended to 
create a pipeline to privatize the VA health care system. I 
want to be completely clear about that. Everyone who 
participated in the roundtable earlier this morning and 
contributed to the development of this legislation to be 
completely clear on that. Everyone listening today should also 
be completely clear on that.
    Supplemental care sources from within the community has 
been a part of the VA health care system since the 1940s, and 
services to expand VA's reach and strengthen and support the 
care that VA provides. Rhetoric aside, strengthening and 
supporting VA is what this conversation is about.
    It should go without saying that VA cannot be everywhere, 
providing everything to every veteran. Expecting VA to perform 
like that sets up the VA to fail. That is why my draft bill 
preserves VA's role as the central coordinator of care for 
enrolled veteran patients.
    In addition to consolidating VA's menu of existing 
community care programs into one cohesive program, my bill 
would create a seamless, integrated VA system of care that 
incorporates VA providers and VA medical facilities where and 
when they are available to provide care a veteran seeks in a 
network of VA providers in the community who can step up when 
needed.
    Under my draft bill, the VA generally retains the right of 
first refusal, meaning that if VA medical facilities can 
reasonably provide a needed service to a veteran, that care 
will be provided in that facility. But when the VA can't do 
that, my bill would ensure that veterans aren't left out to 
dry.
    My bill would also modernize VA's medical claims processing 
system to ensure that community providers can be expected to be 
paid on time, every time, and for the care they provide to 
veterans on VA's behalf.
    My bill would further require VA to consolidate periodic 
capacity and market assessments to identify how gaps in care 
can be addressed through improvements to both internal and 
external capacity, standardize the rates VA pays to community 
providers, and authorize VA to enter into provider agreements 
for needed care when contracts are not available or achievable.
    That said, my bill remains a work in progress and we still 
have work to do together. For example, we still need to figure 
out how to pay for all these improvements, which will be no 
easy or pleasant feat for any of us, I can assure you.
    I am committed to remaining as transparent and open as 
possible moving forward, and I want everyone here to know the 
doors of this Committee are open to anyone who is honestly 
interested in working with us to resolve this issue once and 
for all before the year runs out and the Choice funds, once 
again, run dry.
    With that, I look forward to hearing what all of our 
witnesses have to say this morning and thank them for being 
here.
    The Chairman. I will now yield to Ranking Member Walz for 
any opening statement that he might have.

         OPENING STATEMENT OF TIM WALZ, RANKING MEMBER

    Mr. Walz. Well, thank you, Mr. Chairman.
    Earlier this summer, the New York Times did a story and the 
headline in it was, ``If You Want to Know How Congress is 
Supposed to Work, Look at the VA Committee.'' That is a 
testament to Chairman Roe's leadership, it is a testament to 
what is basically the who's who of those who care for veterans 
who are in this room today. For those veterans that will be 
watching and following this closely, they expect nothing less 
of us; they expect nothing less than bipartisanship aimed at 
common values and outcomes, and for that I am grateful.
    Secretary Shulkin and your team, thank you. It is not a 
rare occurrence to have you in this room. You are accessible. 
We pick up the phone, we talk often, and you are always 
proactive in that and I think that changes the conversation.
    To the VSOs that are here, we will talk a little bit about 
your input that is absolutely invaluable.
    We have even been joined by a neighbor to the east of me 
from Wisconsin, Mr. Leinenkugel. I wanted to thank you for 
taking the time to come down. I know you are a busy man, so you 
may have missed the Vikings and the Packers did play, just by 
the way. Okay, I thought we would share that. Passive-
aggressiveness runs deep in Minnesotans--
    [Laughter.]
    Mr. Walz [continued]. --but thank you for that.
    Over 3 years ago, the Committee worked together under 
significant public pressure and time constraints to establish 
the Veterans Choice Program, in response to the immediate 
access to care crisis. At that time, I think we all understood 
Veterans Choice would be a temporary fix. Aside from using the 
time to improve VA internal capacity, it also allowed the 
Committee to assess a long-term strategy for consolidating VA's 
multiple community care programs into one streamlined, easy-to-
use program, based on all the lessons learned from Veterans 
Choice.
    During this period, the Chairman is absolutely right, we 
have held countless hearings on the topic, and today we have 
the opportunity to discuss the product of these hearings: draft 
legislation to replace the Veterans Choice Program and 
consolidated community care.
    I want to begin by thanking the Chairman again and his 
incredible staff for the hard work on this issue. When you look 
at their willingness to consider and incorporate stakeholder 
feedback into their draft, it is evident this is not a partisan 
issue, it is a veteran issue. And this Committee continues to 
prove that veterans, not politics, come first.
    In preparation for this hearing, I had the opportunity to 
go with Congressman Nolan up to International Falls in 
Koochiching County, Minnesota. They are famous for lots of 
things and not just being the coldest place in America. And 
they told me this to be very clear about it is, is that 
International Falls is not the end of the road, it is the 
beginning of the road when you come from Canada. And the room 
was filled with about a hundred veterans from all of this 
Nation's conflicts and, just like so many of you and the 
Members who are here hold these hearings all over, we were 
talking about what it is going to take to deliver that care. 
And the Chairman is right, it is very difficult. There is no VA 
hospital in International Falls. The nearest community-based 
outpatient clinic is miles away. Community care in hospitals 
are even spread out some, but the willingness of that community 
hospital there, a small rural hospital willingly taking Choice, 
willingly taking TRICARE, willingly taking CHAMPVA, to try and 
serve their people.
    And out of that meeting, and we will get a chance to talk 
about it, is some of the things that they want to know we hear 
about. They love the care they get in the VA, but they don't 
want to drive to Minneapolis or, more importantly, fly to 
Minneapolis every time they need it. They want to try and 
figure out how we can best deliver that care. So today, the 
county veterans service officer in the VFW, they are holding a 
watch party today in the VFW out in International Falls. They 
wanted to hear what we had to say and ask them, and they are 
curious about this, just like all of your veterans are.
    So I thank the VSOs for that engagement. Your members are 
listening, they are paying attention, and they care deeply 
about this. And to the VA for their support. Each has continued 
to provide a level of insight and expertise necessary to make 
this program work.
    I am pleased that we are as close as we are to settling on 
policy underlying a Choice replacement program. I am concerned 
with how we fund it, as the Chairman said. I continue to 
believe that veterans do not benefit when we scrape the barrel 
for money by skimming from some veteran's benefits or health 
programs to pay for others. That is something that came out of 
that meeting. I asked them, if we could deliver everything you 
are asking for on CARE, would you be willing to do it with 
round-down and other things, and that cause's great 
consternation amongst that group.
    We need to have that open, honest dialogue, which we have 
always had. A program of this magnitude will require more than 
round-downs, and I look forward to learning more about how we 
plan to pay for this legislation and bring in those 
stakeholders.
    A critical component of consolidating community care is 
improving VA's ability to enter into provider agreements with 
state veteran's homes. That is why I have included language in 
the minority draft to do just that. Without the modification to 
VA's authority, veterans' access to high quality nursing homes 
will decrease. I hope my colleagues will support this 
legislation as it advances through the Committee. We must 
ensure the needs of our aging veteran's population are met and 
future demand on these services will rise.
    Today, this Committee will also discuss legislation to 
improve the current Veterans Choice Program. These improvements 
include changes to organ transplant authorizations and 
eligibility. Also some changes I am concerned with, such as 
changes to the eligibility of veterans to seek mental health 
from VA and in certain locations the eligibility of veterans to 
seek treatment for military sexual assault. I am concerned 
these changes to eligibility could lead to VA ultimately losing 
its role as the coordinator and the guarantor of one of the 
most important responsibilities: to provide high-quality mental 
health care.
    I believe that by concentrating our efforts within the VA 
we can better treat veterans with mental health concerns or 
that are suffering from military sexual trauma. I look forward 
to hearing from our witnesses. We can do more on this.
    With that, I would once again thank you, Chairman, for your 
leadership, thank you for once again proving that Congress can 
work in tackling the toughest issues on those shared values. 
And I yield back.
    The Chairman. I thank the gentleman for yielding and his 
comments.
    And I am honored today to be joined by a number of 
colleagues who have sponsored the bills on our agenda and will 
be joining us on the first panel.
    With us is Representative Jim Banks from Indiana, who will 
be testifying from his seat here on the dais; Representative 
Mike Gallagher of Wisconsin. Welcome.
    Judge John Carter from Texas; G.T. Thompson from 
Pennsylvania. And Representative Dr. Neal Dunn from Florida 
will also be testifying from the dais. And Representative Andy 
Barr, my friend from the north in Lexington, from Kentucky.
    Representative Banks, you are now represented for 5 
minutes.

                STATEMENT OF HONORABLE JIM BANKS

    Mr. Banks. Chairman Roe, Ranking Member Walz, thank you for 
holding the hearing today and for including my bill on the 
agenda,
    Our gratitude for our servicemembers demands that we 
address the personal impact of their service. Suicide is our 
Nation's tenth leading cause of death, claiming over 40,000 
lives a year. That is almost five times as many people as my 
entire hometown Columbia City, Indiana. This rate has increased 
by over 32 percent since 2001. Veterans account for 18 percent 
of those deaths, even though they are only 8.5 percent of the 
Nation's population.
    Every day, as we know, 20 veterans die from suicide. 
Veterans are 22 percent more likely to commit suicide and our 
female veterans are two and a half times more likely than 
civilian women. The invisible wounds of PTSD are a large 
contributing factor, afflicting 11 to 20 percent of those who 
have served in war zones.
    Our veterans were vigilant in fighting for our freedoms, we 
must be vigilant in addressing their needs.
    In recognizing the increase from 2001 to 2014, the VA has 
focused many resources to tackle this issue. One resource is 
the 24/7 Veterans Crisis Line, or the VCL, which was created in 
2007. As of May 2016, the line answered over 2.3 million calls 
and over 55,000 texts. Emergency services were dispatched over 
61,000 times and there were over 376,000 referrals to VA 
suicide prevention coordinators, ensuring veterans reach 
further care options.
    The VCL, as you can see, is a critical tool. My draft bill 
seeks to enable it to be even more effective. In this 
information age, the power of data analytics can greatly help.
    An Inspector General report from March of 2017 indicated 
room for improvement regarding data analysis and performance 
measures. Currently, there is still no overarching approach to 
ensure the VA knows the efficacy of the VCL in preventing 
future suicide attempts after the initial one is prevented, or 
in how well it is integrated into the entirety of VA's mental 
health services.
    My bill would require the VA to give us quantitative 
insight regarding the following. First, the VCL is a conduit 
for veterans to be connected to opportunities for sustained 
mental health treatment through the VA. Next, it would look for 
the visibility of the VCL to veterans who have never used VA 
care, and VA health care's effectiveness at ensuring that those 
receiving physical care find help for any mental needs; and VA 
mental health care decreasing the chance of a veteran needing 
to contact the VCL again; if the amount of times a veteran 
contacts the VCL changes outcomes; and, lastly, what is mental 
health care's effectiveness at decreasing suicide risk. These 
answers will further empower the VA in this fight.
    We must ensure that our veterans know that they are not 
alone after the phone call. Suicide attempts usually result 
from mental health concerns that require further care to find 
complete resolution.
    Through talks with Veterans Service Organizations, I have 
learned of their concern for veterans' information privacy. I 
share this belief in privacy and seek to maintain it. That is 
why this bill will not change the nature of the phone 
conversations. Veterans who wish to are still able to maintain 
anonymity.
    Additionally, the bill provides for a study of data from 
January 1, 2014 through the end of 2018, almost 80 percent of 
which has already been collected. The last year of data for 
2018 would be acquired no differently or extensively. This bill 
has no data-acquisition purpose at all, it serves solely for 
data analysis.
    Another concern raised is the privacy of the information 
during analysis. This bill does not intend to jeopardize that 
either. I intend to work with the Committee and veterans 
organizations to ensure that there is no ambiguity allowing for 
the possibility of any such interpretations.
    With the quantitative insight this bill would provide, the 
goal all of us share could be accomplished, which is saving 
more veterans' lives.
    With that, I urge my colleagues to support this bill. With 
the loss of 20 veterans each day, we must do everything that we 
can, it is our duty.
    Thank you, Mr. Chairman. I yield back.

    [The prepared statement of Mr. Banks appears in the 
Appendix]

    The Chairman. Thank you, Mr. Banks.
    Mr. Gallagher, you are now recognized for 5 minutes.

             STATEMENT OF HONORABLE MIKE GALLAGHER

    Mr. Gallagher. Thank you, Chairman Roe, Ranking Member 
Walz--although I represent the Packers in Congress, that was 
tough to hear--and distinguished Members of the Committee, 
thank you for inviting me to join you here today.
    My draft legislation before you seeks to address the unmet 
suicide-prevention needs of America's military veterans. As my 
colleague Mr. Banks laid out, 20 veterans take their own lives 
on average each day and, on average, 14 of the 20 veterans who 
commit suicide each day did not receive care within the VA.
    In May 2017, Secretary Shulkin stated the following: 
``Nothing is more important to me than making sure that we 
don't lose any veterans to suicide. As you know, 20 veterans a 
day are dying by suicide. That should be unacceptable to all of 
us. This is a national public health crisis, and it requires 
solutions that not only the VA will work on, but all of 
government and other partnerships in the private sector, 
nonprofit organizations.''
    As a veteran myself, I could not agree more with Dr. 
Shulkin. That is why my colleague Seth Moulton, a fellow 
Marine, and I have been working on legislation to address this 
crisis.
    Simply stated, our bipartisan legislation would improve 
veterans' access to evidence-based mental health care services 
at community or nonprofit mental health providers participating 
in the Veterans Choice Program. Our bill would allow eligible 
veterans in need of mental health services to access the care 
they need on a same-day basis in the community without a 
referral. This narrow provision would apply only to mental 
health services in order to address the suicide crisis 
affecting the men and women who have served our Nation.
    We believe this legislation is sorely needed. In 2016, the 
VA Center for Innovation published a report titled ``Veteran 
Access to Mental Health Services.'' The report, which is a 
compilation of interviews with veterans from across the 
country, is absolutely remarkable. I believe the candor of 
these findings is truly a testament to the VA's commitment to 
transparency and I commend the Department for recognizing that 
some veterans need mental health care choices outside the VA.
    For example, the report states, ``For many veterans, 
private providers and non-profits that offer confidential, 
bureaucracy-free access to timely care feel like a positive and 
desirable alternative to VA processes.''
    The report also states, ``Many veterans are dismayed and 
left feeling like the VA wants to fob them with drugs when they 
are offered psychotropic medication before exploring non-
medicated treatment options.''
    Further, in discussing proposed solutions, the report 
finds: ``Many veterans don't want to use VA services for mental 
health care even if the red tape is cleared, so how can we 
enable other avenues for care that benefit both veterans and 
non-VA providers?''
    These findings exemplify why Congressman Moulton and I are 
teaming up to find a bipartisan, commonsense solution to this 
crisis. It is my belief that by allowing eligible veterans 
access to same-day, evidence-based mental health care services 
at community and nonprofit providers that are credentialed 
under the Choice Program's care delivery network, veterans in 
crisis will be able to get the help they need when and where 
they need it.
    The United States has now lost more veterans to suicide 
than the Nation has lost in Iraq or Afghanistan, and we believe 
our Nation has a continuing obligation to the men and women who 
have served to help address their mental health needs.
    Tragically, only this past Friday a 33-year-old veteran 
committed suicide in the parking lot of the Phoenix VA. I would 
simply say, and I know everyone on the Committee feels the same 
way, that this can't continue. And I believe community-based 
and nonprofit mental health care providers stand ready to help 
fill the gap in addressing the unmet need in veterans' mental 
health care.
    This legislation would give Dr. Shulkin and his team the 
ability to allow such providers to meet these urgent needs in 
order to continue to address what the Secretary has described 
as his number one clinical priority.
    I hope every Member of the Committee will support this 
effort. I thank you for your time and I look forward to working 
with all of you to move this forward.
    Thank you.

    [The prepared statement of Mr. Gallagher appears in the 
Appendix]

    The Chairman. I thank the gentleman for yielding.
    Now I would like to recognize Representative Carter, Judge 
Carter. And I understand you have some special guests with you 
today, Judge.

             STATEMENT OF HONORABLE JOHN R. CARTER

    Mr. Carter. Thank you very much, Mr. Chairman. And, yes, I 
do, and I'll introduce them in a moment.
    Chairman Roe, Ranking Member Walz, and other Members of 
this Committee, it is an honor to speak here before you this 
morning.
    Mr. Chairman, thank you for including our bill, H.R. 1133, 
Veteran Transplant Coverage Act of 2017, in today's hearing.
    I am here this morning on behalf of thousands of American 
veterans who find themselves in need of transplant care. Under 
current law, a veteran in critical need of a live donor 
transplant can't, with their VA coverage, receive a donation 
from a non-veteran. This excludes children, siblings, and other 
non-veteran family members, the people a veteran would be most 
likely and willing to enter into a successful organ match. This 
is unacceptable.
    My legislation, the Veterans Transplant Coverage Act of 
2017, removes unnecessary barriers that prevent veterans from 
receiving the care they deserve. H.R. 1133 will allow veterans 
to receive donations from a live donor, regardless if the donor 
is a veteran or a non-veteran, and allows them to have the 
procedure done in a non-VA facility if that makes more sense 
for the patient.
    This is a commonsense, live-saving policy, and I am proud 
that it has received robust and bipartisan support as a stand-
alone bill.
    This legislation is a good fit for the Veteran Coordinated 
Access and Rewarding Experiences, CARE Act, because it seeks to 
give veterans more options when it comes to their health care, 
both in donors and providers. This is especially beneficial for 
veterans who live in rural areas, far away from the closest VA 
medical center, to say nothing of the closest VA transplant 
facility.
    Mr. Chairman, I want to take the time to pause and 
recognize my constituents, the inspiration for this bill, Mr. 
and Mrs. Charles Nelson and their son Coty, who are here from 
Leander, Texas, a city in my district.
    The Chairman. Please stand, if you would.
    Mr. Carter. Mr. Nelson is a 100-percent disabled service-
connected veteran, who served his country and ran into this 
roadblock. That is why we are here today.
    They brought up what I thought was a commonsense, crazy 
thing that should be changed. I want to thank them for coming 
out here and doing this. And they care enough about it to come 
all the way here from Texas to let you know they care.
    [Applause.]
    Mr. Carter. Mr. Nelson, a 100-percent disabled service-
connected veteran, served his country and did everything his 
grateful Nation asked him to.
    Unfortunately, while serving in Korea, he developed kidney 
disease, which further led to a need of a kidney transplant. 
His then 28-year-old son Coty was a willing donor and a match. 
Initially, Mr. Nelson was told the surgery would be covered 
under the VA Choice Program of 2014 and able to be performed at 
the University Hospital in San Antonio. However, because his 
son was not a veteran, the VA central office denied coverage 
and costs.
    The Nelsons were forced to use Medicare and private 
donations, and their own savings to cover the surgery costs. 
Mr. Nelson deserves better, our veterans deserve better.
    VA health should be there to address the health care needs 
of those who have served our country in uniform. For Mr. 
Nelson, who served our Nation bravely, to be forced to solicit 
donations to cover life-saving medical treatment was a failure 
of the VA system and an insult to his service.
    I am proud to represent Mr. Nelson and the more than 84,000 
veterans in my congressional district. Each of them, along with 
the 22 million nationwide, deserve access to life-saving 
transplant procedures, regardless of donor, in a facility that 
makes sense for them and their family.
    I hope that with the passage of H.R. 1133, Veterans 
Transplant Coverage Act of 2017, and of the entire Veteran 
Coordinated Access and Rewarding Experiences, CARE Act, our 
veterans can access the care they need in the best facility 
through their VA coverage. Our veterans deserve nothing less 
and the very best, and the best we can offer them for their 
service.
    Mr. Chairman, Ranking Member Walz, I want to thank you 
again for the opportunity to speak here today. I want to thank 
all the Members of this Committee for their service to our 
country and to our veterans.
    With that, I yield back.

    [The prepared statement of Mr. Carter appears in the 
Appendix]

    The Chairman. I thank the gentleman for yielding.
    And, Mr. and Mrs. Nelson, thank you and your son Coty for 
being here today, and thank you for bringing this up to Judge 
Carter. It is that you can see that your particular situation 
will benefit many, many veterans in the future and their 
families. And I want to thank you personally for you being here 
and coming all the way from Texas up here. And just remind you, 
there wouldn't be a Texas if it weren't for Tennessee, I want 
to point that out.
    [Laughter.]
    The Chairman. But I too served in Korea, I appreciate your 
service. And, once again, we very much appreciate what you have 
done for veterans for this country and your service.
    Judge, thank you.
    And now my friend G.T. Thompson, you are recognized for 5 
minutes.

             STATEMENT OF HONORABLE GLENN THOMPSON

    Mr. Thompson. Well, Chairman Roe, Ranking Member Walz, 
thank you so much for inviting me to testify before the House 
Veterans' Affairs Committee, with regards to H.R. 2123, the 
Veterans E-Health and Telemedicine Support Act, also known as 
the VETS Act.
    The issues before this Committee are critically important 
to ensure that those who have selflessly served our Nation 
receive the care and support that they rightfully deserve. With 
this in mind, a constituent approached me a few years ago to 
discuss the barriers to care that his fellow veterans were 
experiencing through the VA system.
    As an active duty soldier, he told me the stories of his 
friends coming home from deployments and fall through the 
cracks in our systems. Some were suffering post-traumatic 
stress disease, some traumatic brain injury, and depression, 
and required the care of specialists. Others had difficulty 
traveling from their rural communities to VA medical centers 
because of the injuries sustained during combat.
    It broke my heart to hear the stories of this soldier's 
friends not receiving the care that they deserve and, quite 
frankly, many of them wound up taking their own lives. What 
made it more difficult was the fact that this constituent, this 
soldier, was my son.
    After numerous conversations about how we can help our 
servicemembers when they return home, we determined that 
expanding access to telehealth would be a great start. Many of 
our veterans live in rural areas and are unable to travel far 
distances. Allowing them to see their health care provider in 
the comfort of their home would increase their access to care.
    As a result, I introduced the Servicemembers Telemedicine 
and E-Health Portability Act of 2011, or the STEP Act. Now, 
this bill allowed the Department of Defense health care 
professionals and contractors to provide telehealth care to 
members of our Armed Forces anywhere in the country, even 
across state lines, and that bill was included in the fiscal 
year 2012 NDAA, which was subsequently signed into law.
    The STEP Act has allowed more than 32,000 servicemen and 
women to gain access to telehealth and has been the basis for a 
number of telehealth expansions throughout the years. The DoD 
recently decided to expand telehealth care for recipients of 
TRICARE based on the success of that legislation.
    The STEP Act has proven that telemedicine can be expanded 
safely and responsibly across state lines. And while DoD 
patients can receive telehealth care no matter where they are 
located, those who receive care through the VA are not afforded 
the same liberties. That is why Representative Julia Brownley, 
a proud Member of this Committee, and I introduced H.R. 2123, 
the Veterans E-Health and Telemedicine Support Act.
    The VETS Act will similarly allow VA-employed health care 
providers to practice telehealth across state lines no matter 
where the doctor or the patient is located. It also commissions 
a study of the effectiveness of telemedicine programs utilized 
by the Department of Veterans Affairs.
    And while the VA has made major strikes in advancing 
telehealth access, outdated barriers limits its growth. My bill 
will eliminate these barriers by giving VA-employed providers 
an exemption to practice telehealth across state lines.
    Currently, each state has its own licensing requirements 
for health care providers to practice medicine within its 
borders. For example, if a doctor has offices in Pennsylvania 
and Ohio, they must hold a license from each state. VA provider 
licensing requirements are different. As long as the doctor is 
licensed and in good standing in a single state, they can 
practice in-person care within the VA system in any state. This 
reciprocity, however, is not afforded to their practice of 
telehealth.
    VA providers seeking to provide telehealth care to patients 
must also be licensed in the state where the patient is 
located. And while this licensing requirement can be waived if 
both the doctor and the patient are located in a Federal 
facility such as a VA medical center, this still forces a 
veteran to travel to a VA facility, and applies a separate, 
unnecessary level of regulation to VA telehealth providers.
    These outdated regulations are hurting our Nation's 
veterans. The Department of Veterans Affairs has successfully 
been using telemedicine for quite some time. Since 2002, more 
than 2 million veterans have received telehealth care through 
the VA. In 2016 alone, more than 12 percent of veterans 
receiving VA care utilized telehealth in some capacity; 45 
percent of these veterans live in rural areas.
    Veterans who have access to telehealth are overwhelmingly 
pleased with the quality of care and access they had received. 
Those receiving at-home care, for example, cite an 88 percent 
satisfaction rate.
    The VETS Act continues to expand telehealth access for 
veterans in a responsible manner, allows states to hold 
providers accountable while increasing access to quality care 
for veterans who need it. The VETS Act is the result of 
legislators, practitioners, and advocates coming together to 
negotiate workable language in good faith, and these efforts 
will result in veterans across the country gaining access to 
quality care in the comfort of their homes.
    Our veterans should receive the best care available to them 
and this starts with the passage of the VETS Act.
    Again, thank you, Chairman Roe and Ranking Member Walz, for 
inviting me to testify before the Committee, and I look forward 
to working with you to expand access to quality care for all 
our veterans.
    Thank you.

    [The prepared statement of Mr. Thompson appears in the 
Appendix]

    The Chairman. I thank the gentleman for yielding.
    Dr. Dunn, you are now recognized for 5 minutes.

              STATEMENT OF HONORABLE NEAL P. DUNN

    Mr. Dunn. Thank you, Chairman Roe and Ranking Member Walz, 
for including my bill, H.R. 2601, the Veterans Increased Choice 
for Transplant Organs and Recovery Act, VICTOR Act, in today's 
legislative hearing agenda. I also want to thank all of the 
witnesses here for their testimony.
    It goes without saying that timely organ transplants can 
make the difference between life and death. It is always a race 
to bring the organ and the transplant team together on time. 
Patients have to be ready at a moment's notice, and the stakes 
and the risks are always high.
    The Department of Veterans Affairs has participated in 
transplant medicine since 1962, but is a relatively small 
program, which is limited both by scope and location. As a 
result, veterans in need of organ transplants suffer unique 
challenges in trying to receive transplant care.
    Currently, when a veteran receives care through the VA for 
a transplant, they are forced to travel to one of only 14 VA 
transplant centers throughout the United States. This means 
that a veteran must be required to travel hundreds or even 
thousands of miles across several states for a transplant 
despite potentially passing many other transplant centers on 
the way.
    To illustrate this point, in the United States there are 
currently 147 liver transplant centers, 141 of those are 
civilian and six are in the veterans system. As a veteran in 
Florida who needs a liver transplant, there are seven liver 
transplant centers in Florida, but they can't go to any of 
them. They have to travel to Nashville or to Pittsburgh. 
Similarly, a veteran in California has 13 transplant centers in 
their state, but cannot go to any of them. The difficulties 
associated with transplant care are particularly apparent with 
liver transplants. Given the incidence of end-stage liver 
disease in the veteran population, liver transplants are 
especially important, especially live-saving, and a common 
concern within the VA system.
    Out of the 14 veterans centers, just six of these 
transplant centers are designated for liver transplants. And 
for those veterans who are waiting for a liver transplant at a 
veterans center, they face a 32-percent increase in waiting 
time compared to civilian centers.
    The VICTOR Act addresses these challenges by simply 
reducing the existing barriers to care. If a veteran who needs 
a transplant lives more than 100 miles away from a veterans 
transplant center, the bill allows them to seek care at any 
federally approved transplant center closer to them that also 
treats Medicare patients.
    Speaking as a surgeon, a veteran, and a former student of 
Tom Starzl, the father of liver transplants, this is the right 
thing to do. This policy change in transplant medicine builds 
on our larger strategy to improve the quality of health care 
access for those who, as Lincoln said, ``shall have borne the 
battle.''
    Thank you very much, Mr. Chairman, Ranking Member Walz, for 
allowing me to testify today on behalf of 2601.
    I yield back.

    [The prepared statement of Mr. Dunn appears in the 
Appendix]

    The Chairman. Thank you, Dr. Dunn.
    Congressman Barr, you are now recognized for 5 minutes.

                STATEMENT OF HONORABLE ANDY BARR

    Mr. Barr. Good morning. First of all, I would like to thank 
Chairman Roe and Ranking Member Walz for allowing me the 
opportunity to speak before the House Veterans' Affairs 
Committee and all the Members of the Committee this morning 
about providing access to community care for survivors of 
military sexual trauma, or MST, which my legislation, H.R. 
3642, the Military Sexual Assault Victims Empowerment Act, also 
known as the Military SAVE Act, helps to improve.
    According to the findings of the Department of Veterans 
Affairs National Screening Program, 1 in 4 women and 1 in 100 
men report that they have been victims of military sexual 
assault during their time serving in the military. This problem 
was first brought to my attention by a group of very courageous 
and inspirational female veterans in the 6th Congressional 
District of Kentucky, led by MST therapist Karen Tufts. Sadly, 
due in part to the emotional trauma as a result of their MST 
experiences, two women that were part of this group were lost 
to suicide.
    In fact, according to an independent nationwide study 
conducted by the National Victims Center, the Medical 
University of South Carolina, and Florida State University, 
research has found that female victims of MST are 14 times more 
likely to commit suicide than women who have never been 
assaulted.
    In addition, according to the Nation's largest anti-sexual 
violence organization, sexual assault is also commonly 
associated with adverse mental health outcomes such as 
depression, anxiety, substance abuse, and non-suicidal self-
injury, which are also commonly associated with suicidal 
ideation attempts and death by suicide.
    While Congress has taken several actions recently to better 
protect survivors of MST within the military justice system, 
many survivors have expressed concern that services available 
within the Department of Veterans Affairs health care system 
may still not match their specific post-MST needs.
    This is why I have been working closely with this 
Committee, Veterans Service Organizations, and my VA Pilot 
Program Development Task Force in the 6th District of Kentucky, 
to improve medical care for survivors of MST in order to help 
get those survivors the care that best fits their unique 
physical and psychological needs.
    This legislation would allow survivors of MST the ability 
to seek treatment specifically related to their MST injuries by 
a private health care provider of their choice during a 3-year 
pilot program. MST survivors would be given a choice: to 
participate in this pilot program or remain in the VA health 
care system for treatment options. Participants in both this 
pilot program and those being treated within the VA health care 
system for MST-related injuries would participate in a pre-
treatment and post-treatment survey, as well as a development 
survey conducted every 6 months to study individual progress.
    This pilot program would study the results of the effects 
that direct-access care provides that the VA does not.
    A certified VA researcher will be assigned as a member of 
the VA community care office, which will ensure the quality and 
integrity of collecting and analyzing data for the study, which 
would then be submitted to Congress for review.
    As I mentioned before, this legislation was developed with 
the contributions of many interested parties. It has been 
through the dedicated support and trusted advice of MST 
survivors themselves, and subject matter experts who are 
members of the VA Pilot Program Development Task Force. And we 
created this task force by carefully selecting each of these 
outstanding and in many cases courageous individuals who helped 
develop and determine what best possible pilot program for MST 
survivors should look like. Each of these members brought a 
unique experience and different skill sets to the table, which 
was ideal for this task force, and I thank them all for their 
contributions.
    In conclusion, I ask that this legislation be included in 
the Veteran Coordinated Access and Rewarding Experiences, CARE 
Act, in order to provide survivors, both male and female, the 
proper medical care that best fits their unique medical needs, 
care that they have earned through the service to their 
country.
    Again, thank you for allowing me to testify before this 
Committee today, and I am happy to answer any questions you may 
have about this legislation.
    I yield back.

    [The prepared statement of Mr. Barr appears in the 
Appendix]

    The Chairman. I thank the gentleman for yielding.
    And now I will just simply ask the panel, I know that the 
Members have other places they need to be, but I will just 
simply now open it up, first to my colleagues over here. Does 
anyone have a question of the panel?

              STATEMENT OF HONORABLE JULIE BROWLEY

    Ms. Brownley, you are recognized.
    Ms. Brownley. Thank you, Mr. Chairman. And thanks to all 
the witnesses who are here today and participating in our 
hearing.
    We will be considering the Choice 2.0 legislation later 
this morning and I am looking forward to that discussion, but I 
would like to just briefly note my support for one of the bills 
that were presented this morning, H.R. 2123, the VETS Act. It 
has been my pleasure to work with Congressman Thompson on this 
bill and I thank him for all his efforts pushing the bill 
forward.
    This bill really came out of a field hearing last year that 
I held with our Health Chairman, Dr. Wenstrup. During that 
hearing in my district in Ventura County, the VA testified 
about their growing and successful telemedicine program. The 
rapid growth of technology has created new possibilities for 
providing timely, quality health care that best suits veterans' 
needs, including care at home.
    The VA has seen tremendous growth and interest in 
telehealth, and we should continue to find innovative ways to 
connect veterans with the providers that they need no matter 
their physical location. This will particularly help rural 
veterans and is a key way to expand access to specialty care 
from the medical centers to the CBOCs, and even into the 
veteran's home.
    Under current law, however, VA doctors can only provide 
telehealth treatment across state lines if the veteran and the 
doctor are located in Federal facilities. The VETS Act removes 
those barriers and allows VA providers to offer treatment free 
of this restriction. After significant discussions with the 
relevant stakeholders, including a roundtable last month, we 
found widespread agreement about this fix.
    I would like to enter into the record a recent letter of 
support for the VETS Act from a broad coalition of patient 
groups, provider organizations, employers, and payers. This is 
a targeted fix that will help strengthen the telehealth 
medicine program at VA.
    The VA recently took steps to address this through 
executive action, which I think is a good step forward, and our 
bill will codify that action into law.
    Thank you, Mr. Chairman, and I yield back.
    The Chairman. I thank the gentlelady for yielding. And, 
without objection, those letters are submitted for the record.
    The Chairman. Anyone else have a question?
    Mr. O'Rourke.
    Mr. O'Rourke. Mr. Chairman, just a quick comment.
    I want to thank all of my colleagues who have brought very 
thoughtful legislation forward and for the fact that so much of 
it has been inspired by the real-life circumstances of their 
constituents, the veterans that they are here to serve in 
Congress.
    And I want to especially thank Judge Carter for 
highlighting the Nelson family and for the example that you 
give, which is incredibly motivating to us. Sometimes we 
discuss policy in the abstract, but to actually see you here 
and know of your sacrifice. I agree with the Chairman that it 
is not going to just be better for you and others in Leander 
and Texas, it is really going to be good for veterans across 
the country. So I want to thank you for being the inspiration 
for this, and Judge Carter for bringing it to us and to our 
attention, and hope that it is successful in passing.
    I yield back.
    The Chairman. I thank the gentleman for yielding.
    And before he leaves here, Coach Luce, hold on just a 
second before you leave. I don't know whether they caught him 
or not. I'll get that a little bit later.
    Anyone else?
    Well, if there are no further questions, the first panel is 
excused, and I will introduce the second panel momentarily.
    Yes, the gentleman who was leaving is one of my very dear 
friends, who just retired, is head basketball coach where I 
went to college for 27 years. He is the winningest coach in 
Ohio Valley Conference history and has won over 500 Division 1 
basketball games. So he is a great guy and his wife is here. So 
he sneaks out before I could introduce him.
    [Pause.]
    The Chairman. I am honored to be joined on our second panel 
by the Honorable Dr. David Shulkin, Secretary of the Department 
of Veterans Affairs. Secretary Shulkin is accompanied today by 
Dr. Carolyn Clancy, the Executive in Charge of the Veterans 
Health Administration, and Dr. Laurie Zephyrin, the Acting 
Deputy Under Secretary for Health in the Community Care.
    Mr. Secretary, thank you for being with us this morning. At 
your request, we are going to provide a few additional minutes 
for you to present your testimony. You are now recognized for 
as much time as may consume.

         STATEMENT OF HONORABLE DAVID J. SHULKIN, M.D.

    Secretary Shulkin. Great. Well, Chairman Roe, Ranking 
Member Walz, and distinguished Members of the Committee, good 
morning to everybody.
    Mr. Chairman, first let me express my deep thanks to you 
and the entire Committee for your hard work on community care 
issues. And thanks for including the VA's Coordinated Access 
and Rewarding Experiences bill, what I'm going to refer to as 
the Veterans CARE Act from now on.
    The work that all of you have done on accountability, on 
the GI Bill enhancements, on the PLS modernization, shows that 
we can work together in a bipartisan way to make dramatic 
improvements in VA health care and VA services.
    And I would agree with you, Ranking Member Walz, that this 
is the example of Committees in Congress, I tell people we have 
the best leadership and the best Committees in both the House 
and the Congress anywhere, that I am very, very proud of the 
work that all of you do. So, thank you.
    The Veterans CARE bill reflects our overarching veterans-
centric effort that has been driving our transparency 
initiative. So you may have seen that we are now posting wait 
times publicly, we are posting our quality data publicly, we 
are posting our veterans satisfaction data publicly, and all of 
that is about empowering veterans with information they need to 
make the best health care choices. And, most importantly, it is 
representative of what the private sector has been doing to 
improve health care over the past decade.
    The Veterans CARE bill leaves behind the old days when 
administrative needs, not the veterans' needs, governed 
decisions. It is about individualized care, community care, 
well-coordinated health care designed for a positive 
experience. The VA will take back customer service and treat 
veterans as valued customers.
    Veterans CARE ensures that veterans get the right care, at 
the time right time, with the right provider. It is a system 
that is driven by good clinical decisions rather than 
administrative rules, where clinical assessment determines what 
the veteran needs, that is a VA primary care provider or VA 
specialist, or a primary care provider or specialist in the 
community, if the community care is the answer the veteran 
chooses from our integrated, high-performance network.
    And if VA doesn't offer the necessary service, if VA can't 
provide timely services, if there are unusual burdens to 
receiving care, or if the service at the VA isn't meeting 
quality metrics compared to the community, we will look towards 
the community while working hard to improve these services 
within VA.
    Under Veteran CARE eligibility, criteria will align closely 
with TRICARE and private sector criteria.
    And let me just say that we are working closer and better 
with the Department of Defense than ever before. This plan 
builds off coordination with the Department of Defense, other 
Federal agencies, and our community partners.
    Under the Veteran CARE Act, veterans will have new access 
to a network of walk-in clinics for occasional needs such as 
minor illnesses and injuries. Under Veterans CARE, we are 
proposing consolidating Choice and all VA's Community Care 
programs into a single program. Under the Veteran CARE Act, we 
will make sure the community providers have patient records and 
we will get the records from veterans back.
    Veterans CARE is a new path that gives veterans more to say 
in their health care, and makes the program work like it 
should. It is a new direction for VA, where VA is accountable 
for its own performance. In my opinion, that is going to mean 
sustained improvements and modernization in this vital 
resource. In short, it brings VA health care into the 21st 
century and in line with the industry best practices.
    But the Veteran CARE bill is more than purchasing care 
outside of VA. Much of the bill aims to strengthen and improve 
VA health care with enhanced telemedicine authority, as you 
just discussed; better tools to recruit medical residents and 
other personnel enhancements; and tools to improve VA's leasing 
programs, and make it easier for VA to enter into shared 
facility arrangements with its academic partners and the 
Department of Defense. They all strengthen our capacity to 
deliver better health care. I know this Committee shares that 
goal.
    I recognize there are going to be concerns about how we 
will pay for this new system of care. Over 10 years, the cost 
will be billions less than maintaining the Choice in Community 
Care Programs that we currently in place. Savings will come 
from buying community care smarter and spending less money on 
administrative processes, so we can invest more money in 
veterans' care.
    We can achieve savings by focusing on clinically-driven 
care; paying Medicare rates for all community services except 
in areas with severe provider shortages; reducing 
administrative burdens; improving internal and external 
efficiencies in the revenue program to collect more dollars 
from other health insurance; and using value-based purchasing 
strategies already proven in the private sector.
    We are committed to exploring innovative ways to achieve 
more efficient health care delivery and will seek authorities 
to test reforms for that purpose.
    This program will require financial offsets and mandatory 
spending, and I am glad to discuss these offsets.
    Mr. Chairman, there is much to commend in the House 
discussion draft on Community Care that you have presented. I 
think any bill moving forward must allow veterans greater 
choice in their site of care; simplify veteran eligibility by 
replacing administrative rules with clinical criteria; add 
convenient care benefits; set timely payment standards; allow 
VA to take back customer service; include provider agreements 
with flexible payment rates that streamline how we pay for 
care, including care in State veterans homes; allow VA to 
record obligations at payment for community care--without this, 
it is going to be very challenging for us to calculate 
financial projections, as we have shown--permit medical record 
sharing in the network when needed for veteran care; 
consolidate all non-VA care into a simple program; provide 
additional tools for VA to expand and fill residency positions; 
and address clinical staffing shortages by improving VA hiring 
and retention of staff.
    We need top-quality health care professionals to deliver 
excellent care and it is a very competitive market. The direct-
hire authority that you provided in Choice funding helped us in 
hiring network and medical center directors, and I would like 
to work with you and the Committee to find other ways to 
address personnel shortages in health care.
    Mr. Chairman, to bring Veteran CARE to veterans in October 
of 2018, we need to move quickly. We need Congress to pass this 
legislation before December, as you said, Mr. Chairman, to 
avoid the program running out of money in the Choice Program, 
and to give veterans a system that works, and that meets or 
exceeds the best the private sector has to offer.
    This is about building a VA that veterans choose for their 
care. We want veterans to choose VA.
    Thank you, and I look forward to your questions.

    [The prepared statement of Secretary Shulkin appears in the 
Appendix]

