    [Senate Hearing 116-179]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 116-179

                         HEARING ON PENDING LEGISLATION

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                         ONE HUNDRED SIXTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                  MAY 22, 2019

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

                  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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

                                   __________

                          U.S. GOVERNMENT PUBLISHING OFFICE

    40-363 PDF                 WASHINGTON : 2020

                         COMMITTEE ON VETERANS' AFFAIRS

                       Johnny Isakson, Georgia, Chairman
    Jerry Moran, Kansas                  Jon Tester, Montana, Ranking
    John Boozman, Arkansas                   Member
    Bill Cassidy, Louisiana              Patty Murray, Washington
    Mike Rounds, South Dakota            Bernard Sanders, (I) Vermont
    Thom Tillis, North Carolina          Sherrod Brown, Ohio
    Dan Sullivan, Alaska                 Richard Blumenthal, Connecticut
    Marsha Blackburn, Tennessee          Mazie K. Hirono, Hawaii
    Kevin Cramer, North Dakota           Joe Manchin III, West Virginia
                                         Kyrsten Sinema, Arizona
                           Adam Reece, Staff Director
                    Tony McClain, Democratic Staff Director

                                C O N T E N T S

                                  ----------

                                  May 22, 2019
                                    SENATORS

                                                                       Page
    Boozman, Hon. John, Acting Chairman, U.S. Senator from Arkansas..     1
    Tester, Hon. Jon, Ranking Member, U.S. Senator from Montana......     6
    Murray, Hon. Patty, Chairman, U.S. Senator from Washington.......    25
    Brown, Hon. Sherrod, U.S. Senator from Ohio......................    23
    Blumenthal, Hon. Richard, U.S. Senator from Connecticut..........    64

                                   WITNESSES

    Casey, Hon. Bob, U.S. Senator from Pennsylvania..................     1
    Gardner, Hon. Cory, U.S. Senator from Colorado...................     2
    Cotton, Hon. Tom U.S. Senator from Arkansas......................     4
    Ernst, Hon. Joni, U.S. Senator from Iowa.........................     5
    Boyd, Teresa, DO, Assistant Deputy Under Secretary for Health,
      Veterans Health Administration, U.S. Department of Veterans
      Affairs; accompanied by David Carroll, Ph.D., Executive
      Director, Mental Health and Suicide Prevention, Veterans Health
      Administration; and Beth Murphy, Executive Director,
      Compensation Service, Veterans Benefit Administration..........     8
        Prepared statement...........................................    10
        Response to posthearing questions submitted by:
          Hon. Jon Tester............................................    68
          Hon. Thom Tillis...........................................    78
          Hon. Patty Murray..........................................    79
    Bryant, Melissa, Chief Policy Officer, Iraq and Afghanistan
      Veterans of America............................................    29
        Prepared statement...........................................    31
    Richardson, Michael C., Vice President of Independence Services
      and Mental Health, Wounded Warrior Project.....................    34
        Prepared statement...........................................    36
    Nembhard, Greg, Deputy Director of Claims Services, The American
      Legion.........................................................    46
        Prepared statement...........................................    48
    Phillips, Maj. Gen. (Ret.) Jeffrey, Executive Director, Reserve
      Officers Association...........................................    56
        Prepared statement...........................................    58

                                    APPENDIX

    Burr, Hon. Richard, U.S. Senator from North Carolina; prepared
      statement......................................................    81
    Rubio, Hon. Marco, U.S. Senator from Florida; prepared statement.    82
    Carlson, Robert M., President, American Bar Association (ABA);
      letter.........................................................    83
    The American Federation of Government Employees, AFL-CIO and its
      National Veterans Affairs Council (AFGE); prepared statement...    85
    Chenelly, Joseph P., Executive Director, AMVETS; prepared
      statement......................................................    92
    McClain, Hon. Tim S., Chairman, Board of Directors and James
      Lorraine, President & CEO, America's Warrior Partnership (AWP);
      prepared statement.............................................    96
    Falke, Ken, Chairman, Boulder Crest & EOD Warrior Foundation;
      prepared statement.............................................    98
    Blinded Veterans Association (BVA); prepared statement...........   102
    Brennan, Liam, Executive Director, Connecticut Veterans Legal
      Center (CVLC); letter..........................................   108
    Atizado, Adrian, Deputy National Legislative Director, DAV
      (Disabled American Veterans); letter...........................   109
    Elkins, Daniel, Legislative Director, Enlisted Association of the
      National Guard of the United States (EANGUS); prepared
      statement......................................................   117
    Scott, Carol Wild, Esq., Legislative and Veterans Affairs Chair,
      Veterans & Military Law Section (V&MLS), Federal Bar
      Association (FBA); prepared statement..........................   120
    Chaudhry, Humayun, DO, FACP, President and CEO, Federation of
      State Medical Boards (FSMB), submitted by Hon. Cory Gardner;
      letter.........................................................   123
    Muolo, Alie, Staff Attorney and Michele Levy, Managing Attorney,
      Homeless Advocacy Project (HAP); prepared statement............   124
    The Institute for Veterans and Military Families (IVMF) at
      Syracuse University; prepared statement........................   125
    Loidolt, Neal, President/CEO, Minnesota Assistance Council for
      Veterans (MACV); letter........................................   132
    Military Officers Association of America (MOAA); prepared
      statement......................................................   134
    Moser, John P., MSgt USAF (Ret.), submitted by Hon. Sherrod
      Brown; prepared statement......................................   137
    Kimball, Angela, Acting Chief Executive Officer, National
      Alliance on Mental Illness (NAMI); prepared statement..........   138
    National Congress of American Indians (NCAI); prepared statement.   139
    Benton, David C., RGN, Ph.D., FRCN, FAAN, Chief Executive
      Officer, National Council of State Boards of Nursing (NCSBN);
      letter.........................................................   141
    Paralyzed Veterans of America (PVA); prepared statement..........   143
    Powers, James, veteran, Columbus, OH, submitted by Hon. Sherrod
      Brown; letter..................................................   147
    Student Veterans of America (SVA); prepared statement............   147
    Craig, James, J.D., Ed.D., President, United Veterans Committee
      of Colorado (UVCC), submitted by Hon. Cory Gardner; letter.....   150
    Fuentes, Carlos, Director, National Legislative Service, Veterans
      of Foreign Wars of the United States (VFW); prepared statement.   151

                         HEARING ON PENDING LEGISLATION

                                  ----------

                            WEDNESDAY, MAY 22, 2019

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 2:28 p.m., in
    room 418, Russell Senate Office Building, Senator John Boozman,
    presiding.
        Present: Senators Moran, Boozman, Tester, Murray, Brown,
    Blumenthal, and Sinema.

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

        Senator Boozman. The hearing will come to order. We are
    pleased to have some of our colleagues here to talk about some
    important pieces of legislation. So, we will begin with Senator
    Casey of Pennsylvania. He is going to speak in support of
    S. 746, the Department of Veterans Affairs Website
    Accessibility Act of 2019.
        Senator Casey.

                     STATEMENT OF HON. BOB CASEY,
                     U.S. SENATOR FROM PENNSYLVANIA

        Senator Casey. Thanks so much, Senator Boozman. I am not
    allowed to call you Mr. Chairman today, or you are the acting
    chair?
        Senator Boozman. John.
        Senator Casey. Senator Boozman, thanks so much. I want to
    thank you and thank the Ranking Member, Senator Tester, for
    this opportunity and for inviting me to speak as well as our
    colleagues.
        As you mentioned, I am here to discuss the VA Website
    Accessibility Act, which is Senate Bill 746, which I introduced
    with my colleague, Senator Moran, who, of course, is a Member
    of this distinguished Committee. I want to thank Senator Moran
    for his partnership on this legislation which aims to help
    disabled veterans. We look forward to continuing our work in
    the future to help those who have served our Nation.
        I also want to acknowledge our colleagues in the House for
    advancing similar bipartisan legislation under the leadership
    of Representative Elaine Luria.
        The VA Website Accountability Act--Accessibility Act, I
    should say--seeks to ensure that all veterans have access to
    electronic and information technology provided by the
    Department of Veterans Affairs, including those who are blind.
    This should not be a controversial idea, of course. In fact, it
    is already required by law. In the 1990s, Congress amended the
    Rehabilitation Act to include Section 508, which requires
    Federal agencies, including the VA, to make their electronic
    and information technology accessible to people with
    disabilities.
        Unfortunately, the VA has faltered in its compliance with
    Section 508. The Blinded Veterans Association reports that all
    too frequently the VA releases new websites or apps that cannot
    be easily used by the blind. This often occurs after the agency
    promises, at the initial developmental stages, that the
    technology will be accessible. This, I know for everyone in the
    room, is unacceptable.
        The act that we have introduced will promote a common-sense
    approach to solve the problem. It will require the VA to
    examine its websites, web-based applications, and VA medical
    facility kiosks to determine if they are accessible. The bill
    also requires the VA to report to this Committee and its House
    counterpart detailing which technology is not accessible. For
    technology that is identified as not accessible, the VA must
    develop and provide a plan for bringing that technology into
    compliance with Section 508.
        We have an abiding duty to provide for the brave men and
    women who have served our country. As President Lincoln said,
    when he outlined a very basic test or standard, he said, it is
    our obligation to, ``care for him who shall have borne the
    battle and for his widow and his orphan.'' We have to live up
    to that standard in everything that we do as it relates to the
    VA and veterans.
        This legislation takes a small, but important, step in
    ensuring that we meet our abiding obligation to serve and help
    every veteran, including those who are blind.
        I want to thank the Committee under the leadership of
    Chairman Isakson and Ranking Member Tester, and Senator Boozman
    today, for examining this important piece of legislation. Thank
    you very much.
        Senator Boozman. Thank you, Senator Casey, and again, thank
    you for being with us today.
        Next we are going to hear from Senator Gardner of Colorado.
    He is going to talk about the two pieces of legislation,
    S. 221, the Department of Veterans Affairs Provider
    Accountability Act, and S. 450, the Veterans Improved Access
    and Care Act of 2019.
        Senator Gardner.

                    STATEMENT OF HON. CORY GARDNER,
                       U.S. SENATOR FROM COLORADO

        Senator Gardner. Thank you, Senator Boozman. Thank you, as
    well, Ranking Member Tester, for allowing me this opportunity
    to talk about Senate Bill 450 and Senate Bill 221, to improve
    the VA hiring process and strengthen accountability at the VA.
    I would like to thank the Colorado veterans who helped us get
    this legislation to where it is today, and the many providers
    and VSOs that helped provide guidance.
        When meeting with veterans across Colorado, I often hear
    concerns about the amount of time it takes to get in to see a
    VA provider. In order to reduce wait times and provide timely
    care to our veterans, we have to address the root problem at
    many VA facilities in Colorado and across the country--staffing
    and staffing shortages.
        As the Wounded Warrior Project notes in their testimony
    today, there are over 24,000 medical or dental shortages in the
    VHA. Many VA hospitals continue to experience long wait times
    and staffing shortages as a result of lengthy hiring processes.
    The primary driver of this protracted hiring process is the
    onboarding process for licensed medical providers. According to
    a recent study by McKinsey and Company, the VA hiring timeline
    spans between 4 to 8 months, while a typical private sector
    organization hires staff between 0.2 and 2 months.
        This bipartisan legislation, Senate Bill 450, the Veterans
    Improved Access and Care Act, aims to address this problem by
    directing the VA to establish a pilot program to expedite the
    hiring of licensed medical professionals in locations where
    there are shortages of available providers. The bill also
    requires the VA Secretary to submit a report detailing a
    strategy on how to reduce the shortages and how to expedite the
    VA hiring process.
        It is essential the Department of Veterans Affairs and
    Congress collaborate on ways to find innovative solutions to
    the bureaucracy and red tape that serves as a barrier to
    employment at a VA medical center, to ensure that veterans
    receive quality, timely care they deserve.
        Another essential component of ensuring our Nation's heroes
    receive the highest quality care is accountability for medical
    errors that put patients in harm's way. The vast majority of VA
    employee and medical providers provide exceptional care to our
    veterans, and I am grateful for their service. So, there is no
    excuse for allowing certain medical providers with a history of
    committing major medical errors to continue putting other
    patients at risk.
        A troubling GAO report from 2017 revealed an unacceptable
    trend of VA facilities failing to report providers who made
    major medical errors to the National Practitioner Data Bank and
    the relevant State licensing boards responsible for tracking
    dangerous practitioners. As a result, these practitioners can
    go into private practice or move across State lines without
    disclosing prior mistakes to patients or State regulators.
        As we speak, the Comptroller General of the United States
    is testifying before the House Veterans' Affairs Committee, the
    Subcommittee on Oversight and Investigation, that since that
    2017 GAO report, the VA has failed to implement recommendations
    regarding the appropriate reporting to State licensing boards.
        Originally the VA indicated that they would take such steps
    by October 2018. It is now May 2019. We are no closer to
    ensuring the VA facilities are following advisable medical
    reporting standards.
        The VA Provider Accountability Act would solve this problem
    by requiring the VA to inform the National Practitioner Data
    Bank and State licensing boards of major adverse actions
    committed by medical providers at the VA. Additionally, it
    would prevent the VA from signing settlements with fired
    employees to hide major medical mistakes in their personnel
    files.
        We owe every single veteran the best possible care and we
    can only provide that care with increased accountability. My
    bipartisan bill will protect veterans and potential patients
    outside the VA system from mistakes by medical providers who
    have proven themselves to be dangerous.
        I look forward to collaborating with our Nation's veterans,
    the Senate Veterans' Affairs Committee, the VA, and other
    stakeholders on furthering these critical solutions.
        I ask for the Chairman's consent to allow the letters that
    I have with me to be submitted to the record in support from
    these organizations: the Federation of State Medical Boards;
    National Council of State Boards of Nursing; and the United
    Veterans Committee of Colorado.
        Senator Boozman. Without objection.
        Senator Gardner. Thank you.

        [The letters appear in the Appendix.]

        Senator Boozman. Thank you, Senator Gardner.
        Next we are going to hear from my fellow Senator from
    Arkansas, Senator Cotton. He is going to speak in support of
    S. 857, a bill to increase the Medal of Honor pensions. And,
    congratulations on your efforts chronicling the Old Guard and
    becoming truly an expert on Arlington.

                     STATEMENT OF HON. TOM COTTON,
                       U.S. SENATOR FROM ARKANSAS

        Senator Cotton. Thank you. A great story that is available
    for purchase on Amazon right now. [Laughter.]
        I want to thank the Committee, Chairman Isakson, and
    Ranking Member Tester for inviting me to speak at this hearing.
    I also want to thank my colleague from Arkansas, Senator
    Boozman, as well as Senator Blumenthal for cosponsoring Senate
    Bill 857, which would increase the special pension for Medal of
    Honor recipients.
        Medal of Honor citations often read like Hollywood scripts,
    only the heroism is so amazing most people would not believe it
    really happened if it were a movie. But, it did happen, and
    Medal of Honor recipients who lived to tell their stories
    become public figures overnight. They are inundated with
    requests for speeches and appearances at schools, veterans'
    groups, and civic organizations. Many appear at as many as 200
    events every year. They do this out of a sense of duty to the
    Nation and to their buddies who did not survive.
        Our country, therefore, pays Medal of Honor recipients a
    special pension to defray the costs of their demanding travel
    schedules. The pension began at about $10 a month, more than a
    century ago. Congress has increased it periodically and it now
    stands at about $1,300 per month. That amount can no longer
    cover basic expenses, such as lodging, food, and
    transportation.
        That is not right, so let's make it right. Our bill would
    increase the Medal of Honor pension to $3,000 per month. This
    is a modest change, and even more modest expense for our
    country. The pensions would cost barely $1 million a year out
    of our $4 trillion budget, but that money would go a long way
    to help these Medal of Honor recipients share their stories.
        These are not the stories of celebrity or fame. They are
    stories of valor and patriotism. They give young men and women
    honorable examples to follow, indeed, inspiring many of them to
    enlist themselves. That is why Medal of Honor recipients are
    some of our military's best recruiters and Ambassadors. It is
    only fair we reimburse them for the job they do.
        Time is of the essence. We once had hundreds of living
    recipients but now we are down to only 70. Just last week, we
    lost another Medal of Honor recipient, Robert Maxwell, who
    passed away at the age of 98. A generation of heroes is slowly
    passing from the scene, so let's act now to make sure their
    stories are shared as widely as possible.
        Every Medal of Honor recipient has sacrificed for his
    country in the words of the citation ``above and beyond the
    call of duty.'' That sacrifice continues well beyond the
    battlefield but it should not require financial sacrifice. So,
    let's give Medal of Honor recipients the raise they deserve.
        Thank you.
        Senator Boozman. Thank you, Senator Cotton.
        Senator Ernst, it is good to have you here. The senator
    from Iowa is going to be speaking in support of S. 123, the
    Ensuring Quality Care for Our Veterans Act, which is very
    important. We appreciate your leadership in this area, and we
    have had, you know, a great deal of pleasure in trying to help
    and play in a role, so thank you again.

          STATEMENT OF HON. JONI ERNST, U.S. SENATOR FROM IOWA

        Senator Ernst. Thank you. Senator Boozman and Ranking
    Member Tester, thank you so much for the invitation today so
    that I can advocate for S. 123, the Ensuring Quality Care for
    Our Veterans Act. I also want to thank you, Senator Boozman, as
    well, as a Member of this Committee and for also supporting
    S. 123, as well as Senator Grassley and Senator Coons. So,
    thank you very much for your support on this issue.
        Today, folks, I want to share a story of Anthony, who is an
    Iowa veteran. In 2017, Anthony was experiencing headaches, so
    he went to the Iowa City VA medical center to get an MRI of his
    head and neck. Anthony's MRI results came back and they
    unfortunately indicated that he had a brain tumor.
        Anthony was referred to Dr. John Schneider, a neurosurgeon
    at the Iowa City VA. Anthony was struck by Dr. Schneider's
    demeanor. He was personable and genuinely seemed to care about
    Anthony's well-being. Dr. Schneider was going to operate on
    Anthony with the goal of removing the tumor, and Anthony was
    confident he was in good hands.
        After Anthony's surgery, Dr. Schneider proclaimed that he
    had removed all of the tumor--all of the tumor. In the weeks
    and months following the surgery, it became clear to Anthony
    that something was amiss. His health had not improved, and when
    Anthony would bring this up to Dr. Schneider, Schneider claimed
    that it would take at least a year for his symptoms to improve.
        All of this changed on December 3, 2017. A disturbing
    report in USA Today found that the VA had knowingly hired
    providers with revoked medical licenses and who have a history
    of providing substandard care. One of those providers was Dr.
    Schneider.
        After that report broke, Anthony immediately went to the VA
    and had another MRI. It turned out that Dr. Schneider had never
    removed the tumor.
        Members of the Committee, Dr. Schneider never should have
    been hired to treat our veterans. While the VA reformed its
    hiring practices--thank goodness--there are still veterans out
    there who were treated by physicians with revoked licenses, but
    who do not know if they received bad care. That is absolutely
    unacceptable.
        Every veteran who was treated by a physician with a revoked
    license should have their medical care scrutinized by a neutral
    third party. That is exactly what my bill does. The Ensuring
    Quality Care for Our Veterans Act ensures that every provider
    who was hired with a revoked license will have their care
    scrutinized by a neutral third party. If that third party
    determines that the care was substandard, the veterans will be
    notified.
        The VA conducted a review of all their providers and found
    a small number of providers who were hired with revoked
    licenses. This bill focuses on that small group of providers.
    It is a targeted oversight measure with minimal costs, that
    will give our veterans peace of mind.
        I thank the Committee again for the opportunity to testify
    in front of you today, and I do urge the Committee to support
    this bill. Thank you.
        Senator Boozman. Thank you, Senator Ernst.
        Senator Tester.

      OPENING STATEMENT OF HON. JON TESTER, RANKING MEMBER, U.S.
                          SENATOR FROM MONTANA

        Senator Tester. Thank you, Senator Boozman. I appreciate
    you filling in today for Chairman Isakson.
        Yesterday I hosted a roundtable of veteran service
    organizations. I am very concerned that they are not being
    provided adequate information on implementation of the VA
    Mission Act.
        These VSOs are essential figures in this process. They can
    help provide information to their members and answer questions
    when problems arise. But, what I heard yesterday is that the
    group lacked real opportunities for questions and answers.
        In some instances, VA is requiring questions in advance so
    that no real dialog is occurring. In particular, the groups
    noted that they have not been provided information about what
    veterans do if they run into problems accessing care starting
    the 6th of June. VA needs to get this right. Congress gave the
    agency a full year to roll out this program. The agency
    absolutely needs to provide the VSOs with an opportunity for
    real back-and-forth within the next few days, given that this
    Mission Act will go live in 2 weeks.
        As far as this hearing goes, I just want to say that we
    have got a fairly heavy load for this hearing and I greatly
    appreciate that you have included so many bills that I have on
    this agenda today. I want to briefly touch on a few bill that I
    have worked on, and we will get views on it today.
        One of the main focuses in Congress is on mental health and
    suicide prevention. I want to thank all of my colleagues on
    this Committee for being such good partners in this effort, in
    particular, Senator Moran, for helping expand access to mental
    health care for our veterans and increasing oversight over VA
    mental health programs.
        S. 785--this is the Commander John Scott Hannon Veterans
    Mental Health Care Improvement Act--does just that. It also
    eases transition for recently separated veterans, improves and
    expands VA mental health infrastructure, increases community
    engagement through grants.
        I also want to thank Senators Sullivan, Murray, Sanders,
    Blumenthal, Hirono, Manchin, and Sinema for their support of
    this bill.
        S. 711, Care for Reservists, allows members of the National
    Guard and Reserve to receive care at Vet Centers, and includes
    them in VA suicide prevention planning. I worked with Senators
    Moran, once again, Sullivan, Cassidy, Tillis, Sanders, and
    Manchin to improve and expand care for our guardsmen and
    reservists.
        Today's agenda also includes S. 514, the Deborah Sampson
    Act, which would eliminate barriers to care in services that
    many women veterans face and would expand services for women
    veterans most in need, such as those experiencing homelessness.
        And, a very special thank you to the man to my left,
    Senator Boozman, who reintroduced this critical bill with me,
    as well as 32 other cosponsors, 7 of whom sit on this
    Committee.
        Another bill that I worked on was S. 805, the Veteran Debt
    Fairness Act, which helps veterans by reducing VA's ability to
    recover overpayments from veterans that are caused by VA
    errors. Again, I want to thank Senators Boozman, Brown, and
    Blumenthal for being great partners in this legislation and
    assuming that the VA, not our veterans, are held accountable
    when it makes mistakes.
        Finally, I have got a couple of bills that increase
    oversight and accountability of the VA. S. 1154, the Department
    of Veterans Affairs Electronic Health Record Advisory Committee
    Act, would create a panel of experts to oversee and give
    guidance to the VA as they embark on the $16 billion, 10-year
    Cerner electronic health record project. Thank you to Senator
    Blackburn for working together with me to ensure that this
    massive project gets rolled out correctly.
        Last, but not least, S. 524, the Department of Veterans
    Affairs Tribal Advisory Committee Act, which would create an
    advisory committee made up of Tribal members from across the
    Nation to advise the Secretary on issues specific to Indian
    country. I want to thank Senators Sullivan, Cramer, and Sinema
    in pushing for greater representation of Indian country in VA
    policy at the highest level.
        I look forward to hearing the rest of our witnesses here
    today's views on the bills as we look forward for a very
    productive hearing.
        Thank you, Mr. Chairman.
        Senator Boozman. Well, thank you, and let's go ahead and
    hear from our panel. We will start with Dr. Teresa Boyd. She is
    accompanied by Dr. David Carroll and Beth Murphy. We do
    appreciate you being here.
        Dr. Boyd.

    STATEMENT OF TERESA BOYD, DO, ASSISTANT DEPUTY UNDER SECRETARY
    FOR HEALTH, VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF
        VETERANS AFFAIRS; ACCOMPANIED BY DAVID CARROLL, Ph.D.,
       EXECUTIVE DIRECTOR, MENTAL HEALTH AND SUICIDE PREVENTION,
      VETERANS HEALTH ADMINISTRATION; AND BETH MURPHY, EXECUTIVE
           DIRECTOR, COMPENSATION SERVICE, VETERANS BENEFITS
                             ADMINISTRATION

        Dr. Boyd. Thank you. Good afternoon, Senator Boozman,
    Ranking Member Tester, and Members of the Committee. I
    appreciate this opportunity to be here to discuss the bills on
    today's agenda. I am accompanied today by Dr. David Carroll,
    Executive Director of the Office of Mental Health and Suicide
    Prevention, and Beth Murphy, who leads VBA's Compensation
    Service.
        With just a few minutes for my introductory statement I can
    only highlight a few key points on some of the bills today, but
    I will cover as much territory as I can. Our written testimony
    goes into greater detail, and most importantly, after the
    hearing we are glad to bring subject matter experts to the
    Committee and work closely with you and your staff on any of
    the legislation you have brought forward today.
        There are a few matters where we could not conclude views
    in time to include in our written testimony. We will be
    following up with those view for the record and provide them to
    the Committee as soon as possible.
        Preventing veteran suicide is, of course, a serious topic
    the country is rightfully focused on now and it is reflected in
    the largest bill on the agenda today, S. 785. Suicide is a
    public health tragedy that affects communities across the
    country.
        As we discuss suicide prevention legislation it is
    important to first place it in the context of what VA is doing
    now. VA's efforts are organized around the 2018 National
    Strategy for Prevention Veteran Suicide, which is a framework
    for identifying priorities, organizing efforts, and focusing
    community resources to prevent suicide among veterans.
        There is much in S. 785 that keys in on what we believe are
    the right elements, including suicide prevention coordinators
    at every medical center, a grant program that taps into the
    resources of the local community, focused research projects and
    deployment of promising clinical approaches to suicide
    prevention, the use of complementary and integrative health
    care, outreach efforts to reach those veterans that are not in
    our system of care, and the use of joint clinical practice
    guidelines, among other features.
        As we detail in our written testimony, some requirements
    found in the bill are already underway at VA. Even though we
    applaud the fact that VA initiatives are recognized as worthy
    in S. 785, we do urge caution in terms of prescribing those
    initiatives into detailed legislation, where the specifics of
    the bill requirements have the potential to work at cross
    purposes or not be flexible enough to allow VA to tailor its
    implementation to be most effective. Situations could arise
    where our public health experts decide that shifting resources
    from a mandated responsibility into a newly promising
    initiative will give us a better chance of success.
        Our testimony also details instances where we believe a
    study or report would be duplicative or would be less effective
    and useful for public health purposes than intended. There are
    also provisions that would come on top of related requirements
    in the recently enacted MISSION and CARE Acts. We want to make
    sure that we help keep records and compliance mandates as
    streamlined as possible for the benefit of our veterans. That
    is why we especially value further discussion with the
    Committee where we can give our best advice on how we ensure
    any legislation will produce the outcomes we all want.
        We especially want to work with you on Section 201, as we
    believe this kind of grant program shows a great deal of
    promise. Specifically, we would like to discuss how we could
    broaden the scope to include veterans who do not have a mental
    health diagnosis and allow grantees to provide more forms of
    assistance.
        Both S. 785 and S. 711 address a critical component of our
    suicide prevention efforts, access to care. Recently, Congress
    and VA have acted to open VA access in a limited way for those
    who do not meet the standard definition of veteran eligibility
    because of their nature of discharge and for reservists who
    have simply not been federally activated.
        But, VA wants to do more. While we do not endorse the
    eligibility changes in these bills as drafted, we are committed
    to working on these issues with the Committee so that we can
    better reach those individuals where VA could make a life-
    changing difference.
        S. 514 and S. 318 address a topic that is also a big
    priority for VA, making sure our services meet the needs of
    women veterans whose use of VHA has tripled since 2000. As
    noted in our testimony, we support many provisions among the
    numerous initiatives in S. 514, including expanded newborn
    health care, convening retreats especially for women veterans,
    and standing up partnerships to provide legal services to women
    veterans. We would like to work with the Committee on some
    technical concerns with S. 318 regarding health-related
    transportation for newborns.
        VA has not let up in our efforts to combat veteran
    homelessness, which is the subject of S. 980. We appreciate the
    recognition of legal services as an element of how we can help
    homeless and at-risk veterans. We welcome discussion on other
    provisions in that bill.
        We also appreciate your support on VA's Highly Rural
    Transportation Grant Program, the subject of S. 850. We support
    that measure and, in fact, would be very pleased if Congress
    extend that authority through 2029.
        I am glad to share the table today with Beth Murphy, who
    can speak to the bills that concern VBA programs. I will say,
    on her behalf now, that VA appreciates the inclusion of bills
    that will increase special pension benefits for Medal of Honor
    recipients, expand the types of professionals who can conduct
    disability examinations, and allow VA to continue payment of
    education benefits when a school is closed under certain
    emergency situations such as hurricanes. VA does support these
    bills.
        S. 805 addresses a complicated subject, which is VA's
    management of debts that veterans may owe to VA. Committee
    staff has spent a lot of time with VA subject matter experts
    this year in efforts to make changes to ensure fairness and
    reduce frustration for veterans. In this area, we run into some
    decentralization among different parts of VA, some
    inconsistencies simply because of the nature of a debt with
    VBA, perhaps resulting to an education benefit, is very much
    different than a debt to VHA, which could be over a copayment.
        While we do not support the bill in its current form, we
    will keep working with the Committee on legislation that could
    improve matters while we continue to work on improving our own
    internal processes.
        Finally, we appreciate and support S. 524, which would
    stand up a VA Tribal Advisory Committee to focus on issues
    important to Native American veterans and tribal organizations,
    as well as advise the Secretary on those issues. The special
    sovereign nature of Native American tribes and the unique needs
    of those veterans merit this kind of forum, which I know will
    result in ideas that will help VA better serve this population.
        I will need to close without addressing some of the bills
    on the agenda, but before I do I want to thank you and the
    Committee for holding this important hearing. Our objective is
    to give our Nation's veterans the top quality of experience and
    care they have earned and deserve. We appreciate the continued
    support and encouragement from this Committee and our VSO
    partners here with us today as we identify challenges and find
    new ways to care for veterans.
        This concludes my testimony. My colleagues and I are happy
    to respond to any questions you and the Committee may have.
        [The prepared statement of Dr. Boyd follows:]
    Prepared Statement of Teresa Boyd, DO, Assistant Deputy Under Secretary
     for Health, Veterans Health Administration (VHA), U.S. Department of
                             Veterans Affairs (VA)
        Good afternoon, Chairman Isakson, Ranking Member Tester, and
    Members of the Committee. Joining me today are Dr. David Carroll,
    Executive Director of Mental Health and Suicide Prevention, Veterans
    Health Administration, and Ms. Beth Murphy, Director of Compensation
    Service, Veterans Benefits Administration (VBA).
        I want to thank the Committee for putting forward legislation on
    critical issues such as suicide prevention, mental health care, and the
    needs of women Veterans, among other important topics. In this
    testimony we are providing background information on many of our
    ongoing efforts and strategies for addressing these important issues,
    so that we can provide context for our analysis of the proposals before
    us today. I am confident that we can, in partnership with Congress,
    ensure VA has the tools to deliver the state-of-the-art health care and
    other benefits that Veterans deserve.
        VA was not able to address the draft Janey Ensminger Act of 2019.
    We are also still analyzing sections 101(a) and (b) and section 104 of
    S. 785, and will provide views soon in a follow-up letter.
    Legislation Concerning Mental Health and Suicide Prevention
        Suicide is a national public health issue that affects all
    Americans, and the health and well-being of our Nation's Veterans is
    VA's top priority. On average, twenty Veterans, active-duty
    Servicemembers, and non-activated Guard or Reserve members die by
    suicide each day, and of those twenty, fourteen have not been in our
    care. That is why we are implementing broad, community-based prevention
    strategies, driven by data, to connect Veterans outside our system with
    care and support. The Department's Fiscal Year (FY) 2020 budget
    requests $9.4 billion for mental health services, a $471 million
    increase over 2019. VA's budget specifically invests $221.7 million for
    suicide prevention programming, a $15.6 million increase over the 2019
    enacted level. The budget request funds over $5.4 billion to support
    mental health outpatient visits, an increase of nearly 78,000 visits
    over the 2019 estimate. This builds on VA's current efforts. VA has
    hired more than 3,900 new mental health providers yielding a net
    increase in VA mental health staff of over 1,000 providers since
    July 2017. Nationally, in the first quarter of 2019, 90 percent of new
    patients completed an appointment in a mental health clinic within 30
    days of scheduling an appointment, and 96.8 percent of established
    patients completed a mental health appointment within 30 days of the
    day they requested.
        Preventing Veteran suicide requires closer collaboration between
    VA, the Department of Defense (DOD), and the Department of Homeland
    Security (DHS). On January 9, 2018, President Trump signed Executive
    Order (EO) 13822, Supporting Our Veterans During Their Transition from
    Uniformed Service to Civilian Life. The EO directs DOD, VA, and DHS to
    develop a Joint Action Plan that describes concrete actions to provide
    access to mental health treatment and suicide prevention resources for
    transitioning uniformed Servicemembers in the year following their
    discharge, separation, or retirement. On March 5, 2019, President Trump
    signed Executive Order 13861, National Roadmap to Empower Veterans and
    End Suicide, which creates a Veteran Wellness, Empowerment, and Suicide
    Prevention Task Force that is tasked with developing, within one year,
    a road map to empower Veterans to pursue an improved quality of life,
    prevent suicide, prioritize related research activities, and strengthen
    collaboration across the public and private sectors. This is an all-
    hands-on-deck approach to empower Veteran well-being with the goal of
    ending Veteran suicide.
        For Servicemembers and Veterans alike, our collaboration with DOD
    and DHS is already increasing access to mental health and suicide
    prevention resources, due in large part to improved integration within
    VA, especially between VBA and VHA, which have worked in collaboration
    with DOD and DHS to engage Servicemembers earlier and more consistently
    than we have ever done in the past. This engagement includes support to
    members of the National Guard, Reserves, and Coast Guard.
        VA's suicide prevention efforts are guided by our National Strategy
    for Preventing Veteran Suicide, a long-term plan published in the
    summer of 2018 that provides a framework for identifying priorities,
    organizing efforts, and focusing national attention and community
    resources to prevent suicide among Veterans. It also focuses on
    adopting a broad public health approach to prevention, with an emphasis
    on comprehensive, community-based engagement.
        However, VA cannot do this alone, and suicide is not solely a
    mental health issue. As a national problem, Veteran suicide can only be
    reduced and mitigated through a nationwide community-level approach
    that begins to solve the problems Veterans face, such as loss of
    belonging, meaningful employment, and engagement with family, friends,
    and community.
        The National Strategy for Preventing Veteran Suicide provides a
    blueprint for how the Nation can help to tackle the critical issue of
    Veteran suicide and outlines strategic directions and goals that
    involve implementation of programming across the public health
    spectrum, including, but not limited to:

         Integrating and coordinating Veteran Suicide Prevention
    across multiple sectors and settings;
         Developing public-private partnerships and enhancing
    collaborations across Federal agencies;
         Implementing research-informed communication efforts to
    prevent Veteran suicide by changing attitudes knowledge and behaviors;
         Promoting efforts to reduce access to lethal means;
         Implementation of clinical and professional practices for
    assessing and treating Veterans identified as being at risk for
    suicidal behaviors; and
         Improvement of the timeliness and usefulness of national
    surveillance systems relevant to preventing Veteran suicide.

