[Senate Hearing 115-299]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 115-299

                     HEARING ON PENDING LEGISLATION

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

                                 HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                     ONE HUNDRED FIFTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 17, 2017

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
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                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman

Jerry Moran, Kansas                  Jon Tester, Montana, Ranking 
John Boozman, Arkansas                   Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Richard Blumenthal, Connecticut
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia

                  Thomas G. Bowman, Staff Director \1\
                  Robert J. Henke, Staff Director \2\
                Tony McClain, Democratic Staff Director

                      Majority Professional Staff
                            Amanda Meredith
                             Gretchan Blum
                            Leslie Campbell
                            Maureen O'Neill
                               Adam Reece
                             David Shearman
                            Jillian Workman

                      Minority Professional Staff
                            Dahlia Melendrez
                            Cassandra Byerly
                                Jon Coen
                              Steve Colley
                               Simon Coon
                           Michelle Dominguez
                             Eric Gardener
                               Carla Lott
                              Jorge Rueda


\1\ Thomas G. Bowman served as Committee majority Staff Director 
through September 5, 2017, after being confirmed as Deputy Secretary of 
Veterans Affairs on August 3, 2017.
\2\ Robert J. Henke became the Committee majority Staff Director on 
September 6, 2017.
                            C O N T E N T S

                              ----------                              

                              May 17, 2017
                                SENATORS

                                                                   Page
Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     2
Murray, Hon. Patty, U.S. Senator from Washington.................     3
    Prepared statement...........................................     3
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     4
Heller, Hon. Dean, U.S. Senator from Nevada......................    37
Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    42
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    49
Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    52
Boozman, Hon. John, U.S. Senator from Arkansas...................    55

                               WITNESSES

Hatch, Hon. Orrin, U.S. Senator from Utah........................     5
Rubio, Hon. Marco, U.S. Senator from Florida.....................     7
Lee, Jennifer S., M.D., Deputy Under Secretary for Health for 
  Policy and Services, Veterans Health Administration, U.S. 
  Department of Veterans Affairs; accompanied by Meghan Flanz, 
  Acting General Counsel, Office of General Counsel; Donnie 
  Hachey, Chief Counsel for Operations, Board of Veterans' 
  Appeals; Dave McLenachen, Director of Appeals Management 
  Office, Veterans Benefits Administration; Margaret Kabat, 
  National Director, Caregiver Support Program, Veterans Health 
  Administration; James Ruhlman, Assistant Director for Policy 
  and Procedures, Veterans Benefits Administration; and Phil 
  Parker, Acting Associate Deputy Assistant Secretary, Office of 
  Acquisitions, Logistics, and Construction......................    10
    Prepared statement...........................................    12
    Response to request arising during the hearing by:
      Hon. Dean Heller...........................................    39
      Hon. Patty Murray.......................................... 45,47
    Response to posthearing questions submitted by:
      Hon. Bill Cassidy..........................................   117
      Hon. Mazie K. Hirono.......................................   118
Celli, Louis J., Jr., Director, National Veterans Affairs and 
  Rehabilitation Division, The American Legion...................    57
    Prepared statement...........................................    58
Keleher, Kayda, Associate Director, National Legislative Service, 
  Veterans of Foreign Wars of the United States..................    70
    Prepared statement...........................................    71
Atizado, Adrian, Deputy Legislative Director, Disabled American 
  Veterans.......................................................    79
    Prepared statement...........................................    81
Jaslow, Allison, Executive Director, Iraq and Afghanistan 
  Veterans of America............................................    97
    Prepared statement...........................................    99
Cox, J. David, Sr., National President, American Federation of 
  Government Employees, AFL-CIO..................................   103
    Prepared statement...........................................   104
    Response to posthearing questions submitted by Hon. Mazie K. 
      Hirono.....................................................   119

                                APPENDIX

Tillis, Hon. Thom, U.S. Senator from North Carolina; prepared 
  statement......................................................   121
Reilly, Michael V., Executive Director, American Association of 
  Collegiate Registrars and Admissions Officers (AACRAO); letter.   122
Broad, Molly Corbett, President, American Council on Education 
  (ACE); letter..................................................   124
Webb, Amy, Legislative Policy Advisor, AMVETS (American 
  Veterans); prepared statement..................................   126
Augustine, Lauren, Director of Government Relations, Got Your 6; 
  prepared statement.............................................   134
Military Officers Association of America (MOAA); prepared 
  statement......................................................   137
Wells, CDR John B., USN (Ret.), Executive Director, Military-
  Veterans Advocacy (MVA); prepared statement....................   141
Kriesel, John, Legislative Chairman, National Association of 
  County Veterans Service Officers; prepared statement...........   145
Wescott, Dr. Joseph, Legislative Director, National Association 
  of State Approving Agencies (NASAA); prepared statement........   146
Reeves, Randy, President, National Association of State Directors 
  of Veterans Affairs, Inc. (NASDVA); letter.....................   148
Sganga, Fred S., Legislative Officer, National Association of 
  State Veterans Homes (NASVH); prepared statement...............   150
Spagnolo, Samuel V., M.D., President, National Association of VA 
  Physicians and Dentists (NAVAPD); prepared statement...........   153
Rauber, Diane Boyd, Esq., Executive Director, National 
  Organization of Veterans' Advocates, Inc. (NOVA); prepared 
  statement......................................................   154
Stichman, Barton F., and Ronald B. Abrams, Joint Executive 
  Directors, National Veterans Legal Services Program (NVLSP); 
  prepared statement.............................................   161
Lerner, Carolyn N., Special Counsel, U.S. Office of Special 
  Counsel (OSC)..................................................   166
Hempowicz, Liz, Policy Counsel, Project on Government Oversight 
  (POGO); prepared statement.....................................   167
Paralyzed Veterans of America (PVA); prepared statement..........   172
Valdez, Bill, President, Senior Executives Association (SEA); 
  prepared statement.............................................   183
Davis, Hon. Robert N., Chief Judge, U.S. Court of Appeals for 
  Veterans Claims................................................   185
Scott, Carol Wild, Esq., Legislative Chair, The Veterans & 
  Military Law Section (V&MLS), Federal Bar Association; letter..   187
Linnington, Lt. Gen. Michael S. (Ret.), Chief Executive Officer, 
  Wounded Warrior Project (WWP); prepared statement..............   201
    Exhibit A....................................................   205
    Exhibit B....................................................   212

 
                     HEARING ON PENDING LEGISLATION

                              ----------                              


                        WEDNESDAY, MAY 17, 2017

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 2:30 p.m. in room 
418, Russell Senate Office Building, Hon. Johnny Isakson, 
Chairman of the Committee, presiding.
    Present: Senators Isakson, Boozman, Heller, Cassidy, 
Sullivan, Tester, Murray, Brown, Blumenthal, and Manchin.

   OPENING STATEMENT OF HON. JOHNNY ISAKSON, CHAIRMAN, U.S. 
                      SENATOR FROM GEORGIA

    Chairman Isakson. I call the hearing of the Senate 
Veterans' Affairs Committee to order. I would like to thank all 
of you for coming and visiting with us today. I want to 
particularly thank Cindy Rampley--where is Cindy? That is one 
Georgian who came to see--and Barbara Kennon. Thank you all so 
much for being here. When the home folks come you have got to 
brag about them, so I apologize for that.
    Let me thank all of you for being here, for a very 
important hearing of the Senate Veterans' Affairs Committee. I 
will begin with my opening remarks, which will be very brief, 
followed by Senator Tester's. After his, he will have to leave 
for a few minutes to go to Indian Affairs Committee, at which 
time we will begin the testimony of our distinguished guests, 
Chairman Hatch and Senator Rubio. Following those we will have 
the Veterans Administration testimony, followed by questions 
and answers by the Committee Members, followed by testimony 
from our VSOs and other important guests, followed by Q&A for 
them.
    Thank you all for being here for what is the most important 
hearing that we have had in this Committee all year. I am not 
going to go over every issue, but I am going to say this: we 
are about to hear testimony on accountability, meaningful 
accountability, which addresses the concerns that for 2 years 
have plagued this Committee and plagued the Veterans 
Administration. We have all come together--I am very 
appreciative of the Ranking Member and what he has done to make 
it possible, plus other Members of the Committee, Republican 
and Democrat alike. We have worked through some thorny issues. 
We have navigated some rough seas. But, thanks to Senator 
Tester and the other Members of the minority, as well as the 
Members of the majority, we have come forward with the 
legislation you will hear about today.
    In terms of the appeals process, we are on the cusp of 
dealing with what has been the black eye of the Veterans 
Administration for decades, and that is long backlogs of 
appeals that are heard over and over and over again without 
resolution. One of the things I had hoped to accomplish before 
I left the Committee as its Chairman would be to have 
meaningfully dealt with that appeals process. We are close to 
having done it; I worked closely with Senator Blumenthal in 
that process and will continue to so this Committee can, in 
fact, deal with it.
    Then, as every Member knows, Choice has been a big issue 
since Choice became an issue, and it became an issue about 3 
years ago when this Committee passed the first Choice bill, 
dealing with the veterans' backlog, veterans' problems, and the 
veterans' claims. We now are in the process of trying to 
perfect Choice--and that is my word. We will be talking about 
some bills that are being introduced today to be completed 
before this session is over, where with the Choice Act, we 
waived the sunset unanimously a couple of weeks ago on the 
floor of the Senate. The bill and its corrections will be in 
place. Then, we will have dealt with appeals, we will have 
dealt with Choice, and we will have dealt with accountability, 
which will be a major accomplishment for this Committee, or any 
committee in this year. It has been an honor for me to work 
with the Ranking Member, whom I will introduce now, by simply 
saying, here is big Jon.

  OPENING STATEMENT OF HON. JON TESTER, RANKING MEMBER, U.S. 
                      SENATOR FROM MONTANA

    Senator Tester. Thanks, Senator Isakson. I appreciate your 
work as Chairman, too. You are a straight-up guy. It is a 
pleasure to work with you, which is a fact.
    There are a number of bills on the agenda today that I am 
excited about, and bills that I think are going to go do some 
great things for our veterans across this country. These bills 
are also representative of the bipartisan work of this 
Committee and they reflect the fact that we are taking our cues 
directly from the veterans and the organizations who represent 
them here today.
    With that said, I want to also recognize a couple of key 
Members of our Committee who are not with us here today, Tom 
Tillis and Mazie Hirono. Both those folks are tough as nails. 
They are tremendous advocates for veterans and for their 
States. They are in our thoughts today and we look forward to 
welcoming them back very soon.
    In terms of accountability legislation, I am glad that the 
Chairman and I could work together with Senator Rubio to make 
some changes to the House bill. The end result is a compromise 
in which none of us got all that we wanted, but which better 
allows the VA to hold bad actors accountable while ensuring 
employee protections and rights to appeal are protected.
    I appreciate the VA and the VSOs for their constructive 
input and for their strong bipartisan support of this 
legislation. I am also pleased that the Deborah Sampson Act, 
which I introduced with Senator Boozman, is on today's agenda. 
Allison Jaslow with IAVA, it is good to see you again, and 
thank you for your tremendous advocacy on this legislation.
    It is critical that the Members of this Committee hear from 
you and other women veterans about how and why we need to move 
forward on this legislation. Women are courageously signing up 
to serve our country at a higher rate than ever before and we 
need to make sure that the VA is fully capable of addressing 
their needs.
    We also need to take steps to increase accountability in VA 
contracting to establish more medical residencies at the VA, to 
expand the caregiver program, and to reform an outdated appeals 
process that has left veterans waiting months, or even years, 
for their claims to be resolved. Many of the bills that we will 
discuss today will do that just.
    Again, thank you, Senator Isakson, for your leadership, and 
I look forward to the discussion.
    Chairman Isakson. Thank you, Senator Tester.
    To the other Members of the Committee, we will leave the 
record open for 10 days to submit opening statements that you 
might want to submit.
    I want to echo and repeat what Senator Tester said, both 
about Senator Hirono as well as Senator Tillis. I understand 
Senator Tillis is doing well. He had a collapse this morning in 
a 5K or a 3K, but he is OK. As for Mazie, we all got the report 
today. She obviously is going to be confronted with dealing 
with kidney cancer, but she is doing it. She has done 
everything she has ever done bravely, so she is going to be 
here with us; we are going to be pulling with her together to 
pull her all the way through. So, thanks, Jon, for mentioning 
that, and thanks to all the Members of the Committee for your 
support for our fellow Committee Members.
    Do you want to say something?

                STATEMENT OF HON. PATTY MURRAY, 
                  U.S. SENATOR FROM WASHINGTON

    Senator Murray. Mr. Chairman, if I could just say, I will 
submit my full comments in an opening statement for the record. 
I know you want to get to many witnesses. I want to thank you 
for holding this hearing and especially I wanted to mention the 
bill on caregivers that I have been working on for a long time.
    I know time is important here, but this is a critical 
issue. We have a responsibility to take care of those 
caregivers. There are a number of important parts of this bill, 
which I will speak to later during the questioning.
    [The prepared statement of Senator Murray follows:]
 Prepared Statement of Hon. Patty Murray, U.S. Senator from Washington
    Thank you, Mr. Chairman, for holding this hearing. We have some 
critically important bills on the agenda today that could really 
improve care for the men and women in our military--something I believe 
everyone in this room is interested in doing.
         caring for our veterans shouldn't be a partisan issue.
    I think we all agree that our country has a duty to do whatever we 
can to improve the lives of those who have sacrificed so much for our 
country.
    I was very pleased to introduce my military caregivers legislation 
that will help us do just that. This program recognizes the sacrifice 
of the friends and family who take care of our injured servicemembers 
by offering assistance to ease their burden. This bill would finally 
open the caregiver program to veterans of all eras, through a 
responsible, phased-in approach that will allow VA to manage the 
additional workload.
    I was very concerned when just this year we heard stories from 
veterans and their caregivers of the inconsistent application of the 
current program's eligibility rules. We got reports of veterans and 
their caregivers abruptly losing access to the program, which is a 
terrible way to treat our military families. The VA must take 
responsibility for ensuring that consistent, comprehensive guidelines 
are applied throughout the country to protect the caregivers who have 
earned this resource.
    I believe VA should address these concerns and strengthen the 
program, while also finally opening up the program to veterans of all 
eras who desperately need these services.
    I am committed to working with my colleagues to make sure VA has 
the resources it needs to effectively administer this program, which is 
why I authored an amendment to the Fiscal Year 2017 VA appropriations 
bill that invested $10 million to hire more caregiver support 
coordinators, because it's critical we do this right. This additional 
staff is essential for strengthening the current program and preparing 
VA to finally meet the needs of veterans of all eras.
    This bill also expands the services available for caregivers, and 
aligns eligibility for VA and DOD services.
    Finally, the bill takes a major step toward improving caregiver 
support for the whole country by coordinating the many services offered 
across the government.
    We know that treating a veteran through the Caregiver Program is 
far less expensive than through a private nursing home or through a VA 
nursing home, but most importantly, it helps veterans stay out of the 
hospital, and have shorter stays when they do have to go in. It allows 
veterans to be in their own homes, surrounded by their loved ones. 
Giving veterans a better quality of life is not just the cost-effective 
thing to do, it's the right thing to do.
    This is just common sense, and it's the right thing to do for our 
veterans and their caregivers. Our veterans shouldn't have to wait any 
longer for these important improvements to their care.
    Finally, thank you to our witnesses and a special thank you to the 
VSOs for appearing today and for your support for this bill.

    Thank you, Mr. Chairman, and I look forward to working with you to 
get these bills through markup and then through the Senate floor.

    Senator Brown. Mr. Chairman, real quick.
    Chairman Isakson. Senator Brown.

               STATEMENT OF HON. SHERROD BROWN, 
                     U.S. SENATOR FROM OHIO

    Senator Brown. Thank you, Mr. Chairman. I echo Senator 
Murray's words about the importance of this hearing. Welcome, 
Senator Hatch, and, Mr. Chairman, thank you for your 
leadership.
    I am working one bill particularly, S. 764, the Veterans 
Education Priority Enrollment Act, which I announced with 
Youngstown State President Jim Tressel, and am working with 
Senator Tillis, who is the other sponsor.
    There are a number of pieces of legislation with Senator 
Murray, Senator Moran, Senator Tester, and with the Chairman 
that will be a priority. It is important this Committee 
continues to do its bipartisan work together, as we do in the 
Finance Committee, Mr. Chairman.
    Chairman Isakson. Well, I thank two great Members of the 
Committee, Senator Brown from Ohio and my favorite 
Northwesterner.
    Senator Murray. Thank you.
    Chairman Isakson. We will go that far. Anyway, she is in 
the north and she is on the west.
    Senator Brown. I thought Tester was your favorite 
Northwesterner.
    Chairman Isakson. Well, he is not----
    Senator Brown. Is that not west enough? He is not west 
enough.
    Chairman Isakson. When he is here, he is my favorite.
    Senator Brown. To me, Mr. Chairman, Iowa is west, so I do 
not know.
    Chairman Isakson. Well, you are one of my favorites and you 
and I have got a mutual friend that tells on both of us.
    I just want to add one particular thing, Senator Murray. I 
would not be here today were it not for a caregiver over the 
last 12 weeks. So, I do not even see anything more appropriate 
for us to be dealing with today than the people who make it 
possible for our soldiers to transition from care to 
independence. It is the greatest contribution people make in 
this country and I think it is very appropriate that you 
brought it up. I thank you for crafting that Bill.
    Senator Brown, we will hear your testimony, I mean hear 
your questions later on.
    Senator Rubio has arrived so I am going to introduce both 
of our special guests from our membership, who will testify, 
and then we will hear from our two panels.
    I had the good pleasure, when I got elected to the U.S. 
Senate 13 years ago, of meeting Orrin Hatch and getting to know 
him. He is everything he looks like. He is distinguished, 
intelligent, kind, generous, and the most knowledgeable person 
on the financial affairs of the United States of America of any 
member of the U.S. Senate. It is an honor for us to have him 
here today to testify. We welcome you, Senator Hatch, for being 
here today.
    I cannot say all those things about Senator Rubio because 
he is young, he does not have gray hair, has not been here near 
as long, but he does one hell of a job promoting what he 
believes in, and he has done a great job on bringing together 
the accountability bill, which is before us today.
    I heard him three times over the weekend, where he did the 
best job of articulating the hard work that went into both 
these products. I am so glad that he is here today and a member 
of the U.S. Senate.
    So, I welcome both of you to be recognized for up to 5 
minutes. You may submit your remaining remarks for the record, 
you do not have to submit yourselves to questions, and you are 
welcome to be excused after your testimony is over.
    First of all, Senator Hatch.

                STATEMENT OF HON. ORRIN HATCH, 
                     U.S. SENATOR FROM UTAH

    Senator Hatch. Well, thank you, Mr. Chairman and other 
Members of the Committee. I appreciate the leadership you 
provide, and Ranking Member Tester as well.
    I welcome the opportunity to join you as a guest of the 
Committee for this year. Today the Committee will hear 
testimony on pending legislation, including one of my bills, 
S. 324, the State Veterans Home Adult Day Health Care 
Improvement Act of 2017. I appreciate the opportunity to speak 
in support of this bipartisan legislation and the many veterans 
whose lives it would improve.
    Veterans have served and sacrificed on behalf of our 
country. It is, therefore, the duty of every Senator here to 
ensure that our country makes good on the promises we have made 
to them. Every person's presence in this room indicates an 
interest in working for--or working to fulfill our country's 
commitments to our veterans. How to provide quality long-term 
care is an important question for everyone, particularly for 
aging veterans, many of whom need long-term care to live with 
service-connected disabilities.
    Traditionally, long-term care is provided in an 
institutional setting like a nursing home. Nursing home care 
for one person can easily cost thousands of dollars a month and 
that does not include the added cost of specialized health care 
services which are especially important for some of our most 
disabled veterans.
    Moreover, in many areas, more people are in need of long-
term care than there are available beds in nursing homes. This 
scarcity drives up costs and forces individuals to travel 
farther away from home and family to access care, in my home 
State of Utah, and I think other States as well. Our waiting 
list for State veterans home nursing care is over 600 people 
long.
    Adult day health care is a sensible, cost-saving 
alternative to traditional long-term care. ADHC is a home- and 
community-based program that hosts participants in a care 
setting during the day but allows them to live at home at 
night, and it provides participants assistance with activities 
of daily living and coordinates medical, dental, and mental 
health services. At the end of each day, ADHC participants 
return home to their family or caregiver.
    Most home caregivers for individuals in need of long-term 
care are spouses and adult children, and this is especially 
true for veterans. Many caregivers need to work during the day, 
making care for a disabled family member challenging. ADHC 
gives caregivers, in many cases veterans' families, the respite 
and some security in the knowledge that their loved one is safe 
and in good hands, receiving specialized care.
    Medical professionals and adult day care users agree and 
studies confirm that medical model ADHC provides an equal 
standard of quality health care services, as nursing home care 
at less cost to participants. In fact, the ADHC programs this 
bill opens to veterans, are offered by VA-approved State 
veterans' nursing homes as an alternative to full-time care. 
These nursing homes offer ADHC programs because they want to 
help more of our veterans receive the quality care they need.
    My bill helps them to do that. My legislation also enables 
veterans access to ADHC by setting the per diem rate the 
Department of Veterans' Affairs pays for these services at 65 
percent of the nursing home per diem rate paid for veterans 
with service-connected disabilities of 70 percent or more. The 
VA already pays 100 percent of the cost of nursing home care 
for these veterans. It makes no sense--indeed, it is wrong--to 
deny veterans the flexibility to maintain their independence 
and live at home in their communities, especially when we can 
do so at a lower cost to everyone involved.
    My State Veterans Home ADHC Improvement Bill is a cost-
neutral, bipartisan bill. It enjoys widespread support from 
veterans' organizations and is based on the most up-to-date 
research on the best ways to improve long-term care quality and 
options.
    I want to thank the Committee for considering my bill as 
part of today's hearing, and I thank the Chairman and Ranking 
Member again for their invitation to join the Committee as a 
guest. I also wish to thank all those in attendance here today. 
I trust that my bill will be given open and fair consideration 
and I hope for its timely passage out of Committee and on to 
the Senate floor.
    I am very grateful to all of you and thank you for inviting 
me to be able to testify here today.
    Chairman Isakson. Well, thank you, Senator Hatch. I can 
assure you it will be open and it will be fair. We are glad to 
have you on the agenda today and appreciate very much your 
attendance. Thank you.
    Senator Hatch. Thank you. If I can leave I would be happy. 
[Laughter.]
    Chairman Isakson. With your seniority, you can do anything 
you want to do.
    Senator Hatch. I like that, Mr. Chairman. Thanks so much.
    Chairman Isakson. We are delighted to have you, Orrin.
    Senator Hatch. Glad to be here.
    Chairman Isakson. It is now my pleasure to introduce the 
Senator from Florida, my friend, Marco Rubio.

                STATEMENT OF HON. MARCO RUBIO, 
                   U.S. SENATOR FROM FLORIDA

    Senator Rubio. Thank you to the Chairman. Thank you very 
much for this, to the Ranking Member and to all the Members of 
the Committee. First, thank you for allowing me to appear today 
to speak on Senate Bill 10994, the Department of Veterans 
Affairs Accountability and Whistleblower Protection Act of 
2017.
    I want to, at the outset, I know that the majority of 
people that work at the VA are good, they are hard-working, 
they are competent, and they serve our Nation's heroes 
admirably. They act in the best interest of veterans, they are 
passionate about their work, and many of them are veterans 
themselves, so nothing in this bill is designed to punish them, 
stigmatize them, or in any way hurt them. On the contrary, it 
is designed to reward those who work so hard.
    But, it is necessary because the Secretary of the Veterans 
Administration currently does not have the authority he needs 
to remove, to demote, or to suspend employees who are unwilling 
and/or unable to do their jobs, or employees engaged in 
misconduct or illegal activity.
    Americans who do not work for the Federal Government 
understand that if they violate their employers' policies they 
will face consequences. They may even lose their jobs. And 
things should be no different at the Department of Veterans 
Affairs. Indeed, the Federal employees charged with taking care 
of military men and women must be held to the highest standard.
    The bipartisan legislation that you will consider today has 
been refined over the course of several years, thanks to you, 
Mr. Chairman, the Ranking Member, and many others, and it 
includes real reforms that are aimed at fixing the problems 
that have plagued the Department for many years. These are 
formed to ensure the best interest of our veterans come first 
at the VA.
    To craft this legislation, we worked with a number of the 
veteran service organizations represented here today, including 
the Paralyzed Veterans of America, The American Legion, the 
Veterans of Foreign Wars, the Concerned Veterans of America, 
the Reserve Officers Association, Iraq and Afghanistan Veterans 
of America, American Veterans, the Military Officers 
Association of America, and several others. The members of 
these organizations have borne the brunt of the VA's 
mismanagement and failures. They understand the VA must be 
properly managed so it can provide timely quality care to our 
veterans.
    I thank these organizations and their members, not just for 
their service to our country and to their fellow men and women 
in uniform, but also for helping to inform our policy 
solutions.
    Since the passage of the Veterans Access, Choice, and 
Accountability Act in 2014, poor performance and misconduct by 
a few but significant number of VA employees has continued to 
come to light, and it is clear that there is, sadly, a 
pervasive lack of accountability. Just to list a few examples, 
one VA employee was arrested and spent time in jail for armed 
robbery. Another employee was caught watching pornography on 
the job. In my home State of Florida there have been several 
instances of prescription drugs being diverted, gone missing 
from VA facilities. It is terrible to think that some VA 
employees may have actively contributed to the opioid epidemic 
gripping the State of Florida and the country.
    In all these cases, the employees involved were ultimately 
allowed to keep their jobs, or resign with their benefits 
intact. Other management failures at the VA include 
construction projects that are over budget and behind schedule, 
and billions of taxpayer dollars wasted through the illegal use 
of government purchase cards.
    It is clear that under existing civil service rules and 
pressure from unions and others, VA leaders are not--have not 
been able to hold individuals accountable for their actions. 
Over and over again, we have seen the VA attempt to take 
disciplinary action against an employee, only to see the 
appeals process prove so complex, lengthy, and lenient that 
real accountability was virtually impossible to achieve.
    So, the bipartisan, common sense provision of the 
legislation that you will consider will put our veterans first, 
by reforming the Department's broken civil service system, 
maintaining appropriate due process protections, and empowering 
whistleblowers to come forward without having to fear 
retaliation from bureaucrats who would rather sweep wrongdoing 
under the rug.
    Last week, Secretary Shulkin appeared before the 
Appropriations Subcommittee on Military Construction and 
Veterans Affairs, where I asked him about this bill, and what 
he needs to ensure capable workforce, and he stated, and I 
quote, ``I wish today I could tell you I have the tools to do 
the right thing, to be able to remove those employees. I do 
not, so, unfortunately, I need a new set of tools if I am going 
to be held accountable for turning this system around and doing 
what we all want to do to serve veterans. So, I thank you for 
introducing this bill. I think it is necessary.''
    Mr. Chairman, to the Ranking Member, Senator Tester, to 
Senators Moran, Heller, and Boozman, thank you for your hard 
work and leadership on this bill and for considering it today. 
I am hopeful we will see this bill signed into law soon, so 
that our veterans will be more likely to receive the quality 
health care they earned and deserve.
    Thank you again, Mr. Chairman, for having me today, and I 
look forward to working with you, with your staff on the 
Committee and others to move the bill forward.
    Chairman Isakson. Well, thank you, Senator Rubio. For the 
benefit of the entire audience here today, as well as those 
watching on the network, Senator Rubio has worked tirelessly 
over the last 2 years, along with almost every Member, if not 
every Member of the Committee. There have been a lot of issues 
that we have worked on. He has been cooperative in working 
toward those to a responsible bill which brings about 
accountability and pride in the Department, allows us, for the 
first time, to be able to, as Members of the Senate Veterans' 
Affairs Committee to answer tough questions on television in 
terms of what we have done to keep, or help prevent bad things 
from happening at the Veterans Administration. The rank and 
file veterans employees at the Administration are the best in 
the country. They are fantastic people. But one bad apple can 
drag down an entire agency, even one as large as the Veterans 
Administration.
    I am appreciative--I want to publicly thank Senator Rubio 
for his conscientious effort, and Senator Tester for working 
time and again to go to meetings, to bring people together, so 
we have a bipartisan bill that deals with the accountability of 
the VA and the employees in that agency. Thank you, Senator 
Rubio, for doing that.
    You are both--Senator Hatch is already excused. Senator 
Rubio, you may be excused if you like, and you can stay and 
listen to the entire hearing if you like.
    Senator Rubio. I will watch it on TV. [Laughter.]
    Chairman Isakson. That is the right choice.
    We have two great panels today. I am going to introduce 
Panel I. As I call your names, if you will come forward. There 
will be a nameplate in front of the place where you are to sit. 
After we hear the opening statements by Panel I we will have 
questions from Members of the Committee, then we will go to 
Panel II. After that, we will do both questions of Panel II as 
well, as Members who come back to catch up with questions on 
Panel I, if necessary.
    First, Dr. Jennifer S. Lee, Deputy Under Secretary for 
Health for Policy and Services, Veterans Health Administration, 
U.S. Department of Veterans Affairs; accompanying Dr. Lee are 
Meghan Flanz, Acting General Counsel, Office of General 
Counsel; Donnie Hachey--did I do that right? I did it right? 
OK, well, that is close enough--Chief Counsel for Operations, 
Board of Veterans' Appeals; David McLenachen, Director of 
Appeals Management Office, Veterans Benefits Administration; 
Margaret Kabat, National Director, Caregiver Support Program, 
Veterans Health Administration; James Ruhlman, Assistant 
Director for Policy and Procedures, Veterans Benefits 
Administration; and Phil Parker, Acting Associate Deputy 
Assistant Secretary, Office of Acquisition, Logistics, and 
Construction.
    Hopefully I did not miss anybody, and I apologize to 
anybody whose name I did not do a good job with. I apologize 
for that.
    Dr. Lee, you are on board, and I think everybody else is 
here in a supporting role. Is that correct?
    Dr. Lee. It is a team effort.
    Chairman Isakson. A team effort.
    Dr. Lee. Yes, sir.
    Chairman Isakson. Well, it is my pleasure to introduce Dr. 
Jennifer Lee, Deputy Under Secretary for Health for Policy and 
Services, Veterans Health Administration. Dr. Lee.

STATEMENT OF JENNIFER S. LEE, M.D., DEPUTY UNDER SECRETARY FOR 
HEALTH FOR POLICY AND SERVICES, VETERANS HEALTH ADMINISTRATION, 
  U.S. DEPARTMENT OF VETERANS AFFAIRS; ACCOMPANIED BY MEGHAN 
   FLANZ, ACTING GENERAL COUNSEL, OFFICE OF GENERAL COUNSEL; 
DONNIE HACHEY, CHIEF COUNSEL FOR OPERATIONS, BOARD OF VETERANS' 
   APPEALS; DAVE McLENACHEN, DIRECTOR OF APPEALS MANAGEMENT 
   OFFICE, VETERANS BENEFITS ADMINISTRATION; MARGARET KABAT, 
 NATIONAL DIRECTOR, CAREGIVER SUPPORT PROGRAM, VETERANS HEALTH 
 ADMINISTRATION; JAMES RUHLMAN, ASSISTANT DIRECTOR FOR POLICY 
  AND PROCEDURES, VETERANS BENEFITS ADMINISTRATION; AND PHIL 
PARKER, ACTING ASSOCIATE DEPUTY ASSISTANT SECRETARY, OFFICE OF 
            ACQUISITION, LOGISTICS, AND CONSTRUCTION

