[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]


  DRAFT LEGISLATION INCLUDING H.R. 100, H.R. 712, H.R. 1647, H.R. 2191

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

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

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        TUESDAY, APRIL 30, 2019

                               __________

                            Serial No. 116-7

                               __________

       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                    
38-957                       WASHINGTON : 2021                     
          
--------------------------------------------------------------------------------------        
        
        
                     COMMITTEE ON VETERANS' AFFAIRS

                   MARK TAKANO, California, Chairman

JULIA BROWNLEY, California           DAVID P. ROE, Tenessee, Ranking 
KATHLEEN M. RICE, New York               Member
CONOR LAMB, Pennsylvania, Vice-      GUS M. BILIRAKIS, Florida
    Chairman                         AUMUA AMATA COLEMAN RADEWAGEN, 
MIKE LEVIN, California                   American Samoa
MAX ROSE, New York                   MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire          NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia            JACK BERGMAN, Michigan
SUSIE LEE, Nevada                    JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina       ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR.,           DANIEL MEUSER, Pennsylvania
    California                       STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota        CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
                 Ray Kelley, Democratic Staff Director
                 Jon Towers, Republican Staff Director

                         SUBCOMMITTEE ON HEALTH

                 JULIA BROWNLEY, California, Chairwoman

CONOR LAMB, Pennsylvania             NEAL P. DUNN, Florida, Ranking 
MIKE LEVIN, California                   Member
ANTHONY BRINDISI, New York           AUMUA AMATA COLEMAN RADEWAGEN, 
MAX ROSE, New York                       American Samoa
GILBERT RAY CISNEROS, Jr.            ANDY BARR, Kentucky
    California                       DANIEL MEUSER, Pennsylvania
GREGORIO KILILI CAMACHO SABLAN,      W. GREGORY STEUBE, Florida
    Northern Mariana Islands

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                           
                           C O N T E N T S

                              ----------                              

                        Tuesday, April 30, 2019

                                                                   Page

Draft Legislation Including: H.R. 100, H.R. 712, H.R. 1647, H.R. 
  2191...........................................................     1

                           OPENING STATEMENTS

Honorable Julia Brownley, Chairwoman.............................     1
Honorable Meuser, Ranking Member.................................     3

                               WITNESSES

The Honorable Earl Blumenauer, U.S. House of Representatives, 3rd 
  District; Oregon...............................................     4

The Honorable Lou Correa, U.S. House of Representatives, 46th 
  District; California...........................................     5
    Prepared Statement...........................................    35

The Honorable Conor Lamb, U.S. House of Representatives, 17th 
  District; Pennsylvania.........................................     7
    Prepared Statement...........................................    35
The Honorable Max Rose, U.S. House of Representatives, 11th 
  District; New York.............................................     8

Dr. Keita Franklin, National Director of Suicide Prevention, 
  Office of Mental Health and Suicide Prevention, U.S. Department 
  of Veterans Affairs............................................     9
    Prepared Statement...........................................    36

        Accompanied by:

    Dr. Tracy Gaudet, Director, Office of Patient Centered Care, 
        U.S. Department of Veterans Affairs

    Dr. Larry Mole, Chief Consultant Population Health, U.S. 
        Department of Veterans Affairs

Ms. Joy Ilem, National Legislative, Director, Disabled American 
  Veterans.......................................................    12
    Prepared Statement...........................................    41

Mr. Carlos Fuentes, Director, National Legislative Service, 
  Veterans of Foreign Wars.......................................    13
    Prepared Statement...........................................    45

Ms. Stephanie Mullen, Research Director, Iraq and Afghanistan 
  Veterans of America............................................    15
    Prepared Statement...........................................    47

           MATERIALS SUBMITTED FOR THE RECORD - UPON REQUEST

Draft Bill, Suicide Notification.................................    50

Draft Bill, Suicide Prevention...................................    50

Draft Bill, VA Whole Health......................................    50

Draft Bill, Hon. Steube..........................................    50

H.R. 100.........................................................    50

H.R. 712.........................................................    50

H.R. 1647........................................................    50


 
  DRAFT LEGISLATION INCLUDING H.R. 100, H.R. 712, H.R. 1647, H.R. 2191

                              ----------                              


                        Tuesday, April 30, 2019

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 10:00 a.m., in 
Room 2253, Rayburn House Office Building, Hon. Julia Brownley 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Lamb, Brindisi, Rose, Cisneros, 
Peterson, Dunn, Radewagen, Barr, Meuser, and Steube.

        OPENING STATEMENT OF JULIA BROWNLEY, CHAIRWOMAN

    Ms. Brownley. Good morning. Thank you all for being here, 
and welcome to the Subcommittee on Health's first hearing of 
the 116th Congress.
    First, I would like to thank all of you who were present at 
our suicide prevention hearing yesterday, last night. I 
appreciate everyone's commitment to tackling the issue. And 
today's hearing is another important step in our efforts to end 
the epidemic of veteran suicide. I believe we had productive 
dialogue on the subject yesterday and I look forward to our 
continued discussion today.
    In the 116th Congress, the Health Subcommittee's key focus 
is ensuring equitable access to high quality health care for 
our Nation's heroes. The Veterans Health Administration is the 
largest integrated health care system in our country, serving 
over 9 million enrolled veterans annually at over 170 medical 
centers nationwide. It is vital that we ensure VHA is meeting 
the health care needs of these deserving veterans.
    I am also committed to ensuring rigorous oversight of the 
VA's implementation of community care under the Mission Act, 
enacted in the 115th Congress. As VA rolls out this program, it 
is crucial that it is well implemented to ensure that veterans 
have access to the care they need, while also preserving the 
unparalleled services that only the VA can provide.
    Chairman Takano has given our Committee an important goal 
with his VA 2030 vision, and it will be the duty of this 
Subcommittee to identify and carry out the objectives within 
our jurisdiction. I intend to make this Subcommittee a 
bipartisan and collaborative body and I encourage my colleagues 
on both sides of the aisle to share with me their thoughts and 
concerns.
    That brings me to the work before us. Today, we are holding 
the first Health Subcommittee legislative hearing of the 116th 
Congress. We will consider eight pieces of legislation, 
including discussion on three important areas: suicide 
prevention and mental health, cannabis, and whole health 
programs.
    Each year, roughly 6,000 veterans commit suicide. Each and 
every one of these lives lost represents a heartbreaking 
tragedy. Many of these veterans were not enrolled in VA health 
care. We must ask how VA can better assist those currently 
enrolled and how it can better reach those not enrolled, and 
how can VA partner with different government agencies and 
community partners to expand its public health approach model 
for suicide prevention.
    As we discussed last night, the tragedy of veteran suicide 
is not just a VA problem, but rather a topic that needs to be 
addressed through partnerships across agencies and community 
resources to provide the best possible services to our 
veterans. To that end, we will be discussing four bills today 
to enhance VA suicide prevention and mental health programming.
    In addition to these four bills, we will discuss three 
proposed bills on cannabis. Thirty-three states, to include my 
home state of California, have now legalized medicinal 
cannabis. The bills being discussed today will help VA, a 
national leader in health research, conduct research on health 
care benefits of cannabis for veterans and ensure health care 
providers and veterans can have informed conversations about 
the use of cannabis, while abiding by state level cannabis 
programs so that veterans in these 33 states have access to the 
same health care treatment that their civilian counterparts 
have access to.
    Last, but surely not least, the final bill for discussion 
today will be centered around VA's whole health program. In May 
2018, VA designated 18 whole health flagship sites and 13 
additional whole health design sites, which promote a whole 
veteran approach to health and centered around what the veteran 
finds important to his or her--
    The whole health bill introduced by Vice-Chairman Lamb will 
ask the VA to generate a report to Congress on the 
implementation, utilization, and efficacy of VA's whole health 
program. As chair of this Health Subcommittee, I am truly proud 
of the work we are doing here today, and I am especially proud 
of the way we are doing it in a bipartisan manner.
    In closing, I would like to thank our witnesses for 
appearing and I look forward to your testimony. With that, I 
would like to recognize Mr. Meuser, who is standing in for 
Ranking Member Dunn, who I understand will be arriving here 
shortly for opening remarks he may wish to make.
    Mr. Meuser. Thank you.
    Ms. Brownley. You are recognized.

          OPENING STATEMENT OF MEUSER, RANKING MEMBER

    Mr. Meuser. Thank you, Chairwoman Brownley, very much. Yes. 
Ranking Member Dr. Dunn is on his way. It is a pleasure to be 
here with you at our vest first Subcommittee on Health hearing 
of the 116th Congress. I hope that we will have a productive 2 
years and that our work will continue to represent the spirit 
of patriotism and bipartisanship that veterans embody.
    On that note, we do want to note that our disappointment--
we do have disappointment that the agenda for today's 
legislative hearing was developed without any input from the 
minority. There are a number of worthy proposals from our 
colleagues on both sides of the aisle that Ranking Member Roe 
and I would like to see considered this morning.
    However, our request to include them in today's hearing 
were, in fact, denied. One of them is Dr. Roe's bill, H.R. 
1812, that would expand eligibility to Department of Veterans 
Affairs vet centers to members of the National Guard, Coast 
Guard, and Reserves. As was discussed in detail at last night's 
Full Committee hearing, approximately 20 servicemembers and 
veterans die by suicide every day. Approximately four of those 
suicide deaths occur among members of the National Guard or 
Reserve who were never deployed and are not eligible for VA 
care. Ensuring that those individuals are able to access 
readjustment counseling services could literally be lifesaving.
    Given that, and that four of the eight bills we will be 
discussing this morning are similarly aimed at preventing 
suicide among our military and veteran populations, a priority 
we all share, it is a shame that Dr. Roe's proposal is also--is 
not also up for discussion today. I certainly hope that this 
was a one-time oversight and that we can return to a more 
collaborative working relationship moving forward.
    That said, I am grateful to all of our witnesses for being 
here this morning and we look forward to receiving input on the 
proposals before us. With that, I yield back.
    Ms. Brownley. Thank you, Mr. Meuser, and I just will add 
that we have several Republican bills before us today, and Dr. 
Roe's bill or any other bills for that matter, doesn't mean 
that they have been rejected. We are just not hearing them 
today. So I appreciate your comments.
    And we have two great panels joining us today. And I thank 
each of you for joining us in what we hope to be a fruitful 
discussion on these eight bills. For the first panel, we have 
Representative Blumenauer from Oregon; next, we have 
Representative Brindisi from New York; next, we have 
Representative Correa from California; next, we have 
Representative Lamb from Pennsylvania; Representative Rose is 
from New York; and last, but surely not least, we have 
Representative Steube from Florida.
    With that, I now recognize Representative Blumenauer for 5 
minutes.

             STATEMENT OF HONORABLE EARL BLUMENAUER

    Mr. Blumenauer. Thank you very much, Madam Chair. And it is 
a pleasure to be here. I wanted to focus in particularly as it 
relates to the issue of cannabis and our veterans. You have 
rightly identified truly a tragedy in terms of what has 
happened to our veterans in terms of suicide, pain management, 
a series of things.
    We are convinced that there is an opportunity in the area 
of medical cannabis to make a difference. I am pleased that in 
the past, we have been able to move things along, advancing, 
demonstrating majority support on the--this is the first time 
we have had a hearing like this with a substantive Committee, 
the authorizing Committee, not just appropriations.
    One of the great tragedies of our time is the failure to 
adequately address the needs of veterans returning home from 
Iraq and Afghanistan. We sent more than two million brave men 
and women to fight under very difficult circumstances, to say 
the very least. And while there continue to be debate about the 
wisdom of entering these wars, we can all agree on the need to 
provide the care to those veterans as they return home with 
wounds that are most visible and in some cases unseen.
    And it is no secret that our VA facilities have struggled 
to absorb these returning veterans, which coincided with a 
national opioid epidemic. And of course, it is not just 
veterans. Opioids steal the lives of 115 Americans every day, 
more than 30,000 were killed last year.
    As veterans with PTSD, chronic pain, and any number of 
ailments are looking for relief, lethal opioid overdoses among 
VA patients are almost twice the national average. We are doing 
something wrong. This is a time when an overwhelming number of 
veterans tell me that cannabis has reduced PTSD symptoms, their 
dependency on addictive opioids.
    We have seen evidence that medical cannabis can be a less 
addictive way to manage pain and other symptoms currently 
treated with opioids. The National Academy of Science and 
Medicine recently confirmed the efficacy of medical cannabis 
for chronic pain in adults. Another study in the journal 
``Pain'' found no evidence of serious side effects among 
medical cannabis users after a year of treatment. A study 
published in ``JAMA, the Internal Medicine'' found states with 
medical cannabis saw a 24 percent reduction in opioid overdose 
deaths. Currently, 47 states, the District of Columbia, and 
most territories have passed some laws that provide for legal 
access to medical cannabis in some form.
    Well over one million patients across the country, 
including many veterans, now use cannabis on the recommendation 
of their physicians to treat conditions ranging from seizures, 
glaucoma, anxiety, chronic pain, nausea, and PTSD. Yet, the VA 
official policy prevents the doctors who know the veterans best 
from recommending medical cannabis to our veterans, even in 
states where it is legal.
    As a result, veterans are forced outside the VA system to 
seek a simple recommendation for treatment for these 
conditions, or any eligible conditions granted to them by state 
law, or even consult with them about it. The Veterans Equal 
Access Act that I have introduced would reverse this policy and 
allow VA health care providers to provide recommendations and 
opinions regarding treatment that is legal in their--the 
veteran in a state where medical cannabis program is 
authorized.
    Veterans should not be forced outside the VA system to seek 
a treatment that is legal in their state. VA physicians should 
not be denied the ability to offer recommendations they think 
may meet the needs of their patients. And I hope my colleagues 
will join me in supporting this effort.
    It is no secret I have been working on this issue for a 
number of years. I have talked literally to thousands of people 
about medical cannabis, including veterans, who tell me some of 
the most heartwarming stories. I appreciate the Subcommittee's 
attention to this. This is something that is overwhelmingly 
supported by the American public. Survey research suggests in 
the range of 90 percent. In your home state of California, you 
had a very visible example at the polls. In Florida, it was 
over 70 percent that approved it.
    It is time for the Federal government and the VA to keep 
pace with what the American public wants and an opportunity to 
make the lives of our veterans better. Thank you very much.
    Ms. Brownley. Thank you, Mr. Blumenauer. And this is an 
important bill. Thank you for bringing it forward and as you 
said, as you hear from your veterans, I hear from mine as well. 
So thank you very, very much for your bill.
    I don't see Mr. Brindisi, so we will move Representative 
Correa from California. Mr. Correa.

               STATEMENT OF HONORABLE LOU CORREA

    Mr. Correa. Thank you, Madam Chair and Ranking Member Dr. 
Dunn. It is good to see both of you. I want to start off by 
thanking our veterans for your service to our country and for 
your sacrifice, not only of you and your families. Thank you 
again, Ms. Brownley and Mr. Dunn, for your invitation to appear 
before you today. I appreciate the opportunity to testify about 
this bipartisan legislation written by myself and Mr. Higgins, 
H.R. 712, The VA Medical Cannabis Research Act.
    As you know, veterans experience physical and psychological 
injuries at a higher rate than their civilian counterparts as a 
result of their military service to our country. Unfortunately, 
the current treatment of prescription opioids to address PTSD 
and chronic pain has, at times, been ineffective. And this had 
dangerous results, such as addiction or even death.
    In response to this crisis, Congress correctly and the VA 
have joined other national organizations trying to figure out 
how to reduce veterans' addiction of opioids. Twenty veterans a 
day commit suicide. We have got to find better ways of 
addressing the needs of our veterans.
    Solution. Over the years, when I was in California sitting 
on the Veterans' Affairs Committee, chairing Veterans' Affairs, 
I used to get a stream of veterans coming to me and quietly and 
privately asking, ``Can we use cannabis? Can the VA prescribe 
cannabis for us? Can we talk to our doctor at the VA about 
cannabis without losing our VA benefits?'' And of course, the 
answer is, ``Yes, you can talk to your cannabis--about cannabis 
with your doctor at the VA, but the problem is, there is nobody 
at the VA that can give you information about how cannabis can 
benefit you.''
    Time went on. We recently had two polls, one by the 
Afghanistan Veterans of America, 80 percent of those veteran's 
support cannabis research, support looking at the cannabis for 
veterans. The American Legion did another poll, 92 percent of 
those veteran's support research and the cannabis treatment of 
veterans and their invisible wounds.
    Solution. This bill. This bill requires the VA to conduct 
double digit blind clinical test trials on the impact of 
different forms of cannabis and delivery methods of cannabis on 
specific health conditions of eligible veterans with PTSD and 
chronic pain.
    Madam Chair, Members of this Committee, a few years ago 
after the veterans came to me in my district and said, ``Lou, 
we want you to talk to us about cannabis,'' I started visiting 
different cannabis groups in my district. One of them was a 
cannabis shop. Legal, medical cannabis shop in my district. I 
went and I asked the lady at the counter, I said, ``Tell me 
what it is that you do to talk to folks that come to you to ask 
for medical cannabis. How do you prescribe different cannabis 
strengths for them?''
    She started telling me what she did, and I said, ``Ma'am, 
what are your qualifications? What is it that got you qualified 
to talk to patients about cannabis?'' And she said, ``I have 
been using cannabis for 20 years.'' Those were her 
qualifications. And I say to all of you here, it is time to 
move on. It is time to do research. It is time to make sure 
that our veterans get to know what cannabis is good for and 
what cannabis is not good for. We need medical research.
    And that is why I brought this legislation forth to simply 
tell our veterans what cannabis is good for. We owe our 
veterans a tremendous amount, the least we can do is make sure 
we are giving them their proper treatment for those invisible 
wounds that they brought back from the battlefield. Thank you 
very much.

    [The prepared statement of Lou Correa appears in the 
Appendix]

    Ms. Brownley. Thank you, Mr. Correa, and we miss you on the 
Committee, but very happy that you are continuing to persevere 
and one of your priorities that I know has been a priority for 
you and so thank you for continuing on and I agree, we need to 
push the VA forward on this issue.
    Mr. Correa. Madam Chairperson, I miss being on this 
Committee. I think it is that one place in Congress that both 
Democrats and Republicans come together to do what is right for 
all veterans.
    Ms. Brownley. Thank you very much. I now recognize Mr. Lamb 
for 5 minutes.