        Every day, more than 400 Suicide Prevention Coordinators and their
    teams--located at every VA medical center--connect Veterans with care
    and educate the community about suicide prevention programs and
    resources. Through innovative screening and assessment programs such as
    REACH VET (Recovery Engagement and Coordination for Health--Veterans
    Enhanced Treatment), VA identifies Veterans who may be at risk for
    suicide and who may benefit from enhanced care, which can include
    follow-ups for missed appointments, safety planning, and care plans.
        With that background and foundation established, I will now turn to
    the suicide prevention and mental health-related bills on the agenda
    today.
                                     s. 711
        The CARE for Reservists Act of 2019 would authorize VA, in
    consultation with DOD, to furnish readjustment counseling, without a
    referral, to any member of the Reserve Components of the Armed Forces
    with a behavioral condition or psychological trauma; outpatient
    services and mental health services would also be available. The bill
    would further allow VA to include members of the Reserve Components in
    VA's comprehensive program for suicide prevention and would also allow
    VA to provide care and services to such members who served in
    classified missions. Finally, the bill would require VA to submit a
    report to Congress on the use of certain VA services by members of the
    Armed Forces and the Reserve Components of the Armed Forces.
        Although we support the principle of providing suicide prevention
    services to members of the Reserve Components, we do not support the
    expansion of VA's Readjustment Counseling Service (RCS) eligibility to
    any member of the Reserve Components as this bill is currently written,
    for reasons tied to the special role of Vet Centers as distinguished
    from medical care. We would emphasize that we are looking for ways to
    provide suicide prevention services to members of the Reserve
    Components in VA's mental health programs. We welcome the opportunity
    to discuss section 4 of the bill with the Committee to explore those
    ideas.
        The RCS was created to help Veterans who experienced traumatic
    events or served in combat and are facing readjustment issues as a
    result. While the bill would focus on members of the Reserve who have a
    behavioral health condition or psychological trauma, Vet Center
    counselors are not prepared to treat serious mental illness because
    many cases of such care require prescription medications, and these
    Centers lack the infrastructure to support such care as this care is
    beyond the scope of what Vet Centers provide. While well-intentioned,
    we believe such an expansion could undermine this focus of the RCS and
    could compromise the quality of the services they provide to Veterans
    who are currently eligible. This would also blur the line to some
    extent between VA's Vet Centers and medical clinics. Concerning section
    3 of the bill, which would permit VA to furnish mental health services
    to members of the Reserve Components, we are concerned this could have
    the unintended result of providing greater benefits to members of the
    Reserve Components than Veterans who meet statutory eligibility under
    other provisions of law. On a technical level, we are unsure whether
    the legislation is intended to permit DOD to reimburse VA for such
    care. We would appreciate the opportunity to discuss the intent of this
    provision with the Committee. Finally, we do not support section 5,
    which would require VA to submit an assessment to Congress on current
    and future utilization. We believe this would be redundant in some
    respects, as VA's RCS already submits an annual report on its workload,
    including services provided to members of the Armed Forces. We would
    like to work closely with the Committee on our efforts to augment the
    availability of VA services to those in Reserve Components.
                                     s. 785
        The Commander John Scott Hannon Veterans Mental Health Care
    Improvement Act of 2019, is a sweeping bill that includes 35 different
    provisions. VA would like to discuss with the Committee in detail the
    abundance of ideas in the bill, so that any legislation Congress enacts
    will ensure VA can maintain a strong focus on suicide prevention, and
    not create overlapping initiatives that pose the risk of confusing
    duplication of programs and undue complications in our efforts.
        Title I of S. 785 would expand eligibility for mental health care
    for Veterans, amend VA's statutory authority regarding the enrollment
    system for VA health care, require the Department of Labor (DOL) to
    promote information on VA benefits and issue grants to support
    transition assistance, require VA to enter into an agreement to compile
    a list of community-based programs, and modify VA's authority to
    furnish care to Veterans with other than honorable discharges.
        VA defers to DOL on sections 101(c) and 102. VA does not support
    section 103 as VA is already implementing a similar provision enacted
    as section 401 of Public Law 115-407.
        Title II is focused on suicide prevention. Section 201 would
    require VA to provide grants to eligible community entities to provide
    or coordinate the provision of mental health supportive services for
    Veterans with mental health conditions. VA strongly supports this
    concept as it supports recently-issued Executive Order 13861, National
    Roadmap to Empower Veterans and End Suicide, which requires the
    establishment of a grant program and aligns with a similar proposal in
    VA's FY 2020 budget request. We do have concerns with some aspects of
    the language of the section 201 grant program, as it may be too
    limiting as far as the Veterans the grantee entities could assist.
    There are also other technical issues we'd like to work with the
    Committee to resolve. We are eager to partner with you on a grant
    program that could truly make a difference for at-risk Veterans.
        Title II would also require VA to designate one week per year to
    organize outreach events and educate Veterans on how to conduct peer
    wellness checks, or ``Buddy Checks.'' It would also direct VA, in
    consultation with DOD and DHS, to enter into partnerships with non-
    profit mental health organizations to facilitate posttraumatic growth
    among Veterans who have experienced trauma, as well as develop metrics
    to track progress on each of the 14 goals and 43 objectives outlined in
    the National Strategy for Preventing Veteran Suicide. There are several
    associated reports included within these provisions. Similarly, VA
    would further be required to complete a study on the feasibility and
    advisability of providing complementary and integrative health (CIH)
    treatments at all VA facilities and would also be required to begin a
    program to provide CIH services to Veterans for the treatment of Post
    Traumatic Stress Disorder (PTSD), depression, anxiety, and other
    conditions. Finally, Title II would require the Comptroller General to
    report to the Committees on Veterans' Affairs on VA's efforts to manage
    Veterans at high risk of suicide.
        Outreach, partnerships, studies and evaluation are a core part of
    the VA's current suicide prevention efforts. VA's current efforts
    address many of the elements of Title II, and as a result we believe
    those provisions are duplicative. For example, we believe the Buddy
    Check week provision is redundant, given other robust efforts to
    increase awareness and support. We do not believe it is advisable to
    pursue the posttraumatic growth (PTG) program required by this section,
    because currently there is little scientific evidence to support its
    effectiveness as a separate clinical intervention (Wagner et al, 2016;
    Zoellner et al, 2011). VA currently has a range of effective treatment
    approaches that promotes recovery and is well-grounded in the academic
    literature. Concerning CIH treatments, these treatments are already
    available at many VA facilities; we strongly support the use of CIH
    treatments within VA and are actively working to comply with the
    requirements of Subtitle C, Complementary and Integrative Health, from
    the Jason Simcakoski Memorial and Promise Act (Title IX of Public Law
    (P.L.) 114-198, the Comprehensive Addiction and Recovery Act of 2016).
    As a result, we do not believe further statutory requirements would be
    beneficial. We are also concerned that animal therapy, agritherapy, and
    outdoor sports therapy, as referenced in the bill, are not widely
    available, nor well studied as effective treatments (Strauss et al,
    2011; Wehbeh et al., 2014). Further studies into these complementary
    therapies are underway and we hope to know more in coming years.
        Title III of S. 785 would focus on programs, studies, and
    guidelines on mental health. Specifically, VA would be required to: (1)
    commence a program to assess the feasibility and advisability of using
    computerized cognitive behavioral therapy to treat eligible Veterans
    experiencing depression, anxiety, PTSD, military sexual trauma (MST),
    or substance use disorder (SUD) who are already receiving evidence-
    based therapy from VA; (2) conduct a study (which could be performed in
    part through a contract with academic institutions or other qualified
    entities) on the connection between living at high altitude and the
    risk of developing depression or dying by suicide among Veterans; (3)
    complete the development of clinical practice guidelines for the
    treatment of PTSD, MST, and Traumatic Brain Injury (TBI) that is
    comorbid with SUD or chronic pain; (4) issue an update to the VA/DOD
    Clinical Practice Guidelines for Assessment and Management of Patients
    at Risk for Suicide; and (5) develop and implement an initiative to
    identify and validate brain and mental health biomarkers among
    Veterans, with specific consideration for depression, anxiety, PTSD,
    TBI, and other mental health conditions.
        In general, we do not believe these provisions are necessary,
    either because Veterans already have access to some services in the
    case of computerized cognitive behavioral therapy or because current
    efforts will satisfy these requirements, as in the case of the two
    provisions regarding clinical practice guidelines. For example, the
    topic of altitude related to hypoxia and suicide is already undergoing
    scientific investigation (see Reno et al, 2018; Riblet et al, 2019).
    Regarding the provision concerning biomarkers, the use of data
    collected must be specified in a research protocol and informed consent
    so that participating study enrollees may make an informed decision
    about what happens to their private health information. We generally do
    not believe the research studies that would be required by this Title
    are necessary either, given ongoing and completed work. VA has been
    actively engaged in biomarker research for numerous years, having
    highlighted numerous findings in precision medicine including blood
    tests that can predict which mental health patients will begin thinking
    about suicide or attempt it and apps developed to help patients monitor
    their mood and stressors (Le-Niculescu et al, 2013; Niculescu et al,
    2015). In response to the provision on VA/DOD clinical practice
    guidelines for comorbid mental health conditions, we have concerns
    about the feasibility of implementing this section and believe it would
    be redundant to current efforts and there are other concerns regarding
    implementation. VA and DOD are also updating the clinical practice
    guidelines on the assessment and management of patients at risk for
    suicide, and we expect this work to be completed soon.
        Title IV is focused on oversight of mental health care and related
    services. It would require a number of reports and studies from VA or
    others (including the Comptroller General) on the effectiveness of VA's
    suicide prevention and mental health outreach materials and campaigns
    and on VA's progress in meeting the goals and objectives of EO 13822.
    VA also would be required to establish goals for its mental health and
    suicide prevention media outreach campaigns in raising awareness about
    these topics. The Comptroller General would be required to submit to
    the Committees on Veterans' Affairs a management review of VA's mental
    health and suicide prevention services, as well as a report on VA's
    efforts to integrate mental health care into VA primary care clinics.
    Finally, VA and DOD would be required to submit to Congress a report on
    VA mental health programs, DOD mental health programs, and joint
    programs of the Departments.
        Similar to Title III, we believe many of these provisions would
    impose significant reporting requirements that would be burdensome to
    meet, could divert employees' attention from patient care and program
    management, and in our view would not produce significant additional
    value. Moreover, similar reporting requirements already exist for
    several areas, particularly concerning VA and DOD programs.
        Title V is focused on improving VA's medical workforce. Title V
    would modify VA's appointment authority for psychologists, require a
    staffing plan to address shortages of psychiatrists and psychologists,
    require VA to develop an occupational series for licensed professional
    mental health counselors and marriage and family therapists, require VA
    to assess the capacity of women peer specialists in VA, establish a
    readjustment counseling service scholarship program, and require VA to
    ensure that each VA medical center is staffed with no less fewer than
    one suicide prevention coordinator. It would further direct the
    Comptroller General to submit to the Committees on Veterans' Affairs a
    report on VA's RCS, while also requiring VA to report on the resources
    required to meet unmet needs for VA's Vet Centers and to conduct a
    study on the attitudes of eligible Veterans toward VA offering
    appointments outside the usual operating hours of VA facilities. Title
    V would also establish direct hiring authority in Title 5 U.S.C. for
    certain VA health care positions.
        We note generally that recruitment and retention of medical
    professionals are critical to ensuring that VA has the right doctors,
    nurses, clinicians, specialists and technicians to provide the care
    that Veterans need, and VA has placed a special focus on bringing the
    best mental health professionals into VA service. The FY 2020 budget
    strengthens VHA's workforce by providing funding for 342,647 full-time
    equivalent positions, an increase of 13,066 over 2019. VA is also
    actively implementing authorities enacted as part of Public Law 115-
    182, the Maintaining Internal Systems and Strengthening Integrated
    Outside Networks (MISSION) Act, which increased VA's ability to recruit
    and retain the best medical providers by expanding existing loan
    repayment and clinical scholarship programs; it also established the
    authority to create several new programs focused on medical school
    students and recent graduates. VA is also implementing additional
    initiatives to enhance VA's workforce, such as the expanded utilization
    of peer specialists and medical scribes.
        With that background established, turning to the provisions of
    Title V, the Department does not object to section 509, requiring that
    the Secretary ensure that all VA medical centers have at least one
    suicide prevention coordinator. VA agrees with that policy, and in fact
    that goal is already being met. VA defers to the Government
    Accountability Office (GAO) on section 506, which would require a
    Comptroller General report regarding VA's RCS, though it is important
    to note that RCS already has similar reporting criteria as a part of
    the annual congressionally mandated report currently outlined in 38
    U.S.C. 1712a. As noted above, the remainder of Title V includes
    numerous changes in personnel authorities, a new specialized
    scholarship program, and multiple reports and plans. Especially with
    the enactment of significant VHA workforce provisions in the MISSION
    Act in June 2017, which VA is now implementing, VA would like to
    discuss these provisions in detail with the Committee. Some we believe
    would be duplicative of ongoing efforts and planning. VA wants to be
    careful that layering new requirements in light of the multitude of
    ongoing programs in the same area could distract personnel and
    resources from VA's current efforts. In addition, there are technical
    issues with some of the provisions we would like to discuss with the
    Committee.
        Title VI would seek to improve VA's telehealth services, which are
    an important means of expanding access to high quality care, by
    requiring VA to enter into partnerships and expand existing
    partnerships between VA and community entities to expand telehealth
    capabilities and the provision of telehealth services to Veterans
    through grants. It would also require VA to assess current telehealth
    security protocols.
        We are continuing to enhance our telehealth programs and appreciate
    the Committees' interest in bolstering VA's efforts. The first
    provision in Title VI includes provisions that are similar to VA's
    Advancing Telehealth Through Local Access Stations initiative. The bill
    would go farther, though, in also creating a grant program to support
    these efforts. We welcome the Committee's support of these efforts and
    would appreciate the opportunity to discuss this further with the
    Committee to ensure that any legislative action does not limit our
    existing efforts. There are some details included in the legislation
    that could present problems that we believe could be avoided. For
    example, the inspection requirement would be difficult to scale and, we
    believe, impossible to fully maintain and enforce. Concerning the
    latter part of Title VI, we believe the language in this bill is
    ambiguous, and VA is uncertain what exactly the intended effect of this
    language is. We believe that elements of section 602, particularly in
    the networks, equipment, operators, and organizations involved, are
    outside the scope of VA's mission and authorities. We are also
    concerned that attempting to undertake the requirements of Title VI
    could affect other critical efforts of VA. We believe it would be
    advisable to have further discussions with the Committee, along with
    the Federal Communications Commission, to discuss this provision in
    more detail.
    Legislation Concerning Women Veterans
        On our ongoing efforts to ensure the needs of women Veterans are
    met, VA has made significant progress. We now provide full services to
    women Veterans, including comprehensive primary care, gynecology care,
    maternity care, specialty care, and mental health services. The FY 2020
    budget requests $547 million for gender specific women Veterans' health
    care, a $51 million increase over 2019.
        The number of women Veterans using VHA services has tripled since
    2000, growing from nearly 160,000 to over 500,000 today. To accommodate
    the rapid growth, VA has expanded services and sites of care across the
    country. VA now has at least two Women's Heath Primary Care Providers
    (WH-PCP) at all of VA's health care systems. In addition, 91 percent of
    community-based outpatient clinics have a WH-PCP in place. VA now has
    gynecologists on site at 133 sites and mammography on site at 65
    locations. For severely injured Veterans, we also now offer in vitro
    fertilization services through care in the community and reimbursement
    of adoption costs.
        VA is in the process of training additional providers, so every
    woman Veteran has an opportunity to receive primary care from a WH-PCP.
    Since 2008, 5,800 providers have been trained in women's health. In FY
    2018, 968 Primary Care and Emergency Care Providers were trained in
    local and national trainings. VA has also developed a mobile women's
    health training for rural VA sites to better serve rural women
    Veterans, who make up 26 percent of women Veterans. This budget will
    also continue to support a full-time Women Veterans Program Manager at
    every VA health care system who is tasked with advocating for the
    health care needs of women Veterans.
        VA is at the forefront of information technology for women's health
    and is redesigning its computerized patient record system to track
    breast and reproductive health care. Quality measures show that women
    Veterans who receive care from VA are more likely to receive breast
    cancer and cervical cancer screening than women in private sector
    health care. VA also tracks quality by gender and, unlike some other
    health care systems, has been able to reduce and eliminate gender
    disparities in important aspects of health screening, prevention, and
    chronic disease management. We are also factoring care for women
    Veterans into the design of new VA facilities and using new
    technologies, including social media, to reach women Veterans and their
    families. We are proud of our care for women Veterans and are working
    to increase the trust and knowledge of VA services of women Veterans,
    so they choose VA for benefits and services.
        With that background and foundation, we will turn now to related
    bills on today's agenda.
                                     s. 514
        We appreciate the intent and focus of S. 514, the Deborah Sampson
    Act, which seeks to improve the benefits and services provided by VA to
    women Veterans in a variety of ways. For example, subject to the
    Congress appropriating additional funding to support implementation,
    the Administration can support authorization for VA to furnish
    counseling in group retreat settings to persons eligible for RCS from
    VA including retreats specifically for women Veterans, as well as
    extending, from 7 to 14 days, coverage of newborns of a woman Veteran
    receiving delivery care. VA does not object to section 102, regarding
    Women Veterans Call Center, as we implemented the texting feature
    called for by the provision in April of this year. VA also agrees with
    the bill's intent to buttress the Women Veterans Health Care Mini-
    Residency Program by one million dollars annually, to provide more
    opportunities for participation by primary care and emergency care
    clinicians. We would like to discuss this provision with the Committee,
    however, as the ambiguous wording of the provision could have the
    unintended consequence of actually reducing the resources VA dedicates
    now to the program.
        VA estimates the cost of these provisions to be:

         Approximately $505,000 to conduct six retreats in FY 2019,
    $2.7 million over 5 years, and $6.07 million over 10 years;
         $8.8 million in FY 2020, $46.6 million over 5 years, and
    $100.6 million over 10 years to provide extended coverage of newborns;
    and
         $1 million in FY 2019, $5 million over 5 years, and $10
    million over 10 years to provide opportunities for participation in the
    Women Veterans Health Care Mini-Residency Program.

        We also support, conditioned on the availability of additional
    appropriations, section 201 which would require VA to establish a
    partnership to provide legal service to women Veterans, and, again
    subject to the availability additional appropriations, section 202,
    which would authorize additional amounts for the Supportive Services
    for Veterans Families (SSVF) grant program to support organizations
    that have a focus on providing assistance to women Veterans and their
    families. Regarding section 201, we support this provision with
    modifications, specifically allowing such assistance to be available to
    male Veterans as well; we also have some further recommendations on
    improvements to this section as well. We do not believe the gap
    analysis required by section 203 is necessary. We estimate the
    authorization of additional amounts for the SSVF program would cost $60
    million for FY 2020 through FY 2022.
        Other provisions of the bill, though, present challenges that VA
    would appreciate the opportunity to discuss with the Committee. For
    example, we appreciate the intent of section 401, which would require
    VA to retrofit existing VA medical facilities with fixtures, materials,
    and other outfitting measures to support the provision of care to women
    Veterans at such facilities. VA currently has the authority, and has
    made it a priority, to renovate or improve its facilities to protect
    the privacy, safety, and dignity of women Veterans. We are concerned
    that subsection (a), for example, would legislate specific requirements
    that are better addressed through current construction standards. Other
    provisions, such as section 402, are unnecessary because VA already has
    authority to employee women's health primary care providers, resources
    permitting.
        We also do not support other provisions of the bill, particularly
    those in Title V dealing with data collection and reporting. In
    general, we believe these requirements are too onerous and will provide
    too little benefit to justify the time and expense involved in
    collecting this information.
                                     s. 318
        S. 318 would expand the scope of benefits for newborn children of
    women Veterans by authorizing VA to furnish transportation necessary to
    receive covered health care services. The bill also would allow VA to
    furnish more than 7 days of health care services to a newborn child and
    to provide transportation necessary to receive such services, if such
    care is based on medical necessity, including cases of readmission.
        VA supports in principle providing medically necessary
    transportation benefits for newborns. The bill presents, however, a few
    technical concerns, such that we do not support the bill in its current
    form. For example, it would allow VA to ``waive'' a debt that a
    beneficiary owes for medically necessary transportation provided for a
    newborn that was incurred prior to enactment of this Act. VA would
    generally have no ability to waive such a debt because the debt would
    not be owed to VA; further, VA would not have been a party to the
    transportation agreement or arrangement entered into by the beneficiary
    and a third party. In addition, the bill's exception to the otherwise
    applicable 7-day limitation on the duration of services is sweeping in
    scope. We would welcome the opportunity to discuss this to better
    understand the Committee's intent.
    Legislation on Health Care Quality and Access
        VA has been making a concerted effort to improve the quality of
    care we furnish and the ability of Veterans to access this care. Our
    efforts are paying dividends. Since 2014, the number of annual
    appointments for VA care has increased by 3.4 million, with over 58
    million appointments in FY 2018. Simply put, more Veterans are choosing
    to receive their health care at VA. Patients' trust in VA care has
    risen steeply--currently at 87.7 percent--and a 2019 study in the
    Journal of the American Medical Association\1\ shows that VA average
    wait times are shorter than those in the private sector in primary care
    and two of three specialty care areas reviewed. A 2018 Rand study\2\
    found that the VA health care system ``generally delivers higher-
    quality care than other health providers,'' and a 2018 Dartmouth
    study\3\ found that ``Veterans Health Administration hospitals
    outperform non-Veterans Health Administration hospitals in most health
    care markets.''
    ---------------------------------------------------------------------------
        \1\ Penn, M. (2019, January 18). Comparison of Wait Times for New
    Patients Between the Private Sector and VA medical centers. Retrieved
    April 17, 2019, from https://jamanetwork.com/journals/jamanetworkopen/
    fullarticle/2720917
        \2\ Anhang Price, R., & Farmer, C. (2018, April 26). VA Health
    System Generally Delivers Higher-Quality Care Than Other Health
    Providers. Retrieved April 18, 2019, from https://www.rand.org/news/
    press/2018/04/26.html
        \3\ https://tdi.dartmouth.edu/news-events/veterans-health-
    administration-hospitals-outperform-non-vha-hospitals-most-healthcare-
    markets
    ---------------------------------------------------------------------------
        We appreciate Congress' support of our efforts and its interest in
    further improving the quality and accessibility of VA care. In addition
    to the telehealth provisions of S. 785, numerous bills address the
    provision of health care to Veterans.
                                     s. 123
        The Ensuring Quality Care for Our Veterans Act would require VA to
    enter into a contract or agreement with a non-Federal organization to
    conduct a clinical review for quality management of hospital care or
    medical services furnished by certain VA providers. We do not support
    S. 123, as VA already closely monitors the quality of care provided and
    uses peer review to further ensure we are delivering safe and effective
    care. We also have a strong institutional disclosure process and
    policy.
                                     s. 450
        The Veterans Improved Access and Care Act of 2019 is intended to
    improve access by requiring VA to conduct a pilot program to assess the
    feasibility and advisability of expediting the onboarding process for
    new medical providers and to submit to Congress a strategy to reduce
    the duration of the hiring process by half for licensed professional
    medical providers. The pilot program would have VA seek to reduce the
    time to onboard medical providers to no more than 60 days. While we
    appreciate the intent of this bill, we do not support S. 450 because VA
    can achieve the goals of the proposed pilot program with currently
    available approaches and strategies. We are glad to brief the Committee
    regarding this initiative.
                                     s. 850
        The Highly Rural Veteran Transportation Program Extension Act would
    allow VA to continue operating the Highly Rural Veteran Transportation
    Program through FY 2021; this program helps provide grantees greater
    flexibility to employ new approaches to serving such Veterans,
    resulting in improved service and health care access for Veterans. VA
    strongly supports S. 850, but VA would like to extend this authority
    through 2029, as requested in our FY 2020 budget request.
    Legislation Addressing Veteran Homelessness
                                     s. 980
        The Homeless Veterans Protection Act would make a number of
    improvements to VA's authorities that VA generally supports, on the
    condition of the availability of additional resources. In particular,
    we support section 3, which would require VA to enter into partnerships
    with public or private entities to provide general legal services to
    Veterans who are homeless or at risk of homelessness. The language
    further specifies that VA is only authorized to fund a portion of the
    cost of legal services. VA supports the intent of section 3--this was a
    legislative proposal in VA's FY 2020 budget request. Legal services
    remain a crucial but largely unmet need for homeless and at-risk
    Veterans, but we respectfully recommend technical amendments to the
    bill language. We believe some additional changes could be made to
    other provisions to improve the bill and would welcome the opportunity
    to work with the Committee in this regard. We appreciate the intent of
    section 4, which would extend dental benefits to additional Veterans
    enrolled in the VA health care system.
        However, because of likely very significant costs for section 4 we
    cannot support it absent a realistic prospect of future funding
    availability.
    Legislation Regarding Other Health Care Matters
                                     s. 221
        This bill would require VA to report certain health care employees
    against whom a performance or conduct-based major adverse action was
    taken to the National Practitioner Data Bank (NPDB). VA would be
    prohibited from entering into settlement agreements with employees that
    conceal a serious medical error or purge a negative record from a VA
    employee's personnel file. While we certainly agree with the principles
    underlying this bill in terms of ensuring quality care, we do not
    support this legislation. NPDB reporting is for substandard care,
    professional misconduct, or professional incompetence. VA is in the
    process of rewriting policy and regulations related to reporting to
    NPDB to incorporate more comprehensive and stringent reporting
    requirements than those outlined in this bill. We also note that
    existing VA regulations and policy forbid any formal or implied
    agreement prohibiting the reporting of a licensed health care
    professional to a State licensing board or the NPDB.
                                    s. 1154
        S. 1154, the ``Department of Veterans Affairs Electronic Health
    Record Advisory Committee Act,'' would establish an advisory committee
    to provide guidance to the Secretary and Congress on VA's
    implementation of and transition to an electronic health record system.
        VA does not support S. 1154. We believe the Department, in concert
    with DOD, is already fulfilling the aims of the bill by its continuing
    collaboration with clinical, business, and information technology
    stakeholders and Veterans Service Organizations, as well as our work in
    partnership with the Congress to advance the best possible technology
    to support the best possible care for Veterans. We also believe there
    are already multiple avenues for robust Congressional oversight,
    including regular briefings and Congressional hearings on the progress
    of the Electronic Health Record Modernization (EHRM) effort, engagement
    with GAO, regular statutory reporting requirements, and responses to
    Congressional inquiries. We believe the additional layers of review by
    an 11-member advisory committee would not only be unnecessary given the
    above but would also be unduly complicated and distract attention and
    resources from our core EHRM efforts and partnerships.
        We also believe the requirement to have meetings no less frequently
    than monthly for an 11-member advisory committee would be excessive.
    Moreover, that requirement will present what we believe would be
    unworkable conflicts with the Federal Advisory Committee Act (FACA),
    which would be applicable to the new EHRM Advisory Committee. FACA
    requires a detailed meeting notice of a meeting be published in the
    Federal Register no later than 15 days before the date of the meeting.
    In addition, should the Advisory Committee wish to close all or part of
    a meeting to the public, the Department would need to be accorded 30
    days to respond to the request. We believe these requirements are
    incompatible with a monthly meeting schedule.
    VA Benefits Measures
                                     s. 857
        S. 857 would amend 38 U.S.C. Sec. 1562(a) to increase the amount of
    special pension for Medal of Honor recipients to $3000, effective 180
    days after the date of enactment, but if this date is not the first day
    of a month, the first day of the first month beginning after the date
    that is 180 days after enactment. If the effective day is prior to
    December 1, 2019, the monthly rate of the pension would not be
    increased by the cost of living adjustment (COLA) for FY 2020, and the
    annual COLA would resume effective December 1, 2019. VA supports an
    increase in the pension for these heroes provided Congress can identify
    an offset for the mandatory benefit costs. Benefit costs are estimated
    to be $693,000 in the first year, $6.6 million over 5 years, and $14.7
    million over 10 years. There are no additional full-time equivalent or
    general operating expense costs associated with the proposed
    legislation.
                                    s. 1101
        S. 1101, the ``Better Examiner Standards and Transparency for
    Veterans Act of 2019'' (``BEST for Vets Act of 2019''), would amend
    section 504(a) of the Veterans' Benefits Improvements Act of 1996 to
    authorize VA to contract with non-physician healthcare providers to
    conduct disability examinations. VA would have to report to Congress no
    later than one year after the date of enactment of this Act and not
    less frequently than once each year thereafter, on the conduct of the
    program.
        VA supports this bill with the clarification that VA will contract
    with licensed non-physician providers to perform medical disability
    examinations. Along with licensed physicians, VA has historically
    utilized VA physician assistants, audiologists, and nurse practitioners
    to perform disability examinations. These individuals have been
    medically trained and have demonstrated their competence to conduct
    examinations. Enabling licensed non-physicians to perform contract
    examinations would greatly increase the number of examiners available
    for this important segment of the disability claims process.
        We believe that section 2(a)(2) of S. 1101 is not in fact a
    ``prohibition'' because section 2(d) of the bill expands the medical
    professionals authorized to provide exams from licensed contract
    physicians to licensed contract health care providers. VA would
    appreciate the opportunity to provide technical assistance to the
    Committee to streamline this bill.
        There are no costs associated with this bill.
        draft bill regarding continuance of educational assistance for
                 temporary closure of educational institutions
        The draft bill would extend the authority of the Secretary of
    Veterans Affairs to continue payments of educational assistance and
    subsistence allowances to eligible persons when educational
    institutions are temporarily closed until 8 weeks after the temporary
    closure. VA supports this bill because it would ensure that
    beneficiaries are not disadvantaged during emergency situations that
    are due to no fault of their own. Benefit costs associated with this
    bill are insignificant.
    Legislation on Other Matters
                                     s. 805
        The Veteran Debt Fairness Act would (1) require VA to improve
    notice about debts that is provided to VA beneficiaries, (2) limit the
    authority of the Secretary of Veterans Affairs to recover overpayments
    made by the Department and other amounts owed by Veterans to the United
    States, and (3) makes changes regarding the adjudication of disputes
    over collections.
        With respect to improving the processing of Veteran's benefits, VA
    continues to make progress in centrally tracking debts incurred by
    Veterans, to include providing more standardized electronic and
    standard mail notifications that would, to the fullest extent possible,
    and considering the limitations, consolidate the full scope of each
    Veteran's debt into one notification. The Office of Enterprise
    Integration is working with all internal VA stakeholders (i.e., Office
    of Management (OM), Veterans Experience Office, Office of Information
    Technology, VHA, and VBA) to establish an integrated program management
    plan and identify a lead office for implementation of our Veteran debt
    management efforts from an enterprise level.
        While VA appreciates the intent of this bill and is continuing to
    work with Committee staff to address VA debt management, VA does not
    support the bill in its current form. We believe some provisions are
    duplicative of current efforts, while others present technical and
    implementation issues as detailed below. We pledge to continue to work
    with the Committee to improve our debt collection program.
        Regarding the requirement in section 2(a) of the legislation that
    VA develop a method by which individuals may elect to receive notice of
    debt by electronic means in addition to standard mail, VHA is currently
    developing an electronic option to permit viewing of monthly Patient
    Medical Statements via the ``My Healthevet'' portal (https://
    www.myhealth.va.gov/mhv-portal-web/home). By July 2019, Veterans will
    be able to view or print their statements electronically via the
    portal. These statements are currently delivered by standard mail to
    Veterans who are required to make co-payments; the statements advise
    Veteran patients of their medical copayment debts, provide a
    description of those debts, and present all payment options available
    to them. VBA and OM are in the initial scoping and planning phases for
    electronic notification of VBA-related debts.
        Some of the proposed amendments to 38 U.S.C. Sec. 5314, set forth
    in section 3 of the legislation, are not consistent with other statutes
    outside of Title 38. For example, 31 U.S.C. Sec. 3711, entitled
    ``Collection and Compromise,'' provides that, ``The head of an
    executive, judicial, or legislative agency shall try to collect a claim
    of the U.S. Government for money or property arising out of the
    activities of, or referred to, the agency.'' Pursuant to existing law
    and regulation, VA returned to our respective programs over $1.6
    billion through debt collection in FY 2018, thereby allowing recovered
    funds to be reused for Veterans programs. Failure to collect any
    portion of these funds would therefore increase the mandatory benefit
    budget request by that amount.
        With respect to the due process notice periods set forth in the
    legislation, VA notes that in cases where a debt dispute is not
    submitted within 30 days from VA's initial notification of
    indebtedness, the Department will still have to comply with Public Law
    104-134 and the Debt Collection Improvement Act (DCIA) of 1996 to refer
    the debt to the Department of the Treasury Offset Program (TOP) when
    the debt reaches 120 days. Not referring the debt to TOP timely would
    be a violation of the DCIA.
        The prohibition in section 3 on recoupment of debt by offset more
    than 5 years after the date the debt was incurred is contrary to 31
    U.S.C. Sec. 3716, which does not place a time limit on VA's ability to
    collect via offset. Further, the prohibition on recoupment of debt by
    offset more than 5 years after the date the debt was incurred is also
    contrary to 28 U.S.C. Sec. 2415(i), which does not impose any
    limitation on the time period for agencies of the United States to
    collect claims by means of administrative offset. Additionally,
    disputing and appealing a debt sometimes takes years, delaying
    collections significantly. Considering such appeals delays,
    particularly in cases where a debt is discovered after the fact and
    established retroactively, VA may end up not being able to collect some
    debts.
        With respect to reforms intended to improve due process, VA
    appreciates the bill's recognition that different notice periods are
    appropriate for different benefit programs. For example, the 45-day
    notice period for debts incurred as a result of a person's
    participation in a program of educational assistance administered by
    the Secretary recognizes that, with education debts, there was a risk
    in extending the notice timeline to 90 days before a deduction may be
    made as there may not be an education benefit to offset after 90 days.
        Another concern is that limiting VA's ability to recover debts
    through offset could impact agreements VA has with the Defense Finance
    and Accounting Service, which acts on behalf of DOD, to collect such
    debts. For example: VBA awards Dependent and Indemnity Compensation
    benefits to a surviving spouse, which results in an offset of DOD
    Survivor Benefit Plan benefits and a potential debt to DOD. VA would
    collect any potential debt by withholding it from any retroactive
    benefits and then reimburse DOD. However, this debt is not a result of
    any of the five elements of the proposed legislation and may go back
    more than 5 years.
        Additionally, VA routinely creates debts in excess of $2,500. For
    example, VA's compensation program has over 150,000 such debts. All VA
    benefit debts currently have a dispute process in place for validation.
    A secondary review would impose a significant additional burden which
    would further delay the collection process, potentially causing non-
    compliance with the DCIA, which requires debt referral within 120 days.
        Finally, with respect to the issue of correcting erroneous
    information submitted to consumer reporting agencies (CRA), it is
    important to note that VHA does not submit debt information to CRAs.
    However, pursuant to 31 U.S.C. 3711(g)(1), VHA is required to refer
    delinquent accounts to the Treasury Cross Servicing program.
    Notwithstanding the fact that VHA does not submit debt information
    directly to CRAs, the VA's Debt Management Center (DMC) does refer
    delinquencies to them for VBA debts. However, the DMC also corrects CRA
    reports when needed, either through the Online Solution for Complete
    and Accurate Reporting or when internal processing determines a
    negative remark needs to be corrected. An internal processing example
    would include if the DMC sent debt notification letters to a deployed
    reservist; DMC would remove the negative remark when the reservist
    advised DMC of the situation. VA also provides written notice to a
    debtor when a CRA referral is changed.
        As noted above, VA has been working with the Committee staff on
    these and numerous other Veteran debt management issues and looks
    forward to continuing such work for the benefit of Veterans.
                                     s. 524
        S. 524, the ``Department of Veterans Affairs Tribal Advisory
    Committee Act of 2019,'' would establish an advisory committee to
    provide advice and guidance to VA on matters relating to Indian tribes,
    tribal organizations, and Native American Veterans and to annually
    report to Congress on the Committee's recommendations.
        VA supports this bill as an opportunity to strengthen and
    potentially expand opportunities for partnerships between the
    Department and tribal governments, provided Congress appropriates
    additional funds to support implementation. VA also supports this bill
    because it would provide a forum in which the Secretary and senior VA
    leadership could engage with tribal leadership on a scheduled,
    recurring basis. Native American Veterans may sometimes be viewed as
    members of a minority group rather than citizens of political entities
    which should be consulted with and engaged on a government to
    government basis in regular discussion and partnership. However, many
    issues involving Native American Veterans are not related to Native
    American Veterans' minority status, and thus do not fall within the
    purview of the Advisory Committee on Minority Veterans. The Committee
    proposed by this bill would provide a forum for consideration of issues
    related to the relationship tribal governments have with the United
    States, such as opportunities for VA collaboration with the Indian
    Health Service and Tribal health programs and land tenure issues.
        Costs for S. 524 would range between $45,000 and $60,000 annually
    for committee member travel reimbursement and compilation and
    distribution of an annual report.
                                     s. 746
        S. 746, the ``Department of Veterans Affairs Website Accessibility
    Act of 2019,'' would require VA, within 180 days after enactment, to
    conduct a study on the accessibility of VA websites to individuals with
    disabilities in accordance with section 508 of the Rehabilitation Act
    of 1973 and to report to Congress within 90 days after completion of
    the study on the websites that are not accessible and a plan to bring
    such websites into compliance.
        While VA agrees with the purpose of the bill, we believe it is
    unnecessary as system owners scan and remediate their websites as
    needed. Moreover, we have some concerns with the mandated schedule
    regarding conducting a review and developing a remediation plan. VA's
    Section 508 Office currently scans VA websites to identify non-
    compliant websites, files, and web-based applications. The results of
    these scans are shared with the Administrations and staff offices
    responsible for maintaining the Web sites. Furthermore, the inclusion
    of kiosks and file attachments in the definition of ``Web site''
    significantly expands the scope of what are considered Web sites for
    VA's section-508 compliance regime. As an example, a file attachment
    could include any number of items that are not covered under section
    508. Finally, we believe that, in practical terms, it would be
    unrealistic to conduct a universal review within 180 days. While VA
    does not support S. 746 in its current form, we wish to emphasize that
    VA system owners are scanning their systems and implementing
    remediation when necessary in accordance with section 508.

        Mr. Chairman, 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.

     OPENING STATEMENT OF HON. JOHN BOOZMAN, ACTING CHAIRMAN, U.S.
                         SENATOR FROM ARKANSAS

        Senator Boozman. Thank you so much, Dr. Boyd, and in the
    interest of time I am going to forego my opening statement.
        We do appreciate you all being here very much.
        We have 17 bills here that we are going to talk about. Last
    Congress, in a very, very bipartisan way--that is the hallmark
    of this Committee--we were able to pass several really
    significant pieces of legislation that are going to help
    veterans. We appreciate Secretary Wilkie and the staff that
    make these things happen, working so hard to actually get those
    into law, get them in place, so that our veterans will benefit
    from the legislation we have done.
        As you know, this Committee is committed to working with
    the VA to end the tragic epidemic of veteran suicide. Your
    testimony mentions a need for an all-hands-on-deck approach to
    empower veterans' well-being with the goal of ending veteran
    suicide.
        You know, we have talked about this ever since I have been
    in Congress and it seems like we still have essentially the
    same number and lots of resources. I guess the question is,
    what resources or assistance does VA need from Congress in
    order to move the needle so that we do not continue to talk
    about the same number year after year?
        Mr. Carroll. Thank you, Senator. I would be happy lead off
    on answering that. We appreciate your support. Suicide in
    America is a public health crisis at this point. It affects
    veterans, which is our focus, but it affects all of the
    American population. We know, from working with our colleagues
    in DOD, other Federal agencies, academic experts, that there is
    no single cause of suicide, in general, and certainly in the
    veteran population overall. We are working on bundled
    approaches, implementing the National Strategy for Preventing
    Veteran Suicide, which was published last year, which looks at
    care within the facility, and we appreciate your support in
    terms of advancing our mental health care.
        We also know that suicide is not simply a mental health
    issue. It is not simply something that can be treated on the
    way forward. We need to support veterans in the communities
    where they live, work, and thrive. That is why the grant
    program would be very important to us; working with our State
    and community partners to make sure that veterans and their
    families feel supported and welcomed, have a sense of
    belonging, including in their work places. We need to get
    beyond the walls of VA. Mental health care is important but we
    need to get beyond simply the health care system and support
    these women and men where they live and work.
        Senator Boozman. I totally agree that this is something
    that really does stretch society. The reality, though, in
    Arkansas and I think throughout much of the country, is the
    incidence of veteran suicide is quite a bit higher than in the
    general population. So, you know, there is a problem, yet there
    is a greater problem in the VA, which we really need to figure
    out the source of. It is a difficult problem that we are
    spending lots of money, lots of resources on. So, hopefully we
    will have some metrics in place to go forward.
        One of the things that seems to be working in Arkansas is
    the private entities. Tell us about public-private
    collaboration. What are we doing in that area?
        Mr. Carroll. We are working in several ways in that space.
    We have arrangements with over 60 organizations in partnership,
    supporting the work that they do. We are also working with VSO
    groups, including those who are here today with us, both on a
    national level and working with their local chapters to make
    sure that veterans and their families are supported in those
    spaces.
        The effort which we have recently launched, in terms of
    Mayors' and Governors' challenges, is an important effort to
    get the local community involved. VA is providing the data and
    resources to help local communities look at the footprint of
    veterans within their community, look at perhaps the unique
    risk factors or groups of veterans in their communities that
    may be at risk for suicide, helping those communities, working
    with our SAMHSA partners to put together a plan that is
    tailored for their individual communities.
        Senator Boozman. I appreciate that. Thank you very much. In
    Arkansas, the suicide rate is 48 per 100,000, versus 22 per
    100,000; so, there is a significant difference. Again, I think
    that we would find that throughout the rest of the country.
        Your testimony expresses support for S. 980, Section 3,
    which would enable VA to enter into partnerships to provide
    legal services to homeless veterans. How would the ability to
    provide legal services strengthen VA's efforts to combat
    veteran homelessness, which is another issue that we are
    actually making, I think, significant headway.
        Dr. Boyd. Yes, we are. Thank you for recognizing that. In
    fact, overall homelessness has decreased about 49 percent since
    2010. We are not there yet. We have a long way to go, but we
    are improving.
        We do know that if we could address the many issues around
    homelessness, why folks get into a homelessness state, and many
    times that is a--there are legal issues there. There are legal
    roots to that. Likewise, the legal issues that maybe crop up
    and force someone into not having a roof, being homeless,
    actually then feeds into what we were talking earlier about,
    the increased risk for suicide and self-harm.
        So, anything that we can do to help folks get on the right
    footing, housing first, work on those other supportive
    services, and I do believe that we will be in a much better
    place. We will start nicking away at the rest of that 51
    percent.
        Senator Boozman. Senator Brown.

               HON. SHERROD BROWN, U.S. SENATOR FROM OHIO

        Senator Brown. Thanks, Chair. Thank you, Senator Tester.
        First I want to thank the two of you, Senator Boozman and
    Senator Tester, for the Veterans Debt Fairness Act. Many of my
    colleagues have had conversations with local veterans, with
    veterans in our States where this had been a problem. I would
    like to enter two letters in the record, one that came out of
    testimony from James Powers when we did a field hearing in
    Columbus, and then the other from John Moser, Master Sergeant
    John Moser, who read an article about the hearing and had a
    similar situation.
        If I could ask for your consent.
        Senator Boozman. Yeah. Without objection.
        Senator Brown. Thank you, Mr. Chairman.

        [The letters appear in the Appendix.]

        Senator Brown. I will not recount their stories except to
    say that he was overpaid a considerable amount--Mr. Powers,
    $26,000--and it caused him great hardship. He notified the VA a
    number of times. You know this story; it has happened far too
    many times. Veterans deal with enough stress. They should not
    have to deal with stress created by the VA and then the VA
    unwilling to accept its responsibility.
        I have a series of questions about that, first for you, Ms.
    Murphy. You know, your testimony concerns of the bill, the VA
    is already working to provide notice for debt collecting
    activities, actions that this Committee required in a law
    passed last year. Wouldn't almost all the concerns, Ms. Murphy,
    that VA raised about the bill be addressed if the VA did a
    better job keeping track of its payments to veterans in the
    first place?
        Ms. Murphy. So, the debt issue is certainly a concerning
    one and no one wants to get a debt letter, and sometimes we
    acknowledge that those could be more clear, better written. So,
    we have been working with improving and modernizing the way
    that----
        Senator Brown. Well, no. It is not just more clear and
    better written. Acknowledge it was a--they are mistakes.
        Ms. Murphy. Well, and to understand what the root of the
    debt was, what did or did not happen. We have--we administer--
    --
        Senator Brown. Wait, wait, wait. I know--I mean, you do not
    work at the White House. I know the White House has not
    admitted a mistake in 2 years, but the VA could admit a mistake
    when you one is made. If you overpaid, you made a mistake. I
    understand it is a huge--I think the VA does great work in
    CBOCs like Mansfield and the VA in Cleveland, but if you make a
    mistake, you make a mistake. Acknowledge it to the Committee
    and then work with veterans to fix this, right?
        Ms. Murphy. Certainly, we have a broad array of benefits
    that we administer. There is the health care side, the benefit
    side. I know that these have been worked in different systems,
    and I think we are taking one of the first efforts,
    holistically, across the enterprise in VA, at a department
    level, to look at how we approach debts, how that affects
    veterans, how we communicate, modernizing the way that we
    notify. It is a complicated issue----
        Senator Brown. I am sure it is.
        Ms. Murphy [continuing]. And we acknowledge that we need to
    do a better job.
        Senator Brown. OK. Thank you.
        All right. You said that your debt collection allows you to
    fund other VA initiatives. What about the toll it takes on
    other--on veterans like James and John?
        Ms. Murphy. Well, sir, we acknowledge individual
    circumstances have to be addressed. We have provisions for if
    we need to make a different repayment plan, if it would affect
    someone. But, we also have to be good fiscal stewards and make
    sure that we are administering our programs responsibly.
        Senator Brown. When updating the bill language, working
    with Senators Boozman and Tester, we wanted to make sure that
    while a veteran is disputing a debt, VA could not take action
    to collect or reduce a benefit. We want to make sure the VA
    realized the burden should be on the Department. I understand
    you make mistakes. We all do. I understand that. But, the
    burden should be on the Department, not the veteran,
    understanding that this process could cause additional stress
    and hardship for a veteran or for the veterans' families.
        My question, for Drs. Carroll and Boyd, is this. You work
    on mental health issues at VA. Do you consider financial
    hardships as a stressor or risk factor for suicide?
        Mr. Carroll. Yes, sir.
        Senator Brown. Dr. Boyd?
        Dr. Boyd. Yes, sir.
        Senator Brown. OK. Do you think VA should have clear
    policies in place to limit additional stressors for veterans?
        Mr. Carroll. Yes.
        Senator Brown. OK. Dr. Boyd?
        Dr. Boyd. Yes, sir.
        Senator Brown. Thank you. Certainly this is part of it. It
    is, of course, not everything, but these mistakes--if these
    mistakes ever contribute to a veteran's more likely taking her
    own or his own life then we obviously have a lot of work to do.
        Thank you. Thanks, Mr. Chairman.
        Senator Boozman. Senator Murray.

