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





 
 H.R. 712; H.R. 1647; H.R. 3083; H.R. 485; DISCUSSION DRAFT, SPECIALLY 
           ADAPTIVE HOUSING, AND DISCUSSION DRAFT, WORK STUDY

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

                                HEARING

                               before the

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

                     ONE HUNDRED SIXTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        THURSDAY, JUNE 20, 2019

                               __________

                           Serial No. 116-21

                               __________

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


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

              U.S. GOVERNMENT PUBLISHING OFFICE 
40-822                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

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

                              ----------                              

                        Thursday, June 20, 2019

                                                                   Page

H.R. 712; H.R. 1647; H.R. 3083; H.R. 485; Discussion Draft, 
  Specially Adaptive Housing, And Discussion Draft, Work Study...     1

                           OPENING STATEMENTS

Honorable Mark Takano, Chairman..................................     1
Honorable David P. Roe, Ranking Member...........................     3
Honorable Luis Correa, U.S. House of Representatives (CA-46).....     5
    Prepared Statement...........................................    41
Honorable Gilbert Ray Cisneros, Jr...............................     7
Honorable Gus M. Bilirakis.......................................     8

                               WITNESSES

Mr. Adrian M. Atizado, Deputy National Legislative Director, 
  Disabled American Veterans.....................................    10
    Prepared Statement...........................................    41

Mr. Travis Horr, Director, Government Affairs, Iraq and 
  Afghanistan Veterans of America................................    11
    Prepared Statement...........................................    46

Mr. Carlos Fuentes, Director, National Legislative Service, 
  Veterans of Foreign Wars.......................................    13
    Prepared Statement...........................................    48

Mr. Derek Fronabarger, Director, Government Affairs, Wounded 
  Warrior Project................................................    15
    Prepared Statement...........................................    52

Dr. Igor Grant, M.D., F.R.C.P.(C), Director, Center for Medicinal 
  Cannabis Research, University of California....................    16
    Prepared Statement...........................................    55

Larry Mole, BA, PharmD, Chief Consultant, Population Health 
  Services, Patient Care Services, Veterans Health Administration    32
    Prepared Statement...........................................    56

Honorable Scott R. Tipton, U.S. House of Representatives, (CO-
  03), prepared statemnt only....................................    59
Mr. J. David Cox, Sr., National President, American Federation of 
  Government Employees (AFGE), prepared statemnt only............    60
Mr. Eric Goepel, Founder & CEO, Veterans Cannabis Coalition 
  (VCC), prepared statemnt only..................................    60
Mr. Randy Erwin, National President, National Federation of 
  Federal Employees (NFFE), prepared statemnt only...............    62
Thelma Roach-Serry, BSN, RN, NE-BC, President, Nurses 
  Organization of Veterans Affairs (NOVA), prepared statemnt only    63

                       STATEMENTS FOR THE RECORD

Paralyzed Veterans Of America (PVA)..............................    64
Veterans Healthcare Policy Institute.............................    65

           MATERIALS SUBMITTED FOR THE RECORD (UPON REQUEST)

1. H.R. 2943.....................................................    70

2. H.R. 2942.....................................................    70

3. H.R. 2676.....................................................    70

4. H.R. 2677.....................................................    70

5. H.R. 712......................................................    70

6. H.R. 1647.....................................................    70

7. H.R. 3083.....................................................    70

8. H.R. 485......................................................    70

9. Discussion Draft - Specially Adaptive Housing.................    70

10. Discussion Draft - Work Study................................    70


 H.R. 712; H.R. 1647; H.R. 3083; H.R. 485; DISCUSSION DRAFT, SPECIALLY 
           ADAPTIVE HOUSING, AND DISCUSSION DRAFT, WORK STUDY

                              ----------                              


                        Thursday, June 20, 2019

            Committee on Veterans' Affairs,
                    U. S. House of Representatives,
                                                   Washington, D.C.
    The Committee met, pursuant to notice, at 2:06 p.m., in 
Room 210, House Visitors Center, Hon. Mark Takano [Chairman of 
the Committee] presiding.
    Present: Representatives Takano, Brownley, Rice, Lamb, 
Levin, Brindisi, Rose, Pappas, Luria, Lee, Cunningham, 
Cisneros, Peterson, Sablan, Allred, Underwood, Roe, Bilirakis, 
Radewagen, Bost, Dunn, Bergman, Barr, Meuser, Roy, and Steube.

           OPENING STATEMENT OF MARK TAKANO, CHAIRMAN

    The Chairman. Good afternoon. I call this hearing to order.
    I would like to start by thanking the Veterans Service 
Organizations for being here. Without your advocacy, the Blue 
Water Navy Vietnam Veterans Act would not be on the President's 
desk awaiting his signature.
    [Applause.]
    The Chairman. Thank you, everybody, actually. Thank 
everyone on this Committee. Dr. Roe, thank you especially, and 
our Republican colleagues. This is a tremendous accomplishment.
    We rely on you, the Veterans Service Organizations, to 
provide feedback and expert testimony on legislation affecting 
veterans, and today we ask you for the same. The legislation on 
the agenda for this hearing covers a range of veterans' issues, 
from health care to educational and housing benefits, to 
transition assistance. Today, we hope to generate discussion on 
each of the agenda items, so we can make informed decisions on 
whether the legislation is ready to be considered in markup.
    Four agenda items are related to medicinal cannabis. Now, I 
believe cannabis must be objective researched, period. Medical 
cannabis may have the potential to manage chronic pain better 
than opioids and treat PTSD. However, other research shows that 
cannabis may significantly affect brain development into early 
adult. Young servicemembers enlisting at age 17 or 18 and 
separating from the military at age 22 may be particularly 
vulnerable to its negative side effects.
    I want to make sure that any research legislation this 
Committee votes on is not written to achieve one outcome or 
used to fast-track treatments for veterans. Clinicians need to 
understand the efficacy of this drug and any negative side 
effects. In those states that allow medical cannabis, VA 
doctors should be able to provide recommendations to veterans 
for medical cannabis programs.
    I also place H.R. 3083, the AIR Acceleration Act, on the 
agenda today, because I have serious concerns about VA's 
implementation of the AIR Act. We have received no information 
from VA on the market assessments to give this Committee 
confidence that the mission when it is scheduled to meet will 
actually have the data it needs to make informed decisions. It 
is important that we have a public discussion of these concerns 
and hear from stakeholders, because I do not believe it makes 
sense to speed up this process now. VA's lack of transparency 
should be concerning to us all.
    I would also like to highlight two bills introduced by 
Representative Cisneros that I support, H.R. 2942, that 
authorizes an existing Air Force Women's Health TAP pilot 
program, and H.R. 2943 would codify an existing regulation that 
all VA fact sheets be available to veterans in Spanish.
    During a recent visit to the VA Medical Center in San Juan, 
Puerto Rico, Committee staff saw firsthand why VA should be 
mandated by law to provide materials in Spanish. I was shocked 
to learn that key letters, fact sheets, and employee training 
modules developed to educate veterans and staff on the MISSION 
Act were only produced and mailed to veterans in English. In 
Puerto Rico, where Spanish is the predominant language, this 
means veterans and hospital employees were not notified about 
the upcoming changes with the MISSION Act and employees were 
not prepared to implement the law on June 6th. Hospital staff 
in San Juan, to their credit, translated and reproduced 
materials in Spanish on their own, because the translation 
provided by a contracted vendor was poor and inadequate.
    The Veterans Crisis Line, a lifeline for veterans thinking 
about suicide, operates only in English. The Puerto Rico VA 
Medical Center established its own local crisis line in 
Spanish, but when my staff called the number on several 
occasions, no one answered. Well, think about that for a 
moment: help is only available at the VA in Puerto Rico if you 
understand English.
    According to the 2015 census, on average, 73 percent of 
Hispanics speak a language other than English at home, and 31 
percent of Hispanics state that they are not fluent in English. 
VA statistics predict an increase in the Hispanic veteran 
population from 7.4 percent in 2017 to 11.2 percent by 2037. 
Failing to provide veterans with clear explanations of their 
benefits in Spanish means Latin veterans will lose out on GI 
Bill benefits, VA home loans, or health care programs like the 
MISSION Act. Veterans won't receive their burial benefits if 
their surviving family members do not understand English. A 
Spanish-speaking veteran's call to the Veterans Crisis Line 
would in effect remain unanswered.
    So VA should be providing Spanish language materials, but 
it is falling short in too many cases. And, when I became 
Chairman of this Committee, I committed to you that we would 
work to break down barriers for veterans from minority and 
under-served communities; Mr. Cisneros' bill is one small step 
towards this effort. It is not enough that this is a VA 
regulation, we must make this the law and exercise this 
Committee's oversight authority to make sure VA is following 
it.
    So I want to just say this slightly different--
    [Speaking Spanish.]
    The Chairman. So, that concludes my opening remarks.
    Dr. Roe, you are now recognized for 5 minutes to give your 
opening statement.

       OPENING STATEMENT OF DAVID P. ROE, RANKING MEMBER

    Mr. Roe. Thank you, Mr. Chairman. I appreciate you holding 
this hearing this afternoon to discuss ten bills, many of which 
I support, for and including my bill, H.R. 3083, on today's 
agenda.
    H.R. 3083, the Asset Infrastructure Review, or AIR, 
Acceleration Act would eliminate the requirement in current law 
that the AIR Commission meet only in calendar years 2022 and 
2023.
    The AIR Act was signed into law last year as part of the 
MISSION Act. It established a methodical, objective, 
transparent process to recommend how the VA health care system 
could be realigned and modernized to better meet the needs of 
our veterans. That process was developed in response to a 
recommendation made in the 2016 Bipartisan Commission on Care, 
after finding that VA medical sites on average are five times 
older than medical facilities in the private sector, and have 
been designed and built to meet markedly different health care 
needs in a markedly different health care market than veterans 
experience today. That finding was further supported by a 2017 
Government Accountability Office report, which found that the 
VA health care system is misaligned with the veteran population 
and no longer well-suited to providing care in many instances.
    VA concurred with the GAO in testimony before this 
Committee later that year and further noted that the majority 
of VA facilities have outlived their useful life cycle. It is 
clear beyond a shadow of a doubt that the AIR Act is necessary 
for those and for many other reasons. That is why every major 
Veterans Service Organization joined together in support of the 
inclusion of the AIR Act in the MISSION Act last year.
    At the time, it was expected that the market assessments 
that will underlie much of the commission's work could take 
many years to complete and, therefore, the commission should 
not be allowed to meet until 2022 at the earliest. However, in 
the last several months Secretary Wilkie has testified multiple 
times before this Committee and before the Senate Committee on 
Veterans' Affairs that those market assessments will be 
complete next summer. Because of that, the Secretary has urged 
Congress to give the AIR Commission the flexibility to begin 
their deliberations prior to 2022; the AIR Acceleration Act 
would provide that flexibility. This would give the commission 
more time to do its work by allowing deliberations to begin 
before 2022 and extend after 2023, as needed.
    Note that none of the other deadlines including in the AIR 
Act deadlines that were carefully coordinated with the Veterans 
Service Organizations, who I worked very closely with on every 
aspect of this legislation, would be impacted by the AIR 
Acceleration Act. I am grateful for the support of the Wounded 
Warrior Project, and Iraq and Afghanistan, the IAVA, on this 
legislation.
    Also, Mr. Chairman, I would appreciate a letter that we 
received just yesterday from Concerned Veterans For America 
that it be admitted into the record. At the newest--
    The Chairman. Without objection, so ordered.
    Mr. Roe. Thank you, Mr. Chairman.
    As the newest VSO representing the most recent generation 
of veterans, IAVA and WWP are perhaps uniquely positioned to 
recognize just how critical the AIR Act is to VA's future 
success and sustainability, and just how much veterans stand to 
lose by waiting to begin the commission's important work while 
VA's infrastructure continues to worsen. I thank these VSOs for 
their support.
    That said, I recognize that VSOs have concerns about the 
AIR Acceleration Act, primarily because they fear rushing the 
AIR Act process. And while I note that only in government is 
the thought that starting something 2 years after it was signed 
in law rushing, I still look forward to beginning the dialogue 
with them today about that fear and how we can move forward to 
address their concerns.
    And just off script for a minute. It is not just the VA 
health care system; it is the American health care system is 
going to have to be re-looked at. Heads in beds actually 
maximized in 1981 and 1982; in other words, the number of 
people who were in a hospital bed maximized then. The 
population has grown 40 percent since that time and we actually 
have 10 percent--on any one day, 10 percent less people in a 
hospital bed than we did 40 years ago almost. And why? Because 
of the changes in medicine, the way we deliver health care, and 
I am a perfect example of it. I have had two major operations 
in the last 2 years and spent less than 48 hours in the 
hospital for both of them.
    So it is not just VA and we no longer can support 1100 
empty buildings. We need to take those resources and put those 
resources where the veterans are, into their health care, into 
other benefits for veterans.
    The two other bills that I support on the agenda are draft 
bills. The first draft bill was sponsored by Representative 
Rodney Davis and would improve the payment of work study 
benefits to GI Bill beneficiaries. The idea of this bill came 
from the student veterans themselves at a GI Bill forum that 
Representative Davis hosted in his district last year, which I 
was glad to attend that forum with Congressman Davis, and I 
commend him for representing the student veterans in his 
district so well.
    The other draft bill is sponsored by my good friend Gus 
Bilirakis, the Ranking member on Economic Opportunity 
Subcommittee. It would make needed improvements to the 
Specially Adaptive Housing Program to help severely disabled 
servicemembers and veterans adapt their homes to meet their 
needs.
    This afternoon's agenda also includes several bills, 
including medical marijuana. One of those bills, 712, the VA 
Medicinal Cannabis Research Act, I fully support requiring VA 
to conduct research regarding medical marijuana and have said 
so for many years. And that is why under my chairmanship last 
year this Committee unanimously reported bipartisan legislation 
sponsored by then Ranking Member Walz and me that would 
authorize VA to research medical cannabis. It is also why I 
introduced the same bill, H.R. 747, this year after 
strengthening it to not authorize, but require the VA to 
conduct research in medicinal cannabis.
    However, H.R. 712 includes numerous restrictions regarding 
what the research VA must conduct on medicinal cannabis should 
look like. According to VA, those restrictions are inconsistent 
with the standards and practices of scientific research. It is 
wholly inappropriate for members of Congress to dictate the 
research that scientists are being asked to perform and, 
therefore, I oppose H.R. 712 and express disappointment that, 
despite my request, H.R. 747 was not included on today's 
agenda, so that we could have an open discussion about which 
approach this important issue is most likely to benefit our 
Nation's veterans.
    With that, I thank the witnesses for being here, and I 
yield back.
    The Chairman. Thank you, Chairman Roe. And we will discuss 
this more, but I recognize your--I think you have raised some 
very valid points about the research.
    I would now like to welcome non-committee members to our 
first panel. I see that we have the Honorable Lou Correa, Luis 
Correa, a Member of Congress from my own home state, 
California, California's 46th District. We have two other 
Members, but they are not here, and I will introduce them as 
they arrive.
    So, Mr. Correa, you are recognized for 5 minutes. Go ahead.

                OPENING STATEMENT OF LUIS CORREA

    Mr. Correa. Thank you, Mr. Chairman, Chairman Takano and 
Ranking Member Roe, for inviting me to speak on my bipartisan 
bill, H.R. 712, the VA Medicinal Cannabis Research Act. I 
appreciate the chance to return to the VA Affairs Committee 
where I served in the last Congress to speak on this very 
important issue on the need of research on medical cannabis as 
a possible treatment option for our Nation's veterans.
    The U.S. Department of Veterans Affairs is in a unique 
position to pursue necessary research in what cannabis can and 
cannot do for our veterans.
    Our brave men and women return from military service from 
Iraq and Afghanistan, and many times with both visible and 
invisible wounds sustained in battle.
    Unfortunately, for many of these veterans with PTSD and 
chronic pain, the use of prescription opioids has been 
ineffective in providing relief. And, even worse, the use of 
prescription opioids has led to addiction and even death.
    Tragically, VA patients are almost twice as likely to die 
from accidental opioid overdose than non-veterans.
    In California, I have met with many veterans who use 
medical cannabis as an alternative to prescription opioids and 
other medical treatment options, and all of them vouch for the 
therapeutic benefits of medical cannabis and support further 
research into this issue.
    In fact, according to the Iraq and Afghanistan Veterans of 
America, over 90 percent of their members support medical 
cannabis research. And more veterans use cannabis for medical 
purposes, and it is important that doctors be able to fully 
advise on the potential benefits and effectiveness of medical 
cannabis.
    Presently, VA doctors can discuss cannabis usage with their 
patients, but they have very limited federally approved 
research on which to base recommendations or clinical options.
    For that reason, with my colleague and friend Congressman 
Clay Higgins of Louisiana, we have introduced the VA Medicinal 
Cannabis Research Act.
    The bill requires the U.S. Department of VA to conduct 
double-blind clinical studies on the safety and effectiveness 
of medical cannabis. Let me repeat: this bill requires the VA 
conduct double-blind clinical study on the safety and 
effectiveness of medical cannabis. The legislation provides a 
framework for that research to ensure that scientifically-sound 
studies are conducted on this issue.
    And, finally, let me thank the Iraq and Afghanistan 
Veterans of America, Veterans of Foreign Wars, Disabled 
American Veterans, and many others for their support of this 
bill. And I look forward to working with you on this most 
important piece of legislation.
    And, if I may, Dr. Roe, I just wanted to address some of 
your concerns with this legislation.
    I know last year we worked together on some of this 
legislation and I understand your concern that we are mandating 
to the VA how to conduct scientific research. Yet, I have to 
tell you, over the last 2 years and dealing with the VA, they 
have told us different opinions as to what they can and can't 
do at the VA. First, they said, we don't have the authority to 
do the research; then they said, we have the authority to do 
research.
    I am not quite sure who is telling us the truth, where 
there is a truth, but what we are simply doing with this bill 
is assuring that there is no bias in the research of medical 
cannabis, there is no bias on the part of the researchers or on 
the individuals that are actually being researched. That is 
what this bill is about, making sure we get good data for our 
veterans.
    Thank you very much.
    The Chairman. Thank you, Mr. Correa, for your testimony.
    I now would like to recognize Dr. Roe for 5 minutes to 
speak about his bill.
    Mr. Roe. Thank you. And, Mr. Correa, thank you for your 2 
years of service on this Committee and your service in 
California for veterans there. And I know of no one who has the 
interests of veterans any more than you do. You and I are good 
friends, and I respect you and respect what you want to do. And 
we authorized, Congressman Walz and I, last year the VA to do 
the studies; they didn't do it.
    My concern is just this, is that we don't need to be 
prescribing from on the high here in Washington how to carry on 
clinical research. We need to make sure that they do--that the 
VA not authorizes, but has to study either chronic pain or 
opioid, a substitute for opioids, or PTSD treatment. And I have 
read this morning probably a dozen articles on various research 
that is done around the country. I just don't think that--I 
know, as a scientist, we shouldn't as politicians be telling 
the scientists how to design their studies.
    I agree with everything you said and your bill and would 
support it, if it just allowed VA the ability to be able to 
design their trials based on what they think are the best ways 
to do it and not how we think are the best ways. And that is 
all my bill said was that, look, you have to do the studies, 
but let the scientists at Yale or wherever they are, at 
whichever medical center or multiple medical centers that are 
done, that are able to do it.
    And, with that, I yield back.
    The Chairman. Okay. I now would like to recognize Mr. 
Cisneros, Congressman Cisneros, you are recognized for 5 
minutes.

             OPENING STATEMENT OF GILBERT CISNEROS

    Mr. Cisneros. Thank you, Chairman Takano and Ranking Member 
Roe. I really appreciate the opportunity to testify about my 
bill, the Providing Benefits Information in Spanish for 
Veterans and Families Act.
    This legislation would direct the Secretary of Veterans 
Affairs to make all Department of Veterans Affairs fact sheets 
available in English and Spanish.
    According to the U.S. Census, as of July 1st, 2017, the 
U.S. Hispanic population is approximately 58.9 million, 
constituting 18.1 percent of the Nation's total population, 
making people of Hispanic origin the Nation's largest ethnic 
and racial minority.
    With the changing demographic of the U.S. population 
overall trending towards a more racially and ethnically diverse 
majority, the veteran population is diversifying at similar 
rates. The share of veterans who are Hispanic is expected to 
double from 7 to 13 percent, according to the Pew Research 
Center.
    With Spanish as the first language of an increasing number 
of veterans and their families, it is important that the facts 
sheet offered by the VA are made available. This bill would 
serve as an important first marker in ensuring veterans and 
their families with limited English proficiency have full 
access and information on VA services without burden or 
barriers, benefits they have rightfully earned.
    Additionally, I have been informed by Representatives from 
this Committee that this issue is of particular importance to 
veterans in Puerto Rico, in which approximately 300,000 
veterans live.
    I urge you to join me in support of this legislation, H.R. 
2943.
    I yield back the balance of my time.
    The Chairman. Mr. Cisneros, thank you for your testimony on 
your bill.
    I understand you have a second piece of legislation that 
you would like to discuss, so I recognize you for 5 minutes to 
discuss your second bill.
    Mr. Cisneros. Yes. Thank you again, Mr. Chairman, and thank 
you again, Ranking Member Roe.
    This bill is H.R. 2942, Health for Women Veterans Act. I 
really appreciate the opportunity to testify about my bill 
helping to expand and launch Transitional Health--or Health for 
Women Veterans Act, introduced with my distinguished colleague 
and fellow vet Congresswoman Chrissy Houlahan.
    As a veteran myself, one of my top priorities is ensuring 
active servicemembers who are transitioning into the civilian 
world who are connected to the VA system--well, to make sure 
that they are connected to the VA and provided with the best 
education and tools needed to succeed as civilians.
    Despite being the fastest-growing cohort in our military 
community, many servicewomen face unique challenges related to 
their transition into civilian life. Too often, women veterans 
report not feeling comfortable seeking woman-specific care in 
the male-dominant VA health system.
    Studies have shown that women veterans do not connect with 
the VA until approximately 2.7 years post-military service on 
average or until health issues have manifested, contributing to 
higher rates of mental health issues. In fact, over 60 percent 
of servicewomen report that military service has negatively 
affected their mental health, often due to military sexual 
trauma and issues surrounding gender isolation.
    My bill would require the Department of Veterans Affairs to 
extend an ongoing pilot program jointly run with the U.S. Air 
Force under the Transition Assistant Program that educates 
transitioning servicewomen about women's health care at the VA. 
Participants of this pilot program have shown higher rates of 
confidence with the VA, and reported an increased likelihood to 
use the VA health care and resources.
    Specifically, the bill would mandate an extension of the 
program across all service branches and require a report on the 
feasibility of making it permanent. It is time our women 
servicemembers and veterans receive the care they need.
    I would like again to share my sincere appreciation for my 
colleague Representative Houlahan for her work with me on this 
effort to expand transitional assistance for women 
servicemembers and veterans. Under her leadership, we secured a 
complementary provision in the fiscal year 2020 National 
Defense Authorization Act as approved by the Committee on Armed 
Services last week, requiring DoD to expand and encourage 
participation in this program. I look forward to closing the 
loop on the VA's responsibility in this pilot program through 
this Committee as well.
    And the last thing I will say is that it was testified in 
front of this Committee, I believe maybe the Health 
Subcommittee, but this program is working in the Air Force, 
this pilot program, and it is time for us to expand it into the 
other services to make sure that our women veterans are getting 
the support that they need when they transition into civilian 
life.
    I thank you all for the consideration of my bill and I 
yield back the balance of my time.
    The Chairman. Thank you, Mr. Cisneros.
    Congressman Bilirakis, I understand you have a bill you 
would like to present.
    Mr. Bilirakis. Yes.
    The Chairman. You are recognized for 5 minutes.

               OPENING STATEMENT OF GUS BILIRAKIS

    Mr. Bilirakis. Thank you very much, Mr. Chairman. I 
appreciate it. Again, thank you for recognizing me and thank 
you for putting my draft bill, the Ryan Kules Specially 
Adaptive Housing Improvement Act of 2019, on today's agenda.
    This bill, which I will be introducing soon with Chairman 
Levin--by the way, I commend you for selecting Chairman Levin 
as the Chairman of the Economic Opportunity Committee; he is 
doing an outstanding job, Mr. Chairman. So this bill would make 
needed improvements to the VA's Specially Adaptive Housing 
Program.
    This benefit provides funding to severely service-connected 
disabled and services to adapt their homes and meet the needs 
of their disability. This grant can be used on all kinds of 
adaptations, to include grab bars, wheelchair ramps, lifts, 
lower counter tops, wider doorways, and other necessary home 
adaptations.
    While this great benefit has helped thousands of veterans 
over the years, there is a need to make improvements. Many of 
the ideas proposed in this bill came from testimony provided 
last Congress to the Subcommittee on Economic Opportunity by 
several VSO witnesses.
    One of these many witnesses was Mr. Ryan Kules of the 
Wounded Warrior Project. Mr. Kules is an Iraq War veteran of 
the U.S. Army and is a recipient of this grant. And Mr. Kules 
is here.
    Mr. Kules, thank you so very much for your input. I am so 
excited about this bill and we are going to get it across the 
finish line. Can you please wave?
    Thank you so very much, sir. Thank you for your service to 
our country and your continued service.
    And I want to thank the Wounded Warrior Project as well. I 
thank you and the other VSOs who testified, especially the 
Paralyzed Veterans of America, for their suggestions on how to 
improve this program, very important program.
    This bill would require prioritization when processing SAH 
for those with serious life-threatening illnesses such as ALS, 
better known as Lou Gehrig disease. It would also double the 
number of times a veteran may use this grant from three to six 
times, and increase the base amount of funding available to 
participants by 15 percent.
    Finally, this bill would authorize VA to provide a second 
part of funding for veterans 10 years after they use the SAH 
grant to make further improvements if they need more 
assistance.
    While I know that this bill is not the perfect remedy to 
address every issue some veterans have within the SAH program, 
I am hopeful that this bill will be viewed as a down payment on 
much-needed reforms that will help the most severely disabled 
veterans live more independently in their own home. That is the 
goal, Mr. Chairman.
    So I want to thank you for agenda-ing me this draft and I 
look forward to the discussion today. I yield back the balance 
of my time.
    The Chairman. Thank you.
    We have--I think that concludes the presentation of bills 
from our first panel. If there are any questions from members 
of the members who presented on the first panel? I don't see 
any and we will move on to the second panel. All right, so we 
will move on to the second panel.
    The second panel consists of members of our Veterans 
Service Organizations and a clinical expert. I would like to 
call up to the table Mr. Adrian Atizado, Deputy National 
Legislative Director of Disabled American Veterans; Mr. Travis 
Horr, Director of Government Affairs of the Iraq and 
Afghanistan Veterans of America; Mr. Carlos Fuentes, Director, 
National Legislative Service of the Veterans of Foreign Wars; 
Mr. Derek Fronabarger, Director of Government[DF1] Affairs at 
the Wounded Warrior Project; and Dr. Igor Grant, Director for 
the Center for Medicinal Cannabis Research at the University of 
California.
    Are we all situated there? We will give people a chance to 
get settled. I see Mr. Atizado is settled in.
    Mr. Atizado, you are recognized for 5 minutes.

