    [Senate Hearing 115-616]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 115-616

                         HEARING ON PENDING LEGISLATION

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                         ONE HUNDRED FIFTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                                 AUGUST 1, 2018
                                   __________

           Printed for the use of the Committee on Veterans' Affairs

                     [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

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

                                  ___________

                        U.S. GOVERNMENT PUBLISHING OFFICE

    34-881 PDF                 WASHINGTON : 2019

                         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

                        Robert J. Henke, Staff Director
                    Tony McClain, Democratic Staff Director

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

                          Minority Professional Staff
                                Dahlia Melendrez
                                Cassandra Byerly
                                    Jon Coen
                                  Steve Colley
                                   Simon Coon
                               Michelle Dominguez
                                   Amy Smith

                                C O N T E N T S

                                  ----------

                                 August 1, 2018
                                    SENATORS

                                                                       Page
    Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia........     1
    Brown, Hon. Sherrod, acting Ranking Member, U.S. Senator from
      Ohio...........................................................     2
    Boozman, Hon. John, U.S. Senator from Arkansas...................    20
    Sanders, Hon. Bernard, U.S. Senator from Vermont.................    29
    Manchin, Hon. Joe, III, U.S. Senator from West Virginia..........    31
    Cassidy, Hon. Bill, U.S. Senator from Louisianna.................    36
    Hirono, Hon. Mazie K., U.S. Senator from Hawaii..................    38
    Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    40
    Tillis, Hon. Thom, U.S. Senator from North Carolina..............    45

                                   WITNESSES

    Peters, Hon. Gary C., U.S. Senator from Michigan.................     3
    Gillibrand, Hon. Kirsten E., U.S. Senator from New York..........     4
        Prepared statement...........................................     5
    Daines, Hon. Steve, U.S. Senator from Montana....................     6
    Lawrence, Paul R., Ph.D., Under Secretary for Benefits, Veterans
      Benefits Administration, U.S. Department of Veterans Affairs;
      accompanied by Ralph Erickson, M.D., M.P.H., Dr. PH, Chief
      Consultant, Post-Deployment Health, Veterans Health
      Administration, Tammy Czarnecki, Assistant Deputy Under
      Secretary for Health/Administrative Operations, Veterans Health
      Administration; and Jessica Bonjorni, Acting Assistant Deputy
      Under Secretary for Health for Workforce Services, Veterans
      Health Administration..........................................     8
        Prepared statement...........................................    10
        Additional views.............................................    26
        Response to request arising during the hearing by:
          Hon. Johnny Isakson........................................    27
          Hon. Mazie K. Hirono.......................................    40
        Response to posthearing questions submitted by:
          Hon. John Boozman..........................................    47
          Hon. Sherrod Brown......................................... 47,50
          Hon. Joe Manchin III.......................................    48
          Hon. Mazie K. Hirono.......................................    49
    Nuntavong, Chanin, Director, National Veterans Affairs &
      Rehabilitation Division, The American Legion...................    54
        Prepared statement...........................................    56
    Manar, Gerald T., Blue Water Navy Veteran, Former Director,
      National Veterans Service, Veterans of Foreign Wars of the
      United States..................................................    69
        Prepared statement...........................................    71
    Snee, Thomas J., National Executive Director, Fleet Reserve
      Association....................................................    77
        Prepared statement...........................................    79
    Weidman, Rick, Executive Director for Policy and Government
      Affairs, Vietnam Veterans of America...........................    81
        Prepared statement...........................................    83

                                    APPENDIX

    Cantwell, Hon. Maria, U.S. Senator from Washington; prepared
      statement......................................................    91
    Feinstein, Hon. Dianne, U.S. Senator from California; prepared
      statement......................................................    91
    Advanced Medical Technology Association (AdvaMed); prepared
      statement......................................................    92
    Appraisal Institute (AI); letter.................................    94
    Webb, Amy, National Legislative Policy Advisor, American Veterans
      (AMVETS); prepared statement...................................    95
    McClain, Hon. Tim S., Chairman, Board of Directors and James
      Lorraine, President & CEO, America's Warrior Partnership (AWP),
      Augusta, GA; prepared statement................................   100
    Johnson, Cinthia, Interim Executive Director, Connecticut
      Veterans Legal Center (CVLC); prepared statement...............   103
    Villanueva, Jeremy M., Associate National Legislative Director,
      Disabled American Veterans (DAV); prepared statement...........   109
    U.S. Department of Defense (DOD); prepared statement.............   119
    Denton, Ivan, Director, Office of National Programs, Veterans'
      Employment and Training Service, U.S. Department of Labor
      (DOL); prepared statement......................................   123
    Mortgage Bankers Association (MBA); prepared statement...........   129
    Military Officers Association of America (MOAA); prepared
      statement......................................................   133
    Military Order of the Purple Heart (MOPH); prepared statement....   138
    Wells, CDR John B., USN (Ret.), Executive Director, Military-
      Veterans Advocacy (MVA); prepared statement....................   139
    Mendenhall, Elizabeth J., 2018 President, National Association of
      REALTORS (NAR); letter........................................   145
    Murphy, Sharon L., President, National Association of State
      Veterans Homes (NASVH); prepared statement.....................   146
    Stewart, Joshua, Director of Policy, National Coalition for
      Homeless Veterans (NCHV); letter...............................   147
    Co-Directors, National Military and Veterans Alliance (NMVA);
      letter.........................................................   149
    Paralyzed Veterans of America (PVA); prepared statement..........   150
    Augustine, Ms. Lauren, Vice President of Government Affairs,
      Student Veterans of America (SVA); prepared statement..........   155
    Tragedy Assistance Program for Survivors (TAPS); prepared
      statement......................................................   159
    Bandzul, Thomas, Esq. Legislative Counsel, Veterans & Military
      Families for Progress (VMFP); prepared statement...............   161
    Bardorf, Rene C., Senior Vice President of Government and
      Community Relations, Wounded Warrior Project (WWP); prepared
      statement......................................................   164

                         HEARING ON PENDING LEGISLATION

                                  ----------

                           WEDNESDAY, AUGUST 1, 2018

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 2:32 p.m., in
    room 418, Russell Senate Office Building, Hon. Johnny Isakson,
    Chairman of the Committee, presiding.
        Present: Senators Isakson, Boozman, Heller, Cassidy,
    Tillis, Sullivan, Sanders, Brown, Blumenthal, Hirono, and
    Manchin.

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

        Chairman Isakson. Good afternoon. I call this meeting of
    the Senate Veterans' Affairs Committee to order.
        This is a hearing on legislation that will be pending
    before the U.S. Senate at some point in time in the future, in
    some cases the near future. I have had conversations with the
    authors before and told them that we would have a hearing as
    early as I could have one so we could get the preliminary
    information out there. I appreciate everybody who is here today
    from both the Senate and the members of the VA, plus VA staff
    and the advisory committees.
        We have a full agenda. We have 15 pieces of legislation to
    address. We have two panels with four speakers each. We have a
    number of big issues, but probably no bigger than the Blue
    Water Navy issue, which has come up for some time in the past.
    The House has passed a Blue Water Navy bill. Senator Gillibrand
    and others in the Senate have asked me if we are going to
    consider one in the U.S. Senate Veterans' Affairs Committee. I
    said we are going to, but we are going to do it in regular
    order. That is the way we did everything. We had some big
    issues last year which we were able to get through, like the
    Caregivers' bill, which had never gotten out of this Committee
    before because of the way we handled it, which is the reason we
    got it out.
        I know from time to time I irritated some people during the
    last couple of months by being deliberate, not slow but
    deliberate, on the way we handled that. We will handle it the
    same way this year in terms of Blue Water Navy, and I think we
    will come out with a similar result in terms of a thorough
    examination of the legislation.
        This is all very important legislation. For everybody's
    knowledge, we passed in the last 18 months 18 pieces of
    legislation to reform the Veterans Administration. Every Member
    of this Committee has had significant input into those reforms,
    had a lot to say about them.
        We have a new Secretary of the VA, Robert Wilkie, whom you
    heard from when we had our hearing, who I was with Monday with
    the President for the swearing in. He is a great individual, a
    fine individual, and someone who is known to all of you that
    are here. I know he will do a great job.
        My opening statement is this: Be ready. Fasten your seat
    belts. We have got a lot of work to do, and today is to find
    out what the authors of the legislation want us to know about
    the bills they have proposed and for the people who will be
    affected to have testimony and input on that.
        Each one of the Senators who are here, Mr. Peters, Mr.
    Daines, and Ms. Gillibrand, will speak first and will be
    welcome to leave as soon as your speech is over. You do not
    have to, but I know you are busy and got other things to do, so
    you are welcome to do that.
        I am proud to recognize Sherrod Brown, my good friend from
    the great State of Ohio, a good baseball State, and he, a good
    baseball player. Senator Brown is filling in for Jon Tester,
    our ranking member. We got out early today, as many of you
    know, and Senator Tester had to leave town early, as I
    understand it. I appreciate his tremendous help and cooperation
    over the last year and a half. He has pledged it for the
    remainder of this term as well. We are going to have a great
    time together in this Committee, and we need to get good stuff
    done.
        So, Senator Brown?

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

        Senator Brown. I will be brief, Mr. Chairman. I would add
    on behalf of everybody on this Committee that Johnny Isakson is
    the least irritating member of the U.S. Senate. [Laughter.]
        I think you would all agree with that. I think we all are
    an irritating group of people, by and large, and he is not. So,
    thank you, Johnny, for that.
        Senators Daines, Gillibrand and Peters, thank you for
    joining us, and I speak on behalf, in part, Senator Daines, of
    the senior Senator, for Senator Tester.
        Thanks for holding the hearing, Mr. Chairman.
        There are two specific bills that I am interested in: (1)
    Better Access to Technical Training, Learning, and
    Entrepreneurship for Servicemembers Act, or BATTLE for
    Servicemembers Act that I have worked on with Senator Rounds,
    and I thank him; and (2) the Blue Water Navy bill, which is so
    important. This Committee will review two different pieces of
    legislation to address the needs of active-duty servicemembers
    as they transition to civilian life. We need to do everything
    we can to ensure they have the information and tools they need
    to succeed. Additional days of training to pursue education,
    technical training, entrepreneurship will help to set
    servicemembers up for good-paying jobs when they reenter
    civilian life, and I was pleased that this year's NDAA that
    Senator Isakson was so helpful on, too, included a version of
    this provision in the final conference report.
        I will not be able to stay for the second panel's
    discussion, but I wanted to say a few words about Blue Water
    Navy veterans. I appreciate Thomas Snee being here from Lake
    County, OH. I appreciate very much seeing him today. He knows
    all too well, we all do, the energy it takes to push the VA to
    do the right thing by those who have borne the battle,
    particularly those who were drafted to fight and felt forgotten
    when they returned home, only to develop conditions directly
    tied to their service.
        Our Vietnam vets, many of them, many of you, do not have a
    lot of years left, and it is important that they get these
    benefits regardless of whether they served on the land, in the
    Brown Water, or in the Blue Water. It does not matter.
        Mr. Manar will speak in a moment. I want to quote from him,
    if I could sort of a little bit steal his thunder with this
    quote: ``If there was dioxin in the water, we would have been
    exposed to it while swimming. Week after week, patrolling up
    and down the coast, we took in sea water and processed it
    through our fresh water evaporator system. We know from the
    Australian Navy study, validated by the National Academy of
    Medicine. . . that fresh water evaporator systems concentrated
    toxic material, including dioxin, which was then transmitted to
    sailors through drinking water.''
        ``As a matter of observation,'' he goes on, ``absent the
    cleaning and sanitation of the entire fresh water evaporator
    system, it is conceivable that every person who ever served on
    board my ship could have been exposed to dioxin after its first
    visit to Vietnam. Further, by the time we completed our last
    deployment. . . in 1972, the evaporator system would have
    accumulated concentrated dioxin from dozens of visits to
    Vietnam, not simply the final three that I experienced while on
    board.''
        Nobody could have said that better. My question for the
    record will be: why hasn't the VA concluded that the science
    behind the Australian study, in which NAM collaborated, is
    sufficient? Why hasn't VA done right by our veterans?
        So, Mr. Chairman, thank you for letting me offer those
    words. And, I appreciate all the panel members being here.
        Chairman Isakson. Thank you, Senator Brown. Thank you for
    being here, and thank you for your opening statement.
        Our first panel is made up of Senator Peters, Senator
    Gillibrand, and Senator Daines. Senator Peters will be
    recognized for 5 minutes, Senator Gillibrand for 5 minutes. I
    understand you are going to yield some time, is that correct,
    to Senator Daines, Senator Gillibrand? [Both nodding in
    agreement.]
        We will start with Senator Peters. You are recognized for 5
    minutes. If it gets to 7 or 8, you are in trouble.

                   STATEMENT OF HON. GARY C. PETERS,
                       U.S. SENATOR FROM MICHIGAN

        Senator Peters. I will be brief, Mr. Chairman.
        Thank you, Mr. Chairman, and thank you to all my colleagues
    for your service on this Committee. I certainly appreciate the
    opportunity to speak in support of Senate bill 1596, which is
    entitled the ``BRAVE Act.'' I was proud to introduce this
    bipartisan legislation with Senator Rubio.
        The BRAVE Act is a bicameral piece of legislation, and I
    also appreciate the leadership of Representative Duncan Hunter,
    who is shepherding this bill in the House of Representatives.
        Our brave men and women in uniform have sacrificed so much
    in the defense of our Nation. We owe it to them to ensure that
    they receive the benefits that they have earned through their
    service, including a dignified burial. Unfortunately, current
    VA burial benefits are woefully insufficient.
        The national median cost of a funeral in 2017 was $8,755.
    However, the VA burial benefits provide a mere $2,000 for
    service-connected deaths, $762 for non-service-connected deaths
    for veterans who pass away in a VA facility, and $300 for all
    non-service-connected deaths.
        It is clear that these benefits have not kept pace with the
    rising cost of funeral and burial expenses, which is why
    Senator Rubio and I have introduced the BRAVE Act. The BRAVE
    Act will make funeral benefits for non-service-connected deaths
    the same, regardless of where the veteran passes away.
        The legislation also ensures that all burial benefits are
    indexed for inflation, eliminating the need for Congress to
    make further readjustments and providing future generations of
    our Nation's veterans with the dignified burial that they have
    earned through their honorable service.
        The BRAVE Act enjoys support from organizations including
    the Veterans of Foreign Wars, Vietnam Veterans of America, the
    National Funeral Directors Association, the Association of the
    U.S. Navy, The American Legion, and Disabled American Veterans.
    I believe we should honor our Nation's heroes by making
    commonsense updates to VA burial benefits, ensuring that every
    veteran has a proper funeral and burial no matter the
    circumstances at the end of their lives.
        Thank you again, Mr. Chairman and the Committee, for the
    opportunity to speak today, and I look forward to working with
    you as you pass this important legislation. I yield the rest of
    my time to the Senator from New York, Senator Gillibrand.
        Chairman Isakson. Senator Gillibrand, you are recognized
    for 5 minutes plus whatever he yielded to you.

               STATEMENT OF HON. KIRSTEN E. GILLIBRAND,
                       U.S. SENATOR FROM NEW YORK

        Senator Gillibrand. Thank you so much, Mr. Chairman and Mr.
    Ranking Member. I am very grateful for your leadership. I am so
    grateful for this hearing--we really want to support our Blue
    Water Navy veterans--and for your commitment to finally passing
    this long overdue bill.
        It is my sincere hope that now that we have an offset that
    has been identified and passed in the House, 382-0, that we may
    also quickly pass this bill and send it to President Trump as
    expeditiously as possible.
        As you know, during the Vietnam War, thousands of patriotic
    Americans were exposed to the chemical Agent Orange, which we
    now know is highly toxic. Some of our veterans were exposed to
    Agent Orange on the ground, some patrolling rivers, some while
    stationed on ships off the Vietnamese coast. These are called
    the ``Blue Water Navy vets.''
        Now, all these years later, Agent Orange has made many of
    them very sick, many of them severely ill, and many of them
    have already died because of Agent Orange. But, the VA is only
    helping some of the veterans exposed to this dangerous
    chemical. They are helping the Vietnam veterans who were
    exposed to Agent Orange on land or on rivers, but excluding
    those who served on the Blue Water. It does not make any sense.
    It is arbitrary. It is a bureaucratic rule that is preventing
    veterans who served in Vietnam from getting the treatment they
    desperately need.
        In Congress, we have been fighting for this legislation for
    nearly a decade so that the VA could just deliver the benefits
    that these men and women have already earned. With today's
    markup, we are finally there. Thanks to the tireless effort of
    both members of the House and Senator Veterans' Affairs
    Committees, we have a bipartisan bill, and we have a bipartisan
    pay-for.
        Now, I want to address the pay-for because that is
    important to a lot of our colleagues. The offset is nearly $1
    billion to care for our Blue Water Navy veterans, their
    families, and for some, their survivors. The way we pay for it
    is from the VA Home Loan Program because it provides a home
    loan guarantee benefit to help servicemembers, veterans, and
    surviving spouses who become homeowners. Private lenders
    provide VA home loans, but the VA guarantees a portion of that
    loan, enabling veterans to receive more favorable terms.
        Now, these loans are different from those that are offered
    to nonveteran civilian populations. Instead of paying annual
    fees or interest on the loan, the veteran only pays a one-time
    up-front loan fee. Currently that fee is 0.25 percent lower if
    you are active-duty versus National Guard or Reserve. All this
    bill does is equalize that number at 2.4 percent. It pays for
    the entire bill. It passed unanimously in the House of
    Representatives.
        So, I hope that our Senate colleagues can look at this pay-
    for favorably and allow this bill to be fully paid for to help
    our veterans.
        Now, our Blue Water Navy veterans have waited a very long
    time for basic health care and basic benefits they have already
    earned. They have suffered consequences to their health, to
    their families, to their lives. I think this is an injustice
    that we can and must rectify, and I think we can do it in this
    Congress. So, I ask all of you to please consider this bill
    since it has had such bipartisan favorable response in both the
    House and Senate. I think the time is now to actually pass it.
        I would now like to yield the remainder of my time to my
    colleague Senator Daines.
        [The prepared statement of Sen. Gillibrand follows:]
                Prepared Statement by Hon. Kirsten Gillibrand,
                           U.S. Senator from New York
                  blue water navy vietnam veterans act of 2017
        Chairman Isakson and Ranking Member Tester, Thank you for the
    opportunity to speak again before this Committee in support of the Blue
    Water Navy Vietnam Veterans Act of 2017--and for your commitment to
    finally passing this long overdue bill. It is my sincere hope that now
    that an offset has been identified and passed the House 382 to ZERO,
    that we may also quickly pass this bill and send it to President Trump
    as expeditiously as possible.
        As you know, during the Vietnam War, thousands of patriotic
    Americans were exposed to a chemical called Agent Orange, which we now
    know is highly toxic.
        Some of our veterans were exposed to Agent Orange on the ground.
    Some of them were exposed to Agent Orange while patrolling the rivers.
    And some of them were exposed to Agent Orange while they were stationed
    on ships off the Vietnamese coast--these are the Blue Water Navy
    veterans.
        And now, all these years later, Agent Orange has made many of them
    sick. They are severely ill. Many of them have already passed away
    because of Agent Orange.
        But, the VA is only helping SOME of the veterans exposed to this
    dangerous chemical. They're helping the Vietnam veterans who were
    exposed to Agent Orange on land, or on rivers . . . but NOT the Blue
    Water Navy veterans. That doesn't make any sense.
        This arbitrary, bureaucratic rule is preventing veterans who served
    in the Vietnam War from getting the treatment they need now.
        In Congress, we have been fighting for nearly a decade to deliver
    VA healthcare and benefits to the Blue Water Navy veterans exposed to
    Agent Orange. And with today's markup of H.R. 299, we are finally
    there. Thanks to the tireless efforts of both the House and Senate
    Veterans' Affairs Committees, we have a bipartisan bill and a pay-for.
        I think it is important, in this hearing, that we directly address
    the pay-for in H.R. 299 that will offset the nearly $1 billion cost of
    caring for our Blue Water Navy veterans, their families, and--for
    some--their survivors.
        The VA Home Loan program provides a home loan guaranty benefit to
    help servicemembers, veterans, and eligible surviving spouses become
    homeowners. Private lenders provide VA home loans, but the VA
    guarantees a portion of the loan, enabling veterans to receive more
    favorable terms.
        These loans are different from those offered to the non-veteran,
    civilian population. Instead of paying annual fees or interest on the
    loan, the veteran only pays a one-time, up-front loan fee at the
    initiation of their loan.
        Currently, the rate of this fee is 0.25% lower if you are active
    duty than if you are in the National Guard or Reserve. This bill would
    equalize the rate at 2.40%.
        I believe our colleagues in the Senate will agree with the
    unanimous, bipartisan consensus in the House--that this pay-for is
    appropriate and measured. The VA Home Loan program will remain a
    powerful, unparalleled tool to help America's veterans become
    homeowners, and the rates will remain far better than rates in the
    private market.
        Our Blue Water Navy veterans have waited far too long for the
    healthcare and benefits owed to them. They've suffered health
    consequences that left them and their families on the hook for medical
    expenses that our government should have provided. Many have lost their
    lives. This is an injustice we can--and must--address here in this
    Congress.
        I ask that each of you here vote today to move H.R. 299 out of
    committee without changes or delay--so that our Nation can do right by
    our veterans and their families as quickly as possible.
        And now I'd like to yield to my colleague and lead cosponsor of
    this legislation, Senator Daines.

        Chairman Isakson. Senator Daines.

                    STATEMENT OF HON. STEVE DAINES,
                       U.S. SENATOR FROM MONTANA

        Senator Daines. Chairman Isakson and Ranking Member Tester,
    thank you for allowing us to be here today to testify at this
    hearing.
        I am the lead Republican on this bill, and I want to thank
    my colleague and friend Senator Gillibrand for her leadership.
    I urge the Committee to pass this critical bipartisan measure.
        Since 2002, our U.S. Navy veterans who were exposed to
    Agent Orange while serving in Vietnam have been denied proper
    care through the VA. As background, you have to go back to the
    Agent Orange Act of 1991, 27 years ago. That bill passed
    unanimously by both Houses of Congress, and it extended
    presumptive health care coverage for all illnesses linked to
    Agent Orange.
        Here is the problem: The VA thwarted congressional intent
    by choosing the narrowest possible definition of ``service in
    the Republican of Vietnam,'' which excluded the country's
    territorial waters. Our Federal records show, the science shows
    a documented 19 million gallons of herbicide was sprayed over
    Vietnam between 1962 and 1971. No reasonable person would
    conclude that the runoff from these powerful chemicals was
    contained just to the shoreline.
        I am encouraged by the recent action our colleagues in the
    House have taken and the growing bipartisan push here in the
    Senate to correct, frankly, a senseless disparity once and for
    all. I urge this Committee to take a critical step toward that
    end today.
        Chairman Isakson. Thank you very much, Senator Daines. I
    think we go to questions and answer on the first panel.
        I am trying to exercise executive privilege over here. Just
    a second. I will be right back to you. [Pause.]
        The staff tells me I am out of order. [Laughter.]
        That is not the first or would be the last time. Senator
    Daines, thank you for coming.
        Senator Daines. Thank you, Mr. Chairman.
        Chairman Isakson. Ms. Gillibrand, thank you very much for
    your comments.
        Senator Gillibrand. Thank you all. Thank you for the time.
        Chairman Isakson. Senator Peters has already left. I thank
    him very much.
        The first panel, which I will introduce right now, is
    coming forward. Panel number 1 is Paul Lawrence, Ph.D., Under
    Secretary for Benefits, Veterans Benefits Administration,
    Department of Veterans Affairs.
        Ralph Erickson will be accompanying him. Ralph is a doctor,
    Chief Consultant, Post-Deployment Health, Veterans Health
    Administration.
        Tammy Czarnecki is Assistant Deputy Under Secretary for
    Health/Administrative Operations, Veterans Health
    Administration.
        And, Jessica Bonjorni--I hope you are Italian; that would
    be great--is Acting Assistant Deputy Under Secretary for Health
    for Workforce Services, Veterans Health Administration.
        Will you all please come forward and take your seats? Thank
    you very much for being here. This is an important panel, and I
    will get to ask you all questions. Just because the Senators
    dodged the bullet, you all will not be able to.
        We will start with Ms. Bonjorni--no, I am sorry. You are to
    be an acting aide. You are not going to be the main presenter.
    That is correct. I almost got you in trouble, too.
        Mr. Lawrence, you are on. You have 5 minutes, but if you
    take a little extra time because of the complexity of a couple
    of these issues, that will be fine with me.

       STATEMENT OF PAUL R. LAWRENCE, Ph.D., UNDER SECRETARY FOR
    BENEFITS, VETERANS BENEFITS ADMINISTRATION, U.S. DEPARTMENT OF
    VETERANS AFFAIRS; ACCOMPANIED BY RALPH ERICKSON, M.D., M.P.H.,
      DR. PH, CHIEF CONSULTANT, POST-DEPLOYMENT HEALTH, VETERANS
    HEALTH ADMINISTRATION; TAMMY CZARNECKI, ASSISTANT DEPUTY UNDER
    SECRETARY FOR HEALTH/ADMINISTRATIVE OPERATIONS, VETERANS HEALTH
     ADMINISTRATION; AND JESSICA BONJORNI, ACTING ASSISTANT DEPUTY
      UNDER SECRETARY FOR HEALTH FOR WORKFORCE SERVICES, VETERANS
                         HEALTH ADMINISTRATION

        Mr. Lawrence. Thank you very much, sir. Good afternoon,
    Chairman Isakson, Ranking Member Sanders, 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. You generously introduced our panel, so I
    will not repeat their names.
        With 15 bills on the agenda, I will cover a few in my oral
    statement.
        We are glad to support the bill to provide grants to
    coordinate suicide prevention efforts for veterans in our
    communities. There is no bigger or more urgent priority for VA.
        Other bills we support will provide long-overdue increases
    in burial benefits as well as improving benefits for surviving
    spouses.
        There are other bills on the agenda that raise concerns,
    including Blue Water Navy. We oppose this bill. Let me explain
    why.
        We know it is incredibly difficult to hear from groups of
    veterans who are ailing and ill. Many of us in this room are
    veterans with empathy and compassion. We also understand there
    are practical effects from this bill that give us great concern
    and pause. In the case of this legislation, we should be very
    clear on the precedent this bill attempts to create and the
    broad effects it will have over time.
        As you know, when a veteran files a claim, our pledge is to
    work hard to honor it. In the process of evaluating a veteran's
    claim, we rely on science and medical opinions. For example, a
    person suffers an injury during service or has a condition
    later in life that we think is connected to their time in
    service. They submit a claim for service-connected benefits
    based on the injury or condition. We apply science, in this
    case a medical exam, to demonstrate the injury or condition was
    caused during military services or has rendered them with a
    disability for which they should receive compensation.
        But, with Blue Water Navy, there is no conclusive science
    from the Institute of Medicine to support claims of toxic
    exposure. This Committee set the standard to use science to be
    fair and consistent in cases such as this. Once that standard
    is removed from the equation, it becomes nearly impossible to
    adjudicate a claim of this type on the merits. The resulting
    lower threshold sets in motion the prospect of uncontrolled
    demands for support. What remains eliminates this rationale,
    and instead we are left with a situation where there are no
    limits; therefore, no claims can be denied.
        This in turn invites other sympathetic causes without valid
    science to petition Congress for compensation. If this bill
    becomes law, this Committee is setting a precedent for
    potentially unwieldy policy with consequences to the future of
    Veterans Benefits, VA, and in other areas of Government.
        The bill before us today will then be referenced when other
    exposure claims are presented to this Committee. At that point
    Congress will be under greater pressure to accommodate these
    requests, too, regardless of the evidence.
        The National Academy of Medicine reviewed all available
    scientific evidence, concluding that it was unable to state
    with certainty that Blue Water Navy personnel were or were not
    exposed to Agent Orange. They recognized that the oft-mentioned
    Australian study does not directly support the contention that
    Blue Water Navy personnel were exposed to the dioxins of Agent
    Orange. This laboratory simulation was based on the false
    premise that water for ship distillation would be drawn near
    shore where pollution accumulates. To avoid these contaminants,
    established U.S. Navy policy was only to draw water from 12
    miles offshore where pollutants and dioxins would be diluted
    from trillions of gallons of sea water.
        Because we are always looking for new information, VA
    continues to review and monitor the peer-reviewed scientific
    and medical literature in collaboration with VSOs. To further
    address the medical aspects of Section 2, Dr. Erickson is with
    me today and is prepared to discuss ongoing VA studies of
    Vietnam veterans, one of which compares the health effect of
    Vietnam veterans with veterans who did not serve in Vietnam and
    with U.S. nonveteran populations. It has the advantage of
    including Blue Water Navy veterans on the steering committee.
    Results will be published in peer-reviewed scientific
    literature starting in 2019. Nearly 1,000 Blue Water Navy
    veterans are included in the study at this time.
        Additionally, VA is opposed to paying for the provisions of
    this bill by increasing the costs that some veterans must pay
    to access their benefits. Veterans will have to either finance
    the VA funding fee with interest or pay up-front in cash. This
    means fewer veterans will buy homes or buy homes using non-VA
    options, potentially opening them to predatory lenders.
        Another impact we need to raise regards the recent ongoing
    efforts to reduce the appeals and claims backlog. These efforts
    would be impacted through additional FTEs and costs, but also
    adding time to the 125 days to process a claim due to the
    verification study that would need to go into the processing of
    that claim.
        In summary, we oppose this bill because the science is not
    there, and what we do depends upon science. We care so we keep
    looking. Increased fees levied on home loans place additional
    financial burdens on veterans who are trying to buy a home,
    opening them further to predatory lending. The ongoing efforts
    and momentum of appeals and claim backlog would be set back.
        A final thought. Congress has always relied on science. If
    this bill passes, the legacy of this Committee could be forever
    changed.
        Let me now briefly address the draft bill on Veterans
    Dental Care Eligibility Expansion and Enhancement Act of 2018.
    We feel part of the bill is unnecessary and that the
    significant expansion of dental care called for in this bill is
    simply not feasible. VA does not have the infrastructure to
    provide that care, and the significant expense of adding the
    benefit we fear would squeeze resources from other critical
    veteran health care needs.
        State nursing homes are addressed in S. 3184. We know
    extended care for veterans is an important issue for the
    Committee and every Senator. However, we believe S. 3184, as
    drafted, could result in negative unintended consequences,
    including move State veterans' homes away from their core
    mission of serving veterans. We are glad to discuss ideas to
    improve this bill further with the Committee.
        This concludes my testimony. We look forward to answering
    any questions the Committee has.
        [The prepared statement of Mr. Lawrence follows:]
        Prepared Statement of Dr. Paul R. Lawrence, Under Secretary for
                 Benefits, 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 are Ralph
    Erickson, M.D., M.P.H., Dr. PH, Chief Consultant, Post Deployment
    Health, VHA; Tammy Czarnecki, Assistant Deputy Under Secretary for
    Health/Administrative Operations, VHA; and Jessica Bonjorni, Acting
    Assistant Deputy Under Secretary for Health for Workforce Services,
    VHA.
             h.r. 299--blue water navy vietnam veterans act of 2018
    Section 2: Clarification of Presumptions of Exposure for Veterans Who
            Served in Vicinity of Republic of Vietnam
        Section 2 of H.R. 299 would add a new section 1116A to title 38,
    United States Code (U.S.C.). The bill would expand the presumption of
    Agent Orange exposure to all Veterans who served ``offshore'' of the
    Republic of Vietnam, as defined in subsection (d) of the bill, and
    would presume the in-service incurrence or aggravation of all diseases
    covered in 38 U.S.C. Sec. 1116 for these Veterans. It would also
    provide retroactive benefits for Veterans who had a previous claim for
    a covered disease denied and then file a new claim, comparable to the
    retroactive benefits available for Veterans who went ashore. This
    retroactivity would be accomplished via a special effective date rule
    contained in the bill. The bill would also expand the definition of
    ``Vietnam-era herbicide-exposed veteran,'' codified at 38 U.S.C.
    Sec. 1710(e)(4)(A), to include Veterans with ``offshore'' service for
    purposes of the provision of health care.
        VA is opposed to section 2 of this bill. The legislative history of
    Veterans' disease presumptions dates back to 1921 when Congress
    established a presumption of service connection with an amendment (P.L.
    67-47) to the War Risk Insurance Act (P.L. 63-193). In the following
    years, additions to the presumptive list were made by regulation,
    executive order, and legislation. In 1991, the Agent Orange Act (P.L.
    102-4) established for Vietnam Veterans a presumption of a service
    connection for diseases associated with exposure to Agent Orange and
    certain other herbicides. For the first time, this Act required VA to
    contract with the Institute of Medicine (IOM) to biennially conduct a
    scientific review of the evidence linking certain medical conditions to
    herbicide exposure. VA was instructed to use the IOM's findings, and
    other evidence, to provide the rationale for establishing regulations
    and determining that a presumption for any disease would be warranted
    when there is scientific evidence of an association with herbicide
    exposure.
        VA's view is that the evidence-based approach to creating or
    expanding presumptions should be maintained. Although presumptions
    exist to assist in proving claims that may otherwise be difficult for
    individual veterans to establish on a direct basis, the presumptions of
    exposure and/or medical causation should always be supported by
    historical, scientific, and/or medical evidence about the specific
    population of Veterans affected. VA recognizes Congress's prerogative
    in creating or expanding presumptions. However, VA is concerned that
    new Congressionally-created presumptions that are not adequately
    supported by evidence will erode confidence in the soundness and
    fairness of the Veterans' benefits system. Such statutory presumptions
    will lead to increased pressure on VA to create or expand additional
    presumptions administratively, under a similarly liberal approach.
    Because VA generally cannot establish regulatory presumptions that are
    not reasonably grounded in evidence, Veterans petitioning VA for new
    presumptions that are not supported by the required level of evidence
    will likely be unsatisfied with VA's response. These Veterans may feel
    that the system is inequitable in providing expansive presumptions
    favoring certain groups of Veterans but not others.
        As a means of further assessing the potential for Agent Orange
    exposure, VA commissioned the IOM to produce the report, Blue Water
    Navy Vietnam Veterans and Agent Orange Exposure (2011). The report
    concluded that exposure among Blue Water Navy Veterans ``cannot
    reasonably be determined,'' and it did not find supported and
    compelling evidence of Agent Orange exposure due to aerial spray drift,
    river water runoff, or potable sea water distillation. The report
    indicated that Agent Orange was destroyed by sunlight within hours of
    application and any that survived would rarely make it out to the South
    China Sea because of the major dilution factor. Additionally, United
    States Navy ships were required to draw up seawater for conversion to
    shipboard potable water at least twelve miles offshore from any river,
    a distance at sea where the presence of Agent Orange was unlikely.
        Although there is insufficient scientific evidence to grant a
    blanket presumption of Agent Orange exposure for all Navy Vietnam
    Veterans, VA has a liberal policy of presuming exposure for all
    Veterans who served aboard Brown Water vessels operating on Vietnam's
    inland waterways, and for those Veterans serving aboard Blue Water
    ships that temporarily entered the inland waterways. Additionally, if
    evidence shows that a Blue Water ship off the coast sent crew members
    ashore for duty or visitation, any Veteran on the ship at that time
    will receive the presumption of exposure if they state that they
    personally went ashore.
        As such, VA opposes section 2 because there is insufficient
    scientific evidence at this time showing Blue Water Navy Veterans were
    exposed to Agent Orange. At VA's request, the IOM (now National Academy
    of Medicine (NAM) ) reviewed all available scientific evidence,
    concluding that it was ``unable to state with certainty that Blue Water
    Navy personnel were or were not exposed to Agent Orange and its
    associated TCDD'' (ref: Blue Water Navy Vietnam Veterans and Agent
    Orange Exposure, 2011). VA continues to review and monitor the peer-
    reviewed scientific and medical literature and is collaborating with
    Veterans Service Organizations (including the Veterans of Foreign Wars
    and the Blue Water Navy Vietnam Veterans Association) to gather more
    information. A new VA health study of Vietnam Veterans that includes
    the collection of data on Blue Water Navy Veterans is currently
    ongoing. VA researchers are currently analyzing data from this effort.
    The timeline for initial results is expected to be in 2019, with
    publication of results potentially within 1-2 years. VA is committed to
    examining all available evidence on this issue and gathering input from
    stakeholders in order to make well-informed, scientific, evidence-based
    decisions for our Nation's Veterans.
        VA is also concerned with the special effective date provisions of
    the bill. Our understanding is that these provisions are intended to
    provide Blue Water Navy Veterans with effective date treatment that is
    similar to that available under the Nehmer court decision and orders
    for those who served in the Republic of Vietnam. However, in enacting
    provisions extending benefits to other groups of Veterans, Congress
    generally has not extended those benefits retroactively, much less for
    such a significant time period. VA is concerned about the apparent
    inequity of this disparate treatment of different groups of Veterans.
    Further, VA is concerned that the procedures necessary for applying
    these special effective date provisions, including determining proper
    effective dates and establishing awards covering large retroactive
    periods, would be complex and labor-intensive tasks that would divert
    resources from other important claim adjudications.
        Further, VA has concerns associated with the demarcation line used
    in this bill. Implementation of this provision would be impracticable.
    Currently, VA maintains a ship list for ships that operated on inland
    waterways. This requires VA to research and review deck logs in
    individual cases to assess the geographic coordinates of the ship, as
    well as the time periods on which the ship operated on an inland
    waterway. This bill would essentially extend that ships list to
    encompass an area no more than 12 nautical miles seaward of a line
    commencing on the southwestern demarcation line of the waters of
    Vietnam and Cambodia and intersecting certain geographic points. VA
    would be required to assess many more deck logs and coordinates to
    place additional ships on that list for certain time periods. Because
    of the nature of deck logs, it may be impossible to determine an exact
    location and determine whether a ship did, or did not, cross this line
    on a particular date. Additionally, based on the available scientific
    and medical evidence, VA is unaware of any association between a line
    twelve miles offshore and exposure to Agent Orange. VA understands that
    the Department of State also has concerns regarding this provision of
    the bill.
        This bill would also add significantly to the number of benefit
    claims pending over 125 days. Because of the retroactive provisions and
    the intricacies of reviewing deck logs, each claim would take longer--
    more than twice as long, on average--to review than claims VA generally
    receives. In addition, a large volume of claims would be expected as a
    result of this bill. Thus, unless additional employees are provided, VA
    would expect the backlog to grow significantly due to this expected
    claims burden.
        Finally, VA does not support paying for the provisions of this bill
    by increasing the costs that some Veterans must bear to access their
    benefits. Section 6(b) of the bill would adjust the loan fee that
    certain Veterans, Servicemembers, and surviving spouses must pay to
    obtain home loans in VA's home loan program. In many cases, the
    adjustment would require borrowers to pay higher loan fees to obtain
    home loans. In other words, it appears that the bill would partially
    offset the Government's cost of increased benefits spending on some
    Veterans by raising loan fees for others. Granting new benefits for
    some Veterans at the expense of other Veterans is counter to VA's
    mission.
        VA's cost estimate for the bill is broken down into four
    categories: benefits, general operating expenses, information
    technology (IT), and health care expenditures. VA estimates the total
    benefits cost of this bill would be $1.8 billion during fiscal year
    (FY) 2019, $3.4 billion over 5 years, and $5.7 billion over 10 years.
    In addition to benefits cost, VA estimates the Veterans Benefits
    Administration (VBA) General Operating Expenses (GOE) costs for the
    first year would be $90 million and include salary, benefits, rent,
    training, supplies, other services, and equipment. Five-year costs are
    estimated to be $215.2 million and 10-year costs are estimated to be
    $349.1 million. VA further estimates that the IT cost to support VBA
    would be $2.9 million for the first year, $5.3 million over 5 years,
    and $7.6 million over 10 years. This cost would include the IT
    equipment for full-time equivalent employees, installation,
    maintenance, and IT support. Regarding health care expenditures, VA
    estimates the costs of section 2 of the bill would be $27.8 million in
    FY 2019, $275.1 million over 5 years, and $625.0 million over 10 years.
    In total, VA estimates section 2 of the bill would carry costs of
    approximately $6.7 billion over 10 years.
    Section 3: Presumption of Herbicide Exposure for Certain Veterans Who
            Served in Korea
        Section 3 would add a new section 1116B to title 38, U.S.C.,
    extending the presumptions of service connection for diseases
    associated with exposure to herbicide agents to all Veterans who served
    in the Korean demilitarized zone (DMZ) between September 1, 1967, and
    August 31, 1971. It would not provide retroactive benefits comparable
    to those available for Veterans who served offshore of the Republic of
    Vietnam, as proposed in section 2 of this bill.
        VA is not opposed to presumptions for Veterans of service in the
    Korean DMZ, but has concerns with the prescribed presumptive dates,
    which we believe would unduly expand the start of the time period of
    presumptive exposure.
        Following consultation with the Department of Defense (DOD), VA
    promulgated 38 Code of Federal Regulations (CFR) Sec. 3.307(a)(6)(iv),
    which provides a presumption of exposure to an herbicide agent to
    Veterans who served between April 1, 1968, and August 31, 1971, ``in a
    unit that, as determined by [DOD], operated in or near the Korean DMZ
    in an area in which herbicides are known to have been applied during
    that period.'' As VA explained in the proposed and final rule notices
    implementing 38 U.S.C. Sec. 1821, DOD has identified April 1968, as the
    earliest known use of herbicides along the Korean DMZ. See 74 Fed. Reg.
    36,640, 36,641 (Jul. 24, 2009) (''[s]pecifically, DOD has reported that
    herbicides were applied between April 1968 and July 1969''); 76 Fed.
    Reg. 4245, 4246 (Jan. 25, 2011).
        Additionally, the lack of retroactive benefits for Veterans who
    served in the Korean DMZ highlights the disparity between the treatment
    of Veterans who served offshore of the Republic of Vietnam, as
    addressed in Section 2 of this bill, compared to other groups of
    Veterans.
        Costs associated with Section 3 are estimated to be insignificant.
    Section 4: Benefits for Children of Certain Thailand Service Veterans
            Born with Spina Bifida
        Section 4 would add a new section 1822 to title 38, United States
    Code, authorizing VA to provide the same benefits to children of
    Veterans with Thailand service, as defined in the bill, suffering from
    spina bifida as the benefits required to be paid to children of Vietnam
    Veterans suffering from spina bifida.
        VA supports assisting family members who may have been adversely
    affected by a Veteran's in-service exposure to Agent Orange. However,
    VA is concerned with Section 4 because there is continued scientific
    uncertainty surrounding the association of spina bifida and exposure to
    Agent Orange. As found in the last relevant NAM report, an association
    between spina bifida and exposure to Agent Orange is no longer shown.
    Spina bifida was moved from the category of limited or suggestive
    evidence of association in update 2012 to the category of inadequate or
    insufficient evidence of association in update 2014.
        VA estimates the total benefits cost of this bill would be $748,000
    during FY 2019, $3.9 million over 5 years, and $8.1 million over 10
    years. GOE and IT costs are not associated with this section. We are
    unable to provide health care cost estimates at this time.
    Section 5: Updated Report on Certain Gulf War Illness Study
        Section 5 of the bill would require VA, within 180 days of the date
    of the enactment of this Act, to submit to the Committees on Veterans'
    Affairs of the House of Representatives and the Senate, an updated
    report on the findings, as of the date of the updated report, of the
    Follow-up Study of a National Cohort of Gulf War and Gulf Era Veterans
    under VA's epidemiology program. VA has no objection to this
    requirement, as we anticipate this update would be available within
    that time period.
    Section 6: Loans Guaranteed Under Home Loan Program of Department of
            Veterans Affairs
        Section 6(a) would amend 38 U.S.C. Sec. 3703(a)(1) by revising the
    definition of maximum guaranty amount to tie the maximum guaranty
    amount to the loan, regardless of whether the loan exceeds the Freddie
    Mac conforming loan limit.
        Subsection (b) would amend the loan fee table at 38 U.S.C.
    Sec. 3729 to adjust the statutory loan fees charged to borrowers
    obtaining loans made, guaranteed, or insured under VA's home loan
    program. Certain Veterans, Servicemembers, and surviving spouses would
    pay increased loan fees when obtaining purchase, construction, and
    fully underwritten loans.
        Subsection (c) would waive the statutory loan fees for
    Servicemembers who have received the Purple Heart award. However,
    subsection (c) would impose new statutory loan fees on disabled
    Veterans that have a service-connected disability rated as less than
    total and surviving spouses who are currently exempt from the loan fee.
        VA does not support section 6(a). Under current law, the maximum
    guaranty amount can prevent Veterans who live in high-cost areas from
    being able to obtain a zero down payment loan. By tying the maximum
    guaranty amount to the loan rather than to the Freddie Mac conforming
    loan limit, subsection (a) would eliminate what has restricted
    Veterans' use of their home loan benefits in certain high-cost areas.
    However, this provision may increase risks to the portfolio by
    increasing the effective loan-to-value ratio for these non-conforming
    loans. Higher loan-to-value ratios may lead to higher claim payments
    and lower recoveries in events of default.
        VA does not support subsections (b) and (c) of the bill. As
    previously explained, VA does not support paying for the provisions of
    this bill by increasing the costs that some Veterans must bear to
    access their benefits.
        VA still is refining estimates for benefits savings associated with
    section 6, but the 10-year savings likely will fall below $3 billion.
    Therefore, VA anticipates that the bill's costs would far exceed any
    savings associated with this section.
    Section 7: Information Gathering for Department of Veterans Affairs
            Home Loan Appraisals
        Section 7 would amend 38 U.S.C. Sec. 3731 to permit appraisers to
    make appraisals based solely on information gathered by a person with
    whom the appraiser has entered into an agreement for such services. The
    provision would result in less wait-time for Veterans who want to close
    their loans, particularly those Veterans who live in remote areas.
    Section 7 would also better align VA-appraisal policy and procedures
    with industry standards. VA believes this provision would address
    recent stakeholder concerns regarding timely delivery of VA-required
    appraisals. VA estimates that there are no costs associated with this
    section.
      s. ___--veterans dental care eligibility expansion and enhancement
                                  act of 2018
        Section 2 of the draft bill would amend 38 U.S.C. Sec. 1710(c) to
    authorize the Secretary to furnish dental services and treatment, and
    dental appliances, needed to restore functioning in a Veteran that is
    lost as a result of any services or treatment furnished under this
    subsection.
        VA does not support this section because it is unnecessary. VA
    already has the authority to provide these services. While VA currently
    has limited authority to furnish dental care and services, VA can
    furnish care and services under a different provision of law to
    Veterans who have been disabled by treatment. If the intent of this
    section is otherwise, VA would appreciate the opportunity to discuss
    this further with the Committee.
        Section 3 of the draft bill would require VA to begin a 3-year
    pilot program not later than 540 days after the date of the enactment
    of this Act. Through this pilot program, VA would assess the
    feasibility and advisability of furnishing dental services and
    treatments to Veterans enrolled in VA health care who are not eligible
    for such care under other authorities. VA would have to carry out the
    pilot program at not fewer than 16 locations meeting certain criteria
    and based on certain considerations. No more than 100,000 Veterans
    could participate in the pilot program, and the Secretary would have to
    distribute this limitation among locations selected for the pilot
    program in a manner that takes appropriate account of the size and need
    of dental services at each location. The services that would be
    provided would have to be consistent with the services the Secretary
    furnishes to Veterans with service-connected disabilities rated 100
    percent disabling under VA's laws. Veterans would be able to
    participate in the pilot at their election. VA would have the authority
    to collect copayments for dental services in accordance with
    authorities on the collection of copayments under VA's existing
    authorities, but could not be more than the copayments for medical care
    under chapter 17. VA would have to inform all Veterans eligible to
    participate in the pilot program of the services and treatment
    available, and VA could enter into contracts with appropriate entities
    for the provision of dental care, although each contract would have to
    specify performance standards and metrics and processes for ensuring
    compliance with such standards. Within 540 days and again within 3
    years of the commencement of the pilot program, VA would have to submit
    a report to Congress on the pilot program, and 180 days after the
    completion of the pilot program, VA would have to submit another report
    to Congress. These changes would take effect on the date that is one
    year after the date of the enactment of this Act.
        While VA supports the expansion of dental services and oral health,
    VA cannot support this section without additional resources,
    specifically funding, infrastructure, and staffing, to support such an
    effort. VA does not have the infrastructure or staff to furnish care to
    an additional 100,000 Veterans in 16 or more locations without reliance
    upon community providers. Therefore, implementation of this pilot
    program would significantly increase VA's financial obligations for
    community care at a time when VA is in the process of implementing the
    new Veterans Community Care Program required by the Caring for Our
    Veterans Act of 2018. We further note that, as this is structured to be
    a pilot program, we have significant concerns on how we would implement
    this and believe that Congress should make additional policy decisions
    concerning how this program would operate. While VA may be able to make
    these decisions through rulemaking, we expect these would potentially
    be controversial and could delay implementation of the program if VA is
    forced to decide these matters instead of Congress. For example, the
    bill provides no guidance on how VA should administer this benefit
    fairly--whether VA should rely upon first in time, a clinical
    assessment, priority group, or some other criterion for determining
    which 100,000 Veterans receive care under this program. Similarly, the
    legislation offers no guidance on how VA should make determinations
    concerning where such care would be furnished. Finally, as a term-
    limited program, VA is concerned about how VA would manage care
    authorized near the end of the pilot program, as some Veterans may
    actually be worse off, if they received only a portion of a fuller
    episode of care. We would appreciate the opportunity to discuss these
    concerns in greater detail with the Committee.
        VA anticipates that the total cost for clinical care (not including
    administrative or other costs) during the three year pilot program
    would exceed $600 million.
        Section 4 would require VA to construct or lease a VA dental clinic
    in any State that does not have a VA facility that offers onsite dental
    services. Within 180 days of the date of the enactment of this Act, VA
    would have to submit a plan to Congress for construction or lease of a
    dental clinic in each applicable State and begin construction of any
    such clinic not later than 1 year after such date of enactment. There
    would be authorized to be appropriated, and would be appropriated, $10
    million to carry out this section.
        VA supports ensuring Veterans have access to dental services, but
    we believe decisions about establishing a new VA health care presence,
    whether leased or government-owned, should be made based upon an
    analysis of local conditions, namely the density of the population of
    eligible Veterans and the availability of other options to deliver
    cost-effective care.
        Section 5 would require VA to carry out a program of education to
    promote dental health for Veterans who are enrolled in VA health care,
    although nothing in this authority would alter or revise the
    eligibility of any Veteran for dental care under VA's authorities. This
    education program would have to provide information concerning the
    association between dental health and overall health and well-being;
    proper techniques for dental care; signs and symptoms of commonly
    occurring dental conditions; and treatment options for commonly
    occurring dental issues. The education program would also provide
    information pertaining to options for obtaining access to dental care,
    including information on eligibility for care through VA, State and
    local governments or non-profit organizations; purchasing private
    dental insurance; available and accessible options for obtaining low or
    no-cost dental care, including through dental schools and federally-
    qualified health centers; and such other matters relating to dental
    health as the Secretary considers appropriate. The education material
    would have to be provided through a variety of mechanisms, including
    print, online, and through presentations.
        VA does not support section 5 because it is unnecessary. VA already
    develops, provides, and promotes educational information, including
    training and the availability and accessibility of options for
    obtaining low or no-cost dental care, including through dental schools
    and federally-qualified health centers.
        Section 6 would require VA, no later than 540 days after the date
    of the enactment of this Act, to expand the dental insurance pilot
    program established by 38 CFR Sec. 17.169 (as in effect on the date of
    the enactment of this Act) to establish a mechanism by which private
    sector dental care providers shall forward to VA information on dental
    care furnished to individuals under the pilot program for inclusion in
    the electronic medical records of VA with respect to such individuals.
    VA could continue the dental insurance pilot program for 2 years in
    addition to what is otherwise provided for in 38 CFR Sec. 17.169 if the
    Secretary determines that the continuation is needed to assess the
    mechanism required by this section. Individuals could elect whether to
    participate in the mechanism. VA would have to include information on
    the mechanism in each report to Congress on the dental insurance pilot
    program. This section would take effect on the date that is one year
    after the date of the enactment of this Act.
        VA does not support this section. We are concerned about the
    language in this section could create a requirement concerning medical
    records interoperability that is separate from VA's efforts to
    modernize its electronic health records generally. Many dentists are
    not accustomed to providing health record information electronically to
    other providers; the claims they submit to patients and insurers for
    payment are generally all that they provide. As a result, this could
    create additional requirements on individual providers, which could
    either become difficult for them to implement or could result in their
    refusal to participate in the Dental Insurance Program. We believe it
    is necessary to balance the interests of a complete medical record with
    the obligations and expectations of community providers. We further
    note that the dental insurance program is no longer a pilot program,
    but is now a permanent program that is codified at 38 U.S.C.
    Sec. 1712C; moreover, the pilot program authority (Public Law 111-163,
    section 510) was repealed through the Act that codified this authority
    (Public Law 114-218). VA fully supports the existing VA Dental
    Insurance Program.
        Section 7 would authorize VA to carry out a demonstration program
    to establish programs to train and employ alternative dental health
    care providers to increase access to dental care for Veterans who are
    entitled to such services from VA and reside in rural and other
    underserved communities. VA would give priority for participation in
    the demonstration program to VA medical centers or health systems in
    States with a technical college within the State college system that
    has established a degree or certificate level program for the training
    of alternative dental health care providers. Services through the
    demonstration program could be administered through telehealth-enabled
    collaboration and supervision when appropriate and feasible.
    Alternative dental health care providers would have the meaning given
    that term in 42 U.S.C. Sec. 256g-1(a)(2).
        VA is opposed to unproven alternative delivery of dental care
    models. While we support programs that expand dental health care to
    Veterans in a safe and effective manner, the scientific evidence does
    not currently support the proposed model for Veteran patients who
    require management of multiple physical and mental comorbidities and
    multiple prescription medications. The average VA dental patient is
    approximately 60 years old and is taking over 10 medications. Allowing
    Veteran patients to seek restorative oral health care from a non-
    dentist practitioner poses too great of a potential overall health
    risk. VA strongly believes that the professional education and clinical
    expertise of a licensed dentist is essential for the thorough
    evaluation and comprehensive treatment of patients in VA.
        Section 8 would authorize to be appropriated $500 million for
    fiscal year 2020 to carry out this Act, other than section 4. The
    amount authorized to be appropriated would be available for obligation
    for the 5-year period beginning on the date that is one year after the
    date of the enactment of this Act.
        VA has no views on section 8.
         s. 3184--to amend title 38, united states code, to modify the
    requirements for application for construction of state home facilities
    to increase the maximum percentage of nonveterans allowed to be treated
                  at such facilities, and for other purposes.
        S. 3184 would amend one of the requirements for applications for
    State home construction grants in 38 U.S.C. Sec. 8135(a)(4).
    Specifically, it would require States that submit an application to
    provide reasonable assurance that, for purposes of providing care to
    spouses of Veterans, during a period in which a facility is operating
    with a bed occupancy rate of 90 percent or less, not more than 40
    percent of the bed occupancy at any one time will consist of patients
    who are not receiving such level of care as Veterans.
        While VA appreciates the intent of this legislation, we cannot
    support it as drafted. First, it is inconsistent with the intent of
    VA's grant program for State Veterans Homes, as this would allow a
    significant portion of the population in a State Veterans Home to be
    non-Veterans. This authority would only apply if the home has less than
    90 percent occupancy, which suggests that there may be insufficient
    demand for the Veterans Home in the first place.
        VA also has concerns with this legislation because the technical
    effects of the bill would result in adverse effects on Veterans and
    non-Veteran residents. Initially, we note that the additional language
    that would be added in Sec. 8135(a)(4)(B) only refers to providing care
    to ``spouses of veterans,'' but State homes may also provide services
    to other non-Veterans besides spouses, such as persons whose child or
    children died while serving in the Armed Forces. We note that this
    creates some ambiguity as to how VA is to calculate the percentages
    further discussed in that subparagraph.
        VA's greater concern, though, is that we believe that the language
    concerning occupancy rates could lead to unfortunate outcomes. Our
    reading of this language is that it would prohibit a State home from
    having a relative percentage of non-Veterans above 40 percent; for
    example, if a 100 bed facility only had 90 beds filled, there could be
    no more than 36 non-Veterans (40 percent of 90). We would interpret
    this language to mean that the occupancy rates would refer to the
    relative percentage of residents; VA has interpreted similar language
    concerning bed occupancy rates in VA's regulations at 38 CFR
    Sec. 51.210(d) to refer to the total number of residents, rather than
    the total number of beds in the home. Applying this interpretation to
    this legislation, though, could result in significant disruptions in
    care. For example, if the 40 percent occupancy rate is a percentage of
    the relative number of beds and 90 beds were filled, 36 could be filled
    with non-Veterans and 54 with Veterans. However, if the next applicant
    for a bed were a Veteran, the facility would exceed the 90 percent
    total occupancy rate, as it would have 91 residents if it admitted the
    Veteran. Because of this, it would no longer be authorized to have 40
    percent of its available beds for non-Veterans; instead, it could only
    have 25 percent of its beds available for non-Veterans.
        We think this requirement could force the facility to take actions
    that could lead to unfortunate outcomes. First, the facility could
    simply discharge a non-Veteran patient immediately and admit the
    Veteran, which would be very disruptive to the discharged non-Veteran
    patient. This also would be a perverse incentive because it would
    discourage States to fully use the beds already in place. Second, the
    facility could tell the Veteran to wait until a non-Veteran left the
    facility on his or her own, but this would delay the Veteran's care and
    would be a waste of resources, as the facility would have open beds
    available. We think one of these results would be required by the
    legislation because the bill would prohibit exceeding the 40 percent
    occupancy rate ``at any one time,'' which we interpret to mean that if
    at any point, even only momentarily, a facility is not in compliance
    with this requirement, it cannot have the additional flexibility the
    bill intends. The phrase ``at any one time'' has been very difficult
    for State homes to administer in other contexts, as it requires them to
    take action in anticipation of even momentary changes in their resident
    population. If the legislation, instead, referred to an average over a
    period of time (monthly or quarterly would likely be appropriate), that
    would seem to provide more flexibility and prevent unnecessary
    discharges as described in the scenarios above.
        VA does not anticipate that this bill would result in any
    additional costs.
        s. ___--discussion draft regarding transition assistance reform
        The draft bill would amend title 10, U.S.C., to improve the
    Transition Assistance Program (TAP) for members of the Armed Forces,
    and for other purposes. VA generally defers to DOD, to the extent that
    it is responsible for administering title 10. However, we provide input
    on sections of the bill affecting VA.
        Section 2 of the draft bill would direct the interagency partners
    for TAP to improve the counseling, information, and services currently
    furnished to transitioning Servicemembers, and to provide these
    services to transitioning Servicemembers' spouses as appropriate. It
    would require that transitioning Servicemembers begin TAP no later than
    one year before their date of separation. It further would require
    sequencing of instruction and training provided by other agencies while
    allowing Servicemembers to complete VA training at a pace and order
    satisfactory to them.
        VA appreciates Congress's interest in TAP and shares its desire to
    make sure that the program serves as many transitioning Servicemembers
    as possible, in the most effective way possible. To that end, VA and
    our TAP interagency partners currently have several interagency
    evaluations under way. These studies will provide us with the
    information needed to continue to make evidence-based policy decisions
    as to what improvements to TAP should be made, and how best to make
    them. While these evaluations are under way, we believe that
    legislation to mandate additional evaluations is premature at this
    time; nevertheless, we look forward to working with the Congress to
    improve TAP once we have completed these evaluations and have the
    evidence available to make evidence-based policy decisions.
        With regards to requiring Servicemembers to begin TAP no later than
    one year before separation, VA continues to take action to fulfill its
    commitment to integrate TAP into the Military Life Cycle in order to
    inform, equip, and provide support to Servicemembers earlier and at
    critical touchpoints throughout their career.
        With regards to the specific elements of counseling to be provided,
    VA supports the intent of proposed section 1142(f)(3)(A), regarding
    information on programs and benefits related to Veteran status, but is
    already providing benefits information to active duty Servicemembers
    who are separating from military service. This has facilitated earlier
    and easier enrollment and access to VA health care. Further, VA does
    not support subparagraph (E), which would require the pre-separation
    counseling include a description, developed in consultation with VA, of
    the assistance and support services for family caregivers of eligible
    Veterans furnished by VA under 38 U.S.C. Sec. 1720G, including the
    Veterans covered by the program, the caregivers eligible for assistance
    and support through the program, and the assistance and support
    available through the program. VA does not support this subparagraph
    because VA has been working closely with DOD to implement a similar
    provision enacted in section 541 of the National Defense Authorization
    Act for Fiscal Year 2018 (Public Law 115-91). VA fully supports
    ensuring Veterans understand the benefits that may be available to
    them, including those provided by VA and DOD (such as Special
    Compensation for Assistance with Activities of Daily Living), and we do
    not believe further legislation is required. VA supports the intent of
    subparagraph (F), which would require the pre-separation counseling to
    include information on survivor benefits available under the laws
    administered by VA or DOD. VA supports efforts to increase awareness of
    survivor benefits, such as the Civilian Health and Medical Program of
    the Department of Veterans Affairs, which is an important health care
    benefits program available for the family members of certain severely
    disabled or deceased Veterans. However, VA already provides much of
    this information.
        Subsection 1142(g)(4), would also extend VA's current 6-hour
    briefings into a one-day course of instruction. VA interprets a full
    day of instruction as 8 hours. VA is in support of extending the VA
    benefits briefings to a full-day of instruction, which will ensure that
    VA can better prepare Servicemembers for their transition and help
    foster what will be a lifetime relationship between their families and
    the Department. A full-day will further ensure that transitioning
    Servicemembers are presented information in a manner that is conducive
    to promoting increased awareness and understanding of VA benefits,
    services, and support tools. Increasing the VA benefits briefings to a
    full-day of instruction would require additional funding. VA suggests
    that the term ``registration'' in this section be replaced with the
    term ``application.''
        With regards to mandating the sequencing of TAP, VA encourages that
    transitioning Servicemembers undertake the VA Benefits I/II training in
    an order satisfactory to their own personal transition goals,
    emphasizing that early and consistent training on VA benefits is
    crucial to the Servicemember's successful transition outcomes.
        In addition to the changes to TAP, the draft bill would require
    changes to interagency data-sharing requirements. Section 4 would
    require DOD to establish and maintain an electronic tracking system and
    database that contains data on Servicemember participation, survey
    answers, available resources, and counselor notes for the Department of
    Labor (DOL), VA, commanders, and other TAP partners. Section 5 would
    require the gathering of information and survey responses regarding TAP
    participation at various stages by various agencies and would require
    the information be made available electronically to VA, among other TAP
    partners.
        Section 11 of the draft bill also calls for the identification of
    opportunities where VA can provide training to members which will lead
    to employment in critically understaffed positions in VA, using the DOD
    SkillBridge programs. With regards to identifying opportunities for job
    training and employment with VA in SkillBridge programs, VA and DOD
    have a shared goal to enhance services and employment opportunities at
    VA for transitioning Servicemembers through SkillBridge programs. Since
    2014, VA has offered opportunities for transitioning Servicemembers to
    complete a national-level training program that leads to an opportunity
    for an interview and potential job as a benefits claims examiner. More
    recently, VA launched the Military Transition and Training Advancement
    Course (MTTAC) which trains Servicemembers to become medical support
    assistants. Furthermore, VA and DOD are working to develop an
    overarching agreement that will expand these types of opportunities to
    additional VA job fields.
        In sections 5, 12, and 13, the bill would require several different
    Servicemember studies and other evaluations of the effectiveness of
    transition-related training. It would require Servicemember surveys in
    order to assess the Servicemembers' and their spouses' experiences of
    the assistance provided through TAP. It also would require the
    evaluation of transition training and counseling relating to post-
    secondary education and use of educational assistance. Last, it would
    require VA, in consultation with interagency partners, to conduct a 5-
    year longitudinal study on three separate cohorts of Servicemembers who
    have separated from the Armed Forces.
        VA has already begun development of a post-transitional
    longitudinal program, which will survey Veterans over time to gain
    detailed information about their outcomes and their evaluations of how
    TAP helped them prepare for their transitions to civilian life. The
    assessment instrument was submitted to the Office of Management and
    Budget (OMB) for review in February 2018, and the Federal Register
    notice has been published. To conduct full execution of this study, VA
    will require additional funding.
        With regards to Servicemember surveys, VA receives feedback from
    participating Servicemembers and dependents through the Transition GPS
    Participant Assessment, which is a web-based instrument designed to
    measure and improve customer satisfaction with the curriculum and TAP
    overall. Using this transitioning Servicemember feedback, VA conducts a
    deep dive every other year to look for ways to improve the
    instructional delivery and design of its curriculum. In addition, we
    conduct a technical review every year to ensure all content is up to
    date.
        Section 14 would require the establishment of a board within the
    Veterans Benefits Administration (VBA) to exchange information and
    develop partnerships to support the prevention of suicides, substance
    abuse, and homelessness among Veterans. This board would include
    representatives from VBA, VHA, DOL, the Department of Homeland Security
    (DHS), and DOD. The existing VA/DOD Joint Executive Committee
    established during the 108th Congress and the TAP interagency Executive
    Council have significantly enhanced interagency exchange of information
    and partnership development to support the prevention of suicides,
    substance abuse, and homelessness. Furthermore, the Federal Government
    is improving collaboration on suicide prevention as a result of
    Executive Order (EO) 13822. These existing governance bodies provide a
    valuable forum for information sharing and collaboration on addressing
    mental health and at-risk populations. VA agrees that there is a clear
    need to improve coordination between the administrations and offices
    within VA, as well as among other agencies, regarding suicide, drug
    overdose, and alcohol-related mortality prevention efforts. As we
    recently released in the National Strategy for Preventing Veteran
    Suicide, data and surveillance form the foundation of a public health
    approach to ending Veteran suicide. Coordination within VA has already
    begun under our annual Veteran suicide data reports but there is more
    to be done. While VA supports the intent of this section, VA is
    concerned that the language prescribes that this board reside in an
    office which no longer exists in the VBA organizational structure,
    rather than affording VA the ability to determine which VA office
    should lead this board, should it be established. In addition, VA notes
    that the proposed board would have no experts on substance use
    disorders.
        Finally, section 15 would require VA, within 90 days of the
    enactment of this Act, to submit to Congress a report on current and
    future studies supported by VA's Office of Research and Development
    (ORD) and others relating to economic risk factors affecting suicide
    prevention and a report on how the Department's REACHVET program is
    incorporating or will incorporate economic risk factors in its
    algorithm for suicide prevention.
        VA does not support this section, as we can already provide this
    information, or will provide this information upon its completion, at
    the Committee's request without legislation. Assessment of the effect
    of economic-related variables on risk for suicide is already part of
    the strategic plan within ORD that focuses on the transition period
    from active military status to Veteran status. Epidemiological data
    analyses indicate that the transition period is a high risk period for
    suicide and related behaviors. The ORD strategic plan for suicide
    prevention aligns with EO 13822, which requires VA, DOD, and DHS to
    provide seamless access to mental health care and suicide prevention
    resources for transitioning Servicemembers. The EO specifically
    emphasizes access to services during the critical first year period
    following discharge, separation, or retirement from military service.
        In order to more closely examine the economic factors affecting
    suicide, ORD will leverage the existing data coordinating center at the
    Canandaigua VA Suicide Prevention Center of Excellence to identify,
    extract, and analyze data critical for a comprehensive suicide
    prevention program. ORD has identified funds (beginning in FY 2019) to
    support the Canandaigua data coordinating center in this added effort.
    It is expected the work will be conducted in collaboration with various
    units across VA as well as with external agencies such as DOD and the
    National Institutes of Health.
                       s. ___--va hiring enhancement act
        Section 2 of this legislation proposes to exempt VA physician
    hiring from the applicability of private sector covenants not to
    compete by adding new language to Subchapter 1 of Chapter 74 of Title
    38 U.S.C. The applicability of covenants not to compete or non-compete
    clauses to Federal hiring has been a recurrent problem around the
    country, especially for physician hiring. In short, the proposed 38
    U.S.C. Sec. 7413 states that any covenant not to compete with a non-
    departmental entity, facility or individual shall have no force or
    effect as it relates to an appointment to a physician position within
    VHA. It requires the appointee to provide clinical services at a VA
    medical facility for the duration of the covenant not to compete or for
    one year, whichever is longer. This service requirement may be waived
    by the Secretary. If the physician's appointment is terminated for any
    reason before the termination date of the covenant not to compete, then
    the proposed 38 U.S.C. Sec. 7413 would no longer be applicable to the
    covenant not to compete.
        VA supports section 2 of this proposed legislation as written, as
    it solves a problem known to medical facility Chiefs of Staff across
    the country and clarifies that VHA hiring is not subject to private
    sector covenants not to compete. This legislation should make it easier
    to hire physicians with these contractual obligations. It should be
    noted that exempting VA physician hiring from covenants not to compete
    entered into with non-Departmental facilities, entities and individuals
    should not result in additional costs to the Federal Government or VA.
        While VA supports the intent of section 3, we do not support this
    provision as written. VA supports raising the qualification standard
    for physician hiring to completion of a full specialty residency
    program. This is the community standard and elevates VA standards to
    typical norms. VA changed the physician qualification standard over a
    year ago, and this section brings the statutory language in line with
    the current qualification standard. However, the inclusion of language
    regarding contingent appointments is unnecessary and confusing. VA
    already has the authority to extend job offers well before graduation
    from residency. Applicants must always meet the qualification standard
    prior to appointment. In addition, depending on state law, some
    residents may not gain the ability to be licensed immediately upon
    graduation from the residency program, as appears to be contemplated by
    section (3)(C)(ii).
        VA anticipates that this bill would result in no additional costs.
     h.r. 5418--veterans affairs medical-surgical purchasing stabilization
                                      act
        H.R. 5418 would require multiple regional prime vendors to carry
    out the Medical Surgical Prime Vendor (MSPV) Program and successors. It
    would require each employee that conducts formulary analysis or makes
    decisions on formulary management have medical expertise relevant to
    the items being considered. The proposed legislation would also require
    a quarterly report to Congress of the names and medical expertise of
    employees who are participating in formulary management.
        VA agrees that there is a need for a clinically driven sourcing
    capability. The proposed legislation limits consideration of the full
    spectrum of MSPV delivery solutions available to efficiently provide
    medical products to VA healthcare facilities. The requirement to
    provide quarterly reports on clinicians who participate in formulary
    management is excessively burdensome.
        Further, MSPV costs are affected by many variables including:
    contract language; vendor geographic presence; mix of items purchased;
    etc. These variables change in relation to one another and in relation
    to how many vendors VHA uses. VA believes the MSPV legislation will
    likely increase medical commodity identification and procurement costs.
    Further, Congress has already provided tools for evaluating options for
    changing the number of vendors in subsequent acquisitions. Statutes on
    contract bundling and consolidation provide criteria for evaluating
    potential cost savings or other acquisition benefits to determine if
    such actions are necessary and justified. Thus, VA does not support
    this proposed legislation as written.
        VA is unable to provide a cost estimate at this time. MSPV costs
    are affected by many variables including: contract language; vendor
    geographic presence; mix of items purchased; etc. These variables
    change in relation to one another and in relation to how many vendors
    VA uses. VA believes the bill would likely increase medical commodity
    identification and procurement costs.
                           s. 1596--brave act of 2017
        S. 1596 would increase the basic non-service-connected monetary
    burial benefit allowance and tie monetary burial benefit allowances to
    the current rate of inflation according to the Consumer Price Index
    (CPI). Under current law, VA may only pay a sum not exceeding $300
    under section 2302 of title 38 U.S.C. for basic burial allowance. This
    bill would increase the basic burial allowance payment to $749 and
    increase it by the CPI on an annual basis. The bill would also increase
    the service-connected burial benefit under section 2307, title 38
    U.S.C. based on the CPI.
        As a technical matter, VA notes that the burial allowance under
    section 2303 is currently $762, after the CPI adjustment. The $749
    amount in this bill may be derived from FY17's CPI calculation.
    However, the legislation would apply to deaths that occur one year
    after the bill's enactment. Therefore, we suggest changing the starting
    amount from $749 to $762 in order to achieve parity between the burial
    benefits in sections 2302 and 2303.
        VA supports S. 1596 provided Congress finds corresponding funding
    offsets. The last increase in the non-service-connected burial
    allowance under section 2302 occurred October 1, 1978, through the
    enactment of Public Law 95-479, increasing the allowance from $250 to
    $300. The last increase in the service-connected burial allowance under
    Sec. 2307 occurred December 27, 2001 through the enactment of Public
    Law 107-103, increasing the allowance from $1,500 to $2,000.
        In 2007, and 2008, VA's Office of Policy and Planning (OPP)
    conducted a study to determine whether the burial program was achieving
    expected outcomes and to determine the program's impact on Veterans and
    families. OPP found that funeral costs had increased at a greater pace
    than the cost of other services since 1990. OPP noted that in 1973, the
    service-connected burial allowance covered 72 percent of a Veteran's
    funeral and burial expenses, and the non-service-connected allowance
    covered only 22 percent of a Veteran's funeral and burial expenses.
    According to OPP, by 2007, the value of these benefits had decreased
    significantly; the service-connected burial allowance reimbursed only
    23 percent of the cost of a Veteran's burial, and the non-service-
    connected burial allowance reimbursed only four percent of the cost of
    a Veteran's burial. The National Funeral Directors Association (NFDA)
    reports on its Web site, www.nfda.org, that the median cost of a
    funeral and burial was $7,045 in 2012. The reported cost did not
    include the cost of a vault or cemetery plot or other miscellaneous
    cash advance charges, such as charges for flowers or obituaries.
    Further, NFDA reports that the median cost for an adult burial and
    funeral in the United States had increased from $708 in 1960, to $7,045
    in 2012.
        The proposal will allow VA to offer a more valuable reimbursement
    for the costs of a Veteran's funeral during a very difficult and
    vulnerable period of transition for the survivor. Additionally, the
    proposal will tie the burial allowances to the current rate of
    inflation consistent with burial benefits under section 2303.
        Benefit costs are estimated to be: no budget impact in 2019, $75.8
    million over five years, and $259.2 million over ten years. This
    estimate is based on the rate of $749 for basic burial allowance in the
    bill. The cost would increase slightly if the rate is corrected to
    match the rate for burial benefits under section 2303.
                s. 2881--mare island naval cemetery transfer act
        S. 2881 would require VA to seek an agreement with the city of
    Vallejo, California, under which the city would transfer all right,
    title, and interest in Mare Island Naval Cemetery to the control of VA,
    at no cost to VA. If the cemetery is transferred, VA would be required
    to maintain the cemetery as a national shrine.
        VA does not support S. 2881, because the transfer of the Mare
    Island Naval Cemetery to VA could disrupt efforts currently underway to
    address the condition of the cemetery, and because acquisition of the
    cemetery by VA does not align with VA's current strategic objectives
    with respect to providing burial access to Veterans and their families.
    Finally, VA does not support S. 2881 because it sets an unwanted
    precedent regarding Veteran cemeteries in disrepair managed by
    localities, allowing them to eschew their responsibility to our
    Nation's heroes.
        In 2017, concerned citizens began an effort to persuade VA to
    ``take back'' the Mare Island cemetery to address the deteriorating
    condition of the property. However, Mare Island cemetery has never been
    under the jurisdiction of VA. Mare Island was a Naval Base and a Navy
    shipyard that was closed in 1996; the on-base cemetery was closed to
    new interments sometime prior to that. When the base closed in 1996,
    the physical land and facilities, including the cemetery, were
    transferred to the city of Vallejo, at its request, which agreed to
    maintain the cemetery and has been solely responsible for its
    maintenance since that time. Despite the subsequent sale of some of the
    transferred land by the city of Vallejo, no funds were set aside to
    ensure the upkeep of the cemetery.
        VA is very concerned with the conditions observed at the Mare
    Island Cemetery and has been aiding the city of Vallejo to find ways to
    address the repairs needed. VA's National Cemetery Administration (NCA)
    has provided expert advice to the city in developing its application
    for support from DOD's Innovative Readiness Training (IRT) program. IRT
    establishes partnerships between DOD and U.S. communities that provide
    training for Servicemembers while addressing public and civic needs.
    DOD assessed Mare Island Naval Cemetery as a potential IRT project in
    May 2018 and has reported that a decision is pending evaluation of
    legal and historical considerations, as well as Federal and state
    environmental review requirements. DOD has indicated that the city's
    application for IRT assistance would not transfer to VA should
    ownership be transferred from the city of Vallejo to VA. Costs of
    repairs and upkeep for the cemetery would become a VA responsibility,
    one for which VA has received no appropriation.
        In addition to disrupting the current efforts to address the
    condition of Mare Island Naval Cemetery, transfer of the cemetery to VA
    does not align with VA's strategic objective to provide reasonable
    access to a burial option to 95 percent of eligible veterans and their
    families. Because this cemetery is closed to new interments, it does
    not offer new burial options for Veterans, and the transfer of the
    cemetery to VA would divert resources that should be used to provide
    additional burial options elsewhere. The service area within which Mare
    Island is located is already covered by other open VA national
    cemeteries. For instance, NCA currently operates the Sacramento Valley
    National Cemetery in Dixon, California, to serve Veterans and families
    members in the northern Bay Area. NCA also is seeking to improve burial
    access in this area with development of a columbaria-only urban
    cemetery (currently in design) at the new Alameda Point National
    Cemetery, which will provide enhanced access to burial benefits for
    approximately 420,478 Veterans, spouses and other eligible dependents.
        Finally, transfer of Mare Island Naval Cemetery to VA would
    establish an unwanted precedent with respect to Veterans cemeteries or
    sections of cemeteries not managed by VA, a state or tribal government
    that may fall into disrepair. VA could be asked to assume operational
    responsibility for gravesites in some of these locations and does not
    have the resources to address these requirements.
        VA cannot accurately assess the costs associated with S. 2881,
    because we have not performed our own assessment of the extent of
    repairs necessary to remediate the deterioration of the cemetery. In
    particular, we do not know the extent of structural problems that may
    not be visible from the surface, nor the cost of addressing those
    problems.
        Issues noted on visual observation include headstones that are
    misaligned and lacking proper maintenance, some of which may need to be
    replaced; restoration or replacement of perimeter fencing, foundation
    wall, and flagpole; turf restoration; and replacement of the irrigation
    system and water source. Based on a subject matter expert comparison of
    prior cemetery projects of similar size and potential scope, we
    estimate the cost of these discernable repairs to have a rough order of
    magnitude between $1.5 million and $3.2 million.
        VA is aware of media reports that raised the possibility of sub-
    surface issues with the property, but we are unable to verify these
    reports without a complete survey and assessment of the cemetery. If
    those reports are validated, the estimated costs to restore the
    cemetery in compliance with S. 2811 could be $15 million or more.
                s. 1952--va financial accountability act of 2017
        Section 2 expresses the sense of Congress regarding VA's budgeting
    process. We defer to Congress in expressing its sense.
        Section 3 would require, not later than 90 days from the date of
    the enactment of this Act, VA to enter into a contract with an
    independent third party to, within 180 days, review and audit VA's
    financial processes, including reporting structures, and actuarial and
    estimation models, and develop recommendations for improving such
    structures. Within 60 days of the completion of this review, VA would
    have to submit a plan to Congress to implement the recommendations
    developed by the third party. VA would have to appoint one individual
    within the Office of the Secretary of Veterans Affairs to be
    responsible for monitoring the status and progress of implementation of
    recommendations submitted to the Secretary by third parties, including
    those submitted pursuant to the contract described above, and all such
    other recommendations as may be submitted to VA by the Comptroller
    General, the Special Counsel, and the VA Office of Inspector General.
    Subsection (c) would require VA to, not later than 45 days before the
    date on which a budgetary issue would start affecting a program or
    service, submit a justification for any supplemental appropriation
    request it submits to Congress, including a plan for how VA intends to
    use the requested appropriation, how long the requested appropriation
    is expected to meet the needs of VA, and certification that the request
    was made using an updated and sound actuarial analysis. Subsection (d)
    would require starting in FY 2019 and in each FY thereafter, the VA
    Chief Financial Officer (CFO) to submit to Congress a statement of
    assurance that the financial projections included in the President's
    annual budget request or the supporting materials submitted along with
    such budget are sufficient to provide benefits and services under laws
    administered by VA; a certification of the CFO's responsibility for
    internal financial controls of the Department; and an attestation that
    the CFO has collaborated sufficiently with the financial officers of
    the facilities and components of VA to be confident in such financial
    projections.
        VA concurs with the intent to make our Departmental resource
    requests more analytically based and transparent to Congress and other
    stakeholders. However, we do not support this bill as we find it to be
    duplicative of existing laws and policies within the Department. For
    example, subsections (a) and (b) are duplicative of current processes.
    VA's budget and financial processes are already the subject of frequent
    external audits and reviews. In particular, the Enrollee Health Care
    Projection Model (EHCPM) has been reviewed extensively by stakeholders,
    including OMB, VA leadership, Congressional staff, the Congressional
    Budget Office, , and the Government Accountability Office (GAO). GAO
    published a review of the EHCPM in 2011, ``VA Uses a Projection Model
    to Develop Most of Its Health Care Budget Estimate to Inform the
    President's Budget Request'' (GAO-11-205) and is currently reviewing
    the EHCPM as part their review of the VA Community Care Budget
    (102732). The RAND Corporation has also conducted an external review of
    the EHCPM The Department always takes the findings and recommendations
    of external audit bodies, including GAO and the VA Inspector General,
    seriously. Our progress in addressing these recommendations is
    described annually in our Congressional Budget Justification books, and
    we regularly monitor progress throughout the year via internal reviews.
        Similarly, subsection (c) is redundant, as it was enacted through
    section 141 of the VA MISSION Act of 2018. Moreover, as with all
    appropriations requests to Congress, VA already provides the most
    detailed justification possible to explain the need for resources and
    the consequences should they fail to be provided. While we try to
    anticipate funding needs well in advance of their becoming urgent, some
    funding needs are true emergencies, and we are concerned that the
    rigidity of the 45-day advance timeline required will constrain both
    Congress and VA in ensuring Veterans' needs are adequately met in the
    face of unexpected funding crises.
        Finally, subsection (d) is duplicative of laws and administration
    policies governing the Budget request and annual audit process,
    including the Congressional Budget Act and the Chief Financial Officers
    Act of 1990.
     s. 1990--dependency and indemnity compensation improvement act of 2017
        S. 1990 would change the formula for calculating Dependency and
    Indemnity Compensation (DIC) payments, which would increase the payment
    amounts. The bill would also lessen the number of years a Veteran must
    be rated totally disabled prior to death for a surviving spouse to be
    entitled to DIC and it would entitle a surviving spouse to all benefits
    under Chapter 13 when the surviving spouse remarries after the age of
    55.
        VA supports the bill. Increasing the amount of DIC benefit payments
    will help survivors continue to live a sustainable life. Lowering the
    remarriage age to 55 creates parity with certain DOD survivor benefits.
        VA is developing a cost estimate, but no estimate is available at
    this time. Although the bill would not require additional employee
    resources, there would be additional mandatory costs and associated
    required PAYGO savings, as well as information technology development
    costs.
       s. 2485, medal of honor surviving spouses recognition act of 2018
        S. 2485 would codify the current rate of $1,329.58 for the Medal of
    Honor special pension paid to eligible Veterans. The bill would also
    establish entitlement for surviving spouses of Medal of Honor (MOH)
    recipients to this special pension at the same rate. To be eligible,
    the surviving spouse must have been married to the Veteran for one year
    or more prior to the Veteran's death or for any period of time if a
    child was born of the marriage, or was born to them before the
    marriage.
        VA supports this bill provided Congress finds corresponding funding
    offsets. Paying special pension to surviving spouses would provide
    assistance to dependents of our most courageous Servicemembers and
    Veterans.
        Additionally, setting specific parameters concerning receipt of
    only one special pension, regardless if a surviving spouse has been
    married to more than one Veteran who was in receipt of a MOH,
    remarriage, and age is in-line with the other survivor benefits VA
    administers. Benefit costs are estimated to be $1.7 million in 2019,
    $9.0 million over five years, and $19.1 million over ten years.
                     s. 2748--battle for servicemembers act
        S. 2748 would make participation in the Transition Assistance
    Program (TAP) to prepare for higher education, technical training, or
    entrepreneurship mandatory for Servicemembers unless a waiver is
    granted.
        VA defers to DOD and DHS, as those Departments would have
    responsibility to implement the bill. VA fully collaborates with our
    interagency partners to address the complex challenges faced by our
    transitioning Servicemembers and Veterans. VA notes that a complicating
    factor in rapid identification of risk--or lack thereof for groups--is
    that often the signs and symptoms that stem from the challenges
    experienced during transition do not appear or begin until well after
    transition from military service. This delayed onset presents further
    challenges, as there are times when the Departments do not have regular
    contact with the transitioning Servicemember/Veteran.
        VA anticipates no additional costs to VA resulting from this bill.
      s. ___--to require the secretary of veterans affairs to establish a
       program to award grants to persons to provide and coordinate the
      provision of suicide prevention services for veterans transitioning
      from service in the armed forces who are at risk of suicide and for
                    their families, and for other purposes.
        The draft bill would require VA, not later than 1 year after the
    date of the enactment of this Act, to establish a program to award
    grants to persons to provide and coordinate the provision of suicide
    prevention services for eligible Veterans who are at risk of suicide
    and for their families. A Veteran would be eligible for services under
    this section if the Veteran is within the first 3 years of
    transitioning from a member of the Armed Forces to civilian status.
    Grant applicants would be required to submit an application that
    describes the suicide prevention services to be provided; the
    identified need for these services; a detailed plan describing how the
    suicide prevention services would be delivered, including the community
    partners with whom the applicant proposes to work, the arrangements
    currently in place with such partners; and how long such arrangements
    have been in place. Additional information required is a description of
    the types of Veterans at risk for suicide and the families of such
    Veterans to be provided such services; an estimate of the number of
    Veterans at risk for suicide and the families of such Veterans proposed
    to be provided such services and the basis for the estimate; evidence
    of the experience of the person and proposed partners in providing
    suicide prevention services to individuals at risk for suicide, and
    particularly to Veterans at risk for suicide and the families of such
    Veterans; and a description of the managerial capacity of the applicant
    in several different areas.
        VA would be required to give priority in awarding grants to
    applicants who: have been providing or coordinating the provision of
    suicide prevention services for Veterans at risk of suicide and the
    families of such Veterans; have demonstrated the ability to provide or
    coordinate such services to such persons; have demonstrated the ability
    to provide opportunities for social connectedness for Veterans; and
    have demonstrated how they measure the effectiveness of their program.
    VA would also have to give priority to applicants providing services in
    rural or tribal areas, or in areas that have experienced high rates of
    or a high burden of veteran suicide and where no health care is
    furnished by the Department. Grants awarded under this program would be
    used to provide or coordinate the provision of suicide prevention
    services for Veterans who are at risk of suicide and their families.
    The suicide prevention services provided or coordinated would have to
    include the following: outreach to identify Veterans at risk of
    suicide, with an emphasis on Veterans who are at highest risk of not
    receiving health care or services from VA; screening risk assessment
    and referral to care; education of suicide risk and prevention to
    families and communities; case management services; peer support
    services; assistance in obtaining benefits from VA and other Federal,
    State, and local government entities; temporary assistance in
    transportation in the form of a voucher, when appropriate and
    applicable, to be used in accessing services; personal financial
    planning; legal services to assist with issues that interfere with
    obtaining or retaining housing or supportive services; and other
    services necessary for improving the resiliency of veterans at risk for
    suicide and their families.
        VA could require grantees to submit to the Secretary reports
    describing the use of the grant amounts. Grantees would have to notify
    each person who receives services that the services are being paid for
    in whole or in part by VA. VA would have to establish evaluation
    criteria for grantees under this section, require each grantee to
    submit a report with information necessary to evaluate the grantee at
    least annually, and evaluate each grantee at least annually. In
    planning and preparing to carry out this program, VA would have to
    consult with Veterans Service Organizations and various national and
    local organizations. VA would be required to report to Congress within
    1 year of starting the program on the program and on the grant
    recipients under the program.
        VA strongly supports the concept of this legislation subject to
    Congress finding appropriate offsets. In June 2018, VA published a
    report on its findings from the most comprehensive analysis of Veteran
    suicide in our Nation's history, examining more than 55 million Veteran
    records from 1979 to 2015 from all 50 States and four territories. The
    report built on previous VA Suicide Data Reports. Key findings include
    that in 2015, on average, 20 Veterans died by suicide each day. Six of
    the 20 were users of VHA services, while 14 Veterans had not used any
    VHA care in the calendar year of or prior to their death. While VA has
    a number of programs devoted to reducing Veteran suicide, and we
    continue to develop and enhance these programs and efforts, they are
    designed to reduce risk of suicide in the population of Veterans who
    are under VA care. Therefore, we believe this legislation could provide
    a critical tool for coordinating with other entities in the community
    to reach this population of Veterans who do not rely on VA for care.
    VA's efforts to reduce the incidence of suicide ideation, behavior (and
    suicide completions) among all Veterans could be complemented by
    partnering with community-based providers who are able to replicate
    VA's suicide prevention programs in the community and to connect with
    Veterans that are currently beyond VA's reach. VA considers effective
    partnering with eligible grantees key to being able to reduce the
    number of Veterans dying by suicide.
        We would appreciate the opportunity to work with the Committee to
    explore some technical alternatives or modifying language that may
    improve this proposal. For example, we have concerns about the narrow
    scope of eligibility for Veterans, as the bill would exclude Veterans
    who separated from the Armed Forces more than 3 years before; this
    would include the population of Vietnam Veterans who have some of the
    highest rates of suicide. We also recommend including members of the
    Armed Forces (including members of the Reserve Forces and the National
    Guard) up to a year prior to their separation. This would better inform
    them of VA services and help facilitate needed wraparound services for
    this high-risk population as they transition. It would also facilitate
    a warm handoff to VA upon their separation should the new Veteran be
    interested. Further, we recommend that the legislation authorize
    eligible entities, rather than persons, to receive grants. We are also
    concerned about the timeline for implementation, as pursuant to 38
    U.S.C. Sec. 501, VA will need to publish regulations for this program
    prior to awarding grants. Finally, we note that additional resources
    would be needed to support a new grant program, including funding for
    grant awards and program administration.
        s. ___--modernization of medical records access for veterans act
        The proposed legislation would require VA to establish a pilot
    program that would provide patients with a physical device, the size of
    a credit card, which would be used by patients to support the review of
    their personal health information and the exchange of information with
    other healthcare providers they might see, both inside and outside of
    VA. VA would be required to conduct a full and open acquisition and
    award a contract within 120 days of the enactment of the Act. VA would
    need to conduct a pilot in at least one VISN for a one-year period.
        VA agrees that patient-mediated health information exchange is a
    valuable strategy to support making health information available
    directly to patients and then under their direction, making that same
    health information available to the providers across the health system
    they entrust with their care. However, VA does not support this bill as
    written.
        Currently, VA has technologies that support interoperable patient
    health information exchange nationwide. VA's My HealtheVet Blue Button
    is piloting technology that allows Veteran patients to share their VA
    health records with their community care provider directly from their
    personal devices. VA's eHealth exchange technology is a rapidly growing
    network that connects VA with community health providers who can then
    securely share clinical information using a standardized approach.
        As noted above, the proposed legislation would require VA to
    establish a pilot program that would evaluate a physical device, the
    size of a credit card, which would be used by patients to support the
    exchange of information. Providing physical devices to patients with
    their health information has not been a part of VA's strategy for
    supporting patient-mediated data exchange, and we do not believe that
    this approach would add significant value beyond current efforts. VA
    believes Veterans would prefer to minimize the number of physical
    devices or items they would need to manage. Given the near ubiquity of
    smart mobile devices owned and used by health care consumers, VA
    believes a strategy that focuses on improved health data availability
    and exchange on a mobile platform would be preferred.
        VA believes that continued work on expanding query based exchange
    and on patient-mediated exchange via mobile and web applications
    supported by Federal Health Interoperability Resource Application
    Program Interfaces should remain top priorities at this time.
    Additionally, VA is preparing for the Department of Health and Human
    Services Trusted Exchange Framework direction that supports the ability
    for patients to access their health information electronically without
    any special effort. This direction supports a significant step toward
    achieving interoperability for the patient.
        Finally, no additional funding will be provided to support any
    efforts that would be required, should this bill become law. This would
    adversely affect other higher-priority health interoperability
    programs.
                       s. 514--no hero left untreated act
        S. 514 would require VA, within 90 days of enactment, to begin a
    one-year pilot program in no more than two VA facilities by providing
    access to magnetic EEG/EKG-guided resonance therapy (Magnetic
    eResonance Therapy (MeRT)) to treat Veterans suffering from Post
    Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI),
    military sexual trauma (MST), chronic pain, or opiate addiction. VA
    would provide access to MeRT to no more than 50 Veterans in carrying
    out this program. VA would have to submit a report to Congress on the
    program no later than 90 days after the completion of the program. The
    bill would not authorize additional amounts to be appropriated to carry
    out the requirements of this bill.
        While preliminary experience with this technology is promising, a
    study by the Newport Brain Research Laboratory to establish the
    efficacy of MeRT in treating PTSD in veterans is still in progress. VA
    offers repetitive transcranial magnetic stimulation (rTMS), which is a
    treatment related to MeRT that has the Food and Drug Administration
    (FDA) approval for treatment-resistant depression, a common comorbid
    condition in PTSD, TBI, MST, and chronic pain and opioid addiction.
    There is no existing evidence that MeRT is superior to rTMS for
    treating any disorder. To date, no medical device using MeRT technology
    has been cleared or approved by the FDA for the uses described in the
    legislation. While VA research continuously examines new treatment
    methods and modalities, independently collected evidence of the safety
    and efficacy of this technology has yet to be obtained. The additional
    pilot data that would be obtained under the proposed legislation would
    not address the critical issues of determining MeRT's efficacy against
    a placebo or against rTMS. For these reasons, VA does not support the
    legislation. VA estimates the bill will have a one-time $1.83 million
    cost to implement.