    The Chairman. I thank the gentleman for yielding.
    I will now yield myself 5 minutes for questions.
    And thank you very much, Mr. Secretary, for being here. 
Your written testimony notes that the cost of the CARE proposal 
are still being discussed with OMB, and what is the status of 
those discussions, and when do you expect to have more 
information regarding the bill's budgetary impact?
    Secretary Shulkin. Well, Mr. Chairman, you are correct, we 
still are in discussions with OMB. We have presented very 
detailed descriptions of where we think that these cost savings 
will come and what the overall cost impact will be. And as I 
said in my oral testimony, we believe that this program, 
compared to continuing Choice and Community Care Programs as 
they are, will actually be billions of dollars less over 10 
years.
    The reason for those cost savings are, we believe by 
recording community care obligations at the time of payment, 
that is going to save money. When we make it easier to share 
information with community providers, we are going to avoid 
duplicative testing and have money savings. We are going to 
have increased authorities to collect money, to do better in 
our collections. But mostly it is going to be the decreased 
administrative costs.
    The administrative costs associated with the Choice Program 
in its complexity has been extremely high, 13 percent of all 
money goes towards administrative costs, and that is not 
consistent with what the private sector would do.
    So we want to save on administrative costs and invest that 
into both the VA system and more care that veterans can receive 
in the community.
    The Chairman. A couple things that we--the system that we 
have put together is really no different than what you see, 
what I personally have, which is a gatekeeper. I have a 
physician, a primary care doctor that I go to; depending on 
what my primary care doctor says, I am then referred if I need 
a specialist. That is pretty much what we are saying. If the 
specialty care can be provided within the VA, it is done so, 
and, if not, referred out.
    And here is my concern, and your proposal was a little 
light on details, is what if there is a conflict when the 
veteran goes in about either specialty care and/or primary 
care? We know that, I visited Medford, Washington with Greg 
Walden, Chairman Walden about a week ago, and they are short 
four PACT teams there. So if a veteran calls in at Medford, 
they can't get in because there is no PACT team there.
    So two things: What does that veteran do? And then, one, 
when there is a conflict, if they get in there, how do you get 
out of the system if you want out? That is Choice. So how is 
that resolved?
    Secretary Shulkin. Well, there is a lot there and we have 
actually worked a lot on these details. So I am not going to be 
able to do everything right here, but let me just comment 
exactly on what you said.
    I completely agree. We are trying to model this after the 
way that you and I have practiced medicine, and the way it is 
practiced across America. Doctors, patients, providers, 
patients, make decisions on what's best for the patient. So 
that is clinical criteria as opposed to a bunch of rules like 
40 miles in 30 days. So we want the rules to go away; we want 
this to be a clinical decision.
    What we have learned over the past couple years in VA is, 
first of all, our top priority is to define the clinical 
urgency of a problem. That concept was missing a couple years 
ago in VA when we got into trouble in Phoenix with the wait 
time crisis. So there will be no issues when patients have 
clinically urgent needs.
    And we are also going to add or propose to add this 
convenience care benefit, so that people don't have to drive in 
hundreds of miles just to get something simple.
    When it comes to what you are talking about, which is where 
many people say, look, the VA can provide something within a 
clinically appropriate time, but I would rather not wait that 
long; I would rather go someplace more convenient. This is 
where we want to align with the TRICARE eligibility criteria 
and align with private sector standards.
    And so we are prepared to sit down and to share some of 
those eligibility criteria on how we would deal with that, just 
like any other health system does.
    The Chairman. The other thing is, if I get in there and I 
am seeing you as my doctor, and it is just not working out, and 
there is no other--how is that resolved where that veteran can 
then get either outside care or if they can't provide a PACT 
team in there? I think that is critical, because we have 
trapped the veteran in the same system if it didn't work. And 
so how is that resolved?
    Secretary Shulkin. What we are signaling in this is 
beginning to start doing what we should have been doing more, 
which is giving the veteran more choice in the say of their 
care. There is no doubt about that. You know, in the private 
sector we are seeing more consumer-driven health care and we 
need to be moving in the same direction.
    Nobody should feel trapped in the VA system. What you are 
seeing here is, we are saying where the VA is not meeting 
community quality standards, we want to give veterans more 
choice. Where the capacity isn't there, like you are talking 
about where the PACT teams cannot handle the capacity or the 
demand, that is where we will give veterans more choice in the 
community.
    The Chairman. Okay. My time has expired.
    Mr. Walz, you are recognized.
    Mr. Walz. Well, thank you.
    Secretary Shulkin, again, thank you. As I said, no one is 
more accessible, no one is more engaged in talking to folks, 
and I am grateful. That changes the entire dialogue and helps 
us be successful.
    Dr. Zephyrin, thank you for being in the work you do. And, 
Dr. Clancy, thank you once again.
    I was just thinking in my head, I think you and I have the 
most seniority of the people here today. You keep stepping back 
into the breach and for that I am grateful.
    Up in International Falls again, I bring it back, because 
if you want the example of rural, if you want the example of 
people who are committed to this, of trying to get the care. I 
asked them in a room of about 100 veterans and family, how many 
have used Choice, about 30; how many had successful 
experiences, two. It didn't change their concept, though, that 
we needed to make this work.
    And I think all of us in here, the reason we have been 
successful is that we have tried to make sure there is not a 
hidden agenda, there is not--people fear VA is a choice. Being 
able to get into a VA hospital with a fully-staffed staff is a 
choice with people too. And every time we say and we all are up 
here, and I think we have talked about this before, every time 
we say it is not privatization, it is the exercise in don't 
think of a draft, that is exactly what they are thinking about.
    So if the idea is, we have to figure this out, emergency 
funding for Choice cannot continue. That is what we have all 
talked about, we have to fund this. We have to understand what 
is the proper balance that is struck between a VA that, as the 
Chairman always said, we have always used CARE in the 
community, we have always tried to figure that part out.
    I think getting veterans engaged in this, making sure they 
are very clear about what this is and where these intersect is 
absolutely critical, because I think most of us agree on 
principle that getting veterans timely access to health care as 
near to home as possible in a manner they want, that is what we 
should do. Trying to match that up, it is no small thing. As we 
found out when we first did Choice, you can't have the concept 
and not talk about the money, because when they came back from 
CBO with $100 billion, a lot of people stepped back and re-
looked at this.
    So with that being said, how does a draft VA proposal and 
the HVAC proposal align or not align with that request for a 
proposal that was issued last year? How is the alignment 
happening here, as you see it?
    Secretary Shulkin. With the proposal last year?
    Mr. Walz. The RFP that was issued, December, is that 
correct?
    Secretary Shulkin. Oh, yes, yes, yeah.
    I think that these are working out very well in terms of 
the alignment. What we are looking for in revising the approach 
towards the Choice Program, what we learned is, is that VA 
needs to take back customer service, you can't outsource that. 
No successful company does that and survives. And we learned 
that the relationships that we have developed with our veterans 
over the years is very important to maintain.
    So the RFP is out there. What that is going to do is to ask 
for external help in areas that VA does not have expertise. It 
is network development and maintaining the network in 
potentially processing claims and in paying bills, and in some 
of the other administrative areas that we have put into the 
RFP.
    We believe we are going to have to phase in that RFP over 
the next year, because we can't do everything at once and we 
want to do this well. Again, another lesson that we learned 
from the Choice Program when we tried to turn it on across the 
country all at once in 90 days.
    So I think that this is a well-thought-out plan and I think 
we all align well.
    Mr. Walz. Okay. I think all of us are trying to get 
simplicity here. A lot of those failures were complexity. So 
you talked about consolidating into a single program. A few 
bills on today's agenda seek to make changes to Veterans 
Choice. In your opinion, based on the fact the Committee is 
discussing draft legislation to consolidate CARE, does it make 
sense to do that in best practices? Because it is well 
intentioned, but once again, we are talking about consolidation 
and streamlining, and we are proposing things to do carve outs 
and start different tracks.
    Secretary Shulkin. Well, there were a lot of really good 
ideas presented on the first panel and there is no doubt that 
everybody is addressing significant issues with the various 
bills. I think that we would have to sort of go through them 
one by one. Some are absolutely essential to do.
    Our family from Texas, there is no reason we shouldn't be 
able to take an unrelated or non-veteran donor and be able to 
help a veteran, that is absolutely clear. Others, I think that 
we would want to do is to make sure that we are not making the 
program more complex by setting a whole bunch of different 
rules.
    But the intents of these programs are all well designed, 
focusing on suicide, military sexual trauma, mental health 
issues, and we want to work with the Members and the Committee 
to make sure we can accomplish that.
    Mr. Walz. I appreciate that.
    I yield back, Chairman.
    The Chairman. I thank the gentleman for yielding.
    Mr. Bilirakis, you are recognized for 5 minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman, I appreciate it 
very much. And thank you, Mr. Secretary, for thinking outside 
the box and putting our veterans first, I really appreciate 
that so very much, and being so open-minded when it comes to 
this.
    Can you speak to how you envision VA assessing and 
monitoring the quality of care received in the community, and 
whether you believe community providers should be required to 
meet or excel the same quality standards VA providers are 
required to meet? And if so, how would you accomplish that? Is 
that something the VA can do on its own or will it require 
legislation?
    Secretary Shulkin. Yeah, Congressman, we have a very 
extensive set of metrics in which to do that, but I have to my 
left Dr. Clancy, one of the country's experts on this and it is 
her area of responsibility, so I am going to ask her to talk to 
that.
    Dr. Clancy. So it is a very, very important question. The 
issue of what you can learn about the quality of care in the 
community is a picture that is changing and growing rapidly, 
because more and more people want to know. If I am going to 
seek care from Dr. Hill or Dr. Roe, how do I know that that is 
the right provider for me?
    It is a bit spotty right now, but we are working with 
private sector partners, and they too are facing increased 
demands from the private and public sectors to be far more 
transparent about their care. Right now, the greatest 
transparency that we see is in cardiology, because their 
professional organization has been building this out for a 
while, but we will see more and more of that over time.
    And that becomes a big resource for us to be able to hold 
ourselves accountable that we are providing care that is at 
least comparable, and hopefully better, than that provided in 
the private sector. But it is also going to be, as Dr. Shulkin 
just said, a key part of our decision matrix in terms of when 
are veterans eligible for Choice or care in the community.
    Mr. Bilirakis. Thank you. Thank you. Please continue to 
communicate with us on that issue.
    Mr. Secretary, Doctor, of course, please respond to 
concerns that the $2.1 billion Congress provided in August to 
supplement the Choice Act, the fund will run out before the end 
of the 6-month period that money was intended to cover. How 
much money is in the Choice Act now and do you have any 
concerns that the VA will over-obligate that fund before the 
end of the year?
    So we just want a report on what is there.
    Secretary Shulkin. Yes. There were some erroneous reports 
earlier that we were quickly running out of money on that fund, 
that is not the case. We do plan on the $2.1 billion lasting 
until the end of the year. As you know, you authorized this 
again in August, so we believe we will get through the end of 
the calendar year.
    I think as the Chairman said and I reiterated, we believe 
there is some urgency to get this done before the December 
recess so we don't fall into crisis. We are tracking the 
financial projections on the $2.1 billion and it is tracking 
according to plan; we follow it every week.
    Having said that, this is a very challenging program to do 
financial projections on. I know it sounds like it should be 
easy, but when you have to record your payments before, when 
you have to obligate your funds before you provide the service, 
it is like looking into a crystal ball and trying to guess what 
services a veteran will use, and no other private sector 
company would do that.
    So that it is very tough for us to do this, but we are 
doing the best we can and we think that we are on plan.
    Mr. Bilirakis. Okay, very good. Thank you.
    Skilled nursing care centers were not included in the 
Choice Program as an eligible provider, as you know. Utilizing 
existing resources like skilled nursing centers could help 
alleviate access issues for quality care, again, in our own 
communities.
    Does the VA support provider agreements for skilled nursing 
centers? And can you explain potential benefits or initial 
concerns?
    Secretary Shulkin. Yes, we do support that.
    Right now, as you know, Medicare reports on the quality of 
community nursing centers and many of the most popular or 
highest quality nursing centers won't deal with the VA because 
of the complexity of our Federal contracting rules and the 
requirements that we put in place. Provider agreements and 
being able to do this directly with the skilled nursing 
facilities with less burdensome contracting rules would help 
veterans, it would allow us to have access to the best centers 
that are out there in the community.
    So we would very much support that.
    Mr. Bilirakis. Thank you for that input, I appreciate that. 
Thank you.
    I yield back, Mr. Chairman.
    The Chairman. I thank the gentleman for yielding.
    Mr. Takano, you are recognized for 5 minutes.
    Mr. Takano. Thank you, Mr. Chairman.
    Secretary Shulkin, my first question is about the Veterans 
Crisis Line. I recently came back from a codel to visit 
deported veterans living in Tijuana, Mexico. I traveled with my 
fellow Committee Members Representatives Correa and Rice, and 
while there we learned that veterans abroad can't access the 
Veterans Crisis Line. We tried calling from several different 
cell phones and land lines, but couldn't get through. This 
doesn't just affect deported veterans, it affects any veteran 
living or traveling abroad who may need immediate access to the 
VCL.
    While I understand today's draft legislation to study the 
VCL doesn't focus on veterans abroad, has the VA looked into 
creating a toll-free line that veterans could call when they 
are out of the country?
    Secretary Shulkin. You know, I will ask the Members that 
are--Dr. Clancy and Dr. Zephyrin. I was not aware of that and I 
don't see any reason why we wouldn't want to do that. Our goal 
with the Veterans Crisis Line should be to help anybody who 
needs help and I was not aware that you couldn't call from 
abroad and reach the number.
    So that is something that I don't think would be 
technically difficult to do and we should be able to do that.
    Mr. Takano. I thank you for that answer, Mr. Secretary. 
And, you know, we have many deported veterans who wore the 
uniform of the United States, some in combat, one veteran was 
actually at the barracks in Lebanon that was bombed, and I 
believe veterans like this should be able to get access to that 
crisis line.
    What kind of resources or support would the VA need from 
Congress so that veterans could access the VCL from anywhere in 
the world?
    Secretary Shulkin. Well, as I said, I don't see it as a 
technically difficult process to have. You know, on the back of 
your credit card you have one phone number when you are trying 
to reach it domestically and one internationally. So I think 
that we should be able to work with our telecommunications 
provider to set up a toll-free number.
    Mr. Takano. Well, I certainly hope to engage with you on 
this issue further.
    Secretary Shulkin. Yes.
    Mr. Takano. Secretary Shulkin, two of the draft bills 
before us today make changes to the VA's graduate medical 
school education residencies, including the VA's CARE Act. I 
was thrilled when the Choice Act included 1500 residency slots 
to help train and attract doctors to the VA.
    In part, thanks to Choice, the University of California 
Riverside School of Medicine in my district has been able to 
build an academic affiliation with the VA Loma Linda Health 
Care System to gain residency slots and begin treating veterans 
in our local CBOCs.
    I would like to ask unanimous consent right now to insert 
into the record a letter from Dr. Deborah Deas, Dean of the UCR 
Medical School of Medicine, commenting on the current program 
and the program bills we are discussing today.
    The Chairman. Without objection, so ordered.
    Mr. Takano. Thank you, Mr. Chairman.
    Dean Deas raises questions about what incentives residents 
have to enter into the service-obligated residencies in the 
draft legislation. What incentive is there for veterans to 
apply for these residencies? And I think that is a concern 
about whether or not they would apply.
    Secretary Shulkin. Well, first of all, thank you for being 
a consistent champion on this effort.
    Mr. Takano. Of course.
    Secretary Shulkin. I know that you have strongly supported 
the expansion of graduate medical education and strengthening 
people joining VA as a career.
    This has been my private sector life, working in academic 
centers and running graduate medical education programs, so I 
have an opinion on this, and I'm sure the Dean does too and I 
would be glad to follow up with her.
    We are now in a situation where there are more U.S. medical 
school graduates than residency spots. So it is becoming 
extremely competitive to get a graduate medical education spot. 
If the VA expands the number of spots available, I believe 
these will be highly competitive positions for highly 
competitive candidates.
    The best asset that the VA has is its academic partners, 
thanks to General Bradley in 1946 and his vision of 
establishing these teaching relationships. So you are going to 
have the very best medical schools and residency programs in 
the country expanding spots and medical students deciding 
whether they want to apply for those spots or not, even if they 
are tied to giving back service to the VA.
    So I believe it will be an experiment whether they are 
competitive. I believe these spots will fill. I believe our 
academic partners have terrific teaching programs and people 
will want to be in those residency spots.
    Mr. Takano. Wonderful. I think the question is whether our 
most competitive medical students will want those residency 
spots. But I wish I could ask you a couple more questions, but 
my time is up and I will submit them for the record, and they 
are related to mainly the residencies.
    But thank you so much for your testimony.
    The Chairman. I thank the gentleman for yielding.
    General Bergman, you are recognized for 5 minutes.
    Mr. Bergman. Thank you, Mr. Chairman and Ranking Member 
Walz. And Dr. Shulkin, it is always good to see you and Dr. 
Clancy and Dr. Zephyrin here. I know you appear before us quite 
regularly.
    Dr. Shulkin, you mentioned earlier that VA must take back 
customer service. Does that mean that the VA will be moving 
towards, shall we say, reducing third-party contracts which 
naturally create, if you will, a disconnect between the VA and 
the veteran?
    Secretary Shulkin. Yes, I think that is exactly what it 
means. And, Dr. Zephyrin, maybe you want to expand on that.
    Dr. Zephyrin. Sure, absolutely. Thank you for your 
question.
    So by taking back, taking back the administrative services 
and really connecting with the veteran directly is going to be 
critical. When we talked with veteran stakeholders, when we 
talked with community providers, when we talked with our staff 
at the medical centers, that was the area that was most lacking 
in Choice. And so with our new CCN, we will actually be taking 
back scheduling, taking back communication with the veteran, 
and really the veteran will really--and also taking back care 
coordination as well, so that we are interfacing with veterans 
directly.
    Mr. Bergman. Thank you.
    Also, I have this was a news release dated July 7th, 2016 
about ``VA Conducts Nation's Largest Analysis of Veteran 
Suicide.'' You know, we have talked a little bit before about 
those 20-some veterans a day and the breakdown of, as I look at 
the numbers here, the question still is a little bit unanswered 
in my mind of those veterans, especially in the OIF/OEF, who 
have actually been in the fight. Because we know that in an 
all-recruited force, that we have not an all-volunteer force in 
this country, an all-recruited force, that the demographics of 
those young men and women who join and, you swear an oath to 
support and defend the Constitution, that doesn't necessarily 
reflect a cross-section of the age-eligible people in our 
society.
    Further take that into that subcategory of those who did 
sign, those who did complete training, those who did deploy, 
but those who deployed let's say into areas that didn't put 
them out on combat patrols, in combat convoys, and different 
things that are those natural mental stressors.
    What I am still looking for is how we--we, you know, the 
VA, in conjunction with DoD--continue to dissect the relevant 
data to see where the stressors are. And I just, I mean, if you 
have any comments, anybody, I would like to hear them.
    Secretary Shulkin. Well, our data analysis capabilities 
have been limited. We are able to identify those that are 
deployed out of country and so we do some analyses that way, 
but we have not been able to do the finer analyses that you are 
talking about, about what type of conflict and what their 
duties have been. We continue to work with the Department of 
Defense on that.
    What we do know, and I am sure you are aware, that there 
are clusters of suicides that come out of specific units, and 
they may be exactly the types of factors that you are talking 
about. And so we are working with particularly the Marines in 
some of the recent clusters of suicides to try to dissect that 
and understand that further.
    Mr. Bergman. Well, it is relevant and essential that we 
don't create support structures that don't hit the target, if 
you will, because the goal is to help our veterans work through 
those naturally difficult and stressful times that life gives 
all of us, work them through the rough spots and a, you know, 
one-size-fits-all, cookie-cutter approach does not work.
    And thank you, thank you for continuing to lead and to make 
those tough decisions as only a secretary of a department gets 
to do. So thank you for continuing to do that.
    And, with that, I yield back.
    The Chairman. I thank the gentleman for yielding.
    Ms. Brownley, you are recognized for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chairman, and thank you, Mr. 
Secretary, for your continued service to our Nation's veterans.
    I wanted to ask a question relative to telemedicine. You 
heard our discussion earlier and I am very, very interested in 
breaking down barriers, so that telemedicine certainly can be 
utilized for our veteran community. And Representative Thompson 
and I have worked on the VETS Act bill and I can assure you, it 
has taken almost a year to get consensus really from all of the 
stakeholders, internally and externally, to get consensus 
around this bill.
    And then I have noticed that in your proposal that you have 
chosen different language around telemedicine. And so I was 
wondering if you could tell us a little bit, you know, why and 
for what purpose your approach is?
    Secretary Shulkin. Yes. Well, first of all, thank you for 
leading this and this is very important. As you know, VA is 
already the largest provider of telehealth services, but those 
barriers that you have identified are real and we want to get 
them addressed.
    I am not aware of any meaningful differences between what 
you are trying to do and what we are trying to do. We very much 
support your bill, and I would be glad to go back and 
understand why there are language differences, but your bill I 
think hits exactly what we want to do.
    The one area that I know that we were concerned with and 
that some of our stakeholders or outside stakeholders were 
concerned with is, is that we were only seeking authorities for 
VA employees and VA clinicians, and not trying to expand this 
beyond into the community providers, which I think is a whole 
different set of issues. But I looked at your bill and I don't 
see any problems with it.
    Ms. Brownley. Well, I am happy to hear that answer. I 
think, you know, our interpretation of the language in your 
proposal would expand the use of telemedicine, which, you know, 
I think in the future we want to get there. But basically, the 
way I understand it, it would include contracting authority or 
other community care options, which is, you know, taking those 
community clinicians and saying, yes, you can use telemedicine 
too. And I think, obviously, the stakeholders and so forth 
involved in this are very worried about liability issues and 
other kinds of things, and certainly liability from the VA if 
this was extended that way.
    So I think that is where the rub is, so to speak. So I 
certainly would like to pursue further the conversation.
    Another question are really around choke points in the 
system and I think back in March the GA testimony laid out a 
lot of different choke points, you know, the VA preparing and 
sending the veteran's clinical files or the contractors waiting 
10 days to hear back from the veteran. So I am wondering from 
you and the VA perspective on how you are going to address some 
of these choke points.
    Secretary Shulkin. Yes. I mean, I invite either of you to 
join in on this.
    Many of these choke points are related to the 
administrative complexity of running multiple programs. As you 
know, we have seven different ways of choosing how we pay for 
community care. We don't seem to get exactly the spending rate 
out of each of the buckets to align all the time, which is the 
difficulty with our financial projections. But what we want to 
do is to simplify this, to take some of the red tape out, to 
put veterans more in control of their decision-making, in many 
cases take having to do unnecessary steps and multiple calls 
completely out of the way.
    I think that will eliminate many of the choke points, 
probably not all of them, and we are going to continue to have 
to work at this system until we can get it so it is completely 
user-friendly, but I think what we are proposing is a big step 
forward.
    Ms. Brownley. Thank you. And just lastly, I only have a few 
more seconds left, I think, you know, health record 
interoperability is going to be, you know, a big savior to all 
of this, but I guess I would just like to hear your perspective 
on the feasibility and the timing. I mean, when do you really--
and I really want an honest answer here--when do you really 
think we will have true interoperability?
    The Chairman. Thirty seconds or less.
    Secretary Shulkin. Okay. We have given Congress a 30-day 
notification of our intent to negotiate a contract that would 
give us the true interoperability with the Department of 
Defense. We released last week in the Federal Register an RFI 
for industry to help us with interoperability for community 
providers. This is a total package where that is what we seek, 
real and full, true interoperability for veterans.
    Ms. Brownley. Thank you.
    I apologize, I yield back.
    The Chairman. I thank the gentlelady for yielding. Four and 
a half minutes next time around.
    [Laughter.]
    The Chairman. Mr. Higgins, you are recognized for 5 
minutes.
    Mr. Higgins. Thank you, Mr. Chairman, and I thank the 
Ranking Member for your leadership in drafting this Choice 
legislation that would better serve our veterans.
    And, Mr. Secretary, I thank you for your continued 
dedication towards the same cause.
    The newly established coordination between the DoD and the 
VA is long overdue and it is just great to hear as a veteran. 
And I believe this will help ensure, you know, a seamless 
transition for our veterans. It is just a commonsense approach, 
which the bipartisan nature of this Committee and your own 
dedicated efforts certainly reflect a commonsense approach that 
we are all looking for.
    I was pleased to see that the VA included in its draft CARE 
legislation provisions allowing for the certain use of urgent 
care walk-in medical facilities. Would you please speak to how 
you and the VA envision the use of urgent care facilities for 
our veterans?
    Secretary Shulkin. Yes. This would be an added new benefit. 
We think having a veteran have to drive 100 miles to get a lab 
test or a flu shot or something simple for a minor illness just 
doesn't make sense, it is not good for veterans. So we would 
add a benefit.
    A national network of urgent care would be developed by our 
third party. We would allow veterans two visits a year under 
essentially their current structure, which would be no payment 
for service-connected veterans and a small copay that currently 
exists for non-service-connected veterans. After two visits a 
year, there would be an additional or a copay that would be 
required, so that we could control the cost of a new benefit, 
but still allow veterans to have access to these services in 
their community.
    Mr. Higgins. And this would in its very nature expand the 
choice available to--
    Secretary Shulkin. Yes.
    Mr. Higgins [continued]. --our veterans. There is a large 
difference between driving 5 blocks to have a sprained ankle 
treated or driving 50 miles or 100 miles and waiting 9 hours to 
get the same treatments.
    Secretary Shulkin. Exactly. Yes, this doesn't exist today, 
so it would be a new benefit.
    Mr. Higgins. Yes, a reasonable copay is certainly something 
that most veterans would not argue about.
    I was also pleased to see the VA included provisions to 
enable medical facility sharing with other departments, as well 
as expanded and enhanced use lease authority. Could you please 
elaborate on the VA's future vision for facility sharing and 
extended use leases, sir?
    Secretary Shulkin. Yes. Well, first of all, I think you are 
absolutely right, Congressman, that there has never been a 
closer relationship and better working relationship with the 
Department of Defense, and I have to thank Secretary Mattis for 
that spirit of cooperation.
    We now have discussions going on all over the country about 
where the Department of Defense has excess capacity and where 
we have veterans that need care and services, and vice versa. 
And so we are working to figure out what makes sense for 
veterans, active servicemembers, and the taxpayers in coming up 
with a number of different plans and facilities.
    And so what you are going to see, I think we are asking for 
some ability even in this legislation to avoid having to 
exchange bills. You know, we are probably spending more on 
administrative costs than we are on taking care of, you know, 
our veterans in this case. So we want to try to decrease some 
of the barriers and regulations to doing more of this work 
together.
    Mr. Higgins. Thank you, sir, for your answers. And I again 
commend you and your staff for working tirelessly as we 
endeavor to reform the VA and provide greater service for our 
veterans that certainly deserve it.
    Mr. Chairman, I yield back.
    The Chairman. I thank the gentleman for yielding.
    Ms. Kuster, you are recognized for 5 minutes.
    Ms. Kuster. Thank you, Mr. Chairman. And thank you, 
Secretary Shulkin, for being with us.
    I want to first thank you publicly for your prompt response 
and support in New Hampshire to the problems that we are having 
at the Manchester VA and the changes that you are making to the 
administration there, and we look forward to continuing to work 
with you. And in particular the task force that is looking into 
how to restructure availability of access to health care for 
every veteran within the State of New Hampshire.
    So along those lines, how will the VA consider geographic, 
seasonal, and other issues around eligibility? And, in 
particular, can you comment on the reasonable-distance 
standard? In New Hampshire, we don't have a full-service VA 
hospital and people have to travel long distances in the 
mountains and the snow. How will these decisions be made? Is it 
a case-by-case basis, is it subjective, or are there 
guidelines?
    Secretary Shulkin. Yes. Great, great questions, and I think 
the Chairman was referring to this as well where he said the 
details are very important in this.
    The short answer is, is that we want this done on clinical 
criteria. So we want a provider and a patient making the best 
decision for the patient. When it comes to New Hampshire, 
neurosurgery, as long as it is not urgent or emergent, we do 
believe will still be referred to regional providers. Maybe in 
the case of New Hampshire continue to flow into Boston.
    But we don't believe that you should have strict mileage 
criteria or wait time criteria, because there are patients 
that, frankly, are not able to get into VAs who may live 20 
miles away where it is best for them to get care in the 
community. So this 40-mile standard just isn't what is best for 
them. There are others that may live 45 miles away, but getting 
into a regional medical center is not a problem.
    So these are going to be individual, clinical decisions, 
and based on feasibility and access, and the drive time in the 
West may be easier to get to in a certain amount of mileage 
than it would be in a more congested area.
    Ms. Kuster. Okay. Thank you.
    Another question about VA CARE proposal, you include 
innovative pilot programs, and I wanted to ask if you have ever 
considered--in your proposal you include them between 
Department of Defense and Veterans Affairs, I have legislation 
to establish pilot programs to coordinate health care resources 
with other providers, including specifically federally 
qualified health centers, and I just wonder if you have thought 
about that.
    For example, in my rural district that is where the 
veterans frequently get their health care. It is a 
comprehensive health care with dental and eye care and 
podiatry, which I know has a big, long wait list at the VA. 
Have you considered that and would you consider a pilot 
project?
    Secretary Shulkin. Well, as Congressman Higgins said, we 
have included the piece about the Department of Defense, but, 
frankly, it just makes sense to do this with all Federal 
agencies. Federally qualified health centers, absolutely; 
Indian health service, absolutely. We have just announced the 
first time a relationship with the Public Health Service, so 
Public Health Service officers can begin to serve in the VA.
    So, 100 percent we believe this is good for veterans and 
good for taxpayers, and we want to pursue that.
    In addition, we want to pursue the things that we know the 
private sector has already shown makes sense. Our current 
system allows us to pay a Medicare fee schedule flat, that is 
not happening anymore in the private sector. I used to run a 
very large accountable care organization. We know these work, 
we know that value-based purchasing works, differential 
payments. We want those same systems for the VA, and we want 
that authority and flexibility to test these out.
    Ms. Kuster. Good. Thank you.
    And just very briefly, at the end there is VACA, the 2014 
bill had 1500 positions for graduate medical education 
residency, have those all been used? And why not just increase 
that program? Why do you start over with a new program?
    Secretary Shulkin. Thank you for this question. I wanted to 
try to get this with Representative Takano, but I didn't have 
time.
    So you gave us 1500 positions, we have only used 750 of 
them. And the reason is, is that the program, the way it was 
designed, well intentioned, for all the right reasons, we 
learned some challenges over these last 3 years. The first is, 
is that we are only allowed to pay for the time the resident is 
in VA. So the academic partners have to come up with their own 
money to at least match that and they are capped out at the 
Medicare rate. So that is essentially one of the big problems.
    So the other problem is, is that as we train more 
residents, they don't necessarily come back to the VA. We are 
training them and they are going out into the community, which 
is fine, it doesn't necessarily help VA.
    So what we are proposing is to do this smarter: allow the 
VA to pay for the entire cost of the resident, that way 
academic programs are going to want to train more residents, 
because that is what they do and that is what they do well, but 
tie it back to a service component back into the VA.
    So it is what we have learned over the last 3 years, why we 
have only used half the spots you gave us. We would like to 
suspend that program and invest that money back into a new, 
better-designed program.
    Ms. Kuster. Thank you, and I am well over time.
    Thank you, Mr. Chairman. I yield back.
    The Chairman. I thank the gentlelady for yielding.
    Dr. Dunn, you are recognized for 5 minutes.
    Mr. Dunn. Thank you very much, Mr. Chairman.
    Let me echo the comments that have been made by Ranking 
Member Walz and others that you have made yourself very 
available to this Committee and that is a breath of fresh air, 
and also you are a great partner, you and your professionals. 
Thank you so much.
    So I want to address the VICTOR Act, that is one of the two 
organ transplant bills that are sitting before us. And I know, 
with your background you understand the barriers that time and 
distance impose, specifically on transplant medicine. How do 
you suggest that we can better meet the specialized needs of 
the transplant patients in a consolidated community care 
program?
    Secretary Shulkin. Right. Well, first of all, I have 
already indicated my strong support for allowing us to be able 
to access a non-veteran donor. And I think that the way that 
you presented your testimony today just makes a great deal of 
sense. You want what is best for veterans, and you know that 
getting organs and getting it done well is a challenging 
program anywhere in the country.
    So what I think we want to try to come out of this with, 
and hopefully to work closely with you to do this, is to make 
sure that veterans that need access to organs have the best 
available access. And in particularly cases of urgent 
transplantation, we do want the ability to use community 
programs, but we also want to make sure that we maintain the 
strength of the transplant programs in the VA. So it is this 
balance between making sure that the 14 sites or 21 different 
transplant programs that we have are strengthened and 
supported, and at the same time making sure that veterans who 
need access to those community programs have them.
    Mr. Dunn. Thank you. Can you compare the costs of 
delivering, just say a liver transplant in a VA transplant 
center as compared to a civilian center?
    Secretary Shulkin. Well, one of the--our transplant 
programs do many things; they care for pre-transplant
    work-ups and post-transplant work-ups. So when you take a 
look at the entire package of these 21 different transplant 
programs at 14 sites, we think that they are less costly than 
the private sector alternative.
    When we send patients out through the Choice Program for 
transplants, we pay the Medicare fee schedule. It is very 
challenging to get a private sector hospital to accept the 
Medicare fee schedule rate for transplantation. So that what we 
are seeing is, is that the costs in the private sector can be 
in some cases higher. Now, quality is what makes the biggest 
difference, because you don't want to have to re-transplant an 
organ, that is where it can get really costly.
    Mr. Dunn. So if I could just make a comment to your answer, 
which is the other transplant bill, Judge Carter's bill, which 
was the living related donors being covered in the VA, is a 
great answer for keeping your VA--
    Secretary Shulkin. Yes.
    Mr. Dunn [continued]. --centers busy and actually, as you 
say, training up to snuff. That is a beautiful dovetail there 
of those two.
    So it is fair to say, listening sort of in between the 
lines here, that there is no clinical purpose that is served by 
requiring veterans per se to be driving past these other 
centers to get to VA centers?
    Secretary Shulkin. Right.
    Mr. Dunn. Very good. Thank you very much.
    Mr. Chairman, I yield back.
    The Chairman. I thank the gentleman for yielding.
    Mr. O'Rourke, you are recognized.
    Mr. O'Rourke. Thank you.
    Mr. Shulkin, I first want to begin by again thanking you 
for your service, and commending the Administration for 
nominating you and the Senate for confirming you. We are 
grateful for your responsiveness and the work that you and your 
team are doing.
    I want to make sure, though, that I don't let you off the 
hook. Ms. Brownley asked you a very good question and you 
didn't answer it. She asked you how long it would take to get 
an electronic health records system going, true 
interoperability with Department of Defense, and much of your 
plan is predicated on ensuring that we confidentially and yet 
effectively share private patient health record information 
with providers in the community, how long for us to be able to 
implement that effectively 100 percent?
    Secretary Shulkin. Well, thank you for holding me 
accountable, but, you know, I was sensitive to her time that 
was running out.
    Mr. O'Rourke. Don't use too much of mine, because I have 
other questions.
    [Laughter.]
    Secretary Shulkin. Okay. The answer is, once we negotiate 
the contract, it will be 18 months from the time that the 
contract is complete to the first site in VA going up.
    Mr. O'Rourke. How about, to fully answer my question, to 
get to 100 percent?
    Secretary Shulkin. We are thinking 7 to 8 years.
    Mr. O'Rourke. Okay. It is good for us to know and to be 
aware of as we think about implementing this that we are 
looking at 7 to 8 years. And this is not a scientific analysis, 
but I have yet to see a VA budget for time or cost exceeded, 
you know, it usually goes beyond the budgeted time, beyond the 
budgeted costs. So I think that is important for us to--
    Secretary Shulkin. This is a new VA, Congressman.
    Mr. O'Rourke. Well, I am encouraged by what you have done 
so far, but I want to make sure that we are going into this 
eyes wide open.
    Secretary Shulkin. Yes.
    Mr. O'Rourke. You have seen a number of proposals to reduce 
veteran suicide, many just here today. You know that 
Representative Coffman has been an exceptional leader on this 
Committee on this. We were able to join him on a proposal to 
reduce suicides from those veterans who have an other than 
honorable discharge.
    You have told me you are doing everything you can to your 
administrative capacity to admit people on an emergency basis. 
For those OTH veterans who are precluded from getting care now, 
we are dependent on the bill that we passed out of this 
Committee and I believe has been passed in the Senate from 
getting to the floor, and I want to work with Chairman Roe and 
the Administration to make sure that it has got the political 
push to get that done. I think that is going to make a huge 
difference.
    I want to ask you, using an example in El Paso, how you can 
both now administratively meet the crisis, and, two, how you 
will be able to do that through your proposed legislation.
    While we have seen the number of total health care 
providers delivering mental health care in El Paso increase 
from 68 providers to 112 today, we just got the third quarter 
sale data and we see a drop of 222 percent in continuity of 
care for mental health care provision. I can only imagine what 
that means for the veterans who have been trying to receive 
that care.
    I want to know you are going to meet that challenge in El 
Paso and in VA medical centers and clinics around the country, 
because I think it is directly connected to ensuring that more 
veterans live and do not take their own lives. And, two, and I 
think this is related, how you are going to better focus on 
hiring and retaining the best primary care providers. We have a 
real crisis in El Paso and, from traveling Texas, I am hearing 
it in community after community, people unable to get to see a 
primary care provider or losing that primary care provider and 
not having a replacement.
    So I asked you a bunch, we have got about a minute and a 
half left, I will let you answer.
    Secretary Shulkin. And you are going to make sure I answer 
them all.
    Mr. O'Rourke. Okay, thanks.
    Secretary Shulkin. Very quickly. Look, our top clinical 
priority is suicide. We also are very grateful to 
Representative Coffman for his leadership on other than 
honorable. We took some initial steps, we think that, working 
with you, we need to go much further. You are going to hear 
some announcements from us in the month of November. We are 
going to take some additional, very big, bold steps to address 
the transition problem, addressing suicide with active 
servicemembers coming out of the Department of Defense. We are 
working with the Department of Defense on that now.
    We are working on new, innovative ways to address the 
mental health issue. We are looking at new ways of using 
telehealth to get more access for mental health, some ideas 
that we haven't yet shared with you, but we are working on 
right now. We need your help on hiring and retention.
    As you know, I am not very happy that our retention and 
recruitment dollars were cut in half to pay for the CARE Act. I 
have asked for the authority to spend more on retention and 
recruitment without any additional dollars to the budget. I 
want the flexibility to put money towards paying our providers 
more and providing retention and recruitment bonuses where we 
are needed.
    We need greater direct hire authority on those mental 
health workers that are now Title 5 or Title 38 hybrids, such 
as psychologists and licensed social workers. It is too hard to 
get them hired and we need that. We need it from you. Just put 
it into the bill, direct hire authority for mental health 
professionals, and that would be a great help to us.
    We essentially are trying to hire 1,000 more mental health 
professionals. Over this past year, we went backwards by 45. We 
hired 900, but we lost 945. So we need to do more. And primary 
care doctors are challenging as well.
    So we would love to work with you on additional help.
    Mr. O'Rourke. Thank you.
    Thank you, Chairman, for the additional time.
    The Chairman. I think that is something we can put in the 
bill. I have no objection to that at all.
    Dr. Wenstrup.
    Mr. Wenstrup. I think it goes to Mrs. Radewagen.
    The Chairman. Mrs. Radewagen, you are recognized.
    Mrs. Radewagen. Thank you, Mr. Chairman and Ranking Member, 
for holding this hearing today. And I also want to thank 
Secretary Shulkin and the rest of the witnesses for their 
testimony.
    As you know, Secretary Shulkin, one of the challenges 
veterans in remote areas like the U.S. Territories face is a 
lack of access to care. Not only do they find themselves 
traveling ludicrous distances to receive VA care, but often the 
local community is also lacking sufficient health care 
facilities to meet their needs closer to home. Even if this 
very important legislation passes and veterans are able to take 
advantage of community care, little will change if there is no 
accessible care in their communities in the first place.
    I have a few questions, I am going to put them all out 
there.
    Secretary Shulkin. Yes.
    Mrs. Radewagen. Mr. Secretary, your draft legislation would 
allow the VA to coordinate and share resources with other 
Federal agencies for the purposes of developing shared medical 
facilities. How can this be used for the benefit of our 
veterans in remote areas? Will this bill allow VA to develop or 
build upon medical facilities in the territories that meet care 
standards and allow our veterans to receive care close to home?
    Another proposed solution to provide care for veterans in 
remote areas is the use of telehealth, as was mentioned, 
something we are addressing today with Representatives Thompson 
and Brownley's bill, H.R. 2123.
    Mr. Secretary, VFW's written statement alleges that some VA 
providers are actually reluctant to provide telemedicine across 
state lines under the authority granted by an executive order. 
Similarly, AFGE's written statement for the record alleges that 
VA providers have serious concerns about risks to their state 
medical licenses even if such authority were granted via 
legislation, and have received no assurances that VA would 
offer assistance to them if state licensing boards pursue 
disciplinary actions against them for violating state licensing 
requirements.
    Would you please respond--
    Secretary Shulkin. Yeah, yeah.
    Mrs. Radewagen [continued]. --to those allegations?
    Secretary Shulkin. Well, thank you for continuing to keep 
at this issue of providing our veterans in remote areas access. 
It is extremely important. These are not easy answers or else 
we would have probably done it already, but we are as committed 
as you are to finding solutions.
    So working with the other Federal facilities, as 
Congressman Kuster had mentioned, absolutely, we need to do 
that, and we are doing that with the Department of Defense and 
other Federal agencies.
    On telehealth, I can't give a stronger assurance to our 
providers that they absolutely will be protected using these 
telehealth authorities. We have the Department of Justice that 
has agreed to do that. I practice from here in Washington to 
Oregon. I do not have an Oregon license, I have a Pennsylvania 
license and a New York license. So they can see me doing it, 
and I want them to feel assured that they can and should be 
using their medical capabilities to help veterans in remote 
areas using telehealth.
    Mrs. Radewagen. Thank you.
    Mr. Chairman, I yield back.
    The Chairman. I thank the gentlelady for yielding.
    We have, you know, Dr. Shulkin and I came along way before 
we used telephones to do health care, and we have done that for 
a long time. And we need to clear up, because we are going to 
have to clear up how Medicare compensates, that is a different 
discussion and I think Ms. Brownley's bill with G.T. Thompson, 
Congressman Thompson, really narrows the focus of the VA. And 
that is a great pilot program, I think, for the country to try 
it and see how it works. I totally agree with that.
    Ms. Esty, you are recognized.
    Ms. Esty. Thank you very much, Mr. Chairman. I thank you so 
much, Dr. Shulkin. And I would just say on behalf of the 
Committee, we do want [audio difficulties] I think we have 
agreement on that. And so I did want to follow up on mental 
health issues and in particular on the issue about military 
suicide prevention, which remains and I think you had properly 
noted as your number one clinical and in fact sole clinical 
priority.
    I was reminded of this in a conversation with a family last 
week who a year ago their son was in crisis and wound up with a 
standoff with a SWAT team. They tried calling the crisis line 
and found it not at all helpful. Fortunately, the situation was 
resolved with a friend who was a veteran, who was able to get 
into the house and help. But that was last year.
    So we need to hear from you, I know you are committed to 
this, what resources you need, what training is necessary, 
because, frankly, we were just fortunate that a friend was able 
to get there in time. So please know how committed we are to 
providing you the resources, but it is not just numbers of 
people on the phone, it is the quality of what they receive, 
and in that crisis situation it just--you know, fortunately, we 
were able to get a live person there in time, but it was a 
reminder of that, of that challenge.
    I wanted to follow up with your conversation with 
Congressman O'Rourke about retention and recruiting and 
retention of mental health professionals. I have a brother-in-
law who worked a long time doing VA psychiatric work and found 
it very frustrating. He felt he did not have the time or 
support to do anything other than write scripts. And that was 
in Southern California and I do think his experience was 
unique.
    So that may not only be direct hires, but that is about how 
their time is accounted, what directions they are given and 
latitude they are given to practice medicine as licensed 
psychiatrists. So I would ask you to work with us and provide 
the resources you need to do that.
    Again, it is not just having the bodies, it is a special 
population. So when we are losing ground, you are losing 
talent, you are losing experience. And so, again, in looking to 
recruit, I think that retention is an issue. And I don't know 
what you are doing. Are you systematically interviewing people 
who are leaving to find out what their reasons are? Is it 
money? My guess is it probably has more to do with the 
conditions in which they are practicing.
    Would you care to comment?
    Secretary Shulkin. Well, I am going to rely upon my 25 
years of private sector experience as well.
    The number one reason why people leave their jobs is 
usually not money, so you are correct, it is usually their 
relationship with their boss, and whether they believe that 
they are valued and they are heard. And too often I think that 
we have not paid enough attention to the management structure 
and have the right people leading our clinicians. So that is a 
focus of ours.
    Burnout among health care professionals in general is huge. 
We have had a dedicated effort to reducing burnout. We have 
reduced the number of alert notifications on our computers. And 
in fact burnout is actually better, if you can be better in 
burnout, than in the private sector where the billing and 
productivity and financial pressures are much larger than you 
even see in the VA.
    But these are real issues. So I think your insights are 
right and we are trying to focus on it. We have a lot of work 
to do.
    Ms. Esty. You mentioned needing to have congressional 
direct authority to do direct hires. Are there other elements 
that you need us to take action on to facilitate this critical 
need now to recruit and retain the best mental health 
professionals to deal with this cherished population, who has 
served this country, who we owe this more than anything?
    Secretary Shulkin. I would love to see a comprehensive 
hiring and retention act for VA. We have met last week with 
OPM, we have asked them for a number of waivers. They seem 
willing to do this, but we haven't gotten the final responses 
from them.
    We know that it just takes too long to hire people into the 
VA. We know that in many cases in Southern California--maybe it 
is not just Southern California, but that would be an example--
our pay caps for nurses are now 20 to $30,000 below, our caps 
between what starting salaries are in the private sector. We 
have asked for some consideration of that as well.
    So we would love to work with you on a comprehensive hiring 
and retention authorities.
    Ms. Esty. Thank you very much, I really appreciate that. 
And because I think we really do want to get this right, but we 
need guidance from you about what are the stumbling blocks that 
you are facing right now in doing this.
    Thank you and I yield back.
    Mr. O'Rourke. Dr. Wenstrup, you are now recognized for 5 
minutes.
    Mr. Wenstrup. Thank you. Thank you very much for being with 
us today, it is always a pleasure, and I mean that sincerely.
    You know, everyone who is a veteran at one time wore the 
uniform. That is a given for everyone who is a veteran. And 
there is a transition and you mentioned some interactions with 
DoD, and my feeling is that we should have more interactions 
with DoD, which I know you are working on from the medical 
record on down, and I think that is important.
    Post-traumatic stress to me is normal. Having served, it is 
a normal thing to reflect on where you have been and what you 
have done. Now, I deployed at 46 years old and I think that is 
a big difference between 19 years old. And as a doctor, I had 
seen trauma, et cetera, so it was a little bit different as you 
come back. When you come back as a Reservist, for example, they 
say, oh, you have 90 days before you go back to work, and I 
said I am going next week. And part of that is because I was in 
a job where I was very necessary and the last thing I wanted to 
do was come home and be unnecessary. And I think that is what 
we face today.
    We talk about suicide prevention. You know, I feel for the 
VA, because the VA only gets to be reactive, they don't get to 
be proactive, because the proactive component needs to come 
when you are still in uniform. And, as we know, most of the 
suicides don't occur when you are in uniform, and I would 
contend that is because you are still necessary.
    And I would like you to weigh in with me on this, because I 
feel, serving on both Armed Services and VA, we need to do a 
better job in uniform that, you know what, when you sign up to 
serve your country, there is a success at the end of that. And 
we need to be more proactive on the uniform side that when you 
take that uniform off, you know where you are going, you are 
going to school, you are going to use your GI Bill, you know 
what you are going to major in because it leads to a job, or 
you are going to a job. And we need to do a better job on that 
end. We talk a lot about suicide prevention, I think we can do 
a lot more if we are proactive. And so amongst the mental 
health providers, I am wondering if they are coming to any kind 
of consensus in that arena to say, I am getting them too late.
    Secretary Shulkin. I don't think we could say it better 
than you did. I think you are exactly on target with that.
    Mr. Wenstrup. So, hopefully, we can engage and I will be 
more than happy to reach out, serving on both Committees, to 
try and make those connections. And we have a few Members like 
Mr. O'Rourke that serve in the same capacity and I know it is a 
point of passion for him as well.
    But I would like to get some feedback from the mental 
health providers that you have to get their opinion on what we 
can do on the front end to try and be more helpful to the VA 
ultimately.
    Secretary Shulkin. There is no doubt that I think you have 
hit the most important part of why. Being in service, when you 
talk to veterans that are struggling the most and, you know, 
there is a great film coming out soon called Thank You for Your 
Service, which really highlights many of the things you are 
saying, and many people struggling say, if I could go back, I 
would go back, because I knew I belonged, I felt like I was 
contributing, and they miss that when they transition out.
    Mr. Wenstrup. Thank you. I look forward to working with you 
further on that.
    I yield back.
    The Chairman. I thank the gentleman for yielding.
    Miss Rice, you are recognized.
    Miss Rice. Thank you, Mr. Chairman.
    Just to kind of continue along Dr. Wenstrup's questioning. 
First of all, thank you, Dr. Shulkin, for being so focused on 
the mental health of our veterans. From what I have heard, it 
sounds like there is a focus on addressing their particular 
needs, but the statistic that keeps coming back to me is, if 
you take the number of 20 servicemembers killing themselves a 
day, and I think the number is 16 of them were not accessing 
their benefits through the VA--or 14.
    So I guess my question is, you can do telehealth, you can 
increase community care, you can do all of that, but if you 
can't identify these people before they separate, it is a lost 
cause. So in any of this plan, do you have a thought process 
about how we can engage veterans before they separate?
    And I am glad to hear that, you know, there is a lot more 
coordination between the VA and DoD, because that was where a 
lot of people fell through the cracks during their separation 
process, but can you just, you know, expound on that?
    Secretary Shulkin. Well, two things, and, Dr. Clancy, I 
would invite if you want to add anything.
    First of all, within by the end of November, we will be 
announcing a new plan with the DoD to work exactly on that 
issue of the transitioning servicemember. We know that there is 
a very high risk or a higher risk of suicide in the first 12 
months after leaving service. So that is what we are trying to 
address. And we are fortunate, we now have Dr. Keita Franklin, 
who had headed up the Suicide Prevention Office at the 
Department of Defense, now detailed over to VA. So that is one 
of these reasons you are seeing a much closer working 
relationship than ever before between these two agencies to 
deal with this transitioning issue.
    Secondly, you are also going to see this next month, a 
public service announcement come out with Tom Hanks talking 
about how do we reach out to those 14 servicemembers and what 
do you do as a member of the community to help identify those 
14--
    Miss Rice. Oh, that is great.
    Secretary Shulkin [continued]. --veterans that aren't 
getting access to services at all the right times. So those are 
two important things.
    Dr. Clancy?
    Dr. Clancy. Some of the people of the 14 veterans who are 
not using our system now, some of them will have recently 
transitioned and we are very, very excited about working more 
closely with Defense in this area, but the largest proportion 
is actually in veterans over 55.
    Miss Rice. Right.
    Dr. Clancy. And so we have got to figure out ways to reach 
out to those particular individuals, some of whom may be quite 
isolated, which may in fact be a big part of the underlying 
issue.
    To that end, I serve as the public sector co-chair on a 
national alliance focused on suicide prevention. You know, my 
private sector co-chair is from the railroads, because on 
average they have one person a day suicide by lying on tracks 
and so forth. This is really a broad U.S. public health 
emergency.
    So we are trying to exploit all of those levers as well and 
reach those who are not plugged into other obvious sources from 
our system to VSOs or what-not.
    Miss Rice. Great. Thank you.
    Mr. Chairman, I want to thank you so much for coming to New 
York and visiting our VA in Northport. I can't tell you what it 
did for morale there and it was a great visit, and I thank you 
for your time.
    So my question to you, Mr. Secretary, is with the focus on 
doing more care in the community and putting more financial 
resources there, I can tell you that whenever we ask our 
veterans, raise your hand if you like the service that you get 
at the VA Northport, the majority of the people say, yes, I 
like it. That is not to say that at some point they wouldn't go 
outside of it. But I guess my question is, how do I assure 
those veterans that this push to doing more care in the 
community, which I support and I think they want, is not going 
to mean taking resources away from their VA that they feel very 
committed to.
    And I also want to thank you for your commitment to 
realigning a lot of the bill. I mean, Northport in some ways is 
falling apart and needs massive money, but that might not 
necessarily be--you know, it has buildings that need to be 
taken down, but their concern is, the VA may have problems, but 
it is my VA and I like the VA, and I want to make sure that it 
is not going to be sacrificed for more care in the community.
    Secretary Shulkin. Well, it is one of the things, finding 
the way to strengthen the VA, at the same time to make sure 
that we are meeting the current needs of veterans, is really 
exactly what I am focused on and I know it is one of the things 
that works well about both the House and the Senate.
    When you take a look at the bill that was just passed, the 
Choice extension in August, it did exactly that. It gave 
resources to allow veterans to go out into the community, but 
it also invested more resources into the VA, 28 new leases 
authorized by you to allow us to do that. The President's 
budget, while it provides more money for community care, 
provides an even greater amount for investment back in the VA.
    So I would assure your constituents, your veterans that 
that is our focus, strengthen the VA, but at the same time make 
sure that veterans aren't waiting while we are strengthening 
the VA, so that they can get care in the community.
    Miss Rice. Thank you very much, Mr. Secretary.
    And I yield back. Thank you, Mr. Chairman.
    The Chairman. Thank you. And as my trip up there, I said, 
look, there are a lot of strengths here and you have five CBOCs 
out here that could be strengthened. And taking the care, what 
we are doing is taking the care, as we are everywhere, away 
from big hospital systems where you have got to go in and get 
lost, and take the care to the veteran, which is the CBOC. It 
puts it right in their community, it is close by, and they 
really like that. So I think that is one of the things you can 
do there.
    Mr. Coffman, you are recognized.
    Mr. Coffman. Thank you, Mr. Chairman.
    Secretary Shulkin, the draft legislation for VA Care in the 
Community Program broadly provides that DoD would be an 
eligible provider for community care.
    First of all--and then I think you talk about a 2-year 
pilot program for that. Why is a pilot program necessary, 
number one, and, number two, to what extent have you worked 
with the Department of Defense on this?
    Secretary Shulkin. Well, the pilot program would be to 
avoid having to spend a lot of administrative time billing each 
other. And right now, I think at the end of last year the 
difference between what VA and DoD owed each other was like $30 
million, and we figured it cost us $40 million to bill that. 
You know, the DoD is not set up for billing commercial 
insurance, so the greater requirements are on their end. So we 
are trying to simplify this process.
    The reason for a pilot would be to make sure it doesn't get 
too imbalanced, because they have an appropriation for health 
and we have an appropriation for health, and we don't want it 
to fall, the burden too much on each other.
    I happen to think it is going to equal out, you know, that 
the amount we will use DoD and vice versa will be relatively 
awash, and that is why I think we could save the taxpayers 
money by not billing each other.
    Mr. Coffman. Okay. So you envision then that U.S. military 
personnel or active duty personnel and their families would 
then utilize the VA system?
    Secretary Shulkin. Yes. And they do and we charge them for 
it and we use--we send veterans to DoD facilities and they 
charge us for it. And so the pilot would be, let's take down 
some of the administrative burdens and let's see what happens.
    Mr. Coffman. But I think it is fairly limited right now 
where you are serving military personnel and their families, is 
it not?
    Secretary Shulkin. Yeah, and we wouldn't expand, the pilot 
would not be expanding the eligibility criteria; the pilot 
would say, Where there are areas where we are working closer 
together, let's make it easier to work closing together and 
save the taxpayers some dollars.
    Mr. Coffman. Because I think there is no question that we 
have to work to make the VA better and we have done some things 
in this Committee like reforming the personnel system; 
although, I think we probably have a little further to go with 
that. But you really have two different very--two very 
different systems culturally.
    The active-duty military is a solid merit-based system and 
you have a unionized workforce in the VA system, albeit, 
somewhat reformed with recent legislation.
    Secretary Shulkin. Uh-huh.
    Mr. Coffman. So, I do--and we have had patient-safety 
concerns.
    Secretary Shulkin. Uh-huh.
    Mr. Coffman. I am sure we have had them in DoD, but
    we have had some fairly significant patient safety concerns 
in the VA and we really need to get those cleared up when you 
are talking about the families of our military personnel. I 
wouldn't want them concerned about a patient--the patientsafety 
issues. We have to clean them up for our veterans, but until we 
do, I don't want to increase the patient load there.
    Secretary Shulkin. Yes.
    Mr. Coffman. We clearly have excess capacity on the 
military side simply because of the fact that our operational 
tempo is down right now, relative to what it has been. But it 
should certainly plus up again, where we have a casualty flow 
much greater than it is today. So that is really going to vary 
in terms of the military, the Department of Defense's ability 
to handle patients from the VA, but I think it is positive for 
them to do it on the DoD side because we have so many 
providers, quite frankly, that because of the fact that the 
casualty flow is down that aren't getting expense, now we are 
trying to get them into the ER for trauma.
    But doing surgery is doing surgery, and so if we can get VA 
patients, and particularly those who are service-connected 
first in terms of priority, I think that would be very helpful.
    Secretary Shulkin. Yes.
    Mr. Coffman. Okay. And, again, on the mental health issue, 
I just want to say that I get that you are doing a lot of 
things administratively, but we want to set a policy that is 
permanently in motion, beyond this administration. And so it is 
important for you to have authorizing language to be able to do 
that and therein lies the legislation that I have done with 
Representative O'Rourke on allowing ``other than honorable 
discharged'' military personnel--veterans--to be able to have 
access to mental health care.
    Secretary Shulkin. Yes.
    Mr. Coffman. Mr. Chairman, I yield back.
    The Chairman. I thank the gentleman for yielding. Mr. 
Poliquin, you are recognized for 5 minutes.
    Mr. Poliquin. Thank you, Mr. Chairman very much.
    And thank you, Dr. Shulkin, for being here and your other 
great staff; we really appreciate it.
    Mr. Secretary, you have been to Northern Maine a couple of 
years ago when we first met and we really appreciate that. And 
I just want to make sure I make this statement clear to 
everybody who is paying attention to this hearing, is that the 
Choice Act or the Choice Program or Choice 2.0, whatever you 
are going to be calling it going forward, Mr. Secretary, is in 
no way intended to replace the VA; it is just not.
    Veterans love serving time with veterans. They love healing 
with veterans. They heal better with veterans. So, I get this 
and I think everybody on the Committee does; however, there are 
opportunities where it makes so much sense, so much made common 
sense to be able to receive your health care closer to home. 
For example, the Second District of Maine is not the Portland 
area, the Southern Coast area, but it is everything else in 
Maine. It is highly rural, the most rural district east of the 
Mississippi River and it is about an 8-hour drive from one 
point to the other.
    So, where you went, Dr. Shulkin, up in Caribou, it is a 
little bit of a drive to Togus, our only VA hospital in the 
state; the first in the country, I might add, and we are very 
proud of that.
    Secretary Shulkin. Yeah.
    Mr. Poliquin. So, we are very concerned that we continue to 
make sure in the rural part of our country--where about 40 
percent of our population lives, roughly--have access to the 
health care they have earned and they so deserve.
    Now, Dr. Shulkin, I am going to give you something that 
hasn't been asked here today, so I know you will be ready for 
it. You and I have discussed, many times, sat down personally 
with you and your staff--not these two nice folks, but other 
folks about paying your bills on time.
    Now, I am not a bill collector, but I have no problem doing 
that on behalf of my constituents. We have had a number of 
hospitals in my district who have come to us and said--in our 
state, not only in our district--say, look, we love the VA. We 
serve veterans at our hospital, we are a nonprofit property, 
and we are just not getting paid on time.
    Now, I don't worry much, to be honest with you, Mr. 
Shulkin, about the big hospitals who have the wherewithal to 
absorb this, but when I get a call from Calais Regional 
Memorial Hospital in Calais, Maine--where you go all the way 
down, as you hit Canada, take a left; that is where Calais is--
there is not a lot of opportunities out there and when you 
folks owe them 600 grand and I have got to show up.
    By the way, Mr. Chairman, I think I am the only office in 
America that makes house calls now. We just got in a car and I 
said, where are these Health Net folks to try and straighten 
out this problem? We showed up at their doorstep and they were 
awfully nice to us. We spent about an hour. And I thank them 
and I thank you, if you were involved, for sending a few people 
up to Calais to make sure they got paid so they could make 
payroll.
    However, my concern, Doctor, going forward is I don't mind 
making house calls and I will continue to do it to put pressure 
wherever it needs to be to get our hospitals paid. But can you 
assure me now and everybody else on this Committee that this 
new Choice Program going forward is going to be able to fix 
this bill-paying problem?
    Secretary Shulkin. Laurie, do you want to?
    Dr. Zephyrin. Sure.
    Mr. Poliquin. I can see where you passed the buck just like 
that, Doctor.
    Secretary Shulkin. Yeah.
    Dr. Zephyrin. Well, thank you for bringing that to our 
attention, and as you know, we have connected with your 
providers. Part of what we have done is also implement training 
and train the providers in terms of the difference between 
billed charges and Medicare charges, as well.
    The other training we have provided is around submission. 
The one thing about this legislation, it really allows us to 
consolidate into one program with multiple programs and 
multiple eligibility--
    Mr. Poliquin. When is that going to happen?
    Dr. Zephyrin. It is in the CARE legislation.
    Mr. Poliquin. Say it again.
    Dr. Zephyrin. It is in the CARE legislation, having one 
community care program.
    Mr. Poliquin. Great.
    Dr. Zephyrin. So, with one program, that simplifies 
eligibility. We have also been improving our business processes 
moving from manual, because we touch a lot of our claims to 
more electronic processing of claims with our new community 
care network, as well. The TPAs will be providing claims 
processing and we will hold them accountable with measures so 
that they are processing 90 percent of claims--
    Mr. Poliquin. So, it is going to get better. It is going to 
get faster. Members are--house calls, right?
    Dr. Zephyrin. That is correct.
    Mr. Poliquin. Great. Thank you.
    Dr. Zephyrin. Thank you.
    Mr. Poliquin. Dr. Shulkin, I have a little bit of time left 
here. In August, we appropriated about $2.1 billion for the 
next six months to make sure Choice went on. How are we doing? 
How much money we got left?
    Secretary Shulkin. We have, I think, when I saw it last 
week, we have about 1.1 billion left.
    Mr. Poliquin. Are we going to make it through the end of--
    Secretary Shulkin. Let me make sure I am accurate.
    Dr. Zephyrin. A little more. We have about--when we last 
looked for medical care, we have for total, we have 1.4.
    Secretary Shulkin. Yeah, but we need to obligate at the 
very end, about 300,000--about 300 million. So you have to stop 
spending because of the final obligation. That is why I said it 
is about 1.1 billion left in the fund.
    And if you--that is why we will get to the end of the year, 
but not much beyond that, the calendar year.
    Mr. Poliquin. Okay. How can we make sure this is not a 
continuing problem, Mr. Secretary?
    Secretary Shulkin. What we are seeking in the President's 
budget is to permanently authorize the Choice Program, whatever 
we are going to call it--Choice 2.0. And that would allow us 
never to have to go through this exercise of, Are we running 
out of money? We want to permanently authorize this and that is 
where the issue of us identifying some final offsets to pay for 
this comes in, but we think that this is doable and it is the 
right thing to do for veterans.
    Mr. Poliquin. Thank you, Mr. Secretary. I appreciate it.
    Thank you, Mr. Chairman. I yield back.
    The Chairman. I thank the gentleman for yielding.
    Mr. Rutherford. Thank you, Mr. Chairman.
    And thank you, panel, for your very lengthy testimony 
today, and I really appreciate it, Mr. Secretary.
    I want to address the issue of physician-need within the 
VA. And I know in the VA's draft legislation around in the 
minority's legislation, there is a plan to increase the number 
of resident-trainee positions, in exchange for service at the 
VA. And your legislation requests an additional 1500 residency 
slots and the minority's legislation requires VA to increase 
the financial support for positions, some already authorized in 
the Choice Act.
    And it is my understanding that under these plans, 
residents will not necessarily be taking care of veterans, so 
VA could actually be paying for care not for veterans, which is 
one issue and then the real concern that I have, though, is, as 
you know, the way residents choose their residency slots is via 
a matching system in which over 78 percent of medical students 
get their first, second, or third pick. And these slots don't 
come with that service or obligation to the VA.
    Secretary Shulkin. Right.
    Mr. Rutherford. And so my question is: Why would a medical 
student commit to service at the VA when they know that they 
have a three and four chance of getting there, three out of 
four chance of getting their selection?
    Secretary Shulkin. Well, two reasons. First of all, all 
that we are doing is borrowing from the military model where 
students, residents choose to go into the military in exchange 
for it is paid for and it is exchanged for years of service. 
So, we are saying the same thing, which is, we will pay for the 
training of that resident in exchange for service given back.
    The reason why I believe this will be a competitive slot, 
why students will choose this, to do the residency, because of 
our academic partners. We partner with the very, very best 
medical schools in the country and the very best residencies. 
And it is prestigious to get your training at major academic 
centers.
    So, our partners are not the community hospitals that are 
training many of the residents, but they are the topteaching 
hospitals in the country; I believe they will be competitive 
spots.
    Mr. Rutherford. So, you don't fear that the VA would simply 
get those who don't get their match, which is going to be those 
folks at the bottom academically?
    Secretary Shulkin. Well, the academic centers, I will tell 
you, having been in charge of graduate medical education for 
places like the University of Pennsylvania--
    Mr. Rutherford. Uh-huh.
    Secretary Shulkin [continued]. --those places will leave 
their slots empty and not take non-competitive candidates. So, 
it is the academic partners who are choosing these residents, 
not the VA.
    Mr. Rutherford. Okay.
    Secretary Shulkin. I believe they are going to choose very 
competitive residents.
    Mr. Rutherford. So, it costs, roughly, 100,000 a year to 
train a resident. So, assuming a 4-year residency and a 4-year 
VA commitment, the total cost is 400,000 for--so, for the 1500, 
it would be 600 million; of course, that is without the 
administrative cost.
    I actually have a bill that we have introduced--and I don't 
know if you are familiar with it--but it deals with a residency 
loan payback program that would cost you about 160,000 a year 
for four years for that same VA--with that same VA commitment, 
and that cost would be $240 million for the same number of 
doctors committed to VA. VA would get to choose the doctors 
that they want and I will tell you that they'd also be serving 
veterans while they are in that program.
    Would that not be a better program than the graduate 
medical education proposals now?
    Secretary Shulkin. Dr. Clancy said the same thing to me the 
other day. So, these are the two ways of accomplishing what we 
both are trying to do.
    Mr. Rutherford. Right.
    Secretary Shulkin. And we very much would like to take a 
look at that bill and if that gets us to where we need to get 
to, absolutely, because I think there is--that is a very sound 
way to do it. We were actually trying to create some more slots 
for the country because, frankly, as I said, there are more 
U.S. graduating medical students than residency spots.
    Mr. Rutherford. Right.
    Secretary Shulkin. But I absolutely want to do the thing 
that achieves the objective at the best value for the taxpayer 
and we will work with you on that.
    Mr. Rutherford. And the best service for our veterans.
    Secretary Shulkin. Absolutely.
    Mr. Rutherford. And I know that is at the top of your list, 
as well. Thank you very much.
    Mr. Chairman, I yield back.
    The Chairman. Mr. Secretary, one final question, and I 
think probably, you know this well, is I have been eager for 
almost nine years now to take up legislation for our Blue Water 
Navy veterans--
    Secretary Shulkin. Yes.
    The Chairman [continued]. --and place it up on a mark-up 
agenda. And from our discussions, I know that you share my 
desire to pass this Blue Water Navy bill as soon as possible. 
We may be adjusting some of the legislative language and I hope 
these changes will allow us to get this bill on the floor as 
soon as possible to help the remaining thousands of Vietnam 
veterans.
    Do I have your support for moving forward on this drafting 
legislation language to accomplish that goal?
    Secretary Shulkin. There is no doubt, our Vietnam veterans 
have waited way too long for us to bring this to resolution. 
The problem, as you know, is this will not be guided by 
scientific evidence. I wish it--that is good policy for us to 
be able to get solid scientific evidence, so we just have to do 
the right thing.
    And I appreciate your leadership on this and you wanting to 
bring this to resolution. I will be meeting this afternoon with 
Blue Water Navy veterans. I am absolutely committed to working 
with you and the rest of the Committee to bring this to 
resolution. They shouldn't be waiting any longer. Thank you.
    The Chairman. Thank you, Mr. Secretary.
    Mr. Walz, do you have any closing comments?
    Mr. Walz. Just again, thank everyone here. Mr. Secretary 
and your team, thank you. To the VSOs, again, it is not--it 
wasn't a pat on the back to say this is the way it is supposed 
to work; you are not supposed to get patted on the back for 
what you are supposed to do. But it is so rare now to bring 
folks together to continue to get this right and I appreciate 
the candid discussion and we move to draft proposal.
    So thank you, and I yield back.
    The Chairman. Okay. And I thank the gentleman for yielding.
    And just a final comment: This is an incredibly important 
meeting, because it is going to shape how care is provided for 
the VA and we will have other changes, but basically just to 
outline it succinctly, it will be a primary care-oriented 
system, just exactly like our system is around the country now. 
The gatekeeper or your primary doctor will be managing your 
care. You will be able to get some of that care either in the 
VA or outside of the VA, depending on where the best care is. 
And we have heard many good ideas today about how care should 
be provided both, in and out, of the VA. So, that is one idea.
    Two, consolidating seven to one makes absolute sense. It 
takes confusion out of administrative burdens and costs. 
Implementing to EHR is a huge undertaking, but that is very 
much a part of this, how you share back and forth.
    One of the things that we have a problem now with is 
sharing information where a doctor is referred a patient from 
the VA, how they access the VA's record currently to see what 
is going on with that patient.
    Facilities is another issue that we will bring up later, 
along with a new, very innovative new way to practice health 
care, which is telehealth. And who knows what that is going to 
look like in five or ten years? We are just on the beginnings 
of doing that. If you need a specialist and you are at North 
Port and that specialist is in Denver, you might be able to 
access that specialist now and very quickly be provided care. 
So, there are huge opportunities with what we are doing.
    This is a big undertaking, and Mr. Secretary, I wanted to 
just amplify what Mr. Walz and the rest of the Committee said: 
Thank you for being available and thank your team for being 
available and working with us, hand-in-hand, to try to get this 
as right as we possibly can. So, thank you all for being here.
    Secretary Shulkin. Thank you.
    The Chairman. You are dismissed and we will bring our next 
panel in.
    And now, I would like to welcome our third panel for the 
morning and with introductions, first, Mr. Adrian Atizado, the 
Deputy National Legislative Director for Disabled American 
Veterans, welcome; Roscoe Butler, the Deputy Director for 
Health Care of Veterans Affairs and Rehabilitation Division of 
The American Legion, welcome; and Kayda Keleher, the Associate 
Director for the National Legislative Service Veterans of 
Foreign Wars of the United States. I thank all of you all for 
being here and the hard work you do every day for veterans each 
and every day.
    Mr. Atizado, you are now recognized for 5 minutes.

                 STATEMENT OF ADRIAN M. ATIZADO

    Mr. Atizado. Mr. Chairman, Members of the Committee, on 
behalf of our 1.3 million wartime service-disabled veteran 
members, I want to thank you for inviting DAV to testify at 
this legislative hearing.
    DAV is a nonprofit veteran's service organization dedicated 
to a single purpose and that is to empower veterans to lead 
high-quality lives with respect and dignity. We are pleased to 
offer our views on the bills under consideration by the 
Committee and for the sake of brevity, I will limit my comments 
to just a few bills on today's agenda.
    DAV support H.R. 2123, the VETS Act of 2017, which would 
help more veterans receive care from VA-employed providers 
through telehealth. We believe VA, a system designed to meet 
unique needs of ill and injured veterans offers certain patient 
protections not equally available elsewhere. The ability for a 
VA health care system to hold VA providers accountable through 
training, research, and the direct oversight, helps establish a 
standard of care veteran patients enjoy in this otherwise 
emerging field of health care delivery.
    We are supportive of VA's efforts and the recent regulatory 
notice to support Secretary Shulkin's Anywhere to Anywhere 
health care initiative. We applaud VA for these efforts.
    We would also like to thank Representative Banks and his 
staff for their commitment to work with DAV, the VA, and the 
VSOs to strengthen the draft bill for a study on the crisis 
line. DAV Resolution 245, adopted by our members and our most 
recent national convention, supports improvements in data 
collection and reporting, relative to suicide prevention; 
therefore, DAV supports the intent of this bill.
    We are committed to working with a sponsor and the 
Committee to ensure the data-collection efforts proposed in the 
bill does not have unintended consequences, particularly on the 
care being delivered as well as VA's current efforts in 
collecting and analyzing the effectiveness of their program.
    Now, regarding the draft bills for Care agreements with the 
state veterans home, the draft bill for the Care Act, and a 
revised draft bill, making permanent, the VA Care in the 
Community program, we would first like to express our deep 
appreciation for your commitment, Mr. Chairman, Ranking Member 
Walz, all the Members on the Committee, particularly the staff, 
for their hard work, as well as VA, in their--finding a way 
forward to reform the VA health care system.
    Evidence by many of DAV's recommendation reflected in the 
Committee's revised draft bill, pursuant to our resolution, 
calling for the strengthening, reforming and sustaining the VA 
health care system. DAV is pleased to support many of the 
provisions in these measures, which would improve access to 
care in the community, while preserving and enhancing the 
unique benefit and vital services VA provides to DAV members 
and all eligible veterans.
    There are provisions we continue to have concerns and 
others which we would oppose, such as a proposal to eliminate 
the current practice of offsetting a veteran's to payment when 
VA is paid by their health insurance. We urge the Committee to 
stop this proposal from moving forward, as the Committee has 
done, with regards to the 10-year COLA round down. We believe 
that asking veterans to pay for their health care after they 
have served and sacrificed is simply not the right thing to do.
    DAV and our Independent Budget partners have proposed a 
comprehensive framework to reform the VA health care based on 
the principle that it is the responsibility of the Federal 
government, to ensure that disabled veterans have proper access 
to a full array of benefits, services, and supports promised to 
them by a grateful Nation. In order to achieve this goal, our 
comprehensive framework has four pillars: Restructure, 
redesign, realign, and reform.
    Mr. Chairman, these structures really are guard rails that 
we hope Congress will take into account when they draft their 
legislative proposal moving forward. In those instances where 
VA is unable to deliver timely veteran-centric care, university 
affiliates, other health partners, such as DoD, service travel 
organizations, state organizations, such as state veterans 
homes, aging and disability network and community providers 
should be able to meet the obligation to care for our Nation's 
veterans.
    Our goal is to strike a balance between access to care, 
simply access, and access to veteran-centric care. This really 
deals with the creation of local veteran-centric integrated 
networks to ensure that veterans do not fall victim to 
fragmented care that is rampant in the private sector.
    Mr. Chairman, DAV and our members urge serious reform of 
the VA health care system to address access problems by 
preserving the strengths of the system in its unique model of 
care. This concludes my statement. I would be happy to answer 
any questions you may have.

    [The prepared statement of Mr. Atizado appears in the 
Appendix]

    The Chairman. Thank you.
    Mr. Butler, you are recognized.

                 STATEMENT OF ROSCOE G. BUTLER

    Mr. Butler. Chairman Roe, Ranking Member Walz, and 
distinguished Members of the Committee of Veterans Affairs, on 
behalf of our national commander, Denise H. Rohan, and The 
American Legion, the country's largest patriotic wartime 
service organization for veterans, compromised of over two 
million members and serving every man and woman who have worn 
the uniform of this country, we thank you for inviting The 
American Legion to testify today and share our position 
regarding The American Legion's position on pending legislation 
before this Committee.
    You have my written testimony, which discusses The American 
Legion's views and positions in great detail; therefore, I 
would like to devote the majority of my time discussing the 
highlights of today's hearing, the Choice Program.
    The 2014 wait-time scandal helped to expose what veteran's 
service organizations have been warning lawmakers about for 
years; that the VA has been systematically underfunded and was 
being forced to manage the budget and not budget to need. Where 
there is a vision, anything is possible. The draft legislation 
introduced by this Committee, combined with the legislative 
requests for VA begins to address Congress and the VA's vision 
for the evolution of a 21st century medicine at VA in a way 
that will allow the department to provide greater access and 
develop stronger relationships with non-VA providers, moving 
toward a more integrated system.
    This is just the first step in a long overdue 
transformation and The American Legion expects greater emphasis 
on VA's modernization and successive legislation that is able 
to capitalize on VA's strengths and core competencies, while 
ensuring that veterans continue to have access to the best care 
anywhere. The American Legion is aware of criticism that 
suggests that this transformation moves purposefully close to 
increase privatization of VA's services and does not dismiss 
these criticisms as without merit.
    Nefarious intentions can, indeed, serve to undermine 
modernization efforts and The American Legion will continue to 
be a watchdog and ensure further political interests do not 
diminish the capacity or value VA represents in the medical or 
veteran community. It is with this in mind that The American 
Legion asks this Committee to include a requirement in the 
final legislation that requires VA to ensure an annual report.
    For the sake of time, I ask that you refer to our written 
report to review these six requirements. This effort to refine 
and make permanent, a consolidated community-care program 
begins a redesign of VA's infrastructure and capabilities that 
will next cause a review of what services VA hospital and 
community-based outreach centers perform and how.
    The legislation, language introduced by this Committee 
provides greater detail in a number of areas that VA request 
lacks and The American Legion would only caution the Committee 
to remember the number of times that VA, VSOs and the Committee 
were called to introduce and support legislation needed to fix 
unintended consequences of the original Choice legislation.
    The American Legion is particularly grateful for the 
Committee's diligent and well-articulated procedures, as 
detailed in primary and specialty care in Section 101 of the 
Committee's draft. The American Legion appreciates this 
Committee's dedication and hard work while producing this 
comprehensive draft, and in our written report, I have 
highlighted some areas we believe need further discussion. And 
for sake of time, I will only discuss two.
    Included in the VA request is a provision that seek to 
increase capacity while saving on emergency room visits by 
creating or contracting with a network of walk-in clinics. The 
American Legion believes Section 202, improving veterans access 
to walk-in care, will be a benefit for VA patients and will 
decrease the prevalence of illnesses that if left untreated 
because patients are deterred from going to the emergency room 
until their illness or injury becomes so severe that more 
costly and time-consuming measures are needed to stabilize and 
cure the patient.
    The American Legion is concerned about the introduction of 
copay features that would be assessed for care directly related 
to illness or injuries caused or aggravated by a veteran's 
honorable service.
    The American Legion looks forward to working with the VA 
and this Committee to come up with a plan to mitigate these 
charges.
    Thank you, again, Chairman Roe, Ranking Member Walz, and 
distinguished Members of the Committee on Veterans Affairs. I 
appreciate the opportunity to present The American Legion's 
views and look forward to any questions that you may have.

    [The prepared statement of Mr. Butler appears in the 
Appendix]

    The Chairman. Thank you very much, Mr. Butler.
    Ms. Keleher, you are recognized for 5 minutes.

                   STATEMENT OF KAYDA KELEHER

    Ms. Keleher. Chairman Roe, Ranking Member Walz, and Members 
of the Committee, it is my honor to represent the women and men 
of the VFW and our auxiliary.
    Over the last three years, the VFW has surveyed thousands 
of members asking them about their VA care. Their answers are 
clear; the majority of VFW members like and prefer using their 
VA health care. They want to fix, not dismantle, their health 
care system.
    This is why the VFW is grateful for the hard work this 
Committee and its staff has put into moving forward, not just 
with consolidating community care, but overall improvements for 
a better and stronger VA.
    While VFW members may prefer using VA, the VFW understands 
that sometimes care in the community is necessary. Whether that 
decision is based on a provider shortage for one veteran or 
travel barriers for another, the VFW thanks this Committee and 
VA for their efforts to ensure if a patient should use VA or 
community care as a clinical decision made between a patient 
and their provider. This is also why the VFW believes it is 
imperative for VA primary care providers to remain the 
coordinators of care.
    The VFW is also pleased to see in the Committee's draft 
legislation that this program would finally be made 
discretionary. This transition from mandatory has been a long 
time coming and will ensure that the program not only becomes 
permanent, but also assists in avoiding a gradual erosion of 
the VA health care system. Though, we must add that the VFW 
would oppose using COLA round downs to offset funds for the 
Choice Program.
    In VA's Care Act, there are multiple improvements made to 
personal practices in collaborations with Federal partners, 
which is something the VFW is eager to see passing into law. 
Some of these include telemedicine authorities, medical 
residency programs, partnering with other Federal agencies, and 
a pilot program between VA and DoD health care facilities.
    Moving forward with this legislation, this Committee must 
make sure that all unintended consequences are avoided to the 
fullest extent possible. This includes making sure no veterans 
are forgotten, such as those in need of a live-organ transplant 
or IVF.
    The VFW opposes H.R. 3642. All veterans deserve access to 
mental health care, whether that access is needed due to 
chronic mental health disorders, current life events, or 
previous sexual trauma. And aside from data showing that VA has 
the best mental health care for veterans, VA must also have an 
active role in coordinating all community care.
    The VFW has opposed handing out universal Choice cards like 
candy in the past, and we still do. Not only is it opening the 
floodgates to allow veterans to receive lesser quality care, 
but it fragments VA's current continuum of care, and this 
legislation would do so for one of the most vulnerable 
populations within the veteran community.
    If all VA survivors of sexual trauma are given a full 
access card to private providers, they will be faced with most 
of those providers probably not understanding their veteran-
specific needs. VA would have no guarantee of receiving their 
health records or knowing whom to offer the assistance of VA 
sexual assault coordinators. If a veteran who has been sexually 
traumatized needs care which the VA is unable to provide, then 
they should absolutely be able to get that care. But, if the 
needs of the veteran can be met by VA, then they should be met 
by VA.
    Survivors of sexual trauma are among the highest for 
increased risk of suicide and we all know that 14 of the 20 
veterans who die by suicide each day are not currently using VA 
health care. The VFW believes Congress and VA must do all they 
can to assist sexual trauma survivors and that means increasing 
their ability to access VA.
    The VFW understands the intent of Representative Banks' 
draft legislation, but must oppose it as written. Though this 
legislation does not explicitly state VA must begin gathering 
data not currently collected by VCL, the VFW is concerned that 
passing legislation requiring VA to report data not currently 
collected will result in VA having to collect that data and 
then gamble with the possible unforeseen consequences.
    Without asking for personally identifiable information, VA 
would not be able to report some of the information required in 
this legislation such as the number of veterans who contact VCL 
who have every received VA hospital care or medical services. 
By forcing VCL to ask for this information to obtain data, the 
VFW is concerned veterans would be frightened to use the crisis 
line, and I am confident, and we are all aware, how fast 
veterans like to spread information that they are dissatisfied 
with VA. And, unfortunately, we believe that would only further 
defer veterans from using the VCL.
    The VFW is supportive of using data already collected by VA 
and VCL, such as the data referred to those who use the suicide 
prevention coordinators or those whom VCL must send emergency 
dispatch to assist. This is why we believe removing reporting 
requirements for information not gathered by VA must be done 
before legislation is passed.
    The VFW would be happy to support this legislation once it 
removes those reporting requirements and looks forward to 
working with the Committee to make sure that happens.
    Chairman Roe, Ranking Member Walz, and Members of the 
Committee, this concludes my testimony. Thank you, again, for 
the opportunity to represent the Nation's largest combat-
veterans organization, and I look forward to your questions.

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

    The Chairman. Thank you, all and I thank the panel. And I 
am going to go rather quickly because I just got a note that we 
have votes at 12:50 to 1:05, so I will move on.
    A couple of things, first of all, thank you for working 
with us. And do any of you all just briefly see any deal 
breakers? We have really worked hard on this legislation with 
you all and other stakeholders, including the secretary. Is 
there anything in there that is really a deal-breaker in the 
legislation that we have--that you would say, this absolutely--
we wouldn't support it because of this provision?
    Mr. Atizado. So, Mr. Chairman, based on a revised draft 
that we received, not in particular.
    The Chairman. Okay. We still want to continue to work with 
you, absolutely, to iron out these problems that you all 
clearly brought up and we want to see if we can work our way--
but I mean, is there anything in there that really just--
because we have tried to avoid that and if there is, we need to 
know about it so we can work it out.
    Mr. Atizado. Yes, sir. So, as I mentioned, some of the pay-
fors for the bill is of a concern for our organization. We 
understand that is part of a much larger package and we take 
that with the consideration of this bill. By all means, we will 
continue opposing that, of course, but the overall approach, I 
think is appropriate.
    I think a couple of things that require continued 
clarification and that really deals with the execution of this 
bill from VA's standpoint. A lot of issues with regards to 
coordination of care--VA is required to coordinate care, 
although, some of its tools to do that seem to be a little bit 
hampered. So, we have some concerns, but overall, sir, nothing 
that would come to the deal-breaker, I think.
    The Chairman. And Mr. Butler?
    Mr. Butler. Mr. Chairman, thank you. We really appreciate 
the bill. We think that the House Bill and the VA draft has 
come a long way and working together, you guys will be able to 
deliver, the Committee will be able to deliver a very 
comprehensive bill. So, we don't see any deal breakers.
    There are things in our written testimony, which we stated 
we oppose to--
    The Chairman. Okay.
    Mr. Butler [continued].--but otherwise, we think that the 
bill and VA's draft is a great start.
    The Chairman. Thank you.
    Ms. Keleher. Good afternoon. I would agree with my 
colleagues here that I don't believe that there is anything 
that is necessarily a deal-breaker for the VFW. We mirror 
concerns with the proposals for different pay-fors and offsets, 
but generally speaking, we are very grateful for the Committee 
and staff and how much they have been working with us to iron 
out those technical differences that we have had and seeing 
those changes made in the most recent draft legislation.
    The Chairman. Well, that goes both ways.
    Ms. Keleher. Yes, thank you. There are, as we put in our 
testimony, different provisions we would like to see added into 
your Committee's legislation; Urgent Care, the different 
personnel provisions that are in Title III and Title IV of the 
Care Act and we are happy to continue working with you to see 
if we can get those in there, but nothing that is going to make 
the VFW oppose.
    The Chairman. Well, your point on Urgent Care, I read a 
statistic the other day that as late as 2010, half the care in 
this country is provided, half the visits were in emergency 
rooms. And I think you make a great point; you are seeing these 
walk-in clinics all over the country.
    And the VA is doing a pilot project, I think in California 
and Arizona, and I think those are going to be very helpful to 
us. It may not be ready for prime time yet, but I think it is 
coming, where you have access to walk-in. I mean, maybe, it may 
be the next thing we do, but I think you are spot-on right 
about that, easy, convenient care. Maybe keeping the CBOC open 
until 9:00 or 10 o'clock at night, maybe one provider there.
    I know our practice has an Urgent Care center with it, now. 
We have about 120 providers in our practice that we open early 
in the morning before people go to work. We are open until 
10:00 or eleven o'clock at night. You have x-ray, you have all 
these things that you are able to do. And maybe it won't be 
that comprehensive at every one, but I think if you kept it 
open at the CBOC, I think that is absolutely right. The problem 
is finding providers.
    One of the things before my time is expired that I want to 
get to is when we were in Canandaigua about, what, 3 weeks ago? 
Yeah, 3 weeks or so I visited Canandaigua, and I told the folks 
there and they agreed with me and I said, Look, we are doing 
all this work and you are answering all these calls, but are we 
actually reducing suicide by doing it. And we need to evaluate 
whether we are or whether we are not. That is one thing.
    And two, on Andy Barr--Congressman Barr's--my concern--I am 
an OB/GYN doctor and VA's many times, are not set up to take 
care of women. And we have a program in Tennessee called Guard 
Your Buddy. And the guard commander told me when he first took 
over, I think it was in 2011, he had four--in the first six or 
eight weeks he was a commander, he had like four suicides. They 
had immediate access to people. You pick up the phone, you 
call, you are talking to a master's level person literally in a 
minute or two. They dropped that number by 70 percent. So, we 
know that immediate access to care reduces that.
    And Dr. Wenstrup mentioned some other things. My time is 
expired. I am preaching now, so I am going to yield to Mr. 
Walz.
    Mr. Walz. Well, I would say preach on, brother. We need the 
choir to sing loudly. We know that is who is here.
    But to each of you, thank you all. And full disclosure, to 
the millions of veterans that you represent, those--Dr. Roe and 
I included in that up here--we are grateful. We are grateful 
for that and I think about those folks who are out there in 
Koochiching County, Minnesota sitting there watching if they 
are still awake are watching this thing, but they are engaged 
and that he want to know. And they are sharing their impact--
their experiences and they just want to get care. They just 
want it to be as efficient as it possibly can and they 
understand that that is going to mean maybe some changes and 
some sacrifices.
    But I think Dr. Roe's question is one I would ask you. Keep 
us apprised of redlines. I know they talk about the sausage-
making or whatever. At least the sausage-making here is done in 
the open and it is done forward, and I don't necessarily see 
sausage-making as a pejorative. I represent the Hormel 
Corporation and every can of SPAM is made in my district, so 
sausage-making is good. But you need to let us know on the 
redlines.
    And something Dr. Roe has done that I very much appreciate, 
when I have brought up issues and we have talked about pay-
fors, I think a fair challenge was, well, then help me find one 
that is satisfactory. I would ask all of us and your Members, 
if we can't live with the round down, what would you suggest? 
How do we go about this? And there is a broad array of things 
that we can do to make that happen. So, I am grateful. So, just 
let us know on that.
    I just have one question on another bill, a specific one. 
One of the draft bills on today's agenda seeks to improve 
veterans' access to same-day mental health care, which is a 
goal all of us share. It was part of the emphasis on us working 
together on the Clay Hunt Act and making sure those things 
happen. So, there is great agreement on that.
    But on this one, it removes VA from the process of allowing 
Community Care and nonprofit providers for say who is eligible 
for accessing that care. That idea of the guarantor and the 
coordinator was always--and I bring this up because this is 
nothing new--many of you in this room remember in 2013 in 
Atlanta when we couldn't get in, we gave vouchers to enter the 
private sector, which basically we lost track of those folks.
    Well, it turns out a year later, there were 372 people on 
the waiting list, the back waiting list in the private sector. 
VA's showed zero and it looked like we had great efficiency. 
The problem was we lost total track of them. We lost total 
track of how they were getting their care and many were not 
getting their care. So, I ask you in this, and I know this came 
late to the review on this piece of legislation, have you got a 
chance to review this and what concerns do you have when, 
again, the goal is noble, the goal is shared, but I am very 
hesitant because of our experiences on the guarantor and the 
coordinator, if anyone wants to tackle that if you are ready.
    Mr. Atizado. Mr. Walz, thank you for asking that question. 
And I appreciate you recognizing that we got that bill late. We 
did do a preliminary read on that and based on that preliminary 
read, we are unable to support the SAV Act. I think that is 
what you were referring to, is the SAV Act.
    Mr. Walz. That is correct.
    Mr. Atizado. Simply because, you know, military sexual 
trauma or post-traumatic stress disorder, and the depressed 
disorder that comes from that event requires not just access--
yes, access is important--but the kind of care they get, the 
follow-up care that they need, the full range of services 
beyond just clinical care that VA provides as a provider of 
military sexual trauma care is what appears to be lacking in 
this bill. And so, that is where our concern really stems.
    Yes, it does provide access, but what kind of care is being 
provided? How does it link up with VA? Like you said, a 
coordination of care? Many folks that work in a veterans health 
policy space know that mental health patients in the VA health 
care system require a lot more care and services and benefits 
than just health care and so that is where the weaknesses are 
that I think we see.
    Mr. Butler. For The American Legion, we have not had an 
opportunity to review it, but we will get back to you with our 
comment.
    But for your explanation of what happened in Atlanta, that 
is concerning, and so the coordination of care and all the 
things that have to come together in such a bill like this 
would--we would have to have the assurance that everything that 
needs to occur is articulated in that particular bill so that 
there isn't any unintended consequences. But we will review it 
and get back to you with our official comment.
    Mr. Walz. Thank you.
    Mr. Butler. We will take it for the record.
    Ms. Keleher. Thank you for that question, Ranking Member. 
The VFW mirrors your same concerns with making sure that where 
these five pilot sites would be, making sure VA would have 
access to the health care records, making sure there is the 
continuum of care, making sure that the veterans who may 
possibly use that pilot program still have the ability to get 
into VA for say, sexual dysfunction or whatever other physical 
health--I hate using that term because mental health and 
physical health are all health--whatever physical ailments they 
have.
    And to mirror with your concerns regarding Atlanta in 
seeing if that might be something that would tie into this, at 
the VFW we had psychologists from the Atlanta VA, which we 
worked with the Committee to bid on, after their crisis, they 
had thousands of veterans seeking care in the community that 
they weren't keeping track of those contracts which actually 
ended in, I believe, September and their estimate was they were 
about to have a thousand veterans without access to VA mental 
health care services because they still had the provider 
shortage.
    So, how would that play out in a pilot such as this if we 
were allowing everybody to seek private practice in five 
different location sites?
    Mr. Walz. I appreciate that input. We will follow up on 
this. It is new to it and we have work to do.
    The Chairman. Thank you. Mr. Poliquin, you are recognized.
    Mr. Poliquin. Thank you, Mr. Chairman. I appreciate it. 
Thank you all very much for being here and being a service to 
our country. We very much appreciate it.
    Mr. Dunn has submitted a draft form of a bill, the VICTOR 
Act, H.R. 2601. Are you folks familiar with that? I want to 
make sure we submit a copy of this report. For the record, it 
was in March of 2014 and it was conducted by the Journal of 
American Medical Association and it is entitled, ``The 
Association of Distance From a Transplant Center With Access to 
Wait List Placement, Receipt of a Liver Transplantation and 
Survival Among Our Veterans.''
    And the study effectively concludes that if veterans live 
beyond 100 miles, that they are less likely to be put on a wait 
list or on a list for transplants or a transplant. And they 
have a lower likelihood of actually getting the transplant and, 
therefore, an increased risk of death or severe injury.
    So, my question to you, folks--and Ms. Keleher, if you 
don't mind, I will direct this question to you--the study 
concludes that this 100 mile from a transplant center is not 
arbitrary; it is based on science. And I know that the sponsors 
of this bill wants to make sure that science backs up this 
study and that this is recognized.
    Have you studied this and how can you comment on that?
    Ms. Keleher. Thank you for the question. I will say, I 
haven't seen that study specifically, but the VFW does believe 
that the decision should be based on patient and provider 
decision. We clearly want everybody in need of an organ 
transplant to, aside from actually being able to receive the 
organ, get that transplant done in the quickest and most 
efficient manner for the most likely outcome of survival and 
lack of infection, so on and so forth, later on down the road.
    Mr. Poliquin. Any of the other gentlemen, either of the 
other gentlemen like to comment?
    Mr. Atizado. So, thank you for raising that study. That is 
actually in our testimony with regards to the bill. And our 
organization's position on the bill is such that because we 
don't have a specific resolution that would allow us to support 
the bill, we are unable to take that position. That is to say, 
we wouldn't oppose its favorable consideration.
    You know, clearly, going through a transplant is the kind 
of procedure that could end somebody's life, not just having it 
done, but leading up to it. And I think these bills that look 
at allowing these veterans to be involved in a veteran-centric 
procedure, process and policy, I think is a good way forward 
and hope that this bill does get favorable consideration by 
this Committee.
    Mr. Poliquin. Thank you. Mr. Butler?
    Mr. Butler. The American Legion supported the bill. We 
understand and when we did our analysis of everything, we saw 
an either IG or GAO Report that we included in our written 
testimony that talked about VA experiencing difficulties in 
providing timely access to transplant patients. And we believe 
that that is a critical health care need. Veterans can't 
survive--and the donor--without the transplant and the 
ancillary services immediately following the transplant. That 
is a lifelong event. So, we believe that that is a needed 
service, which we support.
    Mr. Poliquin. Thank you. Mr. Chairman, before I yield back, 
I just want to, for the record, make sure we submit this for 
the record, this study that, in fact, concludes that there is 
worse care for veterans that live beyond 100 miles of a 
transplant center. I know Mr. Dunn from Florida has done a heck 
of a job on H.R. 2601 and I yield back, sir.
    The Chairman. Thank you. And so, without objection, so 
ordered.
    The Chairman. Mr. Takano, you are recognized.
    Mr. Takano. Thank you, Mr. Chairman.
    First of all, I would like to say I want to associate 
myself with Ranking Member Walz's comments earlier about the 
VA's role as a coordinator of care. I think that is an 
essential function of the VA.
    And one of the other bills on the agenda that was added 
late--and I was disappointed it was added late last week and 
didn't provide you all with enough time to review the text and 
prepare testimony--is Representative Gallagher's bill and it 
had to do with the veteran suicide. Have you had a chance to 
review that bill and ascertain whether or not your 
organization's support can support this bill, and starting with 
Mr. Atirazo--Atizado, I'm sorry, Atizado.
    Mr. Atizado. Is this the military SAV Act; is that what we 
are talking about?
    Mr. Takano. No, no. This is the--
    Mr. Atizado. I couldn't.
    Mr. Takano. It is the Same Day Access to Mental Health 
Care.
    Mr. Atizado. Yeah, I think we share the same concerns with 
regards to the comprehensiveness of that and I think that the 
approach of the bill was, if I understand it correctly, was 
concerning about the comparing these services, but I hesitate 
to answer this question in full. If I could answer that for the 
record, Mr. Takano, I would appreciate it.
    Mr. Takano. Please. I would be interested in your response.
    The American Legion?
    Mr. Butler. We did not have an opportunity to review any of 
the bills that came in late, so we are going to have to go back 
and take a look at those and submit our comments for the 
record.
    Mr. Takano. Great.
    Ms. Keleher. The VFW will have to submit for the record as 
well; we don't have an official stance right now.
    Mr. Takano. Already thank you very much.
    Mr. Atizado--I will look forward to those responses--Mr. 
Atizado, in your testimony regarding the minority's draft 
language, you indicated DAV generally supported the intent of 
the section that would provide VA with new authorities to 
incentivize medical students to fill the 1500 slots created 
under the VA CAA; however, you indicated alternative incentives 
should be considered as well.
    Would you care to elaborate on what those alternatives are, 
in your opinion?
    Mr. Atizado. Sure. I would--first of all, I would like to 
take that for the record, Mr. Takano.
    Mr. Takano. Okay.
    Mr. Atizado. Only because I know there are specific--there 
are very specific recommendations that we have and I don't want 
to misspeak. This is a very important issue, Mr. Takano.
    Mr. Takano. I appreciated the secretary's response, I mean, 
he believes that the sheer numbers of medical students 
competing for these slots is going to be enough of an incentive 
for students to compete for slots that will require them to 
serve in the VA; however, my concern is that certain market 
realities may actually put that belief in doubt. And why? 
Because I have no doubt that many medical students will take 
the opportunity to serve at the VA; those slots can be filled.
    My question is: Will they be filled with our best student? 
I think we need to incentivize our best students to serve at 
the VA and I think maybe we--I would love to hear what the 
American--what the DAV has to say about that.
    Anybody else happy to answer that question? If not, we will 
just take it for the record.
    Ms. Keleher, in your written testimony, you mentioned VFW's 
concern on how VA's Care Act continues to treat care in the 
community as a mandatory program. Can you explain why that is 
so concerning to VFW and what it could mean for VA.
    Ms. Keleher. Thank you for the question, Mr. Takano. VFW, 
as well as, I believe, all the VSOs here in front of you, 
support seeing the Choice Program being made into discretionary 
and we are thankful for the legislation containing that. There 
are concerns in the community that if the program were to stay 
mandatory, first of all, we don't want to continuously have the 
crisis that we keep having with having to find money to fund 
them again; it is rather exhausting.
    And also, we were concerned that over time, there would be 
a gradual erosion of VA health care systems. If we are 
continuously having to find money to put into mandatory 
spending for VA and Community Care providers and then we are 
having to put up a fight to make sure VA is receiving matching, 
or at least somewhat close to the similar amount of money so 
that they can continue building VA, whether that be 
infrastructure, IT, hiring more providers, there are various 
things that VA needs to continuously do. So, by making it 
discretionary, that makes sure that we are not continuously 
handing money over that we have to keep finding while allowing 
money that VA already has to--
    Mr. Takano. We would have to continue to ask the question 
about the proper balance instead of it being on auto-pilot 
mandatory spending, we would have to continually ask that 
question and take a look at making sure that our core VA 
programs are being funded properly.
    Ms. Keleher. Yes.
    Mr. Takano. Thank you very much.
    The Chairman. Thank you. I thank the gentleman for 
yielding.
    I now ask unanimous consent that all Members have five 
legislative days to revise and extend their remarks and include 
extraneous material.
    Mr. Walz, do you have any closing thoughts?
    Mr. Walz. Just final thoughts. Thank you, all.
    And, again, I think it is important, sometimes people don't 
process--process does matter. There--out--one of those 
veterans, I saw Joe Bousea [ph] and his service dog were 
sitting next to me and he leaned over to me in confidence and 
said, I don't trust politicians very much, but I am hopeful. I 
am hopeful that you guys can get this together.
    They are watching. They are watching how we act. They are 
watching you, as organizations on what we are doing. And once 
again, I think that word that Joe said, I am hopeful that we 
are in a good spot here, I am hopeful for as your feedback. I 
always remain committed that we can find these answers. And, 
again, if we never lose sight, providing quality access to care 
for our veterans in a timely manner. That is what we are 
looking for.
    So, thank you, Mr. Chairman.
    The Chairman. Thank you, Mr. Walz.
    And I totally agree with that. That is the whole purpose of 
all of these hearings this morning. And one of the challenges 
Dr. Shulkin mentioned was he is going to hire a thousand new 
mental health providers and he lose--and he hires 900 and he 
loses 945, that is going backwards.
    And I think you see that--and as I travel around the 
country to go to VAs and I will do some more traveling in a 
couple of weeks to the West Coast and into the middle part of 
the country, you hear that a lot: We don't have enough primary 
care people. But you also hear that in the private sector. It 
is not just a VA problem; it is a problem of our health care 
system in this country.
    So, what Mr. Takano has done in trying to add new primary 
care slots at VA, and others are going to come up with ideas to 
add more slots, I think those are all good ideas.
    I can't thank you all enough for the work that your teams 
have put in, with putting this Choice Program pilot program--
not pilot, but program together. Without your help, we couldn't 
have gotten to where we are. We have got a few little things we 
have got to change and we will start working on those this 
afternoon. We have got our marching orders.
    And hopefully we can get this marked up. And the reason 
that we need to do that as soon as we can is because the 
Secretary just pointed out how much money we have left in the 
program and I agree with you on the discretionary versus 
mandatory; we need to get it in one pot. We can then find out 
what the needs are and appropriate the money for it. So, I 
agree with that, it makes it simpler to certainly administer. 
As he pointed out, a 13 percent administrative fee is 
incredibly high. That money could be going for health care for 
veterans or a new clinic somewhere.
    So, I want to thank you all very much and without any 
further comments, this meeting is adjourned.

    [Whereupon, at 1:07 p.m., the Committee was adjourned.]