                  STATEMENT OF ADRIAN ATIZADO

    Mr. Atizado. Thank you, Mr. Chairman, members of the 
Committee. I would like to thank everybody here for inviting 
DAV to testify at this legislative hearing.
    DAV is a non-profit Veterans Service Organization. We have 
about more than one million wartime service-disabled veterans 
and they are all dedicated to making sure veterans lead high-
quality lives with respect and dignity.
    We are pleased to support both the Medicinal Cannabis 
Research Act and the VA Survey of Cannabis Use Act based on 
DAV's Resolution No. 023. This resolution calls for more 
comprehensive and scientifically rigorous research into the 
therapeutic benefits and risks of cannabis and cannabis-derived 
products as a possible treatment for service-connected disabled 
veterans.
    Medical literature has thus far been rather inconclusive 
about the effectiveness of marijuana for improving symptoms of 
chronic pain and PTSD in veterans, noting that there are both 
risks and in some cases benefits, and many veterans report the 
use of medical cannabis for these purposes is in fact 
beneficial to them. So we want to ensure the survey and the 
research contemplated by these bills will yield scientifically-
valid and reliable data, and we do urge this Committee to work 
with the research community on any issues with regards to 
research design. Correspondingly, we urge VA to recognize its 
current effort in this area is not meeting the needs of 
veterans.
    These bills should be treated as an opportunity to find the 
right balance between the glacial movement of research in this 
particular area and the need for expedience, with the health 
and well-being of our Nation's veterans being on the line.
    DAV also supports H.R. 485, which addresses VA's routine 
denial of medical ambulance reimbursement claims, because the 
Department does not consistently apply its existing authority 
to pay for such transportation to a VA facility for additional 
care. In light of VA's inconsistent performance in 
administering this authority, we do urge the Committee to 
include an evaluation and reporting requirement of VA's actual 
performance in executing the intent of this legislation, and it 
should be conducted by an entity independent of the Veterans 
Health Administration.
    DAV is proud to be a strong supporter of H.R. 2942 and 
thanks Congressman Cisneros for introducing this bill that 
would build from a successful ongoing transition assistance 
pilot program between VA and the Air Force.
    DAV made this policy recommendation in our report, ``Women 
Veterans: The Long Journey Home.''
    Our report also recommends the TAP program address 
employment, educational opportunities, and gender-specific 
information needs in additional workshops 6 to 12 months after 
separation. We believe this kind of training may arm women 
veterans with information they need to prevent or otherwise 
minimize transition challenges, and prevent health and mental 
health conditions from getting worse or leading to tragedies 
such as homelessness or even suicide, which too many of our 
veterans, both male and female, are lost to.
    DAV strongly opposes H.R. 3083, the VA Asset and 
Infrastructure Review Acceleration Act, which would eliminate 
the prohibition for the Asset and Infrastructure Review 
Commission to convene before 2022.
    By removing the time constraints on the commission, VA will 
accelerate the asset and review process and, in doing so, 
undercut one of the key elements of the compromise that allowed 
the AIR Act to be part of the MISSION Act to begin with, and 
that is to have a truly transparent, inclusive, deliberative, 
and data-driven process.
    VA has already shown its proclivity to move unilaterally or 
otherwise not meaningfully consult with veterans and Veterans 
Service Organizations in other matters regarding the VA health 
care system on which our members depend.
    The timing within the AIR Act is another key element to 
guard against premature decisions on VA's health care 
infrastructure. The new integrated networks under the VA 
MISSION Act must first be optimized. Note it was just rolled 
out a few weeks ago. The new patient demand and referral 
patterns that will result because of this new integrated 
network must yield sufficient historical data before accurate 
forecasting and market assessments can begin the process to 
decide the future alignment of VA's health care infrastructure.
    Mr. Chairman, this concludes my testimony. I would be happy 
to answer any questions the Committee may have.

    [The prepared statement of Adrian Atizado appears in the 
Appendix]

    The Chairman. Thank you, Mr. Atizado.
    Mr. Travis Horr, you are recognized for 5 minutes.

                    STATEMENT OF TRAVIS HORR

    Mr. Horr. Thank you, Chairman Takano, Ranking Member Roe, 
and members of the Committee. On behalf of Iraq and Afghanistan 
Veterans of America and our more than 425,000 members 
worldwide, thank you for the opportunity to share our views, 
data and experiences on the pending legislation before the 
Committee today.
    While I serve as Director of Government Affairs at IAVA, I 
am also a Marine Corps veteran. I enlisted in the infantry in 
2007 and deployed to Helmand, Afghanistan in 2010. The issues 
of the Post-9/11 generation are my issues. I was exposed to 
burn pits on a remote patrol base, I utilized the Post-9/11 GI 
Bill, and I have seen first-hand the positive impact that 
medicinal cannabis can have. Sadly, I have lost too many of my 
friends to the veterans' suicide epidemic. These issues are 
personal to me and I am proud to represent IAVA's views in 
front of the Committee today.
    In IAVA's latest member survey, a resounding 90 percent 
believe cannabis should be researched for medicinal uses. IAVA 
members are vastly in support of cannabis research and it is 
time for the VA to catch up.
    For these reasons, the VA Medicinal Cannabis Research Act 
is the centerpiece of IAVA's Cannabis for Vets campaign. 
Without this research, we are unable to make policy decisions 
that could improve the lives of veterans.
    One such veteran whose life was improved through medicinal 
cannabis is Army veteran and former IAVA intern Julie Howell. 
Her story, in her own words, follows.
    ``For years after I returned from Iraq, I struggled to 
sleep through the night. As it turns out, I suffer from 
something known as maintenance insomnia. I would fall asleep, 
but would wake for hours in the middle of the night, and then 
fall back asleep right before needing to wake up. Thanks to 
California passing legislation regarding medicinal cannabis, I 
now have access to a product that I ingest that helps me sleep 
through the night. I do not use cannabis recreationally, but 
this product has allowed me to thrive. I am currently working 
through a master's degree in public policy with the hope of 
assisting veterans like me.''
    In addition to Julie, over 100 IAVA members have shared 
their stories of their cannabis use, with dozens sharing how VA 
retaliated against them or mishandled them. In fact, it is 
because of these reasons that Julie herself, even after 
advocating here on Capitol Hill and back home in California, 
still hasn't talked to her VA doctor about her use, and Julie 
isn't alone. Twenty percent of IAVA members report using 
cannabis for medicinal purposes and of those only 31 percent 
have talked to their doctor about it.
    If veterans are unable to receive the care that they 
deserve, then they will go around it. We must ensure that VA 
clinicians can have open and honest discussions with their 
patients.
    For these reasons, IAVA is proud to support the Veterans 
Equal Access Act.
    IAVA is also supportive of the VA Survey of Cannabis Use 
Act, and H.R. 2677 to increase clinician training for medicinal 
cannabis.
    Millions of veterans also rely on VA for their health care. 
We need a system that leverages the use of these new 
technologies and streamlined processes and enable VA to respond 
to the needs of today's veterans. Even so, the best technology 
will not save a system if it is built upon outdated structures. 
Because of these reasons, IAVA supports the AIR Acceleration 
Act, which will allow the commission to be nominated, 
appointed, and start their important work as soon as possible. 
However, we strongly recommend that the Secretary not move 
forward with this process until the VA completes local capacity 
and commercial market assessments with full stakeholder 
consultation, and stabilizes community care efforts.
    Additionally, IAVA is supportive of H.R. 2943, to ensure 
that all VA fact sheets are produced in both English and 
Spanish; H.R. 485, to expand VA's ability to reimburse 
emergency ambulance services; and the draft legislation 
concerning specially adaptive housing.
    Data shows that women veterans on average do not seek 
support from VHA until 2.7 years after leaving service. Women 
veterans also tend to face more health-related challenges than 
their male counterparts. And most importantly, since 2001, the 
suicide rate for women veterans has increased by 85 percent 
while the suicide rate for males has increased by 30 percent.
    It is because of these reasons that the VA Air Force 
Women's Health Transition Training pilot was created. It is 
aiming to provide servicewomen with a deeper understanding of 
women's health services within the VA system and allow a warm 
handoff between DoD and VA.
    The Helping Expand and Launch Transitional Health for Women 
Veterans Act is consistent with IAVA's groundbreaking She Who 
Borne the Battle campaign, to recognize the service of and fill 
gaps in care for women veterans. Women veterans are the 
fastest-growing cohort of veterans and it is critically 
important that they receive the same care as their male peers. 
IAVA supports H.R. 2942.
    Veterans are proven to be more productive and have higher 
retention rates once hired into careers, and ensuring that they 
have appropriate training and degrees is paramount to their 
success. The successful transition to the civilian workforce 
often begins on college campuses.
    To this end, IAVA is supportive of the draft legislation 
that addresses and improves the VA Work Study program. We 
believe that by using the Department of Education as a model VA 
will be able to make work study payments more reliably. 
Ensuring that veterans are supported on campus is of utmost 
importance.
    Members of the Committee, thank you again for the 
opportunity to share IAVA's views on these issues today and I 
look forward to answering any questions you may have. Thank 
you.

    [The prepared statement of Travis Horr appears in the 
Appendix]

    The Chairman. Well, I am impressed, 5 minutes exactly.
    [Laughter.]
    The Chairman. I was like, will he do it or not?
    Thank you, Mr. Horr, for your very exact timing.
    Mr. Fuentes, you are recognized for 5 minutes.

                  STATEMENT OF CARLOS FUENTES

    Mr. Fuentes. Thank you, Mr. Chairman. I first want to say 
kudos with the Spanish. I think you may be speaking better 
Spanish than I do, but well done.
    Chairman Takano, Ranking Member Roe, and members of the 
Committee, on behalf of the 1.6 million members of the VFW and 
our Auxiliary, I would like to thank you for the opportunity to 
present our views before the Committee.
    The VFW is proud to support the VA Medicinal Cannabis 
Research Act of 2019. VA's over reliance on opioids to treat 
chronic pain and other conditions has, unfortunately, led to 
addiction and even death. To its credit, VA has made a 
concerted effort to reduce the reliance on pharmaceutical 
treatments, now VA must expand research on the efficacy of 
nontraditional alternatives to opioids, like medical cannabis 
and other holistic approaches.
    VFW members tell us that medicinal cannabis works, and it 
is a better alternative than the cocktail of drugs the VA 
provides. The VFW and Student Veterans of America Fellow 
Christopher Lamy, an Army veteran and LSU Law School student, 
focused his semester-long research on medicinal cannabis. Chris 
found that veterans experience chronic pain at 40 percent 
higher rates than non-veterans and, if not properly treated, 
such chronic pain leads to depression, anxiety, and decreased 
quality of life.
    Chris also discovered that veterans fear they may be 
wrongfully denied care or have their care altered without their 
consent if they discuss their use of medicinal cannabis with 
their VA doctors.
    To ensure participants of this study do not have their VA 
health care impacted, the VFW recommends prohibiting VA doctors 
from denying or altering treatment to patients without 
consultation and concurrence of such veterans.
    The VFW also supports the Veterans Reimbursement for 
Emergency Ambulance Service Act and has a recommendation to 
improve it. The VA emergency transportation reimbursement 
process is cumbersome and unreasonably long. Veterans who 
believe they are experiencing an emergency should not be 
delayed or deterred from contacting 911 for emergency 
assistance because VA may refuse to cover the cost of emergency 
transportation and leave them in crippling health care debt.
    This bill would rightfully streamline VA's authority to 
reimburse emergency transportation costs; however, it would 
require that veterans be taken to the closest and most 
appropriate medical facility as a prerequisite for 
reimbursement. Veterans experiencing emergencies typically 
don't have the ability to influence where they are taken. For 
that reason, we would recommend removing that restriction, so 
that veterans aren't forced to pay ambulance fees simply 
because the VA and ambulance service can't agree on what 
constitutes closest and most appropriate.
    The VFW fully supported the Asset and Infrastructure 
Review, or AIR, provisions of the VA MISSION Act of 2018. They 
are important to fully examine VA's aging infrastructure and 
determine what changes are needed to improve the high-quality 
care VA provides veterans. However, we would be very concerned 
with expediting this process. It is vitally important that the 
AIR process be implemented correctly. The VFW warns Congress 
not to rush the AIR process, because it may cause irrevocable 
harm to the care and benefits America provides veterans.
    The VFW supports draft legislation to expand the VA's 
Specially Adaptive Housing grants, which help veterans with 
service-connected conditions live independently in barrier-free 
environments by providing critical housing adaptation. The VFW 
is pleased this would increase the number applicants VA is able 
to approve annually from 30 to 120; however, we do not think a 
cap is needed for this important. Every veteran who needs to 
adapt their house because of a service-connected condition 
should have the ability to do so.
    The VFW also thanks the Committee for its intention on a VA 
Work Study program, which student veterans use to supplement 
their income. This important program must be improved to ensure 
veterans receive their payments on a timely basis. VA's 
outdated, paper-based payment process forces veterans to wait 
several weeks or months to receive their work study payments, 
which they need to make ends meet.
    Mr. Chairman, this concludes my statement. I am happy to 
answer any questions you or members of the Committee may have.

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

    The Chairman. Thank you. Thank you, Mr. Fuentes.
    I would now like to recognize Mr. Fronabarger for 5 
minutes.

                 STATEMENT OF DEREK FRONABARGER

    Mr. Fronabarger. Chairman Takano, Ranking Member Roe, 
distinguished members of the Committee, thank you for inviting 
Wounded Warrior Project to testify about legislation before 
this Committee this afternoon. While there are many significant 
bills and issues being considered today, and our written 
testimony outlines our stance on each of them, Wounded Warrior 
Project would like to use this time to highlight one bill that 
is extremely important to us, the Ryan Kules Specially Adapted 
Housing Improvement Act of 2019.
    As you already know, he is currently sitting directly 
behind me and I invite you all to speak with him after the 
hearing to better understand his personal story. Retired Army 
Captain Kules is 24 years old and newly married when he was 
injured in Iraq in 2005. While on patrol, an IED struck his 
vehicle. In that attack, Captain Kules lost his right arm and 
left leg and fellow servicemembers from his unit. While this 
was a tragic loss, this event did not define him or hold him 
back from leading a productive life.
    After multiple surgeries and rehabilitation, Captain Kules 
is ready to transition into civilian life. And in 2019, he was 
in the position to purchase a home in the DC area for his 
growing family. He used the specially adapted housing grant to 
alter this home to meet current needs. The key phrase being his 
current needs. Unfortunately, the existing SAH grant does not 
account for future needs of the catastrophically injured 
veteran population.
    Although Captain Kules was provided with $64,000 through 
the VA SAH grant, there was a gap of nearly $40,000 that was 
needed to cover in order to make necessary home modifications 
that would ultimately total more than $100,000.
    Captain Kules would then move six years later to a new home 
after he and his wife welcomed their second child into their 
family. As is the case for some homeowners, the Kules family 
did not recoup the cost of their home adaptation improvements 
when they sold their first house. As a result, Captain Kules 
and his family were required to financially pay for the new 
adaptations. These new adaptations would total more than 
$90,000 for a second home.
    Catastrophically injured veterans should not be obligated 
to pay for disability accommodations due to injuries sustained 
while service to this country. The SAH grant program honors 
that commitment but it does not reflect the fact that many 
veterans, like other adults in this country, will have needs 
that change. In this case, younger critically injured veterans 
will age, many will marry, and some will be fortunate enough to 
grow families with children.
    Injured veterans can also be expected to have disabilities 
that worsen over time. Adaptations for one stage of a 
disability may not be suitable for later stages and new 
adaptations will cost money. Additionally, we want warriors to 
thrive in their workplace and personal lives. For those who 
seek new and better opportunities in life and career, 
relocation has to be an option. It is, in our estimation, 
unreasonable to expect a veteran to buy a home and never leave. 
Therefore, we are pleased to see that this draft legislation 
before the Committee today addresses the points raised in this 
testimony.
    The bill would allow previous beneficiaries the opportunity 
to refresh their specially adapted housing grant every ten 
years. This means that veterans can update or move homes and 
not be expected to pay for adaptations. Moreover, this bill 
raises the current grant amount of $85,000 to $98,000, which 
falls in line with what home adaptations can cost. It will also 
eliminate the three time use cap that restricts the full and 
intended potential of this program.
    If passed, this bill would ensure that when critically 
injured veterans need a new home, whether it is because they 
have had more children, found a different job, or retire, that 
they will not be expected to pay for these home adaptations 
themselves. This benefit is reserved for those catastrophically 
injured and who deserve our assistance throughout their entire 
life, not just one portion of it.
    On behalf of Wounded Warrior Project, I thank the Committee 
and its distinguished members for the invitation to testify. 
Additionally, a special thank you to Congressman Bilirakis and 
Congressman Levin for your continued work on this legislation. 
We look forward to any questions this Committee may have.

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

    The Chairman. Thank you, Mr. Fronabarger. Dr. Grant, you 
are recognized for 5 minutes.

                    STATEMENT OF IGOR GRANT

    Dr. Grant. Thank you, Chairman Takano, Ranking Member Roe, 
and distinguished members. Good afternoon. My name is Igor 
Grant. I am a physician, neuro-psychiatrist, and professor at 
the University of California, San Diego, where I direct the 
center for medicinal cannabis research. During my career, I 
also served three decades as a staff physician at the VA San 
Diego Medical Center.
    Some of the prevalent health problems of our veterans 
include chronic pain, post-traumatic stress disorder, traumatic 
brain injury, as well as sleep disorders. Our veterans have not 
always found the treatments that we offer them to be fully 
beneficial and they therefore sought recourse outside the VA 
medical framework, including with medicinal cannabis in states 
where it has been legalized.
    I am here today to provide you with my medical opinion as 
to the current state of knowledge on medicinal cannabis. 
Clearly, this is a controversial area, but there are important 
facts that are emerging. The Center for Medicinal Cannabis 
Research at UC San Diego was established following the passage 
in 1996 of the Compassionate Use Act, which was California's 
initiative to enable medicinal cannabis.
    We have since completed eight different shorter term 
clinical trials with cannabis provided to us by NIDA through 
their drug supply program. As you may know, NIDA is the only 
legal source of cannabis for medical research. Our studies 
found that THC contained in cannabis, ranging in strength from 
two percent to seven percent showed benefit--type of chronic 
pain called neuropathic pain, which is sometimes difficult to 
control with traditional medicines.
    Our results dovetailed with emerging data from other 
investigations, as well as the 2017 report from the National 
Academies of Sciences, Engineering and Medicine. Now, that 
report also noted that there was some evidence for benefits for 
certain sleep disorders, particularly where pain was a factor 
and possibly for anxiety control, including PTSD.
    As you know, most recently cannabidiol, which is a non-
psychoactive constituent of cannabis has been shown to be 
effective in control of certain uncommon intractable epilepsies 
of children. We have started, or will be beginning studies 
soon, to determine whether THC, THC CBD combinations, or CBD 
alone may be helpful in the treatment of some symptoms of PTSD, 
psychosis, anxiety, autism, essential tremor, and sleep 
disorders.
    Another area of increasing interest, as has been mentioned 
already is the possibilities the cannabinoids may have a so-
called opioid sparing effect. What this means is it may be 
possible that the administration of cannabis or cannabinoids 
may reduce requirement for opioids or potentially completely 
substitute for them.
    Now, in summary, I would recommend to you that the area of 
medicinal applications of cannabis and cannabinoids have 
matured to the level that it is now clear these drugs can be 
helpful for some conditions, including conditions that are 
found in moderately high prevalence among our veteran 
population.
    As such, it is my opinion that the VA would be benefitting 
veterans by making sure providers are informed of the state of 
medical science concerning the cannabinoids and that ultimately 
providers are authorized to recommend these products, where 
that is legal and medically and scientifically justified.
    This leads me to my final comment. It is essential, as 
everyone has said previously that high quality medical studies 
continue to be done in this area. I recommend that the VA work 
closely with academic universities that have expertise in the 
area to pave the way to a better understanding of efficacy and 
limitations of these products. It is important, also, to focus 
on specific cannabinoids, their combinations, their 
pharmacology, which we don't know a lot about, particularly as 
it is influenced by root of administration and interaction with 
other medicines, as well as understand the optimum duration of 
treatment.
    May years ago, when I was in training as a psychiatrist, I 
learned about the VA's landmark role in determining the value 
and limitations of anti-psychotic medicines in the treatment of 
schizophrenia. I believe the VA, with its academic partners, 
can be at the forefront again of creating a better 
understanding of the place of cannabis and cannabinoids in 
addressing the health needs of our patients.
    Thank you, Mr. Chairman.

    [The prepared statement of Igor Grant appears in the 
Appendix]

