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

                       LEGISLATIVE HEARING ON H.R. 3495;
                     AND A DRAFT BILL TO ESTABLISH A PILOT
                       PROGRAM FOR THE ISSUANCE OF GRANTS
                              TO ELIGIBLE ENTITIES

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                          WEDNESDAY, NOVEMBER 20, 2019

                                   __________

                               Serial No. 116-47

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT][

                        Available via http://govinfo.gov
                                  __________

                        U.S. GOVERNMENT PUBLISHING OFFICE
    41-377                     WASHINGTON : 2022

    -----------------------------------------------------------------------------------

                         COMMITTEE ON VETERANS' AFFAIRS

                       MARK TAKANO, California, Chairman

    JULIA BROWNLEY, California           DAVID P. ROE, Tennessee, 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

                                  ----------

                          WEDNESDAY, NOVEMBER 20, 2019

                                                                       Page

                               OPENING STATEMENTS

    Honorable Mark Takano, Chairman..................................     1
    Honorable David P. Roe, Ranking Member...........................     4

                                   WITNESSES

    Honorable Robert Wilkie, Secretary, U.S. Department of Veteran
      Affairs........................................................     6

            Accompanied by:

        Dr. Richard Stone, Executive in Charge, U.S. Department of
            Veterans Affairs

        Dr. David Carroll, Executive Director, Office of Mental
            Health, U.S. Department of Veterans Affairs

    Mr. Adrian Atizado, Deputy National Legislative Director,
      Disabled American Veterans.....................................    34

    Mr. Blake Bourne, Executive Director, Veterans Bridge Home.......    36

    Mr. Sherman Gillums Jr., Chief Efficacy Officer, AMVETS..........    38

    Ms. Melissa Bryant, National Legislative Director, The American
      Legion.........................................................    40

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Honorable Robert Wilkie Prepared Statement.......................    57
    Mr. Adrian Atizado Prepared Statement............................    59
    Mr. Blake Bourne Prepared Statement..............................    62
    Mr. Sherman Gillums, Jr. Prepared Statement......................    66
    Ms. Melissa Bryant Prepared Statement............................    70

                           Statements For The Record

    American Federation of Government Employees......................    73
    Veterans of Foreign Wars.........................................    75
    Paralyzed Veterans of America....................................    77
    Iraq and Afghanistan Veterans of America.........................    79
    National Organization of Veterans' Advocate, Inc. and Partners...    80
    Institute of Veterans and Military Families......................    83
    Union Veterans Council...........................................    86

                       LEGISLATIVE HEARING ON H.R. 3495;
                     AND A DRAFT BILL TO ESTABLISH A PILOT
                     PROGRAM FOR THE ISSUANCE OF GRANTS
                     TO ELIGIBLE ENTITIES

                                  ----------

                          WEDNESDAY, NOVEMBER 20, 2019

                         Committee on Veterans' Affairs
                                  U.S. House of Representatives
                                                       Washington, D.C.
        The committee met, pursuant to notice, at 9:59 a.m., in
    room 210, House Visitors Center, Hon. Mark Takano (chairman of
    the committee) presiding.
        Present: Representatives Takano, Lamb, Levin, Brindisi,
    Rose, Pappas, Luria, Lee, Cunningham, Cisneros, Peterson,
    Allred, Underwood, Roe, Bilirakis, Dunn, Bergman, Barr, Meuser,
    Roy, and Steube.

               OPENING STATEMENT OF MARK TAKANO, CHAIRMAN

        The Chairman. The hearing will come to order. Without
    objection, the Chair is authorized to declare a recess at any
    time.
        Good morning, everybody. This legislative hearing is an
    opportunity for stakeholders to make their comments and
    concerns public following last week's closed door roundtable.
    Today's hearing follows months of meetings and discussions with
    veteran service organizations, mental health professionals,
    experts in suicide prevention, suicide prevention policy, union
    leadership, and other stakeholders. I am grateful for their
    responsiveness and willingness to work toward improved language
    that delivers VA's finite resources to the communities that
    need the most.
        In order to mitigate veteran suicide, in order to reduce
    veteran suicide, we need new solutions. We all acknowledge that
    VA has the ability to provide top level mental health services,
    but that only works for veterans connected with VA.
        Today, we will hear about two measures that attempt to
    address veteran suicide: H.R. 3495, as it stands in its current
    form; and my discussion draft. While I agree with the
    underlying intent of H.R. 3495, I do have significant concerns.
        First, this bill would allow VA grants to fund community
    based clinical care and would clearly circumvent the MISSION
    Act that streamlined clinical care under one program. We worked
    awfully hard in this committee to streamline the many different
    lines of community--care in the community, and the way I see
    H.R. 3495 as currently written, it would create a lane outside
    of the MISSION Act.
        This legislation creates a separate lane for care in the
    community without critical safeguards and accountability
    measures in place. I will oppose any language that authorizes
    use of VA grants to provide clinical care, clinical mental
    health care.
        At the roundtable, the coordinating groups or hub
    organizations that we heard from said that they had the ability
    to make clinical services available to veterans ineligible for
    care at VA. Veterans, with other than honorable discharges, can
    already receive mental health care at VA facilities. Current
    law allows that to happen.
        Furthermore, grant funding for clinical health care does
    not solve the problem of underresourced and underserved
    geographic areas suffering from a general shortage of
    providers. I am going to repeat that. Allowing grant funding
    for clinical health care will not solve the problem of
    underresourced and underserved geographic areas suffering from
    a general shortage of providers. That is a whole other problem.
        Clinical care paid for with VA dollars should be subject to
    accountability and we should ensure that any such clinical care
    be culturally competent, be provided by a clinically competent
    providers in the community. And these providers should be part
    of VA's community care network created under the MISSION Act.
    There is no reason why this should not be possible. That is the
    responsibility of the VA leadership to make the MISSION Act
    work in this particular case.
        The urgency of addressing the crisis of veteran suicide
    should not be the pretext for allowing VA money to go to
    providers who are not held to account for measurable outcomes
    or for providing culturally competent care, and who are not
    subject to any oversight.
        Second, H.R. 3495, as introduced, would provide direct
    temporary cash assistance to veterans, their families, and
    anyone else who may live with them. My understanding is that
    cash assistance to veterans needs further, more careful
    consideration, and should be taken up in separate legislation.
    Third, H.R. 3495, as introduced, would also distribute VA's
    limited funds to community partners without any controls in
    place to ensure that those funds are properly utilized
        H.R. 3495, as introduced, authorizes the VA Secretary to
    award grants to organizations unbound to any performance
    criteria and irrespective of whether there is demonstrated
    local need for the services provided by these organization.
        I believe, and I think--well, we believe, funding decisions
    should be driven by local coordinated organizations, otherwise
    known as hubs, who have the pulse on their communities and
    regions. The coordination should be as local as possible. There
    are many examples--many, many examples of such excellent
    organizations, which are known also by the term hubs, by many
    who do the work.
        Funding grants through hubs promotes accountability through
    widely recognized metrics and effectiveness through local
    funding determination. Without local need and metrics tied to
    the award of grant funding, this is not consistent with a
    policy goal of reaching the 60 percent of veterans at risk for
    suicide, who are not connected with VA.
        Now, all this being said, I am very grateful for General
    Bergman's commitment to ensuring we work together to ensure
    vital accountability measures are in place and my concerns on
    H.R. 3495, as introduced, are addressed. I am very pleased that
    he is addressing my concerns.
        My legislation presented today as a discussion draft
    delivers a public health solution focused on upstream
    intervention. The idea that if we provide wrap around services
    to addressing housing, and security, unemployment, and social
    isolation, we can better prepare veterans to deal with life
    stressors that may lead to suicidal ideation itself.
        We want to intervene far upstream before even a crisis
    occurs. That is the public health model. My discussion draft
    seeks to channel Federal grants into local community
    organizations, through local coordinated organizations that
    mirror the recommendations embedded in the president's own
    prevents executive order. I do not believe the Office of the
    Secretary, with an advisory committee in Washington, D.C.,
    meets the intent or spirit of the president's executive order,
    especially Section 5, establishing metrics and coordination of
    local resources are emphasized in Section 5 of that executive
    order.
        Veterans' daily lives do not solely revolve around VA. The
    veterans frequent small businesses. They attend classes at
    community colleges and universities. They volunteer in their
    neighborhoods and participate in the local workforce, just like
    everybody else.
        My draft legislation aims to leverage these deep ties
    already existing in the community by using the hub model, which
    can help connect veterans with existing community based
    partners, already working to serve veterans and their families.
    Hubs are similar to the vet centers, resource centers, and case
    managers VA provides. They also can coordinate services, make
    referrals, and track effectiveness, demand, and capacity across
    a network, in a sense creating that network for service that
    already exist. I underscore ``already exist.''
        I realize in some parts of the country, they may not exist.
    My discussion draft goes beyond doling out cash to
    unestablished organizations and ensures key accountability
    measures are in place that require organizations with a
    demonstrated track record of providing services to veterans. It
    creates an opportunity for coordination. It creates an
    opportunity for communities as a whole to surround and support
    veterans with the services they wish to access most often.
        My draft legislation would authorize VA to provide grants,
    up to $500,000 in the first year, matched by--well, matched 100
    percent by the organization for up to 10 community based
    coordinating organizations each year. Qualifying organizations
    are those that provide social services, that mitigate known
    life stressors like employment counseling, family counseling,
    debt forgiveness, higher education assistance, housing
    services, legal counseling, and recreational therapy.
        We must create a public health infrastructure. If we fail
    to provide our communities with the support they need in order
    to assess, increase, and leverage community-based services to
    better serve veterans, then veterans will not be able to access
    these services.
        By allowing VA to responsibly partner with community
    organizations already serving veterans, while at the same time
    protecting VA's expertise and providing clinical care--
    culturally competent clinical care, I believe we can reduce the
    overall number of veteran suicides.
        These hubs already have their fingers on the pulse of their
    communities and have collectively served hundreds of thousands
    of veterans. They speak to veterans and their families every
    day. They do not care about Veterans Health Administration
    (VHA) eligibility or disability ratings. They just care about
    offering solutions to life's problems, and when and where
    veterans need it.
        Focusing VA's limited funds to fill gaps in resources will
    provide the most sought after services based on recommendations
    from local stakeholders in the community, not from politicians
    in Washington, D.C. We have long been debating how to address
    the crisis of veteran suicide. My draft--my discussion draft is
    a clear solution that will direct resources to those who need
    the most increased coordination in our own communities, improve
    the quality of life for veterans and their families, and help
    reduce veteran suicide as a result.
        With that, I would like to recognize Ranking Member Dr. Roe
    for 5 minutes for any opening remarks that he may have. Dr.
    Roe.

           OPENING STATEMENT OF DAVID P. ROE, RANKING MEMBER

        Mr. Roe. Thank you, Mr. Chairman. I am glad today that we
    are having this hearing. I very much appreciate it. Since this
    bill was introduced in the House on June 26th, so 148 or so
    days ago, 2,960 service members and veterans have died by
    suicide. There is undoubtedly a lot to discuss about this bill
    today, but I want to ask all committee members, and all of our
    witnesses, and all of those watching not to lose sight of that
    number, 2,960. That 2,960 families that will not have all of
    their loved ones around for their Thanksgiving tables or
    Christmas this year or ever. That 2,960 lives are forever lost.
        That is what this bill is about, finding the lost and
    saving their lives. The stakes could not be higher. Of the 20
    service members and veterans who die by suicide each day, 14
    did not seek care from the Department of Veterans Affairs in
    the 2-years prior to their death. We do not know much about
    those men and women, except they are not VA users. Some of them
    are not likely--are not eligible for VA benefits and services,
    others likely unfamiliar or uninterested in them.
        The Improve Act would give VA the means to identify and
    support those veterans. The ones who do not will not or cannot
    seek VA out for themselves. By assisting the organizations and
    entities caring for them in their communities so that the VA
    can meet them where they are and offer them whatever help they
    might need to save their own lives.
        There are precious few things Elizabeth Warren and I agree
    on, but we are both co-sponsors of the Improve Act. We are
    joined by more than 200 of our colleagues in the House and more
    than 27 of our colleagues in the Senate, with widespread
    bipartisan support that this bill is received from
    Representatives and Senators across the political spectrum is
    rare and evidence of both the seriousness of the impact, the
    national suicide crisis having on our Nation's veterans, and
    the wisdom of the broad public health approach to suicide
    prevention the Improve Act embodies.
        The Improve Act would significantly expand the reach of VA
    suicide prevention programs and give more veterans the
    opportunity to be indirectly served by VA, and to learn about
    VA benefits and services they may be entitled to. It would also
    provide a necessary mechanism to deliver care and supportive
    services to veterans who are at risk and who are living outside
    the VA's influence.
        It is not a threat to VA, much less to the health and well
    being of our Nation's veterans, as some have alleged. It is a
    lifeline. As you know, we will hear shortly from Blake Bourne,
    with the Veterans Bridge Home, one of my fellow Army veterans.
    No single entity can adequately meet the needs of every veteran
    in every community in every instance. Not even the second
    largest department in the Federal Government with a budget and
    staff that grows every year.
        Because the Improve Act is based on a legislative proposal
    in Fiscal Year 2020 budget submissions, specific funding has
    already been allocated for it in the Department's Fiscal Year
    2020 budget request. That funding would compromise far less
    than one half of 1 percent of the total mental health budget,
    and yet it has the potential to reach 70 percent of service
    members, veterans, who die by suicide every day without being
    known to the VA.
        Mr. Chairman, after last week's roundtable, which was very
    good, I might add, you asked that I draft a compromise proposal
    that addressed the concerns that had been raised by you and
    others about the bill as written, especially with regard to
    provision of clinical care, the provision of temporary cash
    assistance, and the provision of grant funding to direct
    service providers.
        I believe the draft proposal I produced and shared with you
    and our witnesses preserve the life serving intent of Improve
    Act as introduced, and effectively addresses those three areas
    of concern by: number one, putting specific mechanisms in place
    to connect veterans with VA medical facilities so that if
    possible, any ongoing care of veteran requires is provided by
    VA; two, allowing grantees to assist veterans struggling with
    common risk factors, but prohibiting them from provided direct
    cash assistance to veterans and their families; and number
    three, requiring VA to prioritize grant funding to so-called
    hub organizations, but not limiting grants only to those
    organizations which do excellent work, but may not effectively
    serve at-risk veterans in rural or remote areas where I live.
        My compromise language is truly a compromise. Accepting it
    would require concessions from both of us, Mr. Chairman. It
    includes many of the suggestions that were made during our
    roundtable last week by our veteran service organization
    partners. I look forward to discussing that language today and
    hope that we can soon come to an agreement on it and commit at
    last to marking it up as soon as we return to D.C. in December.
        I am grateful that Secretary Wilkie is with us this morning
    to participate in the discussion. It is his leadership and
    foresight on the Improve Act has been steadfast. I am also
    grateful for the many Veteran Service Organizations (VSOs) who
    are testifying here today, and those who have submitted
    statements for the record, and those who appeared at our closed
    door roundtable just last week. Their input and support are
    invaluable and I appreciate their willingness to engage with me
    and my staff to make sure that we are on the right track with
    respect to this bill and all of our work.
        I am also grateful to Mr. Bourne for being here to discuss
    the great work that the Veterans Bridge Home does for veterans
    and their families in North Carolina, and the wonderful life
    saving opportunity we have with the Improve Act to sustain that
    work across the country.
        Just, Mr. Chairman, a couple of comments, and why I want to
    do this and I why I think this is important. We have had
    accountability. We have had metrics. We have call centers. We
    have quality measures. We have all of those things, and guess
    what? Still today, 20 veterans are going to commit suicide. So
    we have to reach out and try to find those 14 who never get to
    the VA, never get the care. I know as a clinician, if I am
    seeing someone in extremus, I am going to worry a whole lot
    less about when I get paid then to take care of that person in
    need right then. We do it all the time in health care. We take
    care of the patient and then figure out who all gets the money.
        I think certainly with this small amount of investment, it
    is not a large investment. I agree with you on that. The money
    is in a different silo anyway. We have gone from 2 and a half
    billion in 2005 to a $9 and a half billion budget and our
    suicide rate is exactly the same. We have to start doing
    something differently. With that, I yield back.
        Mr. Chairman, thank you for holding the hearing today.
        The Chairman. Thank you for those kind words, Ranking
    Member Dr. Roe. I have to say that I understand that the
    minority staff and the majority staff have been, I think, in
    meaningful dialog, something that I did not perceive to be
    happening before the last markup. I am--so I am pleased that
    there is discussion going on about the concerns that I have,
    the three main concerns that I have with H.R. 3495, as
    introduced.
        Appearing before us today, and we are delighted to welcome
    Hon. Robert Wilkie, Secretary of the U.S. Department of
    Veterans Affairs. Welcome, Mr. Secretary.
        Secretary Wilkie. Thank you, sir.
        The Chairman. I recognize you for 5 minutes for your
    opening statement.

                       STATEMENT OF ROBERT WILKIE

        Secretary Wilkie. Thank you--thank you, Dr. Roe. I am going
    to pick up on Dr. Roe's theme. While we are here, two veterans
    will take their lives. Since the first shots were fired at
    Lexington, 41 million Americans have put on the uniform, and
    well over a million have paid the ultimate price. This issue,
    the issues that we faced in dealing with the incommunicable
    experience of war and its aftermath is not new.
        In the 1890's, President Benjamin Harrison, who was not
    known for much other than being in between non-successive terms
    of Grover Cleveland, was alarmed at the reports he was
    receiving from the Department of War, that suicides among the
    officer corps were spiking. He was the first president to order
    statistics to be gathered on the trends and the costs of
    suicide amongst those in uniform.
        In the last 2 years, we have been the first to finally come
    to the table and say, ``This is a crisis that needs to be
    addressed.'' As Dr. Roe said, every day 20 veterans take their
    lives; 60 percent of those have no contact with us, and the
    majority of those are from the Vietnam era. I saw through the
    eyes of the child the residue and the cost of that conflict. My
    own father, three purple hearts, after 3 years of recovery from
    his last wounds returned to the 82d airborne division, the most
    decorated combat unit in the armed forces of the United States,
    and because of the times was not allowed to wear his uniform
    off post.
        It is his comrades who have been suffering the most. To put
    that into a timeline, Lyndon Johnson left Washington 50 years
    ago in January. That is how long the problems that our Vietnam
    veterans have faced, have been going on.
        The idea that General Bergman has presented, and the ideas
    that have been supplemented by Dr. Roe are not new. In fact,
    the idea came from the Speaker of the House many years ago in
    her attempt to combat veterans' homelessness. What General
    Bergman and Dr. Roe have done, they have substituted the word
    homelessness with suicide in an attempt to get the entire
    community of the United States engaged in finding those 14
    veterans that we do not see.
        This is not an attempt to circumvent VA health care. This
    is an attempt at triage on the streets and in our rural areas,
    to help us find those veterans we cannot touch, and perhaps
    save them from the consequences that they have experienced as a
    result of their service.
        I want to get to the argument that I believe was made in
    the roundtable, and that is privatization. Let me put this in
    context. The budget for this department set aside $18 million
    for these programs. $18 million is not a lot of money for us.
    We have a $9 and a half billion mental health budget, inside of
    a $220 billion VA budget. Only in Washington, D.C. would
    someone say that using $18 million to get community partners
    engaged in the lives of veterans is a pathway to privatization
    and the degradation of services. It will not happen.
        As the Chairman and the ranking member have said, we have
    been in contact with the VSOs and both sides of this committee
    in the last few weeks to hammer out a way forward, a way
    forward that Dr. Roe just articulated.
        We recognize that we need help, that we need help in
    finding those veterans. I will not sit here and tell you that I
    am going to give you a metric and that we will eliminate
    veteran suicide. Human life is not linear. I will give you an
    example of some of the problems that we faced this year.
        In Ohio, a 69 year old veteran took his life on one of our
    grounds. He was facing life changing surgery, cancer surgery
    that would have removed his left eye, his jaw, and his vocal
    cords. He made a decision to take his life, but he left us a
    note asking us to take care of his mother. That is the kind of
    tragedy that we see on a daily basis, the ones that we do see.
    It is those 14 we do not see that are the crux of this
    legislation.
        This is an important step forward in a time--and I am
    considered a pretty good historian by some--in a time when
    Washington, D.C. is divided as it has not been certainly since
    Vietnam and perhaps the Civil War. This is an opportunity to
    say when it comes to warriors, that enough is enough. This
    legislation has brought together conservatives. It has brought
    together liberals. It has brought together moderates on both
    sides of the House.
        It is our way of supplementing what this committee has
    already done with the MISSION Ace, with accountability, in
    letting us get out to those communities and say, ``Please help
    us find these warriors.'' As I said at the beginning, it
    started in the 1890's, and we are sadly finally getting around
    to addressing this as a Nation. We have an opportunity here and
    this is a very good first start, and I thank you, Mr. Chairman.

        [The Prepared Statement Of Robert Wilkie In The Appendix]