                            A P P E N D I X

                              ----------                              

             Prepared Statement of The Honorable Jim Banks
    Chairman Roe, Ranking Member Walz, thank you for holding this 
hearing today and for including my bill on the agenda. I am proud to be 
a member of the Veterans Affairs Committee in which the focus of our 
work is to ensure the brave men and women of our armed services are 
never forgotten. Our gratitude for our servicemen and women leads us to 
address the personal impact of their service. We are responsible for 
their care and healing.
                            Veteran Suicide
    Suicide is our nation's 10th leading cause of death, claiming over 
40,000 lives a year, almost five times as many people as make up my 
entire hometown of Columbia City, Indiana. This rate has increased by 
over 32% since 2001. Veterans account for 18% of those deaths, even 
though they only constitute 8.5% of the nation's population. Every day, 
20 veterans die from suicide. Veterans are 22% more likely to commit 
suicide. Our female veterans are two and a half times more likely to 
commit suicide than their female civilian counterparts. Post-Traumatic 
Stress Disorder (PTSD) affects 7-8% of the regular population, but for 
those who have served in warzones, it affects between 11-20% of our 
veterans. The invisible wounds of PTSD are a large contributing factor 
to many of the suicides that take place among veterans. As research on 
PTSD continues and treatments are refined, we must remain vigilant in 
addressing the needs of our veterans.
              The Department of Veterans Affairs' Efforts
    In recognizing the increase in veteran suicides from 2001 to 2014, 
the Department of Veterans Affairs (VA) has refocused their services 
for veterans. Part of those efforts is the creation of the 24/7 
Veterans Crisis Line (the VCL) in 2007. The hotline serves as a space 
for those in crisis to discuss their feelings privately. As of May 
2016, the hotline answered over 2.3 million calls and 55,000 text 
messages. Emergency services were dispatched 61,000 times and 376,000 
referrals to VA's Suicide Prevention Coordinators were made to help 
make sure veterans reach further care options. The VCL is a critical 
component to providing direct, immediate care to those in crisis and 
aid in the prevention of suicide.
                         Draft Bill Background
    My draft bill seeks to enable the VCL to be an even more effective 
component in the VA's overall approach to veteran mental health. In our 
information age, the power of data analytics is useful tool to help the 
Veterans Crisis Line continue the mission of decreasing the number of 
veteran suicides. As the current crisis continues, analyzing the data 
collected by the hotline can help determine the efficacy of VA mental 
health services.
    An Inspector General report from March 2017 indicated room for 
improvement regarding data analysis and performance measures. 
Currently, there is no overarching approach to ensure the VA knows the 
efficacy of the VCL in preventing future suicide attempts.
    My bill seeks to ensure the VA has the proper research tools and 
data necessary to continue comprehensively integrating the VCL in the 
VA's mental health services program.
                           Draft Bill Summary
    The draft bill would require the VA to conduct research and prepare 
a report that would provide the following answers:

      The efficacy of the VCL as a conduit for veterans to be 
connected to opportunities for sustained mental health treatment 
through the VA.
      The visibility of the VCL to veterans.
      The efficacy of VA health care in ensuring that those 
receiving physical care find help for any additional mental needs.
      The efficacy of VA mental health care in decreasing the 
chance of a veteran needing to contact the VCL again.
      The efficacy of the VCL as a conduit for non-veterans to 
be connected to opportunities for their veteran friends to receive 
sustained mental health treatment through the VA.
      If the amount of times a veteran contacts the VCL changes 
outcomes.
      The efficacy of mental health care decreasing the risk of 
suicide.

    With these answers, the VA can be further empowered and enabled to 
fight suicide. These answers will allow the VA to determine the impact 
of mental health services to veterans in need and the impact of the 
VCL. We must ensure our veterans know they are not alone after the 
phone call. Suicide attempts usually result from mental health concerns 
that require further care to find complete resolution. This bill would 
help ensure that suicide is not simply delayed but that the mental 
health concerns leading to it are being addressed and treated.
           Addressing Veteran Service Organizations' Concerns
    Through talks with the Veteran Service Organizations, I have 
learned of their concerns for veterans' information privacy. I firmly 
believe in that privacy and seek to maintain it. That is why this bill 
will not change the manner of the phone conversations that veterans 
have with the VCL. This bill does not require any change in the 
practices and procedures already implemented by the VCL.
    With the call method remaining the same, veterans are still able to 
maintain anonymity. The VA will simply be required to analyze the data 
that is collected, and provide a report detailing the findings to the 
Committee on Veterans Affairs in the House and the Senate.
    Another concern raised is in regards to the privacy of the 
information that would be analyzed. This bill does not intend to 
jeopardize the privacy and therefore, I intend to work with the 
committee to clarify stringent privacy protection during data analysis. 
With these concerns addressed, the VA can receive quantitative insight 
into the efficacy of its life-saving programs.
                               Conclusion
    To stem the tide of veteran suicide, I urge my colleagues to 
support this bill. With 20 veterans taking their lives every day, we 
must do everything we can to better understand and improve the 
effectiveness of the currently available assistance programs.

                                 
             Prepared Statement of Honorable Mike Gallager
    Chairman Roe, Ranking Member Walz, and distinguished Members of the 
Committee: Thank you for inviting me to join you today.
    My draft legislation before you seeks to address the unmet suicide 
prevention needs of America's military veterans. Every day, 20 veterans 
take their own lives, and on average, 14 of the 20 veterans who commit 
suicide each day did not receive care within the VA.
    In May 2017, the Secretary of Veterans Affairs, Dr. David Shulkin, 
stated the following: ``[N]othing is more important to me than making 
sure that we don't lose any veterans to suicide. As you know, 20 
veterans a day are dying by suicide. That should be unacceptable to all 
of us. This is a national public health crisis, and it requires 
solutions that not only VA will work on, but all of government and 
other partnerships in the private sector, nonprofit organizations.''
    As a veteran myself, I could not agree more with Dr. Shulkin. That 
is why my colleague Seth Moulton-a fellow veteran-and I have been 
working on legislation to address this crisis.
    Simply stated, our bipartisan legislation would improve veterans' 
access to evidence-based mental health care services at community or 
non-profit mental health providers participating in the Veterans Choice 
Program.
    Our bill would allow eligible veterans in need of mental health 
services to access the care they need on a same-day basis in the 
community, without a referral. This narrow provision would apply only 
to mental health services, in order to address the suicide crisis 
affecting the men and women who have served our nation.
    We believe this legislation is sorely needed. In 2016, the VA 
Center for Innovation published a report titled ``Veteran Access to 
Mental Health Services.'' The report-which is a compilation of 
interviews with veterans from across the country-is remarkable. I 
believe the candor of these findings is truly a testament to the VA's 
commitment to transparency and I commend the Department for recognizing 
that some veterans need mental health care choices outside of the VA.
    For example, the report states: ``For many Veterans, private 
providers and nonprofits that offer confidential, bureaucracy-free 
access to timely care feel like a positive and desirable alternative to 
VA processes.''
    The report also states: ``Many Veterans are dismayed (and left 
feeling like the VA wants to fob them with drugs) when they are offered 
psychotropic medication before exploring non-medicated treatments 
options.''
    Further, in discussing proposed solutions, the report finds: ``Many 
Veterans don't want to use VA services for mental health care even if 
the red tape is cleared so how can we enable other avenues for care 
that benefit both Veterans and non-VA providers?''
    These findings exemplify why Congressman Moulton and I are teaming 
up to find a bipartisan, commonsense solution to this crisis.
    By allowing eligible veterans to access same-day, evidence-based 
mental health care services at community and non-profit providers that 
are credentialed under the Choice program's care delivery network, 
veterans in crisis will be able to get the help they need, when and 
where they need it.
    The United States has now lost more veterans to suicide than the 
nation has lost in Iraq or Afghanistan, and we believe our nation has a 
continuing obligation to the men and women who have served it to help 
address their mental health needs.
    Community-based and non-profit mental health care providers stand 
ready to help fill the gap in addressing the unmet need in veterans' 
mental health care. This legislation gives Dr. Shulkin the ability to 
allow such providers to meet these urgent needs, in order to continue 
to address what the Secretary has described as his number one clinical 
priority.
    I hope every Member of the Committee will support this effort, and 
I look forward to working with you all moving forward. Thank you again.

                                 
             Prepared Statement of Honorable John R. Carter
    Chairman Roe, Ranking Member Walz, and other Members of the 
Committee, it is an honor to speak before you this morning. Chairman, I 
thank you for including my bill, H.R. 1133 Veterans Transplant Coverage 
Act of 2017, in today's hearing.
    I am here this morning on behalf of the thousands of American 
veterans who find themselves in need of transplant care. Under current 
law, a veteran in critical need of a live donor transplant can't, with 
their VA coverage, receive a donation from a non-veteran. This excludes 
children, siblings, and other non-veteran family members the people a 
veteran would most likely find a willing and successful organ match 
with.
    This is unacceptable. My legislation, the Veterans Transplant 
Coverage Act of 2017, removes unnecessary barriers that prevent 
veterans from receiving the care they deserve. H.R. 1133 will allow 
veterans to receive donations from a live donor regardless if the donor 
is a veteran or non-veteran, and allow them to have the procedure done 
at a non-VA facility if that makes more sense for the patient. This is 
common-sense, life-saving policy, and I'm proud that it has received 
robust and bipartisan support as a standalone bill.
    This legislation is a good fit for the Veteran Coordinated Access & 
Rewarding Experiences (CARE) Act because it seeks to give Veterans more 
options when it comes to their health care, both in donors and 
providers. This is especially beneficial for veterans who live in rural 
areas, far from the closest VA Medical Center, to say nothing of the 
closest VA transplant facility.
    Chairman, I want to take this time to pause and recognize my 
constituents, the inspiration for this bill, Mr. and Mrs. Charles 
Nelson and their son Austin, in from Leander, TX. Mr. Nelson, a 100% 
disabled service-connected veteran, served his country and did 
everything this grateful nation asked of him. Unfortunately, while 
serving in Korea, he developed kidney disease which further led to the 
need of a kidney transplant. His then 28-year old son Austin was a 
willing donor, and a match. Initially, Mr. Nelson was told the surgery 
would be covered under the VA Choice Program of 2014 and able to be 
performed at the University Hospital in San Antonio. However, because 
his son is not a veteran, the VA Central office denied coverage of the 
costs. The Nelsons were forced to use Medicare and private donations, 
and their own savings to cover the surgery's costs.
    Mr. Charles Nelson deserved better..Our veterans deserve better. VA 
Health should be there to address the health care needs of those who 
have served this country in uniform. For Mr. Nelson, who served our 
nation bravely, to be forced to solicit donations to cover life-saving 
medical treatment was a failure of the VA system and an insult to his 
service.
    I am proud to represent Mr. Nelson and the more than 84,000 
veterans in my congressional district. Each one of them, along with the 
22 million nationwide, deserves access to life-saving transplant 
procedures regardless of donor, and in a facility which makes sense for 
them and their family. I hope that, with the passage of H.R.1133 
Veterans Transplant Coverage Act of 2017, and of the entire Veteran 
Coordinated Access & Rewarding Experiences (CARE) Act our veterans can 
access the care they need in the best facility though their VA 
coverage. Our veterans deserve nothing less than the best we can offer 
them for their service.
    Chairman Roe and Ranking Member Walz, I want to thank you again for 
the opportunity to speak here today, and I want to thank all the 
Members of the Committee for their service to our country and our 
veterans.
    I yield back.

                                
          Prepared Statement of Honorable Glenn `GT' Thompson
    Chairman Roe and Ranking Member Walz, thank you for inviting me to 
testify before the House Veterans Affairs Committee with regard to H.R. 
2123, the Veterans E-Health and Telemedicine Support Act, also known as 
The VETS Act.
    The issues before this committee are critically important to ensure 
that those who selflessly served our nation receive the care and 
support they rightfully deserve.
    With this in mind, a constituent approached me a few years ago to 
discuss the barriers to care that his fellow Veterans were experiencing 
through the VA system.
    As an active-duty soldier, he told me stories of his friends coming 
home from deployments and falling through the cracks in our system. 
Some were suffering from PTSD, TBI and depression, and required the 
care of specialists. Others had difficulty traveling from their rural 
communities to VA Medical Centers because of injuries sustained during 
combat.
    It broke my heart to hear the stories of this soldier's friends not 
receiving the care they deserve.
    What made it more difficult was the fact that this soldier is my 
son.
    After numerous conversations about how we can help our service 
members when they return home, we determined that expanding access to 
telehealth would be a great start.
    Many of our Veterans live in rural areas or are unable to travel 
far distances. Allowing them to see their health care provider in the 
comfort of their home would increase their access to care.
    As a result, I introduced the Service members Telemedicine and E-
Health Portability Act of 2011, or The STEP Act. This bill allowed 
Department of Defense healthcare professionals and contractors to 
provide telehealth care to members of our Armed Forces anywhere in the 
country, even across state lines. This bill was included in the Fiscal 
Year 2012 NDAA, which was subsequently signed into law.
    The STEP Act has allowed more than 32,000 servicemen and women to 
gain access to telehealth and has been the basis for a number of 
telehealth expansions throughout the years. The DoD recently decided to 
expand telehealth care for recipients of TRICARE based on the successes 
of the bill.
    The STEP Act has proven that telemedicine can be expanded safely 
and responsibly across state lines. While DoD patients can receive 
telehealth care no matter where they are located, those who receive 
care through the VA are not afforded the same liberties.
    This is why Rep. Julia Brownley and I introduced H.R. 2123, The 
Veterans E-Health and Telemedicine Support Act.
    The VETS Act will similarly allow VA-employed health care providers 
to practice telehealth across state lines, no matter where the doctor 
or patient is located.
    It also commissions a study of the effectiveness of telemedicine 
programs utilized by the Department of Veterans Affairs.
    While the VA has made major strides in advancing telehealth access, 
outdated barriers limit its growth. My bill will eliminate these 
barriers by giving VA-employed providers an exemption to practice 
telehealth across state lines.
    Currently, each state has its own licensing requirements for health 
care providers to practice medicine within its borders. For example, if 
a doctor has offices in Pennsylvania and Ohio, they must hold a license 
from each state.
    VA-provider licensing requirements are different. As long as a 
doctor is licensed and in good standing in a single state, they can 
practice in-person care within the VA system in any state.
    This reciprocity, however, is not afforded to their practice of 
telehealth. VA providers seeking to provide telehealth care to patients 
must also be licensed in the state where the patient is located.
    While this licensing requirement can be waived if both the doctor 
and patient are located in a federal facility, such as a VA Medical 
Center, this still forces a Veteran to travel to a VA facility and 
applies a separate, unnecessary level of regulation to VA telehealth 
providers.
    These outdated regulations are hurting our nation's Veterans.
    The Department of Veterans Affairs has successfully been using 
telemedicine for quite some time. Since 2002, more than two million 
Veterans have received telehealth care through the VA. In 2016 alone, 
more than 12 percent of Veterans receiving VA care utilized telehealth 
in some capacity. 45 percent of these Veterans live in rural areas.
    Veterans who have accessed telehealth are overwhelmingly pleased 
with the quality of care and access they have received. Those receiving 
at-home care, for example, cite an 88 percent satisfaction rate.
    The VETS Act continues to expand telehealth access for Veterans in 
a responsible manner. It allows states to hold providers accountable 
while increasing access to quality care for Veterans who need it. The 
VETS Act is the result of legislators, practitioners and advocates 
coming together to negotiate workable language in good faith, and these 
efforts will result in Veterans across the country gaining access to 
quality care in the comfort of their homes.
    Our Veterans should receive the best care available to them, and 
this starts with the passage of The VETS Act.
    Thank you, again, Chairman Roe and Ranking Member Walz for inviting 
me to testify before the Committee. I look forward to working with you 
to expand access to quality care for our Veterans.
    I yield back the balance of my time.

                                 
           Prepared Statement of Honorable Neal P. Dunn, M.D.
    Thank you, Chairman Roe and Ranking Member Walz for including my 
bill, H.R. 2601, the Veterans Increased Choice for Transplanted Organs 
and Recovery, or VICTOR, in today's legislative hearing agenda. I'd 
also like to thank all the witnesses for their testimony.
    It goes without saying that timely organ transplants can make the 
difference between life and death. It's always a race to bring the 
patient, organ and transplant team together in time. Patients must be 
ready at a moment's notice, and the stakes and risks are always high.
    Now, the Department of Veterans Affairs has participated in 
transplant medicine since 1962, but is a relatively small program which 
is limited by scope and location. As a result, veterans in need of 
organ transplants suffer unique challenges in trying to receive 
transplant care.
    Currently, when a veteran receives care through the VA for a 
transplant, they are subject to traveling to one of only fourteen 
Veterans Affairs Transplant Centers (VATCs) throughout the United 
States.
    This means that a veteran may be required to travel hundreds, even 
thousands of miles across several states for a transplant, despite 
potentially passing many other transplant centers on the way.
    To illustrate this point, in the United States, there are currently 
147 liver transplant centers. 141 of those transplant centers are 
civilian transplant centers, 6 are VA transplant centers. A veteran in 
Florida has 7 liver transplant centers in the state and cannot go to 
any of them if relying on the VA for care. Similarly, a veteran in 
California has 13 liver transplant centers in the state but again 
cannot go to any of them.
    The difficulties associated with transplant care are particularly 
apparent with liver transplants. Given the incidence of end-stage liver 
disease in the Veteran population, liver transplants are an especially 
important, life-saving healthcare concern within VA transplant care.
    Out of the fourteen VATCs, just six of these transplant centers are 
designated liver transplant centers. For those veterans who are waiting 
for a liver transplant at a VATC, they face a 32 percent longer wait 
time on average than those at non-VA facilities.
    The VICTOR Act addresses these challenges by simply reducing the 
existing barriers to care. If a veteran in need of a transplant lives 
more than 100 miles from a VATC, the bill allows them to seek care at 
any federally approved transplant center closer to them that also 
treats Medicare patients.
    Speaking as both a surgeon and a veteran, this is the right course 
of action.
    And this policy change in transplant medicine builds on our larger 
strategy to improve quality health care access for those, as Lincoln 
said, ``who shall have borne the battle.''
    Thank you, Mr. Chairman for allowing me to testify on behalf of 
H.R. 2601 before the Committee today. I yield back the remainder of my 
time.

                                
               Prepared Statement of Honorable Andy Barr
    Congressman Andy Barr's Testimony Before the House Committee on 
Veterans Affairs Legislative Hearing On
    Community Care
    Tuesday, October 24, 2017
    Good morning. I would first like to thank Chairman Roe and Ranking 
Member Walz for allowing me the opportunity to speak before the House 
Veterans' Affairs Committee this morning about providing access to 
community care for survivors of military sexual assault (MST), which my 
legislation, H.R. 3642, the Military Sexual Assault Victims Empowerment 
Act also known as the Military SAVE Act helps to improve.
    According to the findings of the Department of Veterans Affairs' 
National Screening Program, 1 in 4 women and 1 in 100 men reveled that 
they have been victims of military sexual assault during their time 
serving in the military. This problem was first brought to my attention 
by a group of women in the Sixth Congressional District of Kentucky, 
led by MST survivor Karen Tufts. Sadly, due in-part to this emotional 
stress, two of these women have since committed suicide.
    In fact, according to independent nation-wide studies conducted by 
the National Victims Center, the Medical University of South Carolina, 
and Florida State University, research has found that female victims of 
MST are 14 times more likely to commit suicide than women who have 
never been assaulted.
    In addition, according to RAINN (Rape, Abuse & Incest National 
Network), the nation's largest anti-sexual violence organization, 
sexual assault is also commonly associated with adverse mental health 
outcomes such as depression, anxiety, substance abuse, and non-suicidal 
self-injury, which are also commonly associated with suicidal ideation, 
attempts, and death by suicide.
    While Congress has taken several actions recently to better protect 
survivors of MST within the military justice system, many survivors 
have expressed concern that services available within the Department of 
Veterans Affairs (VA) healthcare system may still not match their 
specific post-MST needs.
    That is why I have been working closely with this committee, 
veteran service organizations, and my VA Pilot Program Development Task 
Force to improve medical care for survivors of MST, in order to help 
get those survivors the care that best fits their unique physical and 
psychological needs.
    This legislation would allow survivors of MST the ability to seek 
treatment specifically related to their MST injuries by a private 
healthcare provider of their choice during a 3 year pilot program. MST 
survivors would be given a choice to participate in this pilot program 
or remain in the VA healthcare system for treatment options. 
Participants in both this pilot program and those being treated within 
the VA healthcare system for MST related injuries would participate in 
a pre-treatment and post treatment survey as well as a development 
survey conducted every six months to study individual progress. This 
pilot program would study the results of the effects that direct access 
care provides that the VA does not.
    A certified VA researcher will be assigned as a member of the VA 
Community Care Office, which will ensure the quality and integrity of 
collecting and analyzing data for the study, which would be submitted 
to Congress for review.
    As I mentioned before, I did not create this legislation alone. It 
has been through the dedicated support and trusted advice of MST 
survivors and subject matter experts who are members of my VA Pilot 
Program Development Task Force. I created this task force by carefully 
selecting each of these outstanding individuals who helped to develop 
and determine what the best possible pilot program for MST survivors 
should look like. Each of these members brought a unique experience and 
different skillsets to the table, which was ideal for this task force, 
and I thank them for their contributions.
    In conclusion, I ask that my legislation be included in the 
``Veteran Coordinated Access & Rewarding Experiences (CARE) Act,'' in 
order to help provide survivors, both male and female, the proper 
medical care that best fits unique medical needs.
    Again, thank you for allowing me to testify before this committee 
today, and I am happy to answer any questions that you may have about 
my legislation.

                                 
          Prepared Statement of Honorable David Shulkin, M.D.
    Good morning, Chairman Roe, Ranking Member Walz, and Members of the 
Committee. Thank you for inviting us here today to present our views on 
bills on the agenda today, including very critical legislation to 
improve-in a comprehensive way-the delivery of health care to Veterans. 
Joining me today are Carolyn Clancy, Executive in Charge, Veterans 
Health Administration, and Dr. Laurie Zephyrin, Acting Deputy Under 
Secretary for Health for Community Care.
    We greatly appreciate the Committee including the Administration's 
proposal for comprehensive improvements to the Department of Veterans 
Affairs' (VA) Community Care program, the Veteran Coordinated Access & 
Rewarding Experiences (CARE) Act. We look forward to working with the 
Committee in the days ahead to continue our dialogue on how we move 
forward together on the critical and complex issue of how we provide 
the best possible health care for Veterans, using the best that VA and 
other health care providers can deliver in a complementary way.
    We received a discussion draft from the Committee describing the 
future of VA Community Care, dated September 19, 2017, and it is this 
draft we will discuss in this statement. We understand this discussion 
draft continues to evolve, and we are happy to assist the Committee in 
this effort.
    We are unable at this time to provide views on the following bills: 
H.R. 2601, the VICTOR Act, H.R. 3642, the Military SAVE Act, a draft 
bill to furnish mental health care to veterans at community or non-
profit mental health providers that participate in the Choice program, 
and a draft bill to conduct a study of the Veterans Crisis Line. We 
will be glad to follow up with the Committee on these bills after the 
hearing.

H.R. 1133 Veterans Transplant Coverage Act of 2017

    H.R. 1133 would add section 1788 to Title 38, authorizing the 
Secretary of Veterans Affairs to provide for an operation on a live 
donor to carry out a transplant procedure for an eligible Veteran, 
notwithstanding that the live donor may not be eligible for VA health 
care. VA would be required to provide to a live donor any care or 
services before and after conducting the transplant procedure that may 
be required in connection with the transplant. The bill would 
specifically authorize the Secretary to furnish this care at a VA 
facility or through an agreement or contract with a non-Department 
entity or provider
    VA supports H.R. 1133, contingent on the provision of additional 
resources to support implementation, although we recommend some 
clarifications in the bill language. We believe it would be appropriate 
to limit the duty and responsibility to furnish follow-on care and 
treatment of a living donor to 2 years after the procedure is furnished 
by VA. This would be consistent with the recommendations of the United 
Network for Organ Sharing and the Organ Procurement and Transplant 
Network. We further recommend that the duty to provide follow-on care 
and treatment should be limited to that which is ``directly related 
to'' the living donor procedure (rather than what ``may be required in 
connection with such procedure,'' as the bill would provide).
    There are other potential issues related to organ transplantation 
that the bill does not address that we would be pleased to discuss with 
the Committee in its contemplation of this proposal.
    We estimate the bill as written would cost $1.8 million in fiscal 
year 2018, $9.7 million over 5 years, and $21.5 million over 10 years.

H.R. 2123 Veterans E-Health and Telemedicine Support Act of 2017

    Section 2(a) of H.R. 2123, the ``Veterans E-Health and Telemedicine 
Support Act of 2017,'' would amend title 38, United States Code 
(U.S.C.), to add a new section 1730B, which would permit a covered 
health care professional to practice their health care profession at 
any location in any state, regardless of where such health care 
professional or the patient is located, if the health care professional 
is using telemedicine to provide treatment under chapter 17 of title 
38. New section 1730B would specify that this authority would apply 
regardless of whether the covered health care professional is located 
in a facility owned by the Federal Government. In addition, new section 
1730B would state that nothing in that section would be construed to 
alter any obligation of the covered health care professional under the 
Controlled Substances Act (21 U.S.C. 801 et seq.). New section 1730B 
would define ``covered health care professional'' to mean an individual 
who: (a) is employed by VA and appointed under the authority of 
sections 7306, 7401, 7405, 7406, or 7408 of title 38, or title 5; (b) 
is authorized by the Secretary to provide health care under chapter 17 
of title 38; (c) is required to adhere to all quality standards 
relating to the provision of telemedicine in accordance with applicable 
VA policies; and (d) has an active, current, full, and unrestricted 
license, registration, or certification in a state to practice the 
health care profession of the health care professional.
    Section 2(b) would provide a clerical amendment to the table of 
sections at the beginning of chapter 17 of title 38.
    Section 2(c) would require the Secretary, not later than 1 year 
after the date of enactment of the Act, to submit to Congress a report 
on VA's effective use of telemedicine. The report would require 
specific elements such as the assessment of the satisfaction of 
Veterans and health care providers with VA telemedicine; the effect of 
VA-funded telemedicine on the ability of Veterans to access health 
care; the frequency of use by Veterans of telemedicine; the 
productivity of health care providers; wait times for appointments; any 
reduction in the use of in-person services by Veterans; the types of 
appointments for telemedicine that were provided; the number of 
requested appointments for telemedicine disaggregated by Veterans 
Integrated Service Networks (VISN); and any VA savings, including 
travel costs.
    VA supports this bill, which is similar to section 301 of the 
Administration's Veteran CARE Act and section 4 of one of the draft 
bills; however, VA prefers the language in section 301 of the 
Administration's Veteran CARE Act and section 4 of the draft bill to 
the language in H.R. 2123 for the reasons expressed in our views on 
those bills.
    VA does not have a cost estimate for section 2(a) of the bill at 
this time. VA estimates that implementation of the one-time reporting 
requirement in section 2(c) of the bill would cost $17,000.

H.R. XXXX Draft Veteran Coordinated Access & Rewarding Experiences 
    (CARE) Act

    VA presented the House and Senate Veterans' Affairs Committees on 
October 6, 2017, with its draft Administration legislative proposal, 
the Veteran CARE Act, designed to improve Veterans' experiences with 
and access to healthcare, building on the best features of VA's 
existing Community Care programs and strengthening VA's ability to 
furnish care in its facilities. The bill also would provide new 
workforce tools to assist in maintaining and strengthening VA's world-
class medical staff, enhance business processes to improve financial 
management of the Community Care program, and strengthen VA's ability 
to partner with other Federal agencies and streamline VA's real 
property management authorities.
    The bill's provisions would clarify and simplify eligibility 
requirements, set the framework for VA to continue to build a high-
performing network, streamline clinical and administrative processes, 
implement new care coordination support for Veterans, and merge and 
modernize community care programs.
    The bill would replace the current wait-time and distance 
eligibility criteria under the Choice Program (30 days/40 miles) with 
criteria based on clinical need in light of access, quality of care, 
and convenience.
    A description of each provision of the CARE Act follows.
    Section 101 of the bill would improve VA's flexibility to meet 
Veterans' demands for hospital care, medical services, and extended 
care services by authorizing VA to enter into agreements (Veterans Care 
Agreements, or VCA) that, in general, would not be subject to the 
competition or other requirements associated with Federal contracts, 
while still subjecting eligible entities and providers to all laws that 
protect against employment discrimination or that otherwise ensure 
equal employment opportunities.
    Section 102 would allow similar flexibility for State Veterans 
Homes.
    Section 111 would create a new section 1730B to allow VA to record 
an obligation for community care when the amount is certain (i.e., when 
VA approves the payment of the claim for the incident of care). This 
provision would reduce the potential for large de-obligation amounts 
after the funds have expired.
    Section 112 would reform VA's payment process to provide prompt 
payment of all community care.
    Section 113 would clarify the payment rates for VA-provided 
community care..
    Section 114 would allow the Secretary to pay a provider for 
services rendered even if the Secretary has not entered into a 
contract, agreement, or other arrangement for the furnishing of care 
and services with that specific provider. This would provide a legal 
authority for the Department to pay for care or services furnished in 
good faith by a provider.
    Section 121 would amend the existing provision in section 
7332(b)(2)(H) that permits VA to disclose protected information to 
community providers and create a new exception in subparagraph (I) that 
would allow VA to share records with third parties to recover or 
collect reasonable charges for care provided. The amendment to existing 
law would revise subparagraph (H) to clarify that VA could share 
records with non-Department providers for the purpose of furnishing 
hospital care, medical services, or extended care services to an 
individual and for performing other health care-related activities or 
functions. This authority would also allow VA to disclose medical 
records for purposes of billing, thereby increasing VA's ability to 
recover funds from Veterans' other health plan contracts or other 
responsible third parties for care furnished by VA.
    Sections 131 and 132 would strengthen VA's ability to collect 
reimbursements due for non-service-connected care from health plan 
contracts and third parties responsible for the payment of such care.
    Section 201 would amend section 1703 to establish the eligibility 
criteria for the consolidated VA Community Care program to improve 
Veterans' access to community care. The bill would provide for a 
clinically-driven referral process that would enable a Veteran to 
access community care if the service they need is not available at a VA 
facility, if the Department could not schedule an appointment for the 
Veteran within a clinically acceptable period of time, or if the 
Veteran and the Veteran's primary care provider agree that it would be 
in the best medical interest of the Veteran to receive care in the 
community. In making the determination regarding the best medical 
interest, the Secretary would consider, for example, the distance the 
Veteran would travel for such care, the nature of the care or services 
required, and the frequency that such care or services need to be 
furnished.
    In addition, Veterans would be authorized to opt to receive 
community care if the Secretary determines that a certain type of care 
furnished by a VA facility does not meet the quality and access 
standards of the Department. The Secretary would make regular 
determinations once each year and would have the authority to limit 
access to community care by the type of care or service required, the 
length of time such services would be available, and where such 
services would be available.
    Decisions under either of these scenarios would be considered 
clinical determinations and outside the jurisdiction of the Board of 
Veterans' Appeals.
    Section 202 would create a new section 1725A to provide Veterans 
access to walk-in care from community providers that are part of VA's 
community care network to ensure their access to care when minor injury 
or illness arises.
    VA would be required to develop procedures to ensure that enrolled 
Veterans who have received care from VA within the prior 24 months are 
able to access walk-in care from qualifying non-Department entities or 
providers.
    Section 211 would amend section 802 of the Veterans Access, Choice, 
and Accountability Act of 2014 (VACAA) to authorize VA to use the 
existing Veterans Choice Fund to pay for any health care services under 
Chapter 17 of Title 38 at non-VA facilities or through non-Department 
providers furnishing care in VA facilities.
    Section 221 would repeal and amend current authorities to account 
for the changes to section 1703 made by section 201 of the bill.
    Section 301 would create a new section 1730C to authorize VA health 
care professionals to practice in any state, including by telemedicine, 
notwithstanding the location of the health care provider or the 
patient.
    Section 302 would rescind section 7409, which is VA's authority to 
contract for scarce medical resources. This authority has not been used 
by VA recently as other authorities are sufficient to fulfill the 
purpose of section 7409.
    Section 303 would authorize VA to increase the number of graduate 
medical education residency positions at covered facilities by up to 
1,500 positions in the 10-year period following enactment of this Act. 
The Secretary would be authorized to provide a stipend and other 
benefits for residents appointed under this section, whether they are 
assigned in a Department facility or not. Individuals would be required 
to apply to participate and agree to serve a period of obligated 
service in return for payment of educational assistance. These benefits 
and requirements would apply solely to the new positions and will 
assist the Department in determining whether such a program is 
attractive to graduate medical education residents.
    Section 304 would repeal section 705 of VACAA (Public Law (P.L.) 
113-146; 38 U.S.C. 703 note), which currently prescribes limits on 
awards and bonuses that can be paid to VA employees through fiscal year 
2024.
    Section 305 would amend 38 U.S.C. Sec.  7411 to include authority 
to reimburse continuing professional education for full-time board 
certified Advanced Practice Registered Nurses.
    Section 306 would modify 38 U.S.C. Sec.  7309 to remove the 
requirements for the Chief Officer of the Readjustment Counseling 
Service (RCS) to have at least 3 years of experience in providing and 
administrating direct counseling services or outreach service that is 
specifically within RCS. This would expand the pool of applicants for 
the RCS Chief Officer position.
    Section 307 would enact a technical correction to ensure that 
individuals appointed under 38 U.S.C. Sec.  7401(4) can be compensated 
within the full-range for Senior Executive Service pay, $124,406 to 
$187,000. Section 207 of the VA Accountability and Whistleblower 
Protection Act of 2017 (P.L. 115-41) allows for an individual to have 
their pay set up to $187,000, but because the Act failed to amend 38 
U.S.C. Sec.  7404(d), it prevents such an individual from being paid 
more than $151,700.
    Section 308 would expand the definition of compensation to include 
pay earned by employees when performing duties authorized by the 
Secretary or when the employee is approved to use annual, sick, family 
medical, military, or court leave, or other paid absences for which pay 
is not already regulated.
    Section 309 would amend 38 U.S.C. Sec. Sec.  7455 and 7401 to 
include Certified Clinical Perfusionists in the list of excepted 
positions and convert such positions to full Title 38 status to assist 
in the recruitment and retention of highly skilled Perfusionists.
    Section 321 would amend section 8104(a)(3)(B) to redefine the term 
``major medical facility lease,'' providing a cost increase to a dollar 
threshold that was last changed in October 2008.
    Section 322 would amend sections 8101 and 8104 to expand VA's 
capacity to do more detailed planning and design, leasing, and 
construction of joint facilities in an integrated manner.
    Section 323 would amend section 8104(a)(3)(A) to exclude the 
Department's non-recurring maintenance projects from the definition of 
a ``major medical facility project.''
    Section 324 would amend section 8162 to improve VA's Enhanced-Use 
Lease (EUL) authority. Specifically, it would modify section 8162(a)(2) 
to allow the Secretary to enter into new EULs if the lease will not be 
inconsistent with or adversely affect the Department's mission and will 
either enhance the use of the property or be for the provision of 
``supportive housing'' as defined in section 8161(3).
    Section 401 would allow VA and DoD to collaborate to carry out a 
joint pilot program to determine the feasibility and advisability of 
sharing health care resources without entering into reimbursement 
agreements for such services.
    Section 501 would amend section 101(p) of VACAA to modify the 
termination date for the Veterans Choice Program. VA would have 
authority to authorize care and services under the Veterans Choice 
Program through September 30, 2018, and would be able to complete all 
episodes of care authorized on or before that date.
    Section 502 would authorize to be appropriated to the Veterans 
Choice Fund established by section 802 of VACAA, as amended, 
$4,000,000,000 in mandatory funds.
    Section 503 would extend until 2027 the requirement that, in 
computing cost-of-living adjustments for disability compensation and 
dependency and indemnity compensation, increased monthly rates and 
limitations must be rounded down to the nearest whole dollar amount.
    Section 504 would amend section 3313 to impose tuition and fee 
payment caps at Institutions of Higher Learning with flight training 
programs and establish that only flight courses determined necessary 
for completion of a degree program may be approved for payment.
    Section 505 would amend section 5503(d)(7) to extend by 1 year 
until September 30, 2028, VA's authority to reduce the amount of 
pension furnished by VA for certain Veterans covered by Medicaid plans 
for services furnished by nursing facilities.
    Section 506 would amend section 3729 to extend by 1 year until 
September 30, 2028, VA's authority to continue collecting home loan 
fees at their current rates.
    VA strongly supports enactment of all of these provisions. We will 
continue to work closely with the Committee as we create additional 
legislative proposals to strengthen our ability to modernize the VA 
healthcare system and to develop innovative ways of delivering high-
quality, timely healthcare to our Nation's Veterans.

H.R. XXXX Draft Bill to Establish a Permanent Veterans Choice Program

Description of Discussion Draft
    The draft bill contains a number of provisions amending different 
authorities related to VA's Community Care program. Section 101(a) 
would create a new section 1703A in title 38, U.S.C., titled ``Veterans 
Choice Program.'' Proposed section 1703A(a) would broadly require the 
Secretary, subject to the availability of appropriations, to furnish 
hospital care and medical services to eligible Veterans, at the 
election of the Veteran, through contracts or agreements with network 
providers. The Secretary would be required to establish regional 
networks of providers and would be required to determine the regions 
based on annual capacity and market assessments of the VISN; such 
assessments would be required by a later provision of this bill.
    Proposed Sec.  1703A(b) would require the Secretary to assign each 
Veteran upon enrollment into the VA health care system to a VA patient-
aligned care team (PACT) or otherwise to a dedicated primary care 
provider of the Department. If the Secretary were unable to assign a 
Veteran to a VA PACT or primary care provider, the Veteran would select 
a community primary care provider from a list of such providers among 
network providers in the Veteran's community. Each year, the Secretary 
would determine if the Veteran could be assigned to a VA PACT or 
primary care provider and make such an assignment if able. VA could 
only furnish specialty care or services to eligible Veterans upon the 
referral from the Veteran's primary care provider. The Secretary would 
determine whether or not to furnish such specialty care in a VA 
facility, through a network provider, or pursuant to another agreement 
where a non-Department provider furnishes care in a VA facility or a VA 
provider furnishes care in a non-Department facility. In determining 
where to furnish the care, the Secretary would give priority to VA 
medical facilities and providers, but would take into account several 
factors, including whether the Veteran faces an unusual or excessive 
burden in accessing such specialty care based on several criteria and 
whether the Veteran's primary care provider recommends the care be 
furnished by a network provider.
    Proposed Sec.  1703A(c) would require the Secretary ensure that, at 
the election of an eligible Veteran receiving care and services under 
this section, the Veteran receives care through the completion of the 
episode of care, including all specialty and ancillary services 
determined necessary by the provider. If the provider were a network 
provider, the provider would consult with the Secretary to determine 
which specialty and ancillary services are necessary.
    Proposed Sec.  1703A(d) would require the Secretary to enter into 
contracts or agreements with network providers to furnish care and 
services to eligible Veterans under this section. The Secretary would 
be required to negotiate rates for the furnishing of care and services 
under this section. In general, reimbursement rates could not exceed 
the Medicare rate, although the bill includes six exceptions to or 
conditions on this requirement. Under proposed Sec.  1703A(d)(5), the 
Secretary could compensate a provider for furnishing care and services 
if any part of care or services were furnished by a medical provider 
who was not a network provider, but the Secretary would be required to 
take reasonable efforts to enter into a contract or agreement with that 
provider.
    Proposed Sec.  1703A(e) would require the Secretary to ensure that 
claims for payments for care and services furnished under this section 
are processed in accordance with the prompt payment standards 
articulated in this subsection. This requirement would apply regardless 
of whether the claim was made by a network provider to the Secretary, 
by a network provider to a regional network, or by a regional network 
to the Secretary. This subsection would define deadlines for submission 
and payment of claims for covered claimants and covered payers.
    Proposed Sec.  1703A(f) would require an eligible Veteran to pay a 
copayment for the receipt of care or services under this section only 
if the Veteran would have owed a copayment for the receipt of such care 
or services at a VA medical facility and such copayments could not 
exceed what the Veteran would have owed if the care or services were 
furnished at a VA medical facility. VA would be authorized to recover 
or collect reasonable charges from a health care plan for care or 
services for a non-service-connected disability in accordance with 
section 1729 of title 38, U.S.C.
    Proposed Sec.  1703A(h) would require the Secretary to ensure that 
the Veterans Health Identification Card, or its successor, includes 
sufficient information to act as an identification card for an eligible 
entity or non-Department facility. The Secretary would not be 
authorized to use any available funds to issue separate identification 
cards with respect to care or services furnished under this section.
    Proposed Sec.  1703A(k) would require the Secretary, on an annual 
basis, to assess the capacity of each VISN and VA medical facility to 
furnish care and services under chapter 17 of title 38, U.S.C., 
including how network providers can fill gaps in care or services. In 
forecasting shortand long-term demand, the Secretary would have to 
forecast based on future projections, rather than historical trends.
    Proposed Sec.  1703A(l) would require the Secretary to develop a 
plan to allocate funds from the Medical Community Care account and such 
plan would have to be modeled on the Veterans Equitable Resource 
Allocation system or any successor system.
    Section 101(b) would make various conforming amendments to reflect 
this new authority.
    Section 101(c) would amend section 1701 of title 38, U.S.C., to 
include definitions of the terms ``network provider'' and ``Veterans 
Choice Program.''
    Section 101(d) would prohibit this Act, and the amendments made by 
this Act, from being construed as affecting the Secretary's obligations 
under contracts or agreements for the furnishing of care or services 
under contracts or agreements entered into before this Act's enactment.
    Section 102 would require, by the implementation date of the new 
Veterans Choice Program created by section 101, VA's Chief Information 
Officer to ensure the information technology system used by VA to 
receive, process, and pay claims under the Veterans Choice Program 
includes a number of specific elements.
    Section 103 would provide that funding to carry out the Veterans 
Choice Program would be derived from the Medical Community Care 
account. It would further provide that any amounts in the Veterans 
Choice Fund would be transferred to the Medical Community Care account 
on the date that is 1 year from the date of the enactment of this Act. 
Section 802 of VACAA (P.L. 113-146, 38 U.S.C. 1701 note), which 
established the Veterans Choice Fund, would be repealed, and section 
4003 of the Surface Transportation and Veterans Health Care Choice 
Improvement Act of 2015 (P.L. 114-41) would be amended to allow for the 
use of the Medical Community Care account for the Veterans Choice 
Program.
    Section 104 would terminate VA's authority in section 1703 
effective on the date the Secretary certifies to the Committees on 
Veterans' Affairs of the House of Representatives and the Senate that 
the Secretary is fully implementing section 1703A, as established by 
section 101 of this bill. It would further make conforming repeals to a 
number of authorities in title 38 and title 42 to reflect the new 
program's authority and to repeal other authorities.
    Section 105 would require the Secretary to commence operation of 
the new Veterans Choice Program established by section 101 of this bill 
by not later than 1 year from the date of the enactment of this Act. 
Before commencing the new Veterans Choice Program, the Secretary would 
be required to certify to the Committees on Veterans' Affairs of the 
House of Representatives and the Senate that each network provider and 
non-Department health care provider that furnishes care or services 
under the new section 1703A has been trained to furnish such care and 
services under this program, and that each VA employee that refers, 
authorizes, or coordinates such care or services is trained to carry 
out this program. It would also require the Secretary to establish 
standard, written guidance for network providers, non-Department health 
care providers, and any non-Department administrative entities acting 
on behalf of such providers with respect to the policies and procedures 
for furnishing care or services under such section.
    Section 106 would establish a new section 1703B in title 38, 
U.S.C., authorizing the Secretary to enter into Veterans Care 
Agreements (VCAs) with certain providers. Under proposed Sec.  
1703B(a)(2), these VCAs could be entered into to furnish hospital care, 
medical services, and extended care services when the Secretary 
determines that it would be impracticable or inadvisable to furnish 
care to a Veteran at a VA facility or through contracts or sharing 
agreements otherwise established by the Secretary.
    Proposed Sec.  1703B(c) would define eligibility criteria for 
providers. First, the gross annual revenue of the provider under 
contracts or agreements entered into with the Secretary in the 
preceding year could not exceed $2 million, as adjusted in a manner 
similar to the amounts adjusted pursuant to section 5312 of this title. 
Second, the provider could not otherwise provide care or services to 
patients pursuant to a contract entered into with a Federal department 
or agency. Third, the provider would have to be a Medicare or Medicaid 
provider or supplier; an Aging and Disability Resource Center, an area 
agency on aging, or a state agency; or a center for independent living. 
The provider would also have to meet any further criteria determined 
appropriate by the Secretary.
    Proposed Sec.  1703B(d) would require the Secretary to establish a 
process for the certification of eligible providers to enter into VCAs 
under this section.
    Proposed Sec.  1703B(e) would stipulate a number of terms in these 
agreements. In general, payment under VCAs would be limited to the 
Medicare rate, but VA could pay higher amounts in six different 
situations or areas.
    Proposed Sec.  1703B(f) would provide that the Secretary could 
enter into a VCA using procedures other than competitive procedures. In 
general, eligible providers that enter into a VCA would not be subject 
to any provision of law that providers of services and suppliers under 
the original Medicare fee-for-service program or the Medicaid program 
are not subject to. Providers entering into a VCA would be subject to 
any applicable law regarding integrity, ethics, or fraud, or that 
subject a person to civil or criminal penalties. Providers would also 
be subject to certain identified provisions of law, including Title VII 
of the Civil Rights Act of 1964, to the same extent as such title 
applies with respect to the eligible provider in providing care or 
services through an agreement or arrangement other than under a VCA.
    Proposed Sec.  1703B(g) would allow an eligible provider and VA to 
terminate a VCA at such time and upon such notice as the Secretary may 
specify.
    Proposed Sec.  1703B(h) would require the Secretary to establish 
administrative procedures for eligible providers to present any dispute 
arising under or related to a VCA.
    Proposed Sec.  1703B(i) would authorize the Secretary to compensate 
a provider who is not an eligible provider, but who furnished hospital 
care, medical services, or extended care to an eligible Veteran 
pursuant to a VCA. The Secretary would be required to make reasonable 
efforts to enter into a VCA with any provider who is compensated under 
this subsection.
    Proposed Sec.  1703B(j) would require the Secretary to report by 
October 1 of each year after VA has first begun using VCAs a list of 
all VCAs entered into as of the date of the report.
    Proposed Sec.  1703B(k) would require the Secretary, in carrying 
out this section, to use the quality of care standards set forth or 
used by the Centers for Medicare & Medicaid Services.
    Proposed Sec.  1703B(l) would allow the Secretary to delegate the 
authority to enter into or terminate a VCA, or to make a determination 
under the dispute resolution procedures referenced in subsection 
(h)(2), at a level not below the Assistant Deputy Under Secretary for 
Health for Community Care.
    Section 201 would amend section 1725(c) of title 38, U.S.C., to 
require the Secretary to treat such services as emergency services for 
which reimbursement may be made under this section if the Secretary 
determined that the request for ambulance services was made as a result 
of the sudden onset of a medical emergency and that the individual was 
transported to the closest and most appropriate medical facility 
capable of treating the emergency medical condition. These amendments 
would apply with respect to ambulance services provided on or after 
January 1, 2018.
    Section 202 would amend section 7332(b) of title 38, U.S.C., to 
authorize the disclosure of certain medical records of Veterans to a 
public or private health care provider to provide treatment or health 
care to a shared patient, and to third parties in order to recover or 
collect reasonable charges for care furnished to a Veteran for a non-
service connected disability under section 1729 of title 38, U.S.C.
    Section 203 would establish that copayments required by chapter 17 
of title 38, U.S.C., would apply notwithstanding any other provision of 
law that would allow the Secretary to offset a Veteran's copayment 
obligation with amounts recovered from a third party under section 
1729.

Commentary on Discussion Draft

    First, we would like to thank the Committee for their hard work in 
preparing this discussion draft and for your willingness to share prior 
drafts with the Department for discussion and consideration, including 
the Committee's October 3 Roundtable. We look forward to continuing to 
collaborate closely on the future of VA Community Care.
    We recognize that both the Committee and the Department are 
committed to developing legislation on the future of VA Community Care, 
and we believe there is a fair amount of alignment between the 
Department's proposed Veteran CARE Act and the discussion draft.
    There are a number of provisions in this bill that are consistent 
with the Department's proposals. For example, the discussion draft 
provides broad flexibility in payment rates, which we have found to be 
important in ensuring we are able to bring the most talented providers 
into our network to furnish care to Veterans. We appreciate the 
legislation's recognition of the role of contractors in establishing 
the provider network and in the importance of conducting market 
assessments to determine what services are available in VA and the 
community. The discussion draft also clarifies prompt payment standards 
in ways that generally match the Department's proposal. We appreciate 
the discussion draft's efforts at providing clear funding for this 
program and in consolidating existing authorities to streamline 
community care. The discussion draft would further authorize VA to 
enter into VCAs, which is a critical authority for furnishing Veterans 
with timely and appropriate care when other options (such as care 
within the Department or obtained through other contracts or 
agreements) are not available. The discussion draft would give VA more 
authority to share records for shared patients and would also eliminate 
the current process whereby VA offsets a Veteran's first party 
copayment liability through use of funds received from their other 
health insurance or third-party payer.
    There are some important differences in our approaches, however, 
that we wish to highlight in our statement.
    Initially, the discussion draft defines eligibility for a Veteran 
to make a choice to receive community care in a manner that is 
considerably different from the Department's proposal. The Committee's 
discussion draft, for example, defines Veteran eligibility to choose to 
receive community care based on whether or not VA is able to assign the 
Veteran to a primary care provider of the Department. We are concerned 
that this approach is narrow and relies upon administrative, rather 
than clinical, criteria. We further believe that in operation, this 
could produce confusion among Veterans, as well as among VA and 
community providers. The discussion draft would allow any Veteran to 
receive community care, but the decision where to furnish such care 
would largely be in VA's control, except for those who are unable to be 
assigned a VA primary care provider and thus are able to select a 
primary care provider from a list of primary care providers. The 
Department's proposed CARE Act would base eligibility for all community 
care on clinical factors and the Veteran-provider relationship. We 
believe this is a more appropriate approach to determining whether or 
not a Veteran should receive community care, as it empowers Veterans 
and their providers to work together to make these decisions.
    Furthermore, the scope of the Veteran's choice is noticeably 
different between the two proposals. Under the discussion draft, 
Veterans would only be able to choose a community primary care provider 
if VA were unable to assign the Veteran to a Department primary care 
provider. If VA had enough primary care providers, Veterans would have 
no choice in terms of where they receive care. Under the Department's 
CARE Act, Veterans and their VA providers would collaborate to 
determine the most appropriate place to receive subsequent care.
    A third concern is the discussion draft's reliance on a clear 
distinction between primary and specialty care. We understand the 
Committee's intent with this approach, but we have found in practice 
that the distinction between primary and specialty care is not all that 
clear. Certain services that would generally be considered specialty 
care, such as audiology and optometry, are now available at VA 
facilities without a referral from a primary care provider. 
Additionally, through the current Veterans Choice Program, VA 
authorizes the full episode of care, including necessary specialty and 
ancillary services, to be furnished by community providers when needed. 
The discussion draft's approach would interrupt these referral patterns 
and create confusion among Veterans and community providers alike. It 
would also increase VA's workload without an appreciable improvement in 
patient care or care coordination.
    Finally, while we appreciate the Committee's inclusion of provider 
agreement authority, we are concerned that, as drafted, this provision 
would only address some of the problems that require the use of such 
agreements in the first place. Provider agreements are intended as a 
backup only in cases where our contracted network cannot provide the 
care a Veteran requires. The discussion draft would impose a cap of $2 
million on how much VA could spend in a year through a provider 
agreement. In our experience, providers of certain services or in 
certain areas have exceeded this threshold, and such providers would 
generally be unable to comply with the requirements of a Federal 
contract. For example, the top nine highest value provider agreements 
currently in effect (all of which are in excess of $2 million) are with 
providers of homemaker/home health aide services, but these 
organizations could not operate and furnish these services if they were 
subject to Federal contracting requirements. We also note that the 
requirement that each provider agreement be signed by someone at or 
above the level of the Assistant Deputy Under Secretary for Health for 
Community Care would be administratively burdensome and create a 
bottleneck that could impede Veterans' access to care. We understand 
the intent behind these and similar limitations, but we caution against 
constraining our authority in this area. We would be pleased to discuss 
this further with the Committee.
    We look forward to working closely with the Committee on its draft 
bill as well as concepts and provisions in the draft Veterans CARE Act. 
Together I know VA and Congress can provide the comprehensive 
improvements Veterans deserve.

H.R. XXXX Draft Bill on Agreements with State Homes, Graduate Medical 
    Education Expansion, and Other Matters

    Section 1 of the draft bill would amend section 1745 to authorize 
the Secretary to enter into agreements with State Veterans Homes that 
would not be subject to laws requiring competitive procedures in 
selecting the party with which to enter the agreement. State Homes 
entering into these agreements would not be subject to any laws that 
such a provider would not be subject to under the original Medicare 
fee-for-service program under Parts A and B of title XVIII of the 
Social Security Act (42 U.S.C. 1395 et seq.), except for laws applying 
to integrity, ethics, fraud, or that subject a person to civil or 
criminal penalties. Title VII of the Civil Rights Act of 1964 (42 
U.S.C. 2000c et seq.) would apply to State homes entering into these 
agreements. These changes would become effective upon the Secretary's 
publishing regulations to implement these new authorities.
    We generally support section 1, although we have some concerns with 
respect to the applicability of certain laws. Section 102 of the 
Administration's CARE Act, we believe, includes language that addresses 
these concerns, and we support enactment of our proposed language.
    Section 2 of the draft bill would create a new section 1730B in 
title 38 authorizing the Secretary to record as an obligation of the 
United States Government amounts owed for hospital care or medical 
services furnished at non-Department facilities on the date on which a 
claim is approved, rather than the date on which the services are 
authorized.
    Section 2 of the draft bill is similar to section 111 of the 
Administration's Veteran CARE Act, but we prefer the language in the 
Veteran CARE Act for several reasons. First, the Veteran CARE Act's 
language is not discretionary. Second, the Veteran CARE Act's language 
includes additional services by using the term ``health care'' instead 
of the more limited ``hospital care or medical services'' in section 2 
of the draft bill. Third, the Administration's Veteran CARE Act delays 
the effective date of these changes until the beginning of the next 
fiscal year after enactment. This would allow VA to begin a fiscal year 
using a common approach, rather than attempting to change how 
obligations are recorded during the middle of a year, which could 
create administrative confusion and budgeting issues.
    Section 3 of the draft bill would require the Secretary to carry 
out a program of educational assistance (which would be determined by 
the Secretary) to encourage individuals to fill currently unfilled 
graduate medical education residency positions established pursuant to 
section 7302 of title 38 and section 301(b)(2) of the Veterans Access, 
Choice, and Accountability Act of 2014 (P.L. 113-146, as amended). This 
section further provides terms and conditions relating to 
administration of this benefit,
    This section is similar to section 303 of the Administration's 
Veteran CARE Act, and we prefer the language in the Veteran CARE Act, 
as it is discretionary and would provide greater flexibility to the 
Secretary in terms of recruiting residents and offering them benefits 
(in particular when they are not at a VA facility).
    Section 4 of the draft bill would create a new section 1730B that 
would authorize VA health care providers to practice, regardless of 
their location within a State, their health care profession, including 
through the practice of telemedicine. Such authority would extend to 
situations where the provider is not located on Federal property. It 
would specifically invoke Federal Supremacy to protect VA health care 
providers operating within the scope of their employment from any 
adverse action by a state or local government based upon their Federal 
employment. It would also require a report on how this authority has 
affected the use of and satisfaction with telemedicine by VA providers 
and patients.
    VA strongly supports section 4 of the draft bill, which matches 
section 301 of the Administration's draft Veteran CARE Act. We have one 
minor technical edit to offer, amending the proposed section 1730B(a) 
to refer to ``the direction of the Secretary,'' rather than ``the 
discretion of the Secretary.'' While VA has published a proposed rule 
to assert Federal Supremacy for telemedicine providers, this 
legislation would go further by providing statutory protection and by 
codifying VA's longstanding practice of allowing VA providers to 
practice in any state as long as they are licensed in a state. We 
greatly appreciate Congress' attention to this issue and inclusion of 
this proposal in the draft bill.
    Mr. Chairman, this concludes my prepared statement. My colleagues 
and I would be pleased to answer any questions you may have.

                                 
           Prepared Statement of Honorable Adrian M. Atizado
    Mr. Chairman and Members of the Committee:
    Thank you for inviting DAV (Disabled American Veterans) to testify 
at this legislative hearing of the House Veterans' Affairs Committee. 
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 Committee.
          H.R. 1133, Veterans Transplant Coverage Act of 2017
    This legislation, if enacted, would require the Secretary to extend 
health care eligibility through the Department of Veterans Affairs (VA) 
to a live organ donor before and after conducting a transplant 
procedure for a qualifying veteran, even if the donor is not eligible 
for VA health care. The bill also authorizes transplant surgery to be 
performed at non-VA facilities and be paid for through the Veterans 
Choice Program, at the discretion of the Secretary.
    Currently, enrolled veterans have limited options through the VA 
health care system when requiring transplantation surgery. Since there 
are only 13 VA medical centers that offer transplantation procedures, 
many seriously ill veterans are forced to travel great distances, or 
even move near a VA facility that provides this service in order to 
receive necessary preand post-operative care, and to await a donor 
match. Some veterans are forced to relocate their families for months 
at a time with no guarantee that a donor will even be found.
    Unfortunately, due to the overall lack of organ donors nationally, 
and the current statutory constraints in the VA system, many veterans 
pass away while awaiting donors. Furthermore, due to the expenses 
involved in traveling while pursuing organ donation through the VA 
health care system, veterans as well as surviving family members are 
often left in difficult financial situations.
    Extending limited eligibility and care to live organ donors who are 
not otherwise eligible for VA care could open up additional 
possibilities for some seriously and terminally ill veterans. Allowing 
VA to cover the cost of transplantation procedures in non-VA facilities 
through the Choice program could also alleviate some of the burden and 
cost that veterans and family members incur when traveling to distant 
VA medical centers that perform these life-saving procedures.
    DAV does not have a resolution from our membership on this specific 
proposal; however, we are not opposed to passage of this legislation.
 H.R. 2123, the Veterans E-Health and Telemedicine Support or VETS Act 
                                of 2017
    This bill would enable a VA health care professional licensed, 
registered, or certified in a state to practice his or her profession 
at any location in any state, regardless of where the professional or 
veteran is located, to treat a veteran through telemedicine. If 
enacted, the bill would permit telemedicine treatment regardless of 
whether the professional or the patient were physically located in a 
federally owned facility.
    The bill would require VA to report to Congress one year following 
its implementation on a variety of aspects of the Department's 
telemedicine program, including patient and provider satisfaction, 
access, productivity, waiting times and other information related to 
appointments made and completed through telemedicine.
    Because health professional licensure is a state-regulated 
function, as a national system, VA has experienced barriers in its 
efforts to broaden the use of telemedicine across state lines. A number 
of VA telemedicine initiatives have been frustrated because of the 
interstate restriction. Enactment of this bill would eliminate that 
barrier, and would promote much greater use of telemedicine, especially 
in facilities whose treatment populations come from multiple states 
(Martinsburg, West Virginia-patients from Virginia; Washington, DC-
patients from Virginia and Maryland; Pittsburgh, Pennsylvania-patients 
from Ohio; New York City, New York-patients from New Jersey; Boston, 
Massachusetts-patients from New Hampshire, Vermont and Maine; 
Fayetteville, Arkansas-patients from Missouri, Oklahoma, and Kansas, 
etc.). Enactment of this bill would open the door to VA specialists 
treating veterans through telemedicine irrespective of state 
jurisdiction, physical location, or the distance that separates patient 
from provider (for example, VA specialists in Seattle would use 
technology in real time to treat VA patients at the VA Outpatient 
Clinic in Anchorage, Alaska), and should also be highly cost-effective 
and more convenient for veterans who live at a distance from their VA 
medical centers, or who must travel long distances for access to basic 
VA care.
    Delegates to our most recent DAV National Convention approved 
Resolution No. 128. Among other priorities, this resolution calls on VA 
and Congress to establish and sustain effective telemedicine programs 
as an aid to veterans' access to VA health care, particularly in the 
case of rural and remote populations. Our delegates also approved 
Resolution No. 230, fully supporting the right of rural veterans to be 
served by VA. This bill is consistent with these resolutions and DAV 
policy; therefore, DAV strongly supports its enactment and appreciates 
the sponsors' intention to promote the use of telemedicine in the care 
and treatment of veterans.
H.R. 2601, Veterans Choice for Transplanted Organs and Recovery Act of 
                                  2017
    This legislation, if enacted, would allow a veteran in need of 
organ transplantation who lives more than 100 miles from a VA 
transplant center to receive hospital care and services related to the 
required organ transplant at an outside facility that meets the 
requirements under the Veterans Choice Program.
    Under current policy, veterans needing organ transplantation 
surgery must travel to travel to one of the VA's 13 transplant centers, 
which requires seriously ill veterans to travel hundreds of miles not 
only for the surgery, but also for preand post-operative care. A 2014 
study published in the Journal of American Medicine found that longer 
travel distances between a patient's home and transplant center 
correlated to higher mortality rates.
    DAV does not have a specific resolution in regards to this 
legislation; however, we are not opposed to its passage. Veterans who 
require organ transplantation but have serious access challenges to 
receiving that care because they reside far from a VA transplant center 
should have additional options for necessary life-saving surgery.
 H.R. 3642, the Military Sexual Assault Victims Empowerment Act or the 
                           Military SAVE Act
    This bill would require the VA Secretary to establish a three-year 
pilot program in five locations to provide non-VA medical care to 
veterans with conditions related to military sexual trauma (MST). For 
eligibility, veterans must, in the judgment of a Department mental 
health professional, have experienced an incident of sexual trauma 
while the veteran was serving in the military during active duty, 
active duty for training or inactive duty training, and reside in an 
area offering the pilot. Pilot participants would be able to select a 
non-VA care provider of their choice as long as they accept VA's pay 
rate for services rendered through Vas Choice Program or an existing 
contract.
    VA would be required to notify all eligible veterans about their 
opportunity to participate in the pilot and provide ``educational 
referral materials'' regarding non-Department providers in the area. 
Additionally, on a case-by-case basis, VA would be authorized to 
provide veterans who elect to participate in the community care pilot 
continued access to that provider until the completion of the episode 
of care.
    The measure would also require VA to survey, at six-month 
intervals, all eligible veterans at the pilot site who are receiving 
care for a MST-related condition to determine the quality and 
effectiveness of VA versus non-VA care. The survey must include 
information about the differences in wait times, distance to a 
treatment facility, frequency of appointments, duration of treatment, 
medication use, access to emergent mental health care services and 
clinical outcomes. Survey findings must be collected and analyzed by a 
qualified VA researcher and a final report provided to Congress not 
later than 60 days before completion of the pilot program.
    While this bill's stated goal is to ``improve the access to private 
health care'' for MST survivors its more apparent intent appears to be 
to evaluate quality of care and access to services for a MST-related 
condition in VA compared to a non-VA care setting. DAV has no 
resolution calling for a comparative survey for MST-related care, but 
we would like to take this opportunity to express our concerns with 
this bill.
    Currently, VA has the authority to send veterans to the private 
sector for care in cases where VA cannot provide the care needed, or 
cannot provide care in a timely manner, at the recommendation of a VA 
physician, when there is geographical hardship in commuting to a VA 
facility, and in cases where the veteran may have a special 
circumstance or need to be seen outside of the VA. DAV supports 
veterans access to care in the community in these noted circumstances; 
however, we want to ensure the care is high quality and that the non-VA 
provider has the cultural competency and expertise in treating patients 
who have experienced sexual trauma during their military service.
    VA is well known for its targeted MST-related research, clinical 
training and specialized treatment for veterans. All enrolled veterans 
using VA care are screened for MST, and survivors who are in need of 
mental health care receive tailored treatment plans. In fiscal year 
2016, VA provided nearly 1.5 million MST-related outpatient visits to 
veterans (male and female) who screened positive for MST.
    All VA mental health and primary care providers are required to 
complete MST training to ensure they are sensitive to the unique 
factors surrounding sexual trauma and can provide effective treatment 
to veterans who have experienced MST. According to VA more than 6,300 
mental health providers have received extensive training and 
supervision in the most effective evidence-based psychotherapies (EBP) 
for PTSD to include Prolonged Exposure and/or Cognitive Processing 
Therapy. More than 1,800 VA providers have received extensive training 
and supervision in one of three EBPs for depression. VA reports that 
veterans who received this specialized treatment have experienced 
clinically meaningful and significant improvement in their PTSD and 
depressive symptoms.
    By contrast, RAND's Ready to Serve national study of therapists who 
treat PTSD and major depression found that compared to providers 
affiliated with the VA or the Department of Defense, ``a 
psychotherapist selected from the community is unlikely to have the 
skills necessary to deliver high quality mental health care to service 
members or veterans with these conditions.'' According to the study 
only 18 percent of Tricare and six percent of non-Tricare community 
therapists were trained in and used an EBP.
    Additionally, VA reports there is a national initiative within the 
Department to disseminate evidenced-based therapies for mental health 
conditions related to MST as well as web-based resources, monthly calls 
with mental health providers and an annual conference for clinicians to 
ensure they receive up-to-date information about delivery of care 
options to this population. VA also has a designated coordinator in 
every VA medical center who serves as the contact person for veterans 
for MST-related issues and services.
    VA's ability to provide high quality care to MST survivors is more 
than providing specialty treatment; it is also understanding military 
culture and that this population often has other mental health and 
physical comorbidities, in addition to an increased likelihood of 
experiencing homelessness, substance use disorder and an elevated risk 
for suicide. VA's comprehensive care model allows providers to address 
the whole veteran by having an array of health care treatment options, 
benefits and wraparound services to support them. VA's mental health 
programs, VA's Vet Center, the Veterans Crisis Line and other 
complementary and alternative care options along with specialized care 
programs for PTSD, homelessness and substance-use disorders, are just a 
few ways in which VA coordinates its resources, benefits, and medical 
services to not only meet the health needs of veterans, but also 
simultaneously address their psychosocial and economic well-being.
    There is no comparable program in the private sector and providers 
are less likely to have the necessary skills and experience to provide 
the most effective care and health outcomes for MST survivors. When it 
comes to caring for these veterans, it is essential that they receive 
the right care, at the right time, by a qualified health care provider 
that is able to deliver effective care and supportive services. Given 
VA's comprehensive and integrated health care response to military 
sexual trauma and proven expertise in effectively treating veterans 
with PTSD or other mental health conditions resulting from MST, we 
believe these veterans are best served in VA. For these reasons DAV is 
unable to support this measure.
   Draft Bill, to modify the authority of the Secretary of Veterans 
 Affairs to enter into agreements with State homes to provide nursing 
 home care to veterans, to direct the Secretary to carry out a program 
    to increase the number of graduate medical education residency 
            positions of the Department of Veterans Affairs
    Section 1 of the draft legislation would amend Section 1745(a) of 
title 38 to modify VA's authority to enter into provider agreements 
with State Veterans Homes for the purpose of providing skilled nursing 
care to certain service-connected veterans. Public Law 109-461 as 
amended by Public Law 112-154 authorizes VA to pay the ``full cost of 
care'' for veterans who require skilled nursing care due to a service-
connected disability, or who have a disability rating of 70 percent or 
greater and are in need of skilled nursing care. Since enactment of 
these laws, VA has entered into provider agreements with each State 
Home for the provision of such care to eligible disabled veterans.
    However, a few years ago, the Administration made a determination 
that the use of provider agreements by VA for this program and others 
in lieu of more burdensome federal contracting requirements was in 
conflict with federal labor laws. Since that ruling, VA has been 
prevented from entering into new provider agreements.
    This section would provide VA with specific statutory authority to 
enter into provider agreements with State Homes to continue providing 
care to seriously disabled veterans under Section 1745(a), while 
ensuring that State Homes fully adhere to federal laws concerning 
integrity, ethics, fraud, as well as Title VII of the Civil Rights Act 
of 1964 prohibiting discrimination in hiring. State Homes would also 
remain subject to all applicable State labor laws concerning employment 
discrimination.
    DAV supports Section I of the draft legislation in accordance with 
DAV Resolution No. 062, supporting the State Veterans Homes program, 
which calls for providing, ``.states greater flexibility in providing 
long-term supports and services to veterans in State Veterans Homes,'' 
and specifically addresses VA's ability to ``.enter into provider 
agreements with State Veterans Homes to pay the full cost of care 
provided to veterans with 70 percent or higher service-connected 
disabilities or who require nursing home care for service-connected 
disabilities.''
    Section 3 of the draft legislation would provide VA with new 
authorities to incentivize medical students to fill the 1,500 graduate 
medical education residency positions created by Public Law 113-146, 
the Veterans Access, Choice, and Accountability Act of 2014.
    Under this section, the Secretary would create a program to provide 
additional educational assistance to individuals in return for a period 
of ``obligated service'' working for the VA health care system. The 
legislation contains specific penalties for failure to complete the 
residency program or to fulfill the service obligation to VA.
    While DAV supports creating additional financial incentives to help 
VA recruit, hire and retain high-quality medical professionals, 
concerns have been raised about whether the requirement for ``obligated 
service'' is the most effective manner in which to achieve that goal. 
The underlying graduate medical education residency program currently 
does not have such a requirement. Further, this provision lacks 
specificity regarding the level and type of financial assistance to be 
provided, as well as the length of the required ``obligated service.''
    While we support the intent of creating new incentives to bring 
clinicians into the VA health care system, we believe that further 
discussion and consideration of alternate incentives should occur 
before moving forward with this provision.
      Draft Bill, to establish a permanent Veterans Choice Program
 VA Legislative Proposal, the Veteran Coordinated Access and Rewarding 
                         Experiences (CARE) Act
    DAV deeply appreciates the commitment and work of the members and 
staff of this Committee and the VA for the two draft bills being 
considered in today's hearing. Both bills seek to improve veterans' 
access to community care by, among other things, consolidating some of 
VA's purchased care authorities, ensuring coordination of care and 
health information sharing. DAV is pleased both bills contain some of 
our recommendations to reform the VA health care system while 
preserving and strengthening it so that DAV members and all eligible 
veterans may continue to enjoy the unique benefits and vital services 
VA provides well into the future.
    Over the past year, DAV and our Independent Budget (IB) partners 
developed a comprehensive framework to reform VA health care based on 
the principle that it is the responsibility of the federal government 
to ensure that disabled veterans have proper access to the full array 
of benefits, services and supports promised to them by a grateful 
nation. In order to achieve this goal, our comprehensive framework has 
four pillars-Restructure, Redesign, Realign, and Reform. We offer our 
views on specific provisions of these draft bills that we believe fit 
within this framework and recommend it be part of the final legislation 
this Committee passes to reform VA health care.

I. Restructure our nation's system for delivering health care to 
    veterans, relying not just on a federal VA and a separate private 
    sector, but instead creating local Veteran-Centered Integrated 
    Health Care Networks that optimize the strengths of all health care 
    resources to seamlessly integrate community care into the VA system 
    to provide a full continuum of care for veterans.
Veteran-Centered Integrated Health Care Networks
    Veteran-Centered Integrated Health Care Networks were proposed in 
response to fragmented care delivery by providing a coordinated 
continuum of services-from wellness and preventive services to urgent 
care, inpatient care, outpatient care, extended care and hospice-to a 
defined veteran patient population. The goal of improving veterans 
health outcomes at lower cost by operating effectively and efficiently 
greatly depends on the performance level and degree of integration.
    Degrees of such integrations can be measured by the use of 
evidence-based disease management, formularies, continuum of care and 
mix of available services, and the use of technology such as 
information systems and integration level as well as real time central 
medical records.
    CARE Act: To this end, the CARE Act provides little concrete 
description as to how Veteran-Centered Integrated Health Care Networks 
will be created, implemented, administered, overseen and how to 
determine if they are successful.
    Veterans Choice Program (VCP) draft bill: The VCP draft bill would 
establish the Veterans Choice Program under which VA would, subject to 
appropriations and the election of veterans, provide hospital care and 
medical services to eligible veterans through contracts and agreements 
with non-VA providers. The Secretary would be required to establish 
regional networks of providers and may enter into one or more contracts 
to manage the operations of these networks.
    To assure quality throughout the network of providers contemplated 
under the VCP draft bill, DAV recommends that any contracts made by the 
VA health care system with non-Department providers contain standards 
and requirements that allow VA to ensure these providers are able to 
uphold at least the same quality of care available at medical 
facilities within the Department, allowing the Secretary to measure, 
monitor and thereby be accountable for, care delivered through non-VA 
providers. VA, and not the network provider, should be held accountable 
for coordinating the veteran's care (1703A(a)(3), (b), (c), 
(d)(5)(A),(g)) and the ability to generate efficiencies (1703A(k)) that 
reduce costs (1703A(d-f), Sec. 102(a)(1)) while meeting certain 
quality, or care metrics (1703A(i)).
    Such standards would include all matters related to scheduling and 
timely access to care standards, quality of care standards, and health 
information sharing capability. This proposed change directs the 
Secretary to use the Veterans Choice Program as it uses Department 
facilities and employees to furnish care to ill and injured veterans 
(see 38 USC 1710).
    From a veteran patient's perspective, a Veteran-Centered Integrated 
Health Care Network should provide veterans information they would need 
to make an informed decision. For example, information about the 
quality of the community providers in this network will give veterans 
the ability to discern between those community providers that are more 
knowledgeable about the veteran experience and their unique needs, 
information about the satisfaction rating from other veterans who have 
seen that provider, and whether there is a good working relationship 
with the VA that facilitates care coordination.
    The Veteran-Centered Integrated Health Care Network would create 
and preserve the kind of community-VA provider partnership that mirrors 
the care our members value most in the VA health care system.
    To ensure formation of the local Veteran-Centered Integrated Health 
Care Networks requires the function of a high performing network. Our 
framework places VA as the coordinator and principal provider of care, 
which we discuss immediately below. VA's primary care (medical home) 
model with integrated mental health care, is more likely to prevent and 
treat conditions unique to or more prevalent among veterans, 
particularly those with disabilities or chronic conditions, but is not 
a requirement of non-VA primary care providers, which is a concern for 
DAV.