            HON. PATTY MURRAY, U.S. SENATOR FROM WASHINGTON

        Senator Murray. Well, thank you. Thank you very much, Mr.
    Chairman. I am really glad to be here today and have an
    opportunity to talk about my legislation that will help clarify
    current law and provide relief and peace of mind to countless
    veteran moms and their newborns during the most critical
    moments after a child is born.
        But, Mr. Chairman, before I say more about my proposal, I
    wanted to voice a very grave note of concern regarding the rash
    of veteran suicides that we have seen across our country. It is
    a crisis that impacts all of our communities, including my home
    State of Washington. Over the weekend we had another one of our
    veterans take their lives, this time at the VA hospital in
    American Lake.
        Every case like this is a tragedy. It defies explanation.
    For any of our veterans or servicemembers, including those who
    survived combat in our service, to die by suicide, I believe we
    cannot just stand by while this epidemic claims more of our
    veterans. It crushes families and it is overwhelming our
    communities. I cannot just stand by.
        I know the Chairman is not here today but if you and his
    staff just tell him that I really believe this Committee needs
    to hold some hearings and take some action to uphold our
    promise to our veterans, that we will have their back, and do
    what is necessary to get a handle on this really growing
    tragedy. I would appreciate it.
        Now about today's topic, I am really glad to have a moment
    to talk about my legislation, to help make life easier for
    veteran moms and help them get the care that they need for
    their newborn infants in the event of a medical emergency.
    Under current law, veterans expecting a child are eligible to
    have that care covered by the VA, and in some cases, when there
    is an emergency, the veteran and the newborn may need to be
    transferred, often by a helicopter, to a hospital that can
    provide them a higher level of care in that emergency.
        However, anecdotal reports from our veterans have unveiled
    that the VA often improperly refuses to pay the cost of
    transporting newborns to a more advanced facility and that
    leaves the veteran stuck with the thousands of dollars in
    surprise billing.
        Now, as this Committee knows, current law clearly states
    that the VA can cover all post-delivery care services a newborn
    may need, but bizarrely, the VA so far has refused to pay for
    those expenses, not to mention current law limits care for
    newborns to only 7 days, which is a threshold, actually, that
    can be far too restrictive in certain cases, like premature
    births.
        I know this is not how we, at Congress, intended for this
    to work for our veterans. So, the bill that I have, in my
    proposal, called the VA Newborn Emergency Treatment Act, makes
    clear Congress' intent in the law and makes sure that veterans
    and their newborns are getting the care they need while being
    treated with the dignity that they deserve.
        The idea that transportation to get newborn infants
    emergency treatment, would not be covered by the VA is really
    shocking, and it really is a needless gap in care. I firmly
    believe Congress must ensure that no veteran ever faces a
    surprise bill for benefits they have earned through their
    sacrifice to our country, especially new moms and babies
    dealing with emergency situations.
        So, I hope colleagues from both sides of the aisle will
    join me in supporting this necessary fix and make sure we are
    doing right by our veteran moms and military families, and I
    look forward to the markup we will have on this.
        Dr. Boyd, in my short time left I wanted to tell you I
    really appreciate the assistance the VA provided us in putting
    together the Newborn Emergency Treatment Act with working
    through our technical concerns. I have already incorporated a
    number of those recommendations you have made to help everyone
    understand the urgent need for this bill. I did want to ask
    you, can you describe for us some of the situations when a
    newborn would need to be moved to a higher-level facility and
    how urgent it is to get that child into care?
        Dr. Boyd. Well, I am not a neonatologist or a pediatrician.
    However, I am a family doc and a mom. I can share with you that
    my youngest daughter, who is 28 years old, was born at 30
    weeks, so I truly understand where you are coming from on this.
        It could be anything from--especially in that 7-day time
    period, within the 7- to 14-day time period--it could be
    anything from injuries or issues at birth, through the actual
    birthing process, all the way to some very rare complications
    or rare disorders or diseases that manifest within that first
    time period. There are many things that it could be.
        We all wish to have a normal birth and delivery, and all
    wish to have a healthy newborn. It is not always the case.
        Senator Murray. Please speak to the 7-day requirement. Tell
    me when a newborn child would need care longer than 7 days,
    which is the current coverage.
        Dr. Boyd. Again, I would need some SMEs on that for the 14,
    anything beyond 7, but just so you know we absolutely do
    support, within S. 514, the expansion of up to 14 days. So, we
    have no issue with that.
        Senator Murray. OK. I have some questions about cost and
    how you came to your cost estimates. I will submit them in
    writing.
        Dr. Boyd. Thank you.
        Senator Boozman. Senator Tester.
        Senator Tester. Thank you, Mr. Chairman, and I want to
    thank you all for being here.
        Dr. Carroll, I think you got into the importance of
    incorporating community-based public health approach to veteran
    suicide prevention with Senator Boozman's question so I will
    skip that on mine.
        For you, Dr. Boyd, I asked for technical assistance on 10
    sections of the Command John Scott Hannon Mental Health
    Improvement Bill on February 28, and for the entire bill on
    March 26. It has been a while ago, quite frankly. I have not
    received any technical feedback. You guys were not fully
    enamored with the bill. That technical feedback is important.
    When can I expect it?
        Dr. Boyd. First of all, you must know that it is at the
    utmost front line and center for the Secretary to be very
    responsive to Congress. So, my understanding is this, that the
    technical review had begun on the first 10 provisions, that had
    been submitted, and then came the remainder, as you stated,
    later in March. As that was really getting kind of rolling--
    because some of these are very complex, have multiple decision
    points and authorities. Then we had the remaining initially 17
    new bills that was whittled down to 16. So, it blanketly
    overtaxed some of our system to ensure that we had the entire
    agenda to speak from.
        But, I do want you to know this. S. 785 is at the center of
    everything that we do. In fact, there is a lot that we are
    already doing, and we want to be extremely careful in the
    vision that you did have. We are at a better place than we were
    back in February or March. I think that we can move forward
    with this with continued discussion with the Committee.
        Senator Tester. That is good but I need that technical
    input. I am just telling you, I just flat need it.
        Dr. Boyd. Absolutely.
        Senator Tester. If I do not have it then we are going to do
    what I think is best, without your input----
        Dr. Boyd. I understand, sir.
        Senator Tester [continuing]. And that could be a problem.
        S. 711 is another bill that we have got, the Care for
    Reservists bill, that I do not think the Department is too
    enamored with, quite frankly. I have got a bunch of questions
    to put you on the spot but I am not going to do that to you.
        I am just going to tell you that everybody who spoke here,
    from Senator Boozman to Senator Brown to Senator Murray and now
    I, and quite frankly you guys too, have talked of the
    importance of reducing suicide. Senator Boozman put it most
    articulately, that we have done a lot of things which has not
    affected the numbers. It has not done it. It has not gotten us
    where we need to be. Not that one suicide is acceptable, but it
    has not even gotten us close to a point where we can say, ``You
    know what? We have done some good stuff here and we have moved
    the ball.''
        We are using reservists in a way that we have never used
    them before in the past, and it did not start with this
    administration, by the way. It started in previous
    administrations. And these folks are coming back with pretty
    serious problems, that, quite frankly, we created for them. So,
    if we do not step it up for active duty and for Guard and
    Reserve, we should not be asking them to sign up to serve, and
    that is as simple as that.
        So, we have got to do something in that area. And, as we
    look at whether it is S. 785 or S. 711, it is critically
    important that we figure out what we can do different to make a
    difference. If we are able to do that then we both can be much
    prouder of what is going on.
        The last thing, then I will kick it back to the Chairman.
    To Senator Brown's questions on S. 805, he is right, this
    should not be on the veteran. This should be on the VA. If we
    do not look at it from that perspective, we are making a big
    mistake. I do not think you are going to find anybody on this
    Committee, either side of the aisle, that does not believe
    that.
        So, we look forward to working with the Department to get
    that fixed too, amongst the other bills.
        Thank you, Mr. Chairman.
        Senator Boozman. Well, thank you, Senator Tester. Let me
    just say a couple of things about two or three bills. First of
    all, I really enjoyed working with Senator Tester on the
    Deborah Sampson bill. We appreciate your leadership. There are
    2 million women vets, 20,000 in Arkansas. As I go around the
    State, and I am sure Senator Tester, as he goes around Montana,
    very similar, rural States, I hear that we are blessed with
    some of the most progressive VA facilities in the country,
    through a lot of hard work from lots of individuals.
        But, one of their top concerns is the inequality of health
    care between men and women. It is all kinds of things. It is
    shortage of primary care providers; the lack of respect
    sometimes shown to our women veterans in the sense of asking
    where their husbands are in the sense of thinking that they are
    the wife of a veteran; the gender-specific providers; and the
    list goes on and on. You all understand that. You are very,
    very familiar with it. I know you have got some problems with
    our bill, but certain data collection about where women
    veterans need their care is something that we can be doing.
    Some of them are things that you have the ability to do now,
    without legislation.
        I hope that you will work with us. Our VSOs are on board
    and are doing a great job of pushing this forward. But, this is
    something unlike suicide, as Senator Tester talked about, the
    panel talked about, you talked about, which is something that
    involves all kinds of factors and is a difficult problem.
        Inequality is not a difficult problem. This is something
    that we can solve. It is going to take some work. It is going
    to take a little bit of change of attitude in some cases, but
    we can do a better job of providing the resources that we
    need--privacy, I mean, just these basic things that with the
    significant increase in our veteran population of women, which
    is only going to grow substantially as we go forward, are
    necessary.
        Again, I hope that we can work together in that regard.
        The other bill that I would like to talk about is Senator
    Ernst's bill and the idea that you do not hire these
    practitioners that have had significant problems. You know,
    there is simply no excuse for that. We need to do a much, much
    better job in that. I would lump currently licensed, impaired
    in the past, all those things together. You know, there is
    simply no excuse for that.
        Last, Senator Cotton's bill that increases the stipend for
    our Medal of Honor winners. I think that is something that we
    can be so proud of and looking at inflation, that is something
    else that we need to take care of.
        Have you got any other things? Again, thank you all very,
    very much. We do appreciate your hard work and appreciate your
    testimony.
        Dr. Boyd. Thank you to the Committee. Thank you.
        Senator Boozman. OK, Panel 2. Are you guys ready to jump up
    here and get seated? [Pause.]
        Well, we want to welcome our panel. Thank you for taking
    the time. We do appreciate all of your hard work and all that
    you represent.
        I have a list of organizations that have submitted written
    statements on today's hearing agenda. We have 4 represented
    here. We have 19 others that have submitted data. So, without
    objection, that is so ordered.

        [The statements appear in the Appendix.]

        Senator Boozman. Today we are blessed to have Ms. Melissa
    Bryant, Chief Policy Officer of Iraq and Afghanistan Veterans
    of America; Michael Richardson, Vice President of Independent
    Services and Mental Health, Sounded Warrior Project--again, it
    is great to have you here; Greg Nembhard, Deputy Director of
    Claims Services, The American Legion--thank you, Greg; Maj.
    Gen. (Ret.) Jeffrey Phillips, Executive Director, Reserve
    Officers Association.
        We will start with you, Ms. Bryant.

      STATEMENT OF MELISSA BRYANT, CHIEF POLICY OFFICER, IRAQ AND
                    AFGHANISTAN VETERANS OF AMERICA

        Ms. Bryant. Thank you, Senator Boozman, Ranking Member
    Tester, and to the distinguished Members of the Committee who
    could not be here at this moment. On behalf of Iraq and
    Afghanistan Veterans of America, or IAVA, and our more than
    425,000 members worldwide, we thank you for the opportunity to
    share our views, data, and experiences on the legislation in
    front of the Committee today.
        As you have heard me speak to in the past, I am not only
    the Chief Policy Officer for IAVA, but I am also a third-
    generation combat veteran. These bills we are discussing today
    are largely issues which impact me personally, especially as a
    woman veteran who has been exposed to burn pits, borne of a
    father who still suffers injuries that he was exposed to by
    Agent Orange in Vietnam.
        I am here as a former Army officer who has lost soldiers to
    suicide and worked with several others who struggled with
    suicidal ideation for a variety of factors, ranging from
    financial stress to survivor's guilt. I am here as a student
    veteran who used her earned GI Bill benefit to obtain a
    master's degree in policy mid-career, which is what landed me
    here today as Chief Policy Officer for IAVA, and to give voice
    to the voiceless so they can get the support that they deserve
    from their government so they can live their lives to their
    fullest potential.
        I am going to highlight just a few items here, but overall
    there are 16 bills contained within the legislation today that
    IAVA does support. Of our Big Six priorities for 2019, it
    remains number 1 to be the campaign to combat suicide among
    troops and veterans. Suicide rates over the past 10 years have
    been rising at a shocking rate. In 2016, the Centers for
    Disease Control reports that 45,000 Americans had died by
    suicide.
        To clarify and reiterate what many others have said today,
    while suicide is an American epidemic and public health crisis,
    it is severely impacting the veteran population in particular.
    According to the most recent Department of Veterans Affairs
    data, 20 veterans and servicemembers die by suicide every day,
    which is over 7,000 per year. At-risk populations include women
    veterans, like myself, who are almost twice as likely to die by
    suicide than their civilian counterparts; and veterans aged 18
    to 34, the post-9/11 generation, which IAVA represents, have
    the highest rate of suicide among any generation of veteran.
        We have been watching this trend line for years. In our
    latest member survey, 59 percent of IAVA members reported
    knowing a post-9/11 veteran who died by suicide; 65 percent
    know a post-
    9/11 veteran who has attempted suicide. In 2014, these numbers
    were 40 percent and 47 percent, respectively.
        More alarmingly, our newest data shows that 43 percent of
    IAVA members report having suicidal ideation since leaving the
    military, a 12 percent increase since 2014, showing that more
    and more veterans and servicemembers in IAVA's community are
    experiencing suicidal ideation, which is also a risk factor in
    and of itself for suicide.
        This information tracks with the final report under the
    Clay Hunt SAV Act: the VA Mental Health Program and Suicide
    Prevention Services Independent Evaluation from 2018. The
    report shows that veterans ages 18 to 45, the post-9/11
    generation, had the greatest proportion of suicidal behaviors,
    including suicidal attempts and ideation, among any age group
    and made up almost 40 percent of the overall suicidal behavior
    totals.
        We believe the best next step in addressing this crisis is
    the passage of the Commander John Scott Hannon Veterans Mental
    Health Care Improvement Act, S. 785, as discussed earlier
    today. We thank you, Senator Tester and Senator Moran, who was
    here earlier. We believe that this bill will bring even greater
    attention to resources that the VA needs in order to combat the
    veteran suicide crisis, and IAVA is very pleased with the
    provisions in the bill to provide grants to organizations to
    provide mental health care services for veterans not receiving
    VA care, as well to organizations that provide transition
    assistance to veterans and their spouses. We were proud to
    stand with Commander Hannon's family, partner VSOs, and
    Senators Tester and Moran to introduce the Commander John Scott
    Hannon Veterans Mental Health Care Improvement Act, and it has
    IAVA's unqualified support going forward, sir.
        We also support the Care and Readiness Enhancement for
    Reservists Act, otherwise known as CARE, because we do
    recognize that this is a gap where reservists and our National
    Guard men and women are not necessarily receiving the same
    amount of care due to the fact that they are in units that do
    not necessarily have the same continuum of care as if you were
    on active duty. We wholeheartedly support this effort as well
    to close this gap for their mental health as well.
        In support for She Who has Borne the Battle, over the past
    few years there has been a groundswell of support for women
    veterans' issues. We made the bold choice to lead on this
    issue, going back, in 2017, when we launched our
    #SheWhoBorneTheBattle campaign. That is why this year we are
    wholeheartedly in support of S. 514, which is the
    reintroduction of the Deborah Sampson Act, which thank you
    both, gentlemen, in reintroducing this year. We strongly
    support the passage of that bill, along with the other
    provisions that have been updated for the version for the 116th
    Congress.
        Again, there are 16 other bills that I could go on to. I am
    going to focus just on burn pits and toxic exposures. Knowing
    that we support both CONUS (Contiguous United States) and Camp
    Lejeune, we also support this bill, as well as defending the GI
    Bill, which has always been a long-standing issue for IAVA,
    since we championed the post-9/11 GI Bill in 2008.
        Thank you. I am happy to go through anything else that is
    within our testimony and to speak more to the support that we
    have for the 16 other bills that are within this hearing.
        [The prepared statement of Ms. Bryant follows:]
          Prepared Statement of Melissa Bryant, Chief Policy Officer,
                    Iraq and Afghanistan Veterans of America
        Chairman Isakson, Ranking Member Tester, 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
    legislation in front of the Committee today.
        IAVA is pleased to see that much of the legislation in front of the
    Committee today addresses components of our Big Six Priorities for 2019
    which are: the Campaign to Combat Suicide, Advocate for Government
    Reform, Support for Injuries from Burn Pits and Toxic Exposures, Defend
    Veterans Education Benefits, Support and Recognition of Women Veterans,
    and Support for Veteran Medicinal Cannabis Use.
        As you've heard me speak to in the past, I am not only the Chief
    Policy Officer for IAVA, but also a third-generation combat veteran.
    The bills we're discussing today are largely issues which impact me
    personally--especially as a woman veteran who has been exposed to burn
    pits, borne of a father who was exposed to and still suffers injuries
    from Agent Orange. I'm here as a former Army officer who has lost
    Soldiers to suicide and worked with several others who struggled with
    suicidal ideation for a variety of factors ranging from financial
    stress to survivor's guilt. And I'm here as student veteran who used
    her earned GI Bill benefit to obtain a masters degree in policy mid-
    career, thus landing me here before you today to passionately advocate
    for the voiceless veterans worldwide who need the support of their
    government in so they can live to their lives' fullest potential.
                           campaign to combat suicide
        IAVA's top Big Six priority for 2019 remains the Campaign to Combat
    Suicide Among Troops and Veterans. Suicide rates over the past 10 years
    have been rising at a shocking rate; in 2016, the Center for Disease
    Control reports that 45,000 Americans died by suicide. While suicide is
    an American epidemic and public health crisis, it is severely impacting
    the veteran population in particular. According to the most recent
    Department of Veterans Affairs data, 20 veterans and servicemembers die
    by suicide every day, which is over 7,000 every year. At risk
    populations include women veterans who are almost twice as likely to
    die by suicide than their civilian counterparts. And veterans aged 18
    to 34, the post-9/11 generation, have the highest rate of suicide among
    any generation of veteran.
        We've been watching this trendline for years. In our latest member
    survey, 59 percent of IAVA members reported knowing a post-9/11 veteran
    who died by suicide; 65 percent know a post-9/11 veteran who has
    attempted suicide. In 2014, these numbers were 40 percent and 47
    percent respectively.
        More alarmingly, our newest data shows that 43 percent of IAVA
    members report having suicidal ideation since leaving the military--a
    12 percent increase since 2014; showing that more and more veterans and
    servicemembers in IAVA's community are experiencing suicidal ideation--
    a risk factor for suicide. This information tracks with the final
    report under the Clay Hunt SAV Act: The VA Mental Health Program and
    Suicide Prevention Services Independent Evaluation from 2018. The
    report shows that veterans ages 18 to 45--the post-9/11 generation--had
    the greatest proportion of suicidal behaviors, including suicidal
    attempts and ideation, among any age and made up almost 40 percent of
    the overall suicidal behavior totals.
        We believe the best next step in addressing this crisis is passage
    of the Commander John Scott Hannon Veterans Mental Health Care
    Improvement Act (S. 785), introduced by Sens. Tester and Moran, which
    will bring even greater attention and resources to VA to combat the
    veteran suicide crisis. IAVA is very pleased with the provisions in the
    bill to provide grants to organizations that provide mental health care
    services for veterans not receiving VA care, as well to organizations
    that provide transition assistance to veterans and spouses. S. 785 also
    invests in a number of studies, including the link between elevation
    and suicide and an evaluation of Vet Centers' Readjustment Counselors
    efficacy; it also provides for an increased number of tracking metrics
    to ensure that VA is providing the best possible mental health care
    possible. We were proud to stand with Commander Hannon's family,
    partner VSOs, and Sens. Tester and Moran to introduce the Commander
    John Scott Hannon Veterans Mental Health Care Improvement Act, and it
    has IAVA's unqualified support.
        In addition to expansion of mental health care for our veterans, we
    must also focus on our military's Guard and Reserve components.
    Currently, members of the National Guard and Reserve undergo annual
    health assessments to identify medical issues that could impact their
    ability to deploy, but any follow-up care must almost always be pursued
    at their own expense. Though some National Guard units have worked to
    expand care, many of these efforts are funded with limited dollars that
    must also cover training and equipment expenses. The Care and Readiness
    Enhancement (CARE) for Reservists Act (S. 711) would allow Guardsmen
    and Reservists to access Vet Centers for mental health screening and
    counseling, employment assessments, education training, and other
    services to help them return to civilian life. Access to care for Guard
    and Reservists is a top concern for IAVA as almost 60 percent of our
    membership is either currently serving or has served in the Guard or
    Reserves. It is for those reasons that IAVA supports the passage of
    this legislation.
                    support for she who has borne the battle
        Over the past few years, there has been a groundswell of support
    for women veterans' issues. From health care access to reproductive
    health services to a seismic culture change within the veteran
    community, women veterans have rightly been focused on and elevated on
    Capitol Hill, inside VA, and nationally. In 2017, IAVA launched our
    groundbreaking campaign, #SheWhoBorneTheBattle, focused on recognizing
    the service of women veterans and closing gaps in care provided to us
    by VA.
        IAVA made the bold choice to lead on an issue that was important to
    not just the 20% of our members who are women, but to our entire
    membership, the future of America's health care and national security.
    We continue to fight hard for top-down culture change in VA for the
    more than 700,000 that have served since 9/11, including 345,000 women
    who have deployed to Iraq or Afghanistan in support of the most recent
    wars.
        This is why in 2017, IAVA worked with Congressional allies on both
    sides of the aisle and in both chambers to introduce the Deborah
    Sampson Act (S. 514). This bill called on the VA to modernize
    facilities to fit the needs of a changing veteran population,
    increasing newborn care, establishing new legal services for women
    veterans, and eliminating barriers faced by women who seek care at VA.
    This bill would also increase data tracking and reporting to ensure
    that women veterans are getting care on par with their male
    counterparts.
        Although the Deborah Sampson Act, the centerpiece of IAVA's She Who
    Borne The Battle campaign, was not passed in the 115th Congress, IAVA
    is pleased with progress made overall in support of women veterans,
    with key provisions of the legislation passed or funded in the last two
    years. These hard-fought victories included funding to improve services
    for women veterans, such as research on and acquisition of prosthetics
    for female veterans, increased funds for gender-specific health care,
    women veterans' expanded access and use of VA benefits and services,
    improved access for mental health services, and for supportive services
    for low income veterans and families to address homelessness.
        While we have seen greater awareness and progress toward improving
    services for women veterans, there is much more we can do. Toward this
    goal, IAVA strongly supports passage of the updated Deborah Sampson Act
    reintroduced by Sens. Tester and Boozman. Provisions of the new bill
    include expanded peer to peer services, such as the ability for women
    to receive reintegration counseling services with family members in
    group retreat settings, increased newborn care services, and an
    increase in spending in order to retrofit VA facilities to enhance the
    privacy and environment women are being treated in, including privacy
    curtains and door locks. It also provides for legal and support
    services to focus on unmet needs among women veterans, like prevention
    of eviction and foreclosure and child support issues. This must be the
    year that Congress passes the Deborah Sampson Act into law.
        In addition to the increase in newborn care under the Deborah
    Sampson Act, IAVA is pleased to support another bill in front of the
    Committee today, the VA Newborn Emergency Treatment Act (S. 318). This
    legislation would allow VA to reimburse the cost of emergency
    transportation related to newborn care. Coupled with provisions in the
    Deborah Sampson Act this will finally allow VA to give greater care to
    veteran mothers.
                          burn pits & toxic exposures
        Another Big Six priority for IAVA is Support for Burn Pits and
    Toxic Exposures. Unfortunately, the exposures our servicemembers face
    isn't only overseas in the wars in Iraq and Afghanistan, but for some
    it was back home as well. From 1953 to 1987 the drinking water in
    Marine Corps Base Camp Lejeune was contaminated with chemicals that
    caused a number of diseases. In 2012 the original Jane Ensminger Act
    was passed, which allowed those who were exposed to Camp Lejeune's
    contaminated water to access the treatment that they deserved. The
    Janey Ensminger Act of 2019 will allow additional research into the
    symptoms and diseases of those that were exposed to contaminated
    drinking water on Camp Lejeune. It is for those reasons that IAVA
    supports the bill in front of the Committee today.
                               defend the gi bill
        A temporary school closure can be a very stressful time for
    military-connected students, and losing their housing allowance adds an
    additional layer of stress to that situation. Allowing students to
    continue to receive their housing allowance is a needed fix for this
    problem. IAVA supports the draft bill in front of the Committee to
    allow military-connected students affected by temporary school closures
    to continue to receive their housing allowance during the temporary
    closure.
                modernize government to support today's veterans
        As of August 2018, there were over 40,000 job vacancies within VHA.
    While these are difficult-to-fill positions, we need to do more to
    ensure that VA is capable of closing this employment gap. While closing
    this gap is critical, we must also guarantee that our Nation's veterans
    are receiving the best care that is available. It is with this in mind
    that IAVA supports three additional bills to improve VA hiring and
    employment practices; the Ensuring Quality Care for Our Veterans Act
    (S. 123), the VA Provider Accountability Act (S. 221), and the Veterans
    Improved Access and Care Act of 2019 (S. 450).
        The VA Tribal Advisory Committee Act (S. 524) would improve VA
    outreach, health care, and benefits for Native American veterans
    through the establishment of a VA Advisory Committee on Tribal and
    Indian Affairs. Native American and Alaska Native servicemembers face
    unique challenges when accessing VA services and experience
    homelessness and health disparities at higher rates than other
    veterans. The bill aims to eliminate health disparities for Native
    American veterans by establishing a 15-member Committee comprised of a
    representative from each of the 12 regions of the Indian Health Service
    (IHS) and three at-large Native American members. This Committee would
    ensure greater collaboration between Tribal governments and VA,
    ensuring that our Native servicemembers are getting the benefits that
    they deserve. IAVA is proud to support this legislation.
        IAVA is pleased to see the Committee take up the important issue of
    VA overpayments. Overpayments from the VA have been on the rise since
    2013. In 2016 alone, the VA issued upwards of 200,000 overpayment
    notices to veterans, often recouping funds by withholding some or all
    of a veteran's monthly disability benefit payments. In many of these
    cases, the overpayment was caused by no fault of the veteran, which
    only increases frustration when payments are withheld. The Veteran Debt
    Fairness Act (S. 805) aims to fix this issue with common sense
    solutions, such as only allowing the VA to collect debts that occur as
    a result of an error or fraud on the part of a veteran, only allowing
    the VA to deduct 25 percent of a veteran's monthly payment, and
    preventing the VA from collecting debts incurred more than five years
    prior. These are common-sense solutions that will protect veterans from
    financial hardship caused by accounting errors at VA. IAVA fully
    supports the passage of this legislation.
        The Highly Rural Veteran Transportation Program Extension Act
    (S. 850) would expand the ability of VA to make grants for qualifying
    VSOs to provide transportation to veterans in highly rural areas to VA
    facilities. Veterans that live in highly rural areas deserve the same
    care as veterans that may live close to a VA facility and this program
    will allow those veterans to seek that care at no cost to themselves.
    IAVA is pleased to support this legislation.
        The VA Website Accessibility Act (S. 746) would require VA to
    review all of its websites to determine if they comply with
    requirements in current law that they be accessible to individuals with
    disabilities. The bill would require VA to report to the Congress on
    its findings, and describe its plans to bring its websites into
    compliance. IAVA supports this bill to ensure that VA's website is
    accessible to all veterans.
        The Medal of Honor is the highest award for valor in action against
    an enemy force which can be bestowed upon an individual serving in the
    Armed Forces. Presented to its recipient by the President of the United
    States of America in the name of Congress. These American heroes often
    attend and speak at events about their military service at their own
    expense. While Medal of Honor recipients receive a modest pension, it
    has not been updated in 15 years. S. 857 would provide necessary
    funding to allow Medal of Honor recipients to share their personal
    stories in even more character development programs and speaking
    engagements, and has IAVA's support.
        The VA is currently undertaking a decade-long transition to bring
    veterans' health records into the 21st century by ensuring that
    veterans can have access to a seamless electronic health record across
    the VA and Department of Defense (DOD) health systems. The VA
    Electronic Health Records Advisory Committee Act (S. 1154) would create
    another level of oversight on this important transition. The 11-member
    Committee would operate separately from VA and DOD and would be made up
    of medical professionals, Information Technology and interoperability
    specialists, and veterans currently receiving care from the VA. The
    Committee will analyze the VA's strategy for implementation, develop a
    risk management plan, and ensure that stakeholders across VA and DOD
    have a voice in the process. The Committee will meet with the VA
    Secretary at least twice a year on their analysis and recommendations
    for implementation. IAVA supports the spirit of this legislation and
    increased oversight over the electronic health records project, however
    we would like to see the Committee work with VA to implement systems
    that are effective and will not add unnecessary burden on the project.
        The Better Examiner Standards and Transparency (BEST) for Veterans
    Act (S. 1101) ensures that only licensed health care providers are
    conducting medical disability examinations (MDEs) on behalf of VA. Last
    year, reports revealed that contract physicians with revoked medical
    licenses have been performing MDEs on behalf of the VA due to a
    loophole in current legislation. IAVA supports the closure of this
    loophole and ensures that veterans are only being treated and screened
    by health care providers that are licensed and qualified.
                            end veteran homelessness
        The number of homeless veterans has declined in the past decade,
    and in fact, has dropped nearly 50% since 2010. Despite the enormous
    advances made in recent years, there are still tens of thousands of
    veterans who remain homeless on a single night. VA cannot solve this
    challenge alone. Veterans who struggle with substance abuse or who have
    been previously incarcerated are often unable to be placed in housing
    programs. Even more struggle to maintain a permanent home. In our
    latest member survey, over 20 percent of IAVA members reported going
    without a home for over a year after they transitioned out of the
    military, and 84 percent reported couchsurfing temporarily. Housing and
    homelessness related referrals are among the services most requested
    through IAVA's RRRP; in 2018 alone, IAVA provided hundreds of veterans
    and family members with housing and homelessness related support. IAVA
    is pleased to support the Homeless Veterans Prevention Act (S. 980),
    which includes several important provisions to address veteran
    homelessness, such as an expansion of vouchers to dependents of
    homeless veterans, increased legal and financial services, and studies
    in order to track the effectiveness of these programs.

        Thank you for allowing IAVA to share our views and we look forward
    to answering any questions you may have.

        Senator Boozman. Good. Thank you, Ms. Bryant.
        Mr. Richardson.

         STATEMENT OF MICHAEL C. RICHARDSON, VICE PRESIDENT OF
       INDEPENDENCE SERVICES AND MENTAL HEALTH, WOUNDED WARRIOR
                                PROJECT

        Mr. Richardson. Good afternoon, Senator Boozman, Ranking
    Member Tester, and distinguished Members. Thank you for the
    opportunity to testify at today's hearing and offer Wounded
    Warrior Project's perspective on legislation before the
    Committee.
        My name is Mike Richardson and I serve as Vice President at
    Wounded Warrior Project for all mental and brain health
    programming. I am a combat veteran and a military retiree, as
    is my wife. Together we have over 50 years of active duty
    service.
        During my service I also commanded a warrior transition
    battalion in Europe, so I have not only observed but
    experienced first-hand the challenges that combat and
    transitioning cause our veterans.
        Before moving our attention to how today's legislation can
    help address these challenges, I want to praise the Committee's
    focus on: improving programs and services for female veterans
    through S. 514; its effort to improve accountability and trust
    in the VA system through bills like S. 123, 221, and 1101; and
    its focus on strengthening transition and civilian readjustment
    with S. 711.
        As our community works together to meet the needs of all
    veterans, these bills and others before the Committee are
    helping to enhance care and services and increase faith in the
    VA's ability to evolve with changing demographics and needs.
        As I sit before you today, suicide prevention is VA's top
    clinical priority, as it should be. Wounded Warrior Project's
    largest program investment is in mental and brain health, and I
    am here to express our organization's support for the
    Committee's efforts to bring greater attention to the tragic
    trend of veteran suicide and its initiative to deliver
    legislative changes to improve access to care, drive research
    forward, keep the community accountable, and foster
    collaboration among stakeholders throughout the mental health
    spectrum.
        As one of those community stakeholders I would like to use
    this opportunity to focus on mental health more generally so
    that the Committee can be informed of what we have learned as
    an organization that unifies programming, provides advocacy,
    and funds organizations that assist us in delivering our
    mission to honor and empower wounded warriors.
        Our approach to mental health care is grounded in several
    core and scientifically supported beliefs. To that end we
    acknowledge that no one organization, no single agency, if you
    will, can fully meet all the veterans' needs, that empirically-
    supported mental health treatment absolutely works when it is
    available and when it is pursued, and that we will find the
    best results by embracing an integrated and comprehensive
    public health approach focused on increasing resiliency,
    psychological well-being, and an aggressive prevention
    strategy.
        All of these concepts are embraced by the intent of the
    Commander John Scott Hannon Veteran's Mental Health Care
    Improvement Act, and we believe several proposals in the bill
    can help veterans not just survive, but really thrive in their
    communities by helping them create lives worth living, with a
    purpose.
        This bill recognizes that networks of support already exist
    and new ones can be developed to help VA reach more veterans
    and enter more communities, and that VA is an indispensable
    partner in this process.
        As an example, through our Warrior Care Network, Wounded
    Warrior Project is in partnership with four academic medical
    centers: Emory Healthcare, Massachusetts General Hospital, Rush
    University, and UCLA Health, who we directed to develop an
    innovative, 2- or 3-week intensive outpatient program that
    integrates evidence-based treatments with wellness,
    mindfulness, nutrition, yoga, art, and family support.
        Veterans are not required to be enrolled in VHA to
    participate in our Warrior Care Network, but every veteran,
    including active duty, National Guard, Reservists, and retirees
    who come through the program consults with an on-site VA
    employee who enrolls, provides education on essential VA
    resources, drives referrals to their systems back in the
    veteran's community before they leave the care of these
    academic medical centers, and helps create the trust in a VA
    system that is performing, as studies show, at the same level,
    or better, than other providers in some communities.
        The Warrior Care Network fully incorporates complementary
    and alternative therapies for veterans while they are in our
    care, approaches that are embraced in Title II of S. 785.
        Our network also drives veterans toward supportive
    organizations and services back in the home when they depart
    from us. Many of those organizations are funded through grants
    from Wounded Warrior Project. We understand that mental health
    and wellness goes beyond just clinical care.
        Our approach to this type of partnership is focused on
    uniting resources, driving change through maximizing collective
    impact, serving as a force multiplier, and expanding the
    network of support. Looking at the Warrior Care Network as the
    sum of these parts, one of the most telling results is that
    after completing the intensive outpatient program over 96
    percent of warriors are recommending the program to another
    warrior. This is an example of how we are normalizing the
    conversation and helping end the stigma around seeking mental
    health care.
        In closing, just this past Monday I was in the great State
    of Georgia, in the beautiful city of Atlanta, at Emory
    University, where we had the grand opening of their newly
    expanded space named Wounded Warrior Project's Brain Health
    Suite. Because of our space expansion investment in Emory we
    increased access for the veterans to this life-saving care.
    Space was a barrier; it no longer is.
        I am sure the leadership of Emory, the veterans' programs,
    and, of course, Wounded Warrior Project would love for the
    Chairman and any Member of this Committee to stop by for a
    visit the next time you are in Atlanta.
        Again, thank you for allowing us to be part of this very
    important work as we care for and serve those that served our
    Nation. Thank you.
        [The prepared statement of Mr. Richardson follows:]
                 Prepared Statement of Wounded Warrior Project
    S. 123, S. 221, S. 318, S. 450, S. 514, S. 524, S. 711, S. 746, S. 785,
            S. 805, S. 850, S. 857, S. 980, S. 1101, S. 1154, Draft Bill--
            Janey Ensminger Act of 2019, Draft Bill--A Bill to Amend Title
            38, United States Code, to Extend the Authority of the
            Secretary of Veterans Affairs to Continue to Pay Educational
            Assistance or Subsistence Allowances to Eligible Persons When
            Educational Institutions are Temporarily Closed, and for Other
            Purposes.
        Chairman Isakson, Ranking Member Tester, and distinguished Members
    of the Senate Committee on Veterans' Affairs, Thank you for inviting
    Wounded Warrior Project (WWP) to testify on these important issues.
        Wounded Warrior Project's mission is to honor and empower wounded
    warriors. Through community partnerships and free direct programming,
    WWP is filling gaps in government services that reflect the risks and
    sacrifices that our most recent generation of veterans faced while in
    service. Over the course of our 15-year history, we have grown to an
    organization of nearly 700 employees in more than 25 locations around
    the world, delivering over a dozen direct-service programs to warriors
    and families in need.
        Through our direct-service programs, we connect these individuals
    with one another and their communities; we serve them by providing
    mental health support and clinical treatment, physical health and
    wellness programs, job placement services, and benefits claims help;
    and we empower them to succeed and thrive in their communities. We
    communicate with this community on a weekly basis and are constantly
    striving to be as effective and efficient as possible.
               s. 123--ensuring quality care for our veterans act
        According to the 2018 WWP Survey,\1\ 68.4 percent of WWP's alumni
    reported using the Department of Veterans Affairs (VA) as their primary
    health care provider.\2\ Additionally, through the delivery of direct
    services provided to over 125,000 registered alumni, WWP teammates
    frequently encourage warriors eligible for VA medical benefits to
    enroll in the Veterans Health Administration (VHA). In contrast, the
    2018 WWP Survey also indicates that 43.7 percent of the warriors who
    chose not to utilize the VA as their primary care provider do so
    because there is a perception that higher quality care is available
    outside of the VA. This perception contradicts an April 2018 RAND study
    which stated:

        \1\ The 2018 WWP survey is the tenth iteration of our
    organization's annual poll of registered warriors (``alumni''). The
    2018 edition received over 33,000 completed surveys.
        \2\ https://www.woundedwarriorproject.org/media/183005/2018-wwp-
    annual-warrior-survey.pdf

            ``VA hospitals performed on average the same as or
            significantly better than non-VA hospitals on all six measures
            of inpatient safety, all three inpatient mortality measures,
            and 12 inpatient effectiveness measures, but significantly
            worse than non-VA hospitals on three readmission measures and
            two effectiveness measures. The performance of VA facilities
            was significantly better than commercial HMOs and Medicaid HMOs
            for all 16 outpatient effectiveness measures and for Medicare
            HMOs, it was significantly better for 14 measures and did not
            differ for two measures. High variation across VA facilities in
            the performance of some quality measures was observed, although
            variation was even greater among non-VA facilities.\3\ ''
    ---------------------------------------------------------------------------
        \3\ https://www.rand.org/news/press/2018/04/26.html

        While we know via the recent RAND study that VA is performing on
    average at the same level or significantly better than non-VA
    hospitals, there are always ways to improve. One such improvement is to
    ensure that no medical providers are practicing with revoked licenses.
    The Ensuring Quality Care for Our Veterans Act aims at ensuring
    veterans seeking care at VA medical facilities are not being seen by
    providers who are practicing with a revoked license. It is our
    understanding that the VA has conducted a thorough review of all
    providers and has taken the appropriate human resource measures to
    ensure providers who have had their license revoked are no longer
    employed. Additionally, the VA has taken actions to address internal
    hiring practices in order to ensure providers with a revoked license
    are not considered for employment in accordance with VA policies.
    Furthermore, S. 123 requires the VA to contract with a non-Federal
    entity to conduct a third party-clinical review of the care provided by
    those who were found to be practicing with a revoked license. If any
    previously provided care is deemed to be substandard, VA would be
    required to notify the veteran. If such instance exists, WWP requests
    VA implement a process for patient notification of those deemed to have
    received substandard care and how, if appropriate, VA will address
    medical needs.

    Wounded Warrior Project supports the intent of S. 123 and recommends VA
    submit a report to Congress providing the results of the original
    review. For VA providers found to have practiced with a revoked
    license, WWP supports a third party-clinical review to ensure veterans
    seen by these providers did not receive substandard care. This would
    help VA combat the narrative that VA care is substandard and reinforce
    their commitment to quality care.

       s. 221--department of veterans affairs provider accountability act
        The Department of Veterans Affairs Provider Accountability Act
    would require VA to report employees who had major adverse actions
    taken against them for conduct or performance to the National
    Practitioner Data Bank and the employee's applicable licensing board.
    Like S. 123, this bill proposes to hold VA health care providers
    accountable for substandard care and substandard conduct, both of which
    negatively impact the veteran experience. VA would be required to
    report such actions 30 days after the date on which such major adverse
    action is carried out.
        While WWP appreciates the intent of S. 221, what remains unclear is
    how VA providers' appeals will be considered, or how employment status
    will be affected by reports to the National Practitioner Data Bank.
    Additionally, WWP recommends expanding on the language ``major adverse
    action'' to clearly define when an employee should be reported. WWP
    recommends expanding on this piece of legislation to address these
    concerns.

    Wounded Warrior Project supports S. 221.

                   s. 318--va newborn emergency treatment act
        The VA Newborn Emergency Treatment Act proposes to provide clear
    authority for VA to cover the costs of medically necessary emergency
    transportation services for newborn babies of certain women veterans.
    This bill would alleviate payment issues that arise when a female
    veteran mother does not travel with her newborn child.
        As women continue to be one of the fastest-growing veteran
    populations, it is crucial to recognize that VA benefits must be
    aligned and be responsive to those who rely on VA for maternity care.
    Unlike their civilian counterparts, these women may have service-
    connected disabilities that place them at higher risk for pregnancy
    complications, including pre-term labor or low-birth weight newborns.
    In such situations, it is critical for VHA to be able to link these
    mothers and their children with specialized and intensive services when
    necessary--a step that can require emergency transportation if a
    particular VA facility cannot provide such care internally.