               STATEMENT OF HONORABLE CONOR LAMB

    Mr. Lamb. Thank you, Madam Chairwoman. And before I get to 
my bill, I just want to thank Representative Blumenauer and 
Representative Correa for their efforts and for really leading 
the way on this issue. You know, we say all the time that 
veterans deserve the best when it comes to health care and 
medical treatment. And I think part of what that means is that 
we have to look at the VA as an institution that can lead, that 
can break new grounds, that can cross these frontiers. And when 
there is innovation and reform in health care, we need to be at 
the front, not behind, not entrenched in the old way of doing 
things. And I think these are some great efforts to try to help 
us move forward on an issue that can get veterans better 
treatment, that can attract a better workforce, that actually 
wants to be able to prescribe these treatments that they know 
work. And so I thank you for your efforts.
    The whole health bill that I am introducing is really in 
the same vein. In a lot of areas of American health care right 
now, we are seeing experimentation with a wider array of 
traditional and non-traditional treatments. Anything from 
incorporating chiropractic services, massage, acupuncture, to 
just whole health coaching, in diet, in nutrition, and sleep, 
acupuncture, meditation, yoga. I mean, tai chi. There are all 
of these things out there and different practices work for 
different people.
    So the idea of this bill is that we would like the VA to 
look at the places where their whole health program is in 
effect right now. Tell us how it is doing, but more 
importantly, tell us what the availability in access is across 
the VA system for veterans and where there is no access in 
availability and help us figure out how we can expand it.
    I had the opportunity last year to visit the whole health 
program at Washington, D.C., which is one of, I believe, about 
18 or so places that they have the whole health program in 
place. And what you saw there were patients who were happy, and 
successful, and felt like they had some measure of control over 
their own health care. And that is the biggest thing.
    We talk about the practices themselves, you know, the way 
that yoga can help someone who is dealing with chronic pain. 
That is good. But what struck me as even better is that we were 
giving veterans an array of options, and the ability to try a 
few different ones and see what works. And when I--I remember 
asking an older Vietnam veteran that was there, ``Do you like 
this program?'' ``Yes, of course, I do.'' ``Why do you like 
it?'' And he was like, ``Because I get to pick. I get to pick 
which classes I come to, and how often, and it doesn't cost me 
anything. And if I like one of the instructors, and I like the 
other people who come to the class, I can keep coming back.'' 
And they get to know each other.
    And there is plenty of research that shows why that is a 
better way to do health care, when someone feels like they have 
control over it, it is just going to work better, but I think 
we all know that. It is common sense.
    So that is what is behind this bill, the Whole Veteran Act 
introduced by myself and my colleague, Mr. Ryan, from Ohio. So 
I appreciate everybody's support that can get behind it, and I 
think we can do some great things to help veterans and push the 
frontier of how we are doing health care going forward. Thank 
you, Madam Chairwoman. I yield back.

    [The prepared statement of Conor Lamb appears in the 
Appendix]

    Ms. Brownley. Thank you, Mr. Lamb, and again thank you for 
bringing this important bill forward. And I now recognize Mr. 
Rose for 5 minutes.

                STATEMENT OF HONORABLE MAX ROSE

    Mr. Rose. Thank you, Madam Chairwoman, and thank you 
Ranking Member Dunn, and just to reiterate my friend Conor's 
statements, I know Representative Blumenauer left, but Rep. 
Correa, thank you for your leadership on this issue as well.
    As a more recent vet, and someone who still serves in the 
Guard, we need to utilize all tools available to us to deal 
with folks as they are still encountering the wounds of combat 
and of service. So thank you again.
    I, like many veterans, as I am, the issue under discussion, 
that of veteran suicide, is personal. Based on recent events, 
it is clear that this mental health crisis requires action, 
both on the part of Members of Congress, and certainly on the 
part of the VA.
    The rising rate of veteran suicide is beyond a tragedy. 
Every veteran who struggles with mental health issues, physical 
scars of war, and who dies by suicide is another casualty of 
combat. And they are a casualty of combat, and of war, and of 
their service irrespective of whether they deployed to war or 
not. And we are noticing a truly jarring phenomenon: veterans 
attempting or completing suicide on VA campuses, four veterans 
just this month alone lost their lives to suicide within a VA 
facility or on VA grounds.
    Something must be done about this and we need to do it now. 
A thorough, multi-faceted approach is required to not only 
assess whether the services these veterans received were 
adequate, but to make sure that the VA has the framework to 
provide the necessary data to Congress and to other appropriate 
entities.
    That is why my legislation, I am proposing the Fostering 
Intergovernmental Health Transparency and Veteran Suicide Act, 
or Fight Veteran Suicides Act is a key first step. This bill 
would make sure the VA reports critical information to Congress 
when these events occur and requires these metrics quickly.
    Having these data points would help Congress fully 
understand the scope of this crisis. You know, as I have said 
time and time again, we need all of the information necessary 
so we can better serve our fellow veterans in need, while 
ensuring the VA has the necessary tools and resources to tackle 
this trend properly. I would like to thank AMVets, Paralyzed 
Veterans of America, the Reserve Officers Association, the 
Military Order of the Purple Heart, as well as the Disabled 
American Veterans here with us today for their support of this 
bipartisan legislation. And I strongly urge my colleagues to 
support it as well. Thank you for addressing this and I yield 
back the balance of my time, Madam Chairwoman.

    [The prepared statement of Max Rose appears in the 
Appendix]

    Ms. Brownley. Thank you, Mr. Rose. And thank you also for 
bringing this bill forward. I think the suicides that we have 
all witnessed on VA campuses, in my mind, is a cry for help. 
And I think that is what last night was about. And I think your 
bill, in terms of reporting, is extraordinarily important. So 
thank you for bringing it forward.
    And I will say thank you to the first panel, and we will 
have a little transition period here where we set up the second 
panel. And when that happens, I will introduce the second 
panel. Thank you very much.
    Ms. Brownley. I now recognize the second panel. And we have 
Dr. Keita Franklin, national director of suicide prevention 
from the Department of Veteran Affairs. Dr. Franklin is 
accompanied by Dr. Tracy Gaudet, director of patient centered 
care and Dr. Larry Mole, chief consultant population health. 
Next, we have Joy Ilem, national legislative director of 
Disabled American Veterans. And also here is Carlos Fuentes, 
national legislative director at Veterans of Foreign Wars. Last 
but not least, we have Jeremy Butler, chief executive officer 
at Iraq and Afghanistan Veterans of America. Wrong person. I am 
sorry. We have Stephanie Mullen. I apologize. It is a good 
reason to look up, as opposed to--we have Stephanie Mullen, 
chief--from the Iraq and Afghanistan Veterans of America.
    With that, I now recognize Dr. Keita Franklin for 5 
minutes. Dr. Franklin.

                STATEMENT OF DR. KEITA FRANKLIN

    Ms. Franklin. Good morning, Chairwoman Brownley, Ranking 
Member Dunn, and Members of the Subcommittee. Thank you for 
inviting us here today to discuss a number of important bills 
about mental health and suicide prevention, as well as VA 
policy on veteran participation in state approved marijuana 
programs, and cannabis research, and whole health.
    Madam Chair, before turning to the specific bills, I want 
to emphasize that suicide prevention is a top priority in the 
Department. I think you heard that last night. Suicide is 
complex. It is a serious national public health issue that 
affects people from all walks of life, not just veterans, and 
for a variety of reasons. And while there is much to learn, we 
know that it is preventable. We know that treatment works, and 
that there is hope. And I want to thank you for your leadership 
on this issue.
    Although VA is creating the path forward, we know that one 
agency alone cannot solve the issue. Preventing suicide 
requires bundled approaches, working across multiple sectors. 
And our work is guided by the national strategy for preventing 
veteran suicide. This strategy published in 2018 expands beyond 
crisis intervention and provides a framework for identifying 
the priorities, organizing efforts, and focusing resources 
through a broad public health approach, with an emphasis on 
comprehensive community level engagement. It is a plan for what 
we can all do to work together to prevent veteran suicide 
across the entire Nation, not just within the four walls of the 
VA.
    Legislatures play an important role in this integrated 
approach, not only because of the importance of policy 
interventions, but also in your ability to reach out across the 
Nation. For example, as you may know, this month we started 
working with you and other Members of Congress to spread 
awareness about this important topic through a PSA drive on 
Capitol Hill. Again, we want to thank all of you that have 
already developed your PSAs, and for your continued support and 
concern for this important issue of veteran suicide.
    So just turning right to the bills that are presented 
today. These are complex issues. They call for multi-layered 
solutions that require a rigorous level of review and analysis. 
And we provided some of our views in our written statements and 
we are prepared to continue that conversation today. And I will 
jump right in with the Veteran Overmedication and Suicide 
Prevention Act of 2019.
    This bill calls for the VA to partner with the national 
academies and to conduct in-depth, post mortem data analysis. 
Data and surveillance are at the core of our comprehensive 
public health approach and they inform our suicide prevention 
efforts and our partnerships with agencies like the National 
Academy are an essential piece to what we do.
    We appreciate Congress' interest in advancing those 
partnerships and in furthering how suicide data is collected, 
analyzed, and reported. VA was one of the first institutions to 
implement a comprehensive suicide surveillance and has 
continuously improved data and surveillance related to veteran 
suicide.
    Part of this bill reflects a specific requirement to 
further that analysis that we already do. Other pieces in the 
bill involve outside organizations and authorities that we 
don't directly own. And therefore, it will make full compliance 
with a proposed bill in its existing form very difficult to 
implement. Yet we know there is room to improve, and this is 
why we are eager to work with the national academies and to 
further study this issue. And I do stand ready to work through 
any and all details and barriers with this Committee.
    Moving to the next piece of legislation related to the 
draft suicide notification bill, this would require VA to 
submit notification of veteran suicide deaths or suicide 
attempts that occur on VA facilities to Congress within 7 days 
of the event. The VA supports this legislation. There are few 
details that need to be worked out in terms of technical 
issues, ensuring that we preserve surviving family members' 
privacy and dignity with regard to deaths that occur. But 
regardless, we are pleased to work with the Subcommittee on 
this initiative.
    The two remaining suicide related bills call for GAO review 
of suicide prevention, MOAs, and our memorandums of agreement 
and understanding, and a review of the role of our suicide 
prevention coordinators. VA would defer to the GAO on these 
bills. We defer to the GAO on these proposed bills. I would let 
the Committee know that we are already in the midst of an in-
depth analysis on both of these issues and I am happy to turn 
over and share any of that information with this Committee.
    Third, I am moving from the suicide prevention bills to the 
piece on cannabis. The VA Medical Cannabis Research Act of 2019 
would require VA to conduct a clinical trial to examine a 
multitude of health outcomes among veterans with varying 
medical diagnoses and would involve multiple strains of 
cannabis compositions and routes of administration.
    Typically, a smaller early phase trial designs would be 
used to advance our knowledge of benefits and risks regarding 
cannabis, before moving to a type of more expansive approach, 
as described in this proposed legislation. VA is currently 
supporting a clinical trial of cannabis for the treatment of 
post-traumatic stress disorder. Any trial with human subjects 
must include an evaluation of the risks and the safety and 
include the smallest number of participants to avoid putting 
subjects at increased risk unnecessarily. So and for these 
reasons, we don't support this proposed legislation. I do have 
Dr. Larry Mole here to talk to you more about that during the 
remaining of the hearing.
    And then moving to the Veteran Equal Access Act and the 
Veteran Cannabis Use for Safe Healing Act. This would authorize 
physicians and other health care providers in VA to provide 
recommendations, opinions, and for H.R. 1647, the completion of 
forms regarding participation in state marijuana programs.
    VHA's current policy prohibits VA providers from 
recommending and making referrals to or completing paperwork 
for veteran participation in state marijuana programs. This 
prohibition is the result of the Drug Enforcement Agency, 
guidance that is pushed out from that agency, which advised VA 
that no provision of controlled--of the Controlled Substance 
Act would be exempt from criminal sanctions as a VA physician 
who acts with intent to provide a patient with means to obtain 
marijuana.
    In addition, this proposal would authorize VA providers to 
discuss marijuana use with their patients, record that use in 
the patient's medical record, and prevent VA from denying a 
veteran any benefit for participating in a state approved 
marijuana program. Please know that our existing policy in VHA 
already permits discussion and documentation, and clearly 
states that veterans will not be denied benefits by discussing 
this information with a VHA provider. Thus, VA does not support 
this bill.
    The draft VA Whole Health Bill would require VA to submit 
to Congress a report on the implementation of VA's February 
1st, 2019 memorandum on the subject of advancing whole health 
transformation across VHA. Specifically, this report would 
include an analysis of the deployment of whole health services 
at 36 facilities. VA supports this draft bill, but notes that 
Congress may wish to consider extending the draft bill's 
requirement to a VHA-wide enterprise update. In addition, a 
thorough research report on veteran outcomes, cost, 
utilization, workforce engagement, burnout, and implementation 
will be provided to Congress on the 18 facilities currently 
deploying all aspects of whole health in March 2021 as required 
by the CARA legislation.
    Madam Chairwoman, in conclusion, I cannot emphasize enough 
the commitment of the secretary and all of the VA to use every 
effort to prevent veteran suicide and continue to equip and 
empower all veterans with the resources and care that they need 
to thrive. We appreciate the Committee's attention to this 
issue. We pledge to work hand in hand with the Congress on 
innovative and evidence-based approaches to this problem.
    This concludes my statement and I am happy to answer any 
questions. Myself, my colleagues are here to answer any 
questions that any Member of the Committee may have.

    [The prepared statement of Keita Franklin appears in the 
Appendix]

    Ms. Brownley. Thank you, Dr. Franklin. And I now recognize 
Joy Ilem for 5 minutes.

                     STATEMENT OF JOY ILEM

    Ms. Ilem. Chairman Brownley, thank you for inviting--and 
Members of the Subcommittee, thank you for inviting DAV to 
testify at this legislative hearing.
    We are pleased to offer our views today on the bills under 
consideration by the Subcommittee. In accordance with DAV 
resolution number 023, we are pleased to support H.R. 712, the 
VA Medicinal Cannabis Research Act of 2019. This bill would 
direct the VA to perform clinical research to determine whether 
cannabis is able to reduce symptoms associated with chronic 
pain, and how it may affect alcohol use or dosage of certain 
medications for veterans with PTSD.
    We concur that research is necessary to help clinicians 
better understand the safety and efficacy of cannabis use for 
specific conditions that often co-occur in the veteran 
population, such as chronic pain and post-traumatic stress.
    DAV also supports the draft measure being considered that 
requires GAO to conduct an assessment of the role of VA suicide 
prevention coordinators and their responsibilities within the 
VA health care system. The study would assess associated 
workload, vacancy rates, adequacy and appropriateness of 
training, and oversight of these positions and how these 
factors may vary across the system.
    VHA guidance for delivery of mental health services allows 
for local variation and programs and thus, training and 
oversight of the suicide prevention coordinator position could 
differ somewhat from site to site. Because of these ambiguities 
and the importance of the coordinator's responsibilities, DAV 
agrees this study could yield important information and thus we 
support the draft bill.
    The draft measure focused on advanced--VA's whole health 
transformation model would require the VA to report on access 
and availability on each of several complimentary and 
integrative medicine practices. In accordance with DAV 
resolution 277, we support veterans' access to a full continuum 
of care, including alternative and complimentary care, such as 
yoga, massage, acupuncture, chiropractic care, and other non-
traditional therapies.
    DAV is aware that some facilities may not offer a full 
complement of these types of services or may have to limit the 
number of visits for massage therapy or other popular 
integrative treatments. The report would help to determine to 
what extent these services are available across the system for 
veterans that prefer them over more traditional types of care.
    To provide a more complete picture, DAV recommends and 
suggests that the study also include complementary and 
alternative services the VA provides to its veteran's community 
care program.
    We need to ensure these--DAV supports the draft bill that 
would require GAO to report on the effectiveness of VA 
memorandum of agreement and memorandum of understanding with 
non-VA providers to carry out suicide prevention activities and 
mental health case management services.
    We need to ensure these agreements hold community partners 
accountable for delivering evidence based high quality mental 
health services to veterans who need them. Therefore, community 
partners or network providers, should be held to the same 
competency, training, and quality standards that VA mental 
health providers are required to meet.
    The draft bill would provide needed oversight of agreements 
with non-department entities, providing mental health services 
to veterans to determine regional variances and the extent to 
which VA tracks health outcomes of such entities.
    H.R. 100, the Veterans Overmedication and Suicide 
Prevention Act of 2019 calls for a study aimed at identifying 
suicides among veterans that may be attributed to 
overmedicating patients or inappropriate prescribing patterns 
in the VA. DAV supports the intent of the bill and certainly 
agrees that research and proper oversight of VA clinical 
practices are necessary. But it is difficult to assess if 
appropriate treatment protocols were followed without looking 
at individual case studies, especially in cases of medically 
complex patients with co-occurring physical and mental health 
conditions.
    For these reasons, we are urge the Subcommittee to consider 
working with VA subject matter experts to revise certain 
provisions in the bill related to data collection so that it 
can better advance the important goals of improving patient 
safety, improve poly-pharmacy management, and reducing suicides 
among veteran patients.
    Finally, DAV has no objection to favorable consideration of 
the draft measure requiring VA to notify Congress about any 
suicide or attempted suicide of a veteran that occurs on the 
grounds or in a VA facility.
    Madam Chairwoman, this concludes my testimony. I would be 
pleased to respond to any questions from you or other Members 
of the Committee. Thank you.

    [The prepared statement of Joy Ilem appears in the 
Appendix]

    Ms. Brownley. Thank you, Ms. Ilem. And I now recognize Mr. 
Fuentes for 5 minutes.

                  STATEMENT OF CARLOS FUENTES

    Mr. Fuentes. Chairwoman Brownley, Ranking Member Dunn, and 
Members of the Subcommittee, thank you for allowing the VFW to 
represent our views on legislation pending before the 
Committee. The VFW is proud to support the VA Medicinal 
Cannabis Research Act 2019. The VA's reliance on opioids to 
treat chronic pain and other conditions has unfortunately led 
to addiction, and even death, such as Jason Simcakoski, who 
died from an overdose of medications he was prescribed by his 
doctors at the Tomah VA Medical Center.
    The VFW is proud to have stood next to Jason's family, and 
many Members of the Subcommittee, to champion the Jason 
Simcakoski Memorial and Promise Act, which required VA reduce 
the use of high dose opioids. To its credit, the VA has made 
concerted efforts to ensure it properly uses pharmaceutical 
treatments under the opioid safety initiative. VA has reduced 
the number of patients to whom it prescribes opioids by more 
than 22 percent. Now, VA must expand research on the efficacy 
of non-traditional alternatives to opioids, such as medicinal 
cannabis and other holistic approaches.
    VFW members tells us medicinal cannabis works and it is a 
more suitable option than the drug cocktails VA prescribes. VA 
must research how medicinal cannabis can help veterans cope 
with PTSD and other conditions, such as chronic pain. The VFW 
and Student Veterans of America fellow, Christopher Lamy, an 
Army veteran and LSU law school student, focused his semester 
long research project and advocacy efforts on the VA Medicinal 
Cannabis Research Act of 2019.
    Chris' research discovered that veterans experienced 
chronic pain at 40 percent higher rates than non-veterans and 
if not properly treated, such chronic pain often leads to 
depression, anxiety, and decreased quality of life. Chris also 
found that veterans who discuss use of medicinal cannabis with 
their doctors are often--often have their medications changed 
or discontinued. The fear of reprisal for medicinal cannabis 
use prevents veterans from discussing and disclosing 
information to their VA health care providers, which can also 
lead to drug interaction issues.
    This legislation would prohibit VA from denying benefits 
based on participation in the study. To ensure participants of 
the study do not have their VA health care impacted, the VFW 
recommends prohibiting VA doctors from denying or altering 
treatment for participants without consultation or concurrence 
with such veterans.
    The VFW agrees with the intent of the Veterans Equal Access 
Act, but cannot offer it support at this time. The VFW agrees 
that veterans who rely on the VA health care system must have 
access to medicinal cannabis if such therapies are proven to 
assist--proven to be effective in assisting and treating 
certain health conditions. Without such evidence, the VA would 
not have the ability to prescribe or provide medicinal cannabis 
to veterans.
    It is unacceptable for VA providers to recommend a 
treatment that is unavailable to veterans at their VA medical 
facilities, which forces those patients to pay the full cost of 
such care or rely on other means for those treatments. The VFW 
strongly supports the provisions of the Veterans Cannabis Use 
for Safe Healing Act that protect veterans from having their 
earned benefits eroded or denied simply because they 
participate in a state approved marijuana program.
    Veterans who participate in such programs must not fear 
that VA will take away benefits they have earned and deserve. 
However, we cannot support VA providers recommending 
participation in state approved marijuana programs if VA is 
unable to provide such recommended course of treatment. The VFW 
supports the Veteran Overmedication and Suicide Prevention Act 
of 2019 and they support for Suicide Prevention Coordinators 
Act.
    These two bills would make strides to reduce veteran 
suicide. Suicide is a serious issue. We must do whatever it 
takes to save the 20 veterans who take their own lives every 
day. Madam Chairwoman, this concludes my statement. I am happy 
to answer any questions you or the Members of the Committee may 
have.