        The Chairman. Thank you, Mr. Secretary, for your comments.
    I also want to recognize that we have with us today Dr. Stone,
    the executive in charge of the U.S. Department of Veterans
    Affairs. He is in charge of the VHA. Dr. David Carroll,
    executive director, Office of Mental Health, the U.S.
    Department of Veterans Affairs. Welcome, gentlemen, to the
    committee as well.
        I will begin by recognizing myself for 5 minutes, and I
    will begin. Mr. Secretary, first of all, I want to--does your
    bill or does H.R. 3495 require funds to be directed only toward
    organizations with a history of improving well being?
        Secretary Wilkie. Well, the compromise legislation that Dr.
    Roe talked about and I know----
        The Chairman. Mr. Secretary, I just want to know, regarding
    3495 as currently written----
        Secretary Wilkie. Well, 3495 has evolved. I am a----
        The Chairman. I know it has evolved, but I just want to
    know, as it stands now, it does not require that funds be
    directed toward organizations with a history of well being. Is
    that----
        Secretary Wilkie. Well, it requires funds to be directed to
    those organizations that have an impact in the community.
        The Chairman. It does not have--does not require that they
    be spent only toward organizations with a history of improving
    well being.
        Secretary Wilkie. Well, I will ask--I will say that that is
    probably right.
        The Chairman. Okay, thank you.
        Secretary Wilkie. Because--because----
        The Chairman. Thank you. I want to move on to my next
    question. Does H.R. 3495, as introduced, require organizations
    seeking grants to show evidence that there is a waiting list of
    veterans seeking their help?
        Secretary Wilkie. No.
        The Chairman. It does not. Thank you.
        Secretary Wilkie. No, no, you----
        The Chairman. We will move on.
        Secretary Wilkie. Okay.
        The Chairman. Does H.R. 3495, as introduced, ensure the
    expenditure of funds provided to these organizations are used
    directly to serve veterans in the communities in which they
    live?
        Secretary Wilkie. The only place we should be spending
    money is in the communities with veterans----
        The Chairman. I am glad we agree on that. Does H.R. 3495,
    as introduced, ensure the expenditure of funds provided to
    these organizations----
        Secretary Wilkie. Mr. Chairman, I think----
        The Chairman.--used directly to serve veterans in the
    communities in which they live?
        Secretary Wilkie. Mr. Chairman, I think you know the
    answer, that the intent of that is yes.
        The Chairman. The intent is yes, but is there language that
    ensures that the expenditure funds--in other words, it
    prohibits the expenditure of funds if they are not spent on
    veterans that are serving committees directly where they live.
        Secretary Wilkie. General Bergman's legislation creates a
    mechanism within the Department of Veterans Affairs that will
    take these grants and give them to groups that we approve, that
    we know can reach out to veterans. Let me just say,
    legislation----
        The Chairman. Secretary----
        Secretary Wilkie. I have got to respond. Legislation is not
    static. General Bergman, Dr. Roe, and your staffs have been
    working----
        The Chairman. Reclaiming my time, Mr. Secretary. I
    understand--do not--you tell me a legislation is not static,
    but I am just asking you questions about the legislation that
    you have relentlessly been pushing through your department
    without discussion with me, as the Chairman----
        Secretary Wilkie. But that is----
        The Chairman.--never meeting with me. I want to make clear
    what is in the legislation as introduced----
        Secretary Wilkie. The--that legislation is no longer
    relevant.
        The Chairman. Mr. Secretary. Reclaiming my time, Mr.
    Secretary.
        Secretary Wilkie. Yes.
        The Chairman. Reclaiming my time. It is my time to ask a
    question.
        Secretary Wilkie. I hope you give me time--I hope you give
    me a chance to respond.
        The Chairman. I have, and you have answered very succinctly
    and honestly so far, but the legislation intends, but does
    not--but I am telling you it does not require. When I ask you a
    simple question, does the--does H.R. 34, as introduced, require
    the expenditure of funds provided to these organizations that
    are used--that these organizations are used to directly serve
    veterans and their communities. Your answer was, ``That is the
    intent.'' I am telling you, the legislation as written does not
    require that.
        Secretary Wilkie. Well, I will say, and I am a--you and I
    had this discussion in front of the Speaker. The legislation
    that you are talking about is no longer relevant in the
    discussion, because you have compromise legislation that has
    been offered by the author. You have compromise legislation
    that has been worked on by the ranking member.
        That base bill is no longer--will no longer be passed into
    law.
        The Chairman. I want to make clear----
        Secretary Wilkie. We are going beyond that----
        The Chairman. What I want to make clear, Mr. Secretary, is
    relentless this legislation was pushed. You have pushed out op-
    eds in advance. That meeting with the Speaker was arranged with
    the Speaker. I was an add on. You have never sought a meeting
    with me to discuss my problems with this bill. In fact, there
    is a major shortcoming in terms of there is no inadequate
    accountability for how this grant money is going to be spent.
    Your legislation, as written, the legislation H.R. 3495, as
    written, does not even require that funds be spent on
    organizations that directly serve veterans in their own
    communities.
        Secretary Wilkie. Well, let me say, you are giving me much
    too much credit. This legislation was around long before we had
    a President's Roadmap to Empower Veterans and End a National
    Tragedy of Suicide (PREVENTS) task force. This legislation was
    put forward by members of this committee. The only thing that I
    did was support the efforts by members of this committee to
    finally address suicide.
        The Chairman. Okay. My time has----
        Secretary Wilkie. That is my job as the Secretary of
    Veterans Affairs.
        The Chairman. My time has expired, Mr. Secretary. I now
    call on Dr. Roe for 5 minutes for his questions.
        Mr. Roe. Thank you, Mr. Chairman. Let me get us back on
    track here. This is not--this discussion today should have been
    3 months ago. This is not about who got asked what. This is
    about preventing--helping prevent veteran suicide and finding
    those veterans out there who have not been able to get into the
    VA, and then get them in to where they can get care. I think
    that is what this is about.
        Secretary Wilkie. That is right.
        Mr. Roe. Let me ask a question, Mr. Secretary, and please
    feel free to answer. The compromise language, and again that is
    what I thought the roundtable was for was to go past the base
    bill. We were asked--and I want to thank the minority staff for
    working with the majority staff during this past week. We were
    asked to do that. We brought our VSO partners in, had their
    comments, and we did exactly what we were directed to do, and
    that is provide a compromise bill to address those misgivings
    that the Chairman had.
        The compromise language that we worked on, we prepared,
    would prohibit the provision of direct cash assistance from
    grantees to eligible individuals and their families. Are you
    supportive of that? Why or why not?
        Secretary Wilkie. Yes. Let me take a step back with your
    indulgence, Dr. Roe. I have the legislation that General
    Bergman presented. The provision in Section 2, it says, ``The
    Secretary shall give preference in the provision of financial
    assistance under this section to eligible entities who have
    demonstrated the ability to provide assistance and suicide
    prevention services.'' General Bergman's legislation answered
    all of your questions, Mr. Chairman, in that one paragraph.
        What I have been saying is that the questions that you
    asked are not relevant as we speak now in that that compromise
    legislation is now the vehicle for that presentation. I would
    also add, legislation that at its base has the support of 220
    members of this body. The answer to Dr. Roe's question is yes.
    I want to thank the Chairman for bringing this bill forward,
    and hopefully we can get this thing done and out of here by
    Christmas so the bipartisan group of Senators who are backing
    this can get it done and have us get the ability to get out on
    the streets and find those veterans we do not see.
        Mr. Roe. Mr. Secretary, the compromise language that we
    worked on in the past week would require the VA to give
    preference to so-called hub organizations when awarding grants.
    It would not preclude grants to smaller, non-hub organizations
    where appropriate. Are you supportive of this change?
        Secretary Wilkie. Absolutely.
        Mr. Roe. Yes. I looked at my own State, and we have a thing
    called the First Tennessee Development District. It is 8 of my
    12 counties I represent. All--the board of this organization
    are all the mayors of the counties and the municipalities. They
    have access to all kinds of services that you could go out.
    This would be a perfect organization.
        I looked at Guard Your Buddy in Tennessee for the Tennessee
    Guard that we have used. I think they should be included in
    this type of thing to help find veterans that are out there. We
    have a program that actually works. We know it has worked in
    Tennessee.
        I think, again, to get our discussion back on track,
    really, we have gone past the base bill because that is what we
    were asked to do. Mr. Chairman, when you had the roundtable,
    which was very good, I thought, last week, it really sparked us
    to say, ``Hey, what can we do--'' You had some misgivings and I
    appreciated that misgivings and tried to address those
    misgivings. The staffs did, I thought, did a great job. I think
    we have a good compromised bill, and I think we need to move
    forward with light speed.
        Secretary Wilkie. This is the last I will say about this.
    This is too serious a matter to worry about who gets credit for
    the final product. We have been ignoring suicide amongst
    warriors for over 200 years in this country. We are finally
    getting around to it. I saw what impact it had growing up at
    Fort Bragg. I have seen it now in spades as the Secretary of
    this department.
        I think that what we have seen play out in the last few
    weeks with members coming together is an indication that
    members of this body and the other body have also said,
    ``Enough is enough, and let us get something done.''
        Mr. Roe. Secretary, I want to finish my saying General
    Bergman served in Vietnam. I served in Korea at the same time.
    I would not pick up a coat that had Vietnam written in it. I
    would hang it back up. I would not even put it on. If they gave
    it to me, I would not take it. It has taken me a while to get
    over that, and I have. You have veterans out there that feel
    the same way about the VA. They would not walk in there for a
    certain reason. We have got to get to these men and women and
    help them. I yield back.
        The Chairman. Mr. Secretary, I am--I just want to make
    clear that my concern here is not about who receives credit. My
    concern all along has been to engage with minority staff and to
    get even your office to even respond. You have never taken the
    opportunity to respond to my draft, which has also been out
    there for quite a while. We just received--majority staff never
    received and never worked on this so-called compromise
    legislation. It was sent after 7 p.m. last night.
        It has taken this long to even get people, you know, the
    minority staff to respond. Since you are raising this issue of
    212 co-sponsors on H.R. 3495----
        Secretary Wilkie. Two hundred twenty.
        The Chairman. I guess the number has gone up.
        Secretary Wilkie. Yes.
        The Chairman. Well, since you have raised this issue, Mr.
    Secretary, I hope you can clarify a point for me. Did anyone in
    your office, or the Office of congressional Affairs, contact
    House member offices asking members to sign on to H.R. 3495?
        Secretary Wilkie. Well, I am sure we did.
        The Chairman. Okay. Well, then you can--then, I should not
    be surprised when I see a note that we have printed out,
    actually an e-mail, ``Wanted to shoot you an e-mail today
    because I was reviewing the status of H.R. 3495 and noted that
    bot Reps X and Y were co-sponsors, but your boss has not signed
    on yet. I thought I would reach out and provide some info and
    let you know that it would be great to add Representative Pocan
    as a co-sponsor.''
        This is highly inappropriate. I think--and you seem to be
    very proud of the fact that your office has been engaged in
    this sort of stuff, and this way of operating. This is what has
    caused so many members to sign onto the bill. I want to read
    you 18 U.S. Code 1913, which states, ``No part of the money
    appropriated by Congress shall be used directly or indirectly
    to pay for any printed or written matter, or other device
    intended to or designed to influence in any manner a Member of
    Congress to favor, adopt, or oppose by vote, or otherwise any
    legislation, whether, or before, or after the legislation of
    any bill proposing such legislation.''
        The way I read that section of the U.S. Code, your actions
    were--actions of your office, and people who work in your
    office, were inappropriate and public funds should not have
    been used in that way.
        Secretary Wilkie. Well----
        The Chairman. That can explain why so many members have
    signed onto this bill.
        Secretary Wilkie. Well, Mr. Chairman, you are--I do not
    think you are giving credit to the 220 members who signed on.
    Second, in my professional experience, I have been the
    Assistant Secretary of Defense for Legislative Affairs at the
    Department of Defense, I have also had that job at the National
    Security Council. The section of the law that you cite is about
    corruption. It is not about the offices of the Federal
    Government educating, and informing, and supporting legislation
    that support the activities of that particular Federal
    department. If that were the case, then we would not have any
    Legislative Affairs Office----
        The Chairman. Mr. Secretary, I can tell you----
        Secretary Wilkie. We would not have an effort by any
    department of the Federal Government to do something as simple
    as promote the President's budget and try to get sponsors to
    support the President's budget. I think I will say that we are
    doing our due diligence to help veterans. Again, I go back. I
    really do not care who gets credit. I do not care what went on
    before. We have got 20 veterans who are dying, 2 have died in
    the time that it has taken for you to drop that gavel and me to
    answer your questions. That is what is more important here.
        The Chairman. Do not imply, Mr. Secretary, I care any less
    about the veterans who are committing suicide. I have declared
    suicide prevention to be the No. 1 priority of this committee.
    We have worked diligently on that priority, and we want to get
    it right. There are high stakes in terms of getting it right,
    and there are high stakes in terms of getting it wrong.
        With that, Mr. Secretary--and by the way, in my 7 years of
    being on this committee, I have never seen anything like the
    solicitation of co-sponsorships as indicated in this e-mail
    occur during my watch on this committee. I would now like to
    call on Representative Lamb for 5 minutes.
        Mr. Lamb. Thank you, Mr. Chairman. I just want to reiterate
    the feeling of all members of this committee about the urgency
    of this situation and the determination to get it right,
    whatever decision that we reach. I do not believe there is a
    single member of this committee that does not feel that this is
    the most urgent priority in front of us. Mr. Wilkie, I just had
    the pleasure of finishing Secretary Mattis's new book, and I
    know you are an admirer of him as well. He reminded me of one
    of the lessons of the basic school, which is that time spent
    doing reconnaissance is almost never wasted time.
        Secretary Wilkie. Absolutely.
        Mr. Lamb. I think that is what we are doing here. I would
    like to focus, if I could for a moment, on the--what I see as
    the strengths of the Chairman's hub proposal. First of all, I
    just want to ask up front, the hub proposal that is being
    suggested in the alternative, do you think that VA could make
    that work if that ended up being the decision at the end of the
    day?
        Secretary Wilkie. Absolutely. We have seen it work with
    homelessness. That is why I referenced the Speaker at the
    beginning of my remarks. What the hub proposal did--what the
    hub model did was go out in the communities and find groups
    like Catholic Charities, who have deep tentacles into all areas
    of a community and say, ``Go out and help us find homeless
    veterans.''
        I think the addition that General Bergman has made augments
    that by trying to find those groups, even small ones, that can
    be more creative when it comes to helping us find those
    veterans on the street. Yes, I think it has worked before, and
    I think it would work again.
        Mr. Lamb. I appreciate that. I think it is important for
    people to know that this is actually already working in some
    communities in the country. Not everybody has an America Serves
    hub already, but I am sure you are familiar with the America
    Serves program?
        Secretary Wilkie. Yes. Yes, sir.
        Mr. Lamb. We are fortunate enough to have one in three
    counties of the roughly ten counties of southwestern
    Pennsylvania and it is--you mentioned Catholic Charities. This
    is overseen by the Pittsburgh-Mercy Health System, which is an
    off-shoot of the Sisters of Mercy.
        Secretary Wilkie. One of the best in the country.
        Mr. Lamb. Definitely one of the best. The program
    administrator of that is an artilleryman from the Pennsylvania
    National Guard. The team leader was an engineer in the
    Pennsylvania National Guard with deployments to the Middle
    East. The intake specialist served in the 1st and 23d infantry
    division in Iraq from 2003 to 2004. The other intake
    specialists served as a military police woman in the Army
    Reserves. The other intake specialist was an Air Force enlistee
    for 11 years with deployments to Iraq. The overall head of it
    is a 11 year--10 year social worker with expertise in community
    health for Pittsburgh-Mercy.
        This staff in Pittsburgh knows the community. They are
    veterans. They know mental health treatment. They already are
    coordinating with dozens of local groups all around our area.
    From what they tell me, they could expand their reach beyond
    those three counties and serve a higher number of veterans if
    they had additional funding and support.
        My question, I guess, is if we have hubs like this already
    in existence that already know the difference between a good
    provider and a bad provider--or I should not even really say
    provider, but I guess recruiter of veterans and agency that
    encounters veterans, I think we share the goal of going out and
    finding these people.
        Secretary Wilkie. Absolutely.
        Mr. Lamb. It is often a conservative principal to shift
    decisionmaking down to the lowest level. From where I am
    sitting, why is the PA Serves network not a better
    decisionmaker and better distributor of funds than someone in
    your office, in Washington, D.C.?
        Secretary Wilkie. Well, I do not think that there is a yes
    and no answer to that. I do think that as stewards of the
    Federal dollar, we do have to go out and investigate and
    determine who is good and who is not, and that is just routine
    cost of doing business. Certainly what--and you and I know, I
    was just in Pittsburgh, what is going on in Pittsburgh is a
    model for the country. It is a model for veterans. I think that
    an organization like that would be at the top of the list.
        Mr. Lamb. Thank you. Mr. Chairman, I--one last question.
    Dr. Stone, I did ask you last week about the vacancies in vet
    centers and mental health providers. Do you have that number?
        Mr. Stone. I do. At this time, we have over 24,000
    providers. Our vacancy rate is just over 2,400 or just over 10
    percent.
        Mr. Lamb. Twenty-four hundred on the mental health
    provider?
        Mr. Stone. Right.
        Mr. Lamb. Would that include--that would be like docs,
    nurses, social workers, all inclusive?
        Mr. Stone. These are mental health providers. They are
    psychiatrists, psychologists, psychiatric social workers.
        Mr. Lamb. Got it. Okay. On the vet center side?
        Mr. Stone. The vet center side I do not have in front of
    me, and I promise you I will get that.
        Mr. Lamb. Okay. Thank you. Mr. Chairman, I----
        Mr. Stone. If I could just add one other thing. The
    administrative overhead as part of this bill is about 20
    employees in central office, but specifically, their job would
    be to seek those organizations like you listed with
    relationships in the community that could act in the hub manner
    in order to distribute throughout the community. There is not a
    large administrative overhead anticipated within central
    office.
        Mr. Lamb. Thank you. Mr. Chairman, I yield back.
        The Chairman. Thank you, Mr. Lamb. I call on Dr. Dunn for 5
    minutes. General Bergman.
        Mr. Bergman. I will be glad to take Dr. Dunn's and my 5
    minutes. Let's get to the point. Number one, Chairman Takano,
    thank you to you and the majority staff for all the efforts
    that you have put in, especially collectively with the minority
    staff, Dr. Roe's office, and as we have gotten some
    communication line open with the VA. This is what truly in
    military terms in any operation, if you do not have good
    communications, your chance of mission failure is greatly
    increased or your chance of mission success is greatly
    decreased. The communications that are driving us here today, I
    thank you all.
        You know, we always quote different authors and different
    entities. I am a big Steven Covey fan, and begin with the end
    in mind. I believe we are all here with the end is that we are
    going to do everything we can to reduce veteran suicide.
    Period. Especially in a group that we have not made any dent in
    those suicides in the last several years, because pure and
    simple one reason. We do not have any communications with them.
    We do not have any connection with them. They are out there
    alone.
        You know, one of Covey's other habits is seek to understand
    before trying to be understood. What Congressman Lamb talked
    about as far as General Mattis's quote on reconnaissance, I
    would say seeking to understand is just a different form of
    reconnaissance. You usually develop your understanding through
    your ears, not through your mouth.
        The point is, as my mother would have said, you have got
    two ears and one mouth, so you do the ratio for what you use.
    Veterans have long been part of laboratory experiments. I can
    remember the shotgun, for giving the vaccinations that did not
    really work as well as it should have on the right--you know.
    Bottom line is we all got vaccinated. I could go on with
    different experiments.
        I can think of no better laboratory experiment than to
    figure out ways that we are no currently doing to reach that
    target market of those 20 veterans a day.
        We have heard a lot of things repeated here and I would
    just like to repeat what I believe I heard, and what I see on
    the paper in front of me is that we have gone past the initial
    bill. We have exhibited compromise. We have exhibited
    discussion first, back and forth. We are at a point where now
    the State of this bill as the proposed language that talks
    about, you know, the hubs versus smaller/specialized
    organizations compromise that Secretary Wilkie, you will
    prioritize the hubs. The grants can also be given to non-hub
    direct providers. Clinical services compromise, eligible
    veterans must be referred to the VA for clinical care, but
    grantees can provide some services if urgency needed.
        I guarantee if you are on the battlefield, you really do
    not care, if you are a soldier, if it is a Navy corpsman who
    treats you. You know, if you are in my case in Northern
    Michigan in January and you are in a ditch alongside the road,
    you really do not care who stops to pull you out. I mean, you
    need help when you help it. I think on the, I know on the cash
    assistance compromise that, you know, we are going to--that
    will be prohibited directly to veterans, but the grantee can
    acquire needed service on behalf of the veteran.
        With that, Secretary Wilkie, just one question here. We
    know very little about many veterans who take their own lives
    but are outside the VA system. In my bill, we are working to
    put parameters in place to ensure proper use of grant dollars
    and track their success. Where do you see is the proper balance
    between such parameters in ensuring that the legislation allows
    VA and the community partners to proper--the proper flexibility
    to help at-risk veterans wherever they are and with whatever
    problems they might be facing?
        Secretary Wilkie. Well, I think your base bill actually
    gives us the guidance. This part of the bill has not changed.
    It says, and you wrote it, that we assist those who have
    demonstrated the ability to provide or coordinate suicide
    prevention services or other services that improve the quality
    of life of veterans.
        I think that is--that is the prime directive. We know, as
    Congressman Lamb just said, what works in Pittsburgh. I know
    what works in New Orleans and North Carolina. You know what
    works in Michigan. I think the beauty of the hybrid model that
    you have come up with, and again, it is not the base bill that
    we are dealing with. It is dealing with this compromise. It
    allows for the ability to innovate by allowing us to go out and
    seek organizations that may not be old. They may not be
    hierarchical in their organization. They may be able to reach
    somebody in far rural Montana or Alaska.
        I will give you an example as to the other way. I spoke--I
    have been to Alaska twice to speak to the Federation of Natives
    to ask them to double the number of tribal representatives that
    they have dealing in veterans issues to go out into the
    wilderness of Alaska and help us find them. What you have done
    is allowed us the broadest aperture when it comes to finding
    people in diverse communities who can go out and help. I think
    that is a benefit that is long overdue.
        Mr. Bergman. Mr. Chairman, I yield back.
        The Chairman. Thank you, General Bergman. I appreciate the
    work we have done with each other, and I appreciate your
    legislation. Again, the intent was never--this hearing is not
    about credit. I would love to--and I do not believe you think
    it is about credit. I just assume using--but we will give it to
    you. Thank you so much.
        I would like to now recognize Mr. Levin for 5 minutes.
        Mr. Levin. Thank you, Mr. Chairman. Thank you for being
    with us today, Secretary Wilkie. As you know, I am very
    grateful for all the good work of the VA and San Diego,
    generally, and in my district specifically. I think we all here
    share an objective to deal with the crisis of veteran suicide.
        Your staff had circulated a white paper in support of H.R.
    3495, which states, and I quote, ``We acknowledge there needs
    to be a clear line of referral from the grantee to VA.'' My
    understanding of H.R. 3495 is that it allows grantees to
    provide clinical care to veterans without referring them to VA.
    Could you clarify, Mr. Secretary, the department's position on
    whether grantees should refer veterans to VA?
        Mr. Stone. If I could take that, sir. We think that for all
    chronic mental health issues ought to come back to the VA. We
    do recognize the fact that in our work with organizations like
    the independence fund that brings formations back together that
    have had difficult times, that there are emergent crisis
    situations that those organizations ought to have the ability
    to treat the crisis situation and diffuse it.
        We also know from our roundtable where a number of hub-type
    organizations spoke, that about 85 percent of veterans that
    engaged with those community organizations then enrolled--the
    veteran then enrolled in VA health care. We really believe that
    through the use of these organizations, we will have enhanced
    enrollment in VA health care for chronic conditions. The line
    is between acute, crisis situations, diffusing, and then coming
    to VA.
        Mr. Levin. How do you anticipate that creating a new
    communi-care pathway disconnected from VA could impact
    enrollment, impact coordination of care. You have addressed
    that a bit, but if you care to expand.
        Secretary Wilkie. Let me, as the non-medical person,
    address what I know the intent of General Bergman has been. We
    need to find people. If we find people in crisis, then it is
    imperative that if that crisis is acute, it does not matter
    where the care is. If you cannot get to a VA, the matter needs
    to be dealt with quickly and efficiently.
        I am confident that in a chronic--in an acute situation,
    the imperative will be to get that person to the nearest care,
    and then we can take over.
        Mr. Stone. Let me add to that. At the current time, we have
    our eight categories of eligibility. We also have the ability
    to take humanitarian cases and then figure out their
    eligibility after we are already treating them.
        We expand that another step within our vet centers. It is
    why Congressman Lamb's question was so important. What is the
    staffing of our vet centers? Because we have enhanced
    expandability. What--the difficulty today in the 14 that we are
    losing is that we cannot see them. I cannot sit here and tell
    you that we exactly understand the barriers, except we do know,
    as the Secretary has articulately stated, that 50 years after
    Vietnam, there are a number of veterans that still prefer to be
    lost from us.
        And we need to identify them through community partners and
    then come back to you and say, ``We need this additional
    criteria in order to bring them into the system.''
        Mr. Levin. The one-pager also states, and I quote, ``Grant
    funds will be restricted for the direct use of veterans.'' Yet,
    I believe the bill allows the provision of services, including
    clinical care, to a veteran's family members or housemates. Can
    you clarify the department's position on using its resources to
    care for civilians?
        Mr. Carroll. The care that we want to provide is focused on
    the veterans. I think family members are an integral part of
    their community, and to the extent that family members can
    support the veterans, or maybe if the family dynamic is the
    dysfunctional component, that that needs to be addressed in
    order to reduce that person's crisis at that time.
        Secretary Wilkie. I would add, an example of that,
    Congressman, would be childcare. If we found a veteran in
    crisis, and took that veteran to an acute service, the import
    of General Bergman's legislation and Dr. Roe's compromise would
    be to allow that community-based organization to support that
    veteran by taking care of childcare. That is an example.
        Mr. Stone. Let me move away from sort of the mental health
    answer. We have veterans in crisis because they cannot get to a
    job. It may be paying a family member to drive them to their
    job because they do not have a driver's license. There is--if
    we begin to move away from all the causes of crisis, from
    simply mental health care, you begin to identify areas needing
    support that this bill attempts to get at.
        Mr. Levin. Thank you. I am out of time. Again, thanks for
    your hard work on behalf of our veterans and I hope we are able
    to achieve a favorable outcome from all this.
        Secretary Wilkie. Thank you, sir.
        Mr. Levin. Thank you.
        The Chairman. Thank you, Mr. Levin. I now recognize Mr.
    Meuser. Is he here? Mr. Meuser is not here. Mr. Steube, not
    here. Mr. Barr, 5 minutes.
        Mr. Barr. Thank you. Thank you, Mr. Chairman, and thank you
    very much for holding this hearing on this very, very critical
    issue facing our veteran population.
        Secretary Wilkie, Dr. Stone, good to see you all again.
    Thank you so much for your attendance this morning at today's
    hearing.
        I want to thank General Bergman for his service to this
    country and for his leadership with the Improve Act. I am proud
    to cosponsor it, General, and I thank you for your leadership
    on this.
        I am very heartened that there is bipartisan support for
    this bill and it deserves bipartisan support. I hope that this
    innovative approach of engaging the VA's community partners to
    fight this heartbreaking epidemic will ultimately succeed, I am
    confident it will, and I am confident that we will come
    together in a bipartisan way to address this issue.
        I want to personally thank you, Mr. Secretary, for your
    active engagement on this. Not only do I not think it--not only
    is it not inappropriate for you to be actively soliciting
    support for this endeavor from Members of Congress on both
    sides of the aisle, I would respectfully submit that this is
    your job, it is your job to do it. I thank you for doing your
    job in soliciting support for an effort like this.
        To the extent we need to work out and iron out some
    differences, I think we can do that, and I know the chairman is
    committed to that and I thank the chairman for his interest in
    that. I thank the chairman also for his desire to create
    accountability, and maybe that is what is animating this hub
    concept and I think we can get there.
        As you all know--and, Dr. Stone, you and I have talked
    about this quite a bit, I have asked you about equine-assisted
    therapy; it is a major priority for me and veterans in my
    district.
        Since the Lexington VA began offering equine therapy in
    2016, hundreds of veterans in the mental health resident
    rehabilitation treatment program have been able to take
    advantage of this therapy, really important work that is being
    done to prevent suicide. We can all agree that effective mental
    health rehabilitation is key for avoiding veteran suicide.
    Would any of you all be able to confirm if both bill versions
    would allow for equine therapy groups in my district and other
    districts who already work with veterans, like in my district,
    Central Kentucky, Riding for Hope, the Life Adventure Center,
    would they be able to directly apply for grant funding to help
    serve veterans?
        Mr. Stone. To my understanding, the answer is yes.
        Mr. Barr. In both versions?
        Mr. Stone. In both versions.
        Mr. Barr. One thing I am a little worried about this hub
    concept is that it would cut out equine-assisted therapy and
    some of these smaller groups--and, let us face it, a lot of
    these equine-assisted therapy groups are small organizations,
    there are two, three people involved--they would not be a hub,
    so to speak.
        Secretary Wilkie. I can answer that. That is why this
    hybrid model that General Bergman has come up with almost
    revolutionary, because it allows us to find groups like that
    who provide unique services, things that are not run-of-the-
    mill, that we have not engaged in the past.
        Mr. Barr. Right. I would just say, Mr. Secretary, as I read
    the Improve Act, there is a lot of accountability features in
    the bill that impose on the VA a responsibility to ensure and
    certify that these groups have a track record, there are
    reporting requirements----
        Secretary Wilkie. Yes.
        Mr. Barr.--there is application criteria, there is data
    collection, there is evaluation, you are helping these groups
    to make sure that they qualify, and that they are qualified and
    have experience. They are not fly by-night----
        Secretary Wilkie. That is right. I would also say, sir,
    that many of these small groups are owned and operated by
    veterans and, to me, that is--to use a Kentucky term, that is
    the trifecta, because you have people who understand the
    culture and speak the language and they are on the ground, and
    it is these unique ways--I mean, look at what we are doing now,
    equine therapy, art therapy, music therapy, things that were
    unheard of even when I was a young officer. I am an older
    officer now and these things are now accepted.
        Mr. Barr. Dr. Stone, final question. If this bill were to
    become law, we already have an adaptive sports grant program,
    can you explain how the Improve Act grants would interact with
    the existing Associated Student Government (ASG) grant
    programs?
        Mr. Stone. I think you have to recognize the fact that
    these grants are to bring people that are not participating
    into the system and, once you begin to bring them into the
    system, then the adaptive sports pieces can kick in right away.
    When we go to various adaptive sports events, over and over
    again we hear from veterans, ``I was isolated, I was alone,
    these types of activities brought me in.''
        Mr. Barr. Well, my time has expired, but I would agree with
    that these groups, including equine-assisted therapy groups,
    they are out in the community, they interact with veterans who
    have no interaction with the VA, especially in rural places
    like Kentucky, and that is why this is so important.
        Mr. Stone. That is correct.
        Mr. Barr. I yield back.
        The Chairman. Thank you, Mr. Barr.
        Mr. Brindisi, you are recognized for 5 minutes.
        Mr. Brindisi is not here? Mr. Pappas.
        Ms. Luria.
        Ms. Luria. Well, thank you, Secretary Wilkie and Dr. Stone,
    for joining us today. Thank you, Mr. Bergman, for introducing
    this legislation.
        I would have to say that I reiterate my colleagues that
    this is one of the issues of utmost importance to this
    committee and to our Nation, because those men and women who
    have served and who are suffering need to have access to the
    care.
        Secretary Wilkie. No more so than in your district.
        Ms. Luria. Thank you.
        I really appreciate a comment that Ranking Member Roe made
    in his opening statement. I wrote this down. It says, ``It is
    not a threat to the VA, it is a lifeline to the VA.''
        In research for this, I went through and I looked at the
    wait times within my district's general geographic area to
    receive mental health care and this is just drawn from VA
    websites. At the clinic in Virginia Beach, 33 days; at
    Chesapeake, 23 days; Hampton VA Medical Center, 13 days; and
    Elizabeth City, North Carolina, 34 days.
        For veterans who are in crisis, they need a resource in the
    community and I think that this bill gets after the fact that
    there are more partners within the community that can provide
    an immediate resource. I have been listening and observing the
    debate as to whether clinical services should be provided, but
    I think that where I would like to see us go with this is that
    it is a gap. I mean, 34 days when you are in crisis and you are
    thinking about taking your own life is too long.
        I think that the intent of having these additional services
    within the community--and we can debate how they are delivered,
    whether hubs or a hybrid system--I think the hybrid is
    important and, as Mr. Barr said, there are organizations out
    there that can provide these services immediately and they may
    or may not be clinical care, they could be equine therapy,
    there can be all types of things that change someone's outlook
    on life when they are suffering and contemplating hurting
    themselves that can be helpful, and I think we should expand
    that.
        The reference that you gave earlier to equating this to
    what we did for veterans homelessness, we went to the community
    and said, who out there can help and how can we give you the
    resources to help you help our veterans. That is the direction
    I would like to see this go.
        And I appreciate that there are details within the bill. It
    is very important to me that we do have, you know,
    accountability for where the money is going, that those
    organizations who receive the funds should be able to show us
    back that they are effectively using those funds to serve
    veterans in the communities. I am very confident, you know,
    between Mr. Bergman's efforts and the discussion that we have
    had here that, you know, we can get from the original text to
    something that provides those opportunities for our partners in
    the community to provide more service.
        I do not necessarily have a question, I just want to say
    that, taking in everything that we have considered here today,
    I think that we can get to a yes on this, and I really
    appreciate you personally appearing before the committee today
    to be part of the discussion.
        Secretary Wilkie. Well, I thank you for your kindness to me
    in the time that you have been serving. I have a lot of
    familiarity with your district, having gone to school in
    Norfolk when my father was at Joint Forces Staff College, it
    was the Armed Forces Staff College then, and then in my naval
    service at Little Creek and Dam Neck. No other district in the
    country has as many servicemen and women as yours does and I
    think that is the one place where we better get this right,
    because of the impact that this issue has on the people that
    you live next door to.
        Mr. Stone. Congresswoman, thank you. Thank you also for the
    visits that you have made to our facilities in your region and
    your engagement in helping us change and deal with, frankly,
    what is a very concentrated area of veterans, but also a
    geographically challenging area because of tunnels and bridges.
        I would like to say one thing for those veterans that are
    listening to us today. If a veteran is in crisis, we will see
    you today; if there is an urgent need, we will see you today.
    The numbers that you listed were numbers for our wait time for
    routine care, for non-emergent care, and they are accurate
    numbers. It can take us sometimes 3 weeks to get people in for
    a routine visit, for changing a provider. If there is an urgent
    need, we will see you today.
        Ms. Luria. Well, I appreciate you clarifying that, and I
    also did hear that from the providers at the Hampton VA, that
    the doors are open, if you are in urgent condition, come on in
    and we are here to help, and they can provide that triage, that
    immediate assistance. I think the purpose of this bill is to
    provide more partners in our community who also can be that
    conduit to get people into the care.
        The last thing that I would like to highlight in my last
    few seconds is that I am very concerned that the Hampton VA has
    gone from the watch list to the high-risk list. We look forward
    to working very closely with you, with the new director, Mr.
    Collins, to find the resources and the tools to, you know, get
    them back on track and in a better ranking relative to other
    VAs, and to provide the best service to our constituents.
        Secretary Wilkie. I will visit with you and we will walk
    those halls. As I mentioned, your district is unique among
    unique districts in that part of the world.
        I will add one thing----
        Ms. Luria. I think we are out of time, but----
        Secretary Wilkie. If I could ask the indulgence? I have
    talked a lot about America never having a national conversation
    about mental health, the only person who ever did that was
    Rosalind Carter, God bless her for that, and nobody was
    listening. We have had to change the culture, to begin to
    change the culture, both on the active side and now at the VA
    side. We do have those same-day mental health services, as you
    noted. We are now screening every veteran for mental health
    issues.
        As the former Under Secretary of Defense for Personnel and
    Readiness, General Bergman's former leader General Mattis and I
    plotted out how we begin allowing our recruits in basic
    training and in their basic individual training to start
    hearing the cadence of mental health talk. What do you see in
    yourself, what do you see in your comrade? That by the time
    they get to VA, at whatever stage they had in their military
    career, they know, they have a base knowledge with which to
    move forward and that to me, the culture will change, is the
    most important step that we can take in getting our arms around
    this national issue.
        Ms. Luria. Well, thank you. I know we have already run
    over, but, you know, both being on the Military Personnel
    Subcommittee and Veterans' Affairs Economic Opportunity, I
    think that there is a link from active to veteran where we can
    make that continuum happen and would love to work with you in
    both capacities. Thank you for your attention to the Hampton
    VA.
        The Chairman. Thank you, Ms. Luria.
        Thank you, Dr. Stone and Secretary Wilkie, for emphasizing
    that same-day access to mental health care, urgent mental
    health care, is the policy at the VA and, as emphasized, I am
    very pleased that you clarified that point.
        I would now like to recognize Mr. Bilirakis for 5 minutes.
        Mr. Bilirakis. Thank you, Mr. Chairman. Thanks for holding
    this hearing. I thank the ranking member and of course the
    General for offering this bill, and the ranking member for
    offering the compromise.
        Mr. Secretary, I really appreciate the fact that you are
    thinking outside the box. I went to a vigil, a candlelight
    vigil when I got off the plane this past Friday, a veteran in
    my community committed suicide, and there were several members
    of the community that were there that did not know him
    personally, but wished they had, because they would have done
    everything they possibly could. You know, I did not know the
    veteran, but it did not necessarily mean that he had a mental
    health issue, like you said, sir, but it could have been--I
    know he was having a hard time in life as far as relationships
    are concerned, as far as getting a real, well-paid job, as far
    as having an automobile to drive him to work. I understand he
    was riding a bicycle to work the last few weeks of his life.
        Again, this is so very important, bringing in the
    alternative therapies. The VA does a great job, but thanks for
    recognizing that we need the community involvement as well and
    we need experts in the community. I am in the Tampa Bay area
    and we have terrific nonprofits that do a wonderful job, but
    the funding is not always there, so they cannot see all the
    veterans. Of course we want to make sure that they are experts
    and it is science-based.
        I do have a couple questions, if that's Okay.
        Secretary Wilkie, can you explain the relationship, if any,
    between the grant program that the Improve Act would create and
    the PREVENTS Task Force work which is ongoing? If the Improve
    Act is enacted, how would you ensure that it is implemented in
    accordance and collaboration with the PREVENTS recommendations?
        Secretary Wilkie. Thank you, sir. I can certainly attest to
    what goes on in Tampa. As you know, my sister is a constituent
    and I am in the Tampa VA hospitals quite often. You and I are
    going to go to one of the dinners----
        Mr. Bilirakis. Absolutely.
        Secretary Wilkie.--at the hospital this coming year.
        The PREVENTS Task Force came after this legislation. This
    legislation was here before, but I have said across the country
    that the PREVENTS Task Force is our first attempt at a national
    roadmap, a national health roadmap on suicide. Let me put that
    in perspective too.
        Growing up, the leading cause of death for teenagers during
    my era was automobile accidents; today, the leading cause of
    death for teenagers is suicide. The New York City Police
    Department is ravaged by suicide. We have seen a 56-percent
    rise in the last 10 years in youth suicide. The point of that
    is, PREVENTS, I believe, will provide an opportunity for
    forward movement in terms of veteran suicide that will give the
    rest of the country an opportunity to think more deeply about
    what is going on.
        The first goal, it presents a national roadmap, second is
    to open the aperture to the community. This is the fist step. I
    do not have to wait until the report is done in March to move
    out on what this committee is doing. That is the vital part of
    this, that we start bringing small, medium hubs into our
    family, so that we can have a greater reach than we have ever
    had. I do believe that in the end the public health benefit of
    what we are doing at both PREVENTS and here will offer America
    a way forward during a very tragic time.
        Mr. Bilirakis. Thank you.
        The next question, Mr. Secretary, is the grant program that
    the Improve Act would create is based on this Supportive
    Services for Veterans' Families, SSVF. Why do you think that
    that model has been effective at addressing veteran
    homelessness and why do you think it will be effective at
    preventing veteran suicide?
        Secretary Wilkie. Well, the key word is ``community.'' What
    that model did was allow us to reach into the community with
    non-traditional partners, with hubs as well. A few years ago,
    there were 400,000 veterans and families on the streets of
    America every night, we are down to about 40,000 now. That is
    40,000 too many, but that is a heck of a lot better than
    400,000. The reason this is modeled on that approach is that we
    know that approach works.
        We know that getting into the streets with the people who
    know the streets is the key not only to finding homeless
    veterans, but it can be the way forward on suicide. It is one
    of the most under-appreciated Federal-private partnerships that
    we have and its success rate is palpable going from, as I said,
    400,000 down to 40,000 just in the last few years. We need to
    focus on success and that gives us a way forward.
        Mr. Bilirakis. Thank you. We have St. Vincent de Paul
    Catholic charity that does an outstanding job in the Tampa Bay
    area and has reduced homelessness, but if there is one homeless
    veteran out there, that is one too many. This is so very
    important.
        Again, you talked about the Haley Tampa VA--and I know my
    time has expired--you know, they think outside the box and they
    are making a great deal of progress, but we have got to do
    more.
        Thank you very much, Mr. Chairman. I yield back.
        Mr. Stone. Mr. Chairman, with your indulgence for just a
    few seconds. We will be in Tampa tonight to cap that new
    Patient Care Tower in Tampa and we appreciate it, but I had an
    opportunity a number of weeks ago to talk to your Governor's
    team about exactly these kind of programs in the Tampa area and
    their demonstrated effectiveness. It is exactly these kind of
    programs, sir, that you refer to that we want to get our arms
    around. We thank you for your leadership in this area.
        The Chairman. Thank you, Mr. Bilirakis.
        I now call on Ms. Lee for 5 minutes.
        Ms. Lee. Thank you, Mr. Chairman.
        Thank you for being here today. You know, when I think
    about just today sitting here that 20 men and women are going
    to take their life by suicide, men and women who have fought
    for our freedom, it is completely unacceptable and I do think
    it is the number one issue facing this committee. I thank you
    for your work on this issue.
        I have a history of running non-profit organizations and I
    am an advocate for public-private partnerships. I think that
    issues like this that, as you said, Mr. Wilkie, are not linear
    require that type of unconventional approach. You know, knowing
    that what we are doing right now is clearly not working, that
    14--or we can debate the number--of these veterans who are not
    currently accessing services, so clearly trying to find ways to
    get them to access services and get services to them is
    important. I am also a big proponent of accountability and not
    throwing a ton of money at problems and, you know, throwing
    everything and the kitchen sink and then not really having any
    accountability.
        I do want to get to issues about data, and I want to know,
    what data do you have that indicate that veterans who are
    currently not connected to the VA are likely to use these
    programs under this bill?
        Mr. Stone. I do not think we can say absolutely we can see
    this veteran population and, therefore, this is an effort--and
    that is why it starts at an $18 million investment and then
    bringing you data back before we allow it to grow over a
    decade. We have got to be able, as I said in my previous
    answer, to see this veteran population and get them from, no, I
    do not want anything to do with you to yes, and the greatest
    chance is with using the types of nonprofits that you have
    talked about and represented in bringing them in, we have to
    use their neighbors in order to get them to yes.
        Ms. Lee. Thank you.
        One other question I have is with respect to cash
    assistance and, you know, these veterans who died by suicide,
    but were not connected to the VHA in the 2 years prior to their
    death, is there any data that suggests--I mean, like what is
    the rationale behind providing cash assistance--or that
    suggests that access is or lack of access is a significant
    factor in suicide?
        Mr. Stone. Yes, it is from the SSVF Program that has been
    so effective that it is identified that at-risk families
    present that I have lost my job, I cannot pay my rent, I think
    we are going to be homeless, and it is that reason that we need
    to get at this type of cash assistance. Clearly, we do not want
    to become an ATM, but what we need to do is to recognize the
    fact that my failure to be able to get to work because I have
    lost my driver's license for whatever reason places me and my
    family at risk both of homelessness, as well as at risk for
    possible suicide.
        Ms. Lee. I want to turn now to a different issue that
    concerns. The VA's 2019 National Suicide Prevention Annual
    Report says that in 2017 70.7 percent of male veterans and 43.2
    percent of female veteran suicide deaths resulted as a result
    of firearm injury. In my home State of Nevada, that number is a
    staggering 75 percent of veteran suicide deaths by firearm. I
    know other western states and states with high rural
    populations face those similar challenges.
        Mr. Wilkie, what policies or programs has the VA proposed
    or created to address this issue of death by firearm?
        Secretary Wilkie. Well, we will start with we are dealing
    with a population that by its profession has expertise in
    firearms. We have educational programs, particularly through
    our Vet Centers for--and I point to the Vet Centers, because
    you have to have been in combat to get into a Vet Center--we
    provide gun locks. There was some controversy with some of the
    groups that we did that, but I am four-square behind us
    providing tools to our veterans and their families to promote
    that kind of safety.
        Right now, it is the form of education and material like
    that that we use to address these matters.
        Mr. Stone. We also recognize the decision to commit an act
    of self-harm is also an impulsive act and, therefore, the
    presence of the gun lock helps, but also we talked in previous
    testimonies over these last few months about freezing the keys
    in a glass of water that has got a picture of one of your
    children on it, so that it slows down the distance between
    decision and the ability to execute the act of self-harm.
        These are incredibly emotional decisions in this society.
    Look, I am a gun owner. I spent more than two and a half
    decades in the military around weapons, I am comfortable with
    weapons, I am a hunter, but I recognize the fact that safe
    handling of those weapons, especially with those people
    struggling the tumult of life and loneliness, are things that
    we have got to get around. We have handed out 2 million gun
    locks, but the discussion that goes on between our providers
    and patients is important. This bill allows us to reach an
    enhanced population and, therefore, this dialog will continue.
        Ms. Lee. Thank you. I just would encourage that, obviously,
    organizations that are eligible for support through this
    program be encouraged to implement those programs. Thank you
    very much.
        The Chairman. Thank you, Ms. Lee.
        I now recognize Mr. Roy for 5 minutes--is he still--Mr.
    Roy.
        Mr. Roy. Thank you, Mr. Chairman. I appreciate it. I thank
    all of you for taking your time to come down here and visit
    with us here today.
        A couple questions, Mr. Secretary. Do you agree that the
    MISSION Act was clear that the VA is the primary coordinator of
    care for the enrolled veterans receiving care through the VA
    health care system?
        Secretary Wilkie. Yes, sir.
        Mr. Roy. Do you agree that there is a gap, as evidenced by
    the fact that 14 of the men and women who die by suicide each
    day have not been in contact with the VA or have not been
    receiving VA services for the past 2 years?
        Secretary Wilkie. Yes, sir, a tremendous gap.
        Mr. Roy. It is a gap of service, care, and suicide
    prevention that the VA is unable to meet or fill on its own at
    this time?
        Secretary Wilkie. Yes, sir, yes.
        Mr. Roy. Do you agree that it is incumbent upon us as
    compassionate human beings to figure out how to fill that gap
    regardless of who does it: the government, non-profit
    organizations, private groups, faith-based entities, et cetera?
        Secretary Wilkie. Absolutely.
        Mr. Roy. Anything to add to that?
        Secretary Wilkie. Well, sir, I cannot agree more with that
    sentiment. I do not care where the care comes from. If we are
    finding a veteran in need, we get that veteran to the closest
    possible effective care to save a life.
        Mr. Roy. Thank you. Do you agree that it would be wrong for
    us to be, as Washington often is, arrogant in our wisdom as to
    think that the Government and its selected representatives, a
    bureaucracy, is the only institution equipped to intervene in
    the most dire of circumstances, and capable of mitigating
    suicide and related deaths?
        Secretary Wilkie. Sir, the most effective care is that care
    that is closest to the veteran.
        Mr. Roy. Got it. Do you agree that the stakes are so high,
    life and death that we are talking at here, that the statistics
    have remained constant for so long, at least 20 years or so,
    despite budget increases for mental health that are greater
    than 250 percent since 2005, that it would be irresponsible for
    us to not allow others to come in and to participate in a
    highly structured grant program to bring other possible life-
    saving solutions to the table?
        Secretary Wilkie. Yes, sir, absolutely.
        Mr. Roy. Mr. Secretary, are you aware of the compromise
    language that Dr. Roe has prepared on behalf of some of my
    colleagues here on the committee that would require the VA to
    give a preference to so-called hub organizations when awarding
    grants, but would preclude grants to smaller, non-hub
    organizations where appropriate, are you supportive of that
    change?
        Secretary Wilkie. I am supportive of Dr. Roe's and General
    Bergman's compromise that allows us, as you said in an earlier
    question, to open that space up to unique services and unique
    partnerships. I think we can do both.
        Mr. Roy. One more question. Do you believe that some
    veterans--and do you agree with me that some veterans, and many
    that I have talked to in Texas 21--and I am proud to represent
    Fort Sam Houston, Army Futures Command, and upwards of 80,000
    veterans in and around San Antonio, Central Texas--it is a
    great place for people to move to, so we get a lot of
    veterans--do you agree with me that some veterans, though, do
    not seek care out of concern that they might lose their Second
    Amendment rights--whether they have got a legitimate concern or
    not, but do you believe and agree with me that some veterans do
    not seek care out of concern that they are going to have their
    record submitted to National Instant Criminal Background Check
    System (NICS) and that it would be good for us to make clear
    that the sole reason for getting a veteran's information to
    NICS should not be just because of suffering from conditions
    related to Post Traumatic Stress Disorder (PTSD) and their
    service, and that we should try to make it clear so we can
    attract as many people to get care as needed?
        Secretary Wilkie. I will say that I do not know any data
    along those lines, but we are not in the business of impacting
    someone's fundamental rights. We are in the business, as I
    mentioned to Ms. Lee, of making sure that we have all of the
    means available to make life safe for that veteran.
        Mr. Roy. Would it surprise you that many veterans in Texas
    21 that I talk to have said to me that they do not seek care
    out of that concern?
        Secretary Wilkie. I would not be surprised by that, no,
    sir.
        Mr. Roy. Okay, thank you.
        No more questions, I yield.
        The Chairman. Thank you, Mr. Roy.
        I just want to point out, I mean, Mr. Secretary, you have
    had time to analyze the compromise language proposed by Mr.
    Bergman and the minority staff, but you have offered no
    comments or taken no time to analyze the discussion draft that
    I have put forward that has been available for quite some time.
        Secretary Wilkie. Sir, I just got that legislation from
    your staff last night.
        The Chairman. That is not true, no. Mr. Secretary, this
    is----
        Secretary Wilkie. The compromise legislation I just got
    last night.
        The Chairman. Okay. That is not our--I am just saying that
    you have had a chance to--you have a chance to respond to the
    compromise language, which is fine, but you have not been
    able--you have issued op-eds and not been able to----
        Secretary Wilkie. Well, those op-eds have been on the
    original legislation, which I am understanding from your
    comments is no longer valid, that General Bergman and Dr. Roe
    are going to put forward that compromise that I have been
    talking about as their base legislation. I think that is right.
        The Chairman. All right. Well, Mr. Secretary, I mean, you
    have issued op-eds decrying the draft Amendment in the Nature
    of a Substitute (ANS) that I have had made available. My whole
    frustration is the lack of any attempt between your office to
    reach out to mine and to, you know, deal directly with the
    committee chairman.
        Secretary Wilkie. Well, sir, we have never been asked by
    your staff for any technical assistance on your legislation. I
    am not presumptive enough to interject where I have not been
    asked, having--as you and I talked in front of the Speaker. I
    learned this business from the person she called the master,
    Mr. Lott. I am not in the position of doing that.
        The Chairman. Yes, you went to the Speaker, but you chose
    not to----
        Secretary Wilkie. Well, I am just telling you about----
        The Chairman.--engage me. Anyway, I----
        Secretary Wilkie. You were not ask----
        The Chairman.--I want to call on--I want to call on Mr.
    Rose--or Mr. Cisneros for 5 minutes, please.
        Mr. Cisneros. Thank you, Mr. Chairman. Thank you, Secretary
    Wilkie and Dr. Stone and Dr. Carroll for being here today.
        Like my colleagues, this is an important topic for me and,
    for me, it is also very personal. I had a good friend of mine
    in college who was an Iraqi and Afghan vet, who I served also
    with in the Navy, who had come back and, you know, as friends
    do lose sometimes, we lost contact, and when I tried to get
    back in contact with him I found out that he was deceased and
    had died in a car accident. After talking to his wife following
    his death, you know, she had said that he had kind of suffered
    from problems coming back from his service overseas, and it got
    me to thinking that maybe it was not so much a car accident as
    it was him kind of choosing to make a decision to take his
    life.
        It is something and we do need to make sure that we go and
    serve our veterans.
        I want to ask you really about staffing first with the VA.
    Would filling the nearly 50,000 vacancies reported by the VA
    help expand the VA's own capacity to provide high-quality,
    effective psychotherapy, family counseling, medication,
    treatment, mental health assessments, and other forms of
    clinical care?
        Mr. Carroll. We have, as Dr. Stone said earlier, we have
    roughly 24,000 mental health providers in VA. Over the last
    year and a half, we have hired--we have backfilled around 3 to
    4,000 vacancies and actually added over 1,000 mental health
    providers to the workforce. The vacancy rate is currently
    around 10 percent. We continue to look at mental health
    staffing, we have a staffing model that we work with facilities
    to make sure that they--it is a dynamic model, because it is
    based upon demand. It is not just a fixed number, you need X
    number, but it is really based upon the number of veterans who
    are coming to us for care and, therefore, it always changes and
    increases. As we have staffed up, we have seen a greater demand
    for mental health care within VA.
        Mr. Cisneros. You said you are about 10 percent
    undermanned, about how many people is that?
        Mr. Carroll. It is around 2400 vacancies, but the vacancies
    are dynamic. There may be retirements, people moving on, people
    taking a different job. It is just part of the workforce that
    we have.
        Secretary Wilkie. I would add, sir, that we are not immune
    from the pressures of the rest of society. America has a
    shortage of mental health workers, America has a shortage of
    primary care physicians, America has a shortage of mental
    health workers, and we suffer in that sense.
        I will say, though, that our vacancy rates in those
    categories tend to be lower in the private sector because
    people want to serve veterans.
        Mr. Cisneros. Secretary Wilkie, like your father, my father
    is also a Vietnam Veteran. You know, one thing I do take
    exception to is that you said, Dr. Stone, is that, you know,
    only about 6 out of every 20 are seeking care from the VA, so
    that is an assumption that you kind of made that the other 14
    do not want to seek VA care. I would kind of make the argument
    that a lot of times our veterans just do not know. It took my
    dad 30 years before he went to the VA, he knew that was even an
    option for him, when he was suffering from diabetes. Then later
    on, after he started receiving his treatment from the VA, he
    was also diagnosed with PTSD.
        I have run into numerous veterans in my district who have
    said--you know, I asked one guy who was actually my Uber driver
    one day, you know, another Vietnam Veteran, he knew he was
    eligible for his VA loan, the VA home loan, but did not know
    about any other services that he was eligible for.
        How are we going to--you know, rather than just kind of
    turning this over to the other individuals to say, okay, here,
    take care of this problem, we want to integrate these people
    into the VA, we want to make sure they are getting this
    holistic-approach health care from the VA. I will say the
    health care my dad receives is--it has been good and it has
    taken care of his eyes, it has taken care of his diabetes. How
    are we getting the word out there to make sure that these
    people are getting in, because I do not think it is people just
    do not want to receive their health care from the VA, I think
    there are the people they just do not know what they are
    eligible for.
        Secretary Wilkie. I certainly think that the world has
    changed. I can tell you that this is not the VA that we saw in
    2014, 2015, 2016. The statistics that I have presented show
    that in the last year we have had almost 3 million more
    appointments than we did the previous year. That is 1.7 within
    VA and another 1.3 in terms of the MISSION Act referrals.
    Veterans are voting with their feet.
        The most recent VFW survey, 90-percent satisfaction rate
    with VA health care amongst VFW members and, more importantly,
    to get to the second part of your question, those 90 percent of
    VFW members recommend to those who are not in VA to get
    themselves to us. That is the best way to do it, by word of
    mouth and by going to a place that is in a much better position
    than it has been in the last few years.
        Mr. Cisneros. I am out of time, but I would make the
    argument too, right, the VFW, the American Legion, these VSOs
    may be pushing that, but how many actual veterans are actually
    serving in those organizations? It is very few. We need to have
    a better approach that we are making sure that we are getting
    out to our veterans.
        With that, my time has expired.
        The Chairman. Thank you, Mr. Cisneros.
        Ms. Underwood, you have 5 minutes.
        Ms. Underwood. Thank you, Mr. Chairman for holding this
    important hearing, and thank you to our witnesses for being
    here.
        I know we all share the same goal of halting the veteran
    suicide crisis and ensuring that our veterans' access to high-
    quality suicide prevent services is critical to that goal. As a
    public health nurse, I also know firsthand how important it is
    to build in robust accountability and quality assessment
    measures when designing programs that provide these services,
    which is why I introduced the Veterans Care Quality
    Transparency Act, which passed the House earlier this year. My
    bill helps ensure that outside entities that VA partners with
    for suicide prevention and mental health services are providing
    effective care.
        I appreciate the additional guardrails included in the
    chairman's draft of H.R. 3495, which I think go a long way
    toward addressing concerns that some of the accountability
    metrics in the bill were overly broad.
        I wanted to clarify at the beginning something that you
    said, Mr. Secretary, at the beginning of this hearing. You said
    that there was $18 million set aside by VA for these grant
    programs, can you just clarify that number and what
    specifically you were referring to?
        Secretary Wilkie. We set aside moneys in our budget for new
    grant programs; however, we need authorization to take those
    moneys and use them for programs that are part of the
    legislation. We have to have specific legislative
    authorization, which is what this bill does, it allows us to
    spend that $18 million on the hub, and also on the small and
    medium providers.
        Ms. Underwood. Right. Absent that $18 million, which then I
    would imagine because you do not have the authorities outlined
    in this type of a bill, then how much are you spending
    currently on community-based outreach for veterans who are not
    connected with the VA services?
        Mr. Stone. We have no authority today, Congresswoman, to
    spend that $18 million. It is sitting, waiting for authority to
    spend.
        Ms. Underwood. So----
        Mr. Stone. Because we have been talking about a public
    health approach for a number of years, we thought this was the
    year that we would get authorization passed and, therefore, it
    is in the budget for this year. Should this bill not pass, we
    will not have the ability to spend that $18 million.
        Secretary Wilkie. That is only a part of our nine and a
    half billion dollar mental health budget. I mean, that is what
    is out there.
        Ms. Underwood. Okay, I am going to take this offline. That
    is a little inconsistent with what we had heard previously,
    which is how our legislation was generated. I mean, the VA has
    been spending millions to contract with outside groups to reach
    people doing--and maybe outreach is different than clinical
    care coordination or a clinical service provision, but it is
    our understanding that there has been outreach to these
    veterans who are not connected with the VA, which is why we
    passed this legislation earlier this year to take a look at
    some of those contracts.
        We will be following up with you all separately.
        My question for Dr. Carroll is that, from a clinical
    perspective, what do you believe defines a successful suicide
    prevention service?
        Mr. Carroll. It has to be individually tailored. We have to
    look at the individual person and we want to find the healthy
    balance of risk and protective factors. Everyone has risk and
    protective factors and the successful outcome is to have a
    response to that individual given their situation in life,
    given the demands that are placed upon them, that works for
    them in that situation.
        I think we certainly want to preserve life, but we do not--
    that is not the end. We want to help people thrive in their
    communities and we want people to live well. Our mission in VA
    is to use a whole-health approach----
        Ms. Underwood. Right.
        Mr. Carroll.--to engage veterans in life-long health, well-
    being, and resilience, and that is really the focus of this and
    everything that we do.
        Ms. Underwood. Again from a clinical perspective, then how
    would you determine an organization eligible to receive grant
    funding from this bill as one that is successful at providing
    services that reduce veterans' risk of suicide?
        Secretary Wilkie. Well, the legislation is very clear, in
    Section 2 it says that we have to see evidence from the group,
    that we have to verify that they have an established track
    record of reaching out and helping veterans who are in danger
    of suicide. The standards are already written in the
    legislation.
        Ms. Underwood. Okay. Well, again, based on our review, it
    does seem that that definition of success might be a little
    inconsistent given an organization that might not have a track
    record of that type of clinical success. It is one thing to be
    able to do outreach, it is very different to be able to
    successfully say that you have prevented a suicide.
        Secretary Wilkie. Well, I mean, the language I think is
    indicative here, it says that the only people who are eligible
    are ``those who have demonstrated the ability to provide and
    coordinate suicide prevent services or other services that
    improve the quality of life of veterans and their families to
    reduce factors that contribute to suicide.''
        That is the benchmark that we have to go off based on the
    legislation as presented.
        Ms. Underwood. Okay. We will be following up with you
    separately about the money. Thanks for appearing here today.
        I yield back.
        The Chairman. Mr. Secretary, that language that you were
    quoting, is that from the original bill or is that the so-
    called compromise language?
        Secretary Wilkie. I think it is in both.
        The Chairman. All right. Well, thank you.
        I now call on Mr. Rose for 5 minutes.
        Mr. Rose. Thank you, Mr. Chairman.
        Mr. Secretary, thank you, and thank you to the rest of you
    for coming today, and thank you for your service.
        First off, Mr. Secretary, you should not be so hard on
    yourself; you are not an old warrior.
        Secretary Wilkie. Thank you, sir.
        Mr. Rose. Okay.
        Secretary Wilkie. No, you are the warrior, I am the staff
    officer.
        Mr. Rose. Still your best years are ahead of you.
        I trust we all agree that we have got to get this over the
    finish line, and let's not forget that we are serving warriors
    who put their differences aside and just tried to get the job
    done. We just honored them on Veterans Day, but rather than
    just thanking them for their service, I do think it is
    important that we try to emulate their service and their
    values.
        Now, with that being said, I would like to just briefly
    transition the conversation to that of the Post-9/11 veterans.
    The active duty soldiers of today are the veterans of tomorrow.
    Yes, we have to serve them as best as possible once they become
    veterans, but I also think it is important that we not
    unnecessarily put them through hardship during their active
    duty time which can produce trauma that can ultimately lead to
    suicide.
        In line with that, Dr. Robert Usano [phonetic] of the
    Uniform Services University of Health Sciences did a study of a
    group of solders, 593 men and women in the United States Army
    who had been deployed twice and who attempted suicide between
    2004 and 2009. He found that those who served 12 or fewer
    months before their first deployment were approximately twice
    as likely to attempt suicide during or after their second
    deployment compared with those who had more time to train and
    acclimate to the military before initial deployment. They also
    found that those that redeployed within 6 months or less were
    60 percent more likely to attempt suicide.
        We have asked soldiers post-9/11 to do something that we
    have never asked soldiers to do in the history of this
    country--I deployed once, it is nothing--four, five, six, seven
    times our soldiers have deployed, sometimes with minimum dwell
    time.
        My question to you is this. These stats are shocking, do
    you believe that every General in the United States military
    today, every Colonel in the United States military today, is
    aware of these statistics?
        Mr. Stone. I cannot tell you whether everyone is aware.
    Certainly, rotational and dwell time is something we talked
    about when I was on the Army staff and as the major ground
    force participating----
        Mr. Rose. Mr. Stone, let us--this is an incredibly large
    system and when we want them to be aware of something we put a
    system in place. Let me refine my question, is there a system
    in place right now whereby Generals and staff officers are made
    aware of these statistics whereby a soldier is two times as
    likely to commit suicide or attempt suicide if they are
    deployed before an initial 1 years of training or dwell time,
    or if they are deployed rather quickly?
        Secretary Wilkie. I will answer that as the former Under
    Secretary for Personnel and Readiness, I was aware of them,
    General Mattis was aware of them. I left a year and 3 months
    ago. I would argue that that is policy that should not be left
    up to the Generals and Colonels, that has to be policy that
    comes from the Secretary of Defense himself and the service
    secretaries. I know General Mattis was deep into dwell time, I
    was. I have got to confess, I don't know what they have done
    since then.
        Mr. Rose. We have got to figure out how we can have a
    better answer to my question, we have to. Would you agree with
    that?
        Secretary Wilkie. Oh, I agree with you wholeheartedly.
        Mr. Rose. Do I have your commitment that we can implement
    some type of policy and procedure whereby our United States
    military officers are made aware of the significant health
    ramifications to multiple deployments and minimized dwell time?
        Secretary Wilkie. Well, you have my commitment that I will
    again raise an issue that you and I have talked about, that I
    was once responsible for, with the proper leadership over at
    DOD. I think you are on target.
        Mr. Rose. Okay. Thank you, Mr. Secretary. I give back the
    rest of my time. And thank you again for your service.
        Secretary Wilkie. Thank you, sir.
        The Chairman. Mr. Secretary--well, thank you, Mr. Rose, for
    that very incisive questioning about dwell time and it gives us
    all pause, and to think that we have sent so many people on
    multiple deployments and what we have asked of our men and
    women.
        I thank you, Mr. Secretary, for your testimony today. Thank
    you, Dr. Stone----
        Secretary Wilkie. Thank you, sir.
        The Chairman.--I appreciate your being here. If you have
    time, I hope that you will stay and listen to the testimony of
    our VSOs and get their response to the legislation.
        Secretary Wilkie. Well, I think in the current climate, if
    I stayed, which I would love to do, I would probably be held in
    contempt of Congress for not appearing at another hearing.
        The Chairman. I see. I see, Mr. Secretary. Well, we do not
    want that to happen, sir.
        Secretary Wilkie. No, sir.
        The Chairman. As you know, I have told you that I
    appreciate having a permanent Secretary in place, not an acting
    Secretary, that we need the continuity of leadership and that
    is one of the biggest problems I have seen with this Department
    is that we change leaders so often. We hope to get Dr. Stone in
    some sort of a, you know, confirmed situation. I do not like
    this Executive in Charge business.
        Secretary Wilkie. Well, I will add to that, sir, you are
    absolutely right about the qualities of General Stone sitting
    next to me. As the Colonel, I have to acknowledge that. I will
    also say, I have been privileged to be in this seat now for a
    year and 3 months, I did not expect it--Mr. Lamb and I have
    talked about this, it came out of the blue--I have never had a
    better professional or emotional experience than being part of
    this VA family and it is the one place--and after all of the
    back and forth about process, it is the one place where it does
    not matter where you are on the spectrum, we all have a goal of
    taking care of those who have borne the battle, and thank you
    all for your courtesy to me.
        The Chairman. You are welcome, Mr. Secretary. Let me just
    say that I think we both find enormous satisfaction in the work
    we do, it is a tremendous privilege to serve our veterans and I
    see your sincere commitment to it. I just make a plea for there
    to be more extensive and more frequent communication directly
    between you and I--between you and me, excuse me--I am English
    teacher, I caught myself there----
        Secretary Wilkie. You are the school teacher----
        The Chairman. Yes, I am.
        Secretary Wilkie.--you are the teacher.
        The Chairman. It is you and me, between you and me, object
    of the preposition. So let me just say that I am responsible
    for making sure that the statutes we enact are not just about
    your tenure, because I believe you to be an honorable and well-
    intentioned public servant, but I have seen in this
    administration people switched and changed, and I never know
    when we are going to get somebody who is not so well-
    intentioned and will exploit a weakness in the statutes we
    pass, that is my concern.
        I do not really care about the credit and I do want to get
    this legislation passed before the end of the year, because I
    believe it is vital that we build out our infrastructure, our
    public health infrastructure, so they can reach these veterans,
    the 16 veterans that are not connected to the VA, and we have
    got to reach them and I agree with you.
        Secretary Wilkie. Well, I thank you. I thank you for your
    passion and your commitment too, sir.
        The Chairman. All right, thank you.
        With that, you are excused, and I do not want you to be
    held in contempt.
        Secretary Wilkie. No, sir, I do not want to be part of that
    parade.
        The Chairman. Okay, thank you.
        Let me take a brief recess while we get our second panel
    assembled.
        [Recess.]
        The Chairman. The committee will come back to order.
        I now invite our second panel to the witness table, and
    seated at the witness table are Mr. Adrian Atizado, Deputy
    National Legislative Director for Disabled American Veterans.
    Welcome, Mr. Atizado. Mr. Blake Bourne, Executive Director,
    Veterans Bridge Home. Welcome, Mr. Bourne. Ms. Melissa Bryant,
    National Legislative Director, American Legion. You are kind of
    not in the same order, I went to that side. In between Ms.
    Bryant and Mr. Bourne is Mr. Sherman Gillums, Chief Efficacy
    Officer of AMVETS.
        I want to begin the second panel with the opening
    statements. Mr. Atizado, you are recognized for 5 minutes.