II. Redesign the systems and procedures by which veterans access their 
    health care with the goal of expanding actual, high-quality, timely 
    options; rather than just giving them hollow choices.

Care Coordination

    DAV strongly urges the Committee to discontinue the current 
arrangement under the Choice program that has effectively removed a 
critical part of the care coordination responsibility away from VA 
front-line clinicians. VA Community Health Nurse Coordinators are the 
case managers and coordinators of care and work with the veteran's 
health care team to provide for the veteran patient's medical, nursing, 
emotional, social and rehabilitative needs as close as possible to or 
in the veteran's home.
    While VA Community Health Nurse Coordinators are now better able to 
exercise their clinical authority due to the Section 106 
reorganization, they are frustrated having lost their ability under the 
current Choice program to act as a liaison between community providers 
and VA and as an advocate for their veteran patients-who themselves 
have unsuccessfully tried to exercise their Choice option and asked for 
assistance from their VA nurse coordinator-to get the care they need in 
the community.
    CARE Act: We strongly recommend the language be added to the CARE 
Act to ensure VA remains the coordinator of veterans' care, especially 
if that care is provided in the community and paid for by the 
Department.
    VCP draft bill: While DAV applauds the VCP draft bill for its 
appreciation of the medical home model featuring assignment to a 
primary care team or provider, we strongly recommend the Committee 
ensure VA remains the coordinator of veterans' care, especially if that 
care is provided in the community and paid for by the Department.
    We further recommend the required assignment of a veteran to a 
dedicated VA primary care provider or VA Patient-Aligned Care Team 
(PACT) be made at the time the veteran seeks care, not at enrollment, 
and not necessarily for all veterans. We believe the current proposal 
will lead to gross misalignment of resources because not all veterans 
who enroll in VA access the system and other veterans just use VA for 
certain types of care such as prosthetics, sensory aids, or spinal cord 
injury care. In addition, highly disabled service-connected veterans 
have never been required to enroll for health care.
    Many veterans have several types of health insurance and have 
defined utilization patterns inside of VA and with other providers. If 
all are assigned to VA primary or Choice providers, would veterans be 
required to use them as gatekeepers when they already have a primary 
care provider elsewhere and really just need a new prosthetic limb or 
wheelchair? To relieve waiting times, one medical center looked at the 
effect of allowing veterans to self-refer to audiology for services 
related to hearing loss, rather than requiring a primary care 
provider's referral. During the previous Administration, this change 
was identified as a ``best practice'' for relieving waiting times and 
increasing access. DAV hopes that VA will use its utilization data to 
identify those veterans who are most reliant upon it for care and make 
these assignments to PCPs and PACTs, and case management as 
appropriate. Less reliant veteran patients are accounted for in VA's 
resource allocation methodologies, but may not require assignment to a 
regular primary care provider. In addition, VA should give veterans an 
opportunity to elect a new provider if there are extenuating 
circumstances such as a new VA resource (such as a community-based 
outpatient clinic) becomes available, their medical condition changes 
or their transportation provider is no longer available. Veterans 
should also be able to leave an assigned network provider if that 
provider can no longer provide timely access to care.
    The proposed section 1703A(b)(1)(B)(iii) in the VCP draft bill 
requires VA to ensure an ``eligible veteran is not simultaneously 
assigned to more than one patient-aligned care team or dedicated 
primary care provider.'' We remind Congress and VA in executing this 
provision of the Department's current policy regarding traveling 
veterans who are assigned to a PACT at the veteran's preferred facility 
as well as assignment to a PACT at an alternate facility for their 
annual extended travel. We urge the Committee to ensure this patient-
provider relationship is not adversely affected.

Telemedicine:

    CARE Draft Bill: We support the intent of section 301 of this draft 
measure. DAV has previously testified that, as a national health care 
provider making extensive use of telemedicine, VA must ensure that its 
providers' state licensure is legally protected if they offer medical 
services across state lines. We note H.R. 2123, the Veterans E-Health 
and Telemedicine Support or VETS Act of 2017, is on today's agenda and 
based on previous testimony from VA on a similar bill, section 2(a) 
would remove the barriers that might be imposed by local licensure laws 
of the places where the patient or the covered health care professional 
are located, or the state of licensure of the health care professional. 
Further, section 2(a) would make clear that any telemedicine services 
that involve prescribing controlled substances would have to be 
provided in accordance with the Controlled Substances Act. We refer the 
Committee to our discussion on this authority under H.R. 2123 and urge 
swift and favorable action.

Use of Veterans Health Information:

    VCP Draft Bill: The disclosing of medical information under section 
202 was discussed before the Subcommittee at the June 23, 2016 
legislative hearing on H.R. 5162, the Vet Connect Act of 2017.
    We testified that ``DAV understands and supports increased use and 
appropriate sharing of health data; however, veteran patients also want 
to be assured of the privacy and security provided for protected 
information. We urge the committee and the sponsor of this legislation 
strike a more balanced policy between the competing aims of sharing 
data and protecting privacy. We recommend such broad language be 
amended to affect only shared patients and only for the purpose of 
completing a treatment plan to which the veteran patient has agreed.'' 
Accordingly we recommend language be inserted after line 16:
    ``(II) An entity to which a record is disclosed under this 
subparagraph may not redisclose or use such record for a purpose other 
than that for which the disclosure was made.''

Consolidation of Existing Authorities

    VA has a number of statutory authorities, programs, and other 
methods for purchasing community care. The various methods for 
receiving community care have conflicting structures, responsibilities, 
ownership, and management, with different application at the local and 
national levels and has led to inefficient implementation and 
significant confusion among veterans, community providers, VA 
providers, and staff.
    These authorities, programs and methods have differing requirements 
and processes for key components, including, but not limited to, 
eligibility criteria and eligibility determinations; referrals and 
authorizations; provider credentialing and network development; health 
care and health information coordination; reimbursement/payment rates, 
and; claims management.
    The CARE Act proposes to consolidate existing community care 
authorities under section 221 of the Act but is limited to Section 
1703, dental care under Section 1712, counseling and related mental 
health services under Section 1712A, burial under Section 2303, and 
care for ill Persian Gulf War veterans under Section 1117 (note). This 
consolidation is a far cry from the planned consolidation of Section 
7409 (Scarce Medical Resources), Project ARCH, Section 403 of Public 
Law 110-387 (as amended), the Pilot Program of Assisted Living for 
Veterans with TBI, Section 1705 of Public Law 110-181(as amended), and 
emergency care under Sections 1725 and 1728 and the proposal to 
authorize VA to pay the reasonable costs of urgent care.
    Moreover, it appears section 201 of the CARE Act would impose 
another eligibility criteria on those purchased care authorities under 
section 211.

Veterans Care Agreements \1\
---------------------------------------------------------------------------
    \1\ https://www.dav.org/wp-content/uploads/Atizado20150603.pdf

    We support the establishment of provider agreements to meet the 
need for this authority to be enacted into law without delay. VA 
purchases a broad spectrum of medical and extended services from 
private sector providers for veterans, their families and survivors 
under specific but fragmented authorities. These authorities have in 
some cases created confusion and uncertainty among ill and injured 
veterans and private providers in their community.
    CARE Act: Section 101 the CARE Act would allow VA to use provider 
agreements to purchase medical care and services in certain 
circumstances. The bill appears to preserve key protections found in 
the contracts based on the Federal and VA Acquisition Regulations 
including protections against waste, fraud and abuse. It intends to 
streamline and speed the business process for purchasing care for an 
individual veteran that is not easily accomplished through a more 
complex contract with a community provider, and thus be more appealing 
to some providers.
    We understand this proposal is not intended to supplant long-
standing regional and national contractual and sharing agreements, 
which is helping to build VA's Extended Network of community providers. 
Rather, this authority is intended to play a supporting role in 
specific situations when, for a variety of legitimate reasons, needed 
care cannot be purchased through existing contracts or sharing 
agreements.
    Since VA's current authority to enter into provider agreements is 
in section 101(d) of Public Law 113-146, the Veterans Access, Choice, 
and Accountability Act of 2014 (VACAA), is proposed to be terminated 
after September 30, 2018, under section 501 of the CARE Act, we believe 
section 101 and 501 must be favorably considered simultaneously.
    Furthermore, we believe under Veteran Care Agreements, extended 
homeand community-based care and services will be provided to severely 
ill and injured veterans and aging veterans with chronic conditions. 
For this patient population, it is essential that the care and services 
they receive be carefully coordinated. We therefore recommend language 
be included requiring care coordination to realize the best health 
outcomes and achieve veterans' health goals.
    We appreciate language in the CARE Act intended to improve VA's 
administrative functions, business practices and employment of data 
analytics to ensure the purchases are cost effective, preserve agency 
interests, and enhances the level of service VA directly provides 
veterans.
    VCP Draft Bill: While VA would remain the primary source of care 
for veterans with network providers serving in a back-up role, there 
will be some instances, likely in highly rural or medically underserved 
areas where sole practitioners who cannot meet the same standards as 
network providers are the only available health care resource. We 
support the establishment of Veterans Care Agreements as a necessary 
source of care within the new model this draft develops.
    Because this draft bill would not bar an eligible provider from 
participating as a network provider under 1703A as well as Veteran Care 
Agreements, we recommend language be included to address the potential 
for these ``dual-participating'' community providers to not confuse the 
authority for receiving referrals which may result in their sending 
claims to the wrong payer (VA vs. Network Manager).

Community Care Eligibility

    For veteran patients, waiting for a health service begins when the 
veteran and the appropriate clinician agree to a service, and when the 
veteran is ready and available to receive it. However, we believe it is 
time to move towards a health care delivery system that keeps clinical 
decisions about when and where to receive care between a veteran and 
his or her doctor without bureaucrats, regulations or legislation 
getting in the way.
    CARE Act: DAV supports the approach under Section 201 of the CARE 
Act to determine a veteran's eligibility to elect to receive care in 
the community. However, there is no remediation plan included in this 
draft bill that would reinforce the need for community care to 
supplement rather than supplant the VA health care system. We discuss 
this aspect in greater detail under ``Reform VA's culture.''
    VCP Draft Bill: DAV supports this draft bill's elimination of some 
of the arbitrary restrictions such as distance and waiting times that 
currently limit eligibility for community care. Instead, VA, to the 
extent that resources allow, would be required to make such a 
determination upon enrolling a veteran for care. We have already noted 
our concerns about that approach above. Enrollment would continue 
within VA facilities until such time that the Secretary determines VA 
can no longer assign veterans to primary care providers due to a 
shortage of health care professionals. At that time, VA would provide 
veterans with a list of private providers from which to choose. VA 
would reassess its internal capacity to enroll veterans with a primary 
care provider on an annual basis.
    We are, however, concerned that this system of enrollment may be 
used to lock veterans out of the system should resources for community 
care be exhausted. It is also unclear if VA would use priority groups 
established in 38 USC 1705 for enrollment to primary care providers to 
ensure that service-connected veterans are never denied care. We also 
again note that service-connected veterans with conditions rated at 50 
percent or more are not required to enroll for care, but should never 
be locked out of the system because they are not assigned to a primary 
care provider.

State Veterans Homes

    DAV has previously raised concern when Congress considered 
legislation restructuring VA's relationship with non-VA community 
providers as it affects provider agreements with community providers 
and State Veterans Homes specifically.
    As you know, it took several years, two public laws (Public Law 
109-461 and Public Law 112-154) and an Interim Final Rule (RIN 2900-
AO57) to achieve Congress' original intent of offering the most 
severely disabled veterans the option to receive extended care at State 
Veterans Homes. As the Committee moves forward, it is important to 
ensure that any legislation that addresses VA's provider agreement 
authority with community providers does not modify, diminish, endanger 
or eliminate State Veterans Homes existing provider agreements 
authorizing them to provide these critical long-term care services to 
thousands of severely injured and ill veterans.
    We direct the Committee to our discussion of the other draft bill 
being considered by the Committee to modify VA's authority to enter 
into agreements with State homes to provide nursing home care to 
veterans.

Emergency and Urgent Care

    DAV continues to recommend making urgent care part of VA's medical 
benefits package and to better integrate emergency and urgent care with 
the overall health care delivery system. DAV believes a health care 
benefit package is not complete without effective provisions for both 
urgent and emergency care.
    We have raised the need to address the eligibility and payment 
issues that veterans and community providers face regarding emergency 
care, and this Committee is aware of our organization's long-standing 
position opposing any and all copayments imposed on veterans and 
supporting legislation reducing the copay amount.
    CARE Act: We therefore oppose the imposition of care copayments had 
veterans sought this type of care at VA medical facilities.
    DAV also opposes the provision that would force veterans to pay 
copayments while their health insurance reimburses VA for emergency or 
urgent care. VA should be applauded and allowed to continue its current 
practice of offsetting a veteran's copayment debt with monies VA 
receives from billing the veteran's health insurance plan.
    VCP Draft Bill: DAV supports the draft bill's emergency 
transportation benefit, but regrets that its authors did not address 
the ongoing problems that occur with emergency care or establish a 
benefit for urgent care. An urgent care benefit could limit the number 
of veterans using emergency care for lack of a better option. About 
half of all emergency care users claim that they sought care in that 
setting because their regular source of care was not available. We urge 
the bill authors to address these issues.

Emergency Care Eligibility

    Carrying out the multiple and complex authorities \2\ for VA to pay 
or reimburse emergency care under title 38 are a source of continuous 
complaints and can drive ill and injured veterans and their families to 
financial ruin.
---------------------------------------------------------------------------
    \2\ 38 U.S.C. Sec. Sec.  1703, 1725 and 1728
---------------------------------------------------------------------------
    According to VA, ``In FY 2014, approximately 30 percent of the 2.9 
million emergency treatment claims filed with VA were denied, amounting 
to $2.6 billion in billed charges that reverted to Veterans and their 
[Other Health Insurance]. Many of these denials are the result of 
inconsistent application of the ``prudent layperson'' standard from 
claim to claim and confusion among Veterans about when they are 
eligible to receive emergency treatment through community care.''
    To address the inconsistent application of the prudent layperson 
standard, DAV recommended the ``emergency condition'' under title 38 be 
defined as follows:

    ``A medical [or behavioral] condition manifesting itself by acute 
symptoms of sufficient severity (including severe pain) such that the 
absence of immediate medical attention could reasonably be expected to 
result in placing the individual's health [or the health of an unborn 
child] in serious jeopardy, serious impairment to bodily functions, or 
serious dysfunction of bodily organs. With respect to a pregnant woman 
who is having contractions that there is inadequate time to effect a 
safe transfer to another hospital before delivery, or that transfer may 
pose a threat to the health or safety of the woman or the unborn 
child.''
    We also recommend a change to the current requirement for veterans 
to have received VA care within the last 24-months prior to receiving 
emergency care in the community to be eligible for VA's emergency care 
benefit. This requirement unduly discriminates against otherwise 
healthy veterans who need not seek care at least once every 24 months, 
yet is required to make an otherwise unnecessary medical appointment in 
order to be eligible for payment or reimbursement for non-VA emergency 
treatment. We urge the Committee provide greater flexibility by 
including an exemption authority to the 24-month requirement for this 
and other unforeseen circumstances.

III. Realign the provision and allocation of VA's resources so that 
    they fully meet our national and sacred obligation to make whole 
    those who have served.

Revenue Enhancing Provisions

    CARE Act: DAV adamantly opposes any and all provisions in this 
measure that would effectively offset appropriated funds for VA medical 
care. These proposals can be found in sections 121, 131, 132 and 503, 
whereby this government is proposing to take an estimated $2.7 billion 
over 10 years from service-connected disabled veterans and their 
survivors based on the 10-year round down of cost-of-living adjustments 
for veterans benefits.
    DAV is opposed to this rounding down provision. Veterans and their 
survivors rely on their compensation for essential purchases such as 
food, shelter, utilities and transportation. It also enables them to 
maintain a marginally higher quality of life.
    The co-authors of the IB, DAV along with Paralyzed Veterans of 
America and Veterans of Foreign Wars, sent a letter to this Committee 
on May 24, 2017, stating ``rounding down veterans' COLAs unfairly 
targets disabled veterans, their dependents and survivors to save the 
government money or offset the cost of other federal programs. The 
cumulative effect of this provision of law would, in essence, levy a 
10-year tax on disabled veterans and their survivors, reducing their 
income each year. When multiplied by the number of disabled veterans 
and recipients of Dependency and Indemnity Compensation or DIC, 
hundreds of millions of dollars would be siphoned from these deserving 
individuals annually. All totaled, VA estimates, this proposed COLA 
round down would cost beneficiaries close to $2.7 billion over 10 
years.''
    Equally objectionable is the proposed requirement to charge 
veterans for the care they receive from VA. This provision seeks to 
improve VA's ability to receive information the agency requires to 
identify and receive reimbursements from a veteran's health plan. Such 
a heavy handed approach appears prejudicial considering insurance 
identification is only one of multiple elements across VA's revenue 
cycle to include accurate insurance verification, authorization, 
utilization management, claims processing, accounts receivable, and 
payor relations. We note there are no other provisions in the CARE Act 
requiring specific actions be taken to improve VA's responsibility in 
this area of its revenue cycle.
    VCP Draft Bill: Service-connected disabled veterans must not be 
compelled to pay for their own care. According to DAV Resolution No. 
115, which calls for the reduction or elimination of veterans' 
copayments, we oppose subsection (f) of Section 1703A, and Section 203. 
We recommend both provisions be stricken.
    Section 1703A, subsection (f) would require certain service-
connected disabled veterans to pay VA copayments for care received 
under the proposed Veterans Choice Program.
    Section 203 proposes to eliminate VA's current practice of 
extinguishing veterans copayment debt from any third-party 
reimbursements received from that veteran's health plan. We urge the 
Committee strike this provision from the bill.
    Veterans, especially those who incur disabilities during or as a 
result of military service, have already made their payments for health 
care through their service and sacrifice. Citizens of a grateful nation 
want our government to fully honor our moral obligation to care for 
veterans and generously provide them benefits and health care entirely 
without charge.

Funding Flexibility

    Viewed together, sections 211, 501 and 502 of the CARE Act would 
eliminate the current authority to furnish veterans medical care in the 
community through the Veterans Choice Program, add $4 billion of what 
appears to be no-year mandatory funds into the account designated by 
Section 802 of Public Law 113-146, the VACAA to be used solely for care 
in the community.
    We are concerned this proposal does not provide the funding 
flexibility contemplated under VA's own CARE Plan Consolidation that 
state, ``in future budget requests, [VA] will request that Congress 
appropriate budget authority to this account in the annual 
appropriations act. The account, which will be known as the `Community 
Care' account, will be the sole source of funding for care that VA 
provides to Veterans through community providers. Separating the 
funding of Veteran community care from the current VA hospital care and 
medical service funding will require local leaders to set a clear 
funding level and actively manage community care.'' (Emphasis added.)

Recording Obligations at Payment

    VHA must adhere to certain business standards and practices when 
obligating funds for a variety of goods and services, including 
purchased outpatient, inpatient and extended care, and other health 
care related goods and services. To ensure it does not overspend, funds 
must be available to cover obligations and expenditures prior to 
entering into an agreement to purchase care and services.
    To accomplish this, VHA estimates the amount of funds required for 
such purchase or obligation and payment, verifies that funds are 
available prior to recording the obligation in the financial system, 
monitor all transactions, certify goods and services were received 
prior to approving payments, and close any remaining balances within 30 
days following the end of the month or fiscal year, in which all 
expected activity has been completed.
    In this process it has been found VHA's process has led to 
overestimation of funds needed to pay for approved purchases of non-VA 
care. VA's Office of Inspector General found (VAOIG) in 2016 that VHA 
did not have a performance improvement plan for obligation management, 
did not have adequate tools to accurately estimate costs of goods and 
services, and did not routinely adjust cost-estimates of obligations to 
reflect better estimates of potential costs.
    However, VAOIG also found that the VACAA (Public Law 113-146) 
effectively prohibited VHA from using no-year funds for non-VA care and 
services, which put all over-obligated funds at risk of not being 
available for any purpose.
    We understand the desire to avoid over obligating no-year funds, 
which delays the availability to use these funds and puts single-year 
funds at risk of not being used due to expiration of the appropriation. 
However, the proposed solution to record obligations at payment may put 
VHA at greater risk of underestimating obligations and thus 
overspending, the implication of which is seriously concerning to DAV.
    Unless appropriate monitoring and controls are in place to protect 
against the risk of overspending, community care may begin to supplant 
rather than supplement the VA health care system.
    The other option is to improve VA's current processes, systems, and 
data. It should be noted that VAOIG found certain VHA medical 
facilities that thoroughly analyzed the historical costs of previous 
non-VA care authorizations, while time-consuming due to lack of 
standard data systems and average cost calculation procedures, produced 
reasonably accurate cost tables. Automating manual reconciliation is 
also necessary to timely release unobligated funds for use.
    We believe the proposed sections 112-114 in the CARE Act to reform 
its provider payment rates, claims and payment processing would serve 
to help VHA's ability to more accurately estimate cost of care over 
time. The general lack of automation and refinement of estimations will 
persist longer if not address legislatively.

Claims Processing and Payment

    VA's processing of claims has been a significant weakness to the 
Department's community care programs resulting in costlier care, 
inappropriate billing of veterans and strained partnerships with 
community providers. Government Accountability Office reports 
throughout the years have consistently highlighted disturbing 
limitations in the Department's claims processing system as having 
unnecessary manual operations rather than automatically applying 
relevant information and criteria to determine whether claims are 
eligible for payment and notifying veterans and community providers 
about the results of the determination, payment, and appeal procedures.
    Many veterans worry about claims that are not paid promptly or are 
left unpaid, and they are left in a difficult position of trying to get 
claims paid or be put into collections. These delays or denials create 
an environment where community providers are hesitant to partner with 
VA for fear they will not be paid for services provided. Hospitals and 
community providers have also expressed concern that prompt payment 
laws do not apply to care that is provided to veterans if they do not 
have a contract with VA. We have also heard complaints from veterans 
regarding section 101(e) of the current Choice program, which places on 
them greater financial burden and emotional stress while trying to 
recover from injuries and illnesses. We believe the responsibility of 
the government as first-payer and prompt payer for care and services 
should be reaffirmed.
    CARE Act: DAV supports provisions that would improve VA's timely 
processing of claims and payment to community providers, including 
applying the prompt payment act, govern claims management and payments 
to community providers, and would set a firm date after which VA would 
not accept claims in other than electronic form. Sections 112-114 would 
mandate the establishment of an electronic interface to enable private 
providers to submit electronic claims as required by the section. To 
further strengthen this proposal, we recommend adding certain 
provisions requiring VA be primarily responsible for payment of all 
goods and services, and that equivalent protections for veterans 
proposed in Section 101(h) be provided under Subtitle B.
    VCP Draft Bill: DAV is pleased that the draft bill takes steps to 
address claims processing and urges the Committee to take immediate 
action to protect veterans from suffering the consequences of VA's late 
payments for their care.

IV. Reform VA's culture to ensure that there is sufficient transparency 
    and accountability to the veterans this system is intended to 
    serve.

    Beginning on October 1, 2014, the VACAA transferred Non-VA Medical 
Care (NVMC) Program payment responsibilities from local medical 
facilities to the Veterans Health Administration's (VHA) Chief Business 
Office and separated NVMC funding from other VHA Medical Services 
appropriation funds. We believe it is beneficial to require, rather 
than make discretionary, the transfer of funds and payment of services 
to VHA's Office of Community Care. This would help ensure transparency 
and accountability to a single entity when conducting oversight.
    We also strongly urge the Committee to preserve the organizational 
model required in Section 106 of VACAA in any future consolidation of 
VA's purchased care authorities. Section 106 effectively created a 
``wall'' that separated the financial and clinical operations of the 
current Choice program, which better insulated front-line clinicians, 
such as VA Community Health Nurse Coordinators, social workers, or 
other VA health care professionals against the fiscal pressures that 
have been known to sway clinical decisions and delay or deny community 
care to veterans.
    VCP Draft Bill: DAV supports efforts within the draft bill that 
would better assure that VA networks within the Veterans Choice Program 
are held accountable for outcomes including quality of care, care 
coordination, access, and costs, but recommend that the bill address 
adding standards to allow VA to measure and monitor to their contracts 
with network providers.
    Moreover, in managing resources, capabilities and capacities of the 
VA health care system, DAV believes the development of integrated 
community networks must be based on dynamic demand and capacity 
analysis, which would include modeling of the need to expand, contract, 
or relocate VA facilities. Local stakeholder input would be essential 
to ensure that local health care coverage would not be negatively 
affected by any facility realignment.

Clinical Appeals

    VA's Plan to Consolidate Programs of Department of Veterans Affairs 
to Improve Access to Care clearly indicates, ``a clinical appeals 
process will be available to Veterans who do not agree with the 
clinical referral decision of their providers. This clinical appeals 
process will focus on reaching agreement at the care team level, but if 
disagreements cannot be resolved at that level, an additional level of 
appeal will be available. Veterans will have a single point of contact 
for appeals and an opportunity to be heard at each step. Appeals will 
be timely based on clinical need.'' No such provision exists.
    CARE Act and VCP Draft Bill: It is unconscionable that it is more 
important to propose statutory language requiring a procedure in both 
draft bills for community providers to be able to appeal a decision by 
VA, but did not propose similar language for veterans to appeal 
clinical decisions by VA.
    We believe statutory language should be included in any legislation 
proposing to reform the VA health care system requiring the Department 
to establish by regulation a process for veterans to appeal a VA 
clinical decision.
    DAV agrees with the Commission on Care that VA must ensure that 
veterans have access to a fair and effective appeals process, just like 
other federal health beneficiaries. At a minimum, VA must assure 
veterans access to a uniform process with decisions made within clearly 
defined timelines at different points of the process. Most federal 
health beneficiaries have a right to an external review at their 
discretion and veterans should also be allowed this review at the 
veteran's discretion rather than that of the hospital or VISN director. 
We understand that VA has convened an interdisciplinary group to review 
this process, but these are minimal standards that ensure a veteran of 
due process.

Supplementing the VA Health Care System:

    CARE Act: To ensure community care serves to supplement and not 
supplant the VA health care system, we are disappointed this draft bill 
does not propose any sort of demand and capacity analysis.
    VCP Draft Bill: We support the VCP draft bill's efforts to assess 
capacity in VA and the private sector. To strengthen the proposed 
section 1703(A)(k), we recommend you more fully consider VA's internal 
capacity such as including discrete language in the identification of 
existing gaps under (A) including:

      Considerations of capital and human capital needs and 
planning. Capital planning should include meeting new, renovated or 
replacement space needs, and the orderly disposal of unused, unneeded 
property.
      A plan to remedy such gaps should also be required in the 
assessment-including identifying necessary resources to timely close 
such gaps.

    In forecasting for capacity and commercial market assessment, the 
proposed section 1703(A)(k)(1)(c) calls for the annual capacity and 
commercial market assessments to have ``(C) forecast, based on future 
projections rather than historical trends, both the shortand long-term 
demand in furnishing care or services at such Veterans Integrated 
Service Network and medical facility and assess how such demand affects 
the needs to use such network providers.''
    Demand forecasting can help predict trends for at least three 
years, but not much longer than five years out. For staffing demand one 
generally looks at the primary service area population, its market 
share and out-of-area draw to determine its potential patient volume, 
as well as considering assumptions such as a population growth and 
technology development to help calculate how many physicians would be 
needed to treat that population to estimate potential physician demand.
    We also recommend language indicating such forecasts include valid 
and reliable historical data.
    DAV is concerned that this system of enrollment may be used to lock 
veterans out of the system should resources for community care be 
expended. Also DAV is unclear if VA would use priority groups 
established in 38 USC 1705 for enrollment to primary care providers to 
ensure that service-connected veterans are never denied care. We also 
again note that service-connected veterans with conditions rated at 50 
percent or more are not required to enroll for care, but should never 
be locked out of the system because they are not assigned to a primary 
care provider.

Ensure entitlement for compensation for negligent care:

    VCP Draft Bill: The proposed section 1703A(b)(2)(C) would allow a 
network provider to practice specialty care in a Department facility or 
Department provider to practice specialty care in a network provider 
facility.
    DAV recommends language extending entitlement, in these instances, 
to compensation under 38 USC, section 1151, which in general terms 
provides that veterans' disability or death as a result of negligent 
treatment furnished by VA, and not the result of such veteran's own 
willful misconduct, shall be compensated as if their disability or 
death are service-connected.
    Discussion Draft on title 38, United States Code, appointment, 
compensation, performance management, and accountability system for 
senior executive leaders in the Department of Veterans Affairs.
    Delegates to our most recent national convention passed two 
resolutions that may be relevant to this informal ``discussion'' 
proposal. DAV Resolution No. 126 calls for modernization of the VA 
human resources management system to enable VA to compete for, recruit 
and retain the types and quality of VA employees needed to provide 
comprehensive health care services to sick and disabled veterans. DAV 
Resolution No. 214 calls for meaningful accountability measures, but 
with due process, for employees of the VA-by requiring that any 
legislation changing the existing employment protections in VA must 
strike a balance between holding civil servants accountable for their 
performance, while maintaining VA as an employer of choice for the best 
and brightest.
    The discussion draft would apply personnel laws for Senior 
Executive Service (SES) members now working under title 5, United 
States Code, which covers most civil servants, to title 38, which 
allows greater pay flexibility to provide more competitive wages. 
Hiring under title 38 would also give the Secretary more authority to 
expedite hiring. These are key issues when competing against other 
federal agencies and the private sector for top talent. DAV supports 
the intent of these provisions.
    However, there may be some issues when hiring individuals under 
title 38, which is generally reserved for personnel in health-related 
fields, and applying those standards to those who would lead the 
Veterans Benefits Administration, National Cemetery Administration, and 
VA staff offices. In addition, while the proposed reform would allow 
expedited SES hiring, DAV asks the Committee to carefully consider 
whether the proposed executive compensation, which would still lag far 
behind that of chief executives in private sector health care, is 
nearly sufficient to offset the new risks being created by other parts 
of this proposal.
    In the final analysis, these individuals would serve at the 
pleasure of the VA Secretary, with little protection that is now 
available under current law to guarantee their status under title 5 to 
appropriately protect their due process rights and provide them retreat 
rights to lower-level assignments and to insulate them from politically 
motivated decisions-all hallmarks of the origins of the SES as 
envisioned in the Civil Service Reform Act of 1978. That act 
established the SES, the Merit Systems Protection Board, and created an 
array of procedures and requirements that govern the entirety of the 
SES program and many other aspects of federal personnel law.
    Mr. Chairman, DAV and our members urge serious reform of the VA 
health care system to address access problems while preserving the 
strengths of the system and its unique model of care. We appreciate 
this Committee's hard work and are pleased that many of our 
recommendations have been incorporated into the measures under 
consideration today so that veterans will have more options to receive 
timely, high-quality care closer to home.

Draft Bill Study on the Veterans Crisis Line

    This bill seeks to authorize a five-year study on the efficacy of 
the Veterans Crisis Line (VCL) beginning January 1, 2014. The 
additional information that is to be collected from the VCL includes 
the number of VCL users who, after contacting the VCL and speaking to a 
suicide prevention specialist, begin and continue to receive health 
care furnished by the Secretary and those that do not; the number of 
veterans that begin care, but do not continue; the number of veterans 
who call the VCL, but have not previously received care from the 
Secretary; and those that have previously received such services in 
addition to a number of other data points regarding VCL use and 
suicide.
    DAV Resolution No. 245, adopted by our members during our most 
recent National Convention, supports improvements in data collection 
and reporting relative to suicide prevention; therefore, DAV supports 
the intent of this bill. However, we do have some concerns and want to 
ensure the data collection effort does not impinge upon the mission of 
the VCL-to help veterans in crisis and prevention of suicide.
    The VCL is a vital tool that provides veterans several ways of 
interacting with a qualified suicide prevention specialist. Veterans 
are able to call the VCL 24 hours a day, 7 days a week to receive high-
quality prevention and crisis intervention services. The VCL has helped 
many vulnerable veterans in crisis averaging more than 500,000 calls 
per year. Since its inception, it has answered over 2.3 million calls, 
made over 289,000 chat connections, and completed over 55,000 texts 
resulting in over 61,000 dispatches of emergency service to callers in 
imminent suicidal crisis.
    While we appreciate the desire to evaluate the effectiveness of the 
VCL, we also understand that many veterans utilize the VCL with the 
expectation that their call will be confidential. According to VA, only 
the responder is able to see his or her information, and the 
information will not be shared unless permission is obtained from the 
veteran indicating they would like contact after the call, chat or text 
message; or if the veteran provides their consent to release for other 
purposes. Only in cases of imminent danger will a veteran's location 
and other relative information be shared to facilitate rescue efforts 
that are coordinated with local officials. Veterans experiencing crisis 
are already in distress and at their most vulnerable. The stigma 
associated with mental health, and needing help is sometimes enough to 
keep veterans from reaching out to receive help. DAV understands the 
intent of this draft bill is to gather helpful information to improve 
or enhance VCL services for veterans; however, we urge the Committee to 
work with VA to determine if and what information is already being 
collected and analyzed to monitor the effectiveness of the program as 
it relates to the provisions in the draft measure. Additionally, it is 
not clear if all the information to be collected will be available 
based on the notes from the crisis intervention call and a subsequent 
record review or if the VCL employee taking the call will need to ask 
the caller if they can contact them at a later date to ask additional 
questions.
    Data collection for the purpose of improving the effectiveness of 
the program may not qualify as being in the best interest of the 
patient. The need to collect information cannot outweigh the mission of 
crisis intervention and saving lives. In any case, we recommend a 
mental health provider be consulted about these sensitive issues prior 
to moving forward with the bill.
    Thank you for inviting DAV to submit this testimony. We would be 
pleased to further discuss any of the issues raised by this statement, 
to provide the Committee additional views, or to respond to specific 
questions from you or other Members.

                                 
            Prepared Statement of Honorable Roscoe G. Butler
    Chairman Roe, Ranking Member Walz, and distinguished members of the 
Committee on Veterans' Affairs; on behalf of National Commander Denise 
H. Rohan and The American Legion, the country's largest patriotic 
wartime service organization for veterans, comprised of more than 2 
million members, and serving every man and woman who has worn the 
uniform for this country, we thank you for inviting The American Legion 
to testify today and share our position regarding The American Legion's 
positions on pending legislation before this committee. Established in 
1919, and being the largest veteran service organization in the United 
States with a myriad of programs supporting veterans, we appreciate the 
committee focusing on these critical issues that will affect veterans 
and their families.
Draft Committee Bill to Establish the Veterans Choice Program Permanent
    Draft legislation to amend title 38, United States Code, to modify 
the authority of the Secretary of Veterans Affairs to enter into 
agreements with State homes to provide nursing home care to veterans, 
to direct the Secretary to carry out a program to increase the number 
of graduate medical education residency positions of the Department of 
Veterans Affairs, and for other purposes.
  The Department of Veterans Affairs (VA's) legislative proposal, The 
    Veteran Coordinated Access and Rewarding Experiences (CARE) Act
    Healthcare is evolving. Advances in medicine have allowed surgeons 
to become less invasive, diagnostic tests to become more precise, and 
we now routinely rely on scientific discoveries inconceivable just ten 
years ago. Yet our Department of Veterans Affairs (VA) Veterans Health 
Administration (VHA) is still operating in hospitals more than 50 years 
old and originated under a statutory framework that was established 
during the Civil War.
    The 2014 wait time scandal helped to expose what veteran service 
organizations had been warning lawmakers about for years, that the VA 
has been systemically underfunded and was being forced to manage to 
budget, and not budgeted to need.
    Despite these challenges, as an institution VA has emerged as a 
world-class leader in a number of veteran-centric medical disciplines, 
as well as conducting groundbreaking research, lifesaving emergency 
disaster preparedness, and leading the nation in medical education and 
residency programs and partnerships.
    The draft legislation introduced by this committee combined with 
the legislative requests from VA begin to address the evolution of 21st 
century medicine at VA in a way that will allow the department to 
provide greater access and develop stronger relationships with non-VA 
providers, moving toward a more integrated system. This is just the 
first step in a long overdue transformation and The American Legion 
expects greater emphasis on VA's modernization in successive 
legislation that is able to capitalize on VA's strengths and core 
competencies while ensuring that veterans continue to have access to 
the best care anywhere.
    The American Legion is aware of criticisms that suggests this 
transformation moves perilously close to increased privatization of VA 
services, and does not dismiss these criticisms as without merit. 
Nefarious intentions can indeed serve to undermine modernization 
efforts and The American Legion will continue to be a watchdog and 
ensure future political interests do not diminish the capacity or value 
VA represents in the medical or veteran community. It is with this in 
mind that The American Legion asks this Committee to include a 
requirement in the final legislation that requires VA to issue an 
annual report indicating:

    1. How many patients VA intends to provide healthcare to through 
Veteran Care Agreements (VCAs)?

    2. How many patients received healthcare through VCAs over the 
preceding year?

    3. What is VA's plan to reduce dependency on VCAs for VA's primary 
and core services?

    4. What are the projected costs associated with providing patient 
care through VCAs?

    5. What was the cost for providing patient care through VCAs over 
the preceding year?

    6. An analysis of healthcare services VA believes is more cost 
effective to provide through VCAs.

    This effort to refine and make permanent a consolidated community 
care program begins a redesign of VA's infrastructure and capabilities 
that will next cause a review of what services VA hospitals and 
community-based outreach centers (CBOCs) perform, and how.
    As internal medicine continues to shorten hospital stays and 
telemedicine expands medical access, the VA will need to have the 
statutory flexibility to adjust as patient needs fluctuate, while 
remaining nimble enough to adapt to advancements in technology. The 
legislative language introduced by this Committee provides greater 
detail in a number of areas that VA's request lacks, and The American 
Legion would only caution the Committee to remember the number of times 
VA, VSOs and the Committee were called upon to introduce and support 
legislation needed to fix unintended consequences of the original 
Choice legislation. Well-crafted legislative language that provided 
direction while giving VA sufficient flexibility to promulgate 
regulatory guidance served well during the Appeals Modernization 
project and should be used as an example of how successful legislative 
initiatives can work to serve veterans while providing sufficient 
oversight and stakeholder engagement. With that in mind, The American 
Legion is particularly grateful for the Committee's diligent and well-
articulated procedures as detailed in ``Primary and Specialty Care'' in 
Section 101 of the Committee draft.
    The American Legion appreciates this Committee's dedication and 
hard work while producing this comprehensive draft and we would like to 
take this opportunity to highlight some areas we believe need further 
discussion.
    Under Title I, Section 101 subsection 1703A (a) Program (1) [p.2, 
line13] ``at the election of such veteran'' needs to include ``through 
agreement and consultation of their primary care provider'' or add 
``pursuant to (b)(2)(A).'' Failure to adjust this provision accordingly 
insinuates the veteran maintains unfettered unilateral discretion as to 
whether they are seen by a VA physician, or one contracted by VA.
    Under Title I, Section 101 subsection 1703A (d) [p8, line 20] The 
American Legion believes that the rebates or discounts often negotiated 
by third party administrators, and overpayment recoupment procedures 
should be addressed such as outlined in the September 12, 2017 
Inspector General Memorandum on Accuracy and Timeliness of Payments 
Made Under the Choice Program should be addressed. \1\
---------------------------------------------------------------------------
    \1\ https://www.va.gov/oig/pubs/admin-reports/VAOIG-17-00000-
379.pdf
---------------------------------------------------------------------------
    Under Title I, Section 106 subsection 1703B(b) [p.38 line 16] The 
American Legion recommends adding sufficient protections for veterans 
receiving care not provided by a VA healthcare provider by including 
language that entitles veterans protections under Title 38 U.S.C. 1151, 
which allows veterans who have suffered an added disability while 
getting VA medical care or taking part in a VA program designed to help 
you find, get, or keep a job, to be able to get compensation. \2\ This 
lack of 1151 protection suffered by veterans has always been 
troublesome, and this legislative effort provides the Committee with a 
chance to cure his deficiency in the program. This also highlights the 
dangerous lack of oversight this program would enjoy as there are no 
provisions or discussions that seek to monitor standards or quality of 
care being performed through community agreements, and this Committee's 
oversight jurisdiction ends at VA facilities. Should a contracted 
physician fail to provide the minimum standards of quality care to a VA 
patient, Congress has no ability to hold them accountable. Choice has 
been a functioning program now for three year and it is difficult to 
believe there have no issues or complaints with the quality or 
timeliness of care provided by private providers.
---------------------------------------------------------------------------
    \2\ https://www.benefits.va.gov/COMPENSATION/claims-special-
1151.asp
---------------------------------------------------------------------------
    Included in the VA request is a provision that seeks to increase 
capacity while saving on emergency room visits by creating or 
contracting with a network of walk-in clinics. The American Legion 
believes Section 202 ``Improving Veterans' Access to Walk-in Care'' 
will be a benefit for VA patients and will decrease the prevalence of 
illnesses that are left untreated because patients are deterred from 
going to the emergency room until their illness or injury becomes so 
severe that more costly and time consuming measures are needed to 
stabilize and cure the patient. The American Legion is concerned about 
the introduction of a copay feature that would be assessed for care 
directly related to illness or injuries caused or aggravated by a 
veterans honorable service. The American Legion looks forward to 
working with VA and this Committee to come up with a plan to mitigate 
these charges.
    In Section 201 of the VA's proposal [p.14], the Department 
addresses VA medical facilities the ``Secretary has determined is not 
providing care that meets such quality and access standards as the 
Secretary shall develop''. The American Legion is very concerned about 
this provision and looks forward to reviewing the criteria the 
Secretary will establish to evaluate such facilities. Further, The 
American Legion insists that the Department provide an action plan to 
properly lead and rehabilitate such facilities so as not to drain a VA 
medical center of resources and thereby reduce options for veterans in 
what may already be a community struggling to provide healthcare 
options. Finally, we adamantly oppose and fear it financially 
unsustainable line (4) of that section which states, ``When the 
Secretary exercises the authority under this subsection, the decision 
to receive care or services from a non-Department entity or provider 
under this subsection shall be at the election of the veteran.''
    In both legislative proposals there are provisions for patients to 
appeal the Department's decisions. As it stands now, the VHA is 
America's largest integrated health care system, providing care at 
1,243 health care facilities, including 170 medical centers and 1,063 
outpatient sites. Appeals of this nature are overseen and determined by 
the medical center director, which creates 170 standards for review. 
The American Legion calls on the Department to come up with a minimum 
standard for review that is consistent across the Department and 
referenced in VA's handbook, making appeals equitable for all veterans. 
\3\
---------------------------------------------------------------------------
    \3\ VHA DIRECTIVE 1041: APPEAL OF VHA CLINICAL DECISIONS (October 
24, 2016)
---------------------------------------------------------------------------
    As highlighted in ``VA Healthcare A System Worth Saving,'' a report 
written by Phil Longman, author of ``Best Care Anywhere'', and health-
care journalist Suzanne Gordon, it makes sense for VA to partner with 
community physicians because it serves to enhance VA's ability to serve 
veterans:

    A related challenge is the acute shortage of doctors, nurses, and 
other health-care professionals across the U.S. system generally. The 
problem is particularly acute in rural areas and low-income inner-city 
neighborhoods. Though VA tends to attract health-care professionals who 
have an idealistic commitment to veterans issues and to public service, 
its recruitment efforts are challenged by its inability to offer 
employees the same income they could earn in the private sector.
    For these reasons and many more, in some communities it makes sense 
for VA to partner with other providers rather than offer all medical 
services itself. Instead of operating its own dialysis centers in every 
community, for example, in some medical markets it may be more 
efficient and convenient to patients for VA to contract with an 
existing local facility. Similarly, in smaller communities there may 
not be enough heart patients to keep more than one catheterization 
laboratory working at a safe and efficient volume, and there is no 
point in VA building a cath lab of its own. Where VA lacks the 
infrastructure or personnel to offer patients timely and convenient 
access to a particular kind of care, it may make sense for VA to 
partner with outside providers in order to shorten wait times or give 
veterans a greater choice.
    In doing so, VA must, however, preserve the high levels of 
evidence-based, coordinated care that has made it a model of best 
practices in health care and avoid the dangerous fragmentation and 
overtreatment that is a hallmark of so much of the U.S. health-care 
system. Outsourcing care simply to maximize choice of doctors does not 
make sense when it conflicts with other critically important values 
that VA supplies to its patients, including its excellence in providing 
care that is safe and effective precisely because it is coordinated. 
Practically speaking, outsourcing can reduce the choices available to 
veterans if it causes VA hospitals and clinics to be starved of 
resources and then forced to close. \4\
---------------------------------------------------------------------------
    \4\ VA Healthcare A System Worth Saving (August 2017)

    Overall, The American Legion is extremely pleased with these 
proposals and with some minor adjustments, we believe this will begin 
the type of transformation VA has needed for a very long time.
    In closing, with regard to how Congress will pay for the future 
healthcare for American veterans, The American Legion is appalled that 
either Congress or the Administration would recommend that veterans 
disability checks be debited, even one dime, to cover the costs of 
other veterans benefits. The COLA round down provision as proposed many 
times over the past several years would tax service disabled veterans 
to pay for service disabled veteran benefits. Regardless of what the 
annual amount of money debited from a veterans check would be each 
month, the very thought that this is okay is insulting and offensive. 
Veterans' healthcare should not be subjected to offsets or pay-fors, 
and the full burden of providing care for service disabled veterans 
needs to be borne by the federal government through a debt to the U.S. 
Treasury.
              H.R. 1133: Veterans Transplant Coverage Act
    To amend title 38, United States Code, to authorize the Secretary 
of Veterans Affairs to provide for an operation on a live donor for 
purposes of conducting a transplant procedure for a veteran, and for 
other purposes.

    This bill would authorize the Department of Veterans Affairs (VA) 
to provide organ transplants to veterans from a live donor regardless 
of whether that donor is a veteran or whether medical services required 
are done in a VA facility or non-VA facility.
    Current VA policy excludes non-veteran live donations from coverage 
under the VA Choice Program and requires veterans to travel to specific 
VA treatment facilities. These eligibility constraints mean that 
veterans are required to travel hundreds, even thousands of miles when 
non-VA hospitals closer to home can do the same transplants. Overcoming 
travel distances and other barriers to care is one of the main 
objectives of the Choice Program and its intent should apply when a 
veterans needs a necessary organ transplant too.
    The American Legion can support this bill through Resolutions No. 
25, The American Legion Support of the VA Organ Transplant Program 
which supports a system of organ distribution that will ensure that 
veteran patients receive equitable consideration when in need of 
transplants; and No. 46, Department of Veterans Affairs (VA) Non-VA 
Care Programs, which calls on VA to develop a well-defined and 
consistent non-VA care coordination program, policy and procedure that 
includes a patient-centered care strategy which takes veterans' unique 
medical injuries and illnesses as well as their travel and distance 
into \5\account \6\.
---------------------------------------------------------------------------
    \5\ The American Legion Resolution No. 25 (May 2004): The American 
Legion Support of the VA Organ Transplant Program
    \6\ The American Legion Resolution No. 46 (Oct. 2012): Department 
of Veterans Affairs (VA) Non-VA Care Programs

---------------------------------------------------------------------------
    The American Legion supports H.R. 1133.

 H.R. 2123: ``Veterans E-Health and Telemedicine Support Act'' or the 
                          ``VETS Act of 2017"
    To amend title 38, United States Code, to improve the ability of 
health care professionals to treat veterans through the use of 
telemedicine, and for other purposes.

    This bipartisan legislation would allow U.S. Department of Veterans 
Affairs (VA) health professionals to practice telemedicine across state 
borders if they are qualified and practice within the scope of their 
authorized federal duties. Currently, cumbersome location requirements 
can make it difficult for veterans especially those struggling with 
mental health and/or mobility issues to get the help they need and 
deserve.
    Telehealth is one of VA's major transformational initiatives, one 
aimed at making care more convenient, accessible and patient-centered. 
VA Telehealth services have increased in recent years, creating more 
access to health care for veterans, especially those residing in rural 
areas throughout the country. However, current legal barriers limit the 
level of services and number of veterans VA can serve. American Legion 
Resolution 44, Department of Veterans Affairs Rural Healthcare Program, 
passed at The American Legion's 2016 National Convention urges Congress 
and VA to look for opportunities to expand telehealth services for 
veterans residing in rural communities. \7\ By clearing away certain 
legal barriers, the VETS Act would ease access to the care veterans 
need and deserve.
---------------------------------------------------------------------------
    \7\ The American Legion Resolution No. 44 (2016): Department of 
Veterans Affairs Rural Healthcare Program
---------------------------------------------------------------------------
    The American Legion was pleased by the VA's newly proposed rule 
effectuating the goals of the VETS Act of 2017 and allowing VA 
telehealth providers to more easily administer care across state lines. 
\8\ We look forward to timely implementation of a final rule and 
continue to urge Congress to build on this administrative action with 
permanent legislation in the form of the bipartisan, bicameral VETS 
Act.
---------------------------------------------------------------------------
    \8\ VA proposed rule: Authority of Health Care Providers to 
Practice Telehealth (10.2.17)
---------------------------------------------------------------------------
    The American Legion supports H.R. 2123.

  H.R. 2601: ``Veterans Increased Choice for Transplanted Organs and 
          Recovery Act of 2017'' or the ``VICTOR Act of 2017"
    To amend the Veterans Access, Choice, and Accountability Act of 
2014 to improve the access of veterans to organ transplants, and for 
other purposes.
    This bill would allow veterans who live more than 100 miles from 
one of the nation's 14 Department of Veterans Affairs' Transplant 
Centers (VATCs) to seek care at a federally certified, non-VA facility 
that covers Medicare patients.
    The VA's organ transplant system has a well-known problem: To focus 
specialized expertise and manage costs, the VA only does organ 
transplants at 14 locations nationwide, and each location only does 
certain types of transplants. The result is that veterans are required 
to travel hundreds, even thousands of miles when non-VA hospitals 
closer to home can do the same transplants.
    Currently, these 14 VATCs are located at VA healthcare facilities 
across the country that specialize in solid organ and` bone marrow/stem 
cell transplantation to eligible veterans. They are located in Palo 
Alto, CA (Heart), Portland, OR (Kidney, Liver, Liver-Kidney), Seattle, 
WA (Bone Marrow, Lung), Houston, TX (Kidney, Liver, Liver-Kidney), San 
Antonio, TX (Bone Marrow), Salt Lake City, UT (Heart), Iowa City, IA 
(Kidney-Pancreas, Pancreas), Madison, WI (Heart, Heart-Lung, Liver, 
Lung), Birmingham, AL (Kidney), Nashville, TN (Bone Marrow, Heart, 
HeartKidney, Heart-Liver, Kidney, Liver, Liver-Kidney), West Roxbury, 
MA (Heart), Bronx, NY (Kidney), Pittsburgh, PA (Kidney, Liver, Liver-
Kidney, LiverSmall-Bowel, Small Bowel), and Richmond, VA (Heart, 
Liver).
    A recent study suggests that travel can have a negative impact on 
medical outcomes. \9\ The study looked into the association between 
distance from a VATC and veterans actually receiving liver 
transplantation. The research found the greater the distance from a 
VATC a veteran lived, the lower their likelihood of being placed on the 
waitlist, receiving a transplant, and therefore the greater their 
likelihood of death.
---------------------------------------------------------------------------
    \9\ https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4586113/
---------------------------------------------------------------------------
    How far a veteran resides from one of the VATCs can, therefore, 
reduce the veteran's chances of getting evaluated and eventually 
proceeding with the needed transplant. Some veterans even have to 
consider the possibility of relocating near one of the VATCs in order 
to go through the recovery process. VAOIG's October 2015 March 2016 
Semiannual Report to Congress substantiated that some patients referred 
for liver transplant evaluations at all VATCs experienced delays. \10\ 
Timely organ transplants can be the difference between life and death.
---------------------------------------------------------------------------
    \10\ https://www.va.gov/oig/pubs/sars/VAOIG-SAR-2016-1.pdf
---------------------------------------------------------------------------
    The American Legion can support this bill through Resolutions No. 
25, The American Legion Support of the VA Organ Transplant Program 
which supports a system of organ distribution that will ensure that 
veteran patients receive equitable consideration when in need of 
transplants; and No. 46, Department of Veterans Affairs (VA) Non-VA 
Care Programs, which calls on VA to develop a well-defined and 
consistent non-VA care coordination program, policy and procedure that 
includes a patient-centered care strategy which takes veterans' unique 
medical injuries and illnesses as well as their travel and distance 
into \11\account \12\.
---------------------------------------------------------------------------
    \11\ Resolution No. 25 (May 2004): The American Legion Support of 
the VA Organ Transplant Program
    \12\ Resolution No. 46 (Oct. 2012): Department of Veterans Affairs 
(VA) Non-VA Care Programs

---------------------------------------------------------------------------
    The American Legion supports H.R. 2601.

H.R. 3642: ``Military Sexual Assault Victims Empowerment Act'' or 
    ``Military SAVE Act''

    To direct the Secretary of Veterans Affairs to carry out a pilot 
program to improve the access to private health care for veterans who 
are survivors of military sexual trauma.
    This bill would establish a pilot program that would allow 
survivors of military sexual trauma (MST) to seek specialized care 
outside the Veterans Health Administration through the Choice program. 
H.R. 3642 would make a victim of a military sexual trauma potentially 
eligible for non-VA care under the Veterans Choice Program.
    Ultimately, this is about trying to find the right treatment for 
every patient, and in the case of MST, unique challenges can shape 
treatment needs, so VA should be flexible to ensure these veterans 
receive the care they need. The American Legion is deeply concerned 
with the plight of survivors of MST and has urged Congress to ensure 
the VA properly resources all VA medical centers, vet centers, and 
community-based outpatient clinics so that they employ a MST counselor 
to oversee the screening and treatment referral process, and continue 
universal screening of all veterans for a history of MST. \13\
---------------------------------------------------------------------------
    \13\ Resolution No. 67: (Aug. 2014) Military Sexual Trauma
---------------------------------------------------------------------------
    A January 2011 landmark women veterans survey conducted by The 
American Legion found that respondents reported serious challenges 
receiving gender-specific care sensitive to their needs, particularly 
with regard to MST. The American Legion has since fought for better 
awareness training in VA for MST sensitivity, significant increases in 
outreach, and more comprehensive care options for MST survivors, 
including better availability of female therapists, female group 
therapy and other options to make MST care more accessible. \14\
---------------------------------------------------------------------------
    \14\ Resolution No. 18: (Oct. 2015) Women Veterans
---------------------------------------------------------------------------
    VA is working to improve in these areas, as is evidenced by VA 
publications that note:

      VA knows that MST survivors may have special treatment 
needs and concerns. For example, a Veteran can ask to meet with a 
clinician of a particular gender if it would make him or her feel more 
comfortable. Similarly, to accommodate Veterans who do not feel 
comfortable in mixed-gender treatment settings, many facilities 
throughout VA have separate programs for men and women. All residential 
and inpatient programs have separate sleeping areas for men and women.
      VA has specialized treatment programming available for 
MST survivors. VA facilities have providers knowledgeable about 
evidence-based mental health care for the aftereffects of MST. Many 
have specialized outpatient mental health services focusing on sexual 
trauma. Vet Centers also have specially trained sexual trauma 
counselors. For Veterans who need more intensive treatment and support, 
there are programs nationwide that offer specialized sexual trauma 
treatment in residential and inpatient settings.
      In VA, treatment for all mental and physical health 
conditions related to MST is free and unlimited in duration. Veterans 
do not need to have a disability rating (that is, be ``service-
connected''), to have reported the incident(s) at the time, or to have 
other documentation that MST occurred in order to receive free MST-
related care. There are no time limits on eligibility for this care, 
meaning that Veterans can seek out treatment even many years after 
discharge.
      Veterans may be eligible for free MST-related care even 
if they are not eligible for other VA services. There are special 
eligibility rules associated with MST-related care and many of the 
standard requirements related to length of service or financial means 
do not apply. \15\
---------------------------------------------------------------------------
    \15\ Top Ten Things All Healthcare & Service Professionals Should 
Know About VA Services for Survivors of Military Sexual Trauma

    However, implementation of change within VA can take time, and even 
the best of programs can have irregular results from facility to 
facility. Veterans should not have to suffer because the care they need 
is not well implemented at their local VA facility.
    The American Legion recognized that the Choice program was an 
emergency measure to get care to veterans where VA was struggling to 
deliver care. In recognition of the needs of an integrated system to 
deliver non-VA care when needed, The American Legion believes VA needs 
to ``develop a well-defined and consistent non-VA care coordination 
program, policy and procedure that includes a patient-centered care 
strategy which takes veterans' unique medical injuries and illnesses 
[emphasis added] as well as their travel and distance into account.'' 
\16\
---------------------------------------------------------------------------
    \16\ Resolution No. 46: Department of Veterans Affairs (VA) Non-VA 
Care Programs OCT 2014
---------------------------------------------------------------------------
    One of the unique problems that survivors of MST face is that the 
treatment environment at VA is not always conducive to their comfort 
level, and comfort is critical in particular when dealing with issues 
such as psychiatric care for Posttraumatic Stress Disorder (PTSD) which 
is frequently a major side effect of MST. In the case of these 
survivors, getting them to a treatment program within their comfort 
level can mean the difference between a survivor continuing treatment 
or abandoning treatment. The latter could result in them feeling 
further isolation and possibly cause an escalation of their symptoms.
    For veterans who are suffering right now, they need to get the 
treatment they need, but we should also be mindful that this is not a 
panacea for the problems faced by MST survivors. Ensuring integration 
with the VA system is also beneficial to their overall health picture. 
As with any care outside VA, The American Legion stresses the 
importance of ensuring non-VA care has quality of care standards equal 
to or better than they receive within VA, that the care is coordinated 
effectively to ensure veterans are not stuck with billing problems with 
outside providers that can adversely affect their credit, and perhaps 
most importantly, that the providers have access to VA healthcare 
records for the patient and vice versa. \17\ One of the best assets of 
VA healthcare for veterans is the ability for providers within the 
system to have a total picture of the veteran's health.
---------------------------------------------------------------------------
    \17\ Resolution No. 46: Department of Veterans Affairs (VA) Non-VA 
Care Programs OCT 2014
---------------------------------------------------------------------------
    By seeing all interconnected conditions, and being aware of the 
unique health challenges of veterans, providers can spot patterns 
leading to early screening for conditions such as PTSD, health 
conditions related to environmental exposures like Gulf War Illness and 
Agent Orange, and other things an average civilian provider would miss. 
While sometimes it's necessary for veterans to get the care they need 
outside the system, it's important to make sure when that's done, they 
do not lose out on the real and tangible benefits to care they get as 
part of the integrated care network that is VA.
    But first, for veteran survivors of Military Sexual Trauma, we have 
to make sure they get the care they need in the environment that's 
going to maximize the effects of treatment.
    Through Resolution No. 67: Military Sexual Trauma, The American 
Legion, recognizing the unique and sensitive nature of MST, supports a 
pilot program relying on VA's over 20 years of experience in treating 
veterans with MST to determine if this type of care is most beneficial 
to the veteran and will assess the merits of this program on the 
findings. \18\
---------------------------------------------------------------------------
    \18\ Resolution No. 67 (Aug. 2014): Military Sexual Trauma

    The American Legion supports H.R. 3642.
                           Draft legislation
    To direct the Secretary of Veterans Affairs to conduct a study on 
the Veterans Crisis Line.

    The Veterans Crisis Line (VCL) connects veterans in crisis and 
their families and friends with qualified, caring Department of 
Veterans Affairs (VA) responders through a confidential toll-free 
hotline, online chat, or text. The responders at the VCL are specially 
trained and experienced in helping veterans of all ages and 
circumstances.
    Since its launch in 2007, the VCL has answered nearly 2.8 million 
calls and initiated the dispatch of emergency services to callers in 
crisis nearly 74,000 times. The VCL anonymous online chat service, 
added in 2009, has engaged in more than 332,000 chats. In November 
2011, the VCL introduced a text-messaging service to provide another 
way for veterans to connect with confidential, round-the-clock support, 
and since then has responded to more than 67,000 texts. The VCL plays a 
critical role in VA's initiative of suicide prevention, and ongoing 
efforts to decrease the estimated 20 veterans who die by suicide each 
day.
    This legislation would direct VA to conduct a study on the VCL, 
which would require VA to gather data which it does not currently 
collect nor should it. Focus rather should be on better understanding 
the circumstances of the 14 veterans who die by suicide each day who 
are not actively enrolled in the VA.

    The American Legion opposes this draft bill.

Conclusion

    The American Legion looks forward to continuing to working closely 
with VA and this Committee on these important issues and we applaud the 
Committee for working with VSOs and VA as partners to ensure that The 
Detriment of Veterans Affairs is properly structured to meet the needs 
of the 21st century veteran.
    As always, The American Legion thanks this Committee for the 
opportunity to explain the position of the over 2 million veteran 
members of this organization. For additional information regarding this 
testimony, please contact the Legislative Division at The American 
Legion's Legislative Division at (202) 861-2700.

                                 
             Prepared Statement of Honorable Kayda Keleher
    WITH RESPECT TO
  ``H.R. 1133; H.R. 2123; H.R. 2601; H.R. 3642; Draft legislation to 
  establish a permanent Veterans Choice Program; draft legislation to 
  modify VA's authority to enter into agreements with State homes to 
provide nursing home care to veterans, to direct the Secretary to carry 
  out a program to increase the number of graduate medical education 
   residency positions, and for other purposes; Draft legislation to 
  direct the Secretary of Veterans Affairs to conduct a study on the 
     Veterans Crisis Line; and the Department of Veterans Affairs' 
  legislative proposal, the Veteran Coordinated Access and Rewarding 
                        Experiences (CARE) Act''
    Chairman Roe, Ranking Member Walz and members of the committee, on 
behalf of the men and women 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 committee.

H.R. 1133, Veterans Transplant Coverage Act of 2017

    The VFW supports this legislation, which would authorize Department 
of Veterans Affairs (VA) to provide care and services to non-veterans 
for purposes of donating organs to VA-eligible veterans.
    Currently, VA provides care to certain non-veterans, ranging from 
survivors and dependents, newborn children of women veterans, to 
humanitarian care for emergency room visitors. Under the current Choice 
Program veterans in need of using the program to receive a live organ 
donation are denied access when the donor is not eligible to receive VA 
care. The VFW urges this committee to ensure any future community care 
program is able to be used by veterans who need an organ transplant 
from a live donor. But until then, veterans should not be forced to 
wait any longer to receive the organs they need. Individuals in need of 
an organ transplant are in life or death situations, and finding a 
matching organ donor is time consuming and often rare.

H.R. 2123, Veterans E-Health and Telemedicine Support Act of 2017

    The VFW strongly supports this legislation, which would authorize 
qualified VA health care providers to practice telemedicine across 
state lines. This legislation would be especially helpful for veterans 
who do not live in the same state as the VA facility in which they are 
enrolled. With geographic distance remaining a significant barrier to 
care for many veterans, the use of telemedicine technology has emerged 
as a highly effective method of providing veterans with timely and 
convenient care.
    A recently signed Executive Order authorizes doctors to perform 
many of the duties this legislation would authorize. The Executive 
Order was based on VA's belief that it has authority to conduct 
telehealth in such manner. However, some doctors have expressed an 
unwillingness to practice under the authority of an Executive Order. As 
such, legislation would provide VA doctors the assurance they need to 
practice telemedicine.

H.R. 2601, Veterans Increased Choice for Transplanted Organs and 
    Recover Act of 2017

    The VFW agrees with the intent of this legislation, which would 
ensure veterans in need of organ transplants do not have to travel long 
distances to receive care. Congress and VA have learned that placing 
arbitrary distance and timelines requirements to use VA community care 
programs leads to unintended consequences. For that reason, the VFW 
cannot support this legislation.
    The legislation is an example of why VA has multiple community care 
programs with different eligibility criteria. The VFW supports 
consolidation of community care programs to ensure veterans can receive 
the care they need, where they need it, instead of creating exemption 
or rules for specific circumstances. Doing so would provide VA the 
flexibility it needs without forcing veteran to wait longer than needed 
for life saving care. It would also allow VA to make decisions in 
circumstances where the VA may be under 100 miles away, it is best for 
a veteran to receive an organ transplant in the community, closer to 
home.

H.R. 3642, Military Sexual Assault Victims Empowerment Act

    The VFW opposes this legislation, though understands the intent of 
the bill. After conducting six health care surveys and hearing directly 
from more than 20,000 VFW members, the VFW understands that veterans 
often face barriers accessing needed care. However, we view this bill 
as an overcorrection which would diminish the care veterans receive 
from VA.
    Ensuring sexual assault survivors receive the care they need is a 
top priority for the VFW. This became especially clear when VA released 
their veteran suicide data July 2016. This study showed women veterans 
who have survived sexual trauma from their time in the military are at 
an increased risk of death by suicide compared to those who did not 
experience sexual trauma. That is why the VFW believes we must continue 
providing VA with the resources and authorities it needs to hire mental 
health care providers who specialize in not just the traumas of war, 
but the traumas of sexual assault.
    Health care for survivors of sexual trauma must also be more 
inclusive than strictly mental health care. Survivors may need to seek 
treatment for health issues such as sexual dysfunction or substance 
abuse treatment. These survivors are also at increased risk for needing 
assistance with housing and employment. All of these are specialties of 
VA's continuum of care and holistic medical scope for veteran patients. 
To make accessing these benefits easier VA also offers Military Sexual 
Trauma Coordinators at all VA medical centers yet another example of 
something VA does which is not available in the private sector.
    The VFW strongly believes VA must be the coordinator of care for 
veterans and continue to guarantee the quality of care veterans receive 
regardless of where the care is provided. This legislation would limit 
VA's ability to coordinate care for a very vulnerable segment of the 
veteran population and would lead to such veterans receiving fragmented 
care, which health care experts believe endangers patient safety.
    The VFW also believes there are unclear discrepancies between the 
survey and reporting requirements of this legislation. One example of 
this is the surveying of the private sector timeframe between when a 
veteran would be able to make an appointment and when they have their 
appointment. Currently VA is held accountable for not just the wait 
time between when a veteran makes an appointment and when they get in 
for their appointment, but also for the veteran's preferred date. When 
gathering data to compare VA to the private sector, it is imperative VA 
and the private sector be compared and judged on the same playing 
field. The VFW also believes surveying for all medications a veteran 
may have so VA can later report which ones are being taken for sexual 
assault related illnesses or injuries is overbearing.

Draft Legislation to Modify Authority of the Secretary of Veterans 
    Affairs to Enter into Agreements with State Homes to Provide 
    Nursing Home Care to Veterans

    The VFW supports this legislation and has a recommendation to 
improve it. This legislation would improve VA's current authorities to 
enter into agreements with state veterans homes.
    This legislation would also increase the number of graduate medical 
education (GME) residency positions within VA. While the VFW supports 
increasing GME opportunities within VA, we urge this committee to 
expand this legislation to include psychology residencies. A recent VA 
Office of Inspector General reported entitled ``OIG Determination of 
VHA Occupational Staffing Shortages'' listed psychologists as the third 
largest staffing shortage within VA. This committee must ensure VA is 
able to address all of its staffing shortages.

Draft Legislation to Direct the Secretary of Veterans Affairs to 
    Conduct a Study on the Veterans Crisis Line

    The VFW understands the intent of this legislation, but opposes it 
as written. This legislation would direct VA to conduct a study on the 
Veterans Crisis Line (VCL), which would require VA to gather data which 
is does not currently collect nor should it.
    In 2007, the Veterans Health Administration (VHA) established a 
suicide hotline, which later became known as the VCL, to provide 24/7, 
suicide prevention and crisis intervention to veterans, service members 
and their families. This was necessary as a means of constant 
availability for individuals in need of crisis intervention. The VCL 
provides crisis intervention services to veterans in urgent need, and 
helps them begin a path toward improving their mental wellness. The VCL 
plays a critical role in VA's initiative of suicide prevention, and 
ongoing efforts to decrease the estimated 20 veterans who die by 
suicide each day. The VCL answers more than 2.5 million calls, responds 
to more than 62,000 text messages and initiates the dispatch of 
emergency services more than 66,000 times each year. Recently, the VCL 
has expanded to three call centers located in Canandaigua, N.Y., 
Atlanta, Ga. and Topeka, Ks.
    When veterans contact the VCL they are answered by professional 
staff with extensive background and expertise in social work and crisis 
prevention/intervention. These unseen heroes answer thousands of calls 
by veterans in their most vulnerable moments. No veteran in need should 
contact the VCL only to be asked for their personally identifiable 
information. Just as Vet Centers, veterans must have the ability to 
seek care for the VCL anonymously.
    The VFW understands that when VCL staff must dispatch emergency 
responders, or do a warm hand-off between the veteran and a VA suicide 
prevention specialist that personally identifiable information will be 
collected. At that point, the VFW believes identifying and tracking the 
veteran's progress should begin. The purpose of the VCL is to provide 
crisis intervention and prevent veterans from dying or attempting 
suicide. Prevention is key here. And Congress must not implement 
measures which would deter veterans from utilizing the VCL.
    Tracking the successes and possible downfalls of VCL is important 
to the VFW. But we believe the data already available shows the crisis 
line is successful. One reason for its success is that callers are only 
asked whether they are veterans, therefore veterans who may not be 
eligible for VA services are able to use the line. It is currently well 
known that of the 20 veterans who die by suicide each day, 14 of those 
veterans were not actively enrolled in VA. If Congress and VA sincerely 
want to eradicate veteran suicide then we must dive deeper into data on 
the 14 veterans not using VA. What better outreach can be done? Are 
they eligible for VA and not using it? What can VA do to further assist 
in prevention and intervention for these veterans?
    The VFW firmly believes the VCL has improved and will continue to 
improve. Such improvement will continue to be slow, frustrating and 
life-endangering if the VCL does not begin collaborating with others. 
Aside from working with patient advocacy offices to cut down on non-
crisis calls and VHA Member Services to readjust the advisory board and 
increase clinicians, the VCL must also work more closely with the 
Office of Suicide Prevention (OSP).
    Member Services has undoubtedly assisted the VCL in quantity 
control, but OSP can also assist the VCL in quality control. If the 
goal of the VCL is to intervene for veterans in need of immediate 
assistance while they are in the middle of a mental health crisis, the 
VCL should be working with the subject matter experts and leaders in 
suicide prevention and outreach for VA. If all three offices could 
collaborate together, with better guidelines, Member Services must be 
able to continue improving the VCL call center expertise and business, 
while OSP can make sure the VCL is up-to-date with the most current 
clinical expertise on suicide prevention and outreach.