    [The prepared statement of Carlos Fuentes ppears in the 
Appendix]

    Ms. Brownley. Thank you, Mr. Fuentes. And I now recognize 
Stephanie Mullen, who is the research director for the Iraq and 
Afghanistan Veterans of America. Thank you for being here.

                 STATEMENT OF STEPHANIE MULLEN

    Ms. Mullen. Thank you. Thank you, Chairwoman Brownley, 
Ranking Member Dunn, and distinguished Members of the 
Subcommittee. On behalf of IAVA, and our more than 425,000 
members worldwide, I would like to thank you for the 
opportunity to testify here today.
    As research director for IAVA, I use the collective 
experiences and views of IAVA members to support our policy and 
programmatic work, giving numbers to the narratives of IAVA 
members every day.
    This work is personal for me. I come from a military 
family, with a mother that served 20 years for this country 
while raising a family. Many of the issues IAVA tirelessly 
advocates for directly impacts the people I love most, and it 
drives my work to ensure that all veterans are receiving the 
best care and treatment possible.
    Support for veteran medicinal cannabis use is an important 
part of our work. And it is why it is one of IAVA's big six 
priorities for 2019. For years, IAVA members have been 
supportive of medical cannabis. In our latest member survey, 83 
percent agree that cannabis should be legal for medical 
purposes, and a resounding 90 percent believe cannabis should 
be researched for medicinal uses.
    IAVA members are calling for cannabis research and it is 
past time for the Department of Veterans Affairs to catch up. 
This is why IAVA is proud to support the VA Medicinal Cannabis 
Research Act, which will advance research and understanding 
around the safety and effectiveness of cannabis to treat the 
signature injuries of war.
    However, research takes time. Years, in fact. And veterans 
are suffering from their injuries today. With over 30 states 
legalizing medical cannabis, if veterans are unable to go 
through VA to get medical cannabis, they will go around it. The 
veterans shouldn't feel that they have to hide and circumvent 
VA to access a standard of care their civilian counterparts can 
access easily.
    We know this is already occurring from IAVA members 
nationwide. In just the last month, over 100 IAVA members have 
shared stories of their cannabis use, with dozens sharing how 
VA retaliated against them or mishandled their information. And 
dozens more sharing that they flat out refuse to tell VA about 
their cannabis use.
    While current VA policy allows for clinicians to talk to 
their veteran patients about cannabis, VA clinicians are unable 
to recommend cannabis to their patients, fill out state 
cannabis medical forms, or recommend the best programs and 
options for their patients. These limitations have negative 
impacts on the overall care of veterans at VA. For these 
reasons, IAVA is proud to support the Veterans Equal Access 
Act, the Veterans Cannabis Use for Safe Healing Act, and the 
Whole Veterans Act.
    Though cannabis reform is an important pillar in our 
advocacy efforts, the top priority for IAVA and among our 
membership is suicide prevention among troops and veterans. In 
2016, the latest numbers available, an average of 20 
servicemembers and veterans died by suicide each day, 
accounting for over 7,000 deaths each year. Each one of these 
deaths impacts an entire community, a family, a friend group, a 
military unit, and the lives of each and every person that 
veteran or servicemember touched.
    IAVA members know this well. Fifty-nine percent of our 
membership knows a post 9/11 veteran that has died by suicide. 
That is a rise of almost 20 percent since just 2014. IAVA 
thanks the Subcommittee for highlighting this public health 
crisis and we are pleased to support the Veteran Overmedication 
and Suicide Prevention Act, the Veterans' Care Quality 
Transparency Act, and the Support for Suicide Prevention 
Coordinators Act.
    Increasing our understanding of veteran suicide, the risk 
and protective factors surrounding it, and the effectiveness of 
suicide prevention programs at VA are all essential to tackling 
this issue.
    While we recognize and appreciate the intent regarding 
veteran suicides on VA property behind the FIGHT Veteran 
Suicide Act, IAVA has some concerns regarding this legislation.
    When a veteran dies by suicide on VA property, to include 
the tragic veteran suicide just yesterday at the VA in 
Cleveland, it indicates that the foundation of trust between 
the public and VA has be catastrophically undercut. These 
tragic events should be a call to action to ensure that all VA 
policies and procedures surrounding VA emergency mental health 
care, facility security, and personnel training are up to date, 
acceptable, and being implemented correctly. A failure in the 
system should and must be addressed.
    IAVA recommends that the proposed legislation focused on 
these procedures and policies at VA facilities that may be able 
to intervene in a moment of crisis, rather than the individual 
factors surrounding the tragic event itself.
    Members of the Subcommittee, thank you again for the 
opportunity to share IAVA's views on the issues today. I look 
forward to answering any questions you may have and working 
with you in the future.

    [The prepared statement of Stephanie Mullen appears in the 
Appendix]