                      STATEMENT OF ADRIAN ATIZADO

        Mr. Atizado. Mr. Chairman, members of the committee, and
    General Bergman, I want to thank you for inviting DAV to
    testify at today's legislative hearing on the majority's
    discussion draft, as well as H.R. 3495, the Improve Well-Being
    for Veterans Act.
        First, I want to make sure I get this on record, Mr.
    Chairman, that Disabled American Veterans (DAV) believes that
    one suicide is too many and every one is a tragedy.
        These two proposals, which seek to address the extremely
    complex issue of suicide in the veteran population, is in fact
    needed. The veteran population is at an elevated risk compared
    to the civilian population in terms of suicide. Such complexity
    will likely require a multi-faceted response using a public
    health approach, as evidenced by the establishment of the
    PREVENTS Task Force, which in March 2020, just a few months
    from now, will recommend strategies to integrate private
    partners into the Federal interagency effort on suicide
    prevention. DAV believes the task force's guidance should
    provide the strategic direction for any new interventions on
    suicide prevention, including the bills being considered today.
        The heart of any public health strategy lies in the metrics
    used and the measurements at baseline, and periodically
    thereafter, to determine effectiveness of the intervention. Mr.
    Chairman, we believe both bills in the discussion draft would
    benefit by distinctly stating the purpose of this grant
    program, and that is to reduce suicide in a target population,
    not just to simply provide suicide prevention services. At the
    very least, suicide reduction should be included at its core in
    whatever compromise legislation comes out of this committee.
        Accordingly, grants should be concentrated to entities
    serving a distinct catchment area with a well-defined target
    population. We believe the grant program should contribute to
    the base of evidence, which is scarcely limited, for community-
    based interventions targeting veterans at risk for suicide and
    to reduce population-level suicide rates. Thus, a grantee
    program should be replicable, so that effective programming at
    one site can be used elsewhere for a similar population.
        DAV continues to believe that it is in the best interest of
    veterans that these grantees make some connection to the
    closest VA, which offers several advantages for suicide
    prevention based on a myriad of interventions the Department
    has deployed. We are talking such things as the VA-DoD Clinical
    Practice Guideline for Suicide Prevention; the Recovery
    Engagement and Coordination for Health-Veterans Enhanced
    Treatment (REACH VET) Program, a risk-identification strategy
    using predictive modeling; as well as comprehensive medical
    record data and each suicide prevention coordinator at every VA
    medical center. DAV firmly believes that without VA's efforts
    we would be looking at an even worse scenario than what we have
    today.
        To this point, both proposals before us appear to operate
    from a perspective of veterans not using the VA, want nothing
    to do with it, which is, in DAV's view, a flawed assumption.
        Based on VA's surveys and independent evaluations, veterans
    are often unclear about their eligibility for VA services or
    even their veteran status, a clear barrier to suicide
    prevention.
        Mr. Chairman, we similarly appreciate the broad scope of
    services that would be offered through both a discussion draft
    as well as H.R. 3495, but we are concerned that without more
    structure and a detailed plan with regard to the cash
    assistance, we want to make sure that such a proposal does not
    promote fraud, waste, and abuse.
        DAV is also concerned with the clinical care services
    offered under H.R. 3495 outside the new Community Care Program
    enacted by the VA MISSION Act. The bill provides no assurance
    that clinical care funded through the grant has the additional
    safeguards provided under the VA Community Care Program on
    access, as well as quality. If the committee desires to use
    these grants to reach out to veterans not using VA services, it
    should ensure that the grantees are in areas where VA has low
    market penetration and presence, including its Community Care
    partners. This would ensure that grantees are filling gaps in
    coverage and reaching veterans who do not have good options for
    care and support services.
        Finally, Mr. Chairman, DAV believes VA should be required
    to conduct active monitoring of this grant program, as
    contemplated under the draft proposal.
        In closing, DAV sees the benefit of this approach, both
    bills. The committee has our commitment, as we have done, to
    find a final compromise that will go forward from this
    committee, and hopefully something that the Senate will be able
    to pass themselves.
        Thank you, Mr. Chairman. This concludes my testimony and I
    am happy to take any questions you may have.