    The Chairman. Thank you, Doctor. And you hit the zero, just 
five minutes exactly. All right. Thank you. I am going to begin 
the questioning. I recognize myself for 5 minutes.
    I will start my question with Mr. Fuentes, so the VFW. Your 
testimony states that the VFW members have no indicated that 
lack of Spanish language materials present a barrier to 
accessing benefits. Has the VFW recently spoken to its members 
in Puerto Rico about the Mission Act and whether veterans 
understand the new law?
    Mr. Fuentes. Thank you, Mr. Chairman. We reached out. We 
haven't heard back yet exactly on the barriers to access. Just 
to be clear, the VFW supports eliminating all access--all 
barriers to access to care and benefits for veterans. This is 
just not one that we have been hearing about often.
    The Chairman. Okay. So let us know what you hear from your 
members from Puerto Rico. Has the VFW called the Spanish 
language veteran's crisis line in Puerto Rico?
    Mr. Fuentes. I have not, but I will do so when we get out 
of here.
    The Chairman. Okay. All right. They are probably going to 
turn it on now. That will be--we put them on blast right now. I 
haven't used that word since I was a teacher, ``Put them on 
blast.'' I don't even know if they still use that, the 
students. Do you have any other recommendations to improve the 
bill?
    Mr. Fuentes. We do. So the VFW has posts in Puerto Rico, 
also in Panama, but throughout southeast Asia, in Europe, and 
even in Australia, where their English is a little bit 
different too. But we recommend just do an analysis to 
determine if it is more than just Spanish. I mean, VA does have 
a post--I am sorry, a CBOC in the Philippines and some of its 
literature in Tagalog as well. So maybe there is a need 
elsewhere. It would be good to do an analysis to determine if 
there are other languages that could be barriers as well.
    The Chairman. Okay. Well, thank you. Thank you for that.
    I would like to go to the--is this on the third panel? This 
one? This question here? Okay, great.
    We all want to update and right size VA's medical 
infrastructure, but in an abundance of caution, without 
understanding the impact of the access standards, without 
knowing if they are assessments will accurately depict 
veterans' medical needs today and into the future, and both 
VA's and the community's capability to supply some or all of 
the care, I feel that this is the wrong road to go down.
    What are your chief concerns with accelerating the timeline 
of the Air Act Commission? And I want to just have all of the 
VSOs, starting with Mr. Atizado to give kind of a brief answer 
to that.
    Mr. Atizado. A brief answer?
    The Chairman. Well, what you can. I have two and a half 
minutes.
    Mr. Atizado. Mr. Takano, listen, I thank you for that 
question and I appreciate the comments that Ranking Member Roe 
has made about the bill. You raised the issue about whether 
their role is going to help or hurt the infrastructure 
realignment of the VA and I think--our impression is if you 
allow commission to meet without the preliminary work ready for 
them then there is additional pressure to create the 
preliminary work. And the kind of work that needs to be done is 
quite complex. It is a heavy lift for VA. And the information 
from which they are trying to gather that data for the 
commission still has not been--it is still not there. There is 
no reality for that.
    This Committee is very well aware of VA' ability to 
forecast community care. It has come to VA a couple of times 
over the last several years for emergency supplemental funding 
for care in the community through the Choice Act. There is just 
not enough data in VA's health care system to forecast what the 
demand is going to be like in the Choice program. And now we 
have a new program with, as you had mentioned, different 
eligibility criteria.
    This new network has not been integrated. It hasn't been 
optimized. The behavior patterns and the demand on VA for 
health care because we are allowing a fivefold increase in a 
number of veterans who would otherwise be eligible for 
community care, that kind of data is not going to be had by VA 
for at least two or three years. That is what they need to do 
proper forecasting, accurate forecasting.
    And if we are to look at and realign VA's health care 
infrastructure into the future by using historical data, I 
would think that we would want to make sure we use valid and 
reliable data. And that is what we are most concerned about. 
There will be pressure to accelerate and we have seen what VA 
has done in times of pressure to perform and it has not yielded 
very good results for our members.
    The Chairman. Well, thank you. I want to be consistent with 
myself. I am out of time, so I want to just go ahead and 
recognize Dr. Roe, even though I really want to hear from the 
other VSOs, their response to this question. Go ahead, Dr. Roe, 
5 minutes.
    Mr. Roe. Thank you. I am going to go quickly and put my 
doctor hat on first. And Dr. Grant, thank you for the work you 
have done with our veterans over the years, the decades of 
years you have been spent doing that. I have--look, every 
single person up there I think wants medical marijuana, 
cannabinoids studied. The question is how you do it. And I am 
just going to ask--and let me just introduce this with the NIH.
    U.S. Food and Drug Administration hasn't approved 
marijuana, the plant, for treating any health problems. 
However, some states and the District of Columbia allowed its 
use for certain health purposes. While the marijuana has 
therapeutic benefits and outweighs the health risks is 
uncertain.
    And as a physician, let me just go over how complicated 
this is. Here is a Yale study that I have right here. And 
individual, personal testimonials are good. They can head you 
in a direction, but they are not science. And here is--
basically this Yale study says that stopping marijuana during 
the treatment and contrast was associated with the greatest 
improvement in PTSD. Our findings do now suggest, however, that 
marijuana is associated with improvement in PTSD. Previous 
evidence suggests that marijuana improves PTSD symptoms come 
from--reports. Another possible interpretation of this data is 
that marijuana use in patients with PTSD provides transient 
relief, but the subsequent periods of withdrawal contribute to 
a worsening of baseline symptoms.
    Now, this is what--I have read 15 articles this morning in 
a couple of hours. It is very confusing. What I would like to 
do is to take the shackles off Dr. Grant and the other 
scientists that are out there, and don't prescribe to them how 
we do these studies, but do have a study on whether you can 
reduce opioids. And I do have--multiple studies, actually, 
would be better as you well know in different populations to 
refute or to--look, it may work very well. I don't know from 
reading all of this. And literally, I spent two hours this 
morning doing that, reading, and I have got the articles right 
here in my binder.
    Dr. Grant, would you like to be constrained or would you 
like to be allowed just to open up and study this, an expert 
like you for 30 years, would you like me telling you how to do 
it or would you like to allow the scientists to figure out how 
to do it?
    Dr. Grant. Am I allowed--I don't like to be told what to 
do, but that is just my personality.
    You know, I think it is right that first of all, one should 
get down to the concepts that need to be clarified. And these 
include things that have been mentioned already, for example, 
are there particular conditions that particularly are 
benefitted. If so, for how long? Are there restrictions on age, 
for example, or co-morbidities, like if you have diabetes and 
so on and so forth.
    Another set of questions relates to the compounds 
themselves. It is important to have a certain strength of THC, 
CBD, some mix of those things? We really don't know that. 
Another has to do with root of administration. Not everybody is 
smoking marijuana anymore. In fact, okay, there is vaping, but 
a lot of it is being taken by mouth.
    We know much less about the whole pharmacology of these 
drugs taken by mouth. And we also don't know much about what 
happens to the endo-cannabinoid system, our own internal 
signaling system and physiology in response to these things.
    My own thought would be that what one needs to do is really 
set up some kind of centers of excellence or something of that 
nature, as the VA has done with some other topic areas where 
you could look at this from many perspectives and at different 
parts of the country and look at different populations.
    That might be an approach that would bring together a lot 
more things than trying to do everything in one study. Having 
said that, if it is kind of do this study or zero, I guess I 
would prefer to see this go forward than nothing happen. So I 
don't know if that answers your question.
    Mr. Roe. I would rather do it right and I think what you 
mentioned is right.
    I am just going to make a couple because I have very little 
time left, but just on the Air Act, changing the dates or 
expanding the time available for the commission would not in 
any way impact the status of market assessments, which will be 
done next year.
    And I spoke to the secretary about this at length. His 
concern is you get the market assessments that are done next 
summer and by the time this gets going, those market 
assessments are out of date. That is his major concern. And 
actually, this will give us a time to push even further.
    Look, this is a big undertaking. I totally get that. And 
you all know me well, and everybody at that dais I think does. 
I have said a thousand times, I would rather go slow and get it 
right than go quick and get it wrong, just like the Mission Act 
and everything else. So there is no rush, but I think waiting 
is not going to change.
    And I appreciate your comments. I yield back.
    The Chairman. Thank you, Dr. Roe. I now would like to 
recognize Mr. Lamb for 5 minutes.
    Mr. Lamb. Thank you, Mr. Chairman. Dr. Grant, have you 
actually looked at the requirements of the Cannabis Research 
Act we have today? There are some objections from the VA about 
the way the bill is written and the types of studies it would 
mandate. I think that is what Dr. Roe was asking about. Are you 
familiar with what the bill actually calls for?
    Dr. Grant. Yes. I have it here and I have read it. I don't 
say--I can't tell you I have memorized it, but I have it and I 
have read it. Yes.
    Mr. Lamb. This isn't a pop quiz. I was just trying to get a 
feel for whether you, just as a physician doing research and 
practicing in this area, do you share the same concerns that 
the VA is telling us, which is that it sort of forces them to 
do too many things at once as opposed to earlier, smaller, more 
controlled trials?
    Dr. Grant. Well, as I said earlier, I think what is in this 
bill is very ambitious. It has a lot of elements to it. And as 
you know, in science, you never know exactly where things are 
going to go. You have to be positioned to move in different 
directions. It would be my personal preference that there be 
outlined, ``Here are the things we want to have answers to,'' 
and then develop an approach to that.
    But having said that, I will repeat what I said before, it 
is critically important to do this kind of work. And if this is 
the path forward and everything else will, you know, devolve 
into five years of discussion, then it is better to do this 
than to do nothing. But it would be preferred to have a more 
multi-pronged approach, slightly less prescriptive approach as 
a scientist.
    Mr. Lamb. Thank you. That is very helpful. Now, in your 
testimony when you talked about the possibility that 
cannabinoids could have an opioid sparing effect and the need 
for further research in that area, could you explain maybe in a 
little bit more detail what is the state of knowledge or 
certainty as it exists now with respect to the potential for 
cannabinoids to have that effect? Have there been early initial 
studies? Is that what your comment is based on or is there 
still sort of an unknown?
    Dr. Grant. Well, first of all, there are pre-clinical 
studies, animal studies, that make it clear that there is a 
reduction in an animal's intake of opioid in pain models of 
various kinds when cannabinoids are administered 
simultaneously. So there is pre-clinical data.
    I think the clinical data are still very preliminary and 
really relate a lot to these indirect surveys that you have 
read about where opioid use may or may not decrease in certain 
states where medical marijuana exists, and also the testimony 
of physicians in pain clinics that say that, ``Gosh, I have a 
number of patients that I have not been able to wean off of 
these opioids because they are using medicinal cannabis.'' And 
that is certainly true at our center. But I don't consider that 
a definitive study.
    Mr. Lamb. Right. Has that been true in your own experience 
or is that mainly reported to you by colleagues?
    Dr. Grant. Well, I am not a pain physician myself but one 
of the pain physicians who runs our pain clinic is part of our 
center and he has reported this, that he has been able to 
reduce opioid prescription and in some case discontinued 
totally, in people who have taken medicinal cannabis. Again, 
this is not a formal study, though.
    Mr. Lamb. Right. Do you know if that is typically combined 
with other non-opioid methods of treatment or has that been--
from what you know, has that been sort of solely attributable 
to the use of the cannabinoid?
    Dr. Grant. Well, again, I don't know about other clinics. 
In ours, it is a comprehensive program. It does also involve 
behavioral approaches and such things. But even adjusting for 
that, it seems like the cannabinoids may be helpful. Certainly, 
I think the pre-clinical data is very suggestive.
    Mr. Lamb. Great. Thank you very much, Mr. Chairman. I yield 
back.
    The Chairman. Thank you, Mr. Lamb. I now recognize Mr. 
Bilirakis for 5 minutes.
    Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it. 
Mr. Fuentes, can you please tell us why you believe it is 
important to prioritize SAH grants for veterans with serious 
illnesses such as ALS?
    Mr. Fuentes. ALS is one of those conditions that 
deteriorate very quickly. And unfortunately, VA is limited to 
30 grants per year today and the process takes a good long time 
as well. So not only does it progress really quickly, so we 
want to make sure those adjustments are done very quickly, it 
could also take years because they didn't get in before the 30 
grants were approved.
    Mr. Bilirakis. Okay, thank you. And I understand that, you 
know, we are raising the amount of grants anyhow overall under 
this legislation. But I am not sure whether the caps apply for 
ALS. But in any case, we actually covered this, Mr. 
Fronabarger, you actually covered this in your testimony, but 
it is definitely worth mentioning again. There is no question.
    Why do you believe the reinstatement of SAH benefit ten 
years after the veteran's initial grant would be helpful to 
veterans?
    Mr. Fronabarger. Absolutely. And I appreciate that 
question, Congressman.
    As many of you know, veterans normally do not just stay in 
one location. Specifically, our population, we deal a lot with 
the injured, ill, and wounded of today's generation. So we 
don't find it, I guess, normal for someone to adapt their first 
home and then stay there until they pass away, hopefully at a 
very, very old age.
    So with every 10 years, that lines up with about the 
average house an American homeowner will own, anywhere between 
five and six. So if you get injured at 30, but by the time you 
are 90, you still have that benefit going on and you fall in 
line with the average American. So every 10 years is kind of 
how we came up with that and we feel that it is an equitable 
way to honor those veterans.
    Mr. Bilirakis. Thank you very much. And another question 
for you, sir. How does the current three time usage limit or 
cap on the SAH grant impact a veteran's ability to adapt his or 
her home?
    Mr. Fronabarger. Thank you for that, Congressman. Currently 
the SAH grant has a three time usage cap, as you said. The 
benefit is up to $85,000. So right--as now, the veteran can 
use--if they need $20,000 to adapt their home, they can use 
that $20,000 and they have two more usages up to that cap.
    So for those that are injured but don't require the entire 
amount, changing that from three to six can help them because 
$20,000 times three is $60,000. They are not reaching the full 
potential of what they might need if they move. So we look at 
that as a beneficial way for veterans to utilize the full 
benefit-
    Mr. Bilirakis. More flexibility?
    Mr. Fronabarger. Absolutely. Yes, Congressman.
    Mr. Bilirakis. That is--yeah, very important. Thank you 
very much. And again, we have a lot of non-profits that do a 
wonderful job of building homes for vets, but raising the 
amount by 15 percent and giving the veteran the flexibility, as 
well. And then again, the 10 year rule under this bill is 
wonderful to have the full amount again after 10 years. It is 
just something that the veteran deserves. It is a quality of 
life issue. So I appreciate it and I would like to see the 
whole Committee co-sponsor the bill. I appreciate--for that 
matter, the whole House.
    Thank you very much and I don't know if anybody wants the 
rest of my time, but if not, I yield back.
    The Chairman. I will take it back. Thank you.
    Mr. Bilirakis. All right. Take it back. You got it. You got 
it, Mr. Chairman.
    The Chairman. Thank you. Mr. Levin, you are recognized for 
5 minutes.
    Mr. Levin. Thank you, Mr. Chairman. And I would like to 
thank my friend, Mr. Bilirakis, the Ranking member. I am 
honored to have the opportunity to help introduce this 
legislation.
    And I wanted to begin by asking about it and then move to 
cannabis with the time I have remaining. I appreciated the 
testimony, as always, from all the VSOs today in sort of the 
discussion draft. Mr. Fuentes, in your written testimony, you 
talked about two difficulties. One was long wait times and the 
other was--we were talking about months, which is amazing, and 
the other is the requirements for contractors to meet.
    Can you talk about the--kind of our understanding what is 
causing the roadblocks? Again, it can be up to many months.
    Mr. Fuentes. The application process, you know, 
specifically when it comes to ALS and severe illnesses, these 
are illnesses that require immediate attention and it takes a 
lot--too long for VA to process the applications. The 
contractors, because of the requirements of exactly what needs 
to be met sometimes aren't familiar with those requirements, so 
then it takes time to find one that is not only familiar with 
it, but also willing to undertake the task.
    Mr. Levin. Thanks for that. And the second difficulty again 
is finding contractors. Can you speak more to that, to the 
requirements for finding contractors, why that is such a 
difficult issue?
    Mr. Fuentes. It comes, in terms of the requirements that VA 
has on how it must be completed and also the quantity of 
contractors that are out there as well, even though we do have 
a good amount who are willing to work and assist veterans. 
Because of the long process that it takes to get everything 
approved, some of them may not want veterans to go through the 
SAH process.
    Mr. Levin. Thank you. I appreciate that and your continued 
support, working together with Mr. Bilirakis and my colleagues 
as we get this over the finish line.
    I wanted to turn to cannabis, and Dr. Grant, I wanted to 
thank you for being here today. I represent UC San Diego. SO I 
am really honored that you are doing some of the leading 
research on this. It is a great honor. If you watch the 
Congressional baseball game next week, I will be proudly 
wearing the UC San Diego uniform.
    In your testimony, you explain that research has confirmed 
the benefit of medicinal cannabis in cannabinoids for some 
chronic conditions, but further studies are needed to fully 
understand the effects of these drugs. And of course, we know 
about the supply constraints. And I wanted to ask you about 
that.
    You are basically limited to the University of Mississippi 
and I wanted to understand from you, how did those supply 
constraints impact the work that you are doing?
    Dr. Grant. Yes, well, it is in several ways. First of all, 
the University of Mississippi program is doing its best. So 
this is not about dissing them. But they are one provider and 
they have a lot of difficulty, I think, keeping up with what is 
going on in the real world. So for example, up until a year or 
so ago, there were upper limits on how much THC was in a 
product, whereas on the street now, it is 15 percent and we 
have been studying 4 percent and 2 percent and such.
    Now, it may be that those percentages are all you need 
medicinally. You need a lot more to get super looped, but maybe 
for the treatment benefit, you may need a much lower dose.
    The other has to do with the types of formulations. As you 
know, a lot of people are taking edibles of various sorts. You 
know, if we had to study, say marijuana in brownies, we would 
have to bake them ourselves, literally. We would have to get 
the product from Mississippi and set up and we are not really 
equipped to do those kinds of things.
    The other has to do with different mixes. So it may be the 
case that having a say 20 to 1 mix of CBD, the cannabidiol to 
THC, may be optimal for some things because it may be the CBD 
is cutting the effects of the THC and so forth. These are all 
theories, but we don't have those kinds of products.
    So, you know, one option is to pursue importation because 
in Canada, they have a number of GMP facilities, manufacturing 
practice facilities. Maybe that could be expedited in some way 
while, you know, kind of we catch up in this country. The other 
is the DEA a long time ago, a couple of years ago said they may 
license more manufacturers in the U.S., but as far as I 
understand it, nothing has happened with that process. So the 
supply is a real problem.
    Mr. Levin. Thank you, Dr. Grant. I am out of time, but I 
want to thank you for your decades of good work at the medical 
school and the Department of Psychiatry at UCSD.
    Dr. Grant. Go Tritons.
    Mr. Levin. Go Tritons.
    The Chairman. Say, ``Go Highlanders.'' Okay. Dr. Dunn, you 
are recognized for 5 minutes.
    Mr. Dunn. Thank you very much, Mr. Chairman. I will be 
brief.
    I noted at our VA Health Subcommittee hearing on April 30th 
that Federal laws and state laws often do not exempt VA 
physicians from criminal punishment were they to prescribe 
cannabis or any illegal substance to a veteran. It is our job 
as policymakers to protect both the physicians and the veterans 
before we go off and encourage them to prescribe or recommend 
any illegal substance as a treatment for any of the myriad of 
conditions that have been indicated for cannabis.
    One way I personally support this is by looking into 
rescheduling cannabis into a Schedule 2 substance. The benefit 
of this is just that it facilitates serious scientific 
research. It makes it much easier to get the substrate that the 
good doctor mentioned.
    And I think we have many divergent opinions regarding the 
utility and value of cannabis as a medicine, but I think we can 
all agree that we need more research, serious scientific 
research into this topic. And as a final comment, I would like 
to note that the research should be designed and directed by 
scientists and not policy makers.
    And with that, Mr. Chairman, I yield back.
    The Chairman. Thank you, Dr. Dunn. Ms. Luria, you are 
recognized for 5 minutes.
    Ms. Luria. Thank you. And I would like to start by talking 
about the proposed H.R. 1647, Veterans' Equal Access Act 
proposed by Representative Blumenauer. And just to recap the 
summary of that is to authorize the Department of Veterans 
Affairs Health Care Providers to provide recommendations and 
opinions to veterans regarding participation and state medical 
marijuana programs. So in states where it is legal and 
accessible.
    And I just wanted to address this question specifically to 
the VFW because your testimony states that your opposition to 
this, and I am just trying to quantify if this is the only 
reason for opposition, that it is unacceptable for VA providers 
to recommend a treatment that they are unable to provide for 
veterans. Thus, a treatment that the veteran would have to pay 
for at their own expense. Is that your sole reason for 
objecting to this particular item?
    Mr. Fuentes. Yes, ma'am.
    Ms. Luria. So you otherwise support in states where 
cannabis is legal, VA providers being able to make those 
recommendations to patients?
    Mr. Fuentes. We certainly fully support VA having that 
discussion with veterans. We would not like for VA providers 
and doctors to prescribe a medicine or any type of drugs that 
VA is unable to provide to veterans. I don't know the cost of 
medicinal cannabis in those states, but it could pose a barrier 
for veterans and many of them are already struggling to meet 
VA's copays, certainly don't want to put the full cost of any 
of the medications that their doctor says they need on them.
    Ms. Luria. So in a scenario where potentially there could 
be a reimbursement, if it was anything other than the cost, you 
would not object to it?
    Mr. Fuentes. Correct.
    Ms. Luria. Okay. And then I wanted to shift to the Iraq and 
Afghanistan Veterans of America and I have fortunately had the 
opportunity to speak to some of your colleagues and some of 
your members over the course of the last few months in looking 
across this legislation relative to cannabis, we have a very 
friendly chart here that shows red, yellow, or green based off 
of the level of support of the people who are going to be 
testifying so we can kind of understand the trend.
    But the trend I see for you is that IAVA has support on 
every single one of these. Can you discuss kind of the 
demographics of your membership age-wise, and then the 
statistics you have amongst your members as a younger group of 
veterans, their perception of marijuana as a potential 
treatment for some of the things that they suffer from?
    Mr. Horr. Yeah. We have a younger generation of veterans, 
as you mentioned, who are all post-9/11 veterans. In order to 
take our member survey, the stats I have been quoting, you have 
to be confirmed as deployed to Iraq or Afghanistan. And so to 
talk to some of those statistics that you mentioned, 90 percent 
support cannabis research. I think it is right around 80 
percent that support full legalization of cannabis. 91 percent 
also state that they would take cannabis if it was available to 
them. And currently, as I mentioned, only 20 percent reporting 
are taking it, so that is a huge difference of people that 
could be affected and could benefit from this.
    Ms. Luria. SO if I interpret that data, this is a younger 
group of veterans who think that this is beneficial to them. 
And I would take that as they are asking us as Congress and 
lawmakers to find a way to make that happen: all the elements 
of that, be that research, be that all of the elements outside 
of the purview of this Committee, but you know, making it 
accessible, making it standardized, making production 
standardized, essentially. Just regulating the industry so it 
can become a product and a commodity that we can research and 
use safely. Is that what I would take away from this group of 
younger veterans? They want us to do something to make it 
available to them.
    Mr. Horr. Yes, I believe that is fair. And I think we need 
to start with the research, which is why we are supportive of 
the Medicinal Cannabis Research Act. That is why it has been 
our centerpiece for our cannabis campaign, that we have been 
out and talking with offices like yourself about. So that is 
where we need to start. And I think once we have that data, 
once we have more good data from the VA, then we can go from 
there as far as what we need to do.
    Ms. Luria. Thank you. I yield back my time.
    The Chairman. Thank you, Ms. Luria. Ms. Radewagen, you are 
recognized for 5 minutes.
    Ms. Radewagen. Thank you, Mr. Chairman. My question is for 
Mr. Fuentes. In your written statement, you commented that you 
oppose the change to the work study program because you believe 
VA just needs to do a better job processing claims. Given VA's 
poor track record of delivering education benefits in a timely 
manner, don't you think it may be time for a new approach?
    Mr. Fuentes. Thank you, ma'am, we completely agree that VA 
needs to fix the work study program. It is preventing veterans 
from essentially meeting ends meet. They rely on this benefit 
to pay for housing for food. Right now, the difference is that 
VA pays the veteran directly, so the school simply just 
certifies that the veteran worked the number of hours that are 
required and then the--a similar program under the Department 
of Education pays the school or gives the school a certain 
amount of money and then the school pays the veteran.
    The VA knows how to pay veterans. It does so for millions 
for disability compensation. It does so for the GI bill. We 
have confidence that VA can get it right and fix it, instead of 
changing a new process. We think that VA would probably better 
be able to fix the current process as a paper-based process 
than they would be at adopting a new business process.
    That, again, we certainly refer to VA if they think that a 
better business--a new business process is easier for them to 
manage. At the end of the day, we will hold them accountable to 
it because these veterans need their payments now and as soon 
as possible.
    Ms. Radewagen. Thank you. Mr. Horr, can you please tell us 
why you believe using the way the Department of Education pays 
work study could be a better model than the way that VA 
currently pays benefits.
    Mr. Horr. Yeah, the Department of Education model has been 
proven to where it can get work study payments on time. We 
understand that there have been issues with the VA's IT 
infrastructure, especially with the G.I. Bill payments and 
things like that. But using the Department of Education's 
model, which already exists, the VA can easily more restraining 
order that, in order to get these work study payments out on 
time. So, we believe that is how it can been easily integrated.
    Ms. Radewagen. Thank you, Mr. Chairman.
    I yield back.
    The Chairman. Thank you, Ms. Radewagen.
    Mr. Sablan, you are recognized for 5 minutes.
    Mr. Sablan. Thank you, Mr. Chairman. I have no questions at 
this time for this panel, but I thank everyone for being here.
    The Chairman. Thank you, Mr. Sablan.
    Mr. Barr, you are recognized for 5 minutes.
    Mr. Barr. Thank you, Mr. Chairman.
    Thanks for our witnesses for your service and for your 
testimony here today. As you all can see, this Committee is 
very interested in the possible benefits of medical cannabis.
    I have had an opportunity to listen to veterans of 
different eras--Post-9/11 veterans, Iraq-Afghanistan veterans--
about their interests in the therapeutic benefits for post-
traumatic stress, and anxiety, sleep deficiency, and also 
Vietnam-era veterans in my veterans coalition, who have 
expressed an interest in us proceeding with this.
    So, I am a co-sponsor of Dr. Roe's bill, H.R. 747, which 
does direct the VA to conduct medical cannabis research.
    And I also want to thank Mr. Correa for the VA Medicinal 
Cannabis Research Act.
    I share Dr. Roe's concern that Mr. Correa's bill may be a 
little bit too prescriptive, but I appreciate Dr. Grant's point 
that if that is our only opportunity to proceed with research, 
I would prefer that than nothing. So, I have a preference here 
and it is Dr. Roe's bill, but I do want to see us move 
expeditiously on the research because of the intense interest 
that the veteran's community has expressed to me.
    Let me just ask any of you about that difference between 
the Roe version and the Correa version. Do we need to have an 
approach that lets the researchers, as Dr. Grant has expressed 
a preference for, direct this, as opposed to folks up here--and 
admittedly, I am not a physician and I don't have an expertise 
in this area--what is the best approach here, because maybe we 
can get a larger consensus to pursue this, and I invite anyone 
to offer an opinion on that.
    Mr. Atizado. Mr. Barr, thank you for posing that question, 
and I do appreciate your comments and Ranking Member Roe's 
comments on the matter, as well.
    I think in my testimony I mentioned that we have to 
recognize a couple of things and that is, in fact, VA is not 
doing much in this space when there is a definite need that 
they need to be a leader in this area. I think the veterans 
have spoken. I think Congress is speaking to them.
    I think it would be helpful if we can have members in 
Congress, some of the Veterans Service Organizations, and the 
scientific research community come together and find--and I 
don't want to use this as a way to slow the legislative process 
down. I want to help inform the two bills that are out there 
now and maybe Mr. Roe and Mr. Correa can craft the bill 
together, but with VA's definitive opposition, we need to get 
over that, because they are the ones that are going to have to 
execute on this, and that might be a way forward.
    Mr. Barr. Well, thank you. Any other thoughts on that 
point?
    Mr. Horr. Yeah, I think just to echo what DAV was saying, I 
think there is a concern that if VA is not explicitly told how 
to do it, that they will drag their feet and withhold this 
research or--
    Mr. Barr. Well, maybe there is a middle road.
    Mr. Horr. Yeah.
    Mr. Barr. A mandate that they do it, but give the 
professionals and the scientists and the researchers a little 
bit of control in terms of setting the parameters for the 
research and providing some deference to the expertise of 
people like Dr. Grant. So, I am willing to step in and try to 
work on that compromise to help move this forward and not 
having the delay. And I look forward to working with the VSOs 
on that if I can be helpful.
    In Kentucky, we have kind of led the way in de-scheduling 
industrial hemp, which is low THC/CBD and so, for Dr. Grant--
and we de-scheduled in the Farm Bill. I am interested in your 
research and what your research tells us about low THC/CBD and 
any therapeutic benefits that can provide separate and apart 
from the psychoactive THC substance in marijuana.
    Dr. Grant. Thank you. Let me see if I can address that. 
First of all, as you know, and as we have discussed, 
cannabidiol, which is a common ingredient in cannabis, in 
marijuana, is not thought to be psychoactive, but it may have 
antianxiety, anti-inflammatory, antiepileptic, and other 
qualities. So, clearly, this is a substance, first of all, that 
needs further study, but already in the area of epilepsy, we 
have seen that its benefits children. That drug, in my opinion, 
should not be on a schedule. There is no evidence that it is an 
addictive substance.
    As for THC-containing things, it seems to be a more 
sensible approach would be something along the lines that we 
have used with codeine. So, low-codeine preparations are in 
Schedule 3, for example, and higher-codeine preparations are in 
Schedule 2, and that makes a lot of sense. If you give more or 
the higher potency, it may be more dangerous. And I think the 
THC products belong somewhere in that zone, personally.
    Mr. Barr. My time, obviously, has expired and I have gone 
over and I am sorry. I appreciate the Chairman's indulgence.
    I would just say that as we move forward with research on 
both the high-THC and the low-THC, that the researchers look at 
what CBD cannabidiol could do separate and apart from the 
higher psychoactive, higher-THC psychoactive parts.
    And I yield back, and I appreciate the Chairman's 
indulgence.
    The Chairman. Thank you, Mr. Barr.
    Mr. Bergman--General Bergman, you are recognized for 5 
minutes.
    Mr. Bergman. Thank you, Mr. Chairman.
    And I see a lot of familiar faces out there--good to see 
you all again. And I know I have at least two Marines. Anymore? 
Okay. Well, you guys have already taken over the panel just by 
having two out of five, right? All right. Well, we are not 
going to talk about service cultures here.
    You know, it is always very instructive to sit here and 
listen to people who have, both on the panel and my colleagues, 
who have got a lot of time and effort in researching and trying 
to figure out what the best way is to go forward to help our 
veterans, whether it be in pain management, addiction, or shall 
we say the kind of facilities that they get their care in that 
the VA has.
    And let's talk about the asset review, first of all. You 
know, time is finite; once time is gone, it is gone. And I 
would suggest to you very strongly that the more we wait to 
kick off the asset review and to not speed up the timelines in 
a mission-oriented manner like we would do in the military, of 
prioritization and responding quickly, we have to move forward 
with the asset review and not waste any more time on that.
    Twenty-five-year-old brain development, full brain 
development for the average male, is that--am I in the ballpark 
there?
    Dr. Grant. Some of us take longer.
    Mr. Bergman. Well, some of us are still works in progress, 
as my wife would probably say.
    Dr. Grant, we have a lot of our veterans who will serve 
honorably and complete a four-year enlistment by the age of 22. 
Any comments on what risks we might be accidentally assuming if 
we move forward with cannabis research with the target 
population, what parameters you might put on that so that we 
don't further potentially hinder a young veteran who has, you 
know, put their life on the line?
    Dr. Grant. You know, thanks for the question. And it is 
very complicated, as you very well know.
    I think what I can say with some reasonable confidence is 
that marijuana in the strengths that it has been traditionally 
used--and I am going back now 4 decades--among adults is 
probably not harmful to the brain. There have been a number of 
kinds of retrospective studies that have looked at IQ and 
cognitive function and brain-imaging and so forth. But that is 
marijuana that was not very potent and that, typically, people 
are not using day-in and day-out and many times a day.
    In terms of the developing brain, teenagers and young 
adults, we really don't have the answers. And I have to say I 
see practically every month some report saying, Oh, marijuana 
causes this and that terrible thing to happen to the brain, 
but, actually, when you look at the research, it is not that 
clear. That doesn't mean it isn't bad, but I don't think it is 
very definitive. And, certainly, we don't want to give 
chronically, in high doses, any drug that affects the brain 
because we don't know what is going to happen there.
    Mr. Bergman. I just wanted to make sure that we, you know, 
didn't accidentally put a certain age group at risk moving 
forward with a good idea.
    And I guess you mentioned something that kind of caught my 
attention, Doctor, on some of the things that Canada has to 
offer. Are there any other countries around the world who have 
already walked down this road with the research side that we 
can either partner with, model after, you know, have a list of 
dos and don'ts? Any other countries that stand out?
    Dr. Grant. Well, I think not to the kind of comprehensive 
extent of Canada, but, certainly, the Netherlands has had a 
fairly long history of some permissiveness, at least, in the 
marijuana area, and they have also done a lot of work on 
driving and those kinds of impairments.
    Mr. Bergman. Has there been any outreach made to the 
Netherlands at all?
    Dr. Grant. Well, we certainly have consultations with those 
people, but no, I don't know the answer to that.
    Mr. Bergman. Well, thank you very much.
    Mr. Chairman, I yield back.
    The Chairman. Thank you, General.
    Mr. Meuser, you are recognized for 5 minutes.
    Mr. Meuser. Thank you, Chairman, and thank you Dr. Roe very 
much. Thank you very much all to you for being here with us and 
to the veterans on the panel, and all the veterans, thank you 
very much for your service.
    I'd like to focus my questions on the draft legislation on 
the Specialty Adaptive Housing grant program. I do commend 
Chairmen Levin and Bilirakis for this draft legislation that I 
do plan to be supportive of.
    Mr. Fronabarger, do you hear from disabled veterans 
regularly on the housing issues and the need for adaptive 
specialty access?
    Mr. Fronabarger. Thank you for that question, Congressman.
    We do. We have a program with--called the Independence 
Program. That project that we have going on actually assists 
critically injured, ill, and wounded servicemembers in home 
adaptation, caregiver services, and any other issues they might 
like. So, we do have about 500 individuals in that program 
right now.
    Mr. Meuser. Five hundred.
    Describe briefly, if you would, the type of disability that 
someone would have in order to be eligible for this type of 
housing grant.
    Mr. Fronabarger. Absolutely. I would say you would see two 
primary kinds of individuals with bilateral amputees and also 
those with ALS. Those are relatively common, unfortunately.
    Mr. Meuser. So, those with loss of limb, normally, it was 
lost in the field in combat?
    Mr. Fronabarger. I couldn't break down specifically if it 
was combat or training, but most likely with this most current 
war, yes, I would--
    Mr. Meuser. Yes, great sacrifices.
    And work is pretty difficult for those with these high 
level of disability?
    Mr. Fronabarger. It is. I mean, it is difficult to move 
from an injury like that into a normal civilian life.
    Mr. Meuser. Maybe part-time, just difficult to get there, 
even.
    Mr. Fronabarger. Correct.
    Mr. Meuser. In a normal home environment, how would they 
mobilize?
    Mr. Fronabarger. Well, that is a difficult question. A lot 
of it depends on the home itself. If there are stairs, that can 
be incredibly difficult for somebody who is lost both the lower 
limbs, obviously. If it is, you know, a long walk from the 
driveway up to the house, if there is not a garage on the front 
that leads straight into the house, all of those--
    Mr. Meuser. Typically very, very difficult.
    Mr. Fronabarger. Correct.
    Mr. Meuser. Very difficult.
    Can you describe a project that was--comes to your mind and 
a veteran that has benefited by the current initiative for this 
type of specialty housing?
    Mr. Fronabarger. Absolutely. I [DF2]Captain Kules 
[DF3]right behind me used the program. He was able to purchase 
a house in D.C. And as you all know, D.C. homes are probably 
some of the least adapted homes possible; they were all built 
in the 1930s and older. So, he was able to take a house and add 
the things that he needed, including a ramp, to make that home 
fit his needs.
    Mr. Meuser. Okay. Great. Well, these projects are not only 
life-sustaining, I think they are life-changing. They are quite 
essential.
    And Captain Kohls, thank you very much for your service.
    And I don't have any further questions, so, Chairman, I 
yield back.
    The Chairman. Thank you, Mr. Meuser.
    That concludes, I think, our work with our second panel. 
So, you are all now excused. Thank you all very much for your 
testimony and for your answering our questions.
    I would like to now invite Mr. Larry Mole, Chief 
Consultant, Population Health Services Patient Care Services of 
the Veterans Health Administration to come to the table.
    And I will just take a note that we statements for the 
record from Ms. Thelma Roach-Serry of the Nurses Organization 
of Veterans Affairs; we have Mr. Eric Goepel also submitting a 
statement, Founder and CEO of Veterans Cannabis Coalition, VCC; 
Mr. Morgan D. Brown, National Legislative Director of Paralyzed 
Veterans of America; Mr. J. David Cox of AFGE; Mr. Randy Erwin, 
National President of the National Federation of Federal 
Employees; Mr. William Attig, the Union Veterans Council, AFL-
CIO; Mr. Brett Copeland, Executive Director of the Veterans 
Healthcare Policy Institute; Mr. David Holway, National 
Association of Government Employees; and Mr. Justin Strekal, 
Political Director of the National Organization for the Reform 
of Marijuana Laws, otherwise known as NORML.
    The Chairman. So, Mr. Mole, welcome. Thank you for 
testifying today. I will begin--oh, no, you need to do your 5 
minutes of--go ahead. Five minutes--you have 5 minutes, Mr. 
Mole.
    Dr. Mole. And go Highlanders.