        This concludes my testimony. We appreciate the opportunity to
    present our views on these bills and look forward to answering any
    questions the Committee may have.
                                     ______

      Additional Views Provided by Hon. Robert L. Wilkie, Secretary, U.S.
                         Department of Veterans Affairs

                             The Secretary of Veterans Affairs,
                                         Washington, September 6, 2018.
    Hon. Johnny Isakson,
    Chairman,
    Committee on Veterans' Affairs,
    U.S. Senate, Washington, DC.

        Dear Mr. Chairman: By this letter, the Department of Veterans
    Affairs (VA) is providing deliverables from the Committee's legislative
    hearing on August 1, 2018, and reiterating our opposing views on House
    Resolution (H.R.) 299.
        We know it is incredibly difficult to hear from Blue Water Veterans
    who are ailing and ill, and we have great empathy and compassion for
    these Veterans and their families. However, we urge the Committee to
    consider the scientific evidence, impact on other veterans, and costs
    associated with this legislation:

     Science Does Not Support the Presumption that Blue Water Navy
            Veterans Were Exposed to Agent Orange.
            In 2011, the Institute of Medicine (IOM), now the National
            Academy of Medicine, reviewed all available scientific evidence
            and concluded that exposure among Blue Water Navy Veterans
            ``cannot reasonably be determined.'' The IOM's report indicated
            that Agent Orange was destroyed by sunlight within hours of
            application and any that survived would rarely make it out to
            the South China Sea because of the major dilution factor.
            Media and several Veterans Service Organizations supporting the
            legislation have relied on an Australian study from 2002 that
            was designed to mimic Royal Australian Navy distillation
            policies and procedures; however, this study is irrelevant to
            U.S. Navy policy and practice. U.S. Navy ships were required to
            draw up seawater for conversion to shipboard potable water at
            least 12 miles offshore from any river, a distance at sea where
            the presence of Agent Orange was highly unlikely. As points of
            reference, 12 cubic miles of water is equal to 13.2 trillion
            gallons, and 1 trillion gallons of water flow over Niagara
            Falls in a single month. Thus, the dilution factor would have
            been significant. IOM considered the Australian study in its
            2011 review and stated the significance of the study's findings
            was highly uncertain for U.S. Blue Water Navy ships.
            VA continues to study the science behind this issue. In late
            2019, VA will publish the peer-reviewed Vietnam Era Health
            Retrospective Observational Study. The study will compare the
            health and morbidity of deployed Vietnam Veterans versus a
            cohort of non-deployed Veterans and similarly-aged U.S.
            residents who never served in the military. VA collected data
            from nearly 43,000 participants including nearly 1,000 Blue
            Water Navy Veterans. VA recommends waiting on the findings of
            the study instead of establishing a new presumption without a
            scientific basis.
     Disabled Veterans Would Be Negatively and Disproportionately
            Impacted by Modified Funding Fees for VA-Guaranteed Home Loans.
            Under this legislation, the funding fee would be a new
            requirement for Veterans with service-connected disabilities
            rated as less than total. This would be a departure from the
            longstanding requirement that Veterans in receipt of VA
            disability compensation are always exempt from the VA funding
            fee.
            Currently, Veterans with a disability rating of less than
            ``permanent and total'' pay $0 in VA funding fees, regardless
            of loan amount. However, lenders generally require a down
            payment for loans exceeding the conforming loan limit; that
            down payment creates home equity for the Veteran.
            Under H.R. 299, such Veterans might not need a down payment,
            but they would be required to pay a funding fee. The fee is
            non-refundable, and if rolled into the life of the loan, it is
            paid with interest. For example, on a $500,000 non-conforming
            purchase loan, a disabled Veteran could be required to pay
            $12,000 to VA in funding fees (plus interest if rolled into the
            life of the loan) rather than applying $11,725 as a down
            payment which results in home equity.
     Savings from Funding Fees Would Not Be Enough To Cover Blue
            Water Costs.
            VA estimates we will need $5.5 billion to support the net costs
            of the bill, $5.4 billion more than the approximate $100
            million that the Congressional Budget Office (CBO) estimates
            for the bill. CBO significantly underestimated the number of
            Veterans and survivors who would be newly eligible for Blue
            Water benefits. VA's estimate is based on the actual number of
            Vietnam-era Navy Veterans denied the presumption for Agent
            Orange on the basis of never setting foot on the landmass of
            the Republic of Vietnam or its inland waters. VA records show
            nearly 30,000 of these Veterans were previously denied, but CBO
            estimates only 4,730 of these Veterans were previously denied.
            Similarly, CBO anticipates only 120 survivors receiving
            benefits over 10 years, while VA estimates 2,817 survivors
            would receive benefits in the first year alone. In addition,
            CBO did not account for any expenses to implement this section
            of the bill. The Veterans Benefits Administration (VBA)
            estimates 803 employees would need to be hired in the first
            year, and funding would be required for salaries and related
            expenses such as training and information technology equipment.
            VA is unaware of any plans for CBO to revise its estimate.
     Impact on Claims Backlog.
            Another impact we need to raise is in regard to the recent
            ongoing efforts to reduce the appeals and claims processing
            backlogs. The accomplishments we have made with congressional
            assistance will be stymied due to the fact that we will have to
            research and evaluate what could total over 30,000 potential
            claims. VBA's current resources are not adequate to begin this
            workload. Therefore, these efforts would not only be impacted
            through hiring of additional full-time equivalents and costs
            but also in adding time to the 125 days to process a claim due
            to the verification and study that would need to go into the
            processing of that claim.
     Setting a New Precedent by Creating a Presumption without
            Adequate Scientific Evidence.
            The changes proposed in this legislation will have a greater
            effect beyond what we believe Congress intends. The creation of
            a new statutory presumption that is not adequately supported by
            scientific evidence will encourage increased pressure on both
            Congress and VA to create and expand additional presumptions
            under a similarly liberal approach. This would present a choice
            between taking a similarly unprincipled approach to other
            circumstances where a presumption is sought, but not supported
            by science, or treating different groups of Veterans
            disparately without any reasoned basis for doing so. If we do
            not allow standards in these cases, there is a greater chance
            that such policies will spread to other agencies in the Federal
            Government.
     Unintended Consequences on Disabled Veterans.
            To offset costs for non-housing related programs, a disabled
            Veteran would be required to pay VA a new loan fee of up to 2.4
            percent of the purchase price of a home instead of applying a
            similar down payment amount toward the purchase price. In
            short, certain disabled Veterans would bear the cost of
            providing other benefits by paying a new loan fee, which
            creates no home equity, instead of contributing funds toward
            home equity. This would impose a steep price for many and a
            cost that others may be unable to take on. We do not believe
            that these unintended consequences have been fully considered
            by Congress, and they should be completely understood before
            this legislation is passed.

        As for the deliverables requested during the hearing, VA was asked
    to provide for the record:

     An Estimate of the Additional Funds Generated by the Fee
            Increases Proposed in H.R. 299.
            VA estimates savings associated with modified funding fees
            proposed in section 6 of H.R. 299 would be $140 million in
            2019, $732 million over 5 years, and $1.2 billion over 10
            years.
     The Number of VA Home Loans Provided in 1 Year Based on the
            Most Recent Data Available.
            In 2017, 685,735 home loans were guaranteed by VA.
     The Number of Those Loans that Included a Funding Fee.
            In 2017, 285,282 home loans, or 42 percent of all VA-guaranteed
            home loans, included a funding fee.

        We appreciate this opportunity to comment on H.R. 299 and look
    forward to working with you and the other Committee members on this
    legislation.
                Sincerely,
                                              Robert L. Wilkie,
                                                             Secretary.

        Chairman Isakson. I will open with questions, and the order
    of questioning, by the way, is going to be all the Members that
    are here; we are going to call on everybody in order of
    arrival.
        Let me just start with myself on the Blue Water Navy. You
    made a statement just a second ago that the Australian study is
    flawed?
        Mr. Lawrence. That is correct.
        Chairman Isakson. What is the principal flaw in that?
        Mr. Lawrence. Let me draw on Dr. Erickson. He is the
    medical----
        Chairman Isakson. Dr. Erickson.
        Dr. Erickson. Chairman Isakson, thank you for the question.
    The Australian study--in fact, I even brought a copy of that in
    case we need to refer to it. It is a good study insofar as it
    purports to go after certain answers. In particular, this was
    commissioned by the Australian Government. The lead author was
    a fellow named Muller. It involved wanting to replicate or copy
    the distillation process that we used in Australian ships.
        Part of the problem here is that the Australian format for
    drawing water into the distillation system allowed them to draw
    water close to shore, quite frankly. So, in fact, this
    experiment--it was a laboratory experiment. Think about high
    school chemistry and the distillation apparatus. They wanted to
    replicate an existing amount of sea water with dioxin that they
    would approximate what was near shore.
        The problem is you cannot go from that experiment to then
    make a conclusion about U.S. naval personnel. And, in fact, the
    Institute of Medicine in their report, which Dr. Lawrence
    referred to this conclusion--there was not enough information
    to determine whether Blue Water Navy personnel were exposed or
    not.
        The Committee that wrote this report had the Australian
    study available to them and had an opportunity to really go
    through this. This was not enough information for that
    committee to conclude that U.S. Navy personnel had been
    exposed.
        Chairman Isakson. OK. Is anyone here familiar with the VA
    loan program and the funding fee?
        Mr. Lawrence. Yes. I am.
        Chairman Isakson. It has been a while since I was in the
    business, but if I heard Senator Gillibrand correctly, what she
    wanted to do was raise the funding fee from 2.25 to 2.4
    percent. Is that correct?
        Mr. Lawrence. That is correct.
        Chairman Isakson. That is 1\1/2\ percent of the loan
    amount, correct? An increase?
        Mr. Lawrence. Yeah, that is correct. It is $250 on every
    $100,000 of loan.
        Chairman Isakson. OK. Is that enough money based on the
    number of VA loans that are closed in any 1 year to actually
    fund the difference if it were to pass?
        Mr. Lawrence. Not in our opinion, no.
        Chairman Isakson. I would offer for everybody's benefit, I
    did real estate sales my entire life and did a lot of VA loans
    and FHA loans and things of that nature. You can make those
    numbers look like a lot of things, but that is not a lot of
    money, 1\1/4\ increase. It is a variable, too, because it
    depends on the number of loans that are actually closed and it
    is paid on. If you could get me your calculation, the best
    calculation as to what that yield would be in any 1 year, I
    would appreciate it, Dr. Lawrence.
        Mr. Lawrence. Will do. We will provide that. Thank you.

        [The information requested is included in VA's Additional
    Views letter dated September 6, 2018.]

        Chairman Isakson. I would like a copy of the Blue Water
    Navy report, Dr. Erickson. I would like a copy of that report.
    Not that I have the scientific acumen to understand it, but I
    can learn to ask enough questions about it, because we are
    going to make sure we do not leave any stone unturned in
    getting the information out that is necessary to make an
    educated decision. Our veterans deserve no less than that.
        Senator Sanders?

             HON. BERNIE SANDERS, U.S. SENATOR FROM VERMONT

        Senator Sanders. Thank you, Mr. Chairman, and thanks for
    holding this hearing. Let me thank the representatives of the
    VA for being here.
        I was not happy to hear that the VA is in opposition to
    legislation that we have introduced which does something that I
    think most Americans understand to be correct, and that is to
    understand that when we talk about health care, we must talk
    about dental care. Dental care is health care. Today, with the
    exception of service-connected oral problems, the VA does not
    provide dental care to veterans in this country. What that
    means is that in Vermont and I think in every State in this
    Nation, you have veterans who have teeth rotting in their
    mouths, who have infections, who are in desperate need of
    dental care, but are not able to afford to get that dental care
    and are not getting it at the VA.
        What ends up happening is, I think the panel will
    acknowledge, that a poor dental situation causes other health
    care problems. Many veterans, especially those exposed to Agent
    Orange, suffer from diabetes. Diabetes has a relationship to
    your teeth. So, the idea that we are compensating people
    appropriately for exposure to Agent Orange and the diabetes it
    causes, but not dealing with dental care does not make any
    sense to me at all.
        I think, Mr. Chairman, the time is long overdue for the VA
    to acknowledge what most Americans acknowledge: dental care is
    health care. Too many of our veterans are not getting the
    dental care they need.
        So, what our legislation is is a modest pilot program--and
    I am prepared to discuss with you and others about how we can
    modify it. Let us see how it works. Let us see if the need is
    out there. I think it is. I hear from Vermonters all of the
    time that it is a need. I heard from people around the country.
    Our legislation is supported by the VFW, and I thank them for
    that; The American Legion; the Fleet Reserve Association; and
    the Vietnam Veterans of America; and we will hear from a
    representative from the Vietnam Veterans of America in a few
    minutes.
        The bottom line is, Mr. Chairman, the time is long overdue
    for the VA to understand that dental care is health care, and
    it must be addressed for our veterans.
        Thank you.
        Chairman Isakson. Thank you, Senator Sanders.
        Senator Boozman?

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

        Senator Boozman. Thank you, Mr. Chairman. Thank you so much
    for holding this important hearing that really covers a lot of
    different items.
        We appreciate you all being here, and we appreciate the
    second panel talking to us about the pros and cons, as you see
    it.
        First of all, I would like to start by saying how glad I am
    to see the Blue Water Navy legislation move forward in the
    Senate. This is an important piece of legislation that will
    allow many deserving veterans to receive the care and benefits
    that they have long earned and sought.
        I am also very pleased to see that the House-passed version
    of the Blue Water Navy bill includes a provision from my
    Thailand toxic exposure legislation. The provision authorizes
    the Secretary to provide any child of a veteran of covered
    service in Thailand who is affected by spina bifida the same
    health care, monetary allowance, and vocational training and
    rehab required for the children of Vietnam veterans similarly
    impacted by spina bifida.
        We have a situation where people in Thailand who served, we
    have recognized were affected, yet they are the only ones left
    out in regard to the children with spina bifida that we know is
    directly related to the other.
        Is there a reason that--I mean, are you all for or against
    that provision? Is there any reason, scientifically or not, not
    to include them with every other besides the cost?
        Dr. Erickson. Senator Boozman, thank you for the question.
    Part of the challenge as it relates to spina bifida is that the
    most recent ad hoc committee from the National Academy which
    reviewed this issue actually downgraded the evidence for there
    being an association of spina bifida in the children of Vietnam
    veterans. That does not mean that VA withdrew that benefit.
    However, at the present time, extending the benefit further is
    a little bit tricky because the foundation, the scientific
    foundation, per the National Academy of Medicine, has
    diminished remarkably.
        Senator Boozman. I guess the only argument I would make, a
    benefit for one, a benefit for another is not--it is not the
    way that we do things. So, we need to get that worked out.
        In regard to the Blue Water bill--we would like to get the
    Thailand exposure bill done, and we are going to work really
    hard to do that. But, in regard to Blue Water, we really are
    pleased that this is moving forward. I want to commend
    Commander Wells for his dedicated work to seeing the bill
    through the lengthy but rewarding process that we are
    experiencing. I strongly believe that it is due to people
    giving continued service pushing this forward--Commander Wells,
    Mr. William Rhodes, an Arkansas veteran who served in
    Thailand--that the Committee is able to advocate for
    servicemembers and their families. It is my sincere hope that
    this momentum will continue as we continue to seek care for the
    needs of all of our Nation's veterans well into the future.
        The other thing I would like to mention is a bill that we
    have, the VA Hiring Enhancement Act and just spend a second.
    That is a bill from myself, Senator Heller, and Senator Tester.
    What we have tried to do, you know--we talk about all of these
    situations, whether it is extending Blue Water Navy, Thailand,
    and then all the problems we have at the VA, one of the major
    problems we have right now is we do not have enough providers
    in positions to fill. In talking to our provider community, in
    talking to the people that are running the hospitals, one of
    the things that they mention is that and a couple of other
    things.
        First of all, in their residencies, the ability to offer
    them the opportunity like other providers do fairly early in
    their residency to come to work for the VA. That is not done
    now. I do not know if it is precluded, but it is not being
    done. This bill specifically says let us do that.
        The other thing is the noncompete contracts, which I think
    many people feel like do not hold up anyway. Many people just
    go ahead and do that regardless. We have had, I think, mixed
    judicial things in regard to that. But, what we would like to
    do is based on the fact that if you are in private practice,
    you go to work for the VA, you are not pulling patients from
    the private practice to the VA. It is a different class of
    patients. So, we would like to get rid of that and make it such
    that the VA is exempt from that.
        Do you have any comments about that very quickly?
        Mr. Lawrence. Sure. Let me direct the question to my
    colleague Jessica Bonjorni.
        Ms. Bonjorni. Thank you, sir, for the question. We are in
    support of the provision to remove noncompete agreements. We do
    not have data to suggest how often this is happening, but we do
    certainly have incidents where we have had difficulty bringing
    providers on board because of noncompete agreements in their
    local market, and we have to use work-arounds to try and get
    them on board or wait. We appreciate your support on that.
        Senator Boozman. Thank you very much.
        How about the issue regarding the residencies and trying to
    offer a job earlier than we are now?
        Ms. Bonjorni. We do have the ability to offer contingent
    appointments now. However, this legislation may help clarify
    that we have that ability now and make it more used in the
    community.
        Senator Boozman. Very good. Well, we will welcome you
    working with us on language, if you have concerns about
    specific things, and I do think little things like this really
    are big things in the sense we desperately need the providers
    that we can use in the VA system.
        Thank you, Mr. Chairman.
        Chairman Isakson. Thank you, Senator Boozman.
        Senator Manchin?

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

        Senator Manchin. Thank you, Mr. Chairman. I thank all of
    you for being here. Just a few things.
        The Blue Water Navy, so that I understand, that is for
    anyone who served during the Vietnam era that basically was on
    a ship 10-12 miles out supporting a carrier base, right?
    Probably a carrier fleet.
        Mr. Lawrence. That is correct.
        Senator Manchin. OK. And, they were not coming in. They
    were not combat. You are saying--I mean not ground combat. I
    am----
        Mr. Lawrence. Let me clarify. If your ship came in, in your
    example, and you parked at a port, you went on shore, and you
    make a claim, you would be covered by, as described earlier,
    the ground base presumptive, right? Senator Gillibrand talked
    about it. You were on the ground. So, in the example you are
    talking about, your ship has to stay out of----
        Senator Manchin. So, I never could touch land in Vietnam?
        Mr. Lawrence. Generally speaking, that is correct.
        Senator Manchin. But, now there are people that say that
    basically their ships did come into port, and they are still
    not getting that type--I mean, they are being rejected because
    they were not in combat or not in a combat zone that would have
    been exposed. I am just trying to understand.
        Mr. Lawrence. Sure.
        Senator Manchin. We all want to take care of our veterans,
    OK? I cannot imagine even if a veteran was on a ship that never
    came in and started showing all these symptoms that are
    prevalent with Agent Orange, that that person would not be
    taken care of.
        Mr. Lawrence. Certainly, and he should be. I am unfamiliar
    with the specifics you are referring to. But, we have logs
    during this period of time from the Department of Defense of
    where the ships traveled, where they moved. It is very detailed
    and it is voluminous. So, we are able to track the people you
    are describing. It does not say it does not happen, but, you
    know, you then have to have the diseases or the disabilities
    that are covered by the presumptives. So----
        Senator Manchin. The presumptives are if you were exposed
    in any way, shape, or form, these are the things that could
    happen, and you all can detect that.
        Mr. Lawrence. Correct. That is correct. So, ideally, the
    situation----
        Senator Manchin. But, you should be able to detect that
    also even if they had not come to shore.
        Mr. Lawrence. That is correct. Any veteran at any time can
    apply for a claim, and we adjudicate it the way I described.
        Senator Manchin. It looks like that you all--I mean, here
    is the only thing I can tell you what I hear, is they are
    automatically rejected if they had not been to shore. They are
    automatically--it is not like saying it is unusual, it is rare,
    but you do have the symptoms of being exposed even though you
    were not on land.
        Mr. Lawrence. The only thing I would quibble with, sir, is
    hopefully they are not automatically rejected, because we do
    each case on a case-by-case basis.
        Senator Manchin. OK.
        Mr. Lawrence. They are not automatically----
        Senator Manchin. Tell me how, if I have my constituents--
    and West Virginia has a large military population, a large VA.
    How do I make sure they get proper evaluation and care, not
    just rejected because they had never been--this bill might not
    be needed if we were getting the care that a person showed the
    symptoms and they were taken care of under those conditions. I
    think that is what we are running into, the real stumbling
    block, and the people that are so upset are thinking they are
    just--there is no chance at all that I will get any care
    because I did not--I was on that ship, I was on that fleet, I
    did not come to shore.
        Mr. Lawrence. Sure. We have many, many claims made covering
    the way you are describing, and they are processed through our
    process with quality control. If you would like, I would be
    happy to talk to you about specifics to look in on them, but I
    will tell you, the process I am describing is what we use, and
    it is not automatic rejection the way you are describing. It
    does not say that there could not be things like that which you
    are describing happening, but that is not the intent----
        Senator Manchin. Well, Doctor, that might not be the
    intention, and I respect that. The only thing I can tell you is
    you would not have a vote that you had so strong out of the
    House if the people believed that. You would not have that many
    people supporting it in the Senate if the constituents are
    saying, ``Listen, we are just not being treated fair. We are
    not even given a chance.'' That is why it has come to this
    level.
        So, whatever you have done, whether we have the bill or
    not, we have got to get our veterans the care they need.
        Mr. Lawrence. Sure.
        Senator Manchin. That is the problem we are running into. I
    assume this bill is going to pass, probably, if it comes out
    and goes to the floor. I do not know anybody that would be
    opposed, because we have all had constituents that have been
    rejected without a fair evaluation. That is about it in a
    nutshell.
        I want you to know I am very much concerned about it. We
    should not be at this level. We should have taken care of our
    veterans.
        I have a bill, Senate bill 1952, the Financial
    Accountability Act. I know you all are not crazy about it
    either.
        Mr. Lawrence. Technically, sir, we do not support it.
        Senator Manchin. I want to be as respectful as I can. On
    that, it seems like, you know, you all--veterans is the one
    group of people that keep us together in a bipartisan way.
    There is not another group that we all respond in the same way,
    no matter where you come from, because they have done so much
    and given us a chance to be here. Every time you all need
    money, it is an emergency. It is an emergency. We have run out
    of money. I do not know whether you have got somebody that
    cannot count, somebody that cannot keep track of it, or
    whatever the problem may be, Doctor. I am not trying to be
    facetious about this. But, this bill only asks for 45--I mean I
    can see a crisis coming. If the VA cannot see a crisis coming
    in 45 days to put us always in an emergency position, it is not
    fair for us, not any of us, not to be able to do our job to
    make sure.
        We are very supportive of Mr. Wilkie coming in. We think he
    will do a good job. He is no-nonsense. I think he got
    bipartisan support. I think, from everything I am hearing, he
    has done a pretty good job trying to get things straightened
    out and moving in the right direction. But, I do not know why
    anyone would--you tell me what you are so offended by on
    holding you all accountable financially.
        Mr. Lawrence. I am generally aware of the subject matter
    covered by your bill, and I believe it has to do with----
        Senator Manchin. It is also Mr. McCain's bill.
        Mr. Lawrence. Sorry.
        Senator Manchin. It is also Mr. Tester's bill.
        Mr. Lawrence. All the cosponsors. I am generally familiar
    with that. I believe it has to do with the duplication of yet
    another set of requirements for things that are already in
    place. I will offer to you and others to bring the subject
    matter experts to talk to you directly about their concerns.
        Senator Manchin. Well, I am also for eliminating that, so
    if there is a duplication that we have that allows you all to
    declare an emergency within a week or two and not give us
    enough notice, we will do away with that one. What we believe
    is there should not be anyone that has not done their finances
    or done their due diligence telling us where you are going to
    run into a jam if something hits. That is, I think, what we are
    asking for.
        I know I have used more than my time, Mr. Chairman, and I
    appreciate it. Sir, I just believe our Blue Water veterans who
    are in need of service, we should not even be here talking
    about this. I mean, I do not think that they are asking for
    that much. So, if we have to do the bill, we are going to do
    the bill. But, I wish that we could find another way forward.
        Thank you, Mr. Chairman.
        Chairman Isakson. If I could beg the Committee's
    indulgence, let me expand on Senator Manchin's question. I want
    to make sure I understood your answer.
        When he asked you the question about exposure to Agent
    Orange of someone who had served in the Vietnam theater but was
    in the Navy and was 12 miles out, do I understand you to say
    that if they could demonstrate that they were on the ground
    during that service at any point in time, they could possibly
    be eligible for benefits, but if they were never on the ground,
    they could not be?
        Mr. Lawrence. Sure, let me be precise. As you recall, the
    law that was referenced provides a presumptive for Agent Orange
    for folks on the ground.
        Chairman Isakson. Right.
        Mr. Lawrence. It was expanded then to what was referred to
    as ``Brown Water.'' So, that is why if you are in the Blue
    Water and you are 12 miles offshore, you are not covered, hence
    the conversation we are having now. But, by tracking the ships
    and the flow, if your ship came in and parked on the land, now
    you were in the water that is covered by the presumptive, and
    you went ashore and you can document that you went ashore, and
    you now have the disabilities, the diseases that are covered by
    the presumptive, you would be covered by and be able to receive
    benefits.
        In the example he was talking about, for someone to be 12
    miles off and never be less than 12 miles off, you would not be
    covered. That is what Dr. Erickson was referring to about the
    pollutants being diluted.
        Chairman Isakson. That is the answer I expected, which I
    wanted to hear again so that we are absolutely clear on that,
    because that answer evolved during the course of your exchange.
        Senator Manchin. Mr. Chairman, if I may, just one other
    thing. That is the hardest thing we have to understand. If you
    are exposed, you are exposed. We do not care whether it is
    blue, brown, purple, green, yellow water, whatever it is. If
    you are on a ship and you are carrying--and they are loading
    tons and tons of napalm and tons and tons of Agent Orange, that
    is what we are saying. They have these symptoms, and the
    symptoms are directly involved with what they contacted. That
    is the hardest thing that we have to understand. They are
    automatically just saying, ``Listen, we are not even going to
    test you for that because we do not think there is any way you
    could have that because it is impossible since you were in Blue
    Water.'' That is the thing that does not make sense. That is
    the problem we have.
        Mr. Lawrence. Sure. Let me pull apart your question in a
    couple parts, OK?
        Senator Manchin. OK.
        Mr. Lawrence. So, again, anyone can file a claim, and you
    are not automatically rejected. Let me draw on Dr. Erickson,
    though, to clarify the science of what you described about
    handling weapons with napalm on them and how you actually are
    exposed to dioxin.
        Senator Manchin. Well, basically the aircraft coming back
    being exposed.
        Dr. Erickson. Senator Manchin, there are a couple things
    you referred to. Certainly we work with the Department of
    Defense on a regular basis to try to learn where were these
    agents shipped, how were they shipped, where were they stored,
    where were they used. We actually rely upon them because many
    of your constituents will contact and say, ``I was in country
    X, and I am sure that I was covered with it.'' We talk to DOD.
    DOD says, ``We used commercially available herbicides, but
    those colored agents, such as Agent Orange, were not shipped,
    stored, or used at that location.'' So, there is some precision
    that we would need to know, and if you have specific cases,
    please bring those to us, and we can help you with that.
        The other thing I want to engage you with, sir, is this
    issue of diseases being very clearly Agent Orange or, in
    particular, dioxin caused. Chloracne is one of the 14
    conditions, and that is probably the one of the 14 presumption
    conditions that is sort of a smoking gun. There was a president
    in Ukraine who, in fact, was poisoned with a dioxin, and you
    probably remember his face changed dramatically. He has
    chloracne. But, the other 13 conditions are ones actually that
    are common with age. They are diseases that people who did not
    go to Vietnam actually get. So, when an individual develops one
    of those diseases, that is not immediate proof that it was
    Agent Orange. We need to do other types of studies, other means
    to get to that type of conclusion.
        Senator Sanders. Mr. Chairman?
        Chairman Isakson. Senator Sanders? And, we are going to
    have to move on.
        Senator Sanders. All of this discussion, picking up on
    Senator Manchin's point, tells us why we need universal health
    care. What you are saying, if I got it correctly, if I am on a
    ship 11 miles offshore and I come down with an illness, I am
    covered. If I am on a ship 13 miles offshore and I come down
    with the same illness, I am not covered because under your
    definition I cannot quite prove that it is attributable to the
    water I may have drunk.
        Meanwhile, veterans are becoming ill with the same type of
    illnesses and they need care. Maybe our position should be if
    you are a veteran and you served in the United States military
    and you become ill, you are entitled to VA health care. End of
    discussion.
        Chairman Isakson. I think that is the way to end the
    discussion. I am the one that violated the rule by doing a
    follow-up question, so I hate to reprimand anybody else, but I
    thought Senator Manchin's question was right on point, and we
    needed to get that answer on record. I certainly would never
    cut out the former Chairman from having his say.
        So, with that said, Senator Cassidy.

                    STATEMENT OF HON. BILL CASSIDY,
                      U.S. SENATOR FROM LOUISIANA

        Senator Cassidy. Thank you, Mr. Chair. I may come back to
    Blue Water just because Commander Wells is from Louisiana. I am
    very proud of him. I am also very proud of my Chairman for how
    he is handling this, so thank you both for bringing great
    consideration.
        I will briefly mention, by the way, my Modernization of
    Medical Records Access for Veterans Act, which I understand the
    VA has opposition to the bill's pilot program, but I will
    follow up on that at a later point because I want to focus on
    our suicide prevention.
        I noted, Dr. Lawrence, that the VA is in support. Thank you
    very much. That said, I understand there is both internal and
    external potential opposition to it, and so I would just like
    to make the case for my colleagues and hopefully for those who
    might not be sure about the bill.
        To put this in perspective, when Dr. Lawrence came for his
    nomination hearing, we spoke about suicide prevention and
    veteran community. We know that there are socioeconomic risk
    factors in addition to mental health issues associated with
    suicide. We have spoken previously about so-called deaths of
    despair.
        [To staff: Can you put that chart up?]
        We find from data prepared by Princeton using CDC data that
    suicide, alcohol abuse, and drug abuse are in this unholy
    trinity, which results in folks being at increased risk for
    support. By the way, CDC notes that 54 percent of suicides have
    no known mental health condition.
        The socioeconomic factors, particularly isolation, should
    be part of our approach. Here is the next graphic, put up by my
    assistant; again, social isolation, foreclosure, life events,
    addiction only being one of them, can be associated with so-
    called deaths of despair.
        So, the Community Grant Program that we are suggesting
    would coordinate services within the community, helping
    veterans by integrating and strengthening social networks. I
    smile. My daughter thinks of a social network as being
    Facebook. I do not think that most folks my age would consider
    such.
        The grant, by the way, is also about reaching the 70
    percent of veterans who do not seek care in a VA facility.
    Seventy percent of veterans who die by suicide have not been
    seen within a VA in the past 12 months. We think this is an
    incredibly important statistic and, if you will, a
    vulnerability relying on a VA hospital-central approach.
        So, Dr. Lawrence, you then enter. We are interested in kind
    of a different paradigm. How could we use the Veterans Benefits
    Administration, which is for many the gateway to the VA. In
    fact, more veterans access VA benefits than health care, and in
    many cases that might be their only connection.
        I note that we talked about a VA loan program for homes.
    That is one way a veteran who is probably a little bit better
    off might interact with the VA, but she or he might never
    interact with a hospital. So, we are trying to think of that.
        The other thing--and I think we spoke about this before--
    the Transition Assistance Program legislation which establishes
    a governance board in this legislation to address deaths of
    despair within the Benefits Administration, if you will,
    breaking down the silos within the VA, leveraging all the
    resources, not just the hospital system but also VBA in a
    Department-wide suicide prevention effort.
        I say that, again, per our previous conversation, that the
    first 3 years after leaving service are when veterans are at
    the highest risk of suicide, which is why the Transition
    Assistance Program is a critical partner in our suicide
    prevention effort. So, the Community Grant Program will augment
    the VA's efforts in seeking out veterans in need and connecting
    them to the VA and community services and benefits.
        Defeating deaths of despair requires that we take a
    comprehensive approach to reaching vulnerable veterans, and
    that is why we want VBA.
        Dr. Lawrence, we spoke about VBA's role in suicide
    prevention during your confirmation hearing. Since then, and
    knowing that you have looked at the bill we proposed, can you
    give your thoughts on how you, the VBA, can support this effort
    and place in the governance board within VBA to ensure suicide
    prevention is a department-wide effort?
        Mr. Lawrence. Certainly. I want you to know I took
    seriously our conversation on April 12, and one of the first
    things I did when I was confirmed was begin to understand what
    is the relationship, as you point out, with that despair. VA
    has a series of counselors, called ``voc rehab counselors,''
    vocational rehabilitation. They begin the engagement you
    actually were describing with veterans. One of the things I
    learned from, you know, reports of GAO while watching the House
    hearing, was the ratio of servicemembers to counselors was
    above the ratio prescribed by law. It is supposed to be 125:1.
    It was north of 140. The first thing I immediately did was
    figure out how to streamline staffing to go and hire more of
    these counselors, so by the end of this fiscal year, in a
    couple of months, we will have enough counselors on board so
    that ratio is in compliance with the law. We completely agree
    with you, I completely agree with you that the engagement is
    critical. Part of what these counselors do is exactly what the
    second slide shows. What do you need from us? Is it benefits?
    Perhaps you are homeless. We can expedite your claim. Perhaps
    you need medical attention, and we connect you with VA. I
    totally took our conversation seriously, and it had an impact
    on my actions in the first less than 100 days.
        The second thing, as you know, is transition assistance is
    actually led by the Department of Defense and Department of
    Labor. We work with them. So, you know, I would like to say we
    have reignited--but I do not think it needed that much
    igniting--engaging with them to really work these issues. We
    are conducting a survey--it is now sitting with OMB, so we can
    do that--to analyze servicemembers who are now veterans who
    have gone through TAP afterwards. We get a very good survey
    while it goes on, but sometimes we wonder if they do not know
    what they do not know. We want to talk to them afterwards and
    reflect on now that you have had a job and you have begun your
    life again, how did we do getting you ready.
        So, we are very much in agreement with you that what we
    think about at VA is, you know, you are a member of the
    military for a short period of time, in my case 3 years, but
    you are a veteran forever. We have a longer relationship with
    you that we need to think about how it is maintained and
    continued.
        Senator Cassidy. Thank you very much. I appreciate you all
    looking at this and I look forward to its passage. I urge my
    colleagues to support it when the time arises. Thank you.
        Chairman Isakson. Thank you.
        Senator Hirono?

             HON. MAZIE K. HIRONO, U.S. SENATOR FROM HAWAII

        Senator Hirono. Thank you, Mr. Chairman.
        I am proud to join my colleagues and the veteran service
    organizations here today in support of the Blue Water Navy
    Vietnam Veterans Act. Passage of this bill is needed for
    veterans in Hawaii, like Richard from Kaneohe, who served on
    the USS Hancock in the Gulf of Tonkin from 1972 to 1975.
    Richard was diagnosed with diabetes and is now on kidney
    dialysis. Or veterans like Gordon, also from Hawaii, who served
    in the Navy fleet on the USS Chipola from 1967 to 1969 and was
    diagnosed with soft tissue carcinoma. Both Richard and Gordon
    contend that their illnesses are due to Agent Orange exposure
    while serving off the coast of Vietnam.
        These are some of the thousands of Blue Water Navy Vietnam
    veterans who have applied for VA health benefits, but were
    denied because they happened to serve our country at sea rather
    than on land. We would like to correct that wrong.
        One thing I would like to ask you, Dr. Lawrence, is that
    you said that even for these people who did not serve on land,
    it is not an automatic denial of coverage. Is that correct?
        Mr. Lawrence. That is correct.
        Senator Hirono. So, if they are not automatically rejected,
    what would the servicemember have to show to raise the
    presumption that he or she would be covered?
        Mr. Lawrence. It is very complicated--you have asked a
    question that could easily be very, very complicated, but let
    me try.
        Senator Hirono. What I am getting to is: how much of a
    burden are we placing on the servicemembers themselves to prove
    that they were indeed exposed to Agent Orange? See, that can be
    a burden that is way too high for any servicemember, so we may
    as well just automatically deny them.
        Mr. Lawrence. Let me make a couple of observations. At VBA
    we have a duty to assist the servicemembers to help them find
    the records and the information they need. Often, when you ask
    why does it take so long for a claim to be processed, it is
    because we are trying to help them find the medical records.
    So, hopefully, it is less of a burden because we assist. But,
    they are required to produce some information which we will try
    to figure out and if they are qualified under, does this seem
    presumptive or not.
        In addition, we need a medical exam, as Dr. Erickson
    pointed out, to figure out what is the cause of the situation
    they find themselves in.
        Senator Hirono. I have talked to a lot of veterans, and it
    is hard enough to show that they do come within the parameters
    for treatment even without exposure to Agent Orange. I can only
    imagine what that is like for those who claim to have been
    exposed to Agent Orange. So, I think the burden of proof of
    showing, coming forward with that kind of evidence is very
    high. In fact, it took decades for the VA to even cover or to
    acknowledge that exposure to Agent Orange should be one that
    would be covered under the VA. It took an act of Congress for
    that to happen. So, it looks as though we are going to need to
    have an act of Congress again.
        Let us say that we do that, and obviously we need to work
    with you to make sure that you have the resources necessary to
    provide the kind of care that this additional group of veterans
    are going to need. You did indicate in your testimony that this
    would really strain your resources and that you would need to
    hire more people, et cetera. Can you tell me what kind of
    additional resources you would need to deal with the claims
    burden that would be generated by the passage of this bill?
        Mr. Lawrence. Sure. Based on our estimates that we provided
    in the testimony, it is $500 million over 10 years.
        Senator Hirono. OK. How many veterans are we talking about?
    Something like 70,000?
        Mr. Lawrence. Well, yes, that is an estimate. That is
    correct.
        Senator Hirono. OK. So, I think that, you know, in a
    situation like this where the burden is really extremely high
    for the veterans to show that they should indeed be covered, I
    think we should go ahead with covering this. And, I am pretty
    much in line with our former Chair in saying that, you know, we
    should provide the health care that they need.
        I have a question relating to S. 1990 that is also on this
    agenda, Dependency and Indemnity Compensation Improvement Act.
    I am a cosponsor of this bill, and I certainly applaud Senator
    Tester's work in leading this effort. It has been a long
    overdue increase of approximately $300 a month for DIC
    recipients, including thousands of beneficiaries in Hawaii.
        Dr. Lawrence, you state in your testimony that increasing
    the amount of DIC benefits payment will help survivors continue
    to live a sustainable life, which I wholeheartedly agree with.
    Are there any other programs under your purview which need a
    fresh look at--changing the formula for calculating payments
    similar to how S. 1990 does for DIC payments?
        Mr. Lawrence. None come to mind at this moment, but I would
    like to take that back and perhaps come back and discuss this
    with you.
        Senator Hirono. Yes, because I think we share the goal of
    enabling all these survivors to live, as you put it,
    sustainable lives. I would appreciate that information.
        Thank you, Mr. Chairman.