    Ms. Brownley. Thank you, Ms. Mullen, for your testimony and 
thank all of the witnesses as well for your testimony today. 
And so we will now begin the question portion of the hearing. 
And I will recognize myself for 5 minutes.
    I think the first issue I really wanted to address is the 
cannabis issue. We have got a couple of bills before us, which 
I think are good bills, and the VA doesn't support those bills. 
We have the VSOs all speaking in favor of these bills. This 
is--you know, this seems to be an issue that has been going on 
now for a while, this schism between what the VA believes and 
what the VSOs want. And this is a big frustration for me 
because I think it is overwhelmingly clear amongst the American 
people, and amongst our veterans across the country, that this 
is an issue that they are keenly interested in and want to have 
access to.
    And so I guess my question is, you know, how are we going 
to reconcile this? You give particular reasons for why you 
don't support this legislation. You know, I can't speak whether 
these issues are valid or not, but if they are, how are you 
working with the VSOs to kind of work through, not I mean these 
two bills, but there are going to be more because of the 
interest of our veterans and the interest of the American 
people.
    So Dr. Franklin, if you could just respond to that.
    Ms. Franklin. Sure. I would actually ask Dr. Larry Mole, 
our lead in this area, to respond.
    Mr. Mole. Good morning, and thanks for the opportunity to 
speak today.
    I think for VA, the--and we have seen legislation come in 
over the last few years and our kind of rate limiting step is 
the authority related to being able to recommend or prescribe 
is related to the Controlled Substance Act. And as long as 
cannabis or marijuana remains a schedule 1 drug, then we are 
going to look to the DEA and the Department of Justice to give 
us their opinion on what our prescribers are able to do.
    And that is kind of, I think, a short summary of where that 
process is at. And so I think this Committee can make strong 
proposals to us to move forward with recommendations, filling 
out forms and such, but at the end, we will need to go back to 
DEA and Department of Justice for their opinion. And I have not 
seen anything myself that suggests their opinion will change.
    Ms. Brownley. And so what role does the VA play in terms of 
working with DOJ and DEA? I mean, what kinds of meetings are 
you having? What kind of conversations are you having to try to 
push the envelope in support of our veterans?
    Mr. Mole. I would say there are very few meetings that 
occur, and it is because the--and I am not an attorney, so I 
can't speak from an attorney's opinion--
    Ms. Brownley. Understood.
    Mr. Mole [continued]. --but I think they are waiting to see 
that something changes from a regulation perspective that then 
they would respond to. And that is, I think, the best way I can 
summarize it. I mean, we can go to DEA, and Department of 
Justice, but they are going to continue to point to the 
Controlled Substance Act until there is a change in that act.
    Ms. Brownley. And so you can't even do the research on 
efficacy because of this?
    Mr. Mole. Research is a whole different question. I mean, 
and we can get to that. But in terms of the recommending, 
prescribing, that is where the Controlled Substance Act is the 
authority of what we do.
    Ms. Brownley. Okay, thank you. I would like to hear from 
the other witnesses in terms of the--your perspective on these 
issues.
    Mr. Fuentes. Ma'am, thank you very much for bringing these 
issues and consider them by the Committee. They are very 
important and have the support of the overwhelming majority of 
the veterans' community.
    I would have to say that I agree--the VFW agrees with the 
VA in terms of prescribing something VA can't provide through 
its pharmacies, but VA should conduct research on medical 
cannabis. The claim and previous testimony has also said that 
they have the authority but still haven't done it. CBD is not 
medical cannabis, and I encourage VA--the VFW encourages VA to 
continue CBD research and do more of it, but it is not exactly 
what we are looking for here with this legislation.
    Ms. Brownley. Thank you. Any other comments? Ms. Mullen?
    Ms. Ilem. I would say, as well, research is the key. 
Everyone wants to make sure that these--this medicinal cannabis 
would be beneficial to veterans. We want to make sure that 
there is no harm done. So the research is the first step to 
doing that. And that is essential. But I think even more 
importantly, as Stephanie, and we have mentioned, is that 
veterans are using this as a medication to try to stem their 
symptoms, whether that be from chronic pain, PTSD symptoms, and 
others.
    So we know that they are doing that, and we have heard some 
of repercussions for that happening. And we want to make sure 
veterans are safe and have access to all treatments that may be 
beneficial to them. So this is a critical piece to move forward 
and I hope VA will be able to address on the research side. I 
know they mentioned some of that in their testimony about how 
things like that are conducted. So that type of research.
    Ms. Brownley. Ms. Mullen?
    Ms. Mullen. I think that you described the attention 
between Federal and state policy well and that tends to be the 
biggest factor when we are talking about VA and recommending 
cannabis, and allowing it in pharmacies. I do think it is 
within the purview of this Committee within Congress to close 
some of those loopholes and ensure that VA clinicians, while 
maybe not able to recommend it directly, can at least advise 
what--where to go for it. What state medical places they should 
be looking at, because right now, it is going completely under 
the radar.
    And again, with the VA policy that is currently in place, 
right now, veterans are supposed to be able to talk to their 
providers about their cannabis use and it shouldn't be used 
against them. I think in practice, that doesn't always occur. 
And so having some sort of legislation that would actually 
protect veterans would be very helpful.
    Ms. Brownley. Dr. Dunn.
    Mr. Dunn. Thank you, Madam Chair. So I think the H.R. 712 
has engendered a lot of interest here. I would like to address 
it. Mr. Mole, you went right to the heart of the problem. I 
think that the physicians feel, and that is so there is a 
Federal law that makes it illegal, and there are multiple state 
laws that make cannabis legal to prescribe and discuss. And yet 
the physicians and all the clinicians can be prosecuted under 
either state or Federal law. So there is--we are not, I think, 
in a position here to actually protect the VA physicians who 
want to disburse or prescribe cannabis unless we change that 
law.
    So we might be looking at the wrong leverage point when we 
address these laws without addressing the schedule of the drug 
and the actual punitive actions on it. I could not agree with 
you more that we ought to be research on this. I think we ought 
to change the schedule to schedule 2. It seems like every 
Committee I go in, we have another discussion about cannabis.
    I was in banking not too long ago. Can we bank people who 
sell cannabis? No, we can't. Yes, we can. It depends on if it 
is Federal or state law, right? And so the poor person who gets 
involved in actually helping patients with this substance, 
potentially helping them, you know, can go to jail in any one 
of a number of venues.
    So thank you for bringing out that what we need to do is 
move it from schedule 1 to a schedule 2. And that is the major 
objection, right, on the VA's part of that? But let's take a 
look at 712, the research very quickly here. You have expressed 
reservations on the design of the study, as well as the fact 
that it is not a schedule 2 drug. Would you help us redesign 
this bill in such a way that the protocol would suit the VA? 
Dr. Franklin?
    Ms. Franklin. Absolutely. I am sure we would. Yes, sir.
    Mr. Dunn. Okay. So you could see a way forward doing 
cannabis research, on tetrahydrocannabinol, as well as 
cannabidiols, and all those things, as long as we made it legal 
for your researchers to do that?
    Mr. Mole. Yeah. I would just add that it is legal for our 
researchers to research cannabis, cannabidiols, marijuana, 
whichever label we want to use and whatever product it is. And 
so they are able to do that. That is a folklore that has kind 
of been around, unfortunately.
    Mr. Dunn. But it is difficult?
    Mr. Mole. There are some extra--
    Mr. Dunn. It is very controlled drug.
    Mr. Mole. There are some extra steps you have to do. But as 
Dr. Franklin said, we have one investigator who is funded by VA 
right now, down in San Diego.
    Mr. Dunn. One.
    Mr. Mole. So far.
    Mr. Dunn. Busy investigator.
    Mr. Mole. Well, I can tell you, she has a lot of great 
ideas. But if you look also at some of the state programs, so 
Colorado and California, they have supported a number of 
clinical trials. And in fact, Colorado has a clinical trial 
looking specifically at PTSD and they are funding a VA to do 
that work.
    So I believe this is beginning to expand in the direction 
it needs to go so we get more knowledge, we get some more 
experience to do the more comprehensive study that you have 
proposed.
    Mr. Dunn. Thank you. Also Dr. Franklin, you expressed 
concern about the reporting time. I am now on H.R. 100. Are 
there timelines that do make sense to you for the reporting on 
the--this is the Veteran Over-medication Suicide Prevention 
Act, 100.
    Ms. Franklin. I don't think timeline is the issue. The 
issue, and we spoke about this last night with regard to this 
proposal, definitely in spirit, and intent, there is a need to 
do this type of data and surveillance. The issue is when you 
look at 20 veterans a day and their life by suicide and 14 not 
touching the VHA health care system. The way the proposal is 
laid out, it would call for VA to capture medication, issue, 
and the like from potential deaths that happened outside of our 
system, not only from veterans that might be accessing care 
through our choice program, but veterans access care through 
other entities as well. So if it--
    Mr. Dunn. You are saying difficult, then, to get the data. 
Is that what I understand you--
    Ms. Franklin. For those veterans that don't receive health 
care in our health care system.
    Mr. Dunn. Right.
    Ms. Franklin. If it were strictly VHA health care system 
proposal, provide thus and such as written in the proposal with 
those that get health care through our organization, it would 
be a thumbs up.
    Mr. Dunn. Okay, good. That is exactly what I wanted to 
underscore. With the 30 seconds left, Ms. Ilem, you said that 
DAV could support certain sections of H.R. 100, it is the same 
bill the suicide is reporting. Is there--what part of it do you 
oppose? What part do you favor?
    Ms. Ilem. I think what Dr. Franklin has mentioned, we were 
concerned about the types of data collection and then how--you 
know, it might be misleading in terms of how that is 
interpreted. But you know, certainly, looking at VA data and 
what they have available, we want to see oversight, obviously, 
of black box medications and prescribing practices. So I think 
just making sure that VA's experts in this have looked at it 
and feel that it is going to benefit.
    Mr. Dunn. Thank you, very much. And I want to say, Madam 
Chair, that it comes up again and again, and across all of the 
Committees. We need to get this drug into a schedule 2 status. 
It makes everything so much easier to do. Thank you. I yield 
back.
    Ms. Brownley. Excuse me. Mr. Lamb, 5 minutes.
    Mr. Lamb. Thank you, Madam Chairwoman. Dr. Franklin, we 
talked a little bit about whole health at last night's hearing 
and you heard some of my comments about it today. And I 
appreciate your suggestion on maybe even widening the scope of 
our bill now or in the future. Could you go into a little bit 
more detail about that, about the planned expansion from 18 to 
36, and then also what you think we could learn from the wider 
VHA experience, you know, if we looked beyond those 36 sites? 
And as relevant to suicide prevention, of course, but just 
really in any manner that is effective for veterans.
    Ms. Franklin. Absolutely. I am pleased that we have Dr. 
Gaudet here to talk about it. But I am also, too, happy to 
engage as well.
    Mr. Lamb. Either of you, fine. Yeah. Thank you.
    Ms. Franklin. I will ask her to take the lead.
    Dr. Gaudet. Yeah, thank you. It is an important question. 
And the reason we were hoping to actually expand that report is 
that we do have an intention to do a national deployment of 
whole health. And I am sure you are aware, but other members 
may not be, that whole health includes complimentary 
integrative approaches, but is actually way broader than that. 
It is really redesigning how health care works to start with 
what matters to the veteran, to help them explore a sense of 
meaning and purpose in their life. And that is primarily done 
through trained peers.
    So while we have the 18 flagship sites that are fully 
funded to implement the entire whole health system 140 health 
care systems are doing aspects of whole health. So we would 
love the opportunity to report back to you on the national 
deployment and where those strategies are, along with the next 
36 sites.
    Mr. Lamb. Great. Thank you very much. Can you talk a little 
bit more about--they told me about this when I visited the D.C. 
site, but I presume that the expansion that has happened beyond 
those 18 sites, does it have to do with the trainings that VA 
has made available for peer and other health coaches to then go 
back? I mean, that was kind of the way they explained it to 
me--
    Dr. Gaudet. Right.
    Mr. Lamb. --that there was a voluntary program where you 
could come and learn some of the practices, even if your site 
didn't--
    Dr. Gaudet. Right. So there are three core elements in this 
redesign of health care. Of course, clinical care is critical 
and that is in place. The two newer elements are peer piece, 
which is designed around empowering. And I honestly believe, 
and as it relates to suicide prevention, that this is the most 
powerful piece of this entire approach. Trained peers to work 
with other peers around regaining a sense of meaning and 
purpose in their life. Then from that point, and there are 
peers trained at every facility now. So that is offered whether 
they are a flagship site or what other aspects you are doing.
    In addition to that, the real goal of the peer piece is 
empowerment and engagement in your life. But now veterans need 
support in new ways to approach their life. So the well-being 
programs, which you described in D.C., places where veterans 
can drop in, have experiences in yoga, or mindfulness, or 
nutrition, or battlefield acupuncture, a whole myriad of self-
care strategies that empowers them is the second element.
    So different facilities are doing different elements. The 
18 are doing all of those three components and every facility 
has trained peers.
    Mr. Lamb. That is great. Thank you. Has VA already decided 
what the new sites are going to be from the 18 to 36? Has that 
been--
    Dr. Gaudet. Yeah, we have--so each network has proposed two 
sites, thus 36, and those haven't been announced yet, but we 
have those 36 and that collaborative will start this summer.
    Mr. Lamb. Okay. Excellent. Thank you. I will be hoping 
beyond hope that one of Pittsburgh sites might be included, but 
if not, we will certainly work hard to get our share of the--
    Dr. Gaudet. Absolutely.
    Mr. Lamb [continued]. --program underway. Maybe I could 
become a peer something. You know what I mean.
    Dr. Gaudet. That would be fabulous.
    Mr. Lamb. Yeah. They tried to put one of the acupuncture 
ear things on me when I was there at D.C. It didn't quite work 
out, I don't think, but--
    Dr. Gaudet. We can arrange for that.
    Mr. Lamb. Yeah. I applaud your thinking and your expansion 
efforts on this. You guys are ahead of the game, I think, and I 
do think it is a big part of the future of health care more 
generally, not just for veterans.
    And I guess one last thought, if you have anything, Dr. 
Franklin, on it is I also see a program like this as a way to 
appeal to veterans who are not really using the VA system right 
now because it just--I think it just matches a little bit more 
about what younger people in particular think health care 
should be like.
    Do you think it is a way that we can find to reach these 13 
veterans of the 20 everyday who are not coming to the VA for 
services?
    Ms. Franklin. Yes, absolutely. I have been in close 
collaboration with Dr. Gaudet on this very issue, particularly 
within the first 12 months of time when they leave active duty 
service. We have a project together where we are working on 
trying to help transitioning servicemembers, right when they 
leave the DoD roll right into the whole health program and 
start their VA experience that way.
    Mr. Lamb. Thank you very much for your efforts. Madam 
Chairwoman, I yield back.
    Ms. Brownley. Thank you, Mr. Lamb. And Ms. Radewagen, you 
have 5 minutes.
    Ms. Radewagen. Thank you, Madam Chairwoman. I want to thank 
the panel for appearing today. My question is for Dr. Franklin.
    Ms. Franklin. Yes, ma'am.
    Ms. Radewagen. In your testimony, you referenced the 
development of a new suicide prevention coordinator program 
guidebook and a suicide prevention program directive. When will 
these be approved and released to the field?
    Ms. Franklin. I don't have the exact dates with me, but I 
can definitely get those back to the Committee in very short 
order.
    Ms. Radewagen. So in your opinion, is the suicide 
prevention program and the coordinators who are responsible for 
its execution, are they consistently trained and monitored 
throughout the VA system?
    Ms. Franklin. Yes, they are consistently trained and 
monitored. They are trained through a number of different 
portals and avenues that I can run through with you if you are 
interested. And then there are a number of oversight processes 
and protocols in place at the VISN level and at the VACO level 
through a number of bodies.
    Ms. Radewagen. Thank you.
    Ms. Franklin. I am happy to get into more details with you. 
I am also cognizant of the fact that you might have more 
questions. So--
    Ms. Radewagen. Yes.
    Ms. Franklin. Okay.
    Ms. Radewagen. So Dr. Franklin, I think a study such as the 
one outlined in H.R. 2372 could be useful in helping to define 
the prior scope of VA cooperation with non-profit and community 
entities in its suicide prevention work. Do you have an 
estimate as to how many such agreements currently exist and 
give us an example of one or two and how they are working?
    Ms. Franklin. Sure. Absolutely. So within my program in 
suicide prevention, we have a total right now of 68 partners 
and this is just my little program. This does not--little I 
shouldn't say, but this does not count for the choice program 
and all the partners in other entities across the VA. But we 
have 68. Of those, 34 are signed MOAs or MOUs. And others are 
just informal, and they agreed to partner with us, and we do 
good work together, but we have not solidified it on pen and 
paper.
    And I will give you an example of one with Walgreens. So we 
have an MOA with Walgreens recognizing--reference the 14 
veterans that there may be some veterans that might pick up 
their prescription at Walgreens. And they might touch a 
Walgreens facility. So this MOA has--calls for us to train 
Walgreens pharmacist on veteran culture, cultural competence, 
what it means to where the uniform, and how to ask the 
question, ``Have you served?'' And ``Have you worn the''--
``What is that like?'' And to really join with our veterans. 
And then it teaches them also about suicide prevention risk.
    So I actually train all of the pharmacists in Walgreens on 
suicide prevention, myself. I get on a webinar, and I train 
them, and I go through a series of Q and A with them to bring 
them up to speed on everything from our veteran crisis line, 
our campaign around be there, #be there for veterans, around 
how to ask the question, ``Are you thinking of ending your 
life?'' ``How many prescriptions are you on?''
    And then Walgreens also takes our veteran crisis number and 
pushes it out to all of their employees at the pharmacy. They 
give it also to veterans and veterans' family members. And 
those are just a few examples. But all of that is written into 
stone on the official MOA and we stay true to it. It is not a 
legally binding document, but it does go through legal review, 
and we track the metrics according to it.
    So for example, how many pharmacists have we trained? How 
much engagement have we had with Walgreens? So that is one. We 
also have an agreement with a non-profit called the 
Independence Fund, which is a VSO that works with us on 
reunions. And this is a brand new one, so I will give you sort 
of the other side of the coin because Walgreens is sort of well 
established.
    The Independent Fund, recognizing the role of social 
support in preventing veteran suicide and peer support has 
partnered with the VA to reconstitute military units of 
veterans to bring them back together for a reunion. And we 
partner with them. The VA's role in that is to provide the 
education, the psycho-educational content, classroom 
instruction, and design the evaluation protocol.
    They are in the pilot stage, so we have got to grow the 
evidence on this. It is small pilots. We have had one so far. 
The second one is coming up the first week of May where we will 
continue to test this model of bringing units back together.
    Ms. Brownley. You are running short on time.
    Ms. Radewagen. Thank you. Thank you, Dr. Franklin.
    Ms. Franklin. Yes, ma'am.
    Ms. Radewagen. But looking ahead to the implementation of 
the president's prevents executive order that would provide for 
grants to communities to increase collaboration, how do you 
envision these grantees coordinating with your other partners?
    Ms. Franklin. Yes, this is an important thing that we have 
been talking about in the building as well, so I appreciate the 
question because there is a number of existing partners that 
are going to be able to bring capabilities to the table. And so 
we are planning on hosting a series of webinars and 
informational instructions to share best practices across the 
new and innovative community partners that will likely come to 
the table from Prevents, with the existing infrastructure, in 
such a way that we can leverage--force multipliers in that 
equation.
    Ms. Radewagen. Thank you so much. Madam Chair, I yield back 
my--
    Ms. Franklin. Thank you.
    Ms. Radewagen [continued]. --time.
    Ms. Brownley. Thank you, Ms. Radewagen. Now, we have Mr. 
Cisneros for 5 minutes.
    Mr. Cisneros. Thank you, Madam Chair. Thank you all for 
being here today. First, I have got a question for the VSOs. I 
am getting like an echo.
    I heard repercussions for--you know, that was--somebody 
said that veterans that are going, and they are afraid of 
repercussions if they talk to the VA doctor about marijuana 
use, or they have had repercussions for bringing it up to their 
VA doctors. Can you give me an example of any veteran--what 
type of repercussions have they had, you know, for bringing 
that up to their doctor?
    Ms. Mullen. Yeah, I will start. So I won't use names to 
protect our IAVA members, but we have had several tell us that 
they will talk to their VA clinician about their cannabis use, 
and suddenly in their charts, it will say that they have a 
substance use disorder. And once that happens, it means they 
have to go through certain procedures to get their benefits 
back, to get medications back, or in other instances, they will 
be taken off certain medications because of their cannabis use, 
where there is no interaction.
    For example, perhaps they are on some sort of opioid for 
chronic pain and they talk about using cannabis as another 
factor that helps with that, and there is research to suggest 
that using both in tandem actually does help that. And then all 
of a sudden, that prescription is taken away from them. So that 
is just two examples.
    Mr. Cisneros. And Dr.--
    Ms. Franklin. I also offer that I am happy to take it back 
to the organization to double down on our efforts to educated 
providers and nurses and physicians on this issue to make sure 
that there are no repercussions. And if there are individual 
case studies, I know Dr. Mole and I are happy to chase those 
down and ensure that there are not ramifications or negative 
consequences for veterans.
    Mr. Cisneros. Well, that was my question, you know, to you, 
is you said that patients are allowed to discuss this with 
their doctors. But is there a VA policy in place, is there a 
directive in place that says they are allowed to bring this and 
there won't be any repercussions, or that they won't be listed 
as a substance abuse? What are those policies? What is--
    Mr. Mole. So the policy isn't as prescriptive as you won't 
do A, B, C, D, E. But it says that you will not be denied 
benefits. We encourage you to have a conversation. We encourage 
the providers to document that so that other providers know and 
are aware. And to use that information as part of the treatment 
plan, and how you develop what is appropriate for that 
individual veteran. That is what we ask for the providers to 
do.
    And I second what you are saying is we want to take a look 
at providers who are deviating from that policy. Absolutely.
    Ms. Franklin. Double down on this.
    Mr. Cisneros. Yeah. No, I would appreciate that. And 
Representative Steube, his bill right now that I am happy to 
co-sponsor with him, I think has done a great deal that will go 
and make sure that these veterans don't have to face 
repercussions and that they can feel comfortable talking about 
their plans with their doctors. And I am glad that he brought 
forth that legislation. I am glad he came up to me and asked me 
to be a co-sponsor of that.
    Just another question going in a different direction, as 
far as the study that you said the VA wasn't in support of H.R. 
712. Now, you had mentioned that one of the reasons was that 
there should be a smaller study first. But you know, this is a 
crisis situation. A lot of these veterans are using this to--
because of chronic pain to deal with PTSD. You know, why not do 
the big study first, to go out there and to do this to kind of 
find the problem and do the research that needs to be done so 
that we can get to that point to where hopefully the VA can one 
day can start prescribing cannabis to help treat these 
conditions that our veterans are dealing with.
    Ms. Franklin. Yeah, there are a number of study protocols 
when you are designing a research study and just a number of 
processes and reviews when you are looking for evidence and 
typically you have got to be safe, and do no harm, and start 
small, and grow evidence over time. But certainly we can work 
with the best academics in this space and make sure that we are 
designing it at the right size that both gets after the 
evidence that you are after and protects human subjects at the 
same time, without a doubt.
    Mr. Cisneros. Yeah, no. Like I said, I think we are in a 
situation right now where we can't be taking baby steps. We 
have got to start running to get there. And if it takes a 
bigger study to help us do that, then that is what we need to 
do. So I am also very supportive of H.R. 712. But I yield back 
my time. I just want to thank you very much for being here 
today. Thank you.
    Ms. Brownley. Thank you, Mr. Cisneros. Next is Mr. Steube.
    Mr. Steube. Thank you, Madam Chair. First, I just want to 
thank you for bringing up H.R. 2191, Veterans Cannabis Use for 
Safe Healing Act. I represent Florida and Florida recently has 
gone through a medicinal marijuana ballot initiative. There 
was--I was actually involved in the state legislature where 
there was legislation and then it became a ballot initiative. 
And I will say, Dr. Franklin, you had stated that the VA is not 
denying benefits to veterans. That is not what I am hearing 
from people in Florida.
    Just Google my district and I just went on a local 
newspaper and there is like 10 different articles, interviews 
on local stations. So at the very least, I think there is an 
incredible amount of confusion as to whether veterans who have 
gotten a--the way it works in Florida is you have to get a 
prescription by two independent physicians to then get 
medicinal cannabis. And I think there is definitely some 
confusion, and I have heard from veterans directly who have 
said they have been denied benefits from the VA because they 
have tested positive for marijuana and THC.
    So I think--that is why I did the bill, because at least in 
Florida, I have seen some real challenges in Florida as the 
application of state medicinal cannabis bills and veterans who 
are using VA benefits. So I think it is important that the law 
is clear. You said that there is a directive. The 
Administrative Directive 1315, but isn't it true if a new 
administration came along, or a new secretary came along, can't 
a directive change or be cancelled out?
    Ms. Franklin. Typically, at the bottom of the directive, 
they will have a statement that says something like, and this 
is generally. I haven't looked at this exact one. But it will 
say, ``This remains in effect until,'' and it will have a date 
and time, or it will say, ``Upon the change of leadership, this 
must be updated.'' So without seeing it, although it sounds--it 
looks like maybe Dr. Mole might have a copy of it, but I hear 
your underlying message, which is confusion and need to do 
proper education and outreach to veterans and communities 
across the Nation on what the parameters are and making sure 
folks know about this policy and that it is not taken in a 
negative way for veterans.
    Mr. Steube. Well, but you guys are stating that you are 
against the bill that we are working on that would codify this. 
And that is my question in saying can't directives change? I 
mean, if a new secretary comes in and changes this specific 
directive that allows veterans to utilize medicinal cannabis, 
if we have a law in place that says legally under the 10th 
amendment to the Constitution and the Federal government has 
recognized that if states have legalize medicinal cannabis, 
that the VA shall not deny veterans benefits. I think that 
would go a long way to assuring that there isn't confusion 
within states that have authorized medicinal cannabis.
    So I understand from the DEA perspective why you are 
against part of the bill, but you have a directive that 
basically states what we are trying to make law. And so that it 
is not confusion to people in states that have legalized it.
    So I mean, I would be happy to work with the VA on this 
issue. I am very passionate about this issue because it is a 
big issue for Floridians. I didn't even vote for the ballot 
initiative that passed, but it has passed. And I believe under 
the 10th amendment of the Constitution, that is the law in 
Florida and veterans should not be denied benefits that they 
are due and owed for their service to our country just because 
they now have a prescription for medicinal cannabis.
    I think it needs to be very, very clear that that is not 
going to happen to them.
    Mr. Mole. Yeah. And I think we will take this back. And we 
are happy to work with you and others on that language.
    Mr. Steube. And if there is other--you had mentioned 
several things on that specific bill that I am working on that 
you have issues with, but I am happy to work with you moving 
forward. I think this is--it is certainly an important issue to 
a state like Florida that has--and it is new in Florida. This 
has only been around a couple of years. So they are going kind 
of through their legal growing pains as well. But I think it is 
important that our veteran community in states that have 
authorized it, those veterans know that they are not going to--
and if you Google what I told you to Google and you watch some 
of the interviews, veterans are actually afraid to go to the VA 
to use services that they are accredited to do because if they 
test positive for THC or marijuana, they are afraid that they 
are going to lose their benefits.
    So it is certainly--like there definitely needs to be some 
messaging to the veterans in states like Florida that you are 
not going to lose your benefits if you legally are using a 
state sanctioned medicinal cannabis act. So thank you. And that 
is--I would be happy to work with you on that.
    Ms. Franklin. Appreciate it.
    Mr. Steube. I will yield back the balance of my time.
    Ms. Brownley. Thank you, Mr. Steube. Mr. Rose, 5 minutes.
    Mr. Rose. Thank you, Madam Chairwoman. I just wanted to 
address something quickly with the VA to clear up some 
confusion. We have heard concerns regarding potential HIPAA 
violations in regards to the bill. I, along with several others 
on this Committee, are introducing FIGHT Veteran Suicide Act, 
requiring the VA to notify Congress of certain information 
regarding veterans that died by suicide on VA campuses. 
Particularly, it asked for the enrollment status of the veteran 
with respect to the patient enrollment system of the 
department.
    The most recent encounter between the veteran and the--of 
Veterans Health Administration whether the veteran had private 
medical insurance, the armed force, and time period in which 
the veteran served, the age, employment, marital status, 
housing status to the veteran, and confirmation to the 
secretary of Veterans Affairs has provided notice to the 
immediate family members.
    To your knowledge, does the requested notification require 
the release of any protected health information and is thus 
subject to HIPAA protection?
    Ms. Franklin. I would need to put that through a full HIPAA 
review with our attorneys. I don't have the law memorized and I 
am not sure. But I will tell you that one of the things that is 
concerning that we are trying to balance, although you heard in 
my testimony that we absolutely approve--we recommend and we 
give this a thumb's up in terms of full support for this report 
to Congress, is just making sure that we are careful around 
notifying people in general about suicides that occur in 
districts, perhaps, where there is just a very small number. 
And if that got released out to the media in a way that were 
reported and a mother, or grandmother, or wife of a veteran 
that ended his or her life by suicide saw that swirl out in the 
media in a negative way that impacted their family.
    So it is just a matter of observing the dignity there. But 
in terms of HIPAA, we can run it through the HIPAA legal review 
and tell you what the outcome is.
    Mr. Rose. But you are not seeing any glaring red flags 
right now? Or else--I mean, the VA just endorsed the bill. You 
would--
    Ms. Franklin. So likely the attorneys looked at the--
    Mr. Rose. Sure.
    Ms. Franklin. Looking at it from a social science 
perspective, I don't.
    Mr. Rose. Okay. All right. No, that is very helpful. I 
have--I just wanted to really ask you all a quick question. 
Speaking to the VA folks last night, raised certain facts and 
figures that show that multiple deployments that are packed 
together with minimum dwell time, as well as minimum training 
time prior to an initial deployment, then a second deployment, 
do substantially increase the risk of suicide. Have you seen 
these stats bear out amongst your membership?
    Ms. Mullen. The short answer is absolutely. You can see 
from our members that 75 percent have served in Iraq, 39 
percent have served in Afghanistan. Quick math shows you that 
is more than 100 percent. And we know--we ask about deployments 
as well. And most do at least one OIF and at least one OEF.
    Mr. Rose. Sure.
    Ms. Mullen. So we deal with a population that has multiple 
deployments, most of which are while they are doing Guard or 
Reserve duty, which was another topic of conversation and 
something that IAVA is concerned about, especially when we are 
talking about the suicide rates when it comes to Guard and 
Reservists.
    Mr. Rose. No, absolutely. No, look, as a Guardsman 
presently, as a vet who has too many friends who deployed five, 
six, seven times, I think it is our responsibility as well to 
make recommendations to the DoD as to what is responsible and 
what is not. And so we are here today considering veterans' 
suicide. We are here today considering overall veterans' 
health; all present servicemembers are future veterans.
    So what, if any, specifically, recommendations would you 
make to the DoD, as you are concerned about Iraq and 
Afghanistan veterans as to dwell time, as to op tempo, as to 
minimum training prior to deployment?
    Ms. Mullen. That is a great question. When it comes to 
specific timelines, IAVA does not have specific recommendations 
to that, but we do hold very high the health and well-being of 
servicemembers and their families. Coming into that is not only 
the health of the servicemember, but the experiences 
transitioning back from deployments, moves within military 
families, how many moves they are doing, the impact on their 
children and wives, spouses, husbands, whatever it may be.
    So of upmost concern, but I don't have specific 
recommendations for the--
    Mr. Rose. And do you think in your estimation the VA should 
be in the business of making recommendations to the DoD about 
op tempo and dwell time?
    Ms. Mullen. I would say I don't have the background to make 
that recommendation. I know that VA is doing a lot to support 
transitioning servicemembers, especially in their last 18 
months and as they transition out. I think that is a key 
timeframe where VA should be engaging with servicemembers as 
they are going through the TAP program, and ensuring that they 
are making a smooth transition. Especially because we know that 
is a height in time for suicidality among that age group and 
among that transition service--
    Mr. Rose. Yeah. And look, I am just going to close out with 
this, though. The message I got from the VA yesterday, and we 
all did, was that there are certain things out of their 
control. There are certain things out of their control, one of 
which is op tempo, one of which is the intensity of modern-day 
combat.
    And what I still do not yet understand if there are certain 
things out of the VA's control, why would the VA then not make 
recommendations to the entity unto which that is under their 
purview?
    Ms. Franklin. Look, I will share with you that I worked for 
the DoD and have only come over to the VA in the last year. And 
we can and will make recommendations to everybody and anybody 
in this enterprise when it comes to saving lives. And so 
whether or not DoD will embrace those recommendations is likely 
to be determined. But when you are talking about dwell time, 
there is not only the issue of multiple deployments, but it is 
also the issue of length of deployment. And so--
    Mr. Rose. Totally agree.
    Ms. Franklin [continued]. --there are some studies that 
show that troops can deploy out 3 months, 7 or 8 times and be 
fine, and then there are other studies that show they will 
deploy out 1 time for 18 months, and that particular type of 
combat and/or deployment will crush them for months to come.
    And particularly when it applies to coming in and out of 
roles with regard to being a spouse and a parent. And so all of 
that is quite complicated. And to the extent that that has been 
studied or can be looked at longitudinally, and we can give 
those recommendations to the DA--the DoD, I am sorry, we can 
and will.
    Mr. Rose. So, you know, as I think of my friends who have 
done 15-month deployments, and I never did, but that is two 
Christmases, two birthdays, two anniversaries.
    Ms. Franklin. Yes, sir. Yes, sir. I--
    Mr. Rose. You know, you deploy when your kid is 6 months 
old for 15 months, you come back and your child doesn't 
recognize you, doesn't know who you are.
    Ms. Franklin. Yes.
    Mr. Rose. So what I am hearing is that you are now--the VA 
is comfortable making recommendations to the DoD as to what is 
acceptable or non-risky op tempo, and what are the types of op 
tempos and the lengths of deployments that do present 
potentially undue risk for future suicide?
    Ms. Franklin. We will tell them what we are learning about 
suicide, up, down, and all around. What we won't do is get into 
the business of war fighting with them.
    Mr. Rose. Of course. And no one--
    Ms. Franklin. Very well.
    Mr. Rose. I mean, I understand that. I wouldn't want you in 
that business.
    Ms. Franklin. Yes.
    Mr. Rose. But I do want you--
    Ms. Brownley. Mr. Rose, your line of questioning is very 
good, but your time has--
    Mr. Rose. Understood. Thank you.
    Ms. Brownley. Yes.
    Ms. Franklin. Thank you.
    Mr. Barr. Thank you, Madam Chairwoman, and I agree, great 
line of questioning there. So I was enjoying listening to the 
dialogue.
    Let me shift gears, Dr. Franklin and Dr. Gaudet. Earlier 
this year, Dr. Stone with the VA--stated that the VA had 60 
active equine programs across the VA system and concurred that 
they are very effective in benefitting veterans.
    Last night, we heard from the National Institute of Mental 
Health, similarly that equine assisted therapy programs have 
some benefits in terms of mindfulness and other benefits, 
especially for returning veterans who are struggling with post-
traumatic stress and other issues.
    I was very encouraged by Dr. Stone's statement that the VA 
is actively looking to expand equine assisted therapy, as well 
as all of the VA's adaptive sports programs. Is equine assisted 
therapy included in the services offered through the VA's whole 
health initiative?
    Dr. Gaudet. I can probably take that. Thank you. The 
concept of the whole health initiative is a broad umbrella. So 
while technically that doesn't fall under my office really 
doesn't matter for this conversation. What matters is that the 
concept of supporting people's health and well-being and 
resilience through any means that is of effect and benefit for 
that veteran is a part of that approach.
    Mr. Barr. Well, this is Kentucky Derby week and horses are 
on my mind as a Kentuckian.
    Dr. Gaudet. Yes, of course.
    Mr. Barr. But I can tell you on a more serious note that 
throughout the calendar year, I have witnessed some really 
transformational things, positive things happened with veteran 
constituents of mine who have the benefit of access to equine 
assisted therapy that may not exist in places outside of 
Kentucky, for example, and I encourage you to look at that.
    In legislation offered by my colleague, Mr. Lamb, there is 
a provision that allows the VA to report on the accessibility 
and availability of any other service the secretary determines 
appropriate. If passed, Dr. Franklin, would you be willing to 
include equine assisted therapy as part of this report?
    Ms. Franklin. Yes, sir.
    Mr. Barr. Thank you. Let me shift gears to some of the 
cannabis related legislation on the docket here today. Back to 
you, Dr. Franklin and Dr. Gaudet. As you may know, the 2008 
Pharm Bill took steps to deschedule industrial hemp derived CBD 
products. And a lot of people don't fully appreciate the 
distinction that was made in the Pharm bill related to low THC 
CBD cannabis versus the high THC marijuana that remains 
prohibited under Federal law.
    Given the passage of this legislation, has the VA, given 
some concerns about the existing marijuana legislation on the 
docket today, has the VA changed their approach into 
researching CBD--low THC CBD treatments for veterans?
    Ms. Franklin. I will defer to Dr. Mole.
    Mr. Mole. I am not sure if that bill would have shifted 
people, but I think clearly investigators are interested in CBD 
oils. They are interested in low THC or no THC if that is 
possible. So I know that work is ongoing and there is 
investigators interested in working on those types of products.
    The Pharm bill, I was having to run through some papers 
because we had some struggles with how to interpret the Pharm 
bill versus a schedule one substance. And so--
    Mr. Barr. Well, if I could, to the extent the VA has 
concerns about the psychoactive impact and some of the studies 
relating to schizophrenia with marijuana, let me assure you 
that hemp with low THC doesn't present those potential risks, 
whereas CBD, which is now legal under Federal law, may present 
an opportunity for the VA to take those incremental steps that 
you all were talking about in your testimony before. And the 
Pharm bill, just for informational purposes does authorize the 
FDA and USDA to complete regulations. Those are ongoing. And 
once that is completed, I would encourage the VA to look at CBD 
as an initial step on this road to cannabis as a potential 
medicinal opportunity.
    Mr. Mole. So just very quickly, I don't want to use your 
time. So what Dr. Franklin said earlier in the testimony was 
that our current study under way in San Diego is using CBD.
    Mr. Barr. Okay. Great. Thank you very much. And finally 
just to the VSOs, Ms. Mullen, Mr. Fuentes, and Ms. Ilem, have 
you all had an opportunity to play a role in suicide prevention 
to the extent that I know your organizations can we--we know 
from the testimony last night that there are too many veterans 
who are committing suicide are not accessing, at least 
recently, the VHA system.
    Are you all--do you feel like you all are able to reach 
those veterans?
    Ms. Ilem. I would say for DAV, we just did--recently did 
a--had VA come over and do a save program with us, training, 
making sure that our headquarters staff understands how 
everybody can participate in suicide prevention.
    And then we also included that now in our training for our 
national service officers, who are located throughout the 
country and see veterans every day, assisting them with their 
claims. So we know and subscribe to VA's premise that suicide 
is everyone's business. We all have to play our part. We have 
to include this information in our magazines, our brochures, we 
have to talk to veterans, make sure that we are all taking care 
to watch out for each other.
    So I think, you know, we are doing what we can as an 
organization to spread that.
    Mr. Fuentes. Same thing for the VFW. We have one of those 
unofficial MOUs with VA. Part of our mental wellness campaign 
to essentially help veterans, and their caregivers and family 
members, the community identify the five signs. Emotional 
distress is a partnership with given our Elizabeth Dole 
Foundation and Walgreens as well to bring people into our 6,500 
posts around the world, and train them, part of the day--so we 
are going it. We are going to continue doing. And VA is being a 
good partner.
    Ms. Mullen. Yeah, from IAVA's perspective, we operate a bit 
differently than the legacy VSOs over here and we build online 
communities to engage our members in suicide prevention and 
mental health care. And we do that effectively and efficiently.
    I will also say that our rapid response referral program 
has an MOU with the VA as well. They are master's level social 
workers that work one on one with veterans to do warm hand-
offs. So when a veteran calls our rapid response referral 
program in crisis, they are able to connect them to the VCL 
immediately. Last year we had over 100 saves through that 
program.
    So it is an amazing program. We also have about 25 percent 
of our members that don't access VA health care. They do 
private health insurance only. So I can tell you that the VA 
members, the IAVA members are definitely outside the VA program 
and we are connecting with them with suicide prevention and 
mental health care.
    Mr. Barr. Thank you. I yield back.
    Ms. Brownley. Thank you, Mr. Barr. And last but not least, 
Mr. Brindisi.
    Mr. Brindisi. Thank you, Madam Chair. Sorry for being late. 
Juggling a couple different Committees today, but thank you for 
allowing me to be here and giving me an opportunity to ask a 
few questions about our bill, H.R. 233, the Support of Suicide 
Prevention Coordinators Act.
    And I just want to ask just a couple brief questions 
because I think that coordinators are really the face of the 
VA's efforts to address the veteran's suicide epidemic and many 
report being overworked or unable to keep up with some of their 
responsibilities.
    So essentially what this act would do is give our 
prevention coordinators the resources they need to be able to 
do an effective job. And specifically, the bill would require 
the comptroller general to conduct an assessment of the 
responsibilities, workload, and vacancy rates of the Department 
of Veterans Affairs suicide prevention coordinators and submit 
it to Congress within one year.
    So I know that the VA hasn't taken an official position on 
the bill, but I assume that you would welcome an outside 
assessment by the comptroller general to conduct an assessment 
and report back to Congress.
    Ms. Franklin. Yes. And I also shared with the Committee 
earlier that we have an assessment well underway where we are 
looking not only at just the role of the suicide prevention 
coordinators, but more broadly in the role of other 
capabilities that we might need to bring to the table. As part 
of our new strategy, we are trying to work with veterans and 
get after suicide where they work, live, and thrive, which is 
outside of our four walls.
    The role of the SPCs has largely been focused on clinical 
work with very limited outreach events, five a month. And so we 
are not only looking at their role, but we have a study 
underway and an analysis where we are looking at other 
capabilities as well that might need to get brought to the 
table.
    Mr. Brindisi. Can you talk a little bit about, because I 
represent a very rural district, some of the outreach efforts 
that are being done in more rural areas where you may not be 
close to a CBOC or a hospital, and where public transportation 
options are pretty poor; how do you conduct outreach in those 
areas?
    Ms. Franklin. Yeah, it is a difficult issue, just as you 
describe. And we try to tackle it through a multi-pronged 
approach, whether that is our SPCs, which that alone would not 
solve it because as you describe, it is rural, and they have to 
go long and far to get across the span. Using online technology 
helps, but again alone will not solve it because not all of 
these areas have broadband and the width to do it. And then we 
have our mobile vet centers that will go out. I don't know if 
you have ever interacted with his capability, but it is 
actually like a vet center on wheels, if you will, and they 
will go out to rural areas. We are trying to target when and 
where to place them.
    And we have a movement underway that allows for that to 
happen. So that is the third. And then the fourth is we are 
using partners. And so while we may not be able to outreach and 
get after this issue with every single person ourselves, we are 
trying to have our partners help serve as force multipliers and 
help us with this outreach as well. So when there are local 
entities and community-based folks, that--people that live in 
rural America know well and trust well, and they are equipped 
with the signs and symptoms of risk, and they can carry VA's 
message and help us in a coordinated fashion. I think that adds 
to it.
    But it is a difficult phenomenon that we have to continue 
to work on in rural America.
    Mr. Brindisi. Okay. Well, I am always willing to work with 
you guys on that, representing a very large rural district. And 
we know that access to health care is very hard to come by, 
especially for our veterans in those communities. So any 
initiatives that you would like to partner on, I am always 
willing to work on that.
    Just one last question. I know in your testimony, it says 
that the VA's mental health hiring initiative is active and is 
addressing current hiring plans. What is the timeline? And I 
know that also it said that the suicide prevention coordinator 
program guidebook and suicide prevention program directive are 
currently in development; what is the timeline on those 
initiatives?
    Ms. Franklin. Yes. For the mental health hiring initiative, 
we had a goal of June 2019 to hire over 1,000 mental health 
providers and we have exceeded that goal. I believe it is at 
1,065. We still--we do still have some shortcomings in the area 
of suicide prevention--coordinators, I am sorry.
    Mr. Brindisi. Yeah.
    Ms. Franklin. We did an analysis of that job bucket and we 
determined that we needed an additional 386, of which we have 
hired a good number and we have 244 remaining of that analysis 
in order to get even with that--with the Board with that 
community. So June '19 to answer your specific question on the 
date.
    I do not have the timeline for the directive and the 
suicide prevention guidebook, which will really be the force 
function for working with the suicide prevention coordinators 
on how to do their day to day jobs, an increased layer of 
accountability, if you will, from the VACO office and the local 
SPC. But I committed to one of the Congresswomen earlier this 
morning that I would bring those dates. And as soon as I get 
back to the office, I will pull it. I just hesitate to give one 
that might be off.
    Mr. Brindisi. Absolutely. If you could share that with us 
down the road--
    Ms. Franklin. Will do.
    Mr. Brindisi [continued]. --we would certainly appreciate 
that.
    Ms. Franklin. Yes.
    Mr. Brindisi. I yield back my time.
    Ms. Brownley. Thank you very much. And I think that ends 
our hearing, but before closing, I wanted to make a couple of 
points and really just two. And one is around the topic of 
suicide prevention and we have several bills here today that 
address suicide prevention and I just encourage the VA, the 
VSOs, the author of the bills to try to work together to make 
these bills work because I think their intention, and I think 
most everybody agrees that their intention is good and making 
sure that we can succeed in that.
    And I think, obviously, with suicide prevention, we still 
have a lot more to do. And last night's hearing was good. This 
one has been good. And I am sure we will have more hearings on 
it.
    And the second piece is around the cannabis piece too, and 
trying to make that work. And I will say I have heard from my 
constituents and my veterans as well this issue of fear of 
testing positively and being worried that their benefits will 
be taken away from them. And I remember a couple of years ago, 
we had a family come in to testify whose son had committed 
suicide. And he committed suicide and he left a suicide note. 
And he basically said he was trapped in his body, that he had 
been so medicated and trapped in his body that just life wasn't 
worth living anymore.
    And so I do think this cannabis issue and proceeding with 
it, and this relationship to suicide prevention, there is a 
nexus here, and I think we just have to really be committed to 
the cannabis issue and to the suicide issue, but where this 
nexus is. And so those are the two points and my two take-aways 
from the Committee. And again, I just wanted to reiterate this 
Committee hearing. The Members and witnesses went over a little 
bit in their time, which I allowed. I want to keep the 
conversation as free flowing as I possibly can.
    Other hearings, I might have to call it, this one, we 
seemed to have the time to be able to do it. So I think it was 
a good hearing and again I thank the witnesses for being here. 
And Mr. Barr, if you have any closing comments, the time is 
yours.
    Mr. Barr. Just again, thank you to our witnesses. Thank you 
for your service for addressing these very important issues. We 
have got to get this veteran suicide issued under control. 
Twenty a day is unconscionable, it is intolerable, and I 
appreciate everyone here, both on this side of the desk and 
also at the table for working with us to tackle this very 
important problem. And Madam Chairwoman, thank you for your 
commitment to that issue as well. I yield back.
    Ms. Brownley. Thank you, Mr. Barr. And with that, all 
Members will have 5 legislative days to revise and extend their 
remarks and include extraneous materials. And without 
objection, this Subcommittee stands adjourned. Thank you.