                    STATEMENT OF LARRY MOLE

    Dr. Mole. Good afternoon, Chairman Takano, Ranking Member 
Roe, and members of the Committee. Thank you for inviting us 
here today to present VA's views on a number of important bills 
covering cannabis policy, transitional care for women veterans, 
and ensuring that language is not a barrier to access to VA 
services.
    We are unable to provide views on today's written testimony 
on four proposals that were added recently to the agenda, but 
we will follow-up with the Committee as soon as possible.
    Regarding the bill to require continuation of Women's 
Health Transition Training Pilot Program, I am pleased to share 
that last week, the VA committed to a permanent women's health 
component to the Transition Assistance Program by 2021. In the 
interim, VA will provide the pilot activities currently in 
place for active-duty servicemembers. Although we have no 
objections to its enactment, we do not believe this bill is now 
necessary.
    Concerning the bill, Making Fact Sheets Available in 
English and Spanish, VA agrees that it is important that we 
help ensure that language is not a barrier seeking care or 
other services from VA. VA publishes many critical materials in 
English and Spanish, including VHA enrollment forms and our 
annual guide to benefits.
    More systematically, VA is implementing a language access 
plan covering all organizations to ensure as much as possible 
there are not language barriers for veterans and their 
advocates. Given the breadth and complexity of VA program, VA 
favors this more systematic and flexible approach, as opposed 
to a statutory mandate for one category of document. As a 
result, VA does not support this legislation. We are glad to 
discuss our current efforts with the Committee.
    Next, I begin my discussion on the medical cannabis bills 
by setting out the current landscape. According to the National 
Conference on State Legislatures, 47 states, the District of 
Columbia, and 3 of 5 territories have some form of state or 
territory regulation on medical cannabis use. These laws 
permits various types of cannabis-derived products to cover 
various symptoms and conditions. These laws greatly vary from 
each other and conflict with Federal law which classifies 
cannabis as a Schedule 1 controlled substance. That complex 
legal landscape makes it important that legislation in this 
area receives a thorough airing and we appreciate the 
Committee's attention to these issues today.
    It is critical for the Committee, veterans, and the public, 
to know that the veterans will not be denied VHA services 
solely because they participate in state-approved programs and 
that clinical staff may discuss marijuana use with their 
patients. But we should also be clear that VA cannot pay for 
state-approved marijuana products and VA providers cannot 
recommend, make referrals to, or complete forms or register 
veterans for participation in state-approved marijuana 
programs.
    The Veteran Medical Cannabis Research Act of 2019 would 
require VA to conduct a large-scale clinical trial to examine 
multiple health outcomes among veterans with various diagnoses 
using multiple strains and formulations of cannabis. Typically, 
smaller early-phase trial designs would be used to advance our 
knowledge of benefits and risks associated with cannabis before 
moving to a more expansive trial. VA currently supports a VA 
clinical trial of cannabis for treatment of PTSD. Because we 
believe research on such a scale would be premature ahead of 
other related research, VA does not support this bill.
    The VA Equal Access Act 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. While VA 
encourages its providers to discuss marijuana use with 
veterans, we cannot support this bill for the detailed reasons 
provided in my written statement; namely, that there are legal 
issues presented by the legislation that would require 
significant involvement of other agencies to resolve.
    This VA Survey of Cannabis Use Act would require VA to 
enter into an agreement with a federally funded research and 
development center to conduct nationwide surveys to measure 
cannabis use by veterans. We have significant concerns detailed 
in our testimony, one of which is that we believe veterans and 
providers will not want to participate, despite the survey 
being anonymous; moreover, the survey results would likely only 
be meaningful if we knew where veterans lived and where 
providers practiced, information that could compromise the 
identity of the veterans and the providers. That is why VA 
cannot support this bill.
    The bill, Training in the Use of Medical Cannabis for All 
VA Primary Care Providers would require VA to train these 
specific providers in the use of medicinal cannabis. We already 
make available to all providers, information sessions on 
cannabis, including the latest on marijuana use and side 
effects, treatment implications for veterans with PTSD, and on 
caring for patients who use marijuana at the end of life.
    In addition, VA's academic detailing program provides 
resources for providers to have meaningful conversations on 
cannabis with their patients; as a result, we do not believe 
that this legislation is necessary.
    This concludes my statement. I would be happy to answer any 
questions you or other members of the Committee may have.

    [The prepared statement of Larry Mole appears in the 
Appendix]

    The Chairman. Thank you, Mr. Mole.
    I am going to call upon, as a courtesy to Dr. Roe, call on 
him first for 5 minutes.
    Mr. Roe. Thank you, Mr. Chairman. I have a phone call here 
in just a couple of minutes about some veterans' issues at 
home.
    And just for clarification, Dr. Mole, the secretary's 
testified multiple times before this Committee and before the 
Senate Committee on Veterans Affairs, expressing his desire for 
the AIR Commission to begin their important work as soon as 
possible and asking Congress for our helping in accomplishing 
that. Given that, is it fair to say that VA is supportive of 
H.R. 3083?
    Dr. Mole. I can answer that I don't think VA has put out 
its official position. I agree with you that the secretary has 
made statements in support of that and that is as far as I can 
comment, sir.
    Mr. Roe. And the AIR act requires the VA--and I know 
because we wrote it on this Committee--to consult with VSOs as 
it conducts its market assessments. Explain VA's efforts, 
because we heard some objection to that--probably rightfully 
so--our plans to consult with VSOs as it conducts market 
assessments. Have you all decided how you will do that? I think 
that is a fair ask of the VSOs.
    Dr. Mole. Yeah, and I agree with you. I will need to take 
that back for additional information, because I don't know what 
that particular office is doing, but I can get that and bring 
that information back to you, sir.
    Mr. Roe. We appreciate you doing that. And can you clarify 
for the record that the market assessments that are required 
for the AIR Commission are the same market assessments as 
Secretary Wilkie has testified will be completed by June, one 
year from now?
    Dr. Mole. Yes, they are.
    Mr. Roe. Okay. So, in other words, what we will have a year 
from now are the market assessments across the country, and I 
think what I heard the secretary say multiple times--as a 
matter of fact I know what I heard him say multiple times is 
that if you wait a subsequent year, then you have got data that 
may not be accurate that you are making decisions on.
    The other side of that is--and I have said it from the very 
beginning when I started the discussion in my office with the 
VSOs--that I would rather make sure that we get it right than 
fast. And I don't think this is a fast--and as a matter of 
fact, I don't think we have any choice but to do this. And 
whether it is the AIR Commission or some other commission, it 
is just not the way that VA provides health care anymore.
    And if you look at what the VA is doing around the country, 
which I wholeheartedly applaud them for, is pushing more and 
more of the care out into the community where the veterans 
actually live. That was the idea of the MISSION Act. So, if you 
are in Los Angeles where the traffic--I mean, it is horrific. I 
could drive to several states in the time I could get 30 or 40 
minutes in downtown LA, to put that care closer to the 
veterans. That is the purpose of all of this.
    And to repurpose those bills--and I have challenged every 
medical center that I have gone to in the last 3 years since--
because we have done it at our own medical center at home in 
Mountain Home VA in Johnson City--start thinking about how you 
would like your medical center to look in 3, 5, or 10 years 
from now and what demands are being made. We know that the 
veteran population, the actual numbers are going down.
    Hopefully, the number of veterans will go up. I hope the 
number of veterans that use the VA goes up and not down, and I 
think it will. So, with that in mind, I would think that we 
could get started with this with our partners in the VSOs. And 
it doesn't mean you are going to end any quicker--you aren't by 
law; you are just going to get started a little sooner is all. 
Am I correct in that?
    Dr. Mole. I think I am not--
    Mr. Roe. --AIR Act.
    Dr. Mole. Yeah. I mean, I am not well enough connected to 
know the pieces to know how it starts once you get through the 
market assessments. I don't know all the other milestones, so 
that is hard for me to comment on, but, again, I can take that 
back, sir.
    Mr. Roe. Thank you.
    I yield back. Thank you, Mr. Chairman.
    The Chairman. Thank you, Dr. Roe.
    I will now recognize myself for 5 minutes. Mr. Mole, have 
VA leaders recently spoken to the employees and veterans at the 
VA Medical Center in San Juan, Puerto Rico?
    Dr. Mole. I don't have an answer to that.
    The Chairman. You don't know?
    Dr. Mole. Yeah.
    The Chairman. What I wanted to know was whether the San 
Juan Medical Center has Spanish language materials they need to 
communicate with veterans and conduct training at the hospital. 
I don't imagine you would know that, either.
    Dr. Mole. I only know to some extent because of Spanish 
articles I have worked on historically, but what was mentioned 
earlier today about the MISSION Act and materials developed for 
Spanish, that is the first that I have heard of that.
    The Chairman. Okay. Do you have any effort on VA's part to 
staff the Veterans Crisis Line so it can assist Spanish 
language speakers nationwide?
    Dr. Mole. Yeah, I don't know that. I can get that for you, 
sir.
    The Chairman. Okay. Were you aware that Puerto Rico had 
created its own Spanish language Veterans Crisis Line and that 
it is not being answered?
    Dr. Mole. That, I did not know.
    The Chairman. Okay. I just want to make sure that through 
you, the Department is aware of this--
    Dr. Mole. Yes.
    The Chairman [continued]. --and can maybe address these 
questions.
    Has VA conducted any studies or collected data to determine 
whether Spanish-speaking or non-English speaking veterans are 
accessing benefits at the same rate as English-speaking 
veterans?
    Dr. Mole. Not to my knowledge, but I am not in that program 
office that would do that, but that is another one to be 
answered, yes.
    The Chairman. I appreciate your getting back to my staff on 
that.
    Dr. Mole. Yes, sir.
    The Chairman. Now, I want to turn to the medicinal 
cannabis.
    Dr. Mole. Uh-huh.
    The Chairman. If the VA has concerns with the VA Medicinal 
Cannabis Act and how it could limit the design and research or 
clinical trials, would VA be willing to work with the Committee 
to address those concerns that VA can conduct objective 
research?
    Dr. Mole. Absolutely.
    The Chairman. And you said that, really, that there were 
other research priorities that you didn't support this Act 
because there are other research priorities.
    Dr. Mole. The way that the bill is written--
    The Chairman. Uh-huh.
    Dr. Mole [continued]. --it implies that a big, large 
clinical trial would be designed that would have many, many 
arms that would be studied all at once.
    The Chairman. I understand.
    Dr. Mole. And we are kind of ahead of ourselves in doing it 
that way, because to some extent, we may not know some of the 
products that are being tested, whether they actually do any 
good or what the risks are of using those.
    The Chairman. I see where you guys are coming from.
    Dr. Mole. Yeah.
    The Chairman. So, I mentioned may be working with the VA in 
an approach that the VA would support. So, I see how you guys 
are thinking that this is too prescriptive for you.
    In your previous testimony, you stated that VA has gone so 
far as to, ``Encourage other research on possible medical uses 
for marijuana.'' Specifically, what steps has VA taken to 
encourage this type of research?
    Dr. Mole. So, I can give you a partial answer. Our research 
department would be the best to give you a full listing of 
everything they have done. But they hold seminars. They have 
done series on educating what you can and cannot do, with 
regards to research with cannabis, and actively participate 
with our regional experts in research to determine what they 
can do as a national program office to assist them and help 
them develop good, strong, scientific protocols to then submit 
for funding for research.
    The Chairman. All right. Well, thank you, Mr. Mole. I am 
not going to use all my time, but I would like to now call on 
and recognize Mr. Barr if he has any questions.
    Mr. Barr. Thank you, Mr. Chairman, again.
    And Dr. Mole, thank you for your testimony here today. Just 
to further explore where the VA is, specifically, with its 
research on medical marijuana and cannabis, I understand your 
concerns with the proposed legislation in this hearing that it 
is too prescriptive, and I note in your testimony that you 
would advocate or the VA would advocate for smaller early-
phase, controlled clinical trials with a focused set of 
specific aims that are warranted to determine initial proof of 
concept for medical marijuana for a specific condition. And I 
appreciate the Chairman's overture to work with the VA on what 
the right framework should be going forward on this.
    My question is, you heard the testimony from the earlier 
testimony, some of the VSOs, and the frustration with the 
delays or the concern that this might slow down the process. 
What could you reassure--how could you reassure the Committee 
that if it was structured in a way that made the criteria that 
it wouldn't slow things down?
    Dr. Mole. Well, I think the first thing would be that the 
VSOs have to be at the table when we are having conversations 
about a research plan and what a full research portfolio would 
look like. So, I would start there. There needs to be 
engagement. We need to educate each other on what each other's 
expectations are and then set what those expectations would be 
for that research plan.
    I think some of the times we kind of cross-talk each other 
in terms of trying to explain what is involved in a research-
type program and I think we just miscommunicate, and we need 
everybody at the table from the beginning on this.
    Mr. Barr. Well, again, can you provide an update on the 
specific research that is ongoing now. If there is not a broad-
ranging clinical trial that is going on, what, specifically, is 
happening?
    Dr. Mole. So, what I can comment on is the one study that 
is actually looking at cannabidiol in combination--and it is a 
double-blind, placebo-controlled study; it is actually out at 
UC San Diego--and they just enrolled their first patient last 
week. And they have a number of veterans lined up who wish to 
be involved in the clinical trial.
    And so, that is really our first one that is being done 
specifically for PTSD, taking the standard of care and then 
determining whether or not there is an impact by having 
cannabidiol in that standard of care treatment plan.
    Mr. Barr. That interests me, because as you say, it is 
cannabidiol--
    Dr. Mole. Right.
    Mr. Barr [continued]. --so what is being tested is 
basically hemp; it is low-THC--
    Dr. Mole. Yeah. It is the refined available product that 
was previously mentioned by Dr. Grant.
    Mr. Barr. Or I suppose CBD could also be derived from 
marijuana--
    Dr. Mole. Yes.
    Mr. Barr [continued]. --but there is no THC in it or low 
THC in the substance that is being tested?
    Dr. Mole. That is correct, sir.
    Mr. Barr. So, that is the baby-steps approach, I guess, on 
this.
    Dr. Mole. Right. And I want to point out that this is the 
one that is funded by VA. There are other VA researchers that 
are getting funding from other sources, as well as other 
university researchers and so forth that are looking at this. 
So, I think when we are trying to assess what sort of work is 
going on out there, I think we need some sort of catalog or 
something to understand all of these different studies so when 
VA comes up with, here's the portfolio that we are going to do, 
it actually complements what else is going on.
    Mr. Barr. Doctor, are there any preliminary findings so far 
with the CBD and PTSD?
    Dr. Mole. No, they just started enrolling patients.
    Mr. Barr. Okay. Very good.
    Finally question, could you describe some of the risks of 
requiring the training of VA providers in the use of medical 
cannabis in light of the fact that it remains a federally 
scheduled substance?
    Dr. Mole. I would have to defer to our colleagues over at 
the Department of Justice and what they decide they want to 
prosecute or not.
    Mr. Barr. Yeah. I guess the reason--what motivates that 
question is some of the other legislation that is being 
considered here today on training, it appears to put the cart 
before the horse. I think we do need to come to a consensus on 
an expedited, good, thoughtful, research-driven, evidence-based 
approach to research. But training VA providers before we have 
all the evidence in seems to be a little bit premature.
    So, with that, Mr. Chairman, thank you, and I yield back.
    The Chairman. Thank you, Mr. Barr.
    I now recognize Mr. Levin for 5 minutes.
    Mr. Levin. Thank you, Mr. Chairman.
    And thank you, Doctor, for being here today. I am trying to 
understand the timeline and where VA really is on this issue. 
In 2017, there was a poll conducted for The American Legion, 
showed that support for medical cannabis and research on 
medical cannabis was high across veterans and caregivers, all 
age ranges, genders, political leanings, and geography showed 
92 percent of all respondents supporting medical marijuana 
research, 82 percent of all respondents supporting legalizing 
medical cannabis.
    Are you familiar with that poll?
    Dr. Mole. Yes.
    Mr. Levin. And then in 2017, VA's Evidence-based Synthesis 
Program found, ``Methodologically strong research in almost any 
area of inquiry is likely to add to the strength of evidence'' 
regarding the benefits and/or harms associated with medicinal 
cannabis.
    Also in 2017, VA sent this Committee a letter that stated 
that VA was unable to perform research into medical cannabis. 
Are you familiar with that letter?
    Dr. Mole. Yes.
    Mr. Levin. And then after some back-and-forth in the media, 
your spokesman or VA's spokesman, a gentleman named Curt 
Cashour admitted that VA could, in fact, perform the research, 
but found pursuit of the research to be overly burdensome.
    Are you familiar with that 2018 statement?
    Dr. Mole. Yes, I am.
    Mr. Levin. So, then in 2019, VA met with staff where they 
expressed support for the need for research, but seemed to 
further muddy the waters and confuse things. Can you clarify 
what the VA's position is on cannabis research?
    Dr. Mole. So, VA can do research. The research is initiated 
by our investigators across the field. They are to do research 
on cannabis. Given its schedule on controlled substance has 
some extra steps in the process. None of those steps are 
onerous, as evidenced by the fact that you see--as our San 
Diego site was able to set this up fairly quickly.
    Once they get through their funding and once they started 
moving, actually getting product and bringing it in and working 
with it was relatively straightforward. And that investigator 
has made a nice training video for anyone else who needs to go 
through the process.
    So, we can do clinical trials and the process it takes to 
bring the product in and then study it is doable.
    Mr. Levin. So, when I go back to my district, which I do 
every weekend, which has UCSD in it, and I speak to veterans, 
which I do virtually every weekend, what am I to tell them when 
they ask, When is this actually going to happen? When is this 
research going to occur? When is the VA going to listen to the 
92 percent of veterans across all political stripes and 
ideologies that want to see this done?
    Dr. Mole. I think you can start by hopefully proudly saying 
that your local VA actually has a study. They have begun 
enrollment. If any of those veterans are interested in actually 
participating in the study, they can go to clinicaltrials.gov 
and they can look up that study. They can just type in 
``veterans'' and ``cannabis'' and they will get that study. And 
you may find that some of your voter's back home are really 
interested in participating or not.
    But I think you can tell them that we have begun this 
process. We have gotten over these initial hurdles and we are 
going to continue to encourage VA investigators to investigate 
cannabis.
    Mr. Levin. Thanks, Doctor. I appreciate that.
    I wanted to shift for a minute, with the time I have left, 
to the Veterans Equal Access Act. In the 2009 guidance issued 
by the DOJ that you cited in your testimony, the agency accepts 
that in the Ninth Circuit, which includes my state of 
California, a physician's ability to recommend cannabis use to 
their patients is a right protected by the First Amendment.
    What efforts has VA taken to allow physicians within these 
states to enjoy their First Amendment right to make these 
recommendations?
    Dr. Mole. The opinion that we requested back then from DOJ 
came to us as quoted in the testimony that what is the 
precedent as Federal employees, is the Controlled Substance 
Act. And to my knowledge, since 2008, I do not believe there 
has been another request to DOJ to visit that opinion.
    Mr. Levin. Okay. I appreciate your being here. I look 
forward to working together on this issue and others, and I 
will yield back the balance of my time.
    The Chairman. Thank you, Mr. Levin.
    This legislative hearing has been well-attended and very 
informative. Again, I would like to thank the witnesses.
    I thank you, Dr. Mole, for appearing before us today. You 
are excused.
    I would like to thank all the witnesses from our three 
panels for their testimony.
    All members will have 5 legislative days to revise and 
extend their remarks and include extraneous material.
    Again, thank you for appearing before us today, and this 
hearing is now adjourned.