        [The Prepared Statement Of Adrian Atizado Appears In The
    Appendix]

        The Chairman. Thank you, Mr. Bourne. I now call upon--not
    Mr. Bourne, Mr. Atizado.
        Mr. Bourne, you have 5 minutes to make your opening
    statement.

                       STATEMENT OF BLAKE BOURNE

        Mr. Bourne. Thank you, Mr. Chairman, Ranking Member Roe,
    General Bergman, and the remainder of the committee members. I
    would like to start by thanking you for your work on behalf of
    America's veterans and their families, and for the opportunity
    to address you today on the subject of H.R. 3495 and the
    chairman's discussion draft.
        According to the VA's 2019 Suicide Prevention Report, we
    have lost nearly 6,000 veterans to suicide every year for over
    a decade. We must address this challenge and engage leaders at
    all levels of the government, but especially in the communities
    where our veterans live.
        Dr. Eric Caine from the University of Rochester Medical
    Center recently presented on suicide prevention and mentioned,
    ``Preventing suicide is a public health and clinical care
    challenge. Suicide prevention and caring for suicidal people
    are not the same. Prevention and clinical interventions must be
    woven into the context of communities and families, as well as
    the lives of individuals.''
        I am here to represent Veterans Bridge Home, one of the
    longest standing and most successful hub organizations in our
    country, and we could not agree more with Dr. Caine's
    assessment.
        VBH is focused exclusively on the connections between
    veteran families and the communities where they live. We work
    to ensure the long-term health and success of our veterans via
    a robust, accountable, and responsive community of employers,
    providers, and fellow community members.
        Our organization's geographic footprint is across the
    Charlotte, North Carolina region, including ten surrounding
    counties, we have had the honor of working alongside 5,000
    families, providing nearly 15,000 unique services addressing
    the social determinants of health of veterans of every age,
    era, gender, branch, race, and socioeconomic group.
        This experience has taught us that there are critical
    elements to effectively act as a hub of a community on behalf
    of veterans and their families, the most important of which is
    a servant-leadership role by putting the community's strengths
    at the forefront and matching them with the needs of our
    veterans who live here.
        If we do this, we are able to collectively address the
    complexity of post-service life alongside our veterans in their
    community. This approach is holistic, adaptable, personal, and
    sustainable.
        As I have submitted in my written testimony, we have
    highlighted three veterans that we have recently served just
    this year, to include a 39-year-old Army helicopter pilot who
    came to us 10 years ago when we first started the organization,
    and we have supported his family and a myriad of needs over
    those 10 years, to include most recently his getting his MBA
    and receiving employment and financial services.
        We recently helped a 50-year-old cold war-era veteran who
    moved to Charlotte and had experienced homelessness. We
    connected him to over ten separate community organizations and
    addressed needs across the spectrum of social determinants of
    health.
        Finally, a 42-year-old single mother serving in the Air
    National Guard initially came to us looking for social
    connectivity, as she was new to the Charlotte area, and upon
    meeting her and her family identified a need of transportation.
    She did not have a reliable way to get to work and we were able
    to find a community partner who provided her a nearly new car
    that we presented to her earlier this year.
        Each of these veterans are just a few of the
    representatives that we have been able to support over the last
    10 years. Each of them is at a different point in life, with
    different goals and different challenges, but the one common
    thing that they are looking for is connection in their
    community.
        Our role as the hub is to meet veterans where they are,
    triage their needs, and find local accountable resources and
    solutions within the cities and towns and communities which
    they live. We have been doing this from the four families we
    first helped in 2009 and now to the over 5,000 since then.
        Our team has worked to connect 62 public and private
    organizations via seamless technology platform. We engage over
    200 local employers to hire veterans. We have connected over
    8,000 community members through social fitness and volunteer
    events. This is done at a local level on a daily, weekly, and
    monthly basis to provide personal relationships with each of
    these organizations. This direct approach ensures that the
    relationships and connectedness that we are building and
    facilitating in our community are tangible resources for our
    veterans who call Charlotte home.
        The health and human services in our community are
    fragmented. A recent Institute for Veterans and Military
    Families (IVMF) study showed that the majority of veterans'
    biggest challenge is navigating their community. These hubs, as
    you have coined them, make this navigation easier. Effective
    care coordination across the social determinants of health
    cannot only save lives, but contribute to thriving leaders that
    have the capacity to invest in building healthy communities.
    Barriers associated with navigating these resources across
    variegated community landscapes within these complex systems
    can prolong service delivery and compromise desired outcomes at
    the individual and community level.
        The language and financial support of Chairman Takano's
    draft would allow us to increase our capacity to address the
    needs of veterans and manage the relationships with providers,
    thus increasing efficiency and improving outcomes by working
    with both groups.
        The VA has been a critical partner in this work since we
    have been here and we look forward to continuing to work with
    them.
        Thank you for allowing us to share our experience with the
    committee and including it in your consideration the support of
    this suicide prevention. With respect to Chairman Takano's
    draft legislation, we appreciate and applaud the committee's
    efforts to address the systems-level work at the community
    level, and will welcome the opportunity to more formally work
    alongside our VA partners and this legislation would allow us
    to do so.
        Thank you.

        [The Prepared Statement Of Blake Bourne Appears In The
    Appendix]

        The Chairman. Thank you, Mr. Bourne.
        Mr. Gillums, you have 5 minutes to give your opening
    statement.

                   STATEMENT OF SHERMAN GILLUMS, JR.

        Mr. Gillums. Chairman Takano, members of the committee,
    thank you for this long-awaited opportunity to speak on the
    issue of veteran suicide that touches far too many families and
    communities.
        I have had the heartbreaking privilege of assisting and
    representing the spouses and parents of veterans lost to
    suicide for over 15 years. For me, these veterans are not
    numbers expressed as decimals and percentages. Each human being
    who dies by suicide has a complex story with multiple
    dimensions, a set of seemingly insurmountable circumstances
    that made the permanent solution more desirable than continuing
    to face hardships such as relationship breakups, financial
    issues, poor health, and social isolation.
        There is not a single person within earshot of my voice who
    does not understand how vexing the problem of veteran suicide
    is and has been for quite some time. After all, we are talking
    about human behavior that is motivated by factors both seen and
    unseen, fairly controllable and beyond anyone's control. For
    these reasons, we cannot simply legislate our way out of a
    problem that has no clear, absolute fix in the usual partisan
    manner.
        Veteran suicide is hard to predict, much less to stop. We
    get that. And while there is little we can do to get to
    absolute zero suicides, we have to define some measure of
    success.
        This begs the question, what does success actually look
    like on the issue of veteran suicide? How about we start with
    the ambitious goal of cutting them by half in the next year?
    Fifty percent fewer suicides per year among the veterans who
    exhibit the signs of crisis, who cry out for help, who try to
    access care, but cannot for one reason or another; who have
    loved ones that see the signs, but have no answers; who are
    geographically and socially isolated; or who are more likely to
    reach out to a peer-based group like AMVETS and the other
    veterans service organizations here than the VA. We have a
    responsibility to turn over every stone within our reach to
    find a way to connect them with the help they need. So let us
    focus on those stones.
        The first one examines how Federal funding for local
    programs should be distributed and to whom. One idea
    contemplates the establishment of hubs that currently provide
    intervention services to veterans in need and would work over
    the course of a year to build networks of local service
    providers who receive funding through their respective hub. The
    upside would be tighter control and oversight of funding; the
    downside would be delayed action masquerading as additional
    time needed to lay out another bureaucratic layer and
    restrictive policies, as veterans have to demonstrate yet again
    the patience of a saint to await the help they need.
        The issue goes even deeper as questions persist regarding
    which eligible entities and service providers ought to be
    recognized and funded under H.R. 3495. AMVETS certainly
    appreciates the importance of maintaining traditional
    intervention such as psychotherapy and pharmacological
    treatments, but we also support veteran access to
    nontraditional interventions such as equine therapy, warrior
    retreats, canine companionship, and therapeutic recreation
    opportunities. It also past time to have mature discussions
    about cannabis and the role it could play in healing.
        Short of that, we cannot say with a clear conscience that
    we are absolutely doing all we can to find solutions in saving
    lives. Too many decisionmakers presumably know what works and
    what does not work with no basis in empirically derived fact.
        For example, are fishing trips effective? Ask veterans. Do
    retreats work? Ask veterans.
        What turned my life around after suffering a spinal cord
    injury while serving in the Marine Corps was not a pill or a
    therapy, it was sitting in a bar--and, as a Marine, that should
    come as no surprise--surrounded by 300-plus other severely
    disabled veterans in Aspen, Colorado during the National
    Veterans Winter Sports Clinic and seeing the light, seeing hope
    through their lived experiences.
        It is veterans, with all due respect, not health care
    professionals, bureaucrats, or lawmakers who can ultimately
    decide what works and what does not, in my opinion. Any
    compromise must give great weight to those pathways that
    veterans have chosen for their healing, not simply those that
    were offered or appear to be effective to those who have not
    walked in their combat boots.
        Many of these veterans vote with their feet in terms of
    accessing preferred services based on what is available when
    they need it.
        Case in point. What is the best treatment for a veteran
    with a drinking problem who was recently divorced, receives a
    threatening collection notice for a medical bill he cannot pay,
    because he quit his job due to a disabling condition of cancer
    he believes is linked to his Blue Water Navy service in
    Vietnam, for which he has been awaiting a VA decision and
    benefits for a year and a half? Most might say a pill of some
    type is what he needs to help ease his anxiety, but I disagree.
    This veteran needs to get out of the hole, not something to
    help him forget about the hole in which he finds himself. What
    the veteran needs is the holistic, multi-faceted approach we
    take with our Healthcare Evaluation, Advocacy, Legislation
    (HEAL) Program, where we address the underlying precipitating
    factors that lead to crisis.
        You reach these veterans not by going down familiar paths;
    rather, you go where there is no path and you create one,
    through organizations you might not have previously considered
    or pathways to relief that might run counter to conventional
    sensibilities.
        We cannot keep shooting first and then drawing a bull's eye
    around the impact point by relying on one-dimensional
    approaches that serve a few and only point to those successes.
    As I earlier said, it is time for game-changing ideas that test
    our assumptions and raise expectations.
        I fully appreciate that Congress through this committee
    understands its responsibility to scrutinize how taxpayer
    dollars are spent, but analysis paralysis is what happens when
    Congress over-thinks and under-works. It is far better to make
    mistakes than to fake perfection. There are risks and problems
    that require a trial-and-error approach, not unlike what we
    presently see with homeless veteran and adaptive sports grants
    from the VA.
        I will leave you, our elected leaders, with these
    questions. Is it worth having compromise? Is it worth one side
    or the other getting the lion's share of the credit? Is it
    worth potentially losing the next election to solve this
    problem to the best of our collective ability? The answer is
    yes. You know why, because you live to fight another day when
    you lose a political tug of war, but when our veterans lose so
    that one side can win, the grand prize for the winner is 20
    more bodies a day.
        Thank you for giving the veterans who died by suicide and
    the families they left behind the opportunity to be heard
    through my testimony, Mr. Chairman.

        [The Prepared Statement Of Sherman Gillums, Jr. Appears In
    The Appendix]

        The Chairman. Thank you, Mr. Gillums.
        Ms. Bryant, you are recognized for 5 minutes.

                      STATEMENT OF MELISSA BRYANT

        Ms. Bryant. Thank you, Chairman Takano, Ranking Member Roe,
    and distinguished members of the committee here today.
        On behalf of our National Commander, James W. Bill Oxford,
    and the nearly 2 million members of The American Legion, we
    thank you for the opportunity to testify on H.R. 3495, the
    Improve Well-Being for Veterans Act, and the veteran suicide
    crisis in the United States.
        As the largest patriotic service organization in the United
    States with a myriad of programs supporting veterans, The
    American Legion appreciates the leadership of this committee in
    focusing on the critical issue of suicide prevention and
    improving veterans' overall well-being.
        We all know the numbers, we all know the data. I have lost
    soldiers and friends to suicide, I have personally intervened
    with a soldier who was attempting suicide. We know the human
    cost and we know that we need to act now.
        The American Legion stands behind VA in its efforts to
    collaborate with partners and community nationwide to alleviate
    this public health crisis, of which veterans and military are a
    microcosm of a far greater epidemic. It is imperative that the
    full committee, VA, and other stakeholders work together from
    the outset to tackle this complex issue whenever new proposals
    arise. We are all in this together, and the The American Legion
    stands by as a trusted adviser and partner, now and always, to
    help navigate toward safe and effective suicide prevention
    solutions.
        As I stated at least week's roundtable and in written
    testimony for this hearing, we believe that all suicide
    prevention efforts must be in accordance with the PREVENTS
    Executive Order (EO). I will not belabor further on that; I
    think my colleagues have well covered that throughout the
    course of today's hearing.
        The American Legion supports providing funds to both hub
    organizations and providers of non-clinical services if they
    are subject to a rigorous vetting process based on clear
    metrics and evaluation criteria. The American Legion believes
    that a diversity of quality organizations providing non-
    clinical social services would be useful in combating veteran
    suicide, particularly in rural and highly rural locations.
    However, further questions on the mechanics of how to
    administer said funds and/or clinical care to support veteran
    suicide prevention through non-VA entities should be
    coordinated through the existing VA programs.
        As several partner organizations and VSOs have echoed
    either in testimony today or in discussions that served as a
    prelude to today's hearing, we are happy to support ancillary
    services by community providers or hub organizations in the
    fight against suicide among veterans, but we feel that creating
    a whole new lane outside of VA and the community care network
    will result in fragmented care and will not help those veterans
    who do not use the VA services for care.
        The American Legion does not support the provision of
    clinical care to veterans and their families through non-VA
    providers outside of the VA community care network. VA is the
    most qualified and reliable source of long-term clinical care
    for veterans, and non-VA providers should refer veterans to the
    VA should they need clinical care and should they receive the
    expert care offered by the VA community care network.
        The American Legion also opposes the provision of direct
    temporary cash assistance to veterans and their families. There
    are already numerous mechanisms in place to aid veterans such
    as the Supportive Services for Veterans' Families, SSVF, and
    VSO grant programs, as we have discussed earlier throughout
    this hearing. Giving cash directly to veterans is not an
    effective use of limited resources and it provides unique
    challenges in the oversight of such temporary cash assistance.
    Again, that is what the VSOs are here for and that is what we
    have stood for decades.
        We are thankful that the majority and the minority staff,
    as well as the VA Office of Congressional and Legislative
    Affairs (OCLA) office have consulted with us in the past couple
    of weeks to get closer to reconciliation of these various
    proposals, and we are pleased to have received the compromise
    language from the minority last night that seems to address our
    aforementioned concerns, and we hope that said language creates
    a basis for ongoing discussions.
        In closing, The American Legion appreciates the leadership
    of this committee and remains committed to reducing veteran
    suicide. We are further committed to working with VA and this
    committee to ensure that America's veterans are provided with
    the highest level of support and health care.
        With that, I yield back my time.

        [The Prepared Statement Of Melissa Bryant Appears In The
    Appendix]