    [Whereupon, at 11:49 a.m., the Subcommittee was adjourned.]


                            A P P E N D I X

                              ----------                              

        Prepared Statement of Congressman J. Luis Correa (CA-46)
    Chairwoman Brownley and Ranking Member Dunn, thank you for the 
invitation to appear before you today. I appreciate the opportunity to 
testify about my bipartisan legislation, H.R. 712, the ``VA Medicinal 
Cannabis Research Act.''
    As you know, veterans experience physical and psychological 
injuries at higher rates than their civilian counterparts as a result 
of their military service to our country. Unfortunately, the current 
clinical treatment of prescription opioids to address post-traumatic 
stress disorder (PTSD) and chronic pain have at times been ineffective 
or at worst had dangerous results such as addiction or death. In 
response to the opioids crisis, Congress, the VA, and veterans service 
organizations nationwide correctly focused their attention on reducing 
opioids addiction and overdoses. As twenty veterans tragically die from 
suicide each day, we, as policymakers, should consider alternatives to 
the treatment of PTSD and chronic pain.
    One alternative treatment that has been discussed by veterans that 
I have met in my congressional district and cited by nationwide surveys 
commissioned by the American Legion and Iraq and Afghanistan Veterans 
of America (I-A-V-A) is the therapeutic benefits of medical cannabis to 
manage chronic pain and other health ailments. According to the Legion, 
92 percent of veteran households surveyed supported medical cannabis 
research while an estimated twenty-two percent of veterans reported the 
use of medical cannabis to treat a mental or physical condition. 
Similarly, the I-A-V-A survey demonstrated that over 80 percent of 
their membership supported the legalization of medical cannabis.
    Therefore, with my colleague and friend Congressman Clay Higgins, I 
introduced the bipartisan VA Medicinal Cannabis Research Act to promote 
understanding of the safety and effectiveness of medical cannabis use 
by veterans diagnosed with post-traumatic stress disorder (PTSD) and 
chronic pain. This bill requires VA to conduct a double-blind clinical 
trial on the impact of different forms and delivery methods of cannabis 
on specific health conditions of eligible veterans with PTSD and 
chronic pain.
    With twenty-two percent of veterans currently using cannabis for 
medicinal purposes, it is important that doctors be able to fully 
advise veterans on the potential impacts and benefits of medical 
cannabis use on post-traumatic stress disorder (PTSD) and chronic pain. 
Research into medical cannabis is necessary and supported by the 
veteran community.
    I want to thank Disabled American Veterans, Veterans of Foreign 
Wars, Iraq and Afghanistan Veterans of America, and the many other 
veterans and medical groups for their support of the bill.
    Thank you again for inviting me to testify about H.R. 712, the VA 
Medicinal Cannabis Research Act. This legislation is a pragmatic and 
sensible approach for research on medical cannabis that will hopefully 
result in safe, alternative treatments for our veterans and reduce the 
number of veterans suicides.
    We owe this to our veterans who were willing to make the ultimate 
sacrifice for our Nation's freedom. I look forward to working with you 
all to move this bill forward and am happy to answer any questions you 
may have.