    [Whereupon, at 4:16 p.m., the Committee was adjourned.]




                            A P P E N D I X

                              ----------                              

            Prepared Statement of Congressman J. Luis Correa
    Chairman Takano and Ranking Member Roe, thank you for the 
invitation to speak on my bipartisan bill: H.R. 712, the VA Medicinal 
Cannabis Research Act.
    I appreciate the chance to return to the House Veterans Affairs 
Committee, where I served in the last Congress, to speak on our urgent 
need for research on medical cannabis as a possible treatment option 
for our nation's veterans.
    The U.S. Department of Veterans Affairs is uniquely positioned to 
pursue the necessary research on what cannabis can and cannot do for 
our veterans.
    Our brave men and women return from military service in Iraq and 
Afghanistan, at times with psychological wounds as well as physical 
injuries.
    Unfortunately, for many veterans with PTSD and chronic pain, the 
use of prescription opioids has been ineffective in providing relief.
    Worse, the use of prescription opioids has led to addiction or even 
death.
    Tragically, VA patients are almost twice as likely to die from 
accidental opioid overdoses than non-veterans.
    In California, I have met with multiple veterans who use medical 
cannabis as an alternative to prescription opioids and other treatment 
methods.
    The men and women that I meet back home vouch for the therapeutic 
benefits of medical cannabis and support further research into the 
issue.
    In fact, according to the Iraq and Afghanistan Veterans of America, 
over 90 percent of their membership support medical cannabis research.
    As more veterans use cannabis for medical purposes, it is important 
that doctors be able to fully advise on the potential benefits and 
effectiveness of medical cannabis.
    Currently, VA doctors can discuss cannabis usage with patients, but 
they have limited federally approved research on which to base 
recommendations or clinical opinions.
    For that reason, with my colleague and friend Congressman Clay 
Higgins of Louisiana, I introduced the VA Medicinal Cannabis Research 
Act.
    The bill requires the U.S. Department of Veterans Affairs to 
conduct a double-blind clinical study on the safety and effectiveness 
of medical cannabis.
    The legislation provides a framework for that research to ensure a 
scientifically-sound study on the issue.
    Research on the safety and effectiveness of medical cannabis is 
timely, necessary, and supported by the veteran community.
    I want to thank the Iraq and Afghanistan Veterans of America, 
Veterans of Foreign Wars, Disabled American Veterans, and many others 
for their support of the bill.
    H.R. 712 is a pragmatic and sensible approach to the need for 
research on medical cannabis and could result in potentially lifesaving 
information.
    I look forward to working with you all to move this bill forward.

                                 
                Prepared Statement of Adrian M. Atizado
    Mr. Chairman and Members of the Committee:

    Thank you for inviting DAV (Disabled American Veterans) to testify 
at this legislative hearing of the House Committee on Veterans' 
Affairs. 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. We are pleased to offer our views on 
the bills under consideration by the Committee.
              H.R. 2676, the VA Survey of Cannabis Use Act
        H.R. 712, the VA Medicinal Cannabis Research Act of 2019
    DAV supports both the VA Medicinal Cannabis Research Act of 2019 
and VA Survey of Cannabis Use Act based on DAV Resolution No. 023, 
calling for more comprehensive and scientifically rigorous research by 
the Department of Veterans Affairs (VA) into the therapeutic benefits 
and risks of cannabis and cannabis-derived products as a possible 
treatment for service-connected disabled veterans.
    H.R. 2676 would require VA to partner with a federally-funded 
research and development center that will study how veterans use 
cannabis, their experiences and any side effects of use. It also 
requires VA to report to Congress on the results of the survey. H.R. 
712 would allow the VA to engage in research on the safety and efficacy 
of medicinal cannabis use on health outcomes for veterans with chronic 
pain and post-traumatic stress disorder (PTSD). In addition, the bill 
would allow a long-term observational study of clinical trial 
participants and require VA develop a means of preserving data for 
future studies. The bill would also require VA to submit periodic 
progress reports to Congress not less frequently than annually.
    DAV understands that use of cannabis for medicinal purposes is now 
legal in 33 states and the District of Columbia. However, we note there 
have been no changes made to federal law regarding use of these 
products for any purpose. We further understand that, while the medical 
literature has been inconclusive about the effectiveness of marijuana 
for improving symptoms of chronic pain and PTSD, noting both risks and, 
in some cases, benefits, many veterans report the use of medicinal 
cannabis for these purposes is beneficial.
    DAV is a strong supporter of VA research on common conditions 
related to military service and effective treatments to help veterans 
recover, rehabilitate and improve the overall quality of their lives. 
We must ensure that any intervention for treatment of chronic pain and 
PTSD is both safe and effective for veteran patients, especially 
veterans with clinically complex comorbid conditions such as traumatic 
brain injury, PTSD and chronic pain from amputations and other war-
related injuries.
                    H.R 3083 - AIR Acceleration Act
    DAV strongly opposes H.R. 3083, the AIR Acceleration Act, which 
would eliminate the requirement that the Asset and Infrastructure 
Review Commission, a key element of the Asset and Infrastructure Review 
(AIR) Act, not be allowed to convene any earlier than 2022. This 
requirement was drafted to ensure sufficient time and opportunities for 
stakeholder engagement in the multi-step review and approval process 
that could result in substantial changes to VA's health care 
infrastructure. By removing the time constraints on the Commission, VA 
would be free to accelerate the AIR process, as the title of this bill 
reflects, which would undercut one of the key elements of the 
compromise that led to inclusion of the AIR ACT as part of the VA 
MISSION Act.
    Mr. Chairman, when the original draft version of the AIR Act was 
presented to DAV and other VSOs in 2017, one of the major concerns we 
expressed was that its timeline was far too short for a truly 
deliberative process on something as critical as the future of VA's 
health care infrastructure. Further, we were concerned about the lack 
of mandated stakeholder engagement throughout the proposed AIR process. 
Finally, we argued that VA should wait until after new VA capacity 
enhancements were completed, and after new integrated networks created 
by the VA MISSION Act had been established and stabilized before 
beginning the process to decide which VA facilities would be necessary 
to most effectively deliver medical care to veterans.
    In building a compromise on the proposed AIR Act last Congress, 
then-Chairman Roe, the bill's sponsor, worked closely with DAV and 
other VSO stakeholders to address numerous concerns raised about his 
bill. We greatly appreciated Dr. Roe's open and collaborative approach 
to developing the final language of the AIR Act, which reflected 
significant changes from the bill's original text. On October 30, 2017, 
in a letter to DAV, The American Legion, Paralyzed Veterans of America 
(PVA) and Veterans of Foreign Wars (VFW), he wrote that:

    ``Based on the feedback you provided during those Committee 
meetings as well as in numerous meetings and conversations with me and 
my staff since, I have made a number of changes to the AIR Act to make 
it stronger, more transparent, and more veteran-centric. For example, 
at your request, the revised AIR Act would:

    Greatly expand the entire AIR Act timeline to allow VA sufficient 
time to gather needed data, complete local capacity and commercial 
market assessments, and stabilize community care efforts.''

    It was with these and many other substantive changes made that DAV 
and other VSOs were able to support the inclusion of the AIR Act within 
what became the VA MISSION Act. However, if H.R. 3083 were enacted, and 
Secretary Wilkie were to accelerate the AIR process as he has 
repeatedly indicated his desire to do, it would fundamentally undermine 
the dynamic structure of the VA MISSION Act by forcing premature 
decisions on infrastructure before decisions on health care delivery 
have been finalized.
    Although VA has already contracted for market assessments, and we 
understand that the first tranche have essentially been completed, it 
is important to understand that the MISSION Act had two separate 
sections requiring market assessments. Section 106(a) requires VA to 
undertake a Quadrennial Veterans Health Administration review, which 
would encompass comprehensive market assessments as the predicate for 
Section 106(b), which requires VA to deliver a Strategic Plan to Meet 
Health Care Demand not less than every four years. These market 
assessments and the strategic plan based upon them were due no later 
than June 6, 2019, the effective date for the new Veterans Community 
Care Program. These market assessments were not intended to inform the 
future Asset and Infrastructure Review. In fact, this market assessment 
process was already begun by VA prior to enactment of the MISSION Act, 
when inclusion of the AIR Act was far from certain.
    Section 203(b)(3) of the MISSION Act, in the AIR Act section, 
requires capacity and commercial market assessments to be performed to 
guide the Secretary's recommendations for infrastructure realignment, 
which are due no later than January 31, 2022. These market assessments 
were intended to reflect the capacity and demand after the new Veterans 
Community Care Program had been implemented and reached a point of 
optimization and stabilization. Because the MISSION Act includes 
provisions to increase VA's capacity to deliver care through VA 
facilities, it would be premature to assess VA's capacity before the 
MISSION Act changes were fully implemented. The creation of new 
integrated networks, the expansion of telehealth and the creation of a 
new urgent care benefit will all impact how, when and where veterans 
will seek care in the future; however, these changes will not be known 
for at least a couple of years.
    This was one of the key reasons then-Chairman Roe agreed with our 
request to ``.expand the entire AIR Act timeline to allow VA sufficient 
time to gather needed data, complete local capacity and commercial 
market assessments, and stabilize community care efforts.''
    In addition, the market assessments required under Section 
203(b)(3) have mandatory requirements for VA to ``consult with veterans 
service organizations and veterans.'' different than Section 106. 
However, we are unaware of VA engaging with DAV or any other VSOs in 
any meaningful way regarding either the process or methodology for 
conducting the current market assessments or in the field as they 
performed individual market assessments. It is our understanding that 
VA's contractor has effectively completed the first group of market 
assessments and we remain unaware of any efforts to contact VSOs 
locally or nationally to solicit input regarding veterans' needs or 
preferences for future medical care delivery.
    Mr. Chairman, the AIR Act was included in the VA MISSION Act with 
the very clear understanding among all stakeholders that VA would not 
begin a process that could result in closures of VA health care 
facilities until after the new community care program had been fully 
established and stabilized. Decisions on how VA will ensure the 
delivery of health care to millions of veterans must be made first, and 
only after new demand patterns have stabilized should decisions be made 
about the future alignment of VA infrastructure to deliver that care.
    Furthermore, because of the importance of ensuring that VSO 
stakeholders were fully engaged throughout the process, the MISSION Act 
included numerous specific consultation requirements. Such 
collaboration with VSOs is not only important to help ensure that VA's 
plans for creating integrated networks reflect veterans' needs and 
preferences, but robust engagement is essential to achieve the level of 
support from veterans that will be necessary to implement real reform 
and realignment of VA's health care infrastructure.
    Mr. Chairman, throughout the development of the AIR Act 
specifically, and the MISSION Act in general, DAV and other key 
stakeholder VSOs were regularly engaged with this Committee, working 
closely with both sides of the aisle in the House and the Senate. 
Unfortunately, the implementation by VA has too often been done with 
little or limited engagement with VSO stakeholders, even when the law 
specifically requires such consultation.
    For these reasons, while we recognize the good faith intentions of 
the bill's sponsor, Dr. Roe, throughout the development and passage of 
the MISSION Act, and particularly the AIR Act section, we strongly 
oppose this legislation. Accelerating the AIR process - which Secretary 
Wilkie has indicated is his desire - would run contrary to clearly 
bipartisan and bicameral intentions of the MISSION Act compromise and 
could lead to a fundamentally flawed infrastructure review process.
 H.R. 485, the Veterans Reimbursement for Emergency Ambulance Services 
                                  Act
    With our recommendation, DAV is pleased to support H.R. 485, based 
on DAV Resolution No. 075, calling on Congress to improve 
administration of the emergency care benefit for service-connected 
veterans. DAV believes access to emergency care is a necessary 
component of a robust and complete medical care benefits package.
    This bipartisan bill would clarify the circumstances under which VA 
would be required to reimburse emergency transportation of veterans. 
Veterans seeking reimbursement for both emergency transportation and 
care have routinely been denied because VA does not consistently apply 
a standard definition of ``prudent layperson understanding'' in 
providing reimbursement for claims.
    VA, like many other federal providers and payors, uses the prudent 
layperson standard created under the Emergency Medical Treatment and 
Labor Act (EMTALA) to define what constitutes a medical emergency. 
However, medical literature has shown that there are significant 
differences in perceptions of need for emergency care between laypeople 
and medical professionals-lay people are actually more conservative in 
applying the ``emergency'' label to some specific conditions than 
health care workers; however, they are also more likely to label 
conditions that affect ability to work, conditions that happen after 
business hours and any other conditions the patient believes is an 
emergency as ``emergent'' than health care workers.
    H.R. 485 aims to clarify the language defining a medical emergency 
that qualifies for VA reimbursement for emergency transportation by 
requiring that a condition have a sudden onset; that the layperson 
believes that the emergency is an immediate risk to life or health; or 
that a delay in treatment will result in serious consequences to life 
or health. This reimbursement for emergency transportation would apply 
to veterans who were transported to the closest medical facility that 
can respond to the veteran's needs.
    We understand these more detailed requirements for approval of 
emergency ambulance reimbursement claims may provide better guidance 
for claims administrators and help standardize administration to the 
veteran's favor; however, in light of VA's inconsistent and lackluster 
performance in administering Section 1725, we urge the Committee 
include an evaluation and reporting requirement of VA's performance in 
executing the intent of this legislation to be conducted by an entity 
independent of the Veterans Health Administration.
                               H.R. 2942
    DAV strongly supports this measure introduced by Congressman 
Cisneros based on DAV Resolution No. 304, which urges the Department of 
Defense (DoD) and other transition partners including VA and the 
Department of Labor (DOL) to include VSOs in the program and ensure 
that service members are obtaining meaningful employment and making 
adequate progress toward their life goals in the period of time shortly 
following military service.
    This bill would build from a successful ongoing pilot between VA 
and the Air Force, by establishing a pilot program to assist women who 
are transitioning from military to civilian life with obtaining 
appropriate health care.
    DAV made this recommendation in our 2014 Report, Women Veterans: 
The Long Journey Home. This report found that the effectiveness of the 
Transition Assistance Program (TAP) has yet to be evaluated. Often upon 
returning home from deployment, service members are eager to return to 
their homes and loved ones. Focusing on problems they may encounter 
later on is not something they are prepared to address. DoD often 
conducts TAP immediately prior to separation, but our report recommends 
that DoD consider addressing employment, educational opportunities and 
gender-specific information through additional workshops 6-12 months 
after separation to ensure that veterans are adequately primed to 
receive and make use of the information they receive.
    The report further recommends that DoD share contact information 
with VA and the DOL to ensure that outreach can be conducted and assess 
service members' satisfaction with participation, the effectiveness of 
TAP for all separated service members and the outcomes of participation 
in the program by gender and race in terms of addressing service 
members' need for education and employment opportunities.
    DAV's 2014 report also found that while there were many federal 
programs for women veterans, women were often unaware of the programs 
available to assist them and that there were many ``gaps'' between 
programs that transitioning service members could fall between in 
ensuring their successful transition home. DAV often lauds VA for the 
``wraparound'' services it provides to veterans with significant 
challenges such as homelessness or severe mental illness, yet veterans' 
access to programs that may assist them are often dependent upon one 
discharge planner or case manager's knowledge of them and often the 
crosswalks between VA and other federal agencies' programs are not 
widely understood. We believe that VSOs are part of the answer to this 
challenge if they are included in transition planning activities.
    As we have learned from both our 2014 report and 2018 Report, Women 
Veterans: The Journey Ahead, women transitioning from service often 
have difficult and different challenges to successful reintegration 
with families and communities than their male counterparts. Women are 
less inclined to have awareness of their veteran status, even after 
deployment. They are more prone to divorce and being single parents 
than male veterans. These factors often affect their economic stability 
and create or exacerbate the stress they have experienced during 
deployment. Likewise, more than half of the women veterans using VA 
services have a service-connected condition, use more VA mental health 
services than their male peers, have higher rates of suicide and 
homelessness compared to civilian women peers and a significant number 
report military sexual trauma all complicating their journeys to 
reintegration.
    In a recent hearing of the House Veterans' Affairs Subcommittee on 
Health, Representative Cisneros cited outcomes of the pilot to include: 
99 percent of participants would recommend the program to other women 
veterans and 80 percent agreed to allow follow up. Dr. Patricia Hayes, 
the VA Women's Health Program Director indicated that the program began 
because rates of suicide are high and growing among women veterans. She 
stated that the program allows women veterans to visit a VA medical 
center to dispel any stereotypes they believe may affect women's 
understanding of the program. She also stated that the Navy had agreed 
to have Navy and Marine sites began participating in the program.
    We believe this training may arm women veterans with information 
they need to prevent or minimize their challenges with transition by 
allowing them to acknowledge and obtain resources for addressing the 
residual health issues with which they are struggling in order to 
prevent health and mental health conditions from becoming more severe 
and chronic or leading to tragedies such as homelessness or even 
suicide, which too many of our veterans-both male and female-are lost 
to.
              Discussion Draft, Specially Adaptive Housing
    DAV does not have a resolution on VA's grant program for Specially 
Adapted Housing and Special Housing Adaptation; however, DAV Resolution 
No. 055 speaks to another benefit under VA's Special Housing Adaptation 
Program, the Home Improvement and Structural Alterations (HISA) grant 
program.
    A HISA grant is available to veterans with service-connected 
disabilities or veterans with nonservice-connected disabilities and who 
have received a medical determination indicating that improvements and 
structural alterations are necessary or appropriate for the effective 
and economical treatment of the veteran for disability access to the 
home and essential lavatory and sanitary facilities.
    Notably, a veteran may receive both a HISA grant and either a 
Special Home Adaptation grant or a Specially Adapted Housing grant. 
While this bill seeks to increase the grant amounts for Special Home 
Adaptation and Specially Adapted Housing, DAV's resolution calls for a 
reasonable increase in the HISA benefit for veterans. Correspondingly, 
this bill seeks to increase the amount for Special Home Adaptation from 
$12,756 to $20,271, and Specially Adapted Housing from $63,780 to 
$101,350, which would be help ensure the continued effectiveness of 
these grant programs.
    We note this bill does not cure inherent weaknesses in VA's Special 
Home Adaptation program. For example, the Specially Adapted Housing 
grant program differentiates between veterans who need this benefit 
based on when they were injured. A veteran suffering a loss, or loss of 
use of one or more lower extremities due to service on or after 
September 11, 2001, which so affects the functions of balance or 
propulsion as to preclude ambulating without the aid of braces, 
crutches, canes, or a wheelchair would be eligible. Yet a veteran who 
sustained a loss of or loss of use of both arms, or a loss of or loss 
of use of one leg and is blind in both eyes, or suffers from certain 
severe burns due to military service on or after September 11, 2001 
would not be eligible. Moreover, a veteran who sustained these injuries 
due to military service before September 11, 2001 would be eligible. 
These different eligibility criteria appear as a fundamental problem of 
arbitrary versus responsible government but does little to encourage, 
if not belie, the recognition of military service regardless of when 
such sacrifice was rendered.
    Mr. Chairman, this concludes DAV's testimony. Thank you for 
inviting DAV to testify at today's hearing. I would be pleased to 
address any questions related to the bills being discussed in my 
testimony.

                                 
                   Prepared Statement of Travis Horr
    Chairman Takano, Ranking Member Roe, and Members of the Committee, 
on behalf of Iraq and Afghanistan Veterans of America (IAVA) and our 
more than 425,000 members worldwide, thank you for the opportunity to 
share our views, data, and experiences on the pending legislation 
before the Committee today.
    While I serve as the Director of Government Affairs at IAVA, I'm 
also a Marine Corps veteran. I enlisted in the infantry in 2007 and 
deployed to Southern Helmand, Afghanistan in 2010. The issues of the 
post-9/11 generation are my issues. I was exposed to burn pits on my 
small patrol base in Afghanistan, I utilized the Post-9/11 GI Bill to 
become the first person in my family to graduate college. I've seen 
first hand the positive impact that medicinal cannabis can have on my 
fellow veterans' lives once they transition out of the service. And 
I've lost too many of my friends to the suicide epidemic in the veteran 
community. These issues are personal to me and I'm proud to represent 
IAVA's views in front of the Committee today.
    We thank the Committee for bringing forward important legislation 
that touches on a number of our Big Six priorities for 2019, which are: 
the Campaign to Combat Suicide, Defend Veterans Education Benefits, 
Support and Recognition of Women Veterans, Advocate for Government 
Reform, Support for Injuries from Burn Pits and Toxic Exposures, and 
Support for Veterans who Want to Utilize Medicinal Cannabis.

Support for Veterans Who Want to Utilize Medicinal Cannabis

    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, an increase from 63% 
just last year. IAVA members are vastly in support of cannabis 
research, and support will continue to grow in the months and years 
ahead. It's time for the Department of Veterans Affairs (VA) to catch 
up.
    IAVA members have set out to change the national conversation 
around cannabis and underscore the need for bipartisan, data-based, 
common-sense solutions that can bring relief to millions, save 
taxpayers money and create thousands of jobs for veterans nationwide. 
The veteran community has made it very clear that it supports research 
done on the use of cannabis as a treatment option.
    However, this demand has not resulted in a change in policy. For 
these reasons, the VA Medicinal Cannabis Research Act (H.R. 712) is the 
centerpiece of IAVA's Campaign to Support Veterans who Want to Utilize 
Medicinal Cannabis. This legislation will advance research and 
understanding of 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 ways cannabis might 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. Our 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. Without comprehensive 
cannabis research, we are unable to make policy decisions that could 
improve the lives of veterans.
    One such veteran whose life was improved through medicinal cannabis 
was Army veteran and former IAVA intern, Julie Howell. Her story, in 
her own words, follows:

    For years after I returned from Iraq I struggled to sleep through 
the night. As it turns out, I suffered from something known as 
maintenance insomnia, I would fall asleep but would wake for hours in 
the middle of the night and then fall back asleep right before needing 
to wake up. Thanks to California passing legislation regarding 
medicinal and recreational cannabis I now have access to a product that 
I ingest which contains a small amount of cannabis that helps me sleep 
through the night. I do not use cannabis recreationally, I do not even 
smoke, but this product has allowed me to thrive. Without access to 
cannabis, I would never have been as successful in the pursuit of 
higher education. I am currently working through a masters degree in 
public policy with the hope of assisting veterans like me, to live 
their best lives.

    In addition to Julie, over 100 IAVA members have shared the 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. In fact, Julie herself, even after advocating on Capitol 
Hill and back home in California, still hasn't talked to her VA doctor 
about her cannabis use.
    Julie isn't alone. 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. Twenty-four percent either do not feel 
comfortable or only 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.
    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. Yet VA's 
policies inhibit realistic discussion and open conversations around 
cannabis. If veterans are unable to receive the care that they deserve, 
then they will go around it.
    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 VA Survey of Cannabis Use Act (H.R. 2677), in 
order for VA to understand the scope and scale of veterans currently 
using cannabis. IAVA also supports H.R. 2677, which will allow VA 
physicians to undergo training to understand how to best use medicinal 
cannabis, where it is already available in state programs.

Reform VA for Today's Veterans

    Millions of veterans rely on VA for both health care and benefits. 
Ensuring that the system is able and agile enough to accommodate the 
millions of veterans who use its services is paramount to ensuring the 
lasting success and health of the veteran population. About 48% of all 
veterans and about 55% of post-9/11 era veterans are enrolled in VA 
care. Among IAVA member survey respondents, 81% are enrolled in VA 
health care, and the vast majority have sought care from VA in the last 
year, 81% of these VA users rated their experience at VA as average or 
above average. IAVA members have been clear that access to VA care can 
be challenging, but once in the system, they prefer that care. Further, 
independent reviews of VA health care support that the care is as good, 
if not better than the private sector.
    A bold approach to ensuring today's veterans have a system willing 
to bend and adapt to them will take the full coordination of the 
executive branch and Congress, along with stakeholder partners in state 
and local governments, and the private and nonprofit sectors. We need a 
system that leverages the use of new technologies to streamline 
processes and enables VA to take a more dynamic approach to respond to 
the needs of today's veterans. Even so, the best technology will not 
save a system if it is built upon outdated structures.
    Because of these reasons, IAVA is proud to support the AIR 
Acceleration Act (H.R. 3083) which will remove a restriction of the AIR 
Act to allow the commission to be nominated, appointed, and start their 
important work as soon as possible. Modernizing VA needs to be a top 
priority, the longer we wait, the bigger the problem it will become.
    The Veterans Reimbursement for Emergency Ambulance Services Act 
(VREASA) (H.R. 485) will expand VA's ability to reimburse emergency 
ambulance services. Typically, VA can reimburse ambulance services, 
however, there are still times when veterans are stuck with the bill. 
For instance, if a veteran experiences a medical emergency and a 
bystander calls for emergency services and it was later determined to 
not be life-threatening, then the veteran must pay for ambulance 
services, through no fault of their own. VREASA seeks to fix this 
loophole and aligns reimbursement to current law under Medicare and 
Medicaid. It is for these reasons that IAVA is supportive of the 
legislation.
    H.R. 2943 would direct VA to ensure that all fact-sheets are 
produced in both English and Spanish. The US Military is a diverse 
organization and a cross-section of the United States as a whole. I 
personally served with a large number of Marines who spoke English as a 
second language. All veterans should have equal access to information 
provided by VA in a language they are proficient in and it is for these 
reasons that IAVA is supportive of the legislation.
    IAVA is also supportive of the draft legislation to address 
specially adaptive housing. We are pleased to see the expansion of this 
program, to include the increase in the amount of assistance given, the 
increased amount of applicants that can be approved, and the 
elimination of the cap on grants given out.