        The Chairman. Thank you, Ms. Bryant.
        I now recognize myself. I just want to say that we have
    very few members left and we can be somewhat flexible with the
    response time. That being said, I do want to keep my time
    brief. I recognize myself for ostensibly 5 minutes.
        I would like to get a baseline on where each of your
    organizations are on the major discussion points. Some of you
    have already answered these questions, but I would ask you to
    answer them again. I am not really trying to pin you down, but
    I think it is important for us, it is important for our
    discussion today to understand where you are, more or less. I
    would like to run through quickly some questions and they are
    really yes-or-no questions. If you feel compelled or you need
    to answer some more, we might have some time later on in a
    second round of questioning, or you can revise and extend your
    remarks through written testimony.
        The first question I have for each of you is, should VA
    provide grants directly to providers of non-clinical social
    services without any information, without any information about
    the veteran-specific needs or what services are available
    within their communities?
        We will begin with--we will just start with Mr. Atizado and
    go down the panel.
        Mr. Atizado. Mr. Chairman, I appreciate that question, but
    I think not doing an assessment of need is--I do not even know
    how a service provider would be able to engage a patient or an
    individual that comes through their door without doing some
    sort of assessment. I suppose it would really depend on what
    that assessment is.
        The Chairman. It sounds like you would say probably no, I
    mean that VA should not provide grants directly to non-clinical
    social services without any information about the veteran-
    specific needs or what services are available within their
    community?
        Mr. Atizado. It would be a no. I would be suspicious of any
    service provider that does not.
        The Chairman. Okay, thank you.
        Mr. Bourne?
        Mr. Bourne. Yes, Mr. Chairman, I would agree with my
    colleague Adrian that, no.
        The Chairman. Thank you, thank you.
        Mr. Gillums.
        Mr. Gillums. I feel like I have to peel that question a
    little bit. Are you saying that the information about a
    specific veteran does not go to VA first?
        The Chairman. What I am saying is----
        Mr. Gillums. What is the process we are kind of----
        The Chairman. The question is, should VA provide grants
    directly to providers of non-clinical social services without
    any information about the veteran-specific needs or what
    services are available within that veteran's community?
        Mr. Gillums. Right, I feel like everything up to
    ``without'' is a yes until the ``without'' and----
        The Chairman. Yes.
        Mr. Gillums.--I would say no----
        The Chairman. No, Okay.
        Mr. Gillums.--with that qualification.
        The Chairman. Ms. Bryant.
        Ms. Bryant. I would agree with my colleagues in saying no.
    Essentially, if you have a veteran that is referred to one of
    these hubs or an outside provider, that should be a triage
    point and, from that triage point, it should go forward to
    whether they know what is available to them through VA and
    wrapping around back to VA, or within the community care
    network, but it should not go into clinical provision.
        The Chairman. All right, thank you.
        The second question. Should VA provide grants to allow the
    provision of clinical care to veterans and their families
    through non-VA providers outside of the community care network,
    outside of a CCN, yes or no?
        Mr. Atizado.
        Mr. Atizado. Mr. Chairman, I will say yes, but there has to
    be a caveat to this answer, Mr. Chairman. As was discussed
    earlier by this committee and by the previous panel, we are
    talking about acute situations where an individual has to be
    stabilized if they are in fact in that critical State. In those
    particular circumstances, stabilizing, I think it is critical
    that services, even clinical, be provided at that time.
        The Chairman. You are saying yes, but in very limited,
    carefully defined situations?
        Mr. Atizado. Yes, Mr. Chairman.
        The Chairman. All right. Mr. Bourne.
        Mr. Bourne. Thank you, Mr. Chairman. At this time, I would
    say no. In the 894 health care requests that we have received
    in the last 4 years, we have been able to address the clinical
    needs of veterans both at the VA and in non-VA without this
    payment method. At this time, without further standards of care
    and especially with the work that has come out of the MISSION
    Act, my answer is no.
        The Chairman. All right, thank you.
        Mr. Gillums.
        Mr. Gillums. Could you repeat the question, just so I have
    the full context?
        The Chairman. Should VA provide grants to allow--should VA
    grants allow for the provision of clinical care or should they
    go to clinical care to veterans and their families through non-
    VA providers outside of the community care network?
        Mr. Gillums. I can see why it would be dangerous to go in
    that direction, but I know the reality and veterans are already
    doing that, they are already accessing programs and services
    outside of the VA's view. I think that having some way to
    coordinate this, and maybe through this grant process that
    would be one way to do it, but veterans are going to go, for
    example, if they want to explore cannabis as a possible healing
    option, and the VA is pretty dogmatic about that, they are
    going to go do that.
        I think it really depends on, you know, what the treatment
    is, but I will remain open to the idea that there may be
    instances where a veteran needs to be empowered to explore care
    where he or she desires to get it.
        The Chairman. Okay. Thank you.
        Ms. Bryant.
        Ms. Bryant. So I am clear, Mr. Chairman, you are asking if
    grants should be provided through non-clinical--non-clinical
    services should be provided by the VA through to the veteran,
    correct?
        The Chairman. Yes, should VA provide grants, should VA
    money be used for the provision, to allow for the provision of
    clinical care to veterans and their families through non-VA
    providers outside of the community care network?
        Ms. Bryant. I will refer back to my first answer and the
    answer is no with a but. The but being that we understand that
    points of entry for care, we are okay with any point of entry
    in which a veteran raises their hand and says, ``I need help.''
    It is OK to not be okay. If they come in through a point of
    entry that is a triage point that then refers for clinical care
    after an initial assessment back to the VA, then that is what
    we are in favor for.
        The Chairman. All right, thank you.
        Should VA grant--I have just two more questions here for
    everyone and if you can answer as close to a yes or no, I can
    get through this faster--should VA grant money be used for
    providing temporary cash assistance directly to veterans, their
    families, and their housemates under the pilot program as
    currently written?
        Mr. Atizado.
        Mr. Atizado. No, Mr. Chairman. I think probably the best
    way to tackle this issue is actually have it flow through SSVF,
    who happens to be a very high-risk--a population at high risk
    of suicide.
        The Chairman. Thank you.
        Mr. Bourne.
        Mr. Bourne. Mr. Chairman, our answer is no, because there
    are several local community resources that provide temporary
    financial assistance, in addition to the SSVF programs that
    already exist, and local hubs should know those.
        The Chairman. Mr. Gillums.
        Mr. Gillums. I would say no, but there should be a
    consistent, predictable standard for how it is applied, how you
    would disseminate those dollars.
        The Chairman. Ms. Bryant.
        Ms. Bryant. I concur with my colleagues in saying no.
        The Chairman. Okay. Thank you.
        Finally, do you currently support H.R. 3495 as drafted,
    not--I mean as drafted, the language in the introduced bill,
    not whatever version of compromise language is out there?
        Mr. Atizado.
        Mr. Atizado. Thank you, Mr. Chairman. At this time, as both
    the sponsor of the legislation and the minority committee staff
    know, we are working with them to improve that underlying bill.
        The Chairman. Okay. Thank you. I will take that as no, but
    go ahead.
        Mr. Bourne. Mr. Chairman, I would agree with my colleague
    Adrian that, yes, the answer would be no on the former version.
    By the previous testimony and your version, those compromises
    sound like they are moving in the right direction based on our
    conversation last week.
        The Chairman. Mr. Gillums.
        Mr. Gillums. No, and I think the compromise language speaks
    to some of the concerns we have with the original language.
        The Chairman. Okay. Thank you.
        Ms. Bryant. No to the underlying original bill as written.
    We believe, again, in the compromise language from both your
    staff, as well as from the minority that we have worked with,
    has been taken into account in that language.
        The Chairman. We are moving--and I think you are saying we
    are moving in the right direction?
        Ms. Bryant. We are moving in the right direction between
    the two compromises.
        The Chairman. Okay. Thank you. I went over 3 minutes and,
    Dr. Roe, you are welcome to do what you want.
        Mr. Roe. I will not.
        Mr. Gillums, you mentioned fishing, if you decide you want
    to come fishing for therapy, I have a fish hatchery in my
    district, I can guarantee you big trout. So if you want to
    come.
        Let me just say that I wish we had done this a little
    sooner. We have an opportunity and I got my marching orders at
    the roundtable. We had a lot of hiccups and starts with this,
    but the three things I want to bring up are the following.
        The clinical care, the compromise draft, which is what we
    are really talking about now, would allow grantees to provide
    an initial assessment, a triage, then require them to refer
    eligible individuals to VA for subsequent or ongoing care; such
    care would be provided by VA pursuant to existing authority. We
    agree on that.
        Number two, I know Mr. Atizado had mentioned this at the
    roundtable, the temporary cash assistance, that is the second
    thing that was discussed. The draft compromise proposal would
    prohibit direct cash assistance from the grantees to eligible
    individuals for their families. The hubs, the draft
    compromise--and we worked on this and I agreed to this, because
    I think the hubs in many cases are great ideas--the draft
    compromise proposal would require VA to give preference to hub
    organizations who are referred to as organizations that have
    demonstrated the ability to coordinate suicide prevention
    services in awarding grants, but would not prohibit grants to
    non-hub organizations.
        I think that is what I heard everybody say and we agreed on
    this, and I think this is very simple what we ought to do.
        The other concern that I have is--look, I had guys that I
    was in service with 40-something years ago and many of them
    just will not go to the VA. They are Vietnam Vets, they just
    will not go. We need to not forget these guys and gals, number
    one. The VA is not meeting all the needs, otherwise the suicide
    rate would not be 20 a day and staying there.
        I think this idea about casting a bigger net--Mr. Bourne, I
    really like what you guys are doing--cast a larger net to bring
    these people in and then we will get them in, if they qualify;
    if not, we will find someplace for them that is proper for them
    to get care. I think that is what the whole idea of this is.
        I guess a question I have very simply, and then I will
    yield back my time, is did you hear what I heard during the
    roundtable? We went straight to work on that. We have included,
    by the way, all of these things, and we have emails back and
    forth to the majority staff, letting them know exactly when we
    sent to the staff what we have, do you all--are you all
    comfortable with what we have done in the compromise?
        Mr. Atizado, I will start with you.
        Mr. Atizado. Thank you, Ranking Member Roe, for that
    question. Like was mentioned, we got the draft late last
    night--or I was able to look at it late last night and a little
    bit this morning. I am not comfortable right now to give our
    organization's position on that, but I do--I must point out to
    you that you did, your staff and this compromise that was
    provided last night, did include some of the recommendations
    that were spoken to in the roundtable, and I really appreciate
    your work and the committee staff's work in doing that. There
    are some minor issues in the draft that we have identified and
    we are still working with your staff to cure some of those. I
    think, and my colleagues I think will agree, that we would like
    here is that both at least on a committee staff level are
    working very hard to come to a compromise here and meet the
    chairman's deadline of having a markup here real soon for us to
    be able to push and implement to veterans out in the community.
        Mr. Bourne. Sir, thank you for your kind words of support
    earlier and then just more recently about the work we do. I
    think based on, again, as Adrian said, the limited time we have
    had to look at the compromise version, I think that based on
    the discussions we had last week during the roundtable and that
    I have heard today that, yes, we are on the same page and
    headed in the right direction.
        Thank you.
        Mr. Gillums. I consulted with our staff who was in
    attendance at the roundtable, I think we are headed in the
    right direction. The one caution I would have is it seems like
    we think we have so much time, you know, this idea of building
    a process where you have this hub, take about a year to figure
    out to build these networks, we do not have that kind of time.
    I think if we make it too hard, too stringent, we are going to
    block out more people just by virtue of the fact that it is
    just too hard to deal with the VA on these things.
        I would like to see a shorter time line between these hubs
    and when they are supposed to deploy these networks. I think
    that is the only area where I think there needs to be some
    refinement.
        Mr. Roe. I think some people are locked and loaded and
    ready to go right now; I agree with you.
        Ms. Bryant. Dr. Roe, I want to thank your staff, as well as
    the majority staff, and also to my colleagues here from the VA,
    I think all three entities have had meetings, calls, conference
    calls, I have lost count of how many we have had in the last
    couple of weeks, to try to move this across the goal line. And
    from what I have seen so far, notwithstanding having had a
    chance to review with my full team just yet, I think that the
    compromise language that we received last night is moving in
    the right direction.
        I also want to note that I share your concern for the
    Vietnam era. My father is a Vietnam Veteran, nothing scares me
    more of him losing another friend or me possibly losing him to
    the stressors of suicide, just as I have experienced as an
    Operation Iraqi Freedom (OIF) veteran.
        Mr. Roe. Thank you all.
        I yield back, Mr. Chairman.
        The Chairman. Thank you, Dr. Roe.
        Mr. Lamb, you are recognized for 5 minutes, more or less.
        Mr. Lamb. Thank you, Mr. Chairman.
        I want to reiterate something I said in the last panel,
    which is that nobody on this committee on either side needs to
    be lectured about the urgency of this situation, we all
    understand it very well. I have been a member of this committee
    since April 2018, which means I have served under both a
    Republican majority and a Democratic majority, and I want to
    thank the chairman for making this the first hearing we have
    had in that time on this particular subject, and he has
    committed to getting a bill moved forward by the end of the
    year.
        When you see disagreement between the two parties about how
    actually to get that done, that is so that we can strike, we
    strike fast and hard and effectively. And our debate is about
    how to do this, not whether to do it and not how fast. That is
    what our constituents elected us to come here and do, to be
    sure that every dollar is spent responsibly and that it is
    spent to accomplish the actual mission.
        The reason that the issue of hubs has been such a focus is
    that these are at least 17 to 20, by my count, existing
    networks that already know the local players in their
    geographic region, and know who is good and who is bad at
    providing these services, and have some experience working
    together.
        Mr. Bourne, I would like you to maybe confirm a couple of
    things. Are you part of the AmericaServes network or are you
    guys separate?
        Mr. Bourne. No, we are, sir. Yes, we are the second
    community.
        Mr. Lamb. It seems similar then the work you all have done
    to what PAServes is doing, and just confirm for me if this is a
    similar level of services that you coordinate.
        PAServes, if you look at their list of providers, meaning
    all the places that they can refer out a veteran who comes in
    front of him, you have got Action Housing; you have got
    Advantage Credit Counseling; you have got the Red Cross of
    Western Pennsylvania; you have got Boulder Crest Retreat for
    Military and Veteran Wellness, which is an organization we have
    a ton of respect for; you have got the Community College of
    Allegheny Count; you have got Corporate America Supports You,
    which is an employment organization to get rid of unemployment
    for veterans; you have got the Duquesne University Psychology
    Clinic, which can get people into direct care very quickly; you
    have got the Goodwill of Southwestern Pennsylvania, Hire Our
    Heroes; you have got Interim Healthcare and Hospice; you have
    got Leadership Pittsburgh for building leadership skills for
    people who are looking to get back in the workforce; you have
    got Neighborhood Legal Services Association for someone maybe
    who is facing eviction or other some kind of immediately legal
    action.
        These are just examples, but would you say that your hub
    organization is comprehensive like that as well where it is
    dealing with financial, legal, health care, employment, all
    those things?
        Mr. Bourne. Yes. Thank you very much, Representative Lamb,
    it absolutely is. I know Gene and Matt and Aaron and that team
    well at PAServes, we have had the opportunity to work together
    for over 4 years. We have actually supported families that have
    crossed our boundaries, that have moved from Pittsburgh to
    Charlotte, Charlotte to Pittsburgh.
        Yes, our network is just as comprehensive as theirs are,
    and I think many of the same or similar partners. Our Goodwill
    of Southern Piedmont, they have Goodwills, you know, our
    community colleges and local universities like Queens
    University, our county Veterans Services office.
        When you map and you overlap communities and these
    partnerships, these networks, they begin to look very similar,
    they are similar actors. They might be sitting in a different,
    they might have a different brand, but they are doing very
    similar roles in specifically the key areas that we focus on,
    which are employment, education, housing, health care,
    benefits, and then social enrichment.
        Mr. Lamb. Like PAServes, is your staff--does it have many
    veterans on it as well?
        Mr. Bourne. Yes. Everyone on our staff is either a veteran
    or a direct family member of a veteran of the 12 total.
        Mr. Lamb. In your time there, have you ever encountered an
    organization that wants to be part of the hub network that you
    guys are that you thought was going to be pretty good at
    providing some service, whatever it was, and then time and
    experience showed that they were not a reliable partner or
    someone maybe you did not want to do business with?
        Mr. Bourne. Yes, absolutely. We started the network in 2015
    formally--we had been operating as an organization since 2010,
    but formally with this network, with the help of AmericaServes,
    in 2015 we went live with 32 organizations, that has grown to
    62. We were at one point as high as 78, but we have shrunk some
    of those. Some were national partners that wanted to have a
    presence in Charlotte, but were not a reliable source to be
    able to deliver care in our local community and it was not
    something that our veterans were really asking for.
        Mr. Lamb. Yes, we have seen a similar thing back in
    Pittsburgh where there are just good players and bad players,
    and sometimes there is even bad players that are already doing
    business with the VA. I mean, we had this one experience
    recently where a local veteran who is a retired Marine, First
    Sergeant, and will not take no for an answer from anybody, came
    across a homeless veteran and it took him 15 phone calls to get
    the guy a bed at the VA, which was okay at the end of the day,
    and they kept him and treated him well. Then when it came time
    to get the veteran in housing using SSVF funds, the
    organization that was contracted for that was terrible. They
    would not pick up the phone, nobody was at the office, it took
    days and days and tons of delay, and it was only this Marine
    First Sergeant's persistence that ended up getting the homeless
    veteran in his home, and now there are serious questions about
    whether that non-profit group should be continuing to receive
    these Federal funds based on the record we knew.
        It was just an important example where I think it has been
    suggested that SSVF is somehow a perfect model for what we want
    to do. That program does not always work out perfectly anyway
    and a lot of times it is the person with the local know-how who
    is really able to kind of assemble the team of resources that
    you need to get this done.
        I think we think the hub programs are strong for that
    reason and it is, in my view, really more about who is making
    the decision here. Organizations like yours have years of
    experience figuring out who is good and who is bad at the
    ground level, I am just not certain that people in the
    Secretary's office, however well-intentioned they are, would
    have the same level of expertise or knowledge compared to the
    existing hub networks.
        With that, Mr. Chairman, I yield back.
        The Chairman. Thank you, Mr. Lamb.
        I now call on General Bergman for 5 minutes.
        Mr. Bergman. Or so?
        The Chairman. Or so.
        [Laughter.]
        Mr. Bergman. Great to be last--and I say that seriously.
    Well, I know, because the chairman always gets the last word.
        A quick question, and we will start with Mr. Atizado and
    just go down the line. What percentage--looking now at your
    organizations that you are here representing, okay? What
    percentage of your eligible membership population, so those who
    are eligible for membership in your particular organization, do
    you think you are currently reaching through your current
    communications efforts?
        Mr. Atizado. General Bergman, that is a great question,
    something that I am sure my other----
        Mr. Bergman. Can you give me a bandwidth? Half?
        Mr. Atizado. Well, I wish I could. We have a number of
    platforms, like other organizations here. We have our mail-out
    magazines, we have social media, we have our Facebook, we have
    our website----
        Mr. Bergman. Let me ask the question a different way. Would
    anybody like to offer a percentage before I ask you the
    derivative of that question?
        Mr. Bourne. Ours is approximately 4 percent, sir.
        Mr. Bergman. You are reaching 4 percent of the eligible
    population?
        Mr. Bourne. Our eligibility require if you have served in
    the military or are an immediate family member of someone that
    served in the military, we will address the needs that you
    have.
        Mr. Bergman. Of that eligible 4 percent, what do you think,
    how many are you reaching?
        Mr. Bourne. Oh, no, I am sorry, the 8,000--excuse me, the
    nearly----
        Mr. Bergman. If your target population is 4 percent of the
    total military having-served population, did I hear that right?
        Mr. Bourne. No, sir. I apologize, I might have not been
    clear. Of the families that we have served, we have reached
    about 4 percent of the total eligible population in our
    geographic catchment area.
        Mr. Bergman. Okay, Okay. 4 percent.
        Mr. Bourne. Four percent.
        Mr. Gillums. I will not even venture a guess, because I
    think we have the most liberal membership eligibility criteria.
    20 million point 2 veterans could theoretically join our
    membership. We have about a quarter million members and, if I
    had to venture a guess--you see, here is where the failure of
    communication is assuming that it has occurred--we can reach
    out, but whether they get it, whether they have heard us,
    whether they engage, it is kind of situational.
        As Adrian said, there are many platforms. We venture out in
    social media more than ever and we gauge reach by responses
    oftentimes and how much engagement we get. We will have peak
    engagement on things like maybe this hearing and then we will
    have not that much on other things.
        Mr. Bergman. All right.
        Ms. Bryant. I would have to say, General Bergman, that 100
    percent of our Legionnaires at least receive our magazine. If
    you want to talk, like my colleagues have, on platforms, I am
    sure you have probably received a copy as well----
        Mr. Bergman. I get your magazine.
        [Laughter.]
        Mr. Bergman. I get all the--as, you know, member of the
    Legion, member of VFW, member of----
        Ms. Bryant. Absolutely.
        Mr. Bergman.--you know, okay----
        Ms. Bryant. But it is hard to capture, as my colleagues
    have said.
        Mr. Bergman. Well, the point is, the point is--and I am
    glad you brought up the point of the magazine--regardless of
    what percentage of your target population that you are trying
    to reach, are you trying different ways? Do you have, you know,
    meetings amongst your leadership to say, okay, we think we are
    doing this well, here is what we may try to improve? Anything
    like that going on in your organizations just as a matter of
    routine business?
        Mr. Atizado. General Bergman, thank you for that question.
    Yes, so a part of our business, a part of our strategy as an
    organization is to in fact saturate the target population. I
    think I may have misunderstood your original question when I
    answered. Our population, membership for DAV are all those
    veterans that were injured during military service----
        Mr. Bergman. Yes, you have specific criteria----
        Mr. Atizado. Very much so.
        Mr. Bergman.--for it to be eligible.
        Mr. Atizado. Our members at the most local level, down to
    our chapter level, actually have--are driven through incentives
    to reach out to veterans that they may have heard were injured
    or believe was injured in military service. That is part of the
    leadership at the local levels----
        Mr. Bergman. The point is, in fact you all said it in
    different ways, you are all trying through your organizations
    to get your message out. You are not sure if your message is
    being heard, because sometimes you do not get that sonar ping
    back that there was--you know, that they have received the
    message, and when you send a magazine out, you never know if
    someone read it, okay? Unless somebody looks at a number or an
    email in your Legion magazine and calls and says, hey, I saw it
    in your magazine.
        Why----
        Ms. Bryant. We do have other programs, of course, sir.
        Mr. Bergman. Well, you do, of course you do, we all--but
    the point is, the point is, when I heard earlier when Mr.
    Cisneros talked about the need for the VA to communicate with
    the veterans, communication is not a perfect art. Just because
    you say something or write something does not mean it is heard.
    Even if it is heard, it does not mean it is understood. This is
    communication is a two-way street.
        What I have seen across the board is, if we are not looking
    for new ways to communicate, especially utilizing social media,
    different venues, avenues that may be available today that were
    not decades ago, then we are not doing our job to adjust to the
    changes necessary to get our message out. To get the veterans
    informed about what is going on in the VA, but also get that
    feedback.
        I kind of--what I see in all organizations is you are all
    trying, including the Veterans Administration. I am on all
    their lists as a veteran, so I know exactly what they are doing
    and what kind of communications that are out there.
        Now, here is the challenge, because what we are talking
    about here by and large is reaching out to veterans who we are
    not getting to now, that is the reason we are sitting here
    today. We have urban, we have suburban, we have--I hear the
    term ex-urbs, I have not figured out that one yet--we have
    rural, but I happen to live in a district that is less than
    rural, it is remote.
        I have a couple of maps here of the United States that show
    two things, it shows basically the percentage of veterans that
    are in a district, reflecting the current percentage of the
    population, but also as you look at the geography of the map it
    shows the difference between remote, rural, urban, and
    suburban.
        When I think about reaching out to veterans in my
    particular district--and there are others, this is not the only
    district in the country that has this remoteness--that our
    challenge going forward in reaching out to these veterans who
    are at risk and are vulnerable, if we do not try different
    methods--in some cases they may not have Internet, they may not
    have a cell phone, they may not have a lot of things, so how do
    we, you know, bring the message to them?
        In some cases it is going to be--and I think--Mr. Gillums,
    did you mention the bar? Yes, it could be the local bar, it
    could be the local church, it could be something where there is
    a community care group that is specific to that area. When we
    think about just doing things one way and that is going to hit
    100 percent of the target, we know it is not.
        The point is--well, I guess I am probably not asking you
    too many questions right now, am I? okay, here is the last
    question. Is it better to have an 80-percent plan aggressively
    executed or a perfect 100-percent plan never executed? That is
    a rhetorical question. You know, the fact is we are all,
    everyone who is in this room today wants to reach out to those
    vulnerable veterans.
        Now, I look at things in a Marine Corps way, okay, but I
    also look at things as a pilot and making decisions when you
    have to make decisions to ensure the safety of the people whose
    lives I am responsible for and it may be different than the
    book said at a time, but I had to make that decision to keep
    everybody safe. So when I look at a nice, tidy solution set
    that is perfect bureaucratically, it scares the bejesus out of
    me.
        Having said that, Mr. Chairman, you have indulged my extra
    words and I appreciate your efforts here, and I look forward--
    is anybody here adverse to the word ``compromise''? Good. I
    think we have got a good compromise on the table. And I yield
    back.
        The Chairman. Dr. Roe, closing comments?
        Mr. Roe. I will be briefer than the General.
        [Laughter.]
        Mr. Roe. I appreciate all of you all being here and I think
    we have made great progress. Simply my only concern was, I wish
    we had done this a little sooner, but I think we are moving in
    the right direction. I think we sat down and listened very
    carefully to the roundtable and said what do we do to get
    everybody to the same or as close to the same place as we can.
    I think we have hit that with a few little minor things.
    Basically what Mr. Gillums said was we cannot wait; the wait is
    over, it is time to do this and get it done.
        What General Bergman also said was, you know, with all the
    metrics and good intentions and all of that, the suicide rates
    have not changed, so we need to do something different.
        To Mr. Bourne, who has a very mature there in Charlotte--I
    feel like I am a resident of Charlotte, I fly through there
    twice a week, so I feel like I should be a taxpayer there----
        Mr. Bourne. You should come visit, sir.
        Mr. Roe.--do not send me a notice--but you have a very
    mature, sophisticated organization in Pittsburgh. Those are
    big, mature cities. I have to go to Sneedsville, Tennessee that
    has 2,000 residents and they are across Clinch Mountain. There
    are veterans that live there, they are very patriotic people,
    and there are veterans in Mountain City, Tennessee that I have
    to get to. Where General Bergman was talking about in the UP,
    that is a whole other piece of territory up there.
        We are trying to cast a wide net to bring in more people to
    get care, that is what we are trying to do. I do not think we
    need to get all hung up on the minutia, to look at the goal
    that we all have, I think everyone here has, and not get hung
    up on one little thing or the other.
        I would encourage us to--I think we are just about there
    and I see a solution coming, I really do, if we keep the staffs
    working together, and you guys can tell us the few little
    things that you have that--but do not let a little thing derail
    a big things, I think is what I am saying, do not get hung up
    on one little thing.
        It was easy for me last week when I was listening to the
    roundtable and we talked about the cash assistance. Look, that
    makes perfectly good sense what you guys are talking about,
    provide the service with the cash. I had no problem with that,
    but I think also having people in an emergent situation--I can
    tell you as a doctor, if someone comes in to me and is in
    extreme, I am going to take care of them and I am going to
    worry about who pays for it later. I am not even going to be
    worried about that. Let us get the problem taken care of and
    then get this person where they need to be. I think that is the
    way most people feel.
        Mr. Chairman, I thank you for having this. I think this has
    been a great hearing and I see a solution. I think we can meet
    our deadline of before we get out of here for Christmas, at
    least this Congress. It has not done much, I can say that, to
    my frustration, but this we can and should do.
        With that, I yield back.
        The Chairman. Okay. Before I adjourn today, I would like to
    extend my appreciate to the VSOs, the mental health
    professionals, the union leadership, experts on suicide
    prevention policy, and stakeholders who have assisted committee
    staff in helping to improve legislation to help veterans.
        Last April, following three veteran suicides in 5 days on
    VA campuses, this committee rededicated itself to working
    toward solutions to help our veterans in crisis. We called
    members together for an emergency hearing, convened the press.
    I recall that Ranking Member Roe and all the members, most of
    the members of the committee came together for a bipartisan
    press conference to draw attention to the issue. We passed five
    bipartisan bills and held multiple roundtable discussions.
    These efforts have led us here again today to find solutions.
        Now, I pulled this legislation from the markup, the last
    markup we had, because I did not feel it was ready, I did not
    feel that the staff engagement was earnest at that point, and I
    did not feel that we were going to get where we needed to get
    to in the markup.
        We established a roundtable, which Dr. Roe and I think
    everybody who was present felt it provided information that
    allowed us to, I think, start talking in earnest.
        General Bergman, I really want to thank you. You on the
    floor said, let us talk as member to member without
    interference from the staff. We, the members, are the ones in
    charge. I give you a lot of credit, I give you the credit for
    making that real, asserting the power of the member and to
    remind staff that they serve members and members' intent as
    they author the bill. You have precipitated, I think, the
    earnest discussions we have had today. In the end, I would like
    to see it be your bill that passes.
        I am appreciative that our concerns, even though in the
    majority we could make those concerns the concern, but that is
    not the way I want to do things here. I have been frustrated
    that the Legislative Affairs operation at the Department of
    Veterans Affairs has orchestrated a press effort--we have not
    done that on the majority side, we have been restrained,
    mainly--all in the service of doing something about reducing
    veteran suicides. It was more important to me that we arrived
    at a compromise, arrive at an agreement. In the end, I think a
    good compromise, everybody walks away feeling that they did not
    compromise, that we have reached a mutual understanding.
        Look, I have a high regard for Secretary Wilkie. He served,
    I think, a great Secretary at the Department of Defense before
    he came over to the Department of Veterans Affairs, but, as I
    said, my job as the chairman of a committee is to make sure
    that the legislation that comes out of this committee is not
    written just for a good public servant, a well-intended public
    servant. I have seen parts of this administration spend money
    that has not been appropriated for certain purposes and that I
    have seen a pinhole be made wide enough for a Mack truck to be
    driven through, and the intent of Congress is not met unless we
    carefully craft the language and carefully put language that
    does not allow the intent of Congress to be somehow twisted.
        With that, I say that I implore the staff to work hard at
    hammering out the details, drawing those fine distinctions. We
    have worked hard to create a MISSION Act that is a lot simpler
    than the many lines and many channels of care, community care
    in the community that used to have to be funded by the VA.
        I say to the VA, and the administrators and leadership at
    the VA, that they need to make sure that we engage the
    culturally competent providers of mental health care, bring
    them into our community care networks, and thereby grow our
    capacity, whether we do it internally or whether we do it
    through care in the community, but care in the community that
    is connected, that is accountable, and that is competent to
    deliver the urgent care and the urgent mental health care needs
    that veterans may find themselves in, that we arrive at that
    place where we can do all of the above.
        With that, members will have 5 legislative days to revise
    and extend their remarks, and include extraneous material.
        Again, I thank, my thanks to all of the witnesses appearing
    here today. As we head into the Thanksgiving Day holiday, may
    all of us be blessed with wonderful family time, and
    thanksgiving for our country and thanksgiving for what our
    veterans have done for us.
        Thank you.
        [Whereupon, at 1:04 p.m., the committee was adjourned.]

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

                             A  P  P  E  N  D  I  X

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

                        Prepared Statements of Witnesses

                                  ----------

                      Prepared Statement of Robert Wilkie

        Chairman Takano, Ranking Member Roe, and Members of the Committee,
    thank you for inviting us here today to present our views on two bills
    regarding the establishment of suicide prevention grants. Joining me
    today are Dr. Richard Stone, Executive in Charge for the Veterans
    Health Administration (VHA), and Dr. David Carroll, Executive Director,
    Office of Mental Health and Suicide Prevention.
        Mr. Chairman, in the House Veterans' Affairs Health Subcommittee
    hearing on September 11, 2019, VA presented on its own initiative views
    on H.R. 3495, which are reproduced below. Regarding the second bill on
    the agenda, the Draft bill to establish a pilot program for the
    issuance of grants to eligible entities, VA only received the bill last
    Thursday, November 14, and thus was not able to include written views
    on it today. However, we will follow up with the Committee soon with a
    views letter on that legislation.

    H.R. 3495 Improve Well-Being for Veterans Act

        H.R. 3495 would require VA to provide financial assistance to
    eligible entities approved under this section through the award of
    grants to provide and coordinate the provision of services to Veterans
    and Veteran families to reduce the risk of suicide. VA would award a
    grant to each eligible entity whose application was approved by VA. VA
    could establish a maximum amount to be awarded under the grant,
    intervals of payment for the administration of the grant, and a
    requirement for the recipient of the grant to provide matching funds in
    a specified percentage. VA would ensure, to the extent practicable,
    that financial assistance is equitably distributed across geographic
    regions, including rural communities and Tribal land. VA also, to the
    extent practicable, would need to ensure that financial assistance is
    distributed to provide services in areas of the country that have
    experienced high rates or a high burden of Veteran suicide and to
    eligible entities that can assist Veterans at risk of suicide that are
    not currently receiving health care furnished by VA.
        VA would have to give preference in the provision of financial
    assistance to eligible entities providing or coordinating (or who have
    demonstrated the ability to provide or coordinate) suicide prevention
    services or other services that improve the quality of life of Veterans
    and their families and reduce the factors that contribute to Veteran
    suicide. Each grant recipient would have to notify Veterans and Veteran
    families that services they provide are being paid for, in whole or in
    part, by VA. If a grant recipient provided temporary cash assistance to
    Veterans or Veteran families, the recipient would have to develop a
    plan, in consultation with the beneficiary, to ensure that any
    beneficiary receiving such temporary cash assistance is self-sustaining
    at the end of the period of eligibility for such assistance.
        VA would require each grant recipient to submit an annual report
    describing the projects carried out with VA's financial assistance; VA
    would also specify to each recipient the evaluation criteria and data
    and information to be included in the report, and VA could require
    entities to submit additional reports as necessary. An eligible entity
    seeking a grant would submit a form to VA containing such commitments
    and information as VA considers necessary to carry out this section.
    Each application would have to include a description of the suicide
    prevention services to be provided, a detailed plan describing how the
    entity proposes to coordinate and deliver suicide prevention services
    to Veterans not currently receiving care furnished by VA (including an
    identification of community partners, a description of arrangements
    currently in place with such partners, and identification of how long
    those arrangements have been in place), a description of the types of
    Veterans at risk of suicide and Veteran families proposed to be
    provided suicide prevention services, an estimate of the number of
    Veterans at risk of suicide and Veteran families that would be provided
    services (including the basis for the estimate and the percentage of
    those Veterans not currently receiving VA care), evidence of the
    experience of the applicant (and the proposed partners) in providing
    suicide prevention services (particularly to Veterans at risk of
    suicide and Veteran families), a description of the managerial and
    technological capacities of the entity, and other application criteria
    VA considers appropriate.
        VA would be required to provide training and technical assistance
    to eligible entities under this section regarding the data that must be
    collected and shared with VA, the means of data collection and sharing,
    familiarization with and appropriate use of any tool to measure the
    effectiveness of the financial assistance VA provided, and how to
    comply with VA's reporting requirements. VA would have to establish
    criteria for the selection of eligible entities that have submitted
    applications. In establishing these criteria, VA would have to consult
    with Veterans Service Organizations (VSO), national organizations
    representing potential community partners of eligible grant recipients,
    organizations with which VA has a current memoranda of agreement or
    understanding related to mental health or suicide prevention, State
    Departments of Veterans Affairs, national organizations representing
    members of the reserve components of the Armed Forces, Vet Centers,
    organizations with experience in creating measurement tools for
    purposes of determining programmatic effectiveness, and other
    organizations VA considers appropriate.
        VA would have to develop measures and metrics for grant recipients
    in consultation with the same group of entities or organizations.
    Before issuing a Notice of Funding Availability under this section, VA
    would have to submit to Congress a report containing the criteria for
    the award of a grant under this section, the tool to be used by VA to
    measure the effectiveness of the use of financial assistance provided
    under this section, and a framework for the sharing of information
    about entities in receipt of financial assistance under this section.
    VA could make available to grant recipients certain information
    regarding potential beneficiaries of services, including confirmation
    of the status of a potential beneficiary as a Veteran and confirmation
    of whether a potential beneficiary is currently receiving or has
    recently received VA care.
        VA's authority to provide financial assistance would end on the
    date that is 3 years after the date on which the first grant is
    awarded. Not later than 18 months after the date on which the first
    grant is awarded, VA would have to submit a detailed report on the
    provision of financial assistance under this section. Not later than 3
    years after the date on which the first grant is awarded, VA would have
    to submit to Congress a follow up on the interim report containing the
    same elements and a final report on the effectiveness of the financial
    assistance provided through this authority, an assessment of the
    increased capacity of VA to provide services to Veterans at risk of
    suicide and Veteran families as a result of this financial assistance,
    and the feasibility and advisability of extending or expanding the
    provision of financial assistance.
        Eligible entities would be: (1) an incorporated private institution
    or foundation that is approved by VA as to financial responsibility and
    no part of the net earnings of which incurs to the benefit of any
    member, founder, contributor, or individual and that has a governing
    board that would be responsible for the operation of the suicide
    prevention services provided under this section; (2) a corporation
    wholly owned and controlled by an organization meeting the same
    requirements; (3) a tribally designated housing entity (as defined in
    section 4 of the Native American Housing Assistance and Self-
    Determination Act of 1996 (25 U.S.C. 4103)); or a community-based
    organization that is physically based in the targeted community and
    that can effectively network with local civic organizations, regional
    health systems, and other settings where Veterans at risk of suicide
    and the families of such Veterans are likely to have contact. Suicide
    prevention services would be services to address the needs of Veterans
    at risk of suicide and Veteran families and includes outreach; a
    baseline mental health assessment; education on suicide risk and
    prevention; direct treatment; medication management; individual and
    group therapy; case management services; peer support services;
    assistance in obtaining any VA benefits for which the Veteran or
    Veteran family may be eligible; assistance in obtaining and
    coordinating the provision of other benefits provided by the Federal
    Government, a State or local government, or an eligible entity;
    temporary cash assistance (not to exceed 6 months) to assist with
    certain emergent needs; and such other services necessary for improving
    the resiliency of Veterans at risk of suicide and Veteran families as
    VA considers appropriate. Veteran family would mean, with respect to a
    Veteran at risk of suicide, a parent, a spouse, a child, a sibling, a
    step-family member, an extended family member, or any other individual
    who lives with the Veteran. VSOs would be those organizations
    recognized by VA for the representation of Veterans included as part of
    an annually updated list available online.
        VA strongly supports this bill. VA's efforts to reduce the
    incidence of suicidal ideations and behavior (and suicide completions)
    among all Veterans could be complemented by partnering with community-
    based providers who are able to replicate VA's suicide prevention
    programs in the community and to connect with Veterans that are
    currently beyond VA's reach. This novel approach would assist VA in
    reaching more of the 14 of the 20 Veterans dying each day by suicide
    who are not under VA care at the time of their deaths; effective
    partnering with eligible grantees would be key to our being able to
    reduce, if not prevent, the number of these tragic occurrences.
    Additionally, the legislation aligns with VA's proposal submitted with
    the President's Fiscal Year 202020 budget. This proposal has been
    identified as the Secretary's top legislative priority and the
    legislation provides the necessary authorities clinicians believe will
    help the Department combat suicide among Veterans. Last, we note that
    the legislation is aligned with the President's strategic taskforce to
    combat suicides in the Nation. The taskforce will assist in planning
    and providing strategic guidance with our stakeholders allowing VA to
    operate and implement the grant program. The need for this legislation
    is evident and will enhance and increase the suicide prevention
    measures the Department is currently taking to combat and reduce
    suicides in the Nation.
        We offer one comment for the Committee's consideration, but we
    emphasize that this is not an issue that would alter VA's position on
    the bill. The definition of ``risk of suicide'' in section 2(k)(4)
    would include exposure to or the existence of any of the specified
    conditions. We believe this definition is overly broad and recommend
    instead allowing the Secretary to implement this definition by
    regulation to include the addition of a process for determining degrees
    of risk of suicide based on consideration of the factors set forth in
    section 2(k)(4). Risk is obviously variable, ranging from no risk to
    high risk. Even without this recommended change, the bill would give VA
    sufficient authority to prefer applicants that ensure their services go
    to those Veterans who have the highest risk of suicide.
        We estimate the bill would cost $19.10 million in Fiscal Year 2021,
    $28.36 million in Fiscal Year 2022, and $37.70 million in Fiscal Year
    2023, for a total cost of approximately $85.16 million over the 3-year
    period of the program.