    In order to address these concerns and a lack of clarity in current
    law, WWP supports the VA Newborn Emergency Treatment Act.

             s. 450--veterans improved access and care act of 2019
        During the February 27, 2019, House Veterans' Affairs Committee
    hearing on the future for the VA, Secretary Wilkie expressed concern
    with the 49,000 vacancies across the Department. Of these vacancies
    cited at that time, 42,790 were within the VA health care system, with
    24,800 in the medical and dental fields. Secretary Wilkie indicated
    that the Department is prioritizing staffing efforts based on greatest
    needs, with particular effort focused on staffing primary care, mental
    health, and women's health. ``Primary health because newer veterans are
    used to urgent care, mental health because suicide is an epidemic, and
    women's health because that demographic is growing.\4\ ''
    ---------------------------------------------------------------------------
        \4\ 2019-02-27 Full Committee Hearing: VA 2030 A Vision for the
    Future of VA https://www.youtube.com/watch?v=aByF4NT_06k
    ---------------------------------------------------------------------------
        S. 450 requires the VA to carry out a pilot program to assess the
    feasibility and advisability of expediting the process of the VHA for
    onboarding new medical providers with a goal to reduce the length of
    time it takes to onboard medical providers to no more than 60 days.

    Wounded Warrior Project supports S. 450.

                          s. 514--deborah sampson act
        The National Center for Veterans Analysis and Statistics predicts
    that over the next 25 years the total veteran population will decline
    by an average of 1.8 percent per year; however, that decline will be
    driven by declines in the male veteran population. Over that period,
    the female veteran population is estimated to grow by an average of 0.6
    percent per year as the male population declines by 2.2 percent per
    year.\5\ At a time when female veterans already represent 11.6 percent
    of OEF/OIF/OND veterans and approximately 10 percent of the current
    veteran population, the VHA system must evolve to meet the needs of a
    unique and growing demographic.
    ---------------------------------------------------------------------------
        \5\ Source: https://www.va.gov/vetdata/docs/Demographics/
    VetPop_Infographic_2019.pdf
    ---------------------------------------------------------------------------
        Nearly 16 percent of WWP registered alumni are women and we are
    acutely aware of the need for programs and services tailored to their
    needs. In FY 2018, female warriors registered with WWP had
    significantly higher participation rates than men in nearly all program
    areas, particularly WWP Talk \6\ and our Physical Health & Wellness
    programming. In this context, WWP supports the Deborah Sampson Act's
    pursuit of female-specific services and its intent to eliminate
    barriers to care.
    ---------------------------------------------------------------------------
        \6\ WWP Talk is a helpline for WWP alumni, family members, and
    caregivers that provides emotional support over the telephone.
    Participants speak with the same helpline support member each week,
    developing an ongoing relationship and a safe, non-judgmental outlet to
    share thoughts, feelings, and experiences
    ---------------------------------------------------------------------------
        Wounded Warrior Project supports the S. 514 initiatives found in
    Section 101 (reintegration and readjustment services), Section 202
    (financial assistance for housing), and Section 404 (female-veteran-
    specific training for community providers), among others; however, we
    would support a review of current VA initiatives for female veterans in
    order to ensure the necessity of new legislation. For example, VA has
    already implemented a text messaging capability for the Women Veterans
    Call Center (Section 102) and developed an internet website to provide
    information on services available to women veterans (Section 503).
        Additionally, we wish to bring attention to Section 502 which
    requires VA to submit a report to Congress on the availability of
    prosthetics made for women veterans, including an assessment of the
    availability of such prosthetics at each VA medical facility. Although
    well intentioned, this section is extremely broad and may not be
    specific enough to meet congressional intent. VA Prosthetic and Sensory
    Aids Service (PSAS) is the largest and most comprehensive provider of
    prosthetic devices and sensory aids in the world.\7\ According to VA
    lexicon, the term ``prosthetic device'' may suggest images of
    artificial limbs, but in actuality, it refers to any device that
    supports or replaces a body part or function. In order to get a true
    understanding of the scope of ``prosthetic'' devices for female
    veterans, WWP recommends a report include the following elements:
    ---------------------------------------------------------------------------
        \7\ https://www.prosthetics.va.gov/psas/About--PSAS.asp

        (1) list of all devices the VA classifies as prosthetic devices.
        (2) once a list is compiled; identify whether each device is gender
    neutral or manufactured to be gender specific,
        (3) for gender-neutral devices, identify whether adequate sizing is
    available for female veterans,
        (4) assess whether all VA facilities are adequately resourced to
    meet the demand of female veteran needs,
        (5) for facilities with low demand, identify what procedures are in
    place to expedite the acquisition or manufacture of devices for female
    veterans.

    s. 524--department of veterans affairs tribal advisory committee act of
                                      2019
        The Department of Veterans Affairs Tribal Advisory Committee Act of
    2019 proposes to give a voice to the American Indian Veteran
    population--a population that faces unique issues that are not always
    understood by the country--by establishing the Department of Veterans
    Advisory Committee on Tribal and Indian Affairs. This Committee would
    help VA identify evolving issues that are specific to American Indian
    veterans and communicate these issues directly to the Secretary of
    Veterans Affairs.
        American Indians and Alaska Natives serve in the military at a
    higher rate than members of other racial groups. Due to the unique
    challenges they face in receiving VA medical and benefits assistance,
    it is necessary in allowing this group of veterans a voice in order to
    raise their concerns to the highest level of authority at the VA.
        Given that 5.3 percent of WWP alumni identity as American Indian or
    Alaska Native, we recognize that this population has a different set of
    challenges in accessing care and benefits. At times, this population is
    located many miles from VA medical centers and often lack coordinated
    care for long-term treatment. A recent U.S. Government Accountability
    Office (GAO) report recommended that VA strengthen oversight and
    coordination of health care for this population.\8\ The proposed
    Veterans Advisory Committee can help VA address all recommendations in
    the March 21, 2019, GAO study as well as any additional deficiencies
    yet to be discovered.
    ---------------------------------------------------------------------------
        \8\ https://www.gao.gov/assets/700/697736.pdf
    ---------------------------------------------------------------------------

    Wounded Warrior Project supports S. 524.

      s. 711--care and readiness enhancement (care) for reservists act of
                                      2019
        The CARE for Reservists Act of 2019 proposes to extend VA mental
    health care resources to the National Guard and Reservists. With
    particular emphasis on Vet Centers to help meet demand, the CARE for
    Reservists Act acknowledges that VA--in consultation with the
    Department of Defense (DOD)--can help remove barriers to care that
    exist for a population that interacts with the military health system
    differently than their active duty counterparts.
        As VA and DOD work together in their collective pursuit to reduce
    veteran and military suicides, the CARE for Reservists Act addresses
    critical risk factors that can help connect at-risk National Guard and
    Reservists with mental health care. According to the DOD Suicide Event
    Report for Calendar Year 2016, the suicide mortality rates for the
    Reserve Component (22.0 deaths per 100,000 reservists) and the National
    Guard Component (27.3 deaths per 100,000 members of the Guard
    population) were both higher than the suicide mortality rates for the
    Active Component (21.1 deaths per every 100,000 Active Duty
    Servicemembers). Moreover, the average at-risk Guardsman is between the
    ages of 17 and 24--an age consistent with VA data that reflects a
    higher rate of suicide among younger veterans (ages 18 to 34) than any
    other age cohort.
        Permitted VA is adequately staffed and resourced to handle an
    influx of National Guard and Reservist patients, a concern addressed in
    Section 5, WWP supports the CARE for Reservists Act of 2019 and its
    intent to lend VA resources to help National Guard and Reservists
    successfully readjust to civilian life.
      s. 746--department of veterans affairs website accessibility act of
                                      2019
        Wounded Warrior Project remains vigilant in addressing the needs of
    those with severe physical and cognitive injuries. According to the DOD
    & VA Extremity and Amputation Center of Excellence, as of March 2019,
    there have been a total of 1,724 battle injured amputees treated in
    Military Treatment Facilities. A large portion of those patients were
    treated following high-impact or blast-related injuries--injuries that
    often include immediate or eventual visual impairment. Additionally,
    the 2018 WWP Survey reflects that 41.2 percent of the 33,067 warriors
    who completed the survey self?reported to have a Traumatic Brain Injury
    (TBI). This population includes those with severe TBI who experience
    significant cognitive issues.
        According to DOD's Vision Center of Excellence, eye and head
    trauma, or exposure to a blast, can result in immediate and longer-term
    vision loss and dysfunction that can be difficult to initially detect,
    making those affected with TBIs more prone to vision problems in the
    future.\9\ Research also notes more than 75 percent of all TBI patients
    experienced short- or long-term visual dysfunction, including double
    vision, sensitivity to light, and inability to read print, among other
    cognitive problems.\10\ As veterans rely more on internet access and
    use of smart devices and computers, the likelihood of a veteran or a
    servicemember with a physical or cognitive disability relying on or
    utilizing an electronic or information technology web-based system to
    seek their care or communicate with VA is extremely likely. As VA
    introduces new technologies or modifies old systems, it must recognize
    the potential of inadvertently removing accessibility features that
    were once in place. The VA must ensure that website developers follow
    industry-standard accessibility guidelines to ensure compatibility with
    screen reading software utilized by visually impaired persons.
    Additionally, as VA executes the implementation of the MISSION Act and
    the electronic health record management system, which will have a
    robust external facing platform, it must do so with thoughtful
    consideration of end users who may have visual or cognitive
    deficiencies.
    ---------------------------------------------------------------------------
        \9\ DOD Vision Center of Excellence. Vision Problems Associated
    with TBI
        \10\ DOD Armed Forces Health Surveillance Center, Medical
    Surveillance Monthly Report (MSMR), vol. 18, no. 5, ``Eye Injuries,
    Active Component, U.S. Armed Forces 2000-2010,'' May 2011, 2-7.
    ---------------------------------------------------------------------------
        The Department of Veterans Affairs Website Accountability Act of
    2019 would direct VA to conduct a study regarding the accessibility of
    VA websites to determine is whether such websites are accessible to
    individuals with disabilities in accordance with Section 508 of the
    Rehabilitation Act of 1973 (29 U.S.C. 794d). WWP supports this
    legislation and encourages Congress to continue to exercise oversight
    once the study has been completed.
        s. 785--commander john scott hannon veterans mental health care
                            improvement act of 2019
        Suicide prevention is the Department of Veterans Affairs' highest
    clinical priority, and among the greatest challenges, WWP is trying to
    address in the community we serve. Congress has an important role to
    play in improving access to mental health care and supporting the
    development of a comprehensive network of education and support that
    can protect against isolation and veteran suicide. WWP encourages a
    wide-ranging approach anchored in evidence-based treatment and
    research. This foundation should support private and non-profit sector
    partnerships that keep VA at the center of care and strengthen holistic
    approaches to wellness--important tenets that are captured by the
    Commander John Scott Hannon Veterans Mental Health Care Improvement Act
    of 2019.
        This bill contains 35 provisions that span from transition to
    community grants and incorporate proposals affecting clinical care and
    non-clinical support. Given the immense gravity and importance of
    ensuring that our community works collectively and more effectively to
    improve access to care and prevent veteran suicide, we believe it is
    critical to move forward with as much concurrence as possible on
    legislative solutions that unite our community's efforts. In this
    spirit, we offer our perspective on key proposals that we believe can
    make the biggest impact based on organizational experience.
        In Focus: Section 101--This section would extend VA health care
    eligibility to transitioning veterans for a full year after their
    separation or discharge from the Armed Services. WWP supports this
    provision as it aligns with Joint Action Plan for Executive Order 13822
    and the cross-agency recommendation and goal of proving immediate and
    continuous access to VA health care for all transitioning
    servicemembers during the first 12 months post-transition--a time when
    suicide prevention efforts can align with heightened risk.
        As highlighted by DOD's Defense Suicide Prevention Office,
    servicemembers transitioning out of DOD are at a higher risk of suicide
    within the first 90 days of separation--a trend consistent over a 14-
    year period. Over that period, approximately 50 percent of suicide
    deaths occurring in the first three months of separation happened
    within the first 17 days of separation. As Congress continues to work
    with the executive branch to improve and monitor military-to-civilian
    transition, WWP supports Section 101 as a primary tool to help mitigate
    suicide risk for transitioning servicemembers.
        In Focus: Section 201--This provision would create a new grant
    program aimed at organizations that provide and coordinate mental
    health services for veterans not receiving care at VA. As our community
    strives to reach more veterans and connect them to the care and
    services they need, not just to survive but to thrive, this initiative
    to empower community-based organizations through partnerships with VA
    is critically important. While WWP would defer to the judgment of
    Congress and VA on the specific composition of how grants are awarded,
    we can provide firsthand perspective on our approach to grantmaking and
    the impacts those grants have on ensuring healthy military-to-civilian
    transitions.
        While WWP has many successful direct programs serving needs of
    warriors and their families, we alone cannot meet every need this
    generation of wounded servicemembers and veterans face. WWP knows no
    one organization can fully meet veterans' needs. To this end, we
    proudly partner with other organizations to help our Nation's veterans.
    Since 2012, WWP has granted $80.9 million to 158 other veteran and
    military service organizations. In FY 2018 alone, we executed 38 grants
    to organizations totaling more than $13.6 million in additional impact
    to support our warriors and their families. These efforts reflect the
    value that comes with working with others to harness subject matter
    expertise, reach a greater number of injured veterans, and provide a
    more comprehensive network of support.
        Our approach to grants and partnerships has evolved over time and
    currently reflects leading research in the military-veteran community.
    Together with the Henry Jackson Foundation (HJF), and partners from the
    public and private sectors, WWP has funded a longitudinal study of
    transitioning veterans to better understand the components of well-
    being and the factors necessary for ensuring a healthy military-to-
    civilian transition. Findings from this study--The Veterans Metrics
    Initiative--suggest there are four components of well-being: Social
    Relationships; Health; Finances; and Vocation. Our investments for
    direct services and programming are considered and categorized on this
    evidence-based criteria, and we engage WWP's metrics team to measure
    our collective work and outcomes.
        As a community of service organizations, we each focus on
    complementary initiatives across missions (sometimes, generations) and
    together we are forging partnerships, providing cross-referrals and
    providing a stronger, expanded network of support. We must all work
    together to serve those who need us most throughout their care
    continuum. When assessing potential partnerships, WWP evaluates
    existing and potential partners based on how a program complements WWP
    by:

          Filling a gap in WWP direct services by providing a
    program or service WWP does not offer;
          Augmenting WWP direct services by doubling down on
    services that are in high demand;
          Amplifying messaging around issues affecting post-9/11
    wounded/ill/injured veterans, caregivers, and their families;
          Building relationships and collaboration with
    organizations serving veterans and families;
          Growing small organizations with potential that can have
    the ability to scale and offer innovative programming

        In sum, WWP supports Section 201 and its implicit recognition that
    community-based organizations can extend VA's reach across the country
    and into the lives of veterans who are not currently connected to the
    system. A strong network of clinical care and community support is a
    protective factor in suicide prevention.
        In Focus: Section 205--This section would commission a study on the
    feasibility and advisability of providing certain complementary and
    integrative health treatments such as yoga, meditation, acupuncture,
    and chiropractic care, at all VA medical facilities, either in person
    or through telehealth when applicable. Section 205 would also permit VA
    to provide these treatments. While we would defer to VA and Congress to
    determine the appropriate timing of implementing such a study and
    practice, WWP endorses the utility of complementary and integrative
    health treatments in a holistic approach to mental health care.
        To illustrate this point, WWP's signature Warrior Care Network is
    an innovative program and partnership between WWP and four national
    academic medical centers (AMCs): Massachusetts General Hospital, Emory
    Healthcare, Rush University Medical Center, and UCLA Health. Warrior
    Care Network delivers specialized clinical services through innovative
    two- and three-week intensive outpatient programs that integrate
    evidence-based psychological and pharmacological treatments,
    rehabilitative medicine, wellness, nutrition, mindfulness training, and
    family support with the goal of helping warriors thrive, not just
    survive.
        Through these two- to three-week cohort-style programs,
    participating warriors receive more than 70 direct clinical treatment
    hours (e.g. cognitive processing therapy, cognitive behavioral therapy,
    and prolonged exposure therapy) as well as additional supportive
    intervention hours that incorporate many (and more) of the
    complementary therapies listed in Sections 205 and 206. Warriors in the
    program receive approximately 16 hours of complementary services during
    treatment. Available therapies at each AMC include acupuncture,
    massage, yoga, art therapy, and equine therapy. These services are
    provided in both individual settings and in groups that include
    warriors and family members. Each instance of supportive therapy is
    documented and overall trends are used to develop future complementary
    therapy offerings in the WCN program.
        Providing warriors with best in class care that combines clinical
    and complementary treatment is still only part of the Warrior Care
    Network's holistic approach to care. While AMCs provide veteran-centric
    comprehensive care, aggregate data, share best practices, and
    coordinate care in an unprecedented manner, a Memorandum of Agreement
    (MOA) between WWP and VA has been structured to further expand the
    continuum of care for the veterans we treat. In February 2016, VA
    signed this MOA with WWP and the Warrior Care Network to provide
    collaboration of care between the Warrior Care Network and VA hospitals
    nationwide. Four VA employees act as liaisons between each site and VA,
    spending 1.5 days per week at their respective sites to facilitate
    coordination of care and to meet with patients, families, and care
    teams. Each VA liaison facilitates national referrals throughout the VA
    system as indicated for mental health or other needs, but also provides
    group briefings about VA programs and services, and individual
    consultations to learn more about each patient's needs. In
    November 2018, that MOA was renewed with a growing commitment from VA--
    VA has created full-time billets for liaisons at each AMC to enhance
    their contribution to the partnership. All told, this first-of-its-kind
    collaboration with VA is critical for safe patient care and enables
    successful discharge planning. At WWP, we believe cooperation and
    coordination like this can serve as a great example of ``responsible
    choice'' in the VA health care system.
        Warriors who complete the Warrior Care Network program are seeing
    results. Prior to treatment, over 83 percent of patients reported PTSD
    symptoms at the severe to moderate range based on the PCL-5 clinical
    assessment, with the aggregate average being 51.1 (severe PTSD).
    Following treatment in the intensive outpatient programs, PTSD symptoms
    decreased 19.4 points to 31.7 (minimal PTSD).\11\ A similar pattern was
    seen for symptoms of depression, with a mean score of 16.0 at intake
    and a decrease to 10.2 at follow-up on the PHQ-9 assessment. These
    changes translate into increased functioning and participation in life,
    based on the decrease of psychological distress caused by severe to
    moderate levels of PTSD and depression.
    ---------------------------------------------------------------------------
        \11\ Note: A change in score greater than 5 is indicative of
    clinically significant change rather than statistical change.
    ---------------------------------------------------------------------------
        It is also worth noting that, although effective if completed, many
    who begin evidence-based mental health treatment (cognitive processing
    therapy and prolonged exposure) in non-intensive outpatient (IOP)
    formats--including highly controlled and selective clinical trials
    \12\--discontinue care before completion. While drop-out rates in those
    formats are between 30 and 40 percent,\13\ the IOP model used by
    Warrior Care Network has a completion rate of 94 percent. When combined
    with clinically significant decreases in mental health symptoms, this
    figure is illustrative of the successful approach the Warrior Care
    Network has taken--and patients agree. Ninety-six percent (96.3
    percent) of warriors reported satisfaction with clinical care received,
    and 94 percent of warriors indicate they would tell another veteran
    about WCN, a possible indication of reduced mental health stigma.
    ---------------------------------------------------------------------------
        \12\ Imel, Z., Laska, K., Jakcupcak, M., Simpson, T. (2013). Meta-
    analysis of Dropout in Treatments for Post-traumatic Stress Disorder.
    Journal of Consulting and Clinical Psychology, 81(3), 394-404.
        \13\ Kehle-Forbes, S., Meis, L., Spoont, M., Polusny, M. (2015).
    Treatment Initiation and Dropout From Prolonged Exposure and Cognitive
    Processing Therapy in a VA Outpatient Clinic. Psychological Trauma:
    Theory, Research, Practice, and Policy, 8(1), 107-14.; Gutner, C.,
    Gallagher, M., Baker, A., Sloan, D., Resick, P. (2015). Time Course of
    Treatment Dropout in Cognitive-Behavioral Therapies for Posttraumatic
    Stress Disorder. Psychological Trauma: Theory, Research, Practice, and
    Policy, 8(1), 115-21.
    ---------------------------------------------------------------------------
        As WWP and its partner AMCs remain committed to pioneering this
    innovative approach to treat warriors with moderate to severe PTSD, we
    support further research--and potential expansion of VA authority(ies)
    to provide similar care--into the efficacy of combining complementary
    and integrative treatments with evidence-based treatments to deliver
    first-class mental health care to veterans. For these reasons, we
    support Section 205.
        In Focus: Section 305--This provision would install a Precision
    Medicine for Veterans Initiative at VA in order to identify and
    validate brain and mental health biomarkers. Section 305 places an
    emphasis on biomarkers for PTSD, TBI, anxiety, and depression--
    challenges that face a significant portion of warriors who reach out to
    WWP for help.
        According to results of the 2018 WWP Survey, and for the fourth
    year in a row, Post Traumatic Stress Disorder (PTSD) was the most
    frequently reported health problem from service (78.2 percent),
    followed closely by depression (70.3 percent), anxiety (68.7 percent),
    and even sleep problems (75.4 percent), an issue frequently linked to
    mental health challenges. Accordingly, mental health programs are WWP's
    largest programmatic investment--in 2018, WWP spent $63.4 million on
    our mental health programs.
        Wounded Warrior Project's investments to address these challenges
    extends beyond programming, and our interest in biomarker research
    aligns with the intent behind Section 305. Specifically, WWP supports
    work being performed and funded by Cohen Veteran Bioscience (CVB) to
    fast-track the development of diagnostic tests and personalized
    therapeutics for the millions of veterans and civilians who suffer the
    devastating effects of trauma to the brain. Recent research published
    in Science Translational Medicine and funded in part by CVB, identifies
    a PTSD brain imaging biomarker.\14\ This biomarker is important because
    it may help determine which people with PTSD will respond to PTSD
    first-line treatment of behavioral therapy, and which individuals with
    PTSD who don't respond to first-line treatment may respond to other
    options. This personalized approach may help connect people to the
    right PTSD treatment sooner.
    ---------------------------------------------------------------------------
        \14\ Amit Ekin et al. ``Using fMRI connectivity to define a
    treatment-resistant form of Post Traumatic Stress Disorder.'' Sci.
    Transl. Med. 11, eaal3236 (2019).
    ---------------------------------------------------------------------------
        Wounded Warrior Project supports continued research and
    collaboration into biomarkers for mental health and Traumatic Brain
    Injury treatment. VA would be an integral partner to work already being
    done in the community and as such, we support Section 305.
        In Focus: Section 406--This provision focuses on identifying
    transition and mental health programing operated by the Department of
    Veterans Affairs and the Department of Defense and establishing a Joint
    DOD/VA National Intrepid Center of Excellence Intrepid Spirit Center in
    a rural or highly rural area. These agencies share common goals to
    increase efficiencies, eliminate redundancies, and improve health care
    outcomes. WWP supports the establishment of a center focused on mental
    health that would foster collaboration in treatment, research, and
    prevention initiatives. At its core, research would permit for the
    quantification of successful treatment modalities, ultimately leading
    to the creation of a successful clinical model (i.e., clinical
    intervention hours, clinical interventions to use and supportive
    services) that could be shared and duplicated at different locations.
                   s. 805--veteran debt fairness act of 2019
        The Veteran Debt Fairness Act of 2019 addresses issues related to
    VA's debt collection practices. Historically, VA has been reputed to be
    an aggressive debt collector. The agency has a history of practices
    that include withholding disability benefits payments and sending
    incurred debts to aggressive third-party debt collection agencies.
        Sections 1 and 2 of S. 805 would require VA to update their
    information technology (IT) system to allow veterans to update
    dependency information. Although we find that VA currently has this
    function, we are interested in seeing if VA can make this more user
    friendly, and not have veterans who have adopted, stepchildren, or
    those who have dependent children in college be penalized for needing
    to submit documents that the automated system often fails to recognize.
    This will help address overpayments to veterans who have changes in the
    dependency status. Additionally, VA will be required to electronically
    notify the veteran that a debt has been established. This is critical
    as many veterans have noted that they never received the physical
    letter notifying them that a debt has been incurred. Section 3 of this
    bill would require VA to conduct an annual audit for debt errors on at
    least 10 percent of all debts created. Additionally, this section would
    allow veteran 120 days to contest a debt, allowing the veteran time to
    address possible debt errors before the VA starts the collection
    process.
        These proposed changes, especially to the IT system, would
    facilitate faster dependency claim processing times. Also, the
    definitions of what constitutes a lawful debt will directly affect
    countless warriors, especially Reservists and National Guard, who often
    end up accumulating debt due to their failure to complete and return,
    or have VA acknowledge the submission of a VA Form 21-8951, Notice of
    Waiver of VA Compensation or Pension to Receive Military Pay and
    Allowances when they are activated.
        Wounded Warrior Project is pleased to see language in this
    legislation that would limit the number of funds the VA can deduct from
    a veteran's disability payment to 25 percent. We would also recommend
    defining ``reasonable efforts'' on page 6, line 17, regarding efforts
    made to notify a veteran of their rights.

    WWP is encouraged by S. 805 and supports this legislation.

       s. 850--highly rural veteran transportation program extension act
        For veterans who live in highly rural areas, transportation to VA
    facilities can be a major barrier in obtaining VA health care. The
    Highly Rural Veteran Transportation Program Extension Act would amend
    section 307(d) of the Caregivers and Veterans Omnibus Health Services
    Act of 2010 to add one additional year to a program that provides
    grants to Veterans Service Organizations for transportation to VA
    facilities. The grant amount may not exceed $50,000, and a total of
    $3,000,000 is appropriated each fiscal year.
        The 2018 WWP Survey indicates that 29.2 percent of veterans who do
    not use VA as their primary health care provider cited that it was due
    to their distance from a VA care center.\15\ In this context, WWP feels
    that any program that helps transport veterans to and from a facility
    is imperative in addressing barriers to receiving care.
    ---------------------------------------------------------------------------
        \15\ https://www.woundedwarriorproject.org/media/183005/2018-wwp-
    annual-warrior-survey.pdf
    ---------------------------------------------------------------------------

    Wounded Warrior Project supports this legislation.

     s. 857--a bill to amend title 38, united states code, to increase the
    amount of special pension for medal of honor recipients, and for other
                                    purposes
        This bill would increase the special pension given to Medal of
    Honor recipients from $1,000 a month to $3,000 a month. The Medal of
    Honor special pension has not been increased since 2002 via Public Law
    113-66 which increased the pension from $600 to $1000. Medals of Honor
    recipients are frequently asked to attend speaking events to help
    promote national pride in the military. They often pay the cost of
    attending these events by using their pension for out-of-pocket
    expenses. This legislation aims to help offset these expenses by
    increasing the pension amount.

    Wounded Warrior Project is proud to support S. 857.

                s. 980--homeless veterans prevention act of 2019
        According to our 2018 survey, 5.6 percent of responding warriors
    were homeless or living in a homeless shelter during the past 24 months
    of taking the survey. Additionally, those that were homeless showed
    varied rates regarding how long they were homeless:

            ``Among them [homeless veterans], 26.4 percent were homeless
            for less than 30 days, 49.1 percent were homeless for 1-6
            months, 12.9 percent were homeless for 7-12 months, and 11.4
            percent (10.1% in 2017) were homeless for 13-24 months. Female
            warriors showed somewhat higher rates of homelessness over the
            past 24 months than males (7.1% for females vs. 5.3% for
            males). Homelessness among female warriors was 7.2% in 2017 and
            6.1% in 2016.\16\ ''
    ---------------------------------------------------------------------------
        \16\ https://www.woundedwarriorproject.org/media/183005/2018-wwp-
    annual-warrior-survey.pdf

        There are an estimated 50,000 homeless veterans in the U.S., and
    another 1.4 million considered at-risk of homelessness.\17\
    Additionally, one of the most notable deficiencies for this population
    is legal assistance.\18\ Legal assistance is critical in helping
    veterans access healthcare, veteran disability benefits, and housing
    vouchers. This legislation will authorize VA to fund pro-bono lawyers
    and community legal clinics to help homeless veterans understand their
    rights. Additionally, S. 980 will authorize VA dental care for homeless
    veterans, increase resources for very low-income veteran families, and
    authorize per-diem payments to furnish care to dependents of certain
    homeless veterans.
    ---------------------------------------------------------------------------
        \17\ The Invisible Battlefield (2016)
        \18\ The Veterans Administration annual Community Homeless
    Assessment, Local Education, and Networking Groups (CHALENG) survey
    (2016)
    ---------------------------------------------------------------------------
        Wounded Warrior Project supports the majority of the sections in
    S. 980 but recommends removing Section 8, on page 8. This section would
    repeal a required annual report on assistance available to homeless
    veterans. While this information is duplicative of similar studies at
    the Department of Housing and Urban Development (HUD), WWP feels that
    homeless veterans are more likely to search for information through the
    Department of Veterans Affairs over the Department of HUD.
        Additionally, Section 6, on page 7, of S. 980, conflicts with
    Section 202 in S. 514, the Deborah Sampson Act, in that both provisions
    amend Section 2044 of Title 38 but at different dollar amounts. We
    recommend the Committee deconflict these two sections if both pieces of
    legislation were to move forward.

    Wounded Warrior Project supports S. 980 with the above amendments.

    s. 1101--better examiner standards and transparency for veterans act of
                                      2019
        In 2018, it was revealed that a Logistic Health Incorporated (LHI)
    physician performing medical disability examinations (MDE) had
    previously pled guilty to seven counts of fraud and that their medical
    license was revoked. Currently, Public Law 104-275 allows contract
    physicians to perform examinations in a state other than their state of
    licensure if the physician meets the statutory description of physician
    meeting the following requirements: (1) has a current unrestricted
    license to practice, (2) is not barred from practicing in any State;
    and (3) is performing authorized duties for the VA under a
    contract.\19\ Under VA's current interpretation of the law, only
    physicians that are operating across state lines are required to meet
    the above three requirements thereby opening a loophole that allows
    physicians that have revoked licenses to perform MDEs if they are not
    practicing outside their state of licensure.
    ---------------------------------------------------------------------------
        \19\ https://www.Congress.gov/104/plaws/publ275/PLAW-104publ275.htm
    ---------------------------------------------------------------------------
        The Better Examiner Standards and Transparency for Veterans Act of
    2019 would close this loophole and prohibit contract health care
    providers who have had their licenses revoked in any state from
    performing MDEs. Additionally, it would require VA to ensure that only
    licensed health care providers are conducting MDEs and require VA to
    submit a yearly report to Congress on the outcomes of third-party
    contractors administering MDEs.
        Wounded Warrior Project agrees with the provisions in the
    legislation that relates to closing this obvious loophole. Wounded
    Warrior Project supports S. 1101 but recommends looking at lines 1
    through 8 on page 4 and expanding on the intent to minimize the second
    and third order effects of this proposal.
           s. 1154--department of veterans affairs electronic health
                         record advisory committee act
        Wounded Warrior Project believes the electronic health record
    modernization (EHRM) will provide efficiencies and greater quality
    inpatient and prescription data, all of which will lead to greater
    quality of care, identify high-risk patients related to suicide and
    opioid abuse, and a greater quality of life. With an investment of $16
    billion and an implementation timeline of 10 years, successful
    implementation will deliver--for the first time--a uniform platform to
    manage records and provide seamless capabilities across DOD and VA. WWP
    believes Congress needs to exercise vigilant oversight of the
    implementation process to ensure high levels of interoperability and
    data accessibility between VA, DOD, and commercial health partners.
    Just as important, key stakeholders must also remain vigilant to ensure
    the VA takes account the voices of all stakeholders and veterans.
    Equally important to implementation is ensuring the VA is considering
    an ever-changing IT environment to ensure EHR ``modernization'' does
    not become outdated or obsolete.
        The Department of Veterans Affairs Electronic Health Record
    Advisory Committee Act would establish a VA Advisory Committee on
    Implementation of Electronic Health Record, which acts as an
    independent, third-party oversight entity that will ensure that on-the-
    ground stakeholders have a voice.

    Wounded Warrior Project supports S. 1154.

                       draft--janey ensminger act of 2019
        The Janey Ensminger Act of 2019 would require the Center for
    Disease Control and Prevention's Agency for Toxic Substance and Disease
    Register (ATSDR) conduct scientific analysis and review of scientific
    literature that may be relevant to those affected by contaminated water
    in North Carolina's Camp Lejeune between 1953 to 1987. Although ATSDR
    has found that servicemembers, including their families, suffered from
    increased risk of cancers and other health risks due to contaminated
    water at Camp Lejeune, VA has failed in accepting ATSDR's findings for
    health care treatment. The scientific analysis that ATSDR would conduct
    will include a list of illnesses and conditions that are prevalent due
    to exposure to toxic substances at Camp Lejeune, NC, which will be
    critical in ensuring there is no delay in health care assistance.
        WWP has placed toxic exposure issues as one of its top 2019
    legislative priorities. This advocacy does not only include toxic
    exposures during military service while deployed but also to those
    affected stateside and the families of servicemembers.

    Wounded Warrior Project supports this legislation.

      draft--a bill to amend title 38, united states code, to extend the
       authority of the secretary of veterans affairs to continue to pay
     educational assistance or subsistence allowances to eligible persons
      when educational institutions are temporarily closed, and for other
                                    purposes
        This draft legislation will increase the time limit an institution
    of higher learning can be temporarily closed and still allow their
    student veterans to draw from their GI Bill Basic Allowance for House
    stipend from 4 weeks to 8 weeks. When a school is affected by a
    national disaster, student veterans are sometimes required to attend
    classes online because the school campus is temporarily closed. When
    this happens, the student's Basic Allowance for House (BAH) is reduced
    to 50 percent of the national average. This legislation will minimize
    the hardship of a natural disaster by ensuring that student veterans
    continue receiving appropriate BAH payments for a reasonable amount of
    time.

    Wounded Warrior Project supports this draft bill.

        Senator Boozman. Thank you, Mr. Richardson.
        Mr. Nembhard.

    STATEMENT OF GREG NEMBHARD, DEPUTY DIRECTOR OF CLAIMS SERVICES,
                          THE AMERICAN LEGION

        Mr. Nembhard. Thank you, Chairman Boozman, Ranking Member
    Tester, and distinguished Members of the Committee. On behalf
    of National Commander Brett P. Reistad, and the nearly two
    million members of The American Legion, we thank you for this
    opportunity to testify on our position on pending legislation.
    As the largest veterans service organization in the United
    States, The American Legion appreciates the Committee's focus
    on these critical issues that affect veterans and their
    families.
        We believe, and continue to advocate for, a strong VA, a VA
    that is fully staffed, trained, and equipped to provide the
    highest quality care in the country. Since 2003, The American
    Legion has conducted more than 500 nationwide visits to VA
    medical centers and regional offices. We assess the quality and
    timeliness of veterans' health care and provide feedback from
    veterans about the care and service provided by the VA.
        The VA lists integrity as its first value, and VA employees
    make the promise to act with high moral principles and adhere
    to the highest professional standards. We believe that the vast
    majority of VA health care providers are well trained, caring
    public servants who work hard to care for veterans.
        This, however, does not mean we should neglect the need for
    accountability. The Veterans Affairs Provider Accountability
    Act would impose new oversight measures on the VA. These
    measures would help ensure negative incidences do not go
    unreported, therefore safeguarding the safety and well being of
    veterans. The American Legion supports legislation and programs
    that ensure the safety of our Nation's heroes while holding the
    VA to its core values. The American Legion supports the
    Veterans Affairs Provider Accountability Act.
        Mr. Chairman, to maintain a fully staffed VA, the
    Department must have an onboarding process that does not shun
    applicants. The American Legion is deeply troubled by critical
    staff shortages within the Veterans Health Administration,
    especially shortages among Department leadership, physicians,
    and medical specialists. Since the inception of our System
    Worth Saving program in 2003, The American Legion has
    identified and reported staff shortages and other critical
    deficiencies at VA medical facilities to the VA Central Office,
    Congress, and the President of the United States.
        Our findings were reinforced by the VA's own reporting of
    more than 33,000 full-time vacancies in 2018. Additionally, the
    VA's Office of Inspector General filed a report that identified
    medical officers, nurses, psychologists, physician assistants,
    and medical technologists among the occupations with the most
    critical shortages, consistent with the VA's own reporting.
        Through American Legion Resolution No. 115, Department of
    Veterans Affairs Recruitment and Retention, and Resolution No.
    377, Support for Veteran Quality of Life, we support
    legislation to require the Secretary of Veterans Affairs to
    carry out a pilot program to expedite the onboarding process to
    reduce the time it takes to hire new medical providers.
        Suicide prevention is one of The American Legion's top
    priorities. It is estimated that more than 20 veterans die by
    suicide every day. Of these 20, 14 have received no treatment
    or care from the VA. On April 24, 2019, National Commander
    Brett Reistad teamed up with Dr. Keita Franklin, VA's Executive
    Director of Suicide Prevention, and penned a letter that was
    sent to American Legion members, families, and friends, to let
    them know how we are working together to adopt a public health
    approach toward suicide prevention to involve peers, family
    members, and the community in preventing suicide.
        This is a top priority for the VA but they need help from
    dedicated partners like The American Legion to reach veterans
    outside the VA health care system. The letter provides links to
    VA's National Strategy for Preventing Veteran Suicide, a
    toolkit that includes a guide to online suicide prevention
    resources, and a resource locator for contacting local VA
    Suicide Prevention Coordinators.
        The Commander John Scott Hannon Veteran Mental Health Care
    Improvement Act will improve outreach to veterans. Among its
    many provisions, suicide prevention and access to treatment,
    the legislation directs the VA to work with the Office of
    Personnel Management to create an occupational series for
    mental health counselors. The VA needs to identify and attract
    qualified medical professionals as soon as possible, to ensure
    quality, consistent care for our veterans.
        Mr. Chairman, the provisions of this bill address many
    areas of concern raised by The American Legion. Therefore, we
    support S. 785 as written.
        I want to thank this Committee for the opportunity to share
    The American Legion's position on these vital issues impacting
    veterans and their families. This concludes my remarks and I
    look forward to answering any questions you may have.
        [The prepared statement of Mr. Nembhard follows:]
    Prepared Statement of Greg Nebhard, Deputy Director, National Veterans
             Affairs & Rehabilitation Division, The American Legion
    s. 123; s. 221; s. 318; s. 450; s. 514; s. 524; s. 711; s. 746; s. 785;
    s. 805; s. 850; s. 857; s. 980; s. 1101; s. 1154; and all subsequential
                                  draft bills
        Chairman Isakson, Ranking Member Tester, and distinguished Members
    of the Committee, On behalf of National Commander Brett P. Reistad, and
    the 2 million members of The American Legion, we thank you for this
    opportunity to testify regarding The American Legion's positions on
    pending legislation. Established in 1919, and being the largest
    veterans service organization in the United States with a myriad of
    programs supporting veterans, we appreciate the Committee focusing on
    these critical issues that will affect veterans and their families.
                                     s. 123
    To require the Secretary of Veterans Affairs to enter into a contract
            or other agreement with a third party to review appointees in
            the Veterans Health Administration who had a license terminated
            for cause by a State licensing board for care or services
            rendered at a non-Veterans Health Administration facility and
            to provide individuals treated by such an appointee with notice
            if it is determined that an episode of care or services to
            which they received was below the standard of care, and for
            other purposes.
        The American Legion has taken no previous position on this matter.
    As a large, grassroots organization, The American Legion takes
    positions on legislation based on resolutions passed by our membership.
    With no resolutions addressing the provisions of the legislation, The
    American Legion is researching the material and working with our
    membership to determine the course of action that best serves veterans.
        The provisions in this bill fall outside the scope of established
    resolutions of The American Legion. The American Legion does not have a
    resolution that addresses the authorization of appropriations in the VA
    for awarding grants to VSOs for transportation in highly rural areas.

    The American Legion does not have a resolution to support or oppose
    S. 123.

                                     s. 221
    To amend title 38, United States Code, to require the Under Secretary
            of Health to report major adverse personnel actions involving
            certain health care employees to the National Practitioner Data
            Bank and to applicable State licensing boards, and for other
            purposes.
        S. 221 would require the VA to report major adverse actions to the
    National Practitioner Data Bank (NPDB) and state licensing boards
    within 30 days after the date a major adverse action is taken against a
    VA employee. The NPDB is a U.S. Government program that collects and
    discloses, only to authorized users, negative information on health
    care practitioners, including malpractice awards, loss of license, or
    exclusion from participation in Medicare or Medicaid. It would also
    prohibit VA from signing settlements with terminated VA employees and
    would forbid VA from concealing serious medical errors or to purge
    negative records from employees' personnel files.
        The VA lists integrity as its first core value, and VA employees
    make the promise to act with high moral principle and adhere to the
    highest professional standards. The vast majority of VA healthcare
    providers are well-trained, caring, public servants who work hard to
    take care of this Nation's veterans. Just like in any healthcare
    system, though, there are bad apples. This legislation would help
    ensure that incidences of malpractice do not go unreported by imposing
    new oversight measures on the VA, thus safeguarding the safety and
    wellbeing of those who are cared for by the VA healthcare system.
        Through Resolution No. 377, The American Legion urges Congress and
    the VA to enact legislation and programs within the VA that will
    enhance, promote, restore or preserve benefits for veterans and their
    dependents, including, but not limited to, the following: timely access
    to quality VA health care; timely decisions on claims and receipt of
    earned benefits; and final resting places in national shrines and with
    lasting tributes that commemorates their service.