    Response to Request Arising During the Hearing by Hon. Mazie K. Hirono
      to Paul R. Lawrence, Ph.D., Under Secretary for Benefits, Veterans
          Benefits Administration, U.S. Department of Veterans Affairs
        Question. Dr. Lawrence, you state in your testimony that increasing
    the amount of DIC benefits payment will help survivors continue to live
    a sustainable life, which I wholeheartedly agree with. Are there any
    other programs under your purview which need a fresh look at changing
    the formula for calculating payments similar to how S. 1990 does for
    DIC payments?
        Response. Yes, the VA legislative proposals published in the Fiscal
    Year 2019 President's Budget address identified areas for improvement
    in how VA calculates and provides benefits, including proposals
    pertaining to: (1) the reissuance of VA benefit payments to all victims
    of fiduciary misuse; and (2) the removal of annual income from net
    worth calculations for pension benefits.

        Chairman Isakson. Thank you, Senator Hirono.
        Senator Sullivan?

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

        Senator Sullivan. Thank you, Mr. Chairman. And, Dr.
    Lawrence and your team, I want to thank you. I know that with
    Secretary Wilkie on board you guys are going to work hard, but,
    you know, you have got a tough job here, right? These are good
    bills, but there are some issues with them. Your job is to tell
    us which are the good ones, which are the ones you have issues
    with, how you can work with us on them.
        I appreciate what you and your team are doing. It is not
    easy. It is easier to say yes to all these bills. Now I am
    going to ask you to say yes to one of my bills.
        But, in all seriousness, we do appreciate what you are
    doing.
        I do want to talk about a rather simple bill that I know
    you have looked at, and I want to get your view on it. It is
    the Medal of Honor Surviving Spouses Recognition Act, which is
    S. 2485. This was actually--it is kind of a story you have
    probably heard a lot about from some Senate bills. It was
    inspired by a constituent of mine, a gentleman in Alaska named
    Dave Glenn, a Vietnam veteran from Wasilla, AK, who served as a
    paratrooper in the 101st Airborne. Every Memorial Day and
    Veterans Day, he stands for hours at attention on a bridge in
    Alaska named after one of our two Medal of Honor winners, a
    recipient, Army Sergeant First Class James Bondsteel, who was a
    fellow Vietnam vet of his, who now rests at Fort Richardson
    National Cemetery in Alaska. Dave's one-man Honor Guard on the
    bridge twice a year--he is 73 now--pays respect not only to
    Sergeant First Class Bondsteel, but, importantly, the wife and
    the daughters he left behind after he died in a car accident on
    that very bridge, which is why it was named after him.
        Dave, about a year and a half ago, pitched an idea to me.
    He said, ``Senator, you know this. Families serve in the
    military as well as spouses, even if they are not wearing the
    uniform. I always tell my wife and daughters, you know, they
    have served as much as me or anyone else. Maybe sometimes they
    have even a tougher job.''
        So, in that spirit, and that respect from Dave Glenn, my
    bill is simple. It extends the special pensions granted to
    Medal of Honor recipients to the spouses that survive them
    after they are gone. The spouses obviously have sacrificed as
    well.
        This is a rather small gesture. It is not expensive. I know
    you guys have looked at the dollar amounts. When you are
    talking to VA, there are rounding errors. But, it means a lot
    to the families of these Medal of Honor families. I also think
    it means a lot to Americans.
        Mr. Chairman, I am going to submit for the record an
    article from the Frontiersman in Alaska entitled ``Veteran
    stands Honor Guard alongside the Glenn Highway.'' It is about
    Dave Glenn's Honor Guard. He says, ``The fabric of our country
    is heroes,'' and, ``These people''--Medal of Honor winners--
    ``inspire all of us.''
        I would submit that for the record.
        Chairman Isakson. Without objection.

        [The article follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Senator Sullivan. So, anyway, that is what the bill does. I
    certainly agree with Rick Weidman, the executive director for
    policy and government affairs for the Vietnam Veterans of
    America, when he called this bill a ``no-brainer'' in his
    written testimony. I would appreciate your assessment and your
    team's assessment as well. Then, if I have time, I have a quick
    question on transition assistance.
        Thanks again for the good job you guys are doing. It is not
    an easy job.
        Mr. Lawrence. Thank you. We support the bill.
        Senator Sullivan. Great. Well, I will leave it at that.
    [Laughter.]
        No, no follow-up. Thank you. Wow. OK. Good. I am glad. I
    have another question for you.
        Transition assistance, you know, a number of us right now--
    and I think you guys are working with Senators Crapo, Tester,
    Cassidy, myself--we are working on looking at ways to improve
    that. One issue that I have thought might be something--and I
    know you guys are doing studies on it--is, you know, last time
    I got off active duty for a recall was in 2013. I went through
    the TAP transition, and it is all right at the end there. It is
    all right at the end. But, you get hit with a lot of stuff.
        Now, if you are on active day, say a Marine, you have got a
    4-year tour. You are getting out--usually these young men and
    women, they do it all at the end. Is there any thought about
    saying, hey, Marine, you are going to get out in 6 months, let
    us start thinking about your career in 6 months or, you know,
    maybe even a year so they can start thinking and strategizing,
    as opposed to--and we know how it works. I was in this position
    a couple times. You just want to get out, right? You are not
    thinking about transition. You are just saying, ``I am going to
    go through the classes, do all this, and leave.''
        But, is there any thought about pushing that process kind
    of deeper into the career of an active-duty military member so
    they are actually strategizing and thinking a little bit more
    seriously than, ``Hey, I know I have got to go through this; I
    will check the box, and get out of here''?
        Mr. Lawrence. The short answer is yes, especially at VA. We
    very much think about that. We worry exactly as you described,
    that it is all at the end, and sometimes things at the end,
    events overcome and people miss it.
        Senator Sullivan. Yeah, and you are just not that focused.
        Mr. Lawrence. Right. And, as you know, DOD has the lead on
    this; the Department of Labor is involved and we are involved.
    So, these conversations we have with them are collaborative in
    nature, and that is a perspective we bring. They bring
    different perspectives, so we try real hard to work through
    that. We have always advocated that the sooner we can begin to
    teach people about the benefits they will have as a veteran,
    the better it will be, especially when we think about things we
    are talking about--home loan ownership, for example, not
    something you probably think of right away, but later you will
    look back and say, ``This is a very powerful benefit.'' Access
    to health care, as we have talked about, understanding that,
    you know, you will under certain circumstances be open to
    health care and the like.
        We are very much in favor of that. We try hard to work with
    DOD and Department of Labor to get that point into the
    conversation.
        Senator Sullivan. Great. Well, we want to continue to work
    with you on that, with those and other ideas on the transition
    assistance.
        Mr. Lawrence. Thank you very much.
        Senator Sullivan. Thank you, Mr. Chairman.
        Chairman Isakson. Thank you, Senator Sullivan.
        Senator Tillis?

                    STATEMENT OF HON. THOM TILLIS,
                    U.S. SENATOR FROM NORTH CAROLINA

        Senator Tillis. Thank you, Mr. Chair. I will tell my
    colleague Senator Sullivan that, as Chair of the Personnel
    Subcommittee, that is going to be the focus, TAP, the
    transition assistance program being on VA, not only how much
    earlier we weave it into the life cycle, but recognize some
    young person transitioning may have very different needs than
    someone that has been in 10 years, 15 years, 20 years. So, we
    have got to do a better job of tailoring, we have got to do a
    better job of understanding what sorts of assignments and MOS's
    the military personnel had that may make them at risk for
    certain things they may not even know they are at risk for. So,
    there is a lot of work to be done there, and, Mr. Chair, I was
    going to suggest that we possibly even have a subset of the
    Veterans Committee and Personnel Subcommittee get together so
    we are all hearing the same thing at the same time so the two
    committees can work together.
        Mr. Lawrence, when you were responding to Senator Hirono's
    questions about the documentation and how you process the
    documentation and try to take up claims for outside of which
    you already have a presumption, I was reminded of a constituent
    request that I had about a year and a half ago in my office. We
    are approaching 20,000 cases in North Carolina. I have been in
    3 years, 3\1/2\ years. The majority of them are for veterans.
    This particular one was a veteran who came home with his wife.
    While she was reading the mail, and she said, ``Honey, I did
    not know you died.'' The VA had sent her, as a survivor, a
    notice about the paperwork she needs to do for what was
    apparently her living husband right next to her.
        So, he called the VA, and the VA told him that there was
    this paperwork and these documents that he would have to submit
    to prove that he was, in fact, alive. He then called our
    office. I said, ``Look, it is not our problem to fix your
    problem.''
        Now, I know you are coming in new, and you have got an
    organization that has got a lot of problems to fix. But, I
    would tell you there may be cases where you are trying to help,
    but with the volume you have, I am sure there are a lot of
    cases where people are not getting the kind of help they need,
    and it is very difficult to navigate through the VA. So, I wish
    you well on really trying to make those processes work where it
    is less work for the veteran and more work for the Department
    to get things done.
        He, by the way, is now considered alive again, and he has
    got VA benefits, so that was a happy ending.
        Dr. Erickson, I want to talk with you about the science on
    the Blue Water issue. You may not know--Jerry Ensminger I know
    is on the Hill somewhere, but he was chasing the issue down
    with Camp Lejeune toxic substances before I got here. We had a
    tug and pull with the Department for a while, and to Dr.
    Shulkin's credit, we made good progress there.
        The way we arrived at that is making sure that we kind of
    matched up competing views on the science to a large extent. I
    think that is a fair way to characterize it.
        So, if I look at the Blue Water Navy, I ask myself: how can
    we get a process going that could be driven largely by science,
    but in the same way that we had to pull people together and try
    to bridge the gap, identify a potential class of people that
    right now do not get the presumption? The main reason--I share
    everybody's concerns. I would rather err on the side of the
    veteran in every case. But, one of the concerns that I have
    right now with the bill as proposed is the new pay-for. The
    pay-for that was proposed in the past was an adjustment to the
    COLA, kind of a broad base, relatively low impact, but it
    impacted all veterans. Now, the new proposal is one that gets
    right at loans, home loans. It is something that Senator Warren
    and I worked on. We made some progress on that in terms of bad
    actors for veterans. I am afraid that, one, it actually
    concentrates the cost on a smaller group of veterans, so it
    becomes a higher cost. Depending upon how you get the
    presumptions, it could even be a greater cost. I think we are
    talking about a spread of 25 to 50 basis points, and on certain
    loans that could be a lot of cost borne by certain veterans.
        So, how could we actually accelerate or create a construct
    similar to what we did with Camp Lejeune to come to a good and
    fair conclusion, but also manage the upside risk and costs
    along the way?
        Dr. Erickson. Senator Tillis, thank you for the question. I
    do not know if you remember me. I was part of the tug and pull,
    and I remember all that well.
        Senator Tillis. That is why you got a question. [Laughter.]
        Dr. Erickson. Thank you. I am sure you are aware but
    perhaps other Members of the Committee are not aware that we
    relied initially--and you in legislation relied in the Janey
    Ensminger Act--on the National Academy. In fact, those 15
    covered conditions came from a National Academy report, a 2009
    report. Not a perfect report; I got that. But, that was the
    basis for--the evidentiary basis that initially led to
    legislation.
        Likewise, within the tug and pull with Camp Lejeune, we
    came together with other Federal agencies, in particular, the
    Department of Health and Human Services, ATSDR, looked at a lot
    of the same information together. It was a very profitable
    exercise for us. It is one that, in fact, we are using now for
    lots of other toxic exposure issues. And, in fact, that led to
    our Secretary at the time then promulgating presumptions for
    Camp Lejeune veterans. But, again, based in evidence; based in
    evidence.
        Our challenge right now is that the National Academy did
    not help us out. They said, ``We do not know. We do not know.
    We cannot say that they were exposed. We cannot say that they
    were not exposed.'' So, we are stuck. We are stuck. And, I
    think part of our concern is what are the second- and third-
    order effects when we go beyond this law, as there might be
    other groups that will say, ``Well, you know, our evidence is
    equally strong or weak, and, why don't you take care of us
    either through VA regulation promulgation or through
    legislation?'' That is the challenge.
        Senator Tillis. The main thing for me is I want to make
    sure that those where the science leads us to say we absolutely
    owe it to them--and I do not even mind a little gray area, a
    gray area that favors the veteran. But, if you do not figure
    out how to sustain it--what we do here is pass bills, which we
    forget when we cut or change benefits somewhere else later on,
    because we do not have the money to pay for it. I want to make
    sure that the promises that we made we keep, and if we make a
    promise in this area, it is driven in a way that is
    sustainable, gives care to those who need it and deserve it,
    but does not put us in a situation where, when we run out of
    money and we are already out of money. I do not know if you
    know about our $21 trillion debt. You have always got to be
    mindful of making sure that you are not making empty promises,
    you are not promising progress in one area at the expense of a
    risk for future funding in the other area.
        I look forward to the VSOs. Sorry I ran over, Mr. Chair.
        Chairman Isakson. Thank you, Senator Tillis. We excuse the
    panel and thank the panel for being here. If you wish to stay
    to hear from the VSOs, I hope you will.
        If our VSOs will come forward as quickly as possible, I am
    going to make sure I do not cut you off like I did the last
    time you were here.
        While those testifying are being seated, I am going to ask
    to make a unanimous consent request. I have 20 organizations
    that have submitted written statements for today's hearing and
    agenda. I ask consent that those statements be made part of the
    record of this hearing. Hearing no objection--is there any? [No
    response.]
        Hearing no objection, we will enter them in the record.

        [These statements can be found in the Appendix.]
                                    ------

      Response to Posthearing Questions Submitted by Hon. John Boozman to
                      U.S. Department of Veterans Affairs
        Question 1. I want to thank the VA for your foresight and
    leadership on S. 769, The Medicare Access to Radiology Care Act of
    2017, to require Medicare to recognize RAs. The VA has indicated that
    they are in the process of authorizing Radiology Assistants at the VA
    to align Medicare requirements with state requirements. Will you
    provide a status update for this effort and your sense as to when this
    process will be completed?
        Response. The Department of Veterans Affairs (VA) Office of Human
    Resources and Administration (HRA) is in the process of establishing a
    new qualification standard for the Registered Radiologist Assistant.
    Currently, the qualification standard is in the final stages of
    concurrence for approval and publication. The qualification standard
    provides that a Registered Radiologist Assistant practices under the
    direction and supervision of a physician. HRA is working toward having
    this qualification standard completed by November 2018.
                                     ______

     Response to Posthearing Questions Submitted by Hon. Sherrod Brown to
                      U.S. Department of Veterans Affairs
        Question 2. I am very happy the Committee will review two different
    pieces of legislation to address the needs of active duty
    servicemembers as they transition to civilian life. We need to do
    everything we can to ensure that they have the information and tools
    that they need to succeed. Additional days of training to pursue
    education, technical training, or entrepreneurship will help to set
    servicemembers up for good paying jobs when they reenter civilian life
    and I was pleased that this year's NDAA included a version of this
    provision in the final conference report. Under Secretary Lawrence, in
    your testimony, you say we need to do more to communicate with veterans
    after they transition because rapid identification of risk from
    transition does not present until much later. Are you referring to the
    VFW's suggestion that TAP programs should be offered to veterans once
    they have reintegrated in their communities? Are you referring to risk
    for medical/mental issues, unemployment? Walk me through what you mean
    by that.
        Response. VA agrees with our Veterans Service Organization (VSO)
    partners that consideration must be given to assist transitioning
    Servicemembers to identify and connect with national and community-
    based resources within their new civilian communities--wherever they
    choose to live. VSOs are introduced as a support resource early in VA's
    Transition Assistance Program (TAP) curriculum, and additional
    references are integrated throughout the curriculum to ensure
    transitioning Servicemembers are aware of the support and services they
    can provide. The curriculum highlights how VSOs can support the
    military to civilian transition, including VSO support for filing for
    disability compensation within the pre-discharge program. During the
    curriculum, Servicemembers have the opportunity to use locator tools to
    find their local VSO. The program also allows time to introduce local
    VSO representatives in attendance at VA Benefits I & II Briefings.
        However, VA is not referring to offering TAP to Veterans once they
    have reintegrated into their communities. To that end, VA and its TAP
    interagency partners are currently developing a Military Life Cycle
    module that will introduce transitioning Servicemembers to resources
    located in their civilian communities and inform them on how to connect
    with those resources. VA will complete development of this module by
    December 2018 and will be ready to pilot in coordination with the
    Department of Defense (DOD) and the military services beginning in
    January 2019.
        Moreover, with regard to Servicemembers who are at-risk for
    challenges during their transition, VA and its TAP interagency partners
    recognize the need to be available during the entire transition to
    civilian life. As such, we are working to implement Executive Order
    13822, ``Supporting Our Veterans During Their Transition from Uniformed
    Service to Civilian Life,'' to ensure these at-risk transitioning
    Servicemembers are identified and receive a warm handover to the
    support they need. However, VA notes that the signs and symptoms
    associated with these areas of risk do not always appear or begin until
    after transition from military service. The delayed onset of symptoms
    presents challenges for VA and other agencies, as there are times when
    the Government does not have regular contact with the transitioning
    Servicemember/Veteran.
        In keeping with our enduring commitment to those who have worn the
    uniform, VA and its Federal partners have developed a Joint Action Plan
    which, when fully implemented by July 2019, will improve our ability to
    provide a seamless handoff to VA and ensure early and consistent
    contact with Veterans to keep them informed of access to peer support,
    availability of mental health care after separation, and eligibility
    for health care and VA benefits.
                                     ______

    Response to Posthearing Questions Submitted by Hon. Joe Manchin III to
                      U.S. Department of Veterans Affairs
        In your testimony on S. 1592, VA Financial Accountability Act of
    2017, you stated an independent review of VA financial processes would
    be redundant and that the VA's Enrollee Health Care Projection Model
    (EHCPM) has been extensively reviewed. The two reports you cited, a GAO
    report and a report by The RAND Corporation are from 2008 and 2011
    however, i.e. well before the VA Choice Program was enacted. One of the
    conclusions of the 2008 RAND report was that the EHCPM model could
    yield misleading results, especially in a changing policy and budgetary
    environment.

        Question 3a. Has the EHCPM been updated to model the changing
    demand for healthcare obtained outside of the VA system through Choice
    and other community care initiatives?
        Response. Yes. The 2016 Enrollee Health Care Projection Model
    (EHCPM) that informed the 2019 President's Budget was enhanced to
    differentiate health care provided in VA facilities and care purchased
    in the community. Key enhancements included developing unit costs that
    reflect what VA is expected to pay for purchased care and
    differentiating reliance and other assumptions in the EHCPM by location
    of care.
        The EHCPM has been enhanced to model changes in Veteran demand for
    VA health care recognizing that greater access to care in the community
    closer to the enrollee's home is expected to increase enrollee reliance
    on VA health care and the proportion of that care expected to be met
    outside of the VA system through community care. Since enrollees
    currently rely on VA for less than 40 percent of their health care,
    small changes in reliance can have a significant impact on expenditure
    requirements.
        The total enrollee demand for VA health care projected by the EHCPM
    can be reported separately for care expected to be provided in VA
    facilities and expected to be purchased in the community. However, the
    proportion of total care that will be provided in VA facilities and
    purchased in the community can vary significantly depending upon
    eligibility criteria, operational guidelines, and resource
    availability.
        Health care is very dynamic. Further, the EHCPM projections
    supporting the VA budget are developed based on data that are three
    years removed from the beginning of the budget year (four years for the
    Advance Appropriation). During this time, new policies, legislation,
    regulations, and external factors, such as economic recessions, can
    occur and change the projected demand for VA health care. If so, the
    EHCPM can be updated to reflect this emerging experience, and the
    Budget is updated to reflect the revised projections.

        Question 3b. Has EHCPM been reviewed, by an independent body, since
    the VA Choice program was enacted?
        Response. The EHCPM has been reviewed extensively by independent
    stakeholders, including the Office of Management and Budget,
    Congressional staff, the Congressional Budget Office, and the
    Government Accountability Office (GAO). GAO, which reviewed the EHCPM
    in 2011, is currently reviewing the EHCPM as part their review of the
    VA Community Care Budget (GAO Report 102732). VA is providing extensive
    information on the enhancements to the EHCPM in order to differentiate
    health care provided in VA facilities and purchased in the community
    and will address any recommendations included in GAO's final report.

        Question 3c. Given the sweeping reforms that are part of the VA
    MISSION Act doesn't make sense to have a new, independent review of the
    VA's cost projection models?
        Response. Please see response to Question 3b.

        Question 4. In your testimony, you state that the Blue Water Navy
    bill would add significantly to the number of benefit claims pending
    over 125 days and additional employees would have to be hired to handle
    the case load. How many people would you need to hire if the bill
    passed into law?
        Response. The Veterans Benefits Administration (VBA) would require
    an additional 803 full-time employees (FTE) for 2019 to successfully
    and timely address any new reviews and claims that would be a result of
    the bill passing into law.

        Question 5. In the introduction of the 2011 Institute of Medicine
    (IOM) report on Blue Water Navy, they say the following in the
    introduction: ``The Committee was surprised and disheartened to find a
    dearth of information on environmental concentrations of TCDD during
    the Vietnam War, in spite of large volumes of Agent Orange sprayed
    throughout South Vietnam. Such information is vital to determining
    possible exposures not only of Navy veterans but also veterans who
    served on the ground and on the land waterways of Vietnam.'' Can you
    elaborate on ways the Department of Defense and Department of Veterans
    Affairs have improved service record keeping and transfers of
    information so that they accurately reflect possible toxic exposures
    while in service?
        Response. VA defers to DOD for a full description of initiatives
    and efforts to improve recordkeeping of military exposure events.
    However, VA and DOD work closely to identify situations where
    Servicemembers may be at risk. The Deployment Health Working Group,
    comprised of both DOD and VA officials, meets monthly to discuss
    ongoing and emerging environmental issues and oversees development of
    initiatives to improve interagency sharing of vital information.
        The Individual Longitudinal Exposure Record (ILER) is an example of
    an ongoing joint enterprise initiative between DOD and VA. The purpose
    of this initiative is to establish a complete record of every
    Servicemember's exposure over the course of his or her career. ILER
    will provide a real-time, long-term exposure record matched to health
    status and matched to a Servicemember to a place, time, location, and
    event.
                                     ______

    Response to Posthearing Questions Submitted by Hon. Mazie K. Hirono to
                      U.S. Department of Veterans Affairs

        Question 6. Dr. Lawrence, you state in your testimony that
    increasing the amount of DIC benefits payment will help survivors
    continue to live a sustainable life, which I wholeheartedly agree with.
    Are there any other programs under your purview which need a fresh look
    at changing the formula for calculating payments similar to how S. 1990
    does for DIC payments?
        Response. Yes, the VA legislative proposals published in the Fiscal
    Year 2019 President's Budget address identified areas for improvement
    in how VA calculates and provides benefits, including proposals
    pertaining to: (1) the reissuance of VA benefit payments to all victims
    of fiduciary misuse; and (2) the removal of annual income from net
    worth calculations for pension benefits.

                                     ______

    Response to Additional Posthearing Questions Submitted by Hon. Sherrod
                  Brown to U.S. Department of Veterans Affairs
                                blue water navy
        Mr. Manar's testimony is very convincing, and so was the Australian
    study. ``If there was dioxin in the water, we would have been exposed
    to it while swimming. Week after week, patrolling up and down the
    coast, we took in sea water and processed it through our fresh water
    evaporator system. We know from the Australian Navy study, validated by
    the National Academy of Medicine (formerly the Institute of Medicine),
    that fresh water evaporator systems concentrated toxic material,
    including dioxin, which was then transmitted to sailors through
    drinking water.\1\
    ---------------------------------------------------------------------------
        \1\ Blue Water Navy Vietnam Veterans and Agent Orange Exposure,
    Institute of Medicine, 2011, pg 13, https://www.nap.edu/read/13026/
    chapter/2#13.
    ---------------------------------------------------------------------------
        As a matter of observation, absent the cleaning and sanitation of
    the entire fresh water evaporator system, it is conceivable that every
    person who ever served on board my ship could have been exposed to
    dioxin after its first visit to Vietnam. Further, by the time we
    completed our last deployment to Vietnam in 1972, the evaporator system
    would have accumulated concentrated dioxin from dozens of visits to
    Vietnam, not simply the final three that I experienced while on
    board.''

        Question 7. Dr. Erickson, to date, why hasn't VA concluded that the
    science behind the Australian study, which NAM corroborated, is
    sufficient? What additional science is VA waiting for?
        Response. We thank the Senator for this question and for his
    careful consideration of the evidence underlying this bill. We
    recognize that this is a complex exposure issue that is important to
    our Veterans, and we have been working diligently over the years to
    gain as much understanding as possible and to recommend policies that
    are facts based. The Senator has noted that he finds both the
    Australian study and the Veteran's testimony to be strong evidence in
    support of concluding that Blue Water Navy Veterans were exposed to
    Agent Orange and other tactical herbicides during the Vietnam War;
    however, the statements and conclusions made in both of these, in terms
    of the consumption of water distilled aboard ships while at sea, are
    contingent upon the assumption and requirement that tactical herbicides
    and the contaminant Tetrachlorodibenzo-p-dioxin (TCDD) were present in
    the water. VA's understanding of the science related to that issue,
    including the policies regarding the spray missions, the properties of
    the herbicides, the environmental fate of the herbicide components, and
    the expected behavior of the components in bodies of water off the
    coast of Vietnam, is that it is unlikely that this was a significant
    pathway of exposure to tactical herbicides for most Blue Water Navy
    Veterans.
                    australian study (muller, et al., 2002)
        Researchers in Australia demonstrated it may have been possible to
    concentrate dioxin during the distillation of contaminated water, based
    on laboratory recreations of the major aspects of the distillation
    systems used aboard most ships during the Vietnam War. The theoretical
    nature of this series of experiments and differences in U.S. and
    Australian Naval policies at the time, however, restrict the
    extrapolation of these findings in terms of representing the experience
    of U.S. Navy Veterans who served on the offshore waters of Vietnam.
        The authors attempted to determine this by recreating the major
    principles of the distillation system in a laboratory setting and
    assessing the potential for the co-distillation of several chemicals.
    It is important to note that most of the variables in the experiments,
    including the concentrations of chemicals, were not chosen to directly
    mirror the conditions in the offshore waters of Vietnam but rather to
    evaluate the effects of the physico-chemical properties of water and
    different types of compounds on distillation in this type of system.
    Thus, it was not meant to model the exposure scenario in Vietnam, but
    rather, the type of distillation system aboard the ships that were
    used. Based on the findings of the study, the authors concluded that
    ``the distillation process of water contaminated with TCDD would result
    in contamination of potable water. Subsequent ingestion by sailors on
    board ships (as well as soldiers and airmen, who were passengers) is
    thus a vector for exposure to these chemicals.
        While it is unlikely that accurate exposure of the personnel on
    board ships can be estimated, the study findings suggest that the
    personnel on board ships were exposed to biologically significant
    quantities of dioxins.'' This conclusion may be appropriate for the
    Royal Australian Navy members who served during the war, as their
    protocol at that time was to draw water for drinking from turbid,
    estuarine type waters (or those closer to shore), which would include
    higher levels of salt, suspended particles, and potentially,
    contaminants from herbicide spray drift, while reserving the drawing of
    more pristine waters that were several miles off shore exclusively for
    their steam engines. The U.S. Navy protocol, however, was starkly
    different during that conflict. Per Sec. 2.4.2 of the Naval Ships'
    Technical Manual (NAVMED P-5010-6; Department of the Navy, 1990), which
    is titled ``Polluted Water,'' states that ``unless determined
    otherwise, water in harbors, rivers, inlets, bays, landlocked waters,
    and the open sea within 12 miles of the entrance to these waterways,
    shall be considered to be polluted . . .  The desalting of polluted
    harbor water or seawater for human consumption shall be avoided except
    in emergencies.'' Therefore, U.S. Navy ships that served only on the
    offshore waters several (at least 12) miles off the coast of Vietnam
    were not likely to have drawn contaminated water for drinking.
                    2011 institute of medicine (iom) report
        At the request of VA, IOM reviewed the evidence on this topic and
    issued a report in 2011. In this comprehensive review, the Committee
    detailed several factors that would affect the potential for TCDD-
    contaminated water to reach U.S. ships that were several miles
    offshore, including:

         It has been estimated that 87 percent of the Agent Orange
    sprayed reached the forest canopy, while only 13 percent was lost to
    drift, and of the 13 percent, an appreciable amount was likely degraded
    due to the Vietnamese environment.
         Agent Orange and TCDD would have entered waterways via
    riverbank spraying or runoff; however, a considerable fraction would
    absorb in organic materials that would be deposited in the delta
    regions or estuaries.
         Agent Orange and TCDD would have entered marine water from
    river discharge and spray drift; however, any amount in marine waters
    would be greatly reduced by the initial dilution in river water and
    dispersion in air and further dilution in coastal waters.

        The Committee also reviewed the Australian study and considered
    another theoretical model that appeared to support its findings on the
    potential to concentrate TCDD through the distillation process. The
    Committee concluded that ``it is theoretically possible to concentrate
    dioxin in distilled water, at least experimentally.'' While the
    Committee noted that, based on the available science, ``if Agent
    Orange--associated TCDD was present in the marine water that U.S. ships
    drew for drinking water, distilled potable water would be a plausible
    pathway of exposure,'' they ultimately concluded that ``without
    information on the TCDD concentrations in the marine feed water, it is
    impossible to determine whether Blue Water Navy personnel were exposed
    to Agent Orange--associated TCDD via ingestion, dermal contact, or
    inhalation of potable water.'' Additionally, regarding the Australian
    study, the Committee stated: ``If the purpose of this experiment was to
    demonstrate the plausibility of TCDD exposure to sailors via distilled
    water, then this study is useful; however, the application of these
    findings to actual shipboard distillation systems requires knowledge of
    several factors not addressed in the experiment. The significance of
    this study's findings for contaminant exposures on Blue Water Navy
    ships is highly uncertain.'' Therefore, IOM did not corroborate the
    Australian study in terms of its applicability to U.S. Navy Veterans
    that served during the Vietnam War, but they noted that the study
    findings do support that the concentration of TCDD during distillation
    aboard ships is theoretically plausible.
      current va study that may provide additional scientific evidence on
                                blue water navy
        VA recently conducted a survey study on the health of Vietnam-era
    Veterans that included an ``over-sampling'' of Blue Water Navy Veterans
    as a subpopulation. The study will compare the health of this group to
    that of Vietnam Veterans, Vietnam-era Veterans, and the general U.S.
    population. In the absence of adequate exposure data, we hope to gain
    an understanding of the health of Blue Water Navy Veterans and may be
    able to make some determinations about whether outcomes they are
    experiencing could be related to exposure to tactical herbicides during
    their service. The results are currently being analyzed and are slated
    to be published as early as 2019.

        Question 8. Why has VA denied claims for veterans who were exposed
    to Agent Orange if VA has records of specific ships and the veterans
    who were on those ships within the 12 mile demarcation line?
        Response. Under current laws and regulations, there is not a 12-
    mile demarcation line for determining whether a vessel operated in the
    inland waterways.
        Background:

        VA, under the law, may only pay compensation based on a presumption
    of service connection for an Agent Orange-related disease if the
    Veteran was exposed to Agent Orange or any other covered herbicide.
    Under the law, 38 United States Code Sec. 1116, a Veteran is presumed
    to have been exposed to Agent Orange only if he or she ``served in the
    Republic of Vietnam'' during the period beginning on January 9, 1962,
    and ending on May 7, 1975.
        VA regulations, 38 Code of Federal Regulations
    Sec. 3.307(a)(6)(iii), defines service in the Republic of Vietnam to
    only include service in the offshore waters if the service included
    duty or visitation in the Republic of Vietnam. VA has further clarified
    ``service in the Republic of Vietnam'' to consist of ``boots on the
    ground'' service or service in the inland waterways. VA's
    interpretation of ``service in Vietnam,'' to include encompassing
    inland waterways, but excluding offshore waters has been upheld by the
    courts, to include the United States Court of Appeals for the Federal
    Circuit in its seminal decision in Haas v. Peake, 525 F.3d 1168 (Fed.
    Cir. 2008).
        VA's regulatory definition of service in Vietnam excludes service
    in the offshore waters, as there is no evidence that Agent Orange was
    applied to the waters off the shore of Vietnam, nor is VA aware of any
    valid scientific evidence showing that individuals who served in the
    offshore waters were subject to the same risk of Agent Orange exposure
    as those who served in the geographic land boundaries of Vietnam.
        Therefore, VA would not necessarily award benefits for a claim for
    disability compensation due to Agent Orange exposure for a Veteran who
    had served aboard a ship within 12 miles of the Vietnamese coast, as
    offshore service is not considered service in the inland waterways,
    which meets the statutory and regulatory definition of ``service in
    Vietnam.'' Inland waterways include rivers, canals, estuaries, and
    deltas. Deep-water bays and harbors are not inland waterways but are
    considered to be offshore waters of Vietnam because of their deep-water
    anchorage capabilities and open access to the South China Sea. For
    example, we would consider service aboard a swift boat, landing ship,
    or tank to be service in the inland waterways because those types of
    vessels operated primarily on Vietnam's inland waterways. Agent Orange
    exposure would be conceded for any Veteran who served aboard this type
    of Naval vessel.
        We also would concede exposure to Agent Orange if a Veteran who
    served in a ship operating in the offshore waters that temporarily
    entered an inland waterway. Additionally, we concede Agent Orange
    exposure if the ship docked to a pier or shore or was in the offshore
    waters and delivered personnel or supplies if there is evidence that
    the Veteran went ashore, as this was would be consistent with service
    that ``involved duty or visitation in the Republic of Vietnam.''
        Veterans who are not presumed to have been exposed to Agent Orange,
    including those who served in ships in offshore waters that did not
    enter inland waterways, may submit evidence of actual exposure, and VA
    evaluates such evidence on a case-by-case basis.
              medical surgical prime vendor (mspv) program reforms
        My office has heard that the lack of a comprehensive approach to
    manage medical products throughout the VA system, could lead to an
    inefficient acquisition strategy for the Department. There have been
    efforts to revamp the MSPV program and I would like to know more about
    what the Department's next steps will be.

        Question 9. What additional steps could VA take to reorganize the
    Medical Surgical Prime Vendor (MSPV) Program, and would VA use the
    Pharmaceutical Prime Vendor program as a model?
        Response. VA should continue its efforts on multiple fronts now
    underway to improve the MSPV program, which are:

         The Veterans Health Administration (VHA) Healthcare
    Commodities Program Office (HCPO) near-term efforts to improve the MSPV
    program to increase VA medical centers (VAMC) and clinician access to
    the medical/surgical supplies required to treat patients, and improve
    flexibility for adding supplies to the list of available items, as
    feasible under legal and regulatory constraints. Simultaneously, we are
    pursuing longer term program goals that focus on leveraging VA's buying
    power to deliver more consistent, faster distribution services to the
    facilities, lower costs, and increase enterprise spend visibility via
    the MSPV 2.0 and our Clinically-Driven Strategic Sourcing (CDSS)
    initiative.
         The VHA CDSS initiative will improve processes and tools
    to better involve clinicians in identifying and validating supplies.
         The VHA HCPO's MSPV 2.0 effort is planning new,
    competitively awarded supply and distribution services contracts for
    Prime Vendors to improve VAMC with a more seamless and compliant, end-
    to-end supply chain solution focused on lowering costs, reducing
    acquisition wait times, and delivering essential supplies for Veteran
    care.
        The VHA HCPO has been working closely with the Strategic
    Acquisition Center, Office of Small and Disadvantaged Business
    Utilization, and Office of General Counsel to ensure facility
    requirements and requests are pursued within relevant Federal
    Acquisition Regulations and Veterans Administration Acquisition
    Regulation framework and are compliant with legal statutes, which
    include the Rule of Two and Vets First.
         VHA is evaluating parts of the Pharmaceutical Prime Vendor
    (PPV) program for incorporation into the MSPV Program. One of the
    potential courses of action is to utilize the Federal Supply Schedules
    to make a larger market basket of medical surgical products available
    to all facilities.
         PPV program does currently rely on a single Prime Vendor
    to cover all regions, which is not the preferred approach for the VHA
    MSPV. VHA will propose to have more than one MSPV to reduce dependency
    risk. H.R. 5418, the Veteran Affairs Medical-Surgical Purchasing
    Stabilization Act, would set the expectation to have more than one
    prime vendor for VA medical/surgical supplies.
         The mechanism for communicating pharmaceutical prices to
    PPV may not be scalable for the volume of items that are required by
    the MSPV program. In the existing PPV model, the VA/National
    Acquisition Center (NAC) provides the prices electronically to PPV. PPV
    is only permitted to load prices provided by NAC. In the event the
    contracting office is delayed or unable to provide pricing, item
    availability may be at risk as MSPV would not have the information
    required to effectively procure the necessary items. Given that one of
    the key goals of the new MSPV program is to increase item availability,
    the risks associated with the current PPV model would run counter to
    the future intentions of HCPO.

        Question 10. Has VA consulted with other interagency partners such
    as DOD?

        VA Response:

         As part of the MSPV 2.0 program, we are analyzing
    different course of action for medical/surgical items--which include
    VA's Federal Supply Schedule and Defense Logistics Agency's (DLA)
    Distribution and Pricing Agreements (DAPA). Utilizing the DLA DAPA
    option is a possible solution that DLA has made available to VA.
         VHA views a partnership with DLA as a potential long-term
    solution given the comparable nature of the Department of Defense's
    (DOD) medical programs in terms of service and scope across hundreds of
    facilities; DLA's MSPV program is generally regarded as effective and
    efficient. VHA is including subject matter experts from DLA to assist
    in the MSPV 2.0 development efforts. DLA experts have shared best
    practices for their MSPV program and highlighted key differences
    between the two organizations to provide a more comprehensive
    understanding of the advantages and disadvantages of the different
    supply programs.
         As VA continues to explore migration to DOD's Defense
    Medical Logistics Supply System (DMLSS)/LogiCole solution to replace
    the legacy Integrated Funds Distribution, Control Point Activity,
    Accounting and Procurement system, the synergies of leveraging the DLA
    MSPV contract and DAPAs increase. A migration to DMLSS/LogiCole may
    need to include utilizing the DLA MSPV contracts, to achieve the
    efficiencies desired from this program.

        Question 11. What steps would VA take to ensure the new program is
    staffed properly with individuals who have both clinical and medical
    supply chain expertise?
        Response. CDSS initiative will be piloted next year to better
    leverage and integrate clinical, supply chain, and contracting
    expertise to provide clinicians with the medical supplies and equipment
    required to provide improved patient care for our Veterans. CDSS will
    include comprehensive and extensive coordination with the National
    Clinical Program Offices, clinicians, and supply chain personnel at
    both the facility and the Veterans Integrated Service Network levels.
    The strategy will be driven by clinician feedback and requests, and the
    supply catalog will include items that are safe, effective, and
    clinically sourced. Constant communication and transparency with
    clinicians is essential for the success of CDSS, and every CDSS-sourced
    medical item will leverage the medical expertise of our clinicians in
    the field.
        Current VA Ordering Officer training materials will be updated to
    reflect lessons learned as well as the changes introduced by the MSPV
    2.0 (future state) program.

        Question 12. Would the reorganization include a program office to
    manage the new enterprise?
        Response. In June 2018, VA's Healthcare Commodities Program Office
    in its reorganization established a Medical/Surgical Future State
    effort to support the development of the MSPV 2.0 and other future
    medical/surgical programs. As the future MSPV program transitions from
    development to implementation and sustainment, additional
    reorganization may be required to best support the VAMCs.

        Question 13. Would a reorganization require additional resources,
    either personnel or funding?
        Response. VA is assessing the need for additional resources, in the
    form of both personnel and funding, that may be required to support the
    MSPV 2.0 program as it moves into implementation and sustainment.
    Additional resources may be required to support a successful
    implementation, provide contract oversight and administration, and
    provide general program management support.

        Question 14. Does VA need legislative language to facilitate a
    program reform?
        Response. VA is reviewing ideas for legislation that could
    contribute to its efforts in these areas. We are glad to discuss
    potential improvements with the Committee.

        Chairman Isakson. Those testifying in panel 2 are as
    follows: Chanin Nuntavong--did I get that right, Chanin?
        Mr. Nuntavong. Yes, Senator.
        Chairman Isakson. OK. Chanin Nuntavong is Director of
    Veterans Affairs and Rehabilitation, The American Legion;
    Gerald Manar, former Director, National Veterans Service,
    Veterans of Foreign Wars; Thomas Snee, National Executive
    Director of the Fleet Reserve Association; and Rick Weidman,
    Executive Director for Policy and Government Affairs, Vietnam
    Veterans of America.
        We welcome all four of you to testify, and we will begin
    right now with Mr. Nuntavong. I am sorry if I am not doing well
    with the name. I apologize.

      STATEMENT OF CHANIN NUNTAVONG, DIRECTOR, NATIONAL VETERANS
         AFFAIRS & REHABILITATION DIVISION, THE AMERICAN LEGION

        Mr. Nuntavong. Michael Kvintus, a resident of Cambridge,
    OH, deployed twice aboard the USS Buchanan during the Vietnam
    War. Michael was exposed to the chemical known as Agent Orange
    while guarding aircraft, searching boats, providing field naval
    fire support, and while anchored near Da Nang harbor in August
    1966.
        Chairman Isakson, Senator Sanders, and distinguished
    Members of this Committee, on behalf of National Commander
    Denise Rohan, representing 2 million dues-paying members living
    in every State and American territory, it is my duty and honor
    to present The American Legion's position on the pending
    legislation being discussed here today.
        Michael has been happily married for 55 years, is the
    father of three, and lives with the daily illnesses of exposure
    to Agent Orange. Michael had a heart attack, not one but two
    stents placed in his heart, and quadruple bypass surgery. At
    the age of 72, he currently lives with heart disease, diabetes,
    neuropathy, and erectile dysfunction. All, he believes, is
    connected to Agent Orange exposure.
        H.R. 299 is a massive step forward in recognizing the men
    who were impacted by Agent Orange. Mr. Chairman, it is time we
    as a Nation give veterans like Michael the benefits they
    deserve.
        Beyond the benefits for Blue Water Vietnam veterans, all
    veterans deserve comprehensive health care. The American
    Legion's System Worth Saving program routinely conducts town
    hall meetings across the Nation allowing veterans to share
    their VA experience. We frequently meet with veterans who
    express concerns about VA dental benefit eligibility. A
    majority of the veterans treated by VA do not qualify for this
    benefit. Bottom line, dental care is health care, and The
    American Legion supports this legislation.
        In the 1990s, BRAC was created to assess and close military
    installations no longer paramount to our national defense. An
    unintended consequence of the closures was Mare Island
    Cemetery. The cemetery is in total disrepair. It fell out of
    the purview of the U.S. Navy and is currently under the control
    of the city of Vallejo, CA.
        The proposal in S. 2881 is simple, Mr. Chairman: Transfer
    the cemetery that has more than 850 veterans, including 3 Medal
    of Honor recipients, to the VA's National Cemetery
    Administration, whose mission is to ensure that those who have
    departed us are treated with the respect they deserve. We
    firmly believe NCA is the best authority and only authority to
    restore Mare Island Cemetery to greatness.
        Shifting topics, ensuring servicemembers receive world-
    class training as they transition out of the military has been
    and always will be a priority of The American Legion. The draft
    bill before you would increase the number of DOD TAP employees,
    collect data for studying long-term effectiveness, and
    establish a governing board to help prevent overdoses, suicide,
    and alcoholism, among other provisions. The American Legion is
    thankful for the ability to review and provide feedback on this
    proposed bill.
        In short, we support the draft bill but recommend the
    following changes: require commanding officers to attend TAP so
    they can understand what the program offers to their troops;
    require DOD to report data to Congress on troops who have
    completed TAP, broken down into useful information to enhance
    the program; and, finally, eliminate the postsecondary
    education assessment. This program needs significant
    participation before it can yield helpful results.
        In terms of VA staffing, The American Legion, along with
    Members of this Committee, continues to highlight the shortages
    of more than 30,000 jobs within VHA. Filling these vacancies
    with qualified professionals is a priority for The American
    Legion, the 9 million veterans using VA, and future veterans.
    This legislation will allow physicians to complete their
    education, then immediately begin treating veterans in the VA
    system. The VA Hiring Enhancement Act aligns the hiring
    practices of VA to those of the private sector, ensuring top-
    quality health care is provided to our veterans. We encourage
    you to support this initiative.
        I conclude by thanking this Committee and you, Chairman
    Isakson, for holding the confirmation hearing, ensuring the
    full Senate to vote, and giving veterans of our Nation a
    Secretary of Veterans Affairs. The Department was without
    Senate-confirmed leadership for 124 days. The American Legion
    stands ready to assist Secretary Wilkie in doing what is best
    for veterans.
        We thank Chairman Isakson and Ranking Member Tester for
    their incredible leadership and for always keeping veterans at
    the core of their mission. It is my privilege to represent The
    American Legion before this Committee. I look forward to
    answering any questions you have. Thank you.
        [The prepared statement of Mr. Nuntavong follows:]
      Prepared Statement of Chanin Nuntavong, Director, National Veterans
             Affairs & Rehabilitation Division, The American Legion
       h.r. 299; s. 3184; h.r. 5418; s. 1596; s. 2881; s. 1952; s. 1990;
          s. 2485; s. 2748; s. 514; and all subsequential draft bills
        Chairman Isakson, Ranking Member Tester, and distinguished Members
    of the Committee; On behalf of National Commander Denise H. Rohan, and
    the 2 million members of The American Legion, we thank you for this
    opportunity to testify regarding The American Legion's positions on
    pending legislation. Established in 1919, and being the largest
    veterans 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.
                                    h.r. 299
    To amend title 38, United States Code, to clarify presumptions relating
            to the exposure of certain veterans who served in the vicinity
            of the Republic of Vietnam, and for other purposes.
        Veterans who served on open sea ships off the shore of Vietnam
    during the Vietnam War are called ``Blue Water Veterans.'' Currently,
    Blue Water Veterans must have physically set foot on the land of
    Vietnam or served on its inland waterways between January 9, 1962 and
    May 7, 1975 to be presumed to have been exposed to herbicides when
    claiming service-connection for diseases related to Agent Orange
    exposure.
        Blue Water Veterans who did not set foot in Vietnam or serve aboard
    ships that operated on the inland waterways of Vietnam must show, on a
    factual basis, that they were exposed to herbicides during military
    service in order to receive disability compensation for diseases
    related to Agent Orange exposure. These claims are decided on a case-
    by-case basis.
        We are aware the Department of Veteran Affairs (VA) previously
    asked the National Academy of Sciences' Institute of Medicine (IOM) to
    review the medical and scientific evidence regarding Blue Water
    Veterans' possible exposure to Agent Orange and other herbicides. IOM's
    report, ``Blue Water Navy Vietnam Veterans and Agent Orange Exposure''
    was released in May 2011. The report concluded that ``there was not
    enough information for the IOM to determine whether Blue Water Navy
    personnel were or were not exposed to Agent Orange.''
        However, Vietnam veterans who served on the open sea now have
    health problems commonly associated with herbicide exposure. Just as
    those who served on land were afforded the presumption because it would
    have placed an impossible burden on them to prove exposure, Congress
    should understand the injustice of placing the same burden on those who
    served offshore. Clearly, all the toxic wind-blown, waterborne, and
    contamination transfer stemming from aircraft, vehicle, and troop
    transfer makes it impossible to conclude that Agent Orange-dioxin
    stopped at the coastline.
        Through Resolution No. 246: Blue Water Navy Vietnam Veterans, The
    American Legion supports legislation to expand the presumption of Agent
    Orange exposure to any military personnel who served on any vessel
    during the Vietnam War that came within 12 nautical miles of the
    coastlines of Vietnam.\1\
    ---------------------------------------------------------------------------
        \1\ American Legion Resolution No. 246 (Sept. 2016): Blue Water
    Navy Vietnam Veterans
    ---------------------------------------------------------------------------

    The American Legion supports H.R. 299.

          draft bill: veterans dental care eligibility expansion and
                            enhancement act of 2018
    To improve dental care provided to veterans by the Department of
            Veterans Affairs, and for other purposes.
        The American Legion's System Worth Saving program routinely
    conducts town hall meetings allowing veterans to share their Department
    of Veteran Affairs (VA) healthcare experiences. In addition to hosting
    town hall meetings, The American Legion frequently receives letters and
    telephone calls from veterans expressing concerns about VA dental
    benefit eligibility. Under VA's current eligibility for dental care,
    the majority of veterans treated by VA do not qualify. Generally,
    veterans who suffer from poor dental hygiene are not eligible for basic
    dental care through the VA. These veterans are often not able to afford
    the high cost associated with dental care, especially veterans who live
    on a fixed income.
        Further, the average age of a veteran in the United States is
    currently 58 years old; and The American Legion is concerned the demand
    for dental care will increase as the population ages.\2\ In addition to
    obvious ailments associated with oral care, dental care is a vital
    aspect of general healthcare. Diabetes \3\ and Alzheimer's,\4\
    conditions commonly associated with veterans, have been linked to poor
    oral health. The need to take care of our Nation's veterans dental
    needs should be apparent and a priority.
    ---------------------------------------------------------------------------
        \2\ Veterans Average Age: https://www.va.gov/VETDATA/docs/
    SurveysAndStudies/VETPOP.pdf
        \3\ Prevalence of and Trends in Diabetes Among Veterans, United
    States, 2005-2014: available at https://www.ncbi.nlm.nih.gov/pmc/
    articles/PMC5737977/
        \4\ Veterans and Alzheimers: Meeting the Crisis Head on: available
    at https://www. usagainstalzheimers.org/sites/default/files/
    USA2_Veterans_Issue_Brief_April_10_2018.pdf
    ---------------------------------------------------------------------------
        The Veterans Dental Care Eligibility Expansion and Enhancement Act
    of 2018 is a comprehensive plan to provide needed dental care to
    veterans. This legislation, in addition to expanding needed dental
    services to veterans includes: carrying out pilot programs; acquiring
    new dental facilities; and hiring additional dental healthcare
    providers.
        Section 2 would provide discretionary authority to the Secretary to
    furnish restorative dental services to a veteran, as well as replace
    lost appliances and restore function loss suffered as a result of
    services or treatment furnished by the VA.
        Section 3 would require the Secretary to carry out a pilot program
    to assess the feasibility and advisability of furnishing dental
    services and treatment to all veterans enrolled in the VA healthcare
    system, even those not currently receiving dental healthcare.
        Section 5 would require the Secretary to carry out a program of
    education to promote dental health for veterans who are enrolled in VA
    healthcare system.
        The potential benefits to the veteran community from these expanded
    services is self-evident. The American Legion supports these sections
    through Resolution No. 377: Support for Veteran Quality of Life \5\ and
    No. 186: Department of Veterans Affairs Dental Care.\6\ The American
    Legion believes veterans should have access to timely and quality
    dental care and will support legislation to provide outpatient dental
    care to veterans. We also support legislation or programs within the VA
    that will enhance, promote, restore, or preserve benefits for veterans
    and their dependents with timely access to quality VA healthcare and
    receipt of earned benefits.
    ---------------------------------------------------------------------------
        \5\ The American Legion Resolution No. 377 (2016): Support for
    Veteran Quality of Life
        \6\ The American Legion Resolution No. 186 (2016): Department of
    Veterans Affairs Dental Care
    ---------------------------------------------------------------------------
        In addition to expanding services, this draft bill is likely to
    improve the access and quality of care received by veterans through
    sections 4 and 7. These sections have the ability to greatly expand
    access to dental healthcare to veterans. Section 4 of the act would
    require the Secretary to construct or lease a VA dental clinic in any
    State that does not have a VA facility offering onsite dental services.
    Additionally, section 7 provides discretionary authority for the
    Secretary of VA to carry out a demonstration program to train and
    employ alternative dental healthcare providers in rural areas. These
    sections would provide dental healthcare where none currently exists
    and provide healthcare professionals that are not currently available.
        Similarly increasing flexibility and access for veterans receiving
    dental care through VA, section 6 requires VA to expand the VA Dental
    Insurance Program (VADIP) Electronic Health Record capabilities.
    Section 6 would establish a mechanism by which private sector dental
    care providers could forward the VA information on dental care provided
    to individuals under the pilot program for inclusion in the VA's
    electronic medical records. Increased access to medical information
    ultimately translates into better care for veterans.
        Through our Support for Veteran Quality of Life resolution, we
    support enhancing service to veterans by creating services for veterans
    not currently being provided vital health services. The American Legion
    has also long recommended VA's electronic medical records be revised to
    read DOD's electronic health records. Similarly, The American Legion
    believes ensuring VA has the ability to share electronic health records
    with private sector dental care providers is common sense and should be
    a priority for the VA. The American Legion through Resolution No. 83:
    Virtual Lifetime Electronic Record, supports any legislation that would
    allow the electronic sharing of medical record information.\7\
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        \7\ The American Legion Resolution No. 83 (2016): Virtual Lifetime
    Electronic Record
    ---------------------------------------------------------------------------

    The American Legion supports this Draft Bill.

                                    s. 3184
    To amend title 38, United States Code, to modify the requirements for
            applications for construction of State home facilities to
            increase the maximum percentage of nonveterans allowed to be
            treated 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 or 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. 3184.

              discussion draft bill: transition assistance program
    To amend title 10, United States Code, to improve the Transition
            Assistance Program for members of the Armed Forces, and for
            other purposes.
        The American Legion supports Congress' continued attention and
    efforts in ensuring that Federal agencies and their valued partners
    properly identify and implement necessary changes/improvements to the
    Transition Assistance Program (TAP). We understand that in order for a
    servicemember to transition seamlessly, and successfully, it requires
    the collaboration between all agencies including Department of Defense
    (DOD), Department of Labor (DOL), Department of Veteran Affairs (VA),
    etc., along with congressional oversight. The key is to combine the
    talents, expertise, and innovations of Veterans Service Organizations,
    non-governmental organizations, and private sector organizations in
    bringing solutions forward to champion initiatives with the Federal
    Government for the purpose of improving opportunities of transitioning
    servicemembers.
        Improving employment opportunities for transitioning servicemembers
    includes introducing both service delivery, business process, and
    technology innovations in support of TAP and credentialing of
    servicemembers. Further, this includes examining all aspects of TAP and
    credentialing from resume writing, financial planning, goal setting,
    job search, interviewing, networking, peer-to-peer support, family
    transition support, higher education, individual career development
    plans, entrepreneurship, VA benefits, and other elements of holistic
    support of veterans ``for life'' and transitioning servicemembers.
    Finally, Congress holding all stakeholders accountable is vital; from
    garrison commanders and Federal officials to partnering organizations,
    there must be metrics regarding efficiency and effectiveness in TAP
    with capable managers implementing policy. The primary objective must
    always be to provide a seamless transition from military service to the
    private sector for our Nation's warfighters leaving the Armed Forces,
    along with their families.
                Sec. 2. Recodification, consolidation, and improvement of
                        certain transition-related counseling and
                        assistance authorities.
        TAP is now mandated for all servicemembers and optional for their
    spouses. TAP is presently five-days long with optional two-day classes.
    The Department of Labor and Veterans' Employment and Training Service
    (DOL-VETS) portion, which is three-days long, is responsible for most
    of the information in TAP. Despite the appearance of TAP being widely
    accessible there are still some concerns. First, according to the
    Government Accountability Office report, Transitioning Veterans, less
    than 15 percent of transitioning servicemembers have attended the two-
    day classes.\8\ Second, TAP provides a tremendous amount information
    that at times can be extremely intricate and overwhelming in a
    stressful time for transitioning servicemembers.
    ---------------------------------------------------------------------------
        \8\ Government Accountability Office: Transitioning Veterans
    https://www.gao.gov/assets/690/688203.pdf
    ---------------------------------------------------------------------------
        To help alleviate these two issues, The American Legion first
    recommends that TAP be mandated for servicemembers at different
    intervals of their careers prior to separation or transitioning into
    the civilian sector along with pre-counseling for those servicemembers
    intending to leave military service. Second, we stress the importance
    of the continued evaluation and revamping of TAP to ensure
    transitioning servicemembers are up-to-date on new trends in the
    civilian marketplace. Last, we look to lead by example, by offering The
    American Legion Job Fairs and other related activities with TAP
    personnel in order for them to promote and publicize these activities
    that may benefit transitioning servicemembers.
        Through American Legion Resolution No. 70: Improve Transition
    Assistance Program, we recommend that the DOD expand and standardize
    their existing pre-separation counseling policies to ensure that
    separating servicemembers receive information regarding Federal and
    private sector employment opportunities, GI Bill, and vocational
    rehabilitation and employment programs.\9\
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        \9\ The American Legion Resolution No. 70 (2016): Improve
    Transition Assistance
    ---------------------------------------------------------------------------

    The American Legion supports Section 2.

                Sec. 3. Personnel matters in connection with Transition
                        Assistance Program.
        Section 3 adds full-time personnel to the TAP program with real
    world experience in making the transition to civilian life.
        The American Legion believes adding full-time personnel, with
    experience transitioning to the civilian workforce, to the DOD for the
    purposes of TAP counseling is constructive for transitioning
    servicemembers on their own quest to obtain gainful employment. DOD
    personnel with relevant experience in the civilian workforce will
    provide the necessary information for servicemembers and their spouses
    to make quality decisions on careers, education, and training. TAP is
    vital to assisting servicemembers in mapping out employment
    opportunities and benefits through their honorable military service.
        Through American Legion Resolution No. 70: Improve Transition
    Assistance Program, we recommend that the DOD expand and standardize
    their existing pre-separation counseling policies to ensure that
    separating servicemembers receive information regarding Federal and
    private sector employment opportunities, GI Bill, and vocational
    rehabilitation and employment programs.\10\
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        \10\ The American Legion Resolution No. 70 (2016): Improve
    Transition Assistance
    ---------------------------------------------------------------------------

    The American Legion supports Section 3.

                Sec. 4. Tracking of participation in Transition Assistance
                        Program and related programs.
        Section 4 requires the Secretary of Defense to establish and
    maintain an electronic tracking system and database applicable across
    the Armed Forces.
        The American Legion believes an electronic data system and database
    would be useful in determining participation, access, progress, and
    overall performance of TAP. This database may be utilized by Federal
    agencies to improve, adapt, or change the information shared with
    servicemembers. We believe this section supports The American Legion's
    goal for transitioning servicemembers to view TAP as a high quality,
    engaging, and relevant experience, which leads to opportunities in the
    civilian sector.
        Through American Legion Resolution No. 70: Improve Transition
    Assistance Program, we recommend that the DOD expand and standardize
    their existing pre-separation counseling policies to ensure that
    separating servicemembers receive information regarding Federal and
    private sector employment opportunities, GI Bill, and vocational
    rehabilitation and employment programs.\11\
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        \11\ The American Legion Resolution No. 70 (2016): Improve
    Transition Assistance
    ---------------------------------------------------------------------------

    The American Legion supports Section 4.

                Sec. 5. Information on members of the Armed Forces
                        participating in pre-separation counseling and
                        surveys on member experiences with Transition
                        Assistance Program counseling and services and in
                        transition to civilian life.
        Section 5 requires the collection of basic information from
    transitioning servicemembers.
        The American Legion believes the accumulation of data for
    transitioning servicemembers is critical in properly evaluating the
    different needs of this community. For example, National Guardsmen and
    Reservists have unique challenges differing from those servicemembers
    transitioning from active duty. Other variables of transitioning
    servicemembers include rank, age, marital status, dependents, and time
    in service.
        Additionally, we would implore Congress to require DOD to submit a
    report of servicemembers who have attended TAP, broken down in three
    areas: 1) those attending TAP counseling under their chosen track; 2)
    those attending the other two optional tracks; and 3) those who have
    not attended TAP counseling. The American Legion supports legislation
    that requires conducting an independent assessment of the effectiveness
    of TAP. The purpose of this assessment would be to ensure that
    transitioning servicemembers are receiving the right skills and
    training needed to complete a seamless transition from the military to
    the private sector. The need for verifiable outcomes will aid in
    allocating resources to the appropriate areas of TAP.
        Through American Legion Resolution No. 12: Accountability and
    Enhancements of Transition Assistance Program; Outcomes and Delivery
    for Today's Digital Transitioning Servicemembers, we urge Congress to
    mandate Federal agencies to conduct a survey and assessment of the
    efficacy and efficiency of delivering ``for life'' support to veterans
    and transitioning servicemembers in the digital era; innovations
    responsive to the digital age warrior and digital era employer in the
    TAP.\12\
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        \12\ The American Legion Resolution No. 12 (2018): Accountability
    and Enhancements of Transition Assistance Program; Outcomes and
    Delivery for Today's Digital Transitioning Servicemembers
    ---------------------------------------------------------------------------

    The American Legion supports Section 5 with amendments.

                Sec. 6. E-mailing transition assistance materials to
                        supporters of members of the Armed Forces
                        transitioning to civilian life.
        Section 6 requires the DOD to solicit, from each member of the
    Armed Forces transitioning from military life to civilian life, an e-
    mail address of a supporter of the departing member to whom they can
    send transition assistance materials.
        Transitioning from military life to civilian life can be a
    stressful time for servicemembers; therefore, it is encouraged that
    servicemembers have a support system. In most cases, servicemembers are
    encouraged to bring their spouses to TAP; however, this may not always
    be feasible. The American Legion believes emailing transition
    assistance materials to servicemembers and their spouses (or caregiver)
    can be the missing link that would assist servicemembers in attaining
    gainful employment and financial stability.
        Through American Legion Resolution No. 12: Accountability and
    Enhancements of Transition Assistance Program; Outcomes and Delivery
    for Today's Digital Transitioning Servicemembers, we urge Congress to
    mandate Federal agencies to conduct a survey and assessment of the
    efficacy and efficiency of delivering ``for life'' support to veterans
    and transitioning servicemembers in the digital era; innovations
    responsive to the digital age warrior and digital era employer in the
    TAP.\13\
    ---------------------------------------------------------------------------
        \13\ The American Legion Resolution No. 12 (2018): Accountability
    and Enhancements of Transition Assistance Program; Outcomes and
    Delivery for Today's Digital Transitioning Servicemembers
    ---------------------------------------------------------------------------

    The American Legion supports Section 6.

                Sec. 7. Command matters in connection with transition
                        assistance programs.
        Section 7 requires each command climate assessment to include
    information about TAP participation.
        The American Legion believes the importance of the Transition
    Assistance Program cannot be overstated. Not only is it essential that
    commands ensure all servicemembers are given the opportunity to attend
    TAP, but it is also vital that servicemembers are authorized the
    appropriate time to participate, at minimum, in one of the optional
    tracks in the allotted time specified. In the event that a
    servicemember is unable to attend TAP due to unforeseen reasons deemed
    mission critical, both the Commander and servicemember would need to
    submit in writing with justification as to why the servicemember was
    unable to attend TAP. Further, The American Legion, recommends
    commanding officers be mandated to attend a condensed version of TAP as
    a requirement to assuming command at least once every three years.
        Through American Legion Resolution No. 70: Improve Transition
    Assistance Program, we recommend that the DOD expand and standardize
    their existing pre-separation counseling policies to ensure that
    separating servicemembers receive information regarding Federal and
    private sector employment opportunities, GI Bill, and vocational
    rehabilitation and employment programs.\14\
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        \14\ The American Legion Resolution No. 70 (2016): Improve
    Transition Assistance
    ---------------------------------------------------------------------------

    The American Legion supports Section 7 with amendments.