        This concludes my statement. Thank you for the opportunity to
    appear before you today. We would be pleased to respond to questions
    you or other Members may have.
                                     ______

                      Prepared Statement of Adrian 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. Thank you for inviting DAV to testify
    about the majority's discussion draft and H.R. 3495, the Improve Well-
    Being for Veterans Act today.
        Everyone in this room understands that suicide is an extremely
    complex issue that will not be successfully addressed by any one
    proposal, idea, or intervention--particularly for the veterans'
    population, which is at elevated risk for suicide and suicidal
    ideation. In response, the bills before us today are multifaceted
    attempts to respond to this extremely difficult issue by reaching
    outside of the Department of Veterans Affairs (VA) to allow community
    providers to develop new and innovative programs that may be more
    accessible to veterans who have traditionally not used VA and their
    family members--specifically, those 14 out of 20 suicides by veterans
    who do not seek care in VA, which the Department estimates will occur
    each month.
        We can also agree to the urgency of the situation. It's clear that
    the 20 veterans we need to reach this month cannot wait long for
    Congress and VA to act. But in this case, the Government has taken
    steps to address this critical issue with the establishment of the
    President's Roadmap to Empower Veterans to End a National Tragedy of
    Suicide (PREVENTS) interagency task force (or Task Force), which has
    been charged with identifying a public health strategy that will bring
    all the resources of the Federal Government to bear on this epidemic
    affecting our Nation's veterans. The Task Force will also recommend
    strategies to integrate private partners into suicide prevention
    efforts. The PREVENTS recommendations are due in March 2020--just a few
    months from now. DAV believes the Task Force's guidance should provide
    the strategic direction for any new interventions in suicide
    prevention.
        The Task Force is concentrating on several lines of effort
    including lethal means, partnerships, research strategies, State and
    local action, workforce and professional development and communications
    aimed at universal, selective and indicated audiences to change the
    culture of treatment seeking. VA also has a public health suicide
    prevention strategy developed for 2018-2028 that focuses on
    empowerment, clinical and community prevention, treatment and
    supportive services, and research and surveillance. While we have
    expressed some concerns about VA's readiness to take on this public
    health mission, it is in keeping with public health models that rely
    upon awareness, and changing the culture by addressing stigma and
    perceptions to increase the likelihood individuals affected will seek
    or encourage others in need of care to get the help they need, and
    above all--measuring against clearly defined goals.
        The heart of any public health strategy lies in the metrics it
    establishes and measures at baseline and periodically during and after
    an intervention. DAV is gratified that both bills make use of work
    groups that would include veterans' service organization representation
    among other subject matter experts to establish such
        metrics. Looking at grantees' effects on the population they target
    will require them to tightly define their catchment area and the types
    of veterans they will serve. They will also have to make some well-
    founded assumptions about those they do not reach and measure changes
    in the whole population throughout the intervention. If grantees do not
    see evidence of positive changes from their programs, they will have to
    recalibrate their strategies. As much as possible, the programs should
    also be replicable so that effective programming taking place at one
    site could be used elsewhere for a similar population.
        DAV continues to believe that it is in the best interest of
    veterans that these grantees make some connection to VA. VA and the
    Department of Defense (DoD) have reviewed evidence-based practices that
    have been deployed throughout both systems including at points of entry
    to screen and capture at-risk service members and veterans. These
    practices are--at least--holding the line on rates of suicide among
    veterans that may be among the most complex and severely affected. VA
    has created risk identification strategies, such as the REACH VET
    program, which uses predictive modeling and medical record data to
    identify and target intervention for veterans that are at high risk of
    suicide and most likely to act. Additionally, VA uses appointed suicide
    prevention coordinators at every VA medical center to help identify the
    resources that can help them recover. VA has identified evidence-based
    practices such as cognitive behavioral therapy to treat conditions
    tragically linked to suicidal behavior such as post-traumatic stress
    disorder, depression, substance use disorders and homelessness. The
    Veterans Crisis Line has intervened in thousands of instances to
    forestall tragedies and refer our veterans to local resources for care.
    While DAV shares the frustration many in Congress have expressed about
    not being able to move the needle and lower the rate on the staggering
    rates of suicide in the veteran population, we believe that without VA
    efforts we could be looking at an even worse scenario.
        The bill and discussion draft before us today offer two contrasting
    options that create a role for private or other public providers to
    stem the tide. Both H.R. 3495 andthe discussion draft, however, seem to
    operate from the perspective that veterans not using the VA want
    nothing to do with it, which in DAV's view is a flawed assumption.We
    understand from VA's surveys that veterans are often unclear about
    their eligibility for services or even their veteran status. In its
    most recent report, 2010 National Survey of Veterans: Understanding and
    Knowledge of VA Benefits and Services (November 2011), the National
    Center for Veterans Analysis and Statistics found lowered rates of
    understanding of health care eligibility among non-enrollees, varying
    from 15 percent to about a third who claimed to understand the health
    care services for which they were eligible.\1\ In 2018, National
    Academies of Sciences, Engineering and Medicine Evaluation of the VA
    Mental Health Services also found 40 percent of veterans not using VA
    mental health were unsure of their eligibility for services. Lack of
    awareness of VA and eligibility is clearly still a barrier to many
    veterans who may be eligible and greatly benefit from VA's specialized
    health care and mental health services.
    ---------------------------------------------------------------------------
        \1\  https://www.va.gov/vetdata/docs/SpecialReports/
    2010NSV_Awareness_FINAL.pdf accessed November 15, 2019.
    ---------------------------------------------------------------------------
        VA has had real success publicizing the Veterans Crisis Line, which
    has responded to hundreds of thousands of veterans' calls, texts, and
    emails. We believe it is successful because there is a clear source all
    veterans can access for help while eligibility and lack of awareness
    have obscured veterans' access to VA. DAV would be in favor of Congress
    allowing VA to serve as an initial point of contact for any individual
    in crisis who has served in the military, Reserves or National Guard.
    If VA medical facilities find they are ineligible, and they are not in
    immediate crisis they could refer them to other partners, including
    possibly grant providers. But clear ``no wrong door'' messaging that
    would allow those in immediate need a place to go for help. Using VA as
    the entry point to grant providers would better ensure its ability to
    make appropriate referrals and coordinate care and services for
    veterans at risk of suicide.
        We believe both the bill and the discussion draft would benefit
    from aiming interventions at more targeted patient populations. While
    both bills are clearly drafted to incorporate all of the risk factors
    that might be present in veterans with suicidal ideation, these risk
    factors should not define eligibility for services. DAV would argue
    that even the most resilient among us have one or more of these risk
    factors, histories or life events. For example, the 2015 National
    Firearm Survey found almost half of the veterans' population (44.9
    percent) owns one or more firearms--most often for protection, but
    sometimes for sports and recreation such as hunting.\2\ A quarter of
    all Americans will divorce. Almost all of us will suffer through the
    loss of loved ones and have stressful life events. Yet, as drafted,
    exposure to any one of these factors would define a veteran as ``at
    risk'' of suicide. Using these overly broad factors to target veterans,
    effectively targets no one. While it is important to understand these
    factors and build risk identification strategies and treatment plans
    around them, DAV believes, for these initial grants, the presence of
    any of the defined health risk factors (mental health challenges,
    substance use disorders, serious or chronic health conditions or pain
    and traumatic brain injuries) would create a big enough umbrella to
    allow almost anyone in need of services to participate.
    ---------------------------------------------------------------------------
        \2\  Cleveland, E. , et al. ``Firearm ownership among American
    veterans: findings from the 2015 National Firearm Survey.'' Inj.
    Epidemiol 2017 Dec; 4:33.
    ---------------------------------------------------------------------------
        Mr. Chairman, we similarly appreciate the broad scope of services
    that could be offered both through a bill similar to the discussion
    draft and that of General Bergman. But we are concerned that without
    more structure and a detailed plan, the cash assistance program in H.R.
    3495 may be prone to waste, fraud and abuse. It has been attested that
    this program was modeled after the Supportive Services for Veterans
    Families (SSVF) grant assistance program. We agree that SSVF has been
    effective in combating and sometimes preventing homelessness as one
    program within a constellation of other programs and services that
    provide veterans who are homeless or at imminent risk of homelessness.
    Because it is a homeless service, veterans have also met certain
    qualifications--including demonstrating fiscal need, and there are
    established protocols for administering and monitoring the program and
    veterans in receipt of services.\3\ The cash assistance program in
    General Bergman's bill requires no qualifications for cash awards, and
    offers no assurances that the individual is even a veteran to qualify
    for cash assistance. The language in the bill states that the Secretary
    may make information about veteran status and use of VA medical care
    available, but it does not require the grantee to ask for or use this
    information to provide cash assistance. DAV believes many veterans in
    fiscal circumstances dire enough to affect suicidality may qualify for
    the SSVF program. We also know homelessness is a risk factor for
    suicide so building out this existing program may also assist in
    suicide prevention in the homeless population. DAV recommends that
    Congress simply add more resources to the existing SSVF program--an
    application for this funding could be coordinated through the grantee
    if a veteran's need dictated and the eligibility criteria, financial
    and managerial controls for this program are already established.
    ---------------------------------------------------------------------------
        \3\  VHA Directive 1162.07 Supportive Services for Veterans
    Families (January 23, 2018).
    ---------------------------------------------------------------------------
        DAV is also concerned with the clinical care services that are
    outlined in General Bergman's bill. These services would provide a
    confusing overlay to the new Veterans Community Care Program, just as
    VA medical centers have finished market plans and are beginning the
    process of establishing their community provider networks enacted
    through the MISSION Act of 2018. DAV has recommended using best
    practices, such as VA's maternity care protocol, to manage care for
    veterans as they transition between VA and private sector
    facilities.\4\ VA's maternity care coordinators administer the protocol
    to ensure VA remains in contact with veterans throughout labor and
    delivery process in private sector facilities and assure that veterans
    are receiving necessary and timely care and receive access to other VA
    services for which they are eligible, such as pharmaceuticals,
    prosthetics and mental health care. Suicide prevention coordinators
    should establish similar protocols as veterans identified at risk of
    suicide access community care through VA partners. The Community Care
    Network providers will also have additional criteria to better assure
    access and quality for veterans. We would have no similar assurances of
    access or quality of providers receiving grant funding for suicide
    prevention services.
    ---------------------------------------------------------------------------
        \4\  VHA Handbook 1330.03, Maternity Health Care and Coordination
    ---------------------------------------------------------------------------
        If the Committee wants to use these grants to reach out to veterans
    not using VA services, it should ensure that the grantees are in areas
    where VA has low market penetration and that are distant from VA health
    care resources including medical centers, community-based outpatient
    centers, Vet Centers and community network providers. This would ensure
    that grantees are filling gaps in coverage and reaching veterans who do
    not have good options for mental health care.
        I'd like to give you an example of a grant program that is working
    to reduce suicides among veterans. DAV's Charitable Service Trust, an
    affiliate of DAV, which strives to meet the needs of injured and ill
    veterans through financial support of direct programs and services for
    veterans and their families, is funding a local DAV chapter making a
    difference in the lives of veterans in a remote and rural Arkansas
    county. Learning of the high rate of suicide among veterans in their
    county, DAV's chapter commander and deputy commander, a licensed
    clinician, set a goal lowering the rate of veterans' suicide in the
    area. They began by exploiting or establishing community ties to other
    veterans' groups, churches, business leaders, and health care
    providers, and providing personal outreach, individual or group
    counseling, to veterans who identify a need for these services. They
    refer a few veterans with the most complex needs to the VA. The County
    coroner's office is working with this DAV chapter, identifying
    veterans' deaths from probable suicides so they measure the effects of
    their interventions. According to feedback, their efforts are working,
    with rates of suicide having dropped since their efforts began. These
    two local heroes happen to have the requisite skills and personal means
    to allow them to devote countless hours to this program without
    compensation, which creates an extraordinary circumstance in this area
    that may not be replicable elsewhere. While there are some
    extraordinary features of this program, other features adding to their
    success are:

          Deep community ties to health and supportive resources
    and ongoing relationships with veterans in the area.

          A public health strategy that measures and monitors its
    efforts on an ongoing basis.

          High-touch services that counteract isolation and work to
    integrate veterans into their communities.

          Lack of other health providers, including VA medical
    centers in the area, making their services a critical resource to the
    community.

        In closing, DAV sees the benefit of this approach and supports the
    concept of assisting groups or supportive networks that can make a
    positive difference in the life of at-risk veterans and hopes that the
    Committee takes our views into account when considering these bills.
        Thank you Mr. Chairman. This concludes my testimony I will be happy
    to respond to any questions you or the Committee may have.
                                     ______

                       Prepared Statement of Blake Bourne

        Chairman Takano, Ranking Member Roe, and the Members of the
    Committee, I'd like to start by thanking you for your work on behalf of
    America's veterans and their families, and for the opportunity to
    address you today on the subject of ``HR 3495: the IMPROVE Well-Being
    for Veterans Act.''
        I'm here today representing Veterans Bridge Home, one of the
    longest standing and most successful ``hub'' organizations in the
    country, focused exclusively on the connection between military
    connected families and the communities which with they live after their
    service. Our organization geographic footprint is across the Charlotte,
    North Carolina region including the 10 surrounding counties. We have
    worked alongside over 5,000 families providing nearly 15,000 unique
    services. This firsthand experience of supporting the transition of
    military connected families began in the home of our founders, Tommy
    and Patty Norman in 2009, focusing on one family at a time. Identifying
    their unique goals and needs, finding the most appropriate local
    resource to address that need, and then matching the family and the
    resource together ensuring both parties understood the role and
    opportunity of working together to achieve long lasting sustainable
    success. The Normans were able to support four families in 2009.
        Ten years later, Veterans Bridge Home is still focusing on one
    family at a time, but our team is working with approximately 175
    families each month. With a staff of 12 we have formally connected 62
    public and private organizations via a seamless technology platform, we
    engage with and educate 200 local employers, and have connected over
    8,000 community members and veterans through social, fitness and
    volunteer events. This is all done at a local level on a daily, weekly,
    and monthly basis via personal relationships with each of these
    organizations ensuring that the relationships and connectedness that we
    are building and facilitating in our community are a tangible resource
    for the families who call Charlotte home.
        When they take off their uniform our service members leave a
    hyperconnected, purpose driven, and globally supported community inside
    of the Department of Defense. In many cases, for the first time in
    their adult lives, they must address the professional, social and
    service needs of themselves and their family on their own, in a new
    community, without the guidance and support systems of the DoD. The
    reality is daunting and the stress of transition is real.
        Health and human services in our country are fragmented. Our
    community, like many across the country, has an abundance of services,
    programs and opportunities to ensure the success of our Veterans and
    their families. IF you know where to look, if you know what to ask, and
    if you are able to be patient. That isn't always the case and can
    exacerbate any existing challenges, service connected or not.
        Recent studies suggest that 44 percent to 72 percent of Veterans
    experience high levels of stress during transition to civilian life,
    including difficulties securing employment, interpersonal difficulties
    during employment, conflicted relations with family, friends, and
    broader interpersonal relations, difficulties adapting to the schedule
    of civilian life, and legal difficulties (Castro et al., 2014; Morin,
    2011). This appears to predict both treatment seeking and the delayed
    development of mental and physical health problems, including suicidal
    ideation. Effective care coordination across top social determinants of
    health--Employment, Housing, Healthcare, Social Enrichment, Benefits/
    Finances, and Education--cannot only save lives but contributes to
    thriving leaders that have the capacity to invest in building healthy
    communities. Barriers associated with navigating resources across a
    variegated community landscape within and between complex systems can
    prolong service delivery and compromise desired outcomes at the
    individual and community levels.
        Since 2011, Veterans Bridge Home has been working around the clock
    to grow a system that builds community capacity to welcome and
    integrate Service Member and Veteran Families successfully into its
    fabric. This ``Community Integration'' or ``Collective Impact'' model
    is meant to leverage the strengths of a community and utilize the best
    first use of services for the families that need them. We take a care
    coordination approach, engaging partners, community members and the
    Veteran in holistic relationships. Key components of effective care
    coordination services for Service Member and Veteran Families include
    outreach, triage, ongoing provider network engagement and cultivation,
    and measurement and evaluation. An effective ``hub'' organization must
    be able to connect with and manage relationships with not just the
    Veteran, but with community partners as well. It is not enough to only
    know the Veteran and their needs. You must know who, locally, can
    address those needs, what their eligibility criteria are, how to make
    the match and what to expect from the service delivery.
        VBH continues to refine its growing care coordination program. In
    the past four years alone, our community partner network, has been able
    to connect over 4,800 unique families with over 12,800 unique services
    across multiple service domains. We continue to build this program as
    we do this meaningful work, refining as we go to meet the demand signal
    with the staff and partners willing and able to assist. We work with
    our partners to continuously improve our processes and measurement and
    expect to optimize program protocols and practices that build capacity
    across the network and implement program enhancements that boost shared
    outcomes.
        Routine and targeted outreach is essential to meeting program goals
    to include 5 percent new client reach annually, 120 eligible clients
    for SSVF grant funding aiding housing attainment and/or retention, and
    increased support of suicide loss survivors with local and national
    resources as well as participation in Operation Deep Dive Suicide
    Prevention Study. Effective community engagement / outreach activities
    result in increased help-seeking behaviors and health coping attitudes
    and behaviors, a primary public strategy for suicide prevention.
    Additional goals related to outreach activities include increased
    social connectivity as evidenced by engagement with other veterans
    through workouts, chill time, play, and volunteer opportunities.
    Routine outreach activities include monthly coffees and luncheons,
    weekly workouts, community and partner resource fairs and events, etc.
    Targeted outreach includes working alongside key partners within their
    organization(s) or locations/events with Veterans with known needs. A
    ``hub'' organization must have healthy existing relationships with
    those partners and understand their keep capabilities. Charlotte is
    fortunate to have several incredible local partners addressing specific
    needs such as Liz Clasen-Kelly at the Men's Shelter and Urban Ministry,
    who specifically serves individuals who are experiencing homelessness.
    Or Janene McGee at the Mecklenburg County Veterans Service Office who
    has a team of 13 benefits officers who help navigate the State and
    Federal benefits for Veterans and families. Or finally Noel McCall, who
    leads Patriots Path, an incredible career development course which
    provides 20 hrs of training for Veterans and spouses to finding
    meaningful employment opportunities.
        VBH works with each of these organizations and leader in unique and
    specific ways to ensure the Veterans they serve have access to the full
    domain of local, State, and Federal resources and we are all working
    together as a team to address their needs. No one single organization
    can address everything a Veteran might need today or will need over
    their lifetime. We are creating a system of services, seamless and
    connected the Veteran and their family can benefit from all the
    community has to offer and we reduce the duplication, underlaps and
    lack of effectiveness from outcomes that are not shared amongst the
    community.
        This work also allows for more effective gap analysis. After our
    Outreach, engagement and connection efforts-measurement and evaluation
    play a critical role in understanding the needs of our Veterans and the
    effectiveness of our partners. We have a variety of measures which
    capture:

            What are the demographics of the Veterans or family member
            asking for support?

            What is the military service of the individual requesting
            support?

            What service type(s) are they specifically interested in
            accessing?

            Does that service exist? Is it available? What are the
            eligibility criteria?

            How long it takes to match the individual with the program or
            organization?

            What occurs once they are connected and how long does it take
            to deliver the service?

            What is the outcome of that service delivery and how
            sustainable is the Veteran?

            These are important questions that help us measure the needs of
            our Veterans, the gaps and overlaps in our community, the
            efficiency of our partners and the ultimate outcomes we are
            trying to collectively deliver.
        Consistent client data capture is not only critical to quality
    metrics but also to effective bi-directional communication between
    providers in the business of triaging needs and delivering health and
    human services. Important components of triage involve identifying
    target population--Service Members and Veteran Families--as well as
    person centered goals and needs across social determinants of health,
    prioritizing critical services, and referring individuals to trusted
    and competent providers in the community in the least amount of time
    possible. As the demand signal has increased, screening practices have
    been refined from a more intensive five page / 60+ minute intake form
    to a 22-question screening instrument to a six question screening
    instrument to address holistic needs. We recognize a need to evaluate
    effectiveness of screening tool to effectively address identification
    of holistic needs, prioritization of those needs, mitigate risk for
    complex clients, and improve expeditious responsiveness to priority
    needs across social determinants of health. Currently individuals who
    make contact with our network report 2.6 unique needs.
        We are able to conduct these measurements via a technology platform
    called UniteUS. UniteUS has not only helped transform care for Veterans
    across the Carolinas, thanks to the AmericaServes initiative from IVMF,
    but is not being adopted by health and human service providers across
    the State of North Carolina to address the Social Determinant of Health
    needs of all North Carolinians.
        UniteUs metrics indicate that Veterans Bridge Home has a 96 percent
    accuracy in making smart referrals (effective matching with providers
    who provide the service requested and have capacity to serve the
    client) and takes on average 9.17 days to positively match client with
    service provider. We suspect processes, protocols, and communication
    can be optimized within coordination center and across partner
    organizations to meet goal of >5 days time to match and contribute to
    overall increased client satisfaction and well-being. At this time,
    primarily two staff members are triaging the majority of clients who
    make contact along with the 252 additional network users.
        A diverse, engaged, and efficient provider network is essential to
    effectively care for those who have worn the uniform, especially for
    those with complex care needs. Provider engagement is a key variable to
    this community integration model's success and sustainability. Current
    data indicate that 37 percent of providers are utilizing Unite Us
    platform to connect clients to other providers and resources with a
    network goal of 70 percent of providers adopting technology to make and
    receive referrals. Provider engagement strategy needs to be evaluated
    to improve effectiveness to reach targeted goals. In-depth qualitative
    interviews with our top ten providers identified provider priorities--
    technology needs, process improvements, professional development, and
    improved communication. At this time, two Veterans Bridge Home staff
    are dedicated to provider engagement with substantial support of
    approximately six additional staff members. An area of opportunity is
    leveraging technology to optimize strategic and targeted provider
    engagement efforts to meet outlined goals above.
        The language and financial support of H.R. 3495 would allow us to
    increase our capacity to address the needs of Veterans and manage the
    relationships with providers, thus increasing efficiency and improving
    outcomes by working on both sides of the equation.
        Outputs like 72 percent of service requests have been successfully
    closed by the network since launch help us know that we are moving in
    the right direction with respect to desired outcomes like improved
    health and well-being of military and veteran families in our community
    and increased cultural competency and expert companion skills across
    service providers. At this time, we recognize the need to integrate a
    holistic self-report measure that can be administered at program entry,
    during service episode(s), and post service completion to better
    understand program impact and inform program enhancements. Veterans
    Bridge Home is equipped with diverse talent, time, information,
    technology and capacity to engage in program evaluation with further
    assistance and funding. With strong existing funding partners at the
    local, State and national levels as well as generous community
    goodwill, we believe we will be able to garner the kind of support and
    funding needed to sustain measurement and evaluation capacity built
    through partnership with the VA and Federal partners as outlined in the
    proposed legislation.
        Since 2010, Veterans Bridge Home has provided ongoing leadership to
    shape and/or create six existing collaboratives across stakeholders
    which are directly aligned to the top six needs our SMVF request in the
    Charlotte market--Social Enrichment (14 percent), Employment (27
    percent), Housing (20 percent), Education (2 percent), Benefits (9
    percent), and Healthcare (8 percent). The Charlotte Veteran Network /
    Vet-Charlotte is a network of over 6,000 Veterans that spans 12
    organizations and 34 corporate affinity groups. Founded in 2010, this
    network connects socially and in service through networking, fitness
    and volunteer events. Since 2012, the Carolinas Alliance for Veteran
    Employment has grown to engage over 200 employers and 12 organizations
    in the service of getting an average of 14 veterans employed monthly.
    Housing our Heroes was established in 2014 to end Veteran homelessness
    and consists of 12 organizations that have worked together to see a
    significant decrease in homelessness. NCStrive also stood up in 2014
    and involves over eight organizations to support the resiliency and
    transition of Veteran students attending two and 4 year public and
    private institutions of higher education in the region. A VA Community
    Veteran Engagement Board was established in Charlotte in 2017 to
    improve communication between the VA and community stakeholders on
    behalf of the Veteran families it serves. In 2018, a SMVF Suicide
    Prevention Workgroup was launched and has grown to include over 150
    people across 12 VHA Programs, 19 Healthcare Entities, and 23 community
    organizations. This group has aligned itself with State and Federal
    strategies to reduce suicide among military and veteran families. VBH
    staff hold key leadership positions across these six collaboratives and
    work tirelessly with strategic partners to break down silos and be a
    bridge across systems to support military and veteran families
    holistically.
        These are all examples of the amount of services, resources, and
    efforts that are happening at the local level. VBH and similar hubs
    must engage with and facilitate relationships between these disparate
    groups to improve the overall population health outcomes of our
    Veterans and their families.
        Veterans Bridge Home is one of 17 AmericaServes networks in the
    Nation and has been leading the way in working to align national non-
    profit, local non-profit, county, State and Federal resources to
    address the needs of Veterans. We work closely with the State of North
    Carolina's Governor's Working Group to support State wide initiatives
    to support North Carolinian Service Member and Veteran Families,
    especially in the areas of Employment, Benefits, Education, Healthcare,
    and Suicide Prevention. Veterans Bridge Home staff have professional
    subject matter expertise in a variety of areas including, but not
    limited to health and human service delivery, healthcare, housing,
    employment, community engagement, public relationships. Staff are well
    positioned in a variety of key leadership roles to utilize and leverage
    further program refinement and enhancements and learning to influence
    and impact over 63 organizations in this community as well as State and
    national communities of practice.
        There are similar ``hub'' organizations in our region doing this
    critical work who know the Veterans in their area of operation as well
    as the partners and act as objective and accountable servant-leaders.
    This work requires facilitation, education, relationship management and
    continuous process improvement. Two great examples are Charlie Hall and
    the UpState Warrior Solution team in The Greenville-Spartanburg region
    doing incredible work and Scott Johnson and his team at The Warrior
    Alliance in Atlanta. Both orgs are similarly built and similarly acting
    as a bridge between their military connected families and the
    communities within which they operate. Strong relationships between our
    three markets and developing standards of care ensure that Veterans
    that move between markets are well cared for and connected as they are
    in our local market.
        With respect to the proposed legislation, we appreciate the
    Committees efforts to address the systems level work at the community
    level and would welcome the opportunity to more formally work alongside
    the VA and this legislation would be a conduit to do so. With two
    deployments to Iraq and over 13 years in the military and Veteran
    space, I have had to honor of working alongside of some of the most
    dedicated and well-trained individuals our country has to offer. I have
    seen a myriad of individuals step forward to serve those who have
    served and never back down from what is needed to make sure they are as
    successful out of uniform as they once were in uniform. The commonality
    between my time in the Army and my time in the community is that
    relationships make all the difference. Ensuring that the leaders
    closest to the problems have the resources, tools and training they
    needs as well as the connectivity to their fellow Soldiers or providers
    than amazing outcomes can be achieved. Without investing in that system
    and setting standards of care, we will not adequately combat the
    realities our Veterans and their families are facing in dealing with
    communities that are not aligned and
        Thank you for the opportunity to address you and share our
    experience on this critical challenge facing our country.
                                     ______

                   Prepared Statement of Sherman Gillums, Jr.

        Chairman Takano, Ranking Member Roe, and honorable members of the
    House Committee on Veterans' Affairs, I appreciate the opportunity to
    present AMVETS' views on H.R. 3495 and the draft ``amendment in the
    nature of a substitute'' (ANS) under consideration.
        As the largest veteran service organization that represents the
    interests of our Nation's 20 million veterans, we have prioritized
    addressing the mental healthcare crisis and suicide epidemic in our
    country. We signed a Memorandum of Agreement with the VA Mental Health
    and Suicide Prevention Office in 2018 for the purpose of better
    coordinating access to care and averting personal crises for the
    veterans we serve through our HEAL Program. Also, this month we made
    our scenario-based online crisis intervention program available to the
    public. Finally, AMVETS has steadily raised alarms regarding VA's
    approach to mental health that has fundamentally failed too many
    veterans and their families, as evidenced by statistical data.
        Our Past National Commander provided emotional oral testimony in
    March as he told the story of an AMVETS Post Commander who took his
    life in the parking lot of his post. This issue is not abstract for us.
    Nor is it driven by numbers that cast human lives as averages and
    percentages. It is very raw and real for our AMVETS family.
        In the past decade, we have lost more veterans to suicide than
    those who died in the Vietnam War. Since the start of the wars in Iraq
    and Afghanistan, we have spent more than $70 billion on VA mental
    health programs, a cost that has only grown year after year, with no
    correlating drop in the number of suicides.

        As we stated in March of this year, we must continue to confront
    the inescapable reality: VA's current efforts to curb suicide and
    expand access to mental health services have not measurably decreased
    the incidence of suicide among at-risk veterans.

        After a statistical correction led to a decrease from 22 to 20
    suicides per day, the number of veteran suicides per day remains
    stagnant. While some have chosen to view this as favorable when
    compared to the non-veteran populations, AMVETS will not subscribe to
    this tortured logic.
        Despite billions of dollars spent, new legislation proposed and
    passed, and a considerable amount of pledges and lip service in the
    form of speeches, executive orders, and other initiatives, too many
    veterans are dying by suicide at an unacceptable rate.
        Moreover, significant research has highlighted the need for new and
    more effective approaches. Yet Congress and the VA appear to have
    either turned a blind eye to this research, such as that involving
    genomic studies, peer retreats, and medical cannabis, or suffered from
    a collective failure of the imagination while doubling down on
    methodologies that have gotten us nowhere fast.

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

        Thankfully, Congress has prioritized H.R. 3495. AMVETS is
    supportive in principle of both the proposed bill and amendment under
    consideration, mainly, for the sake of progress. At a time when
    thousands of veterans continue to die by suicide, Congress cannot
    justifiably stay the course or allow partisan deadlocks to win the day.
    The expanded use of care in the community, in both traditional and non-
    traditional forms, is not a job-protecting union issue, a pro/anti-
    privatization issue, or a political issue--it is literally a matter of
    life and death. Put simply, AMVETS believes this bill needs to be a
    bipartisan game changer in the effort to curb veteran suicide.
        In general, there appears to be three points of acute interest on
    the current proposals: direct cash assistance, non-VA clinical
    treatment, and decisionmaking authority for grants. A brief discussion
    on these three points follows.

                             Direct Cash Assistance

        Providing cash payments directly to veterans who are in the midst
    of personal crises has pros and cons. Many veterans find themselves in
    dire financial straits because of their inability to manage their
    finances. Giving them money could serve to deepen their despair. Other
    veterans find themselves in financial trouble due to circumstances
    beyond their control, such as those facing mounting medical expenses or
    unemployment due to barriers to opportunities.
        Regardless of the reason, financial hardship is a common
    precipitating factor among many in suicide cases, so the focus must
    remain on saving lives first and foremost, not treating the situation
    like a credit application evaluation. Whether the moneys are given
    directly to veterans or expenses are paid on their behalf by an
    eligible entity, the focus must remain on eliminating the key
    contributory cause of suicide--lost hope.
        That could mean making financial counseling, employment assistance,
    and/or other supports that offer sustainability-focused solutions a
    part of the process. The point is helping at-risk veterans address
    short-term financial woes is an approach that must be explored,
    whatever the form happens to take. Reasonable compromises in this area
    should be made to move the bill forward.

                           Non-VA Clinical Treatment

        The problem with ``suicide'' is that the word itself catches
    everyone's attention. But it is the actions that lead up to it or
    effectively stop it that go unnoticed. There are myriad clinical and
    non-clinical interventions that have proven effective in achieving
    mental wellness for at-risk veterans. Many veterans suspect they are
    being taken through a generic checklist of protocols that fail to take
    into account their specific needs. This ``process over people''
    approach to treating a patient population with unique needs often
    rewards VA clinicians for following standards while disincentivizing
    novel or nontraditional approaches that could prove more effective, in
    the view of many veterans and advocates.
        Within the context of the proposed bill and substitute amendments,
    AMVETS remains concerned that a failure to compromise and allow for
    innovation in how ``clinical care'' is defined and coordinated at the
    local levels will only serve to exacerbate the problem. If eligibility
    for funding under H.R. 3495 is too tightly defined by traditional
    approaches, such as cognitive processing therapy and prolonged
    exposure, amongst other common treatments, then nothing will markedly
    change. However, the riskiest thing we can do is to just maintain the
    status quo.
        There's a difference between what veterans have gotten and what
    they've needed and deserved, starting with access to all possible
    pathways to wellness, not just those that fit within the boundaries of
    convention. This means offering non-traditional and alternative
    treatments, to include those that involve the intervention of non-
    clinicians and experts in peer engagement outside the clinical setting,
    which needs to be a key aim of the legislation.
        VA already spends the vast majority of funding on tradition
    methodologies, the efficacy of which has been subject to debate in the
    Journal of the American Medical Association and other studies. As such,
    AMVETS supports using this funding to support alternative, effective,
    multi-pronged, and impactful approaches that expand beyond limited and
    costly standards of care.