    The American Legion supports bill S. 221.

                                     s. 318
    To amend Section 1786 of title 38, United States Code, to authorize the
            Secretary of Veterans Affairs to furnish medically necessary
            transportation for newborn children of certain women veterans,
            and for other purposes.
        Title 38 U.S.C. 1786 currently authorizes the Secretary of Veterans
    Affairs to furnish post-delivery care services, including routine care
    services, that a newborn child of a woman veteran who is receiving
    maternity care furnished by the Department at a facility of the
    Department; or another facility pursuant to a Department contract for
    services relating to such delivery.
        Since VA healthcare facilities do not offer a full-range of newborn
    care, women veterans are referred to community hospitals for post
    newborn and routine services at VA expense. The only exception is VA is
    not authorized to pay for medically necessary transportation for
    newborn children of certain veterans. This bill would provide the VA
    Secretary the authority to furnish medically necessary transportation
    for newborn children, which The American Legion supports and believes
    is the right thing to do.
        Through Resolution No. 147, The American Legion works to ensure
    that the needs of the current and future women veteran populations are
    met; and that the VA provides full comprehensive health services for
    women veterans Department-wide, including, but not limited to,
    increasing treatment areas and diagnostic capabilities for female
    veteran health issues, improved coordination of maternity care, and
    increase the availability of female therapists/female group therapy to
    better enable treatment of Post-Traumatic Stress Disorder from combat
    and MST in women veterans.

    The American Legion supports S. 318.

                                     s. 450
    To require the Secretary of Veterans Affairs to carry out a pilot
            program to expedite the onboarding process for new medical
            providers of the Department of Veterans Affairs, to reduce the
            duration of the hiring process for such medical providers, and
            for other purposes.
        The American Legion has testified on similar issues concerning
    identifying and attracting quality candidates to provide health care
    for the Nation's veterans.
        The American Legion is deeply troubled by the Department of
    Veterans Affairs (VA) leadership, physicians and medical specialist
    staffing shortages within the Veterans Health Administration (VHA).
    Since the inception of our System Worth Saving program in 2003, The
    American Legion has identified, and reported staffing shortages at
    every VA medical facility and reported these critical deficiencies to
    Congress, the VA Central Office (VACO), and the President of the United
    States.
        In 2018, VA reported there were more than 33,000 full-time
    vacancies.\1\ Many of these vacancies included hard-to-fill clinical
    positions, as well as occupations identified under 38 U.S.C. 7412.
    These findings were reinforced by a VA's Office of Inspector General
    (VAOIG) report determining the largest critical need occupations are
    medical officers, nurses, psychologists, physician assistants, and
    medical technologists.\2\ The VA needs to identify and attract as many
    qualified candidates as possible as soon as possible.
    ---------------------------------------------------------------------------
        \1\ VA Vacancies--https://www.washingtonpost.com/world/national-
    security/trump-says-veterans -wait-too-long-for-health-care-vas-33000-
    vacancies-might-have-something-to-do-with-that/2018/04/10/d20bc890-
    3ccf-11e8-974f-
    aacd97698cef_story.html?noredirect=on&utm_term=.58facbebf668
        \2\ VAOIG Report 17-00936-835
    ---------------------------------------------------------------------------
        Through American Legion Resolutions No. 115, Department of Veterans
    Affairs Recruitment and Retention,\3\ and No. 377, Support for Veteran
    Quality of Life, we support legislation addressing recruitment and
    retention challenges, and any legislation or programs within VA that
    enhance, promote, restore or preserve benefits for veterans and their
    dependents, including, but not limited to, the following: timely access
    to quality VA health care, timely decisions on claims and receipt of
    earned benefits, and final resting places in national shrines with
    lasting tributes that commemorate their service.\4\
    ---------------------------------------------------------------------------
        \3\ The American Legion Resolution No. 115 Department of Veterans
    Affairs Recruitment and Retention
        \4\ The American Legion Resolution No. 377 Support for Veteran
    Quality of Life
    ---------------------------------------------------------------------------

    The American Legion supports S. 450.

                                     s. 514
    To amend title 38, United States Code, to improve the benefits and
            services provided by the Department of Veterans Affairs to
            women veterans, and for other purposes.
        Women veterans have consistently been overlooked by the Department
    of Veterans Affairs for decades. The American Legion feels that it is
    time that we thank this growing military demographic with, at a
    minimum, the healthcare they deserve. Women veterans are the fastest
    growing demographic serving in the military, so we can expect the
    number of women veterans using Department of Veterans Affairs (VA)
    healthcare to increase dramatically. The United States has more than 2
    million women veterans who live in every Congressional district in the
    Nation, and the number of women veterans seeking VA health care has
    doubled since 2000.
        Although the VA has made improvements in women's healthcare, many
    challenges remain. The Deborah Sampson Act would help rectify many
    issues women veterans face by improving the ability of the VA to
    provide women's care, improve services, and change its culture to
    embrace this growing population. It does so by inter alia:

         Enhancing services that empower women veterans to support
    each other,
         Establishing a partnership between the Department of
    Veterans Affairs and at least one community entity to provide legal
    services to women veterans,
         Make adjustments to care that the VA can provide newborns,
         Addressing significant barriers women veterans face when
    seeking care,
         Require the VA to collect and analyze data for every
    program that serves veterans, including the Transition Assistance
    Program, by gender and minority status, and require that they publish
    data as long as it does not undermine the anonymity of a veteran.

        The American Legion recommends the following change to the bill. A
    separate track to address specific needs of women veterans attending
    the Transition Assistance Program. It has been noted that women
    veterans are more likely to seek assistance by talking with other women
    on gender-sensitive assistance. For example, the VA Trauma Service
    Program (TSP) allows women veterans to choose to partake in a TSP
    information session with a group or with an individual woman
    coordinator. More women veterans opt to conduct the information session
    with an individual woman coordinator. Additionally, The American Legion
    requests the Department of Defense transfer contact information of all
    transitioning women veterans to the VA and the Department of Labor
    (DoL). This would provide an opportunity for the VA, DoL, and Veterans
    Service Organizations to follow-up with women veterans after separation
    to offer additional support, programs, and services. American Legion
    Resolution No. 147, Women Veterans, calls on The American Legion to
    work with Congress and the VA to ensure that the needs of current and
    future women veteran populations are met. It calls on the VA to provide
    full comprehensive health services for women veterans department-wide.
        American Legion Resolution No. 364, Department of Veterans Affairs
    to Develop Outreach and Peer to Peer Program for Rehabilitation
    supports the President of the United States and the U.S. Congress
    passing legislation to call on the Secretary of Veterans Affairs to
    develop a national program to provide peer to peer rehabilitation
    services based on the recovery model tailored to meet the specialized
    needs of current generation combat-affected veterans and their
    families.

    The American Legion supports passage of S. 514.

                                     s. 524
    To establish the Department of Veterans Affairs Advisory Committee on
            Tribal and Indian Affairs, and for other purposes.
        The American Legion has not passed a resolution specific to the
    topic at hand. However, through our congressional engagement on behalf
    of Veterans, VA Mobile Vet Centers will be used to visit Native
    American reservations to provide counseling and other psychological
    services to Veterans. Additionally, American Legion Posts 143 and 165
    have supported the National Native American Veterans Memorial project's
    community consultations, events, and programs.\5\ We believe that the
    Native communities at one of the most underserved population of
    Veterans and that they are not receiving the benefits and critical care
    they, like their veteran counterparts, are entitled to. The American
    Legion supports legislation aimed at directly enhancing veterans'
    quality of life by expanding their VHA, VBA, or NCA benefits.\6\
    ---------------------------------------------------------------------------
        \5\ The American Legion Resolution No. 130 Support for Vet Center
    Expansion to Rural Communities
        \6\ The American Legion Resolution No. 377 Support for Veteran
    Quality of Life
    ---------------------------------------------------------------------------

    The American Legion supports S. 524.

                                     s. 711
    To amend title 38, United Sates Code, to expand eligibility for mental
            health services from the Department of Veterans Affairs to
            include members of the reserve components of the Armed Forces,
            and for other purposes.
        Suicide prevention and mental healthcare remain a top priority of
    The American Legion. As a response to the high rate of veteran suicide
    The American Legion established the TBI/PTSD Committee to study and
    recommend best practices. Access to mental health has been identified
    as a barrier, according to the Department of Veterans Affairs (VA) 14
    out of the 20 veterans who commit suicide were not receiving treatment
    from a VA medical facility. A veteran may not be eligible for VA
    benefits including mental health treatment due to their
    characterization of discharge or duty status. As a response to close
    the gap in access The American Legion passed resolution No. 23 to allow
    veterans with other than honorable discharges to receive mental health
    treatment at the VA. In an effort to reduce the number of veterans and
    Servicemembers who commit suicide The American Legion believes that
    service through the VA should be a viable option.

    The American Legion supports S. 711

                                     s. 746
    To require the Secretary of Veterans Affairs to conduct a study on the
            accessibility of websites of the Department of Veterans Affairs
            to individuals with disabilities, and for other purposes.
        The American Legion has not passed a resolution specific to website
    accessibility. We recognize the barriers that veterans with certain
    disabilities face when trying to navigate and utilize certain VA
    websites and believe that it is essential that we work to remove these
    barriers. Every veteran should have equal access to and the ability to
    navigate VA websites.
        We believe that no veteran should be inhibited in their efforts to
    participate in or benefit from VA programs. The VA should bring into
    compliance, websites that are not currently accessible to individuals
    with certain disabilities. Veterans should not encounter unavoidable
    barriers to benefits and critical care they, like their veteran
    counterparts, are entitled to. The American Legion supports legislation
    aimed at directly enhancing veterans' quality of life by expanding
    their VHA, VBA, or NCA benefits.\7\
    ---------------------------------------------------------------------------
        \7\ The American Legion Resolution No. 377 Support for Veteran
    Quality of Life
    ---------------------------------------------------------------------------

    The American Legion supports S. 746.

                                     s. 785
    To improve mental health care provided by the Department of Veterans
            Affairs, and for other purposes.
        It is estimated that more than twenty veterans die by suicide every
    day. Of those twenty, fourteen have received no treatment or care from
    the VA. Suicide among veterans continues to be higher than the rest of
    the population, with an even sharper increase among younger veterans.
    VA data released in September showed the rate of suicide among veterans
    ages 18 to 34 had significantly increased. Forty-five of every 100,000
    veterans in the 18 to 34 age group committed suicide in 2016.
        In 2018, VA reported there were more than 33,000 full-time
    vacancies. Many of these vacancies included hard-to-fill clinical
    positions, as well as occupations identified under 38 U.S.C. 7412.
    These findings were reinforced by a VA's Office of Inspector General
    (VAOIG) report determining the largest critical need occupations are
    medical officers, nurses, psychologists, physician assistants, and
    medical technologists. The VA needs to identify and attract as many
    qualified candidates as possible as soon as possible.
        The Commander John Scott Hannon Veterans Mental Health Care
    Improvement Act will improve outreach to veterans and their mental
    health care options. Among its many provisions regarding suicide
    prevention and access to treatment, the legislation directs the VA to
    work with the Office of Personnel Management to create an occupational
    series for mental health counselors.
        The bill also would mandate that the Secretary of Veterans Affairs
    submit a staffing plan that would increase the hiring of mental health
    counselors to the Senate and House Veterans' Affairs Committees within
    270 days of passage. The VA would also be required to report on the
    specific number of mental health counselors it has hired based on the
    staffing plan.
        The provisions of this bill address many areas of concern The
    American Legion has raised recently. The American Legion remains deeply
    troubled by the Department of Veterans Affairs (VA) leadership,
    physicians, and medical specialist staffing shortages within the
    Veterans Health Administration (VHA). Additionally, mental healthcare
    is a major concern for The American Legion, we have seen the hardships
    faced by our veterans and their dependents dealing with PTSD, TBI,
    Suicide Ideation, and many other mental health issues. The American
    Legion has created a TBI/PTSD Committee and has a dedicated staff
    member for the sole purpose of advocating on behave of veterans dealing
    with the before mentioned mental health issues.
        Further, last month, National Commander Brett Reistad with Dr.
    Keita Franklin, VA's Executive Director of Suicide Prevention, penned a
    letter to nearly 850,000 American Legion members, family, and friends,
    to let them know we are working to adopt a public health approach to
    suicide prevention.
        The public health approach looks beyond the individual to involve
    peers, family members and the community in preventing suicide. We
    understand preventing veteran suicide is a top priority for VA and we
    encourage VA to look to dedicated partners to reach veterans outside
    the VA health-care system. The letter provided links to VA's National
    Strategy for Preventing Veteran Suicide, a toolkit that includes a
    guide to online suicide prevention resources, and a resource locator
    for contacting local VA Suicide Prevention Coordinators.

    The American Legion supports S. 785.

                                     s. 805
    To amend title 38, United Sates Code, to improve the processing of
            veterans benefits by the Department of Veterans Affairs, to
            limit the authority of the Secretary of Veterans Affairs to
            recover overpayments made by the Department and other amounts
            owed by veterans to the United States, to improve the due
            process accorded veterans with respect to such recovery, and
            for other purposes.
        The VA is responsible for distributing monthly earned benefits to
    veterans and their beneficiaries. Currently, when the VA makes an
    overpayment in error to a veteran, the VA can then withhold some or all
    of a veteran's benefit, without limitation, including monthly
    disability benefit payments. For veterans who live on a fixed income,
    withholding a benefit payment due to no fault of their own can present
    an undue hardship in their ability to pay rent or buy groceries.
        The VA annually sends as many as 200,000 overpayment notices
    totaling thousands of dollars to veterans and their families, sending
    them into crippling debt and withholding future benefits payments until
    the debt is paid. These overpayments are often a result of the VA's own
    accounting errors, but the VA puts veterans and their families on the
    hook for repaying the debt.
        Debt caused by VA overpayments are a major concern for The American
    Legion, we have seen the financial hardship veterans and their
    dependents end up and in many cases through no fault of their own.
    Since 1978 The American Legion has retained a dedicated staff member at
    the Debt Management Center for the sole purpose of advocating on behave
    of veterans and their dependents facing garnishment.
        If enacted, the Veteran Debt Fairness Act, will prevent the VA from
    collecting debt if caused by errors at the VA. The bill would allow the
    VA to recoup overpayments only if the debt was due to an error or fraud
    on the part of the veteran or beneficiary. Additionally, to reduce the
    risk of financial hardship, the legislation states that the VA cannot
    deduct more than 25 percent from a veteran's monthly payment in order
    to recoup overpayment. It also requires the VA to provide veterans with
    a way to update dependency information on their own, eliminating a
    common delay that may affect a veteran's benefits.
        The American Legion has testified and recommended many of the above
    changes, if passed the legislation would greatly improve the way VA
    manages debt collection while minimizing the negative impact for
    veterans.

    The American Legion supports S. 805.

                                     s. 850
    To extend the authorization of appropriations to the Department of
            Veterans Affairs for purposes of awarding grants to veterans
            service organizations for the transportation of highly rural
            veterans.
        The American Legion has taken no previous position on this matter.
    As a large, grassroots organization, The American Legion takes
    positions on legislation based on resolutions passed by our membership.
    With no resolutions addressing the provisions of the legislation, The
    American Legion is researching the material and working with our
    membership to determine the course of action that best serves
    veterans.The provisions in this bill fall outside the scope of
    established resolutions of The American Legion. The American Legion
    does not have a resolution that addresses the authorization of
    appropriations in the VA for awarding grants to VSOs for transportation
    in highly rural areas.

    The American Legion takes no position on S. 850.

                                     s. 857
    To amend title 38, United Sates Code, to increase the amount of special
            pension for Medal of Honor recipients, and for other purposes.
        The American Legion has testified before the Subcommittee on
    Veterans' Affairs in support of improved benefits for Medal of Honor
    Recipients. We have also passed resolutions supporting expanded
    benefits for Medal of Honor Recipients. The Medal of Honor is the
    highest military decoration awarded to a member of the United States
    Armed Forces and the recipients have earned this award by displaying
    heroism and bravery while risking their lives during service to this
    great Nation. The American Legion fully appreciated the service of
    those awarded the Medal of Honor and supports legislation that would
    expand the benefits to Medal of Honor recipients.\8\
    ---------------------------------------------------------------------------
        \8\ The American Legion Resolution No. 366: Honoring those who have
    Earned the Medal of Honor Origin: Convention Committee on Veterans
    Affairs & Rehabilitation
    ---------------------------------------------------------------------------

    The American Legion supports S. 857.

                                     s. 980
    To amend title 38, United States Code, to improve the provision of
            services for homeless veterans, and for other purposes.
        Generally, the causes of homelessness can be grouped into three
    categories: economic hardships, health issues, and lack of affordable
    housing. Although these issues affect all homeless individuals,
    veterans face additional challenges in overcoming these obstacles,
    including: prolonged separation from traditional supports such as
    family and close friends; highly stressful training and occupational
    demands, which can affect personality, self-esteem and the ability to
    communicate upon discharge; and non-transferability of some military
    occupational specialties into the civilian workforce. The Departments
    of Veterans Affairs (VA) and Housing and Urban Development (HUD)
    reported a little over 40,000 homeless veterans on a single night in
    January 2017. We witnessed a slight uptick in homeless veterans last
    year, due mostly to high cost rental markets. Please note--positive
    progress has been driven by consistent action at all levels of
    government and across all sectors. Much progress has been made;
    however, there is still room for significant improvement with access to
    resources for at-risk and homeless veterans.
        The American Legion supports S. 980 because it would allow the VA
    to enter into partnerships with other entities to expand the legal
    services available for veterans experiencing homelessness. The
    legislation would also require housing providers to take steps to
    better meet needs of women veterans, and would amend VA rules to ensure
    the children of homeless veterans are allowed to live in VA-run
    transitional housing programs. S. 980 would also authorize the VA to
    provide dental care to homeless veterans, which has been a top ten need
    in the VA's Project CHALENG (Community Homelessness Assessment, Local
    Education and Networking Groups) survey for many years. Last, the bill
    would increase the authorization limit for the Supportive Services for
    Veteran Families (SSVF) Program to $500 million, opening the door for
    the renewal of surge grants set to expire at the end of the year.
        The American Legion maintains a sustained focus on the prevention
    of veteran homelessness (``get them before they get on the street'').
    We offer support to at-risk and/or homeless veterans and their families
    in the forms of informal advice and counseling, assistance with
    obtaining VA healthcare and benefits, temporary financial assistance
    (TFA), aid from the Child Welfare Foundation (CWF), and assistance with
    employment through our Career Fairs and Veteran-Owned and Service-
    Disabled Veteran-Owned Small Business Development Workshops
    (educational forums). This kind of assistance is available from the
    Post level up to The American Legion's national organization.
        Last, based upon the small rise in veteran homelessness, this is no
    time to stop funding Federal programs or not look to adding necessary
    resources to assist homeless veterans in obtaining housing, treatment,
    and financial stability. Consequently, on behalf of the 2 million
    members of The American Legion, we express support for S. 980, the
    Homeless Veterans Prevention Act of 2017. The American Legion applauds
    Congress for its substantial funding for homeless programs, while
    giving major thanks to VA, HUD, and the Department of Labor, for the
    implementation of their programs that have literally saved the lives of
    thousands of veterans. We strongly believe that with the path VA has
    begun in eliminating veteran homelessness and the proper utilization of
    the resources at the state level and in local communities, we can
    continue to make tremendous progress.
        Resolution No. 324, Funding for Homeless Veterans, supports any
    legislative or administrative proposal that will provide medical,
    rehabilitative, and employment assistance to homeless veterans and
    their families.

    The American Legion supports S. 980.

                                    s. 1101
    Ensuring only licensed health care providers furnish medical disability
            examinations under certain Department of Veterans Affairs pilot
            program for use contract physicians for disability
            examinations.
        The provisions of this bill fall outside the scope of established
    resolutions of The American Legion. As a large, grassroots
    organization, The American Legion takes positions on legislation based
    on resolutions passed by the membership or in meetings of the National
    Executive Committee.

    With no resolutions addressing the provisions of the legislation, The
    American Legion is researching the material and working with our
    membership to determine the course of action, which best serves
    veterans.

                                    s. 1154
    To amend title 38, United States Code, to establish an advisory
            committee on the implementation by the Department of Veterans
            Affairs of an electronic health record.
        The VA is currently undertaking a decade-long transition to bring
    veterans' health records into the 21st century by ensuring that
    veterans can have access to a seamless electronic health record across
    the VA and Department of Defense health systems. The Department of
    Veterans Affairs Electronic Health Record Advisory Committee Act, would
    establish a third party oversight group to monitor the VA's $16 billion
    EHR rollout. The 11-member EHR Advisory Committee would include medical
    professionals, IT and interoperability specialists, and veterans
    receiving care from the VA. This Committee would operate as an
    independent entity.
        The American Legion, through resolution, has long endorsed and
    supported the Department of Veterans Affairs (VA) in creating a
    Lifetime Electronic Health Records (EHR) system. Additionally, The
    American Legion has encouraged both DOD and the VA to either use the
    same EHR system, or, at the very least, systems that were
    interoperable.
        The American Legion recognizes the advantages of a bi-directional
    interoperable exchange of information between agencies. Collaborating
    with DOD offers potential cost savings and opportunities for VA.
    Opportunities include capitalizing on challenges DOD encounters
    deploying its own Cerner solution, applying lessons learned to
    anticipate and mitigate issues, and identifying potential efficiencies
    for faster and successful deployment. The EHR is a high-priority
    initiative that ensures a seamlessly integrated healthcare record
    between the Department of Defense and VA, by bringing all patient data
    into one common system.

    The American Legion supports S. 1154.

                      s. ____, janey ensminger act of 2019
    A bill to amend the Public Health Service Act with respect to the
            Agency for Toxic Substances and Disease Registry's review and
            publication of illness and conditions relating to veterans
            stationed at Camp Lejeune, North Carolina, and their family
            members, and for other purposes.
        This draft bill would allow the Agency for Toxic Substances and
    Disease to collect information regarding servicemembers, veterans, and
    family members who suffer from a variety of illnesses due to
    contaminated drinking water at Camp Lejeune , NC. Additionally, this
    bill would require the Secretary of Veterans Affairs to allocate two
    million dollars a year to assist servicemembers, veterans, and their
    families affected by contaminated water at Camp Lejeune, in applying
    for health benefits through the VA.
        During the early parts of the 1980s, contaminants were found in two
    wells that provided water at Camp Lejeune. These contaminants included
    the volatile organic compounds trichloroethylene (TCE), a metal
    degreaser, perchloroethylene (PCE), dry cleaning agents, and vinyl
    chloride, as well as benzene, and other compounds. It is estimated that
    the contaminants were in the water supply from the mid-1950's until
    February 1985 when the wells were shut down. Additionally, there is
    evidence of an association between certain diseases and the
    contaminants found in the water supply at Camp Lejeune during the
    period of contamination.
        United States Marine Corps (USMC) servicemembers and their families
    living at the base, between the 1950's to 1985, bathed in and ingested
    tap water contaminated with harmful chemicals at concentrations ranging
    from 240 to 3400 times higher than appropriate safety levels. An
    undetermined number of former base residents later developed cancer or
    other ailments, which may be associated with the contaminated drinking
    water. Victims claim that USMC leaders concealed knowledge of the
    problem and did not act appropriately in resolving it or notifying
    former base residents that their health might be at risk.
        The American Legion is appalled that military members serving our
    Nation, and their families, were exposed to harmful chemical
    contaminants at Camp Lejeune. We are equally shocked that the USMC was
    potentially aware of the issue and did nothing to mitigate the risk
    associated with the water contamination at this military instillation.
    This bill would allow individuals affected by water contamination at
    Camp Lejeune to receive healthcare provided by the VA and claim any
    benefits due to them. Resolution No. 377: Support for Veteran Quality
    of Life supports legislation that would allow access to quality VA
    health care and timely decisions on claims and receipt of earned
    benefits.\9\ The American Legion strongly supports this draft bill.
    ---------------------------------------------------------------------------
        \9\ http://www.indystar.com/story/money/2016/09/06/why-veterans-
    have-most-lose-if-itt-tech-closes/89710280/ ``Why ITT closing hits
    veterans hardest''
    ---------------------------------------------------------------------------

    The American Legion supports this draft bill.

                       s. ____, a bill to amend title 38
    A bill to amend title 38, United States Code, to extend the authority
            of the Secretary of Veterans Affairs to continue to pay
            educational assistance or subsistence allowances to eligible
            persons when educational institutions are temporarily closed,
            and for other purposes.
        Presently, when a school closes traditional, non-veteran students
    have Federal protections that support them. Effected students with
    Federal student loans have the ability to discharge their student
    loans. Students who received Pell Grants can have their eligibility
    periods reset for the time spent at a closed institution. The American
    Legion believes strongly that veterans are entitled to the same
    protection as their civilian counterparts. Over 6,000 student veterans
    were attending ITT Tech when they abruptly shut down their campuses,\9\
    and more school closures will inevitably occur, and The American Legion
    applauded provisions in the Harry W. Colmery Veterans Educational
    Assistance Act that restored these veterans.
        Despite this victory, the Forever GI Blil provisions only restored
    benefits for schools tha tclosed between 2015 and 2017. Congress must
    not forget about the student veterans affected by school closures
    outside of this time period, including most recently Argosy University.
        Through resolution No. 21: Education Benefit Forgiveness and Relief
    for Displaced Student-Veterans. The American Legion supports
    legislation that restores lost benefits to student-veterans attending
    schools that abruptly shut down.\10\
    ---------------------------------------------------------------------------
        \10\ The American Legion Resolution No 21: Education Benefit
    Forgiveness and Relief for Displaced Student-Veterans
    ---------------------------------------------------------------------------

    The American Legion supports this draft bill.

                                   conclusion
        The American Legion thanks this Committee for the opportunity to
    elucidate the position of the 2 million veteran members of this
    organization. For additional information regarding this testimony,
    please contact the Legislative Associate of the Legislative Division,
    Mr. Ernest J. Robinson, at The American Legion's Legislative Division.

        Senator Boozman. Thank you, Mr. Nembhard.
        General Phillips.

     PREPARED STATEMENT OF MAJOR GENERAL (RET.) JEFFREY PHILLIPS,
            EXECUTIVE DIRECTOR, RESERVE OFFICERS ASSOCIATION

        General Phillips. Senator Boozman, good to see you again.
        Senator Boozman. It is good to see you.
        General Phillips. We add our thanks to Chairman Isakson and
    Ranking Member Tester for the invitation to come out today.
        ROA, the only national military organization that
    exclusively supports America's Reserve and National Guard
    appreciates the opportunity to testify today on legislation
    that would affect members of the Guard and Reserve, their
    families, and veterans who served in the Reserve components.
        We commend the Committee on proposed legislation that shows
    great commitment to ensuring these patriots, male and female,
    get prompt, attentive, and effective care, and that the
    challenges of the homeless and those considering suicide are
    addressed.
        ROA's focus on our Reserve components is exclusive, as I
    said, and so I will address certain bills that apply, in
    particular, to our Reserve force.
        The Deborah Sampson Act, S. 514, continues our Nation's
    progress in providing services to women veterans. An essential
    component of this service is outreach to service women to both
    explain VA's offerings and to assure them that they are
    veterans who qualify for care and benefits.
        On the ROA staff is a woman who served more than 14 years
    in the Air Force Reserve. Several medical events and conditions
    qualified her for VA disability and medical treatment, yet it
    took more than a decade for her supervisor to convince her to
    submit a disability application. She finally confided that she
    did not feel that she was a real veteran. Well, she is, and she
    just recently got rated for her disabilities--promptly, we are
    pleased to say. She is now getting treatment from the VA
    medical center here in Washington and receiving her benefits. A
    good ending, yes, but regrettably, not an isolated situation.
        The next bill ROA supports is the Care and Readiness
    Enhancement for Reservists Act of 2019, S. 711, to expand
    mental health services from VA. The Reserve components, unlike
    the active component, only perform duty on demand. They are on
    orders for the period of deployment, for example, and then off
    orders until the next demand. Behavioral and mental issues,
    however, show no respect for the duration of a set of orders.
    Manifestation can and often does occur well after the Reservist
    reassumes his or her civilian list.
        A Reservist's medical documents can be scattered around
    various military and civilian health care locations. Getting
    copies of specific documents, for example, to prove a service-
    connected condition, can be excruciatingly difficult. An
    electronic health record that consolidates all these records
    would represent an improvement in readiness and access to care
    because it would facilitate the right care.
        The last bill I will discuss is the Veteran Debt Fairness
    Act of 2019, S. 805. As we have seen, Reserve component
    servicemembers get hit with repayment action from both DOD and
    VA, and debt collection methods can be very aggressive. Members
    of the Guard and Reserve, largely unlike their comrades in the
    active force, can conceivably receive benefits while still
    serving, from DOD, VA, and other Federal agencies. Thus, it is
    possible for debt collection to hit Reservists from both DOD
    and VA, wreaking havoc in their personal finances, ravaging
    credit scores, and depleting funds for a family's daily needs.
        As we have seen, overpayments can and do occur through no
    fault of the servicemember, yet our Federal bureaucracy takes
    no notice as it claws back the money. It is easy to blame the
    warriors themselves for accepting payments, and that is
    precisely what some bureaucrats tend to do. But, GIs, busy with
    a war, may be forgiven for failing to scrutinize an increase in
    pay and allowance, especially given the often-confusing array
    of deployment-related pay schemes and bonuses. Young warriors
    tend to trust the government to know what it is doing.
        ROA appreciates that this bill will improve due process,
    government accountability, and basic decency, and we hope that
    DOD will take the same approach. ROA is committed to working
    with VA and, indeed, any and all, to enhance understanding of
    our reserve components. These citizen warriors, which I think
    is a great name for them, whatever their service affiliation,
    serve America in ways fundamentally different from their
    comrades in the active force. In many cases, they need a
    correspondingly different approach to benefits and care. The
    bills before show that you understand that and are committed to
    providing meaningful help.
        Thank you for your support of our young men and women in
    the National Guard and the Reserve, their families, and
    veterans of Reserve service. I welcome any questions you have,
    Senator, or other Members of the Committee.
        [The prepared statement of Maj. Gen. Phillips follows:]
             Prepared Statement of Reserve Organization of America
                                   statement
        ROA appreciates the opportunity to discuss pending legislation that
    affects National Guard and Reserve servicemembers. While I will not
    address every proposed act, this does not indicate ROA's support for or
    opposition to these other bills. ROA's focus today aligns with our
    congressional charter, `` . . . to support and promote the development
    in execution of a military policy for the United States that will
    provide adequate national security.''
                          s. 514, deborah sampson act
        To amend title 38, United States Code, to improve the benefits and
    services provided by the Department of Veterans Affairs to women
    veterans, and for other purposes.
        This act will help eliminate impediments to the care of women
    veterans. It will help ensure the Department of Veterans Affairs can
    address the needs of women veterans who face homelessness,
    unemployment, and life without health care.
        Women veterans are a growing population. Many VA facilities provide
    adequate care or services to them but as issues specific to women
    veteran are identified, services must keep pace. The Deborah Sampson
    Act would help ensure that VA meets the needs of these women veterans
    by providing access to health care and services to prevent homelessness
    and unemployment.
        There were 3,219 homeless women veterans at the point-in-time count
    that occurred during a single night in January 2018 as reported in The
    2018 Annual Homeless Assessment Report to Congress: Part 1.
    Unfortunately, homeless counts and other Department of Veterans Affairs
    data are not identifying National Guard and Reserve members which have
    different circumstances then those from active duty.
        Understanding what military service the veteran population comes
    from is important. In this instance there were 159,749 women serving in
    the Selected Reserve in 2017; there were 655,367 men in the Selected
    Reserve. The Reserve Component population is significant enough that it
    should be considered as a separate data point.
        If National Guard and Reserve information were available, military
    associations like ROA could better use their resources to help members
    and veterans of the Reserve Components with homelessness, unemployment
    and other issues.
        This legislation is crucial in improving care for women during and
    after military service, and it has ROA's support.
    s. 524, department of veterans affairs tribal advisory committee act of
                                      2019
        To establish the Department of Veterans Affairs Advisory Committee
    on Tribal and Indian Affairs, and for other purposes.
        According to the Department of Defense 2017 Demographics Report,
    for the Selected Reserve, 26.1 percent of the force is identified as
    minority. Of that number Black or African Americans are 16.4 percent;
    those identified as Asian are 4.2 percent; Other/Unknown are 2.5
    percent; Multi-racial are 1.6 percent; American Indian or Alaska Native
    members are 0.8 percent; Native Hawaiian or Other Pacific Islander
    members are 0.7 percent. The report did not include a Hispanic
    category, but ROA knows they are a sizable portion of the minority
    population. For example, the Army Reserve has 16 percent of their
    soldiers identified as Hispanic.
        Much of this minority population lives in rural locations that
    provide access to care challenges for VA. American Indians and Alaska
    Natives are served by the Indian Health Service, a Federal health
    program for them and should be part of the VA health care
    consideration. They are also part of tribal governments that should be
    consulted. Bringing these organizations under an advisory committee
    makes sense to reach an agreement on practices of care.
        This Committee could help in areas such as unemployment; the Bureau
    of Labor Statistics identified that American Indians and Alaska Natives
    suffer unemployment rates exceeding other minorities and Caucasians,
    7.8 percent in 2017.
        ROA supports this legislation.
     s. 711, care and readiness enhancement for reservists act of 2019 or
                      the care for reservists act of 2019
        To amend title 38, United States Code, to expand eligibility for
    mental health services from the Department of Veterans Affairs to
    include members of the reserve components of the Armed Forces, and for
    other purposes.
        The CARE for Reservists Act of 2019 would expand mental health
    services offered by VA to those serving in the reserve components of
    the military, regardless of their deployment status. This Act would
    permit VA to offer a comprehensive, individual exam to those members of
    the reserve components with either a behavioral health condition or
    psychological trauma.
        Currently, members of the National Guard and Reserves undergo
    annual health assessments to identify medical issues that could affect
    their deployable status, but any follow-up care is usually at the
    servicemember's expense.
        This Act further specifies that members of the reserve components
    would be included in certain VA mental health programs, such as the
    suicide prevention program.
        ROA appreciates that the bill also allows members of the Guard and
    Reserve to access Vet Centers for mental health screening and
    counseling, employment assessments, education training and other
    services to help them return to and succeed in civilian life.
        ROA supports this legislation.
        s. 785, commander john scott hannon veterans mental health care
                            improvement act of 2019
        To improve mental health care provided by the Department of
    Veterans Affairs, and for other purposes.
        This Act would expand health coverage for veterans by providing
    grants for transition assistance from the Armed Forces to civilian
    life. It is a comprehensive approach to connect more veterans with the
    mental health care they need. The bill seeks to improve care from VA by
    strengthening the VA's mental health workforce and increasing access to
    care in rural areas.
        A major issue in the prevention of suicides is our ability to find
    veterans who are not seeking treatment at a VA facility. Of the
    approximately 22 veterans who commit suicide each day, 14 have received
    no treatment or care from VA.
        The Department of Defense fiscal year Quarterly Suicide Report
    through June 2018 shows that the military's reserves lost 56
    servicemembers to suicide that quarter and the National Guard lost 88.
    The information for the fourth quarter has not been published.
        If the transition process better equips servicemembers to get off
    to a good start in their next stage of the journey, ROA thinks it will
    reduce unemployment, homelessness, and it will reduce suicides.
        ROA is concerned that Section 101, Expansion of Health Care
    Coverage for Veterans, uses the limiting term of ``active service,''
    that only applies to active duty or full-time National Guard duty. We
    ask that the Committee change the proposed insert to Section 101, ``(B)
    to any veteran during the one-year period following the discharge or
    release of the veteran from active military, naval, or air service;
    and'' be changed to insert after the word service ``and active status;
    and'' which would include reserve component members leaving a
    participating reserve position as defined by Title 10, Section 101.
        ROA appreciates that Section 301, Program to Provide Veterans
    Access to Computerized Cognitive Behavioral Therapy, is written such
    that it includes members of the Reserve and National Guard.
        ROA is particularly pleased with Section 506, Comptroller General
    report on Readjustment Counseling Service of Department of Veterans
    Affairs, and the requirement to assess the use of Vet Centers by
    National Guard and Reserve who were never activated and for
    recommendations on how to better reach those members.
        ROA is concerned that the bill includes so much that implementation
    could be difficult. An incremental approach might give enough time to
    evaluate the effectiveness of each recommendation before committing
    more resources.
        With the edit ROA recommends to Section 101, we support this
    legislation.
                   s. 805, veteran debt fairness act of 2019
        To amend title 38, United States Code, to improve the processing of
    veterans benefits by the Department of Veterans Affairs, to limit the
    authority of the Secretary of Veterans Affairs to recover overpayments
    made by the Department and other amounts owed by veterans to the United
    States, to improve the due process accorded veterans with respect to
    such recovery, and for other purposes.
        This act requires the VA to waive the collection of overpayments if
    the agency was responsible for the mistakes leading to overpayment.
        Often, the veteran is unaware of overpayment. The money recovered
    is often the veteran's only source of income; recovery can cripple the
    veteran's ability to pay mortgages, utility bills, health care,
    groceries, etc. This can increase undue stress as well as mental
    illness issues.
        ROA believes the Department of Defense should adopt this approach
    when debt is incurred through no fault of the member. The department's
    aggressive debt collection process operates with little congressional
    oversight and does not differentiate between debt resulting from
    deception and debt caused by government error.
        ROA supports this legislation.
                s. 980, homeless veterans prevention act of 2019
        To amend title 38, United States Code, to improve the provision of
    services for homeless veterans, and for other purposes.
        This act is imperative in helping homeless veterans care for their
    families while the Department of Veterans Affairs helps them become
    employable. Helping care for veteran families during this time may help
    break the cycle of homelessness, when the children become adults.
        ``We know from the Adverse Childhood Experiences study that
    childhood trauma has lifelong negative effects on physical and mental
    health,'' said Dr. Ellen Bassuk who wrote Child Homelessness: A Growing
    Crisis. Childhood trauma can occur in shelters where homeless families
    are housed. Dr. Bassuk writes, ``There is no privacy or safe place for
    children to play, and boys over the age of 12 are often not permitted.
    If families do not quickly find permanent housing and are forced to
    remain in the shelter system, 40 to 50% of them will break up within 5
    years, with children being sent to live with relatives or placed in
    foster care. These children face almost insurmountable obstacles as
    they become adults and are often trapped in a cycle of poverty, ill
    health, and significant social disadvantages.''
        The bill would also provide dental care for those that are homeless
    and provide preventive care and counseling for people who are at risk.
    The best way to address this issue is to prevent it. ``To end
    homelessness in America,'' the United States Interagency Council on
    Homelessness explains, ``we must strengthen our ability to prevent it
    in the first place. To do that, we must take a multi-sector approach
    that focuses on housing needs, housing stability, and risks of
    homelessness across many different public systems.''
        The council includes healthcare, child welfare, and legal
    assistance which are in this bill.
        The more programs the VA has available, the more access our
    veterans will have to the VA. In turn, the VA will have the time they
    need to asses and treat a multitude of issues that may be contributing
    to the veteran's wellbeing.
        As with S. 514, ROA believes data on homelessness should identify
    National Guard and Reserve members, whose circumstances differ from the
    active duty population.
        s. 1154 department of veterans affairs electronic health record
                             advisory committee act
        To amend title 38, United States Code, to establish an advisory
    committee on the implementation by the Department of Veterans Affairs
    of an electronic health record.
        S. 1154 would establish the independent, 11-member Electronic
    Health Record (EHR) Advisory Committee, comprised of medical
    professionals, information technology and interoperability specialists,
    and veterans currently receiving care from the VA. The Committee's
    duties include specific requirements that will ensure a viable EHR and
    continue to monitor effectiveness after launch.
        National Guard and Reserve members encounter many problems when
    trying to establish service-connected disabilities. This is mainly due
    to how their medical records are scattered among multiple locations
    from their home of record to military schools, to deployment locations
    to places of temporary duty. Added on top of this are the records that
    reside with civilian providers. A centralized EHR will help draw these
    records together.
        ROA believes a VA/DOD Reserve Component Committee should be
    established to act as an advisor to the EHR Advisory Committee and
    other VA committees. The complex organization of the Reserve Component
    requires direct knowledge in order to properly advise on programs,
    policies and legislation that falls under VA.
        ROA supports this legislation.
                  janey ensminger act of 2019 (no bill number)
        To amend the Public Health Service Act with respect to the Agency
    for Toxic Substances and Disease Registry's review and publication of
    illness and conditions relating to veterans stationed at Camp Lejeune,
    North Carolina, and their family members, and for other purposes.
        The bill is directed to veterans and family members who lived at
    Camp Lejeune, however, ROA is concerned that Individual Mobilization
    Augmentees who may have performed duty at Camp Lejeune are not included
    in any legislation to treat toxic exposure. Camp Lejeune also provides
    amphibious assault and parachute training and individuals who attended
    this training may have been exposed to hazardous ground water.
        ROA supports this legislation.
           gi bill educational assistance during temporary closures
                           (no bill number or title)
        To amend title 38, United States Code, to extend the authority of
    the Secretary of Veterans Affairs to continue to pay educational
    assistance or subsistence allowances to eligible persons when
    educational institutions are temporarily closed, and for other
    purposes.
        According to a May 2019 CBO report, The Post-9/11 GI Bill:
    Beneficiaries, Choices, and Cost, National Guard and Reserves
    servicemembers make up about 17 percent of beneficiaries in any given
    year which is approximately 136,000 servicemembers. The average age of
    this group is 37 years old which indicates that most beneficiaries pay
    mortgage or rent. This monthly obligation does not disappear if or when
    the school they're attending is closed temporarily.
        The CBO report also stated, ``The average payment for veterans from
    the National Guard and reserves was considerably lower ($12,500) than
    payments for all other veterans. . .''.
        ROA believes assistance should be provided during temporary school
    closures when Reserve Component members are using their 9/11 G.I. Bill
    and supports this legislation.
                                   conclusion
        ROA appreciates the opportunity to offer thoughts regarding these
    important bills. Because of the unique nature of service in the Reserve
    Components, its members may simultaneously receive care and benefits
    from VA, the departments of Labor and HHS, as well as DOD.
        All too often military and veterans' law and policy are developed
    without an understanding of or appreciation for the important
    distinctions between reserve and active duty service. The members of
    the Guard and Reserve invariably lose out. And so, too, their families.
        America is experiencing perhaps unprecedented challenges to our
    security, and commensurately great reliance on the Reserve and National
    Guard.
        Thus, helping these men and women transition more successfully in
    and out of active duty and deployments, helping them gain access to
    care, and helping their families thrive--all these pieces of
    legislation directly or indirectly enhance readiness and represent an
    insightful and praiseworthy focus on those patriots we call our
    citizen-warriors.