                                 
           Prepared Statement of Conor Lamb Vice Chair, HVAC
Whole Veteran Testimony:

    Madam Chairwoman, I know you and everyone in this room shares my 
deep concern regarding the high rate of veteran suicide across the 
country.
    It is essential that we make all necessary tools available to 
veterans as they face their individual mental health challenges.
    Instead of concentrating on an isolated condition, Whole Health 
programs and treatments focus on the whole veteran.
    Physical, emotional, and mental health are all interconnected, and 
the VA has the important responsibility of supporting veterans in 
achieving their highest overall well-being.
    VA's Whole Health Program is integral to VA's suicide prevention 
efforts, yet these services are not available at every facility leaving 
many veterans wanting.
    The Whole Veteran Act requires the VA to provide Congress with 
information regarding the accessibility and availability of components 
of Whole Health programs.
    By identifying the current gaps in availability, the VA can take 
the adequate steps to improve the mental health and well-being of all 
our veterans no matter where they live.
    Thank you and I yield back.

                                 
                Prepared Statement of Dr. Keita Franklin
    Good morning, Chairwoman Brownley, Ranking Member Dunn, and Members 
of the Subcommittee. Thank you for inviting us here today to present 
our views on several bills that would affect VA health programs and 
services. With me today are Dr. Tracy Gaudet, Director, Office of 
Patient Centered Care, Veterans Health Administration, and Dr. Larry 
Mole, Chief Consultant, Population Health, Veterans Health 
Administration.
    We are providing views on H.R. 100, H.R. 712, H.R. 1647, H.R. 2191, 
and four draft bills relating to Suicide Prevention and Mental Health 
Memoranda between VA and non-VA entities, VA Suicide Prevention 
Coordinators, Congressional notifications of Veteran suicides and 
attempts, and a report on VA's Whole Health Transformation.

H.R. 100 - Veteran Overmedication and Suicide Prevention Act of 2019

    H.R. 100 would direct VA to seek to enter into an agreement with 
the National Academies of Sciences, Engineering, and Medicine (NASEM) 
to conduct an independent review of the deaths by suicide of certain 
covered Veterans during the previous 5 years, regardless of whether 
such deaths have been reported by the Centers for Disease Control and 
Prevention (CDC).
    The review would include the following:

      a description of and the total number of Veterans who 
died by suicide, violent death, and accidental death;
      a comprehensive list of prescribed medications and legal 
and illegal substances as annotated on toxicology reports of these 
Veterans;
      a summary of medical diagnoses by agency physicians or 
through programs of the agency that led to the prescribing of 
medications in the comprehensive list in cases of posttraumatic stress 
disorder (PTSD), traumatic brain injury, military sexual trauma, and 
other anxiety and depressive disorders;
      the number of instances in which one of these Veterans 
was concurrently on multiple medications to treat these disorders;
      the number of these Veterans who were not taking any 
medication prescribed by VA or through a VA program;
      the percentage of these Veterans who received a non-
medication first-line treatment compared to the percentage who received 
medication only;
      the number of instances in which a non-medication first-
line treatment was attempted and determined ineffective, which then led 
to prescribing a medication;
      a description and example of how VA determines and 
updates the clinical guidelines governing medication prescribing;
      an analysis of VA's use of pain scores during clinical 
encounters and an evaluation of the relationship between the use of 
such measurements and the number of Veterans on multiple medications;
      a description of VA efforts to maintain mental health 
professional staffing levels;
      the percentage of Veterans with combat experience or 
trauma related to combat;
      identification of VA medical facilities with markedly 
high prescription rates and suicide rates;
      an analysis of collaboration by VA programs with state 
Medicaid agencies and the Centers for Medicare and Medicaid Services;
      an analysis of the collaboration between VA medical 
centers (VAMC) with medical examiners' offices or local jurisdictions 
to determine Veteran mortality and cause of death;
      an identification and determination of a best practice 
model to collect and share death certificate data;
      a description of how data relating to death certificates 
of Veterans is collected, determined, and reported by VA;
      an assessment of any apparent patterns; and
      recommendations for further action to improve the safety 
and well-being of Veterans.

    Not later than 180 days after entering into the agreement, NASEM 
will complete its review and provide a report to the Secretary 
containing the results of the review. Not later than 30 days after 
completion of NASEM's review, the Secretary will submit to the 
Committees on Veterans' Affairs of the House of Representatives and 
Senate a report on the results of the review, which will also be 
publicly available.
    VA does not support this proposed legislation. This bill would be 
redundant because of the current work occurring with NASEM. The Joint 
Explanatory Statement for the Consolidated Appropriations Act of 2018 
stated that VA's appropriations included $500,000 for NASEM to assess 
the potential overmedication of Veterans during Fiscal Years (FY) 2010 
to 2017 that led to suicides, deaths, mental disorders, and combat-
related traumas. This protocol can be easily augmented to examine 
additional psychotropic medications as needed before the study is 
funded for implementation without additional legislation. In addition, 
hiring and workforce management for mental health professionals is 
currently ongoing and being tracked and is easily reportable without 
legislative action.
    Section 2(a)(1) would require that NASEM use data that would likely 
provide misleading results. VA becomes aware of most suicide deaths 
through data obtained from the National Death Index established by 
CDC's National Center for Health Statistics. However, these data are 
available only after a delay, so the most recent information on 
individuals dying from suicide would not be available within the bill's 
required timeframe. CDC data provides the most comprehensive source for 
determining Veterans' causes of death; utilizing other sources would 
result in incomplete identification of covered Veterans who died from 
suicide. Therefore, requesting a review of deaths by suicide regardless 
of whether these deaths have been reported to CDC, as required by 
section 2(a)(1), could lead to inaccurate or misleading data results.
    Much of the data required to be collected under section 2(a)(2) 
would be difficult to obtain and accurately interpret. Physicians are 
not the only providers who prescribe medications, toxicology reports 
may not always be done following death by suicide, and obtaining 
complete and accurate information about what is (or is not) taken by 
the patient outside VA would be challenging.
    Section 2(a)(3) discusses the compilation of data, and to the 
extent that any of these data could be re-identified to a specific 
Veteran, then an analysis of the Health Insurance Portability and 
Accountability Act (HIPAA) Privacy Act and any other applicable laws or 
regulations meant to protect personal health information would be 
required.
    Finally, the deadline for completion and review of the report in 
section 2(a)(4) is unrealistic. It does not seem possible to provide 
the sheer volume of data the bill demands and have NASEM analyze it 
within 180 days, particularly given that probably hundreds of different 
offices at the local and state levels would have to be contacted to 
provide certain information. Requiring VA's response within 30 days of 
NASEM's findings could also limit our ability to thoughtfully and 
carefully review the evidence they present, which could limit the 
utility of this information.

H.R. 712 - VA Medical Cannabis Research Act 2019

    H.R. 712 would require VA conduct a clinical trial of a size and 
scope to include multiple strains of cannabis and multiple routes of 
administration and to collect, analyze, and report data on covered 
Veterans with multiple medical diagnoses and a multitude of clinical 
outcome measures.
    VA has a rich history of scientifically driven contributions that 
have advanced health care through planning and implementing high 
quality clinical trials so that we can all better understand the 
results and potential for changing clinical practice when trials are 
complete. VA's Office of Research and Development has a program in 
place to fund clinical trials that are submitted to our expert peer 
review system for evaluation of scientific merit based upon the 
rationale, design, and feasibility of a proposal. Such trials could 
include the topic of medical uses of cannabis for conditions that 
impact Veterans. Clinical trial applications must detail the underlying 
rationale for the use of an experimental intervention such as cannabis 
for use in humans.
    The proposed legislation with the mandated requirements is not 
consistent with the practice of scientific design for randomized 
clinical trials nor is it possible to conduct a single trial to obtain 
the information desired. The specification in the legislation of the 
multiple requirements such as type and content, administration route, 
diagnostic specifications representing potential inclusion and 
exclusion criteria, and outcome measures are not consistent with the 
current state of scientific evidence, which suggests that smaller, 
early phase controlled clinical trials with a focused set of specific 
aims are warranted to determine initial proof of concept for medical 
marijuana for a specific condition. Any trial with human subjects must 
include evaluation of risks and benefits/safety and include the 
smallest number of participants needed to avoid putting subjects at 
risk unnecessarily. In any study, the size of the experimental 
population is determined statistically so that the power or ability to 
detect group differences (between control and experimental groups) is 
based on known effects that can be shown using a specific outcome 
measure. For a cannabis trial, some of these effects are not known, 
thus a circumscribed approach to determine dose, administration 
modality, and best outcome measure(s) must still be studied or shown in 
a proof of concept approach to ensure the research would have the 
ability to detect the impact of the intervention in a controlled way. 
Typically, smaller early phase trial designs, instead of the extremely 
large study suggested in legislation, would be used to advance our 
knowledge of benefits and risks regarding cannabis before moving to the 
type of more expansive approach described in this proposed legislation, 
which is more akin to a program of research than a single clinical 
trial. The requirements to simultaneously address different modes of 
administration, different compositions, and different medical diagnoses 
without consideration of underlying rationale and mechanisms would not 
be a good use of taxpayer money, and in fact would not engender a 
favorable scientific peer review evaluation or regulatory approval. A 
plan forward to determine the legislative mandate should start with a 
scientific query or review of what is known for diagnostic categories 
of interest and what is logically called for in exploring next level 
clinical investigation.
    VA is actively encouraging a logical pathway to contribute to the 
overall understanding of the possible contribution of cannabis and 
derivative compounds and products to Veterans' health care. VA is 
reviewing the current clinical evidence regarding use of marijuana for 
medical purposes, and has concluded more research is needed, especially 
related to clinical trials. VA is currently supporting a clinical trial 
of cannabidiol for PTSD based upon a strong design and rationalized 
mechanism in a trial that will assess risks and benefits. VA has also 
encouraged other research on possible medical uses for marijuana and 
compounds or products derived from it. For all these reasons, VA is not 
supportive of this proposed legislation.

H.R. 1647 - Veteran Equal Access Act

    This bill would require VA to authorize its physicians and other 
health care providers to provide recommendations and opinions to 
Veterans who are residents of states with state-approved marijuana 
programs regarding participation in such programs and to complete forms 
reflecting such recommendations and opinions.
    The Veterans Health Administration's (VHA) policy prohibiting VA 
providers from recommending or making referrals to or completing 
paperwork for Veteran participation in state marijuana programs is 
based on guidance provided to VA by the United States Drug Enforcement 
Administration (DEA), the agency with authority to interpret the 
Controlled Substances Act (CSA).
    Under CSA, marijuana is a schedule I controlled substance with a 
high potential for abuse and has no currently accepted medical use in 
treatment in the United States. DEA has advised VA there is no 
provision of CSA that would exempt from criminal sanctions a VA 
physician who acts with intent to provide a patient with the means to 
obtain marijuana, including by filling out forms for state marijuana 
programs. VA defers to the Department of Justice (DOJ) to determine the 
legal effect of the phrase ``notwithstanding any other provision of 
law'' on the enforcement of CSA against VA providers who might assist 
Veterans in participating in state-approved marijuana programs.
    VA encourages its providers to discuss marijuana use with Veterans 
who are participating in state-approved marijuana programs, but we do 
not support VA providers prescribing marijuana to Veterans and so do 
not support this bill. The clinical benefit of most products derived 
from the marijuana plant is still not proven scientifically, and VA 
must provide consistent, safe, science-based care for all Veterans. 
Further, the marijuana industry is largely unregulated, and products 
are often not accurately labeled, so providers cannot ascertain the 
strength and levels of active ingredients in the product being used by 
a particular patient, complicating medication management and treatment.

H.R. 2191 - Veterans Cannabis Use for Safe Healing Act (Veterans CUSH 
    Act)

    Section 2(a) of H.R. 2191 would prohibit VA from denying a Veteran 
a benefit under the laws administered by the Secretary because of their 
participation in a state-approved marijuana program. Section 2(b) would 
require the Secretary to ensure that VA providers discuss marijuana use 
with patients, adjust treatment plans accordingly, and record 
information about marijuana use in the patient's medical records. In 
addition, section 2(c) of the bill would authorize VA providers to 
furnish recommendations and opinions to Veterans who reside in states 
with state-approved marijuana programs regarding participation in such 
programs.
    VA does not support this bill. Sections 2(a) and 2(b) are 
unnecessary. VHA policy, VHA Directive 1315, Access to VHA Clinical 
Programs for Veterans Participating in State-Approved Marijuana 
Programs, is very clear that Veterans may not be denied VHA services 
solely because they are participating in state-approved marijuana 
programs. Veterans may continue to receive VHA benefits, and providers 
should discuss with patients how their use of state-approved medical 
marijuana to treat medical or psychiatric symptoms or conditions may 
affect other clinical decisions (e.g., discuss how marijuana use may 
impact other aspects of the overall care of the Veteran such as 
treatment for pain management, PTSD, or substance use disorder, or how 
it may interact with other medications the Veteran is taking). VA 
treatment plans may be modified based on marijuana use on a case-by-
case basis and in partnership with the Veteran.
    The content of Section 2(c) is the same as one of the requirements 
of H.R. 1647, discussed above. As noted in the previous discussion of 
that bill, VHA's policy prohibiting VA providers from recommending or 
making referrals to (or completing paperwork for) Veteran participation 
in state marijuana programs is based on guidance provided to VA by DEA, 
the agency charged with interpreting the CSA. Also, as noted, DEA has 
advised VA that the CSA contains no provision that would exempt a VA 
physician, who acts with intent to provide a patient with the means to 
obtain marijuana, including by filling out state marijuana program 
forms, from criminal sanctions, and VA would defer to DOJ on the 
enforcement of CSA against VA providers.
    If the intent of the bill is simply to authorize VA providers to 
discuss marijuana use with their patients, such clinical discussions 
are already allowed under VHA policy, as discussed above.

Draft ``GAO MOU and MOA'' Bill

    This bill would direct the Comptroller General of the United States 
to conduct an assessment of the effectiveness of all memoranda of 
understanding and memoranda of agreement entered into by the Under 
Secretary of Health and non-VA entities relating to (1) suicide 
prevention activities and outreach and (2) the provision and 
coordination of mental health services in the last 5 years.
    VA defers to the Comptroller General for views on this bill, as the 
bill relates to action to be taken by the Government Accountability 
Office and has no direct cost implications for VA. Although VA defers 
to the Comptroller General on this bill, we note our belief that the 
Congress already has the authority to request this information without 
legislation.

Draft GAO Suicide Prevention Bill

    This proposed legislation would direct the Comptroller General of 
the United States to conduct an assessment of the responsibilities, 
workload, and vacancy rates of VA suicide prevention coordinators.
    VA defers to the Comptroller General for views on this bill, as the 
bill relates to action to be taken by the Government Accountability 
Office and has no direct cost implications for VA. In any case, a new 
Suicide Prevention Coordinator (SPC) program guidebook and Suicide 
Prevention Program directive are currently in development, which will 
include guidance on responsibilities, workload, training, and staffing 
levels for SPCs. VA's Mental Health Hiring Initiative is active and 
addresses current hiring plans for, as well as retention of, SPCs.

Draft Suicide Notification Bill

    This bill would require VA to submit notification of a Veteran 
suicide death or suicide attempt that occurs in, or on the grounds of, 
a VA facility to the Committees on Veterans' Affairs of the House of 
Representatives and Senate and members of Congress representing the 
district of the facility, within 7 days of the event. Information is to 
be provided by VA within 60 days regarding the Veteran's VA enrollment 
status; military service period; marital, employment, and housing 
status; and confirmation that immediate family members have been 
provided notice of any VA support or assistance for which the family 
may be eligible.
    VA could support this legislation provided certain clarifying 
technical changes are made and provided that the Congress provides the 
necessary resources. We would be pleased to work with the Subcommittee 
on such changes. Also, it should be noted that section 2(B)(i) of the 
bill, which calls for providing the enrollment status of the Veteran 
for health care, might not satisfy the intent of this legislation's 
reporting requirement, since certain categories of Veterans and certain 
treatment authorities do not require Veterans to be enrolled.
    We estimate that enactment of this bill would result in costs of 
$507,000 for FY 2020, $2.739 million over the 5-year period from FY 
2020 through FY 2024, and $6.054 million over the 10-year period from 
FY 2020 through FY 2029.