                      Decision-Making Authority for Grants

        This may perhaps be the most critical issue in terms of reaching a
    compromise on the language in the bill. In the proposed amendment in
    the nature of a substitute, AMVETS reads the intent to be funding
    provided by VA to ``hubs,'' presumably using pre-established screening
    and selection criteria, that will manage funding given directly to
    service providers. The alternative would be for VA to make the decision
    on funding and provide funds directly to service providers.
        Like many aspects of the bills, both approaches bear pros and cons
    to weigh. Lying anterior to the question of who will disseminate funds
    is the question of what standards will be used to decide who should get
    the funds, specifically in terms of program or service quality. All
    programs that purport to serve veterans are not created equal. Some
    services might appear ineffective but render better results than first
    anticipated while others seem effective but only because they're
    common, which is why outcomes matter most.
        Some veteran non-profits and organizations have done excellent work
    in measuring their outcomes and effectiveness while others are better
    at marketing intent than making impact. Not only should outcomes drive
    decisions about who gets funding, they also serve as the absolute best
    measure for judging whether the suicide problem is being adequately
    addressed. We can no longer allow delusions of adequacy to persist in a
    system that treats lives lost to suicide like the ``dog bites man''
    stories they have increasingly become over time for the public and our
    government. The lion's share of any funding under the measure must go
    to programs that can demonstrate sustained effectiveness in preventing
    suicide among the veterans within their reach, particularly in areas of
    the country with the highest risks, such as tribal lands and rural
    regions.
        Further, we are also concerned about the 1-year period that will be
    reportedly needed to determine needs/gaps, as well as what entities
    will qualify as the ``hubs'' that will manage funding and decide who
    will receive it for the provision of services that have yet to be fully
    determined. The number of veteran suicides exceeded 6,000 each year
    from 2008 to 2017, and the numbers have not decreased in subsequent
    years. Staring the problem in the face without meaningful action for
    another year as we, once again, focus on process instead of the people
    that are dying is unacceptable. This process needs to be as streamlined
    and free of red tape as possible so that organizations are incentivized
    to participate and veterans do not need the patience of a saint to deal
    with the system and receive potentially life-saving benefits.
        We understand that someone will have to serve as gatekeeper for the
    funds in the interest of fiscal responsibility, which means, in plain
    terms, deciding who receives funding based on a given criteria. But the
    best approach is that which does not build into the process more rules,
    contingencies, and reporting requirements than are necessary to attract
    the best and most effective non-VA service and support providers to
    augment VA's efforts.

                                   Conclusion

        Chairman Takano, Ranking Member Roe, and members of the committees,
    I would like to thank you once again for the opportunity to present the
    issues that impact AMVETS' members, active duty service members, as
    well as all American veterans. We believe we've only seen the tip of a
    huge iceberg that hides many more issues beneath the visible surface.
    But we can no longer stand for allowing a glacial pace of change to
    continue. As debate on H.R. 3495 continues, we urge you to imagine that
    the lives of those you love depend on your votes and your actions
    reflect the urgency that millions of spouses, parents, caregivers and
    peers live with every day--and tens of thousands of survivors can only
    wish had existed before they lost their loved ones.

              Sherman Gillums Jr., Chief Advocacy Officer, AMVETS

        Sherman Gillums Jr. began his military career in the U.S. Marine
    Corps at age 17, a month after his high school graduation. During his
    12 years of active service, he advanced from the junior enlisted ranks
    to a commission as an officer. He completed his career at the rank of
    Chief Warrant Officer 2 and received an honorable discharge after
    suffering a career-ending injury while preparing to deploy to Operation
    Enduring Freedom with Headquarters Battalion, 1st Marine Division.
        In 2004, Gillums began his journey in veteran advocacy as an
    accredited representative for veterans, dependents, and survivors
    seeking VA benefits in Southern California. He later worked as member
    of Paralyzed Veterans of America's Field Advisory Committee and an
    appellate representative at the Board of Veterans' Appeals in
    Washington DC. Shortly thereafter, he accepted the position of
    Associate Executive Director of Veterans Benefits in 2011 and Executive
    Director in January 2016. Gillums joined AMVETS National Headquarters
    in January 2018 and currently serves as the Chief Strategy & Advocacy
    Officer for AMVETS.
        Gillums Jr. collaterally serves as the vice chairman for the
    Federal Advisory Committee for Veterans' Family, Caregiver, and
    Survivor. He had previously served as a member of the Federal Advisory
    Committee on Prosthetics and Special Disabilities, adjunct faculty for
    the State of the Science Symposia hosted by Pittsburgh University, and
    a research reviewer for the Defense Department's congressionally
    Directed Medical Rehabilitation Program in the areas of Technology
    Development & Devices, Clinical Trials, Qualitative Research, and Early
    Acute Care and Assessment in Neuroprotection.
        Gillums has testified before Congress as an expert witness and
    appeared on CNN, Fox News, CBS News, and CSPAN as a voice for veterans.
    His opinion editorials in The Hill, Military Times, Washington Times,
    and other prominent print publications have proven influential in
    shaping policy and discourse on veterans' issues. His manuscript,
    ``Paving Access for Veterans Employment through Holistic Transition:
    Practice Implications when Working with Veterans,'' was published in
    the Journal of Applied Rehabilitation Counseling in the Spring 2016
    issue.
        Gillums is a graduate of the University of San Diego School of
    Business Administration and completed his executive education at
    Harvard Business School.

                                  About AMVETS

        AMVETS is America's most inclusive congressionally chartered
    veterans service organization. Our membership is open to both active-
    duty, reservists, guardsmen and honorably discharged veterans.
    Accordingly, the men and women of AMVETS have contributed to the
    defense our Nation in every conflict since World War II.
        Our commitment to these men and women can also be traced to the
    aftermath of the last World War, when waves of former service members
    began returning stateside in search of the health, education and
    employment benefits they earned. Because obtaining these benefits
    proved difficult for many, veterans savvy at navigating the government
    bureaucracy began forming local groups to help their peers. As the
    ranks of our Nation's veterans swelled into the millions, it became
    clear a national organization would be needed. Groups established to
    serve the veterans of previous wars wouldn't do either; the leaders of
    this new generation wanted an organization of their own.
        With that in mind, 18 delegates, representing nine veterans' clubs,
    gathered in Kansas City, Missouri and founded The American Veterans of
    World War II on Dec. 10, 1944. Less than 3 years later, on July 23,
    1947, President Harry S. Truman signed Public Law 216, making AMVETS,
    the first post-World War II organization to be chartered by Congress.
        Since then, our congressional charter was amended to admit members
    from subsequent eras of service. Our organization has also changed over
    the years, evolving to better serve these more recent generations of
    veterans and their families. In furtherance of this goal, AMVETS
    maintains partnerships with other congressionally chartered veterans'
    service organizations that round out what's called the ``Big Six''
    coalition. We're also working with newer groups, including Iraq and
    Afghanistan Veterans of America and The Independence Fund.
        Moreover, AMVETS recently teamed up with the VA's Office of Suicide
    Prevention and Mental Health to help stem the epidemic of veterans'
    suicide. As our organization looks to the future, we do so hand in hand
    with those who share our commitment to serving the defenders of this
    Nation. We hope the 116th Session of Congress will join in our
    conviction by casting votes and making policy decisions that protect
    our veterans.

      Information Required by Rule XI 2(g) of the House of Representatives

        Pursuant to Rule XI 2(g) of the House of Representatives, the
    following information is provided regarding Federal grants and
    contracts.
        Fiscal Year 2018--None
        Fiscal Year 2017--None
        Fiscal Year 2016--None
        Disclosure of Foreign Payments--None
                                     ______

                      Prepared Statement of Melissa Bryant

        Chairman Takano, Ranking Member Roe, and distinguished members of
    the Committee on Veterans' Affairs, on behalf of National Commander,
    James W. ``Bill'' Oxford, and the nearly two million members of The
    American Legion, we thank you for the opportunity to testify on H.R.
    3495, the ``Improve Well-Being for Veterans Act,'' and the veterans
    suicide crisis in the United States. As the largest patriotic service
    organization in the United States with a myriad programs supporting
    veterans, The American Legion appreciates the leadership of this
    committee in focusing on the critical issue of suicide prevention and
    improving veterans' overall well-being.

                                   Background

        The latest data on veteran suicide shows more than 6,000 veterans
    have died by suicide every year from 2008 to 2017, and in 2016, the
    suicide rate was 1.5 times greater for veterans than non-veteran
    adults.\1\ Veteran (and military) suicide is a national issue which far
    exceeds the ability of any one organization to handle alone. The
    American Legion stands behind the Department of Veterans Affairs (VA)
    in its efforts to collaborate with partners and communities nationwide
    to alleviate this public health crisis, of which veterans and military
    are a microcosm of a far greater epidemic.
    ---------------------------------------------------------------------------
        \1\  The 2019 National Veteran Suicide Prevention Annual Report
    ---------------------------------------------------------------------------
        The American Legion launched an online mental health survey in
    support of VA's public health approach to reducing veteran suicide.\2\
    It is part of the American Legion's continuing research and efforts on
    mental health issues impacting our Nation's veterans. The survey was
    created by the American Legion's TBI/PTSD Committee and was designed to
    collect data that will help The American Legion bring local resources
    related to TBI, PTSD, and Suicide Prevention to veterans and their
    families. In a yet to be released report, the data collected indicated
    only 10.29 percent of participants were ``very confident,'' they could
    connect a veteran in crisis to the appropriate resources. No veteran
    should be lost to suicide because an individual who identified them as
    ``at-risk,'' was unaware of available resources. The survey identified
    that 84.23 percent of respondents never sought mental health care from
    Vet Centers. Vet Centers are community-based counseling centers and are
    part of the VA. More than a third of respondents (39.73 percent) were
    unsure of the veteran's eligibility for VA mental health services.\3\
    ---------------------------------------------------------------------------
        \2\  Legion launches online mental health survey
        \3\  Report to be released March 2020
    ---------------------------------------------------------------------------
        Again, it is clear that there is a mental health and suicide crisis
    in the United States, and that veterans are an ``at-risk'' subset of
    the ongoing crisis. This makes it all the more important that Congress
    and VA take steps toward combatting this issue and continue looking for
    new tools to accomplish this goal. However, this does not mean rushing
    to pass legislation before it has been fully fleshed out. There is more
    work and due diligence to be done between the Committee, VA, and VSOs
    to ensure that H.R. 3495 is truly a bill which will improve the well-
    being of veterans across the Nation. To that endeavor, The American
    Legion wants to highlight two critical issues before discussing the
    ongoing debate on the proposed legislation: First, in whatever form
    H.R. 3495 becomes, it must be coordinated in concert with Executive
    Order (EO) 13861, the President's Roadmap to Empower Veterans and End
    the National Tragedy of Suicide (PREVENTS), in order to ensure that
    there are no duplicative programs which cause unnecessary confusion or
    obstruction of services to veterans.\4\ Second, it must also have clear
    metrics and evaluation criteria to not only choose grant recipients,
    but to also ensure the quality of care being given to veterans and the
    outcomes of their programs.
    ---------------------------------------------------------------------------
        \4\  Executive Order on a National Roadmap to Empower Veterans and
    End Suicide
    ---------------------------------------------------------------------------

                          Position and Recommendation

        The main point out of three questions recently raised in several
    discussions regarding this bill is whether VA should provide financial
    assistance directly to providers of non-clinical social services or
    should these funds be funneled through ``hub organizations,'' which
    coordinate services between community-based resources.
        The American Legion supports providing funds to both hub
    organizations and providers of non-clinical social services if they are
    subject to a rigorous vetting process based on clear metrics and
    evaluation criteria. The American Legion believes that a diversity of
    quality organizations providing non-clinical social services would be
    useful in combatting veteran suicide, particularly in rural and highly
    rural locations. However, any further questions on the mechanics of how
    to administer said funds and/or clinical care to support veteran
    suicide prevention through non-VA entities should be coordinated
    through existing VA programs.

                                   Conclusion

        In closing, The American Legion appreciates the leadership of this
    committee and remains committed to reducing veteran suicide. Further,
    The American Legion is committed to working with the Department of
    Veterans Affairs and this committee to ensure that America's veterans
    are provided with the highest level of support and healthcare. Chairman
    Takano, Ranking Member Roe, and distinguished members of this
    committee, The American Legion thanks this committee for holding this
    important hearing and for the opportunity to explain the views of the
    nearly 2 million members of this organization. For additional
    information regarding this testimony, please contact Mr. John Medin,
    Legislative Associate of The American Legion's Legislative Division at
    (202) 263-5756 or JMedin@legion.org

                           Statements for the Record

                                  ----------

       Prepared Statement of American Federation of Government Employees

        Chairman Takano, Ranking Member Roe, and Members of the Committee,
        The American Federation of Government Employees, AFL-CIO and its
    National Veterans Affairs Council (AFGE) appreciate the opportunity to
    submit a statement for the record on H.R. 3495, ``Improve Well-being of
    Veterans Act'' and the draft bill to establish a pilot program for the
    issuance of grants to eligible entities. AFGE represents more than
    700,000 Federal and District of Columbia government employees, 260,000
    of whom are proud VA employees.

    H.R. 3495, the ``Improve Well-Being of Veterans Act''

        AFGE strongly opposes H.R. 3495, the ``Improve Well-Being of
    Veterans Act.'' Outsourcing clinical care services for veterans at risk
    of suicide through this proposed grant program will undermine veterans'
    well-being, not improve it. The most appropriate source of clinical
    care for at-risk veterans is the VA's world-class health care system,
    including its highly regarded telemental health program and its
    Community Care Network (CCN). These clinical care services include
    direct mental health treatment, individual therapy, group therapy,
    family counseling, medication management and substance use reduction
    programming.
        Clinical care provided by grantees will be fragmented and lack the
    specialization, provider competency, coordination and accountability of
    care provided through the VA. It would be unprecedented to fund
    clinical care for veterans without any prior authorization from the VA
    but that is exactly what this grant program would do.
        AFGE welcomes the opportunity to share its ideas with the Committee
    on new ways to connect eligible veterans to the VA and expand access to
    ineligible veterans through new administrative and legislative
    initiatives. We should draw on the expertise of mental health experts
    who have studied this veteran population and the barriers to care they
    face, with the goal of ensuring that every veteran receives
    comprehensive, coordinated, world-class VA care.
        We also oppose bill provisions that give the VA Secretary the
    primary role in administration and coordination of the grant program.
    The most effective way to reach and support at-risk veterans through
    the provision of non-clinical wraparound services is by strengthening
    the role of the VA's Readjustment Counseling Service (RCS) Vet Center
    Program. RCS has the proven track record and established relationships
    in communities across the country to select grantees, oversee grantee
    outreach activities and coordinate these wraparound services with other
    community entities and VA facilities.
        AFGE has a number of other significant concerns about H.R. 3495,
    including: lack of geographic requirements, lack of fiscal controls and
    the absence of any role in the grant process for employee
    representatives of VA personnel caring for our wounded warriors.
        VA funds should never be used to duplicate or supplant existing,
    high quality VA health care services but that is exactly what could
    occur under this grant program. There are absolutely no geographic
    restrictions on the location of grant organizations. Under this bill, a
    grantee right next door to a VA medical center could provide the same
    clinical care services a veteran could get (and at much higher quality)
    at the VA. While this bill may claim to be targeting hard to reach
    veterans in remote areas, it would also allow a grant to be awarded in
    a major city.
        The lack of fiscal controls in this bill are also very troubling.
    There are two major areas of concern. First, the maximum grant amount
    is left totally up to the discretion of the Secretary. This would allow
    a large national organization that can exert a lot of influence in the
    grant selection process to receive a large share of the grant funds
    even though they would be better allocated to a greater number of small
    community-based organizations. Second, the bill does not place any caps
    on the percentage of funds than can be spent on large CEO salaries and
    other indirect costs instead of on direct veteran services. This
    potential CEO slush fund is contrary to the requirements of Federal
    contracts which have strict caps on indirect costs. Veterans' well-
    being, not CEO pockets, should always be the priority of VA suicide
    prevention services.
        Finally, absent from the long list of entities who the Secretary
    shall consult under this bill are the labor representatives of the very
    people who are on the front lines of the VA every day providing
    clinical care and wraparound services to veterans. More than one-third
    of the VA workforce are veterans, including many who use VA health care
    themselves. Their unique expertise, personal perspective and their
    ability to hold the VA accountable for mismanagement make them and
    their labor representatives essential to any grant oversight group.

    Draft bill to establish a pilot program for the issuance of grants to
        eligible entities

        AFGE commends Chairman Takano for his draft bill to establish a
    grant program for at-risk veterans. It addresses significant concerns
    already addressed. Most important, it would fund a wide array of non-
    clinical services while prohibiting the use of any funds on clinical
    care or cash assistance. The VA, its telemental health program and CCN
    should be the sources of clinical care for all veterans, and we should
    work together to ensure that more veterans use and are eligible for
    this far superior care. Similarly, cash assistance is already available
    when appropriate through community-based programs that have proven
    track records with Vet Centers.
        We also strongly endorse the draft bill's provisions that make the
    VA's Readjustment Counseling Services and its Vet Centers the grant
    program administrator and coordinator. Veterans across the country
    already turn to Vet Centers for direct care and wraparound services,
    and the longstanding relationships between Vet Centers and community-
    based organizations will ensure quicker program startups, the provision
    of better services and greater accountability for the use of grant
    funds.
        The draft bill encourages more effective allocation of grant
    dollars and provides safeguards against misuse of grant funds. The
    draft bill also sets a dollar cap on first year and second year grant
    and requires organizations to have matching funds which is a valuable
    screening tool for identifying entities with a strong financial track
    record. In addition, grant applicants are required to specify the
    amount of grant funds to be made available to community partnerships
    and the financial controls that will be put in place to track the
    expenditure of grant funds. The draft bill includes critical reporting
    requirements regarding the use of funds for executive compensation,
    overhead costs and other indirect costs.
        AFGE also appreciates that the draft bill includes labor
    representatives of front-line VA employees in the working group that
    will consult with Readjustment Counseling Services on administration of
    the grant program.

    Conclusion

        AFGE has discussed the aforementioned concerns with the Committee
    and we hope to continue to work together to ensure that the best
    interests of at-risk veterans are well served. AFGE urges the Committee
    in the strongest possible terms to oppose H.R. 3495 as drafted.
        In addition, AFGE wants to work with the Committee to identify the
    most effective, least risky ways to fill existing gaps in direct care
    and wraparound services. The VA has already expanded access to those
    with other than honorable discharges; it can do more to fund and expand
    these services. The VA is the Nation's leader in telemental health; it
    can do more to increase use of its unique services to veterans who face
    challenges coming to VA facilities. The VA already has a strong family
    counseling program and clinician training program; it can do more to
    expand services to family members by adding spouse-only therapy and
    filling the over 40,000 unfilled VA health care positions. The VA's Vet
    Centers already work with strong community-based organizations to reach
    out to isolated at-risk veterans; a strong grant program administered
    by Vet Centers themselves will make outreach more effective. VA mental
    health professionals and researchers already work with other experts to
    identify and address barriers that keep veterans from seeking care at
    the VA; with the help of well-managed community-based outreach groups,
    they can do more.
        Fragmented care and unrestricted grants to unknown providers and
    outreach organizations through H.R. 3495 are not in the best interests
    of veterans and will cause us to miss the opportunity to work
    collaboratively and creatively to save more lives. The VA treats the
    whole veteran and is the national model of integrating primary care and
    mental health care; every veteran deserves that high level of care. The
    VA is by far the most cost-effective source of health care in our
    country.
        Thank you.
                                     ______

                 Prepared Statement of Veterans of Foreign Wars

        Chairman Takano, Ranking Member Roe, and members of the committee,
    on behalf of the men and women of the Veterans of Foreign Wars of the
    United States (VFW) and its Auxiliary, thank you for the opportunity to
    provide views on H.R. 3495, Improve Well-Being for Veterans Act, and
    related amendments.
        Suicide among America's veterans is a serious and stubbornly
    persistent issue. Tragically, 16.8 veterans completed suicide in 2017,
    which was an increase from previous years. We also know that there are
    undoubtedly more who attempt but do not complete the act. Thanks to
    recent Department of Veterans Affairs (VA) efforts, we have data that
    gives us a better picture of what populations of veterans are
    completing suicide. Veterans represent approximately 22 percent of U.S.
    suicides; younger veterans have a higher rate of suicide but veterans
    over 60 years of age account for the most suicides; veterans over 50
    years of age account for 65 percent of veterans completing suicide;
    around 62 percent of veterans completing suicide have not been seen by
    the Veterans Health Administration (VHA) in the year of or year
    preceding their suicides.
        The VFW is supportive of the intent of H.R. 3495, Improve Well-
    Being for Veterans Act, to utilize non-VA affiliated community programs
    to reach veterans not currently being seen by VA. This concept has been
    advocated by VA in the National Strategy for Preventing Veteran Suicide
    promulgated by the VA Office of Mental Health and Suicide Prevention,
    to wit ``A wide range of community partners also have an important role
    to play in delivering prevention programs and services to Veterans at
    the local level.''
        The VFW does not agree, however, with the inclusion of clinical
    care in the services covered under the grant program established by
    H.R. 3495. Suicide prevention efforts are often focused on clinical
    factors that lead to veteran suicide, such as drug or alcohol
    dependency, post-traumatic stress disorder (PTSD), traumatic brain
    injury (TBI), and others. We know that veterans who use VA health care
    have access to such clinical programs, but do not know if lack of
    access to clinical care is a contributing factor in suicides among
    veterans who do not use VA health care.
        We do know that VA, other public health care options, and private
    sector health care providers do not always provide access to services
    and programs that address the non-clinical factors of suicide, such as
    life skills, financial instability, housing instability, and emotional
    issues that frequently need to be addressed. These factors often
    coincide and a suicidal act is the culminating event in a chain of
    issues that have developed over time. The National Strategy for
    Preventing Veteran Suicide (National Strategy) recognizes as much,
    saying, ``In addition, many risk factors related to suicide are
    influenced by community and societal factors outside the bounds of VA's
    influence. This will require VA to reach beyond the health care
    setting, through which it has traditionally supported Veterans' health,
    and empower actors to prevent Veteran suicide in other sectors.''
        The VFW has recognized the need to cast a broad net in the
    community as well. The VFW is proud to have partnered with VA and
    community and corporate partners through the VFW Mental Wellness
    Campaign. The campaign raises awareness of mental health conditions,
    fosters community engagement, improves research, and provides
    intervention for those affected by invisible injuries and emotional
    stress. Since September 2016, more than 300 VFW posts around the world
    and 13,000 volunteers have successfully reached 25,000 people in three
    ``Day to Change Direction'' events hosted in partnership with Give an
    Hour's Campaign to Change Direction.
        The purpose of the VFW's Mental Wellness Campaign is to teach
    veterans and caregivers how to identify when they or their loved ones
    are experiencing the signs of emotional suffering--personality change,
    agitation, being withdrawn, poor self-care, and hopelessness--as well
    as promote emotional well-being. In an effort to destigmatize mental
    health, participants learn that mental health conditions such as PTSD
    are common reactions to abnormal experiences.
        The VFW's worldwide cadre of VFW-accredited Veterans Service
    Officers helps veterans and their families as they seek care or
    benefits from VA, and navigate issues and roadblocks. The VFW's Unmet
    Needs program also assists active-duty service members, veterans, and
    their immediate families to assist with basic life needs by providing
    grants and referrals to other organizations. However, those assisted do
    not receive cash directly; the Unmet Needs program makes payments
    directly to creditors. The VFW National Home for Children provides
    active-duty military personnel, veterans, and relatives of VFW and VFW
    Auxiliary members case management services to help families set up
    their plans and goals for the future; educational, recreational, and
    enrichment opportunities; community resources and counseling; and free
    housing and daycare.
        The VFW does not receive Federal funds for any of these programs.
    However, these are among the types of programs that H.R. 3495 must
    support, and the VFW believes in the efficacy of these programs to
    alleviate stressors on veterans and their families. These kinds of
    emotional, financial, housing, and familial stressors are cited as
    potential precursors to suicide attempts. Complementary and integrative
    health programs that have shown evidence of improving the non-clinical
    stressors that contribute to suicide, such as mindful meditation, must
    also be included. We believe that the programs mentioned above are of
    the kind envisioned in Objective 1.4 of the National Strategy for
    Preventing Veteran Suicide: ``Promote the development of sustainable
    public-private partnerships to advance Veteran suicide prevention. In
    addition, VA encourages creation of public-private partnerships that
    focus specifically on preventing Veteran suicide at the local, state/
    territorial, and national levels.''
        The broad nature of the services eligible for grants under H.R.
    3495 will allow for grants to many programs and organizations not
    previously seen in the VA pantheon. Because of the new territory being
    covered, the VFW believes that the legislation creating any community
    grant program and regulations implementing such a program must:

          Focus on non-clinical social factors of suicide
    prevention and protective factors for suicide to include positive
    coping skills, having reasons for living or a sense of purpose in life,
    and feeling connected to other people.

          Facilitate access to mental health care, excluding
    clinical care except in case of emergency.

          Complement and supplement VA suicide prevention efforts.

          Accord with VA's focus on evidence-based suicide
    prevention programs.

        The grant program as written in both bills is still too amorphous.
    The VFW urges the committee to amend the scope of the grant program to:

          Define the population the grant program will target, to
    include service members who do not meet VA's definition of veteran.

          Restrict funding of clinical care solely to emergency
    care.

          Identify clinical care options, if necessary, for the
    population engaged, including a warm handoff to VA for those eligible
    or to other health care options for those not eligible.

          Require the establishment of strong metrics before VA
    awards grants that capture definable measures of success and can serve
    as indicators of therapeutic modalities that should receive further
    funding and study.

        Without both strong, well-defined criteria for programs that will
    receive grant awards and strong, well-defined metrics of success, the
    program envisioned under H.R. 3495 risks conflating a flurry of
    activity with achievement.
        The Supportive Services for Veteran Families (SSVF) grant model
    upon which H.R. 3495 is based has very clearly defined success
    criteria. From the VA's website, SSVF ``support[s] outreach, case
    management and other flexible assistance to rapidly re-house Veterans
    who become homeless or prevent Veterans from becoming homeless.'' Put
    more simply, the success criteria for SSVF is that formerly homeless
    veterans are no longer homeless. That is a straightforward metric.
    Because one cannot prove a negative, services that are meant to
    ameliorate suicide factors and prevent suicide cannot be measured
    against an obvious, simple standard. However, the stated goals of H.R.
    3495 are to alter negative circumstances and connect with veterans who
    are not engaged with VA. Therefore, success must be defined through
    effectiveness in addressing the supportive factors identified, and
    facilitating connection to and utilization of continued services
    provided by VA or other entities as appropriate.
        VA has done excellent work on clinical factors that contribute to
    suicide, such as genetic markers, PTSD, TBI, and even insomnia. The
    grant program proposed under H.R. 3495 should not be used to research
    clinical topics, but for the goal stated by VA leadership and the
    bill's sponsors--to reach the oft-cited 10-veteran cohort not engaged
    with VA and those who have served and are commonly viewed as veterans
    but who are ineligible to use VA. That is why the VFW opposes the use
    of grants under H.R. 3495 to provide clinical care, except in an
    emergency. VA has an established health care system. With the MISSION
    Act, VA has a standardized process to appoint eligible people to
    providers in the community. The VFW believes that eligible people
    should use VA care programs--either VA direct care or VA community
    care--as a matter of course. For consistency and clarity of purpose, VA
    must use these resources as intended.
        If the goal of H.R. 3495 is to ``catch'' veterans in the community
    who are not using VA with a safety net of VA grant-supported community
    programs, the question becomes what to do with the cohort once they
    have been identified? For the VFW, the answer is obvious--connect them
    with VA or health care options for which they are eligible, such as
    TRICARE, Medicare, or employer-sponsored insurance. VA has wraparound
    services that already exist and are funded. H.R. 3495 must not set up a
    parallel track of community providers that supplant VA in provision of
    services. The grants distributed under H.R. 3495 should complement VA
    capabilities to deliver supportive services where applicable and
    supplement VA capabilities where necessary. A grantee that encounters a
    veteran in need of routine mental health care should connect that
    veteran to a local VA medical facility or help the veteran to find
    health care options under a health plan for which the veteran is
    eligible.
        To summarize, the VFW applauds and accepts the stated goal of H.R.
    3495 to engage eligible people who are not utilizing VA services
    through resources in their communities. The purpose of the program,
    criteria for grants, and metrics for success must be strong and clearly
    defined. H.R. 3495 cannot create an alternate path for clinical care or
    supportive services in the community for those eligible to use VA.
    Community services should complement and supplement VA efforts and
    services, and serve as an entryway to VA benefits accompanied by a warm
    handoff. Grants established by H.R. 3495 should not be clinically
    focused, but focused on the protective factors for suicide identified
    by the VA Office of Mental Health and Suicide Prevention: positive
    coping skills, having reasons for living or a sense of purpose in life,
    feeling connected to other people, and others (such as housing,
    financial, and relationship stability and access to education and
    training), as well as access to mental health care through appropriate
    channels.
        The VFW stands ready to assist in the reduction of veteran suicides
    and helping veterans connect and thrive in their communities through
    service. The VFW is willing and able to share its experience in
    assisting veterans through our well-established programs such as Unmet
    Needs and the VFW National Home for Children, and the activities of our
    National Veterans Service.
                                     ______

              Prepared Statement of Paralyzed Veterans of America

        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 pending legislation impacting
    the Department of Veterans Affairs (VA) before the Committee today. PVA
    is proud of its rich history and no group of veterans understand the
    full scope of care and benefits provided by the VA better than PVA's
    members--veterans who have incurred a spinal cord injury or disorder
    (SCI/D), such as Amyotrophic Lateral Sclerosis (ALS).
        We also thank the Committee for last week's roundtable discussion
    on H.R. 3495, the ``Improve Well-Being for Veterans Act.'' Too many
    service members and veterans are dying by their own hand; so, we
    applaud you and the VA for trying to provide veterans with additional
    treatment options to meet their needs and combat their struggles.
    However, we remain concerned that unless veterans are offered evidence-
    based solutions, many of the programs funded by this legislation will
    have little effect on the problem, and waste precious resources.
        To be clear, PVA supports the intent of having VA coordinate with
    Federal, State, and local agencies, as well as private and not-for-
    profit organizations, to combat the epidemic of veteran suicide. We
    believe that legislation focused on assisting veterans at risk for
    suicide should concentrate on identifying those who are not enrolled in
    the VA health care system and assessing their needs. Unfortunately, the
    language in H.R. 3495 is too broad and it needs to be constricted to
    ensure limited resources are directed toward quality programs with
    proven results that can be monitored and assessed on a periodic basis.
    Furthermore, the lack of detail in this legislation makes it difficult
    to gauge its potential benefit for our membership. For example, are
    these programs going to be accessible to veterans with significant
    disabilities? If they are, what is the referral process if a community
    provider encounters a veteran with a spinal cord injury or disorder
    (SCI/D) who is in crisis?
        With this in mind, PVA makes the following recommendations which we
    believe will strengthen the legislation.
        1. PVA does not believe extending clinical care to veterans through
    non-VA providers outside of the Community Care Network is appropriate
    at this time. Instead, there should be greater effort by VA to increase
    its internal capacity to provide mental health care services in
    accordance with Section III of P.L. 115-182, the VA MISSION Act of
    2018.
        2. Many organizations claim to have programs that are designed to
    reduce veteran's risk of suicide, but they lack the empirical data to
    support their assertions. Before an eligible entity can receive a
    grant, they should be required to provide evidence-based, scientific
    data that shows how any services being offered will reduce rates of
    suicide.
        3. The goal of the grant program should be to identify veterans who
    are not connected with VA, assess and assist them with their immediate
    needs, and if they meet eligibility requirements, to help reconnect
    them with VA, which is better equipped to address their long-term
    health care, economical, and educational needs. We do not believe that
    the provision of temporary cash assistance through grantees is an
    appropriate use of resources.
        4. Before a grantee is approved to participate in the program, they
    should be required to submit a detailed plan that addresses the
    following:

            a. The kinds of assistance the grantee is offering.

            b. The number of staff supporting the program.

            c. The number of veterans they can assist at any given time.

            d. A demonstrated capability to assist catastrophically
            disabled veterans and those with significant disabilities. The
            plans should also State how referrals for these individuals
            will be handled.

            e. How the assistance being offered will meet the veteran's
            needs, and most importantly, help them achieve and then sustain
            a healthy lifestyle that can lead to a fulfilling life.

            f. The length of time that services will be required, e.g., up
            to 12 visits over a 6-month period.

            g. A detailed plan on how they intend to conduct one-on-one
            engagement with veterans.

            h. A plan for documenting each veteran's progress that
            increases the likelihood that services being provided can/will
            meet the agreed upon objectives.

            i. In the event the services offered did not meet the
            veterans's expectation, what (if any) avenues of recourse they
            have.