    Dr. Lee. Good afternoon, Chairman Isakson, Ranking Member 
Tester, and Members of the Committee. Thank you for inviting us 
here today to present our views on several bills that would 
affect the VA's programs and services. Joining me today are a 
number of my esteemed colleagues from across the Department, 
with a wide array of subject matter expertise.
    First I would like to thank the Members of this Committee 
as well as our colleagues from the VSOs for your hard work and 
commitment to advancing legislation we believe is absolutely 
critical to modernizing the VA accountability and appeals 
reform.
    The Department also supports many of the bills on today's 
agenda, or their intent, as they provide us with authorities to 
better meet the needs of veterans and their families.
    Regarding S. 23, VA agrees with the objectives of this bill 
but does not support the bill, as written, as it may limit VA's 
ability to maintain distinct identifiers for biologics of human 
origin and could impair our ability to obtain implants quickly 
when a clinical need arises.
    VA supports the intent of S. 112 as long as additional 
resources are available. We feel this authority is needed to 
fully reach the entire homeless population.
    While VA does not support S. 324 as written, VA does 
support growing adult day health care programs in general, as 
they are an important aspect of the continuum of VA's home- and 
community-based programs. VA would like the opportunity to 
establish mutually agreeable adult day health rates with our 
State veteran home partners.
    Although VA agrees with the overall intent of S. 543, we 
are still examining the effect this bill would have and would 
appreciate the opportunity to discuss this further with the 
Committee. VA agrees there are opportunities to improve 
oversight of contractors and program management associated with 
the contracting process.
    While VA does not support S. 591, VA does favor providing 
comprehensive support to family caregivers of veterans of all 
eras. Currently VA is undergoing an internal review of the 
caregiver program to ensure current eligibility criteria are 
applied consistently. VA welcomes further discussion with this 
Committee about the current program as well as the proposed 
expansion.
    VA does not support S. 609. While VA is very supportive of 
increasing access to chiropractic care for veterans, we do not 
believe that it would be prudent to add chiropractic clinics in 
areas where demand may not exist to justify the investment.
    We support much of S. 681, the Deborah Sampson Act. VA has 
placed a high priority on ensuring equitable and high-quality 
care for women veterans and we appreciate this Committee's 
support of this priority. The bill would provide a number of 
authorities to accelerate and expand our efforts to improve 
care for women veterans.
    VA supports the intent of S. 764, the Veterans Education 
Priority Enrollment Act, though we do have concerns we would 
like to discuss with the Committee.
    VA strongly supports S. 784, which expresses in a tangible 
way the Nation's gratitude for the sacrifices made by service-
disabled veterans and their surviving spouses and children. The 
bill would also ensure that the value of dependency indemnity 
compensation keeps pace with increases in consumer prices.
    VA is appreciative of the support for women veterans' 
issues in S. 804, but has, in fact, initiated several of the 
actions required by the bill. As some provisions may be 
duplicative of our current effort, VA does not support the 
proposed legislation.
    VA also supports S. 899, which would require VA to 
establish a leave transfer program and leave bank for the 
benefit of certain disabled VA health care professionals.
    S. 1024 provides much-needed comprehensive reforms to the 
VA appeals process, to ensure veterans receive a timely VA 
decision on their appeal. VA strongly supports the intent of 
S. 1024 and looks forward to working with the Committee to 
address concerns with a few provisions, as drafted. The 
Department stands committed to getting appeals reform 
accomplished for veterans this year.
    VA strongly supports the aims of S. 1094, the 
Accountability and Whistleblower Protection Act. This would 
improve our oversight and investigation of whistleblower 
disclosures and retaliation complaints, and would allow for 
more timely disciplinary action against employees whose 
misconduct or performance undermines veterans' and the public's 
trust in VA care and services. We deeply appreciate the 
Committee's efforts to meet VA's needs for greater flexibility 
in dealing with underperforming and misbehaving employees. With 
the assistance of the Department of Justice, VA looks forward 
to working with the Committee through the technical assistance 
process to resolve the few remaining concerns.
    VA supports, in principle, the draft bill serving our rural 
veterans, in the interest of building graduate medical 
education capacity to better meet the needs of veterans in 
rural and underserved areas, such as Alaska.
    Finally, VA has no objection to the Veteran PEER Act but 
notes VA already has the authority to execute this program to 
include more PEER specialists and patient-aligned care teams, 
subject to the availability of funding.
    My written statement provides the Department's full view on 
each of the bills.
    Thank you, Mr. Chairman, and thank you, Ranking Member 
Tester, for the opportunity to testify before you today. My 
colleagues and I would be pleased to respond to questions that 
you or other Members may have at this time.
    [The prepared statement of Dr. Lee follows:]
 Prepared Statement of Dr. Jennifer S. Lee, Deputy Under Secretary for 
Health for Policy and Services of Veterans Health Administration, U.S. 
                     Department of Veterans Affairs
    Good morning, Chairman Isakson, Ranking Member Tester, and Members 
of the Committee. Thank you for inviting us here today to present our 
views on several bills that would affect the Department of Veterans 
Affairs' (VA) programs and services. Joining me today is Ms. Margaret 
Kabat, National Director, Caregiver Support Program, Veterans Health 
Administration (VHA); Phil Parker; Acting Associate Deputy Assistant 
Secretary, Office of Acquisition and Logistics, Office of Acquisition, 
Logistics, and Construction (OALC); Mr. James Ruhlman, Assistant 
Director for Policy & Procedures, Veterans Benefits Administration 
(VBA); Ms. Meghan Flanz, Interim General Counsel; Dave McLenachen, 
Director, Appeals Management Office, VBA; and Donnie Hachey, Chief 
Counsel for Operations, Board of Veterans Appeals (BVA).
    There are a number of bills on the agenda today, and we are unable 
at this time to provide views and cost estimates on a few of these 
provisions. Specifically, we do not have cost estimates on S. 543 and 
S. 764.
   s. 23, biological implant tracking and veteran safety act of 2017
    S. 23 would direct VA to adopt and implement a standard 
identification protocol for use in the tracking and procurement of 
biological implants by VA.
    Section 2(a) would add a new section 7330B to title 38 to require 
VA to adopt the unique device identification system developed by the 
Food and Drug Administration (FDA) for medical devices (or implement a 
comparable standard identification system) for use in identifying 
biological implants intended for use in VA medical procedures conducted 
in medical facilities of the Department. In procuring biological 
implants under this section, VA would be required to permit a vendor to 
use any of the accredited entities identified by the FDA as an issuing 
agency pursuant to 21 Code of Federal Regulations (CFR) Sec. 830.100. 
The Secretary would be required to implement a system for tracking 
biological implants from donor to implantation that is compatible with 
the tracking system to be adopted and implemented. VA would be required 
to implement inventory controls compatible with the tracking system to 
enable VA to notify, as appropriate (based on an evaluation by 
appropriate VA medical personnel), VA patients who are in receipt of 
biological implants that are subject to a recall. In addition, section 
2 of the bill would provide that in cases of conflict between the 
proposed revision to title 38 and a provision of 21 United States Code 
(U.S.C.) Sec. 301 et seq. or 42 U.S.C. Sec. Sec. 262 and 264, 
(including any regulations issued pursuant to these statutes), the 
provisions of these other statutes or regulations would apply.
    Section 2 of the bill would define the term ``biological implant'' 
as any human cell, tissue, or cellular or tissue-based product or 
animal product: (1) under the meaning given the term ``human cells, 
tissues, or cellular or tissue-based products'' in 21 CFR Sec. 1271.3 
(or any successor regulation); or (2) that is regulated as a device 
under 21 U.S.C. Sec. 321(h). Under section 2(c), the standard 
identification system for biological implants would have to be adopted 
or implemented not later than 180 days after the Act's enactment. With 
respect to products that are regulated as a device, the Secretary would 
be required to adopt or implement such standard identification system 
in compliance with the compliance dates established by the FDA pursuant 
to 21 U.S.C. 360i(f).
    If the tracking system for biological implants is not operational 
within 180 days of the bill's enactment, section 2(d) would require the 
Secretary to submit a written explanation to the Committees on 
Veterans' Affairs explaining why the system is not operational for each 
month until the system is operational.
    Initially, we note that section 2(a) of the bill attempts to create 
a new section 7330B; however, there already is a section 7330B, 
requiring VA to issue an annual report on the Veterans Health 
Administration (VHA) and furnishing of hospital care, medical services, 
and nursing home care. This was enacted last December as part of the 
Jeff Miller and Richard Blumenthal Veterans Health Care and Benefits 
Improvement Act of 2016 (Public Law 114-315, section 612(a)). We 
recommend as a technical matter the bill propose to create a new 
section 7330C, as that would be the next available statute in the 
U.S.C., and that references throughout the bill to 7330B be updated to 
7330C.
    While VA agrees with the bill's intentions, VA does not support 
section 2 of the bill as written. The bill recognizes the need for a 
higher standard for human biologics as indicated by the requirement in 
section 3 for the use of a distinct identifier at all stages in 
distribution. However, as written, the bill could force VA to treat 
human tissues the same as other biologics in terms of identification.
    Additionally, the bill states that VA shall permit vendors to use 
any of the FDA accredited entities identified as an issuing agency for 
a standard identification system for biological implants. This 
effectively limits VA to the use of FDA's minimum issuing agency 
accreditation standards. VA already tracks blood and cellular products 
successfully using ISBT 128 identifiers in its facilities, and as a 
result, VA should be able to extend this system to ISBT 128-labeled 
human tissue products providing both electronic health record 
documentation and inventory control. VA is working with the Department 
of Health and Human Services (HHS) and other Federal partners to 
identify the optimal tracking and tracing systems to ensure the highest 
safety standards for human tissues.
    VA intends to institute new recommendations from HHS for tissue 
tracking. On April 7-8, 2015, the HHS Advisory Committee on Blood and 
Tissue Safety and Availability voted unanimously to recommend that the 
HHS Secretary adopt a step-wise, risk-based approach to standardizing 
the identification, tracking, and tracing of medical products of human 
origin. In particular, the Committee recommended establishing ISBT 128 
labeling as ``a universal standard for mandatory implementation of 
unique donation identifiers for all human tissue products.'' It 
suggested that the HHS Secretary promote the integration of 
transplantation records into searchable, electronic patient records. It 
further recommended taking steps to ensure that patients are informed 
when they receive a tissue product and provided a means of tracing it. 
The Committee asked that the HHS Secretary promote education for health 
care providers regarding the risks of human tissue transplants, the 
need for meaningful informed consent, and the necessity of engaging in 
activities to ensure tracking and tracing of tissue products. Last, it 
noted the importance of promoting international collaboration and data 
sharing on outcomes of tissue transplantation.
    VA notes that HHS does not consider FDA's Unique Device Identifier 
(UDI) appropriate for use as a tracking system for all biological 
implants. Human and animal derived implants, which are not regulated as 
devices, have different requirements from the devices for which the UDI 
was created.
    Section 3 would add a new section 8129 to title 38 to govern the 
procurement of biological implants. VA would be limited to procuring 
human biological implants from vendors that meet several conditions. 
First, the vendors supplying biological implants of human origin would 
have to use the standard identification system adopted or implemented 
by VA under new section 7330B (as added by section 2 of the bill) with 
safeguards to ensure that a distinct identifier has been in place at 
each step of distribution from its donor. Additionally, each vendor 
would have to be registered with the FDA, ensure that donor eligibility 
determinations and other records accompany each biological implant at 
all times, and agree to cooperate with all biological implant recalls 
initiated by the vendor, the manufacturer, or the FDA. Vendors would 
have to agree to notify VA of any adverse event or reaction report it 
provides to FDA as required by 21 CFR Sec. Sec. 1271.3 and 1271.350 or 
any warning letter from the FDA within 60 days of the vendor's receipt 
of such report or warning letter. Vendors would also have to agree to 
retain all records associated with procuring a biological implant for 
at least 10 years and would have to provide assurances that the 
biological implants provided are acquired only from tissue processors 
that maintain accreditation with the American Association of Tissue 
Banks or a similar national accreditation.
    VA would be required to procure biological implants under the 
Federal Supply Schedules (FSS) of the General Services Administration 
(GSA) unless such implants are not available under these schedules. VA 
would be required to accommodate reasonable vendor requests to 
undertake outreach efforts to educate VA medical professionals about 
the use and efficacy of biological implants with respect to implants 
that are listed on the FSS. In the case of biological implants 
unavailable on FSS, VA would be required to procure such implants using 
competitive procedures in accordance with applicable law and the 
Federal Acquisition Regulation (FAR). The bill would also clarify that 
38 U.S.C. Sec. 8123, which addresses procurement of prosthetic 
appliances, does not apply to the procurement of biological implants.
    Additionally, section 3 would establish penalties, in addition to 
any penalty under another provision of law, for procurement employees 
who are found responsible for a biological implant procurement 
transaction with intent to avoid or with reckless disregard of the 
requirements of this section. Such an official would be ineligible to 
hold a certificate of appointment as a contracting officer or to serve 
as the representative of an ordering officer, contracting officer, or 
purchase card holder.
    The new section 8129 would take effect 180 days after the date on 
which the tracking system required by the new section 7330B is 
implemented. The bill also contains a special rule for cryopreserved 
products, allowing VA 3 years to procure biological implants produced 
and labeled before the effective date of section 8129 without 
relabeling the products under the standard identification system 
adopted or implemented under the new section 7330B.
    VA does not support section 3 of the bill as drafted. Vendors would 
be required to retain records for up to 10 years under the bill. VA 
notes that some institutions permanently retain these records. In 
particular, some types of biologics may be stored for extended periods 
prior to use and it may take several years for an adverse outcome to 
manifest. Disposal of records, in particular, the actual production 
identifier and donor documentation, will prevent the ability to track 
human derived biologics to their donor and lead to the use of biologics 
in VHA that cannot reliably be tracked back to the original donor. 
Requiring providers to retain records for only 10 years could produce 
problems in the future, and we believe that permanent record retention 
would be preferable.
    VA also has concerns with the requirement that biological implants 
be procured from FSS sources (unless the products are not available 
from these sources). This would unduly restrict VA clinicians' best 
judgment as to the right implants for a given patient. Clinicians are 
not involved in the decision to place biological implants on the FSS. 
Additionally, VHA has determined that biological implants should be 
procured through national contracts that would take precedence over 
FSS. VA is developing an appropriate initial contract vehicle to 
acquire such products.
    VA is specifically concerned that enactment of the bill would end 
the applicability of 38 U.S.C. Sec. 8123 to the procurement of 
biological implants. This change would have an immediate, measurable, 
and adverse effect on wait times and patient care. This could result in 
considerable morbidity in the Veteran population, who would be forced 
to wait until GSA contracting can arrange for specific implants 
required to restore function. It is important to stress that, for many 
patients, there is an optimal window of opportunity for the use of an 
implant to prevent permanent loss of function. Many of these items are 
custom made and purchased in low volume or single units and will not be 
on a GSA contract or be cost effective for the U.S. Government to place 
on a full contract. Full contracting may take much longer than is 
clinically appropriate for Veterans. Further, it is not uncommon to 
purchase inventory in emergency situations from other local hospitals 
to meet acute needs. This occurs under the authority of 38 U.S.C. 
Sec. 8123. Limiting this authority as provided in the bill will prevent 
this activity and could jeopardize timely patient care. VA may then be 
forced to refer these patients to providers in the community, which 
could increase costs to the Department and reduce patient care if these 
community providers are not subject to the same requirements in terms 
of procurement and tracking of biological implants.
    VA is also concerned that the penalties imposed under proposed 
section 8129(b) could produce unfair results if a procurement employee 
needs to purchase a product off-contract to meet the immediate needs of 
a patient and provider. This could be exacerbated by vendors choosing 
not to contract with VA given the new requirements imposed upon them, 
thereby eliminating or limiting the availability of products for our 
patients. Shortages of biologic products could also affect VA's ability 
to obtain products under contract or through competitive processes. As 
a result, Veterans' medical care could be delayed. VA recommends this 
provision either be stricken or revised to apply penalties only for the 
procurement employees whose off-contract procurement is for 
irresponsible reasons. This would provide the Secretary the authority 
to distinguish between cases when a violation was willful and 
jeopardized patient care and when it was willful, but done with the 
purpose of supporting patient care.
    We estimate that S. 23 would cost $11.2 million in fiscal year (FY) 
2018, $33.6 million over 5 years, and $66.3 million over 10 years.
  s. 112, creating a reliable environment for veterans' dependents act
    S. 112 would amend 38 U.S.C. Sec. 2012(a) to permit a grantee 
receiving per diem payments under the Homeless Providers Grant and Per 
Diem (GPD) Program to use part of these payments for the care of a 
dependent of a homeless Veteran who is under the care of such homeless 
Veteran who is receiving services covered by the GPD grant. This 
authority would be limited to the time period during which the Veteran 
is receiving services under the grant.
    VA supports the intent of S. 112, conditioned on the availability 
of additional resources to implement this provision. We feel that this 
authority is needed to fully reach the entire homeless population. 
However, full implementation of the legislation would require 
additional funding to avoid diminished services in VA's full complement 
of programs for homeless Veterans.
    VA estimates this bill would cost $29.8 million in FY 2018, $159.3 
million over 5 years, and $347.6 million over 10 years.
 s. 324, state veterans homes adult day health care improvement act of 
                                  2017
    S. 324 would amend 38 U.S.C. Sec. 1745 to require the Secretary to 
enter into a contract or agreement with each State Veterans Home (SVH) 
for payment by VA for adult day health care (ADHC) provided to an 
eligible Veteran. Eligible Veterans would be those in need of nursing 
home care for a service-connected disability or who have a service-
connected disability rated at 70 percent or more and are in need of 
nursing home care. Payments for each Veteran who receives medical 
supervision model adult day health care would be made at a rate that is 
65 percent of the payment VA would make if the Veteran received nursing 
home care, and payment by VA would constitute payment in full for such 
care. The term ``medical supervision model adult day health care'' 
would be defined to mean adult day health care that includes the 
coordination of physician services, dental services, the administration 
of drugs, and such other requirements as determined appropriate by the 
Secretary. Currently, under a grant mechanism, VA pays States not more 
than half the cost of providing ADHC. States may currently obtain 
reimbursement for this care from other sources in addition to VA's per 
diem payments.
    VA supports growing ADHC programs in general as they are a part of 
VA's home- and community-based programs that have been demonstrated to 
benefit the health and well-being of older Veterans. However, VA does 
not support this bill as written for several reasons.
    First, VA notes that the bill would base payment rates for ADHC on 
nursing home care rates, though these are two distinctly different 
levels of care and are furnished for different periods of time. VA pays 
per diem for three levels of care at SVHs: nursing home care, 
domiciliary care, and adult day health care. The prevailing nursing 
home rate is calculated based on the cost of providing nursing home 
care, and VA negotiated that rate in conjunction with SVHs. Nursing 
home residents live at the facility and receive 24-hour skilled nursing 
care, including services after normal business hours with registered 
nurses involved in care at all times. ADHC is a distinctly different 
level of care that provides health maintenance and rehabilitative 
services to eligible Veterans in a group setting during daytime hours 
only. ADHC participants live at home and only use ADHC services for a 
portion of time during the day, normally about 8 hours, or one third of 
the length of time that skilled nursing care is provided. A per diem 
payment is made only if the participant is under the care of the 
facility for at least 6 hours (which can be 6 hours in one calendar 
day, or any two periods of at least 3 hours each in any 2 calendar days 
of the month). The nursing home rates that would be used to compute the 
ADHC rates under this bill are based on a formula that was developed in 
partnership with VA's state home partners and is specific to nursing 
home care. VA would like the opportunity to thoroughly review the cost 
of providing ADHC and, as was accomplished for nursing home care, 
establish a mutually agreeable ADHC rate with our SVH partners. VA 
believes revising the language to allow for VA to propose a formula for 
computing ADHC rates and for SVHs to provide comments on the formula 
would be consistent with the way the nursing home care rates were 
developed under 38 U.S.C. Sec. 1745. While this bill would specifically 
apply these payment rates to ADHC programs providing medical 
supervision, rather than any ADHC program, we still believe basing any 
ADHC payment rate on the rate for skilled nursing care is 
inappropriate.
    Second, we note that the bill would direct VA to ``enter into a 
contract or agreement'' with each SVH. Agreements reached under this 
provision would still generally be contracts. VA has requested specific 
authority that would allow VA to enter into individual agreements not 
subject to certain provisions of law governing Federal contracts. We 
request this authority be granted before requiring VA to transition 
state payments from a grant to a contract mechanism.
    We do support the bill's focus on ADHC programs providing medical 
supervision. A medical supervision model would include physician 
services, dental services, and administration of drugs, whereas these 
would not be required for a socialized model.
    Additionally, VA expects the numbers of both socialized and medical 
supervision model ADHCs to increase after publication of the proposed 
regulation. VA is not able to predict how many SVHs will adopt the new 
socialized model, nor how the new model's use will affect costs. Until 
VA has such information, VA recommends against codifying a payment 
rate, as such a limitation could result in VA overpaying or underpaying 
states in the future.
    VA estimates S. 324 would cost an additional $492,972 in FY 2018, 
$3.8 million over 5 years, and $11.6 million over 10 years.
 s. 543, performance accountability and contractor transparency (pact) 
                              act of 2017
    S. 543 would amend section 513 of title 38, U.S.C., to require VA 
to include performance metrics to service contracts under such 
authority and safeguards that will allow VA to levy financial penalties 
on service providers who fail to meet established thresholds of 
quality. The bill proposes to place additional requirements for 
contracts over $100 million to include requiring the service provider 
to document its work in a database and submit reports to VA and the 
Committees on Veterans' Affairs of the House of Representatives and the 
Senate. VA would be required to submit a report to these Congressional 
Committees if a service provider fails to meet its contractual 
obligations or if there are any modifications made on the contract. VA 
would be required to publish online information on the contract, 
including any modifications to the contract.
    We are still examining the effect this bill would have, and would 
appreciate the opportunity to discuss this further with the Committee. 
VA agrees that there are opportunities to improve our oversight of 
contractors and program management associated with the contracting 
process; however, we believe the bill could impose undue additional 
costs to VA and taxpayers, duplicate existing requirements, and/or 
require clarifying language. Of note, the recently signed Program 
Management Improvement Accountability Act (Public Law 114-264) requires 
Agencies to implement program management policies and develop a 
strategy for enhancing the role of program managers within the Agency. 
This law aligns to a program execution and governance model VA is 
currently executing, the Acquisition Program Management Framework 
(APMF). The APMF has been recognized by the Office of Federal 
Procurement Policy (under the Office of Management and Budget), the 
Federal Acquisition Institute, and the Government Accountability Office 
as addressing the critical needs of stronger program management and 
governance.
    Many of the requirements in section 2 of the bill are already 
mandated by various parts of the Federal Acquisition Regulation (FAR) 
and/or Veterans Affairs Acquisition Regulation (VAAR). These 
regulations govern the process by which VA acquires goods and services 
by contract with appropriated funds. VA Quality Assurance, for example, 
requires government-led contract quality assurance at all times and 
places as may be necessary to determine that the supplies or services 
conform to contract requirements. Quality Assurance Surveillance Plans 
(QASP) should be prepared in conjunction with the preparation of the 
Performance Work Statement. These plans should specify: (1) all work 
requiring surveillance; and (2) the method of surveillance. Each 
contract shall designate the place or places where VA reserves the 
right to perform quality assurance.
    Moreover, all major programs should have a Program Management Plan 
(PMP). PMP should identify key milestones, detail activities necessary 
to reach milestones, identify risks and issues, and develop strategies 
to mitigate risks and correct issues. Program Managers should also be 
measuring the health of the program as it relates to cost, schedule, 
and execution of contract through metrics.
    Importantly, VA regulations recognize that a one-size-fits-all 
approach does not work for contracting and that there are times when it 
is not in VA's best interest to be overly prescriptive. Therefore, VA 
encourages work to be described in terms of required results rather 
than either ``how'' the work is to be accomplished or the number of 
hours to be provided; to enable assessment of work performance against 
measurable performance standards; and to rely on the use of measurable 
performance standards and financial incentives in a competitive 
environment to encourage competitors to develop and institute 
innovative and cost-effective methods of performing the work.
    When utilized, such contracts include: (1) a performance work 
statement (PWS); (2) measurable performance standards (i.e., in terms 
of quality, timeliness, quantity, etc.) and the method of assessing 
contractor performance against performance standards; and (3) 
performance incentives where appropriate. In short, VA incorporates 
metrics for incentive or award fees into contracts when it is in VA's 
best interest to do so.
    Furthermore, VA Contracting Officers may utilize liquidated damages 
clauses when appropriate. Before using a liquidated damages clause, VA 
Contracting Officers must consider the potential impact on pricing, 
competition, and contract administration. Liquidated damages clauses 
are only used when: (1) the time of delivery or timely performance is 
so important that the Government may reasonably expect to suffer damage 
if the delivery or performance is delinquent; and (2) the extent or 
amount of such damage would be difficult or impossible to estimate 
accurately or prove.
    Although VA agrees with the overall intent of the proposed 
legislation, VA would like to express a few concerns with key sections 
of the legislation.
    VA also requests clarity on the types of modifications for which 
reports would have to be submitted. The FAR identifies many types of 
contract modifications, some of which may not be of congressional 
interest.
    While VA agrees with much of the language in the bill, there are 
sections of the legislation where VA recommends modest changes such as 
placing ``contract'' with ``program'' (e.g., ``use the appropriate 
project management accountability system of the Department to ensure 
that the contract provides an adequate return on the investment of the 
Secretary'' in proposed section 513(b)(2)(B)) to clarify the broader 
responsibility of the Program Manager in ensuring adequate return on 
investment of programs that may have one or more contracts.
    VA would appreciate the opportunity to discuss the proposed 
legislation with the Acquisition Community, as well as to conduct a 
more formal technical review of the proposed legislation at a later 
juncture. We look forward to ongoing collaboration with the sponsors of 
this legislation.
    VA does not have a cost estimate for this bill at this time.
s. 591, military and veteran caregivers service improvement act of 2017
    S. 591 would expand eligibility for VA's Program of Comprehensive 
Assistance for Family Caregivers, expand benefits available to 
participants under such program, enhance special compensation for 
certain members of the uniformed services who require assistance, and 
make other amendments to increase the provision of benefits.
    The Caregivers and Veterans Omnibus Health Services Act of 2010, 
Public Law 111-163, signed into law on May 5, 2010, provided expanded 
support and benefits for caregivers of eligible and covered Veterans. 
While the law authorized certain support services for caregivers of 
covered Veterans of all eras, other benefits were authorized only for 
qualified family caregivers of eligible Veterans who incurred or 
aggravated a serious injury in the line of duty on or after 
September 11, 2001. These new benefits for approved family caregivers, 
provided under the Program of Comprehensive Assistance for Family 
Caregivers, include a monthly stipend paid directly to designated 
primary family caregivers and medical care under CHAMPVA for designated 
primary family caregivers who are not eligible for TRICARE and not 
entitled to care or services under a health-plan contract.
    Section 2 of S. 591, the Military and Veteran Caregiver Services 
Improvement Act of 2017, would remove ``on or after September 11, 
2001'' from the statutory eligibility criteria for the Program of 
Comprehensive Assistance for Family Caregivers, and thereby expand 
eligibility under the program to Veterans of all eras who otherwise 
meet the applicable eligibility criteria. Family caregivers could not 
receive assistance under this expanded eligibility until FYs 2018, 
2020, or 2022 depending on the monthly stipend tier for which their 
eligible Veteran qualifies. Section 2 would also add ``or illness'' to 
the statutory eligibility criteria, and thereby expand eligibility to 
include those Veterans who require a caregiver because of an illness 
incurred or aggravated in the line of duty. In addition, the bill would 
expand the bases upon which a Veteran could be deemed to be in need of 
personal care services, to include ``a need for regular or extensive 
instruction or supervision without which the ability of the Veteran to 
function in daily life would be seriously impaired.''
    This section would also expand the assistance available to primary 
family caregivers under the Program of Comprehensive Assistance for 
Family Caregivers to include child care services, financial planning 
and legal services ``relating to the needs of injured and ill Veterans 
and their caregivers,'' and respite care that includes peer-oriented 
group activities. The bill would ensure that in certain circumstances 
VA accounts for the family caregiver's assessment and other specified 
factors in determining the primary family caregiver's monthly stipend 
amount. In addition, the bill would require VA to periodically evaluate 
the needs of the eligible Veteran and the skills of the family 
caregiver to determine if additional instruction, preparation, 
training, or technical support is needed, and it would require certain 
evaluation be done in collaboration with the Veteran's primary care 
team to the maximum extent practicable.
    Section 2 would also authorize VA, in providing assistance under 
the Program of Comprehensive Assistance for Family Caregivers, to 
``enter into contracts, provider agreements, and memoranda of 
understanding with Federal agencies, states, and private, nonprofit, 
and other entities'' in certain circumstances. It would expand the 
definition of family member to include a non-family member who does not 
provide care to the Veteran on a professional basis, and it would amend 
the definition of ``personal care services.'' The bill would also end 
the Program of General Caregiver Support Services on October 1, 2022, 
but would ensure that all of its activities are carried out under the 
Program of Comprehensive Assistance for Family Caregivers. Finally, the 
bill would amend the annual reporting requirements for the Program of 
Comprehensive Assistance for Family Caregivers.
    In September 2013, VA sent a report to the Committees on Veterans' 
Affairs of the Senate and House of Representatives (as required by 
Section 101(d) of Public Law 111-163) on the feasibility and 
advisability of expanding the Program of Comprehensive Assistance for 
Family Caregivers to family caregivers of Veterans who incurred or 
aggravated a serious injury in the line of duty before September 11, 
2001. In that report, VA noted that expanding the Program of 
Comprehensive Assistance for Family Caregivers would allow equitable 
access to seriously injured Veterans from all eras (who otherwise meet 
the program's eligibility criteria) and their approved family 
caregivers.
    In the report, however, VA noted difficulties with making reliable 
projections of the cost effect of opening the Program of Comprehensive 
Assistance for Family Caregivers to eligible Veterans of all eras, but 
estimated a population range of 32,000 to 88,000 additional Veterans in 
the first year (estimated for FY 2014), at a cost of $1.8 billion to 
$3.8 billion in the first year (estimated for FY 2014). After VA 
provided this report to Congress, the RAND Corporation published a 
report titled, ``Hidden Heroes: America's Military Caregivers,'' which 
estimates a significantly larger eligible population (1.5 million) that 
may be eligible if the program were expanded to caregivers of pre-9/11 
Veterans and those qualifying due to illness. VA's estimates in its 
2013 report did not account for expansion to eligible Veterans with an 
illness incurred or aggravated in the line of duty, other Veterans who 
would become eligible for the program based on the amendments in 
section 2, or the additional assistance that would become available to 
primary family caregivers under the bill. This estimate also did not 
factor in a phased implementation of stipend expansion, as contemplated 
by the bill.
    VA cannot responsibly provide a position in support of expanding 
the Program of Comprehensive Assistance for Family Caregivers without a 
realistic consideration of the resources necessary to carry out such an 
expansion, including an analysis of the future resources that must be 
available to fund other core direct-to-Veteran health care services. 
This is especially true as VA presses to strengthen mental health 
services and ensure the fullest possible access to care across the 
system.
    We wish to make it very clear that VA believes an expansion of 
those benefits that are currently limited by era of service would 
result in equitable access to the Program of Comprehensive Assistance 
for Family Caregivers for long-deserving caregivers of those who have 
sacrificed greatly for our Nation. However, VA cannot endorse this 
measure before further engaging with Congress on these fiscal 
constraints, within the context of all of VA health care programs.
    Additionally, before expanding eligibility under the Program, we 
believe it prudent for VA to ensure that the current eligibility 
criteria are applied in a consistent manner across the program. For 
example, the National Caregiver Support Program is undergoing an 
internal review to evaluate consistency in revocations and reductions 
from the Program and standardize communication with Veterans and 
Caregivers. On April 17, 2017, VA suspended certain VA-initiated 
revocations in order to carry out this review.
    VA welcomes further discussion of these issues with the Committee.
    Section 3 of this bill proposes to add a new section 3319A to title 
38 to authorize individuals who are eligible for and participating in a 
program of comprehensive assistance for family caregivers under 38 
U.S.C. Sec. 1720G(a) the opportunity to transfer their unused Post-9/11 
GI Bill education benefits to their dependents. Veterans may complete 
the transfer of entitlement any time during the 15-year period 
beginning on the date of their last discharge or release from active 
duty. There is no length of service requirement, and the monthly rate 
of educational assistance would be the same rate payable to the 
individual making the transfer. The Secretary would be authorized to 
prescribe regulations to carry out this section. We note that the 
Survivors' and Dependents' Educational Assistance (DEA) program, or 
chapter 35, currently offers education and training benefits to 
eligible dependents of members of the Armed Forces and Veterans who 
have a service-connected disability rated as permanently and totally 
disabling, including individuals who are eligible for a program of 
comprehensive assistance for family caregivers. Assistance includes up 
to 45 months of full-time benefits.
    VA supports the intent of section 3 to take care of caregivers; 
however, VA cannot support this section as written. The transfer of 
entitlement provisions of the Post-9/11 GI Bill were established as a 
recruitment and retention tool for the uniformed services. As such, the 
Department of Defense (DOD) determines eligibility for transfer of 
entitlement. If enacted, the proposed legislation would require VA to 
develop procedures to receive requests to transfer entitlement for 
certain individuals, determine eligibility, and award benefits for the 
transfer of entitlement program. However, VA notes that Congress would 
need to identify appropriate offsets for the cost of this legislation
    Additionally, under the proposed section 3319A, dependents would 
receive the same rate of payment as otherwise payable to the individual 
making the transfer. This is different than the rate payable for a 
dependent child using transferred entitlement under section 3319. 
Currently, a dependent child is awarded benefits as if the individual 
making the transfer were not on active duty. As such, a child is 
entitled to the monthly housing allowance stipend even though the 
individual transferring benefits is still on active duty. Under the 
proposed legislation, a child would not be eligible for the housing 
allowance while the individual described in 38 U.S.C. Sec. 1720G(a)(2) 
is on active duty. This change would impact the Long-Term Solution for 
processing Post-9/11 GI Bill claims, as VA would have to make system 
modifications in order to apply a blended set of rules for claims 
involving transferred education benefits.
    Section 4(a) would amend 37 U.S.C. 439, providing for special 
compensation for members of the uniformed services with catastrophic 
injuries or illnesses requiring assistance in everyday living, by 
amending the definition of covered members to include those 
Servicemembers who have a serious injury or illness that was incurred 
or aggravated in the line of duty and are in need of personal care 
services as a result of such injury or illness. Section 4(b) would 
further amend section 439 by requiring VA to provide family caregivers 
of a Servicemember in receipt of monthly special compensation the 
assistance available to family caregivers of eligible Veterans under 38 
U.S.C. Sec. 1720G(a)(3)(A), other than the monthly caregiver stipend. 
VA would provide assistance under this subsection in accordance with a 
memorandum of understanding (MOU) between VA and DOD, and an MOU 
between VA and the Secretary of Homeland Security. VA would be required 
to ensure that a family caregiver in receipt of assistance under this 
subsection is able to transition seamlessly to the receipt of 
assistance under 38 U.S.C. Sec. 1720G. Section 4(c) would require DOD, 
in collaboration with VA, to ensure that members of the uniformed 
services in receipt of monthly special compensation are aware of the 
eligibility of such members for family caregiver assistance. Section 
4(d) would define the term ``serious injury or illness,'' which would 
replace the term ``catastrophic injury or illness,'' to mean an injury, 
disorder, or illness that (1) renders the afflicted person unable to 
carry out one or more activities of daily living; (2) renders the 
afflicted person in need of supervision or protection due to the 
manifestation by such person of symptoms or residuals of neurological 
or other impairment or injury; (3) renders the afflicted person in need 
of regular or extensive instruction or supervision in completing two or 
more instrumental activities of daily living; or (4) otherwise impairs 
the afflicted person in such manner as the Secretary of Defense or 
Homeland Security prescribes.
    Regarding section 4 of the bill, VA defers to DOD and the 
Department of Homeland Security regarding sections 4(a), 4(c), and 
4(d). VA does not support section 4(b) because DOD already provides 
many of the services and supports available under VA's Program of 
Comprehensive Assistance for Family Caregivers including health care 
coverage, mental health services, and respite care. Requiring VA to 
provide services under its program would result in a duplication of 
efforts.
    Section 5 would authorize the Office of Personnel Management (OPM) 
to promulgate regulations under which a covered employee, which would 
include a caregiver defined in 38 U.S.C. Sec. 1720G or a caregiver of 
an individual receiving compensation under 37 U.S.C. Sec. 439, to use a 
flexible schedule or compressed schedule or to telework. VA defers to 
OPM on this section.
    Section 6 would amend the Public Health Service Act (42 U.S.C. 
Sec. 300ii), which governs lifespan respite care, to amend the 
definition of ``adult with a special need'' to include a Veteran 
participating in the family caregiver program under 38 U.S.C. 
Sec. 1720G(a). It would also amend the definition of ``family 
caregiver'' to include family caregivers under 38 U.S.C. Sec. 1720G. 
Furthermore, in awarding grants or cooperative agreements to eligible 
state agencies to furnish lifespan respite care, HHS would be required 
to work in cooperation with the interagency working group on policies 
relating to caregivers of Veterans established under section 7 of this 
bill. Section 6 would also authorize appropriations of $15 million for 
FYs 2017 through 2022 for these grants. VA defers to HHS on this 
section.
    Section 7 would establish an interagency working group on policies 
relating to caregivers of Veterans and Servicemembers. The working 
group would be composed of a chairperson selected by the President, and 
representatives from VA, DOD, HHS (including the Centers for Medicare & 
Medicaid Service), and the Department of Labor. The working group would 
be authorized to consult with other advisors as well. The working 
group's duties would include regularly reviewing policies relating to 
caregivers of Veterans and Servicemembers, coordinating and overseeing 
the implementation of policies relating to these caregivers, evaluating 
the effectiveness of such policies, developing standards of care for 
caregiver and respite services, and others. Not later than December 31, 
2017, and annually thereafter, the working group would be required to 
submit to Congress a report on policies and services relating to 
caregivers of Veterans and Servicemembers.
    VA generally supports a working group that would provide a forum 
for analyzing and evaluating different issues that family caregivers of 
Veterans and Servicemembers face. Such a working group would be ideally 
suited to considering in depth the types of issues other provisions of 
this bill are intended to address and would also be able to evaluate 
emerging issues.
    The Department of Justice advises, however, the bill's method for 
selecting members of the working group raises Appointment Clause 
concerns, which DOJ will convey in greater detail under separate cover.
    We also note several technical concerns with the legislation in 
terms of the creation of the working group, its role, the potential 
applicability of the Federal Advisory Committee Act to such a group, 
and which agency (if any) would be responsible for initiating, 
managing, and funding the working group. We would be happy to discuss 
these issues with you upon your request.
    Section 8(a) would require VA to conduct a longitudinal study on 
Servicemembers who began their service after September 11, 2001. VA 
would be required to award a grant to or enter into a contract with an 
appropriate entity unaffiliated with VA to conduct the study. Within 1 
year of the date of the enactment of the Act, VA would be required to 
submit to the Committees on Veterans' Affairs a plan for the conduct of 
the study. Not later than October 1, 2021, and not less frequently than 
once every 4 years thereafter, VA would be required to submit to the 
Committees on Veterans' Affairs a report on the results of the study. 
Section 8(b) would require VA to provide for the conduct of a 
comprehensive study on Veterans who have incurred a serious injury or 
illness and individuals who are acting as caregivers for Veterans. VA 
would be required to award a grant to or enter into a contract with an 
appropriate entity unaffiliated with VA to conduct the study. The study 
would be required to include the health of the Veteran and the impact 
of the caregiver on the health of the Veteran, the employment status of 
the Veteran and the impact of the caregiver on that status, the 
financial status and needs of the Veteran, the use by the Veteran of VA 
benefits, and any other information VA considers appropriate. No later 
than 2 years after the date of the enactment of this Act, VA would be 
required to submit to the Committees on Veterans' Affairs a report on 
the results of this study.
    VA does not support section 8, as it would duplicate research in 
several ongoing or in-development studies. DOD and VA have a 
collaboration on the Millennium Cohort Study, a longitudinal cohort 
study that has and will continue to produce findings on health issues 
of multiple eras of military service. The Million Veterans Program 
creates a repository of clinical and genetic information on Veterans, 
including post-9/11 Veterans, which will provide data for targeted 
studies on health for years to come. VA's Cooperative Studies Program 
is developing a study on the respiratory health of Gulf War and post-9/
11 Veterans. Finally, a study of the life transitions of military 
Servicemembers who served in Iraq or Afghanistan is funded and in 
development.
    VA estimates section 8 would cost $4.3 million in FY 2018, $17.5 
million over 5 years, and $34 million over 10 years, with additional 
close out expenses of $3.3 million in FY 2028 for a total cost of $37.3 
million.
    s. 609, chiropractic care available to all veterans act of 2017
    S. 609 would require VA to carry out a program to provide 
chiropractic care and services to Veterans through VA medical 
facilities at not fewer than 75 VA medical centers (VAMC) by not later 
than December 31, 2018, and at all VAMCs by not later than December 31, 
2020. It would also modify 38 U.S.C. Sec. 1701 to amend the definition 
of ``medical services'' to include chiropractic services, the 
definition of ``rehabilitative services'' to include chiropractic 
services and treatment programs, and the definition of ``preventive 
health services'' to include periodic and preventive chiropractic 
examinations and services.
    VA does not support this bill. While adding chiropractic clinics 
would be consistent with ongoing VA initiatives to improve Veteran 
access to non-pharmacological pain treatment options, this can be 
accomplished through VA's existing policies and processes for hiring, 
credentialing, and privileging chiropractors. Chiropractic treatment 
has been shown to be clinically effective, cost effective, and in high 
demand by Veterans. Patients who have access to chiropractic care are 
less likely to receive opiate medications and spinal surgeries. VA has 
already been expanding access to chiropractic services for Veterans. 
Currently, about half of the Level 1a VAMCs have chiropractic clinics, 
and other facilities offer chiropractic services as well. However, 
mandating that all VAMCs provide chiropractic services by the end of 
2020 is unnecessary. The need for more chiropractic clinics across the 
VA health care system can most effectively be determined by continually 
assessing demand for chiropractic services and usage, and adding 
chiropractic care at those sites as warranted to meet demand. We do not 
believe it would be prudent as a matter of fiscal or clinical 
responsibility to increase the number of clinics in areas where demand 
is insufficient to support investment in such a clinic.
    We recommend the legislation not amend the definition of preventive 
health services in section 1701(9). Chiropractic services are provided 
as part of the medical benefits package and are administered based on 
clinical need, similar to all other medical care. It would be 
inconsistent with the professional standards for other medical 
disciplines and inappropriate to provide periodic and preventative 
chiropractic examination and services when there are no clinical 
indications that such care is needed.
    VA estimates S. 609 would cost $1.68 million in FY 2018, $60.23 
million over 5 years, and $155.9 million over 10 years.
                      s. 681, deborah sampson act
    S. 681 would amend title 38 of the U.S. Code to seek to improve the 
benefits and services provided by VA to women Veterans in a variety of 
ways.
    Section 101 would require VA to carry out a 3-year pilot program to 
assess the feasibility and advisability of facilitating peer-to-peer 
assistance for women Veterans, including those who are separating or 
are newly separated from service in the Armed Forces, with an emphasis 
on women who suffered sexual trauma during their service, have Post 
Traumatic Stress Disorder or suffer from another mental health 
condition, or are otherwise at risk of becoming homeless. Peer-to-peer 
assistance would consist of: (1) providing information about VA 
services and benefits, and (2) employment mentoring. VA would be 
required to commence the pilot program no later than January 1, 2018, 
and conduct outreach to inform women Veterans about the pilot program 
and assistance available under the pilot program. The pilot program may 
include training and the development of training materials for peer 
counselors. Under the pilot program, VA would be required to coordinate 
with specified government and community organizations to facilitate the 
transition of women Veterans into their communities. VA would also be 
required, to the degree practicable, to coordinate the pilot program 
with the Transition Assistance Program carried out under 10 U.S.C. 
Sec. 1144.
    VA supports section 101. Women Veterans who experienced military 
sexual trauma, who have mental health conditions, and/or who are at 
risk of becoming homeless face numerous barriers in seeking and 
accessing assistance, including through VA. Such women Veterans are 
considered to be among VA's most clinically complex patients. The 
program that would be required by section 101 has the potential to 
offer meaningful and powerful support to assist these women Veterans in 
connecting with needed services and assistance. Although section 101 
would focus the provision of information about VA services and benefits 
and provision of employment mentoring, VA's experience with its 
existing peer program suggests that perhaps the biggest benefit the 
program would offer would be role modeling and the instillation of 
hope, as peer specialists have already overcome many of the obstacles 
the participants are experiencing.
    Section 101 would expand VA's existing, well-established peer 
support program, which has demonstrated effectiveness in assisting 
Veterans in outpatient, inpatient, and residential mental health 
settings who are struggling with issues such as Post Traumatic Stress 
Disorder, substance use disorders, serious mental illness, and 
homelessness. These programs include women Veterans, and there are many 
women Veterans currently working as mental health peer specialists in 
VA. VA believes that, if enacted, development of this program would 
have to proceed carefully given the complexity of the clinical needs of 
the target population. In this context, the bill's proposed creation of 
a pilot program seems most appropriate.
    VA estimates section 101 would cost approximately $723,000 in FY 
2018 and approximately $3.7 million over the 3 years of the program.
    Section 102 would require VA to expand the capabilities of the 
Women Veterans Call Center of the Department to include a text 
messaging capability.
    VA supports section 102. To meet the needs of women Veterans, VA 
needs to provide information and answer questions via methods that are 
convenient to them. The Women Veterans Call Center routinely answers 
questions by phone and by chat, and the logical next step would be to 
provide convenient and accessible information for women Veterans via 
text messages. VA understands that women Veterans have expressed 
interest in such a text messaging capability. VA currently includes a 
text messaging response capability for its Veterans Crisis Line.
    VA estimates section 102 would cost approximately $174,000 in FY 
2018, $924,000 over 5 years, and $2.0 million over 10 years.
    Section 103 would amend section 1712A of title 38, U.S.C., to 
authorize VA to furnish counseling in group retreat settings to persons 
eligible for Readjustment Counseling Services from VA. The 
reintegration and readjustment services furnished would include 
information on reintegration of the individual into family, employment, 
and community; financial counseling; occupational counseling; 
information and counseling on stress reduction; information and 
counseling on conflict resolution; and such other information and 
counseling as the Secretary considers appropriate. VA would be required 
to offer women the opportunity to receive such services in group 
retreat settings in which the only participants are women. These 
readjustment and counseling services would be available upon the 
request of the individual.
    VA supports section 103. We agree that providing these retreats is 
beneficial to women Veterans, and believe other Veteran and 
Servicemember cohorts could also benefit from this treatment modality. 
Examples include those who have experienced military sexual trauma, 
Veterans and their families, and families that experience the death of 
a loved one while on active duty.
    VA estimates that section 103 would cost approximately $467,000 to 
conduct six retreats in FY 2018, $2.5 million over 5 years, and $5.6 
million over 10 years.
    Section 201 would require VA to establish a partnership with at 
least one non-governmental organization to provide legal services to 
women Veterans, focused on the 10 highest unmet needs of women Veterans 
as set forth in the most recently completed Community Homelessness 
Assessment, Local Education and Networking Groups for Veterans (CHALENG 
for Veterans) survey.
    VA supports section 201. The consistency of legal issues arising in 
VA's annual CHALENG survey strongly suggests a relationship between 
Veterans' unmet legal needs and the risk of becoming homeless. Legal 
issues can be a significant barrier to resolving homelessness, as these 
issues may be discovered in background checks conducted by landlords 
and employers, subsequently resulting in rejections for leases and 
employment offers. Additionally, legal issues may result in seizure of 
income or bank accounts, making it impossible to pay rent, or could 
result in the suspension of a driver's license, creating significant 
challenges for Veterans seeking employment or needing health care. A 
number of organizations stand ready to serve homeless or at-risk 
Veterans with legal services, but face financial limitations on their 
capacity to do so. The declining accessibility of civil legal aid, 
combined with persistent indicators of unmet need for it among 
Veterans, indicates that this passive approach is no longer viable. 
Providing additional funding for legal assistance would have a direct 
bearing on the housing stability of Veteran households. However, male 
Veterans who are homeless are also in need of legal services, as 
demonstrated by the CHALENG survey referenced in the proposed 
legislation. In the most recent CHALENG survey, five of the top ten 
unmet needs amongst both male and female homeless Veterans are legal 
needs, such as evictions/foreclosures, outstanding warrants/fines, 
child support, restoration of drivers' licenses, and discharge 
upgrades. Consequently, we recommend the bill be modified to make legal 
assistance available for both male and female Veterans needing such 
aid.
    We note, though, that it is unclear what exactly is contemplated by 
entering into a ``partnership'' with a non-governmental organization. 
Typically, VA provides grants (when authorized by statute) or enters 
into contracts or cooperative agreements with non-governmental 
organizations to provide services, particularly to homeless Veterans. 
However, with only the term ``partnership'' in the bill, it is unclear 
that it would provide clear authority for VA to expend Federal funds to 
support legal services for women Veterans; VA would require more 
explicit authority in that regard. It is also unclear why the provision 
only mentions ``at least one nongovernmental organization,'' to 
potentially exclude other public entities from participation. VA would 
be happy to discuss this section further with the Committee to 
understand better what is intended, and we would be pleased to provide 
technical assistance upon request.
    Section 202 would amend section 2044(e) of title 38, U.S.C., to 
authorize additional amounts for the Supportive Services for Veteran 
Families (SSVF) grant program to support organizations that have a 
focus on providing assistance to women Veterans and their families. 
Specifically, section 202 would amend paragraph (1)(E) to strike 2017 
and insert 2016, and add a new subparagraph (F) providing that $340 
million shall be available to carry out the SSVF grant program for each 
of FYs 2017 and 2018. In addition, section 202 would add a new 
paragraph (4) providing that not less than $20 million shall be 
available under paragraph (e)(1)(F) for the provision of financial 
assistance to organizations that have a focus on providing assistance 
to women Veterans and their families.
    VA supports section 202. SSVF is designed to rapidly re-house 
homeless Veteran families and prevent homelessness for those at 
imminent risk due to a housing crisis. Funds are granted to private 
non-profit organizations and consumer cooperatives that will assist 
very low-income Veteran families by providing a range of supportive 
services designed to promote housing stability. In FY 2016, 13.3 
percent of Veterans served by SSVF were women, the largest such 
percentage of any homeless services program. As women represent only 8 
percent of the homeless Veteran population, it is evident that SSVF's 
unique blend of services and capacity to serve all household members, 
including dependent children, has been successful at addressing the 
needs of homeless women Veterans. Further evidence of this success can 
be found in the composition of SSVF enrolled households headed by women 
Veterans: 42 percent have dependent children compared to just 18 
percent for men. The unique needs of these households led by women 
Veterans have imposed increased demands upon SSVF grantees, justifying 
a commensurate increase in resources to organizations providing support 
to these families.
    The SSVF program supports rapid re-housing interventions. Such 
interventions generally are defined as permanent housing opportunities 
and, therefore, are likely subject to fair housing laws. It may be 
helpful for the bill to be amended to indicate that recipient 
organizations that have a focus on providing assistance to women and 
their families would still be subject to complying with all Federal 
fair housing laws.
    VA estimates section 202 would result in additional costs of $20 
million for FY 2017 and FY 2018.
    Section 301 would amend section 1786 of title 38, U.S.C., to extend 
from 7 to 14 days coverage of newborns of a woman Veteran receiving 
delivery care.
    VA supports section 301. A newborn needing care for a medical 
condition may require treatment extending beyond the current 7 days 
that are authorized by law. Additionally, the standard of care is to 
have further evaluations during the first two weeks of life to check 
infant weight, feeding, and newborn screening results. Pending these 
results, there may be a need for additional testing and follow-up. 
There are also important psychosocial needs that may apply, including 
monitoring stability of the home environment or providing clinical and 
other support if the newborn requires monitoring for a medical 
condition. Extending care to 14 days would provide time for further 
evaluations appropriate for the standard of care, as well as sufficient 
time to identify other health care coverage for the newborn.
    VA estimates section 301 would cost $8.8 million in FY 2018, $46.6 
million over 5 years, and $100.6 million over 10 years.
    Section 302 would amend section 1786 of title 38, U.S.C., to 
clarify that amounts paid by VA for medically necessary travel in 
connection with health care services furnished under this section would 
be derived from the Medical Services appropriations account.
    VA supports the intent of section 302. While most travel of a 
newborn is not a concern as the mother and newborn travel together to 
appointments, for those newborns that require transport from a 
community hospital to a neo-natal intensive care unit by ambulance or 
helicopter, VA lacks clear authority currently to pay for this travel 
if the care is exclusively for the newborn. However, we are concerned 
the language in this section, which refers only to a source of funding 
for such travel, does not specifically authorize VA to furnish or pay 
for such transportation expenses under 38 U.S.C. Sec. 1786.
    Depending on how the bill is interpreted, we estimate section 302 
could cost approximately $587,000 in FY 2018, $3.95 million over 5 
years, and $11.86 million over 10 years.
    Section 401 would require VA to retrofit existing VA medical 
facilities with fixtures, materials, and other outfitting measures to 
support the provision of care to women Veterans at such facilities. 
Within 180 days of enactment, VA would be required to submit to the 
Committees on Veterans' Affairs of the House of Representatives and the 
Senate a plan to address deficiencies in environment of care for women 
Veterans at VA medical facilities. There would be authorized to be 
appropriated $20 million in addition to amounts otherwise available to 
VA to carry out this section.
    While we appreciate the intent of this provision, we do not support 
section 401. VA currently has the authority, and has made it a 
priority, to renovate or improve its facilities to protect the privacy, 
safety, and dignity of women Veterans. We are concerned that subsection 
(a), for example, would legislate specific requirements that are better 
addressed through current construction standards. These standards are 
subject to review and revision on a regular basis, which provides 
flexibility for VA to identify and prioritize emerging needs. A 
statutory requirement would provide no such flexibility.
    We believe the current process for identifying needs and obligating 
available resources to remedying them is more appropriate and better 
for Veterans. While we currently have authority to, and in fact do, 
conduct routine evaluations of our facilities to identify deficiencies, 
we would have no objection to a requirement for a recurring, system-
wide assessment to identify deficiencies, similar to the requirement 
contemplated in subsection (b). We recommend that such a review occur 
only periodically, as some projects can take several years to complete, 
and that VA be given flexibility to take the time it needs to complete 
these reviews thoroughly and accurately instead of attempting to 
complete them within a statutory deadline. Such a revised requirement 
to review medical facilities would provide a comprehensive list of the 
specific needs of each facility. We would be happy to discuss our 
thoughts on this further with the Committee and to provide technical 
assistance as needed.
    Without having completed a current, comprehensive review, we are 
unable to estimate the cost of section 401. However, we have reason to 
believe the costs for retrofitting every VA medical facility would be 
more than the $20 million that would be authorized for appropriation 
under subsection (c).
    Section 402 would require VA to ensure that each VA medical 
facility has at least one full-time or part-time women's health primary 
care provider whose duties include, to the extent possible, providing 
training to other VA health care providers on the needs of women 
Veterans.
    VA fully supports the intent of section 402, but notes that the 
provision is unnecessary because VA already has authority to employee 
women's health primary care providers, resources permitting. Currently, 
approximately 475,000 women Veterans receive care at a VA facility, and 
there are approximately 2,500 designated women's health providers in 
our health care system. There are 102 VA sites of care without a 
designated women's health provider. For many sites, there is no 
justification to hire a full-time designated women's health provider 
due to the small number of women Veterans assigned to the clinic, so 
instead, VA trains an existing provider who will treat both men and 
women on their panel. There is approximately a 20 percent turnover each 
year for women's health providers, so training new providers is a 
constant need.
    Section 403 would require VA to ensure that the VA Women Veteran 
Program Manager program is supported at each VAMC with a Women Veteran 
Program Manager and a Women Veteran Program Ombudsman, and that such 
individuals receive the proper training to carry out their duties.
    VA supports the intent of section 403 in part. Currently, VHA 
Directive 1330.01, Health Care Services for Women Veterans, requires 
each VA health care system to have a full-time Women Veterans Program 
Manager. To that extent, the legislation is generally consistent with 
current practice. At the end of FY 2016, VA had 130 permanent Women 
Veteran Program Managers, 9 acting managers, and 1 vacancy. VA conducts 
training for these managers both virtually and face-to-face. VA does 
not support the requirement to appoint a Women Veteran Program 
Ombudsman, as we think this would be duplicative of services already 
available to women Veterans through the Patient Advocate Program.
    Section 404 would authorize to be appropriated $1 million for each 
fiscal year for the Women Veterans Health Care Mini-Residency Program 
to provide opportunities for participation by primary care and 
emergency care clinicians. The $1 million would be authorized to be 
appropriated in addition to amounts otherwise made available to VA for 
purposes of this program.
    VA supports section 404. Today, women are the fastest growing 
subgroup of U.S. Veterans. There are more than 2.2 million women 
Veterans in the United States, and women make up 15.1 percent of 
today's active duty military and 18.8 percent of National Guard and 
Reserve forces; the number of women Veterans is expected to grow in the 
future. VHA's efforts to train clinicians to meet the needs of an ever 
increasing number of women Veterans seeking care has included large 
scale initiatives to deploy core curricula covering the highest 
priority topics in women's health care (i.e., ``Women's Health Mini-
Residencies''). VA has developed four mini-residency programs in recent 
years and offers mini-residency programs as large, national training 
conferences each year. Since 2008, VA has provided mini-residency 
training to over 3,000 primary care providers and more recently to 
approximately 500 primary care nurses and 250 emergency care providers 
and nurses. However, there is an ongoing need to train additional 
primary care and emergency care providers in the care of women Veterans 
to ensure that equitable, high-quality care is provided at all VA 
sites.
    VA estimates section 404 would cost approximately $920,000 in FY 
2018, $4.84 million over 5 years, and $9.84 million over 10 years.
    Section 501 would require VA to collect and analyze data on each VA 
program that provides a service or benefit to a Veteran, to 
disaggregate such data by sex and minority status when the data lend 
itself to such disaggregation, and to publish the data collected and 
analyzed, except for such cases in which the Secretary determines that 
some portions of the data would undermine the anonymity of a Veteran.
    VA opposes section 501 because we are concerned about the breadth 
and potential implications of this legislation. While VA tracks various 
demographic information about Veterans, it does so only to the extent 
that these factors are related to eligibility for benefits or services 
or would assist in the delivery of benefits or services. Many programs 
and services offered by VBA and the National Cemetery Administration 
(NCA) do not differ in any way based upon gender, race, ethnicity, or 
other factors. Many of VHA's programs, though, do collect this 
information, as it is critical to providing quality health care. 
Moreover, many of our existing forms do not collect this information, 
or at least do not require a respondent to report such information (for 
example, for race or ethnicity). If the legislation is intended to 
require VA to collect this information, such an effort would increase 
costs for Veterans and VA. VA could be forced to remove other, more 
mission-critical collections of information to account for these costs 
in order to reduce the burden on the public. New requirements could 
also duplicate other reporting requirements if, for example, this 
section also applied to grants programs.
    We would appreciate the opportunity to discuss this section to 
better understand specifically what information this provision is 
intended to produce. VA would be happy to provide such information upon 
the Committee's request, but we do not believe a statutory requirement 
to provide such information would be appropriate.
    VA is unable to develop a cost estimate for this section at this 
time because we are unsure of the intended scope and effect of this 
provision.
    Section 502 would require VA, not later than 1 year after the date 
of enactment, to submit to the Committees on Veterans' Affairs of the 
House of Representatives and the Senate a report on the availability 
from VA of prosthetics made for women Veterans, including an assessment 
of the availability of such prosthetics at each VA medical facility.
    VA does not support section 502. VA provides comprehensive 
prosthetic and sensory aids and services that support and optimize the 
health and independence of all Veterans, regardless of gender. While VA 
does not oppose providing a national report at the end of each FY 
detailing the types of prosthetic items, quantity of items, and amount 
expended on women Veterans, VA opposes providing an assessment of the 
availability from VA of prosthetics made for women Veterans, including 
an assessment of the availability of such prosthetics at each medical 
facility of the Department. We oppose this provision because the 
process for procuring prosthetic items for Veterans is initiated by the 
clinician. Hence, the types of prosthetic items cannot be predicted due 
to prescription dependency on medical necessity. VA could produce a 
retroactive report regarding the type of prosthetic items provided to 
women Veterans, but providing a report on the availability of such 
items at a specific point in time would not provide meaningful 
information.
    We estimate that section 502 would not have significant costs.
    Section 503 would require VA to survey its Internet websites and 
information resources and publish a website that serves as a 
centralized source of information about VA benefits and services 
available to women Veterans. The website would provide women Veterans 
with information about all services available in the district where the 
Veteran is seeking such services, including the name and contact 
information of each women's health coordinator, a list of appropriate 
staff for other benefits from VBA and NCA, and any other information 
the Secretary considers appropriate. VA would be required to update the 
information on the website at least once every 90 days. Outreach 
conducted under 38 U.S.C. Sec. 1720F(i) would include information about 
the website. VA would be directed to derive funds for this section from 
the amounts made available to publish VA internet websites.
    VA supports the intent of section 503, but the provision is 
unnecessary because VA can accomplish the objectives of the provision 
under existing authority. VA already has in place for each medical 
center a website specific to women Veterans that highlights the 
services available and a point of contact at the facility. In addition, 
VA offers two national websites that offer facility locators on the 
site. The website required by section 503 would complement this 
information and could be more accessible to Veterans.
    Section 504 would express the sense of Congress that the Secretary 
should change the motto of VA to be more inclusive. VA defers to 
Congress in terms of expressing its sense on policy matters.
       s. 764, veterans education priority enrollment act of 2017
    S. 764 would add a new section, 3680B, to subchapter II of chapter 
36 of title 38 U.S.C. that would prohibit the Secretary or a State 
Approving Agency (SAA) from approving a program of education offered by 
an institution that allows certain students priority enrollment, unless 
the institution allows ``covered individual[s]'' to enroll at the 
earliest possible time pursuant to such a priority enrollment system. 
``Covered individual[s]'' would be those individuals using educational 
assistance under chapters 30, 31, 32, 33, or 35 of title 38, U.S.C.; or 
under chapter 1606 or 1607 of title 10, U.S.C.
    VA supports the intent of S. 764 but has some concerns. As 
currently written, the proposed legislation would not impact programs 
that are ``deemed approved'' as per the provisions of 38 U.S.C. 
Sec. 3672(b)(2)(A), which includes accredited standard college degree 
programs at public and private, not-for-profit institutions of higher 
learning. If the intent is to have the requirement apply to programs at 
all types of institutions, then VA recommends inserting a conforming 
amendment to add reference to the new proposed section 3680B to the 
list of requirements affecting ``deemed approval'' section 
3672(b)(2)(A) of title 38, U.S.C.
    In addition, while the proposed amendment prohibits the Secretary 
or a SAA from approving programs that do not meet the specified 
criteria, it does not clearly require the disapproval of non-compliant 
programs that were approved prior to enactment or that cease to be 
compliant after approval. If the disapproval of non-compliant programs 
is intended to be a requirement as well, then we would recommend that 
this be specified in the bill as well. In the event that program 
disapproval is desired, VA would also suggest a future effective date 
of 12 months from the date of enactment in order to allow time for 
schools to change their policies and, thus, minimize the disruption of 
the educational pursuits of beneficiaries that are currently enrolled 
in such programs.
    VA supports the intent of S. 764, and is willing to provide 
technical assistance as needed to ensure that the bill has the intended 
outcome.
    VA does not have a cost estimate for this bill at this time.
s. 784, veterans' compensation cost-of-living adjustment (cola) act of 
                                  2017
    S. 784 would require the Secretary to increase the rates of 
disability compensation and Dependency Indemnity Compensation by the 
same percentage as any increase to Social Security benefits effective 
on December 1, 2017. The bill would also require VA to publish these 
increased rates in the Federal Register.
    VA strongly supports this bill because it would express, in a 
tangible way, this Nation's gratitude for the sacrifices made by our 
service-disabled Veterans and their surviving spouses and children. The 
bill would also ensure that the value of these benefits keeps pace with 
increases in consumer prices.
    VA estimates the cost of this bill to be $1.3 billion in FY 2018, 
$8.1 billion over 5 years, and $17.5 billion over 10 years. However, 
the cost of these increases is included in VA's baseline budget because 
VA assumes that Congress will enact a cost-of-living adjustment each 
year. Therefore, enactment of the bill would not result in additional 
costs, beyond what is included in VA's baseline budget.
           s. 804, women veterans access to quality care act
    S. 804 would seek to improve the provision of health care for women 
Veterans by VA through several different provisions.
    Section 2 would require VA to establish standards to ensure that 
all VA medical facilities have the structural characteristics necessary 
to adequately meet the ``gender specific'' health care needs, including 
privacy, safety, and dignity, of Veterans at these facilities. VA would 
be required to promulgate regulations within 180 days of the date of 
enactment to carry out this section. Within 270 days of the date of 
enactment, VA would be required to integrate these standards into the 
prioritization methodology used by VA with respect to requests for 
funding of major medical facility projects and major medical facility 
leases. Not later than 15 months after the date of enactment, VA would 
be required to report to the Committees on Veterans' Affairs of the 
House and Senate on the standards established under this section, 
including a list of VA medical facilities that fail to meet the 
standards; the minimum total cost to ensure that all VA medical 
facilities meet such standards; the number of projects or leases that 
qualify as a major medical facility project or major medical facility 
lease; and where each such project or lease is located in VA's current 
project prioritization.
    VA appreciates the intent of section 2, but we do not believe it is 
necessary given other actions we are already taking. For example, in 
2012, VA developed and published a Space Planning Criteria Chapter for 
Women Veterans Clinical Service, which identifies space standards for 
the delivery of primary care services to Women Veterans Clinical 
services within VA. These space standards support care for women 
Veterans from basic primary care to ultrasound and mammography 
services. A standard examination room plan for Women Veterans Clinics 
was developed including access to bathroom facilities directly 
connected to the examination room and including such details as privacy 
curtains, locking hardware, and exam table placement. VA's Medical/
Surgical Inpatient Units and Intensive Care Nursing Units Design Guide, 
developed in 2011 and 2012, addresses the needs of women Veterans. 
These standards are available online at: www.cfm.va.gov/TIL. Since 
2012, the health care needs of women Veterans have been an instrumental 
consideration in the development and update of the standards that are 
utilized in the planning and design of all VA facilities to support the 
delivery of Veterans' health care. Moreover, it is unclear why VA would 
need to promulgate regulations for this section. Absent the requirement 
in the bill, VA would not need to promulgate regulations. VA's 
construction standards have been established through policy for years, 
and revising our standards through this process is less resource 
intensive and faster than formal regulations.
    Section 3 would require VA, not later than 60 days after the date 
of enactment, to establish policies for environment of care inspections 
at VAMCs. These inspections would include an alignment of the 
requirements for such inspections with the women's health VHA Handbook, 
a requirement for the frequency of such inspections, and a delineation 
of the roles and responsibilities of staff at the VAMC who are 
responsible for compliance. It would also require the Secretary to 
certify to the Committees on Veterans' Affairs of the House and Senate 
that the policies required under this section have been finalized and 
disseminated to VAMCs.
    VA also appreciates the intent of section 3 but does not believe 
this provision is necessary because VA established a Comprehensive 
Environment of Care (CEOC) Program policy in February 2016. VHA 
Directive 1608, Comprehensive Environment of Care (CEOC) Program, 
outlines the requirements of a CEOC Program and assigns 
responsibilities and accountability from VA Central Office, through the 
Veterans Integrated Service Network (VISN), to the medical centers, 
detailing the requirements for leadership involvement, routine 
environment of care rounds, discipline-based standardized checklists, 
and a requirement to identify and track deficiencies through 
resolution. VHA Directive 1608 is aligned with VHA Directive 1330.01, 
Health Care Services for Women Veterans, and VA believes this meets the 
intent of the proposed language in the bill. We note that the bill 
specifically refers to a ``women's health handbook,'' but the current 
form of this policy is in a Directive. We recommend the language be 
revised to simply refer to a ``policy,'' rather than either a 
``handbook'' or a ``directive'' to avoid possible confusion.
    Section 4 would require the Secretary to use health outcomes for 
women Veterans furnished hospital care, medical services, and other 
health care by VA in evaluating the performance of VAMC directors. It 
would also require VA to publish on an Internet Web site information on 
the performance of directors of VAMCs with respect to health outcomes 
for women Veterans, including data on health outcomes pursuant to key 
health outcome metrics, a comparison of how such data compares to data 
on health outcomes for male Veterans, and explanations of this data to 
help the public understand this information.
    VA already is focused on tracking access and outcomes for women 
Veterans, and on addressing disparities in care, and thus we do not 
believe section 4 is necessary. VA has a robust method for evaluating 
ambulatory care using the Healthcare Effectiveness Data and Information 
Set (HEDIS) measures and inpatient care quality using The Joint 
Commission ORYX measure set. VA also evaluates Veteran assessments of 
their health care experiences by administering the Consumer Assessment 
of Healthcare Providers and Systems survey that focuses on inpatient 
and outpatient services. Both the clinical quality measures and Veteran 
experience measures are collected for men and women, so that 
comparative analyses and reporting are possible. These results are used 
to assess individual medical center Directors and to compare facility 
results to internal and external benchmarks. Results also are posted on 
a publicly available internet Web site.
    Section 5 would seek to increase the number of obstetricians and 
gynecologists employed by VA. Paragraph (a) of this section would 
require, not later than 18 months after enactment, that VA ensures that 
every VAMC have a full-time obstetrician or gynecologist.
    VA supports the intent of section 5(a) and already is taking steps 
to expand access to gynecological care throughout VA. Currently, 
approximately 76 percent of VAMCs have a gynecologist on staff, and we 
plan to add this service at roughly another 20 facilities. This will 
ensure that all facilities with a surgical complexity of intermediate 
or complex will have a gynecologist on staff. At facilities with a 
surgical complexity designation of standard or less, we do not believe 
that there is sufficient patient demand to support a full-time 
gynecologist or obstetrician. For Veterans needing these services at 
these facilities, VA uses its community care authorities to ensure 
these Veterans are able to access care. Moreover, in some areas of the 
country, particularly in smaller or more rural areas, VA faces 
recruitment challenges in hiring new staff, and we anticipate we would 
face similar challenges if this legislation were enacted.
    Paragraph (b) of section 5 would require VA, within 2 years of 
enactment, to carry out a pilot program in not fewer than three VISNs 
to increase the number of residency program positions and graduate 
medical education positions for obstetricians and gynecologists (OB-
GYN) at VA medical facilities.
    VA supports the intent of paragraph (b) of section 5, and would 
respectfully submit that VA already has this authority and is using it. 
VA currently funds 31 OB-GYN residency positions across 40 sites. 
Family Medicine also provides many aspects of gynecological care that 
meet the needs of women Veterans for which VA funds 154 residency 
positions at 81 VAMCs. We would welcome Committee feedback as to how we 
could improve these efforts. While gynecologic services are widely 
available across VA, the limited number of women Veterans seeking care 
and the scope of services at some sites makes it difficult to provide 
the educational resources to fulfill the accreditation needs for 
training in obstetrics and gynecology. This limits an approach to 
national increases in these residency positions. A three VISN pilot 
program would be limited in its ability to start within 2 years given 
the need to develop relationships with residency programs in this area, 
as well as understand the needs of women Veterans in those VISNs.
    Section 6 would require VA to develop procedures to share 
electronically certain information with State Veterans agencies to 
facilitate the furnishing of assistance and benefits to Veterans. The 
information would include military service and separation data, a 
personal email address, a personal telephone number, and a mailing 
address. Veterans would be able to prevent their information from being 
shared with State Veterans agencies by using an opt-out process to be 
developed by VA. VA would be required to ensure that the information 
shared with State Veterans agencies is only shared by such agencies 
with county government Veterans service offices for such purposes as VA 
would determine for the administration and delivery of assistance and 
benefits.
    VA believes strong relationships with State Veterans agencies, as 
well as outreach to Veterans, are critical. However, we do have 
concerns with this section. The information required, we believe, would 
have Privacy Act implications. Also, managing opt-out requests would 
require additional resources, although the amount cannot be projected 
with specificity. We would be glad to discuss with the Committee VA's 
collaborative efforts with State Veterans agencies on outreach and how 
the goals of section 6 could be fulfilled while avoiding the concerns 
expressed above.
    Finally, section 7 would direct VA to carry out an examination of 
whether VAMCs are able to meet the health care needs of women Veterans 
and to submit this report within 270 days of enactment. Again, we would 
respectfully submit that VA has this authority, and is using it in this 
way. VA fully agrees with the importance of assessing access for women 
Veterans and implementing comprehensive primary care at all sites. We 
are already tracking wait times, access, the number of designated 
women's health providers at each site, recruitment efforts, and staff 
training. VA believes that the additional examination required by this 
section is unnecessary as it would include examining sites that we know 
are performing well. VA has begun efforts to use evaluation data to 
work with those sites that have challenges to assist them in improving 
services for women Veterans. Since 2010, VA has assessed the 
implementation of comprehensive women's health through national site 
visits. Women's Health Services contracted with a private company to 
develop the methodology, metrics, and tools needed to evaluate Women's 
Health Programs (WHP) across VA. By end of FY 2016, 100 percent (140) 
of the VA health care system WHPs comprehensive evaluations were 
completed. Additionally, VA monitors access, including wait time data, 
for women Veteran appointments. VA also has evaluated disparities in 
health outcomes since 2008, and we lead the Nation in reducing health 
disparities for women Veterans.
    VA estimates a contract to conduct the examination and prepare the 
report required would cost approximately $10.3 million.
                 s. 899, va transition improvement act
    VA supports S. 899, which would require VA to establish a leave 
transfer program for the benefit of health care professionals appointed 
under 38 U.S.C. Sec. 7401(1) and authorize the establishment of a leave 
bank program for the benefit of such health care providers. Inclusion 
of this provision would ensure that disabled Veteran employees 
performing health care services in Title 38 occupations have the same 
opportunity to schedule medical appointments and receive medical care 
related to their disability without being charged leave as employees in 
Title 5 and Hybrid Title 38 occupations. The bill would also provide 
disabled Veteran employees an opportunity to undergo medical treatments 
for their disabilities without having to consider their leave balances 
or work-life issues to obtain such services outside of scheduled work 
hours.
    It is projected that VA will continue to hire Veterans with 
service-connected disabilities of 30 percent or greater into Title 38 
occupations at a rate that mirrors the current percentage (3.5 percent) 
of employees occupying such positions within VHA. VA estimates that 
this legislation would be cost neutral as it does not increase full-
time employee equivalent levels or salaries of the employees hired into 
the positions.
  s. 1024, veterans appeals improvement and modernization act of 2017
    Modernizing the appeals process is a top priority for VA. It is 
more critical than ever that we continue to work together to transform 
an appeals process that is failing Veterans. There are currently over 
470,000 appeals pending in VA, some 40 percent more than were pending 
only 5 years ago. Those Veterans are waiting much too long for answers 
on their appeals. Although Veterans wait an average of only 116 days 
for a decision on VA disability compensation claims, they are waiting 
an average of 3 years for their appeal to be resolved. Appeals that go 
all the way to the Board of Veterans' Appeals (Board) take even 
longer--an average of 6 years to resolve. A system that can deliver an 
answer on an initial claim in 116 days, but takes many years to resolve 
an appeal is a system that is not working for Veterans. If appeals 
reform is not passed, these already unacceptable wait times will only 
get worse.
    S. 1024 would provide much-needed comprehensive reform for the VA 
appeals process to ensure that Veterans receive a timely, VA decision 
on their appeal. It would replace the current, lengthy, complex, 
confusing VA appeals process with a new appeals process that makes 
sense for Veterans, their advocates, VA, and stakeholders. VA supports 
the intent of S. 1024; however, we have some concerns with certain 
provisions in S. 1024 as drafted, such as the provisions that would 
remove finality from the process upon judicial review and require the 
Secretary to certify that he has the resources necessary to timely 
process appeals in the future. We look forward to working with the 
Committee to address those concerns. The Department stands committed to 
getting appeals reform accomplished for Veterans this year.
    The current VA appeal process, which is set in law, is broken and 
provides Veterans a frustrating experience. In the current process, 
appeals have no defined endpoint. Veterans and VA adjudicators are 
instead engaged in continuous evidence gathering and repeated re-
adjudication of the same appeal. This cycle of evidence gathering and 
re-adjudication means that appeals often churn for years between the 
Board and the agency of original jurisdiction (AOJ) to meet complex 
legal requirements, with little to no benefit flowing to the Veteran. 
The multiple layers of adjudication built into the current appeals 
process exacerbate delays even more. Jurisdiction is also split between 
the Board and the AOJ, meaning that Veterans often don't fully 
understand where in VA their appeal is located any given time. All of 
this has resulted in a system that is complicated, inefficient, 
ineffective, and confusing. Due to this complex and inefficient 
process, Veterans wait much too long for final resolution of their 
appeal.
    Without significant legislative reform, wait times and the cost to 
taxpayers will only increase. It was this stark reality that led to 
VA's unprecedented level of collaboration with stakeholders to design a 
modernized appeals process. The new appeals process contained in 
S. 1024 would provide Veterans an appeals decision that is timely, 
transparent, and fair. The new process is not just a VA idea. It is the 
product of over a year of collaboration between the Board, Veteran 
Benefits Administration, Veteran Service Organizations, the private 
bar, and other stakeholders. The new appeals process we designed is 
simpler and easier for Veterans to understand. It provides a 
streamlined process focused on early resolution of appeals, and 
generating long-term saving for taxpayers. VA is grateful to all of the 
stakeholders for their contributions of time, energy, and expertise in 
this effort.
    S. 1024 would empower Veterans by providing them with the ability 
to tailor the process to meet their individual needs--choice that is 
not available in the current appeals process. Veterans in the new 
process can pursue one of three different lanes. One lane would be for 
review of the same evidence by a higher-level claims adjudicator at the 
AOJ. One lane would be for submitting new and relevant evidence with a 
supplemental claim at the AOJ, and one lane would allow Veterans to 
take their appeal directly to a Veterans Law Judge at the Board. In 
this last lane, the intermediate and duplicative steps currently 
required by statute to receive Board review, such as the Statement of 
the Case and the Substantive Appeal, would be eliminated. Furthermore, 
hearing and non-hearing options at the Board would be handled on 
separate dockets so these distinctly different types of work can be 
managed more efficiently.
    As a result of this new design, the AOJ would be the claims 
adjudication agency within VA and the Board would be the appeals 
agency. This design would remove the confusion caused by the current 
process, in which a Veteran initiates an appeal in the AOJ, but the 
appeal is really a years-long continuation of the claim development 
process. It would ensure that all claim development occurs in the 
context of a supplemental claim filed with the AOJ, which the AOJ can 
quickly adjudicate, rather than in an appeal.
    Currently, VA has a statutory duty to assist the Veteran in the 
development of a claim for benefits. This duty includes obtaining 
relevant Federal records, obtaining other records identified by the 
claimant, and providing a medical examination in certain circumstances. 
The new design contains a mechanism to correct any duty to assist 
errors by the AOJ. If the higher-level claims adjudicator or Board 
discovers an error in the duty to assist that occurred before the AOJ 
decision being reviewed, the claim/appeal would be returned to the AOJ 
for correction unless the claim/appeal could be granted in full. 
However, the Secretary's duty to assist would not apply to the lane in 
which a Veteran requests higher-level review by the AOJ or review on 
appeal to the Board. The duty to assist would, however, continue to 
apply whenever the Veteran initiated a new claim or supplemental claim. 
Moreover, S. 1024 would require VA to modify its claims decision 
notices to ensure they are clearer and more detailed. This notice would 
help Veterans and their advocates make informed choices as to which a 
review option makes the most sense.
    The disentanglement of processes achieved by S. 1024 would be 
enabled by one crucial innovation. In order to make sure that the 
Veteran fully understands the process and can adapt to changed 
circumstances, a Veteran who is not fully satisfied with the result of 
any lane would have 1 year to seek further review while preserving an 
effective date for benefits based upon the original filing date of the 
claim. For example, a Veteran could go straight from an initial AOJ 
decision to an appeal to the Board. If the Board decision was not 
favorable, but helped the Veteran understand what evidence was needed 
to support the claim, then the Veteran would have 1 year to submit new 
and relevant evidence to the AOJ in a supplemental claim without 
fearing an effective-date penalty for choosing to go to the Board 
first. The robust effective date protections built into the draft bill 
enhance Veterans' rights and ensure that Veterans and their advocates 
cannot make a wrong turn in navigating the new appeals process.
    Beyond stopping the flow of appeals into the existing broken 
system, S. 1024 provides opt-ins to allow as many Veterans as possible 
to benefit from the streamlined features of the new process. A claimant 
who receives a decision after enactment and prior to the applicability 
date of the law could elect to participate in the new process, which 
would give VA discretion regarding whether to apply the new process to 
the claimant. However, while subsection (x)(3) envisions the 
possibility of processing individual claimants who opt-in under the new 
system prior to the applicability date, as a practical matter, VA 
cannot realistically offer the new system on a piecemeal basis before 
the entire new system is ready, which in turn depends on the 
certification date. Therefore, in practice, only Veterans who receive 
notice of decision within the 1 year period prior to the effective date 
of the law would be able to opt-in. Veterans who received an earlier 
notice of decision would not be able to submit a timely appeal into the 
new process within 1 year of their decision. Also, a claimant who 
receives a statement of the case or supplemental statement of the case 
in a legacy appeal could elect to participate in the new appeals 
system.
    While VA strongly supports the fundamental features of the new 
process outlined in S. 1024, we have concerns with some aspects of the 
proposed legislation as presently drafted, as discussed below.
    VA opposes a substantive change that would make the effective date 
protection afforded by the filing of a supplemental claim within 1 year 
of a decision applicable to supplemental claims filed within 1 year of 
a decision by the United States Court of Appeals for Veterans Claims 
(CAVC). This provision goes against an essential construct of the new 
process, which encourages Veterans to stay within VA to achieve the 
earliest resolution possible. It would be unfortunate to eliminate 
sources of unnecessary churn in VA, only to create new incentives for 
endless appeal at the CAVC. To the greatest extent possible, judicial 
review should be for substantive legal disagreements between a claimant 
and VA, not for record development questions that can easily be 
obviated simply by pursuing additional development and assistance in 
the supplemental claim lane.
    With regard to applicability and the proposed certification of the 
readiness to carry out the new system by the Secretary, the requirement 
that the Secretary submit a statement to Congress that he has the 
resources necessary to timely operate the system is problematic, given 
the annual budget cycle. While VA will be prepared to implement the new 
system at the end of the 18-month period prescribed in S. 1024 and shut 
off the flow of appeals to the broken process, the Secretary cannot 
predict the outcome of future budget cycles. Therefore, the Secretary 
will only be able to make a certification regarding resources available 
at the time of the certification and not into the future.
    Moreover, if S. 1024 was enacted with this provision, it would 
create significant uncertainty in implementing the opt-in component of 
the law. We note that S. 1024 provides VA discretion to apply the new 
process to claimants who elect to participate in the modernized appeals 
system at any time after enactment and before the applicability date. 
The applicability date in S. 1024 is necessarily indeterminate because 
it depends upon when the Secretary will be able to certify under 
subsection (x)(1) that VA has the resources it needs to operate the 
modernized system; it is not possible to know when the one year period 
allowing claimants the functional ability to elect begins. As 
previously noted, although S. 1024 does not set the 1 year period for 
opt-ins, current law provides that claimants must submit a notice of 
disagreement within 1 year of a decision, and it will not be 
administratively feasible to provide claimants with the new system on a 
piecemeal basis before the administrative and regulatory work necessary 
to stand up the new system is complete. In order to provide Veterans 
with meaningful choice in how their appeal is handled, we must be able 
to inform them as to whether they will have the option of appealing 
into the new system. We would be happy to continue working with the 
Committee to discuss alternative approaches to the applicability date 
of the law.
    S. 1024 also adds notice requirements to higher-level review and 
Board decisions, for the purpose of explaining whether the claimant 
submitted evidence that was not considered, and if so, what the 
claimant or appellant can do to have that evidence considered. VA views 
this addition as unnecessary, as a claimant who had elected either a 
higher-level review or an appeal to the Board would have already 
received notice addressing all lane options in the new process, 
including restrictions on the submission of new evidence. They would 
also be aware of the option to file a supplemental claim, where they 
would have the opportunity to submit new evidence for consideration by 
the AOJ. Additionally, the issue of how to handle improperly submitted 
evidence is an administrative matter that would best be determined by 
VA.
    S. 1024 also includes reporting requirements that we believe could 
be adjusted to be less onerous but still provide valuable information 
to the Congress. We look forward to working with the Committee to 
better shape these provisions in a manner that achieves adequate 
protection for Veterans and robust information for Congressional 
oversight, while at the same time using administrative resources 
wisely.
    VA stands ready to provide additional technical assistance on 
several other aspects of the proposed legislation. We appreciate any 
opportunity to work with Congress to further refine this legislation.
      s. 1094, department of veterans affairs accountability and 
                      whistleblower protection act
    S. 1094, the Department of Veterans Affairs Accountability and 
Whistleblower Protection Act of 2017, would amend and create a number 
of new authorities regarding the Department of Veterans Affairs (VA) 
employment practices.
    VA strongly supports the aims of this bill, which would improve our 
oversight and investigation of whistleblower disclosures and 
retaliation complaints, and allow for more timely disciplinary action 
against employees whose misconduct or poor performance undermines 
Veterans' and the public's trust in VA care and services. We deeply 
appreciate the Committee's efforts to understand and meet VA's needs 
for greater flexibility in dealing with under-performing and 
misbehaving employees. We look forward to continuing to work with the 
Committee, through the technical assistance process, to resolve a few 
concerns we have with the bill, including constitutional ones. The 
Department of Justice (DOJ) has informed us that it also looks forward 
to working with the Committee in the technical assistance process, to 
address these constitutional concerns. DOJ believes that this can be 
done without impeding the aims of the bill.
    By our reading, the bill addresses five different policy areas, 
sometimes in different sections. For ease of discussion, we will 
summarize our understanding of each of these sections individually, 
then relay VA's position on these policy areas in general.
    Section 101 would establish a new Office of Accountability and 
Whistleblower Protection, under the leadership of a new Assistant 
Secretary reporting directly to the Secretary. Among other things, the 
new office would be responsible for receiving and investigating 
whistleblower disclosures, and for investigating allegations of 
misconduct, retaliation and poor performance involving Senior 
Executives, other specified management officials, and supervisors who 
are alleged to have retaliated against employees for making 
whistleblower disclosures. The new Assistant Secretary would also be 
responsible for recommending disciplinary action against individuals 
who are found to have committed misconduct, including whistleblower 
retaliation.
    This section would also require the new office to track 
recommendations made by VA's Inspector General and by external 
oversight bodies such as the Office of Special Counsel and the 
Comptroller General, and to provide annual reports to this Committee 
and to the House Committee on Veterans' Affairs on matters within its 
responsibility.
    Section 102 would strengthen protections for whistleblowers by 
holding supervisors accountable for promoting such protections and by 
requiring VA to provide training to all employees on whistleblower 
processes and protections.
    Section 103 would require VA to report to this Committee and the 
House Committee on Veterans' Affairs on methods used to investigate 
employees, with an eye toward ensuring that investigations are not used 
to retaliate against whistleblowers.
    Section 201 would provide a new framework for removal, demotion, 
suspension, reassignment, or reprimand of Senior Executives for 
misconduct or poor performance. This section would set timelines for 
pre-decisional due process and provide for post-discipline appeals 
through an internal grievance process and/or appeal to a U.S. District 
Court.
    Section 202 would provide a new framework for removal, demotion, or 
suspension of employees who are not in the Senior Executive Service. 
Like section 201, section 202 would set timelines for pre-decisional 
process and authorizes post-discipline appeals. This section would 
provide for appeals to the Merit Systems Protection Board, or for 
bargaining unit employees through the negotiated grievance process, and 
would specify that such appeals would be subject to a more deferential 
burden of proof and penalty review than are applicable under current 
law.
    Section 203 would provide for reduction of retirement benefits for 
an employee who has been removed from service (or retired with a 
proposed removal pending) and is convicted of a felony that influenced 
the employee's performance while employed at VA. This section seeks to 
provide for pre-decisional due process and for post-decisional appeal 
to the Office of Personnel Management (OPM).
    Section 204 would authorize recoupment of a bonus or award paid to 
an employee who engaged in misconduct or poor performance prior to 
receiving the award, where the Secretary determines the award or bonus 
would not have been paid had the misconduct or poor performance been 
known prior to payment. Like section 203, this section seeks to provide 
for pre-decisional due process and for post-decisional appeal to OPM.
    Section 205 would provide for recoupment of relocation expenses 
that were authorized following an act of fraud or malfeasance that 
influenced the authorization. Like the prior sections, this section 
seeks to provide for internal pre-decisional due process and an 
external post-decision appeal to OPM. We have a small technical edit to 
offer on this section and will provide that separately.
    Section 206 would reduce the pre-decisional notice period from 14 
days to 10 days for actions against supervisors who are found to have 
engaged in whistleblower retaliation.
    Section 207 would add Medical Center Directors and Network 
Directors to our title 38 direct hire authority.
    Section 208 would align pre-decisional timelines for title 38 
adverse actions to match the timelines in sections 201 and 202. This 
section would also revamp the appeal process for title 38 disciplinary 
actions that do not involve issues of professional conduct or 
competence.
    Section 209 would require periodic training for supervisors on 
whistleblower rights, motivating/managing/rewarding employees, and 
managing poor performers.
    Section 210 would require the Secretary to report to this 
Committee, and to the House Committee on Veterans' Affairs, on the 
impact of sections 201-208 on Senior Executive morale, engagement, 
hiring, promotion, retention, productivity, and discipline.
    Section 211 would require the Secretary to measure, collect, and 
report information on the outcomes of disciplinary actions taken under 
these new authorities.
    As noted, the bill addresses five different policy areas: 
whistleblower protections, accountability, recoupment authorities, 
hiring authorities, and reporting requirements. Each of these will be 
discussed below in turn. By way of technical assistance, we note that 
the current wording of section 308(a)(1) of title 38 limits VA to seven 
Assistant Secretaries. That would need to be amended to authorize eight 
Assistant Secretaries to include the new position established by this 
bill.
    In general, VA is supportive of the sections regarding 
whistleblower protections and of the Committee's assistance in 
strengthening whistleblower protections and in enhancing VA's oversight 
of whistleblower disclosures.
    Regarding the accountability provisions, VA is strongly supportive 
of these sections, which afford the Secretary much-needed flexibilities 
to hold employees accountable and to take necessary actions more 
quickly and to sustain well-founded actions on appeal. We believe these 
authorities would fix some of the legal problems we had exercising the 
authority contained in the Veterans Access, Choice, and Accountability 
Act of 2014, and would provide the Secretary with the authority needed 
to take timely, decisive action.
    Several sections of the bill would also address recoupment of pay 
or benefits. We appreciate the care with which the Congress has drafted 
these to be narrowly tailored, and to apply only in cases of egregious 
misconduct.
    We strongly support the provisions concerning direct hiring 
authority, which would provide the Secretary with sorely needed 
flexibility in hiring top talent into these critical leadership 
positions. We look forward to working with the Committee to fill in 
some of the blanks around this new authority, such as what pay 
authority would apply to these positions and whether and how Senior 
Executives hired under other authorities could move into or out of 
these roles.
    Finally, several sections of the draft bill would require VA to 
provide detailed reports to this Committee, and to the House Committee 
on Veterans' Affairs, on matters relating to whistleblower protections, 
employee accountability, and Senior Executive recruitment and 
management. While we have some concerns about the administrative burden 
imposed by these requirements, we understand the Committee's interest 
in such information.
  draft, veteran partners' efforts to enhance reintegration (peer) act
    The draft bill would require the Secretary to phase in and conduct 
a program whereby peer specialists would be included in patient aligned 
care teams at VAMCs to promote the use and integration of mental health 
services in a primary care setting. Not later than 180 days after the 
date of enactment, this program would have to be established at not 
fewer than 10 VAMCs. By not later than 2 years from the date of 
enactment, it would have to be in place at not fewer than 25 VAMCs. 
Under the bill, the Secretary would be directed to consider specified 
factors when selecting sites for this program, but, not fewer than five 
would have to be established at VA designated Polytrauma Centers, and 
not fewer than ten would have to be established at other VAMCs. The 
draft bill would also require that all peer specialist programs 
established under this mandate: (1) ensure that the needs of female 
Veterans are considered and addressed; and (2) include female peer 
specialists. Finally, this measure would establish initial, periodic, 
and final Congressional reporting requirements, as detailed in the 
bill.
    VA has no objection to the bill, but notes that it is not necessary 
because VA already has the authority to execute this program. However, 
we would require additional funding to implement it. We also note that 
a few technical changes are needed for clarity. This legislation, if 
enacted, would complement VA's ongoing pilot program (commenced in 
2014) whereby peer support through peer specialists has been extended 
beyond traditional mental health sites of care to include Veterans 
receiving mental health care in primary care settings. Under the pilot 
program, trained peer specialists work with VA primary care teams to, 
in general terms, help improve the health and well-being of other 
Veterans being treated in VA primary care settings. All 25 sites now 
have assigned one peer specialist to work in Primary Care at least 10 
hours per week. The first cohort of eight sites began seeing Veterans 
in primary care in January 2016, the second cohort of eight began in 
August 2016, and the final nine sites began April 1, 2017. To date, the 
peers in this program have provided services to more than 3,000 
Veterans. The response from Veterans, peers, and primary care 
clinicians has been overwhelmingly positive. Sites made a 1- year 
commitment to participate in the project, and VA will have a formal 
program evaluation based on clinical and other outcomes in 2018. It is 
likely that some of the existing sites will not be able to continue the 
pilot program after FY 2017 without additional funding.
    The bill specifies program participation of female peer 
specialists. I am pleased to report that women peer specialists are 
already well represented, with 16.2 percent of the national peer 
specialist workforce being women. While at first glance 16.2 percent 
may seem a low rate, please bear in mind that this figure is higher 
than the percentage of Veterans seeking services through VA who are 
women. We do recognize, however, that the current number of women 
Veteran peer specialists in the pilot is unevenly distributed across 
the country, with some VAMCs having greater difficulty than others in 
attracting qualified applicants.
    Also, it is unclear if the peers will address substance use 
disorders under the umbrella of their mental health duties. Given the 
comorbidity of these issues, the need for integration of substance use 
disorder identification and care, the need for overdose prevention and 
links as needed to Medication Assisted Treatment for opioid use 
disorders, and the need to increase the numbers of Veterans achieving 
long-term recovery, we recommend that this be clarified and, if 
possible, included.
    We estimate this bill would cost $4.94 million in FY 2018, $25.99 
million over 5 years, and $55.48 million over 10 years.
             draft, serving our rural veterans act of 2017
    The draft bill would amend 38 U.S.C. Sec. 7406(c) to authorize 
training and supervision of residents at facilities operated by an 
Indian tribe, a tribal organization, or the Indian Health Service, 
federally-qualified health centers, and community health centers. It 
would also direct VA, in consultation with the Director of the Indian 
Health Service, to carry out a pilot program to establish graduate 
medical education residency training programs at such facilities and to 
affiliate with established programs. VA would be required to carry out 
the pilot program at not more than four covered facilities and would 
carry out the pilot program for a period of 8 years beginning on the 
date that is 180 days after the date of enactment. VA would be required 
to reimburse certain costs associated with the program and to enter 
into agreements with individuals participating in the pilot program 
under which they would agree to serve a period of 1 year at a covered 
facility (including a VA facility) service for each year in which the 
individual participates in the pilot program. The bill would provide 
terms related to breach of the agreement, loan repayment, and 
concurrent service. VA would be required to submit a report to the 
Committees on Veterans' Affairs of the House of Representatives and the 
Senate not later than 3 years before the termination of the pilot 
program on the feasibility and advisability of expanding the pilot 
program to additional locations and making the pilot program or any 
part of it permanent. The draft bill would authorize to be appropriated 
to VA $20 million per year to carry out the pilot program and would 
also authorize appropriations for the Secretary of HHS, acting through 
the Director of the Indian Health Service, and to VA such sums as may 
be necessary to cover loan repayments under each agency's respective 
loan repayment programs.
    VA supports the draft bill in principle. VA strongly supports the 
imperative to build Graduate Medical Education capacity in rural and 
underserved areas with the strategic intent to address a geographically 
inequitable distribution of the Nation's physician and clinical 
workforce.
    While we appreciate the purpose of this bill, it is likely that a 
relatively small proportion of the patients seen by residents in such 
programs would be Veterans, yet VA would incur much of the burden for 
program initiation and maintenance including resident salaries, faculty 
time and development, curriculum development, and recruitment efforts.
    Under the draft bill, a medical resident who participates in the 
pilot program would be eligible for participation in the Indian Health 
Service Loan Repayment Program under section 108 of the Indian Health 
Care Improvement Act (section 1616a of title 25, U.S.C.) and the VA 
Education Debt Reduction Program. The draft bill also would include a 
period of obligated service (1 year of service at VA for each year of 
participation in the program). VA supports such a loan repayment and 
obligated service scheme, but recommends requiring 2 years of service 
for each year of program participation. Moreover, because residents 
typically receive a salary and are not obligated, post-residency, to 
perform services as a result of participating in a residency program, 
VA requests the authority to concurrently provide educational loan 
repayment to residents in the program(s) as a tool to recruit highly 
qualified residents.
    VA fundamentally believes that supporting the practice of rural 
health care in the United States is crucial to fulfilling its mission 
to provide the highest quality care for Veterans and that we must 
include within our broad health professions education portfolio a focus 
on rural health in order to meet our statutory mission to provide 
medical education for VA and for the Nation. VA endorses educating all 
physicians regarding the unique health needs of Veterans and providing 
clinical training opportunities in rural health care delivery systems.
    VA estimates the cost of implementation at four sites would be 
$20.3 million in FY 2018, $90.6 million over 5 years, and $201.8 
million over 10 years.