Draft Legislation to Establish a Permanent Veterans Choice Program & 
    Draft Legislation from Department of Veterans Affairs, Veteran 
    Coordinated Access and Rewarding Experiences Act (CARE Act)

    In the past three years the VFW has assisted hundreds of veterans 
who have faced delays receiving care through the Choice Program, and 
has surveyed more than 8,000 veterans specifically on their experiences 
using VA community care. Through this work, the VFW has identified a 
number of issues and has proposed more than 15 common sense 
recommendations on how to improve this important program. The VFW would 
like to thank the committee for its leadership in addressing many of 
the issues the VFW has identified, such as making VA the primary payer 
for Choice Program care, removing restrictions on when VA is able to 
share medical records with Choice providers and making clinical 
necessity the trigger for community care.
    The VFW must also commend VA and the third party administers for 
their willingness to work with us to address issues veterans encounter 
when obtaining care through the Choice Program. VA has made more than 
70 modifications to the Choice Program's contract to address many of 
the pitfalls that have plagued the program, such as allowing the 
contractors to conduct outbound calls when they have the proper 
authorization to begin the scheduling process. The VFW is also 
supportive and pleased to see VA's eagerness to establish a pilot 
program which would share health care resources with Department of 
Defense at up to five locations.
    However, the Choice Program continues to face several challenges 
that must be addressed. That is why the VFW is very concerned that VA's 
CARE Act does not request to make the Choice Program a permanent 
discretionary program. The VFW believes this program must be improved 
and consolidated with other VA community care programs, but we oppose 
continuing it as mandatory program. VA's medical care accounts are 
under discretionary spending and subject to sequestration budget caps. 
Having the Choice Program as the only VA health care program not 
subject to spending caps could lead to a gradual erosion of the VA 
health care system. Also by consolidating VA's community care programs, 
the VFW believes all programs must be consolidatedto include dialysis.
    The VFW and its Independent Budget partners (DAV and PVA) also 
oppose VA's and this committee's proposal to eliminate of copayment 
offset for veterans who health insurance. The VFW strongly believes 
implementing this change would limit VA medical collections. VA 
recently shared outreach material that urges veterans to share and 
update their health care insurance information with VA. The outreach 
material rightfully incentivizes veterans to share their information 
with VA because their VA copayments would be offset by money VA 
collects from their health insurance and such monies also covers their 
annual deductibles. Removing this offset would remove the incentive for 
veterans to share their health insurance information with VA and may 
even remove the need for veterans to keep their health insurance.
    The VFW also opposes section 503 of VA's draft CARE legislation, 
which would round down cost of living disability pay increases, a 
proposal which the VFW has opposed in the past and continues to 
strongly oppose.
    The Administration has also proposed a cap on the amount of tuition 
and fees that may be paid under the Post-9/11 GI Bill for programs of 
education in which a public institution of higher learning enters into 
an agreement with another entity to provide such education. Currently, 
third party training programs that contract with public schools are 
able to charge unlimited fees since public schools have no set dollar 
amount cap. A couple of years ago, it came to light that some 
contracted flight training programs were charging exorbitant fees, 
which far exceeded the cost of an average in-state education. The VFW 
supports the Administration's proposal to place a reasonable cap on 
these sorts of training programs.
    The biggest issue the VFW hears from veterans who use the program 
is the breakdown of communication between VA, the third party 
administrators, Choice providers and veterans. This breakdown has a 
significant impact on the care veterans receive. The VFW has heard from 
too many veterans that they were sent to the wrong doctor because VA 
and the contractor could not figure out how to make certain the veteran 
sees the specialist that can provide the care the veteran needs. For 
example, veterans who need to receive the recently developed cure for 
Hepatitis C have been sent to hepatologists who cannot provide them the 
lifesaving medications they need.
    The VFW has also heard from veterans that the breakdown in 
communication between VA, contractors and Choice providers often delays 
their care because their Choice doctors do not receive authorization to 
provide needed treatments. What is concerning is that veterans are left 
to piece together the entire story or else they do not receive the care 
they need; or they are left to pay for the care out of pocket because 
their Choice doctors performed treatments beyond the scope of the 
Choice authorization. This is why the VFW is pleased to see the 
committee's draft legislation provide VA with consolidated networks and 
contracts while easing the payment process to the community care 
providers. Though the VFW would like to see the draft legislation 
amended to provide VA with authority to incorporate use of a value-
based reimbursement model, instead of requiring VA to do so. This 
authority would be best utilized initially as a pilot program, similar 
to Centers for Medicare and Medicaid Services, to see if value-based 
payments lead to better outcomes or reduced costs.
    The VFW strongly supports provisions in the committee's draft 
legislation which would ensure VA remains the coordinator and primary 
provider of care for veterans. This includes ensuring VA is maximizing 
its resources before turning the community care to fill demand and 
continually evaluating whether care VA is purchasing from community 
care providers should be delivered in house. However, the VFW urges 
that committee to amend the bill to ensure veterans who are assigned a 
community primary care provider receive assistance from VA in selecting 
the provider that best fits their needs instead of simply giving them a 
list of network providers and left on their own to find one willing to 
see them.
    VA has taken a number of steps to address this breakdown in 
communication. It is in the process of implementing a new authorization 
management system to eliminate the confusion regarding which provider 
veterans need to see. It has also worked with TriWest Healthcare 
Alliance and Health Net, Inc. to have contractors co-located with VA 
community care staff at VA medical facilities to address and issues in 
approving secondary authorizations or ensuring veterans are sent to the 
right doctors. The VFW has received good feedback from VA employees and 
veterans at facilities with co-located VA and contract staff.
    However, the underlying issue that causes this breakdown in 
communication is the fact that TriWest and Health Net are required to 
maintain their own systems to track Choice casework. VA transmits 
information to them instead of granting the contactors access to VA 
systems or using the same systems, which would eliminate the need to 
transmit data and documents between VA and the third party 
administrators. To avoid having to go through a third party when 
scheduling Choice Program appointments, VA has proposed to have its 
community care staff resume responsibilities for all the scheduling, 
which they have done in the past and continue to do under other 
community care programs.
    The VFW supports utilizing VA community care staff to schedule 
Choice Program appointments when possible, but it is unreasonable to 
expect VA to be able to staff up enough to keep pace with the expanded 
use of the Choice Program. For that reason, the VFW recommends VA build 
on its co-located staff model and rely on contracted staff to support 
VA's community care staff when demand for Choice Program care spikes. 
To ensure veterans are not negatively impacted when they are rolled 
over to contract staff, VA must ensure the contracted staff has access 
to the same systems as VA community care staff.
    As the VFW has highlighted in our two Choice Program reports, which 
can be found on our VA health care watch website, www.vfw.org/vawatch, 
the eligibility criteria for the Choice Program must also be reformed. 
The VFW firmly believes that VA must reevaluate how it measures wait 
times. In the VFW's most recent VA health care report only 67 percent 
of veterans indicated they had obtained a VA appointment within 30 
days, which is significantly less than the 93 percent VA reported in 
its most recent access report. This is because the way VA measures wait 
times is not aligned with the realities of scheduling a health care 
appointment.
    VA uses a metric called the preferred date to measure the 
difference between when a veteran would like to be seen and when they 
are given an appointment. However, this completely ignores and fails to 
account for the full length of time a veteran waits for care. For 
example, when veterans call to schedule an appointment they are asked 
when they prefer to be seen. The first question they logically ask is, 
``When is the next available appointment?'' If VA's scheduling system 
does not preclude them from doing so, schedulers have the ability to 
input the medical facility's next available appointment as the 
veteran's preferred date--essentially zeroing out the wait time. VA 
must correct its wait time metric to more accurately reflect how long 
veterans wait for their care.
    However, VA's wait time measurement must not be used as an 
eligibility criterion for the Choice Program. While the VFW agrees 
using a clinically indicated date to determine eligibility is the right 
approach, we do not believe Congress or VA should dictate how long 
veterans must wait before receiving care from community care providers. 
Arbitrary thresholds such as 30-days or 40-miles do not reflect the 
health care landscape of our country. Veterans may not need to be seen 
within 30 days for appointments such as routine checkups. Likewise, 
such arbitrary thresholds do not account for veterans with urgent 
medical needs for which they need to be seen before 30 days, or 
veterans who suffer from disabilities which prevent them from traveling 
40 miles. That is why the VFW is happy to see both this Committee's and 
VA's draft legislation improve community care eligibility to be a 
clinically based decision between a patient and their provider.
    Though, the VFW does suggest amending the draft legislations to 
ensue VA is able to provide care and services to non-veterans if needed 
when caring for a VA-eligible veteran. In particular this has greatly 
affected both live donor organ transplant patients as well as veterans 
seeking In Vitro Fertilization (IVF). If a veteran who uses VA and is 
in need of an organ transplant is matched with a non-VA eligible 
individual, that donor is not eligible to receive the operation or care 
under the current Choice Program eligibility requirements. Also if a 
veteran is approved for IVF services through VA and his or her spouse 
is a non-veteran, the veteran is not able to use the Choice Program to 
receive IVF.
    When scheduling veterans for medical appointments, whether it is 
with VA or a community care provider, VA must take into account 
veterans' clinical needs and personal preferences. If a veteran has an 
urgent care need that must be met within 48 hours, that veteran must be 
seen within 48 hours. Additionally, VA must take measures to meet 
veterans' preferences when seeking care. For example, a male veteran 
who was sexually assaulted by a male may want to seek care from a 
female provider. VA should not have to interrogate veterans every time 
a veteran needs care, but it must give veterans the opportunity to 
discuss their preferences.
    This would also require VA care coordinators to be able to view the 
availability and characteristics of VA and community care providers. VA 
must invest in information technology systems that would allow it to 
compile appointment availability for community care and VA. Doing so 
would enable veterans to truly work with their care teams to determine 
what options are best for them.
    In its draft CARE legislation, VA has requested authority to 
reimburse veterans for walk-in care they receive from clinics around 
the country to fill the gap between emergency care and traditional 
appointment-based outpatient care. Doing so would ensure veterans with 
acute medical conditions that require urgent attention, such as the 
flu, infections, or non-life threatening injuries, do not wait days or 
weeks for a primary care appointment. Enabling veterans to be 
reimbursed for walk-in care would also curb the reliance on emergency 
rooms for non-emergent conditions, which is more expensive for veterans 
and VA. The VFW urges Congress to consider and swiftly pass legislation 
authorizing VA to reimburse veterans for using community walk-in and 
urgent care clinics. The VFW does, however, oppose any attempt to bill 
veterans for the cost of providing service connected care, regardless 
of when or where the care is delivered. Furthermore, the VFW believes 
that copayments for community care programs must be the same as if 
veterans received such care at a VA medical facility. Veterans must not 
be penalized because the care they need is not readily accessible at a 
VA medical facility.
    The VA health care system delivers high quality care and has 
consistently outperformed private sector health care systems in 
independent assessments. The VFW's numerous health care surveys have 
also validated that veterans who use VA health care are satisfied with 
the care they receive. In fact, our latest survey found that 77 percent 
of veterans report being at least somewhat satisfied with their VA 
health care experience. When asked why they turn to VA for their health 
care needs, veterans report that VA delivers high quality care which is 
tailored to their unique needs and because VA health care is an earned 
benefit.
    VA has made significant strides since the access crisis erupted in 
2014 when whistleblowers across the county exposed how long veterans 
were waiting for the care they have earned and deserve. However, VA 
still has a lot of work to do to ensure all veterans have timely access 
to high quality and veteran-centric care. Veterans deserve reduced wait 
times and shorter commutes to their medical appointments. This means 
turning to community care when needed, but also means improving VA's 
ability to provide direct care. In this committee's draft legislation, 
the VFW believes the annual capacity and commercial market assessment 
must include a requirement to identifying how building internal 
capacity either through construction or hiring would improve access, as 
well as identify barriers preventing VA from doing so. This would 
ensure Congress and VA know what improvements are needed within VA.
    The VFW thanks Congress for its commitment to improving VA's 
community care authorities and programs. VA also needs the resources 
and authorities to quickly recruit and properly compensate a high 
performing health care workforce, properly train its employees, hold 
wrongdoers accountable, and update its aging capital infrastructure. 
Community care must continue to supplement direct VA health care. This 
means VA and Congress must continue to invest in VA to ensure it 
remains a premier health care system. That is why the VFW supports 
sections 301, 303, 304, 305, 307, 308, 309, 321, 322, 323, 324 and 401 
of VA's draft CARE legislation.
    The VFW supports passage of provider agreement legislation. 
Authorizing VA to enter into non-federal acquisition regulation (FAR) 
based agreements with private sector providers, similar to agreements 
under Medicare, would ensure VA is able to quickly provide veterans 
with care when community care programs like the Choice Program are not 
able to provide the care.
    Provider agreements are particularly important for VA's ability to 
provide long term care through community nursing homes. The majority of 
the homes who partner with VA do not have the staff, resources or 
expertise to navigate and comply with FAR requirements and have 
indicated they would end their partnerships with VA if required to bid 
for FAR contracts. In fact, VA's community nursing home program has 
lost 400 homes in the past two years and will continue to lose 200 
homes per year without provider agreement authority. This means 
thousands of veterans are forced to leave the place they have called 
home for years simply because VA is not able to renew agreements with 
community nursing homes. Congress must end this injustice by quickly 
passing provider agreement legislation.

                                 
                        STATEMENT FOR THE RECORD
       THE AMERICAN CONGRESS OF OBSTETRICIANS AND GYNECOLOGIGSTS 
                               Regarding
                    H.R. 3642, The Military SAVE Act
    Chairman Roe, MD, Ranking Member Walz, and distinguished Members of 
the Committee on Veterans' Affairs, we are pleased to submit written 
testimony on behalf of the American Congress of Obstetricians and 
Gynecologists (ACOG), representing more than 58,000 physicians and 
partners in women's health, in support of H.R. 3642, the Military SAVE 
Act.

ACOG Supports H.R. 3642, the Military SAVE Act

    We would like to thank Representative Andy Barr (R-KY) for his 
leadership in introducing this legislation, and your leadership, Mr. 
Chairman, in holding this important hearing. ACOG enthusiastically 
endorses H.R. 3642 and we urge Committee to include this legislation in 
the broader VA health reform effort.
    H.R. 3642 represents an innovative effort to ensure access to 
gender-sensitive, high quality care for Veterans who experienced 
military sexual trauma (MST) while serving the United States as active 
duty members of our Armed Forces.
    Women play a vital role in the U.S. military, constituting 16 
percent of all active duty and reserve members of the military, and 
nearly 10 percent of the total Veteran population in the United States. 
Women are at an increased risk for military sexual assault and the 
long-term health effects that can accompany this trauma. ACOG applauds 
the Veterans Health Administration (VHA) for requiring all women 
Veterans be screened for MST, and the significant progress made in 
reducing gender disparities in health care in recent years. Yet while 
there are many mechanisms in place to support the health needs of women 
Veterans, there is more that can and must be done to ensure MST 
survivors get the care they need.

Military Sexual Trauma (MST)

    Sexual assault is a crime of violence and aggression, and 
encompasses a continuum of sexual activity from sexual coercion to 
rape. Military sexual trauma (MST) is the experience of sexual 
harassment or attempted or completed sexual assault during military 
service. MST is a unique risk of military service, and perpetrators may 
include military personnel, civilians, commanding officers, 
subordinates, strangers, friends, or intimate partners. Although 
perpetrators and survivors can be of either sex, women are more likely 
than men to be victims of military sexual assault.
    Military and Veteran women often have increased rates of lifetime 
exposure to interpersonal violence, including sexual assault or abuse, 
and intimate partner violence, when compared to civilian counterparts. 
, Twenty percent of women Veterans who use VHA facilities report a 
history of MST. This is a cause for concern because MST can have long-
term health implications, including diminished levels of function, 
alterations in health perceptions, chronic pelvic pain, dysmenorrhea, 
sexual dysfunction, and post-traumatic stress disorder (PTSD). , , , ,
    Military service can increase the risk of mental health problems 
for all Veterans, including depression, PTSD, and substance use 
disorder, when compared with civilian counterparts. However, the 
prevalence of PTSD is increased more than twofold in women Veterans, 
and is commonly attributed to women Veterans' greater exposure to MST. 
, , PTSD is linked to diminished physical health and decreased 
willingness to pursue preventive reproductive health care in women 
Veterans. ,
    The increased likelihood of mental health disorders, including 
major depression and other mood disorders, has also been associated 
with increased risk for suicide. According to a recent VA report on 
Veteran Suicide, the rate of suicide among younger female Veterans (18-
29) who used VHA services increased at a faster rate from 2001 to 2014 
than that of the civilian population. Notably, the rate of suicide 
among women Veterans is 2.5 times higher than that of civilian women.

Access to Care

    Women veterans have served our country and deserve the best health 
care available. The VA has taken many steps to increase access to 
needed care for survivors of MST. Currently, women can receive MST-
related care at any VA health system. VA policy requires each Veteran 
Administration Medical Center (VAMC) to have an MST coordinator and to 
provide all MST-related care free of charge. VA policy also encourages 
facilities to give Veterans being treated for MST the option of a same-
sex care provider, although this option is not mandatory or always 
available.
    While VA policy requires all facilities to accommodate and support 
women with safety, privacy, dignity and respect, a 2016 Government 
Accountability Office (GAO) report found the VHA lacked complete and 
accurate data on VAMC compliance with sex-specific environment 
requirements. Among the six VAMCs included in the study, compliance 
with select VHA environment requirements, including physical and 
audible privacy, ranged from 65-81 percent. Additionally, the GAO 
report found that 18 percent of VA facilities providing primary care 
lacked a women's health primary care provider, and of those who did 
have a dedicated women's health provider, they were only available on 
average six hours per week.*
    Women Veterans have unique health care needs, but their minority 
status within the VHA has led to disparities in health care access when 
compared to men. While the VHA has made significant progress in 
reducing gender disparities for many measures, there is still a 
perception among women Veterans with a history of MST that they do not 
receive the same quality of care as male Veterans.

A Solution

    Unfortunately, some studies suggest Veteran women who use the VHA 
for their care may experience instances of greater physical and 
psychiatric morbidity, and insufficient social support when compared 
with civilian women. , , At this time, Veterans can only seek treatment 
outside the VA if a VA facility is unable to treat the patient, the 
patient lives outside a reasonable travel distance, the VA cannot 
arrange an appointment in a 30-day time frame, or a VA employee issues 
an official authorization letter.
    H.R. 3642, The Military SAVE Act, would establish a pilot program 
allowing survivors of MST to seek treatment at a provider of their 
choice, either in the VHA or through the private sector. The 
legislation would also establish a survey to assess MST treatment for 
Veterans both inside and outside the VHA. Such research designed to 
evaluate the association of military service and women's sexual and 
reproductive health is critical to ensuring the development of best 
practices for women's care. This pilot program will:

      Ensure MST survivors have increased access to their 
preferred health care provider;
      Enable VHA to collect and analyze data to identify gaps 
in the services available between VAMC and private sector providers, 
and further develop best practices for the treatment of MST; and
      Allow the VA to better serve the unique needs of female 
Veteran survivors of military sexual trauma.

    As the population of women Veterans continues to grow rapidly, it 
will be increasingly important to ensure high quality, gender sensitive 
care that meets the unique needs of women Veterans. ACOG supports H.R. 
3642, the Military SAVE Act as a positive step to providing women 
increased access to their preferred care for treatment of the symptoms 
of MST, while implementing a robust research agenda regarding the 
health needs of women Veterans.
    Thank you for the opportunity to provide written testimony in 
support of H.R. 3642.

    i U.S. Department of Defense: 2015 Demographics: Profile of the 
Military Community. http://download.militaryonesource.mil/12038/MOS/
Reports/2015-Demographics-Report.pdf (last visited June 19, 2017).

    ii Women Veterans Report: The Past, Present and Future of Women 
Veterans. Department of Veteran Affairs: National Center for Veterans 
Analysis and Statistics. February 2017.

    iii Health care for women in the military and women Veterans. 
Committee Opinion No. 547. American College of Obstetricians and 
Gynecologists. Obstet Gynecol 2012;120:1538-42.

    iv Sexual assault. Committee Opinion No. 592. American College of 
Obstetricians and Gynecologists. Obstet Gynecol 2014;123:905-9.

    v Kimerling R, Gima K, Smith MW, Street A, Frayne S. The Veterans 
Health Administration and military sexual trauma. Am J Public Health 
2007;97:2160-6.

    vi Health care for women in the military and women Veterans.

    vii Merrill LL, Newell CE, Thomsen CJ, Gold SR, Milner JS, Koss MP, 
et al. Childhood abuse and sexual revictimization in a female Navy 
recruit sample. J Trauma Stress 1999;12:211-25

    viii Kimerling, supra.

    ix Ibid.

    x Suris A, Lind L. Military sexual trauma: a review of prevalence 
and associated health consequences in veterans. Trauma Violence Abuse 
2008;9:250-69. [PubMed] ?

    xi Frayne SM, Skinner KM, Sullivan LM, Tripp TJ, Hankin CS, Kressin 
NR, et al. Medical profile of women Veterans Administration outpatients 
who report a history of sexual assault occurring while in the military. 
J Womens Health Gend Based Med 1999;8:835-45.

    xii Plichta SB, Falik M. Prevalence of violence and its 
implications for women's health. Womens Health Issues 2001;11:244-58.

    xiii Dickinson LM, deGruy FV 3rd, Dickinson WP, Candib LM. Health-
related quality of life and symptom profiles of female survivors of 
sexual abuse. Arch Fam Med 1999;8:35-43.

    xiv Golding JM, Wilsnack SC, Learman LA. Prevalence of sexual 
assault history among women with common gynecologic symptoms [published 
erratum appears in Am J Obstet Gynecol 1999;180:255]. Am J Obstet 
Gynecol 1998;179:1013-9.

    xv Government Accountability Office. VA mental health: number of 
veterans receiving care, barriers faced, and efforts to increase 
access. GAO-12-12. Washington, DC: GAO; 2011. Available at: http://
www.gao.gov/new.items/d1212.pdf.

    xvi Kessler RC, Sonnega A, Bromet E, Hughes M, Nelson CB. 
Posttraumatic stress disorder in the National Comorbidity Survey. Arch 
Gen Psychiatry 1995;52:1048-60.

    xvii Kulka RA, Schlenger WE, Fairbanks JA, Hough RL, Jordan BK, 
Marmar CR, et al. Trauma and the Vietnam War generation: report of 
findings from the National Vietnam Veterans Readjustment Study. New 
York (NY): Brunner/Mazel; 1990.

    xviii Fontana A, Rosenheck R. Duty-related and sexual stress in the 
etiology of PTSD among women veterans who seek treatment. Psychiatr 
Serv 1998;49:658-62. [PubMed] [Full Text] ?

    xix Schnurr PP, Green BL, Kaltman S. Trauma exposure and physical 
health. In: Friedman MJ, Keane TM, Resick PA, editors. Handbook of 
PTSD: science and practice. New York (NY): Guilford Press; 2007. p. 
406-24

    xx Weitlauf JC, Finney JW, Ruzek JI, Lee TT, Thrailkill A, Jones S, 
et al. Distress and pain during pelvic examinations: effect of sexual 
violence. Obstet Gynecol 2008;112:1343-50.

    xxi Ibid.

    xxii Department of Veteran Affairs. Suicide Among Veterans and 
Other Americans: 2001-2014. Office of Suicide Prevention. Office of 
Mental Health and Suicide Prevention. August 2016.

    xxiii Ibid.

    xxiv Government Accountability Office. Improved monitoring needed 
for effective oversight of care for women Veterans. Report to 
Congressional Requesters. GAO-17-52. Washington, DC:GAO; 2016.

    xxv Ibid.

    xxvi Kehle-Forbes SM, Harwood EM, Spoont MR, Sayer NA, Gerould H, 
Murdoch M. Experiences with VHA care: a qualitative study of U.S. women 
veterans with self-reported trauma histories. BMC Women's Health. 
2017;17:38. doi:10.1186/s12905-017-0395-x.

    xxvii Frayne, supra.

    xxviii Sayers SL, Farrow VA, Ross J, Oslin DW. Family problems 
among recently returned military veterans referred for a mental health 
evaluation. J Clin Psychiatry 2009;70:163-70.

    xxix Bean-Mayberry B, Yano EM, Washington DL, Goldzweig C, Batuman 
F, Huang C, et al. Systematic review of women veterans' health: update 
on successes and gaps. Womens Health Issues 2011;21:S84-97.

                                 
          AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO
    Mr. Chairman and Members of the Subcommittee:

    The American Federation of Government Employees (AFGE) appreciates 
the opportunity to submit a statement for the record on pending 
legislation under consideration today. AFGE represents nearly 700,000 
federal employees across the nation, including 250,000 employees at the 
Department of Veterans Affairs on the front lines providing health care 
and other critical services for veterans.
Draft legislation to amend title 38, United States Code, to establish a 
       permanent Veterans Choice Program, and for other purposes
    AFGE strongly opposes this draft legislation. It would establish a 
permanent Choice program that would continue to divert funding away 
from VA's internal capacity to pay for a costlier non-VA care services 
even when private sector wait times are higher and quality is lower. 
The bill is also likely to result in unsustainable costs by elimination 
of all wait time and distance eligibility restrictions. Increased use 
of non-VA primary care providers will deprive veterans of critical 
screenings for wounds of war and essential integrated care.
    This bill lacks provisions for strengthening the VA's own capacity 
or for sending veterans back to the VA even when private sector primary 
care or specialty care is no longer necessary or adequate. It imposes 
new case manager duties on VHA staff without additional resources; 
Choice has already diverted staff away from direct care of veterans to 
handle overwhelming numbers of consults for non-VA care and to ``clean 
up'' after Choice clinical and bureaucratic problems.
    Proposed market assessments lack transparency and rely too heavily 
on a private sector health care model and do not require an adequate 
focus on staffing and infrastructure needs.
    Choice providers would continue to receive less scrutiny than VA's 
own providers under this bill. It does not require the same 
transparency about wait times for non-VA care as is required for VA 
care. It also makes it too easy for non-VA providers to receive 
certifications that allow them to participate in networks regardless of 
whether their skills and training are equivalent to those of VA's own 
providers.
    In short, this bill would serve the agenda of privatizers but 
ignore the needs and preferences of veterans to receive the vast 
majority of their care from a fully-funded, fully-staffed, world-class 
integrated VA health care system. Rather than continue to expand a 
broken non-VA care program, we urge the Committee to provide the 
mandate and funding needed to fill the nearly 50,000 vacancies reported 
by Secretary Shulkin and finally address the modernization and 
infrastructure needs of the VA that have been neglected for too long.

Draft legislation to modify the authority of the Secretary of Veterans 
    Affairs to enter into agreements with state homes to provide 
    nursing home care to veterans, to direct the Secretary to carry out 
    a program to increase the number of VA graduate medical education 
    residency positions, and other purposes

    AFGE has no specific position on this legislation.
                               H.R. 1133
    AFGE has no specific position on this legislation.
                               H.R. 2123
    This bill would extend federal preemption of state licensing 
requirements to all licensed VHA personnel using telemedicine to 
provide treatment. Last year, the Department amended its provider 
regulations to apply federal preemption to certain advanced practice 
registered nurses (APRN), relying on the federal supremacy clause of 
the Constitution.
    AFGE opposes H.R. 2123. This bill could have unintended 
consequences, including an adverse impact on recruitment and retention 
of licensed medical personnel who are already in critical shortage 
occupations. The licensed health care personnel we represent have 
expressed serious concerns about the risks to their state licenses (and 
therefore their entire livelihoods) if management is allowed to mandate 
the performance of duties outside their scope of practice. These 
clinicians have received no assurances that the Department will assist 
them when their licensing boards pursue disciplinary actions against 
them for violating state licensing requirements.
    This proposed change is premature. The new APRN rule has only been 
in effect for less than a year.
    Therefore, AFGE urges the Committee to delay possible changes to 
current law until completion of a study of the workforce implications 
of a broader application of federal preemption. Current bill provisions 
for a telemedicine study fail to address any workforce issues. We 
recommend a study that focuses on the impact of federal preemption on 
the state licenses of APRNs and other licensed personnel, and the 
Department's ability to remain competitive with other health care 
employers who do not operate under federal preemption.
                               H.R. 2601
    AFGE has no specific position on this legislation.
                               H.R. 3642
    This bill would establish a three-year private sector pilot program 
for the treatment of military sexual trauma (MST). At the completion of 
the three-year period, the Secretary would have permanent authority to 
approve non-VA treatment of MST on a case-by-case basis.
    AFGE strongly opposes H.R. 3642. In fact, it is hard to contemplate 
a more inappropriate combat-related condition to outsource to the 
private sector than MST. This proposed pilot project is unnecessary and 
represents another back-door attempt to dismantle the VA's 
comprehensive, integrated health care system, like almost every other 
VHA private sector pilot project previously implemented.
    VHA is a world leader in the screening and treatment of MST and 
provider training and research in this area. VHA requires that every 
veteran receive screening for MST and screening also plays a critical 
role in data collection on the treatment of this widespread condition. 
All VA mental health and primary care providers are required to 
complete initial and continuing MST training. MST specialists are 
available at every medical center and many outpatient clinics. The VA's 
National Center for PTSD plays an integral role in the VA's treatment 
of MST.
    Rather than proceed with another wasteful pilot project that sends 
MST sufferers out into a broken, fragmented private health care system 
that does not understand their unique needs, AFGE urges the Committee 
to review existing direct care resources and telemedicine capacity 
within the VA to identify ways to increase access for treatment in 
hard-to-serve areas.
    VA Legislative Proposal Veteran Coordinated Access & Rewarding 
                         Experiences (CARE) Act
    AFGE strongly opposes the non-VA care provisions in Titles I and II 
and has concerns about some of the personnel provisions in Title III.
                              Non-VA Care
    The VA's proposal to replace the Choice program would greatly 
accelerate privatization of its health care system through virtually 
open-ended access to non-VA care and the absence of any mandates to 
address short staffing and deteriorating infrastructure. It is absurd 
that non-VA programs would continue to rely on mandatory funds while 
VA's own funding would remain discretionary and therefore continue to 
have to close funding gaps on the backs of veterans through such 
proposals as COLA round-downs.
    The bill's non-VA provisions are as problematic for what they say 
as for what they don't say. The lack of specificity through the bill 
will allow the VA to continue to engage in stealth privatization as 
illustrated by recent agency initiatives to convert specific purpose 
allocations to general purpose allocations and creation of pilot 
projects that send veterans out to CVS Minute Clinics without 
Congressional authorization.
    AFGE strongly opposes the proposed replacement of the 30-day/40-
mile restrictions with a vague patient-provider veteran's ``best 
interest'' evaluation process and criteria such as ``clinically 
acceptable'' wait times (Section 201).
    We also strongly object to the expanded use of non-VA urgent care 
facilities already undertaken through pilot projects in numerous 
locations. This seems totally unnecessary considering Secretary 
Shulkin's recent announcements that the VA is providing same-day 
service at every medical center and significant increases in access to 
urgent care provided directly by the VA.
                          Personnel Practices
    Section 301:

    AFGE objects to the proposed expansion of ``federal supremacy'' 
that would extend federal preemption of state licensing requirements to 
all licensed VHA personnel. (In contrast to Chairman Roe's proposal, 
the VA's draft does not limit federal preemption to telemedicine.)
    As already noted with regard to Chairman Roe's draft bill, this 
provision could have unintended consequences, including an adverse 
impact on recruitment and retention of licensed medical personnel who 
are already in critical shortage occupations. AFGE believes that this 
proposed change is premature as the new APRN rule has only been in 
effect for less than a year.
    Therefore, AFGE urges the Committee to delay possible changes to 
current law until completion of a study of the workforce implications 
of a broader application of federal preemption.

    Section 302:

    This section repeals VA's longstanding statutory authority to 
contract for ``scarce medical specialist services''.
    AFGE opposes this proposed change because it appears to broaden 
VA's authority to contract out medical services even when VA's own 
health care system can provide the care (and there is no scarcity). 
This will further erode VA's critical capacity to provide 
comprehensive, integrated, specialized care to veterans that has 
already been weakened by the Choice program.

    Section 304

    This section repeals the annual caps on VA bonuses across the 
entire VA workforce that were imposed by the Choice Act in 2014 and 
later modified downward through subsequent legislation.
    AFGE supports elimination of annual dollar caps. AFGE appreciated 
the Sense of Congress language in the Choice Act that required fair 
allocation of bonuses to lower wage employees under the caps. AFGE 
urges Congress to continue to address the issue of lower wage 
employees' bonuses through a study of how bonus dollars have been 
allocated over the last five years and whether bonuses are used 
properly to incentivize high-performing non-management employees.

    Section 305:

    This section extends the statutory reimbursement right for 
continuing education from doctors and dentists to Advanced Practice 
Registered Nurses.
    While AFGE supports the expansion of this critical medical 
professional benefit to other professions, we object to this provision 
as currently drafted. Reimbursement for continuing medical education is 
a critical recruitment and retention tool but AFGE opposes setting this 
benefit (for any professional group) at $1000 per year. This amount has 
not been updated since the legislation was first enacted almost twenty 
years ago. With each new year, VA becomes less competitive with private 
sector employees who adjust their reimbursement rates to match actual 
costs of attending these courses.
    AFGE also objects to limiting this benefit to APRNs. It should also 
be available to physician assistants as they too are independent 
providers in the VA. Finally, AFGE urges a study of the reimbursement 
needs of all other VHA licensed professionals.
    Thank you.

                                 
                AMERICAN HEALTH CARE ASSOCIATION (AHCA)
    October 13, 2017

    Chairman Phil Roe, M.D.
    United States House Committee on Veterans' Affairs
    335 Cannon House Office Building
    Washington, D.C. 20515

    Ranking Member Tim Walz
    United States House Committee on Veterans' Affairs
    333 Cannon House Office Building
    Washington, D.C. 20515

    Chairman Roe and Ranking Member Walz:

    I serve as the Senior Vice President of Government Relations at the 
American Health Care Association (AHCA), the nation's largest 
association of long term and post-acute care providers. The association 
advocates for quality care and services for the frail, elderly, and 
individuals with disabilities. Our members provide essential care to 
millions of individuals in more than 13,500 not for profit and for 
profit member facilities.
    AHCA, its affiliates, and member providers advocate for the 
continuing vitality of the long term care provider community. We are 
committed to developing and advocating for public policies which 
balance economic and regulatory principles to support quality of care 
and quality of life. Therefore, I appreciate the opportunity today to 
submit a statement on behalf of AHCA for the hearing record regarding 
establishing a permanent Veterans Choice Program.
    As you know, skilled nursing care centers were not included in the 
Veterans Choice Program as one of the eligible health care providers. 
That being said, AHCA has been advocating for policies which would 
grant the U.S. Department of Veterans Affairs (VA) the legislative 
authority to enter into Provider Agreements for extended care services. 
VA Provider Agreements would ensure that our centers are able to care 
for veterans in their communities or in close proximity to their 
families and support system. Our centers already meet very strict 
compliance guidelines under the Medicare and Medicaid programs. Adding 
additional regulations on top of this is simply inefficient, redundant, 
add cost and takes staff time away from these veterans at the bedside.
    As you are aware, the VA released a proposed rule, RIN 2900-A015, 
on Provider Agreements in February of 2013. This important rule, among 
other things, increases the opportunity for veterans to obtain non-VA 
extended care services from local providers that furnish vital and 
often life-sustaining medical services. This rule is an example of how 
government and the private sector can effectively work together for the 
benefit of veterans who depend on long term and post-acute care.
    In 2014, close to half of the U.S. Senate chamber and 109 U.S. 
House members signed onto a letter to the VA encouraging the release of 
the final VA provider agreement rule. It was ultimately determined that 
the VA needs the legislative authority to enter into these agreements.
    It is long-standing policy that Medicare (Parts A and B) or 
Medicaid providers are not considered to be federal contractors. 
However, if a provider currently has VA patients, they are considered 
to be a federal contractor and under the Service Contract Act. The 
Office of Federal Contracting Compliance Programs (OFCCP) has 
administered onerous reporting requirements and regulations even beyond 
those required by Medicare and Medicaid rules, which have dissuaded 
nursing care centers from admitting VA patients. This limits the care 
available to veterans needing long term care in their local 
communities. Our veterans should not have to choose between obtaining 
the long term care services they need and remaining near loved ones in 
their community. Conversely, the same centers contracting with the 
Centers for Medicare and Medicaid Services (CMS) are not subject to the 
OFCCP regulations.
    AHCA has been advocating for legislation that would make the VA 
requirements for providers the same as they are for CMS and waives the 
OFCCP federal contracting requirements. Legislation has been introduced 
in both chambers in the past to address this issue, including in this 
Congress. Earlier this year, Senators John Hoeven and Mike Rounds 
introduced the Veterans Access to Long Term Care and Health Services 
Act (S. 1611) that would ensure that extended care providers, including 
nursing center care, could legally enter into VA Provider Agreements, 
and would be subject to the same rules and regulations as any other 
Medicare or Medicaid provider. Senator Hoeven secured a commitment from 
Department of VA Secretary Dr. David Shulkin to work together on this 
effort. The Senator also secured a provision in the Fiscal Year 2018 VA 
funding bill expressing congressional support for allowing non-VA long-
term care facilities to enter into provider agreements with the VA. The 
VA is in support of provider agreements for extended care services. 
There are plans for a House companion bill to S. 1611 to be introduced 
in the near future by Representative Bruce Poliquin.
    The use of Provider Agreements for extended care services would 
facilitate services from providers who are closer to veterans' homes 
and community support structures. Once providers can enter into 
Provider Agreements, the number of providers serving veterans will 
increase in most markets, expanding the options among veterans for 
nursing center care and home and community-based services.
    AHCA appreciates the fact that your committee and the U.S. Senate 
Veterans' Affairs Committee has discussed and considered VA provider 
agreement related legislation. AHCA will continue to advocate for a VA 
provider agreement legislative proposal that will ensure that those 
veterans who have served our nation so bravely have appropriate access 
to quality health care. Thank you again for the opportunity to comment 
on this important matter. If you have any questions, please do not 
hesitate to contact me at [email protected] or AHCA's Senior Director of 
Not for Profit & Constituent Services, Dana Halvorson, at 
[email protected].

    Sincerely,

    Clifton J. Porter II
    Senior Vice President of Government Relations

                                 
                   AMERICAN MEDICAL ASSOCIATION (AMA)
    October 20, 2017

    The Honorable Glenn Thompson
    United States House of Representatives
    124 Cannon House Office Building
    Washington, DC 20515

    Dear Representative Thompson:

    On behalf of the physician and medical student members of the 
American Medical Association (AMA), I am writing to express our support 
for H.R. 2123, the ``Veterans E-Health and Telemedicine Support (VETS) 
Act of 2017,'' as introduced. The AMA supports expanding veterans' 
access to clinically validated telehealth services within the VA.
    This legislation would authorize physicians and other health care 
professionals who are employed directly by the Department of Veterans 
Affairs (VA) and have at least one valid state license to provide 
telehealth services to VA beneficiaries without regard to the location 
of the patient or the health professional. This bill would address the 
significant and unique need to expand access to health care services 
for Veterans being treated within the VA system while also ensuring 
that important patient protections remain in place, including the 
direct oversight, accountability, training, and quality control 
specific to VA-employed physicians and other health care professionals. 
Also, under such a system, VA-employed physicians and other VA-employed 
health care professionals are able to rely on the VA's telehealth 
infrastructure (including hardware and software) pioneered by the VA to 
ensure that access to telemedicine services meet and exceed the 
standard of care.
    Importantly, the bill does not authorize a contracted physician or 
other health care professional who is not directly employed by the VA 
to provide health care services via telemedicine to a VA patient 
located in a state in which the contracted physician or other health 
care professional is not licensed. This is consistent with the VA's 
recently proposed rule expanding telehealth services within the VA 
which explicitly provides that multi-state licensure expansion for 
providing telehealth services applies only to VA employed providers and 
will not be expanded to contracted physicians or providers. A 
contracted physician providing health care services via telemedicine 
would still be required to be licensed in the state where the VA 
patient is being treated. This structure of accountability provides 
protections for VA patients receiving health care services outside a VA 
facility, whether in person or via telemedicine, by ensuring that the 
appropriate licensing boards have authority over the contracted 
physician or other health care professional in the state where the 
patient is located. Without such protections, should VA patients be 
subject to services that fall short of the standard of care, they would 
have limited recourse under their own state's medical practice and 
patient safety laws and regulations.
    The AMA is committed to advancing patient access to care through 
new innovations, including telemedicine, and commends you for your 
leadership in expanding access to VA patients.

    Sincerely,

    James L. Madara, MD

                                
                                 AMVETS
    on

    ``Pending Legislation''

    H.R. 1133 Veteran Transplant Coverage Act of 2017
    Support
    H.R. 2123 Veterans E-Health & Telemedicine Support Act of 2017
    Support
    H.R. 2601 Veterans Increased Choice for Transplanted Organs & 
Recovery (VICTOR) Act of 2017
    Support
    H.R. 3642 Military Sexual Assault Victims Empowerment (SAVE) Act
    Oppose
    Draft to establish a permanent Veterans Choice Program
    Support Discussion Draft
    No Position on Amended Draft
    Draft to direct the VA Secretary to conduct a study on the Veterans 
Crisis Line.Support
    VA's legislative proposal, the Veteran Coordinated Access and 
Rewarding Experiences (CARE) Act
    No Position
    Chairman Roe, Ranking Member Walz, and members of the committee; 
thank you for the opportunity to provide a statement for the record on 
behalf of AMVETS and our 250,000 members. We appreciate your efforts to 
address and correct some of the most challenging and longstanding 
veteran health care issues that our country has faced. The dedication 
of you and your staff members who work diligently to formulate policies 
that ensure we are taking care of our Nation's veterans is something 
that affects the lives of our members, and we are grateful for the 
ideas being put forth.
           H.R. 1133 Veteran Transplant Coverage Act of 2017
                       AMVETS supports H.R. 1133
    H.R. 1133 authorizes the Secretary of Veterans Affairs to provide 
for an operation on a live donor for purposes of conducting a 
transplant procedure for a veteran, even if the live donor may not be 
eligible for health care from the VA.
    AMVETS supports this legislation which will help ensure that the 
veteran is getting the lifesaving health care they have earned and 
deserve.
H.R. 2123 Veterans E-Health and Telemedicine Support (VETS) Act of 2017
                       AMVETS supports H.R. 2123
    The VETS Act allows a licensed VA health care professional to 
practice their health care profession at any location in any state, 
regardless of where the professional or patient is located, if the 
covered health care professional is using telemedicine to provide 
treatment. There is a reporting requirement due within the first year 
of enactment which will provide a variety of information including 
patient and health care professional satisfaction, access to 
telemedicine and potential budget savings due to reduction of travel 
reimbursements as a result of accessing care through telemedicine.
    AMVETS applauds the introduction of this bill, and believes that in 
conjunction with VA's Proposed Rule posted on the Federal Register on 
October 2, 2017, Authority of Health Care Providers to Practice 
Telehealth, that veterans will soon benefit from greater access to a 
variety of health care, including mental health. Removing the arbitrary 
state barriers that have no relevance to telemedicine is long overdue. 
It is worth pointing out that while AMVETS is fully supportive of the 
use of telehealth, that the situation of each veteran needs to 
carefully be considered. For instance, some veterans clearly need to be 
seen in-person, but for interim checkups or counseling in between face-
to-face appointments this is quite a valuable tool. For those that use 
telehealth for monitoring a long-term or chronic health condition, this 
is not only a time saver, but a cost saver as well. AMVETS looks 
forward to passage of this measure.
    H.R. 2601 Veterans Increased Choice for Transplanted Organs and 
                     Recovery (VICTOR) Act of 2017
                       AMVETS supports H.R. 2601
    This bill amends the Veterans Access, Choice, and Accountability 
Act of 2014 to enhance access to organ transplants for veterans who 
live more than 100 miles from a VA operated transplant center by 
allowing them to get the medical care needed for the required organ 
transplant at a transplant center, operated by an approved entity under 
Choice, within 100 miles of their home.
    AMVETS supports this legislation which will help ensure that the 
veteran is getting the lifesaving health care they have earned and 
deserve without the undue burden of having to travel over 100 miles for 
an organ transplant in addition to the myriad of preand post-transplant 
medical appointments required for a successful transplant and follow 
up.
    H.R. 3642 Military Sexual Assault Victims Empowerment (SAVE) Act
                        AMVETS opposes H.R. 3642
    The SAVE Act establishes a three-year pilot program for veterans 
who are survivors of military sexual trauma (MST) so they may access 
private, non-Department of Veterans Affairs, medical and hospital 
treatment for physical and psychological injuries resulting from the 
assault. At the end of the pilot, participating veterans may request to 
continue receiving private sector care related to MST.
    Five locations will be chosen in areas where sexual assault has 
been determined to be a substantial problem, and veterans participating 
may still receive VA health care for medical issues other than MST. A 
veteran is deemed eligible for the pilot if they qualify under section 
1720D of title 38, United States Code Counseling and treatment for 
sexual trauma.
    Every VA health care facility has an MST Coordinator and medical 
professionals who are knowledgeable about treating MST, in fact, all VA 
mental health and primary care providers must complete a mandatory 
training on MST. There are a variety of existing treatments available 
to the veteran including specialized outpatient mental health services 
focusing on sexual trauma. Vet Centers also have specially trained 
sexual trauma counselors. Nationwide, VA has over twenty residential or 
inpatient programs that offer specialized MST treatment. The services 
can include cutting-edge treatment methodologies for a range of mental 
health problems associated with being an MST survivor. In addition, VA 
will often treat veterans for MST-related services even if the veteran 
is not eligible for VA health care
    AMVETS is concerned with the open-ended access to private sector 
MST care in the five pilot areas and believes that veterans can be best 
served by receiving the renowned care that VA has long-worked to fine 
tune and provide to both genders who have experienced MST. AMVETS has a 
National Resolution on MST which states, in part, that AMVETS calls 
upon Congress to continue its oversight and hearings related to 
military sexual trauma care and benefits with the goal of improving VA 
and DoD collaboration and improving policies and practices for military 
sexual trauma care and disability compensation. We feel that the 
strengthening needs to occur within DoD and VA, and that having groups 
of veterans being treated in the private sector will lead to fragmented 
care for the veteran at a higher cost.
 Draft to establish a permanent Veterans Choice Program, and for other 
                                purposes
    AMVETS supports the discussion draft, and the consolidation of 
existing community programs into an established network of community VA 
providers.
    Our concern with the draft is based on the premise of sending 
veterans into the community for care because of a shortage of health 
care providers, while not fixing long-term recruitment, hiring, and 
retainment for necessary staff, which would in essence solve many 
access to care issues.
    AMVETS does not support using the Choice Program as a practicable 
option to address the capacity and patient care issues. Diverting funds 
into the community, instead of investing them within the VA system of 
care will quickly erode and eventually dismantle the VA health care 
system.
    Currently over thirty percent of veterans receive community care. 
There is nothing that we have seen that shows that veterans who receive 
their care outside of VA have better health outcomes, or that it is a 
cost saving measure.
    As of the due date for this statement for the record, AMVETS has 
not seen the amended draft bill, and therefore cannot provide a 
statement on the actual bill. We look forward to receiving the amended 
version in the near future.
Draft to direct the Secretary of Veterans Affairs to conduct a study on 
                                  the
                          Veterans Crisis Line
    This draft initiates a study on VA's Veterans Crisis Line (VCL) to 
examine its effectiveness during the five-year period that began 
January 1, 2014. The study will analyze information on the number of 
veterans who began or did not begin VA mental health treatment after 
contacting the VCL, and of those who started treatment how many 
continued it. In addition to other analyzation, it will also determine 
whether receiving sustained mental health care affects suicidality, and 
whether veterans who were receiving VA mental health care utilized the 
VCL in a time of crisis. It will also study how many non-veterans call 
the VCL in the hopes of finding care for a veteran, and how many of 
those individuals received support in having the veteran initiate VA 
mental health care. Additionally, it will track how many veterans who 
contact the VCL tragically attempt or die by suicide.
    AMVETS is pleased to support this draft measure, and we believe 
that five years of data, to include the times where the VCL was not 
operating optimally but where we hope they were still tracking data, 
can hold vital pieces of information in the visibility or knowledge of 
the Crisis Line, how veterans or those who care about them are triaged 
and end up in care (or not), and how many lives have potentially been 
saved based on facts. If we knew how to prevent a person's suicide, 
then we would not need to look into such data; but perhaps learning 
more can save more lives or offer a redirect into a new way of reaching 
those in their darkest days.
VA's legislative proposal, the Veteran Coordinated Access and Rewarding 
                         Experiences (CARE) Act
    At this time AMVETS offers no position on this proposal. There are 
number of Sections that we support, coupled with a number of Sections 
that cause us concern.
    AMVETS supports the consolidation of existing community programs 
into one hopefully more manageable and streamlined program. We also 
wholeheartedly support the measures addressing improving personnel 
practices, and the fact that this reinvests into VA's system of care.
    AMVETS does not support having service-connected disabled veterans 
who are currently qualified to receive medical care with no copay, to 
pay a copay for access to walk-in care. We also do not support the 
round down of certain cost of living adjustments. We cannot fund VA 
health care by instituting copays from veterans who by nature of their 
wounds do not pay for VA health care; or by rounding down their 
benefits. It is not their job to fund VA, and veterans should not have 
to sacrifice further.
    In general, we are not comfortable with some language in the 
proposal that can be open to interpretation such as ``not feasibly 
available,'' ``impracticable or inadvisable,'' or a medical facility 
``not providing care that meets such quality and access standards as 
the Secretary shall develop.'' The latter is particularly distressing 
since a particular medical facility may be experiencing access issues 
due to not being properly staffed. Not fixing that inherent issue and 
sending a veteran out for community care creates a vicious circle, and 
in the end sets up that particular facility to fail.
    We are concerned with not only the vagueness of some language, but 
that the discretion in implementing major portions are left up to the 
Secretary. In the end, massive changes to allowing more veterans to 
seek care in the private sector require specific language and concrete 
boundaries for many reasons. The primary reason would be budget 
allocations, the secondary yet equally important reason would be that 
loosely allowing veterans access into the private sector without clear 
delineations would systematically, over time, dismantle the VA health 
care system.
    We hear that no one wants to privatize the VA health care system 
yet we are left wondering if we are looking at two different 
definitions. If you want to look at the definition literally, it 
explains that privatizing means to transfer from public or government 
control or ownership to private enterprise.
    What we are concerned with is ``the death by a thousand cuts'' 
whereby it can easily be stated that allowing large numbers of veterans 
into the private sector while not fixing long-term recruitment, hiring, 
and retainment for necessary staff, which would in essence solve many 
access to care issues, is a very slow and painful way to bleed the VA 
health care system dry of funds, while lining the pockets of the 
private sector. Who benefits here? Not the veteran patient.

                                 
                ASSOCIATION OF VA PSYCHOLOGIST LEADERS*
                   Association of VA Social Workers*
                Nurses Organization of Veterans Affairs*
                   American Psychological Association
                  Veterans Healthcare Action Campaign
   (*An independent organization, not representing the Department of 
                           Veterans Affairs)
 Furnishing Mental Health Care to Veterans by Choice Program Providers

    WASHINGTON, D.C. October 26, 2017

    Chairman Roe, Ranking Member Walz, and Members of the Committee:

    On behalf of our organizations, we thank you for the opportunity to 
submit this statement for the record on draft legislation to direct VA 
to furnish mental health care to Veterans by community providers 
participating in the Veterans Choice Program (VCP). This statement is 
in addition to our previous submittal that addressed different draft 
legislation on a Permanent VCP. We greatly appreciate your unwavering 
commitment to ensuring that Veterans receive the highest quality care.
    The Veterans Health Administration (VHA), as many recent 
evaluations have documented, provides unrivaled mental health care. 
That care would be gravely undermined by this draft bill which allows 
Veterans to obtain mental health treatment with a VCP provider of up to 
eight visits per episode without any referral from the VHA. Funding for 
this care will be siphoned straight from VHA facility budgets, leading 
to incrementally fewer VHA mental health providers, and a consequent 
erosion and disappearance of the high quality VHA mental health 
services that Veterans now receive. That alone would be calamitous. But 
it is the also the first step on a slippery slope to an unfeterred 
voucher system. As Secretary Shulkin testified in June 2017, ``Just 
giving Veterans a card, a voucher, and let them go wherever they want 
to go. is appealing to some but it would lead to essentially the 
elimination of the VA system altogether.''
    Below we elaborate on the documented superiority and innovations of 
the kind of VHA mental health care that is not readily available in the 
community, including: (1) adherence and training procedures that ensure 
state-of-the art, evidence-based treatment, and (2) unique expertise in 
treating Veterans. All of this would be at risk--as would the benefits 
of VHA's integration of medical and mental health care--if funding is 
diverted from VHA to community care without VHA's referral and 
oversight.

VHA care is superior because it is integrated, monitored and delivered 
    in one location.

    The proposed legislation segregates and reduces coordination of 
Veterans' care, counter to VHA's best practice integrated model. It has 
no requirements for tracking whether non-VA providers are trained in or 
use evidence-based treatments, or how successful are the outcomes. The 
VHA is able to achieve better quality because, as a unified system, it 
has superior ability to implement and monitor adherence to assessment 
and treatment standards. As the Commission on Care Final Report 
recognized: ``Veterans who receive health care exclusively through VHA 
generally receive well-coordinated care, yet care is often highly 
fragmented among those combining VHA care with care secured through 
private health plans, Medicare, and TRICARE. This fragmentation often 
results in lower quality, threatens patient safety, and shifts cost 
among payers''(page 28).

VHA expertise in treating Veterans with Post Traumatic Stress Disorder 
    (PTSD) and depression is missing in the community.

    More than 6,300 VHA mental health providers have received extensive 
training and supervision in the most effective evidence-based therapies 
(EBP) for PTSD--Prolonged Exposure and/or Cognitive Processing Therapy. 
More than 1,800 VA providers have received extensive training and 
supervision in one of three EBPs for depression. Veterans who received 
these EBPs in the VA have experienced clinically meaningful and robust 
improvement in their PTSD and depressive symptoms.
    By contrast, RAND's Ready to Serve national study of therapists who 
treat PTSD and major depression found that compared to providers 
affiliated with the VA or DoD, ``a psychotherapist selected from the 
community is unlikely to have the skills necessary to deliver high-
quality mental health care to service members or veterans with these 
conditions'' (page 21). Only 18% of Tricare and 6% of non-Tricare 
community therapists were trained in and used an EBP.

VHA MH patients are more likely to receive recommended psychiatric 
    medication than are patients in the community.

    Recent publications comparing the VHA to private sector care's 
medication treatment for mental disorders found that for all seven 
indicators, VHA performance was superior to that of the private sector 
by more than 30%. Another study found that only 1-12% of private sector 
patients treated with antidepressants are treated in a manner that is 
consistent with American Psychiatric Association guidelines (with care 
of ethnic minorities tending to be on the lower side of this range).

The VHA's approach to preventing suicides is more comprehensive than is 
    commonly found in the community.

    Each of the 150 VHA medical centers has one or more Suicide 
Prevention Coordinator (SPC) as dedicated positions. SPCs provide 
enhanced care coordination for Veterans identified at high risk for 
suicide and collaborate with VHA's integrated network of care providers 
and community partners to reduce suicide risk among vulnerable 
Veterans. VHA Suicide Prevention policies also include follow ups to 
missed appointments, safety planning, and wraparound services, and for 
high risk Veterans a medical record flagging and monitoring system that 
includes mandatory mental health appointments. VHA also uses predictive 
analytics to identify Veterans at risk for suicide and other adverse 
outcomes and offers enhanced care to these Veterans according to their 
needs. Some of these Veterans may not have been identified as at risk 
based on clinical signs. This novel big data approach which does not 
occur with Veterans seen in the community allows VHA to identify and 
help vulnerable Veterans before a crisis occurs.

Veterans with Serious Mental Illness (SMI) who use the VHA have greater 
    life expectancy and reduced inpatient bed days of care.

    Veterans with SMI conditions who receive VHA care live much longer 
on average than their counterparts in the U.S. population. Veterans 
with SMI who drop out of VHA health care but then resume have 
significantly lower rates of mortality than Veterans who do not return. 
Building on this success, VHA implemented the SMI Re-Engage Program, an 
outreach to Veterans with SMI who have a 12-month gap in VHA service 
utilization. For Veterans contacted between March 2012 and March 2016, 
24% returned to VHA care within 4 months.
    In the VHA's Intensive Community Mental Health Recovery (ICMHR) 
program, MH staff visit Veterans with SMI multiple times weekly to 
provide recovery oriented interventions, typically in the Veteran's 
place of residence, which ensures more routine follow up and alleviates 
the burden to present to a medical facility. Veterans enrolled in ICMHR 
services had 27 fewer bed days of care and 1.4 fewer admissions on 
average as compared to the year prior to admission to the program.

VHA's comprehensive and integrated health care response to military 
    sexual trauma (MST) has no comparable program in the community.

    When screened by a VHA healthcare provider, 1 in 4 women Veterans 
and 1 in 100 men report that they experienced MST. Because most 
servicemembers are men, they constitute 40% of all MST survivors seen 
in VHA. MST is associated with a wide range of mental and physical 
health conditions, as well as lasting impairment in occupational and 
life functioning.
    Given that many survivors never talk about their MST experience 
unless asked directly, VHA's screening, sensitivity and attentive 
efforts are crucial ways to proactively reach survivors who might not 
otherwise seek out care. Each VHA facility has a dedicated MST 
coordinator position, mandatory MST training for primary and mental 
health care providers, free MST-related treatment and outreach efforts. 
All Veterans enrolled in the VHA are screened for experiences of MST, 
and tailored treatment plans are created for survivors in need of 
mental health care. Over 938,000 outpatient MST-related mental health 
visits were provided to Veterans with a positive MST screen in FY14. 
Comparable screening and treatment programs do not widely exist in the 
community, where providers are less likely to have experience or 
recognize that it is important to even ask Veterans about MST.

The VHA's evidence-based interdisciplinary approach to pain management, 
    which is part of the VHA's care of patients with mental health and 
    substance abuse problems, hardly exists outside of the VHA.

    Approximately 50% of Veterans treated in Primary Care report one or 
more chronic pain complaints, disproportionately higher than American 
non-Veterans. CDC Guidelines specifically recommend avoiding the use of 
opioids in favor of cognitive behavioral psychotherapy, exercise 
therapy and non-opioid medications as first-line treatments for chronic 
pain. Instead of routinely triaging Veterans with chronic pain to 
specialists, the VHA introduced in 2009 a Stepped Care Model in which 
patients receive biopsychosocial chronic pain care first within VHA 
primary care. These interdisciplinary clinics collocate and integrate 
PCPs, psychologists, pharmacists and/or physical therapists to provide 
multi-modal pain care. Preliminary results show decreased self-reported 
pain, opioid risk and daily opioid use.
    Interdisciplinary pain management continues to grow in the VHA but 
is very rare in the U.S. private sector where healthcare tends to be 
fragmented and truncated. VHA accounts for 40% of the U.S. 
interdisciplinary pain programs even though it serves 8% of the adult 
population. The importance of effective pain management, including 
behavioral interventions, is further underscored by the fact that pain 
is the most commonly identified risk factor when analyses are conducted 
after a Veteran has died from suicide.

No other healthcare system is as Veteran-centric and Veteran-sensitive 
    as the VHA.

    VHA care is Veteran-centric in many ways not found in general 
community settings. The VHA has hired 1100 Peer Specialists who are 
Veterans in successful recovery from mental health challenges and are 
integrated in programs as staff members providing mental health care. 
Peer specialists are uniquely suited to engage Veterans in ongoing care 
and to instill hope. Across the system, 31% of VHA employees are 
Veterans themselves. RAND's Ready to Serve report found that the 
Veteran and military cultural competency of VHA/DoD providers far 
outstripped that of community providers. VHA providers' cultural 
expertise comes not just from required trainings but also from a 
commitment to the mission of serving those who served and from careers 
in a system that is by, for and about Veterans. Finally, the VHA has 
created a community of healing in which Veterans in therapy groups 
share experiences they have not revealed to anyone else in their lives.

The VHA is the main system of preparing our national healthcare 
    workforce.

    The VHA is involved in training 50% of all U.S. psychologists, 70% 
of all U.S. physicians, and 40 other healthcare professions. 
Significant reductions in the number of VHA attending supervisors would 
disrupt healthcare education nationally. Given the costs of 
establishing and maintaining training programs and residencies, the 
private sector will not be able to compensate for the loss of VHA 
training opportunities for the next generation of providers.
    We recognize that when timely access to VHA services isn't 
feasible, the VHA should continue to purchase services from outside 
partners. Future efforts to reform the care of veterans must ensure 
that funding for high quality VHA mental health services be sustained 
and strengthened. We thank you again for this opportunity to provide 
input that describes the impact of allowing veterans to obtain mental 
health treatment with a VCP provider without any referral from the VHA.

Contacts:

    Association of VA Psychologist Leaders [email protected]
    Association of VA Social Workers [email protected]
    Nurses Organization of Veterans Affairs [email protected]
    American Psychological Association [email protected]
    Veterans Healthcare Action Campaign [email protected]

Notes:

    i Examining the Veterans Choice Program and the Future of Care in 
the Community. Presentation before the Senate Committee on Veterans' 
Affairs, 114th Cong. 1 (June 7, 2017) (Testimony of David Shulkin).

    ii Commission on Care. (2016). Commission on Care: Final Report. 
Retrieved from https://s3.amazonaws.com/sitesusa/wp-content/uploads/
sites/912/2016/07/Commission-on-Care--Final-Report--102217--FOR-WEB.pdf

    iii U.S. Department of Veterans Affairs. (2016). Fact Sheet: VA 
Mental Health Care. Retrieved from https://www.va.gov/opa/publications/
factsheets/April-2016-Mental-Health-Fact-Sheet.pdf

    iv Karlin, B. E., Ruzek, J. I., Chard, K. M., Eftekhari, A., 
Monson, C. M., Hembree, E. A., . Foa, E. B. (2010). Dissemination of 
evidence-based psychological treatments for posttraumatic stress 
disorder in the Veterans Health Administration. Journal of Traumatic 
Stress, 23(6), 663-673. https://doi.org/10.1002/jts.20588

    v Eftekhari, A., Ruzek, J. I., Crowley, J., Rosen, C., Greenbaum, 
M., & Karlin, B. (2013). Effectiveness of National Implementation of 
Prolonged Exposure Therapy in Veterans Affairs Care. JAMA Psychiatry, 
70(9), 949-955.

    vi Chard, K., Ricksecker, E., Healy, E., Karlin, B. E., & Resick, 
P. A. (2012). Dissemination and Experience with Cognitive Processing 
Therapy. Journal of Rehabilitation Research and Development, 49, 667-
678.

    vii Karlin, B. E., Walser, R. D., Yesavage, J., Zhang, A., Trockel, 
M., & Taylor, C. B. (2013). Effectiveness of acceptance and commitment 
therapy for depression: comparison among older and younger veterans. 
Aging & Mental Health, 17(5), 555-563. https://doi.org/10.1080/
13607863.2013.789002

    viii Karlin, B. E., Trockel, M., Brown, G. K., Gordienko, M., 
Yesavage, J., & Taylor, C. B. (2015). Comparison of the effectiveness 
of cognitive behavioral therapy for depression among older versus 
younger veterans: results of a national evaluation. The Journals of 
Gerontology. Series B, Psychological Sciences and Social Sciences, 
70(1), 3-12. https://doi.org/10.1093/geronb/gbt096

    ix Stewart, M. O., Raffa, S. D., Steele, J. L., Miller, S. A., 
Clougherty, K. F., Hinrichsen, G. A., & Karlin, B. E. (2014). National 
dissemination of interpersonal psychotherapy for depression in 
veterans: therapist and patient-level outcomes. Journal of Consulting 
and Clinical Psychology, 82(6), 1201-1206. https://doi.org/10.1037/
a0037410

    x Walser, R. D., Karlin, B. E., Trockel, M., Mazina, B., & Barr 
Taylor, C. (2013). Training in and implementation of Acceptance and 
Commitment Therapy for depression in the Veterans Health 
Administration: therapist and patient outcomes. Behaviour Research and 
Therapy, 51(9), 555-563. https://doi.org/10.1016/j.brat.2013.05.009

    xi Tanielian, T., Farris, C., Epley, C., Farmer, C. M., Robinson, 
E., Engel, C. C., . Jaycox, L. H. (2014). Ready to Serve: Community-
Based Provider Capacity to Deliver Culturally Competent, Quality Mental 
Health Care to Veterans and Their Families. Santa Monica, CA: RAND 
Corporation. Retrieved from http://www.rand.org/pubs/research--reports/
RR806.html

    xii Watkins, K. E., Smith, B., Akincigil, A., Sorbero, M. E., 
Paddock, S., Woodroffe, A., . Pincus, H. A. (2015). The Quality of 
Medication Treatment for Mental Disorders in the Department of Veterans 
Affairs and in Private-Sector Plans. Psychiatric Services (Washington, 
D.C.), Epub.

    xiii Barry, C. N., Bowe, T. R., & Suneja, A. (2016) An update on 
the quality of medication treatment for mental disorders in the VA. 
Psychiatric Services, 67(8), 930.

    xiv Mechanic, D. (2014). More People Than Ever Before Are Receiving 
Behavioral Health Care In The United States, But Gaps And Challenges 
Remain. Health Affairs, 33, 1416-1424.

    xv Kilbourne, A. M., Ignacio, R. V., Kim, H. M., & Blow, F. C. 
(2009). Data points: are VA patients with serious mental illness dying 
younger? Psychiatric Services (Washington, D.C.), 60(5), 589.

    xvi Davis, C., Kilbourne, A.M., Blow, F.C., Pierce, J.R., Winkel, 
B.M., Huycke, E., Langberg, R., Lyle, D., Phillips, Y., & Visnic, S. 
(2012). Reduced Mortality among Department of Veterans Affairs Patients 
with Schizophrenia or Bipolar Disorder Lost to Follow-up and Engaged in 
Active Outreach to Return for Care. American Journal of Public Health 
102 Suppl 1 (March): S74-79. doi:10.2105/AJPH.2011.300502.

    xvii U.S. Department of Veterans Affairs. (2016). Fact Sheet: VA 
Mental Health Care. Retrieved from https://www.va.gov/opa/publications/
factsheets/April-2016-Mental-Health-Fact-Sheet.pdf

    xviii U.S. Department of Veterans Affairs. (2016). Fact Sheet: VA 
Mental Health Care. Retrieved from https://www.va.gov/opa/publications/
factsheets/April-2016-Mental-Health-Fact-Sheet.pdf

    xix Military Sexual Trauma Support Team (2016). Military Sexual 
Trauma Screening and Summary of Military Sexual Trauma-Related 
Outpatient Care: Special Report of Operation Enduring Freedom/Operation 
Iraqi Freedom/Operation New Dawn Veterans, Fiscal Year 2015. 
Washington, DC: Department of Veterans Affairs, Office of Patient Care 
Services, Mental Health Services.

    xx Kimerling, R., Gima, K., Smith, M. W., Street, A., & Frayne, S. 
(2007). The Veterans Health Administration and military sexual trauma. 
American Journal of Public Health, 97(12), 2160-2166.

    xxi Schry, A. R., Hibberd, R., Wagner, H. R., Turchik, J. A., 
Kimbrel, N. A., Wong, M., ... & Brancu, M. (2015). Functional 
correlates of military sexual assault in male veterans. Psychological 
Services, 12(4), 384-393. doi: http://dx.doi.org/10.1037/ser0000053.

    xxii Millegan, J., Milburn, E. K., LeardMann, C. A., Street, A. E., 
Williams, D., Trone, D. W., & Crum-Cianflone, N. F. (2015). Recent 
sexual trauma and adverse health and occupational outcomes among US 
service women. Journal of Traumatic Stress, 28(4), 298-306. doi: 
10.1002/jts.22028

    xxiii U.S. Department of Veterans Affairs. (2016). Fact Sheet: VA 
Mental Health Care. Retrieved from https://www.va.gov/opa/publications/
factsheets/April-2016-Mental-Health-Fact-Sheet.pdf

    xxiv Kerns, R. D., Otis, J., Rosenberg, R., & Reid, M.C. (2003) 
Veterans' reports of pain and associations with ratings of health, 
health-risk behaviors, affective distress, and use of the healthcare 
system. Journal of rehabilitation research and development, 40(5), 371-
379.

    xxv Centers for Disease Control and Prevention. CDC Guideline for 
Prescribing Opioids for Chronic Pain United States, MMWR: 
Recommendations and Reports. March 18, 2016; 65(1):1-49.

    xxvi Personal communication, Seal, K., February 4, 2017

    xxvii Dorflinger, L. M., Ruser, C., Sellinger, J., Edens, E. L., 
Kerns, R. D., Becker, W. C. (2014) Integrating interdisciplinary pain 
management into primary care: Development and implementation of a novel 
clinical program. Pain Med, 15(12), 2046-2054.

    xxviii Schatman, M. E. (2012). Interdisciplinary Chronic Pain 
Management: International Perspectives. Pain: Clinical Updates, 20(7), 
1-5.

    xxix The US Department of Veterans Affairs Behavioral Health 
Autopsy Program (BHAP) Report, December 1, 2012 June 30, 2015. (n.d.). 
Retrieved from http://catalog.data.gov/dataset/behavioral-health-
autopsy-program-bhap

                                 
  AMERICAN SOCIETY OF TRANSPLANT SURGEONS (ASTS), AMERICAN SOCIETY OF 
        TRANSPLANTATION (AST), NATIONAL KIDNEY FOUNDATION, AAKP
    October 20 2017

    Representative John R. Carter
    U.S. House of Representatives
    2110 Rayburn House Office Building
    Washington D.C. 20015

    Re: Letter in Support of the Veterans Transplant Coverage Act of 
2017

    Dear Representative Carter,

    The undersigned transplant patient, physician, and other provider 
organizations write in strong support of H.R. 1133, ``The Veterans 
Transplant Coverage Act of 2017.''
    At this time, Department of Veterans Affairs (VA) policy limits 
veterans' access to life-saving transplants as it does not cover the 
medical expenses of non-veteran living donors. This policy means that 
if a veteran in need of a transplant has a living donor match, a 
lifesaving transplant may remain out of reach simply because of the 
non-veteran status of the donor.
    The Veterans Transplant Coverage Act expands access to lifesaving 
transplant procedures for veterans by authorizing the VA to cover the 
costs of an operation on a living donor to carry out a transplant for 
an eligible veteran even if the living donor is not otherwise eligible 
for VA health care. Currently, other federal government health care 
programs cover live donors' health care needs. The Centers for Medicare 
and Medicaid Services (CMS) provides coverage of living donors for 
kidney transplants. We believe, at a minimum, that our nation's 
Veterans deserve the same access to care that Medicare beneficiaries 
receive.
    The Veterans Transplant Coverage Act would help ensure that the men 
and women who have served our nation are given the same access to life-
saving treatments that other American citizens have. Finally, we note 
that H.R. 1133 also authorizes the VA to cover live donor transplant 
operations at a VA or non-VA facility, increasing access to high 
quality medical care and transplantation.
    We are pleased to support the Veterans Transplant Coverage Act of 
2017 for our nation's veterans and those who give the gift of life to 
sustain their lives. Thank you for your leadership in advancing 
bipartisan legislation to improve transplantation care for veterans. If 
you have any questions, or if we can be of any assistance, please do 
not hesitate to contact any of our legislative representatives listed 
below.

    AAKP Richard Knight [email protected]

    Paul T. Conway [email protected]
    ASTS Peggy Tighe [email protected]
    AST Bill Applegate [email protected]
    NKF Troy Zimmerman [email protected]

                                 
                  CONCERNED VETERANS OF AMERICA (CVA)
Draft Legislation House Veterans Affairs Community Care and Choice 
    Reform Bill

    A bill to reform the Department of Veterans Affairs (VA) community 
care programs and the Veteran Choice Program.
    In 2014, in response to the VA wait list scandal, Congress created 
the Veterans Choice Program (VCP) as a temporary program to offer 
veterans the option to access private sector health care with their VA 
benefits if they live long distances from VA facilities or face long 
waits for care. The creation of the VCP was an important first step 
towards giving veterans who use the Veterans Health Administration 
(VHA) the ability to choose to access private sector providers through 
the VA if they felt that the VHA wasn't the best option for them at 
that time.
    Unfortunately, the VCP was poorly implemented and, as currently 
structured, offers veterans at the VA limited health care choice. 
Additionally, the program recently faced a budget shortfall that had to 
be backfilled by Congress and is likely facing another budget shortfall 
before the end of the year. Accordingly, Congress needs to act to 
ensure that veterans who use the VCP do not experience a lapse in their 
care.
    Concerned Veterans for America (CVA) has consistently advocated for 
increasing health care choice for veterans in the VA health care system 
and for better integrating the VHA with the private health care system. 
While the draft House Veterans Affairs Committee legislation contains 
positive reforms, Concerned Veterans for America encourages the 
committee to make the following modifications to improve the draft 
legislation:

    1. Modify Section 101 to allow an eligible veteran to choose any 
primary care physician within their VA integrated care network 
regardless of whether they are at the VHA or a contracted community 
provider. Currently as written, under the proposed legislation a 
veteran can only choose a primary care provider (PCP) outside of the 
VHA if there is not one currently available at the VHA's facilities 
within their respective integrated care network. In CVA's opinion, this 
model does not properly empower veterans with more control over their 
health care and could potentially lead to some of the same problems we 
currently see with the VCP mainly that the VA would still have too much 
control as a gatekeeper to care outside of the VA. CVA strongly 
recommends modifying this section to conform with recommendation one 
from the 2016 Commission on Care that would allow eligible veterans to 
choose any PCP within the integrated network with available capacity. 
This would give veterans more health care options and flexibility. 
Coordination of care would also not be an issue since a PCP outside of 
the VHA would already be part of the integrated care network. In order 
to control costs and provide some incentive to stay within the VHA, CVA 
also supports implementing higher co-pays for non-service connected 
care for PCPs outside of the VHA if a veteran elects to go a community 
provider. This is similar to how TRICARE Prime operates in the 
Department of Defense.