                Sec. 8. Comptroller General of the United States report on
                        participation in transition assistance programs at
                        small and remote military installations.
        Section 8 requires the Comptroller General of the United States to
    submit a report on the participation in covered transition assistance
    programs of members of the Armed Forces assigned to small military
    installations and remote military installations.
        All transitioning servicemembers should attend TAP without regard
    to command size or remoteness. According to the Transition Assistance
    Program Lead, there are 206 installations DOD-wide that conduct
    TAP.\15\ The American Legion recommends that Commanders ensure that
    transitioning servicemembers be given temporary duty orders to the
    nearest military installation that offers TAP.
    ---------------------------------------------------------------------------
        \15\ The American Legion Resolution No. 12 (2016): Transition
    Assistance Program Employment Workshops for National Guard and Reserve
    Members
    ---------------------------------------------------------------------------
        Through American Legion Resolution No. 81: Transition Assistance
    Program Employment Workshops for National Guard and Reserve Members, we
    support legislation that will provide every member of the Armed Forces
    (including those in the National Guard and Reserves) who are activated
    for 12 months or longer, an adequate amount of time to attend the TAP
    workshop in entirety, within 90 days of separation.\16\

    The American Legion supports Section 8.

                Sec. 9. Education of members of the Armed Forces on career
                        readiness and professional development.
        This section requires the DOD to carry out a program to provide
    education on career readiness and professional development.
        The American Legion believes experience differences between
    separating servicemembers should be considered during their pre-
    separation counseling. There are notable differences between a
    transitioning servicemember who served one enlistment in contrast to
    one who is retiring after 20-plus years of service. Similarly, we
    recognize servicemembers who are being separated for medical reasons
    and/or other unexpected reasons may present different issues.
    Therefore, The American Legion believes pre-separation counseling
    should begin at the time of their first and subsequent duty stations
    with follow-on counseling conducted at different intervals of military
    careers.
        Through American Legion Resolution No. 70: Improve Transition
    Assistance Program, we recommend that the DOD expand and standardize
    their existing pre-separation counseling policies to ensure that
    separating servicemembers receive information regarding Federal and
    private sector employment opportunities, GI Bill, and vocational
    rehabilitation and employment programs.\17\
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        \17\ The American Legion Resolution No. 70 (2016): Improve
    Transition Assistance
    ---------------------------------------------------------------------------

    The American Legion supports Section 9.

                Sec. 10. Employment skills training--by amending striking
                        ``The Secretary of a military department may'' and
                        inserting ``The Secretary of Defense shall.''
                        Expansion of Eligible Participants, such as a
                        spouse of a member of the Armed Forces.
        Section 10 states the DOD should now be responsible for ensuring
    that priority service training is provided to ``covered individuals''
    and not just ``eligible members'' which includes spouses.
        In a recent Chamber of Commerce survey over 44% of military spouses
    reported that they are living paycheck to paycheck or struggling
    financially, with 80% reporting that the employment search process
    created stress between them and their active duty spouses. The anxiety
    that this induces in families already struggling with the challenges of
    potential deployments and family responsibilities presents a clear
    threat to military readiness.
        The American Legion supports legislation that will afford spouses
    the same level of job training and employment skills training that
    would otherwise have be given to only eligible members only. Spouses of
    an active-duty member are considered a ``dislocated worker'' and should
    be afforded the opportunity to receive priority service within the DOL,
    just as their military spouse.
        Through American Legion Resolution No. 70: Improve Transition
    Assistance Program, we recommend that the DOD expand and standardize
    their existing pre-separation counseling policies to ensure that
    separating servicemembers receive information regarding Federal and
    private sector employment opportunities, GI Bill, and vocational
    rehabilitation and employment programs.\18\
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        \18\ The American Legion Resolution No. 70 (2016): Improve
    Transition Assistance
    ---------------------------------------------------------------------------

    The American Legion supports Section 10.

                Sec. 11. Identification of opportunities for Job training
                        and employment skills training for employment with
                        the Department of Veterans Affairs in SkillBridge
                        programs of the Department of Defense.
        Section 11 requires the Secretaries of the military departments to
    identify opportunities where the VA can provide training.
        Since 2014, the DOD's ``Skillbridge Initiative'' has authorized
    transitioning servicemembers to participate in employer-driven job
    skills training, apprenticeships and internships that provide industry-
    recognized skills needed to move into high-demand jobs and careers.
    Since its inception, more than 5,500 servicemembers have graduated from
    135 Skillbridge-authorized programs according to an August 2017 DOD
    report to Congress.\19\ VA has utilized this authority to launch the
    ``Warrior Training Advancement Course (WARTAC),'' which trains
    transitioning servicemembers to become a Veterans Service
    Representatives (VSRs) at the VA.
    ---------------------------------------------------------------------------
        \19\ Report on job training, employment skills training,
    apprenticeships, and internships & skillbridge initiatives for members
    of the Armed Forces who are being separated
    ---------------------------------------------------------------------------
        The American Legion is encouraged by the success of the WARTAC
    program. Additionally, The American Legion believes that transitioning
    servicemembers can serve the VA in a myriad of capacities beyond
    processing veterans' claims. This section will mandate that the VA
    learn from the success of this inaugural program, and identify further
    internal employment needs that can be fulfilled utilizing DOD's
    Skillbridge authority.
        Through American Legion Resolution No. 79: Expanding Department of
    Veterans Affairs Employment Pathways, we support innovative retention
    practices that provide education and training incentives for VA veteran
    employees to achieve credentials and licenses to fill critical
    vacancies.\20\
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        \20\ The American Legion Resolution No. 79 (2017): Expanding
    Department of Veterans Affairs Employment Pathways
    ---------------------------------------------------------------------------

    The American Legion supports Section 11.

                Sec. 12. Evaluation of transition training and counseling
                        relating to postsecondary education and use of
                        educational assistance from the Department of
                        Defense and Department of Veterans Affairs.
        Section 12 would establish standardized assessment criterion for
    evaluating the quality of training and counseling provided through TAP
    that has a focus on postsecondary education or the use of VA
    educational assistance programs.
        While The American Legion applauds efforts to increase quality
    assurance of education training, existing information on TAP education
    module participation indicates that significant restructuring is needed
    before proper evaluation can be applied. A 2017 Government
    Accountability Office study found that only 10.5 percent of all
    transitioning servicemembers receive any additional training on higher
    education.\21\ This level of participation suggests the central
    structure of the two-day `Accessing Higher Education' module has proven
    inimical to widespread adaptation. Before focusing on assessing the
    quality of the existing TAP education syllabus, The American Legion
    urges that its contents be reorganized to increase participation.
    ---------------------------------------------------------------------------
        \21\ https://www.gao.gov/assets/690/688203.pdf
    ---------------------------------------------------------------------------
        Through American Legion Resolution No. 12: Accountability and
    Enhancements of Transition Assistance Program; Outcomes and Delivery
    for Today's Digital Transitioning Servicemembers, we urge Congress to
    mandate Federal agencies to conduct a survey and assessment of the
    efficacy and efficiency of delivering ``for life'' support to veterans
    and transitioning servicemembers in the digital era; innovations
    responsive to the digital age warrior and digital era employer in the
    TAP.\22\
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        \22\ The American Legion Resolution No. 12 (2018): Accountability
    and Enhancements of Transition Assistance Program; Outcomes and
    Delivery for Today's Digital Transitioning Servicemembers
    ---------------------------------------------------------------------------

    The American Legion opposes Section 12.

                Sec. 13. Longitudinal Study on changes to Transition
                        Assistance Program of Department of Defense.
        Section 13 requires the secretaries of VA, DOL, and DOD along with
    the Small Business Administration Administrator to conduct a five-year
    study on TAP.
        The American Legion believes the longitudinal study for the several
    different components would be valuable for the overall performance of
    TAP. This study would identify specific developments or changes in the
    characteristics of transitioning servicemembers. Further, the research
    should drive the design of TAP, while providing confidence in
    servicemembers as they transition into the civilian workforce.
        Through American Legion Resolution No. 12: Accountability and
    Enhancements of Transition Assistance Program; Outcomes and Delivery
    for Today's Digital Transitioning Servicemembers, we urge Congress to
    mandate Federal agencies to conduct a survey and assessment of the
    efficacy and efficiency of delivering ``for life'' support to veterans
    and transitioning servicemembers in the digital era; innovations
    responsive to the digital age warrior and digital era employer in the
    TAP.\23\
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        \23\ The American Legion Resolution No. 12 (2018): Accountability
    and Enhancements of Transition Assistance Program; Outcomes and
    Delivery for Today's Digital Transitioning Servicemembers
    ---------------------------------------------------------------------------

    The American Legion supports Section 13.

                Sec. 14. Establishment of Governing Board to Support
                        Prevention of Drug Overdoses, Death by Suicide, and
                        Alcohol-Related Mortality.
        Section 14 directs VA to establish a governing board to support
    VA's efforts to prevent suicide. The bill directs the board to exchange
    information and investigate impacts of financial insecurity,
    homelessness, and substance abuse contribute to suicide.
        In 2015, The American Legion supported H.R. 271: The COVER Act,
    also known as the Jason Simcakowski PROMISE Act, which established a
    commission to examine the evidence-based therapy treatment model used
    by the Secretary of Veterans Affairs for treating mental illnesses of
    veterans and the potential benefits of incorporating complementary
    alternative treatments available in non-VA medical facilities.
        Through American Legion Resolution No. 377: Support for Veteran
    Quality of Life, The American Legion urges Congress and the VA to enact
    legislation and programs within the VA that will enhance, promote,
    restore or preserve benefits for veterans and their dependents.\24\
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        \24\ The American Legion Resolution No. 377 (2016): Support for
    Veteran Quality of Life
    ---------------------------------------------------------------------------

    The American Legion supports Section 14.

                Sec. 15. Review of economic risk factors in suicide
                        prevention.
        Section 15 calls for two reports to be developed within 90 days of
    this bill becoming law. The first report would include how economic
    risk factors affect suicide prevention efforts. The second report topic
    is about the predictive analytics program Recovery Engagement and
    Coordination for Health--Veterans Enhanced Treatment (REACHVET) that
    utilizes economic risk factors in its algorithm to determine
    suicidality.
        Through American Legion Resolution No. 132: Request Congress
    Provide the Department of Veterans Affairs Adequate Funding for Medical
    and Prosthetic Research, The American Legion urges Congress and the
    Administration to encourage acceleration in the development and
    initiation of needed research on conditions that significantly affect
    veterans, as we firmly believe more research should be conducted on
    this very critical topic.\25\
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        \25\ The American Legion Resolution No. 132 (2016): Request
    Congress Provide the Department of Veterans Affairs Adequate Funding
    for Medical and Prosthetic Research
    ---------------------------------------------------------------------------

    The American Legion supports Section 15.

                Sec. 16. Grants for provisions of Transition Assistance to
                        members of the Armed Forces after separation,
                        retirement, or discharge.
        Section 16 requires DOL, in consultation with VA, to award grants
    to eligible organizations for TAP that include services like legal aid
    and financial services.
        The American Legion supports DOL and VA awarding grants to
    organizations assisting in transition services to servicemembers and
    veterans. In our daily work with veterans, we find many of them having
    difficulties with writing resumes, interview skills and job searches.
    In addition, servicemembers need help with financial literacy and legal
    assistance. These grants would fill a need as servicemembers determine
    their next steps and career goals. We understand the value of these
    programs. In 2018, The American Legion has conducted more than 50
    hiring events, resume, interview workshops, education seminars, and
    small business development workshops. We've witnessed the positive
    impact of these activities on transitioning servicemembers and veterans
    in finding and maintaining suitable employment.
        Through American Legion Resolution No. 70: Improve Transition
    Assistance Program, we recommend that the DOD expand and standardize
    their existing pre-separation counseling policies to ensure that
    separating servicemembers receive information regarding Federal and
    private sector employment opportunities, GI Bill, and vocational
    rehabilitation and employment programs.\26\
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        \26\ The American Legion Resolution No. 70 (2016): Improve
    Transition Assistance
    ---------------------------------------------------------------------------

    The American Legion supports Section 16.

    The American Legion supports this Draft Bill with the noted amendments
    and improvements.

                     draft bill: va hiring enhancement act
    To amend title 38, United States Code, to provide for the non-
            applicability of non-Department of Veterans Affairs covenants
            not to compete to the appointment of physicians in the Veterans
            Health Administration, and for other purposes.
        The American Legion has long expressed concern about staffing
    shortages at Department of Veteran Affairs (VA) and the Veterans Health
    Administration (VHA) medical facilities to include physicians and
    medical specialist staffing.
        The VA Hiring Enhancement Act will help address the shortcomings in
    recruitment and retention of highly qualified physicians. The bill
    allows VA to make binding job offers up to two years prior to
    completion of medical residency, eliminating much of the bureaucratic
    red tape that slows the hiring of newly recruited individuals. This
    legislation allows physicians to complete their education then
    immediately begin treating veterans. By allowing VA to make binding
    offers, veterans will receive treatment by qualified physicians that
    have completed their medical residency. This bill aligns the hiring
    practices of VA to those of the private sector ensuring top quality
    healthcare is provided to our veterans.
        Further, this common-sense bill also releases physicians from
    ``non-compete agreements'' for the purpose of serving in the VHA. The
    American Legion believes enforcing non-compete agreements to VHA hires
    is overbroad and should be unenforceable under public policy.
    Traditional reasoning behind non-compete agreements is to bar
    competitive advantages or protect sensitive information, both of which
    simply do not exist in this context.
        Through American Legion Resolution No. 115, Department of Veterans
    Affairs Recruitment and Retention, we support legislation addressing
    the recruitment and retention challenges of the VA.\27\
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        \27\ The American Legion Resolution No. 115 (2016): Department of
    Veterans Affairs Recruitment and Retention
    ---------------------------------------------------------------------------

    The American Legion supports this Draft Bill.

                                   h.r. 5418
    To direct the Secretary of Veterans Affairs to carry out the Medical
            Surgical Prime Vendor program using multiple prime vendors.
        In terms of contracting, private sector hospitals use multiple
    Group Purchasing Organizations (GPOs) who bid down the price of
    manufactured medical equipment. This practice forces the GPOs to
    compete among themselves, yielding the lowest possible prices, which
    benefits hospitals and the general market place. In summary,
    competition drives down prices.
        Utilizing Medical Surgical Prime Vendor (MSPV) Gen2, VA has
    proposed using only one large single vendor as opposed to the current
    model of using multiple vendors. When purchasing from only one vendor,
    prices may be inflated, simply because of the lack of competition.
    Ensuring there is competition, the VA, and the government as a whole,
    typically receives better pricing, which is ultimately a benefit to the
    U.S. taxpayer.
        The American Legion understands the simplification of utilizing
    only one vendor; however, this practice does not yield the best result
    for the veteran, agency, or the Federal Government. Using a singular
    vendor may be easier, but this procurement shortcut undermines the
    competitive system, and can result in VA overpaying for equipment, or
    not being able to obtain quality materials necessary to supply the
    largest medical network that treats veterans.
        In the current model that VA is employing, Service Disabled Veteran
    Owned Small Businesses (SDVOSBs), works with prime vendors, which not
    only assist and encourages veterans to work in this realm, but also
    allows for competition and to drives down costs. SDVOSBs add value to
    the procurement process by providing last mile delivery, customer care,
    and maintenance services for prime vendors.
        In short, The American Legion opposes the VA switching to a system
    that allows them to simply use one vendor, and urges Congress to force
    VA to allow for competitive bidding.
        Through American Legion Resolution No. 154, Support Reasonable Set-
    Aside of Federal Procurements and Contracts for Businesses Owned and
    Operated by Veterans, we support reasonable set-asides of Federal
    procurements and contracts for businesses owned and operated by
    veterans. Allowing the VA to essentially encourage a monopoly on
    medical supplies and equipment is not only wrong, but it could also
    decrease SDVOSB participation, potentially harming the quality care
    that veterans receive at VA, all while overspending taxpayer
    funding.\28\
    ---------------------------------------------------------------------------
        \28\ The American Legion Resolution No. 154: Support Reasonable
    Set-Aside of Federal Procurements and Contracts for Businesses Owned
    and Operated by Veterans
    ---------------------------------------------------------------------------

    The American Legion supports H.R. 5418.

                                    s. 1596
    To amend title 38, United States Code, to increase certain funeral
            benefits for veterans, and for other purposes.
        The American Legion believes all veterans who have honorably served
    our Nation should be provided adequate funeral benefits and that those
    benefits should be indexed for inflation. It is our Nation's
    responsibility to ensure the families and loved ones of our veterans
    are financially supported in their time of mourning. Further, our
    membership has, by resolution, committed to support increases to burial
    allowances for veterans who have died as a result of service-connected
    conditions and that those benefits be tied to the Consumer Pricing
    Index.\29\
    ---------------------------------------------------------------------------
        \29\ The American Legion Resolution No. 181 (2016): National
    Cemetery Administration
    ---------------------------------------------------------------------------
        According to the National Funeral Directors Association, the
    national median cost of a funeral in 2017 was $8,508.\30\ Over the past
    decade, the median cost of an adult funeral in the United States has
    increased 28.6 percent and Department of Veterans Affairs (VA) benefits
    have not kept up with the pace of inflation.\31\ For instance, in 1973,
    the benefit for a veteran with no next-of-kin and a non-service-
    connected death would have been 22 percent of the national average,
    versus the 2 percent it covers today.
    ---------------------------------------------------------------------------
        \30\ National Funeral Directors Association: Statistics http://
    www.nfda.org/news/statistics
        \31\ National Funeral Directors Association: Statistics http://
    www.nfda.org/news/statistics
    ---------------------------------------------------------------------------
        Currently, VA burial benefit provides: $300 for non-service-
    connected deaths and for veterans who have passed without a next-of-
    kin; $749 if a veteran passes away in a VA facility, and; $2,000 if a
    veteran passes away from a service-connected disability. The Burial
    Rights for America's Veterans' Efforts (BRAVE) Act would update the
    current funeral and burial benefit system to ensure all non-service-
    connected deaths are treated equally, regardless of where the veteran
    passes away. Veterans with no next-of-kin that pass away in a VA
    facility are currently afforded greater funds to cover the costs of
    their funerals and burials than veterans who pass away in a private
    home or other facilities.
        The BRAVE Act will increase the $300 for non-service-connected
    deaths to $749 to equal the benefit received if a veteran passes away
    in a VA facility. The BRAVE Act additionally indexes for inflation both
    the non-service and service-connected passing funeral benefits, thereby
    eliminating the need for Congress to make further readjustments. The
    American Legion supports these provisions recognizing existing non-
    service-connected and service-connected burial allowances benefits have
    been significantly eroded by inflation as they now only cover a small
    fraction of the actual cost of a burial.
        Additionally, The American Legion urges The BRAVE Act be amended to
    reflect the resolution passed by our membership, consisting solely of
    wartime veterans, to increase the burial allowance for service-
    connected causes from the current $2,000 amount to $4,000. This will
    enhance the quality of life for veterans' survivors to increase the
    value of these benefits, especially during their greatest hour of need.
        Through American Legion Resolutions No. 181: National Cemetery
    Administration\32\ and No. 377: Support for Veteran Quality of Life,
    \33\ we support legislation increasing burial allowances and programs
    within the VA that will enhance, promote, restore or preserve benefits
    for veterans and their dependents.
    ---------------------------------------------------------------------------
        \32\ The American Legion Resolution No. 181 (2016): National
    Cemetery Administration
        \33\ The American Legion Resolution No. 377 (2016): Support for
    Veteran Quality of Life
    ---------------------------------------------------------------------------

    The American Legion supports S. 1596 with the noted amendments and
    improvements.

                                    s. 2881
    To direct the Secretary of Veterans Affairs to seek to enter into an
            agreement with the city of Vallejo, California, for the
            transfer of Mare Island Naval Cemetery in Vallejo, California,
            and for other purposes.
        The American Legion's 100-year history is integrally intertwined
    with endeavors to preserve the legacy of this Nation's servicemembers.
    With the creation of the Graves Registration and Memorial Affairs
    Committee in 1962 to the current National Cemetery Committee, The
    American Legion has maintained professional staff dedicated to
    formulate and recommend to our National Executive Committee, through
    the Veterans Affairs & Rehabilitation Commission, polices, plans and
    programs as they relate to the Department of Veterans Affairs (VA)
    national cemeteries, and the interment of veterans, servicemembers, and
    their dependents. The American Legion through its National Cemetery
    Committee believes that all veterans and their eligible dependents are
    entitled a final resting place to commemorate their service to the
    country to include perpetual care of the gravesite.
        Mare Island Naval Cemetery, the oldest military cemetery on the
    West Coast, was deeded to the city of Vallejo, California, under Base
    Realignment and Closure (BRAC) in 1996. Following BRAC, there was no
    mechanism to handle the financial responsibility for these hallowed
    grounds. Since then, the city of Vallejo has struggled financially and
    has not been able to provide for the maintenance and upkeep of the
    cemetery. Due to the lack of maintenance many of the headstones are
    broken, perimeter fences have collapsed, and the vegetation is
    overgrown. More than 800 military veterans who served our country,
    including three Medal of Honor recipients eternally rest in the
    cemetery. Now the lack of upkeep is presenting problems for proud
    veterans.
        S. 2881, directs the Secretary of Veterans Affairs to seek out an
    agreement with the city of Vallejo, under which the city would transfer
    control of the Mare Island Naval Cemetery to the VA. The cemetery would
    specifically be placed under the purview of the National Cemetery
    Administration (NCA). The VA would pay no fee to acquire the land, but
    would assume the obligation of maintaining the cemetery in the future.
    The American Legion has full confidence that the NCA with its proven
    track record of maintaining over 135 cemeteries nationwide, will bring
    dignity and respect to the veterans buried at Mare Island Naval
    Cemetery. NCA's mission is simple: to honor veterans and their families
    with final resting places in national shrines and with lasting tributes
    that commemorate their services and sacrifice to our Nation.
        Through American Legion Resolution No. 181, National Cemetery
    Administration, we support the establishment of additional national and
    state veterans cemeteries and columbaria wherever a need for them is
    apparent.\34\
    ---------------------------------------------------------------------------
        \34\ The American Legion Resolution No. 181 (2016): National
    Cemetery Administration
    ---------------------------------------------------------------------------

    The American Legion supports S. 2881.

                                    s. 1952
    To improve oversight and accountability of the financial processes of
            the Department of Veterans Affairs, 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 or 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. 1952.

                                    s. 1990
    To amend title 38, United States Code, to increase amounts payable by
            the Department of Veterans Affairs for dependency and indemnity
            compensation, to modify the requirements for dependency and
            indemnity compensation for survivors of certain veterans rated
            totally disabled at the time of death, and for other purposes.
        The Department of Veterans Affairs (VA) Death and Indemnity
    Compensation (DIC) Benefit supports surviving family members of
    servicemembers who died in the line of duty, Gold Star families, and
    survivors of disabled veterans who died from a service-connected
    condition. DIC is paid to the widows and widowers of service-connected
    disabled veterans who die as a result of their service-related
    condition or who at the time of death were rated 100% service-connected
    disabled for at least 10 years. Currently, survivors are denied any
    benefit if a veteran passes away before the arbitrary 10-year
    threshold.
        Unfortunately and unfairly, many veterans do not reach the 100%
    level until they are much older because their condition has worsened
    with time. They often pass away before they have received their 100%
    rating for the required length of time. In many of these instances the
    spouse has been the primary caregiver and companion for these disabled
    veterans throughout their lifetime and the VA compensation has been
    their primary means of support. Consequently, the surviving spouse can
    no longer count on VA benefits for assistance due to a 100% rating for
    less than 10 years. This causes a dramatic change in the quality of
    life of the surviving spouse.
        This detriment to their quality of life is something members of The
    American Legion recognized when we passed Resolution No. 255: Reducing
    Eligibility for Dependency Indemnity Compensation (DIC) Payments for
    100% Disabled Veterans from 10 Years to 5 Years.\35\ Through this
    resolution, we commit to sponsor and support legislation to reduce the
    number of years a veteran must be rated 100% from 10 years to 5 years
    for eligibility of DIC payments. Therefore, we support legislation
    reducing the eligibility requirement from 10 to 5 years, but OPPOSE the
    bill's pro-rated reduction of DIC benefits if the veteran was rated
    100% service-connected for a period less than 10 years. The American
    Legion would support a modified bill that reduces the eligibility
    requirements from 10 to 5 years, with NO reduction of benefits if the
    5-year requirement is met.
    ---------------------------------------------------------------------------
        \35\ The American Legion Resolution No. 255 (2016): Reducing
    Eligibility for Dependency Indemnity Compensation (DIC) Payments for
    100% Disabled Veterans from 10 Years to 5 Years
    ---------------------------------------------------------------------------

    The American Legion supports S. 1990 with noted amendments and
    improvements.

                                    s. 2485
    To amend title 38, United States Code, to provide payment of Medal of
            Honor special pension under such title to the surviving spouse
            of a deceased Medal of Honor recipient, 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 or 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. 2485.

                                    s. 2748
    To amend title 10, United States Code, to require members of the Armed
            Forces to receive additional training under the Transition
            Assistance Program, and for other purposes.
        The Better Access to Technical Training, Learning, and
    Entrepreneurship Act (BATTLE Act) seeks to ensure that servicemembers
    who leave the military receive the specific training they need to
    successfully transition to civilian life, whether they choose to pursue
    higher education, a career in a technical field, or entrepreneurship.
        An average of 200,000 servicemembers transition into the private
    sector annually. The American Legion's National Veterans Employment and
    Education Division's mission is to assist with the reintegration of all
    veterans returning to civilian life after service in the Armed Forces,
    to include when necessary, initiating actions concerning all matters
    affecting the economic well-being of veterans. We understand the value
    of additional training because through our programs we conduct hiring
    events, resume workshops, interview workshops, education seminars, and
    small business development workshops. Additional training helps
    veterans find jobs.
        Under current law, the Department of Defense (DOD) is required to
    ensure that eligible departing servicemembers participate in the
    Transition Assistance Program (TAP). In response to this statutory
    requirement, DOD has published regulations and issued instructions that
    require eligible servicemembers to complete TAP and require commanding
    officers to make certain that servicemembers complete TAP. Beyond the
    mandatory curriculum, departing servicemembers have the option to
    participate in a specialized two-day workshop in one of the following
    areas: higher education, conducted by DOD; technical and skills
    training, conducted by the Department of Veterans Affairs; or,
    entrepreneurship, conducted by the Small Business Administration.
        While the core curriculum is mandatory (five days) for all
    servicemembers, the two-day workshops are less emphasized and
    therefore, sparsely attended. In a recent Government Accountability
    Office report, it was noted that less than 15 percent of transitioning
    servicemembers attend the two-day optional track for various
    reasons.\36\ This information can be vital for a seamless transition
    for a servicemember separating or retiring from the military.
    Therefore, The American Legion believes DOD's TAP should require
    servicemembers to choose one of the specific career-oriented tracks
    that best suit their post-service plans and require servicemembers take
    part in one-on-one counseling a year prior to separation to evaluate
    which transition pathway suits them best.
    ---------------------------------------------------------------------------
        \36\ Transitioning Veterans: DOD Needs to Improve Performance
    Reporting and Monitoring for the Transition Assistance Program GAO-18-
    23: Published: Nov 8, 2017. Publicly Released: Nov 8, 2017. Available
    at https://www.gao.gov/products/GAO-18-23
    ---------------------------------------------------------------------------
        Through American Legion Resolution No. 70: Improve Transition
    Assistance Program, we recommend that the DOD expand and standardize
    their existing pre-separation counseling policies to ensure that
    separating servicemembers receive information regarding Federal and
    private sector employment opportunities, GI Bill, and vocational
    rehabilitation and employment programs.\37\
    ---------------------------------------------------------------------------
        \37\ The American Legion Resolution No. 70 (2016): Improve
    Transition Assistance
    ---------------------------------------------------------------------------

    The American Legion supports S. 2748.

                         draft bill: suicide prevention
    To require the Secretary of Veterans Affairs to establish a program to
            award grants to persons to provide and coordinate the provision
            of suicide prevention services for veterans transitioning from
            service in the Armed Forces who are at risk of suicide and for
            their families, 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 or 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.

      draft bill: modernization of medical records access for veterans act
    To direct the Secretary of Veterans Affairs to carry out a pilot
            program establishing a secure, patient-centered, and portable
            medical records system that would allow veterans to have access
            to their personal health information.
        The American Legion, through Resolution No. 83: Virtual Lifetime
    Electronic Record, has long endorsed and supported the Department of
    Veterans Affairs (VA) in creating a Lifetime Electronic Health Records
    (EHR) system.\38\ Additionally, The American Legion has encouraged both
    the Department of Defense (DOD) and the VA to either use the same EHR
    system, or, at the very least, systems that were interoperable.
    ---------------------------------------------------------------------------
        \38\ The American Legion Resolution No. 83 (2016): Virtual Lifetime
    Electronic Record
    ---------------------------------------------------------------------------
        In 2009, The American Legion was pleased when the Obama
    administration announced that the DOD and the VA would finally create a
    path to integrate the flow of patients' information between DOD's Armed
    Forces Health Longitudinal Technology Application (AHLTA) and VA's
    Veterans Information System and Technology Architecture (VistA) EHR
    platforms.
        In 2015, DOD announced that Cerner was awarded a $4.3 billion, 10-
    year contract to overhaul the Pentagon's electronic health records for
    millions of active military members and retirees. However, around the
    same time, VA announced it would maintain and modernize VistA.
        On June 6, 2017, VA Secretary David Shulkin announced that the VA
    would adopt the same Cerner EHR system as the DOD during a news
    briefing at VA's headquarters in Washington, D.C.
        On May 18, 2018, Acting VA secretary Robert Wilkie announced that
    VA signed a 10-year contract with Cerner.
        This information sharing system will set the standard for record
    transferability and standardization in American medicine. This new
    national standard will increase patient access, decrease wait times,
    and enhance good medicine for all Americans, not just veterans.
    Congress should refrain from advancing any recommendation or
    legislation that does not directly support implementation of the VA EHR
    modernization effort.

    The American Legion opposes this Draft Bill.

                                     s. 514
    To direct the Secretary of Veterans Affairs to carry out a pilot
            program to provide access to magnetic EEG/EKG-guided resonance
            therapy to veterans.
        In the wake of serious concerns about over prescription of
    medications by Department of Veteran Affairs (VA) physicians, The
    American Legion believes that VA can do more to ensure veterans and
    servicemembers have the most dependable and precise treatment available
    to alleviate their combat-related illnesses and injuries with the least
    amount of negative side effects.
        We have previously testified on the Veterans Health Administration
    (VHA) implementation of a pilot program at approximately 23 VA medical
    centers across the country using Electromagnetic Therapy to treat
    veterans with depression. VHA is using Repetitive Transcranial Magnetic
    Stimulation (RTMS) therapy, which involves up to 30 sessions over a
    six-week period. Recently we learned that VHA's Repetitive Transcranial
    Magnetic Stimulation pilot program fell short in VA trials. The
    American Legion was hopeful the pilot program would conclude that this
    non-pharmaceutical noninvasive therapy would prove successful and
    provide VA with another tool to help deal with depression and Post
    Traumatic Stress Disorder (PTSD).
        The American Legion has long advocated for complementary and
    alternative medicines (CAM) to be further explored by VA and applauds
    this pilot. The American Legion's PTSD/TBI (Traumatic Brain Injury)
    Committee has reviewed several promising CAM treatments that include
    using electroencephalogram (EEG) technology to help better determine
    the efficacy of certain medications on patients with correlating
    quantitative EEG neuroethics. We believe the EEG/EKG
    (electrocardiogram) pilot program will provide VA with additional
    information to determine whether veterans can benefit from this
    therapy.
        The American Legion has reservations due to VA's March 29, 2017
    testimony before the House of Representatives Subcommittee on Health.
    During that testimony VA stated there is no medical device using MeRT
    technology that has been cleared or approved by the Food and Drug
    Administration (FDA) for the uses described in this legislation.\39\
    Providing non-approved FDA treatment to our Nation veterans is still a
    concern of The American Legion. With the assurance that the EEG/EKG
    pilot program meets FDA approval, The American Legion supports S. 514
    and companion legislation in the House of Representatives, H.R. 1162.
    ---------------------------------------------------------------------------
        \39\ What is MeRT: https://www.braintreatmentcenter.com/mert
    ---------------------------------------------------------------------------
        Through American Legion Resolution No. 377: Support for Veteran
    Quality of Life, we support legislation and programs within the VA that
    will enhance, promote, restore or preserve benefits for veterans and
    their dependents.\40\
    ---------------------------------------------------------------------------
        \40\ The American Legion Resolution No. 377 (2016): Support for
    Veteran Quality of Life
    ---------------------------------------------------------------------------

    The American Legion supports S. 514 with amendments as noted above.

                                   conclusion
        The American Legion thanks this Committee for the opportunity to
    elucidate the position of the 2 million veteran members of this
    organization. For additional information regarding this testimony,
    please contact the Assistant Director of the Legislative Division, Mr.
    Larry Lohmann Esq., at The American Legion's Legislative Division.

        Chairman Isakson. Thank you for your testimony.
        Mr. Manar.

     STATEMENT OF GERALD T. MANAR, BLUE WATER NAVY VETERAN, FORMER
     DIRECTOR, NATIONAL VETERANS SERVICE, VETERANS OF FOREIGN WARS
                          OF THE UNITED STATES

        Mr. Manar. Chairman Isakson, Senator Sanders, Members of
    the Committee, on behalf of the men and women of the Veterans
    of Foreign Wars and its Auxiliary, thank you for the
    opportunity to testify today.
        We talk in support of the Blue Water Navy Vietnam Veterans
    Act of 2017. I am a veteran of the Navy who served on a ship
    which participated in 11 campaigns during the Vietnam War. From
    1964 through 1972, the USS Whitfield County (LST 1169) was sent
    to Vietnam at least 31 times. During those deployments it
    landed Marines and army units in Vietnam. It patrolled endless
    days off the coast, supported riverine patrol boats on the
    rivers of Vietnam, and went up the river to Saigon.
        I served aboard from July 1971 until she was decommissioned
    in March 1973. During that time our ship went to Vietnam three
    times.
        During the Vietnam War, many hundreds of U.S. Navy ships
    spent weeks or longer off the coast, many of them not just once
    or twice, but repeatedly.
        On my first cruise to Vietnam in 1971, we patrolled up and
    down the coast. We were on the lookout for small boats trying
    to infiltrate supplies and personnel into South Vietnam--north
    and south, day after day, within sight of the shoreline. We
    were a floating warehouse, carrying hundreds of tons of
    supplies on our tank deck. We carried extra ammunition for
    patrol gunboats and other smaller ships which might need
    resupply. Whenever we went to Vietnam, we carried extra fuel
    for ships and JP-5 for helicopters.
        We anchored off the coast several times to conduct shore
    bombardment with our 3-inch/50 guns. We spent Christmas Day in
    1971 taking on supplies from a stores ship, then transferred
    some of those supplies and fuel to two patrol gunboats and a
    mine sweeper. We anchored off the coast 1 day, lowered the
    captain's gig into the water, and went swimming. We followed
    that with a barbecue on the main deck. We did this all within
    sight of the beaches of Vietnam.
        I mention these events as an illustration of the kinds of
    activities we performed close to the shore of Vietnam. If there
    was dioxin in the water, we would have been exposed to it while
    swimming. Week after week, patrolling up and down the coast, we
    took in sea water and processed it through our fresh water
    evaporator system. We know from the Australian Navy study,
    validated by the National Academy of Medicine, that fresh water
    evaporator systems concentrated toxic material, including
    dioxin, which was then transmitted to sailors through drinking
    water.
        Absent the cleaning and sanitation of the entire fresh
    water evaporator system, it is conceivable that every person
    who ever served on board my ship could have been exposed to
    dioxin after its first visit to Vietnam. Further, by the time
    we completed our last deployment to Vietnam in 1972, the
    evaporator system would have accumulated concentrated dioxin
    from dozens of visits to Vietnam, not simply the final three
    that I experienced while on board.
        From 2015 through September 2017, I was a member of the
    Steering Committee for the Vietnam Era Health Retrospective
    Observational Study, abbreviated VE-HEROeS. The aim of the
    study was, in part, to obtain self-reported data on the health
    of Blue Water Navy veterans. Instead of the expected 200
    respondents, a total of nearly 1,000 Blue Water Navy veterans
    answered the questionnaire. The raw data is currently under
    analysis and adjustment to assure accurate comparisons between
    other Vietnam and Vietnam era veterans.
        While the results of this study will be published over the
    next few years, there is more than sufficient data, in our
    view, to show that Blue Water Navy veterans suffer from a
    higher incidence of cancers, hypertension, and ischemic heart
    disease than other populations of similar size and similar age.
        It has been 43 years since the war ended in 1975, and even
    the youngest of Blue Water Navy veterans are over 60 years old.
    Many thousands suffer from the same disabilities as do veterans
    who served in-country. Rather than continue studying the health
    of Blue Water Navy veterans for another 10 years while those
    veterans sicken and die from diseases related to exposure to
    herbicides, Congress must grant Agent Orange presumptions to
    the thousands of veterans who served their country off the
    shores of Vietnam.
        In addition, the VFW supports expansion of benefits to
    Korean DMZ veterans who suffer from diseases directly linked to
    exposure to herbicides without forcing them to prove individual
    exposure.
        We also support the expansion of benefits for children of
    Thailand veterans who were born with spina bifida.
        Finally, we believe the elimination of the distinction
    between the National Guard, Reservists, and active-duty
    servicemembers in requirements to pay certain home loan fees is
    an appropriate recognition of their service to our country.
        This concludes my testimony. I will be happy to answer any
    questions you may have for me.
        [The prepared statement of Mr. Manar follows:]
    Prepared Statement of Gerald T. Manar, Blue Water Navy Veteran, Former
     Director, National Veterans 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 offer our views on legislation pending before the
    committee.
             h.r. 299, blue water navy vietnam veterans act of 2017
        I am a veteran of the Navy who served on a ship that participated
    in 11 campaigns during the Vietnam War. From 1965 through 1972, the USS
    Whitfield County (LST 1169) was sent to Vietnam at least 31 times.
    During those deployments it patrolled endless days off the coast,
    supported riverine patrol boats on the rivers of Vietnam and went up
    the river to Saigon. I served aboard from July 1971 until she was
    decommissioned in March 1973. During that time our ship went to Vietnam
    three times.
        When you think of navies, you think of aircraft carriers,
    destroyers, submarines. If you are older, or a fan of WWII movies,
    cruisers and battleships figure into the equation as well. However,
    over its history, the United States Navy has had thousands of ships,
    many of which were not the fastest, stealthiest or biggest. Our fleets
    cannot stay at sea for extended periods without oilers, ammunition, and
    stores ships to support them. They cannot land Marines on distant
    beaches without amphibious ships of all sizes and descriptions. The job
    of our Navy is to project power, wherever and whenever that power is
    needed. To do that, dozens of different types of ships are needed to
    make that happen.
        The United States Navy was in Vietnam from start to finish. While
    the war did not start with the Gulf of Tonkin Incident in 1964, it was
    the catalyst for ramping up American participation to its peak in the
    late 1960s. It ended with the evacuation of American personnel and
    thousands of Vietnamese to ships off the coast in April 1975. In
    between, many hundreds of ships spent weeks or longer off the coast,
    many of them not just once or twice, but over and over again. While
    many of those ships put into Vietnamese ports, many others did not.
        Forty years after I last saw the coast of Vietnam from the deck of
    the USS Whitfield County, I spent two days at the National Achives
    pouring over the deck logs, trying to find entries that supported my
    recollection of tying up to a pier in Cam Ranh Bay, beaching the ship
    on the LST ramp at Vung Tao, putting into port at Qui Nhon and sailing
    off the coast of Da Nang. My search revealed much more than I recalled.
        On my first cruise to Vietnam in 1971, we patrolled up and down the
    coast. We were on the lookout for small boats trying to infiltrate
    supplies and personnel into South Vietnam--north and south, day after
    day, within sight of the shoreline. This was not just a random
    assignment. Operation Market Time started in 1965 and continued through
    the end of American participation in 1973. We were a floating
    warehouse, carrying hundreds of tons of supplies on our tank deck. We
    carried extra ammunition for Patrol Gunboats and other smaller ships
    that might need resupply. Whenever we went to Vietnam, we carried extra
    fuel for ships and JP-5 for helicopters.
        We put into port as needed. We once picked up the pieces of a
    patrol boat that had been blown in half by a mine attached to its hull,
    and carried them to another port in Vietnam. We never knew why. We
    anchored off the coast to conduct shore bombardment with our 3''/50
    caliber guns. We spent Christmas Day in 1971 taking on supplies from a
    stores ship, then transferred some of those supplies and fuel to two
    Patrol Gunboats (USS Asheville and Tacoma) and a mine sweeper (USS
    Guide). We anchored off the coast one day, lowered the Captain's gig
    into the water and went swimming. We followed that with a barbeque on
    the main deck. We did this within sight of the beaches.
        I mention these events as an illustration of the kinds of
    activities we performed close to the shore of Vietnam. If there was
    dioxin in the water, we would have been exposed to it while swimming.
    Week after week, patrolling up and down the coast, we took in sea water
    and processed it through our fresh water evaporator system. We know
    from the Australian Navy study, validated by the National Academy of
    Medicine (formerly the Institute of Medicine), that fresh water
    evaporator systems concentrated toxic material, including dioxin, which
    was then transmitted to sailors through drinking water.\1\
    ---------------------------------------------------------------------------
        \1\ Blue Water Navy Vietnam Veterans and Agent Orange Exposure,
    Institute of Medicine, 2011, pg 13, https://www.nap.edu/read/13026/
    chapter/2#13
    ---------------------------------------------------------------------------
        As a matter of observation, absent the cleaning and sanitation of
    the entire fresh water evaporator system, it is conceivable that every
    person who ever served on board my ship could have been exposed to
    dioxin after its first visit to Vietnam. Further, by the time we
    completed our last deployment to Vietnam in 1972, the evaporator system
    would have accumulated concentrated dioxin from dozens of visits to
    Vietnam, not simply the final three that I experienced while on board.
        From 2015 through September 2017, I was a member of the Steering
    Committee for the Vietnam Era Health Retrospective Observational Study
    (VE-HEROeS). The Committee had input into the study design, the
    questionnaires, communications, and types of analyses and order of
    analyses. The aim of the study was, in part, to see whether Blue Water
    Navy veterans would respond to the survey and describe their health.
    Based on the sample size of all Vietnam and Vietnam Era veterans, the
    researchers estimated that 200 Blue Water Navy veterans would respond.
    In fact, 987 Blue Water Navy veterans answered the questionnaire. As a
    result, the data gathered is more extensive and richer than
    anticipated. The raw data is currently under analysis and adjustment to
    assure accurate comparisons between other Vietnam and Vietnam Era
    veterans.\2\
    ---------------------------------------------------------------------------
        \2\ Blue Water Navy Characteristics, Presentation to the Steering
    Committee Meeting, September 27, 2017.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        While results of this study will be published over the next few
    years, there is more than sufficient data to show that Blue Water Navy
    veterans suffer from a higher incidence of cancers, hypertension, and
    ischemic heart disease than other populations of similar age.
        It has been 43 years since the war ended in 1975. Even the youngest
    of Blue Water Navy veterans are over 60 years of age. Many thousands
    suffer from the same disabilities as do veterans who served in-country.
    Rather than continue studying the health of Blue Water Navy veterans
    for another 10 years while Blue Water Navy veterans sicken and die from
    diseases related to exposure to herbicides, Congress must grant Agent
    Orange presumptions to the thousands of sailors who served their
    country off the shores of Vietnam.
        The VFW supports expansion of benefits for Korean DMZ veterans who
    suffer from diseases and illnesses directly linked to Agent Orange.
    While many of these veterans receive presumptive disability
    compensation for their service-connected disabilities, hundreds of them
    are unjustly required to prove individual exposure. This legislation
    would provide them the benefits they have been unjustly denied.
        This legislation would also provide benefits to children suffering
    from spina bifida because of their parents' exposure to Agent Orange
    while serving in Thailand during the Vietnam War. Spina bifida is a
    debilitating birth defect, which has been found to be more prevalent
    among children of veterans exposed to Agent Orange. This expansion
    would make equal the level of benefits that other children receive due
    to their parents' exposure to Agent Orange.
        The VFW also supports the reporting and outreach requirements in
    this legislation. Research related to Gulf War Illness is vital to
    ensuring veterans receive the care and benefits they have earned as a
    result of illnesses and injuries caused by their service. The outreach
    and reporting components related to the Blue Water Navy portion of this
    bill would ensure veterans receive the retroactive payments they have
    earned, and allow Congress to oversee proper implementation of the
    legislation. On their behalf, the VFW urges you to approve this
    legislation so these veterans can receive the treatment and
    compensation they have earned through their service to our country.
        Ensuring equality between the active, Guard, and Reserve components
    of the military is a key goal of the VFW. For the past decade and a
    half, our country has been sending National Guardsmen and Reservists
    into harm's way at an unprecedented level, and some of them have been
    wounded in the line of duty. The VFW is pleased that H.R. 299, would
    end arbitrary differences in home loan fees and show that service in
    uniform earns equal opportunity to be a homeowner.
     h.r. 5418, veterans affairs medical-surgical purchasing stabilization
                                      act
        The VFW encourages the expansion of opportunities for veteran-owned
    small businesses to compete for Department of Veterans Affairs (VA)
    contracts, but we also see the value in having a single supplier if the
    situation is necessary. Mandating VA to use regional prime vendors
    could have a positive impact on competition in the market place,
    however, we would not want to see it negatively impact overall cost.
    The VFW does not have a position on this portion of this bill.
        We do, however, support prohibiting a single prime vendor from
    developing the formulary for medical surgical supplies. Allowing a
    single vendor to tailor the formulary to fit specific needs that only
    they could provide can lead to unfair advantages in competitive
    bidding. Creating a comprehensive formulary that is designed solely
    with the patients in mind is how they should be developed, and not in
    favor of a particular vendor.
                       s. 514, no hero left untreated act
        The VFW opposes this legislation, which would require VA to carry
    out a pilot program to provide veterans Magnetic eResonance Therapy
    (MeRT) to treat Post Traumatic Stress Disorder (PTSD) and other mental
    health conditions.
        The VFW supports expanding access to integrated and complementary
    therapies that have proven to effectively treat veterans who have not
    responded to conventional or evidence-based mental health care.
    However, MeRT is not approved by the U.S. Food and Drug Administration
    (FDA) and has shown little to no evidence of effectiveness in treating
    PTSD or other behavioral health conditions. VA has a current pilot
    program studying Repetitive Transcranial Magnetic Stimulation, or rTMS.
    While this form of therapy is FDA approved, recent data from this
    research shows the therapy is successful on approximately 40 percent of
    patients, which is the same percentage of success in patients receiving
    sham treatments.
        There is currently no evidence that MeRT would outperform treatment
    for any disorders. Additionally, this legislation would not provide VA
    additional funding to test the efficacy of MeRT. The VFW believes that
    VA must spend its already scarce health care resources on therapies
    that have shown promise or have a proven track record.
                           s. 1596, brave act of 2017
        The VFW supports this important bill, which would increase the
    funeral and burial benefit for eligible veterans. Specifically, this
    important bill would also ensure all three benefits are indexed for
    inflation.
        The cost of funeral expenses in the private sector has increased
    nearly sevenfold since 2001, but VA benefits to cover such costs have
    failed to keep pace with inflation. The VFW urges Congress to ensure
    the loved ones of veterans who do not have access to a state or
    national veterans cemetery within 75 miles are not required to
    accumulate debt to provide their loved ones a final resting place that
    honors their sacrifice to our nation.
    s. 1952, department of veterans affairs financial accountability act of
                                      2017
        The VFW supports this bill, which would require a third-party
    review of VA's financial projections. VA's inability to accurately
    project its budgetary needs, or overestimating its medical collections,
    has impacted its ability to provide veterans timely access to high-
    quality care and benefits.
        When evaluating VA's budget requests and financial projections, the
    VFW urges Congress to consider the impact outdated Budget Control Act
    discretionary budget caps have on the amount of resources VA is allowed
    to request. While VA budget requests should be based on need, they are
    often based on what VA is able to get approved by the Office of
    Management and Budget. For this reason, the VFW urges this Committee to
    include an analysis on the impact of sequestration on VA budget
    requests.
                s. 2881, mare island naval cemetery transfer act
        The VFW strongly supports this bill, which would transfer the Mare
    Island Naval Cemetery to the National Cemetery Administration (NCA) for
    management. The United States Navy used this cemetery as the final
    resting place of more than 800 veterans. Concern that non-veterans had
    been buried there has been raised as a possible reason to prevent NCA
    from managing the cemetery. The VFW feels that the Navy made the
    decision to bury those people there, that the decision should be
    respected, and that this is not a reason to oppose the legislation.
    This cemetery is in disrepair and the VFW will never support allowing
    the final resting place of veterans to be forgotten.
        The lasting legacy of those who have served our country is on
    display in cemeteries and is a testament to the cost of freedom. While
    our Nation remembers the service of veterans who are no longer with us
    on Memorial Day, NCA, and the American Battle Monuments Commission
    ensure that a daily reminder withstands the test of time.
     s. 3184, to modify the requirements for applications for construction
        of state home facilities to increase the maximum percentage of
             nonveterans allowed to be treated at such facilities.
        The VFW supports this legislation which would allow a small
    increase in non-veteran care at State Home Facilities. If certain
    facilities are not operating at full capacity and have the ability to
    treat non-veteran spouses, the facilities should be allowed to do so.
    The VFW believes these decisions should be driven by compassion and
    respect for the aging veterans and their loved ones. If there are open
    bed spaces in State Home Facilities that could be occupied by veterans'
    spouses, we should make that happen.
                       transition assistance legislation
        The period of moving from active duty to civilian life can be
    challenging for many transitioning servicemembers (TSMs). Leaving a
    structured life in the military and moving to an entirely different
    atmosphere brings with it many difficulties. Finding a new job, moving
    away from base, going to school, or leaving friends and comrades are
    just some of the issues servicemembers face with transition.
        The Transition Assistance Program (TAP) is the Department of
    Defense's (DOD) program in cooperation with the Department of Labor,
    VA, and the Small Business Administration to ensure a seamless path for
    servicemembers to civilian life. TAP has improved drastically over the
    past few years, but there are still many changes that need to be made
    to this vital program.
        The VFW supports the discussion legislation on transition
    assistance reform, which would consolidate and streamline the TAP
    overview process. This bill would provide insight and proper reporting
    of the entire TAP curriculum that would provide accurate information
    regarding which parts of TAP are working and which parts need
    improvement. However, there are items we feel should be included in any
    transition legislation in order to improve the entire process.
        The VOW to Hire Heroes Act of 2011 requires TSMs to attend TAP
    class prior to 90 days before leaving active duty service. Currently,
    less than half are attending by the required date. Additionally, less
    than 15 percent are attending the supplemental classes for education,
    entrepreneurship, or career technical training. Late attendance can
    lead to TSMs not having certain VA benefits available as soon as they
    leave active duty service. The VFW supports early participation in TAP
    classes for all servicemembers. We feel beginning TAP 12 months before
    leaving the service will set up TSMs for success better than the
    current three month path.
        The VFW supports S. 2748, BATTLE for Servicemembers Act, and the
    effort to make the supplemental TAP classes mandatory. More than half
    of TSMs utilize their GI Bill benefits after leaving the service, but
    nowhere nearly that many attend classes or briefings dedicated to
    education during their transition classes. Adding the supplemental
    classes to the main curriculum of TAP would expand the knowledge of
    TSMs and better prepare them for civilian life.
        The VFW also recognizes the value in connecting TSMs with the
    communities where they seek to reside. Having the TSMs connect with
    community groups or resources prior to separation could help mitigate
    various hardships as they transition to the civilian sector. There are
    many different organizations that help with education, employment, and
    financial management in communities across the country. Providing a
    connection to local resources during TAP classes is another tool for
    servicemembers to further their success.
        Expanding access for veterans to TAP-style information and
    resources after they leave military service is important for veterans.
    The VFW urges the Committee to revisit the pilot program to offer TAP
    in the community for veterans. Once veterans reintegrate into their
    communities, it is important for them to be able to access specific
    transition resources that apply strictly to their local communities.
    Veterans who participated in the original pilot program were able to
    access information and resources they may have missed during their
    initial TAP classes.
        Another key element the VFW would like to see added to any
    transition legislation is the removal of the 12-year expiration date
    for the Vocational Rehabilitation and Employment (VR&E) Program.
    Education and training are continuous efforts that do not end after 12
    years. Many veterans seek to reeducate and retrain themselves later on
    in life, and removing the expiration date will eliminate an unnecessary
    barrier to do so. There are exemptions that will allow veterans to
    utilize VR&E after the expiration date, however, if a veteran does not
    meet at least one of the exceptions, the veteran is denied due to the
    arbitrary expiration date. Last year, the expiration date on the GI
    Bill was removed so veterans could engage in education and training
    later on in life. The VFW feels Congress must do the same for VR&E.
                veterans dental care eligibility expansion and
                            enhancement act of 2018
        The VFW supports this draft legislation which would improve dental
    care provided to veterans by VA through a pilot program, as well as
    increase the ability for VA to construct and lease dental clinics.
    Though the VFW would prefer to see legislation that would expand
    eligibility for VA dental care to all veterans who are eligible for VA
    health care, the VFW supports this bill.
        Dental care is a vital aspect of general health care. According to
    the Mayo Clinic and a myriad of peer-reviewed medical studies, oral
    health has a direct impact on severe diseases and conditions, such as
    heart disease and adverse birth conditions. Conversely, several health
    conditions that are prevalent among veterans, such as diabetes and
    Alzheimer's disease, have been found to directly impact oral health.
    Until the VA Dental Insurance Program (DIP) was implemented in
    January 2014, veterans enrolled in VA health care had little to no
    options for receiving dental coverage.
        Additionally, there is a large disparity between VA and DOD dental
    coverage, which can have a significant impact on the health care and
    quality of life for veterans. While in uniform, veterans were required
    to maintain a high level of dental readiness, to the extent that they
    would be placed on a non-deployable status if they failed to receive a
    dental evaluation every year. However, only veterans who were 100
    percent service-connected disabled, certain homeless veterans, and
    those who had a service-connected dental condition were eligible for VA
    dental care. The majority of veterans enrolled in VA health care are
    unjustly denied access to VA dental care. Instead, they are offered the
    ability to purchase dental insurance through VA, which has high costs
    and poor coverage. VFW members who are asked for feedback on VADIP
    report that it is better than nothing. Those who have worn our Nation's
    uniform deserve the best, not ``better than nothing.''
        This draft legislation would create a pilot program to expand
    dental care services and treatment to veterans who are enrolled in VA
    at 16 locations across the country. These 16 locations would include
    four VA medical centers with an established dental clinic, four VA
    medical centers with a contract for dental care, four community-based
    outpatient clinics with available space, and four facilities from
    federally qualified health centers and Indian Health Service clinics.
    These pilot sites would assess the feasibility to furnish dental
    services and treatment to no more than 100,000 veterans who volunteer
    to participate in the program.
        This draft legislation would also provide the Secretary with the
    authority to construct or lease a dental clinic for any state that does
    not currently have a VA facility that offers dental services. The VFW
    finds this to be incredibly important, as veterans must have access to
    dental care and they should not have to cross state lines to obtain
    that care.
    draft legislation, modernization of medical records access for veterans
                                      act
        This draft legislation would provide a portable ``credit card
    sized'' health record for veterans. The VFW understands the intent of
    this bill, but opposes its passage. Veterans already have easy access
    to their health care records. Veterans have the ability to get copies
    by using their My HealtheVet account. After logging into their account,
    the first page a veteran sees offers a selection of four large
    ``buttons'' and accessing their medical record is the fourth option.
    VFW staff tested the ability to download their records using this
    method, and in less than 90 seconds an electronic version had been
    downloaded. For those who do not use My HealtheVet, a compact disc copy
    can be obtained by veterans from their local VA medical centers.
        To ensure that the veteran's medical record follows them after
    military service, VA has recently begun the process of adopting a
    commercial off-the-shelf system for the future electronic health
    record. The Electronic Health Record Modernization Program (EHRMP) will
    allow veterans to have more access to their medical records. This
    legislation allows the discharging servicemember to electronically
    ``carry'' their record to VA, and for various portions of VA to
    interact with itself and with community care providers while caring for
    the veteran. The VFW believes this bill could create a competing
    medical record that would prevent VA and the veteran from having all
    needed information on one platform, thus slowing the delivery of care.
    Because of a lack of vital information, this could lead to decisions
    being made that could harm the health of the veteran.
        In looking at our first two concerns together, the VFW worries
    about interoperability between the device that would be created and
    other VA systems, and security of the information stored on it. There
    is no requirement for the device to ever be connected to, or even
    interoperable with, the electronic health record that will result from
    EHRMP. A lost device could also lead to compromised information, and
    this is a real threat in the modern day.
        Finally, the VFW opposes this bill because it specifically bans new
    appropriations for implementation. Unfunded mandates harm other
    programs by forcing VA to take money from other parts of its IT budget.
    The VFW is already concerned about VA's IT budget funding levels. This
    legislation would cause VA to divert precious and limited resources
    from other programs, thus hindering modernization of IT capabilities
    and implementation of EHRMP.
      draft legislation, to require the secretary of veterans affairs to
         establish a program to award grants to persons to provide and
     coordinate the provision of suicide prevention services for veterans
       transitioning from service in the armed forces who are at risk of
                        suicide and for their families.
        The VFW supports this draft legislation, but has concerns the
    current language could provide grants to organizations that compete
    with, rather than complement, VA mental health care.
        This draft legislation would authorize VA to provide grants to
    organizations offering suicide prevention services ranging from
    outreach and education to peer support and referrals to care. While
    providing grants to organizations that complement the care being
    provided by VA is of benefit, Congress and VA must ensure grants will
    not be received by groups competing with VA's suicide prevention
    treatments, or providers who should be enrolled in VA's community care
    program.
        This draft legislation would require the Secretary to consult with
    organizations such as veterans service organizations (VSO's) about
    recipients of these grants. The VFW is grateful to see this, as VSO's
    have extensive background and understanding in programs such as this.
    For example, the VFW has its own mental wellness campaign. Through this
    campaign we have partnered with VA and other groups such as Change
    Direction, One Mind, PatientsLikeMe, Give an Hour, and the Elizabeth
    Dole Foundation. While the VFW does not provide clinical care, members
    work with our partners to provide outreach at home-grown levels to
    educate veterans and their families about recognizing emotional
    distress, as well as what benefits and programs are locally available.
    PatientsLikeMe provides peer support and Give an Hour provides clinical
    care for veterans in need of emergency counseling.
        The VFW also believes the reporting requirement stating the
    Secretary ``may'' require a grant recipient to report how the funding
    is used must be changed to ``shall.'' There are many honest programs
    which can benefit from grants. Still, Congress must work with VA to
    ensure these grants are not used to bankroll bad actors.

        I thank you for the opportunity to testify today and I will answer
    any questions you may have.

        Chairman Isakson. Thank you very much, Mr. Manar.
        Mr. Snee.

    STATEMENT OF THOMAS J. SNEE, NATIONAL EXECUTIVE DIRECTOR, FLEET
                          RESERVE ASSOCIATION

        Mr. Snee. Chairman Isakson, Senator Sanders, Committee
    Members, thank you and on behalf of the veterans for your
    leadership and caring spirit. I am Tom Snee, the national
    executive director for the Fleet Reserve Association, the
    oldest sea service association serving our men and women in the
    U.S. Navy, Marine Corps, and Coast Guard since 1924. We are
    most honored and pleased to have been asked to return again to
    express and share our viewpoints for the Senate's favorable
    vote of H.R. 299 on behalf of the Blue Water Navies.
        I am also a retired Navy master chief petty officer,
    surface warfare, with over 30 years of active duty and a
    Vietnam veteran who probably served on a Blue Water Navy ship
    that was exposed to Agent Orange in the coastal waters off
    Vietnam. Like other ships, we, too, lost a great number of our
    crew due to Agent Orange. Today I am here to put a human face
    on Agent Orange victims and their families. Simply, H.R. 299
    will protect and ensure the poignant care for all Blue Water
    Navy veterans and actions today.
        Mr. Chairman, allow me to read a quote from President
    George Washington: ``The willingness with which our young
    people are likely to serve in any war, no matter how justified,
    shall be directly proportionate on how they perceive veterans
    of earlier wars and how they were treated and appreciated by
    our Nation.''
        Mr. Chairman, every day we delay the well-being of earned
    benefits, quality treatments, and life's sustainability for our
    Blue Water Navy veterans, we are losing their confidence and
    credibility as a Nation. Through despair, addictions,
    homelessness, and suicides, our aging Vietnam veteran
    population can only wonder and frequently ask, do they really
    care?
        For me, as that young 19-year-old from northeast Ohio, I
    never knew that the war was going on, never heard of Vietnam.
    Instead, I took my oath of enlistment seriously. I swore to
    protect and to defend the Constitution of the United States. We
    can all agree on one thing: that the Vietnam era was a very
    unpopular and emotional time back then. I, however, chose to
    serve toward a more deliberate and positive course for our
    country and invest in its national interests and securities.
        The House recently overwhelmingly voted 382-0 for H.R. 299.
    On that day veterans across the Nation lit up phone lines and
    social media that in hope and trust they were finally realized
    and valued for their service. Today this Committee and the
    Senate can further seal that confidence to secure those
    mandates for care and prevention. For those, we have been told
    no. For our Australian counterparts and allies, with the same
    at-sea lifestyles, experienced the same anguish, however,
    initiated the means to provide the needed care for their
    Vietnam sea service veterans. The VA Mission Act of 2018,
    sponsored appreciatively by Chairman Roe, will ensure a
    continuity of care and services for our Blue Water Navy
    veterans. Please consider these points:

         Measurable Blue Water Navy issues have been
    addressed to the House and to the Senate. An identifiable and
    affordable pay has been established.
         The VA Mission Act provides the needed assurances
    of hope and promise of care and sustainability in their own
    personal lives.
         The VA report of 2008 can be qualitatively
    referenced, ``given the availability of evidence, the Committee
    recommends that members of the Blue Water Navy should not be
    excluded from the set of Vietnam era veterans with presumed
    herbicide exposures.''
         A letter sent by 14 Senators in January 2016
    stated, ``There seems to be ample reason for you, the Secretary
    of VA, to make the policy decision in favor of many veterans
    who are suffering from painful and debilitating diseases for
    whom justice is long overdue.''
         Even the statement on dioxin regarding Agent
    Orange brings the point home as requested. ``Dioxins are in
    nature chemical residues from manufacturing processes and are
    often cancerous.'' Typically, the side effects of dioxins in
    human exposures include sarcoma, lymphoma, blood diseases, and
    various birth anomalies and defects of varying magnitudes of
    seriousness.
         And, recently, the VA established a qualitative
    framework to put into practice a positive stance and five
    courses of actions that would support and endorse and decrease
    in suicide instances to match the needs of our service.