    Mr. Chairman and Members of the Committee, this concludes my 
statement. I would be happy to answer any questions you may have.

    Chairman Isakson. Well, Dr. Lee, thank you very much for 
being here and thank you for your concise testimony on a lot of 
subject matter which, obviously--you know, I have got a check 
mark over here. I make marks to keep notes as we go by, yes 
meaning VA supports it, no meaning they do not support it. I 
have added a new one called ``yes, but.'' [Laughter.]
    On almost every response except one the answer was ``yes, 
but,'' so I want to talk about some of those buts for a second 
to make sure we find out where we have got something we need to 
work on.
    In particular, on the Veterans Affairs Accountability and 
Whistleblower Protection Act, which I have been a part of for 
some years now, working with the Secretary and others to 
develop--and Senator Tester has been invaluable in working with 
that, as has Senator Rubio, Senator Moran, and Senator Heller--
in fact, almost everybody on the Committee, at one time or 
another, has had their mark on that piece of legislation.
    You were universally, if I am not mistaken, completely 
satisfied with S. 1094 as it was introduced, as it now exists, 
the Whistleblower Protection Act. Is that correct?
    Dr. Lee. I would like to ask Meghan Flanz, our Acting 
General Counsel, to answer the question.
    Ms. Flanz. Mr. Chairman, we are very happy with the aims of 
it. We did, over the weekend, receive some concerns from our 
colleagues in Department of Justice about a couple of minor 
edits that they would like to see to avoid some of the 
constitutional issues that we saw with the Choice Act, SES 
expedited removal authority, they are minor.
    Chairman Isakson. Would you elaborate on that?
    Ms. Flanz. Sure. I do not want to bore anybody in the room, 
but we had an issue under the Choice Act with the appointments 
clause of the Constitution, in that it specifically directed 
that a decision by the VA Secretary to remove a senior 
executive was reviewable only at the level of an administrative 
judge, before the Merit Systems Protection Board. 
Administrative judges are not Presidentially-appointed and 
Senate-confirmed.
    There is a bit of an issue in the part of this bill that 
deals with a grievance process after a senior executive action 
and directs that the Secretary will ensure that the grievance 
process is handled by a VA employee. As worded, that would put 
an inferior officer, not a Presidentially-appointed, Senate-
confirmed individual, in a position of reviewing decisions by 
the VA Secretary. Very minor fix. Just trying to avoid the same 
litigation outcome with this bill that we had with the Choice 
Act.
    Chairman Isakson. Did any of their concerns arise out of 
the decision made in the Phoenix case----
    Ms. Flanz. Only the----
    Chairman Isakson [continuing]. To your knowledge?
    Ms. Flanz. No. Only to the extent that now that we have a 
decision from the Federal Circuit, pointing out an appointments 
clause issue in a VA bill, our friends at Department of Justice 
are looking at this one very carefully just to make sure that 
there is no similar problem here.
    Chairman Isakson. And what specifically would they have us 
do to make sure that problem does not exist?
    Ms. Flanz. I think it is probably as simple as not having 
the bill specifically state that the grievances will be heard 
by a VA employee, and then in our implementing regulations we 
can ensure that we do not have an issue with an inferior 
officer potentially overruling a VA Secretary.
    Chairman Isakson. OK. Thank you very much.
    On the appeals process, when you were talking, Ms. Lee, I 
think you were generally supportive of what we are trying to do 
on the appeals process modernization. Is that correct?
    Dr. Lee. Yes.
    Chairman Isakson. It is my understanding there have been 
some comments about treating--making sure the case remains open 
for the filing of any corroborating testimony necessary or any 
facts and figures before a final decision is made, but for it 
to be able to be reopened again and again. The intent we are 
trying to do in terms of the appeals process is get to a 
position where once filed, and once everybody has had a chance 
to put their information in, we do not reopen a case and start 
all over again. Do you think we are doing that in S. 1024, or 
are we not?
    Mr. McLenachen. Mr. Chairman, I will take that question.
    Chairman Isakson. I knew somebody was on that one.
    Mr. McLenachen. Yes.
    Chairman Isakson. You are welcome. You are not as pretty 
she is but it is your department. [Laughter.]
    Mr. McLenachen. I will do the best I can.
    Senator, that is one of the major concerns we have left 
with the bill. We strongly support it, of course, and we have 
worked hard on it, but we do still believe that there needs to 
be some finality in the process. There was a provision that was 
added, in the bill that was introduced, to remove that 
finality, so that even after a claim goes to a Federal court, a 
veteran could still submit a supplemental claim and keep their 
effective date for benefits. That is not available in current 
law, and we think it is critical to have that finality in the 
process. So, that is one of the concerns that we do have.
    Chairman Isakson. Is it not true that there is one claim 
yet to be resolved that is 25 years old, because it has been 
reopened so many times?
    Mr. McLenachen. Yes. We have a lot of examples like that in 
the current process, where we have extremely old appeals that 
are churning in the process. There have been several examples 
like that, where there were 30, 40, 50 decisions made by both 
the Board of Veterans' Appeals and BVA, in that appeal.
    So, that is what we are trying to avoid in this current 
process that we have designed. Right now, in this new process, 
you would have a beginning and end point for each of those 
lanes that we have set up for review. In the current process, 
there is no beginning and end point.
    Chairman Isakson. I think it is important that all of us 
stop and think for a second about what that really means. 
Twenty-five years of submission on a claim made for a benefit 
to the Veterans Administration, still open. We have been trying 
for some time to get fully-developed claims, or meaningful 
processes in the Veterans Administration, so the veteran has 
every opportunity to develop a claim, and once it is developed, 
let the decision be made on the information that is submitted, 
not reopened time and time again. So, that is the issue, I 
think, on this particular issue.
    Mr. McLenachen. Yes, and in our view, there is no reason 
for a veteran to go to a court to continue to develop the 
claim. The whole design was earliest possible resolution in VA. 
So if veteran can file a supplemental claim with VA, and still 
maintain their effective date for benefits, and we could decide 
that within 125 days, there would be no reason to go to a court 
first to get a review, which is why we think that finality is 
important.
    Chairman Isakson. The delay not only hurts the veteran, it 
hurts the Veterans Administration as well.
    Mr. McLenachen. Yes. The veteran is not getting the 
benefits when they could get them at the earliest point, if we 
can adjudicate a supplemental claim earlier.
    Chairman Isakson. Thank you very much.
    Senator Heller.

                STATEMENT OF HON. DEAN HELLER, 
                    U.S. SENATOR FROM NEVADA

    Senator Heller. Mr. Chairman, thank you, and to the panel, 
thank you also for being here. If you do not mind, Mr. 
Chairman, I would like to read an opening statement.
    Chairman Isakson. Without objection.
    Senator Heller. First of all, I want to commend you for the 
commitment of getting to view all these bills and, frankly, for 
doing it on a bipartisan basis. Mr. Chairman, you promised to 
work together on the Committee and I do respect that you have 
fulfilled that promise, so thank you for that.
    Chairman Isakson. You are going to be recognized for a 
longer statement if you keep that up. [Laughter.]
    Senator Heller. All right. Today I have two bills on the 
agenda, the Women Veterans Access to Quality Care Act and the 
Care for Veterans' Dependents Act. I am proud to have worked on 
both of these bipartisan bills with Senator Murray, and 
appreciate the input that the VA and the veteran service 
organizations have provided. While the VA has come a long way 
in improving its care to women veterans, there are still some 
gaps that need to be filled, which I think our bill will do.
    The VA needs to improve access to doctors that can meet 
their gender-specific health needs and ensure their policies on 
safety and privacy for women veterans are properly carried out 
in all VA facilities. I appreciate the VA's willingness to work 
with us on this issue and look forward to finding a path 
forward for this particular bill.
    Another bill Senator Murray and I have worked on for years 
is the Care for Veterans' Dependents Act. The concept is quite 
simple: if you are a homeless facility that receives VA 
funding, you want to ensure that you can get reimbursed for 
providing care to dependents who accompany a veteran. We do not 
want to see veterans getting turned away from any facility just 
because they have dependents with them. With over 700 homeless 
veterans still living on the streets in shelters in Las Vegas 
and other parts of Nevada, we must continue working to address 
the needs of veterans who have fallen on hard times.
    I am also proud to support a bill in today's agenda from 
Senator Hatch that ensures that veterans have access to adult 
day care--day health care benefits.
    Last, I want to thank Chairman Isakson and Ranking Member 
Tester for their work in coming to an agreement on an 
accountability bill that has support from both sides of the 
aisle. It is so important that we get the VA the tools that 
they need to get rid of bad employees, and anyone who has 
wronged a veteran should not get to stay on administrative 
leave for months on end. That has to stop and the VA needs to 
have the authority to get rid of these individuals.
    With that, Mr. Chairman, I have a couple of questions and 
comments for Dr. Lee.
    I guess the first question--this is a question I wanted to 
raise with Secretary Shulkin, and I will the next time he is 
here, but have you heard of Ely, NV?
    Dr. Lee. I know there was a gathering there recently----
    Senator Heller. There was.
    Dr. Lee [continuing]. But I have not personally been there.
    Senator Heller. I do not expect you to have been there. I 
just want to make sure you have heard of Ely, NV. We have 
veterans there that were able to get their care from a local 
hospital instead of having to drive to Salt Lake City, which is 
several hundred miles away. The choice out in Ely, and other 
rural small towns in Nevada, is you either have to drive to 
Reno, which is 300 miles one way, or you have to drive to Salt 
Lake, which is 300 miles the other way.
    That contract that they had with the local hospital 
expired, and, frankly, they do not want to use the Choice 
program, and I understand why. One veteran called to schedule 
an appointment with the contractor for Choice and he was told 
that Ely, NV, did not exist. Another veteran called to schedule 
an appointment with the contractor for Choice and was told--
actually, he was a week out from an appointment and still had 
not been told whether the appointment had been authorized.
    Service through the Choice program is not good and Ely 
veterans do not want to be part of it. Last week we learned 
that veterans would be able to access local hospitals through 
September without having to use the Choice program, which was 
good news, but obviously these veterans want a permanent 
solution. I will be asking the same questions to the Secretary 
about what permanent solutions they may have for these Ely 
veterans, yet I do have a couple of questions for you.
    The first question is, what are you doing to hold the 
contractors accountable for their performances?
    Dr. Lee. Senator, we definitely need a better solution for 
those veterans in your home State and Ely. We know there are a 
lot of issues with the program and we are working on them. I 
can get back to you with specifics on that--in that particular 
area, what we are doing, but it also speaks to the larger need 
to look at the entire program and evolve it to better meet the 
needs of veterans.
    Senator Heller. What would be a timeframe that you could 
get back to me on this?
    Dr. Lee. As soon as we possibly can, sir.
    Senator Heller. A couple of weeks? A month? I just want to 
get some kind of timeline. Like I said, they are extended 
through September, which was good news. I just want to make 
sure we are not talking in October.
    Dr. Lee. I think we can get you some response back within a 
few weeks on what we are----
    Senator Heller. Prior to----
    Dr. Lee [continuing]. Yes.
    Senator Heller. OK. OK.
    Dr. Lee. We will put a priority on that.
    Senator Heller. I understand you have a pilot program that 
allows VAs to schedule appointments for veterans in Choice 
programs. Tell me a little bit about this pilot program, and 
has it been successful?
    Dr. Lee. Are you referring to the self-scheduling?
    Senator Heller. It is a pilot program, from what I 
understand, that allowed the VA to schedule appointments for 
veterans in the Choice program. Does that make sense?
    Dr. Lee. Yes. Sir, I have to take that for the record and 
just get some specifics back to you.

    [Ongoing communication between VA and Senator Heller's 
office sufficiently fulfilled these queries.]

    Senator Heller. OK. We can broaden those questions.
    Can you tell me why you think veterans currently dislike 
the Choice program? Why do you think they dislike it?
    Dr. Lee. We want to--I think we strive to make access to 
care very convenient and centered around the veterans' needs, 
and I think some of the issues with the Choice program 
currently are well known, and have to do with cumbersome 
process to get to that care in the community.
    Senator Heller. Can I share a couple of stories with you? 
We have a veteran from Battle Mountain who is fighting cancer 
and needs surgery, but the day before the surgery it was still 
not authorized. Have you heard stories like this before?
    Dr. Lee. Unfortunately, they are----
    Senator Heller. We have another veteran in Reno who had an 
authorized--who had an authorization for surgery that was later 
revoked by the VA, leaving him with a $17,000 bill. Have you 
heard stories like this before?
    Dr. Lee. Senator, that is unacceptable.
    Senator Heller. Is this unique, or is it something you have 
heard before?
    Dr. Lee. Again, I think the problems with the program are 
well documented. I do not know about the exact--the volume or 
the numbers of those particular kinds of cases, but it is 
absolutely not the kind of service that we strive for.
    Senator Heller. So, tell me, what it is going to take? Tell 
me, what it is going to take to change problems like this in 
the system?
    Dr. Lee. We have made a lot of progress already. My 
colleague, Dr. Yehia, in particular, spent a lot of time and 
energy reforming the Choice program through a number of 
contract modifications and other changes. I think that we would 
just ask if we could work together to continue that process as 
we think about how that program should evolve to better meet 
veterans' needs.
    Senator Heller. Mr. Chairman, my time has run out.
    Chairman Isakson. I want to thank you and commend you on 
your questions. For the record, for you and everybody's benefit 
here--Senator Tester is aware of this--Secretary Shulkin and 
the VA have been working for some time to recognize they have 
problems like the ones you have outlined, in terms of Ely, NV, 
in terms of surgery being revoked and things of that nature. As 
we speak, we have been working with Secretary Shulkin to come 
forward with new parameters to try and deal with these glitches 
so it does not happen again. And, this Committee will be 
dealing with it in the not too distant future.
    So, as we modernize the Choice program it is truly a 
choice. It is timely in its responsiveness. It is not as 
cumbersome and difficult as it has been for the veterans. Dr. 
Shulkin has been invaluable as has--what is his name, the 
doctor--Dr. Baligh?
    [Cell phone rings.]
    Chairman Isakson. The Chairman is violating his own rule 
here.
    Senator Heller. Who is calling you now?
    Chairman Isakson. Dr. Baligh has done invaluable work with 
us in making this happen, so we are going to continue to work 
for it and bring it to the Committee to make sure it is 
corrected, because many of those things are basically 
inexcusable. We need to make it work good for our veterans and 
for the Veterans Administration. So, thank you for bringing it 
up.
    Senator Heller. Mr. Chairman, thanks for your attention 
also.
    Chairman Isakson. Senator Tester.
    Senator Tester. Thank you, Mr. Chairman. I have some 
questions on the accountability bill so I am going to probably 
direct most of these to you, Ms. Flanz. Would it be fair to say 
that you are the VA's top lawyer?
    Ms. Flanz. That is what my business card says, yes.
    Senator Tester. That is good. That is not a bad business 
card, top lawyer of VA. That is good.
    Ms. Flanz. Job security.
    Senator Tester. That is it.
    Ms. Flanz. There is always something.
    Senator Tester. And you deal with personnel law quite a 
bit; I would assume, just about exclusively, right?
    Ms. Flanz. Yes.
    Senator Tester. So, when it comes to employee 
accountability, it is something you are up on. It is also true 
that you are a career civil servant within the VA, not a 
political appointee. Correct?
    Ms. Flanz. Yes, that is correct.
    Senator Tester. There is a lot of misinformation about what 
the VA accountability bill would actually do. I have got a few 
clarifying questions and I would appreciate your perspective on 
this. Would this bill allow VA managers to get away with firing 
anybody who challenges them?
    Ms. Flanz. No, sir.
    Senator Tester. Does this bill trample on workers' rights?
    Ms. Flanz. No, sir.
    Senator Tester. Does it provide senior executives within 
the VA with more favorable treatment than rank-and-file 
employees?
    Ms. Flanz. No, it does not.
    Senator Tester. Would you say that senior executives and 
rank and file are treated on parity--equal?
    Ms. Flanz. As I read the bill, each would receive pre-
decisional due process and enough process after a decision to 
pass constitutional muster. The processes would be different.
    Senator Tester. OK. So could you just kind of discuss why 
the VA needs a substantial evidence portion, and the MSPB 
difference provision?
    Ms. Flanz. Sure. Under current law, the Merit Systems 
Protection Board, which is the board that hears all or almost 
all Federal employee appeals. It recognizes two different 
burdens of proof, two different evidentiary standards that 
apply in different circumstances. One is the preponderant 
evidence standard, which is, in essence, a mathematical 
standard. It requires the judge to take a look at all the 
available relevant evidence and decide whether more of it, 51 
percent, supports the agency's view of the case than supports 
the employee's view of the case.
    The other standard, which MSPB currently applies, in some 
cases, in performance-based actions taken under Chapter 43 of 
Title 5, is the substantial evidence standard. That is more of 
a common sense standard. It is more of a ``reasonable person'' 
standard. Under that standard, the judge takes a look to see 
whether the evidence is sufficient that a reasonable person 
could make the decision that the deciding official (the 
individual who imposed an action against an employee) makes, 
even if another reasonable person could make a different 
decision.
    So, under current law, most conduct-based cases have the 
preponderant evidence standard and then the performance-based 
cases, under one of our Title 5 authorities, have the 
substantial evidence standard.
    The difficulty for us--and let me give you kind of a real-
life example----
    Senator Tester. I was just going to ask for that, so you 
beat me to it.
    Ms. Flanz. We had a case recently with a mental health 
provider who was photographed by a veteran patient having a 
pornographic movie playing on an iPad in the exam room while 
the veteran patient was there. We have got photographic 
evidence of misconduct. In this particular case, the 
individual, the psychologist or psychiatrist, also admitted, 
confessed to the issue.
    We had evidence that I think a reasonable supervisor in 
almost any organization would believe is sufficient to take 
action against an employee. But, under the preponderant 
evidence standard, we do not know the total universe of 
evidence. We know what we have but we do not know whether all 
of the evidence together, 51 percent or more, favors the action 
that the supervisor wants to take.
    In a case like that, the concern and the process, 
generally, has been to undertake a thorough investigation so 
that we have the total universe of evidence before an action is 
proposed, so that we, as lawyers, in supporting the Department, 
can sit in the shoes of a judge and say, yes, mathematically, 
more of that total universe of evidence supports the action 
than supports the defense.
    From our perspective, the substantial evidence standard, 
which is by no means a rubber stamp by a judge--the judge still 
has to look at was there a common-sense business reason for the 
action taken--would a reasonable person have looked at the 
evidence and said, yes, that evidence supports the action 
taken? It is not a rubber stamp. It just allows us to get to 
the proposal and decision state faster.
    Senator Tester. And it sounds like that psychologist needed 
a psychiatrist. But would this bill apply to that psychologist?
    Ms. Flanz. Yes, sir.
    Senator Tester. OK. I am out of time. If we have a second 
round I have got some more.
    Chairman Isakson. Senator Blumenthal.

                   HON. RICHARD BLUMENTHAL, 
                 U.S. SENATOR FROM CONNECTICUT

    Senator Blumenthal. Thank you, Mr. Chairman. Thank you all 
for being here today. I am the supporter and sponsor of the 
Veterans' Partners Efforts to Enhance Reintegration, or Veteran 
PEER Act, as it is called, and I have advocated for 
improvements in behavioral health services. I think mental 
health services are critical in so many ways. I do not need to 
elaborate for this panel. Often PEER specialists are borrowed 
from behavioral health centers to assist the primary care 
treatment teams that improve patient outcomes.
    Unfortunately, there is a shortage--the result of this 
practice has been a shortage of PEER specialists in both 
behavioral health and primary care. We have essentially robbed 
Peter to pay Paul. Ensuring there are female PEER specialists 
available to work with women veterans and reporting on the 
outcomes of the program as a whole is also included in this 
measure.
    I would like to ask Dr. Lee whether you are a supporter of 
the Veteran PEER Act. Do you believe that PEER support 
specialists are a necessary and integral part of mental health 
services and primary care for our veterans?
    Dr. Lee. Senator, thank you for your support of PEER 
specialists. VA has no objection to the draft bill, but we 
currently have the authority to implement the increase in PEER 
support specialists, including them in the PACT team, in 
primary care. Currently VA has over 1,000 PEER support 
specialists. About 16 percent of them are women, and we are 
very supportive of growing that because it benefits veterans. 
Veterans who interact with peers are more likely to seek care 
when they need it and to have a better experience with the care 
team.
    Senator Blumenthal. Thank you. Thank you, Mr. Chairman.
    Chairman Isakson. Senator Murray, did you have a question 
that you would like to ask?
    Senator Murray. [Inaudible.]
    Chairman Isakson. You are on. Senator Tester. OK, I will 
recognize Senator Tester, who had another question, and then we 
will go to you.
    Senator Murray. [Inaudible.]
    Senator Tester. OK. You give me a kick when you are ready, 
Patty.
    This is for Mr. Parker. One of the biggest problems I have 
got with Choice is that it had little or no visibility in what 
is going on with our third-party administrator, HealthNet, from 
Montana. We cannot do oversight or help you when you need it, 
when there are contract modifications that are happening 
literally every other month, and we have no reliable 
information as to whether the company is meeting those 
standards. That is why I introduced a bill to require the VA to 
provide the Committee with contract modifications and 
information about contracting performance.
    This kind of goes on to what Senator Heller said. Do you 
see problems with Congress having this type of data on 
performance?
    Mr. Parker. No, sir, and, in fact, I will restate what Dr. 
Lee said, which was, you know, we do support the intent of that 
bill. We want to make sure that we work it appropriately. I 
think sharing that information with the Congress is absolutely 
proper.
    Senator Tester. Good.
    Mr. Parker. What I would suggest is that it comes from the 
Secretary to this body.
    Senator Tester. Yes. OK. So, the bill also requires the 
contracts include authority for the Secretary to level 
financial penalties if the contractor's performance does not 
meet those contractual standards. Your testimony indicates you 
believe you have all the tools you need. If that is the case, 
why has not more been done to hold HealthNet accountable for 
poor performance? And I do not think it is just Montana.
    Mr. Parker. No. I would agree with that. I do argue that 
the tools are available. I think that we need to make sure that 
we, as an organization, use the tools that are available to us. 
The liquidated damages clause gives us remedies. The quality 
performance tool such as a QASP, a surveillance plan, gives us 
the ability to look in and see what performance is.
    We need to do a better job, frankly, on the program 
management side to make sure that we are doing our jobs and 
holding contractors accountable.
    Senator Tester. I appreciate you taking responsibility. Let 
me give you an example of two of the things that have been 
particularly reckless with what is going on. Number 1, people 
who call up and get put on hold and then they get put back on 
hold; and 2, they call up and are told to call back days later. 
This is before they even get the appointment set up. Then, when 
they get the appointment set up it is a hell of a lot longer 
than if they just went to the VA to begin with.
    Then, those providers, initially--this has since changed 
because we entered into that picture and told some folks they 
had to change it--were not paying their providers. We are 
paying these third-party contractors. I do not know how much we 
paid HealthNet and I do not know how many States they are in, 
but I have got a notion it is a fair chunk of change. They 
should not have to hold that money in their bank account to 
collect interest on top; they ought to just pay the damn 
providers.
    So, you pretty much told me it is on you.
    Mr. Parker. Well, what I am trying to impart is that I 
think we, as a Department, need to do a better job of managing 
some of our contracts, and our program, really. I look at it 
more as a program basis than in just a contract-by-contract. We 
are doing things such as putting in the acquisition program 
management framework to have a better program management 
culture, mindset, and practices, which aligns with the new 
PAMIA legislation that still has not been fully implemented 
yet. We are waiting on guidelines coming out of OMB.
    So, we have a couple of big initiatives there that are 
early on, and I am optimistic that once we get those going, I 
am hopeful that we are going to see some very good results 
there. Because you are right--the things that you are citing 
are absolutely unacceptable.
    Senator Tester. OK. Thank you, Mr. Chairman.
    Chairman Isakson. For the benefit of the Members who just 
came in, Senator Murray is next, to be followed by Senator 
Manchin and then Senator Sullivan, unless Senator Sullivan can 
go after Senator Murray and then we do it in Republican-
Democrat order. Will you be ready in 5 minutes?
    Senator Sullivan. Sure, if my friend from West Virginia 
does not mind.
    Senator Manchin. The Senator from Alaska was born ready. 
[Laughter.]
    Chairman Isakson. Given that compliment, you are going to 
be next, after Senator Murray. How about that?
    Thank you, Senator Manchin.
    Senator Murray?
    Senator Murray. Thank you very much, Mr. Chairman. Ms. 
Kabat, I was very concerned when I got reports about veterans 
and their families who were cut off from the Caregiver Program 
really abruptly, so I am glad your department announced it had 
stopped that practice until it can get a better handle on 
things and figure out the program's eligibility rules.
    But, I am very concerned by the Department's plan to issue 
guidance on enrollment criteria and seek to reprioritize who is 
helped by this program. As I talked with Dr. Shulkin last 
month, I am open to hearing your ideas on changes to the 
eligibility criteria, but I expect you will consult with me 
before the Department attempts to make any changes to who can 
be helped by this critical program.
    Ms. Kabat. Absolutely. While I certain cannot speak 
directly for Dr. Shulkin, I believe what he and I have 
discussed is that he really wants to look at the overall way 
that VA is approaching supporting family caregivers, and 
certainly the program of comprehensive assistance is one way 
that we do that. We need to make sure we are doing that well, 
and be able to then look at all of the other areas in which we 
are supporting caregivers, including veterans who are 
caregivers themselves--that is an important piece--as well as 
our caregivers of veterans who were injured or ill prior to 
September 11th.
    So, there are a lot of different options and lots of 
different discussion. There is no definitive plan right now to 
change eligibility. We are working diligently on issuing a 
directive which is the official policy on the current program, 
and I am hopeful that that will be published within the next 
month, which will really provide a framework that is consistent 
with the eligibility that we have now. It will make decisions 
more transparent for veterans and their families.
    Senator Murray. Well, will you keep the suspension in place 
until you have completed all the actions needed to improve the 
program, including the pending GAO and IG recommendations?
    Ms. Kabat. The GAO recommendations surrounding the 
development of an IT solution? I do not believe that our plan 
is to keep the suspension in place until we have that new IT 
solution. I can get you a more specific update on what is going 
on with the IT solution. I can take that for the record and get 
that back to you.

    [The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Patty Murray to 
Margaret Kabat, National Director, Caregiver Support Program, Veterans 
       Health Administration, U.S. Department of Veterans Affairs
    Response. VA's Program of Comprehensive Assistance for Family 
Caregivers (PCAFC) is expected to resume in the coming months following 
a strategic review of the program which, indicated a need for better 
communication with Veterans and caregivers, improved internal processes 
and procedures, and additional staff training. Since that review, VA 
has made significant advancements in communication about eligibility 
determinations, clinical discharges and the appeals process, internal 
processes and procedures, and staff training. Specifically, those 
advancements include:

     Increased communication and engagement with Veterans 
Service Organizations, Military Service Organizations, Members of 
Congress, VA Veterans Integrated Service Network directors, and other 
stakeholders.
     Ongoing work to revise the PCAFC website to include a 
section about connecting caregivers and Veterans to home and community 
based services.
     Work is in progress on a Veterans Health Administration 
(VHA) national policy directive on caregivers, with an expected 80,000 
subscribers to the PCAFC list-serve to promote transparency.
     Work is in progress to promulgate a new, standardized 
letter for use by all VA medical centers when communicating program 
discharges with Veterans and Family Caregivers.
     Implementation a new ``Roles, Responsibilities and 
Requirements'' document that reaffirms that all family caregivers are 
collaborative partners with VHA.

    Throughout this time, the PCAFC has continued to collaborate with 
VA's Office of Information Technology on development efforts for an 
information technology (IT) solution intended to replace the current 
Caregiver Application Tracker. When fully developed and available for 
field use, the new Caregiver Tool (CareT) will enable improved tracking 
and monitoring of Veteran and caregiver participation in PCAFC.

    Senator Murray. OK. I would like to see that. And I want to 
know if you can assure me that the veterans and VA staff across 
the country are going to get very clear national guidance on 
enrollment criteria?
    Ms. Kabat. Yes, I can assure you of that. I can also assure 
you that we are going to increase our oversight from the 
central office perspective. We have a variety of different 
things that are being discussed and will be implemented prior 
to returning to discharging veterans and caregivers from the 
program.
    Senator Murray. OK. Well, in an earlier study by the VA, 
the Department found that for veterans in the caregiver program 
their inpatient hospital admissions decreased by 30 percent, 
and the VA also found that when a veteran was hospitalized, 
their length of stay decreased by 2\1/2\ days. So, tell me, how 
important is it to veteran's health and quality-of-life to 
spend less time in the hospital and more time at home?
    Ms. Kabat. It is essential, and I think everyone in VA 
believes that, so we are moving forward with working to 
providing comprehensive support to all caregivers of veterans.
    I do think it is important to note that that initial study 
that you are referencing was done without a comparison group. 
More recently we have been able to compare veterans whose 
family caregivers participate in the program of comprehensive 
assistance to veterans whose caregivers have not participated 
in the program of comprehensive assistance, and those veterans 
whose caregivers do participate access more outpatient care, 
more specialty care, more mental health care. They are more 
engaged in treatment, which is really an important part of 
helping veterans get to their highest level of independence.
    That research--I am happy to meet with you and discuss this 
in more detail and actually have the VA researcher with me to 
talk more about it--did not demonstrate that there was a 
significant difference in terms of inpatient stay or ER visits. 
Part of it is that the post-9/11 veteran population are fairly 
low users of inpatient stays and ER visits, so there is not--it 
is difficult to get a substantial difference, because they use 
those services less than other cohorts of veterans.
    Senator Murray. Are you working at all to expand research 
to find out what the improvements are?
    Ms. Kabat. Absolutely. We have ongoing work with VA 
researchers at the Durham, NC, VA. Again, I am happy to meet 
with you and your staff and talk more about all that we are 
looking at.
    Senator Murray. OK. I also just want to say that there was 
a September 2014 GAO report that had some really important 
concerns about the Caregivers Program, including very high 
workloads of our veterans per caregiver support coordinator. 
You can get it back to me in the record, but I want to find out 
where you are on hiring new caregiver support coordinators and 
getting those personnel in the field so that this program can 
work.
    Ms. Kabat. Absolutely. We have made significant strides. We 
are up to about 350 caregiver support coordinators across the 
country, but I am happy to get you the specific around ratios.

    [The information requested during the hearing follows:]
Response to Request Arising During the Hearing by Hon. Patty Murray to 
Margaret Kabat, National Director, Caregiver Support Program, Veterans 
       Health Administration, U.S. Department of Veterans Affairs
    Response. The PCAFC monitors Caregiver Support Coordinator (CSC) 
positions to approved Veteran/Caregiver dyads ratios and works with 
sites to discuss facility staffing needs to support local 
administration of the PCAFC. Please see the attached document, titled 
Ratio of CSCs to Caregivers. The most recent and accurate data 
currently available is as of August 18, 2017, at which time the PCAFC 
Office was funding 446 positions. Seventy of these positions are vacant 
and in various stages of recruitment. An update to the CSC staffing 
data set will be available November 2018.








    Senator Murray. OK, because I did include additional 
dollars on the fiscal year 2017----
    Ms. Kabat. Yes, you did.
    Senator Murray [continuing]. For that, and I want it used.
    Ms. Kabat. You did. Yes. Absolutely. And we appreciate 
that. Thank you.
    Senator Murray. All right. Thank you.
    Chairman Isakson. Senator Sullivan.

                STATEMENT OF HON. DAN SULLIVAN, 
                    U.S. SENATOR FROM ALASKA

    Senator Sullivan. Thank you, Mr. Chairman. I know we are 
talking health issues today so I want to take the opportunity 
to first welcome you back, sir. We all missed you and we are 
glad you are doing well. I know we have some health issues with 
a couple of other Senators, namely Senator Hirono, and I know 
we are all wishing her well. I am going to read a statement 
briefly here from Senator Tillis right now, if that is OK, Mr. 
Chairman. He also had a bit of a health issue today and he 
wanted me to read his statement.
    I think he is doing well, so, do not worry about that.
    Senator Tester. Senator Sullivan, since you are confused 
with Senator Tillis all the time, I think you can just say you 
are Senator Tillis. [Laughter.]
    Senator Sullivan. Well, this will really freak out----
    [Laughter.]
    Senator Sullivan. That is only if I keep his 5 minutes and 
then I get my 5 minutes. No. I am just kidding, Joe. I will 
read it quickly.

    This is a statement from Senator Tillis:

          ``Please accept my apologies for not being here this 
        afternoon. I was running in the Capital Challenge 5K 
        this morning and unfortunately was not able to finish 
        the race, even though I was well on my way to easily 
        eclipsing my time from last year.
          ``I want to just briefly comment on two bills on the 
        agenda. On the Veterans Education Priority Enrollment 
        Act I appreciate the VA's support and the valuable 
        feedback we received from all the stakeholders. I 
        understand some of the compliance concerns that were 
        raised and I look forward to discussing with Senator 
        Brown to identify the best path forward that will allow 
        flexibility for schools that are already setting the 
        gold standard while ensuring that all veterans have the 
        opportunity to use their GI Bill to the fullest extent.
          ``And with regard to the State Veterans Home Adult 
        Day Care--Day Health Care Improvement Act, I thank 
        Senator Hatch for his leadership and I look forward to 
        engaging with the VA to address their recommendations 
        that would improve the bill. Together we can empower 
        veterans to receive daily care while living and 
        spending more time at home with their families.''

    Thank you, Mr. Chair.
    Dr. Lee, I want to talk briefly about the Serving Our Rural 
Veterans Act, and I appreciate Senator Tester's commitment to 
that issue as well. As you know, this goes to an issue that 
actually was raised--and the idea was not mine or even Senator 
Tester's, it was actually Dr. Shulkin's. When we were up in 
Alaska visiting he had this idea of, hey, how do we get more 
health providers in rural areas, extreme rural areas; and then, 
is that a way to help get them working at the VA?
    So, we discussed this. This bill is getting ready. We want 
to finalize a couple of elements of that. I appreciate your 
testimony, talking about how you are supportive of the bill.
    What we want to be able to do, though, is just kind of iron 
out some of the final elements. We have gotten some conflicting 
recommendations from the VA, particularly on the issue of a 
service commitment that relates to this, what you guys think 
about that. I think in previous testimony and consultations 
with my staff there has been an interest in that from VA, 
though now I think in your public statement there is not an 
interest.
    We want full VA support. I know Dr. Shulkin does. Like I 
said, he has been not only supportive but was in many ways the 
brainchild of this entire bill. So, we want to work with you on 
that. We want to get this in and we want to get this passed. It 
is an important bill that we think can benefit a lot of our 
veterans, and is very bipartisan.
    So, can I get your commitment on that?
    Dr. Lee. Senator, thank you for raising this issue. We are 
very supportive of wanting to build the capacity for care 
through graduate medical education investments in rural areas, 
and I think where we are--well, we look forward to working with 
you on the specifics of your bill.
    Our concerns just come from wanting to get the most bang 
for our buck, if you will----
    Senator Sullivan. Sure. Absolutely.
    Dr. Lee [continuing]. And service to veterans from those 
residents.
    Senator Sullivan. Yes.
    Dr. Lee. And looking at what the service commitment is back 
for the chance to be a part of the program, and also looking at 
authorities for expanding debt reduction----
    Senator Sullivan. Great. Oh, great.
    Dr. Lee [continuing]. To resident physicians.
    Senator Sullivan. Wonderful.
    Dr. Lee. We look forward to working with you.
    Senator Sullivan. If we can do that sooner rather than 
later, I think that we are all anxious to introduce this bill. 
I think it will have strong bipartisan support in the 
Committee, and we really want to move on it this year.
    Dr. Lee. We would be happy to work with you.
    Senator Sullivan. Great. I just have one final question. 
You know, I have been very interested in the appeals issue. I 
know that we have S. 1024, which is the Chairman, Senator 
Blumenthal, and the Ranking Member's bill.
    My question that relates to that bill, as somebody who has 
been very focused on the appeals issue and concerns about the 
backlog, I believe that bill authorizes kind of the ability to 
test facets of the new appeals system. Is the VA planning on 
using that? And my only concern--I would encourage you once 
this bill becomes law, because we all know we have a challenge 
on the appeals process, but we also do not want to go to out 
with a full--in my view, a full comprehensive approach and then 
realize, uh-oh, there is another problem here, and kind of 
crash the system the way, say, for example, the Choice Act was 
in certain States like mine, where it was fully implemented and 
it just did not work.
    Can you talk to that issue of kind of the ability to test 
case how we are doing appeals correctly under this bill so we 
do not--I am sure there are a lot of good ideas, but this is a 
comprehensive bill, and if we go full authority and then we 
realize something in the bill is actually not working, I do not 
want to have an appeals system that is further broken. Does 
anyone want to talk to that issue?
    Mr. McLenachen. Yes, Senator, I will start, and then maybe 
Mr. Hachey has something to add.
    I think there may be a little bit of a misconception about 
this bill. We are not changing the way that we decide appeals 
or decide claims in BVA, where I work. It is really how we are 
routing the work to the point where you make those decisions.
    So, I think some people believe that, you know, this is a 
very significant change. It is, in fact, somewhat of a 
historical change. On the one hand, what we are really doing is 
just streamlining the process that gets to the point where the 
decision is made, and we are kind of pulling the current 
process apart and realigning it so that it gets to a point 
where a veteran has a choice about how they want to handle the 
review process.
    So, you know, there has been some concern expressed, in 
particular referring to the GAO report that was done on the 
appeals process. But, the critical point to understand is that 
the board is not changing how they are doing their decisions 
and we are not changing how we are doing ours. We are applying 
the law to the facts in the same way. It is just how we get the 
appeals and the claims to the end point where the person makes 
the decision more streamlined.
    We have worked very closely with some of the other 
panelists you are going to hear from today on developing this 
process, the VSOs and other stakeholders. This is a situation 
where we believe that we have the right solution. If we were 
unsure of that, then certainly; it would be important to do a 
pilot or some other type of implementation. But we have such a 
severe problem right now that it would be the wrong thing to 
do, in VA's opinion, to make it only available to certain 
veterans. In fact, it would be unfair if we did that, when we 
know that we have the right solution.
    It is better than what we have today. There is no doubt 
about that. So, it does not make much sense to do a pilot or 
something similar to that.
    Donnie, do you have anything you want to add?
    Mr. Hachey. I would agree with everything that Dave just 
said. I think the substantive law here that is being used to 
decide appeals is the same. What we are really doing is 
simplifying the process and pulling it apart and making it 
easier for veterans by providing them with more choice. We know 
that the system we are working with now is broken, so a 
piecemeal solution, we do not think is the right approach right 
now. We have brought all of the major stakeholders together and 
come up with something we believe is the right answer for 
veterans, that is going to get them faster decisions and 
provide a simpler process. We think the time to do it is now, 
and we cannot delay it any further by engaging in a pilot or 
having a phased-in implementation.
    Senator Sullivan. OK. Thank you. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Sullivan.
    Senator Manchin?

              STATEMENT OF HON. JOE MANCHIN III, 
                U.S. SENATOR FROM WEST VIRGINIA

    Senator Manchin. Thank you very much, Mr. Chairman, and 
thank you all for being here.
    I think you all have seen this. It is a report last week of 
the VA--the DC VA, stopped surgical because of the equipment. 
So, you all know about that, right? OK.
    A lot of my West Virginia veterans use this clinic because 
of our proximity to DC. What are you all doing, or how are you 
handling that--the Inspector General's recommendations on 
what--to correct the problems you have had there, so when they 
call our office we can give an update?
    Dr. Lee. Senator, ensuring the safety of our veterans is 
our top priority----
    Senator Manchin. Sure.
    Dr. Lee [continuing]. Especially at DC VA, and we agree 
with the Inspector General that no patient harm was documented. 
But there is a lot of work left to do and we are actively 
working to support the DC VA in addressing all the issues 
raised, including----
    Senator Manchin. Do you have any other--I mean, I 
understand it was a vascular operation that was going on. They 
put the man under and they found out that they did not have the 
equipment to do the operation with.
    Dr. Lee. I do not have any other details to add to the 
investigation----
    Senator Manchin. Yeah.
    Dr. Lee [continuing]. But we have--we are lending support--
--
    Senator Manchin. OK.
    Dr. Lee [continuing]. From Central Office, from the very 
top.
    Senator Manchin. You can keep me----
    Dr. Lee. We will be happy to update you.
    Senator Manchin [continuing]. Apprised and my staff, I 
would appreciate it, so we can keep our constituents apprised.
    Dr. Lee. Absolutely.
    Senator Manchin. I am happy to join Senator Tester's--he is 
right there--Performance, Accountability, and Contractor 
Transparency. I notice that we are doing more and more with 
contractors, and the problem we have with the contractor is 
this: when there is a problem with the VA and our VA employees, 
they can call our office and we can work with you all, and we 
get an answer. When there is a third party involved, we are out 
of the loop. We just--we cannot connect.
    This is what, I think, we are all concerned about, 
especially in rural States. We here are basically the 
connector. We are the facilitator for that. It looks like you 
are moving more and more to contractors, which is going to take 
us out of the mainstream to where we can have connectivity.
    Is that where you are going, and how do you correct what 
you have already got? Does anybody want to speak to that one? I 
think you are up, Dr. Lee. No one jumped in so I figured it was 
you.
    Dr. Lee. Well, I will ask, on a specific bill I will ask 
Mr. Parker if he wants to----
    Senator Manchin. Well, forget about the bill. Just tell me 
what you are doing with contractors.
    Dr. Lee. All across the board? We--I think it makes sense 
for us to leverage our strengths wherever we are strong and to 
leverage contractors in the private sector wherever we need 
that to complement the services.
    Senator Manchin. Well, let us talk about HealthNet. 
HealthNet is a problematic one we have. How do we have better 
connectivity with them? How can my staff call and help a 
veteran, and you have them as a third-party administrator?
    Dr. Lee. I think the specific issues with HealthNet--
addressing those actually goes back to the greater work that we 
need to do with this Committee and the whole Choice program. I 
know that Secretary Shulkin and my colleague, Baligh, will be 
engaged along with all of us on that work in the weeks and 
months ahead. But that is our priority, to look at the entire 
program and see how do we redesign it to better meet the needs 
of veterans, because we are not doing so well right now.
    Senator Manchin. How much time is that going to take? I 
have been here for a while on this Committee, and I still have 
that same question.
    Dr. Lee. We are just as pressed as you are, sir. We would 
like to move that quickly.
    Senator Manchin. OK. Let us move on.
    Again, I thank my good friend, Senator Murray, for her work 
on the caregiver issue. Some of my Vietnam veterans back home, 
forty percent of my veterans are Vietnam-era veterans--40 
percent. They have concerns, they have needs that were not 
identified, were not recognized, and were not treated. So, they 
need full-time care for their injuries, and if they do not have 
a family caregiver then they are basically institutionalized. 
Are you all looking at that, thinking of this more from a 
moral, humane approach, and also cost-effectiveness, if we can 
have some type of care at home, as we do with caregivers in our 
senior citizens? Where are you on that issue? Does anybody want 
to jump in? How about you--I can tell----
    Ms. Kabat. I am happy to----
    Senator Manchin. You are eager to go. Let us go.
    Ms. Kabat. I am happy to answer at least part of that 
question. I think the Caregiver Support Program, which is my 
area of expertise, is certainly really only one way that VA 
supports veterans who require a lot of assistance in a home 
setting, and we certainly want our veterans to remain at home, 
in their communities.
    So, we offer a lot of different home- and community-based 
services.
    Senator Manchin. Are you having a hard time finding people 
that will give these type of services in-home? Can you contract 
with the same people that do senior services? Do you all 
piggyback on senior services?
    Ms. Kabat. We do work very closely with the aging and 
disability network. We have some partnerships with HHS around 
doing that. I think I am not an expert in that area, but we 
would be happy to have our----
    Senator Manchin. One thing I am saying is I am sure that 
Alaska, and I am sure that Montana and Washington--we have 
senior services to try to keep people living in--with a little 
bit of assistance in their own home, and a lot of veterans, 
especially our Vietnam veterans, would love to do that, but we 
just do not have that service offered, so they end up--they 
cannot live by themselves any longer.
    Ms. Kabat. We would be happy to come talk to you about our 
home- and community-based programs, our in-home nursing, and 
home health aides.
    Senator Manchin. I know Senator Murray has been leading the 
charge on this and I appreciate it very much, but, boy, I am 
sure we all have the same problem. So, I would be happy if you 
would, you know, follow up with us on that.
    Ms. Kabat. Absolutely.
    Senator Manchin. We just--these people deserve answers. It 
really is a shame. Some of them come for the services they need 
and it is not that much. They do not ask for a lot.
    I think that is my time. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Manchin.
    Senator Boozman.

                STATEMENT OF HON. JOHN BOOZMAN, 
                   U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Senator Isakson and Senator 
Tester for having this very important hearing. There are so 
many good initiatives that we are talking about today. As we 
all know, supporting our Nation's veterans is one of the most 
important responsibilities that we do as Members of Congress. I 
know that you all are working hard to do that also, which we 
really appreciate.
    I would like to talk a little bit about S. 681, the Deborah 
Sampson Act, which I am proud to cosponsor with Senator Tester 
and many other Members of the Committee. It is, as you know, a 
bipartisan bill that just tries to put much-needed parity to 
the benefits for our women veterans.
    As you all point out in your testimony, women are the 
fastest-growing subgroup of veterans, 2.2 million women 
veterans in the United States, over 20,000 in my home State of 
Arkansas, which, again, we are very, very proud of.
    The problem is, as we all know, the VA facilities or the VA 
programs, to some extent, have not changed to a large extent, 
yet we are now living in a different era. In fact, it was 
interesting. When we had our press conference, one of the 
female veterans, one of the lady veterans talked about being in 
the VA hospitals, and invariably they were asked if they were 
looking for their husband. So, that is really what we are 
dealing with. Those are honest mistakes, but it is something 
that we simply need to do away with.
    So, I appreciate you, Dr. Lee, in the sense that you voice 
strong support of several of the bill's provisions to include 
the pilot program for peer-to-peer assistance for women 
veterans and expanding the supporting service for veterans' 
families program. These are really important issues and we are 
pleased with that.
    I would like to talk to you a bit, though, about the 
opposition to ensuring that each VA medical facility has at 
least one full- or part-time--and I emphasize part-time, at 
least, women's health care provider. I appreciate the VA may 
already have the authority to make this happen. The fact is 
that, you know, we talk a lot about getting these things fixed, 
but we truly do hear a lot about the issue that are not fixed, 
and I think that is just a common sense way of stepping out in 
the right direction.
    So, I really encourage the VA to think rethink your 
opposition to the provision. The bill is not requiring a full-
time provider. The requirement is at least one full- or part-
time provider. Can you all comment on that?
    Dr. Lee. Senator, as you said, women veterans are the 
fastest-growing segment of the veteran population and VA is 
very committed to ensuring high-quality care and services for 
all of our women veterans.
    We have made a lot of progress. We know now that we have a 
designated women's health provider at every medical center and 
almost every community-based outpatient clinic. Those 
designated women's health providers are trained to especially 
meet the needs of women veterans and address their post-
deployment health issues, including military sexual trauma. We 
also have gynecologists at approximately 130 of our sites of 
care. We have almost 200 gynecologists employed in VA. So, we 
are expanding and interested in expanding that access to 
specialized GYN care as well.
    And we think that some of the results really show the 
investment that we have made. We actually exceed the private 
sector in some of our quality outcomes when it comes to breast 
cancer and cervical cancer screening.
    Senator Boozman. We are going to hold you to that. The 
other thing--because I am running out of time, and I apologize 
for interrupting--but the other thing I would like for you to 
comment on is the--I was surprised at VA's opposition to 
tracking data related to women veterans. Can you tell me the 
metrics that are in place now, so that we know what is going 
on? How we identify health care needs for veterans currently? 
Again, I am a little bit surprised as to why we would not go 
forward with actually tracking data to give us a better idea. 
As we solve this problem--it is not a new problem. It has been 
going on for a little bit.
    Dr. Lee. Sir, we are very committed to transparency of our 
data, and what we are striving to do is to use the private 
sector benchmarks, like HEDIS and CAHPS, which measure quality 
outcomes and also patient satisfaction, and measures like that. 
In particular, with this provision, our only concern was just 
the breadth of the applicability to all of our data. In some 
cases, for instance, in our cemeteries, in the NCA, we may not 
collect gender-based data, and it could impose some additional 
cost to be able to do that.
    So, I would be happy to work with you on narrowing some of 
the scope of the data collection requirements.
    Senator Boozman. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Boozman, and thanks to 
all the Members. Thank you for your testimony for the VA today, 
and we will excuse you at this time. You are welcome to stay 
for the second panel, but I ask the second panelists to come 
forward if you would, at this time.
    Thank you very much, Dr. Lee.
    Our second panel will consist of the following: Louis J. 
Celli, Jr., Director, National Veterans Affairs and 
Rehabilitation Division, The American Legion; Kayda Keleher, 
Associate Director, National Legislative Service, Veterans of 
Foreign Wars; Adrian Atizado, Deputy National Legislative 
Director, Disabled American Veterans; Allison Jaslow, Executive 
Director, Iraq and Afghanistan Veterans of America; and J. 
David Cox, National President, American Federation of 
Government Employees.
    If you would come forward to your designated seat, we will 
start the hearing. [Pause.]
    Chairman Isakson. Let me begin by thanking all of you for 
your patience. You have been sitting through a long but very 
important hearing on the legislation pending before us today, 
and we appreciate our veteran service organizations coming 
forward to offer their testimony on the proposed legislation. 
We look forward to hearing from each and every one of you.
    We will recognize you for up to 5 minutes. If you have an 
additional statement you want to submit for the record, we will 
submit that for the record, and then afterwards, if there are 
any questions, we will have questions.
    We will start with Dr. Celli--Mr. Celli.

 STATEMENT OF LOUIS J. CELLI, JR., DIRECTOR, NATIONAL VETERANS 
    AFFAIRS AND REHABILITATION DIVISION, THE AMERICAN LEGION

    Mr. Celli. Access to veterans' health care, ensuring our 
veterans are able to receive the benefits they have earned, 
quality and services across the spectrum of veterans who 
faithfully served in defense of this Nation, regardless of 
conflict, accountability, and transparency are some of the very 
foundational pillars that The American Legion continues to 
build on.
    Chairman Isakson, Ranking Member Tester, and distinguished, 
dedicated defenders of veterans who proudly serve on this 
Committee, on behalf of Charles Schmidt, the National Commander 
of the largest veteran service organization in the United 
States of America, representing more than 2.2 million dues-
paying members, and combined with our American Legion family 
whose members exceed 3.5 million voters, living in every State 
and American territory, it is my duty and honor to present The 
American Legion's position on more than a dozen or so bills 
being considered by this Committee today.
    In addition to the Deborah Sampson Act, The American Legion 
supports Senate Bill 804, the Women Veterans Access to Quality 
Care Act, the Military and Veteran Caregiver Service 
Improvement Act of 2017, the draft bill addressing 
accountability and whistleblower protections, the tracking of 
biological implants, and a variety of other bills detailed in 
our written testimony today, and, of course, the Appeals 
Modernization Act being reintroduced here today, with 
overwhelming bipartisan administration and stakeholder support.
    The American Legion has been calling on Congress and the VA 
to bring women veterans' issues in line with the availability 
and quality of services provided to their male counterparts for 
years. Throughout the System Worth Saving program, The American 
Legion has been evaluating and reporting on VA medical centers 
for more than 15 years. Over the years, the gap in services 
between men and women who have served, side by side, has been 
so prevalent that in 2013, The American Legion dedicated an 
entire year of this program to detailing and highlighting some 
of the much-needed improvements we are still fighting for 
today.
    Our 2013 report on women's health care addresses all of the 
vital components of the Deborah Sampson Act, as well as in 
Senate Bill 804, which is why we strongly urge this Congress 
and the VA to immediately address these issues. Transparency 
and accountability are the cornerstone of leadership and good 
governance. The American Legion fully supports holding bad 
actors accountable for their actions, and criminals should be 
prosecuted as soon as possible.
    The American Legion supports giving the Secretary any and 
all tools necessary to lead his agency as needed, but wants to 
ensure that congressional language does not cause a type of 
unintended consequences that we have struggled with in the 
past.
    As stated in our written testimony, The American Legion 
wants to ensure that Congress provides VA with the tools that 
are functional, enforceable, and allow the agency to act in a 
manner that promotes good order, discipline, and esprit de 
corps. Poorly crafted legislative language that fails legal and 
constitutional standards only serves to ruin morale and create 
a system of indecision and lack of surety.
    Our first concern with the evidence threshold reduction to 
substantial evidence is that the bill will encourage an 
atmosphere that reduces the burden of managers to collect 
appropriate documentation. Managers need to be held accountable 
to perform expert leadership and oversight, and that includes 
being diligent about documenting poor performance or bad 
behavior. Egregious behavior would not be affected by this 
provision as it would surpass the already established 
evidentiary threshold of preponderance of evidence.
    The second concern we raise is with the provision that 
strips judges of the ability to mitigate penalties. While on 
its face it seems logical to force the judge to accept the 
agency's decision, regardless of discipline or termination, The 
American Legion is reminded of the Linda Weiss decision, in 
which the presiding judge states, in part, ``In conclusion, I 
find the appellant has rebutted the presumption that the 
penalty was reasonable. If the statute did not prohibit it, I 
would mitigate the penalty. However, because that is not 
allowed, the only option is to reverse the action outright.'' 
Please review this language.
    Next, as important as our caregiver program is, it is 
imperative that Senate Bill 591 not only pass but that benefits 
be extended to all pre-9/11 veterans. The American Legion is 
committed and resolute on this issue, and will not waiver in 
our support to ensure all veterans are treated equally under 
the law.
    Finally, it is with great pleasure that The American Legion 
testifies in support of the Appeals Modernization Act. This 
support will streamline and modernize a program that 
desperately needs it, while preserving and expanding veteran 
protections and, in the long run, the increased efficiency will 
save money with providing benefits faster and more efficiently. 
As one of the founding organizations who helped develop this 
new program, The American Legion is proud to support S. 1024, 
the Veterans Appeals Improvement and Modernization Act of 2017.
    [The prepared statement of Mr. Celli follows:]
    Prepared Statement of Louis J. Celli, Jr., Director of National 
    Veterans Affairs & Rehabilitation Division, The American Legion
    Chairman Isakson, Ranking Member Tester, and distinguished Members 
of the Committee; On behalf of our National Commander, Charles E. 
Schmidt, and the over 2.2 million members of The American Legion, we 
thank you for this opportunity to testify 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.
   s. 23: biological implant tracking and veteran safety act of 2017
To amend title 38, United States Code, to direct the Secretary of 
        Veterans Affairs to adopt and implement a standard 
        identification protocol for use in the tracking and procurement 
        of biological implants by the Department of Veterans Affairs, 
        and for other purposes.
    The American Legion remains concerned about the Veterans Health 
Administration's (VHA) lack of a robust prosthetic supply tracking 
system. The American Legion has testified about the Department of 
Veterans Affairs' (VA) prosthetic tracking system at numerous hearings. 
On January 15, 2014, The American Legion testified before House 
Veterans' Affairs Subcommittee on Oversight and Investigations urging 
Congress to require VA to implement an automated tracking system that 
addresses vulnerabilities. The recommendations were: one, initially 
record the serial number of a surgical implant device when procured and 
placed into VA's inventory; two, record the expiration date; and three, 
that a record tracking flag be put into place to alert VA staff when 
the product is nearing its expiration date.
    On March 19, 2015, The American Legion's written testimony for the 
record was presented to the House Veterans' Affairs Subcommittee on 
Oversight and Investigations in support of H.R. 1016: The Biological 
Implant Tracking and Veteran Safety Act of 2015.
    VA's Office of Inspector General (VAOIG) has conducted numerous 
audits looking at VA's prosthetic inventory system with the last audit 
completed in 2012. VAOIG issued Report No. 11-02254-102 on March 8, 
2012, titled ``Audit of VA's Management and Acquisition of Prosthetic 
Limbs.'' The VAOIG identified the following challenges:

          VHA needed to strengthen the VA medical centers (VAMC) 
        management of prosthetic supply inventories to avoid spending 
        funds on excess supplies and disruptions to patient care due to 
        supply shortages. VHA also needs to improve the 
        comprehensiveness of its inventory information and standardize 
        annual physical inventory requirements. It was estimated that 
        during April through October 2011, VAMCs maintained inventories 
        of nearly 93,000 prosthetic supply items with a total value of 
        $70 million. Of the 93,000 items, it was estimated that VAMC 
        inventories exceeded current needs for almost 43,500 items (47 
        percent) and were too low for nearly 10,000 items (11 percent), 
        increasing the risk of supply shortages.
          VAMCs did not maintain optimal inventory levels because of 
        the following reasons:

         Lack of integration between the prosthetic inventory 
        system and other VHA systems,
         Inefficiencies from using two inventory systems,
         Inadequate staff training on inventory management 
        principles and techniques,
         Insufficient VHA Central Office and Veterans 
        Integrated Service Network (VISN) oversight of VAMC inventory 
        management practices, and
         Inadequacies in VHA's Inventory Management Handbook.