    2.Create an appeals process for veterans who feel they were wrongly 
denied referrals to specialty care outside of the VHA. This was 
proposed as part of Secretary Shulkin's initial Coordinated Access and 
Rewarding Experiences (CARE) plan. CVA believes this is essential to 
ensuring that veterans have the ability to have a third party settle a 
disagreement regarding referrals with their PCP.

    3.Return the VA to a secondary payor status for veterans with other 
health insurance for non-service connected care in the community. 
Changing the VA permanently to a primary payor for non-service 
connected care will potentially increase up-front costs by billions of 
dollars and likely lead to future budgetary problems which will limit 
veterans use of choice. There are legitimate reimbursement issues that 
are causing veterans to receive unnecessary bills from community 
providers, but switching to primary payor is not the way to solve this 
problem. Other programs like TRICARE have demonstrated that there are 
better ways of reimbursing providers without switching to primary 
payor.

    4.Authorize the pilot programs that were originally proposed as 
part of Secretary Shulkin's CARE plan to be implemented. The veteran 
population will be rapidly changing over the next decade. By 2030, 
there will be between 4 to 5 million fewer veterans and the VA's 
patient population will be more dispersed and have much different 
health care needs. With that considered, the VA should be continually 
testing new ways of delivering health care to our veterans and should 
also be testing new governance and reimbursement structures for the VHA 
that would better enable the VA to respond to changes in the veteran 
population.

    Finally, CVA would encourage the House committee to consider and 
mark up this legislation in conjunction with the draft Asset and 
Infrastructure Review Act. The VA's infrastructure needs and its use of 
community care are inextricably linked and should be address 
concurrently with each other.
    CVA applauds the House Veterans Affairs Committee for prioritizing 
this important piece of legislation and looks forward to continuing to 
work with the committee to ensure that our veterans are empowered with 
more control over their health care at the VA.

Department of Veterans Affairs Coordinated Access and Rewarding 
    Experiences (CARE) Plan

    A proposal from the VA to consolidate and streamline the VA's 
community care and choice programs.
    CVA believes that the CARE plan contains positive reforms that 
should be implemented. CVA supports establishing contracted urgent care 
clinics for veterans and believes that will increase access to certain 
types of medical care for veterans while also reducing demand at many 
VA medical centers. Additionally, CVA supports the proposal to improve 
the reimbursement process and the appeals process for veterans who feel 
that they were wrongly denied access to community care. However, as 
with the draft House Veterans Affairs Committee legislation, CVA 
supports adding to the CARE plan the ability for a veteran to choose a 
primary care physician outside of the VHA in the proposed integrated 
care networks. This is a commonsense measure that was proposed by the 
Commission on Care in 2016 and has been supported by members of the 
House committee in the past.

Draft Legislation Conducting a Study of the Veterans Crisis Line

    A bill to direct the Secretary of Veterans Affairs to conduct a 
study of the effectiveness of the Veteran Crisis Line.
    CVA supports efforts to ensure that the Veteran Crisis Line is 
operating as effectively as possible and is maximizing its ability to 
best serve veterans in crisis. Accordingly, CVA believes that it is 
appropriate to undertake this study and we applaud Rep. Banks for 
proposing this bill.

Concerned Veterans for America has no position on HR 1133, HR 2123, HR 
    2601, and HR 3642 at this time.


                                 
                    FLEET RESERVE ASSOCIATION (FRA)
                                The FRA
    The Fleet Reserve Association (FRA) is the oldest and largest 
organization serving enlisted men and women in the active, reserve, and 
retired communities plus veterans of the Navy, Marine Corps, and Coast 
Guard. The Association is Congressionally Chartered, recognized by the 
Department of Veterans Affairs (VA) and entrusted to serve all veterans 
who seek its help.
    FRA was started in 1924 and its name is derived from the Navy's 
program for personnel transferring to the Fleet Reserve or Fleet Marine 
Corps Reserve after 20 or more years of active duty, but less than 30 
years for retirement purposes. During the required period of service in 
the Fleet Reserve, assigned personnel earn retainer pay and are subject 
to recall by the Secretary of the Navy.
    The Association testifies regularly before the House and Senate 
Veterans' Affairs Committees, and the Association is actively involved 
in the Veterans Affairs Voluntary Services (VAVS) program. A member of 
the National Headquarters' staff serves as FRA's National Veterans 
Service Officer (NVSO) and as a representative on the VAVS National 
Advisory Committee (NAC). FRA's NVSO also oversees the Association's 
Veterans Service Officer Program and represents veterans throughout the 
claims process and before the Board of Veteran's Appeals.
    FRA became a member of the Veterans Day National Committee in 
August 2007, joining 24 other nationally recognized Veterans Service 
Organizations (VSO) on this important committee that coordinates 
National Veterans' Day ceremonies at Arlington National Cemetery. The 
Association is a leading organization in The Military Coalition (TMC), 
a group of 33 nationally recognized military and veteran's 
organizations collectively representing the concerns of over five 
million members. FRA senior staff members also serve in a number of TMC 
leadership positions.
    The Association's motto is ``Loyalty, Protection, and Service.''
             Certification of Non-Receipt of Federal Funds
    Pursuant to the requirements of House Rule XI, the Fleet Reserve 
Association has not received any federal grant or contract during the 
current fiscal year or either of the two previous fiscal years.
                              Introduction
    Distinguished Chairman Phil Roe, Ranking Member Tim Walz and other 
members of the Committee, thank you for the opportunity to provide a 
statement regarding draft legislation to be discussed and reviewed at 
your October 24, 2017 hearing. At the FRA National Convention in Hunt 
Valley, Maryland, (September 19-24, 2017) the delegates unanimously 
approved FRA's 2018 Legislative Agenda. It calls for the FRA 
Legislative Team to ``Monitor implementation of the Veterans Access, 
Choice and Accountability Act (VACAA) that provides a $10 billion fund 
to pay for non-VA care for veterans who live 40 or more miles from a VA 
facility or have been experiencing wait times for care of more than 30 
days. VA has provided `Choice Cards' to veterans who were enrolled in 
VA health care as of August 1, 2014, and to recently discharged combat 
veterans who enroll within the five-year window of eligibility.''
    The Association does not have any provisions in its Legislative 
Agenda pertaining to operations on live donors for purposes conducting 
transplant procedures for veterans or the VA regulation of state 
veteran's homes. Therefore: the FRA statement focuses on the VA Choice 
program and VA Telemedicine reform.
                           VA Choice Program
    In FRA's recent survey (January/February 2017) nearly 81 percent of 
veterans see quality of VA health care benefits as ``Very Important'' 
(the highest rating). The past three years VA and specifically the 
Veterans Health Administration (VHA) have been embroiled in controversy 
and scandal. Since the Phoenix waiting list scandal was uncovered by 
Congress a robust debate has ensued on how to reform VHA to ensure it 
can provide timely, comprehensive and veteran-centric health care to 
veterans in need. In response to the scandal Congress passed the 
``Veterans Access, Choice and Accountability Act'' (VACAA) that became 
law in 2014. FRA supported this legislation because the VA's first 
priority must be to ensure that all veterans currently waiting for 
treatment are provided timely access.
    FRA supports the Independent Budget (IB) Framework for veteran's 
healthcare reform, and wanted the Choice program at the very least to 
be extended. The Association believes that the ``Choice'' program has 
merit, but will require significant oversight by this Committee to 
ensure it is an effective program that will benefit our disabled 
veterans. VA must ensure that Non-VA Care Coordination teams are 
adequately staffed and funded to be capable of handling the workload. 
Outsourced care has been available for many years but has not been 
well-planned or coordinated with VA care.
    This law gives veterans who have waited more than 30 days for an 
appointment-or who live more than 40 miles from a VA medical facility-
the choice to seek VA-funded care outside of the VA system. About 58 
million medical appointments were scheduled by VA in fiscal 2016, an 
increase of almost six percent in less than two years. Almost a third 
of those appointments were scheduled with doctors working outside the 
VA system, in private clinics. 8,481 patients on VA lists have been 
waiting more than four months for appointment requests, a number that 
swelled to more than 10,000 in early 2016.
    At a recent House Veterans Affairs Committee (HVAC) hearing VA 
Secretary Dr. Shulken claimed that VA community care appointments have 
increased by 61percent overall since Choice was created and, last year, 
30 percent of all VA appointments were held in the community rather 
than in VA medical facilities.
    On August 12, 2017, President Trump signed into law (Public Law 
115-46) the FRA-supported ``VA Choice and Quality Employment Act,'' 
(S.114) sponsored by Senator Dean Heller (NV). This legislation 
provides $2.1 billion to continue the Choice Program for six months 
while Congress works on other reforms to the Choice Program. It also 
authorized 28 major medical facility leases and enhances the 
recruitment, retention and training of the VA workforce.
    Now that the funding short fall has been fixed, FRA is delighted to 
see this Committee's efforts to try to provide a transformational 
change of VA health care by creating an integrated network of VA and 
community health care providers, with the VA serving as the coordinator 
and primary care provider. The networks could make decisions about 
access to community care based on clinical determinations and veterans 
preferences, rather than subjective time and distance as is the current 
practice in the choice program.
    FRA wants to note that the VA decision to use the Department of 
Defense (DoD) Electronic Health Record (EHR) Secretary of Veterans 
Affairs Dr. David J. Shulkin recently announced that the VA will 
dramatically reform this agency's Electronic Health Record (EHR) system 
by replacing the old antiquated system with same system used by the 
Department of Defense. This change is a shift from the VA's previous 
plan to develop its own system to digitize records. It will bring the 
agencies closer to sharing veterans' health information in an effort to 
solve a problem that has plagued the two departments for decades. ``The 
health and safety of our Veterans is one of our highest national 
priorities.'' Shulkin said ``Having a veteran's complete and accurate 
health record in a single common EHR system is critical to that care, 
and to improving patient safety.'' Secretary Shulkin claims that the 
software has a high level of cyber-security.
    FRA has long sought to ensure adequate funding for DoD and VA 
health care resource sharing in delivering seamless, cost effective, 
quality services to personnel wounded in combat and other veterans and 
their families. The Association has repeatedly called for increased 
oversight in its Capitol Hill testimony to keep pushing both agencies 
to make progress on this issue.
                      Draft VA Choice Legislation
    FRA appreciates the provision in the draft legislation that co-
payments for an eligible veteran shall not exceed the co-payments 
required to be paid if services were provided at a VA facility. FRA 
also believes it is important that the ensures that providers within 
any contracted network are appropriately compensated in a timely basis, 
and that Congress will ensure appropriate funding accounts for 
community based care for veterans. Therefore, FRA supports the prompt 
pay provisions in the draft bill that provides payment within 45 days 
for paper clean claims and 30 days for an electronic clean claim. The 
Association also notes the provision in the draft legislation for in 
certain cases the VA to use a ``value-based reimbursement model'' to 
promote high-quality care. The switch to value-based reimbursement 
causes providers to change the way they bill for care. Instead of being 
paid by the number of visits and tests they order (fee-for-service), 
providers' payments will be based on the value of care they deliver 
(value-based care). The transition from a fee-for-service reimbursement 
system to one based on value is a significant oversight challenge.
    FRA wants a VA health care program that is streamline and will 
integrate non-VA care into the broader VA health system, enhancing 
timely access to quality care, and focusing on a system that is easy to 
understand, simple to administer and meets the needs of veterans, 
community providers and VA staff. This program should improve 
collaboration and integration of Department of Defense (DoD)-VA-
Community health care systems as part of a comprehensive, high-
performing network of care. Our veterans deserve nothing less.
               Veterans E-Health and Telemedicine Support
    FRA supports the ``Veterans E-Health and Telemedicine Support Act'' 
(H.R. 2123), sponsored by Rep. Glenn Thompson (PA), that expands the 
current Department of Veteran Affairs (VA) state licensure exemption to 
allow credentialed health care professionals to work across state 
borders performing telemedicine without having to obtain a new state 
license.
    This bill will help veterans struggling with mental health 
conditions, especially those in geographically remote areas. The bill 
will enable the VA to expand key treatment services, including 
behavioral health, which is critical considering the VA is facing 
increasing care demand and mounting provider shortages.
    Under current law, VA health care professionals must be licensed in 
the state where the patient is treated in order to offer services. The 
state licensure requirement has limited the VA's ability to utilize 
telemedicine capabilities, which have been known as an effective 
mechanism for delivering a wide range of care services. The bill 
removes these barriers and allows the VA to provide treatment free of 
this restriction.
    In 2011, Congress passed the Servicemembers Telemedicine & E-Health 
Portability Act, through which the Department of Defense (DoD) is now 
working to expand access to active duty service members through various 
existing programs. This current bill will enable the VA to implement 
the same reforms and provide greater access to care for our veterans.
    Again we wish to thank the Committee for this opportunity to 
express the concerns and opinions of FRA members on these vital issues. 
Our leadership and Legislative Team stand ready to work with this 
Committee to improve benefits for all veterans who have served this 
great Nation.

                                 
                              GOT YOUR SIX
    Statement for the Record
    Prepared By
    Lauren Augustine
    Director of Government Relations

----------------------------------------------------------------------------------------------------------------
          Bill Num.                            Bill Name or Subject                           Position
----------------------------------------------------------------------------------------------------------------
                     Draft     Draft legislation to establish permanent Veterans    Support with recommendations
                                                                 Choice Program
----------------------------------------------------------------------------------------------------------------
                     Draft     Draft legislation to modify VA's authority to enter                No position
                               into agreements with State homes to provide nursing
                               home care to veterans, to direct the Secretary to
                                  carry out a program to increase the number of
                               graduate medical education residency positions, and
                                                             for other purposes
----------------------------------------------------------------------------------------------------------------
                     Draft     Draft proposal to establish the Veteran Coordinated  Support with recommendations
                                    Access and Rewarding Experiences (CARE) Act
----------------------------------------------------------------------------------------------------------------
                     Draft          Draft legislation to require a study on the                   No position
                                                               Veterans Crisis Line
----------------------------------------------------------------------------------------------------------------
                   HR 1133             Veterans Transplant Coverage Act of 2017                       Support
----------------------------------------------------------------------------------------------------------------
                   HR 2123     Veterans E-Health and Telemedicine Support Act of               Support intent
                                                                           2017
----------------------------------------------------------------------------------------------------------------
                   HR 2601     Veterans Increased Choice for Transplanted Organs               Support intent
                                                       and Recovery Act of 2017
----------------------------------------------------------------------------------------------------------------
                   HR 3642      Military Sexual Assault Victims Empowerment Act                Support intent
----------------------------------------------------------------------------------------------------------------

    Chairman Roe, Ranking Member Walz, and Distinguished Members of the 
Committee, on behalf of Got Your 6, I would like to extend our 
gratitude for the opportunity to share our views regarding several of 
these pieces of legislation.
    The mission of Got Your 6 is to empower veterans to lead a 
resurgence of community across the country. Got Your 6 believes, and 
our research confirms, veterans are leaders, team builders, and problem 
solvers who have the unique potential to strengthen communities across 
the country. As a coalition, Got Your 6 works to integrate these 
perspectives into popular culture, engage veterans and civilians 
together to foster understanding, drive veteran empowerment policy, and 
empower veterans to lead in their communities.
    Formed out of Hollywood as a movement to more accurately portray 
veterans in film and television, Got Your 6 has since gone on to lead 
the veteran empowerment movement by spearheading and publishing 
research, which proves veterans are civic assets, granting out more 
than $6 million dollars to our best-in-class nonprofit coalition 
partners, and leading an effort to change the national narrative around 
veterans as ``broken heroes.'' Building on that success, and thanks to 
the direct request from our coalition partners, Got Your 6 was proud to 
launch a policy department in 2017 aimed at advocating on behalf of our 
direct-service nonprofit partners, building on the success of the 
veteran empowerment movement, and challenging the current messaging 
status quo in the halls of Congress.

    The Got Your 6 policy framework includes advocating for legislation 
that:

    1.supports efforts to change the current narrative of veterans as 
``broken heroes'';

    2.identifies common sense reform that does not detract from 
existing services but does increase efficiency or cost savings;

    3.recognizes the entire veteran population, including the 13 
million who do not use the Department of Veterans Affairs (VA) for 
their health care needs; and,

    4.supports a strong VA that adequately meets the needs of those 
veterans who choose to use it.

    The two major draft proposals aimed at addressing the future of 
care contracted outside the VA--referred to as non-VA care--include 
many overlapping provisions Got Your 6 has asked be included in a 
future non-VA care program. However, both bills also include 
fundamental differences in how the program should be set-up and 
managed, particularly as it relates to the establishment of networks of 
providers and the expansion of telemedicine. We encourage this 
Committee to reconcile the two proposals based on feedback from this 
hearing and present one, unified plan that incorporates important 
provisions from each proposal that we as a community can all work 
towards becoming law.
    On the general use of non-VA care, Got Your 6 believes veterans 
should receive care when and where they need it and by a provider that 
clinically best supports that need. Based on feedback from our 
coalition members, the top priorities for any non-VA care program 
should include: the ease of use for all parties, the consolidation of 
community care programs into a singular program, the quick resolution 
of provider payments and record sharing, and the exploration of 
expanding innovative public-private partnerships.
    While both proposals include many provisions that meet or exceed 
those priorities, we found neither substantially addressed a pathway to 
expand the use of public-private partnerships or a call to leverage the 
best-in-class programs and networks that have been established to 
address gaps in VA care or to meet the needs of individuals currently 
not eligible for VA care. We believe many programs--like the Marcus 
Institute for Brain Health and Wounded Warrior Project's Warrior Care 
Networks--are complimentary of the work of VA, allow for innovative 
treatment options outside the current scope of VA options, and provide 
care to veterans with other than honorable (OTH) discharges and 
veterans' families, both groups of people frequently cited as 
underserved in the VA system. We encourage a continued conversation on 
and exploration of how these types of programs can be better understood 
and utilized to fill unmet needs at the VA.

Draft legislation to establish a permanent Veterans Choice Program

    The draft legislation would establish a permanent Veterans Choice 
Program directing the establishment and management of the non-VA care 
options available to veterans utilizing the VA healthcare system.
    Got Your 6 applauds the Committee for developing a comprehensive 
proposal that incorporates many of the stakeholder requests and report 
findings expressed since the creation of the existing Veterans Choice 
program. Generally, the language allows for significant flexibility in 
how the VA will implement specifics of a non-VA care program, which we 
support as the best way to empower the VA to create a program that will 
work better for veterans, VA employees, and the American taxpayer. The 
language also clearly supports the idea that veterans should receive 
care when and where they need it and by a provider that clinically best 
supports that need. Got Your 6 is particularly supportive of the 
following provisions:

    Program eligibility The language makes clear the clinical needs of 
the veteran and the capabilities of the VA will be the key determining 
factors when deciding where a veteran can receive primary and specialty 
care. The language still maintains the VA's central role as the 
coordinator of such care, which we believe will allow for continued 
accountability and oversight of the VA while easing confusing and 
contradictory restrictions related to non-VA care.
    Network creation The well-articulated network creation provisions 
allow for sufficient latitude to develop networks of non-VA providers 
that best align with market realities at a local level. We believe the 
creation of networks will help the VA better manage the overall system 
of non-VA care as opposed to a nation-wide system of individual 
provider agreements.
    Prompt payment standard A lack of standardization for payment 
schedules and common anecdotal evidence of significantly delayed 
payments to providers have proven there is a need for greater attention 
to how community providers are able to submit and receive 
reimbursements. Got Your 6 strongly supports the strict requirements on 
how providers must submit claims and how soon after submission the VA 
must pay the claims, with accrued interest where applicable. These 
clearly defined responsibilities for all parties will better ensure a 
system that is fair and respectful of better business practices.
    Consolidation of non-VA care programs While the existence of 
multiple programs is a well intentioned response from Congress to 
address specific challenges facing the VA or veterans using the VA, it 
easily leads to confusion for veterans, community providers, and VA 
employees navigating a complex system of options. Got Your 6 strongly 
supports the language in this legislation that intends to consolidate 
all existing non-VA care programs into one, easy-to-use program that 
takes into account the need for flexibility to address future regional 
or issue-based concerns.
    Emphasis on electronic transfer of information The emphasis on the 
electronic transfer of information for health records and claims is 
encouraging and strongly supported as we continue to advocate for a 
21st century VA. Got Your 6 encourages the VA to prioritize innovative 
technology and connected electronic platforms as a way to increase 
efficiency and decrease delays and errors in processing. Community 
partners and veterans are increasingly expecting such capabilities and 
the VA should strive to exceed that expectation.

    While the legislation is still in draft form, Got Your 6 encourages 
the consideration of the following:

    Expansion of telemedicine authority The expanded use of 
telemedicine is widely held as a needed part of the solution to many of 
the VA's access constraints. We encourage the Committee to consider 
including the language presented in the draft proposal on the Veteran 
Coordinated Access and Rewarding Experiences Act, and the federal 
supremacy in particular, in the legislation as a part of the whole in 
addressing growth to VA's capacity and capability.
    Protections from previously fired VA employees The language 
specific to what constitutes an eligible non-VA provider does not 
include restrictions on contracting with individual providers 
previously fired from the VA for poor performance, misconduct, or 
criminal charges. In the spirit of the recent efforts to establish 
greater accountability at the VA, we believe that once an individual is 
deemed an unacceptable provider for VA care they should not be eligible 
to provide contracted care either.
    Consideration of appeals process It is imperative for oversight and 
accountability purposes there be a clearly defined, standard process to 
review any concerns related to the use and eligibility of non-VA care.
    Annual market assessments The only concern we raise on this 
provision is the realistic ability to conduct such market assessments 
on an annual basis based on outcomes of similar assessments conducted 
by the VA.

    Underscoring all of the thoughts on this draft legislation is a 
need for Congress, leadership across the VA enterprise, and engaged 
stakeholders to closely monitor the development and implementation of 
the program to ensure it is one the community stands behind. Successes 
and failures during early development and implementation will only 
compound if not resolved while the problem is in infancy. We know 
today's hearing is only one step in a long path to full implementation 
of a new non-VA care program and hope to see continued engagement with 
external partners.

Draft legislation to modify VA's authority to enter into agreements 
    with State homes to provide nursing home care to veterans, to 
    direct the Secretary to carry out a program to increase the number 
    of graduate medical education residency positions, and for other 
    purposes

    This draft legislation would modify VA's authority to enter into 
agreements with State homes, change the recording obligations for non-
VA care, expand telemedicine authority, and establish a program to 
increase the number of graduate medical education residency positions 
within the VA.
    Got Your 6 takes no position on this legislation. The draft 
includes many provisions Got Your 6 has spoken to under other proposals 
before the Committee today, including expansion of telemedicine and a 
change to the accounting procedures used by the VA when tracking non-VA 
care. Got Your 6 has no position on the agreements related to State 
homes and nursing care.

Draft legislation on the Veteran Coordinated Access and Rewarding 
    Experiences (CARE) Act

    The draft proposal would direct the establishment and management of 
non-VA care options available to veterans utilizing the VA healthcare 
system.
    Got Your 6 appreciates the VA's proposal and is encouraged to see 
many similarities to the draft legislation making the Veterans Choice 
Program permanent, such as prompt payment standards and ending 
arbitrary eligibility requirements. However, we find the fundamental 
program development provisions vague and without clear enough 
guidelines to allow for sufficient oversight. Specifically, we have 
concerns with the following provisions:

    Provider agreements The language establishing provider agreements 
is confusing with no clear indication there will be networks or a 
localized system to help reasonably manage provider agreements. As it 
reads, these provider agreements would be handled en masse, which seems 
difficult to maintain with any substantial accountability and 
oversight.
    Enhanced-use leases While the language expanding enhanced-use lease 
authorities is a positive step towards increasing public-private 
partnerships, we find the scope presented extremely limited. It does 
not encourage or facilitate cooperation with organizations providing 
excellent services that do not meet the traditional parameters of 
enhanced-use leases and we would encourage a more innovative, open 
pathway for public-private partnerships.

Got Your 6 is supportive of the following provisions:

    Expansion of telemedicine authority As stated in response to the 
draft legislation making the Veterans Choice Program permanent, we 
strongly support the language within this proposal that expands the 
VA's authority to provide telemedicine.
    Recording obligations change Got Your 6 supports the provision 
requiring the cost of non-VA care be accounted for when a claim for 
payment is approved. We believe this change will allow the VA to have a 
better understanding of the real cost of non-VA care.
    Walk-in care options Utilizing urgent care facilities is a 
comomnsense solution to increasing access to care while simultaneously 
reducing expensive and sometimes unnecessary emergency room visits. Got 
Your 6 supports the intent behind this provision and hopes to see 
access to urgent care options available for veterans under the new non-
VA care program, but we find the specific language in this draft 
proposal too vague and encourage incorporating some additional 
parameters to better articulate the provision.
    Enhancing federal agency partnerships Got Your 6 believes reducing 
bureaucratic barriers between VA and the Department of Defense (DoD) 
will result in quicker access to care with potential cost saving 
benefits. We hope to see more innovative and resource sharing 
opportunities, like the pilot program presented, identified to 
facilitate a more efficient government.

    As previously stated, Got Your 6 encourages the VA and the House 
and Senate Veterans Affairs Committees to consider the best of both 
proposals and integrate stakeholder feedback to present one, unified 
plan we as a community can all support.

Draft legislation to require a study on the Veterans Crisis Line

    The draft legislation would require a study on the efficacy of the 
Veterans Crisis Line.

    Got Your 6 has no position on this draft legislation. While data on 
the efficacy of the Veterans Crisis Line (VCL) could be valuable 
information that would better inform how the VA is responding to the 
mental health care needs of veterans, we are concerned the information 
required in the study may not be feasible or ethical to collect. We are 
researching the matter further and welcome additional conversations on 
the subject.

H.R. 1133, Veterans Transplant Coverage Act of 2017

    The Veterans Transplant Coverage Act would allow the VA to provide 
for an operation on a live organ donor, regardless of that individual's 
eligibility for VA care, including care necessary before and after the 
organ donation surgery.
    Got Your 6 supports this legislation as it better empowers the VA 
to make decisions that best meet the clinical needs of veterans and 
reduces limitations to commonsense, and potentially lifesaving, use of 
eligible organ donors. However, we would encourage articulating more 
specific parameters around the VA's responsibility to provide care 
before and after the operation to non-veteran patients.
    That support stated, Got Your 6 is concerned this legislation is 
short-term solution to providing necessary care for non-veterans. This 
legislation amends the current Choice program, which will be replaced 
in the near future with a new non-VA care program. As the future of 
non-VA care is debated and finalized, this bill should serve as a 
reminder to include sufficient flexibility to provide care to non-
veterans when necessary to meet VA's responsibility, like treatments 
for live donor transplants or intro-fertilization.

H.R. 2123, Veterans E-Health and Telemedicine Support Act of 2017

    The Veterans E-Health and Telemedicine Support Act would expand 
existing authorities for VA providers to practice telemedicine.
    Got Your 6 supports the intent of the legislation and firmly 
supports the expansion of telemedicine capabilities at the VA as a 
innovative, commonsense solution to access and capacity issues for 
veterans seeking care at the VA. However, we would instead encourage 
the use of the proposed telemedicine expansion language presented in 
the draft proposal on the Veteran Coordinated Access and Rewarding 
Experiences (CARE) Act and its use of federal supremacy.
    We also encourage the VA, and this Committee, to use an expansion 
of telemedicine as an opportunity to validate the need for and efficacy 
of expanded telemedicine capabilities for the medical field nationwide. 
Historically, the VA has been a driver of medical innovation for the 
country as a whole, we believe telemedicine is an opportunity for the 
VA to show how innovation and technology can be used to solve national 
medical concerns.

H.R. 2601, Veterans Increased Choice for Transplanted Organs and 
    Recovery Act of 2017

    The Veterans Increased Choice for Transplanted Organs and Recovery 
Act would amend the current Choice program to allow veterans to use 
non-VA care for organ transplantation if the veteran resides more than 
100 miles from a VA transplant center.
    Got Your 6 supports the intent of the legislation based on the 
belief veterans should receive care that best clinically meets their 
needs when and where they need it, including care related to organ 
transplants. However, we do not support the continuation of arbitrary 
eligibility standards, like distance from a facility. Additionally, 
given the implementation date presented, October 1, 2018, being closely 
aligned with the potential implementation of a future non-VA care 
program we believe the intent of this legislation would be better 
served by being included in overall conversations around the future of 
non-VA care.

H.R. 3642, Military Sexual Assault Victims Empowerment Act

    The Military Sexual Assault Victims Empowerment Act would establish 
a pilot program for survivors of military sexual trauma (MST) to 
receive care at non-VA facilities.
    Got Your 6 supports the intent of this legislation--veterans should 
receive the care that best clinically meets their needs--but have 
concerns with specifics of the language. First, the extreme geographic 
limitations this legislation creates severely limits the VA's ability 
to clinically meet the needs of all MST survivors and is not reflective 
of the intent of the language presented on the future of non-VA care. 
Second, the legislation also prohibits the VA from limiting the choice 
of non-VA providers, which does not account for legitimate limitations 
on available providers due to any number of issues including providers 
choosing not to participate with VA contracted care or current 
reimbursement eligibility for programs and providers. Instead, Got Your 
6 would encourage the Committee and VA to include potential needs of 
all MST survivors in the framework and implementation of the future 
non-VA care program.
    In conclusion, Got Your 6--through our 42 direct-impact, non-profit 
partners who collectively represent three million veterans and their 
families, as well as through our efforts to empower and challenge 
veterans to lead when they return home--are a new voice which 
represents all veterans, of all generations, of all backgrounds. We put 
veterans first and challenge them not to think of themselves as broken, 
but as the leaders our country is desperately searching for. The 
veteran empowerment movement is young, but it is already the voice of 
millions of veterans looking to challenge the dominating narrative of 
veterans in America.
    We would like to thank this Committee for its leadership on 
veterans' issues and look forward to working together to empower all 
veterans.

                                 
                             HEALTH IT NOW
    October 23, 2017

    The Honorable Phil Roe
    Chairman, House Committee on Veterans' Affairs
    335 Cannon House Office Building
    Washington, DC 20515

    The Honorable Tim Walz
    Ranking Member, House Committee on Veterans' Affairs
    333 Cannon House Office Building
    Washington, DC 20515

    Dear Chairman Roe and Ranking Member Walz:

    Health IT Now appreciates the Committee's attention to the 
important issue of ensuring access to high quality care for our 
nation's veterans. We agree that breaking down barriers to the 
utilization and nationwide scaling of the Department of Veterans 
Affairs' (VA) telehealth program is a way to accomplish this.
    In order to ensure veterans have access to care when are where they 
need it, we have been strong supporter of the Veterans E-Health and 
Telemedicine Support (VETS) Act for a number of years. The statutory 
language included in the VETS Act, and reiterated in the recent 
proposed rule issued by the VA, reflects the good faith efforts of many 
stakeholders to ensure an important balance is reached that veterans 
have access to care and proper channels are maintained to ensure 
patient safety. That is why we have supported the VETS Act and the VA's 
proposed rule.
    We are concerned that the language included in the VA's proposed 
legislation, the Veteran Coordinated Access and Rewarding Experiences 
(CARE) Act, does not maintain this important balance. We urge the VA to 
remove Section 301 of their proposed legislation and for the Committee 
to advance the VETS Act instead. There is broad stakeholder support for 
the VETS Act, illustrated by the attached letter signed by over two 
dozen organizations.
    Thank you for your consideration and we look forward to working 
with you to pass the VETS Act.

    Sincerely,

    Joel White
    Executive Director

                                 
            IRAQ AND AFGHANISTAN VETERANS OF AMERICA (IAVA)
    Statement of Tom Porter
    Legislative Director

    Chairman Roe, Ranking Member Walz, and Members of the Committee:

    On behalf of Iraq and Afghanistan Veterans of America (IAVA) and 
our more than 400,000 members, thank you for the opportunity to share 
our views on the legislation and legislative proposals being discussed 
today. I will focus our testimony on the proposals on community care 
and Choice program and the draft to address the Veterans Crisis Line.

Community Care and Choice Programs

    The Veterans Choice, Accountability and Access Law of 2014, which 
was enacted in August 2014, was charged with providing a framework for 
designing the Veterans Health Administration (VHA) of the future. This 
legislation was introduced after the Phoenix VA scandal exposed similar 
problems with VA medical centers around the country. IAVA is proud of 
the work that we have done with our VSO partners, the VA, and Congress 
working to ensure that veterans have access to the timely and quality 
health care they deserve.
    Since the 2014 law was passed, IAVA's primary position on this 
issue has remained unchanged: Reforming VHA into a truly 21st century 
health care system will require significant coordination between VA, 
the Administration, Congress, VSO partners, and the veterans we all 
serve. This coordination must be done in a bipartisan, veteran-centric 
manner that understands transformative change requires resources. It 
must focus on a holistic view of the future of VA health care, 
addressing how to best support and improve VA facilities and care while 
supplementing with support from the community. It is only in this way 
that we can work towards a veterans health care system that provides 
timely access to high-quality and comprehensive care. We will also 
stand by our brothers and sisters in the VSO community, especially 
Paralyzed Veterans of America (PVA) and Disabled American Veterans 
(DAV), whose members will be most impacted by any changes.
    IAVA believes that in order for the VA community care programs, 
which includes Choice, to adequately assist in building this 21st 
century veterans healthcare system, certain components must be present 
in the next iteration of the Choice program. These components include a 
dynamic in which community providers are led by the VA primary care 
providers managing the veterans' care. Non-VA community care should be 
fully integrated to fill gaps and expand access, not displace VA.
    Such a model can be beneficial to both VA and community providers, 
mentoring community providers to develop a cultural competency for the 
injuries that veterans present with and providing support to the VA so 
it can ensure all veterans seeking care are accessing it in a timely 
manner. Of note, a 2014 RAND report found that most community-based 
mental health providers are not well prepared to take care of the 
special needs of military veterans and their families.
    Further, IAVA believes the 40-mile and 30-day standards are 
arbitrary access standards; Decisions about when and where veterans can 
receive medical treatment should be clinical between the veteran and 
his or her doctor.
    Overall, IAVA believes that the VA provides a model of care that is 
uniquely positioned to treat the physical, psychological, social and 
economic aspects of a veterans health. Such a model can benefit from 
the experience of the private sector, but cannot be replaced by the 
private sector as it is not positioned to replicate this unique model.
    Such sentiments are reflected in IAVA's membership. According to 
our most recent member survey, 54 percent of respondents oppose full 
privatization of the VA.
    Our latest member survey found that 82 percent of respondents are 
enrolled in VA health care. Ninety percent of those enrolled sought VA 
health care in the last year. Our members rely on VA health care, with 
28 percent using VA health care exclusively, and 38 percent using it in 
combination with other health care.
    While IAVA is supportive of improving the Choice Program, IAVA 
members have given the program very mixed reviews. Only 20 percent of 
IAVA member respondents have actually used the program. Of those that 
have used the program, 37 percent rated the Choice program as ``above 
average'' or ``excellent,'' while a concerning 28 percent rated it as 
``below average'' or ``poor.''
    As more veterans transition from active duty and as we face the 
challenges of physical and mental injuries, we need to be assured that 
a first-rate system of care is in place.
    IAVA appreciates the work that the House Veterans Affairs Committee 
(HVAC) has invested in the interest of improving the VA Choice Act 
through the draft legislation ``to establish a permanent Veterans 
Choice Program,'' as well as the VA's work on its draft proposal, the 
``Veteran Coordinated Access and Rewarding Experiences (CARE) Act.'' 
These proposals are good starting points toward strengthening and 
consolidating the VA's community care programs and improving veterans' 
access to the care they deserve. While more work is still needed on 
these proposals, IAVA is encouraged by the directions that leaders 
within Congress and the VA have taken.
    We are encouraged that both measures would end the arbitrary 30/40 
rule for veterans' eligibility for access to community care programs. 
Any final legislation must ensure the veteran has timely access to 
quality care either within or outside the VA as a result of a decision 
made between the veteran and his or her VA primary care physician.
    Also significant in both proposals is the consolidation of the 
various community care programs into one, which eliminates many 
confusing layers of duplicative bureaucracy, which have sown confusion 
amongst the veteran population.
    We appreciate that both measures establish a standardized claims 
process and system of payments to ensure the VA remains on sound 
financial footing with its health care providers. However, If a 
provider finds it too difficult to do business with the VA and they 
discontinue that relationship because of those problems, veterans lose 
access to care. IAVA is concerned that with the VA now facing 
challenges of paying claims in a timely fashion, how will the 
Department keep to new stringent deadlines under the legislation of 30 
or 45 days, depending on the method of submission?
    Another key omission is how the VA will meet new technological and 
infrastructure needs to make these aggressive changes and enhance 
access to care. These needs should be significant, so we will look 
forward to seeing how the legislation addresses these needs as it 
progresses.
    While the HVAC draft has no mention of how the new measures will be 
funded, the VA draft would round down cost-of living adjustments (COLA) 
a misguided provision that IAVA has stood with other VSOs to strongly 
oppose. We encourage the VA and Congress to look for better ways to 
fund VA benefits instead of reducing disability payments for those 
veterans most in need.
    The VA must also take concrete and aggressive steps to focus more 
on the needs of our increasing population of women veterans, including 
supporting and implementing provisions in the Deborah Sampson Act (H.R. 
2452) championed by IAVA and 16 of our fellow VSOs. Our 
#SheWhoBorneTheBattle legislative, media, and grassroots campaign 
champions this legislation to update VA programs and services and urges 
the change of its motto to be gender inclusive.
    IAVA realizes that consolidating and improving the VA community 
care and Choice programs is a challenge, and that these draft measures 
represent only the beginning of this process, but working together we 
can strengthen the VA in order to provide the highest quality care for 
veterans. IAVA looks forward to continuing to work alongside this 
committee, Secretary Shulkin and our VSO partners to evaluate and 
implement changes necessary to best achieve this goal.

Veterans Crisis Line Study

    IAVA has partnered with the Veterans Crisis Line since 2012 to both 
ensure our members are aware of the critical services the Crisis Line 
offers, as well as to provide crisis support to clients who are seeking 
support from IAVA's Rapid Response Referral Program (RRRP). IAVA 
recognizes the life-saving services the VCL offers every day, and our 
RRRP program has referred nearly 200 clients to the VCL to date. It is 
a vital resource for our community, and we are committed to ensuring 
that it continues to fulfill its mission to provide 24/7, world class, 
suicide prevention and crisis intervention services to veterans, 
service members, and their family members.
    IAVA supports the intent of the draft legislation ``To direct the 
Secretary of Veterans Affairs to conduct a study on the Veterans Crisis 
Line.'' VCL and programs like it must strive to collect data to 
continually assess and improve their impact. IAVA has been concerned 
that this is not happening to the extent that it can be. Section 2 of 
the Clay Hunt SAV Act, requiring a third party independent evaluation 
of VA mental health and suicide prevention programs, is intended to 
address this very concern. This legislation adds a level of specificity 
to such an assessment, prescribing specific data to analyze. However, 
the VCL has an added challenge in its self-assessments in that it must 
first and foremost preserve the anonymity of its callers while also 
assessing its impact. Thus, it is IAVA's belief that any legislation 
requiring VCL to record and report out data on its activity also ensure 
that the anonymous nature of the VCL is not compromised.
    While we agree with the intent of this legislation, we believe that 
it might be too prescriptive in nature and could have unintended 
consequences. We also strongly believe that any legislation requiring 
further assessment of the VCL should involve a collaborative effort 
between VA, Congress, the VSO community, and researchers and focus not 
only on past data, but more importantly chart out how best to assess 
VCL in the future.
    Again, IAVA appreciates the opportunity to express our views to 
this committee.

                                 
            MILITARY OFFICERS ASSOCIATION OF AMERICA (MOAA)
    CHAIRMAN ROE, RANKING MEMBER WALZ, and Members of the Committee, 
the Military Officers Association of America (MOAA) is pleased to 
present its views on pending legislation under consideration by the 
Committee.
    MOAA does not receive any grants or contracts from the federal 
government.
                           EXECUTIVE SUMMARY
    On behalf of the Military Officers Association of America, the 
largest military service organization representing the seven uniformed 
services, including active duty and Guard and Reserve members, 
retirees, veterans, and survivors and their families, MOAA thanks the 
committee for holding this very important hearing and for your 
continued support of our nation's servicemembers and veterans and their 
families.
    MOAA offers our position on the following bills. MOAA takes no 
position on the remaining bills before the committee, as some are 
outside our scope of expertise.

      Draft legislation to establish a permanent Veterans 
Choice Program
      Veteran Coordinated Access and Rewarding Experiences 
(CARE) Act

                               DISCUSSION
    Draft legislation to establish a permanent Veterans Choice Program-
MOAA strongly supports consolidating all six of the VA's community care 
programs into one, as recommended in the June 30, 2016, independent 
Commission on Care report. This bill will accomplish that and prevent a 
confusing set of rules unique to each individual program, as well as 
provide the VA more flexibility in providing care.
    MOAA also supports creating a more formalized network for 
community-based health care professions to become accustomed to working 
with veterans and their unique needs, as well as increasing 
partnerships with community clinics and hospitals. It is vital, 
however, that Congress maintain a strong oversight to ensure the VA 
retains existing special-emphasis resources and specialty care 
expertise such as spinal cord injury, blind rehabilitation, mental 
health, prosthetics, and similar foundational services. To date, the VA 
has not shared a list of expertise and resources it intends to retain, 
nor has it shared a methodology for how it will make such 
determinations in the future. It also has not shared the methodology it 
intends to use to perform the market assessments required in this bill. 
Transparency in this regard is essential to determining whether the 
permanent program will serve veterans' health care needs adequately.
    MOAA offers the following legislative considerations to ensure the 
intended effect is achieved.

      Assignment of a patient-aligned care team or dedicated 
primary care provider should be made only after the VA determines a 
patient will actually be utilizing VHA services. As written, the draft 
legislation mandates that upon enrollment a dedicated primary care 
provider will be assigned. A Congressional Research Service report 
found in 2014 there were 9.1 million veterans enrolled in the VHA, 
while only 5.9 million veterans were patients within the VHA system 
\1\. Assigning primary care providers to veterans who are not utilizing 
the VHA to receive medical care would be inefficient and wasteful.
---------------------------------------------------------------------------
    \1\ Congressional Research Service, ``The Number of Veterans That 
Use VA Health Care Services: A Fact Sheet,'' June 3, 2014.
---------------------------------------------------------------------------
      The draft legislation sets forth three ways a veteran may 
receive medical services, depending upon clinical determinations: at a 
VA medical facility, by a regional network provider, or pursuant to a 
provider agreement. The language contained in the legislation 
pertaining to provider agreements is very broad and has few 
restrictions. The VA should only be able to enter into direct provider 
agreements for services not already covered by regional network 
providers or in locations where regional gaps exist. Duplicating a 
regional network with provider agreements may prove to be inefficient 
and could undermine the existing networks, confuse providers, and 
result in claims being sent to the wrong payer.
      All community providers should be required to meet some 
standards regarding scheduling, payment rates, and care provided. 
Absent such standards establishing reasonable performance expectations, 
the VA will be left attempting to enforce compliance without adequate 
legal authorities.
      Given the broad eligibility criteria, there is 
significant potential veterans will either become confused with the 
requirements or disagree with the determinations made by the VA. An 
appeals process must be included in the statutory language to establish 
a clear, fair, and expeditious process for veterans to dispute the VA's 
determination that they should or should not use care in the community.
      Language should be added to the legislation providing for 
service-connected disability compensation as a result of injuries 
incurred or aggravated by medical care by a community care provider, as 
set forth in 38 U.S.C. Sec.  1151. Absent such a provision, veterans 
will be required to pursue recovery through the civil court system. 
Aside from the onerous burden civil legal action places on an 
individual, including retaining an attorney, years of litigation, and 
steep legal fees (some estimates place them at $30,000-$50,000 for a 
basic case and $100,000 for a complex case), veterans would be 
subjected to any number of additional legal hurdles. Some of these 
include capped recovery amounts due to tort reform legislation and 
potential mandatory arbitration if a health care provider requires it 
as a condition of rendering care. While the draft legislation leaves 
open the option a veteran may reject care in the community and choose 
to instead to be treated at a VHA facility, this places the veteran in 
the position of potentially not receiving timely care in exchange for 
preserving a legal right a decision that could have life-or-death 
implications, and a position in which a veteran should never be placed.

    Veteran Coordinated Access and Rewarding Experiences (CARE) Act-
MOAA reiterates all of the above-stated concerns, as they are relevant 
to this draft legislation as well. In addition, the following 
recommendations are offered.

      Walk-in Care Copayments: The draft legislation states if 
any eligible veteran utilizes walk-in care, the veteran must pay a 
copayment for those services. It does not differentiate between care 
sought for service-connected disabilities and non-service-connected 
disabilities. When a veteran seeks care at VHA facilities for a 
service-connected disability, there is no fee associated with that 
care. The same standards should be applied for care received in the 
community. Although the draft allows the Secretary to adjust those 
copayments based on a veteran's priority group, there is no assurance 
veterans seeking medical care for service-connected disabilities will 
not be required to pay. The legislation should make clear that veterans 
are not required to pay a copayment for any care received in a walk-in 
clinic for a service-connected disability. Because this co-payment 
exclusion would apply only to service-connected disabilities, and 
because walk-in care services are extremely limited in their type and 
scope, the potential that a veteran will overuse a walk-in clinic 
versus seeking primary care for a service-connected disability is very 
low.
      Round-down of certain cost-of-living adjustments: While a 
round-down of cost-of-living adjustments for veterans benefits will not 
have a devastating financial impact on any individual veteran, the 
effects are cumulative and over a period of several years could yield 
significant reductions. The legislation as drafted provides that the 
round down would apply for 10 years (2018 through 2027) but no 
alternative funding source for these changes is apparent and the round-
down will more than likely be extended for several 10 year periods 
thereafter leading to a lifetime of reduced benefits for veterans. Such 
a round down could lead to approximately $2,000 of lost benefits over 
the lifetime of a disabled veteran. It is unsettling that this 
reduction in benefits is proposed in the same bill that rescinds 
limitations on awards and bonuses paid to VA employees. This creates 
the appearance that cuts to veterans' benefits are being used to fund 
bonuses to VA employees. MOAA encourages the VA to continue, in 
earnest, all other potential funding options rather than to reduce 
veterans' benefits to pay for their own or other veterans' health care 
and VA employee bonuses.

    MOAA thanks the committee for considering this important 
legislation and for your continued support of our veterans and their 
families.

                                 
                   MILITARY ORDER OF THE PURPLE HEART
    SUBMITTED BY
    ALEKS MOROSKY
    NATIONAL LEGISLATIVE DIRECTOR

    Chairman Roe, Ranking Member Walz, and Members of the Committee, on 
behalf of the Military Order of the Purple Heart (MOPH), whose 
membership is comprised entirely of combat wounded veterans, I thank 
you for inviting us to offer our views on today's pending legislation. 
The bills being discussed today deal with the future of the Veterans 
Choice Program, as well as several other important issues dealing with 
veterans' access to the health care that they have earned through their 
service, and we thank the Committee for bringing them forward.

Draft legislation, to establish a permanent VA Care in the Community 
    Program, and for other purposes

    MOPH strongly believes that veterans must have access to high 
quality health care that is timely, and within reasonable distances, in 
every instance. Since Department of Veterans Affairs (VA) facilities 
cannot always offer care to every veteran when and where they need it, 
it is critical that seamless, well-coordinated community care is 
available when necessary. Still, community care must be seen as a 
supplement to care provided at VA facilities; not a replacement. The 
necessity for a community care program must be balanced with the desire 
of many veterans who wish to continue to receive most, if not all, of 
their care at VA.
    For the past three years, that balance has been primarily achieved 
by the Veterans Choice Program. While imperfect in many ways, the 
Choice Program was generally successful in easing the well-documented 
access problems from which VA suffered prior to its inception. Now, as 
the Choice Program nears its expiration, a permanent VA community care 
program must be authorized, so that veterans who currently receive care 
in the community under Choice do not experience any gaps in care. This 
creates an opportunity to improve upon the Choice program, and this 
draft legislation does so in many ways. MOPH supports the vast majority 
of the bill, and appreciates the urgency and thoughtfulness with which 
the Committee is addressing this important issue.
    Of all the changes to the Choice Program envisioned by this bill, 
the one that would undoubtedly be most apparent to veterans is the 
elimination of the current 30-day/40-mile rule. Under the current 
program, veterans are only authorized to receive care in the community 
if it is determined that VA cannot provide an appointment within 30 
days, or the veteran lives more than 40 miles from a VA facility. These 
standards are not only arbitrary; they often exclude certain veterans 
who would benefit from care in the community. This includes veterans 
who need an appointment in less than 30 days, and veterans who are 
unable to travel 40 miles due to their disabilities or other reasons. 
This legislation would do away with the 30-day/40-mile eligibility 
requirement, in favor of a clinical determination made by VA, in 
consultation with the veteran and their provider. With the 
understanding that VA would be required to remain the coordinator of 
all community care, MOPH strongly supports this change.
    MOPH is pleased that the bill would require that only active users 
of VA health care, as opposed to all enrollees, will be assigned to 
either patient-aligned care teams (PACT) of the Department or primary 
care providers (PCP) in the community. This will prevent PACTs from 
being filled with enrollees who do not regularly use VA care, thus 
giving an accurate measure of capacity within VA when determining 
whether assignment to a community PCP is necessary.
    We also support the provision of this bill that would allow the 
Secretary to exempt certain specialty care services from the primary 
care referral requirement. While we agree that specialty care ought to 
be granted based on PCP referrals in general, we believe this 
flexibility will allow veterans to continue to engage in direct 
scheduling for specialties that are appropriate, such as optometry and 
audiology, as they do now.
    Other provision of the draft bill we support include the 
establishment of an appeal process for veterans who are not authorized 
community care but wish to be, prompt payment standards for community 
providers, annual capacity and commercial market assessments of each VA 
facility and Service Network, improvements to provider agreements, and 
the consolidation of existing community care programs into a single 
authority. All of these provisions would help to streamline the way VA 
provides care.
    However, MOPH must oppose section 203 which would eliminate 
copayment offsets for veterans who carry other health insurance. 
Currently, when VA bills a veteran's health insurance for certain 
episodes of care, part of the money collected is used to offset any 
copayment for which the veteran would otherwise have been responsible. 
This policy incentivizes veterans to both share their insurance 
information with VA, and continue to carry other health insurance even 
if they receive most of their care at VA facilities. While we 
understand that the improvements contained in this bill will require 
additional funding, we do not believe that veterans should have to 
personally bear that burden with new out-of-pocket expenses. MOPH 
strongly urges the Committee to amend the bill to strike this 
provision.

VA legislative proposal, the Veteran Coordinated Access and Rewarding 
    Experiences (CARE) Act

    MOPH appreciates VA's efforts in drafting its own bill to address 
the future of community care. This proposed legislation contains many 
provisions similar to those in the Committee's bill, but also has 
several key differences. We will primarily focus our comments on those 
provisions of the Care Act to that differ considerably from the 
Committee's draft bill.
    Like the Committee's bill, the Care Act eliminates the 30-day/40-
mile rule in favor of clinical determinations, which MOPH strongly 
supports. In those cases where such a determination would be made, we 
appreciate the concise nature of the text that reads, ``The decision to 
receive such care or services from a non-Department entity or 
provider.shall be at the election of the veteran.''
    However, the Care Act establishes an additional eligibility 
trigger, whereby veterans would be referred to community care if the VA 
facility where they are enrolled does not meet quality or access 
standards, which are yet to be determined. While we generally agree 
with the principle that veterans should not be offered substandard care 
as the only option, we would like greater clarity on what those quality 
and access standards would be before offering our support for this 
provision. Furthermore, we strongly believe that known deficiencies at 
any VA facility should be corrected with the highest priority, and that 
community care should not be viewed as a substitute for remediation.
    MOPH strongly supports the provision of the CARE Act that proposes 
establishing a walk-in community care benefit for active enrollees. We 
believe this would greatly improve convenience and health outcomes for 
veterans suffering from acute illnesses that do not require emergency 
room care. However, we would like the text to be amended to explicitly 
state that copays for walk-in care would be at the same rate as current 
VA copay amounts, rather than leaving those amounts to be determined by 
regulation.
    We further support provisions unique to the CARE Act that would 
expand telehealth authorities, increase the number of graduate medical 
education residencies, provide reimbursement for continuing 
professional education requirements for advanced practice registered 
nurses, and improve collaboration with federal partners.
    However, MOPH strongly opposes the provision of the CARE Act that 
would eliminate copayment offsets for veterans who carry other health 
insurance for reasons previously stated. Likewise, we vigorously oppose 
the provision that would attempt to generate offsets for community care 
by rounding down annual cost-of-living adjustments for veterans' and 
survivors' benefits. Veterans and their families rely on these modest 
increases to ensure their benefits keep pace with inflation. Their 
payment rates should not be diminished in order to ensure that veterans 
receive the high quality care to which they are already entitled. MOPH 
opposes the inclusion of either of these provisions in any future 
drafts of VA community care legislation.
    MOPH does support the provision that would place reasonable caps on 
the amounts that flight schools may charge under the Post-9/11 GI Bill, 
closing a loophole in current law.

H.R. 1133, the Veterans Transplant Coverage Act of 2017

    MOPH supports this legislation, which would authorize VA to provide 
eligible veterans with organ transplants from live donors, in a VA 
facility or a non-Department facility under the Veterans Choice Program 
or a successor program, regardless of whether the donor is eligible for 
VA health care. VA would provide the donor with any care before and 
after the transplant that may be required as a result of the procedure, 
regardless of the donor's eligibility status.
    Organ transplants are often life-saving operations. When a 
transplant from a live donor is a viable option, such as in the case of 
a kidney transplant, and a volunteer donor is identified, MOPH strongly 
believes that veterans should receive the transplants they need as 
quickly as possible. We wholeheartedly support this bill, which would 
remove current barriers to that process.

H.R. 2123, the Veterans E-Health and Telemedicine Support (VETS) Act of 
    2017

    MOPH strongly supports this legislation, which would codify VA's 
authority to provide telemedicine across state lines. Currently, both 
the veteran and the VA provider must be physically located in a federal 
facility in order to conduct telehealth appointments. This legislation 
would eliminate that barrier, allowing veterans to get the telehealth 
care they need at their homes, workplaces, and other locations that are 
convenient for them. This would be particularly helpful for veterans 
who are homebound or live in highly rural areas. This legislation will 
allow VA to continue to expand its growing telehealth initiatives, 
leading to shorter wait times and greater access for all veterans.

H.R. 2601, the Veterans Increased Choice for Transplanted Organs and 
    Recovery (VICTOR) Act of 2017

    MOPH supports this bill's intent, which is to grant veterans with 
greater access to organ transplants through the Veterans Choice 
Program. As previously stated, organ transplants are often life-saving 
procedures, and should be provided as quickly as possible in all cases. 
However, we oppose the provision of this bill that would limit 
eligibility for non-VA transplants to veterans who live more than 100 
miles from a VA transplant center. MOPH believes that the current 40-
mile rule of the Veterans Choice Program is arbitrary and disqualifies 
many veterans who would benefit from care in the community. Likewise, 
we will not support attaching additional arbitrary distance 
requirements to any expansion of community care. If the 100-mile 
requirement were to be replaced with a provision determining 
eligibility based on clinical need, MOPH would fully support this 
legislation.

H.R. 3642, the Military Sexual Assault Victims Empowerment (SAVE) Act

    MOPH supports the spirit of this legislation, which would establish 
a pilot program to allow Military Sexual Trauma (MST) victims to 
receive care in the community if they so choose, without the current 
30-day/40-mile restrictions of the Veterans Choice Program. Such 
restrictions are arbitrary and often wrongfully exclusive for veterans 
seeking care for any reason. Furthermore, victims of MST have unique 
needs, and it is important to their recovery that they are able to 
receive care in an environment in which they are comfortable.
    However, MOPH could only fully support this bill if it were amended 
to more explicitly state that VA would remain the coordinator of care 
for the program. Additionally, VA should be granted the resources to 
continue to improve care and services for MST survivors at VA 
facilities. While we appreciate this bill's intent, and would be most 
interested in the findings of the report it requires, MOPH certainly 
would not want the program it proposes to relieve VA of its 
responsibilities to coordinate care for the veterans who participate in 
the pilot, or be seen as a replacement for high quality MST treatment 
options within VA, in any instance.

Draft legislation, to direct the Secretary of Veterans Affairs to 
    conduct a study on the Veterans Crisis Line

    Although we appreciate the intent of this legislation to determine, 
and potentially identify ways to improve, the efficacy of the Veterans 
Crisis Line (VCL), MOPH must oppose it. The required study would 
contain multiple data points, to include whether or not veterans who 
contact the VCL are already receiving VA mental health care at the time 
of the call, whether they begin and continue to receive VA care 
following the call, and whether or not they eventually die by suicide. 
While this data may be useful in theory, gathering it would require VCL 
responders to collect personally identifiable information from veterans 
in crisis during the call. This would not only run the risk of 
disrupting a suicide intervention in progress, it may steer veterans 
who wish to remain anonymous away from calling the VCL in the first 
place. While MOPH supports continued improvement to the VCL, we do not 
believe this bill offers the correct approach to achieve that goal.

Draft legislation, to amend title 38, United States Code, to modify the 
    authority of the Secretary of Veterans Affairs to enter into 
    agreements with State homes to provide nursing home care to 
    veterans, to direct the Secretary to carry out a program to 
    increase the number of graduate medical education residency 
    positions of the Department of Veterans Affairs, and for other 
    purposes.

    MOPH supports this legislation, which would provide VA with greater 
flexibility when entering into agreements with State Veterans Homes, 
and create a program to fill graduate medical education residency 
positions within VA. Under this program, medical students would receive 
financial assistance with their education, in exchange for a period of 
obligated service as full-time VA employees, as determined by the 
Secretary.
    The ability of VA to meet veterans' demand for medical care is 
contingent on its ability to continuously recruit medical 
professionals. Accordingly, VA must have the programs and funding in 
place to attract those employees. This bill would assist in 
accomplishing that goal.
    Similar to H.R. 2123, this bill would also authorize VA medical 
professionals to provide telehealth services to veterans across state 
lines, irrespective of whether the veteran or the provider are 
physically located in a federally-owned facility. MOPH fully supports 
this provision.
    Chairman Roe, Ranking Member Walz, this concludes my statement. 
Once again, I thank you for inviting me to submit our views, and I 
would be happy to answer any questions for the record that you or any 
other Members of the Committee may have.

Disclosure of Federal Grants and Contracts:

    The Military Order of the Purple Heart (MILITARY ORDER OF THE 
PURPLE HEART) does not currently receive, nor has MILITARY ORDER OF THE 
PURPLE HEART ever received any federal money for grants or contracts 
other than the routine allocation of office space and associated 
resources at government facilities for outreach and direct veteran 
assistance services through its Department of Veterans' Affairs 
accredited National Service Officer Program.

                                 
             The National Alliance on Mental Illness (NAMI)
    Submitted by:
    Emily Blair
    Manager-Military, Veterans & Policy

    Chairman Roe, Ranking Member Walz, and distinguished members of the 
Committee, thank you for affording NAMI, the National Alliance on 
Mental Illness, the opportunity to submit a statement for the record on 
the Committee's draft legislation to establish a permanent Veterans 
Choice Program and the Department of Veterans Affairs' (VA's) 
legislative proposal, the Veteran Coordinated Access and Rewarding 
Experiences (CARE) Act.
    NAMI is the nation's largest grassroots mental health organization, 
dedicated to building better lives for the millions of Americans 
affected by mental illness. NAMI has over 900 affiliates and more than 
200,000 grassroots leaders and advocates across the United States-all 
committed to raising awareness and building a community of hope for all 
of those in need, including our men and women in uniform, veterans, and 
military families.

Veterans Choice Pilot Program

    NAMI applauds Congress, and this Committee specifically, for 
working swiftly and in a bi-partisan way to implement the original 
Veterans Choice Program legislation. Veterans were not receiving the 
timely access to care that America had promised, and Congress worked 
expeditiously to draft a policy framework with the intent of creating 
an unmatched system of care. However, there are many lessons learned 
from the initial three-year Choice pilot program, which presents 
opportunities for us to work together to develop improvements for a 
permanent solution.
    While increased access should continue to be at the forefront of 
this discussion, NAMI remains concerned about ensuring high-quality of 
care standards for mental health care and substance use treatment 
delivered within the walls of VA and through Choice providers in the 
community. Additionally, the need for providers to have a satisfactory 
level of military cultural competency is crucial, especially when 
delivering mental health care services. If a clinician doesn't 
establish a positive rapport with a veteran from the initial 
interaction, or a veteran feels judged by his or her military 
experiences-we know this often leads to disengaging in treatment. VA 
must work to ensure this key need is met among all VA and contracted 
community clinicians.

Draft Legislation to establish a permanent Veterans Choice Program

Title I-Improved Access to Care in the Community

    Sec. 101. Establishment of Veterans Choice Program.

    NAMI agrees that giving the Secretary authority to establish 
regional networks of providers in Veterans Integrated Service Networks 
(VISNs) and enter into contractual agreements for the operation of 
these networks, is a positive step to increase capacity and access to 
care. The establishment of provider networks would also enable a built-
in quality measurement tool to ensure all providers participating in 
the Choice Program meet a satisfactory level of care and cultural 
competency.
    Additionally, after regional provider networks are established, it 
could create an opportunity for VA to implement a tiered system and 
develop incentives, such as the policy outlined in the draft 
legislation-charging the Secretary to utilize value-based reimbursement 
models for providers, in order to better meet the specific health care 
needs of veterans. NAMI suggests the insertion of legislative language 
in the final bill which would require providers to utilize only 
evidence-based therapies for treating post-traumatic stress disorder 
(PTSD) and other mental health conditions as a stipulation for 
reimbursement. This will ensure veterans have access to the best 
treatments, VA is spending Choice program dollars wisely and will begin 
to make a concerted effort at the reduction of suicides among veterans.
    While we understand the positive intent, NAMI strongly disagrees 
with the proposal which would restrict the Secretary in providing 
specialty hospital care or medical services, to include mental health 
care and substance use treatment, unless a referral for these specific 
services is made by the veteran's primary care provider. Research shows 
that requiring a referral from a primary care provider only acts as a 
barrier to care. Concerning behavioral health care specifically, we 
know that referral patterns illustrate a high number of drop-offs, 
often resulting in a lack of treatment for the veterans who need this 
care the most. It is imperative to meet the veteran when he or she has 
a need for mental health care and develop a system of care which allows 
veterans to seek a consultation and treatment without navigating an 
often-burdensome referral process.
    NAMI does agree that primary care providers have an integral role 
in behavioral health care, however would suggest a slightly different 
approach. Recognizing that earlier intervention and treatment produces 
better mental health outcomes, coupled with the provider shortage in 
the behavioral health care field at VA and across America-utilizing 
primary care providers is necessary. Instead of involving PCPs in the 
referral process, NAMI suggests VA move towards broad integration of 
mental health care services in the primary care setting. This could be 
achieved by providing additional training to PCPs within the Department 
and in the regional provider networks by the adoption and wide 
dissemination of a pilot program developed by Dr. Sheila A.M. Rauch, 
PhD, a clinical psychologist at the Atlanta VA Medical Center (VAMC).
    Dr. Rauch's program provides training for PCPs to 1) properly 
administer a PTSD screening tool to veterans, and 2) deliver 6 sessions 
of Prolonged Exposure (PE) Therapy, an evidence-based treatment for 
PTSD, to veterans in the primary care setting. Her data illustrates a 
significant drop in veterans screening positive for PTSD after 
receiving this treatment. In the case a veteran still screens positive 
for PTSD after receiving this treatment, the model had a mechanism in 
place for a direct referral to a mental health provider to assess and 
deliver more intensive sessions of Cognitive Behavioral Therapy (CBT).

VA's Legislative Proposal: The Veteran Coordinated Access and Rewarding 
    Experiences (CARE) Act

Title I-Developing an Integrated High-Performance Network

    Sec.101. Improving VA's Partnerships with Community Entities and 
Providers to Increase Access to Care Through Veterans Care Agreements

    Although VA's proposal utilizes a different approach than the 
Committee's, NAMI sees benefits and disadvantages to each proposal. 
Authorizing the Secretary to increase access through Veterans Care 
Agreements-instead of creating regional provider networks-could be a 
way in which VA could contract to purchase reliable, high-quality care. 
However, NAMI believes in this case it would be too restrictive for 
providing increased access to care. NAMI underscores the importance of 
only entering into contractual agreements and reimbursing providers, 
community-based clinics and networks that utilize evidence-based 
therapies.

Title II-Streamlining Community Care Programs and Eligibility

    Sec. 201-221. Subtitles A, B, C

    NAMI agrees for the need to improve flexibility in the Choice Fund 
and to consolidate all existing Community Care programs and authorities 
into one program with a single set of eligibility criteria. One of the 
primary complaints NAMI receives from veterans on the current programs 
for accessing care outside of the walls of VA-including Choice, 
Community Care and Patient-Centered Community Care (PC3)-is the 
confusion regarding the eligibility and set of restrictions each 
program contains. Combining all of these programs for accessing care 
through community providers into one, streamlined program will make 
great strides in mitigating confusion and will expedite getting 
veterans into the care they need.

Rural Veterans

    The Committee's discussion draft and VA's legislative proposal 
(CARE) each contain a section on giving the Secretary increased 
authority to negotiate a higher rate with providers, health care 
clinics or networks, and hospitals who serve eligible veterans residing 
in ``highly rural areas.'' The definition that is used in each proposal 
would define the term ``highly rural area'' as a specific area in a 
county that has fewer than seven individuals per square mile in 
residence. NAMI believes this definition and criteria set-forth is much 
too specific for many reasons; the primary reason is illustrated by 
VA's recently released state-by-state report on the suicide rate among 
U.S. veterans utilizing 2014 as a sample year. \1\
---------------------------------------------------------------------------
    \1\ Suicide Among Veterans and Other Americans, 2001-2014: Suicide 
Data by State. VA Office of Suicide Prevention. https://
www.mentalhealth.va.gov/docs/data-sheets/Suicide-Data-Sheets-VA-
States.pdf
---------------------------------------------------------------------------
    Observing the top 10 rural states by population in the U.S., the 
suicide rate among veterans ranges between 45.7% (45 per 100,000) to 
68.6% (68 per 100,000). Five of the 10 rural states reporting rates of 
veteran suicide over 50% (50 per 100,000). NAMI would encourage the 
Committee and VA to expand their definitions of rural veterans to 
simply ``rural areas and states.'' In many rural areas and states, 
there are very few mental health professionals for hundreds of miles. 
Using Montana as a specific example due to the state currently having 
the highest rate of veteran suicides in the country, when examining the 
state's most recent Suicide Mortality Review Report illustrated that 
over half of Montana's veteran suicides during the reporting period, 
occurred in Montana's six most populous counties. \2\ VA and Congress 
needs to ensure all rural veterans are able to receive timely access to 
high-quality mental health care.
---------------------------------------------------------------------------
    \2\ 2016 Montana Suicide Mortality Review Report. Page 49. http://
www.sprc.org/sites/default/files/resource-program/
2016%20Montana%20Suicide%20Mortality%20Review%20Report.pdf
---------------------------------------------------------------------------
    Another solution to serve veterans in rural states that NAMI 
proposes is for VA to increase their utilization of telemedicine and 
telepsychiatry. Further, NAMI is supportive of H.R.2123, the Veterans 
E-Health and Telemedicine Support Act of 2017 or the VETS Act of 2017. 
We believe this legislation will allow for an increase in high-quality 
mental health providers to deliver care to veterans in rural settings.

Addressing the unmet Suicide Prevention needs of America's Veterans

    In developing a permanent Veterans Choice/CARE Program, it was 
NAMI's desire to see specific language outlined in each proposal 
regarding the suicide prevention needs of America's veterans that are 
currently not being met. Recognizing that only 6 of the 20 veterans who 
die by suicide each day are under the care of VA, \3\ it is clear that 
while the Department provides excellent mental health care in most 
cases, VA cannot go it alone.
---------------------------------------------------------------------------
    \3\ Suicide Among Veterans and Other Americans, 2001-2014. VA 
Office of Suicide Prevention. https://www.mentalhealth.va.gov/docs/
2016suicidedatareport.pdf
---------------------------------------------------------------------------
    VA and Congress must work together with non-profit and advocacy 
organization partners to 1) better identify the predictive indicators 
and characteristics of the approximately 14 veterans not engaged in VA 
care, 2) recognize and detect the gaps in care which currently exist 
and 3) give the Secretary express guidance and authority to use 
existing VA Choice funds to contract with community and non-profit 
mental health networks and clinics to provide expedited access to 
evidence-based mental health care services. The Secretary should be 
provided with guidance to expedite the credentialing process for these 
community-based clinics to ensure they are delivering evidence-based 
therapies with same-day access to care, and can demonstrate effective 
clinical outcomes in the veterans they serve.

Conclusion

    NAMI is grateful to Secretary Shulkin, Congress and this Committee 
for the continued focus on improving the access and quality of mental 
health care and substance use treatment for America's veterans. We wish 
to express our gratitude to the Committee for the invitation to submit 
a statement for the record to provide feedback on these legislative 
proposals, and the opportunity to weigh-in on the future of the 
Veterans Choice Program-an incredibly important program to veterans 
with mental health care needs.
    It is a devastating tragedy that our nation continues to lose an 
average of 20 veterans each day to suicide. This is an issue of 
personal importance to me, the organization I represent and our 
membership. We continue to commit our organization to working shoulder-
to-shoulder with Congress, VA, and our Veterans Service Organization 
(VSO) partners to achieve our shared goal of the reduction and 
elimination of suicide among veterans in America.

                                 
        NATIONAL GUARD ASSOCIATION OF THE UNITED STATES (NGAUS)
    Dear Chairman Roe, Ranking Member Walz, and other distinguished 
members of the House Veterans' Affairs Committee:

Introduction:

    On behalf of the over 45,000 members of the National Guard 
Association of the United States (NGAUS) and the nearly 500,000 
soldiers and airmen of the National Guard, we deeply appreciate this 
opportunity to share with you our thoughts on the legislation designed 
to reform the Veterans Choice Program for the record. We also thank you 
for your continued oversight to ensure accountability and improve 
Department of Veterans Affairs (VA) services to veterans and their 
families.
    Since our inception in 1878, NGAUS has sought to ensure benefit 
eligibility and equity for the men and women of the National Guard. We 
are grateful for this Committee's work earlier this year in passing the 
Harry W. Colmery Veterans Educational Assistance Act, which was the 
most significant expansion of G.I. Bill benefits since the passage of 
the Post-9/11 G.I. Bill in 2008. Not only did that vitally important 
bill expand eligibility and increase educational benefits for all 
servicemembers, it also corrected a serious benefit inequity and 
provided access to educational assistance for Guardsmen and Reservists 
who serve under U.S.C. Title 10, Section 12304(a) and 12304(b) orders. 
With this legislation to reform the Veterans Choice Program, you have 
again proposed much needed changes to increase benefits equity and 
access to health care for our veterans of the National Guard.