        Senator Boozman. Thank you, General Phillips.
        Senator Tester.
        Senator Tester. Thank you, Mr. Chairman. I am going to
    start with you, Ms. Bryant. Thanks for coming today,
    representing IAVA, and thanks for everything that you guys do
    every day. I appreciate it. You have been a great partner in
    crafting many of the bills that are on the docket here today.
        You are also the only woman on this panel, I noticed, and a
    combat veteran. You have seen--I should say have lived first-
    hand some of the issues that women veterans face in access to
    care within the VA. Just give me kind of an overview on what
    passing the Deborah Sampson Act would mean for a woman veteran.
        Ms. Bryant. Passing the Deborah Sampson Act will not only
    give the expanded mothers' care, newborn care that we have
    talked about earlier in this hearing, but the peer-to-peer
    counseling, the expansion of that, being able to use it in an
    environment in which we can be able to talk to someone who
    looks like us. No offense to my esteemed colleague sitting to
    my left, but it is not necessarily the same message that we
    receive.
        And, as Senator Boozman explained, from your constituents
    of what you have heard about women's experiences, I have to say
    personally that they are universal. I have experienced that at
    the DCVA, where they have asked me, ``Where is my sponsor?''
    ``Where is my husband?'' Then, when I said that I felt harassed
    walking into the VA, which is another problem that VA is trying
    to grapple with--ending harassment there--there is group of
    folks who loiter outside. I was told, ``Well, you can come in
    the back door.'' I should never have to come in the back door.
    My father did not have to go in the back door, so why should I?
        So, that is what the Deborah Sampson Act does, is that it
    gives recognition to our service, as well as the type of
    specialty care that we need. Our anatomies are simply
    different, so we need to have that kind of care, we need to
    have privacy ensured when we go there, and we need to feel safe
    and welcome. That is really the biggest difference that the
    Deborah Sampson Act would make for women.
        Senator Tester. I want to touch a little bit on the safety
    issue as it applies to retrofitting the environment. Can you
    talk about that a little bit? How important is retrofitting to
    make sure that the care is there for women, in appropriate
    conditions?
        Ms. Bryant. Absolutely. The VA, in many facilities, has
    done some of that retrofitting, but it has not been universal,
    as I have stated before, like many things, that is having--be
    it just a curtain that separates you from someone else who is
    walking into an examination room. Imagine a woman who is
    receiving a pelvic exam who is in stirrups, and there is merely
    a curtain that separates you from someone else walking in. You
    are most vulnerable.
        Imagine those who are loitering within the women's clinic
    or outside the clinic. The cat-calling. It is very real and it
    is disconcerting.
        So, having that safety, feeling welcome just walking in the
    front door, then into the women's clinic door, and then, when
    you are your most vulnerable, when you are unclothed and
    someone is giving you an examination, or when you need to talk
    about something like the trauma that you experienced through
    military sexual assault while you were on active duty, or in
    the Guard and Reserve, that is something you need to be able to
    talk with a trusted provider about; that retrofitting is key to
    being able to feel that level of comfort to expose your weakest
    moments.
        Senator Tester. Thank you.
        General Phillips, you addressed the CARE Act, the Care for
    Reservists Act in your statement. Would your organization agree
    that mental health is an urgent issue as it applies to our
    Guards and Reservists?
        General Phillips. Absolutely. In fact, it may be more
    accentuated in the Guard and Reserve because unlike the active
    component, Senator Tester, we scatter back to our communities.
    We get together at drills and when we are deployed and
    mobilized, but we do not tend to have the support of the unit,
    of the organization, that an active component servicemember
    has.
        Senator Tester. So, could you just give me your perspective
    a little bit on Vet Centers and how they can assist the
    Guardsmen and Reservists with the mental health issues, when
    compared to--and the VA too, as far as that goes, especially
    when compared to civilian medical providers?
        General Phillips. Well, not to give a history lesson on the
    Vet Center, but it was formed during the Vietnam years because
    veterans of the Vietnam War were loathe to go to the VA. The
    Vet Center was invented by VA. It was not supposed to look like
    a VA facility, so the vet would feel more free to go to it.
        It achieved great success. It is part of the solution, as
    Dr. Carroll said earlier, and as my colleague, Mike Richardson,
    said. It is part of a total solution. The Vet Center is in the
    community. It is normally staffed by people who have an
    association with or knowledge of the military, so it is very
    much a part of the solution.
        Senator Tester. OK. Mr. Richardson, I want to touch a
    little bit on the Commander Hannon Mental Health Improvement
    Act. Could you speak to the importance of alternative methods--
    and you can go down any road you want--yoga, acupuncture,
    meditation, chiropractic care, whatever you want. Fishing,
    whatever. Could you speak to the importance of that and how it
    impacts your membership?
        Mr. Richardson. Absolutely. Again, a great question,
    because there are emerging trends using alternative--
    complementary and alternative therapies.
        Now within Wounded Warrior Project--and I will specifically
    speak to Warrior Care Network, to where it is anchored in
    evidence-based, while surrounded by complementary and
    integrative services and alternative therapies. Equine therapy
    is one of those as well. I know there is some challenge in
    there, where equine therapy is not evidence-based, but it is
    moving toward evidence informed, as many of these alternative
    therapies are. So, we strongly support the use of complementary
    and alternative therapies in addressing not only mental health
    challenges, but physical health and wellness as well.
        Senator Tester. So, on any of these questions I could have
    asked just about anyone, maybe not the women's care that I
    talked about at the beginning. I do want to ask you, Mr.
    Nembhard, on the debt fairness issue, most everybody has
    touched on it. But, could you just kind of discuss, from The
    American Legion's point of view, the kind of financial and
    mental toll that the veteran goes through when they are trying
    to repay a debt that, quite frankly, they did not think they
    were obligated for to begin with?
        Mr. Nembhard. Thank you for that question, Ranking Member.
    This is actually quite devastating to not just the veterans but
    their entire families. It is tantamount to debt collectors
    banging down your door. And, if you are already suffering with
    other conditions, it just extenuates the problem.
        So, it does create mental health challenges for veterans.
    It also creates a feeling of distrust for the VA, because they
    feel the VA is supposed to be taking care of them and not
    harming them. Do no harm.
        Senator Tester. Yeah. I think one of you pointed out, if
    not more than one of you, about the myriad of payments that
    could come through, and, quite frankly, money is hard to come
    by. When you get these checks and think, ``Well, that is
    cool,'' and then all of a sudden bing, bang, boom, the wolf is
    at the door.
        I want to thank you all for your testimony and the people
    that you represent. I also want to thank the VA staff for
    sticking around and listening. I always appreciate that. You
    guys need to hear from the folks you serve directly. We need to
    do more of that. Thank you all very much.
        Thank you, Mr. Chairman.
        Senator Boozman. Senator Blumenthal.

                       HON. RICHARD BLUMENTHAL,
                     U.S. SENATOR FROM CONNECTICUT

        Senator Blumenthal. Thank you, Mr. Chairman, and thank you
    all for being here today and for your service.
        I want to ask a question about the Caregivers Act. I
    realize it may not be new legislation, but if you could relate
    to us what you are hearing from your memberships about how this
    act is working I would appreciate it.
        Ms. Bryant. Yes, Senator Blumenthal. I will speak from
    IAVA's perspective, in that we appreciate the expansion of the
    Caregivers Act to pre-9/11, but, of course, we do not want to
    see that at the detriment of those who are receiving it for the
    post-9/11 generation. We are still a generation at war, 18
    years into this, and we do not want to see our caregivers left
    behind for those who are coming home with injuries over the
    last two decades.
        Senator Blumenthal. Is that what you are seeing?
        Dr. Boyd. We are not seeing it just yet, but that is the
    fear that we are going to see it, that there is going to be a
    slowness in benefits being distributed to caregivers within the
    post-9/11 community.
        Mr. Richardson. Senator, if I could add, I can absolutely
    concur with Melissa in that we need to make sure, for the pre-
    9/11 caregivers that it is funded, to make sure that management
    is there so we can provide that support and service to them.
        I am responsible for a program called Independence Program,
    under Wounded Warrior Project, which is for those service men
    and women that have moderate to severe Traumatic Brain Injury.
    Most of them have a caregiver. So, we have a very tight
    community and we hear of the many, many issues that are there.
    This is great progress in addressing issues for the caregivers,
    so we appreciate that. We just need to make sure we move in a
    very deliberate fashion with the funding.
        Mr. Nembhard. Senator, just to echo my colleagues here, we
    think it is a fantastic program. It is helping veterans and we
    just want to make sure that the program continues in the right
    direction instead of going backwards.
        Senator Blumenthal. General?
        General Phillips. I echo my colleagues. I will add to that,
    I understand there is some difficulty in becoming certified as
    a caregiver. It can be kind of an awkward, clumsy program.
    Navigating can be difficult. But, at heart, it is a good
    program.
        Senator Blumenthal. I think there have been reports about a
    number of difficulties, that being one of them, and the other
    being premature ending or discharges for folks who continue to
    need caregivers, or caregivers who are tending to folks who
    need it. I would appreciate your keeping us up to date about
    difficulties that you are seeing, because this initiative--and
    I give thanks to Senator Murray and Senator Tester--a number of
    us are very, very interested in it. I think it is part of our
    future, particularly for the post-9/11 generation, as well as
    previous generations.
        What would you recommend in terms of the outreach? You
    know, there is so much talk now about veteran suicide, about
    veterans who are not in the system, which, for the VA,
    sometimes feels like an excuse for not reaching them--they are
    not part of our system. But, there is a responsibility to reach
    out to them, and I think the VA is beginning to recognize that.
    What recommendations would you have for us, and the VA?
        Ms. Bryant. At IAVA we recognize that this is a whole of
    government, whole of community solution that needs to be
    applied. If there were a silver bullet for suicide prevention
    and mental health awareness we would have used it by now. So, a
    lot of what we are talking about are ways in which you can
    reach out to those who are not enrolled in VA care, because we
    do know that those who are enrolled in VA care have a greater
    probability of survival of suicidal ideation. But, it does not
    let VA off the hook.
        So, you have to spend all of your outreach budget in order
    to ensure that you are reaching everyone. It needs to have a
    highly visible digital component, because we know for our
    younger veterans that is the best way we are going to reach
    folks. Even for our older veterans, my father, a Vietnam
    veteran, throws away mail regularly. So, it cannot just be
    outreach through snail mail of how we are reaching out to
    folks; it needs to be all-hands, all methods of outreach. Leave
    no stone unturned, in order to let people know that there are
    the resources out there.
        So, the hope is that, in 2019, given this groundswell of
    messaging around--and we appreciate the efforts, the bipartisan
    efforts of Congress, both in the House and the Senate, to draw
    attention to this matter--the hope is that we will get to a
    part where we can ensure that people at least know what
    resources are out there.
        Mr. Richardson. Sir, if I could just add, in addition to
    the community outreach, our peer-to-peer networks are critical
    in the communities themselves. In addition to that, I would
    just say--and I mentioned this in my testimony before Congress
    in September--is getting left of the bang. Before they
    transition, let's get them engaged in health care,
    understanding, and breaking down the stigma through the
    transition process out of the service; or as the National
    Guarders are demobing to make it normal, normalize the
    conversation so that when they are back in their communities
    they are engaged with mental health care and it is not a stigma
    any longer.
        Mr. Nembhard. Senator, as I mentioned in my testimony, The
    American Legion is already working with the VA on a suicide
    prevention approach, dealing with reaching out to the
    community, peers, family members. I think if the VA continues
    to work with all the VSO partners who have resources out in the
    communities that would be one of the essential steps that can
    help with that progress.
        General Phillips. Senator, as a Bush appointee, I was in
    charge of VA's public affairs, 2001 to 2004, when I went
    voluntarily to Baghdad on active duty. Then I was the Deputy
    Chief of Public Affairs for the Army in 2007, as we were
    grappling, in the Army, with suicide. General Chiarelli was
    Vice Chief of Staff pat of that period. And here we are, 10,
    15, 20 years, whatever, later, and we still have 22 suicides a
    day.
        This is a big problem and no one is blaming the VA for not
    doing enough. I think the VA has bent over backwards. I think
    when I was a Bush appointee in VA we thought about sending out
    a message on people's tax forms, anything we could get out to
    the veterans who are not enrolled in VA care and do not get
    communications from VA. That is very expensive. We thought
    about it.
        I think the solution here, if there is one, is what my
    colleagues are talking about, what I think you talked about,
    and that is engaging entire communities, both governmental and
    non-governmental communities in support and understanding and
    discussions, so people can talk about it, they understand that
    it is OK to talk about it.
        I went through clinical depression myself, and it took an
    Army chaplain to help me through it. Someone I could talk to at
    my level, a peer level, a colleague, who helped me understand
    that what I was going through was fairly normal and I was going
    to get through it, which is what it took.
        But, I am not going around blaming the VA for not doing
    enough, or blaming the Pentagon for not doing enough. I think
    they are trying very hard.
        Ms. Bryant. If I may just dovetail on General Phillips, and
    also to Michael, it does start with a continuum of service. It
    starts in DOD, making that conversation normalized. Like
    General Phillips, I have also, you know, spoken with those who
    are my soldiers under my charge who were attempting--we had an
    attempted suicide, had died by suicide, or were contemplating
    suicidal ideation, and being able to say that I am not OK, and
    being able to report that through your chain of command, or
    talk to a chaplain, or any of the other multiple avenues, if
    they are out there. There is still a stigma that is within the
    uniformed community that we still have not breached yet, and
    being now 18 years into this it is something that we absolutely
    must address from not just a VA perspective. We have to go back
    to the stressors that come out of military service that we need
    to talk about more freely and openly.
        Senator Blumenthal. Well, I appreciate your very thoughtful
    comments. You know, let's be very blunt here. There is a stigma
    in the military but there is a stigma, more generally, in
    society. It may be somewhat greater within the military for all
    the reasons that we understand here. But, mental health and
    physical health are so inextricably connected, yet we still, in
    the civilian world, find resistance to mental health parity. In
    other words, providing insurance benefits in the same way for
    mental health as we do for physical health. I have fought this
    battle for more than a decade, in the civilian world.
        I agree with you that we cannot sort of blame. Blame does
    not get us anywhere. And, I am convinced that the VA is trying
    to find solutions, but we have not gotten there yet, so we need
    to continue that effort.
        Ms. Bryant. What we need to work on collaboratively, sir,
    if I may, is that we need to look at firearms also within our
    community. That is the third rail that people do not want to
    necessarily jump on. It is within that Venn diagram of veterans
    who have familiarity with a lethal--and access to firearms. It
    accounts for lethality of our suicidal ideation that then turns
    to death by suicide. We know that 69 percent of the deaths by
    suicide within our community are due to firearms. So, in our
    messaging we have to talk about that as well. We have got to
    find a way to thread the needle between those who feel as
    though it is government overreach and taking over their weapons
    versus having a safe plan of action when you know that you are
    in crisis.
        Senator Blumenthal. Well, I know I am way over my time, Mr.
    Chairman, but I would just add at that point it is very, very
    salient. We have a couple of bills, and I am hoping we will
    have bipartisan support for them, that, in effect, provide for
    court orders when someone who is talking about suicide in the
    family says we need to take away the firearms, temporarily,
    with a showing about danger to himself or others, and likewise,
    safe storage, so that there is some preventive action.
        It is complicated. I thank you for your attention to it.
    Thank you, Mr. Chairman.
        Senator Boozman. No, thank you. That was a good discussion.
        Mr. Richardson, in that light, you all have come out in
    support of S. 785. Can you talk a little bit about how it would
    be beneficial to have VA as a collaborative partner regarding
    mental health research?
        Mr. Richardson. Absolutely. Research is the forefront of
    the solution for tomorrow. We have got the treatment for today,
    evidence-based complementary, but what we need to get into is
    in the research of tomorrow, biomarker research, in particular.
    VA is already doing much of that, and it is critical that we
    are able to set biology to get the right person to the right
    care at the right time, doing it with precision medicine. We
    are close to doing that. There has been a biomarker discovered
    for Traumatic Brain Injury and one recently for PTSD, as well.
        So, the VA is already well in that space, but we need
    everybody on board to get into the research so that mental
    health can then become precision medicine, much more so than it
    is today.
        Senator Boozman. Very good. General Phillips, you talked
    about data collection in regard to the homeless. Tell us about
    that. Tell us how better data collection would help strengthen
    our efforts to address homelessness.
        General Phillips. Well, of course, some of those homeless
    veterans are members of the Guard and Reserve or veterans of
    the Guard and Reserve, or conceivably family members or former
    family members. Right now, our granularity is such that we do
    not really know. This is part of a larger conversation about
    the Guard and Reserve in America that they have. I think it is
    an artifact of the fact that they have been a strategic Reserve
    since, well, really World War I, when they had been used
    occasionally, and more increasingly, of course, since Desert
    Storm.
        But, they have not been paid attention to, so we do not
    have the systems, the knowledge, and the collection for them
    that we do for the active component. Obviously information is
    power. The more information we can have on who is out there in
    the Guard and Reserve, the more organizations like ROA, NGAUS,
    and EANGUS can help.
        Senator Boozman. I think that makes all the sense in the
    world.
        Ms. Bryant, you note IAVA's support for grant programs to
    support both transition and mental health services for
    veterans. Should we be thinking about these types of services
    as distinct and separate from each other or does it make better
    sense to look at them from a whole health perspective on
    veterans' overall well being?
        Ms. Bryant. Senator Boozman, absolutely the latter; it
    should be considered as part of the whole health solution.
    Again, there is no one way in which we can address mental
    health and suicide prevention within our community. We also
    have to recognize the part that the family has in that as well.
        So, retreats and things that have worked under SSVF could
    now be applied under what we could call an SSSP for suicide
    prevention. That is something that absolutely would be a part
    of a compendium of services that are offered through the
    community as well as through the VA, with the endorsement of
    the VA, in order to find the right fit for everyone.
        Senator Boozman. Thank you. Mr. Nembhard, can you talk to
    us, just for a second, about increasing the Medal of Honor
    recipients' allocation; what the Legion thinks about that and
    the importance of that?
        Mr. Nembhard. At The American Legion, Mr. Chairman, we
    value greatly the contributions of those veterans, to the
    military and to society as a whole. We, the Legion, support
    that and we support increasing that amount for them.
        Senator Boozman. Good. Well, thank you very much. Thank
    you, panel. You did a great job. I think we had a really good
    discussion today and we appreciate your frankness. I would also
    echo Senator Tester in regard to the people at the VA that are
    working hard. I know you all are busy and have lots to do, but
    I think you add a lot by hanging around and being supportive of
    the VSO panel.
        With that, I want to note that the hearing record will be
    left open for 5 days, should any Senators wish to add to their
    statements, to the hearing record, or submit questions to the
    witnesses for the record.
        With that we are adjourned.
        [Whereupon, at 4:07 p.m., the Committee was adjourned.]
       Response to Posthearing Questions Submitted by Hon. Jon Tester to
                      U.S. Department of Veterans Affairs
        Question 1. When can I expect technical assistance from the
    Department on S. 785, the Commander John Scott Hannon Veterans Mental
    Health Care Improvement Act?
        Response. This technical assistance has been in-progress on a
    section-by-section basis and is largely concluded. We have also had
    several productive meetings with Committee staff.

        Question 2. What is VA currently doing to ensure that veterans at
    highest risk for suicide are being followed-up with and cared for
    appropriately?
        Response. To ensure that Veterans at highest risk for suicide are
    being followed-up with and cared for appropriately, the Veterans Health
    Administration (VHA) has implemented specific clinical procedures of
    care with accountability metrics.
        For follow-up care, providers identify Veterans at high risk of
    suicide and notify facility Suicide Prevention Coordinators (SPC). SPCs
    activate a High Risk for Suicide Patient Record Flag (HRS-PRF) on the
    Veteran's electronic health record (EHR). This flag serves as an alert
    to any staff accessing the Veteran's EHR that the Veteran requires
    enhanced care.\1\ This enhanced care is provided by the Veteran's
    treating providers in conjunction with SPCs and includes all the
    following:
    ---------------------------------------------------------------------------
        \1\ VHA Directive 2008-036, Use of Patient Record Flags to Identify
    Patients at Risk for Suicide; and VHA Directive 2010-053, Patient
    Record Flags; these policies are currently being updated.

         Completion of a Suicide Prevention Safety Plan including
    mitigating access to lethal means; \2\
    ---------------------------------------------------------------------------
        \2\ VHA Memorandum Patients at High Risk for Suicide, April 24,
    2008.
    ---------------------------------------------------------------------------
         Four mental health follow-up appointments within 30 days
    of activation of the HRS-PRF and/or discharge from an acute care
    facility; \3\
    ---------------------------------------------------------------------------
        \3\ VHA Memorandum Guidance on Post-Discharge Follow-Up for Mental
    Health Patients, July 17, 2013.
    ---------------------------------------------------------------------------
         One mental health follow-up appointment every 30 days
    thereafter for as long as an HRS-PRF remains on a Veteran's EHR;
         Ensuring follow-up for no-shows to scheduled mental health
    appointments including four separate contacts and by an appropriately
    trained staff member whose scope of practice includes evaluation and
    triage of high-risk behavior; \4\ and
    ---------------------------------------------------------------------------
        \4\ VHA Directive 1230(1), Outpatient Scheduling Processes and
    Procedures, and VHA Notice 2019-09(01), Minimum Scheduling Effort
    Required for Outpatient Appointments: Updates to VHA Directive 1230 and
    VHA Directive 1232(1).
    ---------------------------------------------------------------------------
         Collaborating with treating providers and ensuring review
    and update of the HRS-PRF every 90 days.\5\
    ---------------------------------------------------------------------------
        \5\ VHA Directive 2008-036, Use of Patient Record Flags to Identify
    Patients at Risk for Suicide,Supra, note 1.
    ---------------------------------------------------------------------------
        Veterans who have left against medical advice or otherwise receive
    an irregular discharge from an inpatient mental health unit or
    residential rehabilitation treatment program may be at higher risk for
    suicide and are required to receive follow-up within 24 hours of
    leaving the facility.\6\ Also, no less than two appointments on
    separate days must be offered during the 7-day post-discharge
    period.\7\
    ---------------------------------------------------------------------------
        \6\ VHA Memorandum, Eliminating Veteran Suicide: Enhancing Acute
    Inpatient Mental Health and Residential Rehabilitation Treatment
    Program Discharge Planning and Follow-up, June 12, 2017.
        \7\ VHA Memorandum, Eliminating Veteran Suicide: Enhancing Acute
    Inpatient Mental Health and Residential Rehabilitation Treatment
    Program Discharge Planning and Follow-up, June 12, 2017.
    ---------------------------------------------------------------------------
        Metrics related to the stated enhanced care delivery interventions
    have been developed that track care of Veterans clinically identified
    as being at the highest risk for suicide. The Suicide Prevention
    Quarterly Dashboard reports metrics on core suicide prevention
    priorities, tracking trends, needs, and gaps for quality improvement.
    Specifically, the dashboard maps Veterans who have recently been
    identified as high risk for suicide and placed on our HRS-PRF system.
    This dashboard tracks the percentage of high-risk Veterans that:

         Have a Safety Plan documented within 7 days before or
    after flag initiation, or on or before discharge;
         Received at least 4 mental health encounters within 30
    days of flag initiation, and at least one mental health follow-up
    appointment every 30 days thereafter for as long as an HRS-PRF remains
    on a Veteran's electronic health record; and
         Received a new assignment, reactivated, or continued HRS-
    PRF who received a case review within 100 days after flag initiation.

        These specific measures have also been incorporated into Strategic
    Analytics for Improvement and Learning Value (SAIL) \8\ model, which
    measures, evaluates, and benchmarks quality and efficiency at medical
    centers to promote high quality, safe, and value-based health care. In
    addition to these three measures, additional metrics specific to high
    risk Veterans are part of the Mental Health Continuity of Care measure
    on SAIL, such as the percentage of high-risk patients diagnosed with
    Serious Mental Illness, who have a mental health visit every 6 months,
    and the percentage of individuals discharged from inpatient mental
    health or residential treatment who are engaged in outpatient treatment
    within 30 days.
    ---------------------------------------------------------------------------
        \8\ https://www.va.gov/QUALITYOFCARE/measure-up/
    Strategic_Analytics_for_Improvement_and_Learning_SAIL.asp.

        Question 3. Is there routine monitoring of and outreach to at-risk
    veterans by Suicide Prevention Coordinators, Licensed Clinical Social
    Workers, or other PACT members?
        a. Are these veterans being offered and receiving follow-up care?
        b. What are the protocols for outreach and follow-up care for
    veterans in crisis?
        Response. As noted in the response to question 2, Veterans
    identified at high risk for suicide must be offered and receive follow-
    up care, outreach, and routine monitoring by their care teams and the
    facility suicide prevention team. This may include providers across
    various services to include social workers, Suicide Prevention
    Coordinators (SPC), and/or PACT members.
        Tracking and assessment methods involve monitoring of and outreach
    to at-risk Veterans through a variety of approaches. This includes
    ensuring the following after a high-risk flag has been placed:
    completion of a Suicide Prevention Safety Plan including mitigating
    access to lethal means; four mental health follow-up appointments
    within 30 days of activation of the HRS-PRF and/or discharge from an
    acute care facility; and one mental health follow-up appointment every
    30 days thereafter for as long as an HRS-PRF remains on a Veteran's
    electronic health record.
        Any Veteran reporting or identified as being in crisis will receive
    an immediate crisis response. Each VA health care system must ensure
    the establishment and implementation of localized processes to provide
    immediate crisis response. As part of the My VA Access Initiative, each
    health care system across VHA was required to ensure local standardized
    operating procedures were in place to address the need for immediate
    care for any Veteran voicing suicidality either by phone or in
    person.\9\ The Veterans Crisis Line (VCL) is also available by phone,
    text, or chat to address the needs of Veterans in crisis. Since the
    VCL's inception in 2007, more than 3 million calls have been answered,
    and emergency services have been dispatched to those in imminent crisis
    nearly 78,000 times.\10\
    ---------------------------------------------------------------------------
        \9\ VHA Memorandum, My VA Access: Mental Health Breakthrough
    Initiative, April 22, 2016.
        \10\ VA Office of Mental Health and Suicide Prevention Guidebook
    (2018).
    ---------------------------------------------------------------------------
        In addition to responding to Veterans in crisis, VA also
    proactively works to identify those who are at risk who may not self-
    disclose suicidal thoughts on their own. VA has implemented a
    standardized suicide risk identification process for all Veterans
    receiving VA care.\11\ The process is comprised of three components and
    implements population-based mental health screening for those with
    unrecognized risk (universal), for those who may be at risk (selected),
    and for those at elevated risk (indicated). The components include
    standardized primary and secondary screens specific to risk of suicide
    and a comprehensive suicide risk evaluation for Veterans with a
    positive secondary screen, helping to proactively identify Veterans in
    crisis.
    ---------------------------------------------------------------------------
        \11\ VHA Memorandum 2018-05-21, Suicide Risk Screening and
    Assessment Requirements, May 23, 2018; VHA Memorandum 2018-11-02,
    Eliminating Veteran Suicide: Implementation of Suicide Risk Screening
    and Evaluation November 2, 2018; VHA Memorandum 2019-02-17, Eliminating
    Veterans Suicide: Update on Suicide Risk Screening and Evaluation,
    February 22, 2019.
    ---------------------------------------------------------------------------
        Additionally, VA works to use analytic strategies to identify
    Veterans at high risk to begin to engage them in additional
    interventions. These include the following:

         Recovery Engagement and Coordination for Health--Veterans
    Enhanced Treatment (REACH VET) identifies patients at statistical risk
    of death by suicide in the next month. Using REACH VET, VHA clinicians
    can contact the identified Veterans to collaboratively review health
    conditions and risk factors, ensure access to care, and consider care
    enhancement strategies such as safety planning and increased monitoring
    during stressful life events.
         The Stratification Tool for Opioid Risk Mitigation (STORM)
    identifies patients at statistical risk of overdose or suicide-related
    health care events or death in the next year by using predictive
    modeling to estimate the risk of adverse events for patients receiving
    or considering opioid therapy. It also provides information on risk
    factors, monitoring of applicable risk mitigation interventions,
    treatment alternatives, and information to guide care coordination by
    clinicians.

        Question 4. Have any policies or protocols been changed or created
    since the events in Georgia, Austin, Texas, and Cleveland, Ohio?
        Response. Since the tragic events in Georgia, Austin, Texas, and
    Cleveland, VA created initial guidance \12\ to help medical facility
    leadership, supervisors, and suicide prevention teams respond to this
    type of tragedy. This guidance provides concrete recommendations on how
    to manage patient care, notify the family, alert other parties, and
    support employees affected by a Veteran suicide on campus. Guidance is
    not considered policy, but it provides recommended actions. The initial
    guidance was emailed to Veterans Integrated Service Network (VISN)
    Chief Mental Health Officers and Suicide Prevention Coordinators/Team
    Members in June 2019. Stakeholder feedback on the initial guidance is
    currently being collected. The guidance will be updated and more
    broadly disseminated to VISNs and medical centers when stakeholder
    feedback is incorporated.
    ---------------------------------------------------------------------------
        \12\ Guidance for Action Following a Suicide on a VA Campus,
    June 2019.
    ---------------------------------------------------------------------------
        In general, the initial guidance is geared toward facility leaders
    and supervisors to equip them to respond to the tragedy and support
    affected employees. It enhances existing facility procedures when
    responding to a Veteran suicide by adding to what management and
    suicide prevention teams can and should do to care for employees and
    the Veteran's family.
        In addition, VA has continued to implement ongoing improvements for
    Veterans at high risk for suicide. VA has required all medical
    facilities with an acute mental health unit to install door top alarms
    on swinging corridor doors of patient rooms effective January 1,
    2020.\13\ VISN Network Directors are required to certify this action
    has been taken no later than February 1, 2020.\14\ VA facilities also
    complete Environment of Care Rounds that include identification and
    recommendations for remediation of potential safety issues, including
    those specific to suicide and suicidal behavior. VA's Mental Health
    Environment of Care Checklist is designed to assist units with
    environmental surveys meant to reduce risk of harm.\15\ Mental Health
    Units are required to use the Checklist at least every 6 months to
    identify and mitigate safety risks.\16\ In addition, Mental Health
    Residential Rehabilitation Treatment Programs (MH RRTP) stand down
    clinical operations annually to focus on safety, security, and quality
    of care as part of the VA's ongoing Culture of Safety Stand Down.\17\
    Suicide Prevention Coordinators are required to participate in the
    Stand Down and in the Annual Safety and Security Assessment.
    ---------------------------------------------------------------------------
        \13\ VHA Memo, Use of Over-the-Door Alarms for Corridor Doors in
    Acute Mental Health Units Treating Suicidal Patients, May 10, 2019.
        \14\ Ibid.
        \15\ VHA Directive 1167, Mental Health Environment of Care
    Checklist for Mental Health Units Treating Suicidal Patients, May 12,
    2017.
        \16\ Ibid.
        \17\ VHA 10N Memorandum, Ensuring Safety and Security in the Mental
    Health Residential Rehabilitation Treatment Programs (MH RRTP): Annual
    Safety and Security Assessment and Culture of Safety Stand Down,
    September 14, 2018.
    ---------------------------------------------------------------------------
        VA conducts ongoing monitoring of on-campus suicide attempts and
    deaths to inform policy and practices that ensure the safety of our
    Veterans and staff. This work includes regular tracking and analyses as
    part of ongoing suicide surveillance. Summary reports are routinely
    generated for leadership review. Source information comes from
    facility-reported Issue Briefs (IB) and from the Office of Security and
    Law Enforcement (OSLE). VA police report information is provided to the
    Office of Mental Health and Suicide Prevention (OMHSP) for inclusion in
    ongoing surveillance, and OSLE has also completed a review of on-campus
    suicide events indicated in police reports. The National Center for
    Patient Safety conducts regular reviews of Root Cause Analyses related
    to on campus suicides as well. These processes are intended to examine
    if any changes in policies and procedures are warranted at the facility
    level.

        Question 5. Does VA have the appropriate protocols and training in
    place for staff who are dealing with a veteran in immediate crisis?
        a. What are those protocols?
        b. If those protocols are in place, have all VA facilities adopted
    those protocols, and are they being implemented appropriately?
        Response. VA has the appropriate protocols and trainings for staff
    who respond to Veterans in immediate crisis.
        Whenever eligible Veterans have an urgent need for mental health
    care, appropriate mental health services must be provided.\18\
    Evaluations and treatment for mental health conditions can be provided
    in mental health care services through primary care and other medical
    care settings or by arrangements with non-VA community services.\19\
    ---------------------------------------------------------------------------
        \18\ VHA Handbook 1160.01, Uniform Mental Health Handbook, Page 18.
        \19\ VHA Handbook 1160.01, Uniform Mental Health Handbook, Page 17.
    ---------------------------------------------------------------------------
        All sites with Emergency Departments (ED) or Urgent Care Centers
    (UCC) must provide safe and secure mental health services during all
    hours of operation.\20\ Per VHA policy, all patients presenting to the
    ED or UCC are screened at some point during the visit for suicide and
    homicide risk.\21\
    ---------------------------------------------------------------------------
        \20\ VHA Directive 1101.05, Emergency Medicine, Page 25.
        \21\ Ibid.
    ---------------------------------------------------------------------------
        VA implemented a standardized suicide risk identification process
    for all Veterans receiving VA care, as described above.\22\ The process
    is comprised of three components and implements population-based mental
    health screening for those with unrecognized risk (universal), for
    those who may be at risk (selected), and for those at elevated risk
    (indicated). The components include standardized primary and secondary
    screens specific to risk of suicide and a comprehensive suicide risk
    evaluation for Veterans with a positive secondary screen (more details
    are provided in the response to question 7).
    ---------------------------------------------------------------------------
        \22\ VHA Memorandum2018-05-21, Suicide Risk Screening and
    Assessment Requirements, May 23, 2018; VHA Memorandum 2018-11-02,
    Eliminating Veteran Suicide: Implementation of Suicide Risk Screening
    and Evaluation, November 2, 2018; VHA Memorandum 2019-02-17,
    Eliminating Veterans Suicide: Update on Suicide Risk Screening and
    Evaluation, February 22, 2019.
    ---------------------------------------------------------------------------
        VA is in the process of expanding the use of suicide prevention
    safety plans and follow-up care in the ED.\23\ Veterans presenting to
    the ED who have been assessed as at risk of suicide but are safe to be
    discharged home receive suicide safety planning intervention prior to
    discharge and follow-up outreach to facilitate engagement in outpatient
    mental health care.
    ---------------------------------------------------------------------------
        \23\ VHA Memorandum 2018-09-22 Suicide Prevention in Emergency
    Departments (SPED): Suicide Safety Planning and Follow Up
    Interventions, September 7, 2018.
    ---------------------------------------------------------------------------
        VA has expanded requirements for suicide prevention training
    related to Veterans who are experiencing suicidal crisis.\24\ All staff
    are required to receive suicide prevention training within 90 days of
    entry to duty and annually thereafter.\25\ The training teaches staff
    to identify and respond to a Veteran who is at risk of suicide. The
    Signs of suicidal thinking, Ask questions, Validate the person's
    experience, and Encourage treatment and Expedite getting help
    (S.A.V.E.) Training is required for all staff (clinical and non-
    clinical) and Suicide Risk Management Training for Clinicians is
    required for all clinical staff. These trainings are tracked through
    VA's Talent Management System (TMS).
    ---------------------------------------------------------------------------
        \24\ VHA Directive 1071, Mandatory Suicide Risk and Intervention
    Training for VHA Employees, December 22, 2017.
        \25\ Ibid.

        Question 6. How are facilities and providers held accountable to
    ensure adherence to these protocols?
        a. How does VA monitor adherence to those protocols, and how are
    facilities and providers notified and retrained when protocols are not
    being met?
        Response. Oversight regarding adherence to the standards of
    clinical care is conducted by VAMCs. VHA policies outline quality
    management expectations for facility, VISN, and VHA offices.\26\
    Facilities maintain Morbidity and Mortality Review Boards (which
    includes psychological autopsies) to foster clinical conversations
    among clinicians regarding the care provided to individual patients.
    Facilities engage in Medical Records Reviews to assess the adequacy of
    medical record documentation about the completeness, timeliness, and
    clinical pertinence of care.
    ---------------------------------------------------------------------------
        \26\ VHA Directive 1026, VHA Enterprise Framework for Quality,
    Safety, and Value, August 2, 2013; VHA Directive 2008-077, Quality
    Management (QM) and Patient Safety Activities that Can Generate
    Confidential Documents, November 7, 2008; and VHA Directive 1190, Peer
    Review for Quality Management, November 21, 2018.
    ---------------------------------------------------------------------------
        In addition, facilities engage in Focus Reviews (Protected Peer
    Reviews, Root Cause Analyses) which address specific issues
    (consequences of patient care processes) or specific incidents (a
    discrete episode of care). For situations involving a specific patient-
    provider episode of care, completion of an internal VHA Peer Review
    results in a rating of care. Protected Peer Reviews are non-punitive,
    quality improvement activities. Corrective actions, such as additional
    training, assigned reading, shadowing care, etc., can be generated.
    Providers with identified gaps in care or adherence to protocols can be
    assigned a Focused Professional Practice Evaluation (FPPE) and Ongoing
    Professional Practice Evaluations (OPPE), which monitors performance
    over time to ensure ongoing compliance and quality.

        Question 7. How is VA training providers to perform crisis
    interventions in a way that is safe for both the provider and the
    veteran?
        Response. For crisis intervention training related to suicide risk,
    it is VHA policy that all VHA employees must complete a required
    suicide risk and intervention training module. Clinicians complete
    Suicide Risk Management Training for Clinicians and must pass the post-
    module test, and non-clinicians complete S.A.V.E. training within 90
    days of entering their position and an annual refresher course.\27\ It
    is also policy that all employees must complete the appropriate annual
    refresher training specific to their position.\28\ VHA has also
    developed a Suicide Risk Management Training for Registered Nurses that
    may be assigned annually as an alternative training option to Suicide
    Risk Management Training for Clinicians for nursing staff.
    ---------------------------------------------------------------------------
        \27\ Supra, note 24.
        \28\ Supra, note 24.
    ---------------------------------------------------------------------------
        As noted in question 5, OMHSP implemented a national, standardized
    process for suicide risk screening and evaluation, using high-quality,
    evidence-based tools and practices.\29\
    ---------------------------------------------------------------------------
        \29\ VHA Memorandum 2018-05-21, Suicide Risk Screening and
    Assessment Requirements, May 23, 2019; VHA Memorandum 2018-11-02,
    Eliminating Veteran Suicide: Implementation of Suicide Risk Screening
    and Evaluation, November 2, 2019; and VHA Memorandum 2019-02-17,
    Eliminating Veterans Suicide: Update on Suicide Risk Screening and
    Evaluation, February 22, 2019.

         The Primary Screen is a single item intended to broadly
    screen for individuals who may be at increased risk for suicide
    throughout VHA clinics. Those who screen positive receive the second
    level screen.
         The Secondary Screen is conducted using the Columbia
    Suicide Severity Rating Scale (C-SSRS). The C-SSRS consists of three to
    eight additional questions that specifically query about suicidal
    thoughts, plan, intent, and behavior. Those who screen positive receive
    the VA Comprehensive Suicide Risk Evaluation CSRE.
         The Tertiary Assessment, VA CSRE, was developed by a team
    of subject matter experts to include evidence-based factors to
    determine acute and chronic risk levels and inform a risk management
    plan.

              - This plan is developed to meet the individual needs of the
            Veteran and can be initiated at the time the Veteran is being
            seen and reporting suicidal ideation or behavior, regardless of
            setting type.
              - Using one instrument across all VA settings results in
            standardization of evaluation and management, thereby improving
            quality of care for at-risk Veterans and helping reduce stigma
            associated with discussions about suicide.