    As a result, VAMCs spent $35.5 million to purchase unnecessary 
prosthetic supplies and increased the risk of supply expiration, theft, 
and supply shortages. In addition, VHA could not accurately account for 
these inventories.
    VHA responded to the report stating the VA would work to develop a 
plan to replace the Prosthetic Inventory Package (PIP) and the Generic 
Inventory Package (GIP) with a more comprehensive system. The target 
completion date was March 30, 2015. As noted in the 2012 VAOIG report, 
VHAs hope is to ``removing recalled products from inventory within 24 
hours of a recall.''
    The American Legion is concerned that there is still no clear 
policy on how veterans who have received implants are tracked. 
Attention must be paid to veterans who are already downstream in the 
process. Without consistent tracking of implants, including positive 
identification by serial number and other identifying factors, 
uncertainty remains as to how veterans are served in the case of 
recalls. The American Legion wants to see a more comprehensive 
procedure and policy clearly defined by Central Office to ensure 
consistency in all Veteran Integrated Service Networks (VISNs).
    In 2014, VHA required VA Medical facilities to begin using the 
Catamaran Point of Use (POU) Inventory System that interfaces with the 
Veterans Health Information Systems and Technology Architecture 
(VistA). The system is not utilized at every VA medical center, case in 
point, the Washington DC VA Medical Center.
    In response to allegations made by a confidential complainant, the 
VAOIG investigated equipment and supply issues at the Washington DC VA 
Medical Center. The VAOIG released an Interim Summary Report on 
April 12, 2017, which identified some serious and troubling 
deficiencies at the Medical Center that place patients at unnecessary 
risk. Although VAOIG has not identified at this time any adverse 
patient outcomes, they found that there was no effective system to 
ensure that supplies and equipment that were subject to patient safety 
recalls were not used on patients and over $150 million in equipment or 
supplies had not been inventoried in the past year and therefore had 
not been accounted for.
    Five years have passed since VAOIG reported on this issue and VA 
promised Congress, veterans, and American taxpayers that they would 
develop a plan to replace the Prosthetic Inventory Package (PIP) and 
the Generic Inventory Package (GIP) with a more comprehensive system.
    We are here today because the plan VA put in place is not working. 
Implementing a biological implant tracking system is essential to 
assuring the health, safety and the life of a veteran is safeguarded.
    Resolution No. 377: Support for Veteran Quality of Life, supports 
any legislation and programs within the VA that will enhance, promote, 
restore or preserve benefits for veterans and their dependents, 
including, but not limited to, the following: timely access to quality 
VA health care; timely decisions on claims and receipt of earned 
benefits; and final resting places in national shrines and with lasting 
tributes that commemorate their service.\1\
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    \1\ American Legion Resolution No. 377 (2016): Support for Veteran 
Quality of Life
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    The American Legion supports passage of S. 23.
  s. 112: creating a reliable environment for veterans' dependents act
To amend title 38, United States Code, to authorize per diem payments 
        under comprehensive service programs for homeless veterans to 
        furnish care to dependents of homeless veterans, and for other 
        purposes.
    S. 112 will help ensure that VA funded homeless shelters may be 
reimbursed for services provided to the dependent of a veteran, thereby 
reducing the risk of separating families during a difficult time. Based 
upon the Point-in-Time count on a single night in January 2016, almost 
all veterans were experiencing homelessness in households without 
children (97 percent or 38,340 veterans). About 3 percent (1,131) were 
veterans who were homeless as part of a family. If enacted, S. 112 
would provide reimbursement for VA grantees who house homeless veterans 
with a dependent.
    This would be quite beneficial for those homeless veterans with 
dependents, particularly women veterans who often carry the most 
responsibility of taking care of their children. Housing is a key 
component in stabilizing the veteran and putting him/her back on track 
to independent living. This bill would provide an avenue where the 
veteran would not separate from their child and/or spouse to obtain 
housing, and crucial services, for a successful reintegration back into 
mainstream society.
    The American Legion strongly believes that homeless veteran 
programs should be granted sufficient funding to provide supportive 
services such as, but not limited to, outreach, health care, 
rehabilitation, case management, personal finance planning, 
transportation, vocational counseling, employment, and education. 
Furthermore, The American Legion continues to place special priority on 
the issue of veteran homelessness. With veterans making up 
approximately 11 percent of our Nation's total adult homeless 
population, there is plenty of reason to give this issue special 
attention. Along with various community partners, The American Legion 
remains committed to seeing VA's goal of ending veteran homelessness 
come to fruition. Our goal is to ensure that every community across 
America has programs and services in place to get homeless veterans 
into housing (along with necessary healthcare/treatment) while 
connecting those at-risk veterans with the local services and resources 
they need. We hope to see that with the expansion of assistance 
afforded to homeless veterans and their dependents, there will also be 
an increase in funding to support. We estimate that an additional $10 
million annually will be sufficient to accomplishing this goal.
    Resolution No. 324: Support Funding for Homeless Veterans, supports 
any legislation and programs within and outside the VA that will 
enhance, promote, and assist homeless veterans in a timely fashion.\2\
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    \2\ American Legion Resolution No. 324 (2016): Support Funding for 
Homeless Veterans
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    The American Legion supports S. 112.
 s. 324: state veterans home adult day health care improvement act of 
                                  2017
To amend title 38, United States Code, to improve the provision of 
        adult day health care services for veterans.
    State Veterans Homes are facilities that provide nursing home and 
domiciliary care. They are owned, operated and managed by state 
governments and date back to the post-Civil War era when many states 
created them to provide shelter to homeless and disabled veterans.
    Currently, there are only two Adult Day Health Care programs at 
State Veterans Homes in the United States. Both are located on Long 
Island, New York. However, these programs could easily be offered at 
the other 151 State Veterans Homes located throughout the country.
    S. 324 would provide a no cost, medical model Adult Day Health Care 
to veterans at State Veterans Homes who are 70 percent or more service-
connected disabled. This bill is an extension of Public Law (P.L.) 109-
461: Section 211, Veterans Benefits Health Care, and Information 
Technology Act of 2006, which currently provides no cost nursing home 
care at any State Veterans Home to veterans who are 70 percent or more 
disabled for their service-connected disability and who require 
significant assistance from others to carry out daily tasks.
    Adult Day Health Care is a daily program for disabled veterans who 
need extra assistance and special attention in their day to day lives. 
Adult Day Health Care programs provide disabled veterans and their 
families with a high-quality alternative to nursing home care and 
quality outpatient services for those suffering from debilitating 
illnesses or disabilities. These programs provide a range of services, 
from daily activities such as bathing, full medical services, and 
physical therapy. The focus of the program is on improving a disabled 
veterans' quality of life, which is why we support expanding this great 
option of care for our veterans.
    American Legion Resolution No. 377: Support for Veteran Quality of 
Life supports any initiative that urges Congress and the Department of 
Veterans Affairs (VA) to enact legislation and programs within the VA 
that will enhance, promote, restore or preserve benefits for veterans 
and their dependents, including, but not limited to, the following: 
timely access to quality VA health care; timely decisions on claims and 
receipt of earned benefits, and final resting places in national 
shrines and with lasting tributes that commemorates their service.\3\
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    \3\ American Legion Resolution No. 377 (2016): Support for Veteran 
Quality of Life
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    The American Legion supports passage of S. 324.
 s. 543: performance accountability and contractor transparency act of 
                                  2017
To amend title 38, United States Code, to require the Secretary of 
        Veterans Affairs to include in each contract into which the 
        Secretary enters for necessary services authorities and 
        mechanism for appropriate oversight, and for other purposes.
    The provisions of this bill falls outside the scope of established 
resolutions of The American Legion. As a large, grassroots 
organization, The American Legion takes positions on legislation based 
on resolutions passed by the membership in meetings of the National 
Executive Committee. With no resolutions addressing the provisions of 
the legislation, The American Legion is researching the material and 
working with our membership to determine the course of action which 
best serves veterans.
    The American Legion has no current position on S. 543.
s. 591: military and veteran caregiver services improvement act of 2017
    To expand eligibility for the program of comprehensive assistance 
for family caregivers of the Department of Veterans Affairs, to expand 
benefits available to participants under such program, to enhance 
special compensation for members of the uniformed services who require 
assistance in everyday life, and for other purposes.
    The struggle to care for veterans wounded in defense of this Nation 
takes a terrible toll on families. In recognition of this, Congress 
passed, and President Barack Obama signed into law, the Caregivers and 
Veterans Omnibus Health Services Act of 2010. The unprecedented package 
of caregiver benefits authorized by this landmark legislation includes 
training to help to ensure patient safety, cash stipends to partially 
compensate for caregiver time and effort, caregiver health coverage if 
they have none, and guaranteed periods of respite to protect against 
burnout.
    The comprehensive package, however, is not available to most family 
members who are primary caregivers to severely ill and injured 
veterans. Congress opened the program only to caregivers of veterans 
severely ``injured,'' either physically or mentally, in the line of 
duty on or after Sept. 11, 2001. It is not open to families of severely 
disabled veterans injured before 9/11, nor is it open to post-9/11 
veterans who have severe service-connected illnesses, rather than 
injuries.
    The American Legion has long advocated for expanding eligibility 
and ending the obvious inequity it created. Simply put, a veteran is a 
veteran, and all veterans should receive the same level of benefits for 
equal service. As affirmed in American Legion Resolution No. 259: 
Extend Caregiver Benefits to Include Veterans Before September 11, 
2001, The American Legion supports legislation to remove the date 
September 11, 2001, from Public Law 111-163 and revise the law to 
include all veterans who otherwise meet the eligibility 
requirements.\4\
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    \4\ American Legion Resolution No. 259 (2016): Extend Caregiver 
Benefits to Include Veterans Before September 11, 2001
---------------------------------------------------------------------------
    The American Legion is aware of the obstacles to an expansion of 
the program, though. Perhaps the biggest is protracted frustration over 
how the current caregiver program operates. Thus, we applaud the 
Department of Veterans Affairs (VA) recent decision to conduct an 
internal review of the program. That decision is an acknowledgment that 
the VA cares about the success of this program, and is committed to the 
difficult task of improvement.
    The American Legion is also committed to the success of this 
program. We have long supported our veteran caregivers by providing 
accredited representation, advice and education. We created a new 
Caregiver Coordinator position in our Washington Office. We 
participated in the numerous roundtables conducted during the present 
review of the program. We are honored to be working with a broad 
coalition to identify and bolster support for caregivers, both now and 
long-term.
    We have joined on to a coalition letter organized by the Elizabeth 
Dole Foundation to Secretary Shulkin dated May 15, 2017. This letter 
offers some perspective on the issues that have clouded this program 
since its inception, and its recommendations are informed by the 
experiences and stories of caregivers themselves. The letter is 
incorporated by reference, and we think action based on the letter will 
go a long way to righting the program and preparing it for 
expansion.\5\
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    \5\ VA Caregiver Program Coalition Letter
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    The American Legion is also rolling out a comprehensive caregiver 
program to our Departments and recently passed Resolution No. 24: 
Caregiver Program. The program promises to ``address the needs of 
military and veteran caregivers by assisting with, but not limited to 
employment/vocational referral, Federal and state education assistance, 
Post-9/11 caregiver benefit support, veteran directed care, partner 
support with the Elizabeth Dole Foundation and various caregiver 
support organizations, assistance with death gratuity, and terminal 
illness.'' \6\
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    \6\ American Legion Resolution No. 24: Caregiver Program
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    The American Legion, together with The American Legion Auxiliary, 
is building a comprehensive program that is sustainable and replicable 
and will be included in the department and post activities and programs 
through our network of more than 15,000 posts and detachments across 
the United States and abroad. The American Legion's Caregiver 
Coordinator will work to ensure that veterans and their caregivers are 
well informed and educated about the benefits and resources available 
to them. The burden of ensuring support for these caregivers does not--
and should not--fall to the VA alone.
    The American Legion is optimistic that providing expanded support 
services and stipends to caregivers of veterans to all eras is not only 
possible but also feasible. We are, therefore, proud to offer our 
support for S. 591, the Military and Veteran Caregiver Services 
Improvement Act of 2017.
    The American Legion supports passage of S. 591.
    s. 609: chiropractic care available to all veterans act of 2017
To amend the Department of Veterans Affairs Health Care Programs 
        Enhancement Act of 2001 and title 38, United States Code, to 
        require the provision of chiropractic care and services to 
        veterans at all Department of Veterans Affairs medical centers 
        and to expand access to such care and services, and for other 
        purposes.
    It is not uncommon for veterans who suffer from musculoskeletal and 
connective system diseases to go untreated at VA medical centers 
because of a lack of available chiropractic care and services. At 
present, less than one-third of VA medical centers offer chiropractic 
care. S. 609 will require a program under which the Secretary of 
Veterans Affairs will provide chiropractic care and services through 
the VA at (1) no fewer than 75 medical centers by December 31, 2018, 
and (2) all medical centers by December 31, 2020.
    According to VA, the most frequent medical diagnosis among Iraq and 
Afghanistan veterans are musculoskeletal and connective system 
diseases.\7\ Since 2002, there have been over 195,000 Post-9/11 
veterans that have pursued care for these conditions. The American 
Legion, thus, views easy access to chiropractic care as a priority 
necessity for veterans.
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    \7\ Sally G. Haskell, M.D., Post-Deployment Pain: Musculoskeletal 
Conditions in Male and Female OEF/OIF Veterans (August 2012)
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    American Legion Resolution No. 377: Support for Veteran Quality of 
Life, supports any legislation and programs within the VA that will 
enhance, promote, restore or preserve benefits for veterans and their 
dependents, including, but not limited to, the following: timely access 
to quality VA health care, timely decisions on claims and receipt of 
earned benefits, and final resting places in national shrines and with 
lasting tributes that commemorate their service.\8\
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    \8\ American Legion Resolution No. 377 (2016): Support for Veteran 
Quality of Life
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    The American Legion supports passage of S. 609.
                      s. 681: deborah sampson act
To amend title 38, United States Code, to improve the benefits and 
        services provided by the Department of Veterans Affairs to 
        women veterans, and for other purposes.
    Women veterans have consistently been overlooked by the Department 
of Veterans Affairs for decades. The American Legion feels that it is 
time that we thank this growing military demographic with, at a 
minimum, the healthcare they deserve. Women veterans are the fastest 
growing demographic serving in the military, so we can expect the 
number of women veterans using Department of Veterans Affairs (VA) 
healthcare to increase dramatically. The United States has more than 2 
million women veterans who live in every Congressional district in the 
Nation, and the number of women veterans seeking VA health care has 
doubled since 2000.
    Although the VA has made improvements in women's healthcare, many 
challenges remain. The Deborah Sampson Act would help rectify many 
issues women veterans face by improving the ability of the VA to 
provide women's care, improve services, and change its culture to 
embrace this growing population. It does so by, inter alia:

     Enhancing services that empower women veterans to support 
each other,
     Establishing a partnership between the Department of 
Veterans Affairs and at least one community entity to provide legal 
services to women veterans,
     Make adjustments to care that the VA can provide newborns,
     Addressing significant barriers women veterans face when 
seeking care,
     Require the VA to collect and analyze data for every 
program that serves veterans, including the Transition Assistance 
Program, by gender and minority status, and require that they publish 
data as long as it does not undermine the anonymity of a veteran.

    The American Legion recommends the following change to the bill. A 
separate track to address specific needs of women veterans attending 
the Transition Assistance Program. It has been noted that women 
veterans are more likely to seek assistance by talking with other women 
on gender-sensitive assistance. For example, the VA Trauma Service 
Program (TSP) allows women veterans to choose to partake in a TSP 
information session with a group or with an individual woman 
coordinator. More women veterans opt to conduct the information session 
with an individual woman coordinator.
    Additionally, The American Legion requests the Department of 
Defense transfer contact information of all transitioning women 
veterans to the VA and the Department of Labor (DOL). This would 
provide an opportunity for the VA, DOL, and Veterans Service 
Organizations to follow-up with women veterans after separation to 
offer additional support, programs, and services.
    American Legion Resolution No. 147: Women Veterans, calls on The 
American Legion to work with Congress and the VA to ensure that the 
needs of current and future women veteran populations are met. It calls 
on the VA to provide full comprehensive health services for women 
veterans department-wide.\9\
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    \9\ American Legion Resolution No. 147 (2016): Women Veterans
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    American Legion Resolution No. 364: Department of Veterans Affairs 
to Develop Outreach and Peer to Peer Program for Rehabilitation 
supports the President of the United States and the U.S. Congress 
passing legislation to call on the Secretary of Veterans Affairs to 
develop a national program to provide peer to peer rehabilitation 
services based on the recovery model tailored to meet the specialized 
needs of current generation combat-affected veterans and their 
families.\10\
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    \10\ American Legion Resolution No. 364 (2016): Department of 
Veterans Affairs to Develop Outreach and Peer to Peer Program for 
Rehabilitation
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    The American Legion supports passage of S. 681 with amendments as 
noted above.
       s. 764: veterans education priority enrollment act of 2017
To amend title 38, United States Code, to improve the enrollment of 
        veterans in certain courses of education, and for other 
        purposes.
    S. 764, the Veterans Education Priority Enrollment Act of 2017 
would mandate that if an educational institution administers priority 
enrollment to certain students and receives educational benefits from 
the VA, then they shall also administer priority enrollment to student 
veterans and active military students.
    Resolution No. 318: Ensuring the Quality of Servicemembers and 
Veteran Student's Education at Institutions of Higher Education urges 
Congress to find a solution that ensures colleges and universities that 
receive Federal tuition payments grant priority enrollment to those 
individuals who qualify for either the Department of Defense or 
Department of Veterans Affairs education benefits.
    However, due to inherent complexities with priority enrollment, The 
American Legion requires consultation and endorsement from the military 
education collaborative Servicemembers Opportunity Colleges and the 
National Association of Veterans' Program Administrators before 
supporting. If the present language of the Veterans Education Priority 
Enrollment Act of 2017 results in reputable institutions of higher 
learning choosing to stop processing GI Bill benefits, than it will do 
more harm than good. Additionally, implementation concerns such as 
equity questions (should a freshman student veteran get priority over 
the last semester senior who needs the course to graduate) and existing 
priority systems on public institutions need to be resolved. While we 
applaud the attention that has been shown on this, the unknown second 
and third-order affect preclude our immediate support.
    The American Legion has no current position on S. 764.
  s. 784: veterans' compensation cost-of-living adjustment act of 2017
To increase, effective as of December 1, 2017, the rates of 
        compensation for veterans with service-connected disabilities 
        and the rates of dependency and indemnity compensation for the 
        survivors of certain disabled veterans, to amend title 38, 
        United States Code, to improve the United States Court of 
        Appeals for Veterans Claims, to improve the processing of 
        claims by the Secretary of Veterans Affairs, and for other 
        purposes.
    S. 784 would provide a Cost-of-Living Allowance (COLA) effective 
December 1, 2017. Disability compensation and pension benefits awarded 
by the Department of Veterans Affairs (VA) are designed to compensate 
veterans for medical conditions incurred through service, or who earn 
below an income threshold. When the cost of living increases due to 
inflation, it is only appropriate that veterans' benefits 
correspondingly increase.
    For nearly 100 years, The American Legion has advocated on behalf 
of our Nation's veterans, to include the awarding of disability 
benefits associated with chronic medical conditions that manifest 
related to service of this Nation. Annually, veterans and their family 
members are subjects in the debate regarding the annual COLA for these 
disability benefits. For these veterans and their family members, COLA 
is not simply an acronym or a minor adjustment in benefits; instead, it 
is a tangible benefit that meets the needs of the increasing costs of 
living in a nation that they bravely defended.
    As affirmed in The American Legion's Resolution No. 187: Department 
of Veterans Affairs Disability Compensation, passed at the 2016 
National Convention, The American Legion supports legislation ``to 
provide a periodic cost-of-living adjustment increase and to increase 
the monthly rates of disability compensation.'' \11\
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    \11\ American Legion Resolution No. 187 (2016): Department of 
Veterans Affairs Disability Compensation
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    The American Legion supports S. 784.
           s. 804: women veterans access to quality care act
To improve the provision of health care for women veterans by the 
        Department of Veterans Affairs, and for other purposes.
    Women veterans are the fastest growing demographic currently 
serving in the military. They deserve a robust and comprehensive VA 
health care system to care for them when they transition from active 
duty to civilian life. Over the years, VA has made great strides in 
making healthcare services available for women veterans, such as 
ensuring more women veterans see providers who meet their gender-
specific health care needs. However, there is still much work to be 
done to meet the overall healthcare needs of women veterans. Even 
though the military has seen a significant increase in the number of 
women joining the military, the number of women veterans enrolling in 
the VA health care system remains relatively low when compared to their 
male counterparts.
    Despite improvements VA has taken to broaden their healthcare 
programs and services for women veterans, The American Legion has found 
there are still numerous challenges, and barriers women veterans face 
with enrolling in the VA including:

     Women veterans often do not self-identify as veterans,
     Women veterans are often not recognized by VA staff as 
veterans,
     Among women veterans, there can be a lack of awareness, 
knowledge, and understanding of their VA benefits,
     There is an incorrect, but prevalent stigma, that the VA 
healthcare system is an ``all-male'' healthcare system, and
     The VA does not provide all of the gender-specific health 
care needs of their enrolled women veterans.

    As a result, The American Legion believes in ensuring women 
veterans receive the highest quality VA health care, and that the care 
is tailored to meet their gender-specific health care needs.
    This legislation directs VA to establish standards ensuring all VA 
facilities meet gender-specific healthcare needs, integrate those 
standards into VA's prioritization methodology when determining funding 
needs, and issue reports on those standards, especially where 
facilities may be failing to meet standards. S. 804 would make VA's 
compliance with women's healthcare needs transparent through public 
dissemination of information on VA websites. Finally, S. 804 would 
ensure greater representation within the VA's women's healthcare 
provider positions including obstetricians and gynecologists. These 
measures will help address concerns of women veterans and improve the 
comprehensive nature of healthcare available to women throughout the 
VA.
    American Legion Resolution No. 147: Women Veterans, supports, inter 
alia:

     That the VA provides full comprehensive health services 
for women veterans department-wide, including, but not limited to, 
increasing treatment areas and diagnostic capabilities for female 
veteran health issues, improved coordination of maternity care, and 
increase the availability of female therapists/female group therapy to 
better enable treatment of Post-Traumatic Stress Disorder from combat 
and MST in women veterans;
     That the VA furnish gender-specific prosthetic appliances, 
orthotics, and services while eliminating the male-only approach to the 
treatment of all injuries and illnesses.\12\
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    \12\ American Legion Resolution No. 147 (2016): Women Veterans

    The American Legion supports S. 804.
 s. 899: department of veterans affairs veteran transition improvement 
                                  act
To amend title 38, United States Code, to ensure that the requirements 
        that new Federal employees who are veterans with service-
        connected disabilities are provided leave for purposes of 
        undergoing medical treatment for such disabilities apply to 
        certain employees of the Veterans Health Administration, and 
        for other purposes.
    Wounded Warrior Federal Leave Act (P.L. 114-75) was signed into law 
after unanimous passage by Congress. The Act allowed up to 104 hours of 
paid sick leave available to new Federal employees hired by ``Title 5'' 
Federal agencies with service-connected veteran disabilities rated at 
30 percent or more to attend medical treatment related to these 
conditions.
    Some employers are not required by law to allow veterans with 
service-connected disabilities to be absent from the workplace to 
receive the necessary medical treatment for their disabilities. In its 
current state, the Wounded Warrior Federal Leave Act does not protect 
veterans working for the Department of Veterans Affairs (VA). Senator 
Hirono's bill extends this protection to VA employees, who are ``Title 
38 employees'' and don't have the same level of protection as ``Title 
5'' Federal employees.
    If enacted, this bill would amend Title 38, United States Code, to 
prohibit discrimination and acts of reprisal against persons who 
receive treatment for illnesses, injuries, and disabilities incurred in 
or aggravated by service in the Armed Forces. In addition, it would 
promote the well-being of the veteran and create an atmosphere for 
efficiency and productivity within the agency. The American Legion 
believes it is in the best interest of the veteran, and the VA, that 
this bill pass.
    American Legion Resolution No. 307: Prohibit Discrimination and 
Acts of Reprisal by Employers Against Veterans that Seek Treatment for 
their Service-Connected Disabilities, supports any legislation that 
prohibits the discrimination and acts of reprisals by employers against 
veterans that seek treatment for their service-connected 
disabilities.\13\
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    \13\ American Legion Resolution No. 307 (2016): Prohibit 
Discrimination and Acts of Reprisal by Employers Against Veterans that 
Seek Treatment for their Service-Connected Disabilities
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    The American Legion supports this S. 899.
  s. 1024: veterans appeals improvement and modernization act of 2017
To amend title 38, United States Code, to reform the rights and 
        processes related to appeals of decisions regarding claims for 
        benefits under the laws administered by the Secretary of 
        Veterans Affairs, and for other purposes.
    The American Legion currently holds power of attorney on more than 
three-quarters of a million claimants. We spend millions of dollars 
each year defending veterans through the claims and appeals process, 
and our success rate at the Board of Veterans Appeals (BVA) continues 
to hover around 80 percent.
    When VA invited stakeholders to the table to discuss appeals 
modernization, The American Legion knew that appeals modernization 
could not start with looking at the appellate process; the conversation 
needed to begin at the point of the initial adjudication; so the first 
things the group looked at was the VBA decision notice. As a negotiated 
component of this framework, VBA has promised to improve their decision 
notice which will better inform veterans and their advocates. More 
importantly, a better decision letter will not only help veterans 
better prepare if they need to appeal, but it will help prevent appeals 
from being introduced because the veterans were not properly informed 
about the basis for denial. After VA's commitment to improving the 
initial decision letter, stakeholders helped sort through barriers that 
slowed appeals processing and highlighted another of The American 
Legion's primary concerns--centralized training.
    VA further argued that if there were a process within the appeals 
system that allowed judges to review disputed decisions that were 
adjudicated at the regional offices, based only on the same information 
that the regional office had at the time the claim was originally 
decided, then BVA would be able to provide a ``feedback loop'' they 
could use to help train and educate VBA's regional offices. 
Additionally, this would help identify regional offices where the 
decisions uniformly fail to address specific legal issues and improve 
initial decisions.
    It was with these two foundational underpinnings that the big six 
VSOs, in addition to state and county service officers, veteran 
advocate attorneys, and other interested groups worked with senior VA 
officials from VBA and BVA to design the framework of the legislation 
being discussed again here today.
    The guiding principle leading all of our discussions was ensuring 
that we preserved all of the claimant's due process rights while 
ensuring that they did not lose any claims effective date time, which 
we were not only able to do successfully, but we were able to increase 
protections for veterans through this new process.
    As you are aware, the design of the proposed appeals process allows 
for multiple options for claimants, as well as options for additional 
claim development, the option to have the decision reviewed by another 
adjudicator (difference of opinion) and the chance to take your case 
straight to the court to have a law judge review the decision and make 
a ruling on your claim.
    The proposed bill provides veterans additional options while 
maintaining the effective dates of original claims. Veterans can elect 
to have an original decision reviewed at the ROs through a Difference 
of Opinion Review (DOOR) which is similar to the current functions of 
the Decision Review Officers (DROs). A DOOR provides an opportunity for 
a claimant to discuss concerns regarding the original adjudication of a 
particular issue, or the entire claim, prior to appealing to the BVA. 
Additionally, the administrative actions remove the need for a Notice 
of Disagreement (NOD), a process that took 412.8 days, according to a 
report released to The American Legion following the end of last fiscal 
year. The April 24, 2017, VA Monday Morning Workload Report indicates 
the delay has increased over two weeks, to 429.4 days VA Monday Morning 
Workload Report, April 24, 2017.
    Beyond improvements in administrative functions, the proposed bill 
enables claimants to select a process other than the standard multi-
year long backlog, if they want to have an appeal addressed more 
expediently if they believe they have already provided all relevant and 
supporting evidence. Similar to the Fully Developed Claims program, 
veterans will be able to elect to have their appeals reviewed more 
expeditiously by attesting that all information is included within the 
claim, VA's records, or submitted with VA Form 9 indicating the intent 
to have their claims expeditiously forwarded to BVA for review.
    Veterans indicating that they may need additional evidence or time 
could elect to have their claim reviewed in BVA's current format of 
allowing additional evidence entered. For veterans requiring additional 
evidence, such as lay statements from friends and families or a private 
medical examination rebutting VA's medical examinations, this is a 
viable alternative to allow the time and opportunity to prove a 
veteran's case and secure the benefits they have earned.
    Recognizing that an increased burden is placed upon veterans, VA 
will ensure veterans maintain their effective dates, even if BVA denies 
the claim. If a veteran's appeal is denied by BVA, the veteran can 
submit new and minimally relevant evidence to reopen the claim at the 
RO while holding the original effective date that may have been 
established long before the second filing for benefits.
    Similar to FDC, The American Legion will work tirelessly to ensure 
this program is successful and appreciates the Committee's support by 
including stakeholders in the certification process as this program is 
officially launched. We recognize the increased burden it can place on 
veterans; we also recognize that our approximately 3,000 accredited 
representatives have the tools to ensure success for the veterans and 
claimants we represent. Throughout the year we will continue to work 
with our representatives, our members, and most importantly our 
veterans to understand the changes in law, and how they will be able to 
succeed with these new changes.
    The American Legion recognizes that this is a huge undertaking and 
that as with any contract, the agreement is only as good as the people 
who sign it. We agree that there is a lot that is not going to be 
included in the statutory language and that this initiative places a 
lot of trust and responsibility on VA to do the right thing. The 
American Legion believes that the Secretary needs this flexibility to 
set this program up effectively and that VA will continue to work with 
stakeholders and Congress as we move forward. Any deviation from that 
plan will upset overseers and stakeholders alike, and will surely 
result in veterans being cheated as we all will ending up right back 
here in this hearing room to fix it.
    To come to an agreement, stakeholders needed to trust VA to do the 
things they promised to do, and do them in good faith. There are a lot 
of nuances that aren't able to be legislated, and the VSOs are going to 
be providing constant feedback as we move forward with appeals 
modernization. We believe that the architects of this proposal have 
acted in good faith, and we support their efforts to modernize the 
appeals process for the good of veterans, for the good of the process, 
and for the good of the American taxpayer.
    As affirmed in The American Legion's Resolution No. 5: Department 
of Veterans Affairs Appeals Process, The American Legion urges the 
Department of Veterans Affairs to address all claims, to include its 
growing inventory of appeals in an expeditious and accurate manner.\14\
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    \14\ American Legion Resolution No. 05 (2016): Department of 
Veterans Affairs Appeals Process
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    The American Legion supports S. 1024: Veterans Appeals Improvement 
and Modernization Act of 2017.
     draft bill: department of veterans affairs accountability and 
                      whistleblower protection act
To amend title 38, United States Code, to improve the accountability of 
        employees of the Department of Veterans Affairs, and for other 
        purposes.
    Reacting to the firing of Phoenix VA Healthcare System Director in 
2014, then National Commander of The American Legion Mike Helm noted:

          ``This is one long-overdue step in a journey that is far from 
        over. Unfortunately, as we all soon discovered after the story 
        broke last April, this problem was not isolated to Phoenix. It 
        was widespread, and we expect to see additional consequences, 
        even criminal charges if they are warranted, for anyone who 
        knowingly misled veterans and denied them access to medical 
        services.'' \15\
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    \15\ ``Legion: VA director's overdue firing applauded'': Nov. 24, 
2014

    The American Legion believes it is important to ensure there is 
accountability at all levels within VA and that the process is 
transparent. Where VA employees are found to have engaged in 
wrongdoing, The American Legion supports any legislation that increases 
the authority given to the Secretary of VA to remove unscrupulous 
employees.
    The American Legion supports increased accountability, and those 
employees found guilty of having committed crimes at the expense of the 
veterans entrusted to their care should never profit from those crimes. 
To receive bonuses based on manipulation and lies, to abuse relocation 
reimbursement, or to remain employed found watching pornographic 
material at work is unacceptable. We also believe in providing the 
Department of Veterans Affairs (VA) whistleblowers with a means to 
solve problems at the lowest level possible, while offering them 
protection from reprisals and genuine protection for those who reprise 
against them. This bill would establish a new system that employees 
could use to report retaliation claims, and supervisors would be 
required to report all retaliation claims to facility directors, 
eliminating the possibility for facility leaders to claim plausible 
deniability of such assertions.
    There are some apprehensions with this bill we would like to 
address. The provision that seeks to lower the threshold of evidence 
from ``preponderance of the evidence'' to ``substantial evidence'' is 
concerning. We do not want to encourage an atmosphere that reduces the 
burden of managers to collect appropriate documentation. Managers need 
to be held accountable to perform expert leadership and oversight, and 
that includes being diligent about documenting poor performance or bad 
behavior. Egregious behavior would not be affected by this provision as 
it would surpass the already established evidentiary threshold of a 
preponderance of evidence.
    The second concern we raise is with the provision that strips the 
Merit Systems Protection Board (MSPB) of the ability to mitigate 
penalties. While on its face it seems logical to accept the agency's 
decision regarding discipline or termination, The American Legion is 
reminded of the Linda Weiss decision which the presiding judge stated, 
in part:

          ``In conclusion, I find that appellant has rebutted the 
        presumption that the penalty was reasonable. If 38 U.S.C. 
        Sec. 713 did not prohibit it'; I would mitigate the penalty. 
        However, because that is not allowed, the only option is to 
        reverse the action outright. 5 CFR Sec. Sec. 1210.18(a), (d). 
        Therefore, agency's decision to remove the appellant from the 
        Federal service is reversed.'' \16\
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    \16\ Weiss v. DVA, 2016 MSPB (February 16, 2016)

    The American Legion wants to ensure that Congress provides the VA 
with tools that are functional, enforceable, and allow the agency to 
act in a manner that promotes good order, discipline, and esprit de 
corps. Poorly crafted legislative language that fails legal and 
constitutional standards only serves to ruin morale and create a system 
of indecision and lack of surety.
    The American Legion applauds this bipartisan effort to provide 
Secretary Shulkin additional tools to increase accountability and 
address poor performance within the Department of Veterans Affairs. 
Despite multiple verified cases of gross misconduct for multiple 
employees, the Secretary of the VA had little authority to hold 
employees accountable, and many veterans subsequently lost faith in the 
system. This is why The American Legion vociferously urged Congress to 
provide the Secretary much-needed authorities so that he may take 
action to improve morale, incentivize desired behavior, deter 
misconduct, and eliminate corrupt or uncaring employees.
    American Legion Resolution No. 3: Department of Veterans Affairs 
Accountability, supports any legislation that provides the Secretary of 
Veterans Affairs the authority to remove any individually from the VA 
that the Secretary determines warrants such authority or to transfer or 
demote an individual to a General Schedule position without any 
increased monetary benefit.\17\
---------------------------------------------------------------------------
    \17\ American Legion Resolution No. 3 (2016): Department of 
Veterans Affairs Accountability
---------------------------------------------------------------------------
    The American Legion supports the Draft Bill titled: Department of 
Veterans Affairs Accountability and Whistleblower Protection Act.
               draft bill: serving our rural veterans act
To authorize payment by the Department of Veterans Affairs for the 
        costs associated with service by medical residents and interns 
        at facilities operated by Indian tribes, tribal organizations, 
        and the Indian Health Service, to require the Secretary of 
        Veterans Affairs to carry out a pilot program to expand medical 
        residencies and internships at such facilities, and for other 
        purposes.
    The provisions of this bill fall outside the scope of established 
resolutions of The American Legion. As a large, grassroots 
organization, The American Legion takes positions on legislation based 
on resolutions passed by the membership in meetings of the National 
Executive Committee. With no resolutions addressing the provisions of 
the legislation, The American Legion is researching the material and 
working with our membership to determine the course of action which 
best serves veterans.
    The American Legion has no current position on this Draft Bill 
titled: Serving our Rural Veterans Act
 draft bill: veteran partners' efforts to enhance reintegration (peer) 
                                  act
A bill to require the Secretary of Veterans Affairs to carry out a 
        program to establish peer specialists inpatient aligned care 
        teams at medical centers of the Department of Veterans Affairs, 
        and for other purposes.
    A peer support specialist is a person with significant life 
experience who works to assist individuals with chemical dependency, 
mental disorder, or domestic abuse and other life effecting issues. Due 
to a PEER's life experiences, such persons have expertise that 
profession training cannot replicate. Tasks performed by peer support 
specialists may include:

     Assisting their peers in articulating their goals for 
recovery,
     Learning and practicing new life skills,
     Helping monitor their progress,
     Assisting them in their treatment,
     Modeling effective coping techniques and self-help 
strategies based on the specialist's own recovery experience, and
     Supporting in obtaining effective services in and outside 
the VA.

    This draft bill would expand VA's current use of peer specialists 
being utilized in primary care settings including mental health 
clinics. The PEER Act would require the Department of Veterans Affairs 
(VA) to establish a pilot program of peer specialists to work as 
members of VA's patient-aligned care teams (PACT), for the purpose of 
promoting the integration of mental health services in a VA primary 
care setting. This bill would authorize the establishment of this pilot 
program in 25 VA sites, to include the VA's five Polytrauma centers 
across the country. The bill would also require a series of reports, 
including a final report to recommend whether the program should be 
expanded beyond the pilot program sites.
    As affirmed in The American Legion's Resolution No. 364: Department 
of Veterans Affairs to Develop Outreach and Peer to Peer Program for 
Rehabilitation, The American Legion urges the President of the United 
States and the U.S. Congress to call on the Secretary of Veterans 
Affairs to develop a national program to provide peer to peer 
rehabilitation services based on the recovery model tailored to meet 
the specialized needs of current generation combat-affected veterans 
and their families.\18\
---------------------------------------------------------------------------
    \18\ American Legion Resolution No. 364 (2016): Department of 
Veterans Affairs to Develop Outreach and Peer to Peer Programs for 
Rehabilitation
---------------------------------------------------------------------------
    The American Legion supports the Draft Bill titled: Veteran 
Partners' Efforts to Enhance Reintegration (PEER) Act
                               conclusion
    The American Legion thanks this Committee for the opportunity to 
elucidate the position of the over 2.2 million veteran members of this 
organization. For additional information regarding this testimony, 
please contact the Deputy Director of Legislative Affairs, Mr. Derek 
Fronabarger, at The American Legion's Legislative Division at (202) 
861-2700 or [email protected].

    Chairman Isakson. Thank you very much, Mr. Celli. Ms. 
Keleher?

   STATEMENT OF KAYDA KELEHER, ASSOCIATE DIRECTOR, NATIONAL 
  LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED 
                             STATES

    Ms. Keleher. Chairman Isakson, Ranking Member Tester, and 
Members of the Committee, it is my honor to represent nearly 
1.7 million members of the Veterans of Foreign Wars of the 
United States and our Auxiliary.
    In 2016, the VFW launched our In Their Words campaign, 
which prioritized the needs of women veterans. To do this, we 
knew we needed to hear directly from women veterans to get 
their feedback on what it is that they need and want. We set up 
our women's committee and conducted a survey of 51 questions, 
with nearly 2,000 female servicemembers and veterans who 
responded.
    Since the conclusion of this survey, the VFW has worked 
tirelessly to priority the need to improve gender-specific 
health care, recognition of women veterans, improved outreach 
to them, and to break down the unique barriers that they face 
for homelessness.
    This is why the VFW supports and applauds the work put into 
both the Deborah Sampson and Women Veterans Access to Quality 
Care Acts. Both of these pieces of legislation would greatly 
improve the quality of and access to care and benefits for 
women who use VA.
    Peer-to-peer support is something the VFW has long been 
supportive of and found immense value in. The Deborah Sampson 
Act would greatly expand these programs, providing women 
veterans with more peer and gender-based one-on-one assistance. 
Peer-to-peer support has been proven greatly effective in 
assisting veterans within VA time and time again, and it 
provides low-cost access to basic needs to veterans.
    The VFW does suggest Congress amend the Deborah Sampson Act 
in Title IV, eliminating barriers to access, and recommends 
removing the option of having one part-time provider. One part-
time provider has too much room to leave patients with limited 
access. It is also a common complaint we hear from our 
membership. The VFW believes all clinics must be properly 
employed, which includes maintaining at least one full-time 
primary care provider in every women's clinic.
    The VFW also supports the Creating a Reliable Environment 
for Veterans' Dependents Act, which we believe would be 
invaluable in assisting women veterans who may be single 
mothers to overcome homelessness. No veteran deserves to be 
sleeping on the streets at night, and their children should not 
be forced to sleep alongside them under bridges, without a 
home. This is why the VFW suggests amending the language saying 
that the recipient ``may'' receive per diem payments to the 
recipient ``shall'' receive per diem payments.
    The VFW also strongly supports the Military and Veteran 
Caregiver Services Improvement Act of 2017. This legislation 
would greatly enhance services provided to the caregivers of 
those severely disabled in the line of duty, regardless of 
which era they served in. These improvements are desperately 
needed and the VFW has long supported them. Severely wounded 
and ill veterans of all conflicts have made incredible 
sacrifices, and all their family members who care for them are 
equally deserving of our recognition and support. The 
caregivers from pre-9/11 conflicts, whether they be World War 
II, Vietnam, Korea, or Desert Storm, have suffered long enough. 
It is time Congress properly recognizes their sacrifice and 
supports them with everything that they have deserved.
    The VFW supports the Veteran Appeals Improvement and 
Modernization Act of 2017. The VA claims and appeals process 
has long been in need of reform and reconstruction. The current 
process has become a bureaucratic system impossible for the 
average veteran to understand, and with the time for 
decisionmaking sometimes taking up to 6 years. This legislation 
would provide veterans with three options of how their appeals 
could be reviewed, drastically shortening wait times. That is 
why Congress must pass this legislation to simplify, expedite, 
and modify veterans' appeals.
    The VFW supports the Department of Veteran Affairs 
Accountability and Whistleblower Protection Act of 2017. This 
legislation would ensure VA has the authority to remove their 
bad actors from payroll in a timely manner, while still 
allowing these employees their due process rights. Instances 
where VAs trying to fire an employee but it takes 2 years, 
while the employee is still maintaining their salary, is 
unsatisfactory. It is also unsatisfactory when employees are 
afraid to speak up about wrongdoings for fear of retaliation.
    This legislation would provide a security net of protection 
allowing these employees to voice possible wrongdoings, without 
fearing any form of backlash from their superiors. Those 
employees who are afraid to speak up and uphold--those 
employees who are unafraid to speak up and uphold principles of 
VA should be cherished and not made afraid of what they need to 
do to do the right thing.
    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee, this concludes my testimony. Thank you again for the 
opportunity to represent the Nation's largest and oldest major 
combat veterans organization. I look forward to your questions.
    [The prepared statement of Ms. Keleher follows:]
  Prepared Statement of Kayda Keleher, Associate Director Of National 
   Legislative Service, Veterans of Foreign Wars of the United States
    Chairman Isakson, Ranking Member Tester 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 pending legislation.
   s. 23, biological implant tracking and veteran safety act of 2017
    The VFW supports this legislation that would direct the Department 
of Veterans (VA) to implement a standard identification protocol for 
use in the tracking and procurement of biological implants. By 
implementing one standard for device identification and tracking 
medical devices, such as prosthetics, which is developed and approved 
by the Food and Drug Administration (FDA), VA will be better able to 
inventory, track expiration dates and flag devices nearing their 
expiration. This would also assist in ensuring women veterans are able 
to obtain gender-specific prosthetics in a timely manner.
    In the past, the VA Office of Inspector General (VAOIG) has 
consistently reported on shortcomings within VA in regard to their 
management of prosthetics. The most recent audit--Report No. 11-02254-
102, published March 8, 2012--highlighted challenges the VFW still 
believes must be addressed. VAOIG suggested that VA better manage their 
prosthetic inventories to avoid surplus spending and lack of patient 
access to prosthetics due to supply shortages. This excessive spending 
and prosthetic supply shortages are due to the lack of VA systems 
integrating with the prosthetic inventory system, which causes dilemmas 
between the two inventory systems.
  s. 112, creating a reliable environment for veterans' dependents act
    The VFW supports adding per diem reimbursement for those homeless 
veterans with dependents to the list of services available for veterans 
in need. The struggle for homeless veterans is enough of a burden as 
is, and providing some financial support for veterans with dependents 
while they seek help is something that the VFW sees as an important 
change. While the VFW supports this bill, we ask that some improvements 
be made. The language of the bill states that the recipient of the 
grant ``may'' receive per diem payments under this subsection. We would 
like to see this language changed to ``shall.'' This would ensure 
veterans in the greatest need will receive financial assistance.
 s. 324, state veterans home adult day health care improvement act of 
                                  2017
    The VFW supports this legislation, which would expand adult day 
health care benefits for veterans who are eligible for long-term 
inpatient care. Currently, veterans who are at least 70 percent 
service-connected are eligible to receive cost-free nursing home or 
domiciliary care at any of the more than 120 state veterans' homes 
throughout the country. While nursing home care is a necessity for 
veterans who can no longer live in the comfort of their home, the VFW 
strongly believes veterans should remain in their homes as long as 
possible before turning to inpatient and long-term care options. This 
legislation would ensure veterans have the opportunity to receive adult 
day care so they can remain in their homes as long as possible.
 s. 543, performance accountability and contractor transparency act of 
                                  2017
    The VFW supports the intent of this bill, but we do not believe 
this legislation is needed. There are a few sections of this bill that 
seem redundant with laws or practices already in place. We understand 
the effort to place VA officials, and not contractors, as the first in 
line for accountability for underperforming projects, but that seems to 
be an administrative issue. As for the penalties and website posting, 
we believe those already exist, and adding legislation to those would 
further obscure an already complicated system.
s. 591, military and veteran caregiver services improvement act of 2017
    The VFW strongly supports this legislation, which would greatly 
enhance the services provided to caregivers of servicemembers and 
veterans who were severely disabled in the line of duty. Family 
caregivers choose to put their lives and careers on hold, often 
accepting great emotional and financial burdens, and the VFW believes 
that our Nation owes them the support they need and deserve. This bill 
would accomplish this in a number of ways, including extending benefits 
to caregivers of veterans with service-connected illnesses, offsetting 
the costs of their child care, providing them with financial advice and 
legal counseling, expanding their respite care options, and requiring 
VA to report on the progress of the program.
    This legislation would extend caregiver eligibility to severely 
injured and ill veterans of all eras. This is a desperately needed 
change that the VFW has long supported. Severely wounded and ill 
veterans of all conflicts have made incredible sacrifices, and all 
family members who care for them are equally deserving of our 
recognition and support. The fact that caregivers of previous era 
veterans are currently excluded from the full complement of program 
benefits implies that their service and sacrifices are not as 
significant, and we believe this is wrong. We support the five year 
phase-in plan, which would incrementally grant program eligibility 
based on the severity of the veteran's conditions, as we believe this 
would give VA the opportunity to responsibly expand and improve the 
program without compromising services to current beneficiaries.
    The VFW hears from our member often about eligibility for VA's 
Program of Comprehensive Assistance for Family Caregivers and their 
message is clear: they strongly support expanding full caregiver 
benefits to veterans of all eras. As an intergenerational Veterans 
Service Organization that traces its roots to the Spanish American War, 
this is not surprising. Our members are combat veterans from World War 
II, the wars in Korea and Vietnam, the Gulf War, and various other 
short conflicts, in addition to current era veterans. They rightly see 
no justifiable reason to exclude otherwise deserving veterans from 
program eligibility simply based on the era in which they served.
    This legislation would require an annual evaluation report to 
determine how many caregivers are receiving benefits, assess training 
that VA provides caregiver coordinators, and review outreach 
activities. The VFW believes Congress should also track the number of 
times and reasons why VA revokes the benefit from veterans. The VFW has 
heard from too many veterans that they were kicked out of the program 
despite still needing the assistance of a caregiver for daily living 
activities.
    The VFW commends VA for recently extending the temporary suspension 
of revocations until it is able to properly address the inconsistent 
implementation of the program throughout the VA health care system. VA 
must make several improvements to the existing program including the 
appeals process when veterans disagree with the eligibility 
determination of their care teams, ensuring eligibility determinations 
are consistent throughout the system, and enhancing the off-ramp 
process to ensure veterans and their caregivers are given enough time 
and support to properly adjust before graduating from the program.
    The VFW strongly believes VA must review previous revocations for 
accuracy and improve the program, specifically instances of veterans 
whose eligibility was revoked despite being in the highest tier. 
However, the VFW does not believe that it is necessary to delay 
expansion of the program. The caregivers of pre-9/11 veterans have 
suffered long enough. It is time Congress properly recognizes their 
sacrifice and provides them the support they deserve.
    s. 609, chiropractic care available to all veterans act of 2017
    The VFW supports this legislation which would provide chiropractic 
care and services to veterans receiving health care at VA. According to 
VA, musculoskeletal and connective tissue diseases are commonly 
diagnosed medical issues for Post-9/11 veterans, with nearly 200,000 of 
these veterans pursuing care at VA for these conditions since 2002. Our 
nation is also facing an opioid epidemic, with many Americans and 
veterans struggling with addiction to painkillers. This is why the VFW 
believes it is absolutely crucial that VA be able to provide access to 
chiropractic care to veterans in need. Studies have long proven 
chiropractic adjustments can reduce chronic pain, joint swelling and 
inflammation. Some studies even show chiropractic care can help reduce 
headaches and migraines. The VFW urges Congress to pass this 
legislation which would help improve the quality of care veterans 
receive at VA, as well as provide another avenue to combat opioid 
addiction for patients with chronic pain.
                      s. 681, deborah sampson act
    The VFW supports this legislation to improve VA benefits and 
services for women veterans. As the population of women veterans 
continues to be the fastest growing within the veteran community, the 
VFW has adamantly worked alongside Congress and VA to improve access, 
care and benefits to women veterans. In 2016, the VFW launched our In 
Their Words campaign which focused on the needs of women veterans. To 
evaluate whether VA is meeting the needs and expectations of women 
veterans, we conducted an extensive survey of nearly 2,000 women 
veterans. From that data, the VFW broke down the areas in most need of 
attention into four categories: health care, recognition, outreach and 
homelessness. The Deborah Sampson Act addresses all four of these 
critical areas, which is why we urge Congress to pass this legislation.
Title I--Peer-to-Peer Assistance
    Peer-to-peer support has proven time and again to be invaluable to 
veterans and VA. This is why the VFW advocates so strongly for the 
constant expansion of peer-to-peer support programs. This legislation 
would greatly expand these programs for women veterans, providing them 
more peer and gender-based one-on-one assistance from others to whom 
they can relate and connect. This is extremely crucial in instances 
where a female may suffer from mental health conditions, but especially 
in instances where a female veteran is on the verge of homelessness. In 
our survey, 72 women reported being homeless or at risk of becoming 
homeless. Of those women, 38 percent reported having children. These 
women face unique barriers to overcoming homelessness, and frequently 
commented on the lack of people who actually understand those barriers. 
By providing peer-to-peer support for women with others who have gone 
through the same hardships, VA would provide a level of understanding 
and trust they desperately need.
Title II--Legal and Supportive Services
    Since President Obama and then Secretary Shinseki launched the 
campaign to end veteran homelessness, the VFW has been pleased to see 
the homeless veteran population nearly cut in half, as well as more 
attention brought to this important issue. That is not to say there are 
not more challenges ahead on the road to eradicating veteran 
homelessness. The VFW has long advocated for improvements to voucher 
programs for women veterans, as well as access to gender-specific, safe 
housing for those with families. This legislation would improve access 
to legal and supportive services, which is crucial in instances such as 
preventing homelessness, keeping families together and settling issues 
that may complicate veterans' abilities to find meaningful employment.
Title III--Newborn Care
    Typically, in private sector health care, a new mother has a month 
to enroll her newborn child into an insurance program. Currently, VA 
only covers newborn care for seven days. This week of coverage is not 
enough to provide coverage if anything goes wrong--even in the not 
uncommon instance of false positive testing--nor is it enough to ease 
the new mother of unnecessary stress. Congress must expand coverage for 
newborn children.
Title IV--Eliminating Barriers to Access
    Barriers to health care have not been shunned from the spotlight in 
regard to access at VA. This is all the more reason why VA must 
continue being more proactive than reactive when it comes to access to 
gender-specific care for women veterans. As the women veteran 
population continues to grow, VA must ensure it provides care and 
services tailored to their unique health care needs. Women deserve 
access to the best treatment and care this Nation has to offer. That is 
why it is crucial VA outfit existing facilities with basic necessities, 
such as curtains for privacy, in women's clinics. These clinics also 
need to maintain at least one primary care provider with expertise in 
women's health who is able to train others. However, the VFW recommends 
removing the option of one part-time provider. A part-time provider 
would limit access to care for woman veterans and decrease the 
provider's ability to maintain gender-specific expertise.
Title V--Data Collection and Reporting
    VA has an extensive history of not gathering data which would allow 
the statistical analysis necessary to better veterans' lives. This is 
why the VFW strongly urges Congress to pass this legislation which 
would collect and analyze data by sex and minority status.
           s. 764, veterans education priority enrollment act
    The VFW supports adding legislation that allows veterans using GI 
Bill benefits to enroll in classes before the standard enrollment date. 
Veterans have finite time to use their education benefits, and being 
locked out of required classes due to capacity issues is a real problem 
for student veterans. Many veterans take longer than the 36 months of 
GI Bill eligibility to complete their education due to a combination of 
factors such as the inability to enroll in the necessary classes 
because of capacity issues; limited offering of classes throughout the 
academic year; and restrictions on registration due to academic 
progress or transferal from another school. Therefore, the creation and 
implementation of a priority enrollment system--similar to other 
special college populations such as college athletes--as well as 
revised class enrollment and transfer policies, are necessary to ensure 
that veterans are able to complete their educational goals within the 
36 months of benefits allotted by the GI Bill.
    Priority enrollment for student veterans was an issue championed by 
a recent VFW-Student Veterans of America fellow Robert Davis. In his 
proposal, Veterans Priority Enrollment, Davis highlighted how this no-
cost solution will enable veterans to complete their degrees in a more 
expedient fashion, so as not to waste any unnecessary education 
benefits while doing so. Veterans using the GI Bill have shown to be a 
great return on investment for this country, and we should do 
everything we can to enable their progress toward completion of their 
degrees.
         s. 784, veterans cost-of-living adjustment act of 2017
    The VFW supports this legislation which would increase VA 
compensation for veterans and survivors, and adjust other benefits by 
providing a cost-of-living adjustment (COLA). The VFW is pleased to 
support any bill increasing COLA for our veterans, however, we would 
prefer to make COLA increases permanent and automatic.
    Disabled veterans, along with their surviving spouses and children, 
depend on their disability compensation, plus dependency and indemnity 
compensation, to bridge the gap of lost earnings caused by the 
veteran's disability. Each year veterans wait anxiously to find out if 
they will receive a COLA. There is no automatic trigger that increases 
these forms of compensation for veterans and their dependents. 
Annually, veterans wait for a separate act of Congress to provide the 
same adjustment that is automatically granted to Social Security 
beneficiaries.
       s. 804, women veterans access to quality care act of 2017
    The VFW supports this legislation, which would improve health care 
for women veterans using VA. As the fastest growing demographic within 
the veteran population, women veterans have long deserved access to 
high quality, equitable gender-specific health care. This legislation 
would prioritize integrated standards to determine funding to ensure VA 
facilities meet standard requirements of gender-specific care in areas 
such as gynecology.
    When the VFW conducted its survey of nearly 2,000 female veterans 
in 2016, one of the most overwhelming open ended responses on how to 
improve women's health care in VA was by increasing the number of 
gynecologists. While VA offers gynecology, women veterans prefer seeing 
a gynecologist rather than their primary care provider for this gender-
specific necessity.
    This legislation would also greatly improve the quality of care 
available to women veterans by increasing the number of providers who 
specialize in gynecology, as well as thoroughly examining other areas 
of gender-specific need, such as women veteran wait times, health 
outcomes based on gender, and availability of gender-specific 
equipment.
 s. 899, department of veterans affairs veteran transition improvement 
                                  act
    The VFW supports the Veteran Transition Improvement Act, which 
would authorize service-connected disabled veterans to access care for 
their service-connected injury during their first year of employment 
with VA. Disabled veterans seeking Federal employment are rightly given 
special preference during the hiring process. However, newly hired VA 
employees begin with a paid sick leave balance of zero. This means that 
within their first year of employment, newly hired disabled veterans 
must choose between taking unpaid leave to seek medical care for their 
service-connected conditions, or forego receiving care altogether. At 
this time, disabled veterans who work for VA are the only Federal 
employees forced to make this choice, as recently enacted laws have 
permitted newly hired disabled veterans in other agencies the 
opportunity to receive care for injuries sustained during their 
military service. This legislation would increase the chances for a 
successful transition into the civilian workforce and eliminate a 
barrier to health care access.
  s. 1024, veterans appeals improvement and modernization act of 2017
    The VFW supports this legislation to reform and modernize the VA 
claims and appeals process to better serve the needs of the veterans' 
community. Over the years, the VA claims and appeals process has 
morphed into a bureaucratic leviathan the average veteran cannot 
possibly understand. Moreover, for veterans who disagree with their 
assigned rating decision, they currently have no way to determine 
whether choosing to appeal is a reasonable course of action without 
seeking assistance from an accredited representative or legal counsel. 
Then, should veterans choose to appeal VA's decision, exercising their 
due process rights can take up to five years. To the VFW, this does not 
seem like a veteran-centric, non-adversarial process.
    The goal of this legislation is to once again build a veteran-
centric process that is easy to navigate and protects a veteran's 
rights every step of the way. Last year, the VFW was one of more than a 
dozen veteran community stakeholders that convened to discuss the way 
forward in modernizing the VA claims and appeals processes. At the 
time, the acknowledgement was that the system was cumbersome and no 
longer satisfied the needs of veterans who rightfully expect timely and 
accurate rating decisions on the benefits they earned. The resultant 
product of these discussions is the framework included in this draft 
legislation, and the VFW is proud to support it.
    Through this legislation, Congress will modify the options for 
veterans to pursue accurate rating decisions prior to filing a formal 
appeal, while simultaneously preserving their earliest possible 
effective date. This legislation also directs VA to improve its award 
notifications for veterans, outlining seven specific pieces of 
information each decision notice to a veteran shall include. Improved 
notification letters have been a top priority of the VFW and our 
partner organizations for years, and we are happy to see the Committee 
pursue this aggressively. To the VFW, inadequate notification letters 
have been a fundamental failure in the VA claims process for decades. 
In their current format, veterans have no reasonable way to understand 
how VA arrived at their benefit decision, meaning veterans have no way 
to reasonably conclude whether or not the decision is accurate and 
whether or not they need to pursue another avenue of recourse.
    As accredited representatives, one of our top responsibilities is 
explaining rating decisions to veterans and deciphering which evidence 
was used to render a decision and how VA evaluated that evidence. 
Improved decision notices will put some of this power back into the 
veteran's hands, ensuring they are well informed of their rating and 
how VA arrived at its conclusion. This sets the veteran up for success 
in navigating the process and has the potential to cut down on appeals 
where the veteran simply may have misunderstood their rating decision.
    Coupled with improved notifications, this legislation codifies 
three specific paths through which veterans can arrive at a fair and 
understandable rating decision, while preserving the earliest possible 
effective date. Two of these paths--higher level review and 
supplemental claims readjudication--offer recourse for the veteran 
without filing a formal appeal, offering the veteran and VA the 
opportunity to rectify discrepancies before the veteran formalizes an 
appeal.
    Currently, when a veteran receives a rating decision, they must 
choose whether or not to formally file a notice of disagreement, 
kicking off a potential years-long process to arrive at a new decision, 
sometimes when only small matters of evidence or interpretation of the 
law need to be addressed. By redesigning appeal options, the process 
remains non-adversarial as long as possible, and also encourages VA to 
produce quality rating decisions at the local level, instead of punting 
more complicated cases for the Board of Veterans Appeals (BVA) to 
review.
    Critics have called these two new paths at the regional office an 
``erosion'' of veterans' due process rights. This is an inaccurate 
assessment that fails to acknowledge that the VA claims process is 
supposed to be veteran friendly and easily navigable by any veteran who 
seeks to access his or her earned benefits. Moreover, the new framework 
actually expands veterans' due process rights by offering additional 
recourse at the local level, preserving routes to the BVA and the 
courts, and preserving a veteran's right to seek legal counsel after an 
initial rating decision.
    Though the VFW always encourages veterans to seek professional 
assistance from an accredited representative whenever possible, a 
perfect system would be one where veterans do not need professional 
assistance, and certainly do not need to retain a lawyer, simply to 
claim an earned benefit. The VFW believes this proposed framework, if 
properly implemented, moves veterans closer to such a system.
    The most critical new protection for veterans is the lane in which 
veterans can continually submit new and relevant evidence to VA within 
one year of a rating decision and receive a new rating decision on the 
evidence of record, preserving their original effective date. Coupled 
with improved notification letters, this option could be a game changer 
for veterans, resulting in more favorable decisions at the local level.
    First, lowering the evidentiary threshold to receive a new rating 
decision to only new and relevant is an improvement for veterans. The 
old standard was new and material. While the VFW would prefer that VA 
only be required to consider new evidence, we support this change which 
would ease the evidentiary burden for veteran claimants, potentially 
resulting in more favorable decisions.
    Key to the success of this lane is communication among VA, the 
veteran, and the veteran's advocate where applicable. If a veteran 
receives a clear and understandable rating decision, but notices that 
certain evidence was not contained in the record, they now have an 
opportunity to formally submit this and receive a new, timely rating 
decision, instead of pursuing years of a formal, contentious appeal. 
Moreover, accredited veterans' advocates now have a new tool to help 
resolve claims at the earliest possible time, ensuring that their 
clients receive every benefit they have earned.
    To the VFW, this is the best possible outcome. According to VA's 
own data, more veterans are seeking our assistance every year to access 
their earned benefits. Last year, the VFW took on four new claimants 
for every claimant we lost. While we like to tout that this is a 
testament to the professionalism of our staff, we also know that this 
kind of growth means that we need to help VA get it right the first 
time. Prolonging a veteran's claim is bad all around. It puts 
unnecessary stress on the veteran and it makes VA look like an 
irresponsible steward of benefits. At a time when more veterans need 
access to benefits, the VFW supports offering more non-adversarial 
recourse at the local level to arrive at quality rating decisions. This 
is what our veteran clients expect, and this is why we support this new 
framework.
    The VFW also supports the maintenance of two separate dockets at 
BVA to adjudicate new appeals, though we have persistent concerns about 
the timeliness of decisions in each docket and the potential 
disincentive for veterans to pursue an appeal with a hearing. That 
being said, the VFW supports docket flexibility so that BVA can 
properly manage its workload and provide veterans with timely 
decisions. However, in testimony earlier this year, VFW Commander-in-
Chief Brian Duffy called for the simultaneous maintenance of five 
separate dockets at BVA to best reflect the legacy workload as well as 
the new system workload, including one docket for appeals with no new 
evidence and no hearing; one for appeals with new evidence but no 
hearing; and one for appeals with both new evidence and a hearing.
    When the Committee first started discussing the concept of appeals 
reform for the 115th Congress, the VFW and several of our partner 
Veterans Service Organizations saw this as an opportunity to once again 
discuss potential conflicts that arose in the initial discussions in 
2016. One significant conflict was the ability of veterans with appeals 
languishing in the legacy system to be able to opt into the new 
framework. In this legislation, we are pleased to see that the 
Committee addressed these concerns by articulating formal ``off ramps'' 
for legacy appeals to opt into the new system at critical decision 
points.
    To the VFW, this is a benefit to affected veterans and to VA. 
First, veterans whose appeals have been mired in the old appeals system 
will have several opportunities to take advantage of new processes, 
such as submitting new and relevant evidence when their claims are 
remanded back to the Regional Office. This will allow veterans an 
opportunity to avoid another lengthy appeal process and allow VA to 
address the issues at the Regional Office in a timely manner. For VA, 
the VFW believes this will be a critical tool in helping to adjudicate 
the backlog of legacy appeals, resulting in more timely, favorable 
decisions for veterans.
    The VFW understands that VA had some concerns about these off ramps 
and the strain on resources at the local level. The VFW does not share 
these concerns as VA has the responsibility to adjudicate its workload 
regardless of where the claim happens to be in the process. Moreover, 
this reinforces the VFW's calls on Congress to properly resource the 
Veterans Benefits Administration (VBA) and BVA to manage their 
workload. Without proper resources, any claims and appeals framework 
will fall prey to dangerous backlogs, resulting in unacceptable benefit 
delays for veterans.
    Since the first discussions on appeals reform with VA, the VFW has 
been very clear that any changes to the system must be coupled with 
aggressive initiatives to adjudicate legacy appeals in a timely manner 
through both legislative authority and proper resourcing. The VFW had 
asked for off ramps to allow veterans with legacy appeals to opt into 
the new process, and we thank the Committee for including these off 
ramps in this legislation.
    The VFW must stress the importance of properly resourcing BVA and 
VBA to adjudicate the legacy appeals backlog and the potential influx 
of supplemental claims and higher level review requests at the VA 
Regional Office. The VFW's former National Veterans Service Director, 
Jerry Manar, used to say that VA liked to play Whack-a-Mole with its 
pending workload. When initial claims were backlogged, they 
concentrated resources on initial claims. This has since set off a 
chain reaction that has resulted in a backlog of appeals and other 
claim actions at the Regional Office level. Every time there is a 
crisis, VA has the habit of reallocating its resources to address the 
latest crisis. This only leads to other crises. VA must be properly 
resourced to manage its workload if we expect this new framework to 
succeed.
    The VFW was also happy to see that the Committee is asking for 
extensive reporting from VA on legacy appeals. The VFW supports many of 
these data points, and has had similar questions about the appeals 
process over the years, particularly the disaggregated time that VA 
waits for a claimant to take action and the time a claimant waits for 
VA to take action. We believe that this report will help to better 
understand the pitfalls that led to the appeals backlog and help avoid 
them in the new framework.
    A modernized appeals system must be responsive to future needs of 
veterans. Veterans benefits date from the beginning of the United 
States, and our citizens and government have stepped up to care for 
veterans as the nature of war and society has changed. Judicial review 
of veterans' benefits decisions has been in place for almost thirty 
years, and a decision this past week by the Federal Circuit in Monk v. 
Shulkin recognized veterans have a right to aggregate their appeals 
into class actions. While this decision does not directly affect the 
modernized appeals framework, it will also help to eliminate the 
``hamster wheel'' appeals process, and will affect regulations handling 
new procedural directives from the courts. Congress must maintain close 
oversight over the timely handling of appeals for veterans who have 
been waiting the longest.
    At the same time, the modernized appeals system also needs the 
oversight of Congress to continually improve the process. We believe 
the changes proposed in the legislation being considered today would go 
a long way in forming a more veteran-centric process. But appeals do 
not exist in a vacuum, and the feedback we receive must drive 
improvements to the processes used by VA and stakeholders to obtain 
fair, accurate decisions at the earliest point possible, and improve 
the quality of life for veterans and their families.
    The VFW is encouraged by the legislation you are considering today 
and strongly supports efforts to reform the claims and appeals system 
to build a more veteran-centric appeals process. For years, we have 
been stuck in the same place, afraid to take action out of fear we will 
make the wrong decision. The problem is that if we stay put, the 
situation will never improve. That is unacceptable for the veterans who 
deserve timely access to their earned benefits. The VFW believes it is 
time to improve this process. We encourage the Committee to include the 
VFW's recommendations when marking up this legislation, and we look 
forward to continuing to work with the Committee to advance these 
critical reforms.
      s. 1094, department of veterans affairs accountability and 
                  whistleblower protection act of 2017
    The VFW believes that VA and Congress must ensure the Secretary of 
Veterans Affairs has authority to quickly hold employees accountable 
for wrongdoing which may endanger the lives of veterans. That is why we 
support this important legislation. However, we also believe it is as 
important to ensure VA can quickly fill vacancies within its workforce 
left open by removing bad actors within VA.
    This important bill includes strong accountability reform for VA 
employees who do not live up to the standards that veterans deserve. 
Three years after the patient wait time manipulation crisis at the 
Phoenix VA Health Care System put a national spotlight on employee 
accountability, the Secretary of Veterans Affairs still lacks the 
proper authority to swiftly terminate workers who do not deserve to 
work at VA. The Department of Veterans Affairs Accountability and 
Whistleblower Protection Act of 2017 would improve the Secretary of 
Veteran Affairs' authority to discipline employees who commit 
malfeasances.
    The VFW salutes Chairman Isakson, Ranking Member Tester, Senator 
Rubio and the House Committee on Veterans' Affairs leadership for 
reaching a bipartisan deal on this important bill which would better 
protect whistleblowers and hold employees accountable for their conduct 
or performance. The need for legislation follows a Federal appellate 
court decision this past week that rendered unconstitutional the 
process used to fire the former director of the Phoenix VA Health Care 
System.
    The VFW believes whistleblower protection is an essential addition 
to the accountability legislation. A Federal survey shows that less 
than 50 percent of VA employees feel that arbitrary action, personal 
favoritism and coercion for partisan political purposes are not 
tolerated. More so, only 43 percent felt senior leaders maintain high 
standards of honesty and integrity; only 37 percent are satisfied with 
policies and practices of senior leaders; and only 36 percent feel 
senior leaders generate high levels of motivation and commitment in the 
workforce. These statistics are alarming and suggest that for a culture 
of accountability to be established, change must start from the top, 
not the bottom.
    The VFW also believes VA needs improved authorities to hire high 
quality employees. In our report, Hurry Up and Wait, we highlight 
deficiencies in VA human resources practices, outlining several 
recommendations to improve the hiring process and customer service 
training. We feel that VA's hiring process moves too slowly. Northern 
Virginia Technology Council suggested that for VA to be successful, it 
should aggressively redesign its human resources processes by 
prioritizing efforts to recruit, train, and retain clerical and support 
staff. In today's economy, hiring the best people is extremely 
critical. In many cases, it is more effective to coach a current 
employee, even a poor performing one, than it is to find, interview, 
engage and train new employees.
    We fear that VA's workforce productivity could decline due to 
staffing shortages and low employee morale if VA does not reform its 
hiring processes. The VFW looks forward to working with Congress to 
expedite passage of this legislation and find workable solutions to VA 
human resources' issues to ensure VA can move quickly to fire employees 
who put veterans at risk, and at the same time move quickly to hire the 
best applicants to set VA on a path to restore trust in the system.
     draft bill, serving our rural veterans act (sullivan, tester)
    This legislation would allow for VA to make payments for the 
training of interns and residents at approved locations other than VA 
facilities and to establish a pilot program for additional training. 
The VFW supports this legislation. The use of Indian Health Service 
facilities and other approved Federal locations is a common sense 
answer for VA to use in solving their need to train medical 
professionals. Those who participate in the program would spend time at 
an approved facility as defined in the legislation. This could be an 
opportunity to help solve a known problem and allow VA to recruit 
capable and dedicated medical professionals to care for those who have 
borne the battle.
    draft bill, veteran partners' efforts to enhance reintegration 
                            act (blumenthal)
    The VFW supports this legislation, which would require VA to 
integrate peer support specialists into Primary Care Patient Align Care 
Teams (PACT). Peer support specialists provide a valuable service to 
veterans coping with mental health conditions. Such veterans often look 
for guidance from fellow veterans who have successfully completed 
treatment and have learned to cope with conditions they are 
experiencing. While current law requires each VA medical center to hire 
a minimum of two peer support specialists, it does not require VA 
medical facilities to incorporate them into the clinical settings. As a 
result, many peer support specialists are not used to their full 
potential. Many peer support specialists currently lead successful 
mental health care programs and services. The VFW supports efforts to 
expand such best practices.
    The VFW is glad to see this legislation would require each medical 
center that participates in the pilot program to consider the gender-
specific needs of women veterans when carrying out the pilot program. 
In our survey of women veterans, survey participants identified the 
lack of gender-specific services as the greatest need in VA health care 
facilities. Survey participants also indicated their desire to select a 
provider of the same gender, specifically for veterans who have mental 
health conditions that may be a result of military sexual trauma. The 
VFW supports efforts to hire women peer support specialists to ensure 
women veterans have the opportunity to seek guidance from other women 
veterans who have learned to cope with mental health conditions related 
to military sexual trauma.