        Mr. Chairman, Committee Members, now is the time. We must
    act to forge an informative action for our Blue Water Navy
    veterans. Every day we suspend its passage again, we further
    continue the loss of confidence and psychological setbacks for
    our veterans, including death itself.
        I quote another instance of a widow of a Navy master chief
    who is buried at Arlington Cemetery, who said, ``It is cheaper
    for the VA to bury our veterans than to take them and give them
    the treatment that they need.'' She also said, ``They should
    never have been excluded.''
        The making of fresh water is a universal process on every
    Navy ship. Admiral Zumwalt--I spoke with his daughter and his
    son, and the daughter said at a Navy memorial conference that
    if her Dad had known the following effects of Agent Orange, he
    would never have allowed it.
        In closing, Mr. Chairman, these are the faces and stories
    of the Blue Water Navy vets. We took an oath, we served, we
    made a commitment to the sea--breathing, bathing, drinking,
    cleaning, even brushing our teeth while absorbing Agent Orange.
    Our caretakers are suffering patiently as well and wondering
    just when will that day be.
        Sir, people are not science projects. We are the
    consequences of an era gone by. Vote for H.R. 299.
        Please remember my earlier quote from George Washington,
    because this could have a future impact, as I recently had down
    in Charleston, SC, by a 19-year-old who said, ``Sir, is the
    Government and VA going to take care of me if I should get
    ill?'' just before he went to boot camp.
        Remembering the Vietnam veteran, our resistance will long
    be painful. Sir, we have the means. Let us make sure it does
    not happen to us.
        Mr. Chairman, I thank you and the Ranking Member and the
    Committee and all the members here today, and I respectfully
    request that my statement be placed in the record. I await your
    questions.
        [The prepared statement of Mr. Snee follows:]

        [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Prepared Statement of the Thomas J. Snee, USN (Ret), M.Ed, MCPOC (SW),
             National Executive Director, Fleet Reserve Association
                                  introduction
        Distinguish Chairman Johnny Isakson, Ranking Member Jon Tester, and
    members of the Veterans Committee, We thank you, for the opportunity to
    present the FRA's views on, The ``Blue Water Navy Vietnam Veterans Act
    of 2018,'' sponsored by Rep. David Valadao (R-CA) and other legislation
    listed on the agenda. We would like to recognize and thank Rep Valadao
    for his leadership and direction in the recent House passage of this
    Bill, (382-0) on June 25, 2018. FRA also thanks Senator Kirsten
    Gillibrand (D-NY) for her companion legislation (S. 422), to (H.R. 299)
    as it was introduced in the House. The House bill has 330 co-sponsors
    and the Senate bill has 51 co-sponsors. FRA also thanks House Veterans'
    Affairs Committee Chairman Dr. Phil Roe (Tenn.) and Ranking Member Tim
    Walz (Minn.) for working in a bi-partisan manner to pass the
    legislation out of committee and that recently passed in the House.
                      agent orange/blue water navy reform
        The ``Blue Water Navy Vietnam Veterans Act'' (H.R. 299) not only
    clarifies, but further defines eligibilities for sea service personnel
    that served on ships in the coastal waters off the coast of the
    Republic of Vietnam. This bill also provides a presumptive eligibility
    statute for disability claims submission to the VA for disease and
    ailments from the toxic exposures of the Agent Orange herbicide. FRA
    requests that Congress recognize all ``Blue Water'' veterans who were
    exposed to the Agent Orange herbicide and to authorize immediate and
    presumptive status for VA disability claims submissions. Current
    presumption of service connection only exists for Vietnam veterans who
    served in-country, on land and inland waterways, but limited to those
    who served off its coastal waters. Enactment of H.R. 299/S. 422 will
    ensure a well justified and earned treatments and benefits to the
    thousands of Navy/Marine Corps/Coast Guard personnel who may have been
    denied service-connected claims by the VA since 2002.
        Upon passage of this bill, these servicemembers will no longer have
    to continually prove direct exposures from Agent Orange, and be
    eligible to receive the consideration from the VA for benefits
    associated from presumptive and known associated health conditions
    incurred from exposure from this defoliant while serving on these
    ships. From 1964-1975 more than 500,000 deployed servicemembers serving
    off the coastal waters of Vietnam may have likely been openly exposed
    to the chemical herbicide Agent Orange in the daily performance of
    their shipboard duties. In response to this concern, Congress passed
    the Agent Orange Act of 1991, (P.L. 102-4) under President George H.W.
    Bush.
        Based upon the 1991 Agent Orange Act, the VA policy (1991-2001)
    only recognized servicemember file claims if they received the Vietnam
    Service Medal/Vietnam Campaign Medal with a ``boots on the ground''
    status. These restrictions of service were not applicable to sea
    service personnel on ships in the coastal waters. Agent Orange
    presumption connections were never extended for those shipboard
    personnel in the performance of their daily duties. The herbicide's
    primary use was to destroy foliage on river banks and shores where the
    Viet Cong hid, in order to fire upon passing ships and small vessels.
    The chemical sprayed found in those rivers, eventually had a
    ``natural'' runoff into the coastal waters off Vietnam. As a result,
    shipboard desalination processing, as used daily for bathing, drinking,
    laundering, dish washing, and other onboard daily use were never
    considered from this contamination. It was later determined, that the
    onboard desalinization process for water intensified the toxicity in
    the amounts used in the daily use from these herbicide exposures. In
    addition, consideration must be taken into account from these same
    sprayings, the atmospheric surroundings that were affected on these
    ships.
        FRA is grateful to the 14 Senators, who in joint 2016 letter to the
    Secretary of Veterans Affairs, requested that the VA reconsider its ban
    on presumption for those who served on ships off the coastal waters as
    well as to those who had ``boots on the ground.'' The FRA strongly
    endorsed this letter with its reassurances in the lifting of those
    restrictions. This same letter referenced the recent Gray v McDonald
    decision by the Court of Appeals for Veterans Claims that found that
    VA's exclusion of Da Nang Harbor from the definition of ``inland
    waterways'' to be ``arbitrary and capricious.'' FRA was disappointed
    that the VA issued a court-ordered and ``clarified'' definition of
    inland waterways for the purpose of determining presumption for
    coverage that still maintained its exclusion of the ``Blue Water''
    Vietnam veterans. For the VA, to state with such confidence that the
    toxin, Agent Orange, could not cross from inland water ways and harbors
    into open coastal waters is a total `rejection in itself to the laws of
    nature'. It was as if some imaginary line drawn across the mouth of any
    river or bay had the ability to stop the herbicide from entering into
    coast waters and currents from flowing.
                  house amendments to agent orange legislation
        This current legislation, as amended in the House Veterans' Affairs
    Committee, now extends the presumption of herbicide exposure for
    veterans who served on or near the Korean DMZ between September 1, 1967
    and August 31, 1971. This legislation will now permit and allow
    extended health care, vocational training & rehabilitation and monetary
    allowances to children born with spina bifida, provided that at least
    one parent of the affected child served in Thailand between January 9,
    1962 and May 7, 1975 as determined by the VA Secretary and had been
    exposed to the herbicide Agent Orange during that period.
        This bill also will allow improvements to the VA's home loan
    program. Currently, VA-designated appraisers rely solely on information
    from approved third parties, who, for an example, would use a desktop
    appraisal, when determining a home's value for a VA home loan. This new
    method would combine traditional appraisal methods with modern data
    analytics and market data to expedite and improve VA's appraisal
    process. This bill also eliminates the current conforming loan limit on
    the price of a loan that VA can guarantee. This rate is set by Freddie
    Mac and the amount of the current cap varies depending on the cost of
    living in a particular area. Any veteran who chooses to their benefit
    to purchase a home above the current cap would be required to pay a
    funding fee unless they were rated at the 100 percent service-connected
    level.
                               other legislations
        FRA would like to briefly indicate its position on the other
    legislative proposals being reviewed at this hearing. The FRA's
    position on the other legislative proposals is as follows:

         FRA supports the draft legislation sponsored by Senator
    Bernie Sanders (VT) to authorize a pilot program for expanded dental
    services for certain veterans;
         FRA has no position on Senator Michael Bennet's (CO)
    legislation (S. 3184);
         FRA supports the draft legislation sponsored by Senator
    Michael Crapo (ID) that addresses the streamlining the Transition
    Assistance Program (TAP).
         FRA has no position on Senator John Boozman's ``VA Hiring
    Enhancement Act;''
         FRA has no position on Rep. Jack Bergman's (MI) ``Veterans
    Affairs Medical-Surgical Purchasing Stabilization Act'' (H.R. 5418);
         FRA strongly supports Senator Gary Peters (MI) the ``BRAVE
    Act,'' (S. 1596) that increase benefits for burial, funeral and other
    death related expenses;
         FRA strongly supports Senator Diane Feinstein's (CA)
    ``Mare Island Naval Cemetery Transfer Act,'' (S. 2881);
         FRA supports Senator Jon Tester's (MT) ``VA Financial
    Accountability Act'' (S. 1952);
         FRA strongly supports Senator Jon Tester's (MT)
    ``Dependency and Indemnity Compensation Improvement Act'' (S. 1990);
         FRA strongly supports Senator Dan Sullivan's (AK) ``Medal
    of Honor Surviving Spouse Act'' (S. 2185);
         FRA supports the draft legislation, sponsored by Senator
    Bill Cassidy (LA), to require the VA to create a program to provide
    grants for persons to provide and coordinate provisions of the suicide
    prevention services for certain veterans;
         FRA strongly supports Senator Bill Cassidy's draft bill
    ``Modernization of Medical Records Access for Veterans Act;'' and
         FRA supports Senator David Perdue's ``No Hero Left
    Untreated Act'' (S. 514).
                                   conclusion
        In closing, please allow me again, to express our sincere
    appreciation on behalf of the Association in allowing FRA to express
    its views on legislation at this hearing.

        Chairman Isakson. Your statement will be placed in the
    record, as will the statements of all the members of the panel.
    Thank you, Mr. Snee.
        Mr. Weidman, you are recognized.

     STATEMENT OF RICK WEIDMAN, EXECUTIVE DIRECTOR FOR POLICY AND
            GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA

        Mr. Weidman. Thank you, Mr. Chairman. I appreciate it.
        There are a number of bills that are really worthy bills
    and discussion drafts for consideration today, but I am not
    going to comment on all of them. I will just concentrate on
    two.
        First, H.R. 299 with the amendments is a bill that deserves
    passage. One of the statements by the VA panel--the Under
    Secretary can certainly be forgiven because he is brand-new--
    but when that Blue Water Navy special study was released by the
    Institute of Medicine, I was there, one of Mr. Snee's
    colleagues who was also present in the room was there, and
    about six VSOs. It did not say that people were not exposed.
    What the report said was that, yes, it was biologically
    plausible and that probably some were exposed. We said, ``So,
    why aren't you recommending upping among the categories that
    the National Academy of Medicine,'' as it is now called, ``has
    the opportunity to do under the 1991 law?''
        The response back to that was, ``We do not know how much
    you were exposed.'' To which I said, ``So what? You do not know
    how much I was exposed versus my friends who is down in I Corps
    who served on the ground?''
        Then we asked a key question: ``What is a safe dose of
    dioxin?'' Of course, her eyes got as big as dinner plates,
    because there is no such thing as a safe dose of dioxin.
        We believe that the report itself has been misinterpreted
    by the so-called public health and toxic exposure section of
    VA, because if you go back and read the actual report, it says
    that, in fact, people who served in the Blue Water Navy were
    exposed. How much makes no difference. You do not know how much
    different folks who served in the delta versus the central
    highlands where I served. Who knows? And, you cannot put it
    together 40 years later.
        I do want to comment and save my remaining time for the
    Veterans Dental Eligibility Expansion and Enhancement Act of
    2018. How in the world dental care and periodontal care got
    separated from the rest of physiological care in our society is
    one of those things that you really have to scratch your head
    about. What do we know about people who use VA? They are older,
    they are sicker, and they have multiple and complex
    interactions of physical conditions. Some of that is due to
    poor nutrition. Some of it is due to bad teeth and other dental
    diseases that make it hard for people to eat real food, and so
    they go for processed foods. It is way past time for the VA to
    do this pilot study. Frankly, we believe that there is enough
    evidence in the general literature about overall health in
    general in regard to dental care, good dental care, that you
    cannot do good overall care, physiological care, unless you
    have good dental care.
        Because of the vagaries of the C&P system, there are a lot
    of people--if you served and applied in one regional office,
    you would have ended up 100 percent. If you apply at another
    regional office, you end up being 60 or 70 percent. Whether or
    not you have dental care, which is absolutely necessary to good
    health, should not depend on where you live and the vagaries of
    even adjudicator to adjudicator within the same office.
        So, we urge early passage of both of these bills and that
    science and justice demand early passage of both, because you
    cannot take care of people's health if you ignore the dental,
    and because what the IOM report really said was that, yes, it
    was plausible that people were exposed. That was what we
    needed.
        One last point about the VA. They were under pressure to
    make a definitive statement about who was in the river and who
    was in the harbor. If you were in the harbor, you, ``were not
    exposed.'' But, if you sit where Senator Sanders and the
    Chairman are sitting and the people behind them, you were
    exposed. They literally drew a line on a map across the mouth
    of the river. I mean, you do not have to be an ocean
    hydrologist to know how stupid that is. The Tombigbee River and
    other rivers in Georgia empty into the ocean. How do you say
    whether if you threw orange dye upstream it is going to end up
    in the harbor? Same with the Lamoille River dumping into Lake
    Champlain. While you can say, ``Yes, that is the mouth of the
    river,'' but anything that is in the water that is coming down
    is going to go out into the larger body of water.
        So, I thank you for your indulgence. I know I am over time,
    Mr. Chairman, and thank you so much for this hearing. I look
    forward to discussing these issues, of each one of these
    discussion drafts and bills, with your staff. Thank you.
        [The prepared statement of Mr. Weidman follows:]
      Prepared Statement of Rick Weidman, Executive Director for Policy &
                Government Affairs, Vietnam Veterans of America
        Chairman Isakson, Ranking Member Tester, and your distinguished
    colleagues of the Senate Veterans' Affairs Committee, Vietnam Veterans
    of America (VVA) wants to thank you for your stellar efforts on behalf
    of veterans of all eras. And we appreciate the opportunity to offer for
    your consideration our testimony regarding legislation pending before
    this distinguished committee.
        H.R. 299, the Blue Water Navy Vietnam Veterans Act of 2018,
    introduced by Congressman David Valadao (R-CA). VVA, along with just
    about every other VSO and MSO, has pressed for the passage of
    legislation that will right a long-standing wrong for veterans of the
    so-called Blue Water Navy during the years of the Vietnam War. Its fate
    now rests in this Committee, at this time. We hope you will see the
    wisdom in bringing, at long last, a measure of justice to these worthy
    veterans, men who did the Nation's bidding during that difficult and
    turbulent time.
                                   background
        During the war in Vietnam, from the early 1960s through the first
    years of the 1970s, some 20 million gallons of Agent Orange and other
    toxic chemicals were sprayed to defoliate jungle flora for two
    important reasons: to kill foliage surrounding fire bases that would
    otherwise provide cover for enemy forces, and to deny the enemy the
    ability to grow crops. Toxic chemicals in the herbicide, have been
    associated with serious, life-threatening health conditions, e.g., non-
    Hodgkin's Lymphoma, various cancers, Type II diabetes, and Parkinson's
    disease.
        Agent Orange was sprayed across the former South Vietnam, including
    coastal areas and along the banks of rivers and streams that empty into
    the South China Sea. The dioxin in this defoliant wound up in harbors
    and coastal byways heavily trafficked by military as well as civilian
    vessels. It is virtually certain that this contaminated seawater was
    taken in by ships to be desalinated into potable water for drinking,
    cooking, and showering. Today, too many of the sailors and Marines
    aboard these vessels are afflicted with the same maladies as are so-
    called boots-on-the-ground Vietnam vets.
        We wonder how many in this hearing room remember the words of one
    veteran suffering from cancer who stated, ``I died in Vietnam and
    didn't even know it.'' He was not alone. In 1991, Congress enacted the
    Agent Orange Act in an attempt to rectify what had become a persistent
    outcry from veterans suffering from diseases that peer-reviewed
    scientific studies have associated with exposure to dioxin, the toxic
    element in Agent Orange.
        There was a time when the Veterans Benefits Administration treated
    claims from sailors in the same manner as they did for claims by in-
    country veterans. This was ended, abruptly, in March 2002. The former
    Secretary who made that decision in 2002, without any justification,
    scientifically or otherwise, published an Opinion piece last week
    urging that the Congress ``not ignore science.'' Between 2002 and 2009,
    the VA denied some 32,880 claims, as the VA limited the scope of the
    Agent Orange Act to only those veterans who could provide proof of
    ``boots on the ground'' in Vietnam. Today, approximately 90,000 claims
    by ``Blue Water'' sailors are awaiting adjudication by the VBA.
        (The Department of Veterans Affairs has published on its website a
    listing of ``Navy and Coast Guard Ships Associated with Service in
    Vietnam and Exposure to Herbicide Agents.'' Most of these vessels,
    dubbed ``Brown Water Navy,'' plied inland waterways in the former South
    Vietnam.)
                                    h.r. 299
        On June 25, 2018, the House passed an amended version of H.R. 299,
    382-0. The original bill clarified that servicemembers aboard vessels
    in Vietnamese territorial waters (for the most part up to 12 miles from
    shore) during the Vietnam War can claim service connection for ailments
    associated with exposure to Agent Orange when filing a disability
    claim. The House bill was amended to include certain veterans who
    served near the demilitarized zone in Korea and in Thailand.
        Congress, we believe, should recognize that it is as likely as not
    that these veterans were in fact exposed to Agent Orange and should be
    accorded presumptive status for their disability claims citing such
    exposure. When signed into law, this bipartisan legislation would
    reverse the VA's 2002 decision which prevented Blue Water Navy
    veterans--and those veterans who served near the DMZ in Korea and in
    bases in Thailand--from claiming presumptive status for the diseases
    associated with herbicide exposure.
        VVA supports passage of H.R. 299 as amended, and urges swift action
    by you and your colleagues in the Senate.

        S.____ the Veterans Dental Care Eligibility Expansion and
    Enhancement Act of 2018, introduced by Senator Bernie Sanders (I-VT),
    calls for the VA to carry out a 3-year pilot program at no fewer than
    16 VA healthcare facilities. The purpose of this program is to assess
    the feasibility and advisability of furnishing dental services and
    treatment, and related dental appliances, to enrolled veterans who are
    not deemed to be eligible for such services and treatment, who
    volunteer to participate in the program, and who agree to copayments
    for such treatment and services same as they would for medical care.
    This bill also calls for the VA to initiate a program to educate
    enrolled veterans on the importance of good dental health, a program
    that illustrates the association between dental health and overall
    health and well-being.
        VVA most definitely endorses and fully supports this pilot project,
    and Senator Sanders' initiative. As he has noted, ``Untreated oral
    health conditions can lead to tooth loss, pain and infection, and
    contribute to an increased risk for serious medical conditions such as
    diabetes and poor birth outcomes.'' The bill requires, within a year
    and a half after this pilot program commences, that the VA submit a
    report to both SVAC and HVAC that describes the implementation and
    operation of the project and includes ``an assessment of [its] impact
    on medical care, wellness, employability, and perceived quality of
    life.''
        VVA recommends that the VA be required, within six months of the
    date of enactment of this act, to submit an exhaustive study/literature
    review of all peer reviewed articles in reputable medical journals
    pertaining to the effect of dental/periodontal health on overall health
    of adult individuals. Further, that VA submit a complete and documented
    study of the effect of providing dental services to homeless veterans
    and other veterans who receive such services, by cohort group, at VA.
        If this pilot project proves successful, as we believe it will, the
    introduction of full dental services for veterans who have a disability
    rating of less than 100 percent will have a salutary effect on their
    overall wellness.
        The arbitrary division of health and dental health has never made
    any real sense to us at VVA, since the two are so inextricably
    intertwined.

        S. 2881, the Mare Island Naval Cemetery Transfer Act, introduced by
    Senator Diane Feinstein (D-CA), directs the VA to enter into an
    agreement with the city of Vallejo, California, for the transfer to the
    VA of the Mare Island Naval Cemetery in Vallejo, to be maintained as a
    national shrine.
        Because of persistent fiscal uncertainties, Vallejo has been, and
    will continue to be, unable to properly maintain this cemetery. It is
    certainly appropriate for the VA's National Cemetery Administration to
    add this to its roster of national shrines. To not do so would be an
    abdication of presumed responsibility, because to honor the memory of
    those buried there, this final resting place must be accorded proper
    maintenance. The Navy should have properly transferred it to the
    National Cemetery Administration (NCA) when the Navy pulled out of Mare
    Island.
        VVA supports the passage of S. 2881 and would request that, if it
    cannot be enacted as a stand-alone bill, it should be added via
    amendment to the 2019 National Defense Authorization Act.

        S. 1596, the Burial Rights for America's Veterans' Efforts
    (``BRAVE'') Act of 2017, introduced by Senators Gary Peters (D-MI) and
    Marco Rubio (R-FL). This bill would increase the maximum amount payable
    by the Department of Veterans Affairs for the burial and funeral
    expenses of certain veterans, an amount that would increase each fiscal
    year by the percentage increase in the Consumer Price Index.
        The demise of thousands of veterans can be connected to health
    conditions connected to their military service. Just as the CPI
    fluctuates (usually upward) year to year, recompense for burial
    expenses also ought to be aligned with changes in the CPI. S. 1596
    should achieve this. It makes sense, is logical, and we can see no
    reason not to urge Congress to embrace it.

        S. 3184, introduced by Senator Michael Bennet (D-CO), would modify
    the requirements for applications for construction of State home
    facilities to increase the maximum percentage of non-veterans allowed
    to be treated at such facilities.
        The intent of this legislation is righteous. It would provide
    ``care to spouses of veterans, during a period in which a facility is
    operating with a bed occupancy rate of 90 percent or less, not more
    than 40 percent of the bed occupancy at any one time will consist of
    patients who are not receiving such level of care as veterans.''
        While we have no qualms about the spouses of veterans to be
    admitted to these homes, the language of S. 3194 is ambiguous. It seems
    to us that with the aging of the Vietnam veteran cohort, more and more
    of us will need to avail ourselves of what State homes can provide.
    Just as VA healthcare facilities are for veterans of the Armed Forces,
    so too, we believe, should homes for veterans be just that: homes for
    veterans who can live in dignity at a place where they can bond with
    other veterans. This also avoids having different levels of care, which
    can result in conflict when non-vets feel discriminated against.
    S. 3184 needs to go back to the drawing board.

        Discussion Draft on Transition Assistance reform, to be introduced
    by Senators Mike Crapo (R-ID), Jon Tester (D-MT), Bill Cassidy (R-LA),
    and Dan Sullivan (R-AK).
        This is an ambitious bill, one that seeks to improve DOD's
    Transition Assistance Program, including pre-separation counseling and
    services on such areas as financial planning, transition and
    relocation, and programs and such benefits as health care; educational
    assistance; preparation and requirements for employment; small business
    ownership and entrepreneurship programs; employment and reemployment
    rights; veterans preference; vocational rehabilitation; home loan and
    housing assistance; support services for family caregivers; and
    survivor benefits. This is commendable, and an attempt to bring
    organization and context to an often haphazard conclusion of a
    servicemember's time on a deployment overseas and/or an end to his/her
    active duty.
        Of particular importance is that section of this bill that calls
    for establishing a governing board to support prevention of drug
    overdoses, deaths by suicide, and alcohol-related mortality. This is
    timely and necessary, and should lead to a more sensible allocation of
    resources Vis a Vis prevention activities involving overdoses, alcohol
    dependence, and suicides. Over the past several years, for instance,
    hundreds of millions of dollars have been appropriated in an attempt to
    better understand and hence be able to prevent active-duty troops and
    veterans from taking their life; very little seems to have been
    achieved that can be ascribed as having made a positive impact on
    cutting the numbers of suicides and overdoses.
        Of particular interest and relevance to VVA and other VSOs and MSOs
    is ``a course of instruction, of at least one day, on the benefits and
    services available under the law administered by the Secretary of
    Veterans Affairs.'' There is far too much ignorance by far too many
    veterans on the benefits and services which they have earned by virtue
    of their service in uniform. For this alone we would endorse this
    legislation.
        There are, however, elements of this extremely prescriptive bill
    that ought to be rethought, e.g., the requirement that while all
    members eligible for assistance must participate, no servicemember
    ``shall be required to attend more than one class or counseling session
    in any one-year period.'' This seems self-defeating. And the sheer
    amount of analysis and paperwork that this bill would mandate will
    provide reams of statistics that, we fear, accomplishes little.

        S. 2748, the Better Access to Technical Training, Learning, and
    Entrepreneurship for Servicemembers--or BATTLE--Act, introduced by
    Senators Sherrod Brown (D-OH) and Mike Rounds (R-SD), would require
    members of the Armed Forces receive additional training under the
    Transition Assistance Program.
        It is a far more modest piece of legislation that attempts to
    improve DOD's Transition Assistance Program.
        VVA has no objection to the enactment of this bill.

        S.____, to be introduced by Senator Bill Cassidy (R-LA), would
    require the Secretary of Veterans Affairs to establish a program to
    award grants to organizations (not ``persons'') to provide and
    coordinate the provision of suicide prevention services for eligible
    veterans transitioning from the Armed Forces who are at risk of
    suicide, and for their families.
        Suicide, it has been said, is a permanent solution to a temporary
    problem. Still, despite all manner of attempts by Congress, DOD, the
    VA, and communities to research the reasons why servicemembers and
    veterans attempt or succeed at suicide, and hence to devise initiatives
    and programs to steer them to sources of comfort and assistance,
    suicide still claims far too many of those who have served the Nation
    in uniform.
        Despite the panoply of suicide prevention efforts, especially the
    VA's well- disseminated call-in number which connects those
    contemplating taking their life with well-trained professionals who can
    help them, the VA still does not do consistent evaluations of all
    potential psycho-social, economic, and other material factors in
    suicides, both attempted and completed, in each and every instance.
    This gross failure on the part of VA after 15 plus years of this being
    a major public concern is simply inexcusable, and must be corrected
    prospectively as well as retrospectively before any more funding is
    just thrown at this problem.

        S.____, the Modernization of Medical Records Access for Veterans
    Act, also to be introduced by Senator Cassidy, would direct the
    Secretary of Veterans Affairs to initiate a pilot program to establish
    ``a secure, patient-centered, and portable medical records system that
    would allow veterans to have access to their personal health
    information.''
        It seems to us at VVA that any VA patient can request his/her
    medical records simply by asking, because of the VA's pioneering
    electronic health record system, which should be made even more
    efficient as the $16 billion IT modernization effort gets online.
    Certainly, the kernel of this bill can, and should, be incorporated
    into this effort. And implementation of the pilot program called for in
    this bill ought to help in the re-design of the VA's IT. However, this
    needs to be coordinated with DOD's upgrade of its IT system. With this
    caveat, VVA supports enactment of this legislation.

        S.____, the VA Hiring Enhancement Act, introduced by Senator John
    Boozman (R-AR), would ``provide for the non-applicability of non-
    Department of Veterans Affairs covenants not to compete to the
    appointment of physicians in the Veterans Health Administration.''
        It appears that the goal of this bill is to make it somewhat easier
    for the VHA to hire medical professionals, to unencumber them from a
    covenant they may have entered into that could conceivably be used by a
    soon-to-be ex-employer to thwart their hiring by the VA. Inasmuch as
    there is a crying need in the VHA for more clinicians, so long as this
    bill is on solid legal footing, VVA fully supports its enactment, and
    thanks Senator Boozman for his leadership.

        H.R. 5418, the Veterans Affairs Medical-Surgical Purchasing
    Stabilization Act, introduced by Congressman Jack Bergman (R-MI), would
    require the VA, in procuring medical, surgical, dental, or laboratory
    items for its medical facilities through the Medical Surgical Prime
    Vendor (MSPV) program, to award contracts to multiple regional prime
    vendors instead of a single nationwide prime vendor. It would prohibit
    a prime vendor from solely designing the formulary of items available
    for MSPV purchase. And it would mandate that the VA ensure that each
    employee who conducts formulary analyses or makes decisions about
    including items on the formulary has relevant medical expertise; and
    that the VA provide Congress, on a quarterly basis, with periodic lists
    of these individuals and their medical expertise listed by categories
    of formulary items.
        VVA endorses the intent of this bill, but we balk at the
    requirement of naming individual employees as a matter of course,
    unless said individual is a SES or other senior VA manager. Certainly,
    if there is a question about a particular action by a specific
    employee, said employee needs to be named and called to task. The
    Accountability Act was supposed to make it easier to hold these senior
    managers accountable, not make it easier to scapegoat and fire those
    they manage. With this caveat, we endorse enactment of H.R. 5418.

        S. 1952, the VA Financial Accountability Act of 2017, introduced by
    Senators Jon Tester (D-MT), John McCain (R-AZ), Joe Manchin (D-WV), and
    Tim Kaine (D-VA), would improve oversight and accountability of the
    financial processes of the Department of Veterans Affairs.
        We have no dispute with the statement that ``the normal budget
    process for the VA should be grounded in sound actuarial analysis based
    on accurate demand forecasting,'' or that ``supplemental requests for
    appropriations should be used sparingly and for unforeseen demand or
    natural occurrences.'' We do question, however, the underpinnings of
    this legislation. Certainly, the VA does not come up with its budgetary
    needs in a void, although VVA has long contended that the so-called
    ``Millman formula'' always underestimates the needs of every
    generation. And then . . . the Office of Management & Budget (OMB) gets
    ahold of the VA request, and shrinks an already underestimated set of
    figures. Ultimately it is up to Congress to determine how much is to be
    appropriated.
        The concern, however, seems to be the unanticipated costs of
    fulfilling Congress' promise to give veterans Choice. And going to
    private doctors and hospitals is only going to cost more and more--with
    which both the VA and you in Congress have to come to grips. If some
    ``independent third party'' can be contracted with to review and audit
    the financial processes, and actuarial and estimation models of the VA,
    and make recommendations for improving the reporting structures, fine.
        Perhaps, however, Congress might first want to review the Final
    Report of the Commission on Care, which you created while initiating
    the Choice program back in 2014. Its estimates and forecasts seem
    pretty clear; the only issue is how much ``Choice'' do you want to
    fund--without further undermining the current already inadequate
    organizational capacity at the service delivery point of VA medical
    centers.

        S. 1990, the Dependency and Indemnity Compensation Improvement Act
    of 2017, introduced by Senators Jon Tester (D-MT), Richard Blumenthal
    (D-CT), and Mazie Hirono (D-HI). This bill would increase amounts
    payable by the VA to modify the requirements for Dependency and
    Indemnity Compensation (DIC) for survivors of certain veterans who had
    been rated totally disabled at the time of their death.
        Although this bill does not attempt to correct the inequities
    inherent in the SBP-DIC issue, it does seek to increase the amount of
    DIC compensation payable to surviving spouses. This is commendable. It
    should be of significant help to spouses in financial need. And we
    support its enactment into law.
        However, VVA must again state unequivocally that the gross
    injustice done to the widows ``of those who have borne the battle'' by
    deducting what is essentially an insurance program payout on which the
    soldier's family paid into for years (SBP payments) from Death &
    Indemnity Compensation (DIC) is just wrong, both morally and in every
    other way. And all to save the Federal Government a few bucks on a dead
    GI, ignoring the survivors.

        S. 514, the No Hero Left Untreated Act, introduced by Senators
    David Perdue (R-GA) and Gary Peters (D-MI), would require the VA to
    carry out a one-year pilot program to provide access to magnetic EEG/
    EKG-guided resonance therapy to treat veterans suffering from PTSD,
    TBI, MST, chronic pain, or opiate addiction.
        ``Congress recognizes the importance of initiating innovative pilot
    programs,'' this bill asserts, ``that demonstrate the use and
    effectiveness of new treatment options for Post Traumatic Stress
    Disorder, Traumatic Brain Injury, military sexual trauma, chronic pain,
    and opiate addiction.'' If in a pilot project this therapy proves to be
    promising or effective, initiating the pilot will be well worth
    whatever it might cost. This program should be funded from Deployment
    Health and other virtually useless programs, including Research &
    Development programs that do not in any way contribute to understanding
    toxic or other wounds of servicemembers and veterans, or improving
    veteran health treatments.

        S. 2485, the Medal of Honor Surviving Spouses Recognition Act of
    2018 , introduced by Senator Dan Sullivan (R-AK), would provide payment
    of the Medal of Honor special pension to the surviving spouse of a
    deceased Medal of Honor recipient.
        Bearing in mind that those who have been awarded the Medal of Honor
    are true heroes and not the ``hero'' appellation that so many in
    Congress feel compelled to honor all those who serve in uniform. To
    provide a modest--$1,329.58 a month--special pension to the surviving
    spouse of one of this Nation's heroes should be a no-brainer, and VVA
    is on board for the swift passage of this bill.

        VVA thanks you for the opportunity to present our views on
    legislation pending before this Committee, and we look forward to
    passage of H.R. 499, the Blue Water Navy Vietnam Veterans Act, and will
    be happy to answer any question the Committee may have.

        Chairman Isakson. You may be over time, but you are always
    informative, and we appreciate it. [Laughter.]
        Mr. Weidman. Thank you very much, Mr. Chairman.
        Chairman Isakson. Do you have a question, Senator Sanders?
        Senator Sanders. I do. Let me start off by thanking The
    American Legion, the VFW, the Fleet Reserve Association, and
    the Vietnam Veterans for all supporting the dental legislation
    that we have. I appreciate that very much, and I think the time
    is long overdue, as Rick just mentioned, for us to pass that.
        I would appreciate from Mr. Weidman or any of the other
    distinguished panelists their thoughts about the need for the
    VA to begin a pilot project to take a look at the dental care
    needs of veterans. Rick, do you want to begin it?
        Mr. Weidman. I come back to what we know about the
    demographics of who uses VA, and the demographics are generally
    veterans who are poor. And what do we know about poor people?
    They do not eat as well as upper-middle-class or middle-class
    people. Some of that is because they cannot access it in the
    inner cities, but even in the countryside, what you have easy
    access to in a place like Vermont or rural Georgia or rural
    North Carolina is the little stores that are nearest you, which
    generally do not carry fresh produce. So, people eat stuff out
    of a can or they hit the fast-food joint. When you have got a
    number of kids, the easiest thing, if you are poor, is to take
    them to a fast-food joint because that will fill them up. It is
    not the right thing, and for the person to eat it, the veteran
    to eat it, they know very well it is not the right thing, but
    it is cheap and they are hungry. So, that is what poor people
    eat.
        Senator Sanders. All right. Let me just jump in and ask
    anybody, are you aware of veterans who have serious dental
    needs?
        Mr. Weidman. Yes.
        Senator Sanders. OK. Mr. Manar?
        Mr. Manar. Well, certainly, and it is really frustrating
    for veterans when they come to seek dental treatment at the VA
    and they are told they need to file a claim. Then, it can take
    months while they are suffering from their dental conditions.
    And, more often than not, they are going to get denied for
    treatment because the evidence is lacking that their condition
    started in service or whatever the reason may be.
        I think that if we looked hard enough at the history of why
    dental treatment got separated from health care, it is the same
    reason vision was separated. First, they are very common and,
    second, they are very expensive over the long run. And, they
    decided to save money, your predecessors decided to save money
    and focus on other things.
        I am really thankful, we are really thankful that you have
    presented this legislation, you are supporting it, and we hope
    that the Senate will move on it and grant the veterans this
    opportunity to participate in a test.
        Senator Sanders. Good. Does The American Legion want to
    comment on that?
        Mr. Nuntavong. Senator, The American Legion believes in
    timely and quality dental care for veterans. I am a retired
    Marine, 22 years. I was required to go to medical once a year,
    but I was required to go to dental twice a year. It is very
    important that our veterans receive the health care they need
    in the form of dental care.
        Senator Sanders. Thank you. Fleet Reserve, Mr. Snee?
        Mr. Snee. Yes, sir, the same. I agree with The American
    Legion's statement. You have got to remember that when these
    individuals come out of the service, they are given their final
    dental care, their final check. Then, it comes down to where do
    they go when they get out? It is where they are settling down,
    then access to that dental care. And, of course, the
    availability of socioeconomics that plays on the family. That
    is very important. They have never had to do that, to go out to
    a civilian dentist, not because of disgust or anything else,
    but where do we go next? That is a factor also. Having that
    availability as a total medical picture for the entire body
    being taken care of, it is very important, yes, sir.
        Senator Sanders. Well, let me thank all of the
    organizations here for their support. What we are proposing is
    nothing terribly radical. It is a pilot project to see what
    kind of need is out there, to see how the VA can best address
    that need. I suspect the pilot project will prove positive, and
    we will go from there. I do appreciate all of your support and
    will look forward to passing this legislation.
        Chairman, thank you very much.
        Chairman Isakson. Thank you, Senator Sanders.
        Senator Tillis?
        Senator Tillis. Thank you, Mr. Chair. I will be very brief.
        First, I want to thank Matt sitting in the front row.
    Because you are in the office a lot, I have mistaken you for
    staff once or twice, so we really appreciate your advocacy on
    behalf of The American Legion.
        My wife's uncle died of Agent Orange exposure, very
    personally important. I have worked on toxic burn pits to try
    and get ahead of what I think could be the next Agent Orange. I
    worked on the Camp Lejeune toxic substances. I want you to know
    that I am very sympathetic to what we are trying to do with the
    Blue Water Navy, and I would like to meet in my office so that
    we can have a more fulsome discussion than we can have here. I
    want to see how we can really move on track to where we can
    bring people together, address some of the concerns I have
    about the pay-for. I think when it was previously proposed, you
    all had some--or some of the VSOs, I will not speak for you,
    had concerns with the pay-for. So, it is important to get it
    right. I think we do need to get it right.
        With respect to science, I think on dental health--I have
    done a lot of work in State public policy; dental health and
    physical health are inextricably linked. We need to make
    progress on that.
        I just wanted to thank you all for your service and let you
    know that our office is willing to work with you. We all know
    that the hearings are important, but what happens in the
    offices every day in meetings where we can drill down and talk
    about how you take positive steps and gain support for the
    measures is the way we get things done.
        Thank you all for your past service and your continued
    service.
        Chairman Isakson. I am glad Senator Tillis wants to work on
    this Blue Water Navy because I had the privilege of working
    with him on the Camp Lejeune issues here a couple years ago.
    Many of those questions leading up to that were not any more
    difficult than the ones we are talking about trying to solve
    with the Blue Water Navy. So, I look forward to working with
    him on that and the others.
        I thank all the Members for being here. I ask unanimous
    consent that the testimony of Dianne Feinstein--which was to
    have been made orally at the first panel, but she could not be
    here. She later submitted it in writing to be submitted for the
    record of today's hearing. Is there any objection?
        [No response.]
        Chairman Isakson. Hearing none, so ordered.

        [The prepared statement of Senator Feinstein can be found
    in the Appendix.]

        Chairman Isakson. Second, we received testimony for a
    February 7, 2018, legislative hearing which we had to postpone
    at the last minute due to inclement weather. I ask unanimous
    consent that the testimony received for that hearing be added
    to today's record for the purpose of making it public
    information. Any objection?
        [No response.]
        Chairman Isakson. Hearing none, so ordered.

        [The testimony submitted for February 7, 2018, for which an
    updated version was not received, is found in the Appendix.]

        Chairman Isakson. We thank you for your participation. We
    have more to do on these issues. This is not the end. This is
    the beginning. I appreciate you all being here very much.
        We stand adjourned.
        [Whereupon, at 4:19 p.m., the Committee was adjourned.]

                                A P P E N D I X

                                  ----------

             prepared statement submitted by hon. maria cantwell,
                          u.s. senator from washington

           (brought forward from February 7, 2018, postponed hearing)

        Thank you Chairman Isakson and Ranking Member Tester for moving
    this bill through your committee.
        I would also like to thank Senator Fischer for her co-sponsorship
    and support of servicemembers on this very important issue.
        Currently, the SCRA provides servicemembers the ability to get out
    of term contracts for wireline and wireless telephone service--without
    penalty--upon the servicemember's deployment.
        This bill would extend the same relief for servicemembers that need
    to terminate term cable and Internet service contracts because of a
    deployment. By creating parity with other types of technology that
    servicemembers and their families regularly use we are protecting them
    from unfair termination fees and penalties that may arise when duty
    requires that they, and in some cases their families, move, in order to
    fulfill their duties.
        The text conforms to technical assistance we received from the FCC.
    We vetted with industry, veteran and armed services stakeholder groups.
    The broad support that the bill enjoys speaks to how timely and
    necessary these proposed changes are to bring the SCRA up to date so
    that servicemembers and their families can access the internet and
    cable services we all rely on to stay in touch with their friends and
    loved ones, stay informed about the news and remain connected around
    the world, no matter where they are deployed.
                                     ______

        Prepared Statement by Hon. Dianne Feinstein, U.S. Senator from
                                   California
              s. 2881--the mare island naval cemetery transfer act
        Chairman Isakson, Ranking Member Tester and Members of the
    Committee, Thank you very much for inviting me here today to discuss my
    legislation.
        S. 2881, the bill I have introduced with several of my colleagues,
    is straightforward and would transfer control of the Mare Island Naval
    Cemetery from the city of Vallejo to the Department of Veterans
    Affairs.
        I'd like to briefly provide some background on the history of this
    cemetery. The Mare Island Naval Cemetery is the oldest military
    cemetery on the West Coast. The cemetery was part of a U.S. Navy base
    that closed down in 1993. After the base closed, the nearby city of
    Vallejo assumed control of the property including the cemetery.
        The cemetery has over 900 graves, including over 800 veterans and
    three Medal of Honor Recipients. There are approximately 80 nonmilitary
    graves, the majority of which belong to military family members.
        Unfortunately, the city of Vallejo didn't have the necessary funds
    to care for the cemetery, which has only been maintained by volunteers
    with limited resources. The cemetery is very damaged: gravestones are
    toppled over, broken or sinking into the ground, serious drainage
    issues exist, and plants and weeds are overgrown. The current state of
    the cemetery requires urgent action to restore these graves and the
    grounds to a respectable condition.
        The bill is a simple transfer of the cemetery from the city to the
    Department of Veterans Affairs. This means that the VA would have the
    responsibility to restore the cemetery and maintain the grounds in a
    respectable condition.
        I want to thank you all for considering this bill and I want to
    thank Senators Harris, Markey, Menendez, Warren, Cardin and Booker for
    cosponsoring this legislation.
        We owe our veterans a great deal. By passing this bill we can
    ensure that the Mare Island Naval Cemetery is restored and maintained
    to honor our veterans who are buried there. For those veterans and
    their family members who sacrificed so much for our Nation, it is
    fitting that we do so.
        Thank you.
                                     ______

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      Prepared Statement from The Advanced Medical Technology Association
                                   (AdvaMed)
        AdvaMed is the leading trade association representing medical
    technology manufacturers and suppliers that operate in the United
    States. Our members range from the largest to the smallest medical
    technology innovators and companies. Collectively, we are committed to
    ensuring patient access to life-saving and life-enhancing devices and
    other advanced medical technologies.
        The sacrifice our Nation's veterans and their families make on our
    behalf cannot be overstated. We all have an obligation to ensure they
    receive the highest quality care and have access to the best medical
    technology available. AdvaMed and its member companies believe strongly
    in our collective relationship with the U.S. Department of Veterans'
    Affairs (VA) and share the Department's goal of providing our veterans
    with the highest quality health care possible.
        There are approximately 8 million U.S. veterans of the armed
    services accessing the VA health care system, with another nearly 2.3
    million currently serving in the military on active duty that may do so
    in the future. Through earlier diagnosis and intervention, less
    invasive procedures and more effective treatments, medical technology
    is revolutionizing health care across the continuum of service and
    enhancing the lives of America's troops in the field and beyond.
    Technologies include: spinal cord stimulation; joint/limb replacements;
    wound care products; neurological devices; cardiac technologies; and
    many others. Through these technologies, our companies can help provide
    the standard of care reflective of the respect and commitment we owe to
    our Nation's veterans.
        One person's experience exemplifies our industry's mission when it
    comes to our Nation's veterans. Justin Minyard's story reflects the
    kind of people we are working every day to help--a combat veteran
    injured at the Pentagon while lifting and moving rubble in the search
    for survivors, who has found relief from his chronic back pain thanks
    to Boston Scientific's spinal cord stimulator.
        However, recent changes in VA's procurement of these critical
    medical technologies have created new barriers within the veteran
    health care system. These changes have resulted in significant
    inefficiencies in veterans obtaining access to care and reductions in
    the quality of health care accessible to veterans. In the long term,
    these changes risk pushing high caliber providers and suppliers of
    innovative products out of the VA system.
        Our overarching concern is that, collectively, these problems will
    severely restrict timely patient access to critical technologies and
    quality care, delay access to the right product at the right time and
    in the right setting for veterans and their providers, and possibly
    impact the ability of VA to attract and retain medical professionals.
        Thankfully, Congress has begun to address some of these issues and
    work with both the VA and industry on constructive solutions. H.R.
    5418, the Veterans Affairs Medical-Surgical Purchasing Stabilization
    Act authored by Rep. Bergman, is an important step in improving one
    component of the VA's procurement process. This legislation would place
    procurement decisionmaking for the Medical-Surgical Prime Vendor (MSPV)
    in the hands of clinical experts who are best equipped to advise the VA
    on the most appropriate medical technology to meet the health care
    needs of our Nation's veterans. At the same time, it would preserve the
    ability of the VA to obtain a range of products at a competitive price
    from multiple suppliers. AdvaMed supports the Committee's review of
    this legislation today and looks forward to working further with
    Congress on its adoption into law.
        A well-managed MSPV program would have significant benefits, make
    the VA a more efficient medical system, and reduce overall costs. More
    specifically, a well-run MSPV will give the VA: 1) a full spectrum of
    critical medical products for clinicians to be able to meet every
    veteran's needs that does not exist in today's MSPV program, 2) reduce
    the instances of procedure delays and cancellations at Veterans'
    Affairs Medical Centers (VAMCs) due to lack of needed devices in the
    current MSPV program, 3) reduce excessive and costly medical supply
    inventory levels that currently exist at VAMCs, 4) reduce costs to
    procure products, especially the rampant government purchase card use
    that exists today in VA medical centers due to a poorly run MSPV
    program, 5) reduces the time that VHA physicians and nurses are now
    required to spend away from veteran medical care in order to perform
    medical logistics functions, and 6) reduce the risk of gray market
    medical devices being procured by VA when products re not available in
    the MSPV.
        It is important for the VA to have an efficient procurement system
    across the board that allows for faster adoption of new medical
    technologies and standards of care, while also ensuring appropriate
    reimbursement times for those critical products. Improvements to the
    MSPV program are just one aspect of ensuring veterans have access to
    these life-saving and life-enhancing technologies. It is just as
    important to consider similar improvements to the implant procurement
    program, which includes permanently implantable products not available
    through the MSPV program, like joint replacement technologies, stents,
    etc.
        We welcome today's hearing as another opportunity to understand on
    how the VA, Congress, and industry can take a solutions-oriented
    approach to these issues and work together on the most effective
    resolution. We support efforts to ensure the VA, Congress, and industry
    to work together to review and seek ways to better implement processes
    and to ensure that all procurement policies evaluate technologies based
    on the value to patients. Ultimately, the most important measure of the
    success of the VA's new procurement policies is whether the veterans
    that they serve are getting access to the best medical care in a cost-
    effective manner.
        Again, we are grateful for the Committee's leadership on this issue
    and especially appreciate the work of Chairman Isakson, Ranking Member
    Tester, and their staff.
                                     ______

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                                     ______

     Prepared Statement of Amy Webb, National Legislative Policy Advisor,
                                     AMVETS

                                                    Executive Summary
    ----------------------------------------------------------------------------------------------------------------

    ----------------------------------------------------------------------------------------------------------------
    H.R. 299--Blue Water Navy Vietnam Veterans Act of 2018                                                  Support
    ----------------------------------------------------------------------------------------------------------------
    S.514--No Hero Left Untreated Act                                                                       Support
    ----------------------------------------------------------------------------------------------------------------
    S.1596--BRAVE Act of 2017                                                                               Support
    ----------------------------------------------------------------------------------------------------------------
    S.1952--VA Financial Accountability Act of 2017                                                         Support
    ----------------------------------------------------------------------------------------------------------------
    S.1990--Dependency and Indemnity Compensation Improvement Act of 2017                                   Support
    ----------------------------------------------------------------------------------------------------------------
    S.2485--Medal of Honor Surviving Spouses Recognition Act of 2018                                        Support
    ----------------------------------------------------------------------------------------------------------------
    S.2748--BATTLE for Servicemembers Act                                                                   Support
    ----------------------------------------------------------------------------------------------------------------
    S.2881--Mare Island Naval Cemetery Transfer Act                                                         Support
    ----------------------------------------------------------------------------------------------------------------
    H.R. 5418--Veterans Affairs Medical-Surgical Purchasing Stabilization Act                               Support
    ----------------------------------------------------------------------------------------------------------------
    DISCUSSION DRAFT on Transition Assistances Reform                                                       Support
    ----------------------------------------------------------------------------------------------------------------
    DRAFT Veterans Dental Care Eligibility Expansion and Enhancement Act of 2018                            Support
    ----------------------------------------------------------------------------------------------------------------
    DRAFT VA Hiring Enhancement Act                                                                         Support
    ----------------------------------------------------------------------------------------------------------------
    DRAFT bill to require the Secretary of Veterans Affairs to establish a program to award grants to       Support
     person to provide and coordinate the provision of suicide prevention services for veterans
     transitioning from service in the Armed Forces who are at risk of suicide and for their families
     and other purposes
    ----------------------------------------------------------------------------------------------------------------
    DRAFT Modernization of Medical Records Access for Veterans Act                                           Oppose
    ----------------------------------------------------------------------------------------------------------------

        Chairman Isakson, Ranking Member Tester, and all Members of the
    Committee; Thank you for the opportunity to provide a statement for the
    record on behalf of AMVETS' 250,000 members. We are particularly
    thankful for your efforts to address some of the most challenging and
    longstanding veteran policy issues and appreciate the dedication of
    your staff members who listen to us and work tirelessly to formulate
    policies intended to ensure our Nation's veterans and their families
    are properly cared for.
             h.r. 299--blue water navy vietnam veterans act of 2018
    AMVETS supports H.R. 299
        This bill proposes to slightly raise Department of Veterans Affairs
    (VA) home loan fees to fund Agent Orange benefits for the estimated
    90,000 Blue Water Veterans who served during the Vietnam War. AMVETS
    supports this as the fees are minimally raised, and there hasn't been
    an increase in some time. Blue Water Veterans have advocated staunchly
    for this measure, and it is time that they are finally made whole after
    suffering the toxic wounds they incurred during their service to this
    Nation.
        AMVETS is also pleased that this bill allows for a presumption of
    herbicide exposure to certain veterans who served in or near the Korean
    Demilitarized Zone any time from September 1, 1967 to August 31, 1971
    who have conditions covered under section 1116 of title 38.
        Additionally, this measure recognizes the children of veterans who
    served in Thailand between January 9, 1962 and May 7, 1975 who were
    born with spina bifida. Those now adult children will be provided
    benefits including health care, vocational training and rehabilitation
    and a monetary allowance matching the same benefits provided to
    children of Vietnam Veterans who were born with spina bifida.
        AMVETS looks forward to the reporting requirement in this measure
    requiring the Secretary of Veterans Affairs to provide an update report
    on the most recent findings of the Follow-up Study of a National Cohort
    of Gulf War and Gulf Era Veterans to the House and Senate Committees on
    Veterans Affairs.
        While slightly increasing VA home loan fees as a source of revenue,
    we are pleased that Purple Heart recipients and those veterans with a
    service-connected disability rated as permanent and total will have
    said fees waived.
                       s. 514--no hero left untreated act
    AMVETS supports S. 514
        AMVETS is pleased to support the No Hero Left Untreated Act, which
    seeks to establish a pilot program for two Department of Veterans
    Affairs (VA) medical centers to treat fifty veterans using magnetic
    EEG/EKG-guided resonance therapy.
        Magnetic EEG/EKG-guided resonance therapy has successfully treated
    more than 400 veterans with Post Traumatic Stress Disorder, Traumatic
    Brain Injury, military sexual trauma, chronic pain, and opiate
    addiction. This small pilot would be instructive to VA in understanding
    the benefits and deciding whether to offer this promising therapy to
    those receiving VA health care.
        AMVETS is encouraged by the initial results of those treated with
    magnetic EEG/EKG-guided resonance therapy and supports the pilot which
    would allow VA to see the results first-hand, with the eventual goal of
    supporting this alternative therapy. If it were fully understood how to
    treat these nuanced disorders and health issues, VA would already be
    doing so--and suffice it to say--the veteran suicide rate would most
    assuredly be lower than it is now. It is imperative that we study new
    ways to help those who have stood up and walked the walk and suffer the
    consequences day after day.
     s. 1596--burial rights for america's veterans efforts (brave) act of
                                      2017
    AMVETS supports S. 1596
        AMVETS has a National Resolution, voted on by our membership, which
    advocates for the Department of Veterans Affairs to increase burial
    benefits. This measure seeks modest increases with built-in future
    increases related to the Consumer Price Index for funeral expenses for
    veterans receiving, or eligible to receive compensation who have no
    next of kin or other person claiming the body of the deceased veteran,
    and when there are not available sufficient resources to cover burial
    and funeral expenses. It also increases funeral expenses for those
    veterans who died as a result of a service-connected disability, which
    we wholly support.
    s. 1952--department of veterans affairs financial accountability act of
                                      2017
    AMVETS supports S. 1952
        This bill cuts to the heart of what seems to have become regular
    emergency appropriations requests from the Department of Veterans
    Affairs (VA) to Congress. Often, this includes an appeal that if
    Congress fails to act then veterans will suffer. The processes put in
    place with the passage of this bill would indeed create VA financial
    accountability, and a system of checks and balances that can prevent
    needless emergency appropriation requests. The end result of
    implementation would be a more fiscally sound Department, that would
    have knowledge of every avenue of spending, how to forecast needed
    funds in advance, and how to stop ``living paycheck to paycheck'' where
    one emergency, or the inability to forecast necessary funding, cleans
    out the account. Our veterans and taxpayers deserve better, and we
    applaud the bipartisan leadership that introduced this bill.
     s. 1990--dependency and indemnity compensation improvement act of 2017
    AMVETS supports S. 1990
        AMVETS supports the long overdue increase in dependency and
    indemnity payments made to survivors of eligible servicemembers or
    veterans, and the modifications in the measure which eliminates the 10-
    year rule for veterans rated at 100 percent disability and creates a
    five-year rule where eligible survivors can receive a payment prorated
    relative to a percentage of the full 10-year amount of compensation.
       s. 2485--medal of honor surviving spouses recognition act of 2018
    AMVETS supports S. 2485
        AMVETS supports honoring Medal of Honor survivors with this modest
    increase to their special pension.
          s. 2748--better access to technical training, learning and
                entrepreneurship (battle) for servicemembers act
    AMVETS supports S. 2748
        This measure takes a common-sense approach by allowing groups or
    classifications of those under the purview of the Secretaries of
    Defense or Homeland Security to obtain a waiver to opt out of
    additional training. This would be permitted after consultation with
    the Secretaries of Labor and Veterans Affairs who would need to agree
    that the members in question would not benefit from additional training
    and present a strong reason to believe that they are unlikely to face
    major readjustment, health care, employment and other transition
    challenges that some face. The member may also elect not to receive
    additional training by requesting so in writing, or because they are
    needed to support the imminent deployment of a unit. AMVETS believes
    this could be a cost and time-saving policy, while recognizing that
    many do benefit from such training.
                s. 2881--mare island naval cemetery transfer act
    AMVETS supports S. 2881
        S. 2881 directs the Secretary of Veterans Affairs to seek out an
    agreement with the city of Vallejo in California, under which the city
    would transfer control of the Mare Island Naval Cemetery to the
    Department of Veterans Affairs (VA) National Cemetery Administration.
    The VA would pay nothing to acquire the land, and would assume the
    obligation of maintaining the cemetery in the future.
        The cemetery, which dates back 160 years as part of the oldest West
    Coast military base, is the final resting place of 800 veterans,
    including three Medal of Honor recipients. The Federal Government
    closed the Mare Island Naval Base in 1996 without allotting funds for
    the care and maintenance of the cemetery. After more than twenty years
    of neglect, the state of disrepair at the Mare Island Naval Cemetery is
    a national embarrassment, and a disgrace.
        Congress must move swiftly to enact this measure to repair and
    maintain the Mare Island Naval Cemetery.
     h.r. 5418--veterans affairs medical-surgical purchasing stabilization
                                      act
    AMVETS supports H.R. 5418
        This measure adds a needed level of accountability to the
    Department of Veterans Affairs (VA) Medical Surgical Prime Vendor-Next
    Generation (MSPV-NG) program. One vendor should not be permitted to be
    the sole, uncontested provider of medical surgical supplies in a
    certain region, and this would require that multiple contracts be
    awarded while prohibiting a prime vendor from solely designing the
    formulary of supplies.
        It also ensures that VA employees in charge of formulary analyses
    or who makes decisions regarding to including items on the formulary
    have relevant medical expertise. GAO issued a report at the end of 2017
    outlining the improvements needed in purchasing medical and surgical
    supplies and noted how implementing the improvements could yield cost
    savings and efficiency. AMVETS agrees with the GAO recommendations and
    believes passage of this bill can assist in implementing needed change.
               discussion draft on transition assistances reform
    AMVETS supports this Discussion Draft
        AMVETS supports this Discussion Draft which consolidates sections
    1142 and 1144 of Chapter 58 of title 10 into one cohesive section, with
    large expansions geared toward improving the Transition Assistance
    Program for members of the Armed Forces.
        Some highlights from the draft include that it allows the
    natiSecretary of Defense to not require attendance in more than one
    class or counseling session per year, yet strengthens the
    accountability of reporting attendance for covered counseling,
    information, and services and rates of attendance in-person, online,
    and the number of waivers granted when the mission prevented attendance
    by a member of the Armed Forces. This is information will be part of a
    new reporting requirement to Congress.
        The discussion draft also would require surveys of those in the
    Armed Forces to assess their experiences with the TAP counseling,
    information and services provided to include quality of instruction and
    courses and their opinion on if their transition needs were adequately
    met. The survey will also seek to identify barriers or obstacles of
    members in accessing the services or counseling. There will be a second
    survey undertaken after transition has fully taken place which will ask
    about their employment history since separation or retirement, if they
    have been in receipt of unemployment benefits, if they pursued further
    education, have joined a Veterans Service Organization or other
    veterans support group, and will seek details on the satisfaction of
    their separation, and any challenges they may have faced. If married
    during separation some of the survey questions would include the spouse
    experiences. The survey will also request recommendations for
    improvement in the counseling and assistance provided in connection
    with transition.
        AMVETS is excited about the provisions which focus on career
    readiness and professional development to include resume assistance,
    interview and job recruitment training, behavioral, educational and
    financial services, legal and benefits assistance, and non-clinical
    case management.
        We are also pleased that the measure would establish a governing
    board to support prevention of drug overdoses, suicides, alcohol-
    related deaths and homelessness among veterans through strategic
    partnerships with a vast array of established Federal and community
    entities. The board would also track substance abuse and suicide rates
    in addition to its outreach and support. Economic risk factors which
    may affect suicide prevention efforts will also be reported on.
        AMVETS believes this is a strong discussion draft, and that if the
    new measures are added to enhance the current Transition Assistance
    Program are implemented correctly, that it will go a long way toward
    not only encouraging post-transition employment but will address risk
    factors that can lead to feelings of desperation and sometimes suicide.
    We applaud the work of the Senators Crapo, Tester, Cassidy and Sullivan
    on this in-depth, well thought out reform plan.
       draft veterans dental care eligibility expansion and enhancement
                                  act of 2018
    AMVETS supports this Draft measure
        AMVETS supports Section 2 of this measure and amending Section
    1710(c) of title 38 to ensure that eligible veterans may be provided
    dental services and treatment and dental applications needed to restore
    functioning that was lost due to the hospital care, medical services or
    nursing home care the veteran received under Section 1710.
        Section 3 would initiate a three-year pilot program that would
    provide dental services and treatments to veterans currently enrolled
    as a patient in the Department of Veterans Affairs (VA) who are not
    eligible for dental services, treatment and related appliances. The
    services provided would be consistent with those currently provided to
    veterans who are 100% service-connected, and applicable co-pays would
    be collected commensurate to current copays authorized for medical care
    under chapter 17 of title 38.
        The pilot would take place in at least 16 locations and serve up to
    100,000 veterans and there would be a reporting requirement to include
    assessments and cost analysis of the pilot.
        Sections 4 and 5 would allow the VA to lease a dental clinic in
    states where VA does not have a facility that offers onsite dental
    services along with an appropriation of $10,000,000 to carry this out;
    and would develop a dental health education program for enrolled
    veterans.
        Section 6 expands the dental insurance pilot established by section
    17.169 of title 38 to allow private sector dental care providers
    information to VA on dental care furnished to veterans within the pilot
    and extend the pilot for two years.
        Section 7 would establish a VA demonstration program to establish
    programs to train and employ alternative dental health care providers
    to increase access to dental care for veterans who are eligible to
    receive dental services from VA.
        The full amount of appropriations for this Act, if implemented is
    $500,000,000, over a five-year period not including section 4.
        AMVETS understands that dental care is vital to the overall health
    of an individual, and a common complaint we hear from our members is
    their inability to either access affordable dentistry or that a dental
    procedure was delayed to the point that something small turned into an
    incredibly expensive procedure. Sometimes due to delays they have to
    have teeth pulled. AMVETS supports the proposed pilot and the positive
    health outcomes it can provide veterans.
                        draft va hiring enhancement act
    AMVETS supports this Draft measure
        AMVETS supports the intention of this draft, which seeks to allow
    the Department of Veterans Affairs the ability to waive non-compete
    covenants made with a non-VA facility when aiming to hire a VA
    physician. This step can assist in widening the pool of those eligible
    to apply to become a physician at the VA, and lead to filling vacancies
    in a more effective manner.
    draft bill to require the secretary of veterans affairs to establish a
        program to award grants to person to provide and coordinate the
      provision of suicide prevention services for veterans transitioning
      from service in the armed forces who are at risk of suicide and for
                       their families and other purposes
    AMVETS supports this Draft measure
        AMVETS strongly supports this draft, and is pleased that it seeks
    to reach our most vulnerable transitioning veterans at the highest risk
    of suicide by not only working with people who are trained in
    understanding when someone is at high risk, but who have developed
    strategies to meet them where they are an assist in multiple levels
    including mental health, peer support, financial planning, temporary
    transportation if needed, and child care.
        We think the establishment of a VA Program that offers grants to
    persons/groups to coordinate suicide prevention services to veterans
    who would be eligible for 3 years after separating. It gives priority
    to veterans who are currently not being seen within VHA, but the
    veteran must be notified that the Department is funding the care. It
    also prioritizes rural areas, those areas that have experienced a high
    rate of veteran suicide, and places where no health care is furnished
    by VA.
         draft modernization of medical records access for veterans act
    AMVETS opposes this Draft measure
        We owe it to our veterans to protect them and sensitive information
    regarding their health care. HIPPA laws exist for a reason and we are
    concerned that, encrypted or not, a portable credit card device could
    easily be lost, or tampered with, or could put sensitive information in
    the wrong hands. We also owe it to our veterans, as more and more are
    being seen in the private sector, to have the Department of Veterans
    Affairs devise a secure information sharing framework where a patient's
    information can be shared with private sector medical providers with
    the approval of the patient. This bill relieves VA of that
    responsibility and at what cost? At some point, we have faith that
    CERNER will have developed just this capability, but in the meantime
    this type of measure can easily go down a dangerous road, especially
    with no authorization of appropriations. We have seen all too much
    recently, the proposals to cut one form of veterans' benefits in order
    to fund another. In this situation we have faith that record sharing
    can be made amenable for the veterans of all populations, some of whom
    are homeless, and that the burden will not be placed on them to protect
    their own information, but that the system designed to care for them
    will figure out a way to do just that. The private sector has figured
    it out and there is no reason to complicate this.