        Prior to the implementation of the Suicide Risk Identification
    Strategy in May 2018, an informational memo was distributed to the
    field outlining the new strategy.\30\ A Suicide Risk Screening and
    Assessment SharePoint site was established, a single technical
    assistance email group was established, and all facilities identified a
    Facility Champion/Point of Contact for training and questions.
    Educational Webinars were held throughout August and September, which
    were made available on VA's training platform--Talent Management System
    (TMS)--for sites to utilize. Weekly technical assistance calls were
    also held during this period.
    ---------------------------------------------------------------------------
        \30\ VHA Memorandum 2018-05-21, Suicide Risk Screening and
    Assessment Requirement, May 23, 2018.
    ---------------------------------------------------------------------------
        Assignment and management of training and education are done
    locally. Local facilities may assign training to appropriate staff and
    track this training through TMS.
        Virtual training provides details and guidance on VA's new,
    national three-stage screening and evaluation process. Three courses
    are available in TMS, including Suicide Risk Identification Strategy--
    Overview,\31\ Primary and Secondary Screening Tools,\32\ and CSRE.\33\
    VA's Suicide Risk Identification SharePoint training documents folder
    includes training resources such as Frequently Asked Questions, Suicide
    Risk Identification Clinical Reminder Flowchart, and Suicide Risk
    Stratification Table. In addition, the SharePoint site hosts a
    discussion board for questions. In August 2019, additional trainings in
    support of CSRE implementation are being hosted by Employee Education
    Services (EES). The VA Suicide Risk Identification Technical Assistance
    Group hosts a weekly technical assistance phone call with an email
    group for questions.
    ---------------------------------------------------------------------------
        \31\ TMS item number VA 36829.
        \32\ TMS item number VA 36816.
        \33\ TMS item number VA 36830.
    ---------------------------------------------------------------------------
        To ensure that facilities are made aware of updates related to
    national memos, release of educational materials, changes to
    requirements or guidance documents and any other information related to
    the risk identification process, each facility was required to identify
    a Facility Champion/Point of Contact. The Facility Champion receives
    updated information as it becomes available and disseminates the
    information to the local facility.
        The Suicide Risk Management Consultation Program is available to
    consult on a specific case or talk about suicide risk management
    strategies more generally.

        Question 8. After the tragic shooting in Yountville, CA, and other
    incidents across the country where veterans have brought guns into VA
    facilities, many VHA employees have expressed concerns to the Committee
    about their physical safety. What protocols are in place to ensure the
    safety of VA staff, both clinical and non-clinical, at all VA
    facilities where a veteran in crisis may present?
        Response. VA is deeply committed to the safety and security of all
    persons who are in VA facilities. VHA's Workplace Violence Prevention
    Program (WVPP) meets, and often exceeds, the community practice and
    regulatory standards for violence prevention in health care settings.
    Although the urge may be strong to bar individuals from health care
    whose behaviors undermine a culture of safety, VHA's WVPP operates on
    the foundation that full engagement in the resources available through
    health care access promotes the protective factors that reduce violence
    risk.
        It is understood that comprehensive violence prevention involves
    physical security measures and active threat responses that address
    environmental realities of health care delivery venues. It is within
    that context that VHA's WVPP model emphasizes a data-driven, evidence-
    based approach to the early identification, clinical assessment, and
    individualized management of behaviors that undermine a culture of
    safety.
                       program description and rationale
        Utilization of multidisciplinary teams are the current published
    standard for threat assessment and management in health care. Such an
    approach is not new, having been promoted as best practice in education
    and general workplaces. VHA adapted these models for ethical and
    appropriate use in health care venues, requiring their national
    implementation in 2003. VHA's WVPP model includes threat assessment and
    management teams as the essential ``Assess'' and ``Management Plan''
    components of the 5-element model (see Figure 1).

                  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

        Figure 1. Healthcare Workplace Violence Prevention Program Model

        Employee. The personnel populating health care environments are our
    greatest safety asset. Employee education and training is most
    successful when relevant to the violence-related hazards personnel
    experience in their respective and unique workplaces. VHA's premier
    education program in this area, Prevention and Management of Disruptive
    Behavior (PMDB), emphasizes knowledge and skills necessary for
    employees to successfully identify situations that have the potential
    to escalate toward violence and address them verbally at the earliest
    levels of disruption. If health care personnel experience situations
    during the course of their duties that are not ameliorated by verbal
    de-escalation, then they also should be trained in personal safety
    skills and therapeutic containment techniques that do not leverage
    pain-based or tissue-damage compliance. By being prepared to address
    disruptive behaviors spanning a spectrum of severity, employees report
    increased willingness to intervene at the earliest stages of
    escalation.
        Report. Data about the type, location, severity, and frequency of
    disruptive behavior inform WVPP improvements in, and the relevance of,
    employee education. In VHA, these data are obtained through the
    Disruptive Behavior Reporting System (DBRS). Underreporting of
    potentially dangerous behavioral events in health care is a well-
    documented concern. Additionally, health care administrators and
    leaders are challenged by receiving disruptive behavior event reports
    through numerous different reporting systems that do not integrate all
    information into a comprehensive database.
        One successful strategy for overcoming the underreporting challenge
    is use of secure, Web-based, user-friendly event reporting systems that
    allow for anonymous reporting. DBRS is one such system, specifically
    designed in VHA for health care venues. It is short and easily accessed
    by all VHA employees through any computer terminal across the entire
    health care system. DBRS has 5 reporting pages with a total of 32
    questions, comprised primarily of radio button and check-box responses,
    that elicit data regarding the time and location of the disruptive
    behavior event (e.g., night shift in the emergency department, day
    shift in the outpatient behavioral health clinic, etc.), the person who
    experienced the event (e.g., a direct care nurse, another patient, an
    administrative support worker, etc.), the person who reported the event
    (e.g., the person experiencing the event, a person witnessing the
    event, etc.), the person involved in creating the event (e.g., a
    patient, a visitor, another staff member, etc.), and a description of
    the event itself (e.g., involved verbal behavior only, involved
    physically disruptive behavior, involved behavior with weapons
    resulting in injury, etc.). DBRS automatically and immediately delivers
    an electronic event entry notification to both the reporter and the
    threat assessment team.
        Assess. Leadership's credibility that violence prevention matters
    hinges largely upon its ability to demonstrate action in response to
    event reports. Every incident reported should be assessed by a
    multidisciplinary team trained in violence risk and threat assessment.
    The current state of the science involves the use of Structured
    Professional Judgment (SPJ) guides to ensure that assessment teams
    focus on evidence-based risk and protective factors. Threat assessment
    in health care exists to determine whether a reported behavior poses a
    threat to the delivery of safe and effective health care. As such, they
    operate under the authority of the facility's chief medical officer and
    are chaired by senior clinicians trained in evidence-based, data-driven
    threat assessment practice. Members of these teams also include, but
    are not limited to, professionals from security/law enforcement,
    documented high-risk workplaces, legal counsel, and labor union safety
    representative(s).
        Management (Treatment) Plan. If the behavior reported to the threat
    assessment team is determined to pose a threat, then a customized
    management plan must be developed and implemented. Employing a
    continuum approach to graded levels of invasiveness permits such plans
    to range from non-confrontational interventions (e.g., special
    appointment to determine the patient's understanding of why his/her
    behavior became disruptive, change of health care provider, etc.), to
    more direct interventions (e.g., written letters expressing behavioral
    expectations, redirection of communication with the health care system
    through a personalized point of contact, etc.), to more restrictive
    interventions (e.g., placing limitations upon the time, place, and/or
    manner of health care service delivery). At no time may a behavioral
    threat management/treatment plan in VHA permanently bar individuals
    from receiving health care; venue and manner of health care delivery
    may vary, but health care will be offered consistent with the
    provisions of 38 CFR 17.107.
        Communicate. Violence prevention programs must include mechanisms
    for ensuring the safety/treatment plan developed by the
    multidisciplinary threat assessment team is communicated to personnel
    effectively and ethically. Electronic health record alerts (EHRA) that
    provide a 1-2 sentence summary of the problem behavior and a 1-2
    sentence description of actions personnel should take to promote safety
    are known to be part of an effective strategy for reducing violence in
    health care. EHRAs convey information about customized interventions;
    that said, they are communication tools, and placing an EHRA per se is
    not an intervention in and of itself. The value of using EHRAs to
    convey information necessary to know at the initial moments of a
    patient encounter to promote safety must be balanced carefully with
    potential for inadvertently stigmatizing patients. Signal-to-noise
    value of EHRAs must be maintained, thus over-use of EHRAs should be
    avoided.
        Employees learn of the safety/treatment plan, implement the actions
    described in the EHRAs, and safely provide health care. Through
    continued reporting, assessing, and safety/treatment plan evolution,
    health care systems are empowered to retain even the most behaviorally
    challenging patients, thus promoting access to risk-reducing protective
    factors.
                      physical and infrastructure security
        VA has re-assessed physical security and infrastructure,
    identifying risks that could impact medical facilities, and we are also
    continuously evaluating and developing mitigation strategies to reduce
    the opportunity for a severely dangerous events to occur. VAMCs have
    implemented the following: panic buttons, badge restricted access to
    certain areas, limited guest hours, security camera monitoring,
    emergency preparedness training, and more. Universal signs are posted
    throughout all VA properties alerting all Veterans, staff, and visitors
    that no weapons of any kind are allowed on the property and that
    possession of weapons or explosives on VA property violates Federal
    law.\34\
    ---------------------------------------------------------------------------
        \34\ 18 U.S.C. Sec. 930; 38 CFR Sec. 1.218(a)(13).
    ---------------------------------------------------------------------------
        In addition to physical security enhancements, VA police have
    increased their visibility on campuses to which they are assigned.
    Medical Center Police Chiefs, and other appointed personnel, are also
    connected to fusion centers that are located in the corresponding
    geographical area to each respective medical center. These fusion
    centers gather, analyze, and facilitate the sharing of sensitive
    intelligence between Federal, state, tribal, and territorial partners
    which heightens situational awareness and allows VA to make informed
    decisions concerning issues that could impact VA properties.
        The effectiveness of an integrated response to an identified threat
    situation can be enhanced through proper training and preparation. VA
    police undergo substantial and varied training, including continuing
    training at their respective assigned facilities, and have been
    provided with the necessary equipment to appropriately respond to
    violent threat situations. Focused training specific to the facility is
    provided locally and allows for the incorporation of multiple
    variations of site-specific scenarios involving the necessitated
    response to threat incidents involving dangerous weapons or other
    specific threats. VA Police additionally offer training at all VA
    properties to all employees regarding active threat/shooter incidents
    and VA facilities conduct mock and live drills regularly that are
    designed to identify vulnerabilities, inform needed improvements,
    prepare for eventualities, and to prevent violent acts from occurring.
        In addition to the existing mandatory PMDB employee training in VHA
    addressing verbal de-escalation, personal safety, and therapeutic
    containment skills, the Law Enforcement Training Center also offers an
    optional Verbal Defense in Health Care training program, designed for
    employees to use communications skills to de-escalate potential
    incidents that could result in a Veteran, staff, or visitor from
    reacting violently during contact with them.

        Question 9. In December 2018, the Government Accountability Office
    released a report that highlighted how VA's Office of Mental Health and
    Suicide Prevention (OMHSP) mismanaged funding and spent a mere fraction
    of its suicide prevention outreach budget. Have these problems been
    addressed? Please explain how OMHSP plans to spend Fiscal Year 2019 and
    future funds appropriated for suicide prevention and mental health
    outreach.
        Response. VA is addressing suicide prevention outreach budget
    concerns. Regarding oversight, VA staff and leadership are regularly
    briefed on paid campaign progress. This includes monthly reports
    highlighting both the current status and accomplishments of each
    campaign as well as historical comparisons to past campaigns to gauge
    growth and provide additional context. VA is on track to spend the full
    $6 million allocated for paid media efforts; the Executive in Charge of
    VHA oversees these efforts as well.
        Measurement and evaluation are essential components of VA of paid
    media efforts. VA measures every online interaction with our paid media
    campaign materials to ensure we are reaching the right people with the
    right information. Interactions measured include the following:

         Site usage patterns: traffic to site, time on site, number
    of pages visited;
         Online engagements with the Veterans Crisis Line (VCL):
    calls, chats, texts originating from the Web site; and
         Engagements with other key resources: downloads of
    campaign and materials, uses of S.A.V.E. training, views of our
    educational videos and Public Service Announcements (PSA).

        Targets were developed at the outset for metrics designated as key
    performance indicators and are continually assessed throughout the life
    of a campaign. In March 2019, VA launched a keyword search campaign
    targeting people searching for crisis support for Veterans. The targets
    for that campaign were oriented around the following
    VeteransCrisisLine.net key performance indicators:

         Site traffic consisting of 20,000 visits per month
    originating from paid ads;
         Online calls and texts totaling 2,000 calls and 2,000
    texts per month through the VCL Web site (does not account for calls
    that do not originate on-site);
         Crisis chats totaling 2,000 chats per month originating
    from paid ads; and
         Self-check quiz uses totaling 1,200 link-outs to the self-
    check quiz that originated from paid ads.

        VA deployed additional digital paid media strategies during the
    summer of 2019, for which targets have been set. These targets are
    based on engagement with specific online resources, including but not
    limited to VA-produced toolkits and trainings.
        VA also assesses the digital effort's impact on VCL call volume.
    When VA advertises the VCL, there is a measurable increase in call
    volume.
        Last, a number of special paid media activations have been executed
    or are currently in process, including an advertisement in Times
    Square, placements in Major League Baseball (MLB) gameday programs, and
    rollout of a national billboard advertising campaign in partnership
    with PSA Advertising, Inc.

        Question 10. Congress has provided VA authority to deliver
    counseling services to active duty servicemembers, and members of the
    National Guard and Reserve who have experienced Military Sexual Trauma
    (MST). I am disappointed in how VA is implementing this authority, only
    allowing MST survivors to access counseling services at Vet Centers
    rather than at all VA facilities. While I acknowledge the potential
    privacy issues involved when using an interoperable electronic health
    record (EHR) that shares information with DOD, I support VA exploring a
    work-around that would allow MST survivors to access care at all VA
    facilities, not just Vet Centers. This, and other authorities that
    allow VA to provide care to veterans who are not traditionally eligible
    for VA care but are particularly at-risk for suicide, such as those
    with other than honorable discharges or those within the first 12
    months of separation, must be utilized to the fullest degree in order
    to reach the 14 veterans per day who commit suicide with no interaction
    with VA in the previous 24 months.
        a. Are there any plans to expand MST services to VA facilities in
    compliance with Public Law 115-91?
        b. What are those plans, if any?
        VA Response 10a and 10b: VA and the Department of Defense (DOD)
    have a strongly shared commitment to ensure all Veterans and
    Servicemembers have access to the care they need to recover from
    military sexual trauma (MST). Active duty and Reserve Component
    Servicemembers can currently receive MST-related counseling, care, and
    services at VA medical facilities with a DOD referral or in emergency
    situations. Further, per 38 United States Code (U.S.C.)
    Sec. 1720D(a)(2), VA ``may,'' in consultation with DOD, provide Active
    duty and Reserve Component Servicemembers VA MST-related services
    without a referral from DOD. The Departments have worked closely
    together to develop a strategy to implement this discretionary
    authority in a way that expands services as much as possible, while
    maintaining the trust of sexual trauma survivors and protecting mission
    readiness. As noted in the question, VA and DOD's joint decision was to
    implement this authority at VA Vet Centers, meaning that Servicemembers
    can receive MST-related counseling services from more than 300 VA Vet
    Centers without a referral from DOD. As 38 U.S.C. Sec. 1720D(a)(2)
    authorizes, but does not mandate, VA to provide this care to members of
    the Armed Forces without a referral, the decision to implement this
    authority at only Vet Centers complies with the law.
        A number of intractable barriers exist to expanding implementation
    to VA medical facilities, and the Departments have fully explored all
    possible avenues for addressing them. Indeed, in 2016, the VA/DOD Joint
    Executive Committee (JEC) specifically directed creation of an ad hoc
    VA/DOD Workgroup to establish a strategy to expand access to VA medical
    centers. The Departments worked intensively to develop this strategy,
    including working with VA's Office of Information and Technology (OIT)
    to identify the system-wide IT modifications necessary to ensure
    confidentiality of Servicemembers' VA medical records with respect to
    DOD. Unfortunately, no solution was readily available to allow complete
    confidentiality. At best, records could be marked as ``sensitive,'' but
    they would remain available for DOD clinical providers to access.
    Moreover, even if an IT solution were available to ensure
    confidentiality, limiting information-sharing of MST-related care
    records entirely would pose risks as well, as medical conditions or
    treatment (e.g., psychoactive prescription medications) that could
    degrade mission performance or deployment readiness of Servicemembers
    would be unknown to DOD medical providers or command unless
    communicated by Servicemembers themselves.
        In 2018, the VA/DOD JEC approved maintaining the current course of
    action, with implementation of this authority at VA Vet Centers only.
    The Departments do not currently have plans to expand implementation to
    VA medical facilities, as sufficient privacy of MST-related information
    cannot be ensured even with IT modifications. VA believes that
    maintaining confidentiality is crucial to maintaining patient trust and
    preserving Servicemembers' sense of VA as a source of help, not only
    during their service, but also after transitioning to being Veterans.
    Ethics consults from the American Medical Association and the VA
    National Center for Ethics in Health Care support this perspective and
    underscore the importance of implementing this authority in a way that
    preserves confidentiality. Vet Centers are a widely available resource
    for confidential, high-quality MST-related counseling and referral
    services for Service- members who wish to seek care without a referral
    from DOD. Vet Center counselors are fully trained and licensed mental
    health professionals who are clinically experienced in treating
    psychological trauma and associated issues such as suicide risk,
    anxiety, depression, and substance abuse. Counseling services available
    are comparable to those available at VA medical facilities. Vet Center
    Client Records are maintained independent of, and governed by, policies
    different than VA's medical facility records.

        c. Are there plans for additional outreach efforts to veterans with
    other than honorable discharges?
        d. What are those plans?
        VA Response 10c and 10d: With respect to outreach, VA's Office of
    Mental Health and Suicide Prevention (OMHSP) is responsible for
    national coordination of VA's general outreach efforts to raise
    Veterans' and public awareness of MST and VA's MST-related services.
    Ongoing policies and initiatives help provide information about VA's
    MST-related services to Veterans with an Other-Than-Honorable
    discharge, as well as Veterans more broadly. As a brief overview, under
    VA policy (VHA Directive 1115, Military Sexual Trauma (MST) Program,
    paragraph 4.d.(9)), every VA medical facility Director must ensure
    information regarding VA's services related to MST is visibly posted or
    displayed. Every health care system has a designated MST Coordinator,
    whose responsibilities include directing and engaging in outreach
    activities within the system's facilities and with community allies.
    This includes regular, ongoing activities (such as overseeing the
    public display of MST information within facilities) as well as high-
    visibility facility events (e.g., Clothesline Projects in honor of
    Sexual Assault Awareness Month) and representation at community events
    that serve Veterans. The MST Coordinator also serves as the point
    person for MST-related care issues within the health care system and
    can assist Veterans, including those with an Other-Than-Honorable
    discharge, with accessing MST-related care.
        Additionally, OMHSP initiates and supports MST outreach efforts at
    a national level. Information about MST and VA's related services is
    available on VA's Internet site, and outreach resources are available
    to MST Coordinators and other staff on VA's Intranet. Resources include
    a range of graphic and digital media, such as brochures, posters,
    infographics, fact sheets, and outreach videos. OMHSP has initiated
    additional national-level campaigns, for example to assist facilities'
    efforts to raise awareness specifically of male survivors of MST. As
    implementation continues for recent legislative changes expanding
    eligibility for Veterans with an Other-Than-Honorable discharge, OMHSP
    ensures that its suite of outreach resources and materials remain up to
    date and inclusive of this population. OMHSP continues to ensure that
    MST Coordinators are well aware of new policies as they are implemented
    and provide ongoing guidance and assistance as needed. OMHSP also
    continues its efforts to ensure the broader population of individuals
    with Other-Than-Honorable discharges is aware of available emergency
    services and potential eligibilities for ongoing care. OMHSP's Internet
    website is a key source for the most current information regarding
    these services. VHA will also continue to pursue educational outreach
    efforts at facility level Town Halls and Veterans Services Organization
    meetings.

        Question 11. How will the roadmap slated to be created by the task
    force outlined in Executive Order 13861 be different than the already
    existing National Strategy for Veteran Suicide Prevention 2018-2028?
        a. What will become of the National Strategy once the task force's
    roadmap has been completed?
        b. Will progress toward the goals and objectives laid out in the
    National Strategy continue, or be put on hold pending the release of
    the roadmap?
        Response. Influenced by the National Strategy for Preventing
    Veteran Suicide, the Executive Order 13861 (the President's Roadmap to
    Empower Veterans and End a National Tragedy of Suicide, or PREVENTS)
    Roadmap outlines the specific strategies needed to effectively lower
    the rate of Veteran suicide among our Nation's Veterans, analyzing
    opportunities for collaboration within Federal, state, local, tribal,
    and non-government entities. The Roadmap will buildupon the National
    Strategy for Preventing Veteran Suicide as its foundation and is
    currently, through environmental scans, identifying other initiatives
    across governmental agencies and States, counties, and communities
    Nation-wide as potential strategies to include within the roadmap. The
    National Strategy will continue to be the beacon for public health
    strategies across the Nation for Veteran suicide prevention.
                                     ______

      Response to Posthearing Questions Submitted by Hon. Thom Tillis to
                      U.S. Department of Veterans Affairs
        Question 1. Does VA have a position on S. 1563, the Janey Ensminger
    Act of 2019? Does VA oppose any specific provisions of the Janey
    Ensminger Act? If so, which provisions does VA oppose and why?
        Response. VA is now preparing full views on the Janey Ensminger Act
    of 2019, which will be provided to the Committee separately.

        Question 2. If enacted, could VA fully implement the Janey
    Ensminger Act, as written? If not, could you please provide Technical
    Assistance that would enable VA to fully implement the Act?
        Response. VA's pending formal views on the bill will address
    potential implementation issues with the Janey Ensminger Act of 2019.
    VA will be glad to provide technical assistance to the Committee,
    although, as always is the case with such assistance, we cannot
    guarantee that satisfactory language can be found to mitigate specific
    concerns.

        Question 3. If VA and ATSDR found evidence supporting a causal link
    between Camp Lejeune toxic exposure in utero with birth defects (such
    as Congenital Heart Disease), would VA have the authority to furnish
    hospital care and medical services to said dependent, and would VA have
    the authority to reimburse for such hospital care or medical services
    provided to a family member?
        Response. Birth defects, including congenital heart disease, is not
    one of the 15 illnesses and conditions identified in 38 United States
    Code (U.S.C.) 1710(e)(1)(F). VA's authority to furnish health care to
    family members of Veterans who resided at Camp Lejeune, North Carolina
    during the specified time period is limited to hospital care and
    medical services ``for any of the illness or conditions described'' in
    section 1710(e)(1)(F). As such, VA could not, under its existing
    authority at 38 U.S.C. 1787, furnish hospital care and medical services
    to a dependent for birth defects such as congenital heart disease even
    if VA and the Agency for Toxic Substance and Disease Registry found
    evidence supporting a causal link between such birth defects and Camp
    Lejeune toxic exposure in utero. Accordingly, VA would not have the
    authority to provide payment or reimbursement for such hospital care or
    medical services provided to a family member for such a condition under
    the Camp Lejeune Family Member Program.

        Question 4. Would VA support the establishment of a registry of
    servicemembers exposed to contaminated water at Camp Lejeune, similar
    to the existing VA Airborne Hazards and Open Burn Pit Registry?
        Response. If the question is asking whether VA would support
    legislation establishing such a registry, VA would need to review
    specific statutory language before it could advise on whether it would
    support such a bill.

        Question 4a. Does VA currently have the authority to implement such
    a registry, or would it need additional statutory authority to do so?
        Response. VA has authority to initiate such a registry; however, it
    would require extensive coordination with other executive branch
    agencies and additional funding. We do not believe establishment of a
    new registry is necessary. The U.S. Marine Corps already maintains and
    regularly uses an extensive registry database of names and addresses
    for the purpose of notifying Veterans and family members who lived at
    Camp Lejeune during the period of concern.
        We also should note that for the sake of future research, there are
    significant inherent limitations in the use of registries to draw
    inferences regarding the presence or strength of an association between
    an exposure and a health outcome. Recall bias, self-reporting bias, and
    self-selection bias all severely hinder the use of registry data in
    research of this kind. Camp Lejeune Veterans and family members are
    best served in this regard by well-designed, state-of-the-art
    epidemiologic studies.
                                     ______

      Response to Posthearing Questions Submitted by Hon. Patty Murray to
                      U.S. Department of Veterans Affairs
        Question 1. Please provide and explain VA's cost estimate for
    S. 318, the VA Newborn Emergency Treatment Act, including:

        Question 1a. What is the average cost of medically necessary
    transportation by mode and projected number of cases that were used to
    calculate the estimates?
        Response. In Fiscal Year (FY) 2020, VA estimates that approximately
    3,523 Veterans/newborns will access ground ambulance transportation for
    either delivery and subsequent care of the newborn or for treatment of
    a newborn or Veteran that cannot be provided by the initial treating
    facility. VA calculated an average specialty care ground ambulance rate
    of $1,068.35 per one-way transport based on data in the Ambulance Fee
    Schedule (AFS) Public Use Files of the Centers for Medicare & Medicaid
    Services (CMS).
        Additionally, it is estimated that approximately 293 Veterans/
    newborns will require air ambulance transportation either delivery and
    subsequent care of the newborn or for treatment of a newborn or Veteran
    that cannot be provided by the initial treating facility. VA calculated
    an average air ambulance rate (averaged across both fixed wing and
    rotary wing air ambulances) of $2,684.04 per one-way transport based on
    CMS data.
        An annual inflation rate of 3.9 percent for the cost of air and
    ground ambulance costs were applied to estimate the FY 2021 through FY
    2029 costs.

        Question 1b. How many cases of newborns needing care beyond seven
    days does this estimate project would be covered under this bill?
        Response. We estimate that there will be 647 newborn deliveries
    needing care beyond 7 days in FY 2020, increasing to 672 in FY 2021,
    and then slowly declining to 559 in FY 2029 as the female Veteran
    population ages.

        Question 1c. What is the average cost of care for newborns that
    would be covered under this bill, average cost of care beyond seven
    days, and average length of stay for newborns in these situations?
        Response. The estimated average cost of care for each newborn
    staying more than 7 days is $114,000 in FY 2020. Of this amount,
    approximately $25,000 per newborn is already covered through the
    current newborn benefit, leaving an additional cost of approximately
    $89,000 per newborn. The average length of stay for those admits over 7
    days is 29 days.

        Question 1d. What other factors or data were taken into account to
    calculate this estimate?
        Response. This estimate considers projected changes in the number
    and age distribution of female VHA enrollees to determine expected
    births. We then use VA data on newborn care together with publicly
    available data on newborn lengths of stay to estimate the number of
    newborns requiring a length of stay greater than 7 days and the
    associated number of additional bed days of care; this estimate
    accounts for a higher expected morbidity risk associated with the
    Veteran enrollee population. For ground and air ambulance
    transportation, costs are based on the applicable CMS average specialty
    ambulance rates.

                                A P P E N D I X

                                  ----------

                   Prepared Statement of Hon. Richard Burr,
                        U.S. Senator from North Carolina
        Chairman Isakson, Ranking Member Tester, members of the Senate
    Committee on Veterans Affairs, Thank you for the opportunity to submit
    testimony regarding S. 980, the Homeless Veterans Prevention Act and
    S. 1563, the Janey Ensminger Act.
        The Homeless Veterans Prevention Act is dedicated to reducing the
    root causes of homelessness in the veteran population. In 2017, the
    Department of Housing and Urban Development (HUD) released data that
    revealed roughly 40,000 veterans were living on the street,
    representing a 57% decline since 2010. VA reports indicate almost half
    a million veterans and their families have been permanently housed,
    rehoused, or prevented from homelessness from 2010 to 2017. This is an
    encouraging trend, but effectively ending the problem must be about
    facilitating greater self-determination, not just residential
    stability.
        As a Senator for North Carolina, I'm proud of the tremendous
    leadership and generosity that communities in my state have shown to
    address the homeless veteran issue. With one of the largest veteran
    populations in America, North Carolina has a lower rate of homelessness
    than the national average, and serves as a model for the reforms S. 980
    would direct the Veterans Administration to implement. The North
    Carolina Bar Association has helped provide attorneys that volunteer
    their time at the Salisbury VA Medical Center and the Fayetteville Vet
    Center, where they cover a variety of civil legal areas. Perhaps not
    coincidentally, Forsyth and Cumberland counties, which house the
    Fayetteville and Salisbury VA markets, boast an effective rate of zero
    homeless veterans.\1\
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        \1\ https://www.usich.gov/solutions/collaborative-leadership/
    mayors-challenge
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        Moreover, law schools at North Carolina Central University, the
    University of North Carolina at Chapel Hill, and Wake Forest
    University, all have veteran-specific legal clinics that focus on
    military record correction and discharge upgrades. Recently, a North
    Carolina Vietnam veteran came to one of these clinics with an Other
    Than Honorable (OTH) discharge for misconduct related to PTSD. Until he
    sought these legal services that assisted him with a discharge upgrade,
    he was unable to receive mental healthcare and benefits he needed.
    S. 980 includes a provision that would authorize VA to engage in
    public-private partnerships on a continuing basis with entities to
    provide vital legal services such as these to homeless veterans.
        Time and again, my staff and I hear from veterans who have been
    unable to fully participate in existing programs because their children
    were not allowed to live in the transitional housing or in-patient
    domiciliary care. S. 980 addresses this shortcoming, increasing the
    availability of housing for homeless veterans with dependents.
        S. 980 repeals the sunset on the authority of the VA and the
    Department of Labor to carry out referral and counseling services for
    veterans transitioning from certain institutions, including penal
    institutions. North Carolina has had great success with the system of
    Veteran's Treatment Courts in the State. Since receiving a Federal
    grant in 2016, Harnett County's Veteran's Court sees veterans from as
    far away as 70 miles. Forty-four veterans made their way through the
    program last year, and although the judges who sentence some of these
    veterans cannot reduce a minimum sentence, many of the veterans stay in
    the program to help resolve their issues long-term. Incarcerated
    veterans certainly represent a group that have been more prone to legal
    issues, and could use help to get their life back on track after they
    serve their sentence. Finally, the bill directs the Comptroller General
    to assess and measure the capacity of programs for entities that
    receive grants or per-diem payments to assist homeless veterans, and
    use that information to ensure those programs are serving the needs of
    these veterans effectively.
        The Homeless Veterans Prevention Act is a bi-partisan bill, and I
    am pleased that the American Legion, VFW, and several legal service
    providers and organizations like the American Bar Association have
    offered their support. Surely everyone can agree--the downward trend in
    homelessness among our Nation's veterans population has been
    remarkable. But we can, and should, do more. S. 980 would address four
    of the top ten unmet needs among our homeless veteran population, and I
    urge Committee members to support its passage.
        S. 1563, the Janey Ensminger Act of 2019, is another common-sense,
    bipartisan bill included in today's hearing. As a result of the Camp
    Lejeune Families Act of 2012, the Department of Veterans Affairs
    extends health care to veterans and reimburses medical expenses for
    qualified family members who have diseases and conditions that resulted
    from exposure to contaminated well-water at Camp Lejeune. If enacted,
    the Janey Ensminger Act would require the Agency for Toxic Substances
    and Disease Registry (ATSDR) Administrator to more frequently review
    scientific literature related to exposure of contaminated well-water at
    Camp Lejeune and specific illnesses or conditions incurred by
    individuals who served or lived there for not fewer than 30 days
    between 1953 and 1987. Furthermore, the Administrator would be required
    to categorize the level of evidence for these conditions, and publish
    the information on the Health and Human Services' (HHS) website.
        The transparency that would result from the passage of the Janey
    Ensminger Act is critical because, despite ATSDR determining that a
    number of cancers and other health conditions were caused by the Camp
    Lejeune water contamination, the Veterans Administration continues to
    challenge these findings. This bill will remove the Veterans
    Administration's ability to deny, delay, or dispute the health care
    benefits owed veterans and their family members who are sick because of
    exposure to a toxic substance at Camp Lejeune. Care for veterans and
    their families should not be further delayed by the VA's failure to
    accept ATSDR's findings.

        Thank you again to the Chairman and Ranking Member for the
    opportunity to submit written testimony, and I appreciate this
    Committee's consideration of S. 980 and S. 1563. These proposals ensure
    we keep our promise to support the brave men and women who have
    volunteered to protect and served this great Nation. Thank you.
                                     ______

                    Prepared Statement of Hon. Marco Rubio,
                           U.S. Senator from Florida
        Chairman Isakson and Ranking Member Tester, thank you for
    scheduling today's hearing, which includes the Better Examiner
    Standards and Transparency for Veterans (BEST for Vets) Act. I am proud
    to have worked with Senator Sinema on this bipartisan legislation, and
    I appreciate your consideration today.
        To determine a veteran's eligibility for disability compensation,
    the Veterans Benefits Administration (VBA) often relies on information
    gathered as part of a medical disability examination (MDE). The VBA has
    increasingly relied on contractors to conduct a large portion of these
    MDEs in an effort to avoid delays in the disability claim process.
        Last year, media reports revealed that contract physicians with
    revoked medical licenses have been performing MDEs on behalf of the
    Department of Veterans Affairs (VA). For example, in my home state of
    Florida, a physician was conducting MDEs on behalf of the VA despite
    the fact that her medical license had been revoked in two other states
    and was on probation in another due to a Federal tax fraud conviction.
    A loophole in current law is allowing this to happen. This is
    unacceptable, and legislation is needed. The BEST for Vets Act would
    address this issue by ensuring only licensed health care providers are
    conducting medical disability examinations on behalf of the VA.
        Health care providers who have had their medical licenses revoked
    have no business conducting MDEs that determine the benefits that our
    Nation's heroes receive. Our veterans not only deserve the highest
    quality care, but they have earned it.
        I would like to thank the Veteran Service Organizations supporting
    this legislation, including Paralyzed Veterans of America, Veterans of
    Foreign Wars, and Disabled American Veterans.
        I appreciate the Committee's consideration of the BEST for Vets Act
    and look forward to working together to pass this important, bipartisan
    bill.
                                     ______

                    Letter from the American Bar Association

                  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

    Prepared Statement of American Federation of Government Employees, AFL-
                                      CIO

                  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

       Prepared Statement of Joseph Chenelly, Executive Director, AMVETS
        Chairman Isakson, Ranking Member Tester, and members of the Senate
    Committee on Veterans Affairs, I appreciate the opportunity to present
    you with our views on proposed legislation in the Senate.
        As the largest veteran nonprofit to represent all of our Nation's
    veterans, we are dedicated to pursuing those issues that are most
    negatively affecting our veterans or that stand to provide the greatest
    positive benefit to them. As such, the three most pressing issues
    AMVETS is working to address this Congress are: addressing the mental
    healthcare crisis and suicide epidemic, addressing the critical needs
    of women veterans, and providing timely access to high-quality
    healthcare. We are pleased that the Committee is taking time today to
    discuss legislation that will affect all three of those categories and
    we are proud to put our support behind a number of those bills.
                     prioritize the mental health epidemic
        There are two pieces of legislation referring to the mental health
    epidemic that we will address today. One of these bills is a common
    sense change that would amend Title 38 to allow the VA to furnish
    mental health services to members of the reserve components of the
    Armed Forces. The other bill is a comprehensive piece that would
    improve care during transition, provide suicide prevention resources,
    launch programs and studies on mental health, increase oversight of
    VA's mental health care and suicide prevention efforts, enhance VA's
    medical workforce and telehealth services, and many other components
    that we know all factor into providing our veterans with the mental
    health services they need.
        AMVETS is pleased to support S. 711--CARE for Reservists Act of
    2019. S. 711 allows the Department of Defense to fund needed behavioral
    or mental healthcare, regardless of whether that reservist is within
    his or her pre-deployment window or has never deployed at all. This
    bill also allows members of the Guard and Reserve to access Vet Centers
    for mental health screening and counseling, employment assessments,
    education training and other services to help them return to civilian
    life.
        AMVETS specifically supports Section 5 of this bill which requires
    the Secretary of Veterans Affairs to report back to the Committee on
    the increase of the number of individuals that use readjustment
    counseling or outpatient mental health care from the Department of
    Veterans Affairs. We believe it is crucial that the VA collects and
    shares data on their mental health practices. We urge the Committee to
    take this report even a step further by requiring VA not only to report
    on the number veterans using their care, but to report on how effective
    this care was for them. Congress could gauge this effectiveness by
    requiring VA to track symptom reduction, quality of life/stress
    management, and posttraumatic growth and cognitive flexibility by using
    the instruments: DASS-21 (Depression Anxiety Stress Scale), The
    Insomnia Severity Index (ISI), The Brief Michigan Alcoholism Screening
    Test (bMAST), The Positive and Negative Affect Schedule (PANAS),
    Couples Satisfaction Index (CSI), Perceived Stress Reactivity Scale
    (PSRS), The Ego Resiliency Scale (ER89), The Posttraumatic Growth
    Inventory-Expanded (PTGI-X), The Integration of Stressful Life
    Experiences Scale (ISLES), The Self Compassion Scale-SF (SCS-SF), and
    The Gratitude Questionnaire-Six Item (GQ-6). Further, the effectiveness
    of treatments utilized by VA should be measured over significant
    periods of time, perhaps every 6 months for two years, not only for
    short durations following their treatments. Most evidence based
    practices limit their scope of study to the effectiveness of treatments
    within 90 day windows and we simply don't believe this is an accurate
    portrayal of the real effectiveness of these treatments.
        AMVETS is pleased to support S. 785, The Commander John Scott
    Hannon VA Mental Health Improvement Act, which addresses all three of
    AMVETS legislative priorities. This Congress, our organization is
    dedicated to finding legislative solutions for the mental health and
    suicide epidemic, women veterans, and veteran health care access. The
    Commander John Scott Hannon VA Mental Health Improvement Act is a
    positive start to Congress' and VA's duty to address these challenges.
    The Commander John Scott Hannon VA Mental Health Improvement Act seeks
    to improve VA mental health care by improving care during transition,
    providing suicide prevention resources, launching programs and studies
    on mental health, increasing oversight of VA's mental health care and
    suicide prevention efforts, and enhancing VA's medical workforce and
    telehealth services.
        However, there is a great deal of room for improvement, and we are
    concerned that the legislation offers particular emphasis on increased
    ``access'' to traditional mental health models, while offering few
    meaningful changes to explore alternatives that are having better
    outcomes. We have been chasing the ``access fallacy'' for over a
    decade, while Congress has failed to articulate why most veterans will
    never select VA mental healthcare in the first place, and those that do
    quickly stop utilizing the treatment, or why those that do largely
    retain their diagnoses, or in worse case scenarios utilize VA
    healthcare and still commit suicide, as was the case with John Scott
    Hannon. Little is known about the true proportion of veterans who have
    received VA services only to later commit suicide. VA has been
    highlighting a questionable figure of ``only'' 6 of 20 veterans who
    commit suicide were actively utilizing the VA in the past two years.
        AMVETS is particularly supportive of Section 203 regarding Post-
    traumatic Growth (PTG) Partnerships. PTG is defined as a positive
    change after experiencing trauma, including an increased appreciation
    for life, improved relationships with others, a realization of new
    possibilities in life, increased personal strength, and spiritual
    change. We have been compelled by the limited but significant approach
    of groups like Boulder Crest that are looking at how their programs
    affect veterans over as many as 18 months, not within a limited scope
    of 90 days. They have focused on helping veterans live their best lives
    versus the existing focus on symptomology reduction and endless
    research, which surprisingly is scant in its abilities to show
    increases in the quality of veterans life over time. We have faith that
    programs like this will help our veterans, while the Clay Hunt report
    gives us little reason to believe that our traditional approach is
    providing any meaningful outcomes as the data therein and the continued
    suicides state that it does not.
        AMVETS is pleased that this bill recognizes the need for gender-
    specific treatment, includes funding for telehealth services that will
    reach rural veterans, expands health care options to other than
    honorable veterans, and requires VA to develop and track their goals
    and objectives regarding suicide prevention.
        However, while this is a strong start to the issues plaguing VA
    mental health care, AMVETS will not be satisfied with legislative
    action that simply calls for more reports on the same methodologies to
    be provided back to the Committee 4 years from now as was done with the
    ``2018 Annual Report: VA Mental Health Program and Suicide Prevention
    Services Independent Evaluation'' required by the Clay Hunt SAV Act. In
    the interim of that 4 year period, more than 24,000 veterans lost their
    lives, while suicide at DOD has grown to record highs only to see
    little effort given by Congress to explore the effectiveness of
    existing practices at VA. Veterans can no longer tolerate Congress and
    VA relying on the fallacy of sunk costs when it comes to finding
    effective mental health treatments for our Nation's veterans.
           closing the gap for our women veterans and servicemembers
        AMVETS thanks the Committee for recognizing the unique challenges
    women face during their service and after. Women are the fastest
    growing group of veterans, and we must find a way to give VA facilities
    the ability to provide equitable care or services to women veterans.
    There are two pieces of legislation to be discussed today that we
    believe will positively support our women veterans.
        AMVEST supports S. 318--VA Newborn Emergency Treatment Act. This
    bill clarifies that the VA can cover the costs of transportation for
    newborn babies of certain women veterans. The Act ensures that
    qualified newborns do get access to VA covered medical care and,
    importantly, waives any outstanding debt women veterans may face with
    medically-necessary emergency transportation services for a newborn
    incurred by the veteran.
        AMVETS is pleased to see Section 506 included in the bill. Section
    506 requires the VA to submit a report to Congress on the staffing of
    VA relating to the treatment of women. This Section of the bill will
    importantly require the VA to report on the number of women's health
    centers, the number of patient aligned care teams of the Department
    relating to women's health, the number of full- and part-time
    gynecologists of the Department, the number of designated women's
    health care providers of the Department, the number of health care
    providers of the Department who have completed a mini-residency for
    women's health care through Women Veterans Health Care Mini-Residency
    Program of the Department during the one-year period preceding the
    submittal of the report, and the number that plan to participate in
    such a mini-residency during the one-year period following such date,
    and the number of designated women's health care providers of the
    Department who have sufficient female patients to retain their
    competencies and proficiencies.
        AMVETS supports S. 514--The Deborah Sampson Act. S. 514 was
    introduced to eliminate barriers to care and services that many women
    veterans face and would help ensure the VA can address the needs of
    women veterans who are more likely to face homelessness, unemployment,
    and go without needed health care. The Act expands group counseling for
    veterans and their family members and call centers for women veterans;
    increases the number of days of maternity care VA facilities can
    provide; increases the number of gender-specific providers in VA
    facilities, training clinicians, and retrofitting VA facilities to
    enhance privacy and improve the environment of care for women veterans;
    authorizes additional grants for organizations supporting low-income
    women veterans and increases resources for homeless women and their
    families; and improves the collection and analysis of data regarding
    women veterans, expands outreach by centralizing all information for
    women veterans in one easily accessible place on the VA website, and
    requires the VA to report on the availability of prosthetics made for
    women veterans.
        This year AMVETS has urged DOD and VA to enhance their programs to
    ensure that women veterans receive high-quality, comprehensive primary
    and mental healthcare services in a safe and sensitive environment at
    every VA health-care facility. S. 514 pushes this priority forward and
    that is why we support the passage and full implementation of this
    bill.
                   timely high-quality access to health care
        The VA has pledged to serve our veterans' health care needs, but
    the means to accessing this care is different for every veteran. We are
    pleased to now discuss with you our views on the proposed bills in
    today's hearing that will affect veteran's health care.
        AMVETS supports S. 123--Ensuring Quality Care for Our Veterans Act.
    S. 123 requires the VA to enter into a contract with an organization to
    conduct a clinical review for quality management of hospital care or
    medical services furnished by covered providers. If this review comes
    to show that the standard of care was not met during an episode of
    care, the VA will notify the individual who received such care from the
    provider.
        AMVETS supports S. 221--Department of Veterans Affairs Provider
    Accountability Act. S. 221 requires that whenever the VA brings charges
    based on conduct or performance against a 7401 (1) employee and as a
    result of those charges a major adverse action is taken against the
    employee, the VA will transmit to the National Practitioner Data Bank
    and the applicable State licensing board the name of the employee, a
    description of the major adverse action, and a description of the
    reason for the major adverse action.
        AMVETS supports S. 450--Veterans Improved Access and Care Act of
    2019. At the end of last year, the VA had 49,000 vacancies. We know a
    veteran's access to care will be affected when there is no medical
    professional working in the specialty of care they need. AMVETS
    realizes that the best healthcare option for veterans will provide a
    strong, well run, and fully staffed VA first. AMVETS will support any
    legislation that provides a solution to VA's high rate of vacancies, a
    simply unacceptable situation.
        S. 450 requires the VA to carry out a pilot program to expedite the
    onboarding process for new medical providers. The goal of the program
    is to reduce the length of time onboarding to no more than 60 days. The
    VA shall also submit a strategy to Congress on ways to reduce the
    duration of the hiring process for licensed professional medical
    providers.
        AMVETS supports S. 850--Highly Rural Veteran Transportation Program
    Extension Act. There are an estimated 4.7 million rural and highly
    rural veterans who face a unique combination of factors that create
    disparities in health care not found in urban areas, such as inadequate
    access to care. Rural residents only account for 17 percent of the
    entire U.S. population, yet more than 44 percent of recruits come from
    rural areas and more than 460,000 are veterans of Iraq and Afghanistan.
        S. 850 extends the authorization of appropriations to the VA for
    the purposes of awarding grants to VSO's for the transportation of
    highly rural veterans. AMVETS recognizes in the strongest terms the
    need for appropriate levels of funding to care for the physical and
    mental health care of rural and highly rural veterans. We know
    transportation is critical to veterans who need to access this care. We
    will continue to advocate for rural veterans and support legislation
    that addresses the gaps in care for rural and highly rural veterans.
        AMVETS supports S. 1101--Better Examiner Standards and Transparency
    for Veterans Act of 2019. We are pleased that this legislation was
    introduced after reports surfaced that physicians with revoked medical
    licenses were conducting MDEs for the VA because of a loophole in
    current law. We also urge the House Committee on Veterans Affairs to
    introduce a companion bill in their chamber to fix this loophole.
        S. 1101 ensures that only licensed health care providers furnish
    disability examinations under a certain VA pilot program for the use of
    contract physicians for disability examinations.
        AMVETS supports S. 1154--Department of Veterans Affairs Electronic
    Health Record Advisory Committee Act. The VA is currently undertaking a
    decade-long transition to bring veterans' health records into the 21st
    century by ensuring that veterans can have access to a seamless
    electronic health record across the VA and Department of Defense health
    systems.
        S. 1154 establishes an advisory committee on the implementation of
    the VA's electronic health record. The 11-member Committee would
    operate separately from the Departments of Veterans Affairs and Defense
    and would be made up of medical professionals, Information Technology
    and interoperability specialists, and veterans currently receiving care
    from the VA. The Committee will analyze the VA's strategy for
    implementation, develop a risk management plan, tour VA facilities as
    they transition to the new system and ensure veterans, VA employees and
    medical staff, and other participants have a voice in the process. The
    Committee will meet with the VA Secretary at least twice a year on
    their analysis and recommendations for implementation.
        AMVETS supports The Janey Ensminger Act of 2019. This act was named
    for Janey Ensminger, daughter of Marine Corps member Jerry Ensminger,
    who died from leukemia when she was just nine years old. Years later,
    her father discovered that she likely developed cancer after exposure
    to contaminated water at Camp Lejeune in North Carolina, where his
    family lived when Janey was born. As many as 900,000 may have been
    exposed to toxic contaminants in the water at the base between 1953 and
    1987. The Janey Ensminger Act makes it possible for non-military family
    members to apply for VA benefits for healthcare related to exposure to
    these toxins. This bill amends the Public Health Service Act to direct
    the Agency for Toxic Substances and Disease Registry to review the
    scientific literature relevant to the relationship between the
    employment or residence of individuals at Camp Lejeune, North Carolina,
    for at least 30 days during the period 1953 to 1987, and specific
    illnesses or conditions incurred by those individuals and determine
    whether and to what extent the evidence shows that toxic substance
    exposure is a cause of an illness or condition; and publish and update
    a list of each illness and the categorization of evidence for which a
    determination of cause has been made.
        AMVETS aggressively urges Congress and the Department of Veterans
    Affairs to invest adequate resources to fully research, diagnose, and
    treat conditions associated with toxic exposures. Any significant
    developments stemming from the previously mentioned activities should
    be shared with veterans as it becomes available. AMVETS encourages the
    VA to extend presumptive service-connection to all veterans suffering
    from conditions associated with toxic exposures while serving in the
    military.
        There are several bills that were considered at this hearing that
    did not fall under the scope of our three main priorities. Although
    they are not our top priority, we believe S. 857, S. 980, S. 524,
    S. 746, S. 805, and Mr. Cassidy's draft bill on education assistance
    cover important topics and we offer no objection to them.
                                   conclusion
        Chairman Isakson, Ranking Member Tester, and Members of the
    Committees, I would like to thank you once again for the opportunity to
    present the issues that impact AMVETS' membership, active duty
    servicemembers, as well as all American veterans. As the VA continues
    to evolve in a manner that can improve access to benefits and
    healthcare, it will be imperative to remember the impact that any
    changes to those systems have on millions of individuals who defended
    our country. We cannot stress enough the need to preserve and
    strengthen the VA as a whole, across all administrations, in order to
    ensure the agency can deliver on President Lincoln's sacred promise now
    and in the future.
                                     ______