    Mr. Chairman, this concludes my testimony. I am prepared to answer 
any questions you or the Committee Members may have.

    Chairman Isakson. Thank you, Ms. Keleher.
    Mr. Atizado?

   STATEMENT OF ADRIAN ATIZADO, DEPUTY NATIONAL LEGISLATIVE 
              DIRECTOR, DISABLED AMERICAN VETERANS

    Mr. Atizado. Chairman Isakson, Ranking Member Tester, 
Senator Murray, distinguished Members of the Committee, first I 
want to thank you for inviting DAV to testify on the bills 
under consideration for today's hearing. As many of you know, 
DAV is a nonprofit organization, about 1.3 million strong, all 
wartime service-disabled veterans, and we have one purpose: to 
ensure veterans lead high-quality lives with respect and 
dignity.
    Mr. Chairman, DAV operates the Nation's largest claims and 
appeals assistance program, providing free representation to 
more than 1 million veterans and their families. DAV fully 
supports S. 1024, the Veterans Appeals Improvement and 
Modernization Act of 2017, and we remain committed to reform 
the appeals and claims process.
    As my colleagues have mentioned, the new appeals framework 
proposed within this bill will protect the due process rights 
of veterans, while creating multiple options for them to 
receive their decisions in a more judicious manner.
    The critical core of the new framework would allow veterans 
to have multiple options to reconcile unfavorable claims 
decisions. It would introduce new evidence at both the Board 
and at BVA, and protect earliest effective dates without having 
to be locked into a current long and arduous formal appeals 
process at the board. Now claimants with legacy appeals would 
be able to enter the new system at various junctures, and for 
assurance that BVA and the board are prepared to make this 
major transition, the Secretary is required to submit a 
detailed transition and implementation plan, and, with 
consultation with stakeholders, certify that the new system is 
ready.
    We are also pleased to express our full support for the two 
bills before you today responding to the needs of women 
veterans, S. 681, the Deborah Sampson Act, and S. 804, the 
Women Veterans Access to Quality Care Act of 2017. Together, 
these bills would address longstanding concerns and barriers to 
care that have been discussed in our report, the 2014 report, 
``Women Veterans: A Long Journey Home,'' as well as our 
national resolution number 129, which calls for enhanced 
services for women veterans.
    To name just a few of the important provisions in both of 
these bills, we believe the peer retreats and increased use of 
evidence-based peer specialists will help ease transition, 
isolation, and assist woman veterans with post-deployment 
readjustment issues. A more robust maternity care benefit for 
woman veterans would be offered by extending days of coverage 
for newborn care from 7 to 14 days. It would also cover 
transportation of newborns, if medically necessary.
    There is a provision authorizing $20 million to address 
VA's facility and environmental deficiencies that would ensure 
women veterans' safety, confidentiality, and privacy, as well 
as dignity, as patients in the VA health care system. Requiring 
VA facilities to have either a full- or part-time women's 
health primary care provider and establish a woman veterans 
program ombudsman to help women navigate the very large system 
of the VA, and overcome any access to barriers to care.
    Mr. Chairman, DAV strongly supports S. 591, the Military 
and Veterans Caregiver Services Improvement Act of 2017. This 
measure will allow severely ill and injured veterans from all 
eras, who meet the requisite clinical eligibility criteria, to 
be permitted to participate in VA's comprehensive program for 
caregiver assistance. To ensure the program's integrity, this 
measure would phase in this expansion based on who needs the 
support the most, thus allowing VA to manage the new work load. 
The bill would also improve the comprehensive caregiver program 
by including child care and provide caregivers financial advice 
and legal counsel.
    DAV firmly believes it is simply unconscionable to deny 
comprehensive caregiver support services to caregivers of 
veterans severely injured in prior wars, and to deny same 
services to family caregivers who clearly need help today--
today, after decades of sacrifice. For each year caregivers 
programs keep a veteran at home, outside an institution, that 
can save the taxpayer anywhere from $8,300 to as much as 
$295,000. That is one veteran, 1 year.
    Not only is this bill good for taxpayers, family 
caregivers, and veterans, it is also the right thing to do.
    This concludes my statement, Mr. Chairman. I would be happy 
to answer any questions you or other Members of the Committee 
may have. Thank you.
    [The prepared statement of Mr. Atizado follows:]
 Prepared Statement of Adrian M. Atizado, Deputy National Legislative 
                  Director, Disabled American Veterans
    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee: Thank you for inviting DAV (Disabled American Veterans) to 
present our views on the bills under consideration at today's hearing. 
As you know, DAV is a non-profit veterans service organization 
comprised of nearly 1.3 million wartime service-disabled veterans. DAV 
is dedicated to a single purpose: empowering veterans to lead high-
quality lives with respect and dignity.
   s. 23, biological implant tracking and veteran safety act of 2017
    This bill would require the Department of Veterans Affairs (VA) to 
establish a biological implant inventory identification and management 
system with the same features and requirements of an existing system in 
use by the Food and Drug Administration to regulate origin, movement, 
surgical implantation, and recall (if necessary) of any such biological 
material.
    The term biological implant would be defined as any ``animal or 
human cell, tissue, or cellular or tissue-based product,'' and would 
tie that definition to the existing regulatory definition under the 
Federal Food, Drug, and Cosmetic Act.
    The bill would set a number of milestone and deadline dates for 
implementation, and would require VA to submit a series of reports to 
document its progress in implementation of this system. Procurement of 
biological implants would be restricted to vendors who meet certain 
conditions laid out in the bill, and would sanction any VA procurement 
employee involved in the procurement of biological implants who acted 
with intent to avoid, or with reckless disregard of the requirements of 
the bill.
    A January 2015 report by the Government Accountability Office 
discussed weaknesses in procedures and compliance of those procedures 
on the purchase and tracking of surgical implants at VA facilities. 
Since the report was issued, we understand VA's ability to identify 
veterans who received an implant that is being recalled by the 
manufacturer or the Food and Drug Administration has been sufficiently 
strengthened, but that the compliance and requirements for purchasing 
surgical implants remains a concern.
    VA medical centers (VAMC) or the Veterans Health Administration's 
(VHA) regional network contracting offices (NCO) can purchase, from the 
open market, a specific surgical implant requested by a clinician with 
appropriate clinical justification, rather than purchasing a similar 
item through a VA-negotiated competitive contract.
    However, not recording the serial number or lot number for a 
surgical implant makes it difficult to systematically determine which 
veteran received an implant subject to a subsequent manufacturer or 
Food and Drug Administration recall. VHA policy stipulates that all 
open-market purchases of non-biological implants require a waiver 
approved by the VAMC Chief of Staff when a comparable item would have 
been available through a VA-negotiated national committed-use contract.
    DAV has received no resolution from our membership that deals with 
the specific topic of surgical implants. However, DAV's Resolution No. 
244 calls for VA to provide a comprehensive health care service for all 
enrolled veterans. Better control of the origins, movement, surgical 
implantation and recall, if necessary, of implantable biological 
material would be in keeping with the intent of our resolution. 
Therefore, DAV supports the intent of this bill.
    As a technical matter, we recommend the bill language be amended to 
add a new section ``Sec. 7330C,'' including subsequent references to 
this new section rather than the currently referenced ``Sec. 7330B,'' 
which was has already been added by Public Law 114-315, title VI, 
Sec. 612(a) on December 16, 2016.
  s. 112, to amend title 38, united states code to authorize per diem 
 payments under comprehensive service program for homeless veterans to 
            furnish care to dependents of homeless veterans
    Many community housing and supportive service programs available 
for homeless veterans do not have appropriate and safe accommodations 
to serve single-parent families. According to the National Coalition 
for Homeless Veterans, many organizations with Grant Per-Diem (GPD) 
programs do not have sufficient resources to provide housing for the 
children of veterans, or have major restrictions on the services they 
can provide, including age limits and the number of children per 
veteran they can accept. If enacted, this bill would authorize per diem 
payments under comprehensive service programs for homeless veterans to 
provide services and housing to dependents of homeless veterans funded 
by the VA GPD program.
    According to the United States Housing and Urban Development Annual 
Homeless Assessment Report (AHAR) in 2016, about 9 percent (39,471) 
adults are homeless veterans and 3 percent (1,131) of these veterans 
are homeless and part of a family. Several factors related to military 
service can contribute to an increased risk of being homeless, such as 
having a mental health diagnosis and combat or wartime service. For 
women veterans these factors are increased. Over 300,000 women 
servicemembers served in Iraq or Afghanistan--some with multiple tours 
that exposed them to combat and other hazardous situations during 
deployment. Research finds that women veterans are more likely to have 
experienced sexual trauma than women in the general population, and are 
more likely than male veterans to be single parents.
    According to the Department of Defense (DOD), more than 30,000, of 
the women who served in the wars of Iraq and Afghanistan, were single 
parents and sole providers of dependent children. In its 2014 
Sourcebook, VA reported about 46 percent of its women patients who 
served in Operations Enduring and Iraqi Freedom and Operation New Dawn 
had a mental health or substance use disorder diagnosis. Overall, it is 
estimated that women veterans are between two and four times as likely 
to be homeless as their non-veteran counterparts (according to a 
Congressional Research Service report dated November 6, 2015).
    DAV is pleased to support S. 112. This measure is consistent with 
DAV Resolution No. 139, which calls for support of sustained and 
sufficient funding to improve services for homeless veterans, including 
homeless veterans with children.
 s. 324, state veterans home adult day health care improvement act of 
                                  2017
    If enacted, this bill would authorize the Secretary to enter into 
new agreements with state veterans homes who provide medical 
supervision model adult day health care (ADHC) for veterans who are 
eligible for, but do not receive, skilled nursing home care under 
section 1745(a) of title 38, United States Code. Eligible veterans are 
those who require such care due to a service-connected disability, or 
who have a VA disability rating of 70 percent or greater and are in 
need of such care. Under this new authority, the payment to a state 
home for medical supervision model ADHC would be at the rate of 65 
percent of the amount payable to the state home if the veteran were an 
inpatient for skilled nursing care, and payment by VA would be 
considered payment in full to the state home.
    Viewed as a more cost-effective option than institutional services, 
adult day services today provided in elderly and adult day centers 
include day care, day health, and respite for family caregivers, which 
allows patients requiring long-term services and support to remain in 
their homes near family and friends, and delays institutionalization in 
nursing homes.
    Adult day services have been divided into three models of care: 
social, medical, or combined. Social models tend to focus on 
socialization and prevention services, while medical models include 
skilled assessment, treatment, and rehabilitation goals, and combined 
models cover all areas. The distinction among these models has become 
increasingly unclear as these models have evolved into a dynamic, 
comprehensive model of care. Additionally, access to these centers is a 
challenge and transportation costs of patients must be considered.
    The state veterans home ADHC medical model program is designed not 
just to promote socialization, stimulation, and maximize independence 
while enhancing quality of life, but also to ensure veterans have 
access to comprehensive medical, nursing, and personal care services. 
In addition, veterans have access to a full array of clinical and 
rehabilitative services during their day visits, equivalent to what is 
offered to full time nursing home residents. Currently, VA's per diem 
rate for state home ADHC is financially inadequate for most states to 
operate a medical supervision model program, of which there are only 
three in the Nation at present. This legislation, which is based on the 
same concept as the existing ``full cost of care'' skilled nursing care 
program for severely disabled veterans, would measurably support the 
creation of more such programs, and thereby provide more veterans, and 
their families, with options to avoid full-time institutionalization.
    As this Committee is aware, there are many factors that impact the 
sustainability of adult day centers, including state regulatory 
requirements, staffing requirements and wages within a service area. 
DAV is pleased to support S. 324 based on DAV Resolution No. 142. In 
calling for enhancing VA's comprehensive program of long-term services 
and supports for service-connected disabled veterans irrespective of 
their disability ratings, this resolution also recognizes the need for 
VA to optimize its relationship with State Veterans Homes to ensure 
veterans in need of institutional and alternative forms of long-term 
services and supports may avail themselves of state home facilities to 
consider all options for their provision.
    In addition, DAV understands that VA is close to finally releasing 
long overdue regulations that may create separate per diem rates for 
social and medical supervision model ADHC programs. Should such 
regulations be implemented, Congress should consider expanding this 
legislation to offer a ``full cost of care'' per diem rate for medical, 
social and combined models of Adult Day Services programs for severely 
disabled veterans.
  s. 543, the performance accountability and contractor transparency 
                              act of 2017
    This measure would require entities entering into service contracts 
with VA to include performance metrics on cost, schedule and 
fulfillment of contract requirements. It further requires that the 
Secretary to ensure that contracts set forth plans and milestones for 
delivering specified services. For the largest contracts it requires 
use of VA IT systems to ensure that contractors are fulfilling their 
obligations and maintaining at least a threshold level of quality in 
services rendered. DAV has no resolution on this legislation, but does 
not object to its intent.
s. 591, the military and veteran caregivers services improvement act of 
                                  2017
    DAV strongly supports S. 591, the Military and Veteran Caregivers 
Services Improvement Act of 2017. This measure would allow severely ill 
and injured veteran from all eras who meet the requisite clinical 
eligibility criteria to be permitted to participate in VA's Program of 
Comprehensive Assistance for Family Caregivers. To ensure the program's 
integrity, the measure would phasing in veterans based on need, 
allowing VA to manage the new workload, while keeping service quality 
high. It would add a greater emphasis on mental health injuries and 
Traumatic Brain Injury (TBI), and remove certain restrictions in 
current law on those eligible to become caregivers.
    The bill would also make improvements to the VA caregiver program 
by including child care programs. Many family caregivers and veterans 
with young children are unable to receive VA supports and services they 
need without such a program. VA would also be authorized to provide 
caregivers financial advice and legal counseling. Improvements would be 
made in the DOD's Special Compensation for Assistance with Activities 
of Daily Living (SCAADL) including aligning the eligibility with that 
of the VA caregivers program, as well as making caregivers of 
servicemembers receiving SCAADL eligible for a range of critical 
supportive services provided by VA.
    We support this bill based on DAV Resolution No. 131, which calls 
for legislation that to provide comprehensive caregiver support 
services, including but not limited to financial support, health and 
homemaker services, respite, education and training, and other 
necessary relief to caregivers of veterans from all eras of military 
service.
    VA's comprehensive caregiver program had been operating for over 
three years when Congress held a hearing late last year on how best to 
expand eligibility for the services and benefits of this program to 
severely ill and injured veterans of all eras. During the hearing, 
concerns were expressed about the program, and assertions were made 
that improvements should be made to the existing program prior to its 
further expansion.
    We believe it is unconscionable to deny comprehensive caregiver 
supports and services to family caregivers who clearly need help today 
after decades of having cared for our Nation's severely ill and injured 
veterans. Further, we believe that program improvements can be made 
while expanding eligibility to the Program of Comprehensive Assistance 
for Family Caregivers.
    This is why DAV is bringing to bear our over 90 years of experience 
assisting veterans, their caregiver, families and survivors as we are 
working with the veteran community, VA, and Congress to address 
concerns about the program's operation, communication, transparency and 
fair treatment to ensure caregivers of severely disabled veterans today 
and in the future will receive comprehensive supports and services they 
need.
    DAV recognizes the greatest obstacle to expanding this program is 
the cost for enacting legislation that would provide comprehensive 
caregiver support to all severely disabled veterans; nevertheless, we 
must acknowledge the cost of deploying servicemembers to war. 
Caregivers of veterans severely ill and injured before September 11, 
2001, have borne that cost for years, with little recognition or 
services for their sacrifices.
    The years of sacrifices made by family caregivers has saved 
taxpayer money by reducing reliance on and delaying admission to 
nursing home facilities. The average cost per veteran per year in VA's 
comprehensive program is $36,770 as compared to $332,756 VA pays per 
veteran per year in a VA nursing home; $88,571 in a community nursing 
home; and $45,085 in per diem payments in a State Veterans Home.
    Research has also shown well-supported caregivers of aging 
patients--such as World War II, Korea and Vietnam veterans--reduce 
overall health care costs by minimizing medical complications, lowering 
the number of hospital admissions and delaying admission into nursing 
homes. The business case to expand the comprehensive caregiver program 
has also been made in the report Hidden Heroes: America's Military 
Caregivers, by the RAND Corporation. The loving assistance provided by 
family caregivers saves taxpayers billions of dollars each year in 
health care costs, and enables severely disabled veterans to live at 
home rather than in institutions. DAV believes it is time for Congress 
to act to improve the Program of Comprehensive Assistance for Family 
Caregivers extend these supports and services to caregivers of severely 
ill and injured veterans of all eras.
  s. 609, the chiropractic care available to all veterans act of 2017
    DAV supports S. 609, the Chiropractic Care Available to All 
Veterans Act of 2017. This bill would require VA to offer chiropractic 
care at 75 VA medical centers by the end of 2018 and at every VA 
medical center by the end of 2020. DAV is pleased to support this 
measure, which is in line with DAV Resolution No. 244, calling for 
veterans' access to a ``full continuum of care, from preventive through 
hospice services, including alternative and complementary care such as 
yoga, massage, acupuncture, chiropractic and other nontraditional 
therapies.''
    Veterans with chronic pain and other conditions that do not respond 
well to medical interventions are seeking alternative treatment options 
that do not involve use of opioids or other traditional pharmaceutical 
solutions. One study estimates that up to 40 percent of veterans from 
Iraq and Afghanistan may use complementary or alternative care 
practices. In the past decade, as access to chiropractic in VA has 
grown, veterans' use of chiropractic services has grown dramatically. 
VA currently offers chiropractic services as part of its medical 
benefits package and VA indicates that about 65 VA medical centers have 
chiropractors who are integrated into primary care, rehabilitation and 
other specialized care teams.
    We caution that while some VISN and local VAMC policies restrict 
access to chiropractic services, VA must ensure such policies do not 
subvert congressional intent. This measure would ensure incremental 
expansion of chiropractic services at all VA facilities over the next 
four years, so veterans who want access to this type of care can easily 
access it in a VA health care setting.
                    s. 681, the deborah sampson act
    Women veterans are a rapidly increasing component of today's 
military, yet represent only a small part of the total force. The same 
is true within the veterans' population, which poses a significant 
challenge in delivering necessary health care, and providing supportive 
services to them. S. 681, the Deborah Sampson Act, would seek to 
address several issues women veterans face by resolving some of the 
barriers to care and services. Many women report feeling isolated as 
they transition from military service back into their roles within 
their family and the community. Combat exposure leading to Post 
Traumatic Stress Disorder (PTSD) and other mental health conditions may 
further complicate reintegration.
    DAV's report, Women Veterans: The Long Journey Home recommended the 
establishment of peer support networks in VA, to ease transition, 
isolation, and assist with readjustment problems. The enactment of a 
three-year, peer-to-peer pilot program under Section 101 would help 
many women readjust back into their communities by providing them 
assistance from a peer who can relate to their military service and 
understand the unique issues women face during deployment and 
reintegration. In addition, a peer counselor would offer pragmatic 
assistance in identifying and coordinating the many benefits and 
services administered by VA and other government agencies available to 
best meet their individual needs.
    This program would place emphasis on women who have been exposed to 
military sexual trauma, have PTSD or other mental health conditions or 
who are at risk of homelessness. Peer counseling is an evidence-based 
practice and VA is using peer specialists within many of its programs. 
In addition, Section 103 of S. 681 would expand the types of services 
and counseling available at peer retreats to include financial and 
occupational counseling, and information on conflict resolution and 
stress management to assist veterans with reintegration into family, 
employment and the community. DAV supports these provisions and the 
increased utilization of peer specialists.
    DAV's report highlights the need for legal assistance and support 
for disability law, family law, employment law and criminal law. VA 
does not provide legal services and Section 201 would establish a 
partnership between VA and at least one nonprofit organization to 
address legal issues for which homeless women veterans have identified 
a high need. DAV supports this provision as a means of providing 
comprehensive support, not only to homeless women, but to all veterans 
at risk of homelessness due to legal issues affecting stable income, 
employment and housing.
    DAV's report calls for enhanced housing support particularly for 
women with dependent children. Section 202 would earmark funding for 
grants to support homeless grant and per diem providers committed to 
providing assistance to women veterans and their families. Although DAV 
does not have a specific resolution addressing this issue we support 
the intent of this provision which would authorize VA to provide 
incentives to community grant and per diem providers to adapt and 
modify facilities and programs to support women veterans and their 
dependents. Women veterans frequently identify the need for child care 
and housing as a barrier to accessing needed care and services. Reports 
over the past few years indicate an increase in the number of homeless 
women veterans. Many of these women are single parents, and the sole 
providers for their dependent children. A recent DOD report noted that 
more than 30,000 single mothers deployed to Iraq and Afghanistan. Women 
of the most current deployments are more likely to become homeless than 
their male peers or women in the general population. Final Salute, an 
organization that provides women veterans with housing, indicated that 
over 70 percent of the women they have helped were single mothers. 
Homelessness creates a crisis, not just for the veteran, but for their 
dependent family members as well.
    While we are mindful that certain issues disproportionately affect 
women veterans, the top 10 needs identified in the 2015 CHALENG survey 
for all homeless veterans include the need for legal assistance in 
areas such as housing, child support, restoration of driver's license 
and outstanding warrants and fines. For these reasons, we recommend 
these services be made available to both male and female veterans in 
need of them.
    Section 301 of the Act would authorize VA to extend its coverage of 
newborn care from a maximum of 7 to 14 days. Section 302 would 
authorize VA to cover transportation of a newborn of a woman veteran, 
for the purpose of obtaining medically necessary care at another health 
care facility. DAV supports both of these provisions as a means of 
ensuring women veterans' access to medically necessary care. These 
additions would create a more robust VHA maternity care benefit for 
women veterans. A significant portion of the women returning from 
recent deployments are still in their childbearing years--VHA indicates 
42 percent of its women patients are between 18-44 years of age. 
Improving the VA's maternity care benefit better assures their 
continued access to comprehensive and coordinated care developed to 
meet veterans' needs. Additionally, women of recent deployments--
especially those using VA health care--are likely to be service-
connected and many of their service-connected conditions, such as PTSD, 
are known to put them at risk of adverse pregnancy outcomes. VA must 
assure these women's care continues to be carefully managed during this 
vulnerable time and eliminate the likelihood of women choosing another 
source of care if this basic need is not met satisfactorily.
    Title IV of the Deborah Sampson Act seeks to eliminate identified 
barriers to care for women veterans. DAV supports the provisions within 
this title. Between fiscal years 2003 and 2012, the number of women 
veterans using VA services grew from 200,000 to more than 362,000--an 
80 percent increase within less than a decade. By 2020, women will 
comprise 11 percent of the veteran population and VA projects continued 
growth in the portion of the veteran population comprised of women over 
the next decades. Given this significant and rapid growth, VHA has been 
challenged to adapt its programs to successfully meet women's needs--
particularly for gender-specific and sensitive care.
    Section 401 would authorize $20 million to retrofit VA facilities 
to address deficiencies in environment of care standards critical to 
ensuring the safety, privacy and dignity of women veteran patients. VA 
must modify its medical facilities to serve not only a higher volume of 
women, but also manage their specific health care needs. Safety, 
privacy, and additional needs for gender-specific capital equipment 
should all be taken into consideration in modifying facilities and in 
any new infrastructure designs or capital acquisitions.
    In a December 2016 report, the Government Accountability Office 
found that about 27 percent of VA medical centers and health care 
systems lacked an onsite gynecologist and about 18 percent of VA 
facilities providing primary care lacked a women's health primary care 
provider. Section 402 would seek to ensure that women veterans have 
access to competent women's health providers by requiring that VA have 
a full or part-time women's health primary care provider at every VA 
medical facility and specifies that this individual would be involved 
in training others to meet women's needs. While not every VA medical 
center has the critical mass to necessitate having an onsite 
gynecologist, it is imperative that all facilities without a qualified 
gynecologist, establish a plan or have contracts in place to 
immediately address the needs of women presenting for this type of 
care. In addition, Section 404 would appropriate funds to continue VA's 
Mini Residency program for primary care, and emergency care physicians 
to learn more about treating women veterans' primary care needs.
    Section 403 would establish the role of a Women Veteran Program 
Ombudsman at each VA medical center. Because women's health care needs 
cannot always be met at every VA facility, the role of the Women's 
Veteran Program Manager (WVPM) is essential to ensuring sources of 
gender-specific and veteran-specific health care is available to female 
veterans. WVPMs are responsible for establishing, coordinating, and 
integrating health care services for women veterans within VA medical 
facilities. Often, WVPMs are overburdened by their wide range of duties 
and responsibilities which makes it difficult for them to advocate on 
behalf of the women they serve. This bill provides an Ombudsman to aid 
the WVPM in addressing women's access to needed care and services. An 
ombudsman would also be able to assist with outreach and awareness 
which are often important in creating critical mass to initiate or 
maintain programs and services for women veterans. Because of the 
disparity in access for women veterans to VA benefits and services, DAV 
agrees that a Women Veteran Program Ombudsman would be beneficial. We 
urge the Committee to work with VA to ensure that this position is 
integrated within the Veterans Experience Office.
    Title V of the bill describes data collection and various required 
reports. Section 501 would require VA to submit and publish a report 
that includes information on the sex and minority status of each 
participant of each program operated by the Department. DAV supports 
this provision, but believes that the focus of such a report should be 
narrowed to incorporate those programs and services of most relevance 
to the House and Senate Veterans' Affairs Committees. DAV believes 
narrowing the scope of the report would yield higher quality data that 
was more meaningful to the Committees. In addition, the Committees 
could add programs required to report this data over time as necessary. 
Data on women veterans would allow VA to readily identify programs that 
underserve these gender and minority populations in relation to the 
proportion of the veteran population they represent. This information 
would be helpful in planning outreach or determining the ongoing need 
and demand for the program.
    Section 502 would require the Secretary to report upon the 
availability of prosthetics made for women, including at each VA 
medical center. DAV supports the intent of this measure and believes 
that VA should expand the survey of all veterans using prosthetics, 
oversampling women to ensure their adequate representation, to 
determine their satisfaction with the prosthetic device(s) they obtain 
from the VA and the process used to obtain them. Prosthetics are not 
made available through uniform channels in VA--some are manufactured in 
house and some are purchased from private manufacturers.
    There are special considerations in adapting prosthetics to meet 
women's needs such as using appropriately sized hands and feet and 
having accommodations to address weight fluctuations to ensure fit and 
comfort throughout the month and during pregnancy. Rehabilitation 
facilities throughout VA are accredited by the Commission for 
Accreditation of Rehabilitation Facilities and are required to use 
measures of patient satisfaction to assure full accreditation. Yet it 
is unclear if veterans have been asked about their satisfaction with 
prosthetic limb devices purchased or manufactured by VA, or with any 
training they might be given to properly use and care for the device. 
This information might be valuable to VA in identifying whether 
veterans prefer prosthetics made in VA or by private manufacturers, and 
whether subgroups of veterans such as women or younger veterans are 
more or less satisfied with their prosthetics than other veterans. DAV 
urges the Committee to look beyond just availability and use patient 
satisfaction with timeliness, comfort, durability, usability, and 
appearance as a finer gauge to determine the overall success of the VA 
prosthetics program.
    Section 503 would require VA to create a centralized internet 
database for all VA women's resources, including staff contact 
information, available within the location in which the veteran is 
seeking services.
    Section 504 would provide a sense of the Congress encouraging VA to 
adopt a more inclusive motto. DAV does not have a resolution on this 
provision and takes no position on this section.
    DAV is pleased to support this comprehensive legislation, as it is 
consistent with many recommendations made in our report, Women 
Veterans: The Long Journey Home, and also with DAV Resolutions Nos. 
129, calling for the support of enhanced medical services and benefits 
for women veterans, and 244, calling for support of the provision for 
comprehensive health care services to all enrolled veterans.
     s. 764, the veterans education priority enrollment act of 2017
    This measure, introduced by Senator Sherrod Rep Brown (D-OH) and 
cosponsored by Sen Thom Tillis (R-NC), would extend priority enrollment 
for college courses to veterans, servicemembers, and eligible 
dependents who are utilizing GI education benefits. Expanding priority 
enrollment allows those individuals covered to plan purposefully so 
that they can finish their degrees before their benefits expire.
    Many public colleges and universities currently extend priority 
registration to veterans when signing up for classes. This bill would 
expand this practice nationwide and would also include private schools 
with existing priority registration programs. The bill would not 
require colleges or universities to change their existing priority 
enrollment systems.
    S. 764 would amend educational programs authorized under title 38, 
United States Code. If enacted into law, the Secretary or a State 
approving agency may not approve a program of education offered by such 
institution unless the institution allows a covered individual to 
enroll in courses at the earliest possible time pursuant to each 
priority enrollment system, if the educational institutions have a 
priority enrollment system for some students.
    Covered individuals subject to S. 764 are those eligible for an 
educational assistance program provided for in chapter 30, 31, 32, 33, 
or 35 of title 38, United States Code, or chapter 1606 or 1607 of title 
10, United States Code.
    Our nation needs to support our veterans as they transition from 
military to civilian life. Congress, as well as VA and its partner 
agencies, have an obligation to ensure veterans not only enroll in 
college, but that they succeed when they get there. Education benefits 
provided to ill and injured veterans, their dependents, and survivors 
are essential for a veteran's successful transition. This legislation 
reveals a commitment to those who served by allowing covered 
individuals priority enrollment in courses. While DAV does not have a 
resolution from our membership on this particular issue, we would not 
oppose passage of this bill.
  s. 784, veterans' compensation cost-of-living adjustment act of 2017
    This bill would provide a cost-of-living adjustment (COLA) in the 
rates of disability compensation for veterans with service-connected 
disabilities and in the rates of additional compensation for 
dependents, clothing allowance, and in dependency and indemnity 
compensation for survivors of certain service-connected disabled 
veterans. DAV supports annual COLA adjustments to account for the 
effects of inflation and other rising costs that veterans must bear, 
and therefore supports S. 784. However, we remain concerned that the 
current COLA formula is not always sufficient to account for such 
increases.
    Congress customarily determines COLAs in parity with Social 
Security recipients, but it is important to note there have been years 
in which there were no COLA increases, or such as in 2017 when the COLA 
increase was quite small, only 0.3 percent. In many instances, veterans 
and their families rely on disability compensation as their sole source 
of income. In years when recipients receive no COLA increase, or when 
the increase is minuscule, it simultaneously erodes the value of their 
disability compensation benefits, and jeopardizes the ability of 
injured and ill veterans to maintain an adequate standard of living.
    DAV supports legislation that provides veterans with a COLA 
increase in accordance with DAV Resolution No. 013, and recommends 
discussion and consideration of other methodologies for determining 
annual COLA adjustments that might provide a more realistic cost-of-
living allowance for our Nation's disabled veterans, their dependents 
and survivors. Compensation rates must bring the standard of living in 
line with that which they would have enjoyed had they not suffered 
their service-connected disabilities.
       s. 804, women veterans access to quality care act of 2017
    This measure would seek to improve VA health care facilities to 
better accommodate the needs of women veterans. Section 2 of the 
measure would direct the VA Secretary to establish standards to ensure 
that all medical facilities have the structural features necessary to 
sufficiently meet the gender-specific health care needs of veterans, 
including those for privacy, safety, and dignity. The bill would also 
require the Secretary to revise VA's prioritization methodology for 
funding construction projects to include these projects. Finally, it 
would require the Secretary to report to the House and Senate Veterans' 
Affairs Committees with a list of facilities that fail to meet such 
standards and the cost for renovations or repairs necessary to meet 
them.
    DAV's report Women Veterans: The Long Journey Home points out that 
because of VA's aging infrastructure, many facilities are lacking 
inpatient and residential care for women veterans with separate, 
secured sleeping accommodations. In addition, VA medical centers must 
to provide women veterans primary care with gender-specific equipment 
like mammography units and other diagnostic or treatment equipment that 
is exclusive in the care of women at its medical facilities.
    VHA policy dictates that women veterans will have exclusive space--
space that is a separate physical location for the delivery of 
comprehensive primary care to women and is not shared by other clinics 
providing care to male veterans (VHA Directive 1330.07). VHA has made 
progress in developing such sites, but needs to assure all clinics have 
basic features such as privacy curtains and examination tables faced 
away from doors to assure the environment is conducive to patient 
treatment for all veterans.
    Section 3 would require the Secretary to establish policies for 
environment of care (EOC) inspections, including the frequency of 
inspections and the roles and responsibilities of staff in performing 
inspections and complying with standards.
    VHA's EOC requirements are set in place to protect the privacy, 
safety, and dignity of women veterans when they receive care. In 
December 2016, The Government Accounting Office (GAO) released a report 
illustrating areas of concern in compliance with VHA's EOC 
requirements. A range of oversight deficits has occurred, including in 
the EOC rounds inspections process, weakness in policies and guidance, 
and variability in methods of data collection by facility staff and 
selection of information to report to VHA Central Office. In addition, 
when noncompliance is noted, guidelines to address the issues are not 
clearly delegated, nor is there follow up by VHA to verify the 
information received from its facilities.
    VA must ensure its environment of care inspections process is 
aligned with its women's health handbook to ensure clarity, and 
uniformity throughout its facilities. VHA must also clarify roles and 
responsibility of medical staff responsible for identifying and 
addressing noncompliance of the environment of care rounds, and also 
follow up with its facilities to verify the accuracy of the information 
received, and to see that the deficient areas have been corrected.
    Section 4 would require the Secretary to evaluate the performance 
of VA medical center directors by using health outcomes for women 
veterans who use VA medical services. The VA would be required to 
publish health outcomes for women veterans on a publicly available 
website including comparisons of the data to male veterans' health 
outcomes, and explanatory information for members of the public to 
easily understand the differences.
    While it is imperative for VA leadership to ensure all personnel 
comply with laws, policy and directives, it is equally important to 
ensure the measuring criteria are clearly understood, the goal is 
obtainable, and that adequate resources are supplied. Administrators 
have control over ensuring that policies are disseminated and followed 
throughout their facilities, but they cannot necessarily control health 
outcomes which are a byproduct of patient genetics, patient behavior 
and physicians' care. To attach health outcomes as a performance 
measure of the directors, then, does not appear to be appropriate.
    A more suitable measure would be to hold the directors responsible 
for compliance and non-compliance of VHA law, directives, and policies 
within their facilities. Policy compliance can be verified through 
inspections and audits and used to evaluate administrative performance. 
Adherence to policy seems a better measure to ensure that 
administrators are adequately performing within their span of control.
    Section 5 would ensure that every VA medical center employs a full-
time obstetrician/gynecologist, and mandates a pilot program to 
increase the number of residency program positions and graduate medical 
education positions for obstetricians/gynecologists at VA medical 
facilities, in at least three Veterans Integrated Service Networks.
    Women veterans should be able to receive a basic level of treatment 
and (or) care at any facility of the Department from a knowledgeable 
women's health provider. It is noted that VHA primary care providers 
specially trained in women's health care services, such as breast 
exams--increased by 3 percent and 15 percent respectively, from fiscal 
year 2014 through fiscal year 2015. However, according to GAO, 27 
percent of VA medical centers lack an onsite gynecologist, and 18 
percent of VA's facilities providing primary care lacked a women's 
health primary care provider. All facilities may not have the patient 
volume to merit an onsite gynecologist, but any facility without the 
ability to provide this specialized care should have a seamless process 
to refer women for necessary gender-specific care without delay. DAV 
supports this section; however, we want to ensure that facilities have 
the sufficient volume of women veteran patients to support a full-time 
obstetrician/gynecologist and the residency pilot program.
    Section 6 would require the development of procedures to 
electronically share veterans' military service and separation data; 
email address; telephone number; and mailing address with State 
veterans' agencies in order to facilitate the assistance of benefits 
veterans may need. Under the bill, veterans would retain the option of 
not participating in this information exchange. Sharing of this 
information would make it easier to verify veterans' status and enable 
State agencies to respond more quickly to the needs of eligible 
veterans.
    Section 7 would instruct the Government Accountability Office to 
examine whether VA medical centers are able to meet the health care 
needs of women veterans across a number of specific dimensions of care, 
including access, specialization, outcome differences, outreach and 
other key elements. Such a report would be valuable in determining 
which facilities require assistance to ensure consistency in making 
high-quality care available to women veterans.
    The intent of this bill is consistent with DAV's 2014 Report, Women 
Veterans: The Long Journey Home; thus, the bill carries DAV's full 
support. The bill is also consistent with DAV Resolution No. 129 to 
support enhanced medical services and benefits for women veterans, 
passed by the delegates to our most recent National Convention.
    It is in line with DAV Resolution Nos. 129, calling for the support 
of enhanced medical services and benefits for women veterans, and 244, 
calling for support of the provision of comprehensive VA health care 
services to enrolled veterans.
  s. 1024, veterans appeals improvement and modernization act of 2017
    As this Committee knows, over the past year a remarkable workgroup 
comprised of the Veterans Benefits Administration (VBA), the Board of 
Veterans Appeals (Board) and a group of stakeholders who represent 
veterans, including DAV, spent significant time developing a new 
framework to modernize and streamline the appeals system. Through 
further consultation and collaboration with this Committee and others 
in Congress, we now have bipartisan appeals reform legislation, 
S. 1024, that DAV strongly supports. A similar bipartisan House bill, 
H.R. 2288, was also recently introduced, and we look forward to swiftly 
moving a final version of the appeals reform legislation through 
Congress and onto the President's desk to sign into law.
    It is important to begin with the understanding that the pending 
and growing appeals inventory was primarily an unfortunate, yet 
foreseeable consequence of a long-term lack of adequate resources for 
both VBA and the Board. Over the past five years, there was a clear 
shift of focus and resources inside VBA to bringing down the claims 
backlog, thereby neglecting the appeals processing at VA Regional 
Offices (VARO) and resulting in today's staggering appeals backlog. 
Moving forward, adequate resources will be critical to the success of 
appeals reforms, as well as continuing progress on the claims backlog.
    The new appeals framework developed by the workgroup, and embodied 
within this legislation, would protect the due process rights of 
veterans while creating multiple options for them to receive their 
decisions in a more judicious manner. The critical core of the new 
framework would allow veterans to have multiple options to reconcile 
unfavorable claims' decisions, introduce new evidence new evidence at 
both the Board and VBA, and protect their earliest effective dates 
without having to be locked into the current long and arduous formal 
appeals process at the Board.
    In general, the new framework offers three main options for 
veterans who are unsatisfied with their claims decision. First, there 
will be an option for a local, higher-level review of the original 
claim decision based on the evidence of record at the time of the claim 
decision. Second, there will be an option for readjudication and 
supplemental claims when new and relevant evidence is presented or a 
hearing requested. Third, there will be an option to pursue an appeal 
to the Board--with or without new evidence or a hearing.
    The central dynamic of this new system is that a veteran who 
receives an unfavorable decision from one of these three main options 
may then pursue one of the other two appeals options. As long as the 
veteran continuously pursues a new appeals option within one year of 
the last decision, they would be able to preserve their earliest 
effective date, if the facts so warrant. Each of these options, or 
``lanes'' as some call them, have different advantages that allow 
veterans to elect what they and their representatives believe will 
provide the quickest and most accurate decision.
    For the higher-level review option, the veteran could choose to 
have the review done at the same local VARO that made the claim 
decision, or at another VARO, which would be facilitated by VBA's 
electronic claims files and the National Work Queue's ability to 
instantly distribute work to any VARO. The veteran would not have the 
option to introduce any new evidence, nor have a hearing with the 
higher-level reviewer, although VBA has indicated it may allow 
veterans' representatives to have informal conferences with the 
reviewer in order for them to point out errors of fact or law. The 
review and decision would be ``de novo'' and a simple ``difference of 
opinion'' by the higher-level reviewer would be enough to overturn the 
decision in question. If the veteran was not satisfied with the new 
decision, they could then elect one of two options.
    In addition, for this higher-level review, VA's duty to assist 
(DTA) would not apply since it is limited to the evidence of record 
used to make the original claims decision. If a DTA error is discovered 
that occurred prior to the original decision, unless the claim can be 
granted in full, the claim would be sent back to the VARO to correct 
any errors and readjudicate the claim. If the veteran was not satisfied 
with that new decision, they would still elect the other appeal 
options. It is critical that relevant information be captured relative 
to decisions that have been overturned by a higher-level reviewer, the 
number of decisions upheld, and the number of decisions sent back to 
the VAROs to correct DTA violations. This information is needed to 
correct any claims processing errors that may be taking place within 
VAROs.
    For the readjudication/supplemental claims option, veterans would 
be able to request a hearing and present new evidence that would be 
considered in the first instance at the VARO. VA's full DTA would apply 
during readjudication, to include development of both public and 
private evidence. The readjudication would be a de novo review of all 
the evidence presented both prior to and subsequent to the claims 
decisions until the readjudication decision was issued. As with a 
higher-level review, if the veteran was not satisfied with the new 
decision, they could then elect one of two options to continue redress 
of any contested issues. These first two options take place inside 
VAROs and cover much of the work that is currently done in the current 
Decision Review Officer (DRO) process, although it would be divided 
between two different lanes: one with and one without new evidence or 
hearings.
    For the third option, a notice of disagreement (NOD) would be filed 
to initiate Board review, triggering the formal appeal process. The 
Board would operate two separate dockets, one that does not allow 
hearings and new evidence to be introduced; and a second that allows 
both new evidence and hearings. The Board would have no DTA obligation 
to develop any new evidence presented. For both of these dockets, 
appeals would be routed directly to the Board and there would no longer 
be Statements of the Case (SOCs), Supplemental Statements of the Case 
(SSOCs) or any VA Form 8s or 9s to be completed by VBA or the veteran. 
The workgroup had established a goal of having ``no hearing/no 
evidence'' appeals resolved within one year, but there was no similar 
goal discussed for the more traditional appeals docket. While 
eliminating introduction of evidence and hearings would naturally make 
the Board's review quicker, it is important that sufficient resources 
be allocated to the traditional appeal lane at the Board to ensure a 
sense of equity between both dockets.
    For appeals that request hearings before the Board, veterans could 
choose either a video conference hearing or an in-person hearing at the 
Board's Washington, DC offices; there would no longer be travel hearing 
options offered to veterans. New evidence would be allowed, but limited 
to specific timeframes: if a hearing is elected, new evidence could be 
presented at the hearing or for 90 days following the hearing; if no 
hearing is elected, new evidence could be presented with the filing of 
the NOD or for 90 days thereafter. If the veteran was not satisfied 
with the Board's decision, they could elect one of the other two VBA 
options, and if filed within one year of the Board's decision, they 
would continue to preserve their earliest effective date. The new 
framework would impose no limits on the number of times a veteran could 
choose one of these three options, and as long as they properly elected 
a new one within a year of the prior decision, they would continue to 
protect their earliest effective date.
    If the Board discovers that a DTA error was made prior to the 
original claims decision, unless the claim can be granted in full, the 
Board would remand the case back to VBA for them to correct the errors 
and readjudicate the claim. Again, if the veteran was not satisfied 
with the new claim decision, they could choose from one of the three 
appeals options available to them, and as long as they properly made 
that NOD election within one year of the decision, they would continue 
to preserve their earliest effective date.
Improving Claims Decision Notification
    While the workgroup was initially focused on ways to improve the 
Board's ability and capacity to process appeals, from the outset we 
realized that appeals reforms could not be fully successful unless we 
simultaneously looked at improving the front end of the process, 
beginning with strengthening claims' decisions. A clear and complete 
explanation of why a claim was denied is the key to veterans making 
sound choices about if and how to appeal an adverse decision. 
Therefore, a fundamental feature of the new appeals process must 
include ensuring that claims' decision notification letters are 
adequate to properly inform the veteran.
    Under the new framework, the contents of the notification letter 
must be clear, easy to understand and easy to navigate. The notice must 
convey not only VA's rationale for reaching its determination, but also 
the options available to claimants after receipt of the decision. The 
bill includes this provision to require that in addition to an 
explanation for how the veteran can have a claim decision reviewed or 
appealed, all decision notification letters must contain the following 
information to help them in determining whether, when, where and how to 
appeal an adverse decision:

    (1) Identification of the issues adjudicated;
    (2) A summary of the evidence considered by the Secretary;
    (3) A summary of applicable laws and regulations;
    (4) Identification of findings favorable to the claimant;
    (5) In the case of a denial, identification of elements not 
satisfied leading to the denial;
    (6) An explanation of how to obtain or access evidence used in 
making the decision; and
    (7) If applicable, identification of the criteria that must be 
satisfied to grant service connection or the next higher level of 
compensation.

    Overall, the new framework which is embodied in the legislation 
would provide veterans with multiple options and paths to resolve their 
disagreements more quickly, while preserving their earliest effective 
dates to receive their full entitlement to benefits. The structure 
would allow veterans quicker ``closed record'' reviews at both VBA and 
the Board, but if they believe that additional evidence is needed to 
satisfy their claim, they retain the right to introduce new evidence, 
or request a hearing at either VBA or the Board. If implemented and 
administered as envisioned by the workgroup, this new appeals system 
could be more flexible and responsive to the unique circumstances of 
each veteran's claim and appeal, leading to better outcomes for many 
veterans.
Significant Improvements to the Appeals Framework in this Legislation
    Although this bill embodies the appeals modernization framework 
agreed to by the workgroup last year, it also includes some significant 
improvements.
    First, the legislation would enhance effective date protections for 
claimants that choose to file appeals with the Court of Appeals for 
Veterans Claims (Court). Claimants could preserve their effective dates 
for continuously pursued claims, if they choose to file a supplemental 
claim within one year following a decision from these courts. This is a 
fair and equitable approach to provide claimants with the option to 
exercise their full appellate rights, without having to potentially 
jeopardize their effective date.
    Second, under this proposal, claimants with legacy appeals would be 
permitted to enter into the new system at certain junctures. In 
instances when a SOC or SSOC is issued, claimants would have the 
opportunity to opt into the new processing system. In addition, the 
legislation would allow veterans who file a NOD within one year of the 
new system becoming effective to have the option to enter into the new 
system rather than being forced to undergo processing in the legacy 
system. These changes were proposed by VBA and the Board, and DAV 
supports them. Allowing claimants to make well informed decisions on 
the type of processing that is in their best interest would not only 
help to reduce the number of legacy claims, but provide these claimants 
with options best suited for their individual circumstances.
    Third, in order to provide greater assurance that VBA and the Board 
are prepared to make this major transition to a new appeals system, the 
legislation would require the Secretary to submit a detailed transition 
and implementation plan, and then require the Secretary to certify that 
all elements are in place to efficiently process legacy claims and run 
the new modernized system. Furthermore, VSO collaboration is required 
along with this certification, a provision that serves everyone's best 
interests. DAV looks forward to continuing to work with VBA, the Board 
and Congress to ensure the transition and implementation is as smooth 
as possible.
    Last, the legislation contains detailed reporting requirements, 
along with oversight to be performed by the Government Accountability 
Office (GAO). It is essential to have continuous real-time data 
concerning elements of both the legacy system and modernized system. In 
order to measure VA's progress, these metrics will assess where 
modifications would be needed in order to improve processing within 
either system. The oversight performed by GAO is another effective way 
of ensuring these changes produce a positive outcome for claimants 
within the legacy and modernized systems.
                            recommendations
Options Following decision by the Agency of Original Jurisdiction
    Section 2(h)(1) of this bill sets forth the options available to a 
claimant once a decision has been made, which include, but are not 
limited to, filing a supplemental claim, requesting a higher level 
review, or filing a notice of disagreement.
    Within this provision, there is some uncertainty how the word 
``claim'' would be interpreted. Today a single claim can contain one 
issue, or multiple issues. The intention is to allow a claimant to 
choose any of the three options noted above separately for each 
``issue'' contained within a claim in order to avoid any unintended 
consequences that would disadvantage a claimant. For example, a veteran 
seeking an increased rating for hearing loss should be able to choose 
to file a supplemental claim for that issue, while also filing their 
notice of disagreement to the Board for the denial of service 
connection for a left knee disability. Allowing each issue to flow 
through the most appropriate ``lane'' will not only result in more 
timely decisions for the veteran, it will also make more efficient use 
of both VBA and Board resources.
    DAV recommends:

     The legislation clarifies that claimants can elect 
different appeals options for individual issues decided within a claim.
Appeals to the Board
    The manner in which evidence would be handled by the Board, 
particularly, as it pertains to their DTA requirements would 
fundamentally change under this proposal. The legislation would require 
the Board to establish at least two separate dockets, while providing 
them with the ability to create additional dockets.
    For cases before the Board wherein no hearing is elected on the 
NOD, and where there is no request to submit additional evidence, the 
evidence considered by the Board would be limited to the evidence of 
record at the time of the agency of original jurisdiction decision.
    For cases with no hearing request, but a claimant elects to have 
new evidence considered by the Board in the first instance, that 
evidence must be submitted by the appellant, or his or her 
representative, if any, with the NOD and within 90 days following 
receipt of the NOD.
    For cases wherein a hearing is requested, new evidence would be 
limited to evidence submitted by the appellant, and his or her 
representative, if any, at the Board hearing and within 90 days 
following the Board hearing. In this instance, the legislation does not 
make clear whether evidence presented with the NOD or 90 days 
thereafter would be accepted, returned or ignored. Would the Board 
really ignore evidence that arrived one day prior to a hearing?
    DAV is pleased to see the inclusion of robust reporting 
requirements in the bill, particularly as it pertains to appeals 
processing metrics for each separate docket. Furthermore, we are 
pleased to see the inclusion of a provision requiring the Board to send 
written notice to claimants when new evidence they submit is not 
considered in making the decision because the evidence was not received 
within the established timeframes. The notice would also contain 
information on a claimant's option to have the evidence considered by 
VA following the decision through another one of the lanes.
    DAV recommends:

     That claimants electing a Board hearing, with the option 
to supply evidence, should be permitted to introduce this evidence from 
the filing of the NOD until 90 days after the hearing. Evidence 
presented prior to a hearing should simply be made part of the record 
and considered in conjunction with the appellate issues before the 
Board. Since the Board no longer would have any DTA obligations, all 
new evidence would be considered at the same time after the hearing.
     The legislation would also provide the Board with the 
authority to screen cases in order determine if further development is 
required earlier in the process, rather than waiting longer to 
accomplish the same thing. To assure this authority is properly 
utilized, DAV recommends:

     The Board be required to report on all screened cases, 
delineated by:

        - The number of issues found to require additional development;
        - The types of issues that required additional development, 
        i.e., issues involving service connection, or issues involving 
        increased ratings;
        - The number of claimants that chose to opt into the new system 
        following remand;
        - The number of claimants that chose to remain in the legacy 
        system following remand;
        - The number and types issues that were granted based on 
        screening;
        - The number of cases containing multiple decisions, including 
        how many of the issues were remanded, denied, or allowed.