        Thank you for the opportunity to provide a statement for the record
    for this legislative hearing.
        Please do not hesitate to reach out to AMVETS with any follow up
    questions or concerns.
                                     ______

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      Joint Written Testimony of Hon. Tim S. McClain, Chairman, Board of
     Directors and Mr. James Lorraine, President & CEO, America's Warrior
                            Partnership, Augusta, GA
    Testimony in Support of:

     ``Discussion Draft on Transition Assistance reform''
     S.___(Cassidy), An Act to establish a program to award grants
                to coordinate the provision of suicide prevention
     S. 1990 (Tester/Blumenthal/Hirono), Dependency and Indemnity
                Compensation Improvement Action of 2017
     S. 2485 (Sullivan), Medal of Honor Surviving Spouses
                Recognition Act of 2018

        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee: Thank you for the opportunity to provide testimony today on
    several pieces of proposed legislation that offer the potential to have
    tremendous impact on our Nation's veterans. I am Tim McClain and have
    had the honor of serving our country on active duty for more than 20
    years as a Navy Surface Warfare Officer and JAG Corps Officer, and the
    privilege of serving as a former General Counsel for the U.S.
    Department of Veterans Affairs (VA).
        I am currently the Chairman of the Board of Directors of America's
    Warrior Partnership, a nonprofit organization serving veterans and
    their families. Our mission at America's Warrior Partnership is to
    empower communities to empower veterans. Our approach to the mission
    takes many forms, but it starts with connecting community organizations
    with local veterans to understand their unique needs and situations.
    After gaining this knowledge, we connect local veteran-serving
    organizations with the appropriate resources, services and partners
    that the veteran requires. Our ultimate goal is to create a better
    quality of life for all veterans.
        Our Community Integration model provides the framework for
    organizations to conduct proactive outreach to veterans and
    holistically serve all of their needs. We have seen incredible results
    from this model, which has established relationships with more than
    42,000 veterans since February 2014 in our eight Affiliate Communities
    across the country. Proactive outreach is having a tremendous impact on
    these veterans. More than 90% of our veterans self-report that
    America's Warrior Partnership's proactive engagement and support give
    them a greater level of overall satisfaction, and they believe their
    community really cares about their well-being. America's Warrior
    Partnership's Community Integration model works.
        Providing testimony with me today is the president and CEO of
    America's Warrior Partnership, Mr. Jim Lorraine, who is also a veteran
    of our great country having served for 22 years as an Air Force Officer
    and Flight Nurse. Prior to founding America's Warrior Partnership, Mr.
    Lorraine served as the founding director of the United States Special
    Operations Command Care Coalition, a wounded warrior advocacy
    organization recognized as the gold standard in supporting more than
    4,000 special operations force wounded, ill, or injured and their
    families. He has also served as Special Assistant for Warrior and
    Family Support to the Chairman, Joint Chiefs of Staff, during which
    time he transformed the Chairman's ``Sea of Goodwill'' concept into a
    strategy. Mr. Lorraine will provide America's Warrior Partnership's
    testimony regarding four pieces of proposed legislation.
        Mr. Lorraine. Thank you, Mr. McClain. In my testimony today, I will
    first address the draft of the proposed legislation on Transition
    Assistance Program reform.
        We believe this reform establishes a very important goal for
    improving services to our Nation's warriors and that, in theory, it
    could have a very positive impact on veterans and the community. We
    fully support and embrace a holistic approach to serving veterans'
    needs, as evidenced by our mission and work at America's Warrior
    Partnership. We have seen first-hand the positive effects that
    proactive outreach has on veterans, and we are pleased that this reform
    both acknowledges this fact and empowers organizations to conduct this
    outreach. Specifically, including communities in the Transition
    Assistance Program reform through the proposed grant program will be
    revolutionary in the ability to locally transition veterans and measure
    long-term outcomes. The draft legislation is the first comprehensive
    legislative approach to assisting military members in their transition
    to civilian life. All of the requirements in the draft are sorely
    needed. However, we would like to state how important collaboration
    among the Department of Defense (DOD), Department of Labor (DoL) and
    the VA is to the success of this reform. Each department brings their
    strength to transition, but we strongly feel DoL is in the best
    position to administer the community interface since the path to
    success is employment. With greater DoL emphasis during pre-transition
    training, the end result will prove measurable and impactful.
        Additionally, the notion of these departments working together to
    implement the Transition Assistance Program has been the mission for
    many years, but it has not proven as effective as intended. Strong
    engagement and support from the DOD, DoL and the VA collectively is
    essential to achieving the goal of real and lasting reform in warrior
    transition. I want to reiterate that we at America's Warrior
    Partnership fully support the goal of this reform, and respectfully
    offer our constructive input based on experience in order to make this
    reform even stronger by stressing the importance of collaboration, a
    principle that also forms the foundation of our own organization's
    work.
        The second piece of legislation I would like to comment on concerns
    the establishment of a grant program to support suicide prevention
    services. The VA reported earlier this year that, on average, 20
    veterans die by suicide every day. This is an alarming public health
    concern that affects every community in the country, and this
    legislation is a step in the right direction of ensuring veteran-
    serving professionals have the means to proactively help at-risk
    veterans. The financial support offered by this program will bolster
    the work of researchers who are currently studying the indicators and
    risk factors of suicide and self-harm among veterans. Our team at
    America's Warrior Partnership is collaborating on one such study with
    University of Alabama researchers through funding from the Bristol-
    Myers Squibb Foundation. This project, called Operation Deep Dive, is
    the first of its kind to evaluate the role that community environments
    and less-than-honorable discharges may have in suicide among veterans,
    among other factors. The goal of the study is to provide actionable
    insights that can guide the development of effective programs for
    reducing self-harm among veterans. The findings provided by projects
    such as Operation Deep Dive, combined with the support of this grant
    program, are critical elements that will empower communities to help
    veterans live and thrive long after their service is complete.
        My third testimony addresses Senate Bill 1990, which would increase
    dependency and indemnity compensation to surviving family members of
    veterans who were rated totally disabled at time of death. Military
    families serve in their own way by supporting their loved ones both
    during active duty and in their transition to civilian life. The
    service and sacrifice of our veterans may at times result in a
    disability that puts significant strain on the veteran and their family
    members who care for them. Our team at America's Warrior Partnership
    and the affiliate communities that we collaborate with understand these
    sacrifices, which is why our holistic approach to serving veterans is
    always inclusive of their families as well. This bill has the potential
    to offer a lifeline to the families of disabled veterans who need it
    most.
        Finally, I would like to comment on Senate Bill 2485, which would
    provide payment of a special pension to the surviving spouse of a
    deceased Medal of Honor recipient. Our Nation's Medal of Honor
    recipients go above and beyond the call of duty, and we as a nation owe
    them nothing less in return. America's Warrior Partnership is honored
    to have two Medal of Honor recipients serve on our board of directors.
    Their integrity and example continue to guide our mission of empowering
    communities to empower veterans, and the support provided by this
    legislation can help the families of Medal of Honor recipients continue
    their legacy long after their service is complete.
        I appreciate the opportunity to comment on these critical areas and
    will now let Mr. McClain conclude our testimony.
        Mr. McClain. Thank you, Mr. Lorraine.
        Chairman Isakson, thank you for inviting us to provide testimony
    today. We are both honored and pleased to have this opportunity. Our
    mission is the same as the mission of this Committee: to ensure that
    all veterans are taken care of and provided the benefits that they have
    rightfully earned through their service to our country. There is much
    work to be done, and we look forward to continue collaborating with the
    Department of Veterans Affairs and our partners across the country to
    empower veterans from all walks of life as they transition to civilian
    life.
        Thank you again for the invitation to share our testimony today.
                                     ______

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      Prepared Statement Submitted by Cinthia Johnson, Interim Executive
                  Director, Connecticut Veterans Legal Center

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                                     ______

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        Prepared Statement of Jeremy M. Villanueva, Associate National
                Legislative Director, Disabled American Veterans
        Mr. Chairman and Members of the Committee: Thank you for inviting
    DAV (Disabled American Veterans) to submit testimony for the record of
    this legislative hearing of the Senate Veterans' Affairs Committee. As
    you know, DAV is a non-profit veterans service organization comprised
    of more than one million wartime service-disabled veterans that is
    dedicated to a single purpose: empowering veterans to lead high-quality
    lives with respect and dignity. DAV is pleased to offer our views on
    the bills under consideration by the Committee.
             h.r. 299, blue water navy vietnam veterans act of 2018
        H.R. 299 was passed by the House of Representatives with a vote of
    382 to 0 on June 25, 2018.
        Section 2 (Clarification of Presumptions of Exposure for Veterans
    Who Served in Vicinity of Republic of Vietnam) would provide
    presumption of service connection for herbicide exposure for Vietnam
    era veterans with service in the waters offshore. The bill defines a
    location as being offshore of Vietnam if the location is not more than
    12 nautical miles seaward of a line commencing on the southwestern
    demarcation line of the waters of Vietnam and Cambodia and intersecting
    specific points as noted.
        The Agent Orange Act of 1991 required the Department of Veterans
    Affairs (VA) to provide presumptive service connection to Vietnam
    veterans with illnesses that the National Academy of Sciences directly
    linked to Agent Orange exposure. Yet, in 2002, the VA decided to cover
    only veterans who could prove that they had ``boots on the ground''
    during the Vietnam War. Because of this decision, thousands of Vietnam
    veterans were excluded from receiving benefits although these ``Blue
    Water'' Navy veterans had significant Agent Orange exposure from
    drinking and bathing in contaminated water just offshore. It is simply
    inequitable that veterans who served on ships no more distant from the
    spraying of herbicides than many who served on land have been
    arbitrarily and unjustly denied benefits because they are excluded from
    the presumption of service connection for herbicide-related
    disabilities.
        DAV strongly supports Section 2 (Clarification of Presumptions of
    Exposure for Veterans Who Served in Vicinity of Republic of Vietnam)
    based on DAV Resolution No. 033, which calls for legislation to
    expressly provide that the phrase ``served in the Republic of Vietnam''
    include service in the territorial waters offshore.
        Enactment of this legislation would provide ``Blue Water'' Navy
    Vietnam veterans the disability and health care benefits they earned as
    a result of exposure to Agent Orange. Eligibility for VA benefits under
    this legislation would be retroactive to September 25, 1985, the date
    VA began providing disability compensation to veterans with medical
    disorders related to Agent Orange providing long overdue justice to
    thousands of veterans who were excluded by the VA in 2002.
        Section 3 (Presumption of Herbicide Exposure for Certain Veterans
    who served in Korea) would recognize September 1, 1967 as the earliest
    date for exposure to herbicides on the Korean demilitarized zone (DMZ).
        Currently, VA regulations provide that any veteran who, during
    active military, naval, or air service, served between April 1, 1968,
    and August 31, 1971, in a unit that, as determined by the Department of
    Defense, operated in or near the Korean DMZ in an area in which
    herbicides are known to have been applied during that period, shall be
    presumed to have been exposed during such service to an herbicide
    agent. Section 2 would define the exposure to herbicides as a veteran
    who, during active military, naval, or air service, served in or near
    the Korean DMZ, during the period beginning on September 1, 1967, and
    ending on August 31, 1971.
        In accordance with DAV Resolution No. 090, we also support Section
    3, to recognize September 1, 1967, as the earliest date for exposure to
    herbicides on the Korean DMZ. This change will provide veterans exposed
    to herbicides on the Korean DMZ with greater equity with respect to
    herbicide exposure and the presumptive diseases associated therein.
        Section 4 (Benefits for Children of Certain Thailand Service
    Veterans born with spina bifida) would provide children of veterans
    exposed to herbicides in Thailand, who are suffering from spina bifida,
    the health care, vocational training and rehabilitation, and monetary
    allowance required to be paid to the children of Vietnam veterans who
    are suffering from spina bifida.
        VA provides spina bifida-related benefits for the children of
    Vietnam veterans exposed to herbicides in Vietnam and on the DMZ in
    Korea. This bill would provide the same entitlements to the children of
    Vietnam era veterans exposed to herbicides while serving in Thailand.
    In accordance with DAV Resolution No. 090, we support Section 4, as it
    provides relief and equity to veterans' children suffering from the
    devastating effects of spina bifida.
        Section 5 (Updated Report on certain Gulf War Illness study) would
    require the VA to submit to the Committees on Veterans' Affairs of the
    House of Representatives and the Senate an updated report on the
    findings, as of the date of the updated report, of the Follow-up Study
    of a National Cohort of Gulf War and Gulf Era Veterans under the
    epidemiology program of the VA.
        The VA has recognized certain illnesses associated with Gulf War
    service in the Southwest Asia theater of military operations from
    August 2, 1990 to the present. These medically unexplained illnesses
    are long-term health problems with significant impairments.
        DAV has significant concern regarding the multitude of ailments
    reported by a growing number of Persian Gulf War veterans who were
    exposed to both identified and unknown health hazards. In accordance
    with DAV Resolution No. 261, we support Section 5, the requirement for
    the updated report of the Follow-up Study of a National Cohort of Gulf
    War and Gulf Era Veterans under the epidemiology program of the VA.
        Section 6 (Loans Guaranteed Under Home Loan Programs of Department
    of Veterans Affairs) would make several changes to the VA Home Loan
    Guaranty program. First, it would remove the current limit on maximum
    loan guaranties to align it with other Federal home loan programs that
    allow nonconforming, or ``jumbo'' loans. Second, it would increase the
    fees charged to veterans using the program by approximately .25 percent
    for nine years, thereafter reverting to the fee schedule as it
    currently exists. It is important to note that veterans with a service-
    connected disability are currently exempt from paying any home loan
    guaranty fees. Third, it would require that veterans with less than a
    total disability rating be required to pay fees for loan guaranties if
    they require a jumbo loan guaranty above the conforming limits. These
    fees would apply to the entire loan guaranty, not just the portion
    above the limit.
        DAV Resolution No. 002, adopted at our most recent National
    Convention this July in Reno, Nevada, `` . . . vigorously opposes any
    recommendations made for the purpose of reducing, adding limitations on
    or eliminating benefits for service-connected disabled veterans and
    their families.'' By imposing fees for the first time on VA home loan
    guaranties for service-disabled veterans, this Section would
    effectively reduce the value of benefits that have already been paid
    for through their service and sacrifice. DAV opposes Section 6 of the
    bill.
        DAV does not have a resolution specific to Section 7 (Information
    Gathering for Department of Veterans Affairs Home Loan Appraisals) and
    takes no position on this section.
     h.r. 5418, veterans affairs medical-surgical purchasing stabilization
                                      act
        This measure would require the VA to use multiple vendors in
    procuring medical supplies and ensure that the employees responsible
    for selecting the supplies have medical expertise regarding those
    items. VA currently uses four vendors to purchase its medical supplies
    and employs clinicians on its integrated product teams to select those
    supplies. VA would also be required to submit quarterly reports to the
    Congress identifying the individual employees at VA who determine which
    items to purchase for VA's formulary and describing their medical
    expertise.
        We urge the Committee ensure this bill requires VA support
    businesses controlled by service-disabled veterans in its medical
    surgical prime vendor program. DAV Resolution No. 306 calls for
    legislation requiring the Federal Government make mandatory set-asides
    of not less than 3 percent of the total value of all prime and
    subcontract awards to businesses controlled by service-disabled
    veterans each fiscal year. Additionally, it calls for effective
    monitoring and accountability for Federal agencies that are not meeting
    the set-aside goal of not less than three percent, and a mandate to
    list in their annual reports their prior fiscal year's actual
    percentage of meeting this goal, the results of which would serve as an
    annual report card of which agencies need the most assistance in the
    development and implementation of stronger contracting compliance.
        In addition, DAV Resolution No. 277 calls for the provision of all
    supplies, prosthetic devices and medications, including over-the-
    counter medication, necessary for the proper treatment of service-
    connected disabled veterans. This recognizes VA's more recent efforts
    to aggressively standardize durable/disposable equipment, including
    prosthetics and similar items, to realize greater savings by buying
    fewer distinct items in greater quantity from fewer suppliers while
    minimizing the volume of government purchase card usage to the
    detriment to the veteran patient. We support the provision in this
    measure that would require clinically driven sourcing to ensure
    adequate input from frontline clinical providers with the expertise on
    the specific items within the formulary to ensure veterans receive the
    prosthetics and similar items that promote, preserve, and restore the
    veteran's whole health and not merely for medical necessity.
                       s. 514, no hero left untreated act
        S. 514 would require the VA secretary to carry out a pilot program
    to provide veterans access to magnetic EEG/EKG-guided resonance therapy
    (also known as transcranial magnetic stimulation or TMS). The year-long
    pilot program would take place at not more than two VA facilities for
    not more than 50 veterans. VA would be required to submit a report
    about the pilot 90 days after the termination of the pilot.
        In 2008, the Food and Drug Administration (FDA) approved TMS for
    drug resistant major depression. Other applications of TMS to such
    conditions as to Post Traumatic Stress Disorder (PTSD), Traumatic Brain
    Injury, chronic pain, and opiate addiction (conditions targeted by this
    bill) are considered ``off-label'' meaning that doctors may employ
    them, but the therapy has not been approved for these purposes.
        Emerging research has shown that TMS does reduce symptoms of PTSD
    and helps with some other issues such as autism and Alzheimer's
    although many questions remain about the duration of symptom relief,
    how to most appropriately administer the treatment and whether TMS is
    more effective for all conditions than more conventional treatments.
        As we understand it, VA does own a significant number of these
    machines. Some are being used in studies, but some are beginning to
    offer treatment for depression under the accepted FDA protocol.
        DAV Resolution No. 277 calls for VA to provide access to
    complementary and integrative medicine. Likewise, we have consistently
    called on VA to develop innovative approaches to manage and treat
    mental health conditions (Resolution No. 293).
        While the empirical evidence for TMS applications continue to
    emerge, DAV believes that veterans deserve access to the promising
    results of treatment claimed by veterans who have used TMS and hopes
    that additional studies using this technology will yield more
    information in support of the treatment for other conditions. For these
    reasons, DAV supports S. 514.
     s. 1596, the burial rights for american veterans' efforts (brave) act
                                    of 2017
        S. 1596 would increase the burial allowance payable to the
    veteran's beneficiary regardless of whether the death occurs in a VA
    facility and provides for automatic annual adjustments to keep up with
    future inflation.
        The passage of Public Law 111-275, the Veterans Benefits Act of
    2010, resulted in an increase in both plot and burial allowance from
    $300 to $700 for nonservice-connected deaths in VA facilities. It is
    indexed to the Consumer Price Index for annual adjustments and
    currently pays $762. However, it did not address nonservice-connected
    deaths that did not occur in VA facilities nor did it address service-
    connected death burial payments currently at $2000.
        The current $300 burial allowance for nonservice-connected deaths
    not in VA facilities was last increased in April 1988 and the current
    $2000 burial allowance for service-connected death was last increased
    in December 2001.
        In 1973, the burial allowance for veterans with no next of kin and
    non-service-connected death was 22 percent of funeral and burial costs.
    The current $300 burial allowance for nonservice-connected deaths not
    in VA facilities in comparison to the average cost of a funeral is
    about $9,000, decreasing the value of this allowance significantly to
    approximately 3 percent.
        Service-connected death burial allowance in December 2001 was
    $2,000 and the average funeral cost at that time was $6,000. The
    payment value was 33 percent of the cost. Today, the average funeral
    cost has increased to $9,000, decreasing the value down to 22 percent
    of the burial allowance benefit, a decrease of 11 percent.
        We note that the median cost of funerals and burials is rising
    higher than the Consumer Price Index for all urban consumers (CPI-U).
    S. 1596 would tie the benefit to the CPI-U, providing some needed
    adjustment; however, in the long-term, the benefit will erode if this
    discrepancy continues.
        Notwithstanding, DAV strongly supports S. 1596, in accordance with
    DAV Resolution No. 054, adopted at our most recent national convention.
    Our resolution calls on Congress to support legislation to increase the
    burial allowance payable in the case of death due to service-connected
    disability regardless of whether the death occurs in a VA facility and
    provide for automatic annual adjustments indexed to the cost-of-living
    increases.
                s. 1952, va financial accountability act of 2017
        This bill would require VA to contract with a third-party to review
    and audit its financial processes and models for estimating veterans'
    demand for services that inform its budget request. It would further
    require the contractor to make recommendations about improving such
    models within 180 days of being awarded the contract. VA would then be
    required to submit a plan for implementing these recommendations within
    60 days of completion of the review. VA would appoint an individual to
    ensure that the third party recommendations are implemented along with
    those pertinent recommendations of the Government Accountability
    Office, the Special Counsel and VA's Inspector General. The Secretary
    would have to justify, within 45 days, any requests for supplemental
    appropriations. The bill would also require VA's Chief Financial
    Officer (CFO) to certify that the budget request is sufficient to
    provide benefits and services for veterans required by law, and that
    the CFO has made consultations with budget officers throughout the
    Department to estimate budgets.
        DAV has a long history of supporting predictability and
    transparency in VA's budget process under DAV Resolution No. 112. We
    strongly advocated for the passage of Public Law 111-81 which required
    advanced appropriations for VA's Medical Care account and has
    subsequently protected veterans from delayed or denied care due to
    government shutdowns. This same law required that GAO submit an
    analysis of VA's actuarial models versus its actual obligations in
    fiscal years 2011, 2012, and 2013. We note that in recent years VHA has
    been compelled to deal with a series of major transitions in health
    care delivery such as the Veterans Choice Program, and now the VA
    MISSION Act of 2018 that have drastically changed how the Department
    estimates demand for services. These changes likely account for much of
    the lack of precision in recent budget requests and the subsequent need
    for supplemental funding. Yet it is important to ensure transparency in
    these efforts, which is why DAV opposed the proposal to consolidate
    Medical Services and Medical Community Care accounts.
        We believe as VA continues to evolve its practices such as
    recording community care obligations at the date of payment rather than
    at the date of authorization and gains experience with its new
    contracting authorities, its estimations will likely become more
    accurate. Nonetheless, DAV understands the importance of accurate
    budget models and processes and therefore are pleased to support
    S. 1952.
     s. 1990, dependency and indemnity compensation improvement act of 2017
        S. 1990 would increase dependency and indemnity compensation (DIC)
    for surviving dependents and would lower the threshold of eligibility
    to allow certain survivors to receive this benefit who currently do not
    meet the requirements.
        Under title 38, United States Code, Sec. 1318(b)(1), a survivor, is
    eligible for DIC if the veteran was 100 percent permanently and totally
    disabled for ten years prior to death. S. 1990 would ease the 10-year
    rule for eligibility and replace it with a graduated scale of benefits
    that begins after five years. If a veteran is rated as totally disabled
    for five years and dies as a result of a non-service-connected cause, a
    survivor would be entitled to 50 percent of total DIC benefits. This
    concept of the percentage of benefits payable based the number of years
    is applicable for payments at 60, 70, 80, 90, and then 100 percent of
    the DIC amount.
        This bill would increase the DIC base rate as equal to 55 percent
    of the rate of compensation paid to a totally disabled veteran, making
    it more equitable with rates provided to Federal civilian employee
    survivors, and it would reduce the age allowed for a surviving spouse
    to remarry and maintain their benefits from 57 to 55, consistent with
    other Federal survivor benefit programs.
        DAV's Resolution No. 036, which was approved by our members during
    our most recent National Convention, supports legislation to reduce the
    10-year rule for DIC qualification.
        DAV strongly supports S. 1990. Not only would this bill reduce the
    threshold of eligibility for certain survivors, it would also create
    equitable relief in increasing the compensation rates paid, and reduce
    the age allowed for the surviving spouse to remarry and retain their
    benefits.
       s. 2485, medal of honor surviving spouses recognition act of 2018
        S. 2485 would increase the monthly special pension for Medal of
    Honor recipients and extend eligibility to surviving spouses.
        The bill would codify the increase in the monthly special payment
    from $1,000 to $1,329.58 under title 38, United States Code, Sec. 1562.
    The bill would allow the special pension to be paid to a surviving
    spouse upon the veteran's death.
        DAV does not have a resolution calling for an increase of the
    monthly special pension for Medal of Honor recipients or expanding
    eligibility to the pension benefit to the surviving spouse upon the
    death of the veteran. While we have no formal position on S. 2485, we
    have no objection to its favorable consideration by the Committee.
                     s. 2748, battle for servicemembers act
        S. 2748 would encourage greater participation in the additional two
    day training program that occurs after the three day required portion
    of the Transition Assistance Program (TAP). Specifically, a
    servicemember could choose a two day training session on either higher
    education, technical training, or entrepreneurship. Instead of
    continuing with an opt-in option, the bill would make the training opt-
    out so that more transitioning servicemembers would utilize this
    important training. According to a 2017 GAO report (GAO-18-23), only 14
    percent of separating servicemembers completed at least one additional
    two-day training program after completing the three day required
    portion of TAP.
        Mr. Chairman, DAV has no resolution on this particular issue, but
    believes the intent of this legislation is in keeping with the goal of
    ensuring that all servicemembers have the tools and information needed
    to successfully transition into civilian life. We therefore have no
    objection to this legislation's favorable consideration.
                s. 2881, mare island naval cemetery transfer act
        S. 2881 would direct the Secretary of Veterans Affairs to seek to
    enter into an agreement with the city of Vallejo, California, to hand
    over ownership and care of the Mare Island Naval Cemetery to the
    National Cemetery Administration (NCA). Mare Island Naval Shipyard
    (MINS) was the first United States Navy base established on the Pacific
    Ocean in 1853. During its time of service, it served as the main
    shipyard for naval operations in the Pacific and housed the United
    States Marine Corps' Recruit Depot from 1911 to 1923. The shipyard was
    identified for closure during the Base Realignment and Closure (BRAC)
    process of 1993 and was decommissioned in 1996. Since that time the
    city of Vallejo has owned the property.
        The Mare Island Naval Cemetery was established in 1854 and
    continued internments until 1921. Notable internments are the daughter
    of Star Spangled Banner composer Francis Scott Key and three Medal of
    Honor recipients. It currently is the final resting place for more than
    800 individuals, most of them veterans. It was included in the National
    Register of Historic Places in 1975.
        After the closure in 1996, the cemetery fell into disrepair.
    Multiple structural issues have been noted--tombstones are crumbling,
    and most of the maintenance is done through volunteer efforts. The
    estimated cost for repairing the cemetery and future upkeep is
    currently at $15 million.
        DAV does not have a resolution that addresses this issue and takes
    no position on this bill; however, we understand that there are local
    options that could be pursued to resolve this issue that would not
    divert resources and funding from National Cemeteries that are still
    accepting new internments.
     s. 3184, to modify the requirements for applications for construction
      of state home facilities to increase the maximum percentage of non-
               veterans allowed to be treated at such facilities
        State Veterans Homes are long term care facilities operated by
    states in partnership with the Federal Government. States receive
    matching grants from VA to construct, expand, rehabilitate and repair
    State Veterans Homes, with VA providing up to 65 percent and states
    providing at least 35 percent of the cost of the project. State
    Veterans Homes are constructed and operated principally to care for
    veterans, and current law requires that no more than 25 percent of
    occupied beds can be filled by non-veterans, such as spouses or parents
    as determined by individual states. State Veterans Homes offer three
    levels of care: Nursing Home Care; Domiciliary Care; and Adult Day
    Health Care (ADHC), with VA providing per diem payments to states for
    the care of eligible veterans for each level of care. For nursing home
    care, the State Veterans Home receives a basic per diem payment for
    each eligible veteran, equal to approximately 30 percent of the total
    daily cost of care, with states required to cover the balance through
    other sources, including payments from veterans. Some veterans qualify
    for a higher per diem rate due to their service-connected disabilities,
    which is intended to cover the full cost of their care, and constitutes
    payment in full to the State Veterans Home.
        This bill would amend current law to allow spouses or parents of
    veterans to occupy up to 40 percent of the total occupied beds in a
    State Veteran Home if its occupancy rate is less than 90 percent. This
    legislation is intended to allow additional spouses or parents to
    occupy open beds, often joining their veteran spouse or child, when
    there are no eligible veterans seeking admission to the State Veterans
    Home.
        DAV is a strong supporter of State Veterans Homes. This bill
    intends to assist State Homes utilize available capacity, thereby
    increasing cost-effectiveness and financial viability, while also
    improving the quality of life for certain veterans and spouse by
    keeping couples together. DAV has no resolution on this specific issue
    and takes no formal position on the bill. Because we do not know how
    this proposed policy will affect State Veterans Homes across the
    country, we want to ensure service-connected veterans are not
    disadvantaged or otherwise delayed or denied placement. Accordingly, we
    recommend the Committee consider other reasonable options, such as
    adding reporting requirements to the bill to assess how it affects
    service-connected veterans' admission to State Veterans Homes, using a
    waiver authority to the current occupancy rule, or a starting a pilot
    program in select locations.
                     draft bill, va hiring enhancement act
        This draft bill would render ``non-compete'' agreements between an
    applicant for VA employment and a previous employer non-applicable with
    regard to VA employment. Employees appointed with this understanding
    would be required to serve out the length of their non-compete
    agreement within their VA position or serve in that position for at
    least one year (whichever is longer). The bill intends to allow VA, on
    a contingent basis, to begin recruiting and hiring physicians up to two
    years before they complete their residency, as well as physicians who
    have completed their residencies leading to board certification. These
    contingent appointed physicians must satisfy VA's requirements to
    receive a permanent appointment.
        We appreciate the goal of this legislation aimed at creating as
    large an applicant pool for qualified medical professionals to treat
    our service-disabled veterans as possible in VA. DAV Resolution No. 129
    calls for effective recruitment, retention and development of the VA
    health care workforce. Because this measure attempts to reduce barriers
    for employment at VA for physicians; we are pleased to support the
    bill's passage.
          draft bill, veterans dental care eligibility expansion and
                            enhancement act of 2018
        The ``Veterans Dental Care Eligibility Expansion and Enhancement
    Act of 2018'' would require VA to offer restorative dental services to
    those who lose functioning as a result of dental services or treatment
    rendered by VA. It would also require the Secretary to develop a pilot
    program to assess the feasibility and advisability of offering dental
    care to all enrolled veterans.
        The pilot program would begin 540 days after enactment and take
    place in at least 16 medical centers including: four centers with
    established dental clinics; four centers with a contract for dental
    services; four community-based outpatient clinics with space available
    to furnish care; and, four federally qualified health centers of which
    at least one must be a facility the Indian Health Service with
    established dental clinics. Not more than 100,000 veterans would
    participate in the program on a voluntary basis. Services would include
    those available to veterans with service-related disabilities rated by
    VA at 100 percent. Veterans must contribute to the cost of their dental
    care in a manner consistent with the copayments required of them for VA
    medical care and services.
        Site selection for the selected participating medical centers would
    consider rural facilities; facilities distant from military
    installations and would represent the various geographic locations (or
    census tracts) identified by the Bureau of the Census. VA would
    determine the appropriate performance standards and metrics for each
    contract entered under the pilot, as well as specifying how compliance
    is to be measured.
        VA would be required to report 540 days after enactment and 3 years
    after the date the program commences about the implementation and
    operation of the pilot program in addition to the number of veterans
    receiving services, an analysis of the costs and benefits associated
    with the program as well as findings and conclusions.
        The bill would also require the Secretary to construct or lease
    dental clinics in states in which the Department does not have onsite
    dental services and would appropriate $10 million in emergency funding
    to support construction or lease of such facilities.
        The legislation further specifies an educational program VA would
    be required to operate. The program would promote dental health and
    include information about common dental conditions, treatment options
    and options for obtaining access to dental care including defining
    eligibility for VA services, options available through State or local
    governments or nonprofit agencies; purchasing private dental insurance
    or obtaining free or low cost care through federally qualified health
    centers or dental schools. It would also require VA to develop written
    material with this information, including for blind or visually
    impaired veterans.
        The bill would further require VA to develop a mechanism for
    private sector providers working with veterans under the dental
    insurance pilot program (established under Sec. 17.169 of title 38,
    Code of Federal Regulations) to share information in VA electronic
    medical records. The bill would give the Secretary the discretion to
    continue the pilot for an additional two years after the termination
    date in order to assess the mechanism for sharing this information.
    Individual veterans would be given the option of participating in this
    part of the pilot.
        The draft legislation contains a demonstration program to train and
    employ alternative dental health care providers in rural and
    underserved areas to increase veterans' access to dental care.
        Finally, the bill would authorize an additional $500 million in
    fiscal year 2020, to be available for five years, for the provisions of
    this act excluding the construction or major lease funding.
        DAV recognizes that oral health is integral to the general health
    and well-being of a patient and is part of comprehensive health care.
    According to a 2000 report by the Surgeon General of the United States,
    Oral Health in America, individuals who are medically compromised or
    who have disabilities are at greater risk for oral diseases, and, in
    turn, oral diseases further jeopardize their health. Likewise, such
    diseases are progressive, cumulative and become more complex over time,
    and can affect economic productivity and compromise the ability of
    someone to work, and often significantly diminish their quality of
    life.
        Irrespective of service-connected disability, section 1701(9),
    title 38, United States Code, defines ``preventive health services'' as
    a broad collection of VA health services that improve, protect and
    sustain the general health and well-being of veterans enrolled in VA
    health care, to include ``such other health care services as the
    Secretary may determine to be necessary to provide effective and
    economical preventive health care''
        For these reasons, DAV supports a dental benefit for all enrolled
    service-connected veterans in accordance with DAV Resolution No. 018.
    draft bill, to require the secretary of veterans affairs to establish a
       program to award grants to persons to provide and coordinate the
      provision of suicide prevention services for veterans transitioning
      from service in the armed forces who are at risk of suicide and for
                                 their families
        This draft bill would authorize grants to individuals for the
    purpose of providing and coordinating suicide prevention services for
    eligible veterans or a family member of a veteran who is within 3 years
    of being discharged from military service and may be at risk of
    suicide.
        The grant applicant would be required to identify how they would
    deliver suicide prevention services and any previous experience with
    providing or coordinating such services with veterans and their family
    members including outreach to at risk veterans, screening, education
    about veterans at risk for families and communities, case management,
    peer support, and assistance with obtaining benefits, temporary
    assistance with transportation, personal financial planning, legal
    services, and other services, such as family support and child care.
        The Secretary would be required to give priority to applicants
    serving areas of the country that have experienced a high burden of
    veteran suicide, areas where no health care is furnished by the
    Department or rural and tribal areas of the country.
        DAV is extremely sensitive to the post-deployment mental health and
    readjustment needs of veterans and the challenges they often face
    during transition from military to civilian life. The intent of this
    draft legislation and its apparent goal of utilizing individuals to
    help prevent veteran suicides in locations where services are limited
    or non-existent is notable.
        While we appreciate the intent of the bill, DAV is concerned about
    the quality of care that may be delivered by applicants and the
    difficulty in providing oversight for such an award program and
    individual grant recipients. DAV believes that the range and intensity
    of mental health programs VA and VA's Readjustment Counseling Service
    offers and delivers--from peer-to-peer support, outpatient, in-patient
    and a compliment of specialized services for PTSD, substance use
    disorder and homelessness provide the depth, breath and quality of care
    necessary to meet the mental health care needs of veterans during their
    initial transition period.
        In addition, as VA grapples with establishing the new contract
    program combining existing contracting policies and programs into one
    under the VA MISSION Act of 2018, DAV has concerns about embracing a
    new grant program that would require VA to fund and monitor the
    provision of additional care in the private sector to individual
    persons. We also believe that, under the auspices of the VA MISSION
    Act, many of the goals of promoting access and availability to remote
    vulnerable veterans can be achieved with knowledgeable vetted
    providers. We, therefore, do not support this discussion draft bill.
      draft bill, modernization of medical records access for veterans act
        VA is in the process of a sea change in managing its medical
    information. Last June, VA announced it would contract with Cerner to
    create a new platform for managing electronic health records. The goal
    of this contract is for VA to have information that is more
    interoperable with the Department of Defense, academic affiliates, and
    other community providers. This is a critical tool enabling providers
    to transfer information within the VA and with its partners--done
    correctly, it could assist in coordinating care, timely scheduling of
    appointments, eliminating duplicative services, ensuring patient
    safety, assessing organizational performance and easing administrative
    burdens, including quality assurance and billing. It is a massive
    undertaking that will likely take billions of dollars and staff and
    contractor hours to implement.
        This draft bill would require VA to develop a pilot program to
    assess the use of a portable medical records storage system to store
    patient information in order to share timely information between VA and
    community providers. The pilot program would run in one VISN for at
    least one year using a competitively awarded contract to develop a
    portable device no bigger than a credit card to allow veterans to carry
    at least 4 gigabytes of medical information between VA and non-VA
    providers. While some of the goals of this pilot may be similar to
    those being considered by Cerner, it is difficult to understand whether
    this undertaking would add or detract from the larger effort underway.
    Because the bill appears to approach personal storage of medical
    information using external hard drives and limits the use of cloud
    storage, we urge the Committee consider including provisions that
    require tracking and mitigation when the security of the portable
    device is compromised. DAV does not have a resolution on VA medical
    records management and therefore takes no position on this draft bill.
                transition assistance reform (discussion draft)
        The discussion draft bill on Transition Assistance Reform would
    provide changes to the Transition Assistance Program (TAP) and specific
    requirements on the Departments of Defense (DOD) and Homeland Security
    (DHS), to include training requirements, reports to Congress, creation
    of a five year longitudinal study, inclusion of veteran service
    organizations in TAP, and establishment of a governing board to support
    suicide prevention and substance abuse prevention efforts.
        Section 2 (Recodification, Consolidation, And Improvement of
    Certain Transition-Related Counseling and Assistance Authorities) would
    eliminate the existing title 10, United States Code, Sec. Sec. 1142 and
    1144 and provide a new statue defining the Transition Assistance
    Program. The proposed new statute would incorporate all of the current
    language from both statutes and continue to address information on
    civilian employment including labor market information, instruction on
    resume preparation, job interview techniques and certification and
    licensure requirements in civilian occupations that correspond to
    military occupational specialties.
        DAV Resolution No. 298 urges Congress to establish a clear process
    for military training to meet civilian certification and licensure
    requirements. It is vital to break down employment barriers for
    transitioning servicemembers to successfully adapt to civilian life by
    obtaining the required certification and licensure based on their
    military occupational specialties.
        The proposed statue would add very specific training requirements
    for conducting TAP. Those requirements would include at least a full
    day course on general professional development and employment
    assistance and a full day on the benefits and services available under
    the laws administered by the VA. TAP would also be required to include
    at least two consecutive days of training on post-service pathways. The
    servicemember would be able to choose from topics such as, employment,
    higher education, entrepreneurship, and career and technical training.
        Another major addition in the proposed new statute is a requirement
    of reports and notices from the Secretaries of Defense and Homeland
    Security to the Secretaries of Labor and Veterans Affairs, and the
    heads of any other departments and agencies of the Federal Government
    involved in the furnishing of counseling and other assistance under the
    program. The Secretaries of Defense and Homeland Security would be
    required to provide an annual report to Congress. The reporting would
    require information regarding the timeliness of receipt of covered
    counseling, information, and services, and rates of participation on an
    in-person basis and an online or other electronic basis.
        DOD has publicly reported 92 to 97 percent compliance rates with
    mandated TAP elements. However, a 2017 GAO report (GAO-18-23) found
    that actual TAP participation rates based on DOD internal monitoring
    reports for eligible servicemembers are lower, particularly for Reserve
    Component members (approximately 47 percent compliance). In the 2017
    report, top reasons affecting TAP participation included instances
    where members were separated on short notice, and mission- or duty-
    related requirements that interfered with ability to attend the course.
        DAV Resolution No. 304 calls for expansion of the required training
    of TAP, standardization of all provided training, tracking of member
    participation, and monitoring and oversight of TAP. As noted in the
    above GAO report, there are inaccuracies in the current reporting
    mechanisms of the DOD, therefore, we support the additional
    requirements of training for TAP and the inclusion of reporting by the
    Secretary of Defense and Secretary of Homeland Security to the
    Secretary of Labor, the Secretary of Veterans Affairs, and the annual
    report to Congress. Reporting and oversight will lead to closer
    evaluations and determinations of the effectiveness of TAP for
    transitioning servicemembers. DAV strongly supports the provisions in
    Section 2 (Recodification, Consolidation, and Improvement of Certain
    Transition-Related Counseling and Assistance Authorities) based on DAV
    Resolutions No. 298 and 304.
        Section 3 (Personnel Matters in Connection with Transition
    Assistance Program) provides the minimum number of DOD personnel
    dedicated to TAP, the designation of transition coordinators and an
    annual report to Congress.
        This provision notes the Secretary of Defense shall take
    appropriate actions to ensure that the minimum number of full-time
    personnel of the DOD dedicated to counseling and other activities under
    TAP at each military installation is not less than one for every 250
    members of the Armed Forces currently eligible for participation in the
    TAP at such military installation. It further provides that the
    requirement for full-time personnel cannot be satisfied through the use
    of contractor personnel.
        Section 3 would further require the Secretary to designate at least
    one member of the Armed Forces in each field grade unit of the Armed
    Forces as a transition coordinator to support the transition of members
    in each such field grade unit to civilian life and to support
    completion of the requirements of the Transition Assistance Program.
    Included is a requirement to report annually to Congress on the action
    to implement Section 3.
        DAV Resolution No. 304 notes that it is essential for
    servicemembers to gain full understanding of entitlements and free
    assistance available to them. Mandatory TAP personnel requirements, at
    all grades, provide assurance of dedicated resources and manpower for
    TAP success. Reporting and oversight will lead to closer evaluations
    and determinations of the effectiveness of TAP for transitioning
    servicemembers. In accord with DAV Resolution No. 304, we support
    Section 3 (Personnel Matters in Connection with Transition Assistance
    Program).
        Section 4 (Tracking of Participation in Transition Assistance
    Program and Related Programs) would require the Secretary of Defense to
    establish and maintain and electronic database and tracking system.
    Section 5 (Information on Members of the Armed Forces Participating in
    Pre-separation Counseling and Surveys on Member Experiences with
    Transition Assistance Program Counseling and Services and in Transition
    to Civilian Life) would provide for tracking of members TAP experiences
    and TAP surveys.
        The database would track information on individual member
    participation in TAP, track member surveys and experiences, and notes
    form counselors in connection with TAP. This information would be
    available to the Secretaries of Labor, Veterans Affairs, and the heads
    of any other departments and agencies of the Federal Government
    involved in the furnishing of counseling and other assistance under the
    program. Members of the Armed Forces and commanders will have access to
    the information as well.
        DAV Resolution No. 304 urges Congress to monitor and review TAP,
    its classes, training methodology, delivery of services, and collection
    and analysis of surveys and comments. As noted in the 2017 GAO study
    (GAO-18-23), it was determined that many servicemembers were not able
    to attend TAP or had experiences they felt were not effectively
    preparatory for a successful transition to civilian life.
        Our mission includes the principle that this Nation's first duty to
    veterans is the rehabilitation and welfare of its wartime disabled.
    This principle envisions assisting disabled veterans to prepare for and
    obtain gainful employment and enhanced opportunities for employment and
    job placement. This includes providing servicemembers with the right
    resources and oversight to ensure successful transitions into civilian
    life. Based on DAV Resolution No. 304, we support Section 4 and
    Section 5.
        DAV does not have a position on Sections 6 through 12 of the
    discussion draft.
        Section 13 directs the Secretary of Veterans Affairs, in
    consultation with the Secretaries of Defense and Labor, and the
    Administrator of the Small Business Administration, to conduct a five-
    year longitudinal study regarding TAP that includes those
    servicemembers who have attended the program before the enactment of
    this bill, those who have attended after the implementation of the
    proposed changes, and those who have not attended the program. This
    study would note the percentage of those studied that received
    unemployment benefits, the number of months each member was employed,
    annual starting and ending salaries, suicide rates (to include attempts
    and substance abuse issues), and other pertinent info that occurred
    during the time studied. After the five year period, and every year
    thereafter, the Secretaries of Veterans Affairs, Defense and Labor, and
    the Administrator of the Small Business Administration shall report the
    findings to the House and Senate Veterans' Affairs Committees.
        DAV supports the provisions of this section to monitor and report
    on the effectiveness of TAP. This coincides with the intent of DAV
    Resolution No. 304, which supports monitoring the success rates of TAP
    to ensure the program is meeting its objective and to follow up with
    participants to determine if they found gainful employment following
    training. According to a March 2016 RAND Corporation article, ``merely
    placing veterans in jobs is not enough: veteran employment efforts
    should also enable veterans to build successful careers over the long
    term. To reach this goal, research must provide evidence to inform
    these efforts and ensure their effectiveness.''
        Section 14 directs the Secretary of Veterans Affairs to establish a
    governing board within the Veterans Benefits Administration (VBA) that
    would partner with community and Federal entities whose mission would
    be to support the prevention of suicides, substance abuse, and
    homelessness amongst veterans. This board would consist of
    representatives from the Departments of Labor, Homeland Security,
    Defense, and various representatives from within the VA. The duties of
    this board would be to track suicide rates for each business line,
    dissemination of educational products to veterans participating in
    programs of the VBA, supporting communication between the Veterans
    Health Administration and the VBA to support suicide and substance
    abuse prevention efforts, and management of the VA's Gun Safety Lock
    program in support of suicide prevention efforts.
        DAV Resolution No. 293 supports program improvements, data
    collection and reporting on suicide rates among servicemembers and
    veterans, improving outreach through general media for stigma reduction
    and suicide prevention, and enhanced resources for VA mental health
    programs. DAV appreciates the goal of this section of the bill, which
    would enhance the support between the various Federal entities to lower
    the rate of veteran suicides. This section of the draft measure
    coincides with the intent of our resolution.
        Section 17 states, in part, that the Departments of Defense, Labor,
    and Veterans Affairs should work together with veteran service
    organizations, such as the DAV, to establish points of contacts for
    relocating members of the Armed Forces and provide them employment,
    education, and other appropriate information about the State or locale
    to assist in relocation.
        The transition from military service to civilian life is very
    difficult for many veterans who must overcome obstacles to successful
    employments, such as relocation. TAP was created to help our separating
    servicemembers successfully transition to the civilian workforce, start
    a business, or pursue training or higher education. DAV Resolution No.
    304 states, in part, that participation by DAV and other veterans
    service organizations in TAP is essential to servicemembers to gain a
    full understanding of the entitlements and free assistance available
    upon discharge from military service and the inclusion of DAV and other
    veterans service organizations in the process. We are pleased to
    support this section of the draft bill aimed at addressing this need.

        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.
                                     ______

                Prepared Statement of the Department of Defense
        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee, The Department of Defense (DOD) appreciates the opportunity
    to provide this statement for the record addressing legislation pending
    before the Committee. This statement focuses on the S. 2748, ``Better
    Access to Technical Training, Learning, and Entrepreneurship for
    Servicemember Act'' or the ``BATTLE for Servicemember Act,'' and the
    Discussion Draft on Transition Assistance Reform. We defer to the
    Department of Veterans Affairs and the Department of Labor to provide
    responses on those bills and sections of pending legislation with no
    significant DOD impacts.
         s. 2748, ``better access to technical training, learning and
          entrepreneurship for servicemember act'' or the battle for
                               servicemembers act
        DOD has no objections to H.R. 2748. This bill amends title 10,
    U.S.C., which requires members of the Armed Forces to receive
    additional training under the Transition Assistance Program (TAP), and
    for other purposes. In addition to ensuring members of the Armed Forces
    eligible for the TAP receive additional training in any of the
    supplemental subjects prescribed in section 1144(f) of title 10,
    U.S.C., the Secretary of Defense and the Secretary of Homeland Security
    will have the authority to waive the training for certain groups or
    classifications of members as the Secretaries determine, in
    consultation with the Secretaries of Labor and Veterans Affairs. A
    member may also elect in writing to not receive such additional
    training.
        s.____, discussion draft regarding transition assistance reform
        This draft bill ``amends title 10, U.S. Code to improve the
    Transition Assistance Program for members of the Armed Forces and for
    other purposes.'' This draft legislation directs the Secretaries of
    Defense, the Department of Veterans Affairs, Department of Labor, and
    the Department for Homeland Security to take certain actions to improve
    transition assistance to members of the Armed Forces who separate,
    retire, or are discharged from the Armed Forces, and for other
    purposes. DOD objects to this proposed legislation due to significant
    concerns identified by our review.
        Servicemember feedback, as well as outside of government research
    indicate the Transition Assistance Program works well to meet the needs
    of our transitioning Servicemembers. Despite anecdotal comments, DOD
    has yet to see strong data or evidence that would indicate the need to
    revamp TAP with remedial legislation. Additionally, when Veterans
    Service Organizations were briefed on the updated TAP curriculum in
    June 2018, DOD received overwhelmingly favorable responses. Several
    interagency evaluation efforts currently underway will provide more
    robust evidence to determine what improvements should be made to the
    TAP. For example, a study led by the Department of Labor, a
    longitudinal study led by the Army, and a Post-Separation Assessment
    led by the Department of Veterans Affairs will help DOD identify and
    develop sound improvements. DOD assesses the proposed legislation as
    premature for improving Servicemember transition outcomes. While
    refinements and improvements can always be made to programs (we
    continue to update TAP annually), changes are most effective when made
    based on evidence-based program evaluations and best practices.
        DOD and its partners are extremely careful when implementing
    changes that impact approximately 308,000 transitioning Servicemembers
    and spouses each year. When changes are to be made to TAP, we prefer to
    experimentally evaluate such changes and their outcomes via a pilot
    study to closely analyze the impact of these changes on a smaller group
    of Servicemembers rather than proceeding immediately to full-scale
    implementation. If the pilot confirms that the proposed changes would
    result in a more positive outcome for transitioning Servicemembers, we
    would then implement the changes more broadly. We urge Congress to
    allow time for the TAP interagency governance team to continue to
    collect and analyze the data from our evaluation efforts in progress
    before legislating mandated changes to TAP. Each section of this draft
    bill is discussed in detail below.
    Section 2. Recodification, Consolidation, and Improvement of Certain
            Transition-Related Counseling and Assistance Authorities
        The statute should align organizational authorities and
    responsibilities based on the missions, roles, and responsibilities of
    the Federal agencies and departments; thus, DOD has serious concerns
    about the elimination of section 1144, title 10, U.S.C. By striking
    section 1144, and consolidating it with section 1142, the proposed
    legislation assigns the authority and responsibilities from the
    Secretary of Labor to the Secretary of Defense for employment
    assistance, job training assistance, assistance in identifying
    employment, and training opportunities, and other information and
    services. As the Secretary of Labor is responsible for employment-
    related programs and services for transitioning Servicemembers and
    veterans, DOD requests that section 1144 remain.
        DOD supports eligible transitioning Servicemembers (including
    National Guard and Reserves) to receive resources, counseling,
    information, and services they need for their transition from the
    military to civilian life. The proposed legislation, however, lacks
    clarity about its applicability to members of the National Guard and
    Reserves. National Guard and Reserve Servicemembers eligible for TAP do
    not retire or separate upon demobilization or deactivation. They are
    ``released from active duty'' (REFRAD). Therefore, DOD recommends the
    phrase, ``release from active duty'' be inserted in paragraph (a) (1)
    to read as follows: ``The Secretary of Defense and the Secretary of
    Homeland Security with respect to the Coast Guard when it is not
    operating as a service in the Navy shall, in cooperation with the
    Secretary of Labor and the Secretary of Veterans Affairs, carry out a
    program to furnish individual counseling, information, and services
    described in paragraph (2) to members of the Armed Forces under the
    jurisdiction of the Secretary of Defense or the Secretary of Homeland
    Security, as applicable, whose retirement, separation, or release from
    active duty is anticipated as of a specific date, and to the spouses of
    such members.'' This recommended change will clarify in statute the
    applicability of TAP to the National Guard and Reserve members.
        DOD is also concerned about the lack of clarification as to when
    eligible members of the National Guard and Reserves shall commence and
    complete TAP. While the proposed legislation addresses when members of
    the National Guard and Reserves shall commence TAP, the proposed
    legislation falls short of addressing the completion date for TAP (to
    include all covered counseling, information, and services). The
    legislation does not state how and when members of the National Guard
    and Reserves will receive transition assistance. Given the unique
    operational requirements for demobilizing and deactivating Reserve
    Component Servicemembers and short notice separations, DOD recommends
    the proposed legislation provide the Secretary of Defense waiver
    authority to allow National Guard and Reserve members to complete any
    TAP requirements not accomplished prior to release from active duty,
    not later than 120 days from the date of release from active duty.
        DOD does not support the requirement for ``Preliminary
    Assistance.'' Not all Military Occupational Codes align with a
    credential. Not all Servicemembers wish to pursue employment in their
    same military occupation. Evidence-based research shows that more than
    half of our transitioning Servicemembers want to pursue a civilian
    occupation that is different from their military career. DOD
    effectively utilizes existing GAP Analysis Career Readiness Standard to
    accomplish the objective of ``Preliminary Assistance.'' We recommend
    the requirement for ``Preliminary Assistance'' be deleted from the
    proposed legislation.
        Practices for hiring counselors, vetting and establishing
    contracts, developing training curriculum, and testing information
    technology data fields do not allow DOD to meet the deadlines as
    written in the section of the proposed legislation titled
    ``Commencement of Certain Instructions.'' DOD requests the deadline be
    at least 18 but not later than 24 months after enactment. Additionally,
    DOD requests the Secretary of Defense be given two-year funding
    authority to implement requirements for this proposed legislation.
    Section 3. Personnel Matters in Connection with Transition Assistance
            Program
        DOD recommends synchronizing the staffing ratios to support
    approximately 308,000 eligible Servicemembers and spouses transitioning
    annually because the language specified in Sec. 1142, paragraph (a) (1)
    requires the Secretary of Defense to carry out a program to members of
    the Armed Forces and to the spouses of such members. The proposed
    legislation bases its ratio on military members at installations and
    does not take into account their spouses. We believe the Military
    Services are best positioned to determine the requirements for
    transition counselors.
    Section 4. Tracking of Participation in Transition Assistance Program
            and Related Programs
        DOD's primary concern is to protect Servicemember privacy,
    including each member's Personally Identifiable Information (PII). The
    Military Services capture most, but not all of the data requirements as
    outlined in Section 4 (case work and other services). DOD's existing
    system tracks transitioning Servicemembers. We support enhancing our
    existing TAP web service; however, the cost to develop the enhancements
    necessary to capture all the new data and information prescribed in the
    proposed legislation will require further review and study. DOD
    supports sharing specific data through approved data-sharing agreements
    that preserve the integrity of each individual's PII.
    Section 5. Information on Members of the Armed Forces Participating in
            Pre-separation Counseling and Surveys on Member Experiences
            With Transition Assistance Program Counseling and Services and
            In Transition to Civilian Life
        DOD supports sections 5(a) and (b). We defer to the Department of
    Veterans Affairs regarding the provisions in section 5(c).
    Section 6. E-mailing Transition Assistance Materials to Supporters of
            Members of the Armed Forces Transitioning to Civilian Life
        DOD does not support this provision of the proposed legislation.
    Departmental policy gives Servicemembers the option to include their
    email address in the Remarks section of the DD Form 214, ``Certificate
    of Release or Discharge from Active Duty.'' Members may elect a State/
    Locality Veterans Affairs office to receive information. In addition,
    transition assistance materials, to include the Transition GPS (Goals,
    Plans, Success) curriculum, described in the proposed legislation, can
    be obtained through public web sites as presented during TAP.
    Transitioning Services members and their spouses can avail themselves
    of the websites and the materials at any time before, during and after
    transition. DOD does not support obtaining a third party email address
    to provide information readily available online. TAP materials, to
    include all TAP curricula, can be accessed free of charge through
    public web sites.
    Section 7. Command Matters in Connection with Transition Assistance
            Programs
        DOD accomplishes the requirements of section 7(a) through DOD
    policy, which requires the Inspectors General to assess TAP at military
    installations. The Military Services provide professional military
    education to inform Commanders, at all levels, about all aspects of
    command, including TAP. Therefore, DOD recommends Section (b) be
    deleted.
    Section 8. Comptroller General of the United States Report on
            Participation in Transition Assistance Programs at Small and
            remote Military Installations
        DOD supports Section 8 of the proposed legislation.
    Section 9. Education of Members of the Armed Forces on Career Readiness
            and Professional Development
        DOD recognizes the important role career readiness and professional
    development pursuits can play in professionalizing the Force and in
    enhancing the Servicemember's ability to transition to the civilian
    workforce upon completion of military service. Providing opportunities,
    whether academic-or certification-related, is an investment in our
    people. Whether an individual is acquiring knowledge, skills, or
    abilities needed to perform mission functions or make a seamless
    transition to an industry profession, DOD supports education,
    certification, training, and employment assistance that maximize
    opportunities both in and out of service. DOD collaborates with the
    Departments of Labor and Veterans Affairs on a Servicemember outcomes
    initiative that aligns career readiness and professional development
    opportunities to better ensure Servicemembers are prepared to
    successfully enter the civilian workforce upon completion of service,
    and that veterans are able to capitalize on their Service training,
    education, and experiences in pursuit of civilian career opportunities.
        Although DOD is generally supportive of the proposed provisions of
    section 9, and has already aligned and coordinated appropriate assets
    to support Servicemember lifecycle development opportunities and career
    pathway programs, we recommend removal of the below listed provisions.
        Remove section 9(b)(1) as DOD already informs the transition plan
    required by section 1142(g)(1)(C) through various established tools
    including the Joint Services Transcript, the Community College of the
    Air Force Transcript, and the Verification of Military Experience &
    Training document.
        Remove section 9(b)(2)(B), as DOD has no capability to collect,
    store, and update information provided by hundreds of local communities
    across the Nation. However, DOD is postured to support a trusted
    external data source that provides centralized insight into such civic
    programs and resources.
        Remove section 9(d), as DOD does not support mandating an Alumni
    Network Program. DOD would support language that encourages the
    Military Services to establish a Network Program; however, we recommend
    the decision be left to each Military Service's discretion. Further,
    DOD recommends consideration of alternative terminology such as
    ``Professional'' or ``Veteran'' to describe the Network Program vice
    ``Alumni.'' Alumni historically refers to graduates or formal students
    of a particular school, college, or university, and such a naming
    convention might not properly convey the intent of Congress to focus on
    career mentoring, networking, and advice and not higher education
    solely.
        Last, DOD has significant concerns with section 9(c) as there is
    potential duplication between this effort, those under section 2 of
    this proposal, and numerous other personal and professional development
    authorities of DOD. Additionally, this provision mandates the provision
    of information beyond that available, yet provides no additional
    manpower or financial resources. DOD's Voluntary Education enterprise
    employs approximately 500 professional guidance counselors. Each year,
    this workforce counsels more than 256K Tuition Assistance
    beneficiaries, as well as another 350K Servicemembers participating in
    other Voluntary Education programs such as college-level examination
    and academic skills improvement. Increasing the requirement to provide
    information, without appropriate resources, would jeopardize the impact
    of such legislation.
    Section 10. Employment Skills Training
        DOD supports an expansion of eligible participants under the DOD
    SkillBridge authority with the below comments. Further clarify section
    10(2)(A)(ii). Eligibility does not appear to be limited to spouses of
    transitioning Servicemembers for which 10 U.S.C. 1143(e) was enacted.
    Recent statistics indicate that 54 percent of Servicemembers are
    married. This potential pool of participants far exceeds the roughly
    200K transitioning Servicemembers for which the program was intended
    each year. DOD is concerned that the new eligibility parameters
    drastically change the scope of the program and may have significant
    implications for program implementation.
        Further clarify section 10(2)(A)(iii). Eligibility does not appear
    to be limited to recently transitioned Servicemembers for which 10
    U.S.C. 1143(e) was enacted. With roughly 200K transitioning
    Servicemembers each year becoming eligible in perpetuity, DOD is
    concerned that the new eligibility parameters drastically change the
    scope of the program and may have significant implications for program
    implementation. Additionally, DOD is concerned about the authority to
    expend its operations and maintenance appropriation in support of
    separated Servicemember participation. There is some precedent for this
    in the form of stipends and bonuses paid to veterans participating in
    the Troops-to-Teachers program. However, in this example, eligibility
    for the program expires 3 years after separation.
        The proposed legislation is unclear about whether spouses and
    Veterans may utilize base housing, receive compensation-type benefits,
    etc. For example, spouses and veterans would not be eligible for
    compensation while participating, to include housing and allowances
    funded by DOD. A policy review would need to be accomplished to
    determine whether unemployment compensation paid by DOD would be
    permissible in conjunction with participation in SkillBridge programs.
        Further clarify the intent of the $10M identified in section 4. The
    DOD SkillBridge is intended to be a low/no cost program whereby
    providers fund the necessary job training and employment skills
    training opportunities.
    Section 11. Identification of Opportunities for Job Training and
            Employment Skills Training for Members of the Armed Forces for
            Employment with the Department of Veterans Affairs in
            SkillBridge Programs of the Department of Defense
        DOD supports the proposed change of section 11 with two comments:
    (1) Replace ``the Secretaries of the military departments shall . . .
    '' with ``the Secretary of Defense shall . . . ;'' (2) Consider
    broadening the language, including authority to work with all Federal
    agencies in support of critically understaffed and high-skilled
    positions. While DOD is already working with the Department of Veterans
    Affairs to establish such opportunities, we have been approached by
    other Federal agencies requesting consideration as well (e.g.,
    Department of Homeland Security for cybersecurity professionals).
    Section 12. Evaluation of Transition Training and Counseling Relating
            to Post-secondary Education and Use of Educational Assistance
            from Department of Defense and Department of Veterans Affairs
        DOD supports the proposed evaluation of section 12, with one
    recommendation. Remove Section (d), contract organization. In
    accordance with the Code of Federal Regulations, DOD may leverage
    federally Funded Research and Development Centers (FFRDC) for the
    purpose of the proposed analysis.
    Section 13. Longitudinal Study on Changes to Transition Assistance
            Program of Department of Defense
        DOD defers to the Department of Veterans Affairs for comments on
    section 13.
    Section 14. Establishment of Governing Board to Support Prevention of
            Drug Overdoses, Deaths by Suicide, and Alcohol-related
            Mortality
        DOD defers to the Department of Veterans Affairs for comments on
    section 14.
    Section 15. Review of Economic Risk Factors in Suicide Prevention
        DOD defers to the Department of Veterans Affairs for comments on
    section 15.
    Section 16. Grants for Provision of Transition Assistance to Members of
            the Armed Forces After Separation, Retirement, or Discharge
        The DOD defers to the Department of Labor for comments on section
    16.
    Section 17. Sense of Congress on Transition Assistance Program and
            Other Transition-related Assistance for Members of the Armed
            Forces
        DOD concurs with the provisions of section 17.
        This large and complex piece of proposed legislation brings
    potentially huge resource implications in the form of more counselors,
    Information Technology enhancements, veterans' surveys, the creation of
    professional networks, opening counselor notes to other Federal
    agencies, and adding TAP to command climate assessments, with
    unintended consequences. This proposed legislation would move DOD to a
    TAP case management system and would require more resources to fulfill
    all the mandates outlined. Additionally, requirements that span the gap
    from Servicemember to veteran will require additional attention to data
    privacy, collection, and storage requirements, as well as increased
    public disclosures and opportunity for comment through the Federal
    Register process.

        The Department of Defense thanks the Committee for its outstanding
    and continuing support of our Servicemembers, veterans, and their
    families.
                                     ______

       Prepared Statement from Ivan Denton, Director, Office of National
    Programs, Veterans' Employment and Training Service, U.S. Department of
                                     Labor
                                  introduction
        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee, thank you for the opportunity to submit a statement for the
    record of today's hearing. I thank you all for your tireless efforts to
    ensure that America fulfills its obligations to our servicemembers,
    veterans, and their families. As the Director of the Office of National
    Programs in the Veterans' Employment and Training Service (VETS) at the
    Department of Labor (DOL, or Department), my office is responsible for
    managing DOL's Employment Workshop (DOLEW, or Workshop) and Career
    Technical Training Track (CTTT) courses, as part of the Transition
    Assistance Program (TAP). The move to a civilian career is critical for
    transitioning servicemembers (TSMs) and their entire families as they
    conclude their military service, and it can also prove to be stressful.
    More broadly speaking, successful career transition is vital to
    attracting an All-Volunteer Force, and to building the American
    economy. I appreciate the opportunity to discuss DOL's collaborative
    work with the Department of Defense (DOD) and the Department of
    Veterans Affairs (VA) to administer the TAP and improvements that can
    be made to better assist servicemembers with employment preparation as
    they transition to civilian life.
        The Department stands firmly behind our Nation's servicemembers,
    veterans, and their families. The Secretary has set several clear
    priorities to assist our veterans and military spouses. They include:
    (1) supporting America's veterans by helping veterans, servicemembers,
    and their spouses find family-sustaining jobs; (2) expanding
    apprenticeships in America; and, (3) removing barriers to employment
    through occupational licensing reform.
        DOL is the Federal Government's focal point for workforce
    development, employment services, and information related to the
    economic health of all Americans. The Department maintains the
    expertise and a nationwide network of American Job Centers (AJCs) to
    provide workforce education and employment opportunities for all
    Americans. Within this network, veterans receive priority of service.
    This integrated network and the programs DOL administers are best
    suited to continue generating positive employment outcomes for the men
    and women who serve our country. I am pleased to report the employment
    situation for veterans continues to improve. The unemployment rate for
    veterans was down to 3.7 percent in 2017, which is the lowest since
    2001, and I continue to hear from employers who are hiring veterans
    because veterans provide the technical and leadership skills that
    businesses need. There are 6.6 million job openings in the United
    States.\1\ Transitioning servicemembers and veterans can help to fill
    these jobs, and employers are eager to hire them.
    ---------------------------------------------------------------------------
        \1\ BLS. (2018, July 10). Job Openings and Labor Turnover Summary.
    Retrieved from https://www.bls.gov/news.release/jolts.nr0.htm.
    ---------------------------------------------------------------------------
        While this hearing is focused on several bills under consideration
    by the Committee, I will focus my remarks on the two pieces of
    legislation that would directly impact the programs administered by
    DOL, specifically S.__, ``Improving Preparation and Resources for
    Occupational, Vocational, and Educational Transition,'' or the
    ``IMPROVE Transition for Servicemembers Act, and S. 2748, ``Better
    Access to Technical Training, Learning, and Entrepreneurship for
    Servicemembers Act,'' or the ``BATTLE for Servicemembers Act.''
       s._____, ``improving preparation and resources for occupational,
     vocational, and educational transition,'' or the ``improve transition
                            for servicemembers act''
        As a retired Infantry Officer with 35 years of total service, I was
    blessed with the opportunity to command both a battalion and a brigade
    in Iraq on two separate mobilizations. Sadly, I found these deployments
    to be, in total, less stressful than my transition off of active duty
    in 2016. I trained all of my adult life to lead soldiers; however, I
    only had a fraction of that time to make the transition to civilian
    life. I know firsthand the importance of TAP and fully understand the
    necessity of getting TAP right.
        The IMPROVE Transition for Servicemembers Act would amend title 10,
    U.S. Code, by striking sections 1142 and 1144 and inserting a new
    section 1142, which directs the Secretary of Defense and the Secretary
    of Homeland Security, with respect to the Coast Guard, in cooperation
    with the Secretaries of Labor and VA, to take certain actions intended
    to improve the transition assistance provided to members of the Armed
    Forces who separate, retire, or are discharged from military service.
        The Department opposes this bill as currently drafted, as we
    believe it would negatively impact the transition to civilian
    employment and successful careers for many transitioning
    servicemembers.
        The draft bill removes the Secretary of Labor's statutory authority
    to establish and maintain an employment assistance program for
    transitioning servicemembers and their spouses. This authority and
    responsibility is rightly, and most appropriately, entrusted to DOL;
    however, this bill would place that authority, and concomitant burden,
    on the Secretary of Defense, whose essential and fundamental mission is
    to lead DOD in the defense of our Nation. This bill would unnecessarily
    disrupt an effective interagency Federal program that DOL has
    supported, without fail, for over 25 years.
        The bill would reduce the five-day combined employment-related
    curriculum that is currently available to TSMs to a three-day mandatory
    combined curriculum. For the majority of TSMs, it would also reduce the
    existing three-day mandatory employment workshop, administered by DOL/
    VETS, to a mandatory one-day workshop. This significant reduction may
    decrease the likelihood that our transitioning servicemembers will be
    able to secure meaningful, gainful employment that can lead to a
    successful family-sustaining career. Employment is arguably the most
    important factor in a successful transition, impacting all areas of the
    servicemember's life. We owe it to our servicemembers and their spouses
    to thoroughly prepare them for a smooth transition into the next phase
    of their career.
        To inform any future discussion and collaboration with regard to
    TAP reform, I offer several observations on the contents of the draft
    bill for the Committee's consideration and defer to our partners at DOD
    and VA to discuss other sections which are specific to their TAP
    responsibilities.
    Sec. 2. Recodification, Consolidation, and Improvement of Certain
            Transition-Related Counseling and Assistance Authorities
        Section 2 of the bill would amend title 10 of the U.S. Code to make
    a number of changes to the structure and content of the existing TAP.
    In particular, section 2 would require the Secretary of Defense, and
    the Secretary of Homeland Security with respect to the Coast Guard, in
    cooperation with the Secretary of Labor and the Secretary of VA, to
    carry out a program to furnish individual counseling, information, and
    services to retiring and separating servicemembers. Section 2 further
    requires the Secretaries to work together to: develop and revise
    necessary training documents, resources, and curriculum; use experience
    gained from implementation of the pilot program under section 408 of
    Pub. L. No. 101-237 in providing the pre-separation counseling required
    under section (f)(4) of the bill; work with Military Service
    Organizations (MSOs), Veterans Service Organizations (VSOs), and other
    appropriate organizations to promote and publicize job fairs for TSMs;
    and, furnish covered counseling, information, and services to TSM
    spouses, when appropriate and at the discretion of the servicemember
    and the spouse, as well as job placement counseling for the spouse in
    connection with the transition of the servicemember to civilian life.
    Section 2 of the draft bill also: makes participation in TAP mandatory,
    unless the Secretary of Defense or Homeland Security waives the
    requirement, based upon delineated criteria; requires a servicemember
    to attend TAP no later than 120 days before retirement or 90 days prior
    to separation; establishes the parameters for pre-separation
    counseling, preliminary assistance, introduction of specific post-
    service pathways, instruction on professional development and
    employment assistance, and introduction to VA benefits; and, outlines
    the use of personnel and organizations. This section would also reduce
    the mandatory three-day employment workshop to only one day.
        The Administration believes that the three-day employment workshop
    conducted by the Department is contributing to reduced unemployment
    among TSMs and should continue to be mandatory.
        As the Department interprets this draft bill, the delivery of DOLEW
    and CTTT would no longer be the responsibility of DOL, but would
    instead become the responsibility of DOD and DHS. DOL has significant
    concerns with this fundamental programmatic change, as it fails to
    recognize the Department's expertise and experience in employment and
    training. The draft bill states, ``It is the sense of Congress to
    acknowledge that the Armed Forces face significant and often competing
    pressures in carrying out its essential and fundamental mission to
    defend the Nation.'' However, this bill further adds to these competing
    pressures by dismantling an effective interagency program and placing
    the full responsibility for transition onto the DOD and DHS. Providing
    employment assistance to transitioning servicemembers and veterans is
    an integral program function that the Department has unfailingly
    supported for over 25 years. DOD and DHS should be assisting
    servicemembers in developing and documenting the skills that will make
    them successful both inside and outside of the military, and DOL is
    best equipped to assist them in transitioning to a civilian career.
        Since the Department began providing the Employment Workshop more
    than 25 years ago, the number of workshops, participants, and locations
    has grown considerably and the quality and relevance of the course
    material improves each year. In 2011, the VOW to Hire Heroes Act of
    2011, Title II, Pub. L. No. 112--56 (the VOW Act) made participation in
    the DOLEW mandatory for most transitioning servicemembers, including
    those demobilizing from the National Guard and Reserve Components. Last
    year, DOL conducted more than 6,000 Workshops for over 164,000
    participants at 187 sites worldwide. Of the over 164,000 participants,
    more than 4,800 were National Guard and Reserve. The three-day DOLEW is
    standardized so that all attending servicemembers and their spouses can
    receive the same high level of instruction. The current three-day
    employment workshop has contributed to:

         The unemployment rate for veterans aged 18-24 decreasing
    from a high of 30.2 percent in 2011 to 7.9 percent (2017);
         Overall veteran unemployment being at its lowest rate of
    3.7 percent (2017) since 2001; and
         Unemployment Compensation paid to ex-servicemembers (UCX)
    being reduced by over 72 percent from $944 million to $258 million,
    lower than pre-recession levels.