Veteran Eligibility:

    We greatly appreciate the opportunity to share our thoughts with 
you on your bipartisan effort to ensure the stability of the Veterans 
Choice Program for our veterans and their families. Currently, the 
program provides eligible veterans access to care through a 
comprehensive network of community-based providers and augments VA's 
ability to provide specialty inpatient and outpatient health care 
services to veterans. This access is critical for veterans who face 
wait times longer than 30 days for medical and mental health care or 
for whom a regular VA medical center is inaccessible. As you know, 
National Guard veterans face unique challenges in obtaining access to 
health care because, unlike the Active Component, access to health care 
is dependent on duty status and geographic location. Due to this 
Committee's collaborative efforts, we believe this legislation will 
mitigate those factors and continue to build upon the successful VA-
centric model of increasing access to health care for our veterans.
    We support the proposed provisions that permanently establish the 
Veterans Choice Program. The proposals aim to create a system that 
better delineates the circumstances where veterans can receive primary 
and specialty health care. This legislation does not take VA out of the 
equation. In fact, it puts the VA in the center of an apparatus that is 
targeted toward ensuring veterans receive access to health care. Only 
in cases where the VA is unable to assign their own primary health care 
provider will a veteran have the flexibility to choose a primary 
provider within their community from the contracted provider networks 
established by the VA. In cases where specialty care is required for a 
veteran, VA would also have priority to provide that care. We believe 
accountability and access to health care will increase because of these 
reasons and by requiring VA to continually evaluate on an annual basis 
whether there is capacity for veterans to be assigned to a VA primary 
care provider.
    We are also pleased that this legislation eliminates arbitrary 
distance and wait time criteria for veterans to qualify for community-
based health care from providers, especially when VA is unable to 
provide those services. By eliminating these provisions, it is better 
ensured that veterans are granted access to health care based on their 
individual medical needs and not where they live and/or how long they 
have waited for care. Community providers eligible under this new 
system include Medicare providers, Federally Qualified Health Center 
(FQHC) providers, Department of Defense providers, Indian Health 
Service (HIS) providers, academic affiliate providers, or any other 
health care provider that meets the criteria established by the VA 
Secretary.
    We also support the proposed increased safeguards to protect 
veterans and their health records. Secure and confidential exchange of 
medical records between VA and private health care providers is 
essential. Under this legislation, medical records exchange will be 
required to adhere to HIPPA standards and health services undertaken by 
community-based providers will be added to a veterans' electronic 
health record through a system designed to do so. Additionally, in 
cases where copayments are required to be made by a veteran, we support 
the better defined and targeted limitations that would be put in place 
both on the amount and when a veteran is required to pay.

Access to Behavioral Health Treatment:

    We would also like to convey our continued concern with the high 
rate of suicides throughout the military, especially among Reserve 
Component servicemembers. We greatly appreciate the efforts made by 
this Committee to try to improve the quality and access to behavioral 
health services for our servicemembers and veterans, but much more 
still needs to be done. NGAUS is eager to continue our work with this 
Committee to support and amplify numerous initiatives to provide 
increased resources for our members to more easily receive care within 
this legislation. As you know, veterans of the National Guard and 
Reserves face unique challenges when it comes to behavioral health 
care, especially compared to their Active Component counterparts.
    While National Guard and Reserve servicemembers undergo annual 
health assessments to identify medical issues, any follow-up treatment 
is done at the servicemember's expense with a civilian medical provider 
unless they are within 180 days of a scheduled deployment. While 
TRICARE Reserve Select is an option for all members of the National 
Guard, the majority of servicemembers do not opt to enroll because it 
is prohibitively expensive. In fact, 25 percent of National Guardsmen 
(approximately 114,000 service members) do not have any sort of health 
insurance, which is a serious readiness issue in and of itself. NGAUS 
continues to support innovative solutions to increase treatment 
availability and access to VA medical facilities for our members.
    For these reasons, we strongly support S. 1566, the CARE for 
Reservists Act of 2017, which is sponsored by Senator Jon Tester. This 
legislation was introduced in July and would expand eligibility for 
readjustment counseling at VA Veterans Centers to members of the 
National Guard and Reserves, including access to outpatient care from a 
certified mental health care provider should a Veterans Center 
individualized assessment determine that such care is necessary to 
facilitate successful readjustment to civilian life. Additionally, the 
bill would direct the VA, in consultation with the Department of 
Defense, to furnish mental health services for members of the National 
Guard and Reserves and allow the VA to provide mental health treatment 
for members of the National Guard and Reserves who served in classified 
missions.
    Overall, we strongly believe the VA is uniquely positioned, in 
terms of its mission and infrastructure, to help close this gap in 
mental and behavioral health services for members of the National Guard 
and Reserves. The VA, through its Veteran Centers and health clinics 
around the country, plays a vital role in providing mental and 
behavioral care for those that come in and out of military life on a 
monthly basis. As such, we believe it is essential to continue to 
expand mental health services, especially at the community level, in 
order to deliver evidence-based care to veterans whenever and wherever 
they are located.

Conclusion:

    Thank you again for allowing NGAUS to submit written testimony to 
this Committee and for developing the legislation to reform the 
Veterans Choice Program. We urge your colleagues in the House to 
support this crucial legislation that will provide increased access to 
health care for our veterans and their families. We look forward to 
continuing our work together and cannot thank you enough for your 
steadfast leadership in advocating for the men and women of the 
National Guard.

                                 
            Nurses Organization of Veterans Affairs* (NOVA)
                Association of VA Psychologist Leaders*
                   Association of VA Social Workers*
                  Veterans Healthcare Action Campaign
    (*An independent organization, not representing the Department of 
Veterans Affairs)
    Chairman Roe, Ranking Member Walz and Members of the Committee:

    On behalf of our organizations, we would like to thank you for the 
opportunity to submit a statement for the record on the Veterans Choice 
Program redesign. We appreciate your leadership on this issue and the 
strong bipartisan spirit of collaboration to provide high quality 
healthcare for our nations' veterans.
    We believe the current draft discussion language has several 
positive aspects for how to use community resources to supplement gaps 
in the provision of care. It also contains language that, as written, 
could potentially be harmful to the Veterans Health Administration 
(VHA) and the veterans who depend on it. The bill could accelerate a 
one directional flow of veterans' specialty hospital care and medical 
services out of the VHA and into the community. Choice care would be 
reimbursed first and the VHA would be forced to make do with remaining 
funds, thus draining VHA of staffing resources, and privatizing care 
over time. We provide examples of key aspects below.

Language that enhances the provision of care to veterans:

    1. Right of First Refusal with Primary Care. The bill's most 
beneficial aspect is affording the Secretary the right of first refusal 
when a veteran establishes primary care. It allows local facilities the 
flexibility to determine whether they have a capacity of available 
health care professionals. If they do, the facility automatically 
becomes the care provider. This provision assures stability and 
predictability to VHA facilities in self-managing their primary care 
staffing and services.

    2. Reappraisal of Capacity. After a veteran establishes primary 
care in the community, the bill authorizes the Secretary to conduct an 
annual reappraisal to determine whether the local VHA can resume being 
the provider for that veteran. This incentivizes facilities who have 
inadequate staffing to develop robust capacity. We have concern that 
directing a veteran's care back will be difficult to accomplish without 
explicit language that indicates the VHA can be newly established as 
the PCP if it has capacity at the point of reappraisal.

    3. VHA as Care Coordinator and Case Manager. The bill identifies 
VHA staff to be the assigned as case manager of VA-community care 
coordination. This is a useful structure, and one that we have 
mentioned in previous testimony, but requires a significant increase in 
staffing. The bill doesn't recommend any additional funding for this 
role, so the net offset would be a reduction in staff that provides 
health care. Supplemental VHA allocations are warranted.

Language that erodes the VHA by diverting funds to the community:

    1. Specialty Care Referral and Cost Control. Although the bill 
provides the Secretary a right of first refusal for primary care, a 
weaker prerogative exists for specialty care. Once a veteran receives 
primary care at a non-VA facility, ensuing referrals for specialty 
hospital care or medical services can easily bypass the VHA. The 
Secretary should be authorized to have the right of first refusal to 
provide specialty hospital care and medical services when it has the 
capacity to do so.
    The language indicates that Choice providers only have to 
``consult'' with the Secretary on specialty hospital care or medical 
services referrals. There is no process for VHA review and 
authorization of services. It is important to have an explicit 
requirement for Choice providers to ``refer'' back to VHA, and that VHA 
be required to oversee and control the provision of healthcare.

    2. Demand/Supply Gaps. Although the bill allows local VHAs to 
define whether they have a shortage of available health care 
professionals, it does nothing to remedy shortages. Its' Annual 
Capacity and Commercial Market Assessments makes no mention of 
identifying the supplemental allocations and resources that are needed 
to address human capital and infrastructure gaps. Nor does it show how 
money flowing to Choice providers are impacting local facility staffing 
and services. We strongly affirm that strengthening and improving the 
VHA should go hand in hand with any Veterans Choice Program redesign. 
Without adequate funding, VHA shortages will be inevitable and services 
slowly eroded.

Language that undermines provision of quality care to veterans:

    1. Double Standards for Timeliness and Quality of Care. The bill 
requires the Secretary to publically report every month the average 
wait time at VHA facilities. However, it does not require that Choice 
wait time data be obtained and published. Timeliness of Choice 
services--as well as all other aspects of performance, screenings and 
on-going training requirements--should be reported and held to the same 
high standards of VHA providers. Otherwise, care provided via Choice 
would be held to a lower standard than the VHA. This is a disservice to 
veterans. Finally, Choice providers should be required to continuously 
learn about the extent and quality of services the VHA provides, just 
as the VHA must do about the community.

    2. PCP Referrals and Wait Times. At present, Choice wait time data 
are not published, therefore the Secretary is not able to use wait 
times in determining community providers' availability. A local VHA 
should be restricted from providing the veteran a list of available 
PCPs' until it first verifies that the providers on the list are more 
available than the VHA. It is well established that there exists and 
continues to be a growing scarcity of primary care physicians in the 
community.

    3. Care Coordination via Medical Records. The bill gives network 
providers unlimited time to provide medical records to the VHA, and 
explicitly says they will be paid whether or not their records are 
late. There should be a penalty for undermining care coordination in 
this manner. Providers should be held accountable for any delay in 
care.

    Once again, the Nurses Organization of Veterans Affairs, the 
Association of VA Psychologist Leaders, the Association of VA Social 
Workers and Veterans Healthcare Action Campaign thank the Committee for 
the opportunity to submit testimony on this critical topic. As health 
care professionals providing care and services to veterans across the 
country, we would be happy to assist with language in the final bill to 
accommodate any of the issues mentioned in our statement.

Contacts:

    Nurses Organization of Veterans Affairs [email protected]
    Association of VA Psychologist Leaders [email protected]
    Association of VA Social Workers [email protected]
    Veterans Healthcare Action Campaign [email protected]

                                 
                  PARALYZED VETERANS OF AMERICA (PVA)
    Chairman Roe, Ranking Member Walz, and members of the Committee, 
Paralyzed Veterans of America (PVA) would like to thank you for the 
opportunity to provide comments on these critically important bills 
being considered before the Committee today. Since the establishment of 
the Veterans Choice program in 2014, VA has struggled with ever-
changing requirements enacted by Congress to the program and 
significant new demand for these services. The uncertain nature of the 
Choice program over that time period caused unnecessary complications 
in the implementation of the program. However, the Department of 
Veterans Affairs (VA), with assistance from its community partners and 
the third party administrators, has made great strides to improve the 
program. The draft bills being considered today lead to the next 
logical step of solidifying this program once and for all. That being 
said, concerns still remain.
        Draft Bill to Make the Veterans Choice Program Permanent
Draft ``Veteran Coordinated Access & Rewarding Experiences (CARE) Act''
    Given the similar nature of the two primary draft bills being 
considered regarding future of the Choice program, we will address the 
provisions of both bills together in our statement. We would like to 
say up front that we do not explicitly oppose either draft bill. 
However, we do believe that the bill presented by this Committee 
provides a much better path forward for the implementation of the 
Choice program. It is also important to understand that some of the 
provisions in both bills mirror one another.
    Before the Committee takes steps to reform the delivery of 
veterans' health care in the community, it is important to affirm that 
specialized services are part of the core mission and responsibility of 
VA. As the Department continues the trend toward greater utilization of 
community care, Congress and the Administration must be cognizant of 
the impact those decisions will have on veterans who need the level of 
complex care that, more often than not, only VA can deliver. This 
includes VA's decision to continue concentrating all of its energy on 
expanding the Choice Program balanced against the need to demonstrate 
how it plans to make its own services more competitive with the private 
sector-a key component of the proposed high-performing network.
    In recent months, VA has indicated that, along with improving the 
delivery of care in the community to veterans, it plans to concentrate 
on expanding and improving what it considers ``foundational services.'' 
However, we have yet to see any indication of how this concept is 
defined. Moreover, we are troubled that VA is inclined to have local 
facilities determine what should be defined as foundational based on 
local markets. The Secretary has indicated that it considers spinal 
cord injury and disease (SCI/D) care and blinded care foundational 
services. However, he must make that policy unequivocally clear to all 
networks and all facilities. Additionally, we do not believe 
foundational services end with just those areas; there are many areas 
of service within VA that inform the principle of veteran-centric care. 
We appreciate the fact that the Secretary has committed to expanding 
SCI/D nurse staffing by approximately 1,000 new positions. Guidance has 
been directed towards the field to set aside approximately five percent 
of funds from special use funds to be used to augment foundational 
services. Unfortunately, we are not certain that the steps to set aside 
those funds are actually pointed towards strengthening those 
foundational services. These concerns about foundational services 
cannot be dismissed simply in the interest of focusing attention on 
more community care.
    As we have stated repeatedly, any legislation designed to reform VA 
health care must incorporate or match the attributes that make VA's 
specialized services strong. For example, VA utilizes outcome-based 
standards of care across the SCI/D system, which, in turn, allows us to 
measure and scrutinize the quality of care provided. The system is 
governed by comprehensive policies laid out in Veterans Health 
Administration (VHA) Directive 1176 and the corresponding handbook 
governing procedures. These authorities require VA to track the SCI/D 
population in a variety of ways, specifically capturing data on 
outcomes. When individual facilities are lagging behind, the evidence 
is not just anecdotal. VA's facilities are also accredited by the 
Commission on Accreditation of Rehabilitation Facilities (CARF) and The 
Joint Commission. When the entire system is questioned, Congress can 
commission an independent assessment, similar to the one carried out as 
part of the original Choice legislation. VA officials can also be 
called to testify about the conditions of care in VHA facilities.
    Congress should examine more closely how VA will monitor the 
quality of care veterans are receiving in the community. This question 
goes beyond a plan for care coordination. If VA is unprepared to retain 
ownership of responsibility for care delivered in the private sector, 
Congress will be helpless in conducting adequate oversight. Moreover, 
it places a spotlight on one of the fundamental principles of both bill 
that presumably dictates access to community care-VA facilities not 
meeting an undefined quality standard. Clear comparisons need to be 
made between the VA and the local community when decisions about choice 
are made to ensure that unbiased decisions are made.
    With this in mind, PVA strongly supports the concept of developing 
a high-performing integrated health care network that would seamlessly 
combine the capabilities of the VA health care system with both public 
and private health care providers in the community. The Committee's 
draft proposal clearly considers this concept at the center of its 
bill. The VA has emphasized all along that it would like to evolve into 
a dynamic, high-performing network model. And yet, the proposed CARE 
Act does not address the need for a high-performing network at all. VA 
apparently believes it has the authority to establish such a network 
without Congressional approval. We disagree. Absent a clear plan with 
the design of a fully-integrated health care network, we defer to the 
concepts proposed in the Committee draft bill as the best path forward.
    PVA believes, like many stakeholders and members of Congress, that 
the definition of an integrated VA network is one that utilizes private 
providers to supplement, not supplant, the VA health care system. 
Unfettered choice of provider granted to all veterans is not a 
realistic or financially viable basis for a healthy VA health care 
system capable of sustaining critical, veteran-centric, specialized 
services. In fact, at the end of the Committee round table held earlier 
this month, Chairman Roe emphasized that the notion of unfettered 
choice is a false choice. He explained that the only people who get 
unfettered choice in their health care in America are those who pay 
completely out of pocket. Otherwise, all other people seeking health 
care do so through variously defined types of managed care. This is a 
critical point as some continue to advocate for unfettered choice 
within VA. It is cost-prohibitive and, in many cases, leads to 
fractured care as veterans attempt to navigate the private health care 
system without managed care coordination.
    We believe that the design and development of VA's network must be 
locally driven using national guidance, and it must reflect the 
demographics and availability of resources within that area. VA has 
taken the first steps toward this goal by conducting its pilot market 
assessments using three individual VHA facilities and their surrounding 
health care markets. Unfortunately, none of the stakeholders, 
particularly in the VSO community, have seen the findings and 
methodology developed from these test markets. If that methodology does 
not include a component that considers the actual wants and needs of 
veterans in the given community (market), then we believe it is a 
flawed process.
    Our philosophy is that the development of VA's network of providers 
should be locally driven, contemplating demographics, demand and 
availability of resources within that particular area. It is more, 
though, than just filling access gaps. Quality, both within VA and in 
the community, is inextricable from this analysis. It should be a 
critical factor in determining whether VA should continue to offer a 
service or if it should capitalize on segments of the community that 
are already delivering that service with excellent results. Similarly, 
just because VA is offering poor quality in a particular service line 
does not automatically mean there is a second choice available in the 
community. VA is obligated to raise the quality in its own house in 
those circumstances. Moreover, the Committee bill requires that the VA 
publish its wait times on a monthly basis seemingly as a measure of 
quality and as a means to determine potential access to community care. 
We recommend that wait time data for all facilities with each health 
care market, to include VA and private providers, should be provided to 
afford veterans a clearer perspective. A well-balanced network that 
supplements service gaps in VA's system sets a natural boundary for the 
network. It is efficient and preserves VA core competencies and 
specialized services such as spinal cord injury and disorder care.
    PVA supports the Secretary's plan to move the Department away from 
the current 30-day/40-mile eligibility standards in favor of a case-by-
case clinical determination. The Committee's draft bill targets the 
same desired end goal. Access decisions dictated by arbitrary wait 
times and geographic distances have no comparable industry practices in 
the private sector. This change would shift the organizational mindset 
and focus of VA to clinical outcomes instead of catering to arbitrary 
metrics governing access to care in the community. We have consistently 
advocated for this proposition before Congress and the administration, 
stating that eligibility and access to care in the community should be 
a clinically-based decision made between a veteran and his or her 
doctor. Establishing appropriate eligibility standards will be an 
integral part of a sustainable network.
    We do remain concerned that the Committee draft bill sets up a 
scenario all but asking the VA to fail by requiring an annual capacity 
assessment of each VISN and VA medical center. The administrative 
burden of doing this on an annual basis will almost certainly lead to 
bad information and incomplete data. These assessments should be spread 
out to be done less frequently. Considering that it took months for VA 
to complete three pilot market assessments, we cannot see how VA will 
effectively accomplish this task. Fortunately, in discussions with the 
Committee, there is clearly an openness to modifying this requirement 
to better align with the capabilities of the VA to complete these 
important assessments on a recurring basis. It would also align 
expectation with what is currently being debated in the context of the 
``Asset and Infrastructure Review Act.''
    VA will be able to make greater strides, especially in rural areas, 
if given the ability to bring more community providers into the fold 
with flexible provider agreements. The current requirement that 
providers enter into agreements with VA governed by the federal 
acquisition regulation (FAR) system has suffocated VA's attempts to 
expand access to care in a timely manner. Smaller health care provider 
organizations otherwise disposed to serve the veteran population are 
especially resistant to engaging in the laborious FAR process. And yet 
they remain vital to filling the gaps in health care services in 
certain areas.
    The CARE proposal focuses a great deal of attention on the need for 
provider agreements establishing the authority for Veterans Care 
Agreements. We are pleased to see that the proposed Committee bill also 
provides for the authority to enter into Veterans Care Agreements. PVA, 
along with our partners in The Independent Budget-DAV and VFW-have 
strongly supported the need to give VA this authority over the last two 
years. These agreements are critical to filling gaps that may be left 
by an integrated network.
    One area of this debate that has received very little attention is 
that of Native American veterans and the Indian Health Service (IHS). 
The VA CARE Act does not explicitly address the existing agreements 
with IHS and tribal governments. Due to the unique relationship that 
exists between VA and IHS and tribal governments, we urge the Committee 
to revise the draft language in its bill so it does not consider IHS 
and tribal health programs (THPs) as part of the core provider network. 
This request was made explicitly clear by tribal governments during 
consultations with VA in 2015 and 2016. IHS and THPs must be allowed to 
continue to set up agreements directly with VA as part of the 
government-to-government relationships. According to the VA's 2016 
Tribal Consultation Report tribes have uniformly opposed any proposal 
to consolidate IHS and THPs into a standard community care program.
    VA responded to the tribes' concerns stating that they will 
``ensure VA's consolidated community care program allows for the 
continuation and growth of the unique relationship that tribal health 
programs have with VA.'' It is our understanding that VA intends to 
hold these agreements harmless from the impact of the CARE Act. 
However, VA has not provided any details on how IHS and THPs will be 
treated in their proposal should the national IHS-VA Reimbursement 
Agreement expire on June 30, 2019, as it is currently scheduled to do. 
It appears THPs and IHS would be relegated to community provider status 
which would disrupt the care currently being provided to 9,000 unique 
Native American veterans among the 99 tribes who had finalized 
agreements at the end of 2016. PVA urges Congress and VA to ensure the 
legislation put forward dutifully fulfills the federal trust 
responsibility to provide access to health care eligible native 
veterans.
    PVA, along with our partners in the VSO community, continue to 
advocate for adding urgent care services to the standard medical 
benefits package to help fill the gap between routine primary care and 
emergency care. This is consistent with current health care trends, and 
greater utilization could provide a relief valve to VA emergency 
services, the Choice Program, and the system as a whole. VA previously 
proposed in its Plan to Consolidate Community Care Programs a more 
common sense determination of what constitutes reimbursable emergency 
and urgent care, thereby expanding access, but it came with the 
imposition of cost-sharing for otherwise exempt veterans. We strongly 
oppose co-payments for veterans who are currently exempt. Using co-
payments as a means to discourage inappropriate use of emergency care 
by service-connected veterans is not an acceptable method of 
incentivizing behavior. Unfortunately, the VA's proposed CARE Act 
retains the possibility of all eligible veterans having a co-payment 
requirement to access ``walk-in care,'' albeit with the Secretary 
having discretion to limit the co-payment requirements based on 
Priority Group. What the CARE Act fails to do is exempt all veterans 
who currently are not required to pay any co-payments from paying when 
they access ``walk-in care.'' Any final legislation should affirm this 
exemption unequivocally.
    While there was the promise of an urgent care benefit from the VA's 
originally proposed community care plan, the proposal has evolved to 
provide access to community walk-in care clinics within the community 
care network. It remains unclear whether this is a departure from 
urgent care in favor of retail minute clinics, and whether it has also 
curtailed the number of eligible providers to those who are within the 
community care network. Given the disparity in quality and scope of 
care provided between urgent care and retail minute clinics, we would 
encourage this committee to seek further clarification from VA. We 
would also encourage the Committee to add an urgent care component to 
its own draft proposal or to whatever final version of this legislation 
is passed.
    PVA continues to have serious concerns about the funding mechanism 
for community care going forward. The Independent Budget, as well as 
many of our partners in the VSO community, have advocated for moving 
all funding authorities for the Choice program (and other community 
care programs) into the discretionary accounts of the VA managed under 
the Medical and Community Care account. The Committee draft bill 
clearly makes this necessary change. Unfortunately, the CARE Act is 
unclear at best on how it addresses this question. Our interpretation 
of the VA's proposal is it retains the mandatory funding stream for 
community care. This is a wholly unacceptable proposition. Every member 
of this Committee and all stakeholders in this debate know that this 
program should not be funded through a mandatory funding mechanism. And 
yet, the VA insists on carrying this bad practice forward, presumably 
at the urging of the Office of Management and Budget (OMB), which 
should have no say in this matter. The Committee should without 
question enact the provisions included in its draft bill that would 
ensure proper alignment of funding authorities in the discretionary 
budget of the VA.
    Additionally, as long as the VA continues to propose a mandatory 
funding proposal, we will have to deal with the unacceptable mandatory 
pay-for issue that the Administration continues to bring forward. A 
reasonable debate can be had on the merits of rounding down the cost-
of-living adjustment (COLA) or on the amount that should be provided 
for flight school training under the provisions of the Post-9/11 GI 
Bill. What is not acceptable in this debate is the notion that veterans 
benefit reductions (benefits for service connected disabled veterans in 
the case of the COLA in particular) should be used to pay for access to 
health care, to include for non-service connected disabled veterans, in 
the community. The American public will not accept Congress reducing 
any type of veterans benefit simply because the Administration and 
Congress are unwilling to properly fund the expansion of health care 
services in the community.
    Finally, PVA believes that the Committee and VA need to seriously 
consider the consequences for veterans when they are injured during the 
course of their treatment in the community. When veterans receive 
treatment at a VA medical center, they are protected in the event that 
some additional disability or health problem is incurred. Under 38 
U.S.C. Sec.  1151, veterans can file claims for disability as a result 
of medical malpractice that occurs in a VA facility or as a result of 
care delivered by a VA provider. When PVA questioned VA as to whether 
these protections are conferred to veterans being treated in the 
community, VA officials confirmed in writing that this protection, as a 
matter of law, does not attach to the veteran in such circumstances. If 
medical malpractice occurs during outsourced care, the veteran must 
pursue standard legal remedies instead of VA's non-adversarial process. 
Adding insult to literal injury, veterans who prevail in a private 
action are limited to monetary damages instead of enjoying the other 
ancillary benefits available under Title 38 intended to make them whole 
again. These include treating the resulting injuries as service-
connected conditions, such as a botched spinal surgery resulting in 
paralysis where the veteran did not provide adequately-informed 
consent. It also includes access to adaptive housing and adaptive 
automobile equipment benefits should the veteran require these 
features. Furthermore, the limits on these monetary damages vary from 
state to state leading to disparate results for similarly-situated 
veterans. The disparity in outcomes and the different processes by 
which they are achieved are unacceptable. This Committee and Congress 
must ensure that veterans are treated equally and that these 
protections follow the veteran into the community.
    Ultimately, we believe the House draft proposal is a much better 
proposal for the future of the VA's community care program. It more 
adequately addresses long-standing concerns the VSO community has 
expressed about how to provide access to community care and how to 
ensure proper coordination of care. The mechanics of how it expects the 
VA to operate an integrated community care network are clearer. It 
places the proper focus on how community care should be funded going 
forward, recognizing that this will still be a difficult problem to 
overcome. The draft CARE Act leaves too many unanswered questions. The 
VA claims that it has a plan currently being reviewed by the White 
House and OMB to implement a future community care program. However, it 
has chosen not to share that plan with any key stakeholders. Without a 
clear plan for how VA intends to execute the delivery of community care 
for veterans, and given the clearly unrestricted authorities the draft 
CARE Act provides that could allow VA to go in any number of directions 
for delivery of those services, including a very significant expansion 
into the community, we believe the Committee should move to advance its 
own proposal incorporating key aspects of the VA draft into the final 
bill.

       H.R. 1133, the ``Veterans Transplant Coverage Act of 2017"

    PVA supports H.R. 1133, the ``Veterans Transplant Coverage Act.'' 
This legislation gives VA the authority to provide organ transplants to 
veterans from a live donor regardless of veteran status of the donor or 
the facility they are in. Under the current Choice program, veterans in 
need of organ transplants are denied due to the program's eligibility 
requirement. If a living donor is not a veteran, the transplant 
coverage is denied if the surgery is not performed at a VA facility. 
However, due to the very access problems that prompted the Choice 
program-long distance travel, inaccessible transportation, etc.-these 
veterans are unable to receive the care they so desperately need. 
Whether or not a veteran receives a necessary organ transplant should 
not depend on who or where the donor is.

H.R. 2123, the ``Veterans E-Health and Telemedicine Support (VETS) Act 
                                of 2017"

    PVA supports H.R. 2123, the ``Veterans E-Health and Telemedicine 
Support (VETS) Act of 2017.'' This bill would improve access to 
telemedicine services from the Department of Veterans Affairs. Under 
current law, VA may only provide at home telehealth to a veteran if the 
physician and veteran are in the same state. This requirement can be a 
particularly troubling barrier for veterans who have specific medical 
or mental health needs, have moved, or live in rural communities 
without providers. This bill would alleviate some of these pressures by 
waiving the instate requirement, allowing VA health professionals to 
operate across state lines.

H.R. 2601, the ``Veterans Increased Choice for Transplanted Organs and 
                     Recovery (VICTOR) Act of 2017"

    PVA supports the intent of H.R. 2601, the ``Veterans Increased 
Choice for Transplanted Organs and Recover Act of 2017.'' This bill 
would amend the existing Choice Program to allow veterans who live more 
than 100 miles from one of VA's fourteen transplant centers to seek 
care at federally certified, non-VA facilities. This legislation would 
seemingly improve access for veterans in need of organ transplants. 
However, it does not address the barriers to care for those veterans 
who live less than 100 miles of a transplant center. As we have seen 
over the lifetime of the Choice Program, arbitrary distance and time 
measurements can complicate an already confusing community care system. 
Much as the discussion about the future of community care in the VA has 
trended towards decision-making based on clinical need, we would like 
to see access to transplant services in non-VA facilities be based on 
clinical need and quality of care rather than an arbitrary mileage 
standard.

  H.R. 3642, the ``Military Sexual Assault Victims Empowerment (SAVE) 
                                 Act''

    PVA supports the intent of H.R. 3642, the ``Military Sexual Assault 
Victims Empowerment (SAVE) Act.'' This legislation would establish a 
three year pilot program to furnish non-department medical care to 
eligible military sexual assault survivors in five locations. PVA 
believes Congress must enable VA to provide timely, high-quality care 
for veterans struggling with military sexual trauma (MST). However, it 
is unclear how this legislation as written will achieve that end.
    The bill states the Secretary may not restrict which community 
provider a veteran chooses to receive care from. We would argue that 
such a suggestion is misleading to veterans as the participating 
provider must accept the payment rates of any contract the provider is 
already in or the rates pursuant to section 1703 of title 38, United 
States Code. A veteran's choice of private provider will be unimpeded 
provided their chosen provider accepts the established rates. It is 
with this in mind that we point out VA already has the authority to 
contract for care in the community for the treatment of MST. It is 
unclear what the proposed pilot would make available that is not 
already.
    We are not convinced that the current state of VA care and contract 
authorities necessitates this pilot. While VA does still struggles to 
increase its capacity, and provide timely access to care, they are not 
in isolation. The same barriers to care, wait times and provider 
shortages, often exist in the private sector. Further, this bill makes 
no mention of how or if the care will be coordinated with VA. MST 
survivors often have multiple comorbidities and need access to services 
such as primary care, substance abuse treatment, housing, disability 
benefits and travel assistance. MST coordinators are available at every 
VA medical center to help veterans to access these services.
    Currently all VA mental health and primary care providers must 
complete mandatory trainings on MST and trauma-related disorders as 
specified by VHA Directive 2012-004. These issues may not be commonly 
found in the community. There is no assurance that private providers 
have any such specialized training in evidence-based treatments for 
MST.

          Draft Bill Regarding State Homes and Other Purposes

    PVA generally supports the draft bill addressing state homes and 
other purposes. Section 1 of this proposal seeks to modify the 
authority of VA to enter into agreements with state homes by striking 
contract authority under 1720(c)(1) and relying solely on 
``agreements.'' These agreements could be entered into without the 
requirement that the Secretary use competitive procedures to select the 
party. Further it would stipulate that the partnering state home would 
not be subject to any law to which providers of services and suppliers 
are not subject to under Medicare and Medicaid programs. PVA supports 
the efforts to make available to veterans the long term services and 
supports they need and that VA be able to do so in a timely manner.
    Section 3 seeks to encourage individuals to fill graduate medical 
education residency positions that were established by the Choice Act. 
The Secretary would be charged to carry out a program of educational 
assistance to recruit applicants. While PVA supports such intent the 
legislation as written is not clear what the education assistance would 
look like; whether it be loan forgiveness, competitive compensation, or 
other incentives. Similarly, there is little illumination as to how the 
length of the period of obligated service is to be determined.
    PVA believes VA must be adequately resourced to attract the best 
and brightest medical professionals. There is a current and worsening 
provider shortage in the United States and VA must take steps to see 
that the veterans community be the least affected by this trend. By 
providing competitive incentives in exchange for a period of service, 
VA would become a reasonable choice for residency. Competitive 
incentives and loan assistance for residents can cultivate a culture of 
commitment by those unburdened by debt and revive areas too long 
stressed by continuous shortages.
    Lastly, Section 4 appears to be duplicative of the intent of H.R. 
2123, the ``VETS Act of 2017.'' PVA supports the expansion of the use 
of telemedicine regardless of the state patient and physician are 
located in and would encourage the Committee to consider either of 
these provisions to accomplish the desired end.

          Draft Legislation Regarding the Veterans Crisis Line

    PVA generally supports the intent of the draft legislation that 
would require greater reporting and analytics of the Veterans Crisis 
Line (VCL). The information required by the legislation could prove 
invaluable in analyzing the function and efficacy of the VCL and the 
patterns of veterans who reach out to the VCL. However, we have a 
serious concern about this effort. We wonder how the Committee believes 
that this information that would allow individual veterans to be 
tracked for data collection purposes can be obtained from a veteran, 
who is in crisis, without potentially upsetting them further? Exactly 
what does the Committee believe the reaction of a veteran in crisis 
would be if the VCL representative asked for his or her name and last 
four numbers of the Social Security number in order to open up the 
``log'' for tracking the data about that individual? That would almost 
certainly exacerbate the situation.
    Furthermore, the bill can be interpreted as though it would blame 
VA in instances where veterans commit suicide. But it does not address 
the circumstances of the nearly 70 percent of veterans who commit 
suicide who never touch VA in any way. We are more interested in 
knowing why those veterans do not come to VA; or where are they going 
for help if not VA; and what is the efficacy of that support in the 
community. This bill certainly is well-intentioned. The information 
that it seeks could certainly be valuable, but at what risk. The 
Committee should be very careful as it pursues the information that 
this draft bill seeks.
    Mr. Chairman and Ranking Member Walz, we would once again like to 
thank you for the opportunity to share our thoughts on these critical 
measures. The impact of this legislation could set the course for 
health care delivery in the VA for many years to come, so it is 
important that we get this right. We cannot simply rush to a final 
conclusion just to claim victory. We look forward to working with each 
of you, the members of this Committee, and the respective staffs to 
ensure that VA is best positioned to deliver on the promise of the 
timely, quality health care in the most appropriate setting.
    Thank you again. We would be happy to take any questions for the 
record that you may have.

                                 
                   RESERVE OFFICERS ASSOCIATION (ROA)
    Dear Chairman Roe and Ranking Member Walz:

    The Reserve Officers Association of the United States represents 
all seven of our nation's uni-formed services, both non-commissioned 
and commissioned officers in the Reserve and Guard Compo-nents. Under 
our 1950 Congressional charter, our purpose is to promote the 
development and exe-cution of policies that will provide adequate 
national defense. We do so by developing and offering exper-tise on the 
use and resourcing of America's Reserve and Guard Components.
    The association is pleased to provide this letter of support for 
legislation to establish a permanent Veterans Choice program. We 
appreciate the continued bipartisan leadership of the committee, the 
dedication of the Members and the hard work of the professional staff, 
all who are devoted to en-hancing and improving the VA community care 
system. Additionally, we thank the committee for allowing ROA to 
improve and enhance the bill through offered technical corrections.
    In particular, we thank the committee for adding legislative 
language granting the VA Secretary greater flexibility in giving 
priority for specialty care to VA medical facilities and for giving 
veter-ans more community care options. Specifically, once a veteran is 
enrollment in VHA care the VA will assign them a primary care provider. 
If the VA cannot assign that veteran to a VA primary care provider 
because of a shortage of healthcare personnel, the veteran may select a 
community primary care provider from a list of available networks. 
Factors such as the burden of travel, geography, envi-ronmental 
factors, the veteran's medical condition, and any recommendations from 
the primary care provider will all be considered.
    While the bill is not a ``pathway to privatization'' it also does 
not take away VA benefits from the veterans. We believe this important 
bill ultimately benefits all veterans because it provides flexibil-ity 
and options which are not currently available.
    Thank you again for your strong efforts to improve health care 
choices and flexibility for our military community, especially members 
of the Reserves and National Guard. Please have your staff call John 
Rothrock, ROA's legislative director, at 202-646-7713 or e-mail at 
[email protected] with any questions or issues you would like to 
discuss.

    Sincerely,

    Jeffrey E. Phillips
    Maj. Gen., USA (Ret.)
    Executive Director

                                 
                  UNIVERSITY OF CALIFORNIA, RIVERSIDE
    October 23, 2017

    The Honorable Phil Roe, MD
    Chairman
    House Committee on Veterans' Affairs
    335 Cannon House Office Building
    Washington, DC 20515

    The Honorable Tim Walz
    Ranking Member
    House Committee on Veterans Affairs
    333 Cannon House Office Building
    Washington, DC 20515

    Dear Chairman Roe and Ranking Member Walz:

    On behalf of the University of California, Riverside (UCR) School 
of Medicine, I want to thank you both for your strong support of 
Graduate Medical Education (GME) at the U.S. Department of Veterans 
Affairs (VA). The 1500 new GME slots that were created in the Veterans 
Access, Choice and Accountability Act of 2014 (``Choice Act'') have 
been a boon to Inland Southern California, which is a medically-
underserved region with a high population of low-income and minority 
veterans. The Choice Act has allowed the UCR to have an academic 
affiliation with the VA Loma Linda Healthcare System (``Loma Linda'') 
and to apply for new GME slots to treat veterans in Community Based 
Outpatient Clinics (CBOCs).
    You may know UCR has a new School of Medicine, which graduated its 
first class of medical students this spring. Our School is the first 
public medical school on the West Coast in over 40 years and it is 
desperately needed to address the physician shortage we face. But the 
new medical school is not enough-we must also have local GME 
opportunities for our graduates if we are to retain them in Inland 
Southern California. As you work to craft a Choice Act 2.0, and in 
response to recent draft legislation, UCR would like to offer the 
following comments for the record:

    Sec. 3 Program to Fill Graduate Medical Education Residency 
Position of Department of Veterans Affairs

      The draft legislation proposes the VA would cover the 
cost of a medical resident in exchange for a post-residency service 
contract that is to-be-determined. However, this offers no incentive to 
the resident whose bottom line would be no different if that resident 
accepted any other position. VA academic affiliates could benefit from 
this proposal, but residents would not. As a result, medical students 
from poorly-performing for-profit medical schools overseas may be more 
inclined to accept residency positions under the proposed program. In 
order to maximize benefit to the residents and the VA, UCR strongly 
encourages the Committee consider a student loan forgiveness program 
instead in exchange for VA service obligation. The Indian Health 
Service runs a similar program.
      It is unclear, as the draft legislation is written, if 
this new program would apply to all of the unfilled GME slots from the 
Choice Act. If so, UCR asks you to revisit this proposal. New medical 
schools, like UCR's, are still in the process of building our clinical 
faculty and GME programs. The Choice Act initially allowed for five 
years for academic affiliates to fill all of the 1500 GME slots and, 
last year, Congress passed legislation that extended that time period 
to ten years. The additional five years will be critical for new 
medical schools like UCR and we hope to continue to apply for new 
slots.

    Sec. 4 Practice of Health Care Professional of the Department of 
Veterans Affairs Providing Treatment, Including Treatment Via 
Telemedicine

      The draft legislation proposes that VA healthcare 
professional may provide healthcare to veterans, including 
telemedicine, ``at any location in any State regardless of where in a 
State the covered health care professional or the patient is located.'' 
It is unclear if medical residents are included in the definition of 
``covered health care professional'' and UCR encourages they be so 
included. As you know, medical residents play a critical role in 
veterans' health care. Furthermore, this new program would benefit 
veterans in rural communities where private facilities exist, but VA 
facilities do not, such as the communities surrounding Joshua Tree and 
Twentynine Palms in San Bernardino County, and it would have tremendous 
impact on rural telemedicine.
      UCR supports efforts that would allow VA health care 
provides to give care to veterans across state lines through, 
especially through telemedicine. This would greatly ease the burden on 
disabled veterans who could be treated from the comfort of their own 
home.
      UCR also supports streamlining the process for adding 
non-VA facilities to the approved mix of clinical locations through 
``sole source leasing authority.'' This would allow clinics like UCR's 
new medical clinic in downtown Riverside to host pop-up clinics for 
veterans. UCR believes this is necessary as the City of Riverside has a 
high homeless and low-income veterans population and the nearest VA 
CBOC in Riverside County is a one-hour commute by public transportation 
followed by a 1.5 mile walk-very difficult for a disabled veteran.
      UCR encourages the Committee to consider including 
indirect cost or overhead payments in addition to clinical treatment 
costs. New medical schools like UCR's that do not have a longstanding 
academic affiliation with a VA healthcare system and that do not have 
joint faculty appointments struggle to make these new GME programs 
financially viable due to the lack of overhead reimbursement from the 
VA. This disadvantages new medical schools, many of which are being set 
up to serve rural communities and areas with physician shortages.
      UCR also supports the proposed report on the 
effectiveness of the use of telemedicine.

    Not Included

      UCR strongly encourages the Committee to support housing 
reimbursement for residents in VA GME programs in rural areas. This 
would allow the VA and its residents to better serve rural communities. 
For example, UCR's residents would like to serve the CBOC in Blythe, 
California, which is located 165 miles or 2.5 hours from campus and is 
98 miles or 1.5 hours from Indio, California, which is the nearest 
major city on the I-10 freeway. For residency accreditation purposes 
and personal health reasons, residents cannot drive back and forth to 
Blythe-they must be housed locally.
    Again, I want to thank you for your support of VA GME programs and 
for the opportunity to comment. I am grateful for the Choice Act 
programs and am excited about positive changes that we can make through 
Choice 2.0. The spirit of the draft legislation is positive and it 
provides a strong starting point. I hope you find my comments to be 
constructive and helpful as you make positive changes to the Choice GME 
program to more effectively benefit residents and veterans.

    Sincerely,

    Deborah Deas, MD, MPH
    Mark and Pam Rubin Dean of the School of Medicine
    CEO for Clinical Affairs
    University of California, Riverside
    CC: The Honorable Mark Takano

                                 
                        UNIVERSITY OF PITTSBURGH
    STATEMENT OF DR. ABHINAV HUMAR
    CHIEF, DIVISION OF ABDOMINAL TRANSPLANTATION SURGERY
    UNIVERSITY OF PITTSBURGH
    ON
    ``LEGISLATIVE HEARING: H.R. 2601 VETERANS INCREASED CHOICE FOR 
TRANSPLANTED ORGANS AND RECOVERY ACT OF 2017"

    OCTOBER 24, 2017

    Chairman Roe and Ranking Member Walz,

    Thank you for the opportunity to provide testimony regarding 
Representative Neal Dunn's legislation: H.R. 2601 Veterans Increased 
Choice for Transplanted Organs and Recovery Act of 2017 or, the VICTOR 
Act. I am grateful to Dr. Dunn for offering this legislation and offer 
my strong support for it. It is my hope that the House and Senate 
Veterans Affairs Committees will support this legislation and include 
it in legislation that continues to allow veterans to receive care in 
the community.
    A bit of background on myself: My name is Abhinav Humar, MD. I am 
currently employed by the University of Pittsburgh where I am a 
professor of transplantation surgery as well as the chief of the 
abdominal transplantation surgery division and Director of the Thomas E 
Starzl Transplant Institute. I specialize in intestinal, kidney, liver 
and pancreas transplants with a specialized focus on living donor liver 
transplant and pediatric kidney transplants. I have been published over 
300 times in various medical journals and publications on topics 
related to organ transplant medicine. My curriculum vitae has been 
submitted with this testimony.
    In my capacity as a transplant surgeon, I have performed numerous 
transplants on veterans at the Veterans Affairs (VA) Pittsburgh 
Healthcare System and this is where I first learned of the VA's 
policies pertaining to veterans seeking an organ transplant, either 
kidney or liver transplants. There are currently 6 VA transplant 
centers (VATC) that perform liver transplants and they are: Portland, 
Madison, Houston, Nashville, Richmond and Pittsburgh. A veteran must 
travel to one of those six facilities to receive a transplant. The 
Veterans Access, Choice and Accountability Act of 2014 \1\ (hereinafter 
``Choice Act'') does not apply to organ transplant surgery and 
therefore the veteran is not eligible to receive a transplant in a non-
VA medical facility regardless of the distance that a veteran must 
travel to a VATC.
---------------------------------------------------------------------------
    \1\ Public Law 113-146
---------------------------------------------------------------------------
    As a physician, the standard that I apply is the best medical 
interest of the patient or veteran. Is it in the best medical interest 
of the veteran to travel a significant distance to receive a 
transplant? The medical research that has been conducted on this topic 
clearly indicates that VA's current policy that requires a veteran to 
travel to a VATC to get care, regardless of distance, is not in the 
best medical interest of the veteran. A 2014 study published in the 
Journal of the American Medical Association states, ``Among VA patients 
meeting eligibility criteria for liver transplantation, greater 
distance from a VATC or any transplant center was associated with lower 
likelihood of being waitlisted, receiving a liver transplant, and 
greater likelihood of death.'' \2\ In other words, the farther a 
veteran is from a transplant center the less likely they are to get a 
transplant and the more likely they are to die. There is no rational 
basis, based upon medical research, that would justify the VA forcing a 
veteran to travel a significant distance to receive a liver transplant 
from a VATC when a civilian transplant center exists closer to the 
veteran's home.
---------------------------------------------------------------------------
    \2\ Goldberg, David S., ``Association of Distance From a Transplant 
Center with Access to Waitlist Placement, Receipt of Liver 
Transplantation and Survival Among US Veterans.'' Journal of the 
American Medical Association 311.12 (2014) 1234-1243.
---------------------------------------------------------------------------
    Dr. Dunn's legislation is straight forward and common sense in my 
opinion. It amends the Choice Act to explicitly cover organ transplants 
and applies a distance metric of 100 miles or greater from a VATC. If 
the veteran lives 100 miles or more from a VATC, the veteran can then 
choose whether they want to travel to a VATC for treatment or seek care 
at a civilian transplant center closer to their home.
    The primary reason to support Dr. Dunn's bill is that it is in the 
best medical interest of the veteran. Allowing a veteran to receive an 
organ transplant at a transplant center closer to their home increases 
the chance that the veteran will receive an organ and increases their 
chance of survival. It will reduce the travel requirements for a 
veteran who must travel to the assigned VATC for the transplant 
operation as well as preand post-operation care. It will increase the 
opportunities for the veteran's family to be present to support their 
recovery. It will allow veterans to avoid the prolonged in-patient care 
that is associated with being medically cleared for extended travel 
following the transplant operation. It is simply a veteran friendly 
bill that will improve the quality of care for veterans who require 
organ transplants.
    The system that VA currently has in place is problematic because it 
artificially inflates the demand for organs in certain regions but 
supply remains constant. Currently, the Organ Procurement & 
Transplantation Network \3\, which is administered by the Health 
Resources and Services Administration divides the United States into 11 
regions. Using livers as an example, the VA forces all veterans in the 
United States into the 5 regions where the 6 VATCs that conduct liver 
transplants are located even though the veterans may not live in those 
regions and therefore the veteran population does not get the 
opportunity to benefit from the total supply of organs within the 
United States.
---------------------------------------------------------------------------
    \3\ https://optn.transplant.hrsa.gov/members/regions/
---------------------------------------------------------------------------
    To illustrate this problem, I will use an example of a veteran 
located in Panama City, FL, who needs a liver transplant. VA assigns 
him or her to the Pittsburgh VATC which performs the most liver 
transplants of the 6 VATCs. Florida is in Region 3 \4\ and in 2016 
there were 1,392 livers donated. The 2017 liver waitlist for Region 3 
consists of 1,269 people waiting to receive a matching liver. To put it 
simply, if you live in Region 3 and you need a liver, there is a 
healthy supply of donated livers as compared to demand and you have 
very good chance of getting one. However, the veteran in Florida does 
not get to benefit from that robust supply. Instead, VA assigns them to 
the Pittsburgh VATC which is located in Region 2 \5\. Region 2, in 2016 
had 1,172 livers donated and the 2017 liver waitlist for Region 2 
consists of 2,058 people waiting to receive a matching liver. As you 
probably noticed, there are significantly more people in Region 2 who 
need a liver than livers donated and VA is making that problem worse by 
forcing veterans into the region which inflates demand. This 
requirement is not good for the veteran and it is not good for a 
civilian who needs a liver transplant because it diminishes every 
patient's chance to receive a matching liver.
---------------------------------------------------------------------------
    \4\ Region 3 Alabama, Arkansas, Florida, Georgia, Louisiana, 
Mississippi and Puerto Rico. https://optn.transplant.hrsa.gov/members/
regions/region-3/
    \5\ Region 2 Delaware, DC, Maryland, New Jersey, Pennsylvania, West 
Virginia and Northern Virginia. https://optn.transplant.hrsa.gov/
members/regions/region-2/
---------------------------------------------------------------------------
    H.R. 2601 is legislation that puts the best medical interest of the 
veteran first. It allows the veteran to receive lifesaving care closer 
to home while also allowing all veterans who need an organ transplant 
to benefit from the total supply of organs within the United States and 
not just the organ supplies in the regions where VA has located the 
VATCs. I hope you will support Dr. Dunn's legislation and include it in 
the upcoming legislation that is to replace the Choice Act. Thank you 
for the opportunity to submit this testimony.

                                 
                   VIETNAM VETERANS OF AMERICA (VVA)
    Submitted by
    Rick Weidman
    Executive Director for Policy & Government Affairs

    Regarding
    Draft legislation to amend title 38, United States Code, to 
establish a permanent Veterans Choice Program, and for other purposes; 
Draft legislation to amend title 38, United States Code, to modify the 
authority of the Secretary of Veterans Affairs to enter into agreements 
with State homes to provide nursing home care to veterans, to direct 
the Secretary to carry out a program to increase the number of graduate 
medical education residency positions of the Department of Veterans 
Affairs, and for other purposes; H.R. 1133, Veterans Transplant 
Coverage Act of 2017; H.R. 2123, VETS Act of 2017; H.R. 2601, VICTOR 
Act of 2017; H R. 3642, Military SAVE Act; VA Draft legislation Veteran 
Coordinated Access & Rewarding Experiences (CARE) Act; Draft 
legislation to direct the Secretary of Veterans Affairs to conduct a 
study on the Veterans Crisis Line and Draft legislation direct the 
Secretary of Veterans Affairs to furnish mental health care to veterans 
at community or non-profit mental health providers participating in the 
Veterans Choice Program

    October 24, 2017

Amended

    Good morning, Chairman Roe and other distinguished members of the 
Committee. Vietnam Veterans of America (VVA) is pleased to provide our 
Statement for the Record sharing our views concerning pending 
legislation before this committee.
    Draft legislation to amend title 38, United States Code, to 
establish a permanent Veterans Choice Program, and for other purposes.
    This draft legislation makes a number of changes and improvements 
to the VA health care system. The Veterans Choice Program established 
in Section 101 is generally in line with the Secretary's plan and 
vision. VVA supports the elimination of the arbitrary 30 day and 40 
mile requirements. Eligibility based on clinical need simplifies the 
process for both provider and veteran, making it a much more veteran 
centric program.
    Additionally, the consolidation of care authorities and the 
authorization of veterans care agreements are two big legislative asks 
that the Secretary has been highlighting for over two years. These 
changes not only increase access to care but help streamline the 
process for a successful implementation and transition.
    VVA has no objection to Section 202 of the draft legislation which 
authorizes the Secretary to reimburse for emergency ambulance services 
if the request was made as a result of a sudden onset of a medical 
condition where a prudent layperson who possesses an average knowledge 
of health and medicine would have reasonably expected that a delay in 
seeking immediate medical attention would have been life threatening or 
could reasonably expect the absence of immediate medical attention to 
result in placing the health of the individual in jeopardy and the 
individual is transported to the closest most appropriate medical 
facility.
    While we support the draft legislation, VVA would like to note that 
a priority of any legislation should be to restore the capacity of the 
Veterans Health Administration. We understand that VHA is struggling to 
fill 14,000 clinical positions. Additionally, purchasing care in the 
community, while necessary, should not be the focus of transforming 
VHA, rather preserving the health care system built to address the 
maladies of wartime veterans, should be. We oppose any pretense of 
privatization of the VA health care system.
    Draft legislation to amend title 38, United States Code, to modify 
the authority of the Secretary of Veterans Affairs to enter into 
agreements with State homes to provide nursing home care to veterans, 
to direct the Secretary to carry out a program to increase the number 
of graduate medical education residency positions of the Department of 
Veterans Affairs, and for other purposes.

    Section 1 would modify the authority to enter into agreements with 
State Homes to provide nursing home care. Importantly, these agreements 
are excluded from certain Federal contracting provisions, making it a 
much faster and more fluid process. This will allow the Secretary to 
provide quality, appropriate, care in a timely manner.

    Section 2 provides authority for the Secretary to record 
obligations for care at non-Department facilities on the date the claim 
is approved for payment rather than the date the hospital care was 
authorized.

    Section 3 authorizes a program to fill graduate medical education 
residency positions through educational assistance. This program would 
require individuals who are accepted to incur obligated service as a 
full-time employee of the Department in a clinical practice of the 
participant or in another health care position as determined by the 
Secretary, commensurate with the agreement. If, in the case the 
participant breaches the contract or fails to complete the period of 
service, they become liable to pay back an amount determined by the 
Secretary.

    Section 4 authorizes, at the discretion of the Secretary, covered 
health care professionals who are providing telemedicine to be able to 
do so in any location in any State regardless of the location of the 
provider or the patient. This is a change the VA has been asking for 
and would remove the barrier to care that currently exists and would 
greatly increase access, especially in rural areas.

VVA supports this legislation.

H.R. 1133, Veterans Transplant Coverage Act of 2017, introduced by 
    Congressman John Carter, (R-TX-31), to amend title 38, United 
    States Code, to authorize the Secretary of Veterans Affairs to 
    provide for an operation on a live donor for purposes of conducting 
    a transplant procedure for a veteran, and for other purposes.
    According to the Health Resource Services Administration (HRSA), 
the demand for organs far outweighs the number of donors. Living 
donations offer another choice and extends the supply of organs. Of the 
28,954 organ transplants performed in the U.S. in 2013, over one-fifth 
(5,989) were living donor transplants.
    While VVA has no objection to the bill, as it provides another 
avenue for veterans who receive transplants in the VA, the bill does 
not address potential liability issues for the Department concerning 
operating on someone who is not eligible for VA health care. 
Additionally, we note that VA would need sufficient appropriations to 
carry out this legislation.
H.R. 2123, VETS Act of 2017, introduced by Congressman Glenn Thompson 
    (R-PA-5), to amend title 38, United States Code, to improve the 
    ability of health care professionals to treat veterans through the 
    use of telemedicine, and for other purposes.
    This section authorizes a covered health care professional of the 
Department to furnish telemedicine at any location in any State 
regardless of where in a State the covered health care professional or 
the patient is located.
    This section requires a report on Telemedicine one year after the 
date of enactment. The report would include several elements to include 
satisfaction of veterans with services, satisfaction of health care 
providers, the effect of telemedicine on the ability of veterans to 
access health care, frequency of use, wait times, use by veterans of 
in-person and any reduction. This assessment would also include types 
of appointments that were provided during the year preceding the 
report, number of appointments during the year, disaggregated by VISN 
and finally, savings.
    The authority provided by this legislation regarding furnishing 
telemedicine at any location in any State regardless of where in a 
State the covered health care professional or the patient is located 
removes a formidable barrier and is something VA has been asking for in 
order to improve access to health care through telemedicine.
    VVA supports this legislation as long as there are strict oversight 
policies in place to ensure quality care and coordination of care is 
conducted in the best interest of the veteran.
H.R. 2601, VICTOR Act of 2017, introduced by Congressman Neal Dunn (R-
    FL-2), to amend the Veterans Access, Choice, and Accountability Act 
    of 2014 to improve the access of veterans to organ transplants, and 
    for other purposes.
    This legislation would authorize transplants under the Veterans 
Choice Program at a non-Department transplant center if the veteran 
resides more than 100 miles from a Department transplant center. The 
Secretary would enter into an agreement with the non-Department 
transplant center.

VVA has no objection to this legislation.

H.R. 3642, Military SAVE Act, introduced by Congressman Andy Barr (R-
    KY-6), to direct the Secretary of Veterans Affairs to carry out a 
    pilot program to improve the access to private health care for 
    veterans who are survivors of military sexual trauma.
    Section 2 of the bill establishes a pilot program to be carried out 
for a three-year period, at no more than five locations, to furnish 
hospital care and medical services to eligible veterans at non-
Department health care providers to treat physical and psychological 
injuries or illnesses as a result of sexual assault, battery of a 
sexual nature, or sexual harassment.

    The eligible veteran chooses the health care provider without 
restriction from the Secretary.

    The Department must collect data in the form of a survey for each 
veteran, whether they elect to participate in the pilot program or not, 
to assess the health care treatment furnished to the veteran under 
1720D of title 38. The survey includes a number of elements that would 
be garnered from the survey. The surveys will be taken when the veteran 
elects to participate in the program or as soon as practicable if the 
veteran does not choose to participate. The survey would be conducted 
during every six month period while the pilot program is going on and 
then upon completion of the pilot program. In addition to the survey 
the legislation requires four questionnaires be given to the 
participants of the pilot program. A VA researcher would be assigned to 
the pilot program to ensure integrity of information.
    There is a report required that includes several elements that are 
designed to assess such things as sleeping better, taking fewer or more 
medications, have a lower rate of suicidal thoughts or suicides. The 
report is to include whether eligible veterans who participated in the 
pilot, as compared to eligible veterans who did not participate fared 
in the evaluation.
    VVA has some concerns with the legislation. The first concern is 
that the legislation allows the veteran to choose the non-Department 
provider and restricts the Secretary from intervening in that choice, 
while not addressing the certification and/or qualifications of non-
Department agencies and/or individual providers. We believe this opens 
the veterans up to possibly choosing providers who are not qualified, 
and therefore experiencing poor quality health care, and may endanger 
the veteran. The second concern we have is with the questionnaires. 
Directing that the Secretary use the four that are listed in the 
legislation is very prescriptive. Some flexibility should be given to 
the Secretary to ensure that appropriate information and data are being 
collected. In addition, VVA believes that the Columbia-Suicide Rating 
Scale should not be used as the sole determinant for a veteran's 
suicide risk.
    VA Draft legislation Veteran Coordinated Access & Rewarding 
Experiences (CARE) Act, to amend title 38, United States Code, to 
improve veterans' health care benefits and for other purposes.
    The Surface Transportation and Veterans Health Care Choice 
Improvement Act of 2015 required the Department to provide Congress a 
plan to consolidate care programs and improve access to care for 
veterans. VA submitted that plan to the Committees on October 30, 2015.
    The path forward for this endeavor as outlined in the plan included 
streamlining eligibility, addressing referrals and authorizations to 
the community, developing highperforming networks, improving care 
coordination and medical records management, and improving billing, 
claims, and purchasing care. VVA is pleased to see VA put forth a draft 
that is generally in line with the plan. However, VA cannot move 
forward with this transformation unless they are given the legislative 
authority necessary to implement the changes.
    This draft legislation asks for the authority to engage in Veterans 
Care Agreements with eligible entities or providers. These Agreements 
would not be subject to any provision of law governing Federal 
contracts for acquisition. This would allow for a faster, easier and 
more streamlined process for VA to increase access to quality care for 
veterans. VVA believes this authority is a priority and we urge the 
Committee to act on this request.

    Sections 111through 114 all address the issue of paying providers 
in a timely and efficient manner. VVA supports these sections under 
Subtitle B of Title I, of the draft.

    Title III, Subtitle A, Section 301, authorizes a covered health 
care professional of the Department to furnish telemedicine at any 
location in any State regardless of where in a State the covered health 
care professional or the patient is located. This is at the discretion 
of the Secretary. Additionally, this section adds language on Supremacy 
over States. VA serves a large population of rural veterans who often 
times forgo needed medical treatment due to a variety of barriers that 
rural veterans face. VVA is pleased that this change to the delivery of 
telemedicine was included in the draft and fully supports its 
implementation.

    Title IV, Section 401, authorizes a pilot program for VA and 
Department of Defense (DoD) sharing of health care resources without 
billing. The program will run for two years in no more than five sites 
that would be jointly identified by the Secretaries. VVA fully supports 
collaborations with other Federal entities as long as veterans' timely 
access to quality health care does not take a back seat to other 
beneficiaries.

    Title V, Section 501 and 502 modify the termination date of the 
Choice Program to September 30, 2018, and, authorizes appropriations 
and appropriates $4 billion in mandatory funds from the Treasury to the 
VA Choice fund, respectively. VVA does not support mandatory funding 
for VA health care. The original funding of Section 802 of the Choice 
Act of $10 billion in emergency funding was supposed to be temporary. 
While we understand that mandatory funding may be necessary to bridge 
the gap while VA is implementing the transition plan, we fully expect a 
return to full discretionary funding of VA health care.

    Section 503 is a pay-for and authorizes round-downs of certain 
cost-of-living adjustments from 2018 through 2027. VVA is vehemently 
opposed to this section. We do not support taking money from veterans 
to pay for their own benefits. This is a disservice to all veterans and 
we call on Congress to find another source of funding.

    H.R. (no number), introduced by Congressman Jim Banks, (R-IN-03), 
to direct the Secretary of Veterans Affairs to conduct a study on the 
Veterans Crisis Line. VVA thanks the Congressman from Indiana for 
putting forth this important legislation. However, as recently as June 
2017, our organization called for a comprehensive evaluation of the 
VCL, which we feel is sorely needed. This evaluation is important and a 
needed effort to ensure the efficacy of the hot line. However, we 
cannot support the bill as written. We have several concerns with the 
some of the elements in the bill. Having said that, we would like to 
work with the Congressman and the Committee to improve the bill and 
ensure that the essential data called for in this study can be gathered 
in a less invasive, but more effective manner.

    H.R. (no number), introduced by Congressman Mike Gallagher (R-WI-
8), would direct the Secretary of Veterans Affairs to furnish mental 
health care to veterans at community or non-profit mental health 
providers participating in the Veterans Choice Program.

    Section 2 of this draft legislation would require the Secretary to 
furnish eligible veterans mental health care to a community or non-
profit mental health care provider, regardless of whether or not the 
veteran has a referral for the treatment. The sessions would be limited 
to eight with the Secretary having approval to extend that number 
pending approval of a treatment plan. However, the eligibility of the 
veteran to receive covered medical services would be determined by the 
community or non-profit provider. Additionally, a toll-free hotline, to 
a community or non-profit provider must be maintained by the VA. An 
initial report and final report would be required that lists several 
elements to include recommendations by the Secretary regarding 
extension or making permanent the authority.
    VVA has serious concerns with this legislation and hence cannot 
support it. First, there is no mention of any coordination of care; in 
fact, a veteran does not even have to have a referral. Seriously? This 
distorts the VA's role in navigating a veteran's health care, and would 
likely lead to poor quality and care management for the veteran.

    Second, if enacted, would result in total confusion for the veteran 
because it gives the community or non-profit mental health provider the 
authority to determine the eligibility of a veteran to receive covered 
medical services. This is neither sensible nor necessary.
    In addition, this legislation has privatization written all over 
it. Not only does it take fundamental authority away from the 
Secretary, it puts it in the hands of non-VA entities. It seems that 
the mental well-being and appropriate care of the veteran will take a 
back seat by extending the concept of choice.

    Third, yet another toll-free hotline is redundant and unnecessary, 
given that the VA already has established a Veterans Crisis Line (VCL).

    Finally, we would like to emphasize that the Veterans Health 
Administration provides superior mental health care for veterans. We 
would prefer to see Dr. Shulkin's vaunted CARE plan initiated, 
monitored, and tweaked where necessary. But we are adamant that primary 
care and mental health care must remain the province of the VHA.
    VVA thanks you for this opportunity to provide our Statement for 
the Record supporting our nation's veterans and their families.

                                 
                        WOUNDED WARRIOR PROJECT
    Chairman Roe, Ranking Member Walz, and Members of the Committee:

    Thank you for inviting Wounded Warrior Project (``WWP'') to offer 
our views on legislation currently under consideration by the 
Committee. WWP brings perspectives based on our first-hand experiences 
working directly with warriors who have sustained wounds, injuries, and 
illnesses since 9/11, and their families, through more than twenty 
comprehensive programs and services, as well as from our partnerships 
and collaboration with other community organizations who share our 
commitment to addressing the needs of wounded warriors and filling gaps 
in government care. We offer the following statement to assist the 
Committee in its review of pending legislation.
 Draft Legislation to establish a permanent Veterans Choice Program & 
Draft Legislation entitled the ``Veteran Coordinated Access & Rewarding 
                        Experiences (CARE) Act''
    As our community moves forward to forge a long-term replacement for 
the Veterans Choice Program, we must recognize that those who have put 
their lives in harm's way deserve the best possible care, regardless of 
whether that care is delivered by the Department of Veterans Affairs 
(VA) or community providers. VA provides exceptional care for veterans 
and should be given the resources it requires to continue improving 
health care quality and availability, but leveraging non-VA care to 
expand options and improve outcomes for veterans is a necessary part of 
meeting them where they are and where they want to go in their 
recovery. As such, WWP supports a strong integrated health system that 
provides timely access to optimal care a position based on feedback 
from warriors that provides unique insight to the needs of the post-9/
11 generation of warriors we serve.
    Since 2010, WWP has performed a comprehensive annual survey of our 
warriors to help the organization identify trends among this community, 
to compare their outcomes with those of other military and veteran 
populations, and to measure the impact and mix of WWP programs and 
services all in an effort to determine how we can better serve 
veterans, service members, and their families. Our forthcoming 2017 
Wounded Warrior Project Survey is based on the results of 34,822 
completed surveys and weighted to produce estimates representative of 
the 2017 WWP population, which stood at 106,821 as of October 3, 2017.
    While the final report is being prepared, we are pleased to share 
several data points from our study that illustrate recent trends in the 
community and focal points for emerging veteran-focused public policy. 
Among the most salient points for the Committee to consider are the 
following:

      Growing enrollment in VA health care: Up three percentage 
points from the 2016 estimate, 73.6% of warriors are enrolled for 
Veterans Health Administration (VHA) benefits and services. This 
represents a three-year increasing trend.
       While approximately forty percent of our nation's 
veterans are enrolled for VHA care, this survey indicates that wounded 
veterans who served on or after 9/11 are more likely to use VA health 
care than other segments of the overall U.S. veteran population.
      Use of VA primary care: More than two-thirds (69.0%) of 
responding warriors with VA health insurance use VA as their primary 
health care provider. These veterans may have other insurance in 
addition to VA coverage.
       Among warriors that do not use VA as their primary 
health care provider, the leading reasons why were difficulty accessing 
VA (43.5%), too much trouble or red tape (43.4%), and bad prior 
experiences at VA (43.4%).
      Effects of physical health and mental health problems on 
activities: Over 80% of warriors report that they were less productive 
than they would have liked because of their physical health or 
emotional problems. More than 8 in 10 warriors (82.2%) said that their 
physical health limited them in the kind of work or other activities 
they could perform in the past four weeks. More than 8 in 10 (83.9%) 
indicated that they were less productive than they would have liked 
because of emotional problems.
       Body weight: In 2017, the average body mass index (BMI) 
for our warriors was 30.7, slightly above the cut-off for obesity, 
which is 30.0. More than 8 in 10 (86.7%) warriors reported a BMI 
exceeding the cut-off for being overweight.
      Mental health care services Access/Resources: Among 
warriors, 51.7% had visited a professional to get help with issues such 
as stress, emotional, alcohol, drug, or family problems in the past 
three months, but access to care remains an issue. More than one-third 
of warriors (34.1%) had difficulty getting mental health care, or did 
not get the care they needed.
       VA scheduling: Over one-third of warriors (34.8%) 
indicated that conflicts between their personal schedules and hours of 
operation of the VA sites were the reason they had difficulty getting 
mental health care the most frequently cited reason in the survey.
       Geography: There was a slight decrease from the 2016 
estimate in the percentage of warriors mentioning a lack of resources 
in their geographic area as reason for difficulties in getting mental 
health care (24.7%, compared to 26.0% in 2016).
       Specialists: Warriors seeking mental health care from a 
specialist such as a psychiatrist, psychologist, social worker, or 
counselor averaged 5.7 visits (3.0 mean) over a 3month period.
       Encouraging trends: While 34.8% of warriors indicated 
scheduling conflicts with VA as an impediment to receiving care, that 
percentage has declined from 37.5% in 2015 and 36.4% in 2016. 
Similarly, the percentage of those citing difficulty in scheduling 
appointments has decreased from 31.5% in 2015, to 30.9% in 2016, to 
29.3% in 2017.
      VA top-cited resource for mental health care: Wounded 
warriors utilize various resources and tools to help address their 
mental health issues. VA was the most frequently cited resource 
(70.6%), continuing its trend as the most commonly used resource (66.1% 
in 2016).
       Quality: In addition to being the most frequently used 
resource, VA care was also cited as the most effective (20.3%); talking 
to another OEF/OIF/OND veteran (14.9%) was second; prescription 
medicine was third (10.8%); and service dogs/pets/other animals was 
fourth (9.0%).
      Physical health care services Access: More than 4 in 10 
warriors (42.7%) had difficulty getting health care for physical 
injuries or problems in the past 12 months, or they put off getting 
care, or did not get the physical health care they thought they needed.
       Scheduling: The most frequently cited reason was 
difficulty in scheduling appointments (39.1%).
       Encouraging trend Access: Similar to trends seen in 
mental health care access, difficulty in scheduling appointments was at 
its lowest point in three years, as the frequency has fallen from 42.4% 
in 2015, to 40.3% in 2016, to 39.1% in 2017.
       Discouraging trend Specialists: The percentage of 
veterans reporting that VA requirements make it difficult to get 
referrals to specialty treatment for physical problems has been growing 
since 2015. That percentage has risen from 29.6% in 2015, to 30.9% in 
2016, to 31.1% in 2017.

    While the 2017 Wounded Warrior Project Survey did not ask any 
questions related to the Veterans Choice Program or attempt to create 
control groups to assess the program usage or effectiveness, trends 
indicating improved access to care may reflect positive outcomes from 
the Veterans Choice Program. There is no doubt that veterans across the 
country have benefitted from the two pillars of the Veterans Access, 
Choice, and Accountability Act of 2014 (P.L. 113-146) investing in VA's 
internal capacity to meet rising demand for care, and improving access 
to community-based care to expand that capacity even further.
    The 2017 Wounded Warrior Project survey clearly shows that the 
veterans we serve most frequently look to VA for care, but that 
difficulty scheduling appointments whether due to bureaucratic morass 
or conflicts with VA hours of operation remain an impediment to care. 
Taken together, these points provide a compelling reason to continue 
making investments in VA-based care while recognizing that there are 
still limits in VA's capacity to meet demand for care. We urge the 
Committee to address pending legislation with an eye towards 
strengthening and modernizing VA-based health care and integrating 
community-based care to ensure timely and convenient access for all 
enrolled veterans.
    Moreover, WWP urges the Committee to consider the pending 
legislation as a vehicle to improving collaboration between VA and the 
nonprofit community and ensuring that VA has the requisite authorities 
to partner with private and nonprofit organizations to deliver care in 
new and innovative ways. As these organizations are often able to 
operate nimbly and with fewer restraints, several have become adept at 
identifying gaps in care, developing new and effective treatment 
strategies, and ultimately testing current ideas and practices for 
scalability in the future so that more veterans have access the best 
possible health care.
    At WWP, we have seen first-hand how our community can work together 
to deliver effective care in the present and build the foundation for 
even better care in the future. In January 2016, WWP, Emory University, 
Massachusetts General Hospital, University of California at Los 
Angeles, and Rush University Medical Center officially started 
accepting wounded service members for a first-of-its kind mental health 
program, Warrior Care NetworkT. Warrior Care Network represents a 
three-year, $100 million commitment made by Wounded Warrior Project and 
its partner academic medical centers (AMCs) to build a more systematic 
and evidence-based approach to post-traumatic stress disorder (PTSD) 
and traumatic brain injury (TBI) treatment, but that partnership 
extends even further.
    While AMCs provide veteran-centric comprehensive care, aggregate 
data, share best practices, and coordinate care in an unprecedented 
manner, a Memorandum of Agreement (MOA) between WWP and VA has been 
structured to further expand the continuum of care for the veterans we 
treat. The MOA generates cooperation and collaboration on several 
levels while emphasizing objectives consistent with several principles 
of a strong, integrated health system including the need to improve 
access and timely care, provide care and support networks at the local 
level, and increase the number of community-based providers competent 
in caring for veterans.
    To date, more than 2,300 wounded veterans across the country have 
received care through the Warrior Care Network, and we hope to reach 
thousands more in the years ahead. We believe that partnerships such as 
the Warrior Care Network embody the spirit of collaboration envisioned 
by community care integration, and we encourage the Committee to 
embrace legislative solutions that empower VA to identify and partner 
with organizations that are striving to build better models of care for 
the future.
    In closing, we commend the Committee for prioritizing the need to 
replace the Veterans Choice Program with a carefully designed system 
that is accessible and efficient for veterans, accommodating and 
inviting for providers, and built to ensure a strong and stable 
integrated system of care for those who have bravely served our county. 
While WWP does not currently endorse either of the community care bills 
before the Committee today, we are encouraged by the inclusive nature 
that both VA and Congress have used in crafting their proposals for a 
long-term replacement for the Veterans Choice Program. We are eager to 
engage with Congressional stakeholders as these deliberations continue, 
and wish to make our resources available to help increase understanding 
of the profile and particular needs of post-9/11 wounded veterans, or 
how WWP and others are finding new and innovative ways to serve this 
population.