Recognize and Improve Services for Women Veterans

    Data shows that women veterans, on average, do not seek support 
from the Veteran Health Administration (VHA) until 2.7 years after 
leaving the service, or until mental or physical health issues have 
manifested. On top of that, VA states that women veterans tend to face 
more health-related challenges than their male counterparts. And most 
importantly, since 2001, the suicide rate for women veterans has 
increased by 85.2%, while the suicide rate for males has increased by 
30.5%.
    It is because of those reasons that the VA Air Force Women's Health 
Transition Training pilot was created. It is aiming to provide 
servicewomen with a deeper understanding of womens' health services 
within the VA health care system. The courses are all led by women 
veterans, and everyone has the opportunity to personalize their 
training.
    The Helping Expand and Launch Transitional Health (HEALTH) for 
Women Veterans Act (H.R. 2942) is consistent with IAVA's groundbreaking 
She Who Borne The Battle campaign to recognize the service of, and fill 
gaps in care for women veterans. This legislation not only ensures the 
pilot program remains in place until 2020 but expands it across all 
services, and creates a feasibility study to make the program 
permanent. Women veterans are the fastest growing cohort of veterans 
and it is critically important that they receive the same care as their 
male peers. IAVA supports H.R. 2942.

Defend Military and Veteran Education Benefits

    The Post-9/11 GI Bill can only go so far in ensuring the future 
success of today's fighting force. While an earned benefit, the Post-9/
11 GI Bill is also an investment in America's next ``Greatest 
Generation.'' Veterans are proven to be more productive and have higher 
retention rates once hired into a career, and ensuring they have the 
appropriate training and degrees is paramount to this success. This 
successful transition to the civilian workforce often begins on a 
college campus. In fact, according to Student Veterans of America and 
the Institute for Veterans and Military Families, 2.9 million post-9/11 
veterans have entered higher education since transitioning out of the 
military and I'm proud to be one of them. This means that ensuring 
veterans are supported and successful on campus is of utmost importance 
to the long-term success of each veteran.
    To this end, IAVA is supportive of the draft legislation that 
addresses and improves VA Work Study program. This bill will update the 
work-study program to mirror the already successful program used by the 
Department of Education (ED). By using previous years' data, VA will be 
able to give more timely work-study payments to students and ensure 
that they paid on time and in full. While we are all intimately aware 
that IT issues continue to be a problem at VA, we feel confident that 
by using ED as a model, VA will be able to make their work-study 
payments more reliably.
    Members of the Committee, 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 Committee in the 
future.

                                 
                  Prepared Statement of Carlos Fuentes
    Chairman Takano, Ranking Member Roe, and members of this committee, 
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 committee.

H.R. 485, Veterans Reimbursement for Emergency Ambulance Services Act

    This legislation would decouple ambulance reimbursement from 
reimbursement for emergency room health care services. The VFW supports 
this bill and has a recommendation to improve it.
    The Department of Veterans Affairs (VA) emergency transportation 
reimbursement process is cumbersome and tends to take unreasonably 
long. VA must first adjudicate a claim for emergency room care before 
VA pays for the emergency transportation. In order to have a claim for 
emergency room services approved, VA must confirm the veteran 
experienced an emergency, whether the veteran has received VA health 
care within the past 24 months, if there is an acceptable reason a VA 
medical facility was not used, and whether the veteran notified VA of 
the emergency within 72 hours. When the emergency is for a non-service-
connected condition, the veteran is required to exhaust all other 
health care insurance options before VA can cover the cost of 
transportation.
    Veterans who believe they are experiencing an emergency must not be 
delayed or deterred from contacting 9/11 for emergency assistance 
because they are concerned VA will refuse to cover the cost of 
emergency transportation and leave them with crippling health care 
debt. This bill would rightfully authorize VA to pay claims for 
emergency room transportation without having to first process a claim 
for emergency health care.
    This legislation would require that a veteran be taken to the 
closest and most appropriate medical facility as a prerequisite for 
reimbursement of emergency transportation costs. Ambulance services 
typically take patients to the nearest emergency room. VA must make 
certain emergency transportation services are doing their best to take 
veterans to VA hospitals when possible. Since veterans who are facing 
an emergency typically do not have the opportunity to influence where 
they are taken, the VFW would recommend this committee strike the 
requirement that they be taken to the ``closest and most appropriate'' 
medical facility. Doing so would ensure veterans are not forced to pay 
emergency room reimbursement bills out-of-pocket because VA and the 
ambulance service disagree on what constitutes closest and most 
appropriate.

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

    This legislation would require VA to conduct a double-blind 
scientific study on the efficacy of medicinal cannabis. The VFW is 
proud to support this important bill and thanks this committee for its 
consideration.
    Prescribed use of opioids for chronic pain management has 
unfortunately led to addiction 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 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 
medicinal cannabis and other holistic approaches.
    Medicinal 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 medicinal 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. 
This bill would prevent VA from further delaying needed research.
    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 medicinal 
cannabis programs have, on average, a 25 percent lower rate of death 
from opioid overdose than states without such programs.
    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 medicinal 
cannabis. However, Chris found that veterans who discuss their use of 
medicinal cannabis with their doctors are ostracized and have their 
medications changed or discontinued. The fear of reprisal for medicinal 
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 negatively impacted, the VFW recommends this 
committee amend the bill to prohibit VA from denying or altering 
treatment for veterans who participate in the study. Doing so would 
provide veterans peace of mind.

H.R. 1647, Veterans Equal Access Act

    This legislation would authorize VA doctors to provide 
recommendations for participation in state-approved medicinal 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 medicinal 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 medicinal 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. 2676, VA Survey of Cannabis Use Act

    The VFW supports this legislation, which would require VA to 
commission surveys of veterans and health care providers to measure 
cannabis use by veterans.
    VFW members tell us that medicinal cannabis has helped them cope 
with chronic pain and other service-connected health conditions. 
Conducting a scientific survey of veterans and health care providers 
would assist in identifying the current landscape of medicinal cannabis 
use and measure its effectiveness. The VFW is pleased the survey would 
require anonymity, but it does not preclude VA from affecting the 
employment status of health care providers who participate in the 
surveys or prevent VA from denying or altering treatment or benefits 
for veterans who participate in the surveys. The VFW urges this 
committee to prohibit VA from doing so, which would ensure the fear of 
reprisal does not affect participation in the surveys.

H.R. 2677, to provide training in the use of medical cannabis for all 
    VA primary care providers

    The VFW supports this legislation, which would require VA to train 
its primary care providers on the use of medical cannabis. While VA 
health care providers are precluded from prescribing medical cannabis, 
it is important for them to understand its use and how it affects their 
patients.

H.R. 2942, to direct the Secretary of Veterans Affairs to carry out the 
    Women's Health Transition Training pilot program through at least 
    fiscal year 2020

    The VFW supports this legislation, which would track participation 
in VA health care and Transition Assistance Program (TAP) courses 
developed specifically for transitioning women service members. The VFW 
believes more information about what programs within VA are being used 
and where there needs more attention is vital to improving the 
transition process for women veterans. The United States (U.S.) Air 
Force currently operates a pilot program which adds a voluntary program 
to the end of the TAP classes for women veterans. This bill would 
require VA to participate in the additional workshop for women veterans 
to help guide them toward VA health care and benefits.

H.R. 2943, to make all fact sheets of the VA in English and Spanish

    This legislation would require all VA fact sheets to be published 
in English and Spanish. The VFW agrees that VA must address all 
barriers to access, including language barriers, but VA must first 
evaluate the need before it can devote time and resources to 
translating and publishing its outreach material in different 
languages.
    The VFW represents veterans who live throughout the world and use 
VA health care and benefits. The VFW has posts in Cambodia, Saipan, 
France, Germany, Guam, Italy, Japan, Korea, Panama, Philippines, Puerto 
Rico, Taiwan, Thailand, and Australia. The primary language used by VFW 
members who reside in those U.S. territories or countries may not be 
English. The VFW also has many members who reside in the United States, 
but prefer to use their native language, such as veterans who were born 
in foreign countries, Native Americans, or Pacific Islanders.
    Yet, VFW members have not indicated that fact sheets or outreach 
material written in English present a barrier for accessing the care 
and benefits they have earned. That is why the VFW cannot support this 
bill. To validate the need, this committee should commission a review 
of language barriers to accessing VA care and benefits before requiring 
VA to devote time and resources to translate and publish its fact 
sheets in Spanish.

H.R. 3083, AIR Acceleration Act

    The VFW fully supported the Asset Infrastructure Review (AIR) 
portion of the VA MISSION Act of 2018. The intent of the review is to 
fully examine the physical infrastructure of VA's health care system 
and determine what changes are needed to continuously deliver high-
quality care. We would, however, be very concerned with expediting the 
timeline for the AIR commission without further knowledge of the 
ongoing market area assessments and allowing for proper implementation 
of the new Veterans Community Care Program.
    Secretary Robert L. Wilkie has stated VA would like to move up the 
timeline of the review because of the market assessments, but he has 
not provided veterans service organizations information regarding the 
outcomes of these assessments. Additionally, a significant change to 
community care was recently implemented, which is estimated to impact 
the landscape and demand on the VA health care system. It is vitally 
important VA implements AIR correctly. The VFW warns Congress not to 
rush the AIR process, because it may cause irrevocable harm to the care 
and benefits America provides its veterans.

Discussion Draft to improve the work-study allowance program 
    administered by the Secretary of Veterans Affairs

    The VFW supports the intent of this legislation, which is to 
improve and streamline the VA work-study program. This is a vital tool 
student veterans use to supplement their income. The VFW agrees that 
improvements are urgently needed to ensure veterans who use this 
program receive timely work-study payments.
    VA's outdated paper-based payment process is negatively affecting 
students who have to wait several weeks or months to receive payments 
they need to make ends meet. This legislation would change how VA 
processes claims by authorizing the school to directly pay program 
beneficiaries. This would align the VA work-study program with a 
similar program administered by the Department of Education. The VFW 
recommends that VA analyzes the similarities and differences of the two 
work-study programs to glean best practices to improve the delivery of 
benefits, including alternative ways of delivering payments to student 
veterans.
    However, we cannot support changing the current business practice. 
Instead, the VFW urges this committee to require VA to evaluate and 
address barriers that delay work-study payments to ensure bureaucratic 
processes do not impact the financial well-being of student veterans.

Specially Adapted Housing Discussion Draft

    The VFW supports this draft legislation to expand the VA Specially 
Adaptive Housing Grant Programs (SAH), which help veterans with 
service-connected disabilities to live independently in a barrier-free 
environment by providing critical housing adaptations. The 
accessibility provided through this program greatly increases the 
quality of life for such veterans, but to qualify, the individual must 
endure a lengthy and cumbersome process.
    This draft bill would allow for more eligible veterans to utilize 
this life-enhancing benefit and would also increase the maximum amount 
of each grant. The VFW is pleased this bill would quadruple the number 
of applicants VA is able to approve annually from 30 to 120. However, 
we do not think there is a need for a cap on the number of veterans who 
can use this important program. Every veteran who needs to adapt their 
home because of service-connected disabilities must have the 
opportunity to receive an SAH grant.
    Common issues veterans face when seeking SAH grants are the 
timeliness of approvals and the difficulty in finding contractors who 
are familiar with the SAH grant process. In some cases, the approval 
may take months, which makes completing activities of daily living 
difficult. We are encouraged to see this bill would prioritize the 
application of those veterans who are seriously ill. Veterans with 
illnesses that progress quickly, such as amyotrophic lateral sclerosis, 
must be granted an opportunity to adapt their homes as soon as 
possible.
    Mr. Chairman, this concludes my statement. I am happy to answer any 
questions you or the members of the committee may have.

                                 
                 Prepared Statement of Derek Fronbarger
    Chairman Takano, Ranking Member Roe, and distinguished members of 
the House Committee on Veterans' Affairs, thank you for inviting 
Wounded Warrior Project (WWP) to testify on these important legislative 
priorities.
    Wounded Warrior Project's mission is to honor and empower wounded 
warriors. Through community partnerships and free direct programming, 
WWP is filling gaps in government services that reflect the risks and 
sacrifices that our most recent generation of veterans faced while in 
service. Over the course of our 15-year history, we have grown to an 
organization of nearly 700 employees in more than 25 locations around 
the world, delivering over a dozen direct-service programs to warriors 
and families in need.
    Through our direct-service programs, we connect these individuals 
with one another and their communities; we serve them by providing 
mental health support and clinical treatment, physical health and 
wellness programs, job placement services, and benefits claims help; 
and we empower them to succeed and thrive in their communities.
    We communicate with our warriors on a weekly basis and are 
constantly striving to be as effective and efficient as possible by 
matching our programs - and our advocacy before Congress - to meet 
warriors' needs. We use these weekly engagements, our yearly WWP Alumni 
Survey, and direct programming to inform us of our positions outlined 
in this testimony.
 Draft Bill: Ryan Kules Specially Adaptive Housing Improvement Act of 
                                  2019
    One of WWP legislative priorities is the passage of legislation 
that expands VA's Specially Adaptive Housing Grant program (SAH). These 
expansions are outlined in the draft bill titled the Ryan Kules 
Specially Adaptive Housing Improvement Act of 2019. Ryan Kules is a 
bilateral wartime amputee who works at Wounded Warrior Project and 
helped highlight many of the program's deficiencies.
    One aspect of this legislation that WWP is supportive of is the 
full reinstatement of the SAH benefit every ten years. As younger 
veterans age, get married, and have families, their needs in an 
adaptive home may change drastically. This is also true for those whose 
disabilities get worse over time. A veteran with a prosthetic leg might 
be fine to walk around their home when they are in their thirties, but 
they might require a wheelchair when they become senior citizens. We 
want warriors to thrive in their work and personal lives. Often, they 
must move to take advantage of opportunities to improve their 
socioeconomic conditions. It is not reasonable to expect a veteran to 
buy a home and never leave. This benefit is reserved for those 
catastrophically injured and who deserve our assistance throughout 
their entire life, not just one portion of it.
    This bill also increases the total grant amount from $81,080 to 
$98,492, increases the total amount of applicants into the ``expanded'' 
SAH grant program from 30 to 120 a year, and increases the times a 
veteran may use the grant from three to six. These were all identified 
as deficiencies in the program that needed updating.
    The VA Specially Adaptive Housing Grant assists the most critically 
ill, injured, and recognizes that Wounded Warriors find solitude in 
their homes as they transition from service into the civilian world. 
Wounded Warrior Project supports this Draft Bill as written and 
considers this piece of legislation a major priority for WWP during the 
116th Congress.
H.R. 2942: To Direct the Secretary of Veterans Affairs to Carry Out the 
   Women's Health Transition Training Pilot Program through at Least 
                Fiscal Year 2020, and for other purposes
    There are currently around 2,000,000 women veterans in the United 
States, which comprise 10% of the entire veteran population. Women 
veterans are the fasted growing cohort which is expected to double by 
2045\1\. Transition from military to civilian life is a critical touch 
point for VA and DoD. While women veterans are more likely to attend 
college, they are also more likely to be homeless over their male 
counterparts with a homelessness rate of 7.1 percent versus 5.3 
percent\2\. Understanding the unique challenges that women veterans 
face during transition is critical in ensuring success among this 
population. The Women's Health Transition Training Pilot Program helps 
transitioning women servicemembers by informing them of women's health 
and mental health care services available through the Veterans Health 
Administration, along with other tools that may be of use during their 
transition from military service.
---------------------------------------------------------------------------
    \1\ https://www.pewresearch.org/fact-tank/2017/11/10/the-changing-
face-of-americas-veteran-population/
    \2\ https://www.woundedwarriorproject.org/media/183005/2018-wwp-
annual-warrior-survey.pdf
---------------------------------------------------------------------------
    We support H.R. 2942, which would expand the Women's Health 
Transition Training Pilot Program through fiscal year 2020.
 H.R. 2676, H.R. 2677, H.R. 712, H.R. 1647: VA Survey of Cannabis Use 
 Act, To Require the Secretary of Veterans Affairs to Provide Training 
 in the Use of Medical Cannabis for all Department of Veterans Affairs 
   Primary Care Providers, VA Medical Cannabis Research Act of 2019, 
                       Veterans Equal Access Act
    Several emerging and alternative therapies have reported some 
initial results that are promising for the management and treatment of 
the invisible wounds of war, including post-traumatic stress disorder 
(PTSD) and traumatic brain injury (TBI). A debate surrounding veterans' 
rights to access medical cannabis has emerged as a popular topic of 
discussion in the context of alternative therapies.
    Choosing an alternative treatment method is a personal decision 
that should be made between each warrior, his or her family, and his or 
her medical team. Wounded Warrior Project encourages warriors to make 
informed decisions in pursuing the treatment options that are most 
relevant to their circumstances under guidance from their health care 
providers. Wounded Warrior Project supports evidence-based and 
evidence-informed therapies, as well as complementary and alternative 
therapies that have proven to be successful in rehabilitation and 
recovery.
    While our position is limited in scope, we are using our annual 
survey to try to better understand how warriors are using cannabis. The 
2018 WWP Alumni Survey reveals that around 18 percent of our alumni 
indicate they have used marijuana; 4.7 percent of those used marijuana 
less than once a month and 8.4 percent of them used marijuana more than 
twice a week, with the remainder falling in between\3\. To better 
inform our position on the use of medical cannabis, we added additional 
questions to our 2019 WWP Alumni Survey. While 2019 data is not 
published yet, we did find that 17 percent of our warriors indicated 
they use cannabis to treat a mental or physical condition and 49 
percent of warriors know a veteran who is using cannabis to treat a 
condition.
---------------------------------------------------------------------------
    \3\ https://www.woundedwarriorproject.org/media/183005/2018-wwp-
annual-warrior-survey.pdf
---------------------------------------------------------------------------
                               H.R. 2676
    Wounded Warrior Project supports legislation to expand research, 
evidence-based, and evidence-informed therapies. One avenue to help 
understand the ``whole picture'' of an issue is survey-based data 
gathering. We routinely do this with our WWP Alumni Survey and, to this 
end, support H.R. 2676 as it will require the Secretary of Veterans 
Affairs to partner with a federally funded research center to conduct 
surveys to measure cannabis use by veterans. We would recommend a 
change on page 6, line 5, to strike ``not later than one year after the 
date,'' and replace this with ``not later than two years after the 
date'' as we have found that surveys take a considerable amount of time 
to develop, disseminate, and analyze. We do not think one year is long 
enough for VA to conduct a suitable survey on this topic.
                               H.R. 2677
    H.R. 2677 requires VA to establish a training program to inform 
primary care providers on the use of medical cannabis. While we do not 
have a position on H.R. 2677, we are concerned with the lack of clarity 
on what training VA primary care providers would receive under this 
proposal and whether the fact that they are federal employees limits 
their ability in any way. We think that before VA can start training 
health care providers on the usages of medical cannabis, there must be 
additional studies on the effects of this drug on this population and 
the risks regarding the usage of a schedule I drug for veterans while 
it remains categorized as such.
                                H.R. 712
    Much like H.R. 2676, WWP supports legislation to expand research, 
evidence-based, and evidence-informed therapies. H.R. 712 would require 
the Secretary of Veterans Affairs to carry out a clinical trial of the 
effects of cannabis on certain health outcomes of adults with chronic 
pain and PTSD. While we support the intent of the bill, we do have some 
concerns regarding the ability of VA to implement this research study. 
Specifically, page 5, line 4 through 13, requires the VA to use varying 
forms of cannabis to include, full plants and extracts, at least three 
different strains of cannabis, and varying methods of cannabis 
delivery. Currently, the University of Mississippi is the only 
institution with DEA approval to grow cannabis for research purposes. 
This is also the only institution that the federal government may 
purchase cannabis from for a federal study. Reports from former 
federally funded researchers have indicated that the University of 
Mississippi is limited in what they grow, which would hamper this 
proposed research study. If this bill were to pass, VA could possibly 
be put in a position to perform a study on cannabis strains that may 
not currently available to the federal government.
    While we support the intent of H.R. 712, we recommend reviewing 
page 5, line 4 through 13, to avoid a failure in the study due to lack 
of appropriate cannabis availability.
                               H.R. 1647
    While WWP supports legislation on medical cannabis that is 
researched-based, we are concerned regarding legislation that could be 
detrimental to veterans and VA employees due to complications regarding 
federal and state cannabis laws. Currently, cannabis is a schedule I 
drug, but many States have laws legalizing medical or recreational 
cannabis. H.R. 1647 is concerning as it will authorize VA federal 
employees to recommend and give their opinion on a possible State-level 
approved medical cannabis treatment alternatives. While medical 
cannabis is legal in some States, it is still deemed illegal by the 
federal government. Given that veterans receive medical advice and 
treatment across different states, it is plausible that a federal 
employee would recommend medical cannabis to a veteran who resides in a 
state where it is not legal. This could lead to unnecessary legal 
action against the veteran due to confusion regarding Federal versus 
State medical cannabis laws. Additionally, there are insufficient 
protections in place for veterans regarding employment when using 
medical cannabis. Lastly, there is no protection for federal employees 
who recommend the usage of a federally scheduled I drug. This could 
lead to legal troubles for medical providers who recommend medical 
cannabis to a veteran as an alternative treatment. These fears lead us 
to oppose H.R. 1647 until such a time where these concerns can be 
addressed.
                    H.R. 3083: AIR Acceleration Act
    Wounded Warrior Project acknowledges that VA needs the ability to 
alter its footprint to become more focused and better aligned with 
today's ever-changing veteran population. The Asset & Infrastructure 
Review (AIR) Act was passed in order to assess current resources and 
allow for a more focused and better-aligned infrastructure that will be 
designed to support the care to veterans where they might need it. 
Additionally, this legislation includes stakeholder involvement and 
other safeguards in the review process to ensure that the final result 
of the AIR Act is what the community would approve of. With this in 
mind, we support H.R. 3083 as it would accelerate the implementation of 
the AIR Act but recommend adding language that clearly states that this 
bill will be implemented after the market assessments have been 
completed.
H.R. 2943: To Direct the Secretary of Veterans Affairs to Make all Fact 
   Sheet of the Department of Veterans Affairs in English and Spanish
    Wounded Warrior Project does not have a position on this piece of 
legislation at this time.
 H.R. 485: Veterans Reimbursement for Emergency Ambulance Services Act
    Wounded Warrior Project does not have a position on this piece of 
legislation at this time.
Draft Bill: To Improve the Work-Study Allowance Program Administered by 
                   the Secretary of Veterans Affairs
    Wounded Warrior Project does not have a position on this piece of 
legislation at this time.
                            Closing Remarks
    In closing, we would like to acknowledge the bipartisan and 
inclusive spirit that guides the work of these committees. We share a 
sacred obligation to ensure that our veterans and their families get 
the support and care they have earned, and the success they deserve. At 
Wounded Warrior Project, we are committed to that mission, and we are 
constantly striving to be as effective and efficient as possible in the 
life changing programs we provide, as well as our advocacy efforts. We 
appreciate the committee inviting WWP to comment on these pieces of 
legislation and the work each member has done on behalf of veterans 
across the country.