        5. Because VA is the payer of these services, they retain the
    responsibility to ensure that care and services being provided by
    grantees meet pre-established standards. PVA believes each beneficiary
    should be assigned a VA case manager who will be required to monitor
    the beneficiary's progress. When the case manager determines the
    desired outcomes are not being met, they can make recommendations to
    include terminating the services, if necessary.
        We readily stand behind any effort to improve health care for all
    veterans but remain concerned about the ability of VA to continue to
    meet the health care needs of the most vulnerable veteran populations,
    such as those with SCI/D and polytrauma. Specialized services are part
    of the core mission and responsibility of VA. As the Department
    continues its trend toward greater utilization of community care,
    Congress must be cognizant of the impact these decisions may have on
    veterans who need the level of complex care that only VA can deliver.
    Under no circumstances should funding the programs in H.R. 3594, the
    proposed amendment, or other similar legislation undermine VA's ability
    to provide foundational care and services for all veterans with serious
    disabilities. VA must receive a dedicated, robust funding stream to
    ensure its core functions are not impaired in any way.
        PVA would once again like to thank the Committee for the
    opportunity to submit our views on the legislation considered today and
    are committed to working with you to develop a package that will
    improve the health and well-being of all America's veterans.

      Information Required by Rule XI 2(g) of the House of Representatives

        Pursuant to Rule XI 2(g) of the House of Representatives, the
    following information is provided regarding Federal grants and
    contracts.

    Fiscal Year 2020

        Department of Veterans Affairs, Office of National Veterans Sports
    Programs & Special Events--Grant to support rehabilitation sports
    activities--$253,337.

    Fiscal Year 2019

        Department of Veterans Affairs, Office of National Veterans Sports
    Programs & Special Events--Grant to support rehabilitation sports
    activities--$193,247.

    Fiscal Year 2018

        Department of Veterans Affairs, Office of National Veterans Sports
    Programs & Special Events--Grant to support rehabilitation sports
    activities--$181,000.

                         Disclosure of Foreign Payments

        Paralyzed Veterans of America is largely supported by donations
    from the general public. However, in some very rare cases we receive
    direct donations from foreign nationals. In addition, we receive
    funding from corporations and foundations which in some cases are U.S.
    subsidiaries of non-U.S. companies.
                                     ______

         Prepared Statement of Iraq and Afghanistan Veterans of America

        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
    today.
        The Campaign to Combat Suicide is an incredibly important part of
    our work. It is the top priority in our Big Six Priorities for 2019,
    which also include: Defense of Education Benefits, Support and
    Recognition of Women Veterans, Government Reform for Veterans, Support
    for Injuries from Burn Pits and Toxic Exposures, and Support for
    Veteran Medicinal Cannabis Use.
        Unfortunately, IAVA members know this issue all too well. According
    to our latest Member Survey, 59 percent of our respondents knew a post-
    9/11 veteran who died by suicide. Additionally, 65 percent knew a post-
    9/11 veteran who attempted suicide and over 75 percent believed that
    the Nation is not doing enough to combat military and veteran suicide.
        This is why for nearly a decade, IAVA and the veteran community
    have called for immediate action by our Nation's leaders to
    appropriately respond to the crisis of over 20 military and veterans
    dying every day by suicide. Thanks to the courage and leadership of
    veterans, military family members, and our allies, there has been
    tremendous progress. The issue of veteran suicide is now the subject of
    increased media coverage, there is a reduction in stigma for seeking
    treatment, and there is a surge of government, non-profit, and private
    support. Despite this progress, however, we are not seeing improvement
    in the numbers. We are still losing an astonishing number of veterans
    to suicide each day and that needs to change urgently.
        IAVA thanks the committee for bringing both H.R. 3495 and the
    Discussion Draft forward for discussion today. Grants can be powerful
    tools for VA to use to reach populations of veterans that they would be
    otherwise unable to reach. The majority of veterans that die by suicide
    each day are not currently connected to the VA system; grants are
    another means to bring those veterans into VA and ensure that they are
    getting the care that they have earned and deserve. That is why IAVA
    worked closely with Senate Veterans Committee Ranking Member Jon Tester
    to create a provision in the Commander John Scott Hannon Veterans
    Mental Health Care Improvement Act (S. 785) that would allow a grants
    program, much like the ones proposed here today. It is also important
    to note that while we are supportive of grant programs, we believe that
    VA must remain central to the care of the veteran. VA is uniquely
    structured to provide care for veterans, and more importantly, veterans
    like the care that they receive from VA. According to our latest Annual
    Member survey, a resounding 81 percent of IAVA members rate VA health
    care as average or above average. This program should enhance the
    capability and capacity of the VA, not undermine it.
        While IAVA is supportive of grant programs to increase veteran
    outreach and care, IAVA also understands that these programs must be
    carefully administered in order to ensure that grant funds are being
    received by those most in need. It is to that end that while IAVA fully
    supports the intention of the Discussion Draft in front of the
    Committee today, we also have some concerns over the current language.
        First, IAVA is concerned with the ability of Vet Centers to
    administer the grant program. While Vet Centers are uniquely positioned
    inside communities and can currently offer referral services to other
    community providers, they are not set up to provide grants to their
    community partners. IAVA is concerned that their administration of
    grants could potentially harm their relationship with those important
    community partners. While the administrator of these grants could and
    should work with local Vet Centers, by elevating that authority out of
    the Vet Center we can also ensure that the program is administered by
    officials with experience in dealing with the intricacies of grant
    programs.
        Additionally, IAVA is concerned by starting a pilot program as laid
    out in the Discussion Draft with only 10 organizations. While we
    appreciate the intent behind the low number to start, IAVA has concerns
    that with only 10 organizations receiving grants, coupled with the
    application requirements, there may be too high of a barrier to entry
    for emerging or less established hubs that wish to work in this space
    to receive these important grants. IAVA believes that a potential fix
    for this issue would be to create two separate funding streams, one for
    established hubs that are already providing services outlined in the
    Discussion Draft, and another funding stream to support organizations
    that wish to create the necessary technical and developmental expertise
    in areas where they might otherwise not exist, such as rural states.
    IAVA believes that this would serve to both support organizations that
    are already established, but also truly expand the number of hubs
    available as viable resource centers around the country. IAVA believes
    that by providing two separate funding streams VA could support both
    small, emerging hubs, and large hubs simultaneously.
        IAVA also suggests that an addition of a universal data sharing
    platform would ensure that all hubs and community partners are able to
    share best practices and also identify veterans that might be at high-
    risk of suicide, similar to the highly successful Supportive Services
    for Veterans Families (SSVF) grants. SSVF grants were created to
    address the national veterans homelessness crisis. When VA partnered
    with local programs that are currently working with homeless
    populations `on the ground,' they were able to significantly reduce
    veteran homelessness. IAVA believes that similar models can be created
    to not only identify, but also increase the VA's ability to reach high-
    risk veterans, and in turn better address the veteran suicide crisis.
    By creating similar data sharing platforms for veterans at risk of
    suicide, organizations working with high-risk populations would better
    understand where to refer veterans in crisis if they themselves are
    unable to help, ensuring that no veteran in crisis is ever turned away.
        IAVA thanks the committee for their commitment to helping solve the
    veteran suicide crisis. The time to act is now. However, we also
    understand the need for data in order to make the most informed
    decisions. IAVA urges any grants program to have robust metrics in
    order to track outcomes and ensure that VA is using their limited
    resources in the best possible way. The goal of any grant program to
    address this epidemic should be a focus on simplicity, accessibility,
    and accountability.
        Members of the Committee, thank you again for the opportunity to
    share IAVA's views on these important issues today. I look forward to
    working with the Committee in the future.

                            Biography of Travis Horr

        Travis Horr serves as Director of Government Affairs, assisting in
    IAVA's advocacy efforts in Washington, D.C. Prior to IAVA, he worked at
    a consulting firm, as well as political campaigns in both Maine and
    Delaware. Travis served in the Marine Corps Infantry for 4 years and
    was stationed at Marine Barracks 8th & I in Washington D.C., and Camp
    Pendleton, CA. He deployed to Helmand Province, Afghanistan in 2010 in
    support of OEF. Travis is a Maine native and graduated from the
    University of Southern Maine with a B.A. in Political Science with
    Honors utilizing the Post-9/11 GI Bill.
                                     ______

      Prepared Statement of National Organization of Veterans' Advocates,
                                Inc. & Partners

        Chairman Takano, Ranking Member Roe and Members of the Committee:
        On behalf of our organizations, we thank you for the opportunity to
    submit a statement for the record on the Improve Well-Being for
    Veterans Act. As a collective group who has previously presented
    statements for the record to your Committee, we want to convey our
    appreciation for your leadership on this issue and the Committee's
    commitment to ensure the provision of life-saving services for our
    nations' veterans.
        The Improve Well-Being for Veterans Act would provide pilot funds
    to non-VA entities to offer suicide prevention services to veterans who
    are not using VA healthcare and/or live in geographic areas where the
    risk of suicide is high. It emphasizes a Public Health Model to prevent
    suicide by attending to the full spectrum of social needs--housing,
    employment, relationships, transportation, finances and legal. We
    concur that expansively addressing social risk factors may
    substantively reduce suicide.
        However, the same is not the case for clinical care. Establishing a
    mental health care delivery lane outside of the VA and Community Care
    Network (CCN) would have multiple deleterious impacts, as we identify
    below. We also provide recommendations that could enhance suicide
    prevention efforts.

    The Consequences of Establishing An Outside Lane to Provide Clinical
        Care.

        Under MISSION Act directives, non-VA providers may join the CCN to
    deliver clinical care to at-risk veterans and their families. Since CCN
    is already a pathway for providers, eating another outside system for
    the provision of clinical care would potentially have three deleterious
    consequences:

        1. It would duplicate and erode the mental health care offered by
    VA and CCN.

        Funding non-VA clinicians outside the CCN to provide direct mental
    health treatment, individual therapy, group therapy, family counseling,
    medication management and substance use reduction programming
    duplicates the clinical mental health care offered by VA and CCN.
        Care is targeted in the same geographic locations as VA facilities.
    There is no requirement that entities focus efforts in locations beyond
    the geographic reach of existing VA facilities where care is scarce. On
    the contrary, providers can be located close to VA Medical Centers, VA
    Community Based Outpatient Clinics, Vet Centers and CCN providers.
        For those veterans who distrust the government or are reluctant to
    seek mental health help at a VA facility, there are over 300 Vet
    Centers and 80 mobile Vet Centers available throughout the country.
    More can be added if there is a need.

        2. It would lower the bar for outside providers' qualifications,
    quality of treatment and tracking of relevant outcomes.

        There is no requirement that entities be held to comparable (or
    any) standards of mental health or suicide prevention training,
    provider qualifications or documented best practices to which VA holds
    itself.
        It does not require entities to render services in a timely manner,
    which is mandated in the VA and is crucial for responding to at-risk
    populations.
        Critically important is the fact that there is no requirement that
    entities track and report on suicide attempts of veterans who receive
    their services, as is mandated in the VA, and is the stated purpose of
    the legislation.
        There is no requirement that, in order to receive grants, entities
    have to show a previous track record for measuring successful outcomes
    of their services. They only have to demonstrate throughput.
        Non-VA entities are not capable of using VA's big-data predictive
    analytics REACH VET to prospectively identify individuals who are at
    the very highest risk of suicide.

        3. It would undermine VA's model of providing health care.

        Private sector clinical care would not require VA pre-
    authorization. That plan begins to replace VHA as a health care
    provider system, transforming it into an insurance provider.
        With no parameters for co-payment responsibility, clinical care is
    permitted to be provided for free. While that's laudable, it competes
    with and subverts the basic VA system for veterans' priority group
    eligibility and co-payment.
        By creating a third lane of providing clinical care outside of VA
    and CCN, providers in the community would be incentivized to leave the
    CCN or never join it in the first place. That erodes the whole intent
    of the MISSION Act to create one overarching, coordinated program.
        It covers some veterans/families receiving mental health services
    in the community but not at a VA facility. If the goal is to ensure
    that mental health care is available to all veterans/family members
    (including Priority Category 8), the VA should be allowed to open its
    doors to these veterans/families as has occurred with transitioning
    service members (Presidential Executive Order 13822), military veterans
    who served in combat, and Other Than Honorable (OTH) administrative
    discharged veterans.

    Further Recommendations to Improve Delivery of Mental Health Care and
        Suicide Prevention Efforts for At-Risk Veterans

        1. Better understand the veterans who die by suicide.

        Very little is understood about the 11of 17 veterans who die by
    suicide daily who do not use VA. It is not known whether they are
    already receiving mental health care in the private sector, lack
    knowledge about VA eligibility, or would refuse care in or outside the
    VA even if offered. To be better able to target interventions for
    veterans not using VA who die by suicide, perform a Behavioral Health
    Autopsy of every veteran suicide, especially veterans who don't use the
    VA.

        2. Facilitate greater access to VA.

            a. Educate and assist newly separated service members. Veterans
            who do not seek VA mental health care were studied extensively
            last year in the National Academies of Sciences, Engineering
            and Medicine Evaluation of the Department of Veterans Affairs
            Mental Health Services.\1\ It found that the top reasons that
            veterans with a mental health need do not seek VA care include
            that they (a) lack knowledge of how to apply for VA benefits
            (42 percent of survey respondents), (b) lack certainty whether
            they are eligible for or entitled to mental health care (40
            percent), (c) lack awareness that the VA offers mental health
            care (33 percent), or (d) did not feel they deserved to receive
            mental health benefits (30 percent). We support implementing
            the National Academies' recommendations for facilitating
            greater access to VA mental health care by eliminating barriers
            to accessing care, expanding outreach efforts, enhancing
            awareness campaigns of VA eligibility criteria and mental
            health care services, setting up initial VA health appointments
            as part of the Transition Assistance Program and providing
            liaisons to assist throughout the transition process.
    ---------------------------------------------------------------------------
        \1\  Evaluation of the Department of Veterans Affairs Mental Health
    Services. The National Academies of Sciences, Engineering and Medicine.
    The National Academies Press, Washington, DC. 2018 http://
    nationalacademies.org/hmd/Reports/2018/evaluation-of-the-va-mental-
    health-services.aspx

            b. Enhance capacity. For locations where VA/CCN mental health
    ---------------------------------------------------------------------------
            services capacity is lacking, build more capacity.

            c. Correct myths that hinder veterans seeking VA care. Veteran
            suicide would be significantly reduced by correcting the false
            belief among many veterans that ``the VA wants to take away our
            guns.'' If that misperception were replaced with an accurate
            message, more at-risk veterans would seek out mental health
            care. Establish a workgroup that includes gun constituencies to
            champion such a shift.

            d. Increase the number of video-reception sites where veterans
            could access care via VA telemental health, particularly in
            rural areas (e.g. VFW posts, Community Mental Health Centers).

        3. Establish suicide outcome measures.

        Entities should be required to track and report suicide attempts of
    veterans receiving their services, including for 6+ months post-
    treatment.

        4. Measure success of referring veterans to VA care.

        Entities should be evaluated for their success in referring at-risk
    veterans to the VA for clinical care. VA suicide prevention services
    remain the best in class.\2\
    ---------------------------------------------------------------------------
        \2\  Veteran Suicide Prevention Annual Report, (September 2019).
    U.S. Department of Veterans Affairs, Office of Mental Health and
    Suicide Prevention, https://www.mentalhealth.va.gov/docs/data-sheets/
    2019/2019_National_Veteran_Suicide_Prevention_Annual_Report_508.pdf

    ---------------------------------------------------------------------------
        5. Ensure quality across the system.

        Require that provider qualification and service delivery standards
    in non-VA entities be equal to those used in the VA.

    Conclusion

        The provision of grants that address social risk factors may
    substantially help prevent veteran suicide. However, clinical care for
    at-risk veterans is best provided by utilizing and expanding VA/CCN's
    existing infrastructure. Non-VA mental health care providers should be
    encouraged to join CCN. Creating another outside care delivery system
    for non-VA providers would have multiple deleterious effects.

        We thank you for the opportunity to provide our perspective on this
    urgent matter.

        Contacts:
        American Psychological Association hkelly@apa.org
        Association of VA Psychologist Leaders president1@avapl.org
        Association of VA Social Workers president@vasocialworkers.org
        Nurses Organization of Veterans Affairs tmorris@vanurse.org
        Veterans Healthcare Policy Institute
    execdirector@veteranspolicy.org
                                     ______

       Prepared Statement of Institute of Veterans and Military Families

        The Institute for Veterans and Military Families (IVMF) at Syracuse
    University is grateful to Chairman Takano, Ranking Member Roe, and the
    Members of the Committee for the opportunity to submit written
    testimony on the subject of H.R. 3495 and related Draft bill, to
    establish a pilot program for the issuance of grants to eligible
    entities to provide and coordinate the provision of suicide prevention
    services for veterans at risk of suicide, and in support of veteran
    families.
        The research and programmatic efforts of the IVMF, over the past
    decade, have generated actionable insights into the social and economic
    determinants of veteran health and wellness, particularly as impacted
    by the service member's lived experience navigating the transition from
    military to civilian life. Since 2014, the IVMF has been meaningfully
    engaged in work aimed at improving the coordination of services for
    veterans and military families. Through the AmericaServes initiative,
    over 1,000 participating organizations in 17 communities across the
    country have helped over 30,000 veterans, transitioning service
    members, and spouses with over 65,000 requests for services, resources,
    and care. Given that the average client seeks assistance with at least
    two service requests, it has been essential for communities to have
    hubs empowered with the responsibility to facilitate efficient and
    appropriate referrals among a network of organizations spanning health
    and social service domains.
        Central to the mission of the IVMF is the idea that the lived
    experiences of those who undergo transition from military to civilian
    life are critical to the long-term health and happiness of veterans and
    their families. Veterans and families who undergo successful transition
    are more likely to experience post-service health and prosperity.
    Conversely, a negative transition experience is highly likely to set a
    veteran and the veteran's family on a compromised trajectory from which
    it is difficult to recover.\1\ Additionally, circumstances and events
    occurring before, during, and after service may contribute to the
    stressors associated with suicidal ideation (financial instability,
    social disconnectedness, etc.).
    ---------------------------------------------------------------------------
        \1\  Sonethavilay, H., Maury, R. V., Hurwitz, J., Linsner Uveges,
    R., Akin, J., De Coster, J. L., & Strong, J. D. (2018). Military Family
    Lifestyle Survey. Blue Star Families. Retrieved from https://
    bluestarfam.org/survey
    ---------------------------------------------------------------------------
        With this context in mind, it is the belief of the IVMF that robust
    and well-coordinated support systems should underpin any efforts to
    improve the well-being of veterans and their families, and to reduce
    veteran suicide. This testimony will elaborate on three core ideas and
    practices that the IVMF has identified through the depth and scope of
    its AmericaServes work supporting and evaluating a diverse range of
    community coordination efforts across the country:

            1. Criteria that position organizations to effectively
            coordinate service provision in communities;

            2. Shared measures are critical to establish data-driven
            interventions to improve well-being;

            3. Communities and coordination efforts benefit when given
            opportunities to share learning and receive ongoing technical
            assistance and evaluation support.

    Criteria that position organizations to effectively coordinate service
        provision in communities

        There are a number of important factors that may be used to
    identify appropriate locations for grant program funding to flow as
    part of a pilot program-concentration of veteran population,
    utilization of VA services and/or VA spending, suicide rates, etc. It
    has been the IVMF's experience that there is no shortage of need for
    more robust systems of care; rather, there are other more qualitative
    conditions that should be in place, at least initially, when
    determining whether a community is ``ready'' to undertake efforts to
    coordinate resources and services. ``Ready'' is best assessed by two
    key considerations: 1) strong local leadership committed to changing
    how services are delivered, and 2) dedicated philanthropic resources to
    support (or supplement) coordination infrastructure. Grant dollars have
    the risk of being ineffective if applied to communities with
    stakeholders unwilling or unable to collaborate in a transparent and
    accountable way.
        Additionally, as policymakers address the role of organizations who
    offer direct service provision or the coordination of service
    provision, the IVMF encourages a focus on organizations that
    demonstrate proof of the ability to take on hub-like activities. Across
    17 AmericaServes communities, 17 unique organizations have taken on a
    hub role. These organizations are diverse in size, age, mission, and
    direct service offerings-making it apparent that successful hubs can be
    supported by any organization; however, not every organization has the
    capacity to support a successful hub.
        The IVMF has adopted a set of important criteria organizations
    should meet in order to ensure efficient and effective service
    coordination and delivery to veterans and military families. These are:

          Expertise about benefits and resource eligibility-
    Comprehensive understanding of eligibility requirements for certain
    benefits and program will ensure clients get to the right provider(s),
    and conversely that clients are not referred to provider(s) who can't
    help them.

          Referral management across resources-Experience
    coordinating services across agencies. Alternatively, demonstrates
    strong organizational history, staffing, and ability to stand-up and
    operate a coordination center within a community.

          Trusted relationships with community organizations-
    Established history of collaboration, partnership, and/or participation
    in local efforts to serve population needs. Also, local reputation and
    trust among providers and within broader community.

          Holistic intake of clients for needs spanning social
    determinants of health-Understands how certain needs co-occur and can
    assess and triage clients based on a spectrum of potential needs.

          Outreach to connect with veterans less likely to access
    care - Demonstrates track record and openness for connecting with hard
    to reach veteran subpopulations.

        Organizations that have held these roles, or that exhibit clear
    potential and willingness to build capacity to do so, represent
    grantees well-positioned to make best use of Federal dollars. In the
    experience of AmericaServes, these organizations do not necessarily
    provide an extensive list of service offerings spanning the social
    determinants of health (i.e., not one-stop shops). Rather, community
    hubs are most effective if there is a strong incentive to refer clients
    to partner organizations better suited to meet specific needs.
        Importantly, coordinating services in a community helps create a
    no-wrong door approach to care that early evidence suggests is
    welcoming for difficult to reach populations. For example,
    AmericaServes disproportionately serves women veterans and minority
    veterans. Both are groups more likely to experience greater challenges
    at transition and beyond. Creating systems that are welcoming to
    underserved veteran populations increases the likelihood that they
    receive the services they need, and by extension, ideally contribute to
    suicide prevention.
        Further, finding the right organization to steward Federal grant
    dollars puts both Federal and community resources to the first and best
    use. An example of this comes from our PAServes-Greater Pittsburgh
    network and one of the network's most committed providers, Defenders of
    Freedom Pittsburgh (DOF).
        DOF provides emergency financial assistance for transitioning Post-
    9/11 veterans. In 2018, DOF served 78 veterans and spent approximately
    $145,000. This year, DOF is on track to serve 20 percent more veterans
    yet spend 20 percent fewer dollars. This efficiency is due to the
    network's ability to connect many of the veterans they served with
    other programs for which they were eligible, prior to utilizing limited
    philanthropic dollars through DOF. Pittsburgh Mercy's ability to serve
    as a hub has fostered a healthy network that makes better use of
    programs like LIHEAP, SSVF, and disability compensation, while also
    leveraging the resources found in the community.
        This example is one of many that demonstrates how creating a hub
    role within a community can serve to connect veterans to the programs
    that best suit their needs-which typically means existing public and VA
    programs first, reserving philanthropic dollars to fill in gaps and to
    provide support to veterans and military-connected clients not eligible
    for VA programs.

    Shared measures are critical to establish data-driven interventions to
        improve well-being

        A fundamental tenet of collaborative models that adopt shared
    systems is the commitment to identify shared measures, in order to use
    data analytics to track outcomes, reflect on the insights derived from
    those data, and adapt community priorities based on the evolving needs
    of the population. The IVMF supports this legislation's inclusion of a
    key data collection and analysis component, in order to monitor
    progress, create responsive service delivery networks, and develop a
    common understanding of veteran well-being.
        In the IVMF's experience, once a common language and set of metrics
    are established, a phased approach has been an effective method to
    building community (local) and aggregate (national) measurement
    systems. Additionally, communities need tools that prevent data
    collection from being overly burdensome.
        The first phase represents community-oriented measures. These are
    interim outcomes that help provide a more accurate/near-real time needs
    assessment and gap analysis for the community. These measures
    illustrate critical outputs such as service utilization by category,
    referral volume to providers, clients served, timeliness of care, and
    provider-reported service outcomes. This data would also offer insight
    into the needs and quality of services for understudied populations,
    such as military families.
        Subsequent phases of measurement design should establish and
    monitor long-term improvements in quality of life. In addition to
    survey instruments to assess client well-being over time, evaluation
    activities may include collecting data with the potential of being
    connected to other rich Federal datasets such as those produced by the
    Census Bureau, the Department of Health and Human Services, and the VA.
    In combination, these data can shed insight into outcomes associated
    with the physical, psychological, and social determinants of health
    that affect suicidal ideation.
        Ultimately, the measure of success for this bill will be the long-
    term trends of veteran suicide. If the rate is reduced, especially in
    locations funded by this legislation or in locations with existing care
    networks, it would represent preliminary evidence of the efficacy of
    coordinated approaches in communities.

    Communities and coordination efforts benefit when given opportunities
        to share learning and receive ongoing technical assistance and
        evaluation support

        Improving the way veterans and their families connect with
    services, resources, and care is challenging work. Doing so requires an
    ongoing commitment of both financial and human resources across
    hundreds of stakeholders in each community, and the ability to
    continuously evaluate progress.
        Platforms that support ongoing lines of communication between
    organizations and communities can be powerful mechanisms to address
    these types of challenges-creating space to share best practices and
    solve common problems to help advance the quality and effectiveness of
    care coordination across the country.
        In AmericaServes, this infrastructure is called the Community of
    Practice (CoP). The activities and resources in the CoP provide a
    backbone for communities to work through complex cases, establish
    shared minimum standards of care, and collectively solve problems faced
    by multiple networks. Additionally, CoPs create opportunities for
    exchange between practitioners and analysts around insights derived
    from community data. The IVMF model to embed evaluation support into
    its programs has facilitated faster learning and the adoption of
    evidence-based practices due to open dialog around the interpretation
    of data.
        As this legislation is finalized, the IVMF recommends considering
    creating a robust technical assistance model, for example something
    similar to the offering within the Supportive Services for Veteran
    Families (SSVF) program, or to the cohort model utilized in the
    Institute of Museum and Library Services' (IMLS) Community Catalyst
    Initiative. The IMLS program, in particular, offers an infrastructure
    for grantees to connect, increase capacity in key areas, and learn from
    their experiences.
        These technical assistance models should also include evaluation
    and analytics support. Even if provided with tools for data collection,
    many community organizations do not have the internal capacity or
    expertise to analyze or report on required measures. The IMLS grant
    helpfully included direct evaluation support to complement whatever
    level of in-house effort could be applied.

    Conclusion

        Veteran suicide prevention efforts begin by ensuring that veterans
    have positive post-military experiences. These efforts require
    supportive solutions that build on the extensive fabric of
    organizations that already exist in the communities military families
    call home. The best data available, while likely incomplete, tell us
    that 17 veterans take their lives every day. 11 of those veterans are
    not in VHA care. This legislation importantly prioritizes and seeks to
    empower communities to connect veterans who are falling through the
    cracks of our existing care systems to the services they need, which
    helps the VA enhance its ability to meet its mission.
                                     ______

                  Prepared Statement of Union Veterans Council
    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                                     [all]