[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
       

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                    Available via http://govinfo.gov                    
                              __________

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
41-377                     WASHINGTON : 2022                     
          
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                     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.]
     
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                         A  P  P  E  N  D  I  X

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                    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 [email protected]

                       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 [email protected]
    Association of VA Psychologist Leaders [email protected]
    Association of VA Social Workers [email protected]
    Nurses Organization of Veterans Affairs [email protected]
    Veterans Healthcare Policy Institute 
[email protected]
                                 ______
                                 

   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
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