    The legislation mandates the creation of at least two dockets 
discussed above, and also provides authority for the Board to create 
additional dockets, subject to notifying the Senate and House Veterans' 
Affairs Committees with justification. The Board might consider 
creating a third docket in order to separate appeals that will include 
new evidence, but do not request a hearing. As it stands now, veterans 
who submit new evidence, but do not request a hearing, could be forced 
to wait months or even years behind veterans who request a hearing. A 
third docket could avoid such unnecessary delays for veterans, allow 
greater oversight and make more efficient use of Board resources.
``New and Relevant'' Evidence
    The legislation would replace the standard for reopening claims, 
changing ``new and material'' to ``new and relevant.'' In the current 
system, the ``new and material'' standard has not effectively 
functioned as intended to focus VBA and Board resources on adjudicating 
the substance of claims and appeals.
    In order to monitor whether the ``new and relevant'' standard will 
be more effective in this regard, while continuing to protect veterans' 
rights, DAV recommends:

     VBA and the Board should regularly report on the number 
and outcome of ``new and relevant'' decisions, including--
        - The number of supplemental claims denied because no ``new and 
        relevant'' evidence had been received;
        - The number of higher level reviews filed with respect the 
        issue of no ``new and relevant'' evidence, and the disposition 
        of these higher level reviews;
        - The number of appeals filed with respect to the issue of no 
        ``new and relevant'' evidence, which Board docket or options 
        were used, and the outcome of the Board's determination, i.e., 
        decisions upheld, decisions overturned, cases remanded for DTA 
        violations.
Stakeholder Transition and Implementation Advisory Committee
    Since March 2016, DAV, Congress, VA, the Board and other 
stakeholders have worked very closely to develop and refine the appeals 
modernization proposal. This partnership has been integral to making 
sure a modernized system will benefit our Nation's injured and ill 
veterans, without compromising their due process rights and keeping 
VA's non-adversarial roll intact.
    We are appreciative of the provision contained within this bill 
requiring the Secretary to collaborate and consult with veterans' 
service organizations and other stakeholders considered appropriate by 
the Secretary, as part of the certification required to begin operating 
the new appeals system, and expect that our continued partnership with 
VA will benefit both veterans and the VA. However, the hard work of 
implementing and operating this new system will continue for many 
years, and VSOs and other stakeholders can and must continue to play an 
integral role supporting this effort.
    To ensure this partnership continues on throughout all phases of 
the implementation process, DAV recommends:

     The legislation include a provision to create a 
``Stakeholder Transition and Implementation Advisory Committee'' to 
engage with VBA and the Board during implementation, transition and 
operation of the new system. This advisory committee should be composed 
of at least the three largest VSOs in terms of the number of claimants 
they represent before VBA and the Board, as well as other major 
stakeholders who represent veterans at VBA or the Board, as determined 
by the Secretary.
Planning, Oversight and Public Reporting
    The bill includes a number of new planning, reporting and 
certification requirements that are appropriate for legislation 
embodying such a significant reform. This level of reporting is 
critical to allow Congress and other stakeholders to help identify and 
offer solutions to unintended consequences and problems that may arise.
    To strengthen this oversight, DAV recommends:

     The legislation requires that all VA plans, metrics and 
reports provided to Congress also be made immediately available to the 
public.
Temporary Staffing Increases
    Finally, as mentioned above, the most critical factor in the rise 
of the current backlog of pending appeals was the lack of sufficient 
resources to adequately manage the workload. Similarly, unless VBA and 
the Board request and are provided adequate resources to meet staffing, 
infrastructure and IT requirements, no new appeals reform will be 
successful in the long run. As VBA's productivity continues to 
increase, the volume of processed claims will also continue to rise, 
which has historically been steady at a rate of 10 to 11 percent of 
claims decisions. In addition, the new claims and appeals framework 
will likely increase the number of supplemental claims filed 
significantly.
    We are encouraged that VA has indicated a need for greater 
resources for both VBA and the Board in order to make this new appeals 
system successful; however, too often in the past funding for new 
initiatives has waned over time. We would urge the Committee to ensure 
that proper funding levels are determined and appropriated as this 
legislation moves forward.
    Over the past few years, DAV and our Independent Budget partners 
have recommended that Congress consider providing VBA with the 
temporary authority and resources to hire two-year temporary employees. 
In the past, VBA used such an authority to hire several thousand 
employees for a temporary two-year term. At the end of those two years, 
many of the best that were hired on a temporary basis transitioned into 
permanent positions that became open due to attrition. VBA not only had 
additional surge resources to work on the claims backlog during the 
first two-years, but VBA also benefited by creating a pool of trained, 
qualified candidates to choose from as replacements for full-time 
employees leaving VBA.
    The bill recognizes the need to address personnel requirements 
within the VBA and the Board as they implement and administer the 
modernized appeals system, as well as address the legacy appeals. In 
order to provide a surge capacity to address both appeals and claims, 
DAV recommends:

     VBA and the Board are provided additional authority and 
resources to hire two-year temporary employees, with the goal of 
eventually converting the best of the temporary employees into 
permanent employees based on the future and continuing personnel 
requirements of VBA and the Board.

    This legislation represents a true collaboration between VA, VSOs, 
other key stakeholders and Congress in order to reform and modernize 
the appeals process. We are confident this bill, with the additional 
improvements recommended by DAV and others, could provide veterans with 
quicker favorable outcomes, while fully protecting their due process 
rights.
      s. 1094, department of veterans affairs accountability and 
                  whistleblower protection act of 2017
    This legislation seeks to enhance accountability for VA managers 
and employees, strengthen protections for whistleblowers and enhance 
VA's ability to hire certain senior health care director positions. The 
bill would codify and strengthen the Office of Accountability and 
Whistleblower Protection recently created by Executive Order, in order 
to manage and investigate whistleblower disclosures, train staff about 
protecting whistleblowers and to report upon methods that might be used 
to retaliate against them. The bill would also lower the administrative 
burden for firing, demoting or taking other adverse personnel actions 
against VA senior executives and employees who are poor performers or 
who have engaged in misconduct, including criminal activity.
    As detailed in DAV Resolution 068, we support meaningful 
accountability measures as long as they include appropriate due process 
protections for VA employees. Legislation that changes existing 
employment protections in VA must strike a balance between holding all 
civil servants fully accountable for their professional conduct and job 
performance, while enabling VA to become an employer of choice in order 
to engage the best and brightest employees to care for our ill and 
injured veterans.
    The bill would provide the Secretary with new authorities to hold 
senior managers and employees accountable by streamlining, 
standardizing and shortening certain timelines and processes used to 
implement personnel actions, including reprimands, suspensions, 
demotions or firings. We agree that it is critical that the Secretary 
be given adequate tools to quickly discipline or remove employees who 
endanger veterans' health or welfare, commit a felony, engage in 
misconduct, abuse their positions of trust or otherwise fail to 
adequately perform their jobs. However we must also remain cognizant 
that applying different accountability standards with fewer job 
protections to just one Federal agency could have unintended 
consequences on recruitment and retention, particularly in highly 
competitive fields, such as health care and information technology, 
which already have critical professional staff shortages. For some 
potential VA employees, job stability and due process in employment 
matters are attractive features of Federal employment that help 
mitigate against others including lower pay, benefits or career 
advancement possibilities.
    The legislation also makes a significant change to the evidentiary 
burden imposed on VA when exercising the new authority to reprimand, 
suspend, reassign, demote, or remove employees. Currently, personnel 
actions taken for any reason other than performance, such as for 
misconduct, require that a ``preponderance of the evidence'' standard 
be satisfied, which is generally interpreted to mean greater than 50 
percent of the evidence. This legislation, however, would lower the 
burden to ``substantial evidence,'' which the Supreme Court has 
interpreted to mean ``more than a mere scintilla'' of evidence. This 
significant reduction in evidentiary burden would certainly have the 
effect of making personnel actions against employees, up to and 
including firing, substantially easier for VA to implement, however it 
is unclear how such a change would affect the important balance between 
accountability and due process. For example, it could theoretically be 
possible under this new standard that a ``preponderance of evidence'' 
supports an employee's defense, yet they could still be removed from 
their job as long as there is ``more than a mere scintilla'' of 
evidence produced by VA--that is, there may be some relevant evidence 
as reasonable minds might accept as adequate to support VA's action to 
remove an employee even if it is possible to draw a contrary conclusion 
from the evidence. We have concerns about whether this new standard 
might have unintended consequences in terms of making VA a less 
desirable choice for potential employees, especially in comparison to 
other Federal agencies that are bound by the higher evidentiary 
standard.
    In light of these concerns, we support Sections 210 and 211, which 
would assess the effect of the enactment of the provisions on 
accountability of senior executives, supervisors, and other employees. 
We are hopeful these reports will provide valid and meaningful outcome 
data to help determine whether Title II of this bill is achieving its 
intended purpose.
    Much more important in our view than the evidentiary standard is 
the practical reality that no accountability measure can or will be 
successful unless leaders properly train and hold managers accountable 
for documenting the performance and conduct of employees, and ensure 
administrative procedures required are fully and properly carried out 
to initiate personnel actions. We note Section 209 requires VA to 
provide periodic training to supervisors on, among other things, how to 
effectively manage employees who are performing at unacceptable levels. 
We believe this section is critically important and support its 
inclusion. In our opinion, true accountability relies more on the 
actions of VA leaders and managers than on any underlying laws or 
evidentiary standards.
    DAV supports enactment of the Department of Veterans Affairs 
Accountability and Whistleblower Protection Act of 2017. We applaud the 
bipartisan effort to ensure greater accountability and strengthened 
whistleblower protections within VA and thank Senators Rubio, Tester 
and Isakson for working with DAV to ensure VA is able to enforce 
accountability standards to attract, hire and retain the brightest and 
best employees our Nation has to offer to care for ill and injured 
veterans.
           draft bill--serving our rural veterans act of 2017
    This bill directs the VA to establish an eight-year medical 
residency training program in conjunction with the Indian Health 
Service to train medical residents and interns at ``covered 
facilities,'' which are defined as facilities operated by an Indian 
tribe or the Indian Health Service (IHS).
    Additionally, it amends section 7406 of title 38, United States 
Code, by replacing the term ``department facility'' with ``covered 
facility.'' In this instance, covered facility is defined as any 
department facility or one of the four types of newly added covered 
facilities; IHS facilities, Indian tribe facilities, federally 
qualified health centers, and community health centers. VA would 
reimburse covered facilities for their participation in the program and 
require any participating medical resident to enter into an agreement 
for a period of obligated service of one year for each year served in 
the medical residency training program.
    DAV Resolution No. 055 supports fulfilling the rights and benefits 
earned by service-connected Native American and Alaska Native veterans 
and urges Congress to ensure that the five mutual goals recognized by 
the current memorandum of understanding between the VA and the IHS is 
fully implemented so that these veterans can receive the benefits and 
services they have earned and deserve. In light of our resolution, DAV 
supports the intent of this bill and urges the Committee strengthen 
certain provisions.
    The reimbursement requirements laid out in the bill goes well 
beyond salary and benefit reimbursement for the participating 
residents. Given the defined and already limited resources of the VA, 
Congress must appropriate additional funding for the VA Office of 
Academic Affiliations to ensure existing residency programs are not 
adversely impacted due to the substantial cost of developing, standing 
up, and administering, as well as recruiting for the pilot program. We 
recommend authority for this program be subject to specific 
appropriated funds.
    Furthermore, because it is uncommon for the service obligation to 
exist in other medical programs generally available to most medical 
students seeking a residency, we urge the Committee work with VA and 
other appropriate entities to address the period of obligated service 
required by the bill, which could act as a disincentive to recruiting 
top candidates in the medical field.
    DAV thanks Senator Sullivan and the Committee for its support of 
Native American and Alaska Native veterans, and ask that you confer 
with the VA Office of Academic Affiliations and the Association of 
American Medical Colleges to ensure that the intentions of the bill 
most fully meet the needs of this veteran community.
   draft bill--veteran partners' efforts to enhance reintegration or 
                          ``veteran peer act''
    Enactment of the Veteran PEER Act would require VA to establish a 
program that includes peer specialists within patient aligned care 
teams (PACT) in medical centers of the VA to promote better integration 
of mental health services into the primary care setting. VA would have 
to carry out this program in at least 10 VA medical centers within the 
first 180 days of the Act passing and in no less than 25 locations 
after two years of the enactment of the bill, including within VA's 
five polytrauma center locations.
    The bill also would require VA to consider the feasibility of 
locating peer specialists in rural areas and other locations that are 
underserved by the Department. VA would be required to ensure that the 
unique needs of women veterans are considered and that female peer 
specialists are included in the program. The measure includes 
requirements for routine reporting to include findings and conclusions 
with respect to the program and recommendations related to the 
feasibility of expanding the program.
    Veterans must have the ability to easily access to mental health 
services especially during a crisis. However, even when in crisis, many 
veterans are reluctant to reach out for help and seek the care they 
need. Since 2012, VA has hired over 1,000 Peer Specialists, and some 
mental health providers indicate that peer-to-peer interactions have 
been extremely helpful to both patients and clinicians. The Center for 
Medicare and Medicaid recognized Peer Support as an evidence-based 
practice a decade ago. Studies have found use of peer specialists is 
associated with better treatment satisfaction, more treatment 
engagement, less inpatient care utilization and more engagement in 
patients' communities. However, a recent study published in the Journal 
of Behavioral Health Services and Research found that VA is still 
struggling with identifying appropriate supervision and training for 
these individuals and has been hesitant to fully include them as part 
of the patient care team. The Veteran PEER Act would assist with 
ensuring better utilization and inclusion of these professionals and 
could help to improve efficiency of VA peer specialists and ultimately 
health outcomes for veterans.
    We are pleased the bill also includes provisions that would require 
VA to address the needs of women veterans. Findings show that when 
women return from deployment, the camaraderie and support from their 
male peers is often short-lived, resulting in isolation for many. 
Studies have shown that peer support is important to a successful 
transition, but women often report they cannot find a network of women 
who can relate to their military or wartime service. Including the 
requirement of hiring female peer specialists in this measure helps 
ensure that women veterans will have a peer they can relate to and 
someone that understands their unique needs. Their ability to relate to 
other veterans because of their shared military experiences and mental 
health recovery is a key element of the program.
    DAV is pleased to support the Veteran PEER Act, which is consistent 
with the following DAV Resolutions: No. 250, which calls for program 
improvements for VA mental health services to include increased 
staffing levels, improved outreach to veterans with a focus on reducing 
stigma when seeking post-deployment readjustment and other mental 
health services; and No. 129, which calls for enhanced medical services 
for women veterans as well as additional methods to address barriers to 
care. Finally, the bill is consistent with recommendations in DAV's 
2014 report, Women Veterans: The Long Journey Home that notes the use 
of peer specialists can help reduce stigma and increase the 
acceptability of mental health care for veterans who need it and 
improve recovery.
     draft bill--department of veterans affairs veteran transition 
                            improvement act
    The Wounded Warriors Federal Leave Act of 2015 (Public Law 114-75), 
enacted in 2015, provides a separate new leave category, to be known as 
``disabled veteran leave,'' of 104 hours to any new \1\ Federal 
employee who is a veteran with a service-connected disability rated at 
30 percent or more for purposes of undergoing medical treatment for 
such disability for which sick leave could regularly be used.
---------------------------------------------------------------------------
    \1\ Federal employee newly hired on or after November 5, 2016, with 
no previous Federal service, reappointed with at least a 90-day break 
in service, or military reservists or members of the National Guard who 
return to duty in their civilian positions after a period of military 
service.
---------------------------------------------------------------------------
    Subsequently, because disabled veterans who work for the Federal 
Aviation Administration (FAA) and Transportation Security 
Administration (TSA) did not have access to additional leave to treat 
service-related injuries, legislative relief in the form of Senator 
Hirono's bipartisan Federal Aviation Administration Veteran Transition 
Improvement Act was enacted into law in October 2016. It ensures that 
disabled veteran new hired employees at the FAA and TSA have access to 
the sick leave benefit during their first year on the job just as their 
counterparts in other agencies receive.
    Notably, there are other categories of Federal employees not 
covered by the both the Wounded Warrior Federal Leave Act and the FAA 
Veterans Transition Improvement Act including: employees of the United 
States Postal Service or the Postal Regulatory Commission, since they 
are covered by regulations issued by the Postmaster General; employees 
not covered under title 5, United States Code, section 2105 (such as 
employees of DOD non-appropriated fund instrumentalities); and 
employees not covered by a leave system (such as those with 
intermittent work schedules or leave-exempt Presidential appointees).
    It appears disabled veterans employed under title 38 have a 
separate and distinct leave system than that under title 5 and 
therefore are unable to access the benefits provided under the Wounded 
Warriors Federal Leave Act of 2015.
    We support the intent of this measure as contemplated under DAV 
Resolution 260, urging Congress to extend protection under the Family 
and Medical Leave Act (FMLA) to encompass the medical care needs of 
veterans with service-connected disabilities. We recognize in addition 
to FMLA, there are a variety of leave options and workplace 
flexibilities available to take time off from work to receive medical 
treatment for a veteran's disability, such as annual leave, sick leave, 
advanced annual leave or advanced sick leave, donated leave under the 
voluntary leave transfer program, alternative work schedules, credit 
hours under flexible work schedules, compensatory time off and telework 
and voluntary leave bank program.

    This concludes my testimony, Mr. Chairman. DAV would be pleased to 
respond for the record to any questions from you or the Committee 
Members concerning our views on these bills.

    Chairman Isakson. Thank you very much for your testimony.
    Ms. Jaslow?

   STATEMENT OF ALLISON JASLOW, EXECUTIVE DIRECTOR, IRAQ AND 
                AFGHANISTAN VETERANS OF AMERICA

    Ms. Jaslow. Thank you, Mr. Chairman, Ranking Member Tester, 
and Members of the Committee. On behalf of Iraq and Afghanistan 
Veterans of America, and our more than 425,000 members, thank 
for the opportunity to share our views on the bills under 
consideration today.
    Less than 60 days ago, I sat before the Members of this 
Committee and your counterparts in the House of 
Representatives, to outline IAVA's policy priorities for 2017, 
chief among them being greater recognition and support for 
woman veterans. I am here again today to update you on our She 
Who Borne the Battle campaign and articulate the need for the 
Deborah Sampson Act, S. 681, which would fill many gaps in care 
and offer recognition faced by woman veterans today.
    Nearly 350,000 women have deployed since our Nation was 
attacked on September 11, 2001. I am one of those women, and so 
are over 20 percent of our veteran women members. We are the 
fastest growing population in the veteran community, in fact, 
estimated at about 6 percent of the veteran population in 2001. 
By 2020, that number is expected to grow to 11 percent.
    Women's service has rapidly increased. We are officially 
allowed in the combat roles. The mightiest among us are 
graduating from elite courses like Ranger School. But in IAVA's 
most recent member survey, only 43 percent of IAVA women 
veterans feel that male servicemembers respect their service. 
Even more shocking is just 27 percent feel the public does.
    When it comes to the VA, only 30 percent of IAVA women vets 
rated the agency's support for women as good or very good, and 
less than half felt that VA's staff treated women veterans with 
respect or had a culture welcoming to women.
    I can relate. Not only have I had to prove my war service 
to more than my fair share of older gentlemen and young 
feminists alike, but I have also had the fortune of being 
mistaken as a VA nurse rather than a patient. That is why I 
stand shoulder to shoulder with our members who have made it 
clear that there is a severe gap in respect for a critical 
component of our military force, the recognition of women as 
they transition to veteran status, and in the services provided 
by the VA.
    Thanks to the leadership of Senators Tester and Boozman on 
the Deborah Sampson Act, we have an opportunity to take this 
head-on, and the concerns of the post-9/11 women veterans.
    Deborah Sampson disguised herself as a man to serve in the 
Continental Army during the Revolutionary War, served 
honorably, but sadly was not recognized for her service until 
after her death. This bill is named for her because over 240 
years later, women are squarely in the line of fire, nearly 200 
have been killed in action in Iraq and Afghanistan, yet 
adequate recognition for our sacrifices is still lacking.
    Since the bill's introduction, IAVA members have worked to 
highlight the need for the bill on Capitol Hill and gain 
cosponsors. Eighteen of you and your colleagues now back the 
Deborah Sampson Act, but several of you are dragging your feet, 
or worse, have refused to get behind this initiative that all 
of the 18 major veteran service organizations this Committee 
works with and many support.
    Just last night, the Republican Congresswoman Martha 
McSally, and Democrat Tulsi Gabbard, the only women veterans in 
the House, officially backed the Deborah Sampson Act. The 
effort in this chamber is off to a strong--in that chamber is 
off to a strong start, and as we approach Memorial Day, it is 
our hope that Members of this Committee will remember the women 
fallen by following their lead.
    So, what does the Deborah Sampson Act do? Over the last 15 
years, the VA has worked to improve services for women 
veterans, but it is not enough. The Deborah Sampson Act aims to 
fill critical gaps in VA care for women vets, in addition to 
asking the VA to demonstrate its commitment to culture change 
by updating its motto--to care for him who shall have borne the 
battle, and for his widow, and his orphan.
    I urge you to consider carefully the message that Congress 
supporting a more inclusive motto sends to the women veterans 
back in your home States, or, conversely, what your opposition 
to this provision may indicate to every woman who feels 
alienated by the very agency that is supposed to support them. 
Every veteran walking through the doors of a VA medical center 
should see the words on that door and know that he, or she, is 
welcome.
    Setting the right tone at the VA is critical to driving 
better support and lasting change for women, like peer-to-peer 
assistance--in recent IAVA research, women veterans showed 
overwhelming interest in peer support to help them navigate the 
VA--removing access barriers for women seeking care. IAVA women 
veterans not only have suffered lack of privacy at VA 
facilities but fear about the care they might receive also 
creates a barrier.
    We need to stop hearing stories like the one from a woman 
with a pregnancy who had complications and sought care from the 
VA at the emergency room, but was forced to seek care at an 
alternate ER when the team did not diagnose or treat her 
condition, accompanied by pain and bleeding, correctly. This 
should not happen in any ER, and disappoints me, as an 
American, that it happened at the VA.
    The Deborah Sampson Act also seeks to improve legal 
services and support, data tracking and reporting, and newborn 
medical care.
    Mr. Chairman and Members of the Committee, many of these 
provisions are easy fixes, but some of you have raised your 
arms complaining about costs. Caring for our veterans should be 
considered a cost of war. Period. When my soldiers and I were 
sent to combat in Iraq, the Army and U.S. taxpayers spared no 
expense, and I find it quite bold as we are simply talking 
about equity for women veterans that this is even brought up in 
conversation.
    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee, on behalf of our members, thank you again for 
inviting me here today. I look forward to your support moving 
the Deborah Sampson Act forward, and thank you for putting 
these veterans--excuse me, us veterans--and servicemembers 
first, as our comrades continue to deploy in defense of our 
Nation.
    [The prepared statement of Ms. Jaslow follows:]
       Prepared Statement of Allison Jaslow, Executive Director, 
                Iraq And Afghanistan Veterans of America
    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee: On behalf of Iraq and Afghanistan Veterans of America (IAVA) 
and our more than 425,000 members thank you for the opportunity to 
share our views on the legislation under consideration today.
    For thirteen years, IAVA has been the preferred empowerment 
organization for post-9/11 veterans. Since its beginning, IAVA has 
successfully fought and advocated for policy action to meet the needs 
of the over 2.8 million veterans who have served in our most recent 
wars.
    Less than sixty days ago, I sat before the Members of this 
Committee and your counterparts in the House of Representatives to 
outline IAVA's policy priorities for 2017--chief among them being 
greater recognition and support for women veterans. I am here again 
today to update you on our ``She Who Borne The Battle'' campaign and 
articulate the need for the Deborah Sampson Act (S. 681) which would 
fill many gaps in care and recognition faced by women veterans today.
    Nearly 350,000 women have deployed since our Nation was attacked on 
Sept. 11, 2001. I am one of those women and so are over 20 percent of 
our veteran members. We are the fastest growing population in the 
veteran community. In fact, estimated at about six percent of the 
veteran population in 2001, by 2020, it's estimated women veterans will 
represent 11 percent.
    Women's service has rapidly increased. We are officially allowed 
into combat roles, the mightiest among us are graduating from elite 
courses like Ranger School. But in IAVA's most recent member survey 
only 43 percent of IAVA women veterans feel that male servicemembers 
respect their service. Even more shocking is that just 27 percent feel 
the public does.
    When it comes to the VA, only 30 percent of IAVA women vets rated 
the agency's support for women as good or very good, and less than half 
felt that VA staff treated women veterans with respect or had a culture 
welcoming to women.
    I can relate. Not only have I had to prove my war service to more 
than my fair share of older gentlemen in Legion halls and liberal women 
alike, but I've also had the pleasure of being mistaken as a VA nurse 
rather than patient. That's why I stand shoulder to shoulder with our 
members who've made it clear that there is a severe gap in respect for 
a critical component of our military force, and in the services 
provided by the VA.
    Thanks to the leadership of Senators Tester and Boozman on the 
Deborah Sampson Act, we have an opportunity to take head on the 
concerns of post-9/11 women veterans.
    Deborah Sampson disguised herself as a man to serve in the 
Continental Army during the Revolutionary War, served honorably, but 
sadly was not recognized for her service until after her death. This 
bill is named for her, because over 240 years later women are now 
squarely in the line of fire, and nearly 200 have been killed in Iraq 
and Afghanistan, but adequate recognition for our sacrifices is still 
lacking.
    Since the bill's introduction, IAVA has worked to highlight the 
need for the bill on Capitol Hill and gain cosponsors. Eighteen of you 
and your colleagues now back the Deborah Sampson Act, and we thank you, 
but we need more support from both sides of the aisle.
    We have also worked tirelessly with the military and veterans 
community and I am proud to say that 18 of the groups this Committee 
works with the most are standing with us support of this legislation. 
They include: Veterans of Foreign Wars (VFW), American Legion, Disabled 
American Veterans (DAV), Paralyzed Veterans of America (PVA), Vietnam 
Veterans of America (VVA), American Veterans (AMVETS), Jewish War 
Veterans (JWV), Tragedy Assistance Program for Survivors (TAPS), 
Service Women's Action Network (SWAN), National Military Families 
Association (NMFA), Commissioned Officers Association of the U.S. 
Public Health Service (COA), U.S. Army Warrant Officers Association 
(USAWOA), Marine Corps Reserve Association (MCRA), Fleet Reserve 
Association (FRA), Air Force Sergeants Association (AFSA), The Retired 
Enlisted Association (TREA), Military Officers Association of America 
(MOAA), and Wounded Warrior Project (WWP).
    We also cannot do this without our members, who have been meeting 
with their Congressional offices across the United States and here in 
Washington during our recent ``Storm The Hill,'' and raising their 
voices via social media.
    Our media outreach has been aggressive. More than 5 million people 
have viewed earned media coverage of our campaign, and nearly 4 million 
have engaged with the campaign on Facebook and Twitter.
    Over the last 15 years, the VA has worked to improve services for 
women veterans, but it's not enough. The Deborah Sampson Act aims to 
fills some critical gaps in VA care for women vets in addition to 
asking the VA to demonstrate its commitment to culture changes by 
updating its motto: ``To care for him who shall have borne the battle 
and for his widow, and his orphan.'' I urge you to consider carefully 
the message that Congress supporting a more inclusive motto sends to 
the women veterans in your home states. Or conversely, what your 
opposition to this provision may indicate to women who feel alienated 
by the very agency that's supposed to support them. Every veteran 
walking through the doors of a VA medical center should see the words 
on that door and know that he or she is welcome.
    Setting the right tone at the VA is critical to driving better 
support for women, like Peer-to-Peer Assistance.
    In recent IAVA surveys and focus groups, women veterans showed 
overwhelming interest in peer support to help them navigate the VA. A 
pilot program focused on women vets transitioning from the military is 
included in the Deborah Sampson Act and makes permanent the 
availability of reintegration counseling with family members in group 
retreat settings that has proven successful already in pilot form.
    The bill also expands the capabilities of the women veteran call 
centers to include text messaging, and will be analyzed for performance 
metrics, which will help us understand its impact.
    Legal and Support Services are another key component of the bill. 
The FY 2015 Community, Homelessness Assessment, Local Education and 
Networking Groups (CHALENG) Program Report found that one of the top 
needs for women veterans is access to legal services. The Deborah 
Sampson Act establishes a VA partnership with at least one community 
entity to provide legal services to women veterans as a direct result 
of that finding.
    The bill also ensures that at least $20 million in Supportive 
Services for Veteran Families (SSVF) will be allocated for 
organizations to support women vets. In FY 2015, 14 percent of veterans 
served by this program were women. That number has steadily increased 
since the program's inception. These dedicated funds will help support 
the growing number of women and their families in need of this support.
    In 2012, the VA solidified its policy to provide seven days of 
Newborn Medical Care for children delivered by women veterans who are 
receiving VA maternity care benefits. The Deborah Sampson Act would 
expand that to 14 days to ensure newborn the VA has the flexibility to 
provide that care during this fragile first stage of their life. This 
bipartisan idea is a no-brainer that has stalled in Congress for too 
long and needs to change now.
    There continue to be a number of Access Barriers for women veterans 
seeking care at the VA. IAVA women veterans have shared stories of lack 
of privacy at VA facilities and IAVA members continue to share those 
concerns. The Deborah Sampson Act looks to address this issue by 
authorizing $20 million for enhanced privacy measures for women at VA 
medical centers across the country like door locks and privacy 
curtains, and requires VA to develop a plan to address Department-wide 
deficiencies.
    We also want to stop hearing stories like the one from a woman who 
sought care at the VA's Emergency Room because of an ectopic pregnancy 
accompanied by pain and bleeding. The veteran had to leave and go to 
another VA ER because the ER team did not diagnose or treat her 
condition appropriately. This shouldn't happen in any ER, and 
disappoints me as an American to hear from a women veteran.
    To improve how the VA health system supports women, the Deborah 
Sampson Act: requires every VA facility to employ at least one women's 
health primary care provider; requires each VA medical center be 
staffed with at least one Women Veteran Program Manager to help women 
navigate coordinated care; authorizes $1 million annually to expand the 
Women Veterans Healthcare Mini-Residency Program, which trains VA 
primary care and mental health physicians on gender-specific care with 
demonstrated success, to include ER physicians; and an ombudsman to 
focus on culture change at the VA and support women veterans seeking 
care.
    One in five women veterans responding to IAVA's women veterans 
survey did not feel the VA provided them with access to adequate 
gender-specific health care, so the solutions offered are engineered 
not just to get women the health care support they need, but to do so 
effectively. Fear of poor care should never be a barrier to any VA 
patient.
    The Deborah Sampson Act finally includes valuable Data Tracking and 
Reporting provisions to assess needs and improve services down the 
line.
    Currently, the VA does not collect data on its programs by gender 
and minority status, and as a result, it is impossible to truly 
identify what programs are most effective in supporting women and 
minority populations and which need improvement. The recently enacted 
Female Veterans Suicide Prevention Act was a great first step to do 
this for mental health and suicide prevention programs, but the 
requirement needs to span all programs and this bill requires that.
    Women also shouldn't be telling us stories of the VA being unable 
to provide prosthetics appropriately fitted for women veterans. To 
define this problem and help craft solutions to ensure women veteran 
amputees have access to properly fitted prosthetics, the Deborah 
Sampson Act requires VA to report on the availability of prosthetics 
made for women.
    The bill also importantly requires VA to centralize information and 
resources on women's healthcare at VA on their website to streamline 
the ability of women veterans to find and learn about the services 
offered to them. Less than 60% of women responding to IAVA's women vets 
survey said VA provided sufficient information and resources on women's 
healthcare at VA. As demand continues to rise from women veterans as it 
declines from men, this should be a commonsense fix that is not just 
pro-women, but pro-veteran.
    Among the remainder of the bills under consideration today, IAVA 
strongly supports the Women Veterans Access to Quality Care Act 
(S. 804), as we did in the 114th Congress. Provisions in the bill to 
ensure standards to meet healthcare needs of women are prioritized in 
construction of VA health facilities, establishment of performance 
measures to analyze women's health outcomes, and requirements to 
improve privacy for women are consistent with the goals of our ``She 
Who Borne The Battle'' campaign and we would like to again invite all 
Members of this Committee to cosponsor and work to pass S. 804 and the 
Deborah Sampson Act.
    IAVA thanks Chairman Isakson and the Committee for engaging and 
seeking input from stakeholders in the effort toward VA appeals 
modernization that establishes a new system that is easy to navigate 
and veteran-centric. We are supportive of the general framework 
outlined in Veterans Appeals Improvement and Modernization Act 
(S. 1024) that establishes three separate paths for veterans to choose 
from when appealing a decision on their claims, and strongly believe 
that these new steps are critical to breaking the logjam in the current 
process. Following passage, IAVA encourages the VA to ensure continual 
monitoring and evaluation of the new processes to ensure improvement of 
the system. Congress should also exercise strong oversight over the 
law's implementation to ensure that it truly works for veterans.
    IAVA applauds the leadership and diligence of Senators Rubio, 
Chairman Isakson and Ranking Member Tester toward crafting the 
Department of Veterans Affairs Accountability and Whistleblower 
Protection Act (S. 1094) to enable the removal of bad-acting employees 
at the VA. Nearly three years ago, the scandal in Phoenix alerted the 
country to the outrageous state of the VA health care system. IAVA and 
our members have fought since that time to give the VA Secretary the 
tools needed to address workforce accountability and save veterans' 
lives. We encourage Senate and House leaders to quickly work together 
to pass the strongest VA accountability measure that can be signed into 
law.
    IAVA supports the Performance Accountability and Contractor 
Transparency Act (S. 543), which holds VA contractors accountable for 
services they provide and increases transparency into those contracts. 
These provisions are in line with our members' top priority of bringing 
strong accountability to the VA.
    IAVA also strongly supports the Military and Veterans Caregivers 
Services Improvement Act (S. 591), which makes veterans of all eras 
eligible for the full range of caregiver support services, and would 
allow those veterans to transfer Post-9/11 GI Bill benefits to their 
dependents. All veterans must be afforded the same level of benefits, 
regardless of the era in which they served. It is simply the right 
thing to do.
    We also support the Chiropractic Care Available to All Veterans Act 
(S. 609), to require a program under which the VA will provide 
chiropractic care and services to veterans, as it is consistent with 
IAVA's Policy Agenda which calls for treatment options that include the 
full range of traditional and experimental options that have proven to 
be effective.
    The Veterans Compensation Cost-of-Living Adjustment Act (S. 784) 
would ensure that disabled veterans and surviving spouses receive 
benefits that keep pace with the rising cost of living in our country. 
IAVA supports this bill and we appreciate that all Members of the 
Committee joined Chairman Isakson as original cosponsors.
    The draft Serving our Rural Veterans Act would authorize the VA to 
pay training and supervision of medical residents and interns at 
certain non-VA facilities, to require the VA to carry out a pilot 
project to establish or affiliate with residency programs at facilities 
operated by tribes and the Indian Health Service. It has long been a 
priority in IAVA's Policy Agenda to improve outreach to rural veterans, 
hence we support this legislation.
    IAVA supports the draft Veterans Partners' Efforts to Enhance 
Reintegration Act which requires VA to carry out a program to establish 
peer specialists in patient healthcare teams at VA medical centers. 
IAVA strongly supports peer support programs, including as a way to 
reach rural veterans who do not live in close proximity to military 
medical facilities, and encourages them to represent the diversity of 
the veteran population, to include women peer mentors.
    Finally, the Department of Veterans Affairs Veteran Transition 
Improvement Act (S. 899) would ensure that Title 38 Veterans Health 
Administration employees such as doctors, nurses and other VA medical 
personnel can access paid sick leave in their first year, that they 
would otherwise have to accrue, to undergo medical treatment for their 
service-connected disabilities, as their counterparts in other Federal 
agencies are permitted. IAVA supports this legislation.
    Mr. Chairman, many of these provisions are easy fixes, and some 
will require hard work and additional funds. When my soldiers and I 
were sent twice to face combat in Iraq, the Army and U.S. taxpayers 
spared no expense, with the goal of providing us with an overwhelming 
advantage in war. Veterans are proud to have served our country and we 
need Congress to know that the care we receive as a result of our 
service is a cost of war, and just as important as properly equipping 
those deploying downrange as we speak. We have got to spare no expense 
in caring for them after they return. Veterans are not a special 
interest--they answered the call when more than ninety-nine percent of 
American did not.

    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee, thank you again for inviting me to be here today, and on 
behalf of IAVA, I thank and remember our veterans who have served 
before us and those who are deploying now, again, to fight around the 
globe.

    Chairman Isakson. Thank you, Ms. Jaslow.
    Mr. Cox?

 STATEMENT OF J. DAVID COX, SR., NATIONAL PRESIDENT, AMERICAN 
          FEDERATION OF GOVERNMENT EMPLOYEES, AFL-CIO

    Mr. Cox. Thank you for the opportunity to testify today. It 
is astounding that while the Secretary says there is over 
45,000 unfilled health care vacancies in the Department, we are 
here today talking about firing rather than hiring. Does anyone 
here believe that the firing that has been in the news during 
the last week is an unusual occurrence? Does anyone here 
believe that an executive firing a subordinate to cover up his 
or her own misdeeds never happens in the Department of Veterans 
Affairs? I tell you what--when it happens where workers have 
due process rights, the innocent are protected.
    At workplaces with a process for weighing evidence and 
making decisions based solely on facts, no one gets fired 
without just cause. If this bill passes, you can strike VA from 
that list. The innocent will be fired without good cause, the 
appeals will be a humiliating joke, and the executives will 
continue to ruin the lives of workers and hurting veterans.
    So, let us be honest. None of the personnel provisions of 
this bill are really about veterans or accountability. It is 
about politics. It is about ``you are fired'' as an easy way to 
shift blame of wrongdoing from executives and political 
appointees onto the rank and file.
    We have a bill that reeks of the--wrecks the apolitical 
civil service and is justified only by pretending that the most 
extreme examples of misconduct are occurring all over the 
place. In fact, instances of outrageous misconduct are rare.
    AFGE has no use for people who abuse the public trust, who 
engage in unlawful conduct, or are poor performers, or violate 
government rules or our collective bargaining agreements, or 
the EEO laws. We want them out of the agency. They make 
everything more difficult for the vast majority who perform 
very well. In addition, this bill would supersede existing 
collective bargaining agreements and impose unworkable 
timeframes on the firing processes.
    We have asked the Committee to at least show some respect 
for the integrity of the collective bargaining process by 
agreeing that the provisions that affect the current contract 
go into effect only after a new contract is negotiated, and I, 
again, ask for that change to be made.
    We understand that bashing Federal employees and taking 
away their rights makes for good politics, and it does make for 
bad government. And I promise you that under this bill, more 
employees will be fired for bad reasons than for good reasons.
    You want to make it easy for VA managers to fire people. 
You have bought into complaints that firing is too hard for 
them, when every single study shows that current laws provide 
them all the authority they need to remove anybody who is 
actually a poor performer or engages in misconduct.
    Our objections to the specifics of the bill are as follows. 
The first is lowering evidentiary standards for adverse actions 
for misconduct allegations. Replacing the preponderance 
standard with substantial evidence eviscerates due process. 
With misconduct charges, there needs to be a finding of fact. 
With proposed change, there will no longer be a finding of fact 
with misconduct. As with Mr. Comey, it will be enough for the 
boss to simply want someone gone.
    The second and equally irresponsible provision of the bill 
is to prohibit administrative judges at the MSPB from 
mitigation of penalties. The VA will be able to fire with scant 
evidence of wrongdoing and reviewing authority will have no 
ability to correct the injustices by making the penalty match 
the offense. The prohibition on mitigation throws four decades 
of jurisprudence out the window. No more progressive discipline 
or consideration of whether the penalty is appropriate. No 
consideration of the nature of the seriousness of the offense, 
the level of the job, the employee's record, or whether others 
have committed the same offense and received a similar penalty. 
No rehabilitation and no consideration of the circumstances.
    This bill is a serious mistake. We will all miss the 
apolitical professional civil service when it is gone, and this 
bill will have made a major role in its demise.
    [The prepared statement of Mr. Cox follows:]
 Prepared Statement of J. David Cox, Sr., National President, American 
              Federation of Government Employees, AFL-CIO
                              introduction
    Mr. Chairman, Ranking Member Tester, and Members of this Committee, 
My name is J. David Cox, and I am the National President of the 
American Federation of Government Employees, AFL-CIO (AFGE). On behalf 
of the 700,000 Federal and District of Columbia employees represented 
by our union, including over 250,000 at the Department of Veterans 
Affairs (VA), I thank the Committee for the opportunity to present 
AFGE's views on the subject of this hearing: the ``Department of 
Veterans Affairs Accountability and Whistleblower Protection Act of 
2017.'' In AFGE's view, this bill not only decreases accountability at 
the VA, it eviscerates the agency it is supposed to improve, and 
ensures that no employee ever gets a fair shake on any proposed adverse 
action. Its name should be changed to the ``2017 Scapegoating VA Rank 
and File Employees for Political Expediency Act.''
    In my nearly five years as president of AFGE, I have never 
testified at a more important hearing than this one. It is important, 
not only for the VA and the veterans that the we serve, it is also 
important for the men and women I am proud to represent. Finally, it is 
important because passage of this horrible bill would undermine the 
apolitical American civil service, perhaps the least appreciated and 
most threatened pillar of our democracy.
    At issue is whether the United States, the most advanced country in 
the world and the leading democracy, will continue to have a merit-
based career civil service, selected, promoted and retained on the 
basis of ability and competence, or whether we will descend back into 
19th century corruption and all the maladministration of government 
that brought us.
    Before I was elected to national office in AFGE, I worked for 22 
years at the Salisbury, North Carolina VA Medical Center as a 
Registered Nurse. I love the VA and the veterans we serve, and the 
future of the agency means the world to me. I also care deeply about 
our democracy, and I am appalled at the political cynicism and short-
sightedness that this bill represents.
    While today we are focusing on the VA, much more than just the VA 
is at stake. The Veterans Health Administration is somewhat of a 
microcosm of the many ideas and institutions whose future is being 
hotly debated in politics today. I will discuss three: The first is 
health care. The second is the role of the Federal Government in 
providing essential services and on what terms these commitments will 
be met. The final issue is the status of the career civil service, and 
whether we will continue to administer government programs with 
apolitical professionals hired by the government, or whether most of 
what the VA does should be contracted out to favored private-sector 
firms, or even abandoned altogether.
    First, let's deal with the backdrop--the American health care 
system. The VA operates the country's largest integrated healthcare 
system. The military veterans it serves are the most deserving group 
one can imagine. The commitment we have made to veterans is to care for 
those who have borne the battle. The VA cares for aging Vietnam-era 
veterans, veterans from the Korean War era and even some surviving WW 
II veterans. In the past 15 years we have added many more veterans who 
have served this country in Iraq and Afghanistan and other more recent 
conflicts. Almost all of these veterans often have ongoing service-
connected illnesses and wounds, emotional and physical.
    The VA has always been there to serve them. The economic cost of 
caring for these veterans is high and budget politics have been an 
ever-present threat to quality and accessibility. It is astounding that 
while there are reportedly up to 45,000 unfilled positions in VA 
healthcare, Congress has chosen to focus on attacking the rank and file 
employees who are have made the choice to spend their careers caring 
for this cherished group. Rather than addressing the critical need to 
fill thousands of urgently needed positions at VA in order to better 
serve veterans, this cynical, ideologically driven bill seeks to fire 
more VA personnel. Talk about misplaced priorities.
    Why punish the VA's rank and file? Why punish the employees of VHA? 
There is no question that VA healthcare is of the highest quality. And 
that high quality healthcare is provided by the same VA employees this 
bill attacks. Every independent study has confirmed that the outcomes 
of VA provided healthcare are at least as high, and frequently higher 
than care provided by any other hospital system. Veterans know this and 
numerous surveys show that they very much like their VA-provided health 
care. They want more of it, not less.
    Ever since the Phoenix waitlist scandal, the future of the VA 
became fodder for 24 hour cable news, largely fed by the right-wing. 
The focus of discussion for many politicians has been how to dismantle 
the VA piece-by-piece and outsource it to the private sector. Well-
funded and therefore politically powerful groups have seized the 
opportunity to cement a narrative that the VA is ``broken.'' Their 
purpose is to discredit the VA by blaming its problems on its rank and 
file employees and the fact that it is a government agency. Their real 
objection is that few are able to make profits on VA care.
    I challenge anyone on this Committee to find a major healthcare 
provider, private or public, that doesn't face significant challenges. 
Most don't make the news because they are not answerable to the public 
the way the VA is, and most are able to fire or otherwise silence 
whistleblowers with ease. But anyone who has gone to a private hospital 
or even an emergency room can tell you about long waits, enormous 
bureaucracy, and waste, fraud and abuse. They can tell you about how 
getting an appointment with a specialist takes at least three months. 
That is sadly part and parcel of our healthcare system, including 
private sector providers. Just look at any hospital bill, or talk to 
any physician or nurse, and they will tell you of the complexities and 
contradictions of America's healthcare system.
    Fortunately veterans have the VA, a system that does not charge 
them and that covers them extremely well. It is so much more than just 
a healthcare system. It is also a community that understands the unique 
needs of those who have served this country. Whatever ails VA 
healthcare delivery reflects America's overall healthcare system--and 
in most cases, the faults are more severe among private hospitals and 
healthcare facilities. The critics of the VA will never admit this, so 
I will tell you. There is big money in VA healthcare and the 
privatizers salivate at the opportunity to gain access to those 
dollars. They try to hide their avarice with platitudes about ``serving 
veterans,'' the ``broken'' VA and the miracles of the market, but the 
reality is that they hate the idea that a large government agency so 
successfully provides care to veterans, and they want a ``piece of the 
action.''
    The VA may not be perfect, but it is better than any other 
healthcare system at serving veterans with special needs associated 
with service-connected illness, injury, or disability. The VA makes no 
money off veterans. Its facilities may not be glamorous. Yet every 
important indicator of quality of care strongly confirms that the VA is 
a success. The Committee should recall that the Phoenix scandal began 
with a wait times issue. I will not defend the manipulation of wait 
time data, but that was not an issue of quality of care. It was an 
issue of resources, combined with a performance bonus system for 
executives that incentivized lying and cheating. It is absolutely 
unconscionable that from those facts has come the deplorable 
legislation before you today that undermines the foundation of the 
civil service.
    So let's be honest. None of this is really about veterans or the VA 
or accountability. It's about politics. I do believe that everyone 
wants the best care for veterans. I wish we were having a debate on how 
to provide that care and to ensure accountability for all those who are 
charged within doing so. But that is definitely not what is happening 
here.
    We are here today because politicians understand that ``You're 
FIRED!'' is popular as a way to address complex issues. ``You're 
FIRED!'' is popular as a way to deflect responsibility from management 
decisionmakers and place it on the rank and file. We have before us a 
bill that wrecks the civil service and is justified only by reference 
to the false claim that the most extreme examples of misconduct are 
occurring all over the place. In fact, outrageous instances of 
misconduct are exceedingly rare. It must also be noted that some 
authors of this bill have a long track record of denigrating virtually 
every known government program except those that personally benefit 
them. No one who values the VA or respects veterans should support this 
legislation.
    I have been specifically asked by this Committee to address the 
changes to the civil service due process provisions contained in the 
scapegoat/firing bill, the Department of Veterans Affairs 
Accountability and Whistleblower Protection Act of 2017.
    Before I address the specifics of these proposals, let me state 
that AFGE and its members have no use for people who abuse the public 
trust, who engage in unlawful conduct, who violate government rules, 
and who are demonstrably poor performers. We want those people out of 
the VA every bit as much as anyone--maybe more so. Employees who engage 
in misconduct or who are genuinely poor performers ruin the reputation 
of the agency and add more work for those who perform well and play by 
the rules. So you will not hear me or anyone in this union defend a 
person who steals drugs or watches pornography while on duty. In fact, 
AFGE counsels such employees to resign. We certainly will not defend 
their matters in arbitration.
    The bill before you is a regressive piece of legislation. It takes 
us backward, not forward. Although marketed as a bill to make it easier 
to fire bad employees, the proposals are designed to kill off and bury 
the apolitical civil service. It makes it just as easy to fire a good 
employee, an innocent employee, as it will be to fire a bad employee. 
No one should pretend otherwise. The VA can and should terminate people 
whose conduct or performance justifies termination. But it is 
absolutely not necessary to destroy the foundation of the civil service 
in order to allow them to do so.
    The legislation takes time-tested procedures for civil service 
removals and turns them on their head in order to accomplish a clearly 
political agenda. Every single study or report of civil service removal 
procedures has stated that the principle reasons poor performers are 
not removed expeditiously are management ignorance and aversion to 
conflict, i.e. incompetence. It has nothing to do with the underlying 
laws.
    Federal managers, including those at the VA, do not lack adequate 
authority or tools to discipline those who engage in misconduct or who 
are poor performers. The Government Accountability Office (GAO), the 
Merit Systems Protection Board (MSPB) and the Office of Personnel 
Management (OPM) have all issued reports and analyses that have come to 
the same conclusion: When poor performers are not dealt with it is not 
because the civil service laws or procedures are too difficult to 
utilize. It is because managers do not want to put forward the effort 
to properly document poor performance so that they can remove or demote 
these people.
    A recent GAO report, ``Improved Supervision and Better Use of 
Probationary Periods Are Needed to Address Substandard Employee 
Performance,'' (GAO-151-191), February 6, 2015, found four main reasons 
why agencies do not use the already substantial tools they have 
available to them to remove poor performers. All four reasons related 
to management failures and/or unwillingness to properly identify and 
document poor performance. Had this Committee taken GAO's well thought-
out recommendations into consideration, the bill before us would never 
have been written.
    Instead we have a cynical effort to ride the wave of public outrage 
over some legitimate problems that union whistleblowers and the VA 
Inspector General have brought forward and use it to destroy yet 
another union and the civil service. We continue to hear whining from 
management that civil service due process procedures are just too 
difficult to follow. They sound just like the President whining that 
his new job is too hard. S. 1094 accommodates these pitiful managers 
completely. Firing is too hard for you? Don't worry, we'll make it 
easy. We'll rig the system so no matter what you do, you'll be called a 
huge success. We'll let you fire the employee right away, and deal with 
due process in the future, if ever.
    To call this a dangerous precedent is an understatement. To anyone 
who cares about the apolitical and objectively qualified civil service 
this bill is a disgrace.
    The premise that the procedural hurdles for removing poorly 
performing employees are too high is simply untrue. When an employee 
invokes his/her rights to a formal adjudicatory hearing before the 
Merit Systems Protection Board (MSPB), the agency almost always 
prevails. For example, in 2013 only 3% of employees appealing their 
dismissal to the MSPB prevailed on the merits. In contrast, agencies 
were favored at a rate five times that of employees when formal appeals 
were pursued. The notion that the MSPB makes it impossible to fire a 
Federal employee is simply a myth.
    GAO reviews and reports (e.g., GAO-15-191) have consistently found 
that the underlying reasons for permitting poor performers to remain in 
Federal service are managers' failure or unwillingness to document poor 
performance in accordance with due process procedures available to them 
under the Civil Service Reform Act. The bottom line of the GAO report 
is that lack of performance management by supervisors is the underlying 
reason why poor performers are not dealt with. Indeed, the 
preponderance of the evidence points in only one direction: the 
complaint that ``it's too hard to fire a Federal employee'' is not 
supported.
    Let me address some of the most egregious and shameful aspects of 
the bill:
                  evidentiary standard for misconduct
    S. 1094 replaces the current evidentiary standard for misconduct 
removals (and other adverse actions) from a ``preponderance of the 
evidence'' standard (meaning more than 50% of the evidence must support 
the agency's recommendation) to a ``substantial evidence'' standard 
(meaning the agency only needs, among other things, more than ``a mere 
scintilla of the evidence'' to meet its burden of proof). The 
substantial evidence standard, with strong advance notice safeguards, 
is currently only used for performance-based firings, suspensions, and 
demotions. Applying this standard to misconduct cases would mean that 
even when the majority of the evidence supports the employee, he/she 
will lose.
    With the current preponderance of the evidence standard, agencies 
win about 80% of all contested cases before the Merit Systems 
Protection Board (MSPB). Lowering the standard of review would mean 
that actual misconduct would barely need to be established before an 
employee could be fired. This upends nearly 140 years of civil service 
law, and makes VA employees very close to ``at will'' (which seems to 
be the real objective of the drafters of this provision).
    There is a good reason why Congress has required different 
evidentiary standards for performance and conduct. When an employee 
receives a notice of a proposed adverse action related to performance, 
he or she has the opportunity to repair any performance failures 
through a Performance Improvement Plan (PIP). In contrast, allegations 
of misconduct must be validated with a higher standard of evidence 
because the question is only whether the alleged misconduct occurred.
    This lower evidentiary standard is virtually pro forma, not a 
standard associated with the genuine administration of justice. It is 
yet another example of the cynicism that underlies this legislation, 
providing a false notion that due process is being upheld, when in 
fact, it is being eviscerated.
                     mitigation of proposed penalty
    S. 1094 would prohibit MSPB administrative judges (AJs) from 
mitigating management's proposed penalty for misconduct. Under current 
law, MSPB AJs can reduce a proposed penalty for misconduct if the facts 
of the case warrant a lesser penalty. Removing the ability of MSPB AJs 
to mitigate a proposed penalty is not only unjust, but will also result 
in ``penalty overcharging,'' meaning that a proposed penalty need not 
actually reflect the underlying charge. Combining a lower evidentiary 
standard of review to sustain a misconduct charge along with no ability 
to mitigate a proposed penalty means that employee appeal rights will 
be effectively neutered.
    The VA will be able to fire employees with scant evidence and no 
ability for the reviewing entity to correct these injustices. This 
provision is the antithesis of justice and undermines not only the 
rights of the employee, but also the independence of the MSPB.
    This provision also jettisons almost four decades of jurisprudence 
that followed the MSPB's 1981 decision in Douglas vs. Veterans 
Administration which gave rise to the use of progressive discipline in 
Federal personnel management. The basic principle of justice, that the 
punishment must fit the offense which was enshrined in the Douglas 
decision, has served the government well, and if S. 1094 becomes law, 
the Department of Veterans Affairs will have abandoned this management 
``best practice'' altogether for an ``Apprentice'' TV-show type of 
system (You're FIRED!).
    I ask you to consider these ``Douglas Factors'' for a moment and 
decide whether your intention is actually to throw away this eminently 
reasonable set of considerations. The Douglas Factors allow mitigation 
of proposed penalty after the following are considered:

    1. The nature and seriousness of the offense, and its relation to 
the employee's duties, position, and responsibilities, including 
whether the offense was intentional or technical or inadvertent, or was 
committed maliciously or for gain, or was frequently repeated;
    2. The employee's job level and type of employment, including 
supervisory or fiduciary role, contacts with the public, and prominence 
of the position;
    3. The employee's past disciplinary record;
    4. The employee's past work record, including length of service, 
performance on the job, ability to get along with fellow workers, and 
dependability;
    5. The effect of the offense upon the employee's ability to perform 
at a satisfactory level and its effect upon supervisors' confidence in 
the employee's work ability to perform assigned duties;
    6. Consistency of the penalty with those imposed upon other 
employees for the same or similar offenses;
    7. Consistency of the penalty with any applicable agency table of 
penalties;
    8. The notoriety of the offense or its impact upon the reputation 
of the agency;
    9. The clarity with which the employee was on notice of any rules 
that were violated in committing the offense, or had been warned about 
the conduct in question;
    10. The potential for the employee's rehabilitation;
    11. Mitigating circumstances surrounding the offense such as 
unusual job tensions, personality problems, mental impairment, 
harassment, or bad faith, malice or provocation on the part of others 
involved in the matter; and
    12. The adequacy and effectiveness of alternative sanctions to 
deter such conduct in the future by the employee or others.