                                 
                      NATIONAL INDIAN HEALTH BOARD
    VINTON HAWLEY, CHAIRMAN
    DRAFT LEGISLATION RELATED TO THE VETERANS CHOICE PROGRAM
    THE DEPARTMENT OF VETERANS AFFAIRS' (VA'S) LEGISLATIVE PROPOSAL, 
THE VETERAN COORDINATED ACCESS AND REWARDING EXPERIENCES (CARE) ACT

    On behalf of the National Indian Health Board \1\ (NIHB) and the 
567 federally recognized Tribes we serve, I offer this testimony for 
the record for the legislative hearing held on October 24, 2017. NIHB 
appreciates the opportunity to provide input on VA priorities for 
American Indian and Alaska Native (AI/AN) Veterans in Tribal 
communities across Indian Country, as well as the many non-Indian 
veterans in our communities for whom Tribally operated health care may 
be the only realistic choice. Today we will offer comments on draft 
legislation related to the Veterans' CHOICE program and the Department 
of Veterans Affairs' (VA) legislative proposal the Veteran Coordinated 
Access and Rewarding Experiences (CARE) Act.
---------------------------------------------------------------------------
    \1\ Established in 1972, the NIHB is an inter-Tribal organization 
that advocates on behalf of Tribal governments for the provision of 
quality health care to all American Indians and Alaska Natives (AI/
ANs). The NIHB is governed by a Board of Directors consisting of a 
representative from each of the twelve Indian Health Service (IHS) 
Areas. Each Area Health Board elects a representative to sit on the 
NIHB Board of Directors. In areas where there is no Area Health Board, 
Tribal governments choose a representative who communicates policy 
information and concerns of the Tribes in that area with the NIHB. 
Whether Tribes operate their entire health care program through 
contracts or compacts with IHS under Public Law 93-638, the Indian 
Self-Determination and Education Assistance Act (ISDEAA), or continue 
to also rely on IHS for delivery of some, or even most, of their health 
care, the NIHB is their advocate.
---------------------------------------------------------------------------
    The federal government's trust responsibility to provide health 
care to all AI/ANs extends across all departments and agencies of the 
United States and includes VA. And yet, although AI/ANs serve in the 
U.S. military at higher rates than any other race, they are 
underrepresented among Veterans who access the services and benefits 
they have earned. AI/AN Veterans are also more likely to lack health 
insurance and to have a disability, service-connected or otherwise, 
than Veterans of other races. \2\ Unfortunately, many AI/AN Veterans do 
not have faith and trust in the VA after past experiences and delays in 
enrollment, denial of care, or lack of access to VA services.
---------------------------------------------------------------------------
    \2\ United States Department of Veterans Affairs, American Indian 
and Alaska Native Service Members and Veterans
---------------------------------------------------------------------------
    The Indian Health Service (IHS) is a federal health care program 
designed to provide health care to over 2.2 million AI/ANs. It is an 
agency with a similar mission and purpose to the U.S. Department of 
Veterans Affairs (VA) and other federal health programs with the 
exception of the following differences: (1) American Indians and Alaska 
Natives have treaty rights for the provision of health care; (2) IHS is 
severely underfunded in comparison to other federal health care 
programs (for example, in 2015 the VA medical spending per patient was 
$8,760 compared to $3,136 IHS medical spending per patient); and (3) 
unlike other federal mandatory health programs, IHS is subject to 
sequestration and funded through discretionary funds, which are not 
increased with population growth, inflation, or new technology.

Indian health system and memoranda of agreements with the VA

    Section 813 of the Indian Health Care Improvement Act (IHCIA) 
authorizes Tribes and Tribal organizations to provide health care 
services to non-beneficiaries. \3\ As a result, many Tribes and Tribal 
organizations already serve non-IHS-eligible beneficiaries, many of 
whom are Veterans. In addition, section 405(c) of the IHCIA, as added 
by the 2010 Affordable Care Act (ACA), requires the VA to reimburse 
IHS, an Indian Tribe, or a Tribal organization for services provided to 
beneficiaries eligible for services from either the VA or from IHS. \4\ 
In 2014, the Veterans Access, Choice and Accountability Act (Choice 
Act) established an additional mechanism for the VA to work with Tribal 
health programs to serve Veterans. However, the Choice Act provides 
lower reimbursement rates and is more burdensome for Tribal health 
systems to implement. There is also a general preexisting authority in 
38 U.S.C. 8153 for the VA to enter into ``sharing agreements'' to 
purchase care, and at times the VA and Tribes have used this authority 
to enter into agreements.
---------------------------------------------------------------------------
    \3\ 25 U.S.C. Sec.  1680c. IHS may also serve non-AI/ANs with the 
consent of the tribes being served by the IHS directly operated health 
care program.
    \4\ U.S.C. Sec.  1645(c)
---------------------------------------------------------------------------
    The Tribal memoranda of understanding (MOUs) between the VA and the 
Indian Health Service, Tribes and urban Indian health care providers 
authorized under the Indian Health Care Improvement Act are ideal 
mechanisms for the federal government to preserve and build on the 
existing excellent relationships that the VA has with IHS and Tribal 
Health Programs. To date, the VA has over 100 agreements with the IHS, 
Tribes, and Tribal Organization entered into under the authority of 
section 405 of the IHCIA.
    The first of these MOUs was completed in 2012 well before the 
Choice Act was enacted. Between 2012 and 2017 the VA reimbursed $50 
million to IHS and Tribal facilities, serving over 5,000 eligible 
veterans nationwide. This is just a fraction of one percent of the VA's 
annual budget. NIHB and Tribes have continuously gone on record 
supporting the continuation of the current MOU system. The MOU 
agreements promote access to culturally competent exceptional health 
care for Veterans near home, including services provided in rural and 
medically underserved communities. IHS and THPs are federally funded 
programs carrying out federal responsibilities alongside the Veterans 
Health Administration. IHS and, therefore, THPs are not contractors, 
procurement sources, or outside, private vendors. The MOUs are crucial 
to the delivery of quality health care not only to Native American 
Veterans, but to thousands of non-Native Veterans as well.
    Though the legislation considered at the legislative hearing 
includes the Choice Act, we think this is a critical opportunity for 
Congress to reaffirm its intent for the Indian health system to 
continue to use the MOU agreements as authorized by section 405 of the 
IHCIA. NIHB therefore strongly recommends that the current bill be 
reframed in such a manner so as to reaffirm and maintain the current 
IHCIA Section 405 agreements between VA and IHS and Tribal Health 
Programs (THPs). The current national reimbursement agreements expire 
in 2019, but will hopefully be renewed.
    With these thoughts in mind, NIHB recommends that the bill be 
modified to include Tribes and Tribal organizations, along with IHS, 
and that it also reaffirm Congress' intent to maintain existing MOUs 
with IHS and Tribal providers entered into under Section 405 of the 
IHCIA, and that it further make plain that nothing in the new enactment 
amends or limits in any manner the authorities set forth in Section 
405. NIHB further recommends that provision be made to make clear that 
reimbursements under Section 405 agreements shall be at not less than 
the cost-based rates IHS annually publishes in the Federal Register. 
See, e.g. DHSS Indian Health Service--Reimbursement Rates for Calendar 
Year 2017, 82 Fed. Reg. 5585 (Jan. 18, 2017).
    Above all, it is critically important that the new enactment not 
undermine or substitute for the continuation of MOUs that are already 
in place. Care under IHCIA Section 405 MOU's is both veteran centric 
and community centric because is permits our Veterans to receive care 
in their own communities. It also takes advantage of existing systems 
that the VA could not possibly match, in areas where the private sector 
cannot address the need. \5\
---------------------------------------------------------------------------
    \5\ Finally, we note that the MOU has not been implemented for 
urban Indian health programs even though such programs are explicitly 
included in the 2010 agreement between VA and IHS. AI/AN Veterans may 
prefer to use an urban Indian health program instead of a VA facility. 
The participation of urban Indian health programs in the VA's community 
care network partnerships is important toward improving the quality of 
health care received by AI/AN Veterans.

---------------------------------------------------------------------------
Network Provider Clarification

    The House bill includes IHS as a ``network provider.'' It is 
necessary that legislative language also include Tribes/ Tribal 
Organizations and Urban Indian Health Organizations, so they may 
participate if they so choose. This will ensure that the whole Indian 
health system is clearly included as available providers. Additionally, 
legislative language should reflect that becoming a network provider in 
the Choice program is optional for Indian health providers.

Value Based Reimbursement Models

    We also note that the draft bill would encourage the use of a 
``value-based'' provider system. While we understand that this 
undefined term may make practical sense in other areas, the Indian 
health system should be exempted from such a system. Imposing value-
based standards on Tribal health care systems is simply unworkable. 
Moreover, the existing system of annually-published IHS rates already 
reflects a value-based methodology because it is developed based on an 
analysis of actual costs. For Tribal facilities to have to engage about 
new ``value-based'' quality measures would mean taking away extremely 
scarce resources from patient care. Tribes already report to the 
federal government on Government Performance and Results Act (GPRA) for 
quality of care and adding additional quality standards may just impose 
additional burdens. In short, the Indian health system already utilizes 
quality measures through GPRA and other means, so to add another layer 
would be duplicative and burdensome, and would siphon off already 
sparse resources from patient care. Therefore, we request that the 
Indian health system is specifically exempted from the requirement 
under the value-based reimbursement.

Clarification on Contracted Rates

    This proposed legislation and the Choice Act does not pay at the 
agreed upon Office of Management & Budget (OMB) rate, which is cost 
based and was included in the initial reimbursement agreement between 
the VA and IHS. Each Federal program that reimburses IHS and Tribes for 
health care (Medicare and Medicaid) does so at these rates. The current 
reimbursement structure is based on average costs calculated by an 
independent professional cost report preparer engaged by the IHS 
utilizing costs from audited financial statements and workload 
statistics maintained by the IHS in its National Database Warehouse. 
The calculated rates, which are calculated on a ``per visit'' or ``per 
encounter'' basis, are reviewed by the Centers for Medicare & Medicaid 
Services (CMS) and the OMB and, once approved, are published in the 
Federal Register for the purpose of reimbursing all IHS facilities for 
medical care, including Medicare, Medicaid, and others.
    IHS and THPs utilize robust, established provider networks that 
round out the services provided directly to AI/AN Veterans. These 
networks are critical in providing care to Veterans living in rural and 
remote areas. NIHB strongly opposes the standard rate and any reduction 
in the rate because of the circumstances that AI/ANs face with regards 
to physical health and social determinants of health. Any reduction in 
reimbursement will further exacerbate the conditions that the Indian 
Health System faces.
    Therefore, we recommend adding language to Section 101(d) of this 
draft legislation that would read:

    ``(G) Nothing in this section shall impact reimbursement rates or 
other provisions of agreements entered into by the Veterans' 
Administration and the Indian health service, Tribal Health Programs, 
or Urban Indian Health programs as authorized by 25 U.S.C. Sec.  
1645.''

VA's Legislative Proposal

Section 303 ``Improving Graduate Medical Education and Resiliency''

    NIHB appreciates the inclusion of IHS and Tribal health programs in 
Section 303 ``Improving Graduate Medical Education and Resiliency.'' In 
order to ensure the whole Indian health system is represented, we 
believe that it is appropriate to include Urban Indian Health Programs 
as part of the legislative language. Therefore, we recommend that the 
proposal be amended to read:
    ``(2) A facility operated by an Indian tribe or a tribal 
organization, or an Urban Indian organization as those terms are 
defined in Section 4 by the Indian Health Care Improvement Act (25 
U.S.C. 1603).

    Section 221 of the VA's legislative proposal includes consolidating 
existing programs. Again, we would recommend adding legislative 
language that would ensure that MOUs between the VA and Indian health 
system are not impacted. Therefore, we recommend the following language 
be added to this section:
    ``Nothing in this section shall impact reimbursement rates or other 
provisions of agreements entered into by the Veterans' Administration 
and the Indian health service, Tribal Health Programs, or Urban Indian 
Health programs as authorized by 25 U.S.C. Sec.  1645.''

Additional Recommended Legislative Changes

    Reimbursement for Purchased/Referred Care Services: NIHB also 
believes that this is an opportune time to include other technical 
corrections for AI/AN veterans. As discussed above, the VA-IHS MOU has 
proven to successfully facilitate patient care and provide the least 
administrative burden for VA, IHS, and THPs. Unfortunately, 25 U.S.C. 
Sec.  1645 has not be fully implemented. The current national agreement 
and, by default, all THP agreements do not include reimbursement for 
Purchased/Referred Care (PRC) services. IHCIA provided a broad 
directive to reimburse IHS and THPs for care provided to AI/AN veterans 
and this includes specialty and referral care provided through IHS and 
THPs.
    IHS and THPs utilize robust, established provider networks that 
round out the services provided directly to AI/AN veterans. These 
networks are critical in providing care to veterans living in rural and 
remote areas. Given the minimal amount of funding supporting IHS and 
THPs reimbursement agreements, including PRC services seems realistic 
as we work together to improve access to quality care for veterans 
across the country.
    As VA, IHS, and THPs work to build greater partnerships, we must 
work to address issues with regard to coordination of care. Failing to 
adequately coordinate care is magnified by VA's unwillingness to 
reimburse referral services. For example, if a Native veteran goes to 
an IHS or THP for service and needs a referral, the same patient must 
been seen within the VA system before a referral can be secured. This 
means the VA is paying for the same services twice, first for those 
primary care services provided to the veteran in the IHS or THP 
facilities, and then again when the patient goes back to the VA for the 
same primary care services to receive a VA referral. This is a not a 
good use of federal funding, nor is it navigable for veterans. As 
stated previously, the Indian Health Care Improvement Act provides the 
authority for this reimbursement and the VA needs to adhere to the law. 
Therefore, we recommend legislative language be included in this bill 
that would direct the Veterans Administration to include the 
reimbursement of Purchased/Referred Care to IHS and THPs for services 
provided to AI/AN veterans.
    Exemption for AI/AN Veterans from Co-pays and deductibles: As 
discussed above, the federal government has a unique trust 
responsibility AI/ANs Veterans, like all AI/ANs. In recognition of 
this, AI/ANs do not have copays or deductibles for services received at 
an Indian health facility. Additionally, this was recognized in the 
ACA, which includes language at Section 1402 to exempt all AI/ANs under 
300% of the federal poverty level from co-pays and deductibles on plans 
purchased on the health insurance Marketplace and all AI/ANs are 
exempted from copays and deductibles if they have a referral from the 
from an IHS or THP. Like IHS and the marketplace, the VA is another 
means by which the federal government upholds its trust responsibility 
to AI/ANs. The Veterans' Administration should similarly exempt AI/AN 
Veterans from copays and deductibles in the VA system in recognition of 
the federal trust responsibility. We believe that this legislation is 
an ideal opportunity for Congress to reaffirm this responsibility and 
include statutory language that would ensure that AI/ANs receiving 
services at the VA are similarly treated.

Conclusion

    Thank you again for the opportunity to offer testimony on this 
important legislation. As noted above, the United States has a unique 
trust responsibility to provide health services for all AI/ANs, 
including AI/AN Veterans. While the Indian health system is the primary 
way AI/ANs receive health services, this federal trust responsibility 
also includes other federal providers including the VA. In recognition 
of this fact, the IHS-VA MOU outlines the need for collaboration 
between the two agencies in order to provide AI/AN Veterans and other 
Veterans with the best possible care. We believe that further 
modifications to both the House draft legislation and the VA's 
Legislative proposal are needed before the legislation can move forward 
in order to ensure that the current IHS-VA MOU is preserved and that 
the federal trust responsibility for health is fully honored by the VA.
    We would welcome the opportunity to discuss these or other comments 
as this legislation moves through the legislative process.

                                 
                        Questions For The Record

    POST-HEARING QUESTIONS FOR ADRIAN M. ATIZADO
    DAV DEPUTY NATIONAL LEGISLATIVE DIRECTOR

    Question 1: The draft bill, which would direct the Department of 
Veterans Affairs (VA) to provide mental health care to veterans at non-
profit or community providers and bypass VA's care coordination role, 
was added to the agenda late last week and did not give witnesses 
sufficient time to review and prepare testimony that reflects the views 
of their organizations.

    Q. Does DAV support this bill? If not, what are DAV's concerns?

    Response: Thank you for the opportunity to comment on this draft 
legislation. The bill seeks to increase access for veterans in distress 
who require immediate attention for mental health conditions. While we 
appreciate this intent, DAV does not support this bill. DAV believes 
that mental health treatments for war-related or military sexual trauma 
(MST) are foundational services that VA cannot contract out to 
community providers without significantly impairing the quality and 
continuity of services rendered to enrolled veterans.
    As we understand it, this draft legislation would authorize same-
day mental health care services from non-VA providers participating in 
the CHOICE program without a VA referral as part of VA's comprehensive 
program for suicide prevention. If enacted, veterans could self-refer 
or use a VA referral service to identify CHOICE providers available for 
same-day care and could remain under this provider's care for as many 
as eight visits (and more if authorized). Providers would have to 
verify veterans' eligibility for such care through VA and VA would pay 
providers under the same schedule as negotiated for CHOICE. VA would 
simply act as a payer for eligible veterans and would not restrict 
veterans' choice of a provider.
    DAV acknowledges that veterans occasionally require immediate 
access to care that VA cannot provide, but believes that the CHOICE 
program and the emergency benefit already in law address this problem 
while maintaining VA's role as primary care coordinator. Unfortunately 
this bill, if enacted, would leave VA providers out of the care process 
entirely-DAV believes to the veteran's detriment. Under the 
legislation, VA would be unable to deter veterans' use of outside 
services even if the veteran is already being treated for a mental 
health condition within VA. VA may not be asked to work with the 
provider to identify VA treatment modalities that might be appropriate 
or share patient information that might inform therapy. It would not 
allow VA to establish referral patterns based on the development of a 
trusted relationship between certain CHOICE providers and VA, nor would 
it allow VA to recommend providers that it believes are more proficient 
and knowledgeable in providing evidence-based treatment for mental 
health conditions such as PTSD and depression. It is also unclear if 
the veteran would have to be in crisis in order to receive care or just 
choose not to wait. In short, it would not allow VA providers to 
coordinate services or collaborate on an appropriate care plan for the 
veteran.
    VA has developed an integrated system of health care provision for 
veterans with mental health conditions that is unrivaled in the private 
sector. Starting with primary care, VA trains providers to identify 
prevalent conditions among veterans including post-traumatic stress, 
traumatic brain injury, anxiety, depression, MST, substance use 
disorders and suicidal ideation. Mental health providers are included 
on primary care teams to provide immediate screening and referral for 
veterans who screen positive for any condition. VA has identified 
suicide prevention and MST coordinators at each medical center. Using a 
new algorithm, VA has even begun to ``flag'' veterans at risk of 
suicide in order to monitor and manage their care. Flagged veterans 
must attend appointments to manage their mental health conditions. 
Suicide prevention coordinators routinely follow up to ensure that 
these patients do not miss scheduled appointments and to follow up on 
their care afterward.
    The highly integrated and coordinated approach VA uses to address 
veterans' needs has worked. VA has clearly demonstrated that veterans 
engaged in VA care are at far lower risk of committing suicide than 
veterans who are not. Veterans under VA care for chronic mental health 
conditions are even likely to add years to their expected life span.
    VA does this in large part by coordinating care with all care 
providers through its electronic health record system-it is this tool 
that collates all of the disparate pieces of care together serving as a 
common database for all VA providers and ensuring care continuity for 
the veteran. VA also offers a number of ``wrap around services'' that 
can be supported through case management and care coordination to 
veterans that are at high risk for adverse outcomes. This important 
tool can help to ensure that veterans receive timely access to 
necessary care and services. VA is now beginning to implement a new 
database to manage its patient care programs that will make it easier 
to share this information with outside providers.
    When a veteran is in crisis or at risk, VA can also make a 
continuum of resources available-programs that address veterans at risk 
of homelessness, substance use disorders, and programs that assist with 
learning or relearning independent life and vocational skills. VA can 
often help with transportation and, in some circumstances, with child 
care, to ease veterans' access to care. VA can even help stabilize 
veterans' families through its vet centers and some of its homeless 
programs. Few, if any, private sector providers have the ability to 
offer this array of services in a comprehensive and holistic way.
    There is also a largely unanswered question of availability of 
expertise and capacity within the private sector. Studies done by the 
RAND corporation and others found that outside providers are not 
routinely trained in evidence-based practices. Care outcomes, including 
use of recommended medications, are far lower. Capacity in 
professionals trained to deliver the evidence-based care this draft 
bill calls for may also be severely limited. While VA has trained more 
than 6,000 providers in these treatment protocols for PTSD and 1,800 
for depression, RAND found that fewer than 18% of TRICARE providers and 
6% of non-TRICARE providers had received training on any evidence-based 
practices.
    In addition, this draft bill threatens to undermine VA's programs. 
While CHOICE funding has previously been earmarked, VA has asked for 
the ability to move funding between its own programs and those funded 
under CHOICE. If veterans are allowed unfettered access to any CHOICE 
provider available to see them for a mental health condition, 
resources-mostly providers-may be drawn away from VA programs 
compromising the access to and integrity of these highly specialized 
programs. Additionally, VA would have no ability to control these 
costs.
    Mr. Chairman, the current state of VA's mental health programs is 
the product of a wealth of education from years of clinical experience 
with our nation's veterans that make them culturally attuned and 
effective. The Independent Assessment of VA programs required under 
Sec. 201 of Public Law 113-146 indicates that VA mental health 
providers are operating at a high level of productivity. Programs are 
specialized to meet the needs of veterans and VA uses evidence-based 
practices to ensure care results in the best possible outcomes. Most 
importantly, VA's programs save our veterans' lives. While VA is 
certainly not perfect, it is able to provide far more comprehensive 
services than the private sector. VA's mental health care system sets 
the gold standard for which other mental health providers strive. For 
these reasons, we are unable to support a bill that is likely to result 
in inferior care for our veterans.
    We appreciate Mr. Gallagher's attempt to work through some of the 
most important problems we have with this bill, but suggesting that the 
differences between VA and CHOICE programs can be resolved by requiring 
medical records to be exchanged between CHOICE providers is not 
realistic.
    We would appreciate Congress backing away from this draft bill. At 
the very least, Congress should require a much greater understanding of 
its impacts, including its costs, that are sure to accrue to VA should 
it be enacted.
    Thank you for this opportunity to our views on this draft bill.

    Question 2: Mr. Atizado, in your testimony regarding the Minority's 
draft language, you indicated DAV generally supported the intent of the 
section that would provide VA with new authorities to incentivize 
medical students to fill the 1,500 GME slots created under VACAA. 
However, you indicated alternative incentives should be considered. 
Would you care to elaborate on what those alternatives are in your 
opinion?

    Response: This Committee is to be commended for working to improve 
ill and injured veterans' limited access to the VA health care system 
by expanding use of academic affiliations, federal and state partners, 
and community providers. DAV believes VA is the veterans' first choice 
for health care and this Committee bears the responsibility of 
improving VA's capacity to directly provide veteran-centric care, 
making VA health care more accessible.
    We believe this requires, at a minimum, reforming how VA buys care 
in the community, how the Department modernizes its aging 
infrastructure and align its real property assets, and how the agency 
is able to hire, train and retain medical professionals and effectively 
manage its workforce.
    The Veterans Health Administration (VHA) has serious and long-
standing challenges with its workforce. A multipronged approach is 
required and should include such things as addressing VHA's limited 
human resources (HR) capacity, providing VHA the resources and 
authority to directly hire, pay competitively in local markets, and 
have an attractive work environment. The relationship VA has with U.S. 
medical schools and teaching hospitals, in which veterans gain access 
to high quality care and ensure the next generation of clinicians 
acquire those competencies needed to care for veterans and all 
patients, offers the Department the opportunity to recruit and hire. VA 
is the largest training site for physicians, and funds approximately 10 
percent of national graduate medical education (GME) costs annually.
    While we support the intent of creating new incentives to bring 
clinicians into the VA health care system such as that proposed in the 
draft bill to incentivize medical students to fill the 1,500 GME 
residency positions created by Public Law 113-146, the Veterans Access, 
Choice, and Accountability Act of 2014, we recommend the Committee 
expand its vision to include other federal programs for the VA to 
improve recruitment of physicians during residency training at the VA. 
For example, the VA can partner with the Uniformed Services University 
of the Health Sciences (USUHS) and the U.S. Public Health Service 
(PHS). USUHS medical school graduates each year are assigned to 
shortage areas as PHS officers. With VA financial support, new 
participants in this program could be commissioned into the PHS, attend 
USUHS, and agree to serve seven years with VA post-GME residency. We 
believe VA, USUHS and PHS are close to an agreement but will require 
funding for these positions.
    The Health Professions Scholarship Program (HPSP) has been a 
critical source of trained health care professionals entering the U.S. 
military. The HPSP offers future and current medical school students up 
to four years of paid medical education and living stipend, in exchange 
for service as a commissioned medical department officer. The military 
service obligation is generally one-for-one for every service-paid year 
of schooling, with a minimum of two years for primary care physicians 
and three years for physician specialists. Fulfillment of the 
obligation begins only after postgraduate training is completed.
    Other recruitment options could include loan repayment programs and 
scholarships similar to that offered by the National Health Service 
Corps (NHSC). Its Students to Service (S2S) loan repayment program is 
offered when medical students choose their specialty and residency 
training by providing up to $120,000 to repay student loans during 
medical residency and in return physicians commit to a 3-year service 
obligation in certain medical shortage areas after their training is 
complete. The NHSC scholarship program pays tuition, fees, other 
educational costs, and provides a living stipend in return for a 
commitment to work at least 2 years at certain medically underserved 
community.
    As you are aware, DAV provided testimony for the record on 
September 26, 2017 in support of the discussion draft to, among other 
things, make certain improvements in the Health Professionals 
Educational Assistance Program of the VA. Similar to the options listed 
above, this draft bill would use scholarships to address shortages and 
vacancies and require service obligations for 18 months for each school 
year the scholarship was awarded. Loan repayment would be used, alone 
or in tandem with the scholarship above, for specifically targeted 
medical specialties particularly difficult for VA to recruit or retain.
    Of immediate concern is the effect Public Law 114-198, the 
Comprehensive Addiction and Recovery Act of 2016 has had on VA 
facilities ability to recruit and retain clinicians. This law linked 
VA's Recruitment, Relocation and Retention (3R) Incentives under the 
same spending cap as Performance Awards. It is our understanding that 
this change resulted in a nearly 30 percent cut in FY 2016, compared to 
FY 2015, in individual performance based awards and the cut in 2017 is 
even greater. As you are aware, the 3R Incentives are used by VA 
facilities to ``bump-up'' VA salaries in order to be competitive with 
what their private sector counterparts offer the best and brightest 
clinicians. Notwithstanding VA's disadvantages including tens of 
thousands of VA clinical vacancies, the complexity of federal hiring 
and the relatively low salaries VA is authorized to offer, DAV 
recommends the removal of the 3Rs from the spending cap and redress the 
funding loss for the 3Rs for FY 2017 and for FY 2018.

                                 
                   Material Submitted For The Record

                                  JAVA
    Original Investigation
    Association of Distance From a Transplant Center With Access to 
Waitlist Placement, Receipt of Liver Transplantation, and Survival 
Among US Veterans
    David S. Goldberg, MD, MSCE; Benjamin French, PhD; Kimberly A. 
Forde, MD, MHS; Peter W. Groeneveld, MD, MS; Therese Bittermann; Lisa 
Backus, MD, PhD; Scott D. Halpern, MD, PhD; David E. Kaplan, MD, MSc
    IMPORTANCE Centralization of specialized health care services such 
as organ transplantation and bariatric surgery is advocated to improve 
quality, increase efficiency, and reduce cost. The effect of increased 
travel on access and outcomes from these services is not fully 
understood.
    OBJECTIVE To evaluate the association between distance from a 
Veterans Affairs (VA) transplant center (VATC) and access to being 
waitlisted for liver transplantation, actually having a liver 
transplant, and mortality.
    DESIGN, SETTING, AND PARTICIPANTS Retrospective study of veterans 
meeting liver transplantation eligibility criteria from January 1, 
2003, until December 31, 2010, using data from the Veterans Health 
Administration's integrated, national, electronic medical record linked 
to Organ Procurement and Transplantation Network data.
    MAIN OUTCOMES AND MEASURES The primary outcome was being waitlisted 
for transplantation at a VATC. Secondary outcomes included being 
waitlisted at any transplant center, undergoing a transplantation, and 
survival.
    RESULTS From 2003-2010, 50 637 veterans were classified as 
potentially eligible for transplant; 2895 (6%) were waitlisted and 1418 
of those were waitlisted (49%) at 1 of the 5 VATCs. Of 3417 veterans 
receiving care at a VA hospital located within 100 miles from a VATC, 
244 (7.1%) were waitlisted at a VATC and 372 (10.9%) at any transplant 
center (VATC and non-VATCs). Of 47 219 veterans receiving care at a VA 
hospital located more than 100 miles from a VATC, 1174 (2.5%) were 
waitlisted at a VATC and 2523 (5.3%) at any transplant center (VATC and 
non-VATCs). In multivariable models, increasing distance to closest 
VATC was associated with significantly lower odds of being waitlisted 
at a VATC (odds ratio [OR], 0.91 [95% CI, 0.89-0.93] for each doubling 
in distance) or any transplant center (OR, 0.94 [95% CI, 0.92-0.96] for 
each doubling in distance). For example, a veteran living 25 miles from 
a VATC would have a 7.4% (95% CI, 6.6%-8.1%) adjusted probability of 
being waitlisted, whereas a veteran 100 miles from a VATC would have a 
6.2% (95% CI, 5.7%-6.6%) adjusted probability. In adjusted models, 
increasing distance from a VATC was associated with significantly lower 
transplantation rates (subhazard ratio, 0.97; 95% CI, 0.95-0.98 for 
each doubling in distance). There was significantly increased mortality 
among waitlisted veterans from the time of first hepatic decompensation 
event in multivariable survival models (hazard ratio, 1.03; 95% CI, 
1.01-1.04 for each doubling in distance). For example, a waitlisted 
veteran living 25 miles from a VATC would have a 62.9% (95% CI, 59.1%-
66.1%) 5-year adjusted probability of survival from first hepatic 
decompensation event compared with a 59.8% (95% CI, 56.3%-63.1%) 5-year 
adjusted probability of survival for a veteran living 100 miles from a 
VATC.
    CONCLUSIONS AND RELEVANCE Among VA patients meeting eligibility 
criteria for liver transplantation, greater distance from a VATC or any 
transplant center was associated with lower likelihood of being 
waitlisted, receiving a liver transplant, and greater likelihood of 
death. The relationship between these findings and centralizing 
specialized care deserves further investigation.
    Centralization of specialized health care services is used to 
control costs, concentrate expertise, and minimize regional differences 
in quality of care. Such efforts are common in national health systems. 
In the United States, insurers regionalize care by contracting with 
centers of excellence for services like bariatric surgery, cardiac 
interventions, and treatment for some cancers.1-3 Although efficient, 
centralization may offset any gains in care delivery by increasing the 
distance between patients and hospitals.2,4-9 Prior studies relating 
geography to health care access found less access for rural patients 
and for those patients living far away from hospitals delivering 
specialized services.2,5,10-12 Few studies have examined specialized 
care restricted to a limited number of centers. Previous studies of 
access to care were limited by not knowing the total population in need 
of care.2,12,13 Organ transplantation is a highly specialized service 
requiring concentrated medical and surgical expertise, resulting in de 
facto centralization in metropolitan regions.14 Veterans with Veterans 
Health Administration (VHA) benefits receive care at 1 of 128 Veterans 
Affairs (VA) hospitals or associated community-based clinics. Within 
the VA, liver transplantation is offered at only 5 VA transplant 
centers (VATCs) located in Houston, Texas (since 2008); Nashville, 
Tennessee; Pittsburgh, Pennsylvania; Portland, Oregon; and Richmond, 
Virginia. Veterans with secondary insurance (ie, Medicare) may obtain 
care at either a VATC or non-VATC. Patients at the VA lacking other 
health insurance generally receive care at a VATC except in rare 
emergencies (ie, fulminant hepatic failure).
    Liver transplantation in the VA system serves as a model to study 
the association between distance and access to centralized medical 
resources. We tested the hypothesis that increasing distance between a 
patient and a liver transplant center (ie, VATC) is associated with a 
lower likelihood of being waitlisted for transplantation, a lower 
likelihood of getting a liver transplant, and an increased risk for 
mortality.
    Methods
    We evaluated liver transplantation in the VA between January 1, 
2003, and September 20, 2012. January 1, 2003, was selected as the 
start date because it was about 1 year after the implementation of the 
current model for end-stage liver disease (MELD) allocation system. 
MELD shifted liver transplantation priority away from wait time to 
illness severity.15-17
    The study was approved by the institutional review boards at the 
Philadelphia VA Medical Center and the University of Pennsylvania, 
which included a waiver of informed consent.
    Veterans Eligible for Waitlisting at a VATC
    Any veteran with VHA health benefits who used the VA health system 
was eligible for inclusion. We queried the VHA's Corporate Data 
Warehouse18 to identify transplant-eligible veterans meeting the 
following minimal waitlisting criteria established by the American 
Association for the Study of Liver Diseases: cirrhosis with a 
complication of liver disease (ascites, variceal bleeding, or hepatic 
encephalopathy) or hepatocellular carcinoma.19,20 Transplant-eligible 
veterans were identified using a validated International Classification 
of Diseases, Ninth Revision, coding algorithm.21,22 Weexcluded veterans 
aged 70 years or older (only 4 veterans aged ?70 years were waitlisted 
at a VATC from 20032010) with malignancies precluding transplantation 
or having the human immunodeficiency virus (eTable 1 in Supplement).20 
We only included veterans with incident decompensated cirrhosis from 
January 1, 2003, until December 31, 2010, to ensure sufficient follow-
up for outcomes assessment. Veterans Affairs physicians may not 
directly refer veterans who have secondary insurance to non-VA 
transplant facilities. They may, however, inform patients of their 
ability to refer themselves for non-VA health care. The VA does not 
reimburse veterans for co-pays or deductibles related to non-VA care.
    We restricted our cohort to veterans who were active users of VA 
outpatient care to ensure the ability to be referred for liver 
transplantation in the VA system. We defined active users as patients 
who were seen in VA outpatient clinics for at least 2 physician or 
clinician outpatient visits in the 365 days following the first 
decompensation event or hepatocellular carcinoma event (including the 
index visit if outpatient). Twovisits were required based on previous 
studies evaluating use of VA care,23,24 and the assumption that to 
complete testing prior to referral to a VATC, a veteran must have at 
least 2 outpatient visits. Veterans were assigned to a local VA medical 
hospital using Corporate Data Warehouse data, which identified the VA 
medical hospital where a patient received his or her medical care. 
Patients receiving care at more than 1 VAfacility were assigned to the 
first hospital where he or she met the coding algorithm criteria for 
having decompensated cirrhosis, hepatocellular carcinoma, or both.
    Identification of Waitlisted Veterans
    We cross-referenced Social Security numbers of all waitlisted liver 
transplant candidates from 2003-2012 using the Organ Procurement and 
Transplantation Network (OPTN) database25 linked with the VA Corporate 
Data Warehouse. Among the 110 US liver transplant centers, the 
waitlists of only 5 (the VATCs) were solely composed of patients with 
VA insurance, and these transplant centers could be discriminated based 
on the distribution of zip codes of the waitlisted patients at each 
center.
    Statistical Analysis
    Access to Waitlisting
    In our primary analysis, we evaluated the relationship between a 
transplant-eligible veteran's distance from the local VA hospital to a 
VATC and being placed on the waitlist for a liver transplant at a VATC. 
Secondarily, we evaluated the association between distance to a VATC 
and being placed on the waitlist at any transplant center (VATC and 
non-VATC) to determine whether access to a local non-VATC mitigates 
this relationship between distance and waitlisting. We chose a binary 
waitlisting outcome because access to transplantation once waitlisted 
is based on severity of illness not waiting time unlike kidney 
transplantation.
    Distance was modeled as a continuous variable. The relationship 
between distance and waitlisting was not linear so distance was 
linearized by log transformation in the log 2 base scale.26 In a 
secondary analysis, distance was modeled as a categorical variable with 
5 categories. To our knowledge, no prior regionalization study has 
modeled the effect of distance with the conditions we studied. Thus, we 
created 5 distance categories having broad ranges to prevent 
identification of individual hospitals (ie, no hospital was 100 miles 
from a VATC, but hospitals were 90 or 110 miles, thus 100 miles was a 
cutoff not associated with a specific VA hospital) that were based on 
the observed relationships between certain distance and waitlisting 
outcomes upon initial evaluation of the data (to convert miles to 
kilometers, multiply by 1.6). Because these categories were defined 
after examination of the data, these analyses should be considered post 
hoc
    We assumed that veterans receiving care at a VA within 100 miles of 
a VATC would live at home after discharge from the transplant 
hospitalization given that travel times for these veterans would be 
less than 90 minutes. Thus, the first distance cut point was selected 
to be 100 miles. Distances longer than 100 miles were categorized 
relative to travel times or mode of transportation to a VATC (ie, 
necessity to travel by plane for those living >500 miles from a VATC). 
Privacy regulations precluded our access to a veteran's home address. 
Consequently, the shortest distance in miles was measured between the 
VA medical hospital where the patient received routine care and the 
closest VATC or non-VA transplant facility.
    Regression analyses were performed using generalized estimating 
equation models with a logit link, an exchangeable correlation 
structure, and a robust variance estimator to account for patient 
clustering within VA hospitals27 using Stata version 13.0 (StataCorp). 
Models were adjusted for age at the time of hepatic decompensation 
without inclusion of other patient-level covariates. We did not have 
access to other patientlevel covariates because the VA data use 
agreement only authorized identification of date and age at the time of 
hepatic decompensation. The following data were captured for all 
patients with hepatitis C at a given VA hospital and were adjusted to 
account for hospital characteristics that may be associated with 
waitlisting independently of distance: (1) age (median); (2) 
socioeconomic status estimated by the proportion of patients who are 
below the federal poverty level; (3) race/ ethnicity (proportion self-
reported as white); and (4) mental illness (proportion with anxiety, 
bipolar disorder, depression, posttraumatic stress disorder, and/or 
schizophrenia). Hospital-level measurements of these covariates were 
obtained from the VA Clinical Case Registry: Hepatitis C, which is a 
national VA registry of all patients with hepatitis C because such 
measurements are not available among other data for the entire VA 
population.28-30 We assumed the distribution of these covariates 
mimicked the broader chronic liver population at each VA medical 
hospital.
    Transplantation
    The distance to a transplant center may affect the likelihood of 
receiving a liver transplant. For example, patients living closer to a 
transplant center might have increased access to transplantation 
because they can reach the center in the narrow time window of an organ 
offer, or by virtue of proximity, serve more readily as a backup 
recipient. To evaluate this, we analyzed all waitlisted veterans, and 
modeled deaths while waitlisted as identified by OPTN coding or within 
90 days of being removed from the list. Deaths were identified from the 
Social Security Death Master File found within OPTN. Pretransplant 
deaths were modeled as competing risks31,32 because death while on the 
waitlist serves as a competing risk to transplantation.
    We fit competing risk Cox regression models with transplantation as 
the outcome and all other waitlist removals (ie, condition improved) 
other than death (modeled as the competing risk) as censoring 
events.31,32 The exposure was distance from a patient's home VA 
hospital to a VATC. Covariates included sex, race/ethnicity, age, 
laboratory MELD score,16,17 and albumin measured when waitlisted, 
diagnosis, and hepatocellular carcinoma (binary yes or no as to whether 
a patient was receiving additional waitlist priority for hepatocellular 
carcinoma33). We tested for interactions between distance and being 
waitlisted at a VATC to determine if the probability of being 
waitlisted is directly influenced by distance. We used a robust 
standard error estimator to adjust for the clustering of veterans 
within VA hospitals.34,35
    Survival
    The relationship between mortality and distance to a VATC among all 
waitlisted veterans was modeled with Cox regression. Time from the 
first hepatic decompensation event to death or a censoring event (eg, 
condition improved) was modeled with the exposure variable being 
distance from the patient's home hospital to a VATC. Follow-up began at 
the date of first hepatic decompensation event to account for the time 
a patient first became eligible for transplant, which may have been 
associated with delays in being waitlisted as a function of distance. 
We adjusted the model for covariates available in OPTN (sex, race/
ethnicity, age, laboratory MELD score,16,17 albumin level measured when 
waitlisted, diagnosis, and hepatocellular carcinoma) and insurance 
status at the time of waitlisting. Residential-level poverty was 
adjusted for using OPTN zip code data.36 Death dates were ascertained 
as specified above. We used a robust variance estimator to adjust for 
clustering within VA hospitals.34 The proportional hazard assumption 
was tested for using Schoenfeld residuals.
    Sensitivity Analyses
    Although veterans with decompensated cirrhosis met minimal clinical 
criteria for being waitlisted, a MELD score of 15 or greater may better 
determine eligibility.37 In a preplanned sensitivity analysis, we 
restricted our cohort to veterans having MELD scores of 15 or higher 
following the diagnosis of decompensated cirrhosis, hepatocellular 
carcinoma, or both. The influence of a patient's base hospital having 
advanced liver care available (defined by being located within 20 miles 
of any transplant center, being affiliated with an academic liver 
transplant center, and having a clinician specialized in hepatology) 
was modeled by a distance x advanced liver care interaction analysis. 
Availability of secondary insurance status (defined as none, Medicaid, 
secondary non-Medicaid, or Medicaid plus secondary non-Medicaid) was 
modeled as a covariate for the 45 792 (90.4%) of the cohort who had 
this information available in the VA Corporate Data Warehouse (10% had 
missing data or insurance status reported as unknown).
[GRAPHIC] [TIFF OMITTED] T1343.001

    Abbreviations: IQR, interquartile range; NASH, nonalcoholic 
steatohepatitis.
    a Unless otherwise indicated.
    b Derived from the ?2 test for categorical variables and the 
Wilcoxon rank sum test for the continuous variables.
    c Other race/ethnicity included multiracial, Pacific Islander, and 
individuals who responded as other.
    d Included metabolic liver diseases, acute liver failure, 
polycystic liver disease, and all other diagnoses.
    e Defined as the proportion of people residing in the zip code who 
are living below the federal poverty level. Patient-level zip code data 
were only available for the 2895 waitlisted veterans registered with 
the Organ Procurement and Transplantation Network.
    Statistical significance was defined as P < .05 using 2-sided 
tests. The final multivariable models also include variables with 
biological plausibility for the association with the outcome, even if 
the P value was above the prespecified P value threshold (ie, 
diagnosis). All analyses used Stata version 13.0 (StataCorp), including 
the xtgee module.
    Results
    Among all veterans in the United States having VHA health benefits 
and using VHA medical care, 79 899 had incident decompensated cirrhosis 
or hepatocellular carcinoma (ofany stage) and used VA outpatient 
services from 2003-2010. Although hepatocellular carcinoma stage could 
not be ascertained, which affects transplant eligibility,38 results 
were unchanged when patients with hepatocellular carcinoma were 
excluded. Of the 79 899 veterans, 29 262 were excluded (18 041 were 
aged ?70 years and 11 221 were <70 years, but had a malignancy 
precluding transplantation). This left a total analytic cohort of 50 
637. Overall, 2895 (5.7%) veterans meeting our predefined criteria of 
using VA outpatient care were waitlisted (1418 [49.0%] ata VATC and 
1477 [51.0%] at a non-VATC). Waitlisted veterans had significantly more 
VA clinician visits than veterans who were not waitlisted, but there 
were no differences based on distance to a VATC. Demographic 
characteristics are listed in Table 1 (additional clinical data in 
eTable 2 in Supplement).
    Validation of Distance
    Our method of measuring distance was validated by analyzing the 
cohort of veterans waitlisted at the Pittsburgh VATC (eTable 3 in 
Supplement). Because the home zip codes of waitlisted veterans is 
provided in OPTN data, the distance from the centroid of a respective 
veteran's home zip code to the Pittsburgh VATC was compared with the 
measured distance from that veteran's local VA hospital to the 
Pittsburgh VATC. The median distance between these 2 measured distances 
was 18.7 miles (interquartile range, 5.3-55.7 miles), with nearly 90% 
of such veterans who were categorized as being within 100 miles based 
on distance from a local VA hospital remaining in that category when 
using home zip code as the measure (eTable 3 in Supplement).
    Multivariable Regression Results
    In multivariable models, increasing distance to a VATC was 
associated with significantly lower odds of being waitlisted either at 
a VATC or any transplant center (Table 2). The odds ratio (OR) in the 
multivariable generalized estimating equation model evaluating distance 
and waitlisting at a VATC was 0.91 (95% CI, 0.89-0.93, P < .001; Table 
2). For example, a veteran living 25 miles from a VATC would have a 
7.4% (95% CI, 6.6%-8.1%) adjusted probability of being waitlisted, 
whereas a veteran 100 miles from a VATC would have a 6.2% (95% CI, 
5.7%-6.6%) adjusted probability. The OR signifies a 9% lower odds of 
being waitlisted at a VATC between 2 populations whose distance from a 
local VA hospital to a VATC differs by a multiplicative factor of 2. 
Veterans Affairs hospital academic affiliation or an advanced liver 
care center was neither a significant covariate nor an effect modifier. 
Similar results were obtained when we excluded veterans with 
hepatocellular carcinoma or those with a MELD score of less than 15. 
Even though veterans with secondary non-Medicaid insurance were 
significantly more likely to be waitlisted at a VATC (OR, 1.60; 95% CI, 
1.43-1.81) or any transplant center (OR, 2.22; 95% CI, 2.04-2.41), 
secondary insurance status did not confound the relationship between 
distance and waitlisting with unchanged ORs for distance with inclusion 
of this insurance variable. Increasing distance from a local VA 
hospital to the closest transplant center (VA or nonVA) was also 
associated with a lower odds of being waitlisted overall (OR, 0.94 [95% 
CI, 0.92-0.96] for log 2 base distance variable in multivariable 
generalized estimated equation model, P = .004; Table 3). Similar 
results were seen when distance was modeled as a categorical variable 
(eTables 4 and 5 in Supplement).
[GRAPHIC] [TIFF OMITTED] T1343.002

    a Center-specific covariates of proportion of veterans with mental 
illness and percentage of veterans with a low socioeconomic status 
excluded from final model for listing at VATC because they were not 
significant in univariable or multivariable models (P > .50) and were 
not confounders of the relationship between distance and waitlisting. 
None of the variables were collinear and the models were not overfit 
due to a large number of outcomes relative to the number of covariates 
examined.
    b The odds ratio (OR) for distance corresponds to the difference in 
the odds of being waitlisted between 2 populations whose distance from 
a local VA center to a VATC differs by a multiplicative factor of 2.
    c The number within each racial/ethnic category represents the 
total number of transplant-eligible veterans receiving care at a VA 
center with that specific racial/ethnic composition. The waitlisting 
rate at a VATC is 2.6% (89/3461) for 76%-100% white, 3.0% (670/22 026) 
for 51%-75% white, 2.6% (539/21 107) for 26%-50% white, and 3.0% (120/
1043) for 0%-25% white. The waitlisting rate at any transplant center 
was 4.7% (163/3461) for 76%-100% white, 5.9% (1296/22 026) for 51%-75% 
white, 5.8% (1213/21 107) for 26%-50% white, and 5.5% (223/1043) for 
0%-25% white.
    d Omnibus P value for the overall category.
    e The median center age was based on center-level data from the VA 
Hepatitis C Clinical Case Registry, and for each VA center, there is an 
age in years that is the median center age. The OR thus signifies the 
increase in the odds of waitlisting for every increase in 1 year of the 
median center age when comparing 2 centers.
[GRAPHIC] [TIFF OMITTED] T1343.003

    Abbreviations: IQR, interquartile range; VATC, VA transplant 
center.
    a Data presented per VA medical center and distance category. The 5 
distance categories reflect the distribution of the data and cut points 
in the relationship between distance and waitlisting. Only veterans 
receiving care at a VA center within 100 miles of a VATC would be 
expected to have the opportunity to live at home after discharge from 
the transplant hospitalization.
    b Derived from ?2 tests for the proportion of veterans waitlisted 
(yes or no) within each distance category or the Kruskall-Wallis test 
when comparing median and ranges between centers across distance 
categories.
    c The median values for percentages listed at a VATC vs any 
transplant center do not add up because a different VA medical center 
may represent the median for different variables.
    d From January 1, 2003, through December 31, 2007, the distance 
from a VA medical center to the closest VATC was measured from the 
Nashville VA for the 10 centers for which the Houston VATC is the 
closest because only 1 liver transplant was performed at the Houston 
VATC prior to January 1, 2008.
    e For each VA center, this value represents the proportion of 
veterans eligible for inclusion in the study who were waitlisted at a 
VATC among eligible veterans waitlisted overall (ie, 20% if a specific 
center has 50 veterans waitlisted, of whom 10 are waitlisted at a 
VATC).
    Categorical Analysis
    The proportion of transplant-eligible veterans waitlisted for 
transplantation at any transplant center differed significantly by 
distance from a VATC (?100 miles, 372/3417 [10.9%; 95% CI, 9.9%-12.0%]; 
101-200 miles, 279/5122 [5.5%; 95% CI, 4.8%-6.1%]; 201-300 miles, 424/
7906 [5.4%; 95% CI, 4.9%-5.9%]; 301-500 miles, 550/9528 [5.8%; 95% CI, 
5.3%-6.3%]; >500 miles, 1270/24 664 [5.2%; 95% CI, 4.9%-5.4%]; P < 
.001; Table 3). Of 47 219 veterans receiving care at a VA hospital 
located more than 100 miles from a VATC, 1174 (2.5%) were waitlisted at 
a VATC and 2523 (5.3%) at any transplant center (VATC and non-VATCs). 
The proportion specifically waitlisted at a VATC was also significantly 
varied by distance to a VATC (?100 miles, 244/3417 [7.1%; 95% CI, 6.3%-
8.1%]; 101-200 miles, 142/5122 [2.8%; 95% CI, 2.3%-3.3%]; 201-300 
miles, 184/7906 [2.3%; 95% CI, 2.0%-2.7%]; 301-500 miles, 245/9528 
[2.6%; 95% CI, 2.3%-2.9%]; >500 miles, 603/24 664 [2.4%; 95% CI, 2.3%-
2.6%]; P < .001; Table 3). Among all veterans who were waitlisted, the 
proportion specifically waitlisted at a VATC varied by distance. There 
was a broad range specifically waitlisted at a VATC across VA locations 
within each distance category (Table 3); however, when aggregated by 
distance, 66% of waitlisted veterans from the 8 VA hospitals within 100 
miles of a VATC were waitlisted at a VATC compared with less than 51% 
across the other distance categories (Figure).
    Access to Transplantation
    Waitlisted veterans who received care more than 100 miles from a 
VATC were significantly less likely to receive a transplant once 
waitlisted at a VATC or at any transplant center (eTable 6 in 
Supplement). Among veterans waitlisted at a VATC, the proportion who 
received transplants at a VATC differed by distance from a VATC (?100 
miles, 156/244 [63.9%]; 101-200 miles, 76/142 [53.5%]; 201-300 miles, 
103/184 [56.0%]; 301-500 miles, 125/245 [51.0%]; and >500 miles, 326/
604 [54.1%];P = .045). Among all waitlisted veterans, the proportion 
who received transplants at any transplant center varied significantly 
by distance from a VATC (?100 miles, 262/372 [70.4%]; 101-200 miles, 
164/279 [58.8%]; 201-300 miles, 243/424 [57.3%]; 301-500 miles, 294/550 
[53.5%]; and >500 miles, 700/1270 [55.1%]; P < .001). In multivariable 
models of all waitlisted veterans, increasing distance from a local VA 
hospital to a VATC was associated with a 3% lower odds of 
transplantation at any transplant center between 2 populations of 
waitlisted veterans whose distance from a local VA hospital to a VATC 
differs by a multiplicative factor of 2 (subhazard ratio, 0.97 [95% CI, 
0.95-0.98] for log 2 base distance variable; P < .001; Table 4).
    Survival
    The overall survival rate of waitlisted veterans from the time of 
hepatic decompensation event differed by distance from a local VA 
hospital toa VATC (Table 5). Although the 1-year survival rates were 
similar, they dispersed over time. In multivariable survival models of 
all waitlisted veterans with high health care use, increasing distance 
from a local VA hospital to a VATC was associated with a significantly 
increased risk of mortality after hepatic decompensation event, with a 
3% increased risk of mortality between 2 populations for every doubling 
of distance from a local VA hospital to a VATC (HR, 1.03 [95% CI, 1.01-
1.04]; P = .001). For example, a waitlisted veteran living 25 miles 
froma VATC would havea 62.9% (95% CI, 59.1%-66.1%) 5-year adjusted 
probability of survival from first hepatic decompensation event 
compared with a 59.8% (95% CI, 56.3%-63.1%) 5-year adjusted probability 
of survival for a veteran living 100 miles froma VATC.
    Discussion
    Greater distance between a patient's local VA hospital and a 
transplant center was associated with a lower likelihood of being 
placed on a transplant list when liver transplant was indicated. Once 
waitlisted, longer distances were also associated with a lower 
likelihood of receiving a transplant and increased mortality. These 
findings may be explained by (1) living remotely from a transplant 
center reducing the likelihood of getting evaluated for transplantation 
because of long travel times; or (2) reduced ability to proceed with 
transplantation because of the need for a patient or his or her family 
members to relocate. When analyzed as a continuous variable, distance 
had a dose-response relationship with increasing distance resulting in 
decreased likelihood of being put on a waitlist, receiving a 
transplant, and having a higher mortality. When analyzed as a 
categorical variable, distance appeared to have a threshold effect, 
whereby veterans living more than 100 miles from a VATC had a decreased 
likelihood of transplantation compared with patients who had their base 
hospital located within 100 miles of a liver transplant center.
    Our study has the advantage of a large sample of patients eligible 
for a lifesaving health care service. Our findings are consistent with 
other studies examining the relationship between distance and access to 
transplant services.4,5,7,10 One study did show the opposite effect; an 
examination of US dialysis patients found a greater likelihood of being 
waitlisted for renal transplant for patients living farther from a 
transplant center.13 The investigators hypothesized that rural 
residents treated with dialysis were a highly selected, motivated group 
to even initiate dialysis given the likely longer distances needed to 
travel for this service, that physicians in rural areas were aware of 
the challenges of having rural patients waitlisted due to difficulties 
in access distant transplant centers, thus expediting transplant 
referrals, or both reasons.13 Our cohort met inclusion criteria simply 
by having a disease warranting a transplant, thereby avoiding the 
selection bias that could have influenced that study, which required 
both the presence of a condition (end-stage renal disease) as well as 
receiving routine continuous therapy for that disease (dialysis).
[GRAPHIC] [TIFF OMITTED] T1343.006

    Figure Here after the following paragraph
    The median proportion of veterans waitlisted at a VA transplant 
center (VATC) was 2.3% (interquartile range [IQR], 1.4%-3.7%), and 
waitlisted at any transplant center was 5.5% (IQR, 3.5%-6.7%). The 
median center-specific percentage of veterans waitlisted at a VATC 
relative to overall waitlistings was 54.3% (IQR, 35.1%-66.7%).
    Because we could access the medical records for all VA patients in 
the United States, we could directly estimate the denominator of 
patients eligible for waitlisting. Prior studies relied on estimates of 
hypothetical cohorts of patients who might be at risk for receiving a 
transplant based on census information.10,11 Most prior studies 
assessed care offered at many centers, with travel times of 15 minutes 
to 2 hours. Few prior studies evaluated services offered at only a very 
limited number of transplant centers. Patients in our study who were 
far away from a VATC did not necessarily reside in rural areas (ie, the 
Bronx VA Medical Center is >300 miles from the Pittsburgh VATC), 
resulting in our study being more of an examination of distance rather 
than urban vs rural. Our results were insensitive to adjusting for VA 
hospital academic affiliation, suggesting that our findings were 
related to distance rather than access to advanced liver care services.
[GRAPHIC] [TIFF OMITTED] T1343.004

    Abbreviations: MELD, model for end-stage liver disease; NASH, 
nonalcoholic steatophepatitis.
    a Competing risk model of all waitlisted veterans (Veterans Affairs 
[VA] transplant center [VATC] or non-VATC) with the outcome of 
transplant and the competing risk of death on the waitlist or within 90 
days of waitlist removal. Outcomes reported as subhazard ratios because 
of the competing risk model. The distance x waitlisting at a VA 
interaction term was not included in the final multivariable model 
because it was not significant (P = .22), although waitlisting at a 
VATC was included in the model even though it was not significant (P = 
.60). Primary insurance type was also not significant (P = .72). 
Residential-level poverty was neither independently associated with 
mortality nor was it a confounder.
    b The P value for the individual distance variables represents the 
pairwise comparison in the fully adjusted multivariable model, with 0 
to 100 miles as the reference, whereas the P value for racial/ethnic 
composition, diagnosis, and blood type is the omnibus P value for the 
overall category.
    c The subhazard ratio for distance corresponds to the difference in 
the hazard of transplantation between 2 populations whose distance from 
a local VA center to a VATC differs by a multiplicative factor of 2.
    d The subhazard ratio for every 10-year increase in age at time of 
waitlisting.
    e Unit of comparison is per increase in 1 unit of MELD score.
    f Unit of comparison is per 1-mg/dL increase in albumin.
    Our findings suggest a need to improve access to liver 
transplantation in the VA. Increasing the number of VATCs is one 
solution, and the VA National Transplant Program has approved the 
opening of 2 VATCs: one in Madison, Wisconsin, and the other in Miami, 
Florida. However, this will not eliminate problems related to distance 
from a VATC for many veterans. Other solutions might include (1) 
streamlining referral to VATCs; (2) using telehealth or allowing local 
clinician teams to perform initial waitlisting evaluations; (3) active 
monitoring of liver disease burden at all VA hospitals with assessment 
of hospitals with low transplant referral rates; and (4) lowering 
financial disincentives for access to local transplant services through 
VA-urchased care (ie, payment of medical services delivered outside of 
the VHA health system for VHA beneficiaries). Such measures would 
require significant investment to enact.
[GRAPHIC] [TIFF OMITTED] T1343.005

    Broader Implications
    This issue of distance and access to care is critical given the 
focus on accountable care organizations that create large networks of 
physicians and hospitals. As complex, expensive medical technology 
evolves, certain services may only be offered at a limited number of 
sites (eg, proton beam therapy). Although our findings are consistent 
with prior studies evaluating the association of distance to care, our 
study is the first, to our knowledge, to demonstrate the adverse 
consequences of centralization of specialized care at a limited number 
of sites.8
    For example, since 2006, hospitals performing bariatric surgeries 
on Medicare beneficiaries are required to be a designated as centers of 
excellence.39 A subsequent single-center study demonstrated that this 
initiative was associated with reduced access to bariatric surgery 
based on distance (a subset of patients had to travel distances of >800 
miles)1 despite similar bariatric surgical outcomes at non-centers of 
excellence vs centers of excellence.35 However, such an analysis in a 
national sample of bariatric surgery candidates is practically 
infeasible due to an inability to nationally define potential 
candidates based on body mass index data. Similarly, Blue Cross and 
Blue Shield restricts referrals for complex and rare cancers to centers 
receiving Blue Distinction.2 By demonstrating that increasing distance 
is associated with decreased access to care in a national sample of 
patients, our analysis may serve as a model of the national association 
of centralized care on services offered at selected centers. Future 
work must evaluate whether a causal relationship exists.
    Limitations
    As with any observational study, there may be unmeasured 
confounding, including that veterans living closer to a VATC have more 
severe liver disease. However, we specifically identified veterans with 
decompensated cirrhosis or hepatocellular carcinoma, thus warranting a 
transplant evaluation. Second, we identified our cohort using 
International Classification of Diseases, Ninth Revision, codes, not 
chart review. Even though a subset may be ineligible due to comorbid 
conditions or psychosocial contraindications (ie, alcohol use or 
homelessness), this proportion should not differ by hospital or 
distance. Also, the proportion of veterans waitlisted at a VATC track 
with those of a single VA hospital study,36 and a study of all patients 
hospitalized in Pennsylvania for liverrelated conditions.37 Third, our 
results may have been related to factors beyond distance (ie, VATC 
preference for waitlisting patients from their hospital), yet the 
potential dose-response relationship seen with the continuous distance 
variable may suggest otherwise. Fourth, distance was measured from the 
VA hospital. Nonetheless, hospital assignment is based on geographic 
proximity to a hospital, thus hospital-level distances are 
representative of the distance a veteran would need to travel. Fifth, 
categorical analyses were based on distance grouping that was 
determined after examination of the data; therefore, these analyses 
should be considered post hoc and the categorical findings exploratory. 
Sixth, we could not determine hepatocellular carcinoma stage to 
determine transplant eligibility criteria (Milan criteria38), but the 
results were unchanged with exclusion of all patients with 
hepatocellular carcinoma.
    Conclusions
    Among VA patients meeting eligibility criteria for liver 
transplantation, greater distance from a VATC or any transplant center 
was associated with lower likelihood of being put on a waitlist or 
receiving a transplant, and greater likelihood of death. The 
relationship between these findings and centralizing specialized care 
deserves further investigation.
    ARTICLE INFORMATION
    Author Affiliations: Division of Gastroenterology, Department of 
Medicine, University of Pennsylvania, Philadelphia (Goldberg, Forde, 
Kaplan); Center for Clinical Epidemiology and Biostatistics, Perelman 
School of Medicine at the University of Pennsylvania, Philadelphia 
(Goldberg, French, Forde, Halpern); Leonard Davis Institute of Health 
Economics, University of Pennsylvania, Philadelphia (Goldberg, French, 
Groeneveld, Halpern); Division of General Internal Medicine, University 
of Pennsylvania, Philadelphia (Groeneveld); Center for Health Equity 
Research and Promotion, Philadelphia VA Medical Center, Philadelphia, 
Pennsylvania (Groeneveld); Department of Medicine, University of 
Pennsylvania, Philadelphia (Bittermann); Department of Veterans 
Affairs/Office of Public Health, Philadelphia, Pennsylvania (Backus); 
Division of Pulmonary, Allergy, and Critical Care, Department of 
Medicine, University of Pennsylvania, Philadelphia (Halpern); 
Gastroenterology Section, Philadelphia VA Medical Center, Philadelphia, 
Pennsylvania (Kaplan).
    Author Contributions: Drs Goldberg and Kaplan had full access to 
all of the data in the study and take responsibility for the integrity 
of the data and the accuracy of the data analysis.
    Study concept and design: Goldberg, Backus, Halpern, Kaplan.
    Acquisition, analysis, or interpretation of data: Goldberg, French, 
Forde, Groenveld, Bitterman, Backus, Halpern, Kaplan.
    Drafting of the manuscript: Goldberg, Kaplan. Critical revision of 
the manuscript for important intellectual content: Goldberg, French, 
Forde, Groenveld, Bitterman, Backus, Halpern, Kaplan. Statistical 
analysis: Goldberg, French, Forde, Halpern, Kaplan.
    Administrative, technical, or material support:
    Goldberg, Groenveld, Kaplan. Study supervision: Halpern, Kaplan.
    Conflict of Interest Disclosures: The authors have completed and 
submitted the ICMJE Form for Disclosure of Potential Conflicts of 
Interest and none were reported.
    Funding/Support: This work was supported in part by Health 
Resources and Services Administration contract 234-2005-37011C.
    Role of the Sponsor: The Health Resources and Services 
Administration had a role in the design and conduct of the study; 
collection, management, analysis, and interpretation of the data; 
preparation, review, or approval of the manuscript; and decision to 
submit the manuscript for publication.
    Disclaimer: The content of this article does not necessarily 
reflect the views or policies of the US Department of Health and Human 
Services, the US Department of Veterans Affairs, or the US government. 
The mention of trade names, commercial products, or organizations does 
not imply endorsement by the US government.
    Additional Contributions: We thank Vincent Lo Re III, MD, MSCE 
(Division of Infectious Diseases, University of Pennsylvania), for 
advice with regard to use of the coding algorithm based on the 
International Classification of Diseases, Ninth Revision, and C. Brent 
Roberts, MPH (Center for Health Equity Research and Promotion at the 
Philadelphia VA Medical Center), for assisting with Organ Procurement 
and Transplantation Network and Corporate Data Warehouse cross-
referencing. Neither Dr Lo Re nor Mr Roberts received compensation for 
their role in the study.
    REFERENCES
    1. Livingston EH, Burchell I. Reduced access to care resulting from 
centers of excellence initiatives in bariatric surgery. Arch Surg. 
2010;145(10):993-997.
    2. Blue Cross and Blue Shield. Blue Distinction selection criteria 
overview. http://www.bcbs.com/why-bcbs/blue-distinction/blue-
distinction-overview.html. Accessed September 6, 2013.
    3. Carr BG, Branas CC. Time, distance, and access to emergency care 
in the United States. LDI Issue Brief. 2009;14(4):1-4.
    4. Carr BG, Branas CC, Metlay JP, Sullivan AF, Camargo CA Jr. 
Access to emergency care in the United States. Ann Emerg Med. 
2009;54(2): 261-269.
    5. Evans RW, Kitzmann DJ. Contracting for services: liver 
transplantation in the era of mismanaged care. Clin Liver Dis. 
1997;1(2):287-303, viii.
    6. Gregory PM, Malka ES, Kostis JB, Wilson AC, Arora JK, Rhoads GG. 
Impact of geographic proximity to cardiac revascularization services on 
service utilization. Med Care. 2000;38(1):45-57.
    7. Stitzenberg KB, Meropol NJ. Trends in centralization of cancer 
surgery. Ann Surg Oncol. 2010;17(11):2824-2831.
    8. Stitzenberg KB, Sigurdson ER, Egleston BL, Starkey RB, Meropol 
NJ. Centralization of cancer surgery: implications for patient access 
to optimal care. J Clin Oncol. 2009;27(28):4671-4678.
    9. Axelrod DA, Guidinger MK, Finlayson S, et al. Rates of solid-
organ wait-listing, transplantation, and survival among residents of 
rural and urban areas. JAMA. 2008;299(2):202-207.
    10. Thabut G, Munson J, Haynes K, Harhay MO, Christie JD, Halpern 
SD. Geographic disparities in access to lung transplantation before and 
after implementation of the lung allocation score. Am J Transplant. 
2012;12(11):3085-3093.
    11. Zorzi D, Rastellini C, Freeman DH, Elias G, Duchini A, Cicalese 
L. Increase in mortality rate of liver transplant candidates residing 
in specific geographic areas: analysis of UNOS data. Am J Transplant. 
2012;12(8):2188-2197.
    12. Tonelli M, Klarenbach S, Rose C, Wiebe N, Gill J. Access to 
kidney transplantation among remoteand rural-dwelling patients with 
kidney failure in the United States. JAMA. 2009;301(16):1681-1690.
    13. Scientific Registry of Transplant Recipients website. US 
hospitals with liver transplant centers. http://srtr.org/csr/current/
Centers/TransplantCenters.aspx?organcode=LI. Accessed September 6, 
2013.
    14. Goldberg DS, French B, Thomasson A, Reddy KR, Halpern SD. 
Current trends in living donor liver transplantation for primary 
sclerosing cholangitis. Transplantation. 2011;91(10):1148-1152.
    15. Kamath PS, Wiesner RH, Malinchoc M, et al.A model to predict 
survival in patients with end-stage liver disease. 
Hepatology.2001;33(2):464-470.
    16. Wiesner R, Edwards E, Freeman R, et al; United Network for 
Organ Sharing Liver Disease Severity Score Committee. Model for end-
stage liver disease (MELD) and allocation of donor livers. 
Gastroenterology. 2003;124(1):91-96.
    17. Wang L, Porter B, Maynard C, et al. Predicting risk of 
hospitalization or death among patients receiving primary care in the 
Veterans Health Administration. Med Care. 2013;51(4):368-373.
    18. Murray KF, Carithers RL Jr; AASLD. AASLD practice guidelines: 
evaluation of the patient for liver transplantation. Hepatology. 
2005;41(6):1407-1432.
    19. O'Leary JG, Lepe R, Davis GL. Indications for liver 
transplantation. Gastroenterology. 2008;134(6):1764-1776.
    20. Lo Re V III, Lim JK, Goetz MB, et al. Validity of diagnostic 
codes and liver-related laboratory abnormalities to identify hepatic 
decompensation events in the Veterans Aging Cohort Study. 
Pharmacoepidemiol Drug Saf. 2011;20(7):689-699.
    21. US Department of Veteran Affairs. VA CMS data repository. 
http://www.virec.research.va.gov/VACMS. Accessed September 20, 2012.
    22. Beehler GP, Rodrigues AE, Mercurio-Riley D, Dunn AS. Primary 
care utilization among veterans with chronic musculoskeletal pain: a 
retrospective chart review. Pain Med. 2013;14(7):1021-1031.
    23. Katz IR, McCarthy JF, Ignacio RV, Kemp J. Suicide among 
veterans in 16 states, 2005 to 2008: comparisons between utilizers and 
nonutilizers of Veterans Health Administration (VHA) services based on 
data from the National Death Index, the National Violent Death 
Reporting System, and VHA administrative records. Am J Public Health. 
2012;102(suppl 1):S105-S110.
    24. Gillespie BW, Merion RM, Ortiz-Rios E, et al; A2ALL Study 
Group. Database comparison of the adult-to-adult living donor liver 
transplantation cohort study (A2ALL) and the SRTR US Transplant 
Registry. Am J Transplant. 2010;10(7):1621-1633.
    25. Ballman KV. Genetics and genomics: gene expression microarrays. 
Circulation. 2008;118(15):1593-1597.
    26. Backus LI, Belperio PS, Loomis TP, Yip GH, Mole LA. Hepatitis C 
virus screening and prevalence among US veterans in Department of 
Veterans Affairs care. JAMA Intern Med. 2013;173(16):15491552.
    27. Backus LI, Gavrilov S, Loomis TP, et al. Clinical case 
registries: simultaneous local and national disease registries for 
population quality management. J Am Med Inform Assoc. 2009;16(6):775-
783.
    28. Backus LI, Boothroyd DB, Phillips BR, Mole LA. Predictors of 
response of US veterans to treatment for the hepatitis C virus. 
Hepatology. 2007;46(1):37-47.
    29. Fine JP, Gray RJ. A proportional hazards model for the 
subdistribution of a competing risk. J Am Stat Assoc. 1999;94(446):496-
509.
    30. Kim WR, Therneau TM, Benson JT, et al. Deaths on the liver 
transplant waiting list: an analysis of competing risks. Hepatology. 
2006;43(2):345-351.
    31. French B, Heagerty PJ. Analysis of longitudinal data to 
evaluate a policy change. Stat Med. 2008;27(24):5005-5025.
    32. Yeh H, Smoot E, Schoenfeld DA, Markmann JF. Geographic inequity 
in access to livers for transplantation. 
Transplantation.2011;91(4):479-486.
    33. Bittermann T, Makar G, Goldberg D. Exception point applications 
for 15 points: an unintended consequence of the share 15 policy. Liver 
Transpl. 2012;18(11):1302-1309.
    34. Merion RM, Schaubel DE, Dykstra DM, Freeman RB, Port FK, Wolfe 
RA. The survival benefit of liver transplantation. Am J Transplant. 
2005;5(2):307-313.
    35. Dimick JB, Nicholas LH, Ryan AM, Thumma JR, Birkmeyer JD. 
Bariatric surgery complications before vs after implementation of a 
national policy restricting coverage to centers of excellence. JAMA. 
2013;309(8):792-799.
    36. Julapalli VR, Kramer JR, El-Serag HB; American Association for 
the Study of Liver Diseases. Evaluation for liver transplantation: 
adherence to AASLD referral guidelines in a large Veterans Affairs 
center. Liver Transpl. 2005;11(11):1370-1378.
    37. Bryce CL, Angus DC, Arnold RM, et al. Sociodemographic 
differences in early access to liver transplantation services. Am J 
Transplant. 2009;9(9):2092-2101.
    38. Organ Procurement and Transplantation Network. Policies and 
bylaws. http://optn.transplant.hrsa.gov/PoliciesandBylaws2/policies/
pdfs/policy--8.pdf. Accessed September 2, 2013.
    39. Centers for Medicare & Medicaid Services. Medicare national 
coverage determinations manual. http://www.cms.gov/Regulations-and-
Guidance/Guidance/Manuals/downloads /ncd103c1--Part2.pdf. Accessed 
September 6, 2013.

                                 [all]