        Employment is arguably the most important element of a successful
    transition to civilian life, and the existing DOLEW and CTTT are key
    elements of TAP. Removing the requirement for participation in the
    current DOLEW, or reducing by two-thirds the required employment
    preparation instruction, would have a negative impact on a TSM's
    readiness for civilian employment and career success. The vast majority
    of the courageous men and women who serve our country will enter the
    workforce, whether immediately following their transition, or after
    pursuing additional education or training. The DOLEW provides them with
    employment preparation that is vital for a positive transition and a
    successful future.
        Moving forward, and as discussed in our November 2017 written
    testimony before the House Veterans' Affairs Committee's Subcommittee
    on Economic Opportunity, DOL is working to advance two primary goals
    for TAP. First, DOL will continue to work with our interagency partners
    to improve TAP's timeliness of completion rates. Second, we will also
    work with interagency partners to increase the percentage of TSMs that
    participate in the two-day supplemental career tracks.
        All TSMs are eligible to begin TAP activities, which start with
    pre-separation counseling, as soon as 24 months prior to retirement or
    12 months prior to separation. By law, TSMs are also required to
    complete TAP within 90 days of transition. However, based on statistics
    contained in the November 2017 U.S. Government Accountability Office
    report (GAO-18-23), Transitioning Veterans, DOD Needs to Improve
    Performance Reporting and Monitoring for the Transition Assistance
    Program,\2\ fewer than half of all TSMs actually complete TAP on time.
    DOL's first goal is important because survey data from the
    November 2016 Hiring Our Heroes report from the U.S. Chamber of
    Commerce Foundation,\3\ indicates veterans continue to face challenges
    as they transition from the military, but the survey results show a
    clear relationship between a successful transition and when
    transitioning servicemembers start their job search. Those who begin to
    plan for transition early (more than six months before separation) fare
    better than those who wait.
    ---------------------------------------------------------------------------
        \2\ U.S. Government Accountability Office (2017, November).
    Transitioning Veterans: DOD Needs to Improve Performance Reporting and
    Monitoring for the Transition Assistance Program. (GAO-18-23).
    Retrieved from https://www.gao.gov/assets/690/688203.pdf.
        \3\ Chamber of Commerce. (2016, November 02). Veterans in the
    Workplace: Understanding the Challenges and Creating Long-Term
    Opportunities for Veteran Employees. Retrieved from https://
    www.uschamberfoundation.org/reports/veterans-workplace.
    ---------------------------------------------------------------------------
        The GAO report also noted that only 22,468 (14.1%) of active duty
    TSMs, out of the 160,000 who were eligible, participated in the two-day
    supplemental career tracks. DOL believes that this number is far too
    low and that greater participation in these tracks would allow TSMs to
    identify career opportunities that could increase their long term
    earnings.
        According to the Bureau of Labor Statistics (BLS), the median wage
    for a U.S. worker with only a high school degree was about $37,000 per
    year in 2017. However, four-year degree wages are $60,000 per year.\4\
    Graduates of Apprenticeship programs earn an average of $60,000 per
    year, and more than 8 in 10 graduates retain their employment nine
    months after exiting their apprenticeships. Although participation in
    the supplemental two-day tracks does not guarantee higher wages, our
    assessment shows that attendance metrics for each of the career tracks
    provide an indication of whether or not a TSM is selecting a career
    path that increases the chances of obtaining a meaningful career.
    ---------------------------------------------------------------------------
        \4\ BLS. (2018, April 13). Usual Weekly Earnings of Wage and Salary
    Workers Second Quarter 2018. Retrieved from https://www.bls.gov/
    news.release/pdf/wkyeng.pdf.
    ---------------------------------------------------------------------------
    Sec. 3. Personnel Matters in Connection with Transition Assistance
            Program
        Section 3 of the draft bill requires the Secretary of Defense to
    employ full-time DOD personnel dedicated to counseling and other TAP
    activities at each military installation (no less than one for every
    250 members eligible for transition services in the Armed Forces), and
    prohibits the use of contractor personnel to satisfy this requirement.
    Section 3 also requires the Secretary of Defense to submit a report to
    Congress on the actions taken to implement this section.
        The Department is concerned with the long-term ramifications of
    administering TAP with Federal employees, when contract facilitators
    offer a flexible and cost effective way to provide workforce
    development services to transitioning servicemembers to meet the ever-
    changing needs of the civilian employment sector. The DOLEW and CTTT
    are currently administered by contract facilitators, as directed by the
    VOW Act. The use of contractors allows the Department to ensure that
    the instruction for DOLEW and CTTT is consistently of high quality. The
    use of contractor personnel also made the program more nimble to manage
    as we are able to rapidly schedule or reschedule classes as required by
    the military services.
    Sec. 4. Tracking of Participation in Transition Assistance Program and
            Related Programs
        Section 4 requires the Secretary of Defense to establish and
    maintain an electronic tracking system and database, applicable across
    the Armed Forces, to collect, assemble, and make available information
    on: the participation and progress of individuals in TAP, data
    collected in surveys; resources available for members of the Armed
    Forces and their spouses; and, notes to TAP counselors in connection
    with the provision of casework and other programmatic services.
    Information collected in the tracking system and database is to be made
    available to members of the Armed Forces who are undergoing transition
    from military life, Commanders of the Armed Forces at all levels, the
    Secretaries of Labor, VA, and the heads of any other departments and
    agencies of the Federal Government involved in TAP.
        The Department does not oppose this section and believes that
    tracking information on the progress of TSMs is important. The
    Department continues to process data from the Defense Manpower Data
    Center (DMDC) for the Veterans' Data Exchange Initiative (VDEI). As we
    work with DOD to improve data quality, information about TAP timeliness
    of completion metrics and career technical training track attendance
    metrics will be shared by DOD and DOL leaders at the national and local
    level. The Department will eventually establish a data dashboard that
    allows DOL to see performance metrics for each individual service and
    individual bases within each service branch.
    Sec. 5. Information on Members of the Armed Forces Participating in
            Pre-separation Counseling and Surveys on Member Experiences
            with Transition Assistance Program Counseling and Services and
            in Transition to Civilian Life
        Section 5 requires the Secretary of Defense to collect the
    demographic data on servicemembers entering into pre-separation
    counseling, requires the Secretaries concerned (as that phrase is
    defined in section 101 of title 10, U.S. Code) to conduct surveys of
    the members of the Armed Forces at the conclusion of the receipt of
    counseling, information, and services under section 1142, and requires
    the Secretary of VA, in consultation with the Secretaries of Defense,
    Homeland Security, Education, and Labor, to conduct surveys of veterans
    recently retired, discharged, or released from the Armed Forces, in
    order to assess the experiences of such veterans in the transition from
    military life to civilian life.
        DOL is generally supportive of section five. The Department
    recommends that language also be included to amend the Social Security
    Act to authorize the Secretaries of Labor and Veterans' Affairs to
    access the National Directory of New Hires (NDNH) for purposes of
    tracking veterans' employment. Like VA, DOL strongly supports this
    access to the NDNH, and believes that the information would provide the
    interagency TAP partners with a more complete understanding of post-
    transition employment outcomes and greatly assist us in evaluating the
    efficacy of our transition assistance efforts.
    Sec. 6. E-mailing Transition Assistance Materials to Supporters of
            Members of the Armed Forces Transitioning to Civilian Life
        Section 6 requires the Secretaries of Defense and Homeland Security
    to solicit an e-mail address from each TSM and the e-mail address of a
    supporter so that the Secretary concerned may send transition materials
    as set forth in section 1142(f) of title 10 and additional information
    as the Secretary concerned considers appropriate.
        The Department does not oppose this section. DOL currently receives
    email addresses from DOD via the eForm data. The Department sends
    emails to TSMs to highlight the importance of participating in the
    supplemental career tracks and DOLEW as early as possible. To date, DOL
    has sent nearly 290,000 messages to TSMs on these topics.
    Sec. 10. Employment Skills Training
        Section 10 amends section 1143(e) of Title 10, U.S. Code, by
    directing the Secretary of Defense, in consultation with the Secretary
    of Labor, to carry out job training and employment skills training,
    including pre-apprenticeship programs under the SkillBridge program, to
    transitioning servicemembers and their spouses who are within six
    months of their transition out of the military. Veterans, as defined in
    section 101 of title 38, U.S. Code, who have completed at least 180
    days of active duty or have been awarded the Purple Heart are also
    eligible to receive services from this program, but at a lower level of
    priority than TSMs. Finally, this section authorizes $10 million to the
    Secretary of Defense to carry out this program.
        The Department is supportive of the concept as it would not require
    transitioning servicemembers and some veterans to be excluded from
    training programs like SkillBridge just because they will transition
    off of active duty before completing it. The Department notes that the
    required consultation between DOD and DOL will be necessary to ensure
    that these programs are integrated with and not duplicative of the
    training and employment services for veterans that are funded by DOL.
    Sec. 13. Longitudinal Study on Changes to Transition Assistance Program
            of Department of Defense
        Section 13 tasks the Secretary of the VA, in consultation with the
    Secretaries of Defense, Labor, and the Small Business Administration,
    to conduct a five-year longitudinal study.
        DOL is generally supportive of section 13. Once again, DOL believes
    that access to NDNH would provide the interagency TAP partners with a
    more complete understanding of post-transition employment outcomes.
    Sec. 16. Grants for Provision of Transition Assistance to Members of
            the Armed Forces After Separation, Retirement, or Discharge
        Finally, section 16 requires the Secretary of Labor, in
    consultation with VA, to award grants to eligible organizations for the
    provision of transition assistance to members of the Armed Forces who
    are separated, retired, or discharged from the Armed Forces, and
    spouses of such members.
        The Department supports the intent of section 16, but believes it
    is duplicative of services that are already available through the DOL-
    funded State Workforce System and VA. The Department suggests that the
    grants emphasize case management and referral to Federal, state, and
    local resources that can meet the needs of transitioning servicemembers
    and their families.
         s. 2748, ``better access to technical training, learning, and
        entrepreneurship for servicemembers act,'' or the ``battle for
                              servicemembers act''
        S. 2748 would amend section 1144(f) of title 10, U.S. Code, to
    require members of the Armed Forces to receive additional training
    under TAP.
        The Department supports S. 2748 because, if passed, it would
    increase the amount of days of employment-related curriculum for most
    servicemembers by making the attendance of TAP's Optional tracks
    mandatory. Currently, TSMs have the option to participate in a series
    of two-day tailored tracks within the Transition GPS curriculum: (1) an
    Accessing High Education Track (provided by DOD), for those pursuing a
    higher education degree; (2) CTTT (provided by DOL), for those
    interested in obtaining job-ready skills through apprenticeship or
    other industry-recognized credentials; and (3) the ``Boots to
    Business'' Entrepreneurship Track (provided by Small Business
    Administration), for those wanting to start a business. CTTT is an
    additional two-day workshop focused on apprenticeships and industry-
    recognized credentials for transitioning servicemembers and their
    spouses. The CTTT provides these servicemembers with an opportunity to
    identify their relevant skills, increase their awareness of workforce
    development programs and apprenticeship programs that can lead to
    industry-recognized credentials and meaningful careers, and develop an
    action plan to achieve their career goals. DOL believes that the
    optional courses in TAP provide servicemembers with resources critical
    to their success in the civilian world. By making the attendance of an
    optional track mandatory, the Department expects the number of TSMs who
    would attend these courses, and obtain enhanced employment-related
    curriculum, would increase significantly.
                                   conclusion
        In conclusion, our long-term goal continues to be that military
    service is universally recognized as a path to high-quality civilian
    careers. The future of the Nation's All-Volunteer Force depends upon
    this recognition, as does our economy. The Department views employment
    as a vital element of a successful transition to civilian life. The
    Department thanks the Congress for addressing TAP participation through
    the VOW Act, and for your continued partnership in removing barriers to
    employment.
        The Department remains committed to working with our interagency
    partners to continuously review and improve TAP curricula, including
    the DOLEW and CTTT, through our regular review cycle that incorporates
    input from employers and the public related to the best practices
    across the Nation. Moving ahead, we look forward to preparing
    transitioning servicemembers and their spouses even more effectively by
    improving the timeliness of DOLEW participation and increasing
    participation rates in the supplementary career-related tracks.
        The Department looks forward to working with the Committee to
    ensure that our separating servicemembers have the resources and
    training they need to successfully transition to the civilian
    workforce. The improving employment situation for veterans is a
    resounding testament to the nationwide recognition from stakeholders,
    both public and private, at the national level and within local
    communities, of the value veterans bring to the workforce.

        Mr. Chairman, Ranking Member, and Members of the Committee, this
    concludes my statement for the record. Thank you for the opportunity to
    be a part of this hearing.
                                     ______

             Prepared Statement of the Mortgage Bankers Association
        Chairman Isakson and Ranking Member Tester, The Mortgage Bankers
    Association (MBA) appreciates the opportunity to submit written
    testimony on the pending legislation being considered before the Senate
    Committee on Veterans' Affairs. In particular we are pleased to share
    our views on H.R. 299, the Blue Water Navy Vietnam Veterans Act of
    2017.
        MBA is the national association representing the real estate
    finance industry, an industry that employs more than 280,000 people in
    virtually every community in the country. The association works to
    ensure the continued strength of the Nation's residential and
    commercial real estate markets, to expand homeownership, and to extend
    access to affordable housing to all Americans. MBA promotes fair and
    ethical lending practices and fosters professional excellence among
    real estate finance employees through a wide range of educational
    programs and a variety of publications. MBA's membership of over 2,300
    companies represents all elements of real estate finance, including
    firms serving both the single-family and commercial/multifamily
    markets. Our membership features commercial banks, community banks,
    credit unions, independent mortgage bankers, investors, brokers, and
    industry vendors, among others.
        We applaud the Committee for its efforts to provide adequate
    medical benefits for veterans who were exposed to dangerous chemicals
    in the course of their service. And while H.R. 299 contains a number of
    provisions relevant to such healthcare-related concerns, MBA will limit
    its views to Sections 6 and 7 of the legislation, which address the
    U.S. Department of Veterans Affairs (VA) Home Loans program. We also
    wish to draw the Committee's attention to another pressing problem in
    the market for VA-guaranteed refinances, which has prevented some loans
    from serving as collateral in Government National Mortgage Association
    (Ginnie Mae) pools.
    Section 6(a)
        Section 6(a) of H.R. 299 adjusts the size of the VA loan guaranty
    for a subset of loans. Under existing law, the VA guaranty on loans
    greater than $144,000 cannot exceed the lesser of: (1) 25 percent of
    the government-sponsored enterprise (GSE) conforming loan limit,
    reduced by the amount of entitlement previously used and not restored;
    or (2) 25 percent of the loan. The proposed changes in the legislation
    would adjust the VA guaranty on loans greater than $144,000 to 25
    percent of the loan, reduced by the amount of entitlement previously
    used and not restored.
        For veterans who have not used their entitlement, or have had their
    entitlement fully restored, the new calculation would not change the VA
    guaranty on loans at or below the GSE conforming loan limit. It would,
    however, increase the VA guaranty on loans above the GSE conforming
    loan limit. We believe this adjustment is warranted, as it will promote
    access to credit for veterans living in higher-cost areas of the
    country.
        However, the proposed adjustment would have the effect of lowering
    the VA guaranty on second properties purchased by the veteran, in cases
    in which the second loan is at or below the GSE conforming loan limit.
    As such, this adjustment would make it more difficult for veterans to
    obtain zero-down payment financing for many second properties. Given
    the frequency with which veterans may be required to relocate due to a
    permanent change of station, it is common for veterans to purchase a
    second home in their new station, while continuing to own and rent
    their first home. In such a scenario, we believe it is appropriate to
    allow for zero-down payment financing for the second home, particularly
    if the loan is at or below the GSE conforming loan limit.
        In order to address this concern while maintaining the increased VA
    guaranty on more expensive properties, we recommend that the language
    in Section 6(a) be further amended so as to use the existing
    calculation for loans at or below the GSE conforming loan limit and the
    new calculation contained in Section 6(a) only for loans above the GSE
    conforming loan limit. This amendment would not change the VA guaranty
    for veterans who have not used their entitlement or have had their
    entitlement fully restored, relative to H.R. 299. It would, however,
    allow veterans greater opportunity to use zero-down payment financing
    for their second homes. We would also recommend that such amendments
    clarify the application of existing VA policies regarding restoration
    of entitlement, including any changes to this process.
        We therefore support this section of the legislation, provided that
    it is amended per the recommendations described above.
    Section 6(b)
        Section 6(b) of H.R. 299 changes the VA loan fee schedule. The
    changes to the schedule, which are summarized below, would increase the
    overall fees collected from veterans in association with VA-guaranteed
    loans. The changes would also equalize the fees paid by active duty
    veterans and reservists, as reservists often pay higher fees in the
    current system.
        It appears that these increased loan fees are serving to offset
    other expenditures contained in the legislation. And while we are not
    offering comments on the efficacy of the healthcare provisions of the
    legislation, we firmly believe that mortgage borrowing costs should not
    be increased to pay for non-housing-related expenditures. The loan fees
    charged to veterans should reflect the credit risk associated with the
    VA guaranty, and any fee increases that are unrelated to this risk
    unnecessarily raise the cost of mortgage credit for veterans. As such,
    we oppose any changes to VA loan fees that do not correspond to the
    credit risk associated with the VA guaranty.
        The table that follows displays the change in VA loan fees from the
    existing baseline for each loan type, borrower type, and closing
    date.\1\
    ---------------------------------------------------------------------------
        \1\ Fees are expressed as a percentage of the total amount of the
    loan guaranteed, insured, or made, or, in the case of a loan
    assumption, the unpaid principal balance of the loan on the date of the
    transfer of the property. Red cells indicate an increase in the fee.
    Green cells indicate a decrease in the fee. Yellow cells indicate no
    change in the fee.

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Section 6(c)
        Section 6(c) of H.R. 299 requires VA loan fees to be collected from
    veterans with service-connected disabilities rated as less than total,
    surviving spouses of such veterans, or veterans that receive a loan in
    excess of the GSE conforming loan limit. This section also exempts
    veterans serving on active duty who were awarded the Purple Heart from
    paying VA loan fees. Under existing law, VA loan fees are not collected
    from veterans receiving compensation (or eligible to receive
    compensation) due to a service-connected disability or from surviving
    spouses of veterans who died due to a service-connected disability.
        As noted above with respect to Section 6(b), it is unclear that
    this provision, which would have the effect of increasing the overall
    fees collected through the VA Home Loans program, is being proposed due
    to a commensurate change in the credit risk profile or the financial
    health of the program. Veterans with service-connected disabilities
    have sacrificed for their country, and the existing waiver from paying
    VA loan fees is an appropriate benefit. We would strongly oppose
    removing this benefit for the purpose of raising funds to offset non-
    housing-related expenditures.
        Similarly, the purchase of a home with a loan that exceeds the GSE
    conforming loan limit is unrelated to the veteran's service-connected
    disability. Because the VA loan fees are expressed as a percentage of
    the loan, veterans who purchase more expensive homes already pay higher
    absolute fees than comparable veterans who purchase homes using loans
    below the GSE conforming loan limit. The proposed legislation would
    prevent veterans with service-connected disabilities from utilizing
    their fee waiver if they purchase a more expensive home, but the
    purpose of the waiver is not influenced by the size of the loan. If
    Congress determines that veterans with such disabilities warrant a fee
    waiver, the size of the loan should not be a relevant factor in that
    determination. In other words, we believe that veterans with similar
    disabilities should be treated equally, regardless of the value of
    their home or the size of the loan that is used. As such, we oppose
    Section 6(c)(2) of the legislation.
    Section 7
        Section 7 of H.R. 299 allows VA-approved appraisers to conduct
    appraisals solely on the basis on information gathered and provided by
    a third party. Under existing law, VA maintains a list of approved
    appraisers who are selected on a rotating basis to conduct appraisals
    for properties to be financed with loans that will feature a VA
    guaranty. Such appraisers must meet minimum qualifications to obtain
    approved status, which are verified through written testing, sample
    appraisals, training experience, and recommendations from other
    appraisers. This process better ensures that the VA guaranty is
    properly protected from inflated or otherwise inaccurate valuations.
        In recent years, however, VA-guaranteed financing has been
    inhibited in certain parts of the country due to appraiser shortages or
    other difficulties in obtaining appraisals from approved individuals.
    This problem is often more acute in rural communities where it may take
    an approved appraiser many hours of travel to reach the property. In
    these situations, appraisal ``turn times'' can be lengthy, which can
    then delay closings, force extension of rate locks, or result in
    penalty fees or the loss of earnest money deposits should the borrower
    opt for a non-VA-guaranteed loan.
        Allowing appraisers the ability to receive property information
    from third parties could effectively address this problem by scaling
    back the travel time required of appraisers. This provision could also
    allow appraisers to make better use of the improved technology that is
    facilitating large-scale data collection by industry vendors.
    Importantly, while the appraiser is relying on information provided by
    a third party, the responsibility for conducting the appraisal remains
    with the approved individual.
        However, the legislation as currently drafted provides that VA
    ``may'' issue guidance prior to prescribing regulations to implement
    this change. We would recommend that VA instead be required to issue
    guidance ahead of any regulations that are prescribed. This guidance
    should include details regarding the standards that must be met in
    terms of the collection of property information by third parties. VA
    has already issued similar guidance with respect to third parties that
    provide loan underwriting services, such as verification of borrower
    income, employment, and assets.\2\ And while VA may clarify standards
    for the use of third parties in any implementing regulations, it is
    important that there be no confusion in the market prior to the
    issuance of these regulations, and therefore guidance should be
    required prior to the effective date of this section.
    ---------------------------------------------------------------------------
        \2\ VA, ``Clarification of Third-Party Verification Requirements,''
    Circular 26-17-43, December 29, 2017. Available at: https://
    www.benefits.va.gov/homeloans/documents/circulars/26_17_43.pdf.
    ---------------------------------------------------------------------------
        Similarly, to allow for additional flexibility in VA's
    implementation of this provision, we would recommend that the language
    be amended to clarify that VA may also enter into such agreements with
    third parties.
        We therefore support this section of the legislation, provided that
    it is amended per the recommendations described above.
    Further Improvements to the Seasoning Requirements for VA Refinances
        We also respectfully urge the Committee to support technical
    amendments to the recently passed S. 2155, the Economic Growth,
    Regulatory Relief, and Consumer Protection Act. In particular, Section
    309 of the legislation, which provides enhanced requirements on VA
    refinances that we believe will effectively address the problem of loan
    churning, has caused inadvertent disruptions in this market and is in
    need of revision.
        We appreciate and endorse the urgent need to respond to the
    increased churning of veteran borrowers in recent years. In many
    situations, borrowers are the target of aggressive and potentially
    misleading advertising that encourages them to continually refinance
    their VA-guaranteed mortgage so as to lower their interest rate, even
    if only by a small amount. However, when fees are then added to the
    principal balance of the loan, the borrower may be put in a position in
    which there is no realistic possibility that the fees can be recouped
    through the lower monthly payments. This practice directly harms
    veterans and lowers demand for Ginnie Mae mortgage-backed securities
    (MBS), thereby raising borrowing costs for loans guaranteed or insured
    through a wider array of government mortgage programs.
        To address this problem, MBA supported Section 309 of S. 2155,
    which includes new requirements on refinanced loans to achieve
    eligibility for a VA guaranty and Ginnie Mae pooling. One such
    requirement is a minimum seasoning period for the prior loan. For both
    VA and Ginnie Mae eligibility, at least 210 days must have passed
    between the date of the first payment made by the borrower on the prior
    loan and the note date of the refinance. This seasoning period is
    intended to slow the pace of refinances, thereby deterring extreme
    cases of serial refinancing.
        While we support the use of a minimum seasoning requirement, the
    implementation of Section 309 has led to unexpected disruptions in the
    market. This result has occurred because the seasoning calculation
    described above differs from--and is longer than--that of the seasoning
    requirement instituted by Ginnie Mae through a prior All Participant
    Memorandum.\3\ Ginnie Mae's existing standard requires 210 days to pass
    between the first payment due date of the prior loan and the first
    payment due date of the refinance. The seasoning calculation in Section
    309 differs in both the start point and end point for this timeline.
    ---------------------------------------------------------------------------
        \3\ Ginnie Mae, ``APM 17-06: Pooling Eligibility for Refinance
    Loans and Monitoring of Prepay Activity,'' December 7, 2017. Available
    at: https://www.ginniemae.gov/issuers/program_ guidelines/Pages/
    mbsguideapmslibdisppage.aspx?Para mID=82.
    ---------------------------------------------------------------------------
        Because there was no effective date provided in the legislation,
    the new requirements took effect immediately. Notably, VA implemented
    the requirements of Section 309 for all loans with applications taken
    on or after May 25, 2018.\4\ Ginnie Mae, however, has followed a
    Department of Housing and Urban Development (HUD) interpretive rule
    which states that, while Ginnie Mae securities issued in May 2018 or
    earlier are unaffected, no VA refinances can be included in issuances
    in June or later unless they are compliant with the new
    requirements.\5\
    ---------------------------------------------------------------------------
        \4\ VA, ``Policy Guidance Update: VA Refinance Loans and the
    Economic Growth, Regulatory Relief, and Consumer Protection Act,''
    Circular 26-18-13, May 25, 2018. Available at: https://
    www.benefits.va.gov/HOMELOANS/documents/circulars/26_18_13.pdf.
        \5\ HUD, ``Government National Mortgage Association: Loan Seasoning
    for Ginnie Mae Mortgage-Backed Securities--Interpretive Rule,'' July 3,
    2018. Available at: https://www. Federalregister.gov/documents/2018/07/
    03/2018-14354/government-national-mortgage-association-loan-seasoning-
    for-ginnie-mae-mortgage-backed.
    ---------------------------------------------------------------------------
        As a result, some VA refinances that were in process or recently
    closed at the time the legislation was signed into law in late May lost
    their eligibility to serve as collateral for Ginnie Mae MBS. These
    ``orphaned'' loans cannot be delivered to Ginnie Mae despite carrying a
    valid VA guaranty and being fully compliant with the requirements in
    place at the time the applications were taken and (in some cases) the
    loans were closed. This situation has caused liquidity strains for some
    lenders, particularly if they have originated a significant volume of
    affected loans.
        MBA has noted in formal comments to HUD that this outcome does
    nothing to advance the legislative aim of the statute, actively
    frustrates the purpose of the statute, and ignores both congressional
    intent and the historical relationship between VA and Ginnie Mae.\6\ To
    effectively address this problem, we strongly urge Congress to
    undertake technical corrections needed to restore Ginnie Mae
    eligibility for the orphaned loans and align the VA seasoning
    requirements with those of the other government mortgage programs.
    ---------------------------------------------------------------------------
        \6\ MBA, ``Re: Government National Mortgage Association: Loan
    Seasoning for Ginnie Mae Mortgage-Backed Securities--Interpretive Rule
    [Docket No. FR-6112-IA-01],'' July 12, 2018. Available at: https://
    www.mba.org/Documents/MBA_HUD_Interpretive_Rule_Ginnie_Mae_Loan_
    Seasoning(0).pdf.
    ---------------------------------------------------------------------------
        These technical corrections would entail two components. First, the
    Ginnie Mae seasoning requirement in Section 309(b) of the legislation
    should be eliminated. By striking this language, Ginnie Mae would no
    longer be prohibited from guaranteeing MBS backed by the orphaned VA
    refinances, which would effectively restore the eligibility of the
    loans for pooling. This correction would not diminish the anti-churning
    purpose of the legislation, as the seasoning requirements would remain
    a condition of the VA guaranty, which itself is a condition of Ginnie
    Mae pooling. Therefore, VA loans that do not meet the seasoning
    requirements prior to refinancing would not be eligible to serve as
    collateral for Ginnie Mae MBS.
        Second, the seasoning period defined in Section 309(a) of the
    legislation should be amended to match that of the earlier Ginnie Mae
    requirements. That is, 210 days should be required to pass between the
    first payment due date of the prior loan and the first payment due date
    of the refinance. This amended calculation would align the VA seasoning
    requirement with those of the other government mortgage programs. And
    importantly, it would also facilitate improved adoption in the market,
    as the current calculation suffers from the fact that many lenders are
    unable to determine the date on which the first payment on the prior
    loan was made by the borrower. Without this information, it is
    impossible for lenders to be certain that they are compliant with the
    new requirements.
        These technical corrections would address a pressing need in the
    current market and would allow for more sensible implementation of
    these important anti-churning provisions on an ongoing basis. We
    strongly urge the Committee to work with the Committee on Banking,
    Housing, and Urban Affairs and other relevant stakeholders to enact
    these corrections as soon as possible.
                                  *    *    *
        MBA appreciates the opportunity to provide our views regarding H.R.
    299, as well as the ongoing problems related to VA refinances that are
    ineligible to serve as collateral for Ginnie Mae securities. We look
    forward to our continued work with the Committee as it undertakes
    issues that are critical to maintaining veterans' access to safe,
    reliable, and affordable mortgage credit.
                                     ______

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         Prepared Statement of Military Officers Association of America
        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee on Veterans' Affairs, The Military Officers Association of
    America (MOAA) is pleased to submit its views on pending legislation
    under consideration.
        MOAA does not receive any grants or contracts from the Federal
    Government.
                               executive summary
        On behalf of the 350,000 members of MOAA, 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, thank you for your
    commitment and enduring support of our Nation's servicemembers and
    veterans and their families.
    MOAA offers our position on the following bills.

         H.R. 299, Blue Water Navy Vietnam Veterans Act of 2018
         S. __, Veterans Dental Care Eligibility Expansion and
    Enhancement Act of 2018
         Discussion Draft on Transition Assistance Reform
         S. 1596, BRAVE Act of 2017
         S. 1952, VA Financial Accountability Act of 2017
         S. 1990, Dependency and Indemnity Compensation Improvement
    Act of 2017
         S. 2748, BATTLE for Servicemembers Act
         S. __, Grant Program on Provision of Suicide Prevention
    Services for Veterans
         S. __, Modernization of Medical Records Access for
    Veterans Act
         S. 514, No Hero Left Untreated Act

        MOAA takes no position on: S. 3148; S. __, VA Hiring Enhancement
    Act; S. 5418, Veterans Affairs Medical-Surgical Purchasing
    Stabilization Act; S. 2881, Mare Island Naval Cemetery Transfer Act;
    and S. 2485, Medal of Honor Surviving Spouses Recognition Act.
                              pending legislation
    H.R. 299, Blue Water Navy Vietnam Veterans Act of 2018.
        MOAA supports this legislation.
        MOAA has always supported restoring the presumption of herbicide
    exposure to Blue Water Navy Veterans. MOAA further supports the
    extension of the presumption to veterans who served on the Korean DMZ
    from Sept. 1, 1967, to Aug. 31, 1971, as well as benefits to children
    born with spina bifida of veterans who served in Thailand during the
    Vietnam conflict.
        MOAA is disappointed that the only way found to fund these benefits
    was raising VA home loan fees. This places the financial burden solely
    on the 1 percent of the U.S. population who served their nation in time
    of conflict and relieves the remaining 99 percent of our Nation's
    population of bearing any financial responsibility or liability. Those
    who sacrificed will continue to sacrifice and subsidize a solution to
    resolve the toxic exposure of veterans who provided our Nation's
    security and defense.
        MOAA is grateful the legislation includes a provision proposed by
    MOAA to use a portion of these funds toward a report on a follow-up
    study on certain Gulf War illnesses. It is clear the reason Vietnam
    veterans have had exceptional difficulty in obtaining VA benefits for
    their conditions was the direct result of the failure of the Department
    of Defense to accurately and adequately maintain records of toxic
    exposures. MOAA asks for this Committee to work collaboratively with
    the Committee on Armed Services to ensure future generations of
    veterans are not placed in the same predicament.
    S. __, Veterans Dental Care Eligibility Expansion and Enhancement Act
            of 2018
        MOAA supports this legislation and requests Congress provide the
    associated funding needed to support the legislative requirements of
    this bill.
        It is well established that dental health correlates to overall
    health and affects vital functions such as overall nutrition. According
    to studies, cost barriers are the biggest burden to obtaining dental
    services and the burden is considerably higher than it is for other
    health care services.\1\ Many disabled veterans are unable to either
    afford paying for the cost of private dental care out-of-pocket or they
    lack access to dental insurance, so they go without. MOAA supports a
    pilot program to determine the overall health improvements made in
    veterans' health given access to dental care, particularly in rural
    areas.
    ---------------------------------------------------------------------------
        \1\ Wall T, Guay A. The per-patient cost of dental care, 2013: a
    look under the hood. Health Policy Institute Research Brief. American
    Dental Association. March 2016. Available from:
        http://www.ada.org//media/ADA/Science%20and%20Research/HPI/Files/
    HPIBrief_0316_4.pdf
    ---------------------------------------------------------------------------
        MOAA believes the cost of the initiative could be reduced by making
    the pilot program smaller and still be able to assess overall health
    improvements. Any pilot program, however, should include rural areas.
    Discussion Draft on Transition Assistance Reform
        MOAA supports this draft bill.
        Military spouses experience some of the same issues servicemembers
    face when transitioning out of the military; one of the most common
    being finding employment. After having a resume filled with gaps in
    employment and multiple moves, spouses often need the same
    professional-development advice servicemembers need and receive through
    the Transition Assistance Program (TAP). Additionally, it is vital
    spouses are equally informed on veterans' benefits that not only affect
    the servicemember but also their families. Often, spouses of
    servicemembers handle family matters such as health care and financial
    decisions, which are impacted by transition. TAP addresses these
    changes, and it is important spouses, especially those who handle these
    benefits for their families, are able to receive the information and
    ask questions from the TAP instructors. MOAA is pleased to see
    discussion on including military spouses in TAP, whereas previously
    spouses could attend only if space was available.
        MOAA understands the intent behind the waiver provision for members
    who might not benefit from attending the program. The waiver provision,
    however, does not contain a way for the member to express a desire or
    ability to attend the program even though he or she might be eligible
    for a waiver. The waiver is dictated by the services upon entire groups
    who are ``unlikely to face major readjustment . . .  to civilian life''
    with no option for the member to override the waiver. This is
    problematic, as individuals within those groups might, nonetheless,
    have circumstances that would present them with such challenges and
    have no way of accessing the program. MOAA recommends, for groups or
    classifications designated by the service secretaries as being waived
    from the program, that individual members have a way to opt into the
    program nonetheless. The program, after all, is meant to benefit the
    member, not the service, so the ultimate decision to waive off should
    reside with the member and not the service.
        For members ``possessing specialized skills'' who are unable to
    attend the program ``to support the imminent deployment of a unit,''
    MOAA would like the program to be made available to them within a year
    of their separation from service. The November 2017 Government
    Accountability Office report titled ``Transitioning Veterans; DOD Needs
    to Improve Performance Reporting and Monitoring for the Transition
    Assistance Program,'' noted over one-third (37 percent) of
    servicemembers surveyed did not attend TAP at all, not even the core
    curriculum portion, because they were not released from their duties
    due to having mission-critical skills. Having over one-third of
    transitioning servicemembers unprepared for their follow-in careers is
    simply unacceptable. Allowing these servicemembers to participate
    within a year of separating from service would ensure they still are
    able to receive the training and assistance in a fashion that does not
    compromise the mission.
        MOAA further recommends the inclusion of information specific to
    women veterans in the program. A Department of Veterans Affairs (VA)
    employee recently shared a sentiment that MOAA has heard echoed both
    from women veterans and the VA: ``Women veterans are still coming to us
    in the VA not even knowing how to apply for all the benefits they rate.
    They need to be educated prior to leaving service to ensure we can
    effectively assist them once they get here.'' Data and experience have
    identified areas where women veterans have unique experiences and needs
    following transition, yet women veterans still are bypassing the VA or
    are arriving there unaware of what they should be doing to access the
    women-specific benefits and services available to them in the
    department. This indicates a failure in the agencies communicating
    about the benefits and resources for women veterans.
    S. 1952, Department of Veterans Affairs Financial Accountability Act of
            2017
        MOAA supports this legislation.
        The VA Financial Accountability Act introduced by Sens. Jon Tester
    (D-Mont.), John McCain (R-Ariz.), Jerry Moran (R-Kan.), and Tim Kaine
    (D-Va.) would improve the oversight and accountability of VA financial
    processes.
        The bill provides a sense of Congress as to what a normal or
    standard budget process should look like for the VA in seeking future
    appropriations:

         The process should be grounded in sound actuarial analysis
    based on accurate demand data for forecasting.
         The regular budget process should be the norm.
         Requests for supplemental appropriations should be used
    sparingly and for unforeseen demand or natural occurrences.

    More specifically, the VA would be required to contract with an
    independent third party to: review and audit financial processes and
    reporting structures, including actuarial and estimation models and
    develop recommendations for financial system improvements. The
    secretary of the VA then would submit a plan for implementing the
    report recommendations to both the Senate and House Committees on
    Veterans' Affairs. One individual within the Office of the Secretary
    would be responsible for monitoring the status and implementation of
    the recommendations.
        The secretary also would be required to notify Congress not later
    than 45 days in advance of a request for supplemental appropriation for
    budgetary issues outside of the standard budget process. The VA chief
    financial officer (CFO) would be required to provide a statement with
    supporting materials to the Committees assuring financial projections
    submitted with the president's annual budget request is sufficient to
    provide benefits and services in the department. Additionally, the CFO
    must certify responsibility for internal controls and collaboration
    with department financial officers of all facilities and components
    when submitting the VA's annual budget.
        MOAA, like lawmakers, recognizes VA fiscal problems cannot continue
    to be fixed by adding more money to the budget, particularly during
    fiscally constrained times. Implementation of the Choice Program and
    ongoing funding crises in recent years have brought to light a number
    of problems associated with VA financial, data management, and
    forecasting systems. MOAA supports the VA Financial Accountability Act
    and believes the audit and certification provisions in the bill are
    long overdue and a much needed move in the right direction to get the
    VA's fiscal house in order.
    S. 1596, BRAVE Act of 2017
        MOAA supports this legislation and requests Congress provide the
    associated funding needed to support the legislative requirements of
    this bill.
        The BRAVE Act would correct a long-overdue shortfall that places an
    unnecessary burden on surviving families. In 2017, the average funeral
    cost over $8,000.\2\ The current VA reimbursement rate of $300 for
    veterans not dying of a service-connected disability amounts to less
    than 4 percent of the costs a surviving family may incur. The current
    reimbursement rates for the family of a veteran dying of a service-
    connected cause amounts to 25 percent of the total potential cost.
    Using the Consumer Price Index to increase these amounts periodically
    is a logical solution to attempting to alleviate some of the burden
    that results from these low reimbursement amounts.
    ---------------------------------------------------------------------------
        \2\ National Funeral Directors Association, Statistics, available
    at http://www.nfda.org/news/ statistics
    ---------------------------------------------------------------------------
    S. 1990, Dependency and Indemnity Compensation Improvement Act of 2018
        MOAA is supportive of this legislation, pending modification. We
    request Congress provide the associated funding needed to support the
    legislative requirements of this bill.
        The Dependency and Indemnity Compensation Improvement Act would
    make important changes to Title 38: It would change the computation of
    Dependency and Indemnity Compensation (DIC); it would reduce from 10
    years to five the number of years a veteran must be rated permanently
    disabled for a survivor to become eligible for DIC; and it would reduce
    from 57 to 55 the age at which a surviving spouse may remarry and
    retain DIC.
        The Dependency and Indemnity Compensation Improvement Act would
    change the computation of DIC to 55 percent of the rate of pay for a
    100-percent-disabled veteran. Changing the formula for how DIC is
    calculated would make the benefit more in line with that of other
    Federal programs. The change would provide approximately $300 more per
    month for qualified survivors.
        MOAA commends the desire to increase DIC payments. The increase in
    tax-free compensation would be a welcomed addition to qualified
    survivors. However, the bill, as currently written, omits an important
    provision contained in previous military survivor bills. MOAA would
    like to see the following language incorporated into the bill:

            (g) In the case of an individual who is eligible for Dependency
            and Indemnity Compensation under this section who is also
            eligible for benefits under another provision of law by reason
            of such individual's status as the surviving spouse of a
            veteran, then, notwithstanding any other provision of law
            (other than section 5304(b)(3) of this title), neither a
            reduction nor an offset in benefits under such provision shall
            be made by reason of such individual's eligibility for benefits
            under this section.

        The bill also lowers the number of years a veteran must be rated
    100 percent disabled for a survivor to qualify for DIC. MOAA supports a
    graduated scale of benefits after five years of being rated permanently
    and totally disabled for surviving spouses of veterans.
        The bill also would lower from 57 to 55 the age at which a
    surviving spouse may remarry and retain DIC benefits. The change would
    align DIC with other Federal programs. MOAA supports this change.
        As Members of the Committee know, the Survivor Benefit Plan (SBP)
    and DIC are benefits paid for two distinct reasons. SBP is a voluntary,
    member-purchased annuity provided by DOD, allowing a continuation of a
    portion of military retired pay upon the death of the servicemember.
    DIC is a VA-paid monetary benefit for eligible survivors whose sponsors
    died of a service-connected injury or disease. MOAA remains steadfast
    believing the only way to end the unfair treatment of survivors of
    military retirees and those killed in the line of duty is to repeal
    SBP-DIC offset.
    S. 2748, BATTLE for Servicemembers Act
        MOAA supports this legislation and requests Congress provide the
    associated funding needed to support the legislative requirements.
        The November 2017 Government Accountability Office report titled
    ``Transitioning Veterans; DOD Needs to Improve Performance Reporting
    and Monitoring for the Transition Assistance Program,'' noted that
    participating in the two-day additional classes offered through TAP was
    thwarted by ``lack of commander support'' and that 57 percent of the
    installations that GAO spoke to stated ``commanders and direct
    supervisors were less inclined to allow servicemembers to attend these
    classes because they were considered optional.'' The lack of
    opportunity by these servicemembers to participate in such an important
    transition program element defies the intent and institutional rigor
    dedicated to transition programs in the first place.
        Changing the two-day classes from an opt-in model to a member opt-
    out model has the potential to minimize this level of command
    interference and to reinforce the importance of the program to a
    transitioning servicemember's future career.
    S. __, Grant Program on Provision of Suicide Prevention Services for
            Veterans
        MOAA supports this legislation and requests Congress provide the
    associated funding needed to support the legislative requirements.
        The bill requires the secretary of Veterans Affairs to establish a
    program to award grants to persons to provide and coordinate the
    provision of suicide prevention services for veterans transitioning
    from service in the Armed Forces who are at risk of suicide and for
    their families, and for other purposes. It augments existing VA
    programs and is a natural extension of those resources.
        The bill is comprehensive in its attempt to capture the key
    functional requirements to provide suicide prevention services for
    veterans and their families. The focus and priority is placed on
    veterans and families who live away from any VA medical center and are
    located in more rural or tribal areas, which MOAA supports given the
    sparsity of resources in those areas. MOAA would like the legislation
    to emphasize that this legislation will not compete with or be a
    replacement for existing VA suicide prevention services, but is
    intended only as a compliment to what VA provides.
        It is anticipated that programs selected will have a history of
    providing these services along with the relevant programmatic and
    professional credentialing. A brief review of grants and activities of
    SAMSHA (Substance Abuse and Mental Health Services Administration)
    shows a wide variety of public/private and community partnership
    activities and programs and certified community behavioral health
    clinics. Given the existing precedent in other areas, veterans should
    be allowed to benefit from such arrangements, as well.
        MOAA specifically appreciates including services for families under
    grant uses as family members feel the direct impact of the mental
    health of their veteran and this, in turn, can influence their own
    mental health.
    S. __, Modernization of Medical Records Access for Veterans Act
        MOAA does not support this legislation.
        This bill would direct the VA to carry out, in at least one
    Veterans Integrated Services Network (VISN), a pilot program for at
    least a 12-month period during which veterans enrolled in the VA's
    patient enrollment system will use a portable medical records storage
    system to store and share with VA health care providers and community
    health care providers records of their individual medical histories.
    This is specified to be similar in nature and characteristics to a
    standard credit card. The bill also prohibits new appropriations in
    carrying out this pilot.
        MOAA is supportive of a system that would enable veterans who
    receive care from non-VA providers to be able to consolidate their VA
    and non-VA records in an effective and efficient manner. This is
    important to ensure continuity of care and accuracy of treatment. MOAA
    does not support, however, the express prohibition on new
    appropriations to carry this initiative out. Unfunded mandates have the
    significant potential to harm other VA programs from which the funds
    are extracted. Further, MOAA has supported the implementation of the
    current VA electronic health record initiative and believes that a
    solution for needs such as these could be satisfied through that system
    if properly implemented.
    S. 514, No Hero Left Untreated Act
        MOAA supports this legislation.
        This legislation would establish a pilot program within the VA on a
    promising neurological treatment option for mental trauma called
    magnetic EEG/EKG-guided resonance therapy, also known as Magnetic
    eResonance Therapy (MeRT). This is an individualized non-
    pharmaceutical, non-invasive neuromodulation procedure that applies
    magnetic stimulation to restore proper brain function. To date, open
    label trials and placebo-controlled, double-blind studies indicate over
    400 veterans have reported a marked improvement in symptoms associated
    with PTS, TBI, MST, chronic pain, and opiate addiction. One study done
    at Tinker Air Force Base, after four weeks of testing, specifically
    concluded, ``Transcranial MeRT is a promising adjuvant treatment
    modality to help veterans suffering from PTSD.''
        MOAA believes there is sound research to support a pilot on 50
    veterans. MOAA also notes the bill prohibits new appropriations to
    carry out the pilot program. Although MOAA generally objects to
    unfunded mandates, the fact this pilot is limited to 50 veterans and
    only requires VA to provide ``access to'' the treatment vice directly
    rendering the treatment, MOAA believes the cost will be negligible.
        MOAA thanks the Committee for considering these important pieces of
    legislation, and we look forward to working with Members of Congress in
    making the necessary changes listed above and to move the bills quickly
    through the Congress for final passage.
                                     ______

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      Prepared Statement Submitted by Aleks Morosky, National Legislative
                  Director, Military Order of the Purple Heart
        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee, On behalf of the Military Order of the Purple Heart (MOPH),
    whose membership is comprised entirely of combat wounded veterans, I
    thank you for inviting us to submit our views on pending legislation.
    For the purposes of this statement, we will focus our comments on H.R.
    299, the Blue Water Navy Vietnam Veterans Act of 2018, specifically
    section 6(c), which extends the Department of Veterans Affairs (VA)
    Home Loan funding fee waiver to Purple Heart recipients serving on
    active duty in the Armed Forces.
        As its name implies, the Blue Water Navy Vietnam Veterans Act deals
    in large part with extending presumptive service connection for
    conditions related to Agent Orange exposure to veterans who served
    offshore of the Republic of Vietnam from January 9, 1962 to May 7,
    1975. It would also grant the same presumptive service connection for
    veterans who served on the Korean Demilitarized Zone from September 1,
    1967 to August 31, 1971, extend benefits to the children born with
    spina bifida to certain veterans who served in Thailand, and require VA
    to submit an updated report on its Gulf War Illness study. MOPH
    supports all of these provisions.
        This legislation also makes a number of technical changes to the VA
    Home Loan Program. Among those is section 6(c), which would extend the
    VA home loan funding fee waiver to active duty Purple Heart recipients.
    Since VA home loans require no down payment or mortgage insurance, the
    funding fee is used to cover any losses VA may incur in guaranteeing
    the loans. The fees for first time users of the program are between
    2.15 and 2.4 percent of the loan amount, and may be paid upfront or
    financed as part of the loan. While the VA Home Loan Program is a
    valuable benefit, the funding fee generally adds thousands of dollars
    to the final amount of the loan. However, disabled veterans and
    surviving spouses of veterans who died of service-connected
    disabilities are eligible to have the funding fee waived as a benefit
    of their service.
        Combat wounded veterans still serving on active duty, however, are
    required to pay the funding fee in all cases. MOPH strongly believes
    that these veterans, the vast majority of whom will almost certainly be
    eligible for some level of service-connected disability rating upon
    separation, should be entitled to the funding fee waiver on the same
    basis as disabled veterans who have already been discharged. Many
    active duty Purple Heart recipients were severely wounded in Iraq and
    Afghanistan, and spent many months recovering in military hospitals
    before they were able to return to duty. Others may spend months or
    years in military hospitals before ultimately receiving medical
    discharges, but may wish to purchase homes during that period of
    recovery. MOPH sees absolutely no reason why they should be penalized
    by the VA Home Loan Program in any way, simply because they continue to
    serve on active duty in some capacity.
        This issue was first brought to our attention by a MOPH member,
    Major Byron Owen, United States Marine Corps. A multiple Purple Heart
    recipient, Major Owen was wounded twice in Iraq in 2006, and again in
    Afghanistan in 2008. After recently deciding to use his VA Home Loan
    benefit, and being aware that veterans with service-connected
    disabilities are exempt from the funding fee, he was frustrated to
    discover that he was not eligible for the waiver as an active duty
    servicemember. In his own words:

            ``I think they (VA) unfairly punish active duty personnel who
            choose to remain in uniform instead of accept medical
            separation or retirement. I was medevac'd out of Iraq in 2006
            and had to undergo months of therapy to return to service. Why
            should I have to pay 20 grand to get a VA loan when someone
            with a non-combat related disability gets to waive it? Some of
            my friends are amputees in uniform. They're paying the funding
            fee. Does that seem right? I think someone should advocate on
            the behalf of active duty Purple Heart recipients who would
            almost certainly receive service-connected disability payments
            if we were out.''

        MOPH strongly agrees with Major Owen, and stands with him and the
    approximately 8,000 other Purple Heart recipients currently serving on
    active duty in the U.S. military. Veterans who have been wounded in
    combat with the enemies of our Nation have made incredible sacrifices,
    and under no circumstances should they be excluded from a benefit as
    significant as the VA Home Loan funding fee waiver, simply because of
    their duty status. We strongly urge the Committee to correct this
    injustice by passing H.R. 299 without delay.

        Chairman Isakson, Ranking Member Tester, this concludes my
    statement. On behalf of the Order, I thank you for the opportunity to
    submit our statement, and would be happy to answer any questions for
    the record that you or other Members of the Committee may have.
                                     ______

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        Prepared Statement Submitted by CDR John B. Wells, USN (Ret.),
                 Executive Director, Military-Veterans Advocacy
                                  introduction
        Distinguished Chairman Johnny Isakson, Ranking Member Jon Tester
    and other Members of the Committee, Thank you for the opportunity to
    present Military-Veterans Advocacy's views on H.R. 299, the Blue Water
    Navy Vietnam Veterans Act of 2017.
                        about military-veterans advocacy
        Military-Veterans Advocacy Inc. (MVA) is a tax exempt IRC 501[c][3]
    organization based in Slidell, Louisiana that works for the benefit of
    the Armed Forces and military veterans. Through litigation, legislation
    and education, MVA seeks to obtain benefits for those who are serving
    or have served in the military. In support of this, MVA provides
    support for various legislation on the State and Federal levels as well
    as engaging in targeted litigation to assist those who have served.
        Along with the Blue Water Navy Vietnam Veterans Association, Inc
    (BWNVVA) and the Fleet Reserve Association (FRA), MVA has been the
    driving force behind the Blue Water Navy Vietnam Veterans Act
    (H.R. 299). Working with Members of Congress and United States Senators
    from across the political spectrum, MVA and BWNVVA provided technical
    information and support to sponsors who have worked tirelessly to
    partially restore the benefits stripped from the Blue Water Navy
    veterans sixteen years ago. H.R. 299 passed the House of
    Representatives by a bi-partisan and unanimous vote of 382-0.
                military-veterans advocacy's executive director
                      commander john b. wells, usn (ret.)
        MVA's Executive Director, Commander John B. Wells, USN (Retired),
    has long been viewed as the technical expert on H.R. 299. A 22-year
    veteran of the Navy, Commander Wells served as a Surface Warfare
    Officer on six different ships, with over ten years at sea. He
    possessed a mechanical engineering subspecialty, was qualified as a
    Navigator and for command at sea, and served as the Chief Engineer on
    several Navy ships. As Chief Engineer, he was directly responsible for
    the water distillation and distribution system. He is well versed in
    the science surrounding this bill and is familiar with all aspects of
    surface ship operations. This includes the hydrological effect of wind,
    tides and currents.
        Since retirement, Commander Wells has become a practicing attorney
    with an emphasis on military and veterans law. He is counsel on several
    pending cases concerning the Blue Water Navy and has filed amicus
    curiae briefs in other cases. He has tried cases in state, Federal,
    military and veterans courts as well as other Federal administrative
    tribunals. Since 2010 he has visited virtually every Congressional and
    Senatorial offices to discuss the importance of enacting a bill to
    partially restore benefits to those veteran who served in the bays,
    harbors and territorial seas of the Republic of Vietnam. He is also
    recognized in the veterans community as the subject matter expert on
    this matter.
                   historical background surrounding h.r. 299
        In the 1960's and the first part of the 1970's the United States
    sprayed over 12,000,000 gallons of a chemical laced with 2,3,7,8-
    Tetrachlorodibenzodioxin (TCDD) and nicknamed Agent Orange over
    southern Vietnam. This program, code named Operation Ranch Hand, was
    designed to defoliate areas providing cover to enemy forces. Spraying
    included coastal areas and the areas around rivers and streams that
    emptied into the South China Sea. By 1967, studies initiated by the
    United States government proved that Agent Orange caused cancer and
    birth defects. Similar incidence of cancer development and birth
    defects have been documented in members of the United States and Allied
    Armed Forces who served in and near Vietnam.
        Throughout the war, the United States Navy provided support for
    combat operations ashore. This included air strikes and close air
    support, naval gunfire support, electronic intelligence, interdiction
    of enemy vessels and the insertion of supplies and troops ashore.
    Almost every such operation was conducted within the territorial seas
    of the Republic.
        The South China Sea is a fairly shallow body of water and the
    thirty fathom curve (a fathom is six feet) extends through much of the
    area designated in the bill. The gun ships would operate as close to
    shore as possible. The maximum effective range of the guns required
    most operations to occur within a few thousand yards of shore.
        It was common practice for the ships to anchor while providing
    gunfire support. Digital computers were not yet in use and the fire
    control systems used analog computers. By anchoring, the ship's crew
    was able to achieve a more stable fire control solution, since there
    was no need to factor in their own ship's course and speed. It was also
    common for ships to steam up and down the coast at high speeds to
    respond to call for fire missions, interdict enemy sampans and other
    operational requirements.
                            agent orange act of 1991
        In 1991, the Congress passed and President George H. W. Bush
    signed, the Agent Orange Act of 1991, Pub.L. 102-4, Feb. 6, 1991, 105
    Stat. 11. This Federal law required VA to award benefits to a veteran
    who manifests a specified disease and who ``during active military,
    naval, or air service, served in the Republic of Vietnam during the
    period beginning on January 9, 1962, and ending on May 7, 1975.''
        The Department of Veterans Affairs (hereinafter VA) drafted
    regulations to implement the Agent Orange Act of 1991 and defined
    ``service in the Republic of Vietnam'' as ``service in the waters
    offshore and service in other locations if the conditions of service
    involved duty or visitation in the Republic of Vietnam.'' 38 CFR
    Sec. 3.307(a)(6)(iii) (1994). This was in contrast to a previous
    definition which defined ``service in the Republic of Vietnam'' as
    ``service in the waters offshore, or service in other locations if the
    conditions of service involved duty or visitation in Vietnam.'' 38 CFR
    Sec. 3.313 (1991). The placement of the comma became critical in the
    VA's interpretation. As a result of the comma's omission, benefits were
    stripped from those who served in the bays, harbors and territorial
    seas of Vietnam.
        Originally, the VA interpreted the regulation to allow the
    presumption of exposure throughout the Vietnam Service Medal area,
    which is the dark solid line marked on the Exhibit. Under this
    definition, a ballistic missile submarine was covered as were the
    aircraft carriers on Yankee Station and submarines conducting
    operations where no Agent Orange was sprayed. These ships would not be
    covered under H.R. 299.
        In 1997 the VA General Counsel issued a precedential opinion
    excluding servicemembers who served offshore but not within the land
    borders of Vietnam. The opinion construed the phrase ``served in the
    Republic of Vietnam'' as defined in 38 U.S.C. Sec. 101(29)(A) not to
    apply to servicemembers whose service was on ships and who did not
    serve within the borders of the Republic of Vietnam during a portion of
    the ``Vietnam era.'' The opinion stated that the definition of the
    phrase ``service in the Republic of Vietnam'' in the Agent Orange
    regulation, 38 CFR Sec. 3.307(a)(6)(iii), ``requires that an individual
    actually have been present within the boundaries of the Republic to be
    considered to have served there,'' and that for purposes of both the
    Agent Orange regulation and section 101(29)(A), service ``in the
    Republic of Vietnam'' does not include service on ships that traversed
    the waters offshore of Vietnam absent the servicemember's presence at
    some point on the landmass of Vietnam.''
        After lying dormant for a few years, this General Counsel opinion
    was incorporated into a policy change that was published in the Federal
    Register during the last days of the Clinton Administration. The final
    rule was adopted in Federal Register in May of that year. Comments by
    the VA concerning the exposure presumption recognized it for the
    ``inland'' waterways but not for offshore waters.
        Historically the VA's Adjudication Manual, the M21-1 Manual,
    allowed the presumption to be extended to all veterans who had received
    the Vietnam service medal, in the absence of ``contradictory
    evidence.'' In a February 2002 revision to the M21-1 Manual, the VA
    incorporated the VA General Counsel Opinion and the May 2001 final rule
    and required a showing that the veteran had set foot on the land or
    entered an internal river or stream. This ``boots on the ground''
    requirement is in effect today.
        One exception to this rule deals with Non-Hodgkins Lymphoma. A
    punctuation difference in the regulation allows the VA to exclude Navy
    veterans suffering from other Agent Orange related illnesses.
                              hydrological effect
        The Agent Orange that was sprayed over South Vietnam was mixed with
    petroleum. The mixture washed into the rivers and streams and
    discharged into the South China Sea. In addition, the riverbanks were
    sprayed continuously resulting in direct contamination of the rivers.
        The dirt and silt that washed into the river can be clearly seen
    exiting the rivers and entering the sea. This is called a discharge
    ``plume'' and in the Mekong River it is considerable. Although the
    Mekong has a smaller drainage area than other large rivers, it has
    approximately 85% of the sediment load of the Mississippi. In two
    weeks, the fresh water of the Mekong will travel several hundred
    kilometers. Notably, the Agent Orange dioxin dumped off the east coast
    of the United States was found in fish over one hundred nautical miles
    from shore.
        Eventually, the Agent Orange/petroleum mixture would emulsify and
    fall to the seabed. Evidence of Agent Orange impingement was found in
    the sea bed and coral of Nha Trang Harbor. During the Vietnam War, the
    coastline, especially in the harbors and within the thirty fathom curve
    was a busy place with military and civilian shipping constantly
    entering and leaving the area in support of the war effort. Whenever
    ships anchored, the anchoring evolution would disturb the shallow
    seabed and churn up the bottom. Weighing anchor actually pulled up a
    small portion of the bottom. The propeller cavitation from military
    ships traveling at high speeds, especially within the ten fathom curve,
    impinged on the sea bottom. This caused the Agent Orange to constantly
    rise to the surface. Tidal effects mixed the contaminated river water
    with the salt water in the territorial seas. The contaminated water was
    ingested into the ship's evaporation distillation system which was used
    to produce water for the boilers and potable drinking water. Navy ships
    within the South China Sea were constantly steaming through a sea of
    Agent Orange molecules.
                                judicial impact
        This matter first came before the judiciary in 2006. Haas v.
    Nicholson, 20 Vet. App. 257. The Haas court found that the veteran, who
    was operating off the shoreline, was within the scope of the statutory
    definition and invalidated the VA ``boots on the ground'' policy. The
    Federal Circuit reversed in Haas v. Peake, 525 F.3d 1168, 1196 (Fed.
    Cir. 2008) reh'g denied Haas v. Peake, 544 F.3d 1306, 1309 (Fed. Cir.
    2008).
        In 2015, the Court of Appeals for Veterans Claims considered
    another Blue Water case, as it applied to bays and harbors, in Gray v.
    McDonald, 27 Vet. App. 313 (2015). The Gray Court found the Secretary's
    exclusion of Da Nang from their inland waterways definition was
    arbitrary and capricious. Gray, 27 Vet. App. at 313. The Gray court
    went on to note that the VA failed to address their rationale in
    excluding areas where brown water and blue water mix, such as Da Nang
    Harbor. Gray, supra., at 322. Stopping short of applying a definition
    of inland waters, the Gray Court ruled that they would vacate the BVA
    decision and remand the matter to the VA. The Secretary did not file an
    appeal. The Secretary failed to follow the Gray court's guidance. A new
    regulation issued in the M21-1 Manual on February 5, 2016 renewed the
    same exclusionary policy used to deny the veterans their benefits. A
    petition for review, pursuant to 38 U.S.C. Sec. 502, was filed in the
    Court of Appeals for the Federal Circuit. The petition was dismissed
    due to lack of jurisdiction. Gray v. MacDonald, 830 F.3d 570 (D.C. Cir.
    2016). A petition for rehearing en banc was also denied 7-3. Gray v.
    Sec'y of Veterans Affairs, 884 F.3d 1379 (Fed. Cir. 2018). A petition
    for certiorari is pending in the Supreme Court of the United States.
        Additionally, there is a case pending in the United States Court of
    Appeals for the Federal Circuit, Procopio v. O'Rourke, 17-1821.
    Briefing and oral argument have completed. Procopio asks the court to
    extend the presumption of exposure to the territorial seas. Procopio,
    assuming it is decided in favor of the veterans, will not resolve the
    problem. Without the geographic designations incorporated into the
    bill, the VA would be free to define the territorial seas as they
    desired. Accordingly, H.R. 299 is needed to fix the area to be covered.
                                cost of h.r. 299
        The Congressional Budget Office has scored H.R. 299 at $894 million
    over ten years. This includes $882 million for the Blue Water component
    and the remainder to provide expanded benefits to Korea DMZ veterans
    and additional Spina Bifida benefits. H.R. 299 also called for an
    increase in loan guarantee fees which will generate $1.165 billion over
    ten years. Accordingly, H.R. 299 will result in a $271 million dollar
    savings to the government over ten years.
        The loan guarantee fees vary depending on whether there is a down
    payment and whether it is the first or subsequent use of the home loan
    benefit. The increased rates will vary between 1.25% and 3.30% and are
    expected to cost the veteran $2.00 to $2.50 per month. Disabled
    veterans will generally be exempt from the provision. The cap on jumbo
    loans will be removed which will allow the VA to provide a guarantee on
    the full amount of the loans. The disabled veteran exemption for jumbo
    loans will not apply however, unless the veteran is 100% disabled.
        The bill and the offset have generally received the support of the
    Veterans Service Organizations. The exception seems to be a real estate
    agent, George Varrato II, a Phoenix Realtor has objected to the offset
    although he does not object to the bill. Varrato contacted the
    undersigned several weeks ago but was unable to provide any substitute
    offset significant enough to finance these benefits. He was also unable
    to provide information on how many veterans would be affected by the
    fees.
        Although Military-Veterans Advocacy is unhappy with any offset for
    additional veterans benefits, the reality of the situation is that they
    are required by Pub. L. 111-139. Of the various offsets reviewed by
    MVA, this offset seems the most innocuous.
                          common va misrepresentations
        The VA has consistently opposed the expansion of the presumption of
    exposure. On October 24, 2017, however, former Secretary Shulkin
    expressed support for H.R. 299 in his testimony before the House
    Veterans' Affairs Committee. Given the previous opposition, and the
    lack of a confirmed Secretary to articulate the present VA position,
    MVA feels compelled to address previous VA misrepresentations.
        Some common VA misrepresentations are as follows:

        Misrepresentation: The Australian distillation study was never peer
    reviewed.
        MVA Comment: The report was presented for review at the 21st
    International Symposium on Halogenated Environmental Organic Pollutants
    and POPs and is published in the associated peer reviewed conference
    proceedings: Mller, J.F., Gaus, C., Bundred, K., Alberts, V., Moore,
    M.R., Horsley, K., 2001. It was also reviewed and confirmed by two
    separate committees of the Institute of Medicine.
        Misrepresentation: There is no evidence that the evaporation
    distillation process used by the Australians was the same as used on
    United States ships.
        MVA Comment: All steam ships used a similar system which remained
    in place until the 1990's. In addition many of the Australian gun ships
    were the United States Charles F. Adams class and were built in the
    United States. Both the MVA Executive Director and another experienced
    Navy Chief Engineer have reviewed the Australian report. They concluded
    the distillation systems therein were the same as used by United States
    Navy ships.
        Misrepresentation: There is no evidence that Navy ships distilled
    potable water.
        MVA Comment: Ships carried a reserve of potable water but it was
    normally replenished by distillation daily or every other day. A
    Destroyer sized ship carried less than 20,000 gallons for a crew size
    between 275 and 300 men. The water was used for cooking, cleaning,
    laundry, showering and drinking. As Vietnam is in the tropics,
    significant hydration was necessary. In addition, the warmer sea
    injection temperature below the 17th parallel resulted in less
    efficient water production. Water hours, where showers were limited or
    banned, was common during tropical deployments. Water was constantly
    being distilled to meet the requirements for boiler feed water and
    potable water.
        Misrepresentation: The Australian study monitored the reverse
    osmosis system rather than the evaporation distillation system used on
    United States Navy ships.
        MVA Comment: The only time that the reverse osmosis system was used
    in the Australian study was to purify the baseline sample prior to
    adding the solids and sediments consistent with the estuarine waters of
    Vietnam. The actual distillation process, as confirmed above, was the
    same distillation system used by United States Navy ships.
        Misrepresentation: The IOM found more pathways of Agent Orange
    exposure for land based veterans than those at sea.
        MVA Comment: Technically this is true but irrelevant. The IOM noted
    that discharges from rivers and steams was a pathway unique to the Blue
    Water Navy and that it was one of the plausible pathways of exposure.
    The number of possible pathways is not determinative. What is
    conclusive is that pathways of exposure existed. Misrepresentation: The
    IOM could not quantify any Agent Orange in the water.
        MVA Comment: This again is a red herring. Any amount of exposure
    can do damage to the human body. The IOM also found that the
    evaporation distillation process enriched the dioxin by a factor of
    ten. This is consistent with Australian studies showing a higher cancer
    incidence among Navy veterans and a Center for Disease Control study
    showing a higher incidence of Non-Hodgkins Lymphoma among Navy
    veterans.
        Misrepresentation: Ships operating hundreds of miles off shore who
    were not exposed will be given the presumption of exposure.
        MVA Comment: Not true. This bill applies only to the territorial
    seas which at their widest point off the Mekong extends out to 90
    nautical miles from the mainland. In the central and northern part of
    the Republic of Vietnam, the territorial seas would only extend 20-30
    nautical miles from the mainland.
        Misrepresentation: Submarines would come into the area to obtain
    the Vietnam Service Medal for their crews and would be eligible for the
    presumption.
        MVA Comment: One ballistic missile submarine the USS Tecumseh, SSBN
    628 did enter the VSM area for that purpose but there is no indication
    that they entered the territorial seas. Submarines operating off of
    Haiphong or near Hainan Island would not have been within the
    territorial seas and are not covered by H.R. 299.
        Misrepresentation: No Agent Orange was sprayed over water.
        MVA Comment: Not true. MVA is in possession of statements from
    witnesses that ships anchored in Da Nang Harbor were inadvertently
    sprayed as the ``Ranch Hand'' planes made their approach to the
    airfield. Additionally, there are anecdotal reports of defective spray
    nozzles resulting in spray over the ships at anchor or operating in the
    South China Sea. Finally, the IOM recognized that the offsetting winds
    would blow some spray intended for the landmass over water.
        Misrepresentation: Navy regulations prevented ships from distilling
    water within ten miles of land.
        MVA Comment: This statement was taken out of context from a
    preventive medicine manual and was not a firm requirement. Ships were
    encouraged to not distill potable water near land because of the
    possibility of bacteriological contamination. Commanding Officers could
    allow potable water to be distilled close to land and often delegated
    that authority to the Chief Engineer. The IOM noted that the
    recommendation contained in the manual was widely ignored. More
    importantly, the recommendations in the manual did not apply to the
    distillation of feed water for use in the boilers. Since the same
    equipment was used for potable water, distillation to feed water would
    contaminate the entire system down to the final discharge manifold.
    Additionally, feed water used in auxiliary systems was discharged to
    the bilges via low pressure drains. Crew members would also be exposed
    to Agent Orange residue while cleaning and inspecting the watersides of
    boilers and the steam sides of condensers as well as other equipment.
        Misrepresentation: The IOM confirmed that there was no likelihood
    of exposure to herbicides in Da Nang Harbor.
        MVA Comment: The court in Gray v. McDonald, took the VA to task for
    this statement noting that this was not the conclusion of the IOM.
                                   conclusion
        MVA urges the adoption of H.R. 299. It will restore the earned
    benefits to tens of thousands of Navy veterans that were taken from
    them over a decade ago. This bill is supported by virtually all
    veterans organizations including the American Legion, Veterans of
    Foreign Wars, Vietnam Veterans of America, Reserve Officers
    Association, Fleet Reserve Association, Military Officers Association
    of America, Association of the U.S. Navy and other groups. We have
    always enjoyed the support of the Military Coalition. Enactment of this
    legislation is overdue and Military-Veterans Advocacy most strongly
    supports its passage.
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      Prepared Statement of Joshua Stewart, Director of Policy, National
                        Coalition for Homeless Veterans
        Chairman Isakson, Ranking Member Tester, and distinguished members
    of the Senate Committee on Veterans' Affairs: The National Coalition
    for Homeless Veterans (NCHV) is honored to present this statement for
    the record for the legislative hearing of February 7, 2018. On behalf
    of the 2,100 community- and faith-based organizations NCHV represents,
    we thank you for your commitment to serving our Nation's most
    vulnerable heroes.
        This statement reflects NCHV's mission of ending veteran
    homelessness and the bill presented at the hearing today that has the
    potential to most strongly impact that mission. There are three actions
    we should be carrying out as a country to further the goal of ending
    veteran homelessness: 1) supporting and--only where necessary--
    expanding current services, 2) spurring the creation of affordable
    housing, and 3) filling service gaps in our current system. If passed
    into law S. 1072, the Homeless Veterans Prevention Act of 2017, would
    accomplish the first and last of these.
        S. 1072 would fill long-standing, critical gaps in our service
    delivery system. Despite years of progressively better services,
    accumulated expertise, and best practices, there are still areas in
    which we know we need to do better. For decades, the U.S. Department of
    Veterans Affairs has conducted the CHALENG report and survey which
    among other things identifies the unmet needs of homeless veterans. And
    for decades, this report has consistently revealed that among the
    highest unmet needs of male and female homeless veterans are help with
    legal issues of all kinds. Family law plays a particularly prominent
    role, but also legal issues revolving around restoring driver's
    licenses, discharge upgrades, and financial issues are reported
    annually. And of course, legal assistance to prevent eviction and
    foreclosure is frequently reported.
        The long term, consistent nature of this unmet need points to a
    very real gap in our services. Section 3 of the Homeless Veterans
    Prevention Act would go a long way to ameliorating these issues for
    many veterans. The provision is well crafted and highlights the exact
    service need, while also allowing the Secretary leeway to add
    additional areas for legal services as he or she finds necessary.
        Similar to legal service's frequent appearance on the CHALENG
    report is the issue of dental care. The provision of dental care has
    consistently appeared on the top unmet needs list of homeless veterans
    for decades; in the most recent CHALENG report it was particularly
    pronounced in the female homeless veteran population. Though important
    in their own right, dental care is not merely a comfort or confidence
    concern. Untreated dental needs can cause severe health issues, and
    constant pain can be a trigger for self-medication and/or substance
    abuse. Furthermore, pain or unsightly dental features can wreck the
    confidence of a job seeker- causing a negative impact on the employment
    potential of a veteran.
        Extending dental care eligibility to homeless veterans in the HUD-
    VA Supportive Housing and Grant and Per Diem (GPD) programs, as well as
    those in the care of a Domiciliary, would be a huge step in the right
    direction. And that is exactly what Section 4 of S. 1072 accomplishes.
        In addition to filling these critical gaps in our service delivery
    system, this bill would also support our existing programs in two
    important ways; it allows the payment of per diem to GPD providers who
    serve the dependents of homeless veterans, and it extends the authority
    for the Supportive Services for Veteran Families (SSVF) program.
        As we modernize GPD, our transitional housing program at the VA, it
    becomes more and more clear that these providers need the authority to
    serve dependents of homeless veterans. While there are a very few
    providers who already do this, they must scrape together funding from
    other sources to make it work. Many providers who see the importance of
    this work and who wish to expand into it simply cannot make the math
    work. They need support from VA to make this shift possible. As it is
    now, veterans--in particular female veterans who statistically are more
    likely to be accompanied by children in their homelessness--are faced
    with the choice to get only themselves off the street or to stay with
    their children. Many understandably choose family unity and wait for
    permanent housing options together, out-of-doors. Section 2 of S. 1072
    would open the door for many more GPD providers to serve dependents;
    keeping families together, and improving the efficiency of our system.
        Finally, S. 1072 supports our existing programs by extending the
    authority for the SSVF program. But this is not merely a mundane annual
    re-authorization, and nor can it be. Because of an historical quirk in
    funding, there are 56 communities whose ``surge funding''--awarded in
    FY 2015--expired at the end of FY 2017. To maintain the normal schedule
    of funding ($300 million per annum) and prevent the loss of services
    from the surge grants ($207 million over the next three years) the
    funding for the SSVF program for FY 2018 must be no less than $400
    million. A list of communities who received surge funding and who are
    at risk of losing services without an increased FY 2018 appropriation
    can be found at https://www.va.gov/HOMELESS/ssvf/docs/
    SSVF_September2014_GrantRecipients.pdf.
        Section 6 of S. 1072 provides the SSVF program an authorization of
    $500 million, which would allow VA to redistribute another round of
    surge funding at almost the same level as the FY 2015 round. This is
    the best scenario, and one which NCHV heartily supports. Of course, we
    must also point out that Section 6 would now need a technical
    correction to proposed subparagraph (F), changing ``fiscal year 2017''
    to ``fiscal year 2018,'' or even to ``fiscal year 2019.'' The latter
    change would exacerbate the gap in services felt in communities, but
    would allow the appropriations committees time to fully fund the
    increased authorization.
        This one technical correction notwithstanding, the Homeless
    Veterans Prevention Act of 2017 is an outstanding piece of legislation.
    NCHV strongly supports S. 1072, and asks the Senate and the House to
    quickly pass it in its entirety. We thank the Senate Committee on
    Veterans' Affairs for its tenacity on these issues, as well as the
    bills long-time sponsor, Senator Burr. All of your work on behalf of
    homeless veterans is commendable.
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      Letter from Co-Directors of National Military and Veterans Alliance

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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 for the record on the important
    legislation pending before the Committee. The bills considered today
    can have a significant positive impact on veterans and their families
    who depend on the benefits and services available through the
    Department of Veterans Affairs (VA). Our comments will be limited to
    those bills in which PVA has a specific interest.
         h.r. 299, the ``blue water navy vietnam veterans act of 2018''
        PVA supports H.R. 299, the ``Blue Water Navy Vietnam Veterans Act
    of 2018.'' This legislation would extend presumption of exposure to
    herbicides containing dioxin, including Agent Orange, to veterans who
    served in ``blue water'' areas. Before 1997, Vietnam Veterans were
    eligible for a presumption of exposure to Agent Orange and other
    herbicides if ``during active military, naval or air service they had
    served in the Republic of Vietnam'' unless there was evidence they had
    not been exposed to Agent Orange. This policy was later amended so that
    service on the ground in Vietnam and service in inland waterways,
    ``brown water,'' was required to receive a presumption of exposure. PVA
    applauds you for making the necessary amendments to include veterans
    who served in ``blue water'' areas in the presumption.
       draft bill, the ``veterans dental care eligibility expansion and
                           enhancement act of 2018''
        PVA supports this draft legislation to improve dental care provided
    to veterans by VA. This legislation would establish a pilot program on
    expansion of dental services and treatment to all veterans enrolled in
    VA health care. Due to a lack of dental service providers within VA and
    the strict eligibility criteria for veteran patients to access such
    care, few veterans are able to access oral health care at VA. Veterans
    who do access VA dental care are generally those with service-connected
    dental conditions or injuries or other dental conditions that are
    aggravated by a service-connected injury or illness. For all other
    veterans there are some limited dental insurance plans that can be
    purchased through VA.
        The pilot program would expand dental care services and treatment
    to veterans who are enrolled in VA health care at 16 locations across
    the country. These 16 locations would include four VA medical centers
    with an established dental clinic, four VA medical centers with a
    contract for dental care, four community based outpatient clinics with
    available space, and four facilities from federally qualified health
    centers and Indian Health Service clinics. These pilot sites would
    assess the feasibility and ability to furnish dental services and
    treatment to no more than 100,000 veterans who volunteer to participate
    in the program.
        As the research of the last several years has made clear, oral
    health and overall health are not independent of one another. In 2012,
    the American Heart Association released a statement acknowledging an
    association between periodontal disease and cardiovascular disease.
    Recent studies suggest a connection between periodontal disease and
    kidney disease, diabetes, and strokes. VA must explore resources to
    properly integrate dental care and awareness into their holistic
    approach to veterans' health care.
         s. 3184, to amend title 38, united states code, to modify the
    requirements for applications for construction of state home facilities
    to increase the maximum percentage of nonveterans allowed to be treated
                   at such facilities, and for other purposes
        PVA supports S. 3184. This bill would allow state veterans' homes
    to provide care to spouses of veterans under certain conditions.
    Although many state veterans' homes are at capacity, there are some
    that are not. In these instances, veterans in need of, or already in a
    state home, may wish to have their spouse reside in the state home with
    them. If there is not enough demand by veterans needing access to state
    homes, PVA sees no reason why families need to separate for the sake of
    rigid adherence to the current 25 percent occupancy rules.
       draft bill, to amend title 10, united states code, to improve the
    transition assistance program for members of the armed forces, and for
                                 other purposes
        PVA supports the intent of the draft legislation which would
    improve the Transition Assistance Program (TAP) for members of the
    Armed Forces. This bill would make the first significant changes to the
    TAP since 2011. One of the notable changes this legislation would make
    is to tailor the transition program based on the servicemember's time
    in service, rank, age, and disability status. This will provide more
    specific opportunities to the servicemember instead of one blanket
    program for everyone.
        This legislation also provides transition assistance starting a
    year from the date of separation. One of the reasons servicemembers
    have such a difficult time transitioning is the fact that the TAP
    program is offered just a few months prior to their separation. To be
    fully prepared, servicemembers should begin the transition process much
    sooner. Earlier preparation would help them be better prepared to
    transition to civilian life, which would also support their mental
    health and overall wellbeing.
                 draft bill, the ``va hiring enhancement act''
        PVA supports the ``VA Hiring Enhancement Act.'' The bill would end
    the applicability of non-VA covenants not to compete to the appointment
    of certain Veterans Health Administration (VHA) personnel. It would
    also permit VHA to make contingent appointments and require VA
    physicians to complete residency training.
        This bill intends to fill vacancies and make VA more competitive by
    authorizing VHA to begin the recruitment and hiring process up to two
    years prior to the completion of required training. This would allow
    for physicians to quickly begin work at VA medical centers upon the
    completion of their education. This could help to stem the flow of the
    ever recurring stories of young clinicians who wished to serve veterans
    but were unable to endure the months of an uncertain onboarding
    process. Veterans deserve the best this country can offer. Congress
    should explore every means to ensure VA does not lose out on these
    young professionals due to inefficient hiring practices.
         h.r. 5418, the ``veterans affairs medical-surgical purchasing
                              stabilization act''
        PVA supports H.R. 5418, the ``Veterans Affairs Medical-Surgical
    Purchasing Stabilization Act.'' This legislation would direct the
    Secretary of VA to carry out the Medical Surgical Prime Vendor program
    using multiple vendors and prohibiting a prime vendor from solely
    designing the formulary of supplies.
        In the private sector, hospitals use multiple Group Purchasing
    Organizations that bid down medical equipment prices. With Medical
    Surgical Prime Vendor, VA proposed using only one large vendor as
    opposed to multiple vendors. Arguably, the lack of competition has
    ensured higher prices for VA and thus the taxpayer than would otherwise
    be the case with competing vendors. While one vendor ensures
    consistency and a reliable timeline, it may not be an improvement on
    quality. What we do know is the procurement shortcut can undermine the
    competitive system, and result in VA overpaying for equipment.
      s. 1596, the ``burial rights for america's veterans' efforts act of
                                  2017,'' or
                           the ``brave act of 2017''
        PVA supports S. 1596, the ``Burial Rights for America's Veterans'
    Efforts Act of 2017,'' or the ``BRAVE Act of 2017.'' This legislation
    would increase the amount payable through VA for burial and funeral
    expenses for non-service-connected veterans regardless of whether the
    death occurred in a VA facility. Under the bill, the benefit would
    increase from $300 to $749. The legislation also requires VA to
    increase burial benefits based on the percentage increase in the
    Consumer Price Index. This legislation is critical to ensuring that
    veterans' survivors have additional financial resources available to
    them to help address funeral and burial expenses.
            s. 1952, the ``department of veterans affairs financial
                          accountability act of 2017''
        PVA supports S. 1952, the ``Department of Veterans Affairs
    Financial Accountability Act of 2017.'' This legislation would require
    VA to engage in several efforts to ensure more accurate budgeting for
    the programs and services provided by the Department. First, the
    legislation would require VA to engage the services of a third party to
    conduct a review of its financial processes and to develop a plan to
    address any recommendations that result from the review. Second, it
    would require a member of the Secretary's office to be accountable for
    tracking VA's progress in implementing recommendations received from
    the Comptroller General of the United States, the Special Counsel, and
    the VA's Inspector General. Third, the legislation would require VA to
    provide any special requests for funding to Congress within 45 days of
    when the funding would be needed. Such requests would need to include a
    justification for the extra funds. Last, it would require VA to give
    attestations regarding financial projections concurrent with the
    President's annual budget.
        In order to properly implement the critical legislation that
    Congress has passed in recent months to reform the claims appeals
    process, implement a new community health care program, and expand
    access to comprehensive caregiver benefits, VA needs to ensure that it
    is using appropriated funds in an efficient and effective manner.
    Improved fiscal accountability will help to ensure that VA is able to
    more accurately project expenses and request adequate budgets. Congress
    will in turn be able to provide the funding needed to ensure that VA is
    able to meet its responsibilities to veterans with disabilities and
    their families.
    s. 1990, the ``dependency and indemnity compensation improvement act of
                                     2017''
        PVA supports S. 1990, the ``Dependency and Indemnity Compensation
    Improvement Act of 2017.'' This legislation would increase the amounts
    payable for Dependency and Indemnity Compensation (DIC) by
    approximately $300 per month. It would also provide eligibility to a
    portion of the DIC benefit for survivors whose veterans were rated
    totally disabled for at least five years prior to their death. Last,
    the bill would change the age at which a spouse could remarry and
    retain DIC benefits from age 57 to age 55. The critical changes
    provided by this important legislation will ensure that survivors are
    better able to meet their living expenses following their veteran's
    death.
      s. 2485, the ``medal of honor surviving spouses recognition act of
                                     2018''
        PVA supports S. 2485, the ``Medal of Honor Surviving Spouses
    Recognition Act of 2018.'' This legislation provides a pension for
    survivors of veterans who were awarded the Medal of Honor. The pension
    would compensate surviving spouses $1,329.58 monthly. To be eligible,
    the surviving spouse must have been married to the veteran for one year
    or more prior to the veteran's death; or, for any period of time if a
    child was born of the marriage, or was born to them before the
    marriage. This pension will ensure that the families of America's
    heroes are properly provided for by our Nation.
       s. 2748, the ``better access to technical training, learning and
        entrepreneurship for servicemembers act,'' or the ``battle for
                              servicemembers act''
        PVA supports S. 2748, the ``Better Access to Technical Training,
    Learning and Entrepreneurship for Servicemembers Act,'' or the ``BATTLE
    for Servicemembers Act.'' This legislation provides opportunities for
    servicemembers to receive additional training under TAP. Servicemembers
    will have the ability to receive this training unless they fall into
    specifically exempted categories. PVA supports any efforts that will
    better prepare transitioning servicemembers for returning to civilian
    life.
    draft bill, to require the secretary of veterans affairs to establish a
       program to award grants to persons to provide and coordinate the
      provision of suicide prevention services for veterans transitioning
      from service in the armed forces who are at risk of suicide and for
                     their families, and for other purposes
        PVA supports the intent of the draft bill requiring the Secretary
    of VA to establish a program to award grants to persons to provide and
    coordinate the provision of suicide prevention services for veterans
    transitioning from service in the Armed Forces who are at risk of
    suicide and for their families. We would encourage, however, that the
    program also focus in equal measure on veterans 50 and older, who are
    committing suicide in greater numbers than the post-9/11 generation.
    While we recognize the window in which a servicemember is transitioning
    from active service is a critical time that can correlate with the
    potential for suicide ideation, there is an equal and growing need to
    reach out to older veterans.
        Similarly, women veterans commit suicide at nearly six times the
    rate of other women. Of the annual suicide deaths per 100,000 people in
    the United States, male veterans comprised 32.1, and non-veteran men
    20.9. Among women veterans they comprised 28.7 compared to just 5.2
    among non-veteran women. This is a particularly concerning statistic
    since men, on average, are far more likely than women to commit
    suicide. Thus, this program must give particular heed to interrupting
    the unique factors that lead to such a risk for suicide among women
    veterans.
        Last, 14 of the 20 veterans who complete a suicide every day have
    never touched the VA system. We hope an introduced bill will offer
    further details about how community prevention experts are to be made
    aware of the grant opportunities.
    draft bill, the ``modernization of medical records access for veterans
                                     act''
        PVA supports the intent of the draft bill, the ``Modernization of
    Medical Records Access for Veterans Act.'' We believe, however, that
    some points of the draft bill should be clarified prior to its
    introduction. For example, it is unclear how the proposed medical
    records card will help to efficiently address the issues of
    interoperability for VA electronic health records. Since the card must
    be brought back to VA before VA's records can be updated, we are
    uncertain about how this solution would be more beneficial than cloud
    sharing medical records. This is particularly the case due to the
    inherent delays in updating a veteran's records through such a card. We
    look forward to learning more about how the medical records card could
    address current concerns about medical records access.
                   s. 514, the ``no hero left untreated act''
        PVA has no official position on S. 514, the ``No Hero Left
    Untreated Act.'' This legislation would establish a pilot program with
    VA to use Magnetic eResonance Therapy technology, or MeRT technology.
    This therapy, while not yet FDA approved, is used to treat Post
    Traumatic Stress Disorder (PTSD), Traumatic Brain Injury (TBI),
    military sexual trauma (MST), chronic pain, and opiate addiction. The
    legislation would establish a one-year pilot program on MeRT technology
    for 50 veterans at two VA medical centers.
        VA currently offers veterans access to repetitive transcranial
    magnetic stimulation (rTMS). This treatment is FDA approved to address
    treatment-resistant depression, a comorbid condition in PTSD, TBI, MST,
    and chronic pain and opioid addiction. While it is functionally similar
    to MeRT, there is no existing evidence that MeRT is superior to rTMS
    for treating any disorder.

        Again, PVA thanks you for the opportunity to present our views on
    these bills. We would be happy to take any questions you have for the
    record.
                                     ______

         Prepared Statement of Ms. Lauren Augustine, Vice President of
                Government Affairs, Student Veterans of America

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

        Prepared Statement Submitted by Tragedy Assistance Program For
                                Survivors (TAPS)

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Chairman Isakson, Ranking Member Tester, and distinguished members
    of the Senate Veterans' Affairs Committees, The Tragedy Assistance
    Program for Survivors (TAPS) thanks you for the opportunity to make you
    aware of issues and concerns of importance to the families we serve,
    the families of the fallen.
        While the mission of TAPS is to offer comfort and support for
    surviving families, we are also committed to improving support provided
    by the Federal Government through the Department of Defense (DOD), the
    Department of Veterans Affairs (VA), Department of Education (DoED),
    Department of Labor, state governments, government contractors, and
    local communities for the families of the fallen--those who fall in
    combat, those who fall from invisible wounds and those who die from
    illness or disease.
        TAPS was honored to enter into a new and expanded Memorandum of
    Agreement with the Department of Veterans Affairs in 2017. This
    agreement formalizes what has been a long-standing, informal working
    relationship between TAPS and the VA. The services provided by TAPS and
    VA are complementary, and in this public-private partnership each will
    continue to provide extraordinary services through closer
    collaboration.
        Under this agreement, TAPS continues to work with surviving
    families to identify resources available to them both within the VA and
    through private sources. TAPS will also collaborate with the VA in the
    areas of education, burial, benefits and entitlements, grief counseling
    and other areas of interest.
        The VA Office of Survivor Assistance, including Director Moira
    Flanders and her staff, works closely with TAPS to answer questions and
    concerns that are raised by surviving family members. We also
    appreciate the opportunities provided by the DOD/VA Survivors Forum,
    held quarterly, which works as a clearinghouse for information on
    government and private sector programs and policies affecting surviving
    families. This is ably facilitated by Craig Zaroff of the VA Benefits
    Assistance Service.
                              pending legislation
                                    s. 1990
        TAPS applauds Senator Tester and his staff for this legislation
    which offers an increase to the Dependency and Indemnity Compensation
    (DIC) provided for surviving spouses of those servicemembers who die on
    active duty or die of a service-connected disability. A second
    provision provides a graduated scale of benefits and addresses an
    arbitrary eligibility restriction. The third provision provides equity
    with other survivor benefits by allowing surviving spouses who remarry
    after age 55 to retain DIC benefits.
    History of DIC
        According to the Congressional Research Service (CRS), survivor
    compensation has been paid in some form to survivors since the
    Revolutionary War.
        During the Civil War, survivor compensation was expanded to cover
    all servicemembers at a rate that would be payable to totally disabled
    veterans. The Civil War also led to other changes to survivor
    compensation, especially for survivors of servicemembers with service-
    connected disabilities. They were covered under the Act of July 14,
    1862, which was referred to as General Law, and amended various times
    in the 19th century.
        In 1917, Congress passed the War Risk Insurance Act to eliminate
    the need for non-service pensions and highlighted that service-
    connected payments for death and disability were compensation payments.
    The act changed the system to meet the current needs of World War I
    veterans and their survivors and eliminated the pay discrepancy between
    officers and soldiers.
        The Servicemen's Indemnity Act of 1951 replaced this life insurance
    system with a new system where the servicemembers did not contribute to
    the insurance program, but the government provided monthly payments to
    eligible survivors of $120 with a 2.25% increase per year until a
    $10,000 insurance maximum was reached. Potentially eligible survivors
    included spouses, children, parents, and siblings.
        Because legislation had been written in response to need,
    dependency and indemnity compensation was unorganized and administered
    by four different administrations by the mid-1950s, and congressional
    and executive committees were formed to make the issuance of
    compensation more streamlined and manageable. Death compensation was
    set up similar to the way it is now by the time the final report of the
    President's Commission on Veterans' Pensions, Veterans' Benefits in the
    United States: Report to the President by the President's Commission of
    Veterans Pensions (hereafter referred to as the Bradley Report) was
    written in 1956. Death compensation was provided to survivors (except
    for dependent parents) regardless of income. The rate of compensation
    depended on whether the veteran served in peacetime or wartime.
        In 1969, after review of the Bradley Report, recommendations from a
    commission headed by Robert M. McCurdy in 1967, and extensive testimony
    from several other Federal administrations and veterans' service
    organizations, Congress devised a different, more equitable system for
    survivor compensation that gave fixed rates to each pay grade. The base
    rate was adjusted for a cost-of-living increase to reflect changes in
    the cost of living since the last base rate had been determined in
    1956, 13 years earlier. In 1969, years of service were no longer a
    factor in determining DIC. There were no subsequent changes of
    significance to DIC legislation until 1993, when the rate tables for
    surviving spouses were eliminated and one flat monthly rate was
    reinstated. In 2003, surviving spouses who remarried after reaching the
    age of 57 were able to retain DIC.
        DIC, along with other VA disability payments, are usually increased
    annually by the Federal cost of living adjustment (COLA), when there is
    a COLA. This COLA has been the only increase to the DIC since the new
    rate tables were established in 1993.
    Provision 1
        TAPS appreciates the 12 percent increase to the DIC to bring it up
    to 55 percent of the rate of compensation paid to a totally disabled
    veteran. It is something that we have supported for many years and, for
    those survivors whose only recompense is the DIC payment, long overdue.
        We also appreciate the provision of an additional $350 increase to
    the Special Survivor Indemnity Allowance (SSIA) for those survivors who
    are in receipt of both DIC and the Survivor Benefit Plan annuity. This
    would go a long way to make some survivors who are impacted negatively
    by the DIC offset to SBP whole, i.e. their offset would be completely
    eliminated when combined with the SSIA they currently receive.
        However, we have heard concerns from some survivors. Would the
    proposed SSIA increase also be tied to COLA? Is there a time limit for
    this provision? Where would the funding come from? We hope these
    questions will be addressed.
    Provision 2
        We support the intent of provision 2.
    Provision 3
        TAPS fully supports the provision to allow surviving spouses who
    remarry after age 55 to retain DIC benefits. This makes the DIC program
    consistent with other Federal programs, including the Department of
    Defense survivor benefit plan and the Federal Employees survivor
    benefit plan.
                                    h.r 299
        TAPS strongly supports H.R 299, the Blue Water Navy Vietnam
    Veterans Act of 2018. We stand with our friends in the Military
    Coalition and the Association of the United States Navy in encouraging
    quick passage of this long over due legislation. Many of the families
    impacted by Agent Orange from time in the Navy have become surviving
    families now, and TAPS believes those families should be eligible for
    the same survivor benefits as all other Agent Orange families.
                                    s. 2881
        TAPS supports S. 2881, the Mare Island Naval Cemetery Transfer Act,
    so as to ensure veterans buried in Vallejo, CA are treated with the
    respect they deserve. As the oldest military cemetery on the West
    Coast, it should be treated as a national shrine and elevated to a
    Department of Veterans Affairs national cemetery. We thank Senator
    Feinstein for bringing this issue to light.
                                    s. 2485
        TAPS honors the service and sacrifices made by Medal of Honor
    recipients and their families and is grateful to Senator Sullivan for
    introducing S. 2485 to establish a special pension for surviving
    spouses of Medal of Honor recipients.
                                     s. 541
        New and innovative programs have proved time and again to be
    helpful in treating PTSD/TBI and preventing suicide. If there is a
    possibility that magnetic EEG/EKG therapy can help in treating veterans
    with PTSD/TBI and preventing veteran suicide, then TAPS supports the
    one-year pilot program.
                                    s. 1596
        TAPS supports the BRAVE Act of 2017, which increases the amount
    provided for the burial of a veteran from $300 to $749 with annual COLA
    increases.
                              draft text--cassidy
        Suicide prevention is one of TAPS' top legislative priorities.
    Suicide is the second leading cause of death for active duty
    servicemembers and the numbers are growing. TAPS currently serves over
    12,000 surviving family members whose loved ones died by suicide and we
    are grateful to Senator Cassidy for bringing forth the draft
    legislation to create a grant program through VA for organizations
    working in suicide prevention.
                draft text--transition assistance program (tap)
        Veterans who make a good transition into civilian life are less
    likely to die by suicide, so TAPS is grateful to see such effort put
    into overhauling the Transition Assistance Program. While many key
    aspects were updated by the 2019 NDAA, there is still much work to do.
    TAPS supported the House version H.R. 5649, the Navy Seal Chief Petty
    Officer Bill Mulder Transition Improvement Act, and we look forward to
    seeing the House and Senate versions conferenced to best improve
    transitions for veterans.

        TAPS thanks the Committee and the original sponsors of all this
    important legislation for your thoughtful consideration of the needs of
    our Nation's veterans and surviving families.
        It is the responsibility of the Nation to provide for the support
    of the loved ones of those who have paid the highest price for freedom.
    Thank you for allowing us to speak on their behalf.
                                     ______

                 [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    Prepared Statement Prepared by Ralph Parrott, Captain, Supply Corp., US
     Navy (Ret.) and Thomas Bandzul, Esq., Legislative Counsel, Veterans &
                         Military Families for Progress
        Senate Committee Members, We'd like to take this opportunity to
    thank Chairman Isakson, Ranking Member Tester and all the Members of
    the Senate Veterans' Affairs Committee, to present our position on the
    Mare Island Cemetery Restoration bill, S. 2881. This bill, offered by
    Senator Diane Feinstein (D-CA), will allow for the future care of this
    historic landmark at the discretion of the Department of Veterans
    Affairs (VA).
        The Mare Island Naval Cemetery was established in 1856 on the
    grounds of the Mare Island Naval Shipyard in Vallejo, CA. It is the
    oldest military cemetery on the west coast. The last burial in the
    cemetery occurred in 1921. The following is a summary of the
    internments in the cemetery:

         860 Veterans Navy and Marines, 3 Medal of Honor
    recipients,
         8 Russian sailors killed fighting a fire in San Francisco
    in the 1860s while their ship was visiting at the invitation of
    President Lincoln
         4 French sailors authorized by the US Navy for reasons
    lost to history
         33 Children of Veterans buried there
         40 Spouses of Veterans buried there (includes the daughter
    of Francis Scott Key)
         7 Other civilians authorized by the US Navy for reasons
    lost to history

    TOTAL: 952

        The cemetery was turned over by the Navy to the City of Vallejo in
    1996 as part of BRAC '93. There were no provisions made for the
    perpetual care, maintenance and restoration as part of the turnover
    agreement. The City of Vallejo has been unable or unwilling to provide
    the necessary resources to maintain the cemetery and it has fallen into
    disrepair. The City has also formally requested the Federal Government
    to take over the Cemetery. The VA, who runs the National Cemetery
    Administration, does not have the legal authority to take over the
    cemetery. Senator Feinstein's introduction of S. 2881 will give the
    necessary authority to the VA. Congressman Mike Thompson has introduced
    a similar bill (H.R. 5588) which is currently before the House
    Veterans' Affairs Committee.
        VMFP and our partner Veteran Service Organizations (VSO's) along
    with the many people in California, urgently requests the Senate
    Veterans' Affairs Committee report this bill to the floor of the US
    Senate and provide this historic site the perpetual care, maintenance
    and restoration it so justly deserves.
             h.r. 299, blue water navy vietnam veterans act of 2018
        VMFP full supports this as an issue long overdue. There is some
    trepidation this will cause a large increase to the Veterans Health
    Administration (VHA) overhead and Veterans Benefits Administration
    (VBA) will have a large increase in claims. Since there are no specific
    numbers published on this, my belief is, MOST Veterans with issues
    caused by exposure to Agent Orange (AO) have already qualified for
    benefits, are eligible for care within another program (TRICARE for
    Life, Medicare/Medicaid, etc.) or have some other form of health
    insurance.
       s. ___ (sanders), veterans dental care eligibility expansion and
                            enhancement act of 2018
        It has always been an objective of VMFP to improve the health of
    Veterans everywhere. The one thing missing in society in general is a
    comprehensive dental care program. In VA, unless there is extreme need
    tor most Veterans comprehensive dental care is also missing.
        We believe this legislation will help to measure the costs and
    needs and will help define the alternatives for Veterans for healthy
    teeth and gums. VMFP support this bill as a path to improving
    understanding the needs for this care for veterans.
                                    s. 3184
        To amend title 38, United States Code, to modify the requirements
    for applications for construction of State home facilities to increase
    the maximum percentage of nonveterans allowed to be treated at such
    facilities, and for other purposes.
        VMFP Strongly supports this bill. ft has long been the history of
    other organizations (Gary Sinise Foundation; Habitat for Humanity,
    etc.) to have been helping with the construction of housing for
    deserving Veterans. We support the expansion. of this as a government
    initiative and the inclusion of more Veterans with housing needs.
                  s. ___ (boozman), va hiring enhancement act
        For many years, VMFP has been a strong proponent of hiring
    qualified Veterans, trying to transition from the military to civilian
    life. One of the roadblocks for this transition has been certification
    and review of necessary qualification. We believe this bill is a good
    step to improving the staffing shortages at VA with highly skilled
    medical persons.
        VMFP believes this bill will create a more ``level playing field''
    in competition for many of the skilled people needed to fill the array
    of openings in the healthcare field for VA. We strongly support this
    legislation.
        VMFP believes this bill will create a more ``level playing field''
    in competition for many of the skilled people needed to fill the array
    of opening in the healthcare field for VA We strongly support this
    legislation.
     h.r. 5418, veterans affairs medical-surgical purchasing stabilization
                                      act
        VMFP has no position on this legislation since there are many bills
    with similar clauses. We have not had enough time to review this to
    make a recommendation one way or the other.
                   s. 1596 (peters/rubio), brave act of 2017
        The cost of a funeral has risen over the years and is now estimated
    to be between $7,000 and $10,000 in North America (according to
    PARTING; a funeral home rating website). Through the increase in this
    legislation does provide for more variable adjustments in the future
    and the initial suggested increase is substantial, we believe this
    value should be increased to a minimum level of $3,000.00 (the average
    cost of a cremation funeral--Source: National Funeral Directors
    Association).
        An argument can be made, many Veterans can be interred in a
    cemetery cared for by VA at substantially less, but not everyone can
    take advantage of this benefit. While VMFP supports this bill, we would
    like to see an increase in funding.
          s. 2881 (feinstein), mare island naval cemetery transfer act
        Statement at Page 1 (separate).
      s. 1952 (tester/mccain/manchin), va financial accountability act of
                                      2017
        With budgetary issues, financial accountability and several years
    of increases in VAs budget with proportional instances of overspending,
    cost overruns and program demands (unfunded mandates) left unfulfilled,
    it is VMFP's opinion this legislation would be a good step in the right
    direction.
         s. 1990 (tester/blumenthal/hirono), dependency and indemnity
                      compensation improvement act of 2017
        VMFP takes no position on this legislation.
    s. 2485 (sullivan), medal of honor surviving spouses recognition act of
                                      2018
        VMFP fully support this legislation. While some believe this may
    have consequences in personal relationships in the future, the intent
    of the bill meets a need we feel is long be unfulfilled as an
    obligation by the government to the spouse of a Medal of Honor hero.
             s. 2748 (brown/rounds), battle for servicemembers act
        Our group fully supports this legislation as a necessary step to
    full and timely access to employment and training to meet any need of a
    returning Veteran.
                                s. ___ (cassidy)
        To require the Secretary of Veterans Affairs to establish a program
    to award grants to persons to provide and coordinate the provision of
    suicide prevention services for veterans transitioning from service in
    the Armed Forces who are at risk of suicide and for their families, and
    for other purposes.
        Suicide prevention, in all it's forms, has always been a top
    priority for Veterans and their families within our organization. As a
    person who has dealt directly with suicide (as a police officer) and
    directly involved with the family (my brother). I know this has
    horrible consequences and is a preventable tragedy; given the proper
    resources, awareness and education.
        Any effort to help recognize the symptoms of depression, despair
    and hopelessness leading to a suicidal ideation is a priority for VMFP.
    We fully support this legislation.
    s. ___ (cassidy), modernization of medical records access for veterans
                                      act
        VMFP has no position on this legislation.
               s. 514 (perdue/heller), no hero left untreated act
        VMFP takes no position on this bill but we believe a pilot program
    on Magnetic EEG/EKG-guided resonance therapy could yield significant
    information so as to make a more informed decision on the benefits and
    cost of this treatment program.
                Respectfully Submitted,
                                           Thomas Bandzul, Esq.
                                                   Legislative Counsel.
                                     ______

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        Prepared Statement of Rene C. Bardorf, Senior Vice President of
          Government and Community Relations, Wounded Warrior Project
        Chairman Isakson, Ranking Member Tester, and distinguished Members
    of the Senate Committee on Veterans' Affairs, Thank you for inviting
    Wounded Warrior Project (WWP) to submit this statement for the record
    of today's hearing on pending legislation.
        Since our inception in 2003, WWP has grown from a small
    organization delivering comfort items in a backpack at the bedside of
    wounded warriors here in our Nation's capital, to an organization of
    nearly 700 employees in more than 25 locations around the world
    delivering over a dozen direct-service programs to warriors and
    families in need. Through our direct-service programs, we connect these
    individuals with one another and their communities; we serve them by
    providing mental health support and clinical treatment, physical health
    and wellness programs, job placement services, and benefits claims
    help; and we empower them to succeed and live life on their own terms.
    As we advocate for this community before Congress, we appreciate you
    inviting us to speak on these issues and look forward to helping any
    way we can.
             h.r. 299--blue water navy vietnam veterans act of 2018
        Although we have few alumni that served in Vietnam, Korea, and
    Thailand during the Vietnam war, we consider the military toxic
    exposure problem a cross-generational issue. It is important that if
    servicemembers are exposed to harmful toxins while serving this
    country, the government ensures they have proper health care and
    assistance if any injuries or illnesses arise from their exposures.
    This philosophy was the impetus behind our current partnership with
    Vietnam Veterans of America (VVA) and the Tragedy Assistance Program
    for Survivors (TAPS) to conduct a needs assessment of the landscape
    facing post-9/11 generation warriors who were or who may have been
    exposed to toxic substances during service.
        As individual organizations, VVA, TAPS, and WWP have shared
    concerns for several years about the emergence of toxic exposure as a
    common thread among former servicemembers who are sick, dying, or
    already deceased from uncommon illnesses or unusually early onset of
    more familiar diseases like cancer. In the past, we have advocated for
    initiatives such as the creation of the Airborne Hazards and Open Burn
    Pit Registry in June 2014 and the more recent passage of the Toxic
    Exposure Research Act of 2016 (P.L. 114-315, Sec. Sec. 631-34). Given
    our collective interest in prevention, treatment, and awareness,
    Wounded Warrior Project decided in October 2017 to coordinate efforts
    with TAPS and VVA and invested $200,000 in a needs assessment to guide
    our future advocacy. Wounded Warrior Project remains committed to
    continued investments of resources and expanding its partnerships to
    include others passionate about this important issue. More can be read
    about our partnership from our recent House Committee on Veterans'
    Affairs submitted on June 7, 2018.\1\
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        As this partnership continues to address the challenges faced by
    servicemembers and veterans who served on or after September 11, 2001,
    WWP is pleased that the Committee is considering legislation to provide
    recourse for ``blue water'' Vietnam veterans. We are particularly
    encouraged by Section 5 of this legislation (``Updated Report on
    Certain Gulf War Illness Study'') and further request that future
    legislation add additional research between the Veterans' Affairs (VA)
    and the Department of Defense (DOD) on toxic exposure for Gulf War-era
    veterans as well as for those who served after 9/11.
        Wounded Warrior Project Supports H.R. 299.
    draft bill--veterans dental care eligibility expansion and enhancement
                                  act of 2018
        This draft bill will increase VA's internal dental capabilities by
    expanding its clinical capacities in rural locations and creating a
    pilot program that would open dental coverage to all veterans
    regardless of disability status at select VA hospitals. The pilot
    program will determine if expanding VA-provided dental services to all
    veterans enrolled in the VA healthcare system is feasible. Although we
    agree with the intent of the pilot program and overall dental
    expansion, we have concerns over how the bill will be paid for and how
    the current dental care program is administered to veterans.
        Anecdotally, WWP has heard from veterans struggling to get service-
    connected disability ratings for injuries to the mouth which occurred
    during service. Additionally, only veterans with 100% service-connected
    disability or former prisoners of war (POW) qualify for VA dental
    care.\2\ Before the VA expands dental coverage to all veterans, WWP
    would like to see VA review the current rating system for dental
    eligibility. We recommend that Congress instruct VA to conduct a report
    of how many veterans with face and mouth service-connected injuries are
    not getting needed health care and how many veterans are denied for
    dental coverage when applying for this type of service-connected
    disability. Additionally, we would like to see full coverage of dental
    services expanded to homeless veterans. Dental needs for homeless
    veterans is one of their top three unmet needs and WWP feels that VA is
    not meeting its obligation in supporting homeless veterans when it
    comes to individual dental problems and its impacts in retain suitable
    long-term employment.\3\
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        Wounded Warrior Project supports the provisions to construct
    additional dental clinics in rural areas, increase dental health
    education, establish an electronic health record system, and authorize
    the Secretary to carry out a program to train and employ alternative
    dental health care providers. WWP suggests increasing the appropriated
    funding of this section to include the construction of dental
    facilities at any major VA hospital that does not currently offer
    onsite dental services. Furthermore, Congress needs to appropriately
    fund this dental expansion. As with the current VA MISSION Act funding
    shortfall, Congress should not pass legislation without appropriate
    funding mechanisms attached.
        Wounded Warrior Project supports this legislation with alterations
    to the language as stated above.
    s. 3184--to modify the requirements for application for construction of
    state home facilities to increase the maximum percentage of nonveterans
        allowed to be treated at such facilities, and for other purposes
        Wounded Warrior Project does not have a current position on this
    legislation but welcomes future discussions with the Committee on this
    proposal.
             discussion draft on transition assistance reform and
                     s. 2748--battle for servicemembers act
        With approximately 200,000 servicemembers leaving the military each
    year, it is critical that DOD and VA disseminate information pertinent
    to transition success, VA benefits, and job opportunities.\4\ Wounded
    Warrior Project supports a holistic approach to reforming Transition
    Assistance Program (TAP) that reflects the input of all relevant
    stakeholders. The Departments of Veterans Affairs, Defense, and Labor,
    the Small Business Administration, Congress, and multiple veteran
    service organizations committed to meeting the needs of transitioning
    servicemembers and all have critical voices that must be adequately
    considered, and WWP would support a comprehensive bill that has been
    thoroughly vetted by all parties.
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    Zogas_Veterans%27%20 Transitions_CoW_2.1.17.pdf
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        Wounded Warrior Project was pleased to host leaders from VA, DOD,
    DOL, and over 10 veteran service and nonprofit organizations in
    November 2017 to explore the components of wellness and their
    relationship to a successful military civilian transition. WWP has been
    an active participant in VA's Military-to-Civilian Summits and remains
    committed to being deeply involved with government and nongovernment
    leaders alike who have a stake in the success of TAP. Additionally, we
    are hearing from our transitioning alumni that the current the TAP is
    not comprehensive enough. We have some concerns that the proposed House
    Veterans'
        Affairs Committee (HVAC), Senate Armed Services Committee (SVAC),
    and the National Defense Authorization Act (NDAA) changes to the TAP
    does not expand the overall amount of TAP days. Where the current
    changes look to streamline the TAP while keeping it within the current
    five days, we recommend expanding the overall days dedicated to the TAP
    curriculum.
        While we are encouraged by the time and attention that has been
    given to TAP to date, we believe both bills under consideration by the
    Committee today fall short of what is necessary for meaningful TAP
    reform. Our concern is that there are other proposed changes to TAP
    currently under consideration by the HVAC, the House Armed Services
    Committee (HASC), and the Senate Armed Services Committee (SASC).
    Before supporting any one piece of legislation, we request that
    Congress identify the best provisions in each proposal and work
    collaboratively to form a single TAP bill supported by all relevant
    stakeholders. To this end, we request that Congress have a joint
    hearing between SVAC, HVAC, HASC, and SASC to clearly inform all
    committees of jurisdiction about the issues surrounding the TAP. In our
    opinion, this approach would afford all stakeholders--including outside
    organizations and government agencies--to clearly identify key
    priorities and considerations to improve transition.
        We are concerned that the community is not on the same page when it
    comes to new TAP legislation. We are submitting the following thoughts
    on the TAP bills under consideration at this hearing; however, we
    request Congress to take a step back and develop one piece of
    legislation in conjunction with DOD, VA, community partners, and both
    sides of Congress.
    (1) Discussion Draft on Transition Assistance Reform
                Section 2. Recodification, Consolidation, and improvement
                        of certain transition-related counseling and
                        assistance authorities:

        Wounded Warrior Project is encouraged by section (D) ``the
    availability of mental health services and the treatment of Post
    Traumatic Stress Disorder, anxiety disorders, depression, suicidal
    ideation, or other mental health conditions [ . . . ] and information
    concerning the availability of treatment options and resources to
    address [these issues].'' We would request that WWP programs are
    included as resources for transition servicemembers dealing with mental
    health issues. Wounded Warrior Project has developed a significant
    amount of mental health programming for post-9/11 veterans, and we are
    doing so in concert with VA and several leading community-based health
    providers. We've built these programs within a ``continuum of support''
    designed to meet warriors wherever they are in their recovery while
    also investing substantial resources in other organizations in the
    community, including four of the Nation's leading academic medical
    centers that have come together within our Warrior Care Network®.
                Section 3. Personnel matters in connection with transition
                        assistance program:

        Ensuring that military installations have the proper personnel to
    administer TAP programming is essential. Section 3 would require the
    military to have ``not less than one [full-time TAP personnel] for
    every 250 members of the Armed Forces currently eligible for
    participation in the Transition Assistance Program.'' Additionally,
    this provision would ensure that TAP personnel teaching these classes
    have at least two years of civilian employment experience before they
    can teach transition classes. This is to ensure that the people
    teaching these TAP classes have themselves gone through a successful
    transition. Last, this section would require DOD to identify one point
    of contact (POC) to coordinate all the on-post TAP programming at each
    field grade unit. This will help ensure that information being
    distributed throughout the military is consistent from base to base.
                Section 5. Information on members of the Armed Forces
                        participating in preseparation counseling and
                        surveys on member experiences with transition
                        assistance program counseling and services and in
                        transition to civilian life:

        Collecting and analyzing programmatic data is essential for
    ensuring positive outcomes from programs. Something that the current
    TAP program has failed in is surveying members after they have
    transitioned out of the military and the effectiveness of their TAP
    experience. This section would require the Secretary of Veterans
    Affairs to consult with the Secretary of Defense, the Secretary of
    Homeland Security, the Secretary of Education, and the Secretary of
    Labor to conduct surveys of veterans that have been recently retired,
    discharged, or released from active duty to assess their experiences
    transiting from the military to civilian life. This data can help
    identify areas where the TAP program is assisting and areas where it is
    lacking.
        Wounded Warrior Project suggests editing this section to include a
    set number of veterans that shall be surveyed. We recommend the survey
    track their success over a period of no less than five years after
    separation. Additionally, WWP encourages committee staff to review The
    Veterans Metric Initiative (TVMI) study commissioned by the Henry
    Jackson Foundation--and funded, in part, by WWP--that focuses on post-
    military well-being. The TVMI study's findings regarding vocation,
    finances, health, and social relationships may provide compelling
    evidence to guide the approach under this section.
                Section 6. E-mailing transition assistance materials to
                        supporters of members of the Armed Forces
                        transitioning to civilian life:

        Wounded Warrior Project is particularly interested in this section.
    Section 6 would require DOD to email TAP program materials to family
    member of transitioning servicemembers. The Secretary of Defense will
    solicit an email address from the servicemember to disseminate TAP
    information. When a servicemember transitions out of the military it
    affects the whole family. Ensuring that TAP information is shared with
    the spouse of the servicemember will help the entire family transition
    from DOD to the civilian world. We recommend making this optional for
    those servicemembers who are not interested in share an email with DOD.
    As currently written, it is not clear if the servicemember can opt-out
    of supplying an email address to DOD.
                Section 9. Education of members of Armed Forces on career
                        readiness and professional development:

        Wounded Warrior Project is interested in the Alumni Network Program
    defined in section (d); ``[the] Secretary concerned shall establish an
    alumni network program to connect veterans with members of the Armed
    Forces for mentorship, networking, and career advice.'' In our
    experience, peer-to-peer support is critical to recovery for many
    warriors. According to our 2017 Wounded Warrior Project Survey, more
    than half of those surveyed, or 51.6 percent, used talking with another
    Operation Enduring Freedom, Operation Iraqi Freedom, or Operation New
    Dawn veteran as a resource to address mental health issues. The only
    more frequently utilized resource was VA medical centers.\5\ In this
    context, WWP is highly supportive of permanently authorizing
    reintegration and readjustment counseling services for transitioning
    servicemembers. VA pilot programs that study peer-to-peer or alumni
    networks have been highly successful and WWP has seen similarly
    encouraging results in its own programming. Because of this, WWP
    supports the proposed Alumni Network Program. WWP requests the
    legislation require DOD to partner with and promote successful peer-to-
    peer programs administered by veteran service organizations and
    military service organizations to servicemembers transitioning out of
    the military.
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                Section 10. Employment Skills Training:

        Currently, spouses may attend TAP classes if space is available.
    This provision would require DOD to authorize access to TAP classes to
    spouses. A strong military family is important. A strong civilian
    family is equally as important. Wounded Warrior Project supports the
    concept in ensuring the TAP classes are available to spouses as it will
    assist in the entire family's transition.
                Section 14. Establishment of Governing Board to support
                        prevention of drug overdose death by suicide, and
                        alcohol-related mortality:

        This section would require the Secretary of VA to establish a
    governing board within the Veterans Benefits Administration (VBA) to
    facilitate the transfer of information and to create partnerships that
    would prevent suicide, substance abuse, and assist homes veterans. The
    board would include representatives from DOD, DHS, and DoL, inducing
    representatives from VA staff offices that focus on these issues.
    Wounded Warrior Project requests including veteran service
    organizations into the board as well.
                Section 16. Grants for provision of transition assistance
                        to members of the Armed Forces after separation,
                        retirement, or discharge:

        This section would require DOL to work with VA to award grants to
    outside organizations who provide transition assistance services to
    members of the military that have separated. These grants would be
    awarded to organizations that focus on career skills, behavioral
    health, and education. $10 million dollars would be authorized for the
    grants. WWP has in the past supported increasing the outside
    capabilities of transitioning servicemembers access to information and
    assistance to successfully integrate into the civilian population and
    has invested a substantial amount of fund in peer-to-peer mental health
    and employment transition programs.
        WWP's Warriors 2 Work (W2W) is one such successful program. W2W
    assists veterans transitioning from the military into the civilian
    workforce. WWP does this through resume building, job coaching,
    assistance with building local networks, online LinkedIn workshops, and
    one-on-one job referrals to partnering companies. Currently, we work
    with over 400 companies and focus on small-scale hiring fairs called
    ``micro job fairs.'' WWP feels that there is a natural synergy between
    our peer-to-peer mental health network, our peer-to-peer W2W programs,
    and the proposed grants defined in this section.
    (2) S. 2748--BATTLE for Servicemembers Act
        Under the current TAP, there is a mandatory ``core curriculum''
    consisting of a three-day employment workshop that is conducted by DOL;
    six hours of briefings on veterans' benefits, conducted by VA; and 8-10
    hours of briefings on topics such as translating military skills to
    civilian jobs and preparing a financial plan, conducted by DOD.
    Following completion of the core curriculum, transition servicemembers
    can opt to take one of three additional transition tracks that include
    (1) higher education, conducted by DOD; (2) technical and skills
    training conducted by the VA; or (3) entrepreneurship, conducted by the
    Small Business Administration. Although these additional tracks are
    available, they are often not utilized. This legislation would require
    transitioning servicemembers to take one of the three additional
    tracks. Wounded Warrior Project agrees that transitioning
    servicemembers need all the resources they can get to properly
    transition back into the civilian world. Because of this, we support
    expanding the amount of training given to servicemembers as they leave
    the military. We would request that a fourth track be added for those
    interested in additional employment information.
                     draft bill--va hiring enhancement act
        Wounded Warrior Project does not have a current position on this
    legislation but welcomes future discussions with the Committee on this
    proposal.
     h.r. 5418--veterans affairs medical-surgical purchasing stabilization
                                      act
        H.R. 5418 would require the Secretary to award contracts to
    multiple regional prime vendors instead of a single nationwide prime
    vendor and prohibits the prime vendor from solely designing the
    formulary of such supplies. Wounded Warrior Project is concerned that
    restricting the Secretary of Veterans Affairs' ability to purchase
    medical equipment, the VA may adversely affect veteran safety and
    health because Congress has limited the agency's purchasing options.
    Wounded Warrior Project recommends changing the wording on page 2, line
    8 from ``Secretary of Veterans Affairs shall carry out . . .'' to
    ``Secretary of Veterans Affairs may carry out . . . .''
        Wounded Warrior Project opposes this legislation.
                           s. 1596--brave act of 2017
        Wounded Warrior Project is here to assist injured, ill, and wounded
    veterans and servicemembers. When these disabilities lead to the death
    of a warrior, appropriate assistance should be rendered to the family
    by the Federal Government. S. 1596 would increase funeral benefits for
    veterans and fallen servicemembers and establish a percentage increase
    of this benefit each year. The current $300 payment would be increased
    to $749. With the average cost of burials exceeding $7,000 in 2016,\6\
    this payment increase would represent a small step in the right
    direction in assisting families during this time of mourning; however,
    WWP requests that burial benefit payments be increased to match the
    average cost of a burial.
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        Wounded Warrior Project supports this legislation with amendments.
                s. 2881--mare island naval cemetery transfer act
        Mare Island Naval Cemetery is one of the oldest West Coast military
    burial sites. Over the past decade, the cemetery has fallen into
    disrepair. The cemetery, which is currently owned and operated by the
    city of Vallejo, California does not have the necessary funds to
    maintain the cemetery appropriately. This legislation would direct the
    Secretary of Veterans Affairs to enter into an agreement with the city
    of Vallejo, California to ensure that the cemetery is properly
    maintained. Wounded Warrior Project feels that the final resting place
    of military servicemembers and veterans should be kept to a high
    standard of maintenance. In the rare instance that a local community
    has the responsibility to maintain a veteran cemetery, and is unable to
    maintain that standard, the VA should step up and assist.
        Wounded Warrior Project supports this legislation.
                s. 1952--va financial accountability act of 2017
        Wounded Warrior Project does not have a current position on this
    legislation but welcomes future discussions with the Committee on this
    proposal.
     s. 1990--dependency and indemnity compensation improvement act of 2017
        S. 1990 aims to increase the Dependency and Indemnity Compensation
    (DIC) benefits rate so that it is equivalent to the rate paid to
    survivors of Federal civilian employees. The increase would provide
    approximately $300 more per month to spouses of servicemembers and
    veterans who die while on active military duty or as a result of a
    service-connected injury or illness. Additionally, a spouse will be
    authorized to receive the DIC benefit if the servicemember was rated
    totally disabled for a period of five years. Currently, DIC payments
    are provided to survivors or those rated totally disabled for a period
    of ten years. Wounded Warrior Project has always supported the spouses
    of those injured, ill, or wounded while serving this country. WWP will
    continue to support them after these warriors pass on. We support this
    bill as it will also ensure that these individuals are financially
    supported after their loved one dies.
        Wounded Warrior Project supports this legislation.
       s. 2485--medal of honor surviving spouses recognition act of 2018
        S. 2485 would provide a special pension payment to the surviving
    spouses of a deceased Medal of Honor recipient and increase the special
    pension amount from $1,000 to $1,329.58. Medal of Honor recipients, and
    their families have gone above and beyond in service to this Nation.
    Their sacrifices should not go unnoticed. This pension does not nearly
    cover the gratitude this Nation owes these heroes. Because of this,
    Wounded Warrior Project fully supports this legislation.
        Wounded Warrior Project supports this legislation.
    draft bill--to require the secretary of veterans affairs to establish a
       program to award grants to persons to provide and coordinate the
     provision of suicide prevention services for veterans transition from
     service in the armed forces who are at risk of suicide and for their
                        families, and for other purposes
        This draft bill would establish a program to award grants to
    organizations that are providing and coordinating suicide prevention
    services to veterans. Through offerings such as Warrior Care
    Network®, Project Odyssey, and WWP Talk, WWP has served 17,822
    warriors and family members through interactive programming,
    rehabilitative retreats, and other professional services to address
    their mental health needs.
        The Warrior Care Network® (WCN) has a critical mission to heal
    the invisible wounds of war by increasing access to some of the highest
    quality care for wounded warriors and their families. Launched in 2016
    with a vision of becoming a national leader, innovator, and integrator
    in the delivery of treatment for warriors living with psychological
    injuries as well as those suffering from Traumatic Brain Injury, the
    WCN has enjoyed early success due in part to collaboration with the
    Department of Veterans Affairs (VA).
        In FY 2017, the partnership provided 3,707 hours of transition
    services, 2,612 professional consultations, 383 briefings, and 401
    referrals into VA care. As the need for professional mental health
    treatment for Veterans and their families is great (and growing), the
    WCN is committed to expanding its efforts in the coming years and we
    wish to continue the collaborative partnership with the VA. In the next
    five years, the WCN will invest over $160 million to the care of
    approximately 5,000 Veterans and family members in the intensive
    outpatient program and approximately 6,500 Veterans in traditional
    outpatient care where the partnership with the VHA will be even more
    critical for the continuity of care.
        Additionally, Project Odyssey and the WWP Talk programs support
    veterans through peer-to-peer counseling and rehabilitative retreats.
    With over five Project Odyssey events happening across the Nation each
    week and thousands of one-on-one calls to warriors happening each
    month, WWP is committed to addressing today's mental health needs in a
    variety of ways.
        While WWP has many successful direct programs serving the needs of
    warriors and their families, we alone cannot meet every need this
    generation of wounded servicemembers and veterans face. Because of
    this, WWP supports any effort by VA to increase funding for suicide
    prevention to outside partners. We would suggest increasing eligibility
    into the program to current servicemembers. Additionally, on page 7,
    line 19, we would suggest changing ``The Secretary may require a person
    receiving a grant under this section to submit to the Secretary a
    report that describes the use of the grants amounts by the person or
    such other information as the Secretary considers appropriate'' to a
    ``shall'' statement. WWP feels that it is important for an organization
    that applies for a grant to be required to describe how the funds will
    be utilized.
        Wounded Warrior Project supports this legislation with amendments.
      draft bill--modernization of medical records access for veterans act
        Wounded Warrior Project does not have a current position on this
    legislation but welcomes future discussions with the Committee on this
    proposal. Wounded Warrior Project assists ill, injured, and wounded
    warriors, family members, and Caregivers. We stand ready to assist
    Congress in legislation affecting these individuals. Although we do not
    have a position on this bill we do caution Congress in implementing
    another technological pilot program while there is no VA Chief
    Information Officer and with the electronic health record project
    between DOD and VA ramping up. We request more discussions with
    committee staff before formulating a position.
                       s. 514--no hero left untreated act
        S. 514 would direct the Secretary of Veterans Affairs (VA) to carry
    out a pilot program to provide access to magnetic EEG/EKG-guided
    resonance therapy to veterans. Based on trends we have identified from
    our work through direct mental health programming and partnerships in
    the community, WWP strongly believes that more can be done to address
    the invisible wounds of war, particularly PTSD, TBI, depression, and
    other related conditions; however, we must ensure that new forms of
    treatment are safe for Veterans. Currently, EEG/EKG-guided resonance
    therapy is not approved by the Federal Drug Administration (FDA);
    however, we understand that EEG/EKG-guided resonance therapy is
    primarily used for research applications and therefore not typically
    approved by the FDA. Additionally, the VHA has implemented a pilot
    program at approximately 23 medical facilities. This pilot program uses
    Repetitive Transcranial Magnetic Stimulation, or rTMS therapy, and WWP
    has followed the outcomes of the pilot program. The most recent report
    on the rTMS therapy pilot program indicated that rTMS therapy did not
    assist in reducing PTSD symptoms any more than the control study
    group.\7\ It is obvious that more research is needed regarding this new
    form of mental health treatment. Given the most recent rTMS program
    findings, WWP would support this legislation if the bill language were
    changed to include a double-blind research provision on the outcomes of
    the pilot program. WWP would like to see this research program compared
    to the most recent rTMS pilot program to understand it's longer-term
    viability as a treatment for PTSD, MST, TBI, and depression.
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        Wounded Warrior Project would support this legislation if it were
    presented as a research pilot program as opposed to a treatment pilot
    program and sufficient language addressing this was included in the
    bill.
                                   conclusion
        Wounded Warrior Project thanks the Senate Committee on Veterans'
    Affairs, its distinguished members, and all who have contributed to the
    policy discussions surrounding the bills under consideration at today's
    hearing. We share a sacred obligation to serve our Nation's veterans,
    and Wounded Warrior Project appreciates the Committee's effort to
    identify and address the issues that challenge our ability to carry out
    that obligation as effectively as possible. We are thankful for the
    invitation to submit this statement for record and stand ready to
    assist when needed on these issues and any others that may arise.

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