                                 
                 Prepared Statement of Igor Grant, M.D.
    Good afternoon,

    My name is Igor Grant. I am a physician, neuropsychiatrist and 
Professor at the University of California San Diego where I direct the 
Center for Medicinal Cannabis Research (CMCR). During my career I also 
served for 3 decades as a Staff Physician at the VA San Diego Medical 
Center where I oversaw the opening the hospital's first mental health 
outpatient clinic in 1972. Therefore, I have some familiarity with the 
mental health needs of our veterans.
    Some of the prevalent health problems of our veterans include 
chronic pain, posttraumatic stress disorder (PTSD), certain 
inflammatory disorders, as well as sleep disorders. Our veterans have 
not always found the treatments that we offer them to be fully 
beneficial and they therefore sought recourse outside the VA medical 
framework including with medicinal cannabis in states where it has been 
legalized.
    I am here today to provide you with my medical opinion based on our 
experience with the Center for Medicinal Cannabis Research as to the 
state of current knowledge on medicinal cannabis. Clearly, this is a 
controversial area, but there are important facts that are emerging. 
The Center for Medicinal Cannabis Research at University of California 
San Diego was established in 2000 by legislation of the State of 
California. The establishment of the Center followed the passage in 
1996 of an initiative called the Compassionate Use Act which made 
California the first state to authorize use of medicinal cannabis. The 
legislators wished to be provided with more scientific evidence in 
regard to that initiative.
    Since our establishment we completed 8 different short-term 
clinical trials with cannabis provided to us by the NIDA Drug Supply 
Program. As you may know, the only legal source of cannabis for medical 
research is through NIDA which has a contract with the University of 
Mississippi to grow cannabis.
    Our studies found that tetrahydrocannabinol (THC) containing 
cannabis ranging in strength from 2% to 7% in the several studies 
showed benefit in a type of chronic pain called neuropathic pain, which 
can be a complication of HIV/AIDS, diabetes, and certain kinds of 
injuries; a pain that is sometimes difficult to control through 
traditional pain medicines. We also found that patients with severe 
muscle spasticity due to multiple sclerosis derived benefit. Our 
results dovetailed with emerging data from other investigations, and 
also were consistent with the report of the National Academies of 
Sciences, Engineering and Medicine in 2017. That report noted that 
there was ``conclusive evidence'' for cannabis and/or cannabinoid 
benefit in terms of management of certain types of pain, muscle 
spasticity, as well as nausea control. That report also noted modest 
evidence for benefit in improvement of certain sleep conditions, 
particularly when pain was a component, as well as possible evidence 
for anxiety control, including PTSD. More recently the non-psychoactive 
cannabinoid cannabidiol (CBD) has been shown to be effective in control 
of certain uncommon forms of severe intractable epilepsies of children. 
There are studies that have been initiated to determine whether either 
THC or THC/CBD mixtures or CBD alone may be helpful in the treatment of 
some symptoms of PTSD, psychosis, anxiety, autism, essential tremor and 
sleep disorders.
    Another area of increasing interest is the possibility that 
cannabinoids may have an ``opioid sparing'' effect. What this means is 
that it may be possible that the administration of cannabis or 
cannabinoids may reduce the requirement for opioids for patients with 
severe chronic pain problems, and it might in theory be possible to 
entirely eliminate the opioids. If research shows that these benefits 
are there, then this would be a step forward in combating the morbidity 
and mortality associated with chronic opioid use in our patients.
    In summary, what I would recommend to you is that the area of 
medicinal applications of cannabis and cannabinoids has matured to a 
level that it is now clear that these drugs can be helpful for some 
chronic medical conditions, including conditions that are found in 
moderately high prevalence among our veteran population. As such, it is 
my opinion that the VA would be benefitting our veterans by:

    1)Assuring that VA physicians and other medical staff receive 
education on both the potential value of medicinal cannabinoids as well 
as their side effects and possible harms, as well as what remains 
unknown;
    2)Encouraging VA health providers to provide unbiased, 
authoritative information to veteran patients on medicinal cannabis and 
cannabinoids if the veteran's medical condition might be benefitted 
from these based on emerging scientific consensus, such as articulated 
in the National Academies 2017 report and subsequent analyses;
    3)That in medical marijuana legal states, VA physicians be allowed 
to recommend use of medicinal cannabis if the emerging scientific 
evidence indicates there may be benefit;
    4)That in States that permit medicinal cannabis use, veterans who 
receive medicinal cannabis in a manner compliant with State law not be 
subjected to any adverse action in regard to their VA treatment or 
other benefits as a consequence;
    5)That the VA collaborate with Medical Boards in Medicinal Cannabis 
states to develop protocols and decision trees to guide medicinal 
cannabis and cannabinoid administration based on the emerging science.

    This leads me to my final comment and that is it is essential that 
high quality medical studies continue to be done in this area. I 
recommend that the VA work closely with academic universities that have 
expertise in this area, to pave the way to a better understanding of 
indications, cautions, factors that might affect benefit and risk in 
special populations, such as the elderly or persons with substance use 
disorders, values of specific cannabinoids and their combinations, 
pharmacology related to routes of administration, interactions with 
other medicines, and optimal duration of treatment.. Many years ago, 
when I was training as a psychiatrist, I learned about the VA's 
landmark role in determining the value and limitations of antipsychotic 
medicines in the treatment of schizophrenia. I believe the VA, with its 
academic partners, can be at the forefront again of creating a better 
understanding of the place of cannabis and cannabinoids in addressing 
the health needs of our patients.
    Thank you for your attention.

                                 
               Prepared Statement of Larry Mole, PHARM.D.
    Good morning, Chairman Takano, Ranking Member Roe, and Members of 
the Committee. Thank you for inviting us here today to present our 
views on several bills that would affect VA health programs and 
services, including H.R. 712, H.R. 1647, H.R. 2676. H.R. 2677, H.R. 
2942, and H.R. 2943. Due to the delay in notification regarding H.R. 
485, H.R. 3083, the draft Specially Adapted Housing Improvement bill, 
and the draft Work-Study Allowance Program Improvements bill, we are 
unable to provide views on those bills at this time, but will follow up 
with the Committee as soon as possible. With me today are [TBD].

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 compositions and multiple 
administration methods 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 exploring pathways to contribute to the overall 
understanding of the possible contribution of medical cannabis to 
Veterans' health care. VA is reviewing the clinical state of the 
evidence regarding medical marijuana, which concluded more research is 
needed, especially related to clinical trials. VA is currently 
supporting a clinical trial of cannabidiol for posttraumatic stress 
disorder (PTSD) based upon a strong design and rationalized mechanism 
in a trial that will assess risks and benefits. VA has also encouraged 
other medical marijuana research. 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 presently a schedule I controlled 
substance. 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 this bill. Though research studies are in progress, the 
scientific benefit of most products derived from the marijuana plant is 
still not proven, 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. 2676 - VA Survey of Cannabis Use Act

    H.R. 2676 would require VA to enter into an agreement with a 
federally-funded research and development center to conduct nationwide 
surveys to measure cannabis use by Veterans. The center selected by VA 
would have to have: (1) an in-depth knowledge of all state medicinal 
marijuana programs and the ability to tailor the required surveys 
accordingly; and (2) expertise and a record of independent, peer-
reviewed publications with respect to behavioral health research and 
conducting independent evaluations of mental health programs using 
multidisciplinary methods. In conducting the surveys, the center would 
have to survey Veterans who are enrolled for VA health care and those 
who are not, collect information from VA health care providers and be 
conducted in a manner that ensures the anonymity of the individual 
being surveyed. The surveys of Veterans would have to cover 12 
different topics, and the surveys of providers would have to cover 7 
different topics. Not later than 1 year from the date of the enactment 
of this bill, VA would have to submit a report to Congress on the 
results of these surveys.
    We do not support this bill. The legislation would prescriptively 
define how the surveys would be conducted, but it does not provide the 
purpose, goals, or objectives for the surveys. We have significant 
concerns that Veterans will not want to participate, despite the survey 
being anonymous. The survey of providers would be difficult to complete 
because it is asking for both overall impressions of cannabis use among 
Veterans and specific documentation for patients using cannabis. This 
would produce a significant burden on providers, requiring a review of 
charts for their patient panels. It is very likely that the response 
rate would be low, both because of this burden and because of the 
anonymity of responses (which would make it impossible to identify and 
follow up with non-responding providers). Moreover, the survey results 
would likely only be meaningful if we knew where Veterans live and 
where providers practice, given the variability of state laws, but 
submitting information on the state could reduce the anonymity of the 
survey as well (particularly in small states). Finally, we note that 
the survey of Veterans might be subject to the Paperwork Reduction Act 
(44 U.S.C. 3501 et seq.), and compliance with the requirements of this 
Act could delay VA's implementation of this survey beyond the 1-year 
period the bill would permit.

H.R. 2677 - Training in the Use of Medical Cannabis for All VA Primary 
    Care Providers

    H.R. 2677 would require VA, within 1 year of the enactment of the 
bill, to provide an initial training for all VA primary care providers 
in the use of medical cannabis. VA would be required to provide 
supplemental training, as necessary. In developing this training, VA 
would be required to enter into partnerships with medical schools that 
have incorporated education on medical cannabis into their curricula.
    VA does not support this bill. We do not believe there is 
sufficient scientific study and research findings to support a 
comprehensive training program. Marijuana potency is highly variable, 
and state laws governing medical marijuana are inconsistent, which 
would further complicate our ability to develop training for all 
providers, ultimately making it difficult to construct a curriculum 
that provides recommendations for a standard of care without a 
sufficient evidence base. Additionally, we are concerned that the bill 
requires partnering with medical schools who have incorporated medical 
cannabis into their curricula. A medical school's curriculum in this 
area likely reflects the applicable state laws, but any national 
training VA provided should not be state specific. This would, again, 
make it difficult to adapt any single school's curriculum to the 
Federal level. We further note that VA already makes available to all 
providers information sessions on cannabis, including a course on 
caring for patients who use marijuana at the end of life, a review of 
current findings and clinical considerations regarding cannabis use and 
PTSD, and the latest on marijuana use, effects, and treatment 
implications for Veterans. VA's Academic Detailing Program also 
provides resources for providers to have meaningful conversations with 
their patients. Finally, VA has tried to limit the amount of mandatory 
training directed at clinical providers. Instead, we have used other 
mechanisms to spread awareness and information about key clinical 
issues. Each hour of mandatory training takes over 20,000 doctors, 
80,000 nurses, and thousands of other practitioners away from direct 
patient care duties. This is not only expensive but reduces access to 
vital services for Veterans.

H.R. 2942 - Women's Health Transition Training Pilot Program

    H.R. 2942 would require VA to carry out the Women's Health 
Transition Training pilot program until at least September 30, 2020. VA 
and the Department of Defense would be required, by September 30, 2020, 
to jointly submit a report to Congress on the pilot program including a 
number of specified elements.
    Carrying out this pilot program until at least September 30, 2020, 
is favored by VA for the reasons stated below, and while we do not 
believe this bill is necessary in order to do so, we do not oppose the 
bill. Our authority to operate the pilot program is not limited; VA is 
conducting the pilot under the direction of the VA/Department of 
Defense Health Executive Committee. The pilot program is currently 
funded through December 2019 for an additional 24 face-to-face training 
sessions and initial virtual training sessions. VA will plan to 
continue the pilot through 2020 to ensure additional face-to-face 
sessions are conducted for statistically-meaningful results on the 
efficacy of the pilot program. Currently, the vast majority of the 
pilot program participants have been from the Air Force. Extension of 
the pilot program through Fiscal Year (FY) 2020 will allow for greater 
inclusion of transitioning Servicewomen from the Navy, Marine Corps, 
and Army. We anticipate that robust participation from these services 
could help achieve sample size requirements and greatly inform the 
full-scale implementation of this program. We also will need until 
September 2020 to be able to account for at least half of our current 
cohort's outcomes. We expect that continuing this program through 2020 
will allow us to answer questions about the program's efficacy, 
participant satisfaction, and the impact on participant awareness; it 
will also provide an opportunity to collect a wealth of qualitative 
information for women across various Service branches. Understanding 
the needs of Servicewomen across military branches can help inform 
future VA health education and training programs, including and beyond 
women's health. We believe that completing the pilot program at the end 
of FY 2020 would allow VA to submit a report to Congress by the end of 
that calendar year.

H.R. 2943 - Making Fact Sheets Available in English and in Spanish

    H.R. 2943 would require VA to make versions of all VA fact sheets 
in English and Spanish.
    We agree with the intent of this legislation, but we do not support 
the bill because it is unnecessary as VA currently has the authority to 
produce materials in English and in Spanish, and our efforts already 
meet the goals of the legislation. Initially, we note that VA is 
committed to ensuring no individual is subject to discrimination 
because of national origin. In March 2016, VA adopted a Language Access 
Plan to ensure equal access to services provided by VA to individuals 
with Limited English Proficiency (LEP). The Plan aims to eliminate or 
reduce, to the maximum extent practicable, LEP as a barrier to 
accessing VA benefits and services. The Plan establishes detailed 
policies and processes, including the use of bilingual employees in 
telephone and face-to-face encounters. For written materials, the Plan 
leaves VA discretion concerning what steps it should take regarding 
translation of documents into Spanish or other languages. We believe 
this discretion is necessary given the huge variety and volume of 
written materials produced by VA. We note that the legislation only 
refers to ``fact sheets,'' but does not define that term, which could 
make implementation of this bill difficult if it were enacted. We would 
be glad to discuss with the Committee VA's efforts toward ensuring all 
Veterans and beneficiaries are able to access the benefits and services 
for which they are eligible.

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 Representative Scott R. Tipton (CO-03)
    Chairman Takano, Ranking Member Roe, and distinguished Committee 
Members, thank you for considering H.R. 485, the Veterans Reimbursement 
for Emergency Ambulance Services Act or VREASA, during today's 
legislative hearing.
    Costs associated with emergency ambulance services to non-VA 
facilities are a huge financial burden for our nation's veterans, and 
one that those who have earned healthcare benefits through their 
service to this nation should not be required to pay.
    VREASA is bipartisan legislation intended to address Department of 
Veterans Affairs' (VA) regulations that could unfairly burden veterans 
with the costs of emergency ambulance services to non-VA facilities.
    Historically, some veterans have been denied their reimbursement 
claims for emergency ambulance services to non-VA facilities primarily 
because of how the VA was interpreting its regulations. Unfortunately, 
the VA's interpretation would leave these veterans to pay for these 
ambulance bills out of pocket. VREASA would clarify that veterans' 
expenses for emergency ambulance services to non-VA facilities are 
authorized to be reimbursed by the VA. In addition, VREASA ensures that 
the prudent layperson standard will be applied to emergency ambulance 
services to non-VA facilities.
    I was pleased that the VA promulgated a regulation as an attempt to 
remedy this problem. However, to better ensure that our nation's 
veterans will be reimbursed by the VA for their emergency ambulance 
services at non-VA facilities, Congress should codify this requirement 
since administrations are free to change regulations. VREASA achieves 
codification giving our nation's veterans certainty, stability, and 
peace of mind to know that should the unforeseen occur where they need 
emergency ambulance services to a non-VA facility those expenses will 
be reimbursed.
    Again, I thank the Committee for its consideration of VREASA today 
and look forward continuing to work in a bipartisan manner with the 
Committee to advance VREASA through the legislative process and toward 
final passage in the House.

                                 
                  Prepared Statement of David Cox, Sr.
    The Honorable Mark Takano Chairman
    House Committee on Veterans' Affairs
    B234 Longworth House Office Building
    Washington, D.C. 20515

    The Honorable Dr. Phil Roe
    Ranking Member
    House Committee on Veterans' Affairs
    3460 O'Neill House Office Building
    Washington, D.C. 20024

    June 18, 2019

    Dear Chairman Takano, Ranking Member Roe, Members of the Committee,

    On behalf of the more than 700,000 federal and D.C. government 
employees represented by the American Federation of Government 
Employees, AFL-CIO (AFGE), including the 260,000 frontline Department 
of Veterans Affairs (VA) employees represented by our National VA 
Council (NVAC), I write to register strong opposition to
    H.R. 3083, the ``AIR Acceleration Act,'' a bill that would 
authorize the Asset and Infrastructure Review Commission to begin its 
operations on an earlier schedule than that which was included in the 
VA Mission Act.
    This Mission Act's provision for this Commission was modeled on the 
Defense Department's Base Realignment and Closure (BRAC) process, and 
there has never been any doubt that its purpose is to reduce the number 
of VA medical centers and clinics. AFGE strongly opposed this section 
of the Mission Act and opposes accelerating the dismantlement of VA 
through H.R. 3083.
    From the beginning of the debate surrounding the MISSION Act, AFGE 
has warned against the negative consequences that closing VA facilities 
will have on patient care and the capacity of VA to meet veterans' 
demand for services. Make no mistake: the Asset and Infrastructure 
Review Commission will not result in improved infrastructure, it will 
serve to facilitate the closure of VA facilities.
    Once the closures begin, veterans will no longer have the 
``choice'' of VA's world-class integrated healthcare system. Their only 
choice will be private care. Privatized care will be the only care.
    A closure commission for VA takes away Congressional responsibility 
- and authority - for VA's infrastructure decisions. The default 
position is that the Commission's recommendations will advance unless 
Congress explicitly overrides a Commission decision. It is 
unconscionable to leave the future of VA hospitals and clinics -whether 
they will be built, renovated, or closed and sold - to an unelected 
group of political appointees. To allow H.R. 3083 to become law would 
be a terrible abdication of responsibility on the part of the Congress.
    Please also be aware that BRAC-style closures do not result in cost 
savings. In particular, when healthcare provided in VA facilities is 
replaced by care purchased from providers in the private sector, costs 
will rise substantially. Costly and unaccountable private care does not 
meet the promises our nation has made to veterans.
    In the strongest possible terms, AFGE urges you to oppose H.R. 
3083. We ask instead that the Committee focus its attention toward 
requiring the VA to fully staff its hospitals and clinics and fill its 
more than 50,000 open positions so that veterans can obtain the world-
class, veteran-centric care at the VA that they have earned. If you 
have questions regarding AFGE's position on H.R. 3083, please contact 
Matt Sowards at [email protected].

    Sincerely,

    J. David Cox, Sr.National President

                                 
                   Prepared Statement of Eric Goepel
    Chairman Takano, Ranking Member Roe, and Members of the House 
Committee on Veterans' Affairs,

    The Veterans Cannabis Coalition would like to thank you for the 
opportunity submit a statement for the record to the Committee 
concerning veterans and cannabis issues currently under consideration. 
We would especially like to thank the Committee for its continuing work 
to address the needs of veterans for effective, low-risk treatments. 
The staggering rate of veteran deaths by suicide and overdose (an 
outcome that is too often ignored) is indicative of the ongoing crisis 
in our community. We know what veterans need to be successful, because 
they are the same basic components every citizen needs for success: 
patient-centered healthcare, housing, and gainful employment.

Overview:

    The House Committee on Veterans' Affairs has several bills related 
to cannabis and veteran issues currently before the body. Collectively, 
these bills seek to address the friction that exists between federal 
and state law and better understand cannabis and how veterans use it 
medicinally. The underlying issue of prohibition is beyond the scope of 
the Committee, but there are still many ways to serve veterans by 
addressing specific concerns that have arisen.

Current Legislation

    H.R. 2676 - VA Survey of Cannabis Use Act (Moulton)
    Position: Support. We appreciate the intent to establish the shape 
and extent of cannabis use among veterans but would add that a survey 
of this kind would create the opportunity to collect important 
information about veterans current and past pharmaceutical and drug 
use. There is an immediate need to establish a clear picture of how 
substances are impacting veterans and we should be looking at the full 
range of substance use: alcohol, tobacco, pharmaceuticals (of 
particularly interest is non-steroidal anti-inflammatory drug (NSAID) 
opioid, benzodiazepine, and antidepressant use), and illicit drugs.

    H.R. 2677 - To require VA to provide training in the use of medical 
cannabis in conjunction with medical schools that have incorporated 
education on medical cannabis into their curricula. (Moulton)
    Position: Support. VA physicians are not unique in lacking 
substantive knowledge about cannabis, cannabinoids, or the endo-
cannabinoid system (ECS)-this lack of knowledge is reflected in the 
larger medical community. This particular point was highlighted 
recently in an op-ed in the Journal of the American Medical 
Association. While the need for primary education is apparent, we would 
suggest that conditioning VA participation on the actions of an 
independent party (a medical school, in this case) leaves too much room 
for delay.
    Past statements have made it clear that if cannabis remains a 
Schedule I substance, VA will not support changes to how they interact 
with cannabis beyond some narrow adjustments. Simultaneously, the 
Department has boasted that some 70% of the country's doctors receive 
professional training at VA facilities-this would suggest that VA is 
uniquely equipped in leading the development of cannabis education for 
providers, has the resources necessary, and therefore should do so with 
all haste.

    H.R. 712 - VA Medicinal Cannabis Research Act (Correa)
    Position: Strongly support. The VA Medicinal Cannabis Research Act 
is a much needed, directed effort to jump start VA cannabis research. 
The Department has publicly disclosed two cannabis research studies and 
identified one specifically at the University of California San Diego. 
Our concern is that the UCSD study uses a limited form of cannabis 
(synthetic cannabidiol (CBD) isolate), is still recruiting for a target 
sample of 136, and is scheduled to be completed in 2023. It costs $1.6 
million, which is a rounding error in a Department with a $200 billion 
budget.
    VA has demonstrated that, as mentioned before, they do not intend 
to support changes to the status quo without a change in cannabis' 
schedule. This is, frankly, a shirking of responsibility to veterans, 
of which 1-in-5 surveyed by the American Legion and Iraq and 
Afghanistan Veterans of America (IAVA) self-report using cannabis for 
their service-connected injuries. It is especially striking in light of 
rampant veteran suicide and overdose, a noted lack of urgency or 
results from the VA in stemming or reversing these outcomes, and the 
link many veterans have reported between attempted suicide and legal 
pharmaceutical use. One of the answers to this inertia and a status quo 
that sees at least 6,000 veteran dead by suicide and overdose a year is 
a robust, funded, and coordinated research initiative lead by VA that 
explores the potential of cannabis.

    H.R. 1647 - Veterans Equal Access Act (Blumenauer)
    Position: Strongly support. The language in this bill has been 
introduced for the third Congress in a row and represents a basic 
concession to the needs of veterans who use the VA as well as closing 
an obvious gap in continuity of care. The fact that this effort is 
still not in law, that it is still opposed by VA, and is still being 
asked for by veterans is another demonstration of the disconnect 
between those charged with providing the best care possible and those 
they serve.

Conclusion:

    The sheer number of bills introduced in the 116th Congress dealing 
with veterans and cannabis demonstrates both an immediate need for 
reform and a critical lack of progress at the VA's current self-
directed pace. Congress and the VA both have a historic responsibility 
to veterans that has devolved into endless rounds of delays, denials, 
and unfulfilled promises while veterans die at a staggering pace, day 
after day, year after year. As advocates, we see how this grind is 
damaging our community on a regular basis and see few solutions being 
offered and fewer still being acted on. It is far past time for members 
of Congress to listen to veterans themselves and do everything in their 
power to deliver on the promise the nation makes to every man and woman 
who serves in uniform.

    Respectfully,

    Eric Goepel
    Founder & CEO
    Veterans Cannabis Coalition

    Bill FergusonvCo-founder
    Veterans Cannabis Coalition

                                 
                   Prepared Statement of Randy Erwin
    The Honorable Mark Takano
    Chairman
    House Committee on Veteran Affairs
    B234 Longworth House Office Building
    Washington, D.C. 20515

    The Honorable Phil Roe
    Ranking Member
    House Committee on Veteran Affairs
    3460 O'Neil House Office Building
    Washington, D.C. 20024

    June 18, 2019

    Chairman Takano, Ranking Member Roe, Members of the Committee,

    On behalf of the more than 100,000 federal workers and the 
employees of the Veterans Affairs Department (VA) represented by the 
National Federation of Federal Employees (NFFE), I write to you today 
to urge you to oppose H.R. 3083, the ``AIR Acceleration Act.'' This 
legislation. Should it become law, would authorize the Asset and 
Infrastructure Review Commission to meet earlier than the agreed upon 
timelines established in the VA MISSION Act. While the commission is 
called ``asset and infrastructure review'' it is nothing more than a 
Base Realignment and Closure (BRAC) style panel for VA facilities. NFFE 
unequivocally opposes this section of the law and, without question, 
opposes this legislation.
    From the beginning of the debate surrounding the MISSION Act, NFFE 
has sounded the alarm on this proposal and the negative affect it will 
have on patient care generally and the world-class VA system broadly. 
The commission will result in the closure of VA facilities. That, 
coupled with the MISSION Act's extremely broad access standards, will 
mean the VA's increased reliance on private providers for veterans' 
healthcare needs - privatization of the VA.
    What is especially troubling about this commission is that it will 
take away Congressional authority involving the building, renovating, 
and closing of VA facilities. The way this commission is designed, 
Congress would have to pass a resolution of disapproval in order to 
override a decision made by the commission. Congress should be 
responsible for overseeing the funding and the maintenance of the VA's 
physical plant, not unelected political appointees in Washington, D.C.
    Once VA facilities are closed, every veteran in that area will then 
be issued a voucher and forced to the private sector. Given the 
continuing problems of VA private sector care and standards, under no 
circumstances should we speed up this process by allowing the 
Commission to meet earlier than the agreed upon timelines as H.R. 3083 
would do if enacted.
    NFFE strongly urges you to oppose H.R. 3083; rather, and support 
the world-class, veteran-centric institution that is the VA, employing 
and caring well for America's veterans.

    Sincerely,

    /s/ Randy Erwin

    Randy Erwin, National President

                                 
                   Prepared Statement of Thelma Roach
    June 19, 2019

    The Honorable Mark Takano
    Chairman
    House Committee on Veterans' Affairs
    420 Cannon House Office Building
    Washington, D.C. 20515

    Dear Chairman Takano:

    On behalf of the nearly 3,000 members of the Nurses Organization of 
Veterans Affairs (NOVA), we would like to provide comments to the 
Committee in opposition to H.R. 3083, The AIR Acceleration Act, 
legislation that would accelerate the timeline on the Asset and 
Infrastructure Review Commission. If anything, we believe the timeline 
of the AIR Commission should be slowed down or eliminated entirely.
    P.L 115-182, Sec 202(d) of The MISSION Act, established an external 
Asset and Infrastructure Review (AIR) Commission to evaluate all 
Veterans Health Administration facilities with respect to utilization. 
On final recommendations, the AIR Commission will recommend closure, 
expansion or replacement of VA facilities. Unlike the Department of 
Defense BRAC Commission on which it is modeled, Veterans receiving care 
at a closed facility would not transfer to another VA. Instead, 
Veterans would automatically be moved into the Veterans Community Care 
Program (VCCP).
    As NOVA has asserted in the past, Veterans are served better at a 
VHA facility than in outside communities. Data collected by RAND and 
Dartmouth researchers have confirmed that the quality of VA's 
healthcare in regional markets is as good as, and in many instances 
superior to that of non-VA facilities. Veterans receive care in an 
environment where healthcare professionals are better trained to 
provide the right kind of care for service-connected injuries and 
illness like TBI, PTSD, spinal cord injuries, toxic exposures, military 
sexual trauma and suicide.

    VA remains the expert in treating these health concerns.