    These factors are designed to ensure that the penalty selected by 
the agency fits the employee's alleged offense. Why are these 
controversial? Perhaps it is because those who genuinely wish to see 
this legislation enacted really don't care about the civil service or 
due process, and are particularly enraged that a government program 
such as VA healthcare actually works. Or perhaps, they just see 
political expediency in not challenging well-funded ideology-based 
advocacy courtesy of the Koch brothers and their allies.
                           pension forfeiture
    The proposed legislation authorizes pension forfeitures for certain 
felony convictions for every VA employee. This would include Wage Grade 
2 housekeepers and cemetery workers, virtually all of whom are veterans 
with service-connected disabilities. Private employer pension plans 
under the Employee Retirement Security Act of 1974 (ERISA) do not 
authorize pension forfeitures except for fraud against the pension 
plan. AFGE recognizes that there is precedent for Federal employee 
pension forfeiture, but these forfeitures have always involved involve 
espionage and treason, not drunk driving convictions.
    It is curious that people who usually promote following private 
sector practices for Federal Government personnel have suddenly 
abandoned this principle when it comes to taking away earned pensions.
supersedes collective bargaining agreements and imposes unworkable time 
                     frames on the removal process
    The proposed legislation supersedes the timeframes specified in 
current active collective bargaining agreements (CBAs). It also imposes 
unworkably short timeframes on grievance procedures and non-grievance 
based adverse actions. That Congress would summarily upend collective 
bargaining agreements in the middle of the term of the agreement is an 
unprecedented attack on the integrity of the collective bargaining 
process and union contracts.
    The proposed legislation provides that from date of first notice to 
the employee until actual removal that not more than 15 business days 
elapse. Employees are given only 7 business days to respond to the 
notice. Following removal, employee have only 10 business days to 
appeal the VA's decision to the MSPB.
    Contrast these timeframes with the rights given to VA contractors. 
They have a minimum of 90 days to appeal a contracting officer's 
adverse decision to the Board of Contract Appeals (BCA), and one year 
to appeal to the U.S. Court of Federal Claims, if they decide to forego 
a BCA appeal. It is absolutely stunning, and a very sad commentary on 
the state of Federal agency priorities that employees are given such 
short response and appeal times, while favored Federal contractors are 
given months, and even up to a year to appeal VA decisions to the BCAs 
and a Federal court.
    A merit-based civil service system is a cornerstone of a democratic 
society. It ensures that technical expertise is brought to bear on 
performing government agency work, without the threat of overt partisan 
agendas driving day-to-day operations. Agency career employees remain 
accountable to politically-appointed officials, but those appointees, 
and supervisors who serve under them, may not take actions against 
career employees for misconduct or poor performance without at least 
providing some level of due process to the employee, including third-
party review by neutral decisionmakers. Career employees are only 
supposed to be fired for good cause, and ``good cause'' means reasons 
supported by evidence.
    The Civil Service Reform Act (CSRA) of 1978 provides the modern-day 
basis for both selection of most career civil servants, and their 
protection from unwarranted personnel actions, including firings 
motivated by politics, bias, or other non-merit-based reasons. This 
CSRA protects the public from having their tax dollars used for hiring 
political partisans for non-political jobs, and helps ensure the 
efficient and effective governance of Federal agencies.
    The CSRA provides that employees may be removed for either 
misconduct or poor performance. The employee merely needs to be 
informed of his or her alleged deficiency and the reason that 
management proposes to take an action against him or her, whether it be 
firing, demotion, or suspension.
    Forty years of case law shows unambiguously that the CSRA does not 
give unfair advantages to Federal employees. Agencies prevail in 80%-
90% of all cases at the MSPB administrative judge (AJ) level, and only 
about 18% of all AJ decisions are appealed to the full Board. AJs are 
upheld by the full MSPB in about 90% of all appealed cases.
    It is very important to note that following an agency's adverse 
decision against an employee, the agency's decision is automatically 
effected. For example, the employee is removed from the agency's rolls 
the day of issuance of the decision or within several days following 
the decision. An employee removed by an agency receives no pay during 
the appeal process.
    During the debate on VA firing I have heard several lawmakers and 
others argue that it takes forever to get rid of a bad VA employee. 
This is simply untrue. In almost all cases, an employee may be fired 
within 30 days of the first notice. Even when an arbitration procedure 
under a collective bargaining agreement is invoked the agency can fire 
the employee after 30 days, and the employee receives no pay during the 
entire appeal or arbitration process. They are off the agency's 
payroll. Attempts to portray removed employees appealing their removals 
as somehow lounging on the dole while their appeal is processed are 
simply untrue, and frankly dishonest. It doesn't matter whether the 
appeal route chosen is the MSPB or arbitration. The employee receives 
no pay. Anyone who says otherwise is lying or ignorant or both.
    The importance of maintaining a nonpartisan, apolitical civil 
service in an increasingly partisan environment cannot be overstated. 
First, most Federal jobs require technical skills that cannot simply be 
obtained through non-merit based appointment. Second, career employees 
must be free to perform their work in accordance with objective 
professional standards. Those standards must remain the only basis for 
evaluating employee performance or misconduct.
    Bills like S. 1094 that decrease due process rights are ``dog 
whistles'' for politicizing the civil service, subjecting the Federal 
workforce to partisan or personal whims of supervisors and political 
appointees. Whatever lack of public confidence in government exists 
today will be magnified a hundredfold if all civil servants become de 
facto political appointees, serving at the whim of supervisors. And 
that is exactly what this horrible piece of legislation will do.
    Federal managers are already empowered under existing civil service 
laws to take appropriate action when employees are underperforming or 
engaged in misconduct. There is no group who objects more to the 
continuing presence in the workplace of those who are not performing 
well or who engage in misconduct than fellow Federal employees. When 
someone doesn't perform up to speed, it simply means more work for the 
rest of the people who do perform well.
 the real issue--agency reluctance to document employee performance in 
                 accordance with due process procedures
    In 1978, Congress enacted the CSRA, which is the modern-day statute 
governing civil service protections. In considering the law, Congress 
was specifically concerned about balancing employee rights and 
maintaining a non-partisan civil service with the need for management 
to deal with poor performers, or unacceptable conduct.
    To help agency managers deal with poor performers, the CSRA 
included a new section, Chapter 43, specifically addressing performance 
issues. As previously mentioned, this chapter set a lower standard of 
review of agency decisions with respect to performance issues among 
employees, and restricts the MSPB from modifying agency determinations 
regarding removal of poorly performing personnel.
    The GAO report previously mentioned (GAO-15-191) suggests many 
reasons why managers are sometimes reluctant to address performance 
issues. It also explores the many myths surrounding removal of poor 
performers. GAO's report echoed findings of the MSPB in its reported 
entitled, ``Addressing Poor Performers and the Law'' (September 2009). 
The fact is that the laws governing the firing of poor performers, 
primarily Chapters 43 and 75 of title 5, are straightforward and not 
unduly burdensome to agencies. However, the due process procedures 
inherent in these laws require documentation between the supervisor and 
the employee that addresses the performance or conduct issues. This can 
be very difficult for some supervisors. Nevertheless, the law is clear, 
agency supervisors have many tools available to them to address 
performance issues, and to fire poor performers.
                 continued denigration of va employees
    As Members of this Committee are undoubtedly aware, continuing 
partisan attacks on the work of VA employees only fuels a self-
reinforcing feedback loop. Employees know they are punching bags. 
Morale plummets as a continuous stream of anti-Federal worker 
proclamations, almost all false or highly exaggerated, emanate from 
elected or appointed leaders. Not long ago, the majority leader in the 
House of Representatives wrote an op-ed in the Wall Street Journal 
describing the ``Federal bureaucracy'' as the entity that ``poses the 
greatest threat to America's people, economy and Constitution.'' Such 
criticism is not only false, but misleads people into thinking that 
career civil servants create statutes and regulations wholly apart from 
supervision by elected leaders and political appointees. Anyone who has 
worked in Federal service will tell you that employees follow 
direction, whether that direction comes from Congress, the President or 
other politically-appointed officials. In other words, career Federal 
workers respond to and implement duly enacted laws and policies. They 
do not create these policies.
    In all my years as an elected official of AFGE, I have never seen 
fit to denigrate my own staff. No leader should do that. There have 
been situations where employees have been disciplined or dismissed. But 
taking a battle axe to all employees and describing them in broad terms 
as ``threats'' to the American people heralds a new low in 
misinformation and outright dishonesty. As I told several news outlets 
at the time, ``To call civil servants--one-third of whom are veterans--
a `threat to America's people, economy and Constitution' is an insult 
to the men and women who dedicate their lives to the programs and 
services that benefit all Americans.''
                       holding the va accountable
    AFGE agrees that VA employees should be held accountable, and we 
also believe that includes VA managers, supervisors and political 
appointees. Statements implying that employees cannot be fired for 
months or years, or that fired employees remain on the government 
payroll for long periods while pursuing appeals following removal 
demand accountability every bit as much as an employee who is 
chronically late to work.
    These are dishonest statements and VA leadership should be held to 
account for this dishonesty. If they can't fire, demote or properly 
discipline employees under current civil services rules, AFGE questions 
their competence to manage and lead such a large and complex 
organization. If they cannot hire for 45,000 health care vacancies, the 
same is true. They lack the competence to manage and lead the agency. 
Seeking the easy way out is not leadership. It is a politically-
motivated response to fecklessness and incompetence.
    Regardless of the outcome of the debate on this legislation, AFGE 
calls on this Committee to demand from the VA Secretary the following 
data on the number of employees fired, suspended or demoted (``adverse 
actions'') by the VA under applicable statutory or regulatory 
authority; more specifically the following:

    1. The number of employees proposed for and actually subject to 
adverse actions;
    2. The veterans status of employees subject to adverse actions;
    3. Locations, demographics and grades, and reasons for adverse 
actions; and
    4. Periods of time to effect adverse actions from date of first 
employee notice until final agency decision.

    We have yet to see this data, and we believe it will better inform 
the debate, not only as to whom the VA is disciplining, but also as to 
the level of competence within the agency in managing its personnel 
functions. We also believe that the Committee should focus more of its 
attention on the failure of the agency's leadership to fill the 
reported 45,000 healthcare vacancies. Firing should not be your only 
concern. Hiring deserves at least as much attention.
                          a better way forward
    History is replete with examples of public service corrupted by 
unfettered, politically-based employment decisions. That's why we 
continue to support a merit-based civil service system with appropriate 
due process, and checks and balances to ensure that both hiring and 
firing decisions be merit-based, and subject to meaningful review.
    AFGE strongly supports improvements in agency performance 
management systems, and we look forward to working with lawmakers and 
other interested stakeholders to see this carried-out. AFGE also 
supports better training of both VA supervisors and employees so that 
clear expectations are established, performance is measurable, and 
appropriate steps are taken to either remedy performance problems, or 
to remove poor performers from the workplace.
    AFGE vehemently opposes S. 1094, one of the worst pieces of 
legislation of the modern era. This legislation is an affront to hard 
working VA employees, more than a third of whom are veterans, directly 
lowers objective standards of review of proposed adverse actions, 
impinges on the union's ability to defend meritorious cases, and 
unfairly penalizes employees for what could be trivial offenses. 
S. 1094 will corrupt and ultimately destroy the professional civil 
service and return the country to the days of the ``spoils system'' of 
government employment.
                               conclusion
    Attacks on government employees and the civil service in general 
may make for good politics, but they make for bad government. AFGE is 
aware that dealing with problem employees is essential to sound public 
administration. But the vast majority of employees at the VA perform 
well. Agency systems and the laws and regulations governing employee 
performance are well-thought-out. The issue is not whether the laws or 
regulations governing the civil service are adequate, but whether 
agencies, including VA managers and supervisors have the tools, 
training and will to effectively implement current rules. The current 
mindset of the VA and supporters of this legislation in Congress seems 
to be that fast and easy firing of employees will magically solve the 
VA's problems. Think again. This will cause far more problems than it 
will solve.
    I urge the Committee to reconsider the very dangerous and 
ultimately destructive personnel provisions of this firing bill.

    Thank you for your time and consideration and I will be happy to 
answer any questions you may have.

    Chairman Isakson. Thank you, Mr. Cox. I will start and take 
5 minutes, and then go to the Ranking Member for 5 minutes.
    Let me first of all, Mr. Atizado, in your introduction of 
yourself, or the introduction of your statement, you made the 
reference to your organization being the largest claims 
organization in the world. Is that correct?
    Mr. Atizado. In the Nation. I do not know about the world.
    Chairman Isakson. In the Nation.
    Mr. Atizado. Yes, sir.
    Chairman Isakson. The nation is big enough so we will take 
that.
    Mr. Atizado. Yes, sir.
    Chairman Isakson. I think in your testimony, that caught my 
ear because that is what this appeals process is all about, 
making sure that people are treated right that are injured and 
have an appeal for a benefit and have a right to a benefit. I 
appreciated the time that you took to explain the effort you 
all went through to examine the appeals bill, and I appreciated 
the comments that you made. Would you thank your organization 
for that?
    Mr. Atizado. I am sorry. What was the question?
    Chairman Isakson. Be sure to thank your organization for 
that.
    Mr. Atizado. Definitely, sir. I will be honest. We have a 
lot more intelligent people than in our organization, that have 
worked hand-in-hand with the VA for this bill, so the thanks 
goes to the VA as well.
    Chairman Isakson. DAV is a great organization and our 
disabled veterans bear a scar for the rest of their lives, and 
we owe them a tremendous obligation. One of those obligations 
is to see to it that appeals of any claim that they have made 
are handled expeditiously and quickly. Now with this bill 
passing, hopefully in the next few weeks, they will be doing 
exactly that, and that will be a great day forward.
    Ms. Jaslow, thank you for mentioning Memorial Day. Unless I 
missed it, of all of us on the Committee that asked questions 
and made opening statements, and of all of you who made 
statements, yours was the one that made reference to not 
forgetting that next week is Memorial Day, or within a week or 
so is Memorial Day, which is a very important day for our 
country.
    I would just encourage all the Members--I cannot ask 
anybody or tell anybody to do anything, but I hope all the 
Committee Members will take time during the Memorial Day break 
to spend at least a little bit of time each day making sure our 
young people and our supporters and our voters understand the 
value that we have in the sacrifice that was made by the 
veterans of America who died so that we could have the liberty 
and the freedom that we are enjoying today.
    I always tell the story, when I make Memorial Day speeches, 
about Roy C. Irwin, a veteran from World War II, in 1944. When 
I went to the Margraten Cemetery in the Netherlands and walked 
down the rows of crosses, on row 24 I came to the last cross in 
the row, and I go to each one and look at the dates and the 
place and the name of the individual who is buried there. The 
last grave in row 24, Roy C. Irwin of New Jersey, died December 
28, 1944, was interred. I stopped in my tracks for a second, 
took a deep breath, and realized that the day I was born was 
December 28, 1944, I was standing on the grave of an American 
soldier from New Jersey who died on the same day I was born, so 
that I could enjoy the life that I have enjoyed over the last 
72 years.
    So, I think when all of us take a moment to talk about 
Memorial Day, we can talk about that sacrifice those soldiers 
made so that all of us who are here today, living and enjoying 
the freedoms of the United States of America, realize that, in 
large part and measure, that was paid for by singular American 
efforts who volunteered on our behalf, sacrificed their lives, 
and died for our freedom and our ability.
    So, I just wanted to throw that in. I hope everybody will 
take a second to tell their own stories during that time.
    I want to thank the input that everybody has given to the 
appeals process. We are excited about trying to get something 
fixed that has been broken for a long time and I appreciate the 
VA's attitude toward helping us to do that. I understand there 
is some concern and input on the accountability portion, but I 
think we have done a good job of hearing from everybody and 
putting together a piece of legislation that works for the 
Veterans Administration, the employees of the Veterans 
Administration, and the taxpayers of the United States of 
America, who pay for the Veterans Administration. I also 
appreciate the Ranking Member's cooperation in working with all 
of us on all these pieces of legislation, to make them happen.
    Last, I will make a comment. Of all the legislation we have 
talked about today, everybody left out the one piece of 
legislation that a lot of people would have thought we would 
have mentioned first, but I think it shows the integrity of 
these organizations and the integrity of our vets and the 
integrity of the VA. But nobody mentioned the cost-of-living 
(COLA) increase that Senator Tester and I have put in, because 
they are taking it--that maybe we were going to make sure that 
happens. That shows we have got a good self-interest in part of 
all our people testifying here today.
    Ranking Member, would you like to ask a question?
    Senator Tester. Yeah. Thank you, Johnny. I think we all 
have our Veterans Day memories of what has transpired and what 
that day is all about, and, quite frankly, what every day 
should be about. Every day should be Memorial Day for the 
people of this country.
    I will just pass along a little story. When I was a 
seventh-grader I got tabbed to be the VFW bugler, which was 
kind of a big deal because everybody in the whole damn town 
would show up for Memorial Day. They would do the roll call, 
and at that moment in time--this is the late '60s so there were 
still a few World War I guys around. It was always an amazing 
experience.
    I will never forget what one of them said to a 13-year-old 
kid, which was that we never want to forget that war is a god-
awful thing, and you do not put people in harm's way without 
knowing what you are doing. You know, those are old World War 
II guys that knew what it was like. They knew getting your arm 
blown off was not something that was a pretty sight. Watching a 
guy die was not a pretty sight either. So, kind of interesting.
    So, I thank you guys for your service and the folks you 
represent. I do want to thank--a couple of thank yous--number 
1, to all five of you for the people you represent. Thank you 
for being here and representing them. For the VA staff sticking 
around and hearing this panel, I want to thank you for that. 
Oftentimes we have two panels and the first panel gets up and 
leaves, and I know you have got work to do, but you stuck 
around and I want to acknowledge that.
    I know that Ms. Flanz is here. If there are any questions 
on MSPB, which Mr. Celli, you brought up, and their ability to 
make decisions, certainly utilize her.
    I have got a couple of questions. Actually, I have got more 
than a couple. I want to start with Allison, with the IAVA. 
There was a GAO study that came out in December 2016, that 
found that across the VA system there was a significant lack of 
providers available for women veterans--I think you referenced 
it in your statement--as well as significant privacy issues.
    I am interested to know how seriously you think, or IAVA 
thinks, that the Veterans Administration is taking these 
findings seriously, and if you have seen any changes since that 
report was issued.
    Ms. Jaslow. Well, I certainly believe any person at the VA 
who I have talked to, and I believe many that you all have 
talked to, have very good intent. I think one of the reasons 
why we appreciate not only your leadership, sir, but why we are 
getting behind the Deborah Sampson Act is because, like many of 
the things at the VA, it is not happening fast enough.
    I believe there was somebody on the panel ahead of me who 
said that she was able to quote how many VA facilities have 
gynecologists, but that clearly means that not all of them do, 
which means that you have VA health care centers that 
adequately support men and ones that inadequately support 
women.
    We talk a lot about how the culture needs to be more 
welcoming, but one of the other barriers is women just do not 
think that they are going to get treated in the way that they 
need to be treated when they go into the VA.
    To answer your question, sir, we are still talking to 
members. You know, I already told my story of running into 
snags when I walk into the VA. More work needs to be done, and 
what we really need to do is jump-start it. I think that, you 
know, our approach is not only raising awareness of this issue. 
I really do not think that you get the fuel in the tank that 
you really need to get this done until people really feel like 
it is an issue, so that is the first step. But the other step 
we have outlined in the bill.
    Senator Tester. OK. Very good.
    Adrian, with DAV, you issued a fine report a few years ago 
titled ``Women Veterans: A Long Journey Home.'' It had some 
compelling facts and findings about the challenges unique to 
women veterans. Have you or anybody within your organization 
spoke to the VA about this report, and what kind of reception 
have you received?
    Mr. Atizado. Senator Tester, thank you for that question. 
VA has been more than welcoming of that report. If there is one 
thing I do find quite impressive about VA is that they are not 
shy about asking themselves what they are doing wrong and 
correcting those deficiencies. They are very much involved with 
trying to address those issues in our report, within their 
jurisdiction, because that report spans the entire Federal 
Government. We are trying to update that report now to reflect 
the abundant good work that VA has done.
    I just want to tag on to what Allison had mentioned. You 
know, this bill--these two bills are good for a start, I think. 
It is important that we have these policies in place, these 
artifacts that show that VA's culture is, in fact, inclusive 
and respectful of women veterans and their service.
    Senator Tester. In their testimony, VA said they did not 
support compiling a report--and this is for any of the VSOs--a 
report on how they are doing on providing prosthetics to women 
veterans. We hear, quite frequently, the VA's ability to 
provide gender-specific prosthetics is inconsistent, at best.
    It does not have to be all of you, but it can. Can you 
share some insights from your membership on women veterans 
where it comes to prosthetics?
    Mr. Atizado. So, if I can, for my colleagues, if you do not 
mind, we have a very active member of our organization and she 
had sought a prosthetic appliance from VA; at that time the 
only thing available was a male prosthetic. We thought that was 
falling a little short of what we expected of VA. They tried to 
make it work but clearly it did not.
    We think these reporting measures are critically important. 
Our testimony says, though, that these reports should include a 
little bit more personalized reporting: how women veterans 
perceive these services and these programs, whether it speaks 
to them and their needs, whether it is respectful of them, and 
whether they are satisfied. I think adding those would make 
this bill just a little bit stronger, sir.
    Senator Tester. OK. Thank you. In closing, really quick, I 
just want to say that I met with about a dozen veterans, 
Vietnam veterans and veterans that have come back from the 
Middle East, up in Kalispell, MT, this last week, and we talked 
about many of these bills. I cannot tell you how committed they 
are to making the VA the best it can be and not privatizing the 
VA, which I think is important to be said here, because there 
are people around--I do not know around this dais, but maybe 
around this dais, certainly in the House, that want to 
privatize the VA. If we are not continually working to make the 
VA the best it can be, it will be privatized, and I do not want 
to see that happen, personally.
    So, we thank you for your advocacy, and we look forward to 
working with everybody to try to make the VA the best it can 
be. It is an important backstop for our veterans.
    Thank you, Mr. Chairman.
    Chairman Isakson. Senator Blumenthal.
    Senator Blumenthal. Thank you, Mr. Chairman. Thank you all 
for being here and for all your tireless work for our veterans. 
If you were here earlier you may have heard my questions about 
the Veterans PEER Act, and I would like to reiterate them to 
you, without going through all the provisions which I am sure 
you know. I would like to know from you whether you think that 
these kinds of support specialists are necessary, whether they 
perform a function, and whether they ought to be an integral 
part of our mental health care service and primary care team 
for our veterans.
    Mr. Celli. Well, I can tell you that The American Legion 
has long been a supporter of peer support. We find that it is 
the best way especially for veterans who are new to the VA 
system to become comfortable with the system and to integrate 
well. Incorporating them into the PACT model is really the 
right thing to do. I just do not think that there is any--we 
believe in it so much we actually passed a resolution 
specifically supporting it.
    Senator Blumenthal. Thank you. I would welcome other 
comments.
    Ms. Keleher. The VFW has long been very supportive of 
expansion of peer support specialists, and as we said, we very, 
very adamantly support it, not just for gender-specific care 
but for mental health care and many other areas. It is 
something that we look forward to continuing to work on.
    Senator Blumenthal. Great.
    Ms. Jaslow. I would be happy to chime in, sir. Specifically 
related to women, you know, I think something that I would 
encourage you to think about, as you are working within this 
chamber, if people do not feel like they can navigate the VA 
system, whether they are welcome at the VA, whether it is even 
a place that does not overwhelm them, they are not going to 
take advantage of no matter how great of care that you try to 
provide for them.
    So, simply having somebody, especially somebody who can 
help somebody through foreign territory, which, if you are a 
woman walking in there, not only is there for most of our 
generation a generational divide, but a gender divide. So, we 
are strongly supportive of it as well.
    Senator Blumenthal. Great. Mr. Cox?
    Mr. Cox. Senator Blumenthal, I think that peer support is 
really important, and also I think the greatest peer support is 
that at the VA, over one-third of the employees are veterans 
themselves. They are the shining star. They work there. They 
get their care there. They believe in it. They are committed to 
it. I see that committed staff every day as they find veterans 
that are struggling to maneuver the system, that, hey, they 
reach out, they share, even if they are in VHA, about VBA, and 
other benefits, and the coaching and mentoring. I think there 
is no bond greater than what you find amongst veterans, and I 
believe every one of the veteran service organizations would 
join with me in saying, you know, peer support, let us support 
it, but let us also fill those 45,000 vacancies at the VA so 
that every veteran gets all the care they fully deserve.
    Senator Blumenthal. Well said, and points well taken. We 
tend to overlook the fact, all too often, that a vast number of 
the VA employees are veterans themselves, and they care more 
than anyone about keeping faith with our veterans. I think that 
peer support is extremely important and we should recognize, as 
all of you have said that veterans are often the best source of 
care for other veterans, because they tend to understand their 
brothers and sisters, and it is the reason why veterans want 
the VA health care system to continue to exist. I think of all 
the reasons that veterans support the VA health care system, 
that may include the best equipment, medicine, care, but it is 
also the fact that it is provided, often, by veterans, with 
other veterans at their side.
    I want to just say, finally, in the few seconds that I have 
left, I have been working very, very hard on this Appeals 
Improvement and Modernization Act of 2017. This backlog and 
delay in addressing claims by veterans--many, many of them 
justified and deserving--is a scandal for our Nation. The 
present backlog and delay is unacceptable, and I hope that you 
will join me in pursuing the bill, which is based on a 
framework that the VSOs have helped to devise. I want to give 
you credit for it because you have participated, along with 
experts and the VA itself, in the appeal process. It would 
consolidate the current appeals process into distinct lanes 
that can be pursued more efficiently and effectively and fairly 
for our veterans. So, thank you for your help on it and I hope 
we can get it across the finish line.
    Thanks so much. Thank you, Mr. Chairman.
    Chairman Isakson. Thank you, Senator Blumenthal. I want to 
thank all our witnesses from the VSOs for your testimony today. 
Thank all your membership for their support in continuing with 
the Veterans Administration and this Committee's work. I thank 
the VA employees who were here earlier. I think their comments 
made about the value of those employees cannot be overstated. 
They are a tremendous asset for our country. And as Mr. Cox 
said, in the VA I think about one-third of employees are 
veterans themselves, and it means a lot to them to make sure 
they are providing that service as veterans, to the veterans 
who have served this country.
    I appreciate all your testimony and input. We will leave 
the record open for 10 days, if there are additional 
submissions any of you may have. If there are no further 
questions, the Committee will stand adjourned. Thank you all 
for your attendance.
    [Whereupon, at 4:38 p.m., the Committee was adjourned.]
  Response to Posthearing Questions Submitted by Hon. Bill Cassidy to 
Jennifer S. Lee, M.D., Deputy Under Secretary For Health For Policy and 
 Services, Veterans Health Administration, U.S. Department of Veterans 
                                Affairs
    In your prepared remarks, you note that the Veterans Administration 
would like to require the use of ISBT-128 for all biological implants. 
However, I have several concerns with this position, as noted below. 
Could you address these in turn?

    Question 1.  The VA defines biological implants to include 
xenografts (animal-derived grafts) and not just those products of human 
origin. ISBT-128 (International Standard for Blood and Transplantation) 
is only suitable for products of human origin. How do you intend to 
track xenografts that are biological implants? What system will you use 
for those?
    Response. The VA does not intend to use ISBT-128 for all biological 
implants. Only those implants of human origin would be required to have 
a distinct identifier such as provided by ISBT-128. Currently, ISBT-128 
is the only available identifier for this purpose. VA would accept a 
distinct identifier for HCT/P (Human Cell and Tissue Products) from any 
Food and Drug Administration (FDA) approved source. VA's system will be 
robust enough to track any biologic implant including both allografts 
and xenografts. ISBT-128 will only be used for products of human 
origin.
    Non-human products will be able to use GS1 (Global Standard One), 
HIBCC (Health Industry Business Communications Council) or other FDA 
UDI (Universal Device Identifiers) as appropriate.

    Question 2.  My understanding is that there are only 20 tissue 
processors within the U.S. that produce Human Cells, Tissues, and 
Cellular and Tissue-Based Products (HCT/P's) regulated as devices. 
According to a recent survey, of those 20, only 2 currently use ISBT-
128. Have you checked with your vendors to ensure that you could have 
access to HCT/Ps if you move forward with your proposal to limit your 
issuing agency only to ISBT-128?
    Response. VA has checked with its human tissue contractors and has 
been assured that they can provide ISBT-128 labeled tissue. Those who 
currently do not use ISBT-128, have indicated that they will be able to 
do so within a year if requested, at a minimal cost. As a result, VA 
intends to allow for up to a year for a vendor to come into compliance 
when it negotiates its contracts if they are not already using ISBT-
128. It should be emphasized that a distinct identifier like ISBT-128 
is essential to prevent the entry of prohibited tissue sources into the 
VA supply chain. It allows for the readily auditable trail necessary to 
ensure that only properly sourced tissue is in use by VA; the 
underlying intent expressed in the legislation.
    While mechanical implants are regulated differently than human or 
animal derived implants, they could use the same tracking system for 
blood and biologics. A common system would also be useful with the 
emergence of composite devices which combine both mechanical and 
biologic components.

    Question 3.  Obviously, track and trace efforts should be improved 
for all implants--not just biological ones. What efforts are you doing 
to maintain traceability in those areas? My understanding is that the 
vast majority of medical device companies within the U.S. are opting to 
use GS1 (barcodes) for labeling their devices. Does the VA have a 
process for utilizing GS1?
    Response. VA does not have a process for utilizing GS1 at this 
time. Prosthetic & Sensory Aid Services is currently serving as a 
member of a VA cross-functional workgroup led by the Office of 
Strategic Integration (OSI) Veterans Engineering Resource Center (VERC) 
for implant tracking. This workgroup will identify and develop 
processes and process requirements that will meet all requirements 
established by FDA, The Joint Commission, and Congress for the tracking 
of implantable devices by September 30, 2017.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
Jennifer S. Lee, M.D., Deputy Under Secretary For Health For Policy and 
 Services, Veterans Health Administration, U.S. Department of Veterans 
                                Affairs
              s. 899 va veteran transition improvement act
    Question 4.  Deputy Under Secretary Lee, could you comment on the 
VA's current policies related to paid medical leave for your disabled 
veteran employees and how S. 899 would improve on that?
    Response. Current disabled Veteran employees employed in the 
Veterans Health Administration (VHA) may request and use leave for 
medical purposes in accordance with established agency leave 
procedures. The proposal would require VA to establish a leave transfer 
program for the benefit of health care professionals appointed under 38 
U.S.C. Sec. 7401(1) and authorize the establishment of a leave bank 
program for the benefit of such health care providers. Inclusion of 
this provision would ensure that disabled Veteran employees performing 
health care services in Title 38 occupations have the same opportunity 
to schedule medical appointments and receive medical care related to 
their disability without being charged leave as employees in Title 5 
and Hybrid Title 38 occupations.
    According to January 2017 data from the VA, there are over 13,000 
Title 38 critical medical vacancies in the positions not currently 
subject to the Wounded Warrior Federal Leave Act (these are physicians, 
physician assistants, registered nurses, chiropractors, podiatrists, 
optometrists, dentists, and expanded--function dental auxiliaries).

    Question 5.  Does VA have a goal to hire veterans for these 
positions and if so, could you comment on the impact of the additional 
paid medical leave provided in S. 899 on efforts hire disabled 
veterans?
    Response. VHA continues to encourage the hiring of Veterans for 
healthcare occupations, as well as other administrative, technical, 
professional, and clerical occupations. When filling Title 38 
positions, VHA also needs to ensure the best qualified individuals are 
hired to meet the health care needs of our Veteran patients, as well as 
support our health care mission. The proposed legislation may assist in 
the hiring of Veterans for Title 38 occupations. Extending the current 
provisions of 5 United States Code (U.S.C.) section 6329, Disabled 
Veteran Leave, to Title 38 employees appointed under 38 U.S.C. 
Sec. 7401(1) would provide an opportunity for our disabled Veteran 
employees performing health care services in Title 38 occupations to 
have the same opportunity to schedule medical appointments and receive 
medical care related to their disability without being charged leave as 
employees in Title 5 and Hybrid Title 38 occupations. This will provide 
disabled Veteran employees an opportunity to undergo medical treatments 
for their disabilities without having to consider their leave balances 
or work-life issues to obtain such services outside of scheduled work 
hours. Although the disabled Veteran employees would be eligible for 
paid medical leave, the proposal is considered cost neutral as it will 
not increase VHA full-time employee equivalent levels or salaries of 
the employees.
      s. 1094, department of veterans affairs accountability and 
                  whistleblower protection act of 2017
    We all agree that more can be done to increase accountability for 
those at the VA who have betrayed the trust they have been given to 
serve our Nation's veterans.
    While there are some good provisions in S. 1094, I am deeply 
concerned on the implications of the bill's provision lowering the 
evidentiary standard for misconduct removals from a ``preponderance of 
the evidence'' standard (meaning more than 50% of the evidence) to a 
``substantial evidence'' standard (meaning the agency only needs, among 
other things, more than a ``mere scintilla of the evidence'') as the 
Supreme Court defined in its 1971 decision in Richardson v. Perales. 
This new standard would mean that even when the majority of the 
evidence supports the employee, he/she will lose.

    Question 6.  Deputy Under Secretary Lee, can you explain how the VA 
can ensure due process for its employees under this bill when it says 
if the majority of the evidence supports the employee, he/she will 
lose?
    Response. Employees at VA are entitled to constitutional due 
process and will continue to be entitled to constitutional due process 
even if S. 1094 is enacted into law. A change to the burden of proof 
from preponderant evidence to substantial evidence does not change an 
employee's right to constitutional due process.
    At its simplest, constitutional due process requires that an 
individual receive notice of an action affecting the individual's 
interests and a reasonable opportunity to contest that action. 
Sometimes the notice and opportunity to contest must precede the action 
(pre-deprivation); sometimes it may come after (post-deprivation), in 
the form of a post-decisional appeal, whether to a third-party forum 
like the Merit Systems Protection Board (MSPB) or to the courts. Under 
S. 1094, this constitutional due process will not be adversely 
impacted. Under S. 1094, employees will continue to receive notice of a 
proposed disciplinary action, the ability to respond befsore a decision 
is made, and the ability to go to the MSPB or a court.
    With regard to the burden of proof, a substantial evidence standard 
does not mean that an employee will lose, even if the majority of the 
evidence supports them. The MSPB defines ``substantial evidence,'' the 
standard proposed under S. 1094, as the ``degree of relevant evidence 
that a reasonable person, considering the record as a whole, might 
accept as adequate to support a conclusion, even though other 
reasonable persons might disagree.'' 5 CFR Sec. 1201.4(p). Substantial 
evidence is ``a lower standard of proof than preponderance of the 
evidence.'' Id.
    The MSPB's definition of ``substantial evidence'' is echoed in 
Richardson v. Perales, a case that pertains to a social security 
disability claim rather than the Federal civil service. Richardson v. 
Perales, 402 U.S. 389, 401 (1971) citing Consol. Edison Co. v. Nat'l 
Labor Relations Bd., 305 U.S. 197, 229 (1938) (substantial evidence is 
``more than a mere scintilla [of evidence and it] means such relevant 
evidence as a reasonable mind might accept as adequate to support a 
conclusion''). But, the MSPB further explains that, in the Federal 
civil service context, substantial evidence ``obliges the presiding 
official to determine only whether, in light of the relevant and 
credible evidence[,] a reasonable person could agree with the agency's 
decision (even though other reasonable persons including the presiding 
official might disagree with that decision). Parker v. Def. Logistics 
Agency, 1 M.S.P.R. 505, 531 (M.S.P.B. 1980).
    The MSPB currently uses the substantial evidence standard to 
adjudicate agency actions taken based on performance. See 5 U.S.C. 
Sec. 7701(c)(1); 5 CFR Sec. 1201.56(b)(1)(i). Even with this lower 
burden of proof, there are numerous cases where the MSPB and its 
reviewing court have determined that the agency failed to meet this 
lower burden of proof. See, e.g., Parkinson v. Dep't of Justice, 815 
F.3d 757, 766 (Fed. Cir. 2016); Thompson v. Dep't of the Army, 122 
M.S.P.R. 372, 381-82 (M.S.P.B. 2015); Smith v. Dep't of Veterans 
Affairs, 59 M.S.P.R. 340, 342-43 (M.S.P.B. 1993); Cranwill v. Dep't of 
Veterans Affairs, 52 M.S.P.R. 610, 616 (M.S.P.B. 1992). Consequently, 
it is doubtful that, even with a lower evidentiary burden, the MSPB 
would always agree with an action taken by VA or that, even if the 
majority of the evidence supports an employee, he or she will not 
succeed in a disciplinary appeal before the MSPB.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to 
     J. David Cox, Sr., National President, American Federation of 
                     Government Employees, AFL-CIO
      s. 1094, department of veterans affairs accountability and 
                  whistleblower protection act of 2017
    Introduction: President Cox, in your testimony you reference the 
unworkable timeframes for appeals using the Grievance and Arbitration 
Procedures in the Collective Bargaining Agreement.
    Question 1. Can you explain how the short timeframes would threaten 
the reliability of the collective bargaining process?

    Question 2. Can you share with the Committee any real-life examples 
of how this would impact your rank and file employees and possibly even 
reverse some removal decisions that were in favor of the employee due 
to the lowering of the evidentiary standard?

    [Responses were not received within the Committee's timeframe for 
publication.]

                            A P P E N D I X

                              ----------                              


    Prepared Statement of Hon. Thom Tillis, U.S. Senator from North 
                                Carolina
    Please accept my apologies for not being here this afternoon--I was 
running in the Capitol Challenge 5K this morning and unfortunately was 
not able to finish the race, even though I was well on my way to easily 
eclipsing my time from last year.
    I just want to briefly comment on two bills on the agenda:

     On the Veterans Education Priority Enrollment Act--I 
appreciate VA's support and the valuable feedback we received from all 
the stakeholders. I understand some of the compliance concerns that 
were raised and I look forward to discussing with Senator Brown to 
identify the best path forward that will allow flexibility for schools 
that are already setting the gold standard while ensuring that all 
veterans have the opportunity to use their GI bill to the fullest 
extent.
     On the State Veterans Home Adult Day Health Care 
Improvement Act--I thank Senator Hatch for his leadership and I look 
forward to engaging with VA to address their recommendations that would 
improve the bill. Together, we can empower veterans to receive daily 
care while living and spending more time at home with their families.
                                 ______
                                 
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
                                 ______
                                 
Prepared Statement of Lauren Augustine, Director, Government Relations, 
                               Got Your 6

 
----------------------------------------------------------------------------------------------------------------
  Bill
  Num.                       Bill Name or Subject                               Sponsor            IAVA Position
----------------------------------------------------------------------------------------------------------------
   S.290 Increasing the Department of Veterans Affairs                             Sen. Moran        Supports
          Accountability to Veterans Act of 2015
----------------------------------------------------------------------------------------------------------------
    S.23 Biological Implant Tracking and Veteran Safety Act                              Sen.CassiNo Position
----------------------------------------------------------------------------------------------------------------
   S.112 Creating a Reliable Environment for Veterans' Dependents           Sen.Heller (R-NV)         Support
          Act
----------------------------------------------------------------------------------------------------------------
   S.324 State Veterans Home Adult Health Care Improvement Act               Sen.Hatch (R-UT)     No Position
----------------------------------------------------------------------------------------------------------------
   S.543 Performance Accountability and Contractor Transparency             Sen.Tester (D-MT)     No Position
          Act
----------------------------------------------------------------------------------------------------------------
   S.591 Military and Veteran Caregivers Services Improvements Act           Sen.Murray(D-WA)         Support
----------------------------------------------------------------------------------------------------------------
   S.609 Chiropractic Care Available to All Veterans Act                     Sen.Moran (R-KS)     No Position
----------------------------------------------------------------------------------------------------------------
   S.681 Deborah Sampson Act                                                Sen.Tester (D-MT)         Support
----------------------------------------------------------------------------------------------------------------
   S.764 Veterans Education Priority Enrollment Act                          Sen.Brown (D-OH)     No Position
----------------------------------------------------------------------------------------------------------------
   S.784 Veterans' COLA Act                                                Sen.Isakson (R-GA)     No Position
----------------------------------------------------------------------------------------------------------------
   S.804 Women Veterans Access to Quality Care Act                          Sen.Heller (R-NV)         Support
----------------------------------------------------------------------------------------------------------------
   S.899 Veteran Transition Improvement Act                                 Sen.Hirono (D-HI)     No Position
----------------------------------------------------------------------------------------------------------------
  S.1024 Veterans Appeals Improvement and Modernization Act                Sen.Isakson (R-GA)         Support
----------------------------------------------------------------------------------------------------------------
  S.1094 Accountability and Whistleblower Protection Act                     Sen.Rubio (R-FL)         Support
----------------------------------------------------------------------------------------------------------------
   Draft Serving our Rural Veterans Act                                   Sen.Sullivan (R-AK)         Support
----------------------------------------------------------------------------------------------------------------
   Draft Veteran Partners' Efforts to Enhance Reintegration Act            Sen.Blumenthal (D-CT)      Support
----------------------------------------------------------------------------------------------------------------


    Chairman Isakson, Ranking Member Tester 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.
    This month, we celebrated the five-year anniversary of Got Your 6. 
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 partners, and 
leading an effort to change the national narrative around veterans as 
``broken heroes.'' Building on that success, Got Your 6 was proud to 
launch a policy department early in 2017 aimed at bringing the existing 
successes of the veteran empowerment movement and messaging to 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 
only ``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.
 s. 112, the creating a reliable environment for veterans' dependents 
                                  act
    The Creating a Reliable Environment for Veterans' Dependents Act 
would allow VA-funded homeless shelters to be reimbursed for services 
provided to dependents of veterans.
    Got Your 6 supports this bill, appropriately resourced by Congress, 
as a means to empower veterans with dependents out of homelessness and 
back into their communities. At Got Your 6, we view families and 
dependents as part of the whole of a veteran. Excluding coverage for 
veterans' dependents from the care and services at homeless shelters 
has the potential to exacerbate the complications of homelessness for a 
vulnerable population of veterans and could perpetuate homelessness.
    Allowing the VA to reimburse homeless shelters for veterans' 
dependents goes beyond providing families a place to sleep. The 
ancillary services, such as employment training, available to veterans 
utilizing VA's homeless services, provide the critical tools necessary 
to ensure long-term successful integration into the civilian world. 
Veterans with dependents could especially benefit from these services 
and use them to empower themselves and their families into sustainable 
housing and stronger community reintegration.
  s. 591, the military and veteran caregivers services improvement act
    The Military and Veteran Caregivers Services Improvement Act would 
expand the current VA caregivers program to veterans of all eras, 
expand eligibility parameters for the program, create a national 
interagency working group, and add additional services to the program, 
among other provisions.
    Veteran and military caregivers provide daily care for our Nation's 
most grievously wounded veterans, often leading to their own 
employment, financial, and health challenges. The VA's current 
caregiver program is intended to provide comprehensive support for 
these individuals, connecting them with VA professionals who can aid 
and empower them to best support their veteran while leading fulfilling 
lives of their own. However, the current program is limited to 
caregivers of post-9/11 veterans leaving the vast majority of 
caregivers with limited support and resources.
    Got Your 6 supports this legislation--services and support intended 
to empower caregivers should not be tied to a specific generation of 
service. Got Your 6 appreciates the VA's concerns with expanding its 
current caregiver program and recognizes such an expansion would 
require significant staff resources and appropriations but believes the 
need for expansion is necessary.
                    s. 681, the deborah sampson act
    The Deborah Sampson Act would support the VA's mission to 
adequately meet the needs of women veterans by: increasing peer-to-peer 
assistance, encouraging greater collaboration with community partners, 
expanding maternity and newborn care, eliminating existing barriers to 
care, and collecting and disseminating data specific to women veterans.
    Since our Nation's founding, and especially over the last 16 years, 
women have served in a variety of roles in our Armed Forces, but their 
service is often overlooked and their needs misunderstood by the VA and 
the American public. This March, Got Your 6 challenged the national 
narrative around women veterans by launching the PSA #ShesBadass to 
better illustrate the truly remarkable service of women.
    According to VA data, women now total almost 11 percent of all 
veterans, including 20 percent of veterans under the age of 50, yet 
many people under appreciate their contributions and accomplishments. 
For example, after exiting the military, women veterans are more likely 
to attend and complete higher education degrees compared to their male 
veteran or civilian counterparts; have higher average incomes than non-
veterans ($54,000 vs. $44,000); and are more likely to work in 
management roles and professions compared to their non-veteran 
counterparts. Women veterans are a force of impactful change for our 
Nation as a whole and empowering them to continue to do so only 
strengthens us all.
    While our #ShesBadass campaign serves as a powerful tool in helping 
to reshape the way America views women veterans, there are still real 
challenges many women face when seeking care and benefits at the VA. 
Got Your 6 supports S. 681 as it reduces barriers to care and benefits 
and better equips the VA to address some of the challenges women 
continue to face. The veteran community's support of this legislation 
cannot be held in a vacuum; such transformational change will also 
require adequate appropriations and a continued commitment from VA 
leadership to make equity a priority.
    However, better delivery of benefits and care by the VA should not 
be viewed as the only means to empower women veterans, and it risks 
excluding and further marginalizing those women who choose not to 
utilize the VA. We encourage this Committee to challenge their own 
views on women veterans, to seek out and highlight resources that 
empower women in their communities outside the VA, and leverage the 
amazing contributions women veterans are making to society across the 
country.
         s. 804, the women veterans access to quality care act
    The Women Veterans Access to Quality Care Act would require 
improvements to VA infrastructure, include women's health outcomes as a 
performance measure for VA medical center executives, mandate improved 
policies for environment of care inspections, and ensure greater access 
to Obstetricians-Gynecologists, among other provisions.
    As stated above, Got Your 6 has been a leader in highlighting the 
strength of women veterans through our #ShesBadass campaign, but we 
also recognize the VA continues to have challenges in adequately 
meeting the needs of women veterans seeking care at VA facilities. We 
support S. 804 and the improvements to VA policies and infrastructure 
included in the bill that will address some of these deficiencies. 
Again, we reiterate that these changes cannot be accomplished without 
adequate resources and continued leadership on the issue across the VA 
enterprise.
      s. 1024, veterans appeals improvement and modernization act
    The Veterans Appeals Improvement and Modernization Act would 
address many of the challenges experienced under the current disability 
claims appeals process by creating three routes for veterans to choose 
from if they want to appeal the initial decision made on a claim for VA 
benefits, allowing those veterans currently going through the appeals 
system to opt in to the new system, requiring the VA to test the new 
system before full implementation, and requiring the VA to submit a 
plan on full implementation of the new system and how it will process 
existing appeals.
    Comprehensive appeals modernization is a long-standing priority of 
the veteran community. The current, antiquated system is under the 
burden of a significant backlog, which can often leave veterans waiting 
years for a decision. Eligibility for many of the empowering services 
and benefits offered by the VA are tied to these appeals decisions, 
leaving some veterans in limbo. Additionally, the VA workforce can be 
more efficient in its operations under this new system, opening up 
resources and opportunities for greater efficiency in benefit delivery. 
Because of this, Got Your 6 supports this legislation and encourages 
Congress to finally address the VA's need for a modernized appeals 
process.
      s. 1094, department of veterans affairs accountability and 
                      whistleblower protection act
    This bill comprehensively addresses workforce management needs at 
the VA by shortening the removal process, ensuring removed employees 
are not kept on VA payroll while in the appeal process, and ensuring 
due process protections for whistleblowers, among other provisions.
    The need to provide the VA Secretary greater workforce management 
flexibility has been frequently debated and discussed by many in the 
veteran community over the last three years. But, progress on enacting 
legislation to address this need has continuously stalled due to 
partisan gridlock and legitimate legal concerns over Constitutional 
workforce protections.
    Got Your 6 is encouraged by the bipartisan nature of this bill and 
we support this legislation as a means to provide VA's leadership more 
efficient workforce management options. Our support being stated, we 
also call on leaders within this Committee to work with their 
counterparts in the House of Representatives to address any potential 
differences in intent and specific language, which has stalled movement 
on this issue for three years.
                 draft, serving our rural veterans act
    This bill would create a pilot program to cover the costs 
associated with medical residencies and internships in partnership with 
tribal health care facilities.
    A shortage of health care providers, and mental health care 
providers in particular, is not a unique VA problem, it's an American 
problem. This shortage is felt even more acutely in our rural 
communities where recruitment and retention are especially difficult. 
The pilot program established in this legislation would help address 
some of these barriers by leveraging and expanding the existing 
partnership with tribal health care facilities and allows the VA to 
cover expenses of medical residencies at such facilities.
    Got Your 6 supports this legislation as it encourages the VA to 
continue seeking ways to increase its operational efficiencies and its 
ability to successfully meet the needs of veterans regardless of their 
location. Additionally, this bill could serve the national population 
at-large by creating a lesson in best practices for ways the Federal 
Government can help address the overall provider shortage. We also 
encourage Congress to work with the VA to address any concerns related 
to the implementation and intent of the bill to ensure maximum impact 
and success of such a pilot program.
   draft, the veteran partners' efforts to enhance reintegration act
    This bill would expand the VA's peer support model, currently used 
in mental health care, into the primary care setting.
    Recognizing the importance of addressing common mental health care 
concerns in the primary care setting, the VA has begun to co-locate 
mental health care providers in the primary care setting. This supports 
the VA's unique ability to integrate services and reduce the burden of 
seeking multiple facets of care for veterans. However, peer support 
specialists, who we believe are integral, have yet to be integrated in 
a similar manner.
    The VA's peer support program is directly aligned with the mission 
of Got Your 6: it aims to empower veterans with the tools necessary to 
successfully reintegrate fully into the community. Peer Specialists do 
this partly through storytelling and sharing their own paths to 
success. Got Your 6 believes storytelling is a powerful way to empower 
veterans, reduce the civilian-military divide, and destigmatize seeking 
help when needed and strongly supports this bill as a means to grow the 
peer support program at the VA to meet those objectives.
    In conclusion, Got Your 6--through our 34 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 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 status quo.
    The veteran empowerment movement also addresses the majority of 
veterans who do not use the VA. Got Your 6 encourages this Committee to 
consider holding a topical hearing on community programs and veteran 
organizations currently meeting the needs of and empowering veterans 
outside the walls of VA facilities.
    We would like to thank this Committee for its leadership on 
veterans' issues and look forward to working together to empower all 
veterans.
                                 ______
                                 
     Prepared Statment of Military Officers Association of America
    Chairman Isakson, Ranking Member Tester, 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.
    This is a critical time for the Department of Veterans Affairs (VA) 
as the agency continues its aggressive transformation efforts. MOAA 
believes many of the bills being considered today will buildupon the 
work of the Committee and the secretary of VA to further enhance the 
agency's health and benefits systems. Our association looks forward to 
working with the members and staff to strengthen and improve the 
legislation enacted this year.
    MOAA offers our position on the following select bills. MOAA takes 
no position on the remaining bills before the Committee, as some are 
outside our scope of expertise.
Health Care:
     S. 112, Creating a Reliable Environment for Veterans' 
Dependents Act
     S. 591, Military and Veteran Caregiver Services 
Improvement Act of 2017
     S. 681, Deborah Sampson Act
     S. 784, Veterans' Compensation Cost-of-Living Adjustment 
Act of 2017
     Draft Bill, Serving Rural Veterans Act of 2017
Benefits/Accountability:
     S. 1024, Veterans Appeals Improvement and Modernization 
Act of 2017
     S. 1094, Department of Veterans Affairs Accountability and 
Whistleblower Protection Act of 2017
                              health care
    S. 112, Creating a Reliable Environment for Veterans' Dependents 
Act--The bill would authorize per diem payments for homeless veterans 
receiving comprehensive support services in order to furnish care to 
their dependents.
    MOAA supports the bill. Veteran homelessness continues to be a high 
priority for the VA and our Nation. Since the VA launched a massive 
campaign to end veteran homelessness in 2009, rates have steadily 
declined, down by nearly 50 percent. While rates are declining, 
veterans with families have been increasing in recent years. As the VA 
continues to serve more veterans than ever by providing health care, 
education, job training, and many other wellness and welfare services, 
there is still more to be done--and the needs are so much greater for 
veterans with children. Per diem payments for homeless veterans will go 
a long way toward giving veterans a hand up as they move down a path to 
achieving family stability and long-term security.

    S. 591, Military and Veteran Caregiver Services Improvement Act of 
2017--This measure expands eligibility and comprehensive assistance and 
benefits for family caregivers participating in the VA's Caregiver 
Support Program.
    Specifically, the bill expands eligibility for participation and 
services to family caregivers of veterans of all eras, rather than the 
current population of post-9/11 veterans, and includes `illness,' 
rather than just `serious injury,' as a criterion for eligibility.
    Additionally, the measure provides for a number of other program 
expansions, including:

     Child care services or monthly stipend for such services;
     Financial planning and legal services;
     Adjustment to calculating caregiver stipend for performing 
personal care services;
     Authority to transfer entitlement of unused post-9/11 
education benefits to family members;
     Flexible work arrangements for certain Federal employees;
     Lifespan respite care; and
     Establishment of an interagency working group on caregiver 
policy.

    MOAA generally supports the measure. Since passage of Public Law 
111-163, the Caregivers and Veterans Omnibus Health Services Act of 
2010, MOAA and our partners in The Military Coalition have supported 
the expansion of eligibility for the Caregiver Support Program to 
veterans with illnesses and to those who served before Sept. 11, 2001.
    Given the current challenges and assessment of the program, MOAA 
would not support the additional program expansions in the bill at this 
time until the VA has completed a thorough review of the program and 
offered recommendations to Congress on how to improve the program. The 
association, however, does support the establishment of an interagency 
working group as a valuable asset to the VA as it reforms and refines 
the Caregiver Support Program going forward.
    MOAA urges the Committee to adopt the provisions to expand 
eligibility to veterans who served before Sept. 11, 2001, and veterans 
with illnesses and to establish an interagency working group on 
caregiver policy.

    S. 681, Deborah Sampson Act--The bill would improve the benefits 
and services provided by the VA to women veterans. Women are joining 
the military at rates unlike any other time in history, and they are 
accessing VA health care at higher rates than male veterans. While the 
VA has worked hard to address the growing demand, the department 
requires additional resources to implement system improvements and 
services to meet current and future needs of women veterans.
    MOAA supports S. 681. Offering peer-to-peer assistance and legal 
and supportive services, extending newborn care, eliminating barriers 
to access, and establishing data collection and reporting requirements 
will help the VA better target the needs of women and minority 
veterans. MOAA, however, takes no position on Sec. 504, Sense of 
Congress on changing the motto of the VA to be more inclusive.

    S. 784, Veterans' Compensation Cost-of-Living Adjustment Act of 
2017--Each year legislation is introduced to provide a cost-of-living 
increase in compensation rates for veterans with service-connected 
disabilities and the rates of dependency and indemnity compensation for 
survivors of veterans. This bill provides for such increase effective 
Dec. 1, 2017.
    MOAA supports S. 784.

    Draft Bill, Serving Rural Veterans Act of 2017--The bill would 
authorize the VA to pay for the costs of training and supervision of 
medical residents and interns at certain non-department facilities. 
Additionally, the bill would require the secretary to conduct a pilot 
program to establish or affiliate with residency programs at facilities 
operated by the Indian tribes, tribal organizations, and the Indian 
Health Service.
    American Indians and Alaska Natives have historically had the 
highest rates of representation in the Armed Forces. The VA has 
dedicated significant attention and resources to addressing the unique 
needs of Native American veterans as well as veterans who live in very 
rural areas where access to quality health care can be a challenge. The 
department has worked hard in recent years to develop partnerships to 
expand access to services and benefits for Native American veterans and 
their families so they are able to access the benefits they have 
earned.
    MOAA supports the draft legislation. This legislation builds on the 
existing work the VA has undertaken to improve access for Native 
Americans and rural veterans. The bill would provide the VA with 
additional tools to strengthen existing relationships and agreements 
with the Indian Health Service and tribal health organizations, as well 
as $20 million over an eight-year period to pilot critical educational 
and training initiatives for residency, intern, and graduate medical 
education pilot programs.
                        benefits/accountability
    S. 1024, Veterans Appeals Improvement and Modernization Act of 
2017--This bill makes fundamental changes to the VA claims adjudication 
process. It would break up claims processing into three separate lanes, 
each representing a different phase of the claims process.
    MOAA supports the bill. It is indisputable that the VA claims 
adjudication process is an unworkable solution, and for years the 
veterans' community has urged Congress and the VA to update these 
procedures. MOAA appreciates that the bill defines ``supplemental 
claim,'' makes clear the duty to assist applies to supplemental claims, 
and provides additional effective date protections. Improvements, 
however, can be made in the legislation.
Board of Veterans' Appeals Dockets
    This bill sets forth that the Board of Veterans' Appeals shall 
maintain two dockets, one for claimants requesting a hearing before the 
board and the other for claimants not requesting a hearing before the 
board.
    MOAA supports allowing claimants the opportunity to submit evidence 
to the board directly. This allows claimants with legally complex 
claims to have a veterans law judge consider that evidence in 
conjunction with the questions of law instead of cycling through the 
agency of original jurisdiction (AOJ), where the AOJ may lack the legal 
acumen to adequately resolve the claim.
    MOAA recommends the legislation be modified to provide that 
claimants submitting evidence directly to the board be placed on the 
``non-hearing docket.'' This is the closest docket fit to their 
circumstances because the claimant is not requesting a hearing. 
Further, regardless of whether a claimant's appeal includes additional 
evidence or not, the veterans law judge will be required to review 
evidence within the record. In other words, if a claimant merely 
appeals without submitting additional evidence, the board must still 
review all existing evidence in the record. Thus, the choice not to 
submit additional evidence does not prevent the board from having to 
review evidence.
    We do not recommend the other option of placing these appeals on 
the ``hearing docket,'' as this would disproportionately disadvantage 
the claimant. During roundtable discussions leading up to appeals 
reform legislative proposals, VA officials stated the hearing docket 
would be much slower than the non-hearing docket. It is unjust to force 
claimants not requesting hearings to wait behind those requesting 
hearings for the board to address their appeals, where it does not 
require any additional work of the veterans law judge to consider the 
additional evidence.
    The VA has expressed concerns that including claimants with 
additional evidence amongst those without additional evidence on the 
same docket would confuse the ``feedback loop,'' but we believe this is 
manageable. The feedback loop permits the board to provide input to the 
AOJ regarding errors the AOJ committed in the original adjudication of 
the claim. There appears to be no reason, however, the Board could not 
simply exclude the claims with additional evidence from the feedback 
loop and still provide very useful feedback to the AOJ from the 
remaining claims.
Collaboration with Veterans Service Organizations
    MOAA greatly appreciates that the legislation mandates the VA 
collaborate with and give weight to the inputs of veterans service 
organizations. MOAA recommends, however, that references to ``the three 
veterans service organizations with the most members'' be modified to 
``the three veterans service organizations that file the most claims on 
behalf of claimants.'' Veterans service organizations serve many 
functions in the veteran community, not exclusively confined to filing 
VA benefits claims. Merely because a veterans service organization has 
a large number of members does not necessarily mean the organization is 
the best advisor related to the VA claims process. A more reliable 
gauge of a veterans service organization's value to the process is the 
number of VA claims filed by the organization. The Veterans Benefits 
Administration already tracks the number of claims filed by each 
veterans service organization, making this information readily 
available to VA.
Fully-Developed Appeals
    MOAA supports granting the secretary the authority to carry out a 
fully-developed appeals program because it would allow a claimant to 
expedite a claim to the board with all evidence needed for the appeal. 
This goal is consistent with the overall intent of VA appeals 
modernization.
    This process would also be almost identical to the process for a 
claimant participating in the modernized appeals process who chooses to 
submit additional evidence for the board's consideration. For that 
reason, MOAA recommends appeals processed using this option be docketed 
in the non-hearing option. This would prevent the need for the board to 
maintain a third docket, as the legislation currently contemplates. A 
third docket with varying processing rules would be very confusing to 
claimants in understanding whether their claim is being handled 
properly.
    Although this legislation includes extensive changes to the VA 
claims process, MOAA believes further efforts will be necessary by 
Congress to improve the process, including, but not limited to, 
addressing the precedential value of agency determinations and giving 
equal consideration to both private and VA medical evidence.

    S. 1094, Department of Veterans Affairs Accountability and 
Whistleblower Protection Act of 2017--This bill will provide the 
secretary of VA with additional authorities to expedite the removal of 
VA employees when warranted. MOAA's understanding is the bill would 
allow VA employees to still utilize employee union representation, 
merely within the timeline provided in the legislation.
    MOAA supports this bill. The secretary should have all authorities 
and resources necessary to effectively manage the VA workforce. 
Although VA employees are predominantly very good at caring for 
veterans and take this responsibility very seriously, it is clear from 
recent events there are VA employees who do not and who have spent 
years embroiling the agency in protracted litigation at taxpayer 
expense, despite their clear disregard for the best interests of 
veterans. MOAA believes the agency should be allowed to focus on 
veterans' needs, and these expedited authorities will allow the 
secretary to do so.

    MOAA thanks the Committee for considering this important 
legislation and for your continued support of our veterans and their 
families.
                                 ______
                                 
    Prepared Statement of CDR John B. Wells, USN (Ret.), Executive 
               Director, Military-Veterans Advocacy Inc.