Draft ``VA - Whole Health'' Bill

    This draft bill would require VA to submit to Congress within 180 
days after the date of enactment a report on the implementation of VA's 
memorandum, dated February 1, 2019, on the subject of Advancing Whole 
Health Transformation Across VHA (hereafter referred to as the 
``Memorandum''). Specifically, the report would need to include an 
analysis of the accessibility and availability of each of the following 
12 services with respect to the implementation of the Memorandum: (1) 
massage therapy; (2) chiropractic services; (3) whole health clinician 
services; (4) whole health coaching; (5) acupuncture; (6) healing 
touch; (7) whole health group services; (8) guided imagery; (9) 
meditation; (10) clinical hypnosis; (11) yoga; and (12) tai chi or qi 
gong. The report must also include the same analysis for any other 
service the Secretary determines appropriate.
    The Whole Health System includes three components: 1) Empower: The 
Pathway - in partnership with peers, empowers Veterans to explore 
mission, aspiration, and purpose and begin personal health planning. 2) 
Equip: Well-being Programs equip Veterans with self-care tools, skill-
building, and support. Services may include proactive Complementary and 
Integrative Health (CIH) approaches such as yoga, tai chi, or 
mindfulness. 3) Treat: Whole Health Clinical Care - in VA, the 
community, or both, clinicians are trained in Whole Health and 
incorporate CIH approaches based on the Veteran's personalized health 
plan. VA staff have been working with Veterans around the country to 
bring elements of this Whole Health approach to life. In conjunction 
with VA's implementation of section 933 of Public Law (P.L.) 114-198, 
the Comprehensive Addiction and Recovery Act of 2016, VA began 
implementation of the full Whole Health System at 18 flagship 
facilities in the beginning of FY 2018. This constituted the first wave 
of facilities to be included in the national deployment of VA's Whole 
Health System.
    Flagship facility implementation of the Whole Health System is 
proceeding over a 3-year period (FY 2018 - FY 2020) and is supported by 
a well-proven collaborative model which drives large scale 
organizational change. In addition to the implementation guide, 
flagship facilities are receiving education and training, resources and 
tools, and on-site support. These sites also have designated funding 
for the start-up costs needed. In addition, Veteran outcomes, Veteran 
satisfaction, cost, and utilization rates are being tracked as well as 
the impact, to the extent determinable, of the Whole Health approach on 
opioid safety, suicide prevention, and impact on the VHA workforce.
    More specifically, the Memorandum announces the launch of Whole 
Health Learning Collaborative 2: Driving Cultural Transformation and 
requests that each Veterans Integrated Service Network identify 2 sites 
to participate, for a total of 36 sites across VA (separate from the 18 
flagship facilities mentioned previously). This collaborative 
initiative will help further Whole Health delivery and innovation. The 
collaborative kick-off is scheduled for June 2019 with selection of 
sites currently underway. These 36 sites will then be supported through 
the subsequent 18 months as part of this Learning Collaborative 
process. At this time, specific start-up funding for the 36 sites has 
not been identified.
    It is unclear if the drafters intended to limit the mandated 
analysis and report requirement to the 36 sites participating in the 
Learning Collaborative (under the Memorandum.) In other words, the 
draft bill's incorporation of the Memorandum by specific reference 
could, in operation, limit us to the 36 sites participating in the 
Learning Collaborative initiative. Congress may wish to consider 
extending the draft bill's reporting requirement to the 170 VAMCs and 
myriad outpatient sites operated by the Department.
    VA supports this draft bill, and we would look forward to working 
with you. The reporting required by this bill can be produced by 
current VA staff and would require no additional resources to complete.
    Madam Chair, I conclude my remarks with the following highlights of 
VA's suicide prevention efforts. VA is moving from a purely hospital-
based suicide prevention model to a public health model. We continue to 
care for those in crises, with VA suicide prevention coordinators 
managing care for almost 11,000 Veterans who are clinically at high-
risk for suicide. VA's Recovery Engagement and Coordination for Health 
- Veterans Enhanced Treatment (REACH-VET) program uses predictive 
analytics to identify Veterans with high statistical risk for suicide. 
Annually, 30,000 Veterans receive care review and outreach to ensure 
they are well engaged in care and their needs are being met.
    Under VA's new universal screening for suicidal intent, more than 
2,057,000 Veterans have received a standardized risk screen since 
October 1, 2018; more than 62,000 of these Veterans have received more 
complex screening based on a positive initial screen; and more than 
8,000 have received a full clinical assessment after screening 
positive.
    At the same time, we are implementing the National Strategy for 
Veteran Suicide Prevention and are aggressively pursuing partnerships 
necessary to help us reach all Veterans. Just as suicide is a complex 
issue with no single cause, no single organization can end Veteran 
suicide alone. Every person, system, and organization must work 
together to save lives. We have, for example, in partnership with 
Johnson & Johnson, released a Public Service Announcement (PSA), ``No 
Veteran Left Behind,'' featuring Tom Hanks via social media and a 
communications plan led by Johnson & Johnson. VA continues to use the 
#BeThere Campaign to raise awareness about mental health and suicide 
prevention and educate Veterans, their families, and communities about 
the suicide prevention resources available to them. The National Action 
Alliance helped spread the #BeThere campaign to hundreds of partners 
using #BeThere and the Veterans Crisis Line information during 2018 
Suicide Prevention Month activities.
    We created more than 30 new cross-sector partnerships to involve 
peers, family members, and communities in preventing Veteran suicide. 
We also deliver monthly partnership updates to include content about 
the S.A.V.E. online suicide prevention training video to 60 informal 
and formal partners, providing communications materials (blog posts, 
social media, and emails) for use. The acronym S.A.V.E. summarizes the 
steps needed to take an active and valuable role in suicide prevention 
(Signs of suicidal thinking, Ask questions, Validate the person's 
experience, and Encourage treatment and expedite getting help).
    As you may know, this month we started working with you and other 
Members of Congress to spread awareness about the important topic of 
Veteran suicide through a PSA drive on Capitol Hill. VA's suicide 
prevention experts developed two suggested PSA scripts that Members can 
customize for their specific locations and audiences. The scripts are 
designed to use safe messaging best practices, provide hope, encourage 
help-seeking, and direct viewers to available mental health and suicide 
prevention resources. Thank you to those of you who have already 
developed your PSAs. If you have not yet developed yours, you can 
schedule time to record your PSA at either the House or Senate 
Recording Studio. Please let us know if VA can provide you with any 
further assistance, and we look forward to our continued 
collaborations.

Conclusion

    This concludes my statement. I would be happy to answer any 
questions you or other Members of the Committee may have.

                                 
                   Prepared Statement of Joy J. Ilem
    Chairwoman Brownley and Members of the Subcommittee:

    Thank you for inviting DAV (Disabled American Veterans) to testify 
at this legislative hearing of the Subcommittee on Health. As you know, 
DAV is a non-profit veterans service organization comprised of 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 Subcommittee.
  H.R. 100, the Veterans Overmedication and Suicide Prevention Act of 
                                  2019
    This bill would require VA to enter into a contract with the 
National Academies of Sciences, Engineering and Medicine to 
retrospectively study suicides of any veteran using Department of 
Veterans Affairs (VA) facilities for health care treatment for any of 
the past five years ending with the date of enactment. It would require 
the age, gender, race, and ethnicity among studied veterans and include 
deaths considered violent or accidental among veterans' suicides. In 
particular, the study would evaluate prescription and other drug 
utilization, including VA's prescribing of medications with black box 
warning labels, use of multiple prescription drugs and the number of 
instances when first line treatment therapies without use of 
prescription medications were used with particular regard for veterans 
with diagnosed conditions of posttraumatic stress, traumatic brain 
injury (TBI), military sexual trauma (MST), anxiety and depression. The 
study would also consider staffing levels, VA's use and barriers to use 
of marital and family counselors, and a compilation of pain management 
protocols being used while prescribing medications for other high risk 
diagnoses.
    It appears the study called for by this legislation is intended to 
identify problematic prescribing patterns for mental health care 
conditions in the VA that may be attributable to suicides among 
veterans. While there have been cases of documented over prescribed or 
inappropriate prescription drug therapy, we believe the information 
called for by this legislation could paint a distorted or inaccurate 
picture of mental health practices within VA. Additionally, we believe 
most of the data and analysis called for in this measure can be 
obtained through VA.
    It is difficult to determine whether the drugs prescribed by VA for 
a particular patient were appropriate unless each individual case is 
studied. In calling for the number of instances in which a non-
medication frontline intervention was attempted and determined to be 
``ineffective'' for the veteran, the bill also seems to mistakenly 
assume that VA's clinical practice guidelines do not include use of 
prescription drugs. In fact, VA's training for and use of evidence-
based or ``front line'' practices for conditions such as post-traumatic 
stress disorder (PTSD), MST, depression and anxiety include clinical 
practice guidelines for prescribing medications when clinically 
indicated, and prescription drugs are often given concurrently with 
other types of treatment.
    VA's use of evidence-based practices also far exceeds the use of 
such practices in the private sector. In one RAND study, investigators 
determined that only about 2 percent of private sector providers in New 
York were adequately prepared to meet veterans' needs by making use of 
evidence-based clinical practice guidelines, appropriately screening 
for and managing conditions common to veterans such as TBI, PTSD and 
MST, or asking about military status and being culturally competent in 
delivering care. \1\
---------------------------------------------------------------------------
    \1\ Tanielian, Terri, Carrie M. Farmer, Rachel M. Burns, Erin L. 
Duffy, and Claude Messan Setodji, Ready or Not? Assessing the Capacity 
of New York State Health Care Providers to Meet the Needs of Veterans. 
Santa Monica, CA: RAND Corporation, 2018. https://www.rand.org/pubs/
research--reports/RR2298.html. Also available in print form.
---------------------------------------------------------------------------
    VA's patients are often clinically complex and have a variety of 
mental and physical disorders that frequently require comprehensive 
care and supportive social services. Veterans who are suicidal often 
have a multitude of issues with which they are struggling such as 
homelessness, poverty, unemployment, mental and physical disabilities, 
war-related readjustment issues, substance use and family dissolution. 
Without fully understanding the unique complications within this 
population, this study may unfairly suggest VA prescribing practices 
are excessive and somehow different than those of other health care 
providers. In our opinion without any basis of comparison, this study 
would not serve to enlighten clinical practice.
    DAV certainly agrees that research is essential to determine 
dangerous or ineffective clinical practices, but does not believe that 
this study, as proposed, will be able to provide clear evidence of use 
of such practices in VA. Because of its utilization of a centralized 
electronic health record with a pharmaceutical component, VA is able to 
collect and analyze data about polypharmacy issues and regularly does 
so to ensure that it continues to improve patient safety, quality of 
care and clinical outcomes.
    DAV agrees it is important for VA to look at case studies of 
veterans prescribed medications with black box warnings to determine if 
prescribing was properly indicated and use appropriately monitored for 
certain patients if it is not doing so already. We also agree with 
sections in the bill calling for identifying the adequacy of mental 
health staffing levels, including VA's use of marriage and family 
counselors. In accordance with DAV Resolution No. 293, we support 
enhancing resources to ensure that VA mental health providers are able 
to provide timely comprehensive mental health services to veterans who 
need such care. We also believe more research is necessary to determine 
the root causes of higher suicide rates among veterans in addition to 
identifying the most effective monitoring systems and therapies for 
reducing rates of suicide and suicidal ideation for all veterans and 
certain sub-populations, such as women veterans. While we support 
certain sections in H.R. 100, we urge the subcommittee to work with VA 
subject matter experts to revise provisions within this bill to advance 
improved clinical practice.
        H.R. 712, the VA Medicinal Cannabis Research Act of 2019
    DAV supports and urges swift passage of H.R. 712, the VA Medicinal 
Cannabis Research Act of 2019. This is a bipartisan bill that would 
direct the VA to perform clinical research to determine whether 
cannabis is able to reduce symptoms associated with chronic pain such 
as inflammation, sleep disorders, spasticity, and agitation and effects 
on the use or dosage of opioids, benzodiazepines or alcohol for 
veterans with PTSD. DAV Resolution No. 023, adopted by our members 
during our 2018 National Convention, calls for comprehensive and 
scientifically rigorous research by the VA into the therapeutic 
benefits and risks of cannabis and cannabis-derived products as a 
possible treatment for service-connected disabled veterans.
    At this time, there are few definitive answers about risks and 
benefits associated with the use of cannabis on various medical 
conditions and illnesses. Research is necessary to help clinicians 
better understand the safety and efficacy of cannabis use for specific 
conditions that co-occur with other common conditions found in the 
veteran population such as chronic pain and post-traumatic stress.
                H.R. 1647, the Veterans Equal Access Act
 H.R. 2191, the ``Veterans Cannabis Use for Safe Healing Act'' or the 
                         ``Veterans CUSH Act''
    The December 8, 2017 Veterans Health Administration (VHA) Directive 
1315 sets out the Department's policy on access to VHA clinical 
programs for veterans participating in a State-approved marijuana 
program. VA's policy encourages VHA clinicians to discuss and provide 
information to veterans about cannabis as part of comprehensive care 
planning, and adjust individual treatment plans as necessary. VA's 
policy also ensures veterans that participation in state marijuana 
programs will not affect their eligibility for VA care and services.
    However, while several states have approved the use of marijuana 
for medical and/or recreational use, Federal law classifies marijuana 
as a Schedule I Controlled Substance, which makes it illegal to be 
prescribed, or for a prescription to be filled by the Federal 
government. VA's policy is that VA employed providers may not recommend 
or assist veterans to obtain cannabis unless otherwise approved by the 
Food and Drug Administration for medical use, such as the one cannabis-
derived seizure medication Epidiolex, and three cannabis-related drug 
products; Marinol, Cesamet and Syndros.
    H.R. 1647, the Veterans Equal Access Act and H.R. 2191, the 
Veterans CUSH Act, are aimed at clarifying VA's policy, which currently 
treats recommending marijuana as equivalent to prescribing marijuana. 
This measure would allow VA clinicians to provide recommendations and 
opinions, and to complete forms reflecting such recommendations and 
opinions, to veterans regarding participation in state marijuana 
programs. The CUSH Act adds that VA may not deny a veteran any VA 
benefit due to the veteran participating in a State-approved marijuana 
program and must discuss cannabis use with the veteran related to his 
or her treatment plan.
    DAV does not have a resolution specific to the issues addressed in 
these bills and therefore, takes no position on H.R. 1647 or H.R. 2191.
 Draft bill, to direct the Comptroller General of the United States to 
 conduct an assessment of the responsibilities, workload, and vacancy 
rates of Department of Veterans Affairs suicide prevention coordinators
    This bill would require the Government Accountability Office (GAO) 
to study the role of Suicide Prevention Coordinators within VA. The 
study would be required to determine the adequacy and appropriateness 
of training for these coordinators, if their caseloads are appropriate 
and how much these factors vary across the system. It would also 
determine who has responsibility for oversight of Suicide Prevention 
Coordinators.
    VHA Handbook 1160.01 states that its purpose is to standardize the 
practice of mental health within VHA. It assigns ultimate authority for 
ensuring program coherence and integrity to the Mental Health Executive 
Council, which oversees facility wide practices in suicide prevention, 
but since these councils are made up of professionals representative of 
mental health practitioners, DAV believes lines of authority with 
regard to Suicide Prevention Coordinators may be unclear. The Handbook 
also defines the responsibilities of Suicide Prevention Coordinators, 
making them full-time positions and requiring that they have additional 
support from medical centers to perform their duties if necessary. 
These individuals are to report monthly to mental health leadership and 
the National Suicide Prevention Coordinator on veterans who attempt or 
complete suicide, but there are otherwise no requirements for oversight 
defined.
    Because of these ambiguities and the importance of the Suicide 
Prevention Coordinator's responsibilities, we agree this study could 
yield important information and thus support this draft bill.
 Draft bill, to direct the Secretary of Veterans Affairs to submit to 
 Congress a report on the Department of Veterans Affairs advancing of 
                      whole health transformation
    This draft legislation would require the VA to report on access and 
availability on each of several complementary and integrative medicine 
practices, including: massage; chiropractic services; acupuncture; 
meditation; yoga, Tai Chi or Oi sang; and Whole Health group services.
    We are pleased to support this draft measure focused on advancing 
VA's Whole Health transformation in accordance with DAV Resolution 277, 
which supports the provision of comprehensive VA health care services 
to enrolled veterans, and specifically calls upon Congress to provide 
funding to guarantee access to a full continuum of care, from 
preventive through hospice services, including alternative and 
complementary care such as yoga, massage, acupuncture, chiropractic and 
other non-traditional therapies.
    DAV is aware that some VA facilities have set limits upon provision 
of these practices-for example, a veteran may not be able to get both 
yoga and acupuncture. Facilities may also limit the number of visits or 
treatments allowed or have long wait times for massage and other 
popular services. These limitations are likely the result of policy 
that encourages use of, but does not specifically require, these 
services. The report this draft bill calls for would help to determine 
the extent to which these services are available to veterans that need 
them in accordance with VHA Directive 1137. To provide a more complete 
picture, DAV suggests that the study also include integrative services 
VA provides through its Veterans Community Care Program (VCCP) Network.
 Draft bill, to direct the Comptroller General of the United States to 
 conduct an assessment of all memoranda of understanding and memoranda 
 of agreement between Under Secretary of Health and non-Department of 
  Veterans Affairs entities relating to suicide prevention and mental 
                            health services
    This draft bill would require GAO to report on the effectiveness of 
VA memoranda of agreement and memoranda of understanding with non-VA 
providers to carry out suicide prevention activities and mental health 
case management services, including regional variations, and care for 
certain populations such as women, minorities, older, and younger 
veterans. It requires GAO to look at staffing, licensure and 
accreditation and other relevant program features to determine if these 
entities are adequately addressing roles as identified in MOUs and 
MOAs.
    DAV has been disappointed in the lack of focus on required quality 
standards proposed for non-VA providers who will participate in the 
MISSION Act community care program. Ensuring veterans, who are referred 
by VA to the community or select private sector care, have access to 
quality care is essential to good health outcomes. Notable research 
institutions, such as RAND have questioned private providers' 
understanding of the complexity of treating veteran patients and 
conditions specially related to military service. In accordance with 
DAV Resolution No. 293, which calls on VA to collect data to ensure the 
quality and integrity of mental health services for veterans we support 
this draft bill which would provide an additional layer of oversight as 
VA moves toward more access to care in the community and expand its 
role in suicide prevention to all at-risk veterans using a public 
health model.
 Draft bill, to direct the Secretary of Veterans Affairs to provide to 
 Congress notice of any suicide or attempted suicide of a veteran in a 
                Department of Veterans Affairs facility
    This draft measure would require VA to notify the Congressional 
Committees on Veterans' Affairs in the case of suicide or attempted 
suicide of any veteran that occurs in or on the grounds of a VA 
facility. The bill further requires information about the veteran 
including military service, age, marital, housing and employment 
status, and the date of VA's last documented contact with the veteran.
    While DAV has no specific resolution concerning this issue we 
understand the Committees' desire for VA to communicate any suicides or 
attempted suicides that occur on VA grounds to Congress, thus we have 
no objection to favorable consideration of this bill.
    Chairwoman Brownley, this concludes my testimony. DAV would be 
pleased to respond to any questions from you or Subcommittee members 
concerning our views on the bills under consideration today.

                                 
                  Prepared Statement of Carlos Fuentes
    Chairwoman Brownley, Ranking Member Dunn, and members of the 
subcommittee, on behalf of the women and men of the Veterans of Foreign 
Wars of the United States (VFW) and its Auxiliary, thank you for the 
opportunity to provide our remarks on legislation pending before this 
subcommittee.

H.R. 712, the VA Medicinal Cannabis Research Act of 2019

    This legislation would require the Department of Veterans Affairs 
(VA) to conduct a double blind scientific study on the efficacy of 
medical cannabis. The VFW is proud to support this important bill and 
thanks this subcommittee for its consideration.
    VA is making concerted efforts to ensure it appropriately uses 
pharmaceutical treatments when providing mental health care. Under the 
Opioid Safety Initiative, VA has reduced the number of patients to whom 
it prescribes opioids by more than 22 percent. Prescribed use of 
opioids for chronic pain management has unfortunately led to addiction 
to these drugs for many veterans, as well as for many other Americans. 
VA uses evidence-based clinical guidelines to manage pharmacological 
treatment of post-traumatic stress disorder, chronic pain, and 
substance use disorder (SUD) because medical trials have found them to 
be effective. To reduce the use of high-dose opioids, VA must expand 
research on the efficacy of non-traditional medical therapies, such as 
medical cannabis and other holistic approaches.
    Medical cannabis is currently legal in 33 states and the District 
of Columbia. This means veterans are able to legally obtain cannabis 
for medical purposes in more than half the country. For veterans who 
use medical cannabis and are also VA patients, they are doing this 
without the medical understanding or proper guidance from their 
coordinators of care at VA. Many states have conducted research for 
mental health, chronic pain, and oncology at the state level. States 
that have legalized medical cannabis have also seen a 15-35 percent 
decrease in opioid overdose and abuse. A comprehensive study by the 
National Academy of Sciences and the National Academic Press also 
concluded that cannabinoids are effective for treating chronic pain, 
chemotherapy-induced nausea and vomiting, sleep disturbances related to 
obstructive sleep apnea, multiple sclerosis spasticity symptoms, and 
fibromyalgia--all of which are prevalent in the veteran population. 
While VA has testified that it has the authority to study Schedule 1 
drugs, it has failed to do so and veterans are tired of waiting for VA.
    VFW-Student Veterans of America Fellow Christopher Lamy, an Army 
veteran and Louisiana State University law school student, focused his 
semester-long research project and advocacy effort on this important 
bill. Chris' research discovered that veterans experience chronic pain 
at 40 percent higher rates than non-veterans and if not properly 
treated, such chronic pain often leads to depression, anxiety, and 
decreased quality of life. Chris also found that states with medical 
cannabis programs have, on average, a 25 percent lower rate of death 
from opioid overdose than non-medical cannabis states.
    Veterans Health Administration (VHA) Directive 1315, Access to VHA 
Clinical Programs for Veterans Participating in State-Approved 
Marijuana Programs, provides protections for veterans who use medical 
cannabis. However, Chris found that veterans who discuss their use of 
medical cannabis with their doctors are ostracized and have their 
medications changed or discontinued. The fear of reprisal for medical 
cannabis prevents veterans from disclosing information to their VA 
health care providers, which can lead to problems caused by drug 
interactions. This legislation would prohibit VA from making 
eligibility determinations for benefits based on participation in the 
study. To ensure veterans who participate in the study do not have 
their VA health care impacted, the VFW recommends this subcommittee 
amend the bill to prohibit VA from denying or altering treatment to 
veterans who participate in the study. Doing so would provide veterans 
peace of mind.