    NOVA also would like to remind the Committee that closing a 
facility and sending Veterans into the fee-for-service private sector 
is likely to add, not reduce, overall spending. And timely access to 
care is less likely since VA's Access Standards ensure that VA 
facilities' wait times are monitored and enforced, but there are no set 
expectations of timeliness for care of Veterans in the community.
    Finally, we would like to point out that Members of Congress will 
have limited authority to alter the final proposed recommendations. H.R 
.3083, and in fact any plan to close VHA facilities, must be met with a 
thorough assessment of the many ramifications - cost, quality and 
timeliness of care, research, employment opportunities - and an 
understanding of the vital services that VA Medical Centers provide to 
our Nation's Veterans.

    Sincerely,

    Thelma Roach-Serry, BSN, RN, NE-BC
    President
    Nurses Organization of Veterans Affairs (NOVA)

    CC: Ranking Member, Dr. Phil Roe

                                 
                       Statements For The Record

                  PARALYZED VETERANS OF AMERICA (PVA)
    Morgan Brown

    Chairman Takano, Ranking Member Roe, and members of the Committee, 
Paralyzed Veterans of America (PVA) would like to thank you for the 
opportunity to submit our views on the broad array of pending 
legislation impacting the Department of Veterans Affairs (VA) that is 
before the Committee. No group of veterans understand the full scope of 
care provided by VA better than PVA's members-veterans who have 
incurred a spinal cord injury or disorder. Several of these bills will 
help to ensure veterans receive timely, quality care and benefits. PVA 
provides comment on the following bills included in today's hearing.

H.R. 485, the ``Veterans Reimbursement for Emergency Ambulance Services 
    Act''

    VA is authorized to reimburse the cost of emergency transport for 
veterans but often denies emergency ambulance claims due to improper 
interpretation of its own regulations, leaving tens of thousands of 
veterans to pay these bills out of pocket. No eligible veteran should 
ever have to worry if VA is going to reimburse a transportation company 
for transporting them to the closest and most appropriate medical 
facility capable of treating their emergency. Therefore, PVA supports 
H.R. 485 which seeks to make reimbursement for emergency ambulance 
services consistent with how VA reimburses for other emergency medical 
services.

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

    There is a growing body of evidence that cannabinoids are effective 
for treating conditions like chronic pain, chemotherapy induced nausea 
and vomiting, sleep disturbances related to obstructive sleep apnea, 
multiple sclerosis spasticity symptoms, and fibromyalgia. H.R. 712 
directs the VA Secretary to carry out a clinical trial of the effects 
of cannabis on health conditions like these as well as post-traumatic 
stress disorder. PVA supports evidence-based alternative treatments, 
including research into the efficacy of medical cannabis. A series of 
clinical trials on the use of medicinal cannabis would help to 
determine if it could provide any medical benefits for veterans.

H.R. 2942, the ``Women's Health Transition Training Pilot Program''

    PVA supports this legislation, which would extend and expand an 
ongoing pilot program jointly run by VA and the US Air Force to educate 
transitioning servicewomen about women's health care at VA. Despite 
being the fastest growing cohort in our military community, many 
servicewomen are still unaware of the benefits and services available 
to them. Early indicators suggest this approach may be effective. 
Continuing the pilot program and expanding it to women veterans of 
other services should provide the Department of Defense and VA the data 
it needs to assess the feasibility of making this program permanent 
along with the prospects of offering it in an online version or using 
it to auto-enroll participants in VA health care.

H.R. 3083, the ``AIR Acceleration Act''

    PVA opposes any legislation that seeks to accelerate the 
comprehensive review of VA capital assets directed by the VA MISSION 
Act of 2018 (P.L. 115-182). The timeline established in P.L. 115-182 
was carefully formulated to ensure proper assessment of VA's facilities 
and infrastructure, nomination of commission members, and consultation 
with veterans service organizations were completed prior to any 
official meetings by the commission. Accelerating this timeline for 
commission meetings as allowed under H.R. 3083 would effectively allow 
VA to short-circuit this process. We are concerned that such a decision 
would undermine the protections put in place to ensure VA's Asset and 
Infrastructure Review (AIR) process is conducted in a fair and 
impartial manner, and that the commission has accurate data to work 
with.

Discussion Draft, the ``Ryan Kules Specially Adaptive Housing 
    Improvement Act of 2019"

    PVA gives its strongest endorsement to this proposed legislation 
which raises the number of times veterans can request specially 
adaptive housing grants and directs VA to prioritize Specially Adapted 
Housing (SAH) claims for veterans with a terminal illness. It also 
raises the overall amount for SAH grants to $98,492 and Special Housing 
Adaption (SHA) grants to $19,733, and provides a supplementary grant in 
case the veteran moves.
    VA's specially adaptive housing grant programs help veterans with 
certain service- connected disabilities to live independently in a 
barrier-free environment by providing critical housing adaptations. 
Many PVA members have benefited from the SAH grant program and the 
accessibility they gain through it greatly increases the quality of 
life for these veterans.
    Annual increases for VA's specially adaptive housing grant programs 
are tied to the Turner Building Cost Index but these small rises do not 
take into account for geographical costs associated with construction. 
For example, the cost of an accessibility ramp for a house in western 
New York is far less than it would cost here in the National Capitol 
Region. The one-time increases for SAH and SHA benefits that this bill 
provides will help to accommodate some of these differences.
    The bill will also increase the number of times that the grant can 
be accessed. Currently, veterans can access their specially adaptive 
housing benefit a maximum of three times up to the maximum amount of 
the grant. Unfortunately, there are occasions where severely disabled 
veterans who previously used specially adaptive housing grants to 
modify a home were left without assistance after their disability 
became worse. For example, a patient with Multiple Sclerosis who was 
able to ambulate with an assistance device used the specially adaptive 
housing grants three times to adapt two homes at different periods of 
his life now requires a wheelchair to move as the disease has 
progressed. The veteran needs to make additional modifications to his 
residence to accommodate the use of a wheelchair, but the current cap 
on use forces him to pay for these adaptations out of his own pockets. 
Increasing the number of times a veteran can access the benefit will 
help ensure veterans are able to utilize their maximum specially 
adaptive housing benefits.
    Additionally, in cases where a veteran has exhausted all of his or 
her benefit, this bill would authorize VA to provide a supplementary 
grant to eligible veterans. This would be particularly beneficial for 
veterans who are in a position to relocate. If a veteran is offered a 
job and has to move, historically the veteran would be forced to pay 
for any modifications to her new residence if she has exhausted her 
benefit. By having a supplementary grant, these veterans would now have 
the ability to move to a new residence and receive monetary assistance 
for modifications.
    Finally, since VA first established Amyotrophic Lateral Sclerosis 
(ALS) as a presumptive condition in 2008, PVA has represented the 
majority of veterans who have claimed service-connection for this 
disease. ALS manifests itself very quickly and it is imperative that 
benefits needed to enhance quality of life are approved once a veteran 
is diagnosed with it. Prioritizing SAH benefits for terminally ill 
veterans, such as those with ALS, is simply the right thing to do and 
we appreciate its inclusion in this legislation.
    We urge Congress to pass this important legislation as quickly as 
possible.

Discussion Draft, ``Improvement to Work-Study Allowance Program''

    This draft legislation would grant VA the authority to provide to 
educational institutions an annual amount for the school to use in 
paying work-study allowances to veterans enrolled at the institution. 
PVA supports this proposal which would increase educational 
opportunities for veterans pursuing non-traditional means of education 
to start a new career and facilitate an easier transition from the 
military to civilian life.
    PVA would once again like to thank the Committee for the 
opportunity to submit our views on the legislation considered today. We 
look forward to working with the Committee on this legislation, and 
would be happy to take any questions you have for the record.

                                 
                  VETERANS HEALTHCARE POLICY INSTITUTE
    Chairman Takano, Ranking Member Roe, and Members of the Committee:

    The Veterans Healthcare Policy Institute (VHPI) would like to thank 
you for the opportunity to submit a statement on the record regarding 
H.R. 3083, The AIR Acceleration Act. We appreciate your bipartisan 
recognition that all Americans deserve to know their tax dollars are 
being used efficiently to ensure the highest quality and availability 
of veterans' health care.
    We strongly urge caution when reviewing The AIR Acceleration Act 
(H.R. 3083), which would accelerate the timeline for the Asset and 
Infrastructure Review Commission. As we document in this analysis, 
there are harmful secondary consequences of a Veterans Health 
Administration (VA) facility closure that must be very thoroughly 
studied. Closure will likely increase overall costs and divert critical 
funds away from the national VA healthcare system. Beyond costs, 
shuttering any VA facility will erode the care of veterans, reduce the 
availability of clinicians with veteran-specific expertise, decimate 
healthcare education/research, harm local economies and diminish 
emergency preparedness.

Overview

    Pub.L. 115-182, The VA MISSION Act of 2018, Sec. 202 established an 
Asset and Infrastructure Review (AIR) Commission to evaluate all VA 
facilities' utilization patterns and infrastructure needs, and 
recommend whether to close, replace, expand or repurpose them. Congress 
will have no authority to alter the final set of the Commission's 
recommendations. Instead, Congress may only approve or disapprove of 
the recommendations in their entirety, within a tight time frame. 
Because there will be no ability to walk back the Commission's 
proposals, it is critical that Commissioners and Members of Congress be 
thoroughly aware of the far-reaching repercussions of any recommended 
closures.
    This document analyzes the severe economic, healthcare, training, 
and research consequences of a VA facility closure. As the nation 
debates the future of its largest and only publicly-funded, fully 
integrated healthcare system, it is critical to understand the vital 
role these medical centers play in their communities and the breadth 
and depth of the services they deliver to veterans.
    Following is a summary of the major adverse consequences that 
closing a VA facility will:

    1. Increase overall costs and drain funds from remaining VA 
facilities, ultimately eroding the availability of care throughout the 
system,
    2. Diminish veterans' access to veteran-specific, high quality, 
comprehensive and integrated care in their community,
    3. Increase wait times for veterans and non-veterans at non-VA 
facilities,
    4. Eliminate veterans' choice if they prefer to receive their care 
in the VA,
    5. Decimate residency and fellowship training programs at the 
affiliated medical and health professional schools,
    6. Diminish the number of graduates who enter the local network of 
healthcare providers to treat veterans and the non-veteran public,
    7. Impede efforts to recruit providers at other VA facilities,
    8. Reduce VA research projects that benefits veteran rehabilitation 
and health care for all Americans,
    9. Hamper local governments' ability to respond to national 
emergencies and natural disasters.
    10. Layoff employees, which would significantly impact the local 
economy. (Veterans make up a third of VA employees and many will find 
it difficult to secure employment).

SPECIFIC ADVERSE IMPACTS OF A VA FACILITY CLOSURE

1. Impact on the VA Budget

    Costs associated with closing a VA facility will be higher than 
keeping it open because:

      The number of veterans whose care is financed by the VA 
will increase. Of the approximately 19.6 million veterans, 32% were 
enrolled in the system and had some VA or Community Care paid by the VA 
last year; 14% were enrolled but did not have any care paid by the VA, 
and remaining 54% were not enrolled for VA-paid care\1\.
---------------------------------------------------------------------------
    \1\ ``Avery Dennison Template - VA.gov.'' https://www.va.gov/
vetdata/docs/pocketcards/ fy2019q1.PDF.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

    For as long as a VA facility remains open, the VA pays for VA 
facility or community healthcare only for veterans in column A. But if 
a facility is closed, VA will automatically issue vouchers for the 
Veterans Community Care Program (VCCP) to all local veterans in columns 
A and B, plus to those veterans in column C who decide to enroll 
(because it is advantageous for these veterans to do so). According to 
a 2016 report\2\, the total systemic cost of a proposal to allow 
community care for veterans could increase usage and outlays nationally 
by $96 to $179 billion a year.
---------------------------------------------------------------------------
    \2\ ``Commission on Care - Amazon S3.'' https://s3.amazonaws.com/
sitesusa/wp-content /uploads/sites/912/2016/07/Commission-on-C are--
Final-Report--063016--FOR-WEB.pdf.
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      Health care procedures are more costly in the fee-for-
service private sector, which has a built-in incentive to over treat. 
One example is end of life care for veterans whose illnesses are 
terminal. VA's utilize more palliative and hospice care, while the 
private sector is more likely to use aggressive, expensive treatments, 
even if they are unlikely to significantly increase time and quality of 
life remaining.
      Additional VA administrative staff will be needed for 
oversight and reimbursement of veterans' private sector care in the 
entire affected region.

2. Impact on the Quality of Clinical Care Provided to Veterans

    If a VA facility were to close, the overall quality, 
comprehensiveness and integration of care provided to veterans would 
decline.
    Independent RAND\3\ and Dartmouth\4\ analyses - among many others - 
continually affirm that the quality of VA's healthcare in regional 
markets is as good as, and in many instances superior to that of non-VA 
facilities.
---------------------------------------------------------------------------
    \3\ ``Comparing Quality of Care in Veterans Affairs and Non ... - 
NCBI.'' 25 Apr. 2018, https://www.ncbi.nlm.nih.gov/pubmed/296965 61.
    \4\ ``Veterans Health Administration Hospitals Outperform Non-
Veterans'' 19 Mar. 2019, https://annals.org/aim/fullarticle/2718687/
vete rans-health-administration-hospitals-outperfor m-non-veterans-
health-administration-hospitals.
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    VA healthcare settings provide the best (and arguably only) 
environment for providers and trainees to attain proficiency in 
treating veteran-specific issues. Veterans are at higher risk for 
particular conditions, including combat- related injuries (e.g., 
gunshot, blast, and shrapnel injuries), traumatic brain injury, 
heterotopic ossification, musculoskeletal injuries, spinal cord injury, 
toxic exposures, PTSD, military sexual trauma and suicide. Not only do 
VA trained personnel know how to treat these conditions, they recognize 
which potential sources to investigate. A non-VA practitioner is less 
likely to explore PTSD as the cause of chronic insomnia or the impact 
of traumatic brain injury on mood and decision-making. Non-VA 
practitioners would be less likely to know that conditions such as 
asthma, prostate cancer or Type 2 diabetes may be the result of toxic 
exposures, including Agent Orange, contaminated water or burn-pits. 
RAND's Ready or Not?\5\ study reported that a majority of private 
sector providers do not screen for specific health concerns that are 
common among veterans.
---------------------------------------------------------------------------
    \5\ ``Assessing the Capacity of New York State Health ... - RAND 
Corporation.'' 1 Mar. 2018, https://www.rand.org/pubs/research--
reports/R R2298.html.
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    Private sector providers may, therefore, misdiagnose or 
ineffectively treat these critical conditions, order inappropriate 
diagnostic tests, and fail to collect information that registries need 
for veterans to quality to receive compensation.
    RAND's Ready to Serve\6\ study of therapists who treat PTSD and 
major depression found that compared to providers affiliated with the 
VA or DoD, ``a psychotherapist selected from the community is unlikely 
to have the skills necessary to deliver high-quality mental health care 
to service members or veterans with these conditions.''
---------------------------------------------------------------------------
    \6\ ``Community-Based Provider Capacity to Deliver ... - RAND 
Corporation.'' 12 Nov. 2014, https://www.rand.org/pubs/research--
reports/R R806.html.
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    VA social workers connect patients to veteran-specific follow up 
resources, including VA and other community resources that provide home 
health services, legal services, transportation, community living and 
housing. Such wrap-around services help mitigate homelessness and other 
social determinants of disease progression and prevalence of suicide. 
Veterans being discharged from the VCCP inpatient facilities to VCCP 
outpatient care would not receive the kind of VA expertise and 
systematic planning that links them to the array of veterans' resources 
they need.
    As the Commission on Care Final Report\7\ acknowledged: ``Veterans 
who receive health care exclusively through VHA generally receive well-
coordinated care, yet care is often highly fragmented among those 
combining VHA care with care secured through private health plans, 
Medicare, and TRICARE. This fragmentation often results in lower 
quality, threatens patient safety, and shifts cost among payers.'' 
Compared to VA's best practice integrated model, healthcare delivered 
in the community lacks integration or coordination of veterans' care. 
The VA, as a unified system, has superior ability to implement and 
monitor adherence to assessment and treatment standards.
---------------------------------------------------------------------------
    \7\ ``Commission on Care - Amazon S3.'' https://s3.amazonaws.com/
sitesusa/wp-content /uploads/sites/912/2016/07/Commission-on-C are--
Final-Report--063016--FOR-WEB.pdf.

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3. Impact on the Timeliness of Clinical Care Provided to Veterans

    VA's Access Standards ensure that VA facility's wait times are 
monitored and enforced. There are no set expectations of timeliness for 
care of veterans in the Community Care Network.
    If a VA facility is closed, veterans will struggle to get care in 
an overburdened private sector healthcare system. Delays for 
outpatient, inpatient and emergency room care for veterans and non-
veterans in the local area would increase.
    At present, private sector average outpatient wait times for 
primary care, cardiology, and dermatology (though not orthopedics) are 
68% longer\8\ than wait times at the VA.
---------------------------------------------------------------------------
    \8\ ``Comparison of wait times for new patients between ... - JAMA 
Network.'' 18 Jan. 2019, https://jamanetwork.com/journals/jamanetwor 
kopen/fullarticle/2720917.
---------------------------------------------------------------------------
    Our nation faces an intractable physician shortage, especially in 
primary care. A report\9\ by the American Association of Medical 
Colleges warns that by 2030 the U.S. will be short 14,800 to 49,300 of 
needed primary care doctors. Non-primary care medical specialties 
predict additional shortages of 33,800 to 72,700 physicians. In 
geriatric care, an area in which the VA specializes and the private 
sector is drastically undersupplied, less than half of geriatric 
fellowship positions\10\ even filled last year.
---------------------------------------------------------------------------
    \9\ ``New research shows increasing physician shortages in both 
primary'' 11 Apr. 2018, https://news.aamc.org/press-releases/article/w 
orkforce--report--shortage--04112018/.
    \10\ ``SAP Crystal Reports - 2017 SMS - NRMP.'' http://
www.nrmp.org/wp-content/uploads/201 8/02/Results-and-Data-SMS-2018.pdf.
---------------------------------------------------------------------------
    The delivery of health care to rural populations is a particular 
challenge. While 20% of the U.S. population is rural, only 12 % of PCPs 
are working in rural areas (and only 8% of other specialties)\11\, and 
these provider numbers are actually declining. Sixty percent of 
counties\12\ - all rural--lack a single psychiatrist. Between 2010 and 
2019, 95 rural hospitals closed\13\ and an additional 21% (=430) are at 
high risk of closing.
---------------------------------------------------------------------------
    \11\ ``Rural America Faces Shortage of Physicians to Care for 
Rapidly Aging" https://www.asaging.org/blog/rural-america-fa ces-
shortage-physicians-care-rapidly-aging-po pulation.
    \12\ ``The Silent Shortage - New American Economy.'' http://
research.newamericaneconomy.org/wp- content/uploads/2017/10/NAE--
PsychiatristSh ortage--V6-1.pdf.
    \13\ "2019 healthcare outlook - Navigant.'' https://
www.navigant.com/-/media/www/site/i nsights/healthcare/2019/
navigant2019healthca reoutlook.pdf.

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4. Impact on Veterans Having ``Choice'' for Where to Receive Healthcare

    Explicitly, the MISSION Act was developed to offer greater 
healthcare choices to veterans. When a facility is closed, veterans who 
prefer to receive their care in the VA will no longer have that option.
    Forty-six percent of all veterans are enrolled in VA healthcare, 
and 17% utilize it as their primary source.\14\ VA utilizers are more 
likely to be black, younger, female, unmarried, less educated and have 
a lower income.
---------------------------------------------------------------------------
    \14\ ``US Veterans Who Do and Do Not Utilize Veterans Affairs ... - 
NCBI.'' 17 Jan. 2019, https://www.ncbi.nlm.nih.gov/pubmed/306772 66.
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    Further, many veterans prefer to receive care in a VA facility 
because of the opportunity for peer contact. A third of VA employees 
are veterans. The VA has 1,100 Peer Specialists who are veterans in 
successful recovery from mental health challenges, integrated in mental 
health care programs and uniquely suited to engage veterans and instill 
hope. Closure takes that away.

5. Impact on Training of Medical/Healthcare Professionals

    If a VA facility were closed, required residency/fellowship 
rotations would not be available, core funding would be eliminated, 
leading to shrinkage and in some cases collapse of the local university 
residency training programs.
    There are 135 allopathic medical schools and 30 osteopathic medical 
schools that are formally affiliated with VA's. The residency/
fellowship programs housed at local VA's include, but are not limited 
to: epilepsy, gastroenterology, geriatric medicine, hematology/
oncology, infectious disease, hospice/palliative medicine, internal 
medicine, interventional cardiology, nephrology, neuromuscular 
medicine, nuclear medicine, ophthalmology, orthopedic surgery, pain 
otolaryngology, medicine, anatomic pathology, plastic surgery, 
psychiatry, psychosomatic medicine, pulmonary disease, radiology, 
rheumatology, sleep medicine, general surgery, thoracic surgery and 
urology.
    In addition education would be curtailed for other trainees who 
rotate part or full time at VAMCs, such as medical and nursing 
students, psychologists, and trainees in more than 40 other health 
professions.

6. Impact on the Number of Doctors and Other Healthcare Professionals 
    Providing Healthcare in the Local Area

    Medical schools are a seedbed for training the next generations of 
doctors. Graduating residents tend to remain in their local area to 
live and work. A loss of hundreds of physician and other health care 
profession residency positions means that year by year there will be 
incrementally fewer healthcare providers settling in the community to 
treat patients, including the very veterans being automatically placed 
in the VCCP.

7. Impact on Recruiting a Workforce Committed to Veterans

    Training programs are the single best mechanism for the recruitment 
of VA health professionals, including those that relocate from other 
geographic areas. Positive experiences of treating veterans as well as 
being mentored by renowned experts in veterans' healthcare issues are, 
for a substantial number of trainees, the biggest determinant in their 
decision to seek VA employment. Roughly 60% of current VA physicians 
(and even higher percentages of some other professions) participated in 
VA training programs.
    Closure of a facility means fewer residents, fellows, medical 
students and other health profession trainees would train at VA's. That 
will diminish this recruitment tool, and VA's in other regions will be 
less able to attract physicians and other healthcare professionals 
committed to veterans.

8. Impact on Research on Veterans

    Over the past 70 years, VA researchers and clinicians have worked 
together, along with scientists at academic institutions and the DoD, 
to develop innovative treatments that have benefited not only the 
nation's veterans, but also patients throughout the country and the 
world.
    Take, for example, the San Francisco VA Medical Center, which has 
over 800 current research projects that would cease if the facility 
were closed. These include the study of basic neuroscience and 
neuroimaging of combat-related brain and spinal cord injuries, 
posttraumatic stress disorder (PTSD), fracture/ polytrauma, 
neurological combat-related injuries, rehabilitation after stroke and 
traumatic brain injury, Parkinson's disease, fracture repair, 
heterotopic ossification after polytrauma, prostate cancer, tinnitus, 
oncology, hypertension, stroke, cardiovascular disease, breast cancer, 
musculoskeletal disorders, hepatitis C, HIV, renal dialysis, epilepsy, 
cardiac surgery, mental health and substance use disorders. Closure of 
a VA would shut its lines of research that are unfeasible to transfer 
elsewhere.
    The VA has a stable population that can be followed over the long-
term, enabling researchers to make big data breakthroughs on emerging 
veteran-specific healthcare problems. That will be impossible if 
veterans' care becomes scattered across the private sector in which 
communication is fragmented. Closure of any VA facility weakens the 
VA's ability to identify, diagnose and develop innovative treatments 
for the next PTSD or Agent Orange.

9. Impact on Readiness for Emergencies

    The Fourth Mission of the VA is to support national, state, and 
local emergency management, public health, safety and homeland security 
efforts for veterans and non-veterans in the event of war, terrorism, 
national emergencies, and natural disasters. VAMCs are federal 
emergency response sites.
    In the event of an emergency, there will be fewer ER and inpatient 
beds. It will also be more difficult to set up the kind of command 
center that the VA's routinely organize to track and assist veterans 
who are affected by such emergencies.

10. Impact on the Local Economy

    Each VA medical center has thousands, and smaller CBOCS have 
hundreds, of employees who generate revenue for the local economy. When 
a VAMC or CBOC is closed, those employees are laid off. For many of 
them, especially those in support roles, finding gainful employment 
will be difficult. Veterans on compensated work therapy will likely 
face insurmountable challenges. Any decision about closing a VA 
facility must also consider how job losses impact the local economy.
    The Veterans Healthcare Policy Institute thanks the Committee for 
the opportunity to provide this statement for the record.

Authors:

    Russell B. Lemle, PhD, Senior Policy Analyst

    Suzanne Gordon, Senior Policy Analyst

Contact:

    Brett W. Copeland, Executive Director 
[email protected]

                                 
                  BILLS FOR THE RECORD (Upon Request)
    1. H.R. 2943 - To direct the Secretary of Veterans Affairs to make 
all fact sheets of the Department of Veterans Affairs in English and 
Spanish. (Cisneros)

    2. H.R. 2942 - To direct the Secretary of Veterans Affairs to carry 
out the Women's Health Transition Training pilot program through at 
least fiscal year 2020, and for other purposes. (Cisneros)

    3. H.R. 2676 - VA Survey of Cannabis Use Act- This bill requires VA 
to enter into an agreement with a federally funded research and 
development center to conduct surveys nationwide to measure cannabis 
use by veterans. (Moulton)

    4. H.R. 2677 - To require VA to provide training in the use of 
medical cannabis in conjunction with medical schools that have 
incorporated education on medical cannabis into their curricula. 
(Moulton)

    5. H.R. 712 - VA Medicinal Cannabis Research Act (Correa)

    6. H.R. 1647 - Veterans Equal Access Act (Blumenhauer)

    7. H.R. 3083 - To authorize the Asset and Infrastructure Review 
Commission of the Department of Veterans Affairs to meet in years other 
than 2022 and 2023. (Roe)

    8. H.R. 485 - To amend title 38, United States Code, to provide for 
the circumstances under which the Secretary of Veterans Affairs shall 
provide reimbursement for emergency ambulance services. (Tipton)

    9. Discussion Draft - Specially Adaptive Housing

    10. Discussion Draft - Work Study