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  Prepared Statement of John Kriesel, Legislative Chairman, National 
            Association of County Veterans Service Officers
    Good afternoon Chairman Isakson, Ranking Member Tester, and Members 
of the Committee, It is truly my honor to present this written 
testimony for this hearing. As Legislative Chairman of the National 
Association of County Veterans Service Officers, I am submitting this 
testimony, to give our organization's support for S. 1024, The Veterans 
Appeals Improvement and Modernization Act of 2017.
    The National Association of County Veterans Service Officers is an 
organization made up of over 1,600 local government employees that 
advocate for veterans daily across all facets of veterans' benefits. We 
believe we can help the Department of Veterans Affairs reduce the 
number of cases in the Board of Veterans Appeals (BVA) inventory, 
currently standing at 469,000 appeals. As an organization, we feel this 
legislation is a needed step in the right direction. It is imperative 
that the VA and all Veteran Service Organizations work together to 
relieve claimants of the extreme wait times for decisions from the BVA.
    There are many reasons appeals are generated out of County offices 
every day, it starts with VA Regional Offices failing to explain their 
decision in a way that makes sense to the veteran, and VA's 
unwillingness to work with veterans' advocates on addressing 
inaccuracies in a rating decision. The reason for this is, simply, 
because there is no incentive for the rating authority to work with 
veterans or their advocates. Instead, they must meet quotas to prove 
efficiency and very commonly County Veteran Service Officers are 
instructed DRO's (Decision Review Officers) to appeal to the BVA in 
lieu of them correcting the decision. This practice is one of the main 
contributing factors for the 469,000 appeals backlog at BVA. The 
sweeping changes in the appeals process included in S. 1024 are why 
NACVSO supports this legislation. Claimants in the new process will 
experience less waiting times, and VA Regional Office staff will 
receive meaningful feedback from the BVA on cases that have been 
remanded or overturned. For VA to work efficiently, guidance from the 
BVA on legal discrepancies in initial claims, must be done and within a 
timely fashion that offers solutions to misinterpreted regulations at 
the VARO level.
    While we support S. 1024, we feel that it is important that we 
address our concern with a portion of the legislation. NACVSO believes 
every step in the claims process is an opportunity to adjudicate the 
claim in the claimants' behalf. As the claim continues to mature in the 
process the arguments are solely based on law and legal precedence. To 
allow a claim back into the Regional Office within one year of a Court 
of Appeals for Veterans Claims (CAVC) decision would require the local 
staff to rule against a board of judges. In practicality, the case 
would not receive a fair hearing again until it returns to the BVA. 
Allowing the claims cycle to continue on this journey promotes for-
profit attorneys to keep the case alive based on little to no merit. 
Allowing this will keep the appeals backlog at an unnecessarily high 
number. The process today, and in this proposal, needs to have 
finality. If the CAVC decision maintains a denial on legal grounds the 
attorneys representing that case need to have the wherewithal to 
advance the case to next higher court or simply inform the veteran that 
until evidence can be discovered that would weigh heavily in the 
reversing the decision, the claim and effective date will expire.
    As an organization, the National Association of County Veteran 
Service Officers support the majority of changes included in S. 1024. 
We are proud to stand next to the Department of Veterans Affairs, 
fellow Veteran Service Organizations and Congress as we work toward a 
solution that will deliver quality and timely benefits to our veterans 
and their dependents.
                                 ______
                                 
    Prepared Statement of Dr. Joseph Wescott, Legislative Director, 
            National Association of State Approving Agencies
    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee, The National Association of State Approving Agencies (NASAA) 
is pleased to provide its views on certain education benefits 
legislation under consideration by the Committee today, May 17, 2017, 
particularly S. 764.
    NASAA does not receive any grants or contracts directly from the 
Federal Government, though its member organizations are state agencies 
operating in whole or in part under Federal contracts funded by 
Congress and administered by the Department of Veterans Affairs (VA).
    On behalf of fifty-two State approving agencies (SAAs), including 
the territory of Puerto Rico and the District of Columbia, NASAA thanks 
the Senate Committee on Veterans Affairs for its strong commitment to a 
better future for all servicemembers, veterans and their families 
through its continued support of the GI Bill educational program.
 S. 764, a bill to amend title 38, United States Code, to improve the 
 enrollment of veterans in certain courses of education, and for other 
                               purposes.
    State approving agencies take seriously our role as ``the 
gatekeepers of quality'' and the ``boots on the ground'' defending the 
integrity of the GI Bill and making sure that only quality programs are 
approved by applying Federal and state law and regulation. An 
additional and equally important role is the continued oversight of 
these programs after their initial approval. We do so in conjunction 
with other stakeholders in veteran organizations and higher education, 
including state licensing agencies, state higher education departments, 
the Department of Veterans Affairs, the Department of Education and 
national and regional accrediting agencies.
    We also seek to encourage our approved institutions to provide 
resources and policies which will help guarantee the success of our 
veteran students once they enroll in an SAA approved program. Congress, 
in establishing the laws and regulations governing the manner and 
method by which education could be approved for veterans, has wisely 
provided that the States, through their State approving agencies are 
best situated and staffed to evaluate and oversee educational 
programming being considered for approval and being continued for GI 
Bill payment. Certainly, it is not inappropriate for Congress to 
consider establishing, as a part of requirements for approval that 
educational institutions will extend to veterans the same priority 
registration rights that they provided to other groups or classes of 
students within their institutions. However, we think that given the 
consequences of failing to do so (i.e. none of the institutions 
programs can be approved for reimbursement under the GI Bill), it is 
important that Congress allow the institutions maximum control over how 
the priority enrollment policy is implemented. For instance, the 
following wording ``the Secretary or a State approving agency may not 
approve a program of education offered by such institution unless such 
institution allows a covered individual to enroll in courses at the 
earliest possible time pursuant to such priority enrollment system,'' 
should be amended to allow institutions to implement this requirement 
in such a way that veterans would not compete for classes with students 
from other earlier class years. Likewise, since some schools will need 
time to implement this on their campuses, we would suggest that 
schools, which are already approved and have priority registration 
systems in place, be given adequate time to respond to the new approval 
requirements.
    Finally, we would point out the recent legislation enacted by 
Congress recognizes the primary role played by State approving agencies 
in the area of program approval. As such we would request that Congress 
change the wording of 3680B(a) to read, ``a State approving agency, or 
the Secretary when acting in the absence of a State approving agency, 
may not approve . . .''
    Given the fact that many leading institutions of education, 
particularly accredited public institutions of higher learning (IHLs), 
are already offering student veterans priority enrollment, we don't 
think that it is unreasonable to require that educational institutions 
offering this privilege to other student groups on their campus provide 
it to veterans as well.
    For the reasons cited above, NASAA respectfully requests that the 
language of this bill be changed so that the manner and method of 
offering priority enrollment to veterans will not impede the 
graduation/progress of those students in classes senior to them. 
Likewise, we suggest the insertion of an effective date to allow 
already approved institutions time to develop and implement this 
requirement. Finally, the primary role of the States in the approval of 
programs should be protected and reflected in the language of the bill. 
With those amendments, NASAA supports this bill.
    Today, SAAs throughout our Nation, composed of approximately 175 
professional and support personnel, are supervising over 10,000 active 
facilities with 100,000 programs. We pledge to you that we will not 
fail in our critical mission and in our commitment to safeguard the 
public trust, to protect the GI Bill and to defend the future of those 
who have so nobly defended us. Mr. Chairman, NASAA thanks the Committee 
for the opportunity to share our concerns and suggestions and we commit 
to working together with you and your staff to enhance the pending 
legislation.
                                 ______
                                 
Prepared Statement of Randy Reeves, President, National Association of 
                  State Directors of Veterans Affairs

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  Prepared Statement of Fred S. Sganga, Legislative Officer, National 
                  Association of State Veterans Homes
    Mr. Chairman and Members of the Committee, On behalf of the 
National Association of State Veterans Homes (NASVH), I am pleased to 
submit this testimony in strong support of S. 324, the State Veterans 
Home Adult Day Health Care Improvement Act of 2017, legislation 
introduced by Senators Orrin Hatch (R-UT) and Mazie Hirono (D-HI) to 
provide severely disabled veterans with an enhanced option to receive 
adult day health care services from State Veterans Homes. Similar 
legislation was introduced late in the Senate during the 114th Congress 
(S. 3198), however no further action was taken prior to adjournment 
last year. A companion House bill (H.R. 2460) did pass the full House 
last year without opposition and has been reintroduced (H.R. 1005) in 
the 115th Congress. Both the Senate and House bills were reviewed by 
the Congressional Budget Office (CBO) last year and neither received a 
score that needed to be offset; similar CBO scoring is anticipated for 
the reintroduced bills.
    The State Veterans Home program was established by a Congressional 
Act on August 27, 1888, and for more than 125 years State Homes have 
been in a partnership with the Federal Government to provide long term 
care services to honorably discharged veterans; in some states, widows 
and spouses as well as Gold Star Parents are also eligible for 
admission. There are currently 153 State Veterans Homes located in all 
50 states and the Commonwealth of Puerto Rico. The National Association 
of State Veterans Homes (NASVH) was conceived at a New England 
organizational meeting in 1952 because of the mutual need of State 
Homes to promote strong Federal policies and to share experience and 
knowledge among State Home administrators to address common problems. 
NASVH is committed to caring for our Nation's heroes with the dignity 
and respect they deserve.
    With over 30,000 beds, the State Veterans Home program is the 
largest provider of long term care for our Nation's veterans. Current 
services provided by State Homes include skilled nursing care, 
domiciliary care and adult day health care. The Department of Veterans 
Affairs (VA) provides State Homes with construction grants to build, 
renovate and maintain the Homes, with States required to provide at 
least 35 percent of the cost for such projects in matching funds. State 
Veterans Homes also receive per diem payments for basic skilled nursing 
home care, domiciliary care and ADHC from the Federal Government which 
covers about one third of the daily cost of care.
    Mr. Chairman, a decade ago NASVH led the effort on Capitol Hill to 
assist our most disabled veterans by allowing them to receive skilled 
nursing care in State Veterans Homes under a new program that would 
provide the ``full cost of care'' to the State Home and thereby expand 
the options available to these deserving veterans at no cost to them. 
In 2006, Congress passed and the President signed Public Law 109-461 
which guaranteed ``no cost'' skilled nursing care to any honorably 
discharged veteran who has a 70% or higher service-connected disabled 
rating, or requires nursing care due to a service-connected disability. 
Unfortunately, the bill did not extend the same ``no cost'' program to 
alternatives to traditional institutional care, such as the medical 
supervision model Adult Day Health Care currently provided at three 
State Veterans Homes in Stony Brook, New York, Minneapolis, Minnesota 
and Hilo, Hawaii. S. 324 would fix that.
    Adult Day Health Care is designed to promote wellness, health 
maintenance, socialization, stimulation and maximize the participant's 
independence while enhancing quality of life. A medical supervision 
model Adult Day Health Care program provides comprehensive medical, 
nursing and personal care services combined with engaging social 
activities for physically or cognitively impaired adults. These 
programs are staffed by a caring and compassionate team of multi-
disciplinary healthcare professionals who evaluate each participant and 
customize an individualized plan of care specific to their health and 
social needs.
    As a licensed nursing home administrator, I would like to thank 
Senators Hatch, Hirono and the many bipartisan Senate cosponsors for 
recognizing the need to offer non-institutional alternatives to our 
veterans. Giving our veterans and families choices in how they can 
receive care is just the right thing to do. Making sure that there are 
no financial barriers to care is important to our most medically 
compromised veterans.
    It would be especially important to veterans like Jim Saladino and 
to his wife Noreen. Fifty years ago, Jim answered the call of his 
country and served honorably in the United States Army during the 
Vietnam War. Today, he suffers from the ravages of Agent Orange 
exposure. Specifically, he suffers from chronic illnesses including 
diabetes and Parkinson's disease and he also recently suffered a 
stroke. Although the Saladino family could have decided to put Jim into 
our State Veterans Home because he is a 100% service-connected veteran 
and so it would have been fully paid for by VA, but that is not their 
choice. They would like their loved one to continue enjoying the 
comforts of his own home--for as long as he can. By providing him the 
benefits of our medical supervision model Adult Day Health Care 
program, Jim is able to keep living at home.
    Jim's wife, Noreen, serves as his primary caregiver. She has 
publicly stated that the medical model Adult Day Health Care Program 
has been a true blessing for her. Jim comes to the ADHC program three 
days a week and we work closely with his personal physician to provide 
services that will maintain his wellness and keep him out of the 
emergency room. During his six hour day with us, Jim receives a 
nutritious breakfast and lunch. He receives comprehensive nursing care. 
He also receives physical therapy, occupational therapy and speech 
therapy. He can get his eyes checked by an optometrist, his teeth 
cleaned and examined by our dentist, and his hearing checked by an 
audiologist. If required, he can get a blood test or an x-ray, have his 
vital signs monitored and receive bathing and grooming services while 
on site.
    For Jim's wife, having him come to our program allows her the peace 
of mind knowing that he is in a safe and comfortable environment. She 
can then get a break as caregiver and tend to those issues that allow 
her to run her household. However, because of the way the law is 
currently structured, despite Jim's eligibility for ``no cost'' skilled 
nursing care, they are required to pay out-of-pocket for a portion of 
his Adult Day Health Care, a cost they cannot afford.
    S. 324 will correct this disparity that prevents some of the most 
deserving and severely disabled veterans from taking advantage of this 
valuable program to keep living in their own homes. This legislation 
would authorize VA to enter into agreements with State Veterans Homes 
to provide medical supervision model Adult Day Health Care for veterans 
who are eligible for, but do not receive, skilled nursing home care 
under section 1745(a) of Title 38, the ``full cost of care'' program. 
Veterans who have a VA disability rating of 70 percent or greater or 
who require ADHC services due to a service-connected disability would 
be eligible for this program. The payment to a State Home under this 
program would be at the rate of 65 percent of the amount that would be 
payable for skilled nursing home care under the same ``full cost of 
care'' program. This legislation would not only offer a lower cost 
alternative (ADHC) for severely disabled veterans who might otherwise 
require full time skilled nursing care, but it would also allow them to 
continue living in their own homes.
    Mr. Chairman, NASVH is aware of VA's argument that a veteran 
participating in the ADHC program is physically inside a State Home 
facility for only about one-third of each day they are in the program, 
therefore the per diem should be only about one-third of the skilled 
nursing care per diem. However, this significantly misrepresents the 
level of care and services provided to veterans in medical model ADHC 
programs. First, it completely ignores the cost of transportation, 
which alone accounts for a significant cost for transporting elderly, 
frail, disabled veterans to and from their homes to State Homes. 
Second, the overwhelming majority of services--particularly medical, 
therapeutic and rehabilitation--are provided during the day shift, not 
overnight when veterans residing in State Homes are sleeping. In fact, 
the 65% ratio is identical to the ratio that Medicaid pays for adult 
day health care in New York as compared to what Medicaid pays for 
skilled nursing care. Finally, it is critical to note that allowing 
veterans to use ADHC services two to three times a week is enormously 
less expensive then placing them full-time into a skilled nursing 
facility.
    Moreover, VA has been stressing the need to provide essential long-
term care services in non-institutional settings for our most frail, 
elderly disabled veterans. Medical supervision model Adult Day Health 
Care is a tremendous solution to this challenge faced by VA, one that 
can keep veterans living in their homes while allowing them to receive 
skilled nursing services and supports. There are a number of State 
Homes across the country interested in providing medical model ADHC 
services, however the current ADHC per diem is not nearly sufficient 
for most State Homes to cover the costs of this program. Enactment of 
S. 324 would provide a higher ADHC per diem rate for severely disabled 
veterans in medical supervision model ADHC programs and thereby allow 
additional State Homes across the country to offer this service to more 
needy and deserving veterans.
    For the Saladino family, receiving ``no cost'' Adult Day Health 
Care for their loved one would relieve a huge financial burden that 
they currently incur. Even though Jim's service ended 50 years ago, he 
is still paying a price for his valor related to his service in 
Vietnam. Passing S. 324 would send a strong message to all those who 
have worn the uniform to protect our freedoms that they will never be 
forgotten.
    With 30 Senate cosponsors so far, S. 324 has strong bipartisan 
support, as does the House companion bill, and both are supported by 
major veterans service organizations, including The American Legion, 
the Veterans of Foreign Wars and Disabled American Veterans.
    On behalf of the National Association of State Veterans Homes, I 
urge you to favorably consider and pass S. 324 for Jim and Noreen 
Saladino, and for thousands of others across the country just like 
them. Thank you for the opportunity to submit this testimony to the 
Committee.
                                 ______
                                 
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          Prepared Statement of Paralyzed Veterans of America
    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee, Paralyzed Veterans of America (PVA) would like to thank you 
for the opportunity to submit our views on legislation pending before 
the Committee.
  s. 23, the ``biological implant tracking and veteran safety act of 
                                 2017''
    S. 23 intends to have the VA adopt and implement a standard 
identification protocol for use in the tracking and procurement of 
biological implants by the Department of Veterans Affairs, and for 
other purposes. While we understand and generally support some of the 
provisions of this legislation, PVA objects to the provisions of the 
draft legislation that would exclude the purchase of biological 
implants from the authority of title 38 U.S.C., Section 8123.
    Section 8123 states, ``the Secretary may procure prosthetic 
appliances (which includes surgical biological implants) and necessary 
services required in the fitting, supplying, and training and use of 
prosthetic appliances by purchase, manufacture, contract, or in such 
other manner as the Secretary may determine to be proper, without 
regard to any other provision of law.''
    The Federal Acquisition Regulations (FAR) were issued pursuant to 
the Office of Federal Procurement Policy Act of 1974. Statutory 
authority to issue and maintain the FAR resides with the Secretary of 
Defense, the Administrator of General Services, and the Administrator, 
National Aeronautics and Space Administration--agencies that do not 
bear the responsibility of providing lifelong care for disabled 
veterans. However, the VA does bear the heavy weight of that 
responsibility.
    With this in mind, it is important to note the distinction between 
VA's responsibility to meet specialized needs versus a Federal agency's 
responsibility to respond to emergency needs. The FAR provides for 
procuring prosthetics in cases where, for example, a natural disaster 
damaged a veteran's equipment. However, the writers who formulated the 
FAR in 1974 recognized there was a need for special provisions under 
which VA could purchase prosthetics for disabled veterans with 
specialized needs in a timelier manner than the FAR allowed, 
irrespective of whether a bona fide emergency existed. The authors of 
the FAR recognized this fact and the need for Section 8123 as evidenced 
by the fact that it is referenced in the FAR. This was reconfirmed in 
subsequent updates and amendments to the FAR.
    Unfortunately, this S. 23 seems to imply that the Federal Supply 
Schedule and the FAR is all that is needed to procure Prosthetic 
appliances (biological implants) and services based on a 
misunderstanding of the difference between ``specialized needs'' and 
``emergency needs.'' Rather than erode a clinician's ability to acquire 
these prosthetics in a timely manner or manipulate how these 
prosthetics are defined in order to exclude them from the authority of 
Section 8123, we believe that the legislation should focus on 
accountability and oversight. It should not be making efforts to 
overturn a system that has served veterans well for over half a 
century. We encourage the removal of the provision of the legislation 
that eliminates the authority of Section 8123.
s. 112, the ``creating a reliable environment for veterans' dependents 
                                 act''
    PVA supports S. 112, the ``Creating a Reliable Environment for 
Veterans' Dependents Act.''
    Currently, the VA Grant and Per Diem program does not reimburse VA-
funded facilities for services provided to a homeless veteran's 
dependent. This bill would allow VA to reimburse facilities who care 
for the child of a veteran receiving care at a shelter funded through 
VA.
    Veteran homelessness remains a serious problem. Children of 
homeless veteran parents can be turned away from receiving care at the 
very facilities where their parents are expected to seek services to 
get themselves and their families back on their feet. The supportive 
housing and service centers also provide case management, education, 
crisis intervention, and specialized services to homeless women 
veterans.
    Congress must ensure VA is able to provide consistent, reliable 
services to veterans whose lives are in upheaval. Denying access for 
dependents does nothing but add more uncertainty for veterans in need 
stable circumstances for their families. While PVA supports this 
legislation we urge Congress to see that VA is adequately resourced to 
provide these reimbursements.
  s. 324, the ``state veterans home adult day care improvement act of 
                                 2017''
    PVA supports S. 324, a bill that would provide ``no cost'' medical 
model adult day health care (ADHC) services to veterans who are 70 
percent or more service-connected disabled. By authorizing the 
Secretary to enter into agreements with state veterans homes the bill 
would provide ADHC to those veterans who are eligible for, but do not 
receive, skilled nursing home care under section 1745(a) of title 38, 
U.S.C.. Currently, VA pays State Homes a per diem for ADHC. The per 
diem rate covers around one-third the cost of the program. S. 324 is an 
extension to the Veterans Benefits, Health Care, and Information 
Technology Act of 2006 (Pub. L. 109-461), which provides ``no cost'' 
nursing home care at any State Veterans Home to veterans who are 70 
percent or more service-connected disabled. This means that currently 
there are some veterans making a choice between 100% free nursing home 
care or expensive, out of pocket ADHC. The payment to a state home 
under this legislation would be 65 percent the amount payable to the 
state home if the veteran were an inpatient for skilled nursing care.
    Adult day health care is a crucial service that allows veterans to 
remain in their homes and communities by delaying entry into 
traditional nursing care. While a veteran may need long-term services 
and supports, it is not necessarily the case those must be received in 
an institutional setting. Rather, a veteran can receive comprehensive 
medical care and socializing without the disruption of leaving their 
home. The program is staffed by a team of multi-disciplinary healthcare 
professionals who evaluate each participant and customize an 
individualized plan of care specific to their health and social needs. 
ADHC is designed to promote social stimulation and maximize 
independence while also receiving quality of life nursing and personal 
care services.
    Additionally, we know that the wellbeing of a caregiver directly 
impacts the quality of care they provide to the veteran. ADHC allows 
caregivers the means the ability to meet other professional and family 
responsibilities. Especially for those caregivers whose veteran was 
injured before 9/11 and is not eligible for the VA Comprehensive 
Caregiver Program, ADHC offers critically needed support.
    Delaying institutional settings for veterans with long term care 
needs is the rare jewel in health care, it is the least costly care and 
the best care for certain populations. ADHC saves the taxpayer, is the 
most appropriate care for some sick and disabled veterans, and allows 
spouses, children, parents, and communities more time together.
                        s. 543, the ``pact act''
    PVA has no formal position on the ``Performance Accountability and 
Contractor Transparency Act'' at this time.
 s. 591, the ``military and veteran caregiver services improvement act 
                               of 2017''
    PVA strongly supports S. 591, the ``Military and Veteran Caregiver 
Services Improvement Act of 2017.'' No group of veterans understands 
the importance of caregivers more than PVA members and their families.
    This legislation would expand VA's Comprehensive Family Caregiver 
Program to veterans of all eras. Currently, a veteran is eligible if 
they require the services of a caregiver due to an injury incurred in 
service on or after September 11, 2001. This date of eligibility, and 
the exclusion of service-connected illnesses, is unjust and 
indefensible. As many as 70,000 veterans (with estimates as high as 
88,000) would be eligible for the Comprehensive Family Caregiver 
Program if the September 11, 2001 date was eliminated as a barrier. 
Expansion would make available the resources that caregivers need to 
provide quality care to veterans. These resources include a monthly 
stipend based on the hours of care provided, healthcare through 
CHAMPVA, respite care, additional training, and paid travel expenses to 
and from veterans' medical appointments.
    Caregivers play the most critical role in maintaining the wellbeing 
of a catastrophically disabled veteran. From activities of daily 
living, to psycho-social interaction, to maintaining health to prevent 
institutional care- these caregivers have been sacrificing their own 
financial and physical wellbeing to care for veterans, with little to 
no support from VA. Congress has no justification for denying access to 
veterans because of the date of injury or denying those of any era who 
were made ill as a result of service. This legislation would rectify 
this inequity.
    Additionally, the Military and Veteran Caregiver Services 
Improvement Act would make the program more inclusive of mental health 
injuries; reauthorize the Lifespan Respite Care Act and expand 
essential respite options for caregivers; give veterans the opportunity 
to transfer GI Bill benefits to a dependent, to help unemployed or 
underemployed spouses of injured veterans prepare to become the primary 
income for the family; make caregivers who work in the Federal 
Government eligible for flexible work schedules; provide assistance 
with childcare, financial advice and legal counseling, which are all 
top, and currently unmet, needs.
    The majority of catastrophically injured, service-connected 
veterans who rely on a caregiver for their daily living are ineligible 
for the Comprehensive Caregiver Program. Moreover, the need for a 
caregiver is not lessened simply because a veteran's service left him 
or her with a catastrophic illness, rather than an injury. PVA is 
pleased to see that S. 591 includes catastrophic illness as a program 
qualifier. For PVA's members, a spinal cord disease is no less 
devastating than a spinal cord injury. Veterans that have been 
diagnosed with Amyotrophic Lateral Sclerosis (ALS) and Multiple 
Sclerosis (MS) will eventually experience significant decline in their 
ability to perform activities of daily living and unquestionably become 
dependent on a caregiver.
    Pre-9/11 caregivers have provided decades of uncompensated work to 
our disabled veterans, often with no support services of any kind and 
at the expense of their own health and livelihood. A study by the Rand 
Corp. in 2014 estimated that veterans' caregivers save taxpayers $3 
billion a year.
    When Congress says the cost of expansion of the program is 
prohibitive they suggest financial burden for caregivers is not 
prohibitive, that the insecurity of their lives is a just consequence 
of their family's sacrifice. They are paying for what Congress should, 
and what Congress does when injured after 9/11. Ensuring that a veteran 
is able to reside in their home, in their community, has been shown 
time and again to reduce medical complications, hospital stays, and 
costs. At the same time, the veteran and their family maintain a 
psychosocial wellness that is impossible to achieve in an institution.
    PVA understands the costs concerns with expanding the program but 
believes doing right by veterans is more important, and hopes Congress 
will believe so too. At the same time, we challenge the very premise of 
the concerns about cost. While Congress generally ignores the 
principles of ``dynamic scoring'' except when it is politically 
expedient, consider the cost of providing caregiver services versus the 
cost of institutional services. For catastrophically disabled veterans, 
if their caregiver can no longer afford to continue, or has suffered 
their own injury, their veteran has no option but to be placed in an 
institutional setting. Consider the long term cost savings for the 
taxpayer by providing caregivers the ability to delay their veteran's 
admittance to a nursing home. In a VA nursing home the VA spends, on 
average, $366,000 per veteran, per year. In a community nursing home 
the cost averages $86,000 per veteran, per year. At a state veteran's 
home, costs average $45,000 per veteran, per year. Meanwhile, the 
average costs under the Comprehensive Family Caregiver Program is 
$36,000 per veteran, per year. Expansion could save the Federal 
Government between approximately $2.5 billion and $7.0 billion in a 
given year. Moreover, the health outcomes and quality of life 
experienced by veterans served at home by caregivers outperforms any 
institutional measure.
    The exclusion of ``serious illnesses and diseases,'' and the use of 
the ``date of injury'' as eligibility requirements for such an 
important program are indefensible. As a result, the veterans and their 
families suffer. Congress continues to find excuses to deny access. It 
has never been more urgent for those excuses to stop. As the largest 
cohort of veterans (Vietnam-era) ages, the demand for long-term care 
resources will continue to grow significantly. Catastrophically injured 
veterans will require the most intensive and expensive institutional 
care. By providing their caregivers the means to care for the veterans 
at home with family, they will delay the costs of institutional care. 
But most importantly, these veterans will have more time at home, in 
their communities, and among those they love.
s. 609, the ``chiropractic care available to all veterans act of 2017''
    PVA supports S. 609, the ``Chiropractic Care Available to All 
Veterans Act of 2017.'' Chiropractic care is a widely accepted and 
invaluable medical treatment. This bill would establish a program for 
the provision of chiropractic care and services at all medical centers 
by 2020. Likewise, it would see that ``chiropractic services'' be 
included in title 38, United States Code, as a medical service, a 
rehabilitative service, and a preventative health service.
    The process of integrating chiropractic care into VA health care 
has been slow. At least 65 VA medical centers have chiropractors on 
site, integrated into the care teams. Approximately 52 percent of 
veterans returning from Iraq and Afghanistan are seeking care because 
of musculoskeletal ailments, specifically back and joint pain. The 
common causes for these chronic pains are heavy gear, vehicle 
accidents, and blast injuries. The overwhelming majority of affected 
veterans still do not have readily available access to chiropractic 
care.
    With an ever present awareness of VA overreliance on 
pharmacological solutions for chronic pain and the resulting trends of 
opioid dependence and accidental overdose, PVA strongly encourages the 
utilization of alternative treatments. At the same time we would 
encourage a less prescriptive approach. It is possible that not every 
VA medical center will have need of chiropractic services.
              s. 681, the ``deborah sampson act of 2017''
    PVA supports S. 681, the ``Deborah Sampson Act of 2017.'' This bill 
would help to address some of the quality of care barriers that are 
unique to women veterans. From transition services, to health care 
access, to the availability of prosthetics, this bill is a critical and 
timely step to enhancing the health and well-being of women veterans 
and their families. As women veterans are the fastest growing 
population of veterans, we urge Congress to enable VA to fully meet the 
needs for specialized services for women.
    This bill would initiate a pilot program for peer-to-peer 
counseling for women veterans transitioning out of the military and 
make permanent the availability of readjustment counseling services in 
group retreat settings. Of the existing readjustment counseling 
retreats provided through VA, participants consistently showed better 
understanding of how to develop support systems and to access resources 
at VA and in their communities. The OEF/OIF women veterans at the 
existing retreats are most often coping with effects of severe Post-
Traumatic Stress and Military Sexual Trauma. They work with counselors 
and peers, building on existing support. If needed there is financial 
and occupational counseling. These programs are marked successes and 
the feedback is overwhelmingly positive for women veterans, who show 
consistent reductions in stress symptoms as a result of their 
participation. Other long lasting improvements included increased 
coping skills. It is essential for women veterans that Congress make 
this program permanent. We believe the value and efficacy is 
undeniable.
    The legislation would also direct VA to partner with community 
organizations to provide support services for women veterans needing 
assistance, particularly prevention of eviction, child support issues, 
and the restoration of driver's licenses.
    The bill would authorize hospital stays of up to 14 days for 
newborns under VA care. The current provision allows a maximum stay of 
seven days. As the average stay for a healthy newborn is two days, any 
newborn needing additional coverage is likely to be facing 
complications immediate after birth or a severe infant illness. The 
current seven day coverage is in a non-department facility for eligible 
women veterans who are receiving VA maternity care. Beyond the seven 
days, the cost of care is the responsibility of the veteran and not VA, 
even if complications require continued care beyond the coverage 
period. Post-natal health is critical to newborn health which directly 
impacts the lives and wellbeing of veterans and their families. PVA is 
particularly concerned about those veterans with catastrophic injuries 
or mental illnesses that can cause high-risk pregnancies or pre-term 
deliveries. A seven day limit arguably impacts veterans with 
disabilities at a greater rate than other veterans. Extending newborn 
coverage to 14 days is the right thing to do.
    The legislation aims to eliminate barriers to care by ensuring 
every facility has at least one full-time or part-time women's health 
provider. An additional $20 million would be authorized to carry out 
the retrofitting of existing facilities to improve privacy, safety and 
environmental needs for women veterans. Finally, the bill would require 
data collection and reporting by gender and minority status on VA 
programs serving veterans. PVA is pleased to see the reporting 
requirement of prosthetic availability for women veterans.
   s. 764, the ``veterans education priority enrollment act of 2017''
    PVA supports this measure. Education benefits as administered are 
calculated to fund a veteran through the completion of a standard four-
year course of study resulting in a degree. In some cases, a student is 
unable to register for a prerequisite, which in turn leaves them unable 
to advance on schedule in that degree program. When this happens, the 
student veteran now must continue his or her course of study beyond the 
enrollment period covered by GI Bill benefits. Such a result dilutes 
the overall value of the benefit when the veteran does not earn the 
degree the assistance was intended to cover, and it simultaneously 
wastes government money while the veteran, unable to secure a spot in a 
relevant course, takes unnecessary classes to pass the time.
    Not getting a seat in a class might be due to pure luck of the 
draw, but often veterans have substantially different circumstances 
than traditional students that complicate the course selection process. 
If a servicemember in the National Guard or a Reserve Component gets 
called away for duty, he or she should have priority enrollment to 
ensure they have the ability to quickly get back on track. Many 
veterans might also be coming to school at a later point in their lives 
and have families. Veterans should not be penalized for trying to fit 
courses in around other significant obligations such as caring for 
children.
    The evidence already exists that offering veterans priority 
enrollment is feasible and important. Many private universities already 
offer priority enrollment, and some states such as Pennsylvania, 
California and Ohio require it to be offered in all publicly-funded 
institutions.
 s. 784, the ``veterans' compensation cost-of-living adjustment act of 
                                 2017''
    PVA supports S. 784, the ``Veterans' Compensation Cost-of-Living 
Act of 2017,'' which would increase, effective as of December 1, 2017, 
the rates of compensation for veterans with service-connected 
disabilities and the rates of dependency and indemnity compensation 
(DIC) for the survivors of certain disabled veterans. This would 
include increases in wartime disability compensation, additional 
compensation for dependents, clothing allowance, and dependency and 
indemnity compensation for children.
   s. 804, the ``women veterans access to quality care act of 2017''
    PVA supports S. 804, the ``Women Veterans Access to Quality Care 
Act of 2017.'' This bill would establish structural standards in VA 
health care facilities that are necessary to meet the health care needs 
of women veterans. Implementation of this bill would generate a report 
to the House and Senate Veterans' Affairs Committees listing the 
facilities that fail to meet these standards and the projected cost to 
do so. VA would be required to publish the health outcomes of women in 
each facility, juxtaposed with the men that facility serves. VA would 
be required to hire a full-time obstetrician or gynecologist at every 
VA Medical Center, and pilot an OB-GYN graduate medical education 
program to increase the quality of and access to care for women 
veterans.
    The women veteran population who use VA health care doubled between 
2003 and 2012, from 200,631 to 362,014. By 2040, it will have doubled 
again. Given this projection, VA must increase their capacity to meet 
the needs of women veterans. This legislation is a crucial step in 
assessing the quality of care women veterans receive and the steps 
needed to improve it.
         s. 899, the ``department of veterans affairs veteran 
                      transition improvement act''
    PVA supports S. 899, the ``Department of Veterans Affairs Veteran 
Transition Improvement Act.'' Currently, new Title 5 employees with a 
thirty percent or higher service-connected disability rating are 
entitled during their first twelve-month period of employment to leave 
for purposes of undergoing medical treatment related to such 
disability. PVA supports this bill which would apply the same 
entitlement to health care professionals under 38 U.S.C. Sec. 7401(1).
 s. 1024, the ``veterans appeals improvement and modernization act of 
                                 2017''
    PVA employs a highly-trained force of over 70 service officers who 
develop veterans' claims for both member and non-member clients. These 
frontline employees spend a minimum of two years in specialized 
training. We maintain a national appeals office staffed by attorneys 
and legal interns who represent clients at the Board of Veterans' 
Appeals (Board). We also have attorneys who practice before the Board, 
the Court of Appeals for Veterans Claims (CAVC), and the United States 
Court of Appeals for the Federal Circuit. Of all the major Veteran 
Service Organizations (VSO), only PVA offers such continuity of 
representation throughout subsequent appellate review.
    Our most important attribute, though, is that our service officers 
and attorneys consistently advocate for catastrophically disabled 
veterans. Complex claims are the norm, not the exception. As we attempt 
to bring greater efficiency to the claims and appeals system, our 
perspective is geared toward ensuring that the due process rights of 
the most vulnerable among us--those most deserving of benefits--are not 
watered down for the sake of expediency. To reinforce this position, we 
would advise the Committee to include a sense of Congress or other 
preamble with this legislation indicating that no part of the new 
framework should be read to abrogate or displace the non-adversarial 
nature of VA claims adjudication. An overhaul of this size and scope 
invites subsequent litigation and new legal interpretations. Clarifying 
this point with direct legislative history on the subject would be an 
easy but important effort.
Background
    The number of pending appeals is approaching 500,000. VA projects 
that if we fail to address the process, within a decade the average 
wait time for resolving an appeal will reach 8.5 years. We believe 
reform is necessary, and we support this legislation moving forward.
    There is no shortage of news articles and academic pieces that 
attempt to illustrate for readers the level of complexity and 
redundancy in the current appeals process. It is a unique system that 
has added layer after layer of substantive and procedural rights for 
veterans over the years. The most notable aspect differentiating it 
from other U.S. court systems is the ability for a claimant to inject 
new evidence at almost any phase. While this non-adversarial process 
offers veterans the unique ability to continuously supplement their 
claim with new evidence and seek a new decision, it prevents VA from 
accurately identifying faulty links in the process, whether it be 
individual raters or certain aspects of the process itself.
    It is important that as we approach this major issue that we do not 
lose sight of the fact that veterans have earned these benefits through 
the highest service to their country and have every right to pursue 
these earned benefits to the fullest. As we promote and seek public 
support for change, it is easy to use statements such as, ``there are 
veterans who are currently rated at 100% who are still pursuing 
appeals,'' to illustrate the problems that pervade the system. PVA will 
be the first to point out, though, that a veteran rated at 100% under 
38 U.S.C. Sec. 1114(j) might also be incapacitated to the point that he 
or she requires 24 hour caregiver assistance. A 100% service-connected 
disability rating does not contemplate the cost of this care, and 
veterans may seek special monthly compensation (SMC) to the tune of 
thousands of dollars needed to address their individual needs. Few 
people would disagree that pursuing these added disability benefits are 
vital to a veteran's ability to survive and maintain some level of 
quality of life. Without clarification, such statements lead people to 
believe that veterans are the problem.
    This is why PVA believes it is so important to ensure that VSO's 
remain as involved in the follow-on development process and 
implementation as they are now if this plan is to succeed. This is a 
procedural overhaul, and VSO's are the bulwark that prevents procedural 
change from diluting the substantive rights of veterans.
The Framework
    As the working group came together and began considering ways to 
address the appeals inventory, it became clear that a long-term fix 
would require looking beyond appeals and taking a holistic view of the 
entire claims process. The work product in front of us today proposes a 
system with three distinct lanes that a claimant may enter following an 
initial claims decision--the local higher-level review lane, the new 
evidence lane, and the Board review lane. The work horse in this system 
is the new evidence lane. The other two serve distinct purposes focused 
on correcting errors. A decision to enter any of the lanes must be made 
within one year of receiving the previous decision. Doing so preserves 
the effective date relating back to the date of the original claim--a 
key feature of this new framework.
    When a claimant receives a decision and determines that an obvious 
error or oversight has occurred, the local higher-level review lane, 
also known as the difference of opinion lane, offers a fast-track 
ability to have a more experienced rater review the alleged mistake. 
Review within this lane is limited to the evidence in the record at the 
time of the original decision. It is designed for speed and to allow 
veterans with simple resolutions to avoid languishing on appeal.
    If a claimant learns that a specific piece of evidence is 
obtainable and would help him or her succeed on their claim, the new 
evidence lane offers the option to resubmit the claim with new evidence 
for consideration. VA indicates that its goal is a 125-day turn around 
on decisions within this lane. Another important aspect is that the 
statutory duty to assist applies only to activity within this lane. 
This is where VA will concentrate its resources for developing 
evidence.
    The third lane offers an appeal to the Board. Within this lane 
there are two tracks with separate dockets. One track permits the 
addition of new evidence and option for a Board hearing. The other 
track permits a faster resolution by the Board for those not seeking to 
supplement the record. A claimant within this track will not be 
permitted to submit new evidence, but they will have an opportunity to 
provide a written argument to accompany the appeal.
    If the claimant receives an unfavorable opinion at the Board, he or 
she may either revert to the new evidence lane within one year or file 
a notice of appeal with the CAVC within 120 days. Notably different 
from earlier versions of this legislation, this draft bill would 
preserve the claim's effective date even after an adverse decision at 
the Court.
Concerns Specific to the Framework
    Throughout the development of this new framework, PVA's biggest 
concern has been the proposed dissolution of the Board's authority to 
procure an independent medical examination or opinion (IME) under 38 
U.S.C. Sec. 7109. An IME is a tool used by the Board on a case-by-case 
basis when it ``is warranted by the medical complexity or controversy 
involved in an appeal case.'' Sec. 7109(a). The veteran may petition 
the Board to request an IME, but the decision to do so remains in the 
discretion of the Board. The Board may also request an IME sua sponte. 
Experienced Board personnel thoroughly consider the issues which 
provoke the need for an outside opinion. Complicating the process 
further, the CAVC has carefully set parameters for the proposed 
questions to be answered by experts. A question presented to a medical 
expert may be neither too vague, nor too specific and leading. A 
question too vague renders the opinion faulty for failing to address 
the specific issue, while a question too specific tends to lead the 
fact finder to a predisposed result.
    The standard for granting such a request is quite stringent. 38 CFR 
3.328(c) states, ``approval shall be granted only upon a determination 
. . . that the issue under consideration poses a medical problem of 
such obscurity or complexity, or has generated such controversy in the 
medical community at large, as to justify solicitation of an 
independent medical opinion.'' The number granted each year usually 
amounts to no more than one hundred, with approximately fifty percent 
of those IME's being requested by the Board itself. The regional 
offices have long held a companion authority under 38 U.S.C. Sec. 5109. 
Incredibly, in a room full of practitioners convened in March 2016 as 
part of this current reform process, not one among them could recall an 
instance of a rating officer requesting an IME. And yet the original 
proposal was to eliminate the Board's authority to procure an IME and 
rely solely on a rating officer exercising his or her authority under 
Sec. 5109.
    VA's rationale for dissolving this authority is primarily based on 
having all development of evidence take place at the Agency of Original 
Jurisdiction (AOJ) level in the New or Supplemental Evidence Lane. This 
unwavering desire to rid the Board of any development stems in part 
from an attempt to exploit its experienced Veteran Law Judges (VLJ) to 
the greatest possible extent. VLJ's who adjudicate appeals are a human 
capital commodity and form a critical component of the system. Because 
employees and outside attorneys cannot reach the experience and 
qualifications of a VLJ overnight, VA is limited in its ability to 
scale this particular resource simply by hiring new employees.
    These concerns are valid to a degree, and we have worked with 
officials to find a solution that allows the Board to realize the 
benefit of making the best use of VLJ's while attempting to preserve 
the beneficial aspects of IME's procured by the Board. Part of the 
mitigating measures are reflected in this draft bill's proposed 
amendments to 38 U.S.C. Sec. 5109, permitting the Board to remand 
specifically for procurement of an IME and requiring the VLJ to 
articulate the specific questions to be presented to the expert.
    We applaud the Committee's change to the remand language. In 
earlier versions of this legislation, the Board would only be permitted 
to remand for an IME if it determined an error existed on the part of 
the AOJ to satisfy its duty to assist under 38 U.S.C. Sec. 5103A. Since 
the duty to assist is necessarily inconsistent with the discretionary 
nature of an IME, this circumstance would never arise, and IME's would 
come to a halt. Using an abuse of discretion standard instead fixes 
this issue.
    Dissolving Sec. 7109 would have the additional effect of abolishing 
the centralized office of outside medical opinions. This small staff 
has played a vital role in facilitating IME's and maintaining their 
effectiveness by developing relationships with doctors who are experts 
on particular subjects and willing to do this tedious task for almost 
no money. This office not only expedites the receipt of opinions, but 
it also ensures a high level of quality. VA has committed verbally to 
PVA that it will preserve this resource by moving it from the Board and 
placing it under VBA's management, in essence making it available to 
the AOJ going forward.
    The decreased efficiency with having the process conducted at the 
AOJ level is also concerning. Instead of the VLJ requesting an IME and 
receiving the opinion, now a second person must review the claim--the 
rating officer who received the file on remand. If a veteran wishes to 
appeal this re-adjudication, we have asked for and received VA's 
commitment to reroute the appeal by default, with exceptions, back to 
the same VLJ who remanded the case to avoid yet another person from 
having to review a claim with enough medical complexity to warrant the 
IME. Unless this Committee is willing to outright preserve Sec. 7109, 
we would strongly recommend that the Committee conduct oversight on 
these specific commitments by VA, perhaps as part of the increased 
reporting requirements.
    We also recommend an additional jurisdictional safeguard for the 
Board. In 38 U.S.C. Sec. 7104, it would be helpful to include language 
that addresses situations where the Board finds that an appeal presents 
extraordinary circumstances. The Board, in its sole discretion, should 
be able to retain jurisdiction over a remand of that appeal.
    Some stakeholders have expressed concern over the replacement of 
the ``new and material'' evidence standard with ``new and relevant.'' 
It is true that there are a number of appeals in the system currently 
disputing a decision that evidence submitted was not deemed 
``material.'' The stated concern is that changing ``material'' to 
``relevant'' will simply exchange one appealable issue for another. 
While it is a fair point, ``relevant'' is a significantly lower legal 
threshold and as higher numbers of veterans meet this threshold, it 
should correlate to fewer appeals. Those expressing concern propose 
having VA simply accept all ``new'' evidence and make a decision. Under 
this proposal, if the evidence is so weak that it is not even relevant, 
then VA can easily deny the claim. For every denial, VA will be 
required to do the work of providing the improved notice explaining its 
decision. Conversely, a legal determination that new evidence is not 
relevant would not be subject to this requirement, thus a reduced 
workload for VA. PVA believes ``new and relevant'' is an acceptable 
standard for veterans to meet. But at this point, it is unclear whether 
dealing with continued appeals on relevance determinations or 
processing improved notice for denials will lead to a greater aggregate 
negative impact on the system.
    Earlier objections were raised concerning the specificity with 
which a veteran was required to identify issues of fact or law being 
contested on appeal in a notice of disagreement. At first glance, the 
prior language appeared to be quite ``legalese,'' requiring a 
sophisticated level of pleadings. Placing such burden on veterans would 
be at odds with the non-adversarial nature of the system. We are 
pleased to see that the current draft bill has addressed this issue.
Judicial Review
    We noted above that this draft bill would preserve a claim's 
effective date following an adverse decision from CAVC. It would also 
provide the same relief after an adverse decision from the Federal 
Circuit and the Supreme Court of the United States. The concept of 
imposing finality after a Court decision has provoked a significant 
debate among the stakeholders. Unfortunately, the strongest objections 
to imposing finality at the Court have not been met with much 
discussion regarding why VA, or some of the other stakeholders, are 
comfortable with finality at that stage. We would encourage the 
Committee to draw out this discussion and fully examine the issue. 
There are arguments and perspectives on both sides that warrant 
attention.
    Our initial impression is that while VA is trying to create new 
efficiencies in its claims and appeals processing, we must remember 
that the CAVC is not part of that system, and it does not exist for 
VA's benefit or efficiency. Nor does it exist to create precedent. 
Precedent is a byproduct of an individual availing him or herself of 
the Court. The Court exists to hear veterans' individual claims and 
gives veterans an independent avenue to challenge whether VA considered 
a claim correctly. We in the veterans community fought long and hard 
for judicial review, and it is precious. PVA is uniquely positioned in 
this regard. Our organization has boxes full of claims that, but for 
the Court, the veteran would never have had a full and fair review. 
When we approach analyzing the impact on the Court, we should not focus 
on the systematic efficiencies or precedent, because these are not the 
Court's purpose. We should focus on what an individual veteran's right 
to judicial review is and what it takes to avail him or herself of that 
right.
    There are reasonable assertions that failing to provide effective 
date relief following a Court decision will have a chilling effect on 
the Court. They should be addressed unless willing to be conceded. One 
scenario presented is where a veteran, who having received a denial 
under what she believes is an erroneous application of law to the case, 
also has new evidence to attach to the claim. She is faced with 
deciding whether to pursue Court review on the legal issue or circulate 
back through the system with new evidence. If she chooses the Court and 
loses, she can still continue to pursue the claim with new evidence, 
but she will have lost her effective date. If she chooses to handle the 
new evidence first, her claim will again be adjudicated under what she 
considers to be an erroneous interpretation of law. This predicament, 
so the argument goes, will likely force veterans to choose to avoid the 
Court at the risk of missing an opportunity to strengthen the record. 
Hence the chilling effect. It also inconveniences the veteran by having 
them cycle through the system while being again scrutinized under a 
misinterpretation of the law.
    One might argue, though, that there is no chilling effect in this 
scenario. The veteran is in fact inconvenienced. But ultimately, if the 
veteran cycles through again with the new evidence, strengthening the 
record, she arrives in the exact same position if denied, this time 
without the predicament. The choice is obvious, and she heads to the 
Court. The only person in this scenario who ultimately would not reach 
the Court is one who received an earlier and favorable adjudication at 
a lower level of review. This is precisely what we want for veterans. 
Any reduction in claims reaching the Court would be attributed to more 
efficient outcomes for the veterans. Making a decision about the 
framework that accommodates veterans facing this scenario also requires 
a belief that the veteran's legal interpretation is always correct and, 
necessarily, that VA's is always wrong. This is not how sound policy is 
formed. Further, it is hard to weigh at this point a single veteran's 
inconvenience in this scenario against the potential gains for numerous 
veterans who are benefiting from a more efficient system due to the 
finality imposed after a Court decision.
    There is, perhaps, also an undue assumption that a chilling effect 
on the Court would in fact reduce precedent and oversight on VA. 
Conceptually, one may concede that a reduction in volume of claims at 
the Court raises the possibility that a ``perfect case'' for setting 
precedent will not arrive. But it is possible that a reduction in the 
Court's workload would offer greater opportunity to give more time and 
attention to a precedent-setting claim, which otherwise might have 
slipped through the cracks or not garnered a more thorough opinion.
    There are other scenarios that argue in favor of granting effective 
date relief following review by the CAVC. If the Board rules against a 
veteran and finds that a medical exam being challenged was adequate for 
purposes of his rating decision, he is faced with two choices. He could 
appeal to the CAVC, or he could develop independent evidence that would 
strengthen his argument that the exam provided by VA was inadequate. 
The latter option costs money. If effective date relief followed a 
decision at the CAVC, the veteran could wait and see if the Court 
agreed with his position before he was forced to shell out money he 
likely does not have to invest in proving his claim. Veterans with 
means may not see this as an issue. For those without means, it would 
be an unwarranted obstacle in a system that is designed to be non-
adversarial.
    One aspect of this framework that has not been discussed at all is 
the fact that you can technically take one issue from a multi-issue 
claim up to the Court, and cycle back through the other lanes in the 
framework on the remaining issues. Currently, the Court takes 
jurisdiction over issues that are expressly identified by the veteran, 
and issues not appealed after a Board decision are final. Nothing in 
this draft bill changes the way an issue reaches the CAVC. But because 
this new framework has provided liberal effective date relief, new 
incentives for action have been introduced. There should be further 
discussion among stakeholders and VA about how claims are dealt with 
that end up being split up between the Court and the agency. There is 
no precedent for this in the current system.
    PVA was a supporter early on of judicial review, and we believe the 
availability of that review has improved the appeals process for 
veterans. Determining the best way to preserve that protection deserves 
more conversation at this point in time.
Implementation
    We applaud the heavy reporting requirements found within this bill. 
One of the biggest reservations that the collective stakeholders have 
voiced is the absence of information related to implementation. GAO's 
recent report reinforced our claim that the success of this new 
framework hinges on how VA makes the transition, and VA has yet to 
fully demonstrate what it needs to accomplish this task. We also agree 
that it is important that VA provide a full accounting of the bases for 
certain assumptions that have been used to support the feasibility of 
this new framework. For example, what is the basis for the assumption 
that within the ``hearing lane'' at the Board, thirty-five percent of 
veterans will choose to have a hearing? What is the impact on the 
system if that estimate is drastically wrong?
    Within the reporting requirements, we recommend including a mandate 
to track legacy appeals that have transitioned into the new system. The 
goal would be to ensure that Congress can easily identify how many 
legacy appeals have been truly resolved as opposed to being 
reclassified in the new system.
    We support VA's proposed first step toward combatting the backlog 
of legacy appeals. One of the hurdles to permitting veterans with 
legacy appeals to join the new system was that veterans in the legacy 
system may not have been provided sufficient notice to make an educated 
decision. Allowing veterans to join after they have received a 
statement of the case or supplemental statement of the case addresses 
this concern and will help stem the flow of new claims into the old, 
broken system. The quicker we can shut off that valve, the quicker the 
backlog of legacy appeals will be handled.
    We note in closing that this is not simply a VA problem. As stated 
earlier, PVA has many service representatives and spends a great deal 
of time, funds, and effort on ensuring they accomplish their duties at 
a high level of effectiveness. However, it is important that veterans 
and their representatives also share responsibility when appeals arrive 
at the Board without merit. A disability claim that is denied by VBA 
should not automatically become an appeal simply based on the 
claimant's disagreement with the decision. When a claimant either files 
an appeal on his own behalf, or compels an accredited representative to 
do so with no legal basis for appealing, that appeal clogs the system 
and draws resources away from legitimate appeals. Since 2012, PVA has 
taken steps to reduce frivolous appeals by having claimants sign a 
``Notice Concerning Limits on PVA Representation Before the Board of 
Veterans' Appeals'' at the time they execute the Form 21-22 Power of 
Attorney (POA) form. PVA clients are notified at the time we accept POA 
that we do not guarantee we will appeal every adverse decision and 
reserve the right to refuse to advance any frivolous appeal, in keeping 
with VA regulations.
    PVA believes that substantial reform can be achieved, and the time 
is ripe to accomplish this task. Our organization represents clients 
with some of the most complex issues, and we cannot stress enough that 
moving forward should not be done at the expense of the most vulnerable 
veterans. We must remain vigilant and appreciate the benefits of 
bringing together the variety of stakeholders who are participating and 
bringing different perspectives and viewpoints--it is a healthy 
development process that ensures veterans remain the focus.
                   s. 2210, the ``veteran peer act''
    The ``Veteran Partners' Efforts to Enhance Reintegration Act'' 
would require VA to develop and institute a program to integrate Peer 
Specialists within patient aligned care teams. PVA recognizes the 
importance of promoting the use of mental health care services in the 
context of the primary care setting. The veteran-centric, holistic view 
of the patient epitomizes one of the key distinctions we have long made 
about care in a VA setting and care delivered in the community. We have 
a concern, though, with this bill's strict requirements, as opposed to 
the discretionary nature. To serve as a Peer Specialist, the person 
must be a veteran with a mental health condition, be in recovery for at 
least one year without hospitalization or legal issues related to that 
condition, and willing to openly acknowledge and discuss their 
condition. If there is an insufficient population willing to openly 
discuss their own private mental health history and want to do this job 
professionally, VA may not be able meet this requirement through no 
fault of its own. While PVA supports the intent of this legislation, we 
believe more thought should be put into how best to implement this 
requirement before mandating VA take these steps.
draft legislation, the ``department of veterans affairs accountability 
               and whistleblower protection act of 2017''
    PVA supports the draft legislation, the ``Department of Veterans 
Affairs Accountability and Whistleblower Protection Act of 2017.'' This 
legislation would bring greater accountability and protect those 
employees who have the courage to call out fraud, waste, and abuse in 
VA. We firmly believe that the culture of a company, organization, or 
Federal agency is shaped by the worst behaviors its leader is willing 
to tolerate. The ``VA Accountability and Whistleblower Protection Act'' 
is the first major step toward reshaping behavior in VA by tolerating 
bad behavior and poor performance no more. Our veterans deserve it; and 
so do the hardworking public servants of VA who are tired of being 
overshadowed by the performance of substandard managers and employees.
    PVA has supported efforts to ensure proper accountability at all 
levels of the VA in the past. In recent years there have been numerous 
accounts of bad actors in VA senior and lower level management who have 
failed to fulfill the responsibility of their positions and in some 
cases arguably violated the law. The focus on accountability in this 
proposal strikes a reasonable balance to ensure VA leadership has the 
ability to manage personnel while affording due process protections to 
employees. We recognize that the question of due process is an 
important one, and those rights should not be eliminated. However, they 
cannot be used as a roadblock to accountability either.
    PVA appreciates the strong focus on accountability that the 
Committee has emphasized and we are pleased to see that Secretary 
Shulkin has made this a priority. There is no doubt that accountability 
at all levels is an essential part of improving the VA.
             draft bill, ``serving our rural veterans act''
    PVA supports the draft bill to authorize payment by the Department 
of Veterans Affairs for the costs associated with care by medical 
residents and interns at Indian Health Service (IHS) and Tribal Health 
Program (THP) facilities operated by federally recognized tribes and 
carry out a pilot program to expand such residencies and internships at 
tribal facilities. While recruiting and retaining capable providers 
continues to be a struggle for VA, rural communities feel these 
vacancies two fold. In Indian Country particularly, the minimal 
availability of consistent, high quality health care has resulted in 
some of the worst health outcomes in the United States.
    The Federal Government has legal and moral obligations to provide 
health care to two groups--federally recognized tribal nations and 
eligible veterans. The overlapping, and at times inter-reliability of 
these groups' respective health care systems is necessary, as American 
Indians and Native Alaskans have always served in the Armed Forces at 
the highest rate of any demographic. In Alaska, where this health care 
system interoperability is most prevalent, the need for primary care 
providers is critical.
    Physician shortages in the United States, and rural communities 
particularly, are expected to increase drastically in the coming 
decade, leaving health care systems with a high volume need and little 
capacity. This bill would provide some relief, by incentivizing medical 
residents and interns to work at tribal facilities that have existing 
reimbursement agreements with VA. The eight-year pilot program would 
have VA reimburse the tribal facilities for the recruitment and 
training of residents. These participants would then be eligible for 
loan forgiveness through Indian Health Service or Department of 
Veterans Affairs Loan Repayment Program.
    In 2010, the Indian Health Care Improvement Act was made permanent. 
As a result, IHS and VA signed a Memorandum of Understanding (MOU) 
aiming to improve the health status of American Indian and Alaska 
Native veterans. In 2012, VA began to establish agreements with tribal 
governments to reimburse them for the direct care of native veterans 
enrolled in VA.
    Since then around 108 tribes have established agreements with VA. 
At least 7,000 native veterans have been able receive care. 
Additionally, VA and IHS have strengthened collaborative relationships 
and resource sharing. For much of Indian Country, unreliability or 
unavailability of transportation impacts a veteran's ability to receive 
care from a VA facility. These agreements allow veterans to receive 
their care close to home, in a culturally conscious environment they 
may not find at VA.
    The national authority for VA to make reimbursement agreements 
between agencies is set to expire June 30, 2019. If, for some reason, 
this authority is not renewed, it is unclear what would happen to the 
proposed eight year pilot program that is dependent on the existence of 
an agreement. PVA encourages Congress to ensure this authority is 
renewed in 2019 in order to continue building on the successes already 
achieved.
    This bill offers a sound step forward to ensuring we meet the needs 
of those who have served, no matter their zip code.
                                 ______
                                 
   Letter from Bill Valdez, President, Senior Executives Association

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       Prepared Statement of Hon. Robert N. Davis, Chief Judge, 
               U.S. Court of Appeals for Veterans Claims
    Mr. Chairman and Distinguished Members of the Committee: Thank you 
for the invitation to submit a statement of the Court's views on 
legislation pending before the Committee, in particular S. 1024, the 
Veterans Appeals Improvement and Modernization Act of 2017. The Court's 
comments will be brief.
    Although changes to VA's appeals processing will eventually impact 
the Court, the pending legislation does not amend the statutory 
provisions governing the Court's function. For this reason, the Court 
will not speculate as to potential consequences of changes that pertain 
only to the agency, or comment on specific provisions that may 
ultimately come before the Court in litigation. We do, however, offer 
the following thoughts on the need to ensure that claimants are aware 
of their right to appeal to a court of law, and the potential impact 
this legislation will have on the Court's workload.
    Continued Advisement of Appellate Rights: The proposed legislation 
on appeals modernization provides veterans unlimited opportunities to 
repeatedly pursue a claim within the agency and secure the earliest 
effective date possible following any grant of benefits on a timely 
supplemental claim. That revised appeals structure could potentially 
result in a veteran never securing a Board of Veterans' Appeals (Board) 
decision and accompanying notice of appellate rights, and thus never 
being informed of the Court's existence. The Court states no opinion on 
whether or not the proposed changes are ``good for'' individual 
veterans or VA's overall system of claims processing. We do, however, 
want to ensure that veterans remain aware of the full array of options 
available to them in pursuing a claim, including appealing to the 
Court, and that no option be painted as more or less favorable or 
likely for success than another.
    Unlike earlier draft bills on appeals modernization, S. 1024 
includes language that extends the effective date protection, and in 
essence permits continuous pursuit of a claim via the submission of a 
timely supplemental claim following a decision of the Court. The 
Secretary opposed a similar provision in recent testimony before the 
U.S. House Committee on Veterans' Affairs, where Acting Chairman of the 
Board David Spickler stated that affording that effective date 
protection following a court decision ``is contrary to VA's policy 
interest in encouraging dissatisfied claimants to stay within VA unless 
it is truly necessary to go to a higher court.'' We oppose any effort 
to discourage veterans from exercising their right to appeal to the 
Court. In light of Mr. Spickler's strong statement, the Court feels it 
worth highlighting that whether or not S. 1024 passes as drafted, the 
notices VA includes with its decisions must present to veterans all of 
their post-decision options fully and fairly, and leave the decision as 
to when an appeal to the Court is necessary in the hands of the 
veteran. At a minimum, any revisions to the post-Board-decision 
standard notice of appellate rights must leave intact the notification 
regarding appealing to the Court. Many people fought long and hard to 
secure impartial review of adverse VA decisions by a Federal court that 
by definition is independent of VA. Veterans and their survivors must 
continue to know about and understand that right.
    Implementation: Generally speaking, appeals filed at the Court come 
from veterans who are dissatisfied with a decision of the Board. 
Although not with mathematical precision, history has shown that as the 
number of Board decisions increases, so too do the number of appeals 
filed at the Court. It is impossible to predict to what extent, if any, 
the changes proposed by this broad appeals reform legislation will 
result in some veterans choosing to pursue their claims at the agency 
following an adverse Board decision rather than appealing to the Court. 
It is likewise impossible to predict the extent of the legal and 
procedural questions that will be raised by sweeping legislative change 
and that will ultimately come before the Court for decision. What does 
seem clear is that the manner in which this pending legislation is 
implemented and how that implementation effects the flow of decisions 
made by the Board will have a profound and fairly immediate effect on 
the Court.
    The applicability section of S. 1024, Section (x), addresses how VA 
would implement this legislative change, to include an early 
applicability option and phased rollout. This provision leaves several 
questions as to when the new system would ultimately be implemented, 
when cases under that system would reach the Court, and how legacy 
appeals would be treated. The certification requirement on VA to 
confirm its preparedness to implement amplifies the uncertainty. Any 
implementation plan for sweeping legislative change to the VA claims 
processing system will certainly have its challenges, and we offer no 
comment on what those may be. We are, however, attempting to anticipate 
the impact on the Court and best estimate and prepare for the workload 
that may result from these changes should they become law.
    VA recently testified that more than 460,000 appeals are pending 
before the agency today. The Board decided in the neighborhood of 
52,000 decisions in fiscal year 2016, has pledged to further increase 
its number of annual decisions, and has and continues to grow its 
staffing at an extraordinary pace in order to meet those projections. 
Faced with this data, the Court projects a steady, and likely 
significant increase in the number of appeals over the next several 
years. As we anticipate a growth in appeals, let me take this 
opportunity to thank the Committee for the 2016 authorization to 
temporarily maintain an expanded Court of nine active judges. Once 
judicial nominees are announced, we ask for your prompt attention to 
the confirmation process so that we may return to full strength and 
ensure that we are prepared and able to conduct effective, efficient, 
and expeditious judicial review of all matters that come before the 
Court.
    In closing, we appreciate the Committee's consideration of our 
input, and for the past and continued support of the Court's endeavors, 
including the establishment of a permanent Courthouse building. Thank 
you.

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