H.R. 1647, the Veterans Equal Access Act

    This legislation would authorize VA health care providers to 
provide recommendations for participation in state-approved medical 
marijuana programs. The VFW agrees with the intent of this legislation, 
but cannot offer its support at this time.
    The VFW agrees that veterans who rely on the VA health care system 
must have access to medical cannabis, if such therapies are proven to 
assist in treating certain health conditions. Without such evidence, VA 
would not have the authority to prescribe or provide medical cannabis 
to veterans. The VFW believes it is unacceptable for VA providers to 
recommend a treatment that they are unable to provide veterans and 
force patients to pay for the full cost of such care. If VA recommends 
a treatment plan, it must be able to provide required therapies or 
prescriptions. That is why the VFW supports H.R. 712, which would 
enable veterans to participate in medical cannabis research without 
having to bear the full cost of treatment.

H.R. 2191, the Veterans Cannabis Use for Safe Healing Act

    This legislation would require VA providers to discuss and record 
veterans' use of medical cannabis and participation in state-approved 
marijuana programs. It would also authorize VA health care providers to 
recommend participation in such programs and prohibit VA from denying 
veterans access to benefits solely based on their use of marijuana.
    The VFW strongly supports provisions to protect veterans from 
having their earned benefits eroded or denied simply based on their 
participation in a state-approved marijuana program. Veterans who 
participate in such programs must not fear that VA will take away 
benefits they have earned and deserve. The VFW also believes it is 
important for VA to properly track veterans who use medical cannabis. 
However, the VFW is concerned VA may not implement the requirement to 
record medical cannabis use as intended.
    VHA Directive 1315, Access to VHA Clinical Programs for Veterans 
Participating in State-Approved Marijuana Programs, instructs VA health 
care professionals to record marijuana use ``into the `non-VA/herbal/
Over the Counter (OTC) medication section' of the Veteran's electronic 
medical record.'' Yet, the VFW continues to hear from veterans who have 
been recorded as having a SUD for testing positive for marijuana or 
because their VA health care provider did not follow the guidance 
included in the directive. Veterans who report participation in state-
approved marijuana programs must not be recorded as having a SUD. To 
ensure the recording requirement is implemented properly, the VFW 
recommends this subcommittee require VA to create diagnostic codes for 
medical cannabis use or prohibit VA from recording such use as SUD.
    This legislation would also authorize VA health care providers to 
recommend participation in state-approved marijuana programs. As 
discussed above, the VFW cannot support such authority if VA is unable 
to provide a recommended course of treatment.

H.R. 100, the Veteran Overmedication and Suicide Prevention Act of 2019

    This legislation would commission research and require that VA 
report data on veteran suicides. The VFW supports this legislation and 
has a recommendation to improve it.
    In partnership with the Department of Defense, the Centers for 
Disease Control and Prevention, and other Federal agencies, VA has 
compiled the most comprehensive data and analysis of veteran suicides 
that has ever existed. The most recent analysis of veteran suicide data 
from 2016 found suicide has remained fairly consistent within the 
veteran community in recent years. An average of 20 veterans and 
service members die by suicide every day. While this number must be 
reduced to zero, it is worth noting that the number of veterans who die 
by suicide has remained consistent in recent years, while non-veteran 
suicides have continued to increase.
    However, VA's National Suicide Data Report is delayed by two years 
and misses certain elements which this legislation would include, such 
as the impact of staffing levels on suicide prevention efforts. The VFW 
has long argued that VA's lack of staffing models and inability to 
properly staff its health care facilities impact its ability to provide 
timely and high-quality health care to veterans who face mental health 
crises.
    The report commissioned by this legislation would be conducted by a 
third party, which would also ensure VA bias is eliminated. While the 
majority of veterans who die by suicide every day are not active users 
of the VA health care system, VA must do everything possible to save 
the lives of those who rely on VA. An external analysis of VA practices 
and procedures would ensure VA is doing what it necessary to save the 
lives of the six VA health care users who die by suicide every day.
    To better assist all veterans, the VFW urges this subcommittee to 
require the study to include research and data collection on the 14 
veterans and service members who die by suicide every day without 
receiving VA health care. This legislation would limit the study to 
veterans who have used VA health care within the past five years. Doing 
so would exclude about two-thirds of veterans who die by suicide each 
day without any contact with VA. The VFW urges this subcommittee to 
amend this legislation to include and analyze the demographics, 
illnesses, socioeconomic status, and military discharges of such 
population. There are questions that need to be answered in order to 
properly address this epidemic: did those 14 use private sector care? 
Were they eligible to use VA? Were they among the many who were 
discharged without due process for untreated or undiagnosed mental 
health disorders? Were they discharged for unjust and undiagnosed 
personality disorders due to transgenderism or during the era of 
``Don't Ask, Don't Tell?'' Have they used other VA benefits such as the 
GI Bill?

H.R. 2333, the Support for Suicide Prevention Coordinators Act

    The VFW supports this legislation, which would commission an 
assessment of VA suicide prevention coordinators.
    Suicide prevention coordinators are instrumental in the efforts to 
reduce suicides among veterans. These caring and hardworking 
individuals are at the front line of suicide prevention efforts at VA 
medical facilities, including case management of veterans who are at 
high risk of suicide. The legislation would rightfully evaluate if VA 
is properly supporting those who support veterans in their time of 
greatest need.

Draft Legislation to Submit to Congress a Report on VA Advancing of 
    Whole Health Transformation

    The VFW supports this legislation, which would require VA to report 
on its implementation of complementary and integrative therapies 
throughout the VA health care system.
    Countless veterans have experienced first hand the dangerous side 
effects of pharmacotherapy. Many of these medications, if incorrectly 
prescribed, have been proven to render veterans incapable of 
interacting with their loved ones and even contemplate suicide. VA must 
ensure it affords veterans the opportunity to access effective 
treatments that minimize adverse outcomes.
    Thanks to the VFW-supported Jason Simcakoski Memorial and Promise 
Act, medications are being more closely monitored. Through VA's Opioid 
Safety Initiative, opioids are being prescribed on a less frequent 
basis for mental health conditions and are better monitored for 
negative consequences such as addiction. However, many veterans report 
being abruptly taken off opioids they have relied on for years to cope 
with their pain management, without receiving a proper treatment plan 
to transition them to alternative therapies. Doing so leads veterans to 
seek alternatives outside of VA or to self-medicate.
    With the growing body of research on the efficacy of complementary 
and integrative therapies, such as meditation, acupuncture, and massage 
to treat mental health conditions and manage pain, the VFW believes 
more work must be done to ensure veterans are afforded the opportunity 
to receive these safe and effective alternatives to pharmacotherapy. 
This legislation would provide oversight of VA's efforts to taper 
veterans off high-dose opioid and switch to effective alternatives.
    Madam Chairwoman, this concludes my testimony. I am prepared to 
take any questions you or the subcommittee members may have.

                                 
                 Prepared Statement of Stephanie Mullen
    Chairwoman Brownley, Ranking Member Dunn, and distinguished members 
of the subcommittee, on behalf of Iraq and Afghanistan Veterans of 
America (IAVA) and our more than 425,000 members worldwide, I would 
like to thank you for the opportunity to testify here today on the 
pending legislation before the subcommittee.
    As the Research Director for IAVA, I get to take the collective 
experiences and views of IAVA members to support our policy and 
programmatic work - giving numbers to the narratives of IAVA members 
everyday. I am truly honored to serve those who have served this great 
nation and feel a special privilege in working with the post-9/11 
generation, many of whom are my teachers, leaders, and friends, on the 
issues that impact them most. I am the product of a military family; 
the daughter of a retired U.S. Air Force Lieutenant Colonel who spent 
twenty years of her life fighting on the front lines - from Kuwait in 
the First Gulf War to being one of the few women in leadership roles 
during the 1970s, 80s, and 90s. And yet, my mom still gets asked where 
her husband is when she walked into VA facility and constantly deals 
with many of the wounds of war we see similarly in the post-9/11 
generation like chronic pain and arthritis. So many of the issues IAVA 
tirelessly advocates for directly impacts the people I love most, and 
it drives my work to ensure that veterans of all generations are 
receiving the best care and treatment possible across all areas of 
society.
    Support for Veteran Medicinal Cannabis Use is an incredibly 
important part of our work; it is why it's one of our Bix Six 
Priorities for 2019, which includes, in addition to Support for Veteran 
Cannabis Use, the Campaign to Combat Suicide, Defense of Education 
Benefits, Support and Recognition of Women Veterans, Government Reform 
for Veterans, Support for Injuries from Burn Pits and Toxic Exposures.
    For years, IAVA members have been supportive of medical cannabis. 
In IAVA's latest Member Survey, 83% of IAVA members agree that cannabis 
should be legal for medical purposes. And a resounding 90% believe 
cannabis should be researched for medicinal uses. IAVA members are 
already there in terms of cannabis research, and it's time for the 
Department of Veterans Affairs (VA) to catch up.
    IAVA is proud to support the VA Medicinal Cannabis Research Act 
(H.R. 712) which will advance research and understanding around the 
safety and effectiveness of cannabis to treat the signature injuries of 
war. At this time, we have limited evidence on cannabis' effectiveness 
to treat the injuries that impact huge swaths of the post-9/11 
generation.
    Without research done by VA surrounding cannabis, veterans will not 
have conclusive answers to how cannabis can aide their health needs. 
This is unacceptable. VA houses some of the most innovative and best-
in-class research this country has to offer. It should not be shutting 
its doors on a potentially effective treatment option because of 
politics and stigma. This nation's veterans deserve better.
    In IAVA's most recent Member Survey, a staggering 72% of veteran 
and military members reported suffering from chronic pain. Sixty-six 
percent report joint injuries, and over 50% report either PTSD, 
anxiety, or depression. Cannabis may be an effective treatment option 
for all of these service-connected injuries; but we must invest in the 
research to ensure it is. The VA Medicinal Cannabis Research Act will 
build on this evidence and provide further data to explore the 
effectiveness of cannabis as a treatment option.
    However, research takes time - years in fact. And there are 
veterans suffering with the signature injuries of war now. Thirty-three 
states and the District of Columbia have already legalized medical 
cannabis. Unfortunately, VA's lackadaisical approach to cannabis forces 
many veterans to circumvent VA to access cannabis. In just the last 
month, over 100 IAVA members have shared their stories of their 
cannabis use, with dozens sharing how VA retaliated against or 
mishandled them and dozens more sharing that they flat out refuse to 
tell VA about their use. Left unchecked, this practice is harmful and 
dangerous.
    VA's policies inhibit realistic discussion and open conversations 
around cannabis. While current VA policy allows for clinicians to talk 
to their veteran patients about cannabis, VA clinicians are unable to 
recommend cannabis to their patients, are unable to fill out state 
cannabis medical forms, and are unable to recommend the best programs 
and options for their patients.
    It is unrealistic to think these limitations do not have negative 
impacts. Ensuring clinicians have a full view of what their patients 
are taking and experiencing is paramount to ensuring the veteran is 
getting the best treatment and care possible. But, if veterans are 
unable to have this open discussion or feel unwelcome to do so, it can 
lead to potentially devastating consequences. The access is there, and 
if veterans are unable to go through VA to get medical cannabis, 
they'll go around it. But they shouldn't have to; VA care is an earned 
benefit for our nation's veterans, they shouldn't feel that they have 
to hide and circumvent VA to access a standard of care their civilian 
counterparts access easily.
    We know this is already occurring from IAVA members nationwide. 
Twenty percent of IAVA members report using cannabis for medicinal use 
and of those, only 31% have talked to their doctor about their cannabis 
use and 24% either do not feel comfortable or feel slightly comfortable 
talking about their cannabis use with their doctors. For the vast 
majority of those that use cannabis, they are not talking to their 
doctors about their cannabis use.
    For just one of these stories, we have to look no further than our 
IAVA Member Leaders. After serving for four and half years in the Army, 
one IAVA Member Leader was medically retired with service-connected 
migraines, traumatic brain injury and post-traumatic stress disorder. 
He was later diagnosed with an autoimmune disorder, fibromyalgia, that 
his doctors believe is related to burn pits and toxic exposures. He has 
spent years in and out of doctors' offices for treatment of the 
signature injuries of the post-9/11 conflicts, leading to a moment of 
crisis and a suicide attempt just a few years ago.
    Since then, he has found a way forward and found relief through 
cannabidiol (CBD) and medical cannabis. However, because CBD and 
medical cannabis are not a treatment option through VA, he had to find 
alternative pathways to relief. He was forced to go outside of VA for 
health care and pay out of pocket for treatments that have actually 
helped him move forward in his life. He does not share this information 
with VA for fear of retribution.
    We must ensure that VA clinicians can have open and honest 
discussions with their patients, allowing VA clinicians to recommend 
cannabis to their patients when appropriate, and ensure VA clinicians 
can submit forms for state medical cannabis programs for their veteran 
patients.
    For these reasons, IAVA is proud to support the Veterans Equal 
Access Act (H.R. 1647) that will allow VA clinicians to provide 
recommendations and fill out forms for state cannabis programs. IAVA is 
also proud to support the Veterans Cannabis Use for Safe Healing Act 
(H.R. 2191), which will codify current VA policy around medical 
cannabis and ensure no veteran is punished for speaking to their 
clinician about their cannabis use.
    Additionally, IAVA is pleased to support DRAFT VA - Whole Health 
bill which will examine VA's Whole Health initiative including the 
complementary and alternative therapies provided within the program 
like yoga, meditation, and chiropractic care. IAVA believes that whole 
health is essential to the overall health and care of veterans. In 
practice, 63% of IAVA members use complementary and alternative 
therapies to treat a service-connected injury, most often using 
meditation, chiropractic care, and yoga as therapies. While research is 
still developing around many of these alternative treatments, they have 
proven effective for IAVA members in treating the signature injuries of 
war and we are encouraged to see interest in assessing the efficacy of 
this program at VA.
    Though cannabis reform is an important pillar in our advocacy 
efforts, the top priority for IAVA and among our membership is suicide 
prevention among troops and veterans. In 2016, the latest data 
available, an average of 20 servicemembers and veterans die by suicide 
each day accounting for over 7,000 deaths each year. Each one of these 
deaths impacts an entire community: a family, friends, a military unit, 
and the lives of each and every person that veteran or servicemember 
touched. We often say one death by suicide is too many, and it is so 
true, because every life has value and every death has impact far 
beyond just one moment of crisis. IAVA members know this well; 65% of 
our members know a post-9/11 veteran who has died by suicide, a rise of 
19% since 2014. And when IAVA planted 5,520 flags on the National Mall 
on October 3rd, 2018 to represent the 20 veteran and military souls 
lost to suicide that year to date, many silently wept remembering 
either those who were lost, or their own personal struggles.
    When it comes to accurately understanding and addressing veteran 
suicide, we must know the scope of the problem. While VA does release 
veteran suicide data, it is often years behind and only as good as the 
data provided by the Centers for Disease Control and the National Death 
Index.
    IAVA is pleased to see Congress address this issue through the 
Veteran Overmedication and Suicide Prevention Act (H.R. 100), which 
will commission a study through the National Academies of Sciences to 
analyze violent and accidental veteran deaths. It has been a long 
standing concern of IAVA that there are veteran deaths by suicide lost 
in these other categories and we are not accurately counting all deaths 
by suicide, potentially missing the scope of the problem. That means we 
are also not targeting solutions accurately.
    IAVA also thanks this Subcommittee for highlighting this public 
health crisis by considering additional draft legislation. In 2015, 
IAVA and our veteran service organization partners worked hand in hand 
with Congress to pass the Clay Hunt Suicide Prevention for American 
Veterans (SAV) Act. This landmark legislation focused on mental health 
care and suicide prevention at VA. Progress has been made, in 
particular, under Section 6 of the law in which partnerships with 
nonprofit organizations specializing in mental health care were 
expanded. But the Clay Hunt SAV Act is still lacking overall in timely 
implementation of the loan repayment provision for psychiatrists and 
the final report on the Clay Hunt peer support pilot programs showed a 
systemic need for dedicated funding and increased staffing to ensure 
the program is successful.
    We are pleased to support draft legislation GAO MOU and MOA bill, 
which will review and assess these and other partnerships between VA 
and nonprofit organizations supporting VA's suicide prevention work. 
Similarly, we are pleased to support Draft GAO Suicide Prevention bill 
which will analyze the workload and reporting structure of VA's Suicide 
Prevention Coordinators, those that serve at the front line of this 
public health crisis. Increasing our understanding of veteran suicide, 
the risk factors and protective factors, and the effectiveness of 
suicide prevention programs at VA are all essential to tackling this 
issue.
    While we recognize and appreciate the intent behind DRAFT Suicide 
Notification bill regarding veteran suicides on VA property, IAVA is 
concerned that this legislation will not address the underlying issues 
regarding these tragic events and violates the veterans' privacy and 
personal information without the approval of the veterans' next of kin. 
When a veteran dies by suicide on VA property, it indicates that the 
foundation of trust between the public and VA has been catastrophically 
undercut; VA is supposed to be where veterans go to get healthy and 
seek treatment. When this moment of crisis happens on VA facility 
grounds, it is truly heartbreaking and feels preventable. However, it 
is important that we recognize that every death by suicide is 
different, there are different risk factors, triggers, and moments of 
crisis in each case and a death by suicide on VA property is just as 
tragic and just as great a loss as a death by suicide in a veterans' 
own home, car or workplace. Regardless, these tragic events should be a 
call to action; to ensure that all VA policies and procedures 
surrounding VA emergency mental health care, facility security, and 
personnel training are up to date, acceptable, and being implemented 
correctly. A failure in the system should and must be addressed. IAVA 
recommends that the proposed legislation focus on these procedures and 
policies at VA facilities that may be able to intervene in a moment of 
crisis rather than the individual factors surrounding the tragic event 
itself.
    Members of the Subcommittee, thank you again for the opportunity to 
share IAVA's views on these issues today. I look forward to answering 
any questions you may have and working with the subcommittee in the 
future.

                                 
           Materials Submitted For The Record (Upon Request)

                    Draft Bill, Suicide Notification
                     Draft Bill, Suicide Prevention
                      Draft Bill, VA Whole Health
                        Draft Bill, Hon. Steube
                                H.R. 100
                                H.R. 712
                               H.R. 1647

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