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

     S. 318 To authorize the Secretary of Veterans Affairs to
                furnish medically necessary transportation for newborn
                children of certain women veterans.''
     S. 514 To amend title 38, United States Code, to improve the
                benefits and services provided by the Department of
                Veterans Affairs to women veterans, and for other purposes.
     S. 524 To establish the Department of Veterans Affairs
                Advisory Committee on Tribal and Indian Affairs and for
                other purposes.
     S. 711 To amend title 38, United States Code, to expand
                eligibility for mental health services from the Department
                of Veterans Affairs to include members of the reserve
                components for the Armed Forces, and for other purposes.
     S. 785 Commander John Scott Hannon Veterans Mental Health Care
                Improvement Act of 2019
     S. 805 Veterans Debt Fairness Act of 2019
     S. 850 Highly Rural Veteran Transportation Program Extension
                Act
     S. 857 A bill to amend title 38, United States Code, to
                increase the amount of special pension for Medal of Honor
                recipients, and for other purposes.
     S. 980 Homeless Veterans Prevention Act of 2019
     A bill to amend title 38, United States Code, to extend the
                authority of the Secretary of Veterans Affairs to continue
                to pay educational assistance or subsistence allowances to
                eligible persons when educational institutions are
                temporarily closed, and for other purposes.

        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee: Thank you for the opportunity to provide testimony today on
    several pieces of proposed legislation that offer the potential to have
    a tremendous impact on our Nation's veterans. I am Tim McClain and have
    had the honor of serving our country on active duty for more than 20
    years as a Navy Surface Warfare Officer and JAG Corps Officer, and the
    privilege of serving as a former General Counsel for the U.S.
    Department of Veterans Affairs (VA).
        I am currently the Chairman of the Board of Directors of America's
    Warrior Partnership, a nonprofit organization serving veterans and
    their families. Our mission at America's Warrior Partnership is to
    empower communities to empower veterans. Our approach to the mission
    takes many forms, but it starts with connecting community organizations
    with local veterans to understand their unique needs and situations.
    After gaining this knowledge, we connect local veteran-serving
    organizations with the appropriate resources, services, and partners
    that the veteran requires. Our ultimate goal is to create a better
    quality of life for all veterans.
        Our Community Integration model provides the framework for
    organizations to conduct proactive outreach to veterans and
    holistically serve all of their needs. We have seen incredible results
    from this model, which has established relationships with more than
    48,000 veterans since February 2014 in our eight Affiliate Communities
    across the country. Proactive outreach is having a tremendous impact on
    these veterans. More than 90% of our veterans self-report that
    America's Warrior Partnership's proactive engagement and support give
    them a greater level of overall satisfaction, and they believe their
    community cares about their well-being. America's Warrior Partnership's
    Community Integration model works.
        Providing testimony with me today is the president and CEO of
    America's Warrior Partnership, Mr. Jim Lorraine, who is also a veteran
    of our great country having served for 22 years as an Air Force Officer
    and Flight Nurse. Before founding America's Warrior Partnership, Mr.
    Lorraine served as the founding director of the United States Special
    Operations Command Care Coalition, a wounded warrior advocacy
    organization recognized as the gold standard in supporting more than
    4,000 special operations force wounded, ill, or injured and their
    families. He has also served as Special Assistant for Warrior and
    Family Support to the Chairman, Joint Chiefs of Staff, during which
    time he transformed the Chairman's ``Sea of Goodwill'' concept into a
    strategy. Mr. Lorraine will provide America's Warrior Partnership's
    testimony regarding four pieces of proposed legislation.
        Thank you, Mr. McClain. In my testimony today, I will address a
    number of the draft legislative proposals related to our work at
    America's Warrior Partnership. As an organization that has developed,
    operated, and replicated community-based veteran serving programs
    throughout the Nation we recognize the positive impact a community
    integration approach has on the hopefulness and improved quality of
    life for the veterans, their families, and their communities. To help
    frame our testimony related to the legislation you are considering I
    would like to share what we've learned from veterans across the
    country. Every month we measure the services being sought and
    successfully provided to over 48,000 veterans across the Nation
    additionally, through our annual survey of the same population we
    correlate the holistic services they are seeking with their level of
    hopefulness or hopelessness. We've learned that 49.7% of veterans
    surveyed are seeking greater opportunities for recreation or sports,
    45% are seeking networking with other veterans, and 35% are seeking
    volunteer opportunities. Additionally, access to Veterans Affairs
    benefits and better employment opportunities round out the top 5
    opportunities that veterans are seeking.
        When looking at the veteran's level of hope our research indicates
    that 56% of veterans are very hopeful or what we call ``thriving,''
    with 32% hopeful or what we call ``in transition,'' and 13% of veterans
    as hopeless or ``stuck.'' This 13% is consistent across our communities
    regarding the percentage of veterans who are seeking critical life
    services. In our research, we correlate the veterans level of hope with
    the services they are seeking. Those that are thriving are seeking
    networking with other veterans, better employment, and improved
    education. Those in transition are seeking short term financial
    assistance, legal support, and housing. While those veterans who are
    struggling are seeking access to transportation, short-term financial
    assistance, spiritual support and legal assistance. To summarize our
    research, those who have access to transportation are 22% more hopeful
    than those who do not. Those veterans with self-sustained housing are
    13% more hopeful than those who do not have stable housing. Those
    veterans with a Bachelor's Degree or higher are 10% more hopeful than
    those without a college degree. And those with access to healthcare
    (86.4% of veterans surveyed have health insurance) are 13% more hopeful
    than those without health insurance.
        I provide this information to the Committee to frame America's
    Warrior Partnership's support of legislation that builds stronger more
    collaborative communities around veteran employment as captured in
    S. 785 but would suggest we look beyond encouraging community-based
    collaboration around a single issue and rather focus on holistically
    improving veterans hope and quality of life. We strongly support
    legislation that builds on a plan to improve the quality of life for
    all veterans and their families through alternative care, recreational
    therapy, and engagement outside of the Veterans Affairs services.
        We feel that changing the eligibility criteria for Veterans Affairs
    care for Dishonorable and Other Than Honorable as written in S. 785,
    Section 104 would help those with this characterization of discharge,
    but should be re-thought due to the fact that millions of honorably
    discharged veterans who served without adverse impact are not eligible
    for Veteran's Affairs care and should be first for eligibility
    modification.
        While we agree with the services outlined in S. 785, Section 102
    for transition services we feel that without corporate and educational
    institutions acknowledging the skills acquired within the military the
    services that are outlined do not fully meet the transition needs of
    the veterans.
        Last, we completely support both the S. 857 A bill to amend title
    38, United States Code, to increase the amount of special pension for
    Medal of Honor recipients, and for other purposes and a bill to amend
    title 38, United States Code, to extend the authority of the Secretary
    of Veterans Affairs to continue to pay educational assistance or
    subsistence allowances to eligible persons when educational
    institutions are temporarily closed, and for other purposes. It is
    vital that we support those we recognize as providing the greatest
    sacrifice to our Nation. We also must recognize that those using their
    GI Bill must have the stability of income during the most trying
    periods of natural disaster or government shut-down that are beyond
    their control or ability to plan.
        I appreciate the opportunity to comment on these critical areas and
    will now let Mr. McClain conclude our testimony.
        Thank you, Mr. Lorraine. Chairman Isakson, thank you for inviting
    us to provide testimony today. We are both honored and pleased to have
    this opportunity. Our mission is the same as the mission of this
    Committee: to ensure that all veterans are taken care of and provided
    the benefits that they have rightfully earned through their service to
    our country. There is much work to be done, and we look forward to
    continuing collaborating with the Department of Veterans Affairs and
    our partners across the country to empower veterans from all walks of
    life as they transition to civilian life. Thank you again for the
    invitation to share our testimony today.
                                     ______

          Prepared Statement of Ken Falke, Chairman, Boulder Crest &
                             EOD Warrior Foundation
        May is Mental Health Awareness Month, an opportunity to raise
    awareness of the millions of veterans--and Americans--battling mental
    health challenges, and perhaps more importantly, to discuss what should
    be done to ensure these men and women can live great lives--filled with
    meaning, purpose, connection, and growth.
        When it comes to the subject of mental health and veterans, there
    is no doubt that much is done to raise awareness of their plight.
    However, far too little is done when it comes to talking about and
    taking action on the second part of the story--the journey from
    struggle to strength, pain to purpose, tragedy to triumph.
        As a 21-year US Navy service-disabled combat veteran, and the
    Chairman of the EOD Warrior Foundation and Boulder Crest, which owns
    and operates two privately-funded wellness centers--Boulder Crest
    Retreat Virginia and Boulder Crest Retreat Arizona--as well as the
    Boulder Crest Institute for Posttraumatic Growth, I have a unique
    perspective, from considerable personal and professional experience, on
    the struggles of veterans and their family members, and on their
    opportunities to grow in the aftermath of trauma.
        In March 1989, I was severely injured in a military parachuting
    operation. I broke my back in two places, dislocated my shoulder, and
    was knocked unconscious, suffering a severe concussion. I was told that
    my military career was over. In December of the same year, I was back
    to full active duty primarily thanks to my personal motivation and a
    private medical resource--a chiropractor. You see, the Navy assigned me
    an E-3 physical therapist and bottles of pain killers and Motrin 800
    mg. I am convinced that if I would have stuck to the Navy's regime, I
    would have been discharged. I went on to do a full 21-year career and
    ultimately retired as a Master Chief Petty Officer, the Navy' s senior
    enlisted rank.
        In 1989, Chiropractors were looked upon as ``witch doctors.'' This
    is not the case today. My hope is that we can transform the mental
    health community like we have physical therapy and pain management and
    further hope that it doesn't take 30 years!
        On that front, I am heartened by the language included in S. 785
    related to Posttraumatic Growth, and I am grateful for the opportunity
    to share some of what we are learning on our journey.
                         boulder crest retreat virginia
        In September 2013, we opened Boulder Crest Retreat Virginia--the
    Nation's first privately- funded wellness center dedicated exclusively
    to combat veterans and their families. Our vision was to create a
    place--and programs--where servicemembers and veterans could transform
    struggle into strength and growth and receive what they required to be
    as productive at home as they were on the battlefield. For our first
    nine months, we invited innovative nonprofits to use Boulder Crest
    Retreat Virginia, for free, as a platform to deliver their programs.
    These programs ran the gamut--from 1-15 days, clinical to non-clinical,
    focused on everything from Military Sexual Trauma (MST) and
    Posttraumatic Stress Disorder (PTSD) to relationship and familial
    challenges.
        It soon became clear to us that these programs would not be
    sufficient to allow us to achieve our ambitious vision. Every program
    we witnessed struggled with four key challenges:

        First, the programs were, by their very nature, catch-and-release.
    Participants would come for 1-15 days, experience the program, and
    receive a pat on the back and warm wishes that everything would be
    different now. How to cope with their ``new normal'. Rarely was that
    the case. Second, there was no curriculum related to these programs--no
    sense of what was being done, or how one could scale effective
    programs. Third, there was little to no evaluation being conducted into
    efficacy of these programs. While we know that, in the words of Irwin
    Bernstein, ``the plural of anecdote is not data,'' far too often, these
    programs relied on anecdotes to demonstrate effectiveness. Last, those
    who provided care or delivered programs were often ``wounded healers,''
    people struggling with their own mental health issues and challenges,
    that significantly impaired their ability to connect with and guide
    others.
        In May 2014, leveraging all we had learned thus far, I began a
    journey to understand what actually worked when it came to mental
    health, PTSD, and suicide. I was committed to ensuring that my brothers
    and sisters could live great lives and thrive in the aftermath of
    trauma. I traveled around the country and met with leading
    psychiatrists, psychologists, social workers, life coaches, and trauma
    experts. Time and time again, when I asked them, ``What works to allow
    people to live great lives in the aftermath of trauma?''--I was told,
    ``Nothing.''
        In principle this is true because it is not what our mental health
    system--broadly speaking--is focused on accomplishing. The mental
    health system is nearly exclusively focused on one thing when it comes
    to its clients and patients--managing and mitigating the symptoms
    associated with times of struggle; often through a combination of
    medication and talk therapy. This approach is not working for far too
    many people--something made obvious by the highly distressing
    statistics around veteran's mental health, and also by the words of one
    of the world's most esteemed medical journals, the Journal of the
    American Medical Association (JAMA).
        In August 2015, JAMA called for a new and innovative approach to
    PTSD for veterans. In January 2017, JAMA Psychiatry declared that,
    ``These findings point to the ongoing crisis in PTSD care for
    servicemembers and veterans. Despite the large increase in availability
    of evidence-based treatments, considerable room exists for improvement
    in treatment efficacy, and satisfaction appears bleak based on low
    treatment retention . . . we have probably come about as far as we can
    with current dominant clinical approaches.''
        The first glimmer of hope I encountered on my journey would be
    found at the University of North Carolina, Charlotte, in the person of
    Dr. Richard Tedeschi. Dr. Tedeschi, along with his colleague, Dr.
    Lawrence Calhoun, coined the term Posttraumatic Growth (PTG) in 1995 to
    describe the ways in which people reported growth in areas of their
    life in the aftermath of traumatic events and experiences.
        I asked Dr. Tedeschi if he was interested in partnering with us to
    develop a training-based program for combat veterans that would, for
    the first-time ever, be designed to cultivate and facilitate
    Posttraumatic Growth in those who were struggling. Dr. Tedeschi agreed,
    and since 2014, we have been hard at work at the development and
    delivery of Warrior PATHH.
                             warrior pathh and ptg
        Warrior PATHH is an 18-month program that begins with a 7-day
    intensive and immersive residential initiation. The 7-day initiation is
    supported by Boulder Crest's custom-built myPATHH technology platform,
    which connects and supports students through the remaining 77 weeks--
    providing ongoing training, connection, and accountability.
        Warrior PATHH trains combat veterans through the proven framework
    of PTG: educating them about the value of struggle and what stress and
    trauma do to the mind, body, heart, and spirit; teaching proven non-
    pharmacological techniques designed to regulate thoughts and emotions;
    creating an environment of trust and safety to facilitate disclosure of
    past challenges from combat and pre-combat experiences, which is
    supported by a delivery team composed primarily of combat veterans;
    beginning to craft a new story that harnesses the lessons of the past
    and looks forward; and a renewed commitment to service--to one's
    family, community and country--here at home.
        In January 2016, after more than two years of research,
    development, piloting, and success, the Marcus Foundation funded the
    development of the first-ever curriculum effort designed to cultivate
    and facilitate Posttraumatic Growth. The curriculum effort included
    Student and Instructor Guides, a Journal, Syllabus, and Schedule; four
    pilot programs; and an 18-month longitudinal study.
        The 18-month study, led by Dr. Tedeschi and Dr. Bret Moore, was
    completed in January 2019, focused on exploring the impact of Warrior
    PATHH in three key areas: Symptom Reduction, Quality of Life
    improvement, and Posttraumatic Growth experienced. With responses at
    the pre, post, 1, 3, 6, 12, and 18-month marks and the use of 24 well-
    respected and bespoke measurement tools, this effort represents one of
    the most robust evaluations of a mental health effort ever initiated.
    The evaluation effort included 8 Warrior PATHH Programs (49 students)
    and a response rate of 95 percent. Key highlights include:
    Symptom Reduction:

         54% sustained reduction in PTSD symptoms
         52% sustained reduction in depression symptoms
         41% sustained reduction in anxiety symptoms
         39% sustained reduction in Insomnia
         44% sustained reduction in drug use
          24% sustained improvement in positive emotions
    experienced; and 25% sustained reduction in negative emotions
    experienced
    Quality of Life Improvement:
         14% sustained improvement in Couples Satisfaction
         33% sustained reduction in stress reactivity
         11% sustained improvement in physical activity
         26% sustained improvement in nutrition
         12% sustained improvement in financial wellness
    Posttraumatic Growth:
         56% sustained improvement in personal growth (PTG)
         78% growth in Spiritual-Existential Change
         69% growth in Deeper Relationships
         58% growth in New Possibilities
         36% growth in Personal Strength
         26% growth in Appreciation for Life
          32% sustained improvement in ability to change
    perspective/psychological flexibility
          23% sustained improvement in capacity to integrate
    problematic life experiences.
         22% sustained improvement in self-compassion
         40% sustained increase in reading
         9% sustained decrease in disruption to core beliefs

        In short, we developed a program that achieved the vision that we
    set forth--to ensure combat veterans could be as productive at home as
    they were on the battlefield, and live great lives--filled with
    passion, purpose, growth, connection, and service--at home. In response
    to this unparalleled success, we are now working with partners so that
    Warrior PATHH can be scaled to ten locations across the country.
                           solving the bigger problem
        Regarding PATHH as merely a program, however, is to miss the larger
    point. What we are learning along our journey about what did and didn't
    work transcended the normal divide between so-called clinical and non-
    clinical efforts. We had the opportunity to talk to and be guided by
    not just experts in the psychological and psychiatric community, but
    the very veterans we are seeking to help. What they told us speaks
    volumes about what would represent the new and effective approach that
    so many are calling for. They aren't interested in being pathologized
    or reduced to a diagnosis or set of symptoms. They aren't interested in
    accepting that times of struggle, despair, or trauma serve as limiting
    factors to a great life. They aren't interested in accepting their
    ``new normal,'' a life where they must grow accustomed to a diminished
    life, that is a fraction of what it once was. They aren't interested in
    being permanently medicated, and living a life filled with a constant
    sense of numbness and disconnection that inhibits joy, connection, and
    purpose.
        What veterans are interested in is learning how to maximize the
    value of their struggle, training, and experiences. What they insist
    upon is training, support, accountability, direction, and forward
    movement. What they deserve is the opportunity to grow and live great
    lives.
        The experts are saying we must have a new and innovative approach;
    and the veterans--voting with their feet--are too. We know that half of
    all veterans who might benefit from mental health will never go. That
    of those who do, between 50-80 percent will drop out of treatment
    before the protocol is finished. That of those who complete the
    protocol, only 40 percent will experience meaningful benefits--often
    just a minimal and short-lived reduction in symptoms.
        In a May 2017 editorial entitled ``Changing Mindsets to Enhance
    Treatment Effectiveness,'' JAMA noted that `` . . . growth mindsets are
    also proving critical in health care. While more research is needed,
    what is clear is that instilling a growth mindset in patients about
    their belief in the capacity to change is an important precursor to
    health and healing.'' The editorial also stated that, ``Effective
    communication and the patient physician relationship are central--not
    superfluous--aspects of medical care.''
        The work that Boulder Crest has done over the past six years in
    applying, cultivating, and facilitating PTG is at the heart of the new
    and innovative approach that is required. It speaks to a philosophical
    and systemic approach that looks beyond current struggles, and toward a
    future that is authentic, fulfilling, and purposeful. This attitudinal
    distinction, combined with robust program evaluation and decades of
    research into PTG, serves as the foundation for such an approach, and
    has the potential to not only deliver results in PATHH programs, but to
    substantially enhance the effectiveness of current approaches. In large
    part, this is due to the recognition and strong evidence base
    demonstrating that patient education can be as or even more effective
    than therapeutic treatment.
                         ptg and veterans mental health
        Something must change when it comes to mental health and veterans.
    For years now, we have done the same thing over and over again and
    expected a different result. As a bomb disposal technician, I cannot
    abide this. I come from a field where you don't get the chance to make
    a mistake twice; a career field with the motto, ``Initial Success or
    Total Failure.''
        We must work toward new and innovative approaches--leveraging the
    legions of well- meaning mental health professionals, organizations,
    and peers--to drive better outcomes, and instill a sense of hope,
    possibility, and agency in veterans who struggle. The focus of our
    efforts must be in line with what drove my wife and I to open Boulder
    Crest Retreat Virginia, nearly six years: to ensure that our Nation's
    veterans can live great lives. This means our focus must be far beyond
    preventing suicide or marginal improvements in outcomes; our focus must
    be on ensuring we are training struggling veterans to understand and
    experience Posttraumatic Growth in their own lives because the opposite
    of suicide isn't prevention, its creating a life worth living.
        To that end, Boulder Crest has partnered with the VA in an effort
    to train clinicians, peers, and front-line staff in the principles and
    practices related to PTG. But more must be done--and done quickly. As
    the leading organization focused on PTG in this country, and with a
    strong track record of success within the military and veterans
    community, we strongly support the language in S. 785, calling for the
    VA to enter into partnerships with nonprofit mental health
    organizations to facilitate Posttraumatic Growth among veterans. This
    language--and the possible impact--represents a strong start to
    exploring differential, and more growth-oriented approaches to times of
    struggle, and to the mental health crisis surrounding our Nation's
    veterans.
        S. 785 is also noteworthy for its call for greater collaboration
    between the Department of Defense and VA, another important gap in
    current approaches. The truth is that while the focus tends to be on VA
    when it comes to the subject of veterans, DOD plays a critical role,
    particularly when it comes to transition. While we believe that the
    transition language included in S. 785 would lead to meaningful
    improvements related to community support, we also think that it is too
    narrow to be transformative.
        The current transition approach is myopically focused on helping
    veterans get a job; a laudable and important next step, but not a
    panacea. If it were the answer--at a time of miniscule veteran's
    unemployment--we would see dramatic improvements in mental health
    statistics. But we are not.
        Transition is challenging for the vast majority of servicemembers--
    as demonstrated by VA data showing that the largest mental health
    challenge for transitioning servicemembers is not PTSD, it is
    depression. More notably, as Mobbs and Bonanno wrote in the Clinical
    Psychology Review:

              Recent population survey studies have suggested that 44% to
            72% of Veterans experience high levels of stress during the
            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 (Morin, 2011).
            Struggle with the transition is reported at higher, more
            difficult levels for post-9/11 veterans than those who served
            in any other previous conflict (i.e. Vietnam, Korea, World War
            II) or in the periods in between (Pew Research Center, 2011).
            Crucially, transition stress has been found to predict both
            treatment seeking and the later development of mental and
            physical health problems, including suicidal ideation
            (Interian, Kline, Janal, Glynn, & Losonczy, 2014; Kline et al.,
            2010).

        The military does a tremendous job when it comes to bringing people
    into the service in a relatively short period of time. The Marine Corps
    Museum boasts of how the Corps ``transforms ordinary civilians into
    Marines.'' When it comes time for the transition, we subject our
    transitioning servicemembers to a week of ``death by PowerPoint.''
        We have had countless instances of a veteran who has transitioned
    poorly, self-medicated in response, damaged relationships in the
    process, and found themselves in a mental health office. They are then
    mis-diagnosed with PTSD, medicated, turn to disability payments, and
    become unproductive, unfulfilled, unworthy, and suicidal. What was a
    temporary issue of adjustment became a permanent diagnosis. We can and
    must do better to prepare transitioning servicemembers not just for a
    post-military job; we must prepare them for a post- military life.
    Critical elements of our program, particularly focused on education,
    could be used to that end, and a clear-eyed look of how transition goes
    wrong is critical to understanding how veterans end up at the brink of
    suicide.
        In short, we cannot simply wait for veterans to get to the point of
    crisis or fail to acknowledge what the data and the veteran are telling
    us--whether you served for four years or forty, getting out is hard. We
    must do a better job of getting ``left of boom.''
                                   conclusion
        As a retired disabled combat veteran and a retired CEO, I know the
    power of military experience and the challenges associated with combat
    experiences and long deployments. I also know that I am the man I am
    because of the United States Navy. More than two thousand years ago,
    the Athenian general and philosopher Thucydides said it best: ``We must
    remember that one man is much the same as another, and that he is best
    who is trained in the severest school.''
        Rather than focusing on suicide prevention and more of the same in
    terms of mental health services, we should be focused on ensuring
    veterans can live great lives at home--lives filled with joy, passion,
    love, service, and purpose. We should ensure my fellow veterans can use
    the great military training they receive as a launching pad for a
    productive and purposeful life as a Warrior at home. We must ensure
    that, to paraphrase the words of a good friend and USMC General
    officer, their time in the service cannot be the greatest
    accomplishment of their lives. Doing so requires an integrated and
    collaborative approach, and we look forward to being a part of the
    solution and any questions that arise from this written testimony.
                                     ______

             Prepared Statement of The Blinded Veterans Association
                                  introduction
        Thank you, Chairman Isakson, Ranking Member Tester, and
    distinguished members of the Senate Committee On Veterans Affairs, for
    giving the Blinded Veterans Association this opportunity to comment on
    the legislation under consideration by this Committee. BVA is the only
    congressionally chartered Veterans Service Organization that is
    exclusively dedicated to serving the needs of blinded veterans and
    their families. On behalf of our members and their families, we are
    pleased to support several of the bills under consideration by this
    Committee. Congressional approval of two of these bills is of the
    highest priority to our membership. These include S. 850, The Highly
    Rural Veterans Transportation Program Extension Act, and S. 746, The
    Department of Veterans Affairs Website Accessibility Act. We will
    comment on these in detail in the following paragraphs. We will also
    outline our reasons for supporting the following bills: S. 318, the VA
    Newborn Emergency Treatment Act; S. 514, the Deborah Sampson Act;
    S. 711, the Care and Readiness Enhancement for Reservists Act; S. 785,
    the Commander John Scott Hannon Veterans Mental Health Care Improvement
    Act; S. 805, the Veteran Debt Fairness Act; S. 857, a bill to increase
    the amount of special pension for Medal of Honor Recipients; and
    S. 450; The Veterans Improved Access and Care Act. Our organization has
    not yet taken positions on the other bills that are under consideration
    at this hearing.
    I. S. 850, The Highly Rural Veteran Transportation Program Extension
            Act
        BVA is very pleased to support this legislation, because
    transportation is the most significant, and sometimes insurmountable,
    barrier that stands between our members and their healthcare. When
    veterans lose their eyesight, they also lose their ability to drive.
    When that happens, they do not automatically acquire the assistance of
    another person who will drive them to the places they need to go.
    Efforts to locate such assistance are especially problematic in rural
    areas, where public transit options are few or nonexistent, and
    alternative services are either excessively expensive or unavailable.
    We believe that it is absolutely imperative that Congress provide the
    Department of Veterans Affairs with both the incentive and the
    resources to address this barrier. This legislation will go a long way
    toward this goal by encouraging the development of additional
    transportation options for veterans, but the provision that we are
    particularly pleased to see is the permanent authorization of the
    Veterans Transportation Program. This is long overdue. The current
    situation makes participation in this program by VA medical centers too
    precarious and burdensome, and this fact has harmful consequences for
    the veterans they serve. Having said that, we would be even happier
    with this bill if it provided that once the program is permanently
    authorized, participation by VA medical centers is mandatory, at least
    in rural areas. For veterans with catastrophic disabilities that
    prevent them from driving, lack of transportation can force them to
    choose between health care and food, or to delay getting care, thus
    risking worsened medical conditions that would have been treatable if
    cared for earlier. It is not uncommon for veterans, faced with the
    prospect of paying $100 each way for a trip to their doctor's office,
    to decide to forego treatment because getting to it is too costly. This
    is an unnecessarily harsh situation to put some of our Nation's most
    vulnerable veterans in, and it is avoidable. Avoiding it can begin with
    passage of S. 850.
    II. S. 746, The Department of veterans Affairs Website Accessibility
            Act
        The VA currently faces myriad challenges on multiple fronts, and
    many issues compete for the attention of its leaders. Not the least of
    these concerns the capacity of VA's IT infrastructure to meet the
    demands resulting from ever-changing expectations regarding
    communications between Federal Government agencies and those who
    utilize their programs and services. Federal agencies are now expected
    to make ever-increasing amounts of information accessible through a
    rapidly growing number of media and devices, and VA has struggled to
    keep up with these demands. One area where VA has struggled the most is
    the area of compliance with accessibility guidelines for the design and
    dissemination of electronic information. We believe that this struggle
    will continue unless and until the issue of accessible communications
    becomes a priority of VA's senior leadership. We believe that by
    directing the VA Secretary to evaluate and report to Congress on the
    accessibility of VA's electronic communications, S. 746 will provide an
    impetus for VA's leadership to make the commitment that is needed to
    insure these issues will be addressed in a meaningful manner.
                           why accessibility matters
        Statistics indicate that our Nation's veteran population contains a
    growing number of individuals who have visual impairments. Studies
    conducted by the Veterans Health Administration in 2018 estimated that
    there were 131,580 legally blind veterans in the U.S. Just over 42,000
    of these veterans had cases open with a visual impairment services team
    coordinator at that time. Further, these numbers are expected to grow
    as the U.S. population, including its veterans, ages over the next 20
    years. Veterans who experience vision loss will want and need to access
    VA's websites, apps, kiosks, tele-health tools, claims process, and
    other benefits, programs, and services administered by the VA, both now
    and for the foreseeable future. Already, since many veterans are
    comfortable with today's myriad technologies, they want access to all
    of the communications options the VA offers to other veterans.
    Therefore, when concerns about the accessibility of websites,
    documents, and other equipment and media used to communicate with
    veterans are minimized or ignored, some of our Nation's most vulnerable
    veterans, those with catastrophic disabilities, are left behind.
    Furthermore, when these veterans are denied access to information and
    services, there is a risk that they will suffer serious consequences,
    such as further aggravation of their disabilities, and in some cases,
    suicide. The longer we wait, the greater this risk.
                              what is the problem?
        In the following paragraphs, we will discuss some of the most
    common, and most serious, accessibility barriers that both blind
    veterans, and VA employees who have visual impairments, face on a
    regular basis. Before doing so, we do need to acknowledge that BVA has
    appreciated the efforts of VA's Section 508 compliance Office to
    correct problems promptly, particularly as they relate to VA websites.
    Both the staff, and contractors who work with them, are responsive when
    we alert them to the existence of accessibility barriers. Additionally,
    thanks to the involvement of that office and its contractors, most of
    the applications VA makes available to veterans at this time are
    accessible to and usable by veterans who use adaptive software on their
    computers and smart devices. The problems veterans face in accessing
    VA's new websites have decreased in number as well, though
    unfortunately, website access continues to be a major challenge.
        VA's websites are generally the first point of contact veterans
    have with the Department. Therefore, the layout and content of those
    sites necessarily changes frequently. As a result, there are lots of
    occasions when things can go wrong. It is not uncommon for veterans to
    find that a web page that was easily accessed one day cannot be read or
    navigated during the next visit to the site. Some of the reasons this
    happens include:

         Tables that are not designed so they can be navigated cell
    by cell to allow users of screen-readers and magnification software to
    read them;
         Buttons that are too small, or hidden among other items,
    thus making them hard to locate;
         Elements (such as checkboxes and buttons) that are not
    properly labeled;
         Pop-Ups that cannot be dismissed and interfere with the
    user's ability to navigate the web page by redirecting the focus of a
    screen-reader;
         Forms that are not designed to allow a screen-reader or
    magnification program to be used while filling them out; and a problem
    specific to the va.gov website, Password requirements that exceed
    industry standards. This last item creates major challenges for those
    veterans (especially seniors and others with cognitive disabilities)
    who need to create and remember unnecessarily complex passwords.

        With regard to documents circulated by the VA, there has been some
    recent improvement, as VA now generally posts accessible Pdf documents
    on their public-facing websites. However, individuals, such as Veteran
    Service officers who assist veterans with claims, and VA employees, who
    need access to VA's internal documents, are not nearly so fortunate. VA
    still continues to utilize inaccessible PDF formats for much of its
    internal communications. This practice makes it very difficult for
    individuals who have disabilities that require them to use screen-
    readers to do their jobs and serve our veterans.
        In our testimony at the joint hearing held by the full House and
    Senate Committees on Veterans Affairs earlier this year, we highlighted
    another long-standing access issue related to a vital VA website used
    by Veteran Service Officers. The TRIP Training site is itself compliant
    with accessibility guidelines. However, it is off limits to anyone who
    uses adaptive software because it must be entered through a portal that
    does not follow those guidelines. There is, as of this writing, no
    indication that this situation will be corrected any time soon.
        In addition to website accessibility barriers, the kiosks VA has
    deployed at medical facilities nationwide present major access barriers
    for visually impaired veterans. These devices are supposed to be used
    by veterans to check in when they arrive for appointments, so they
    serve as the veteran's first introduction to the facility. A
    complicated or unsuccessful check-in process can impact the remainder
    of the veteran's experience. For a blind veteran, kiosks are, by their
    very nature, at best intimidating, and frequently unusable, due to
    their perfectly flat screens, and the absence of any tactile or audible
    features to give the potential user an idea of how to make them
    operate. Fortunately, such flat screens are becoming fairly common, and
    as they have been incorporated into other devices, such as ATM machines
    and voting machines at some polling places, industry has developed
    standards and best practices that make them accessible to people who
    have reading disabilities. To begin with, such kiosks generally have a
    3.5mm headphone jack located in a prominent place on the machine, and
    insertion of a headphone into this jack activates an audio feature,
    which speaks information into the user's ear about where to touch on
    the screen in order to make it function. Such instructions often begin
    with a brief orientation to the screen and a brief tutorial on what to
    expect while using the machine. Repeat users can skip such introductory
    material if desired, and all users can adjust things like speaking rate
    and volume. Further, instructions for performing various tasks are also
    read out loud to the person wearing the headset. The machines also
    provide audible feedback whenever the user attempts to perform those
    functions, to indicate whether or not the attempt was successful.
    Therefore, since kiosks can be quite usable, and they do serve a
    beneficial purpose for VA, we don't necessarily object to their
    deployment. What we object to is that the kiosks in use at VA medical
    centers do not comply with the industry standard accessibility
    guidelines described above.
        As recently as April, 2019, BVA received a complaint about the
    accessibility of the kiosk in the Washington D.C. VA Medical Center.
    First, plugging in a headset did not activate any audio features.
    Instead, the veteran who was attempting to use the machine stated that
    a sighted bystander told her that a notice had appeared on the screen
    which said, ``If you are blind, press this button.'' One wonders how a
    ``blind'' person is supposed to know this information was visible on
    the screen. Once the person who did see it had pressed the appropriate
    button, the instructions did begin and they were audible through the
    veteran's headset. However, the veteran continued to encounter
    problems, because unlike other similar devices, which require users to
    touch a particular area of the screen, such as the bottom right corner,
    the top left corner, or the center, in order to make selections or move
    through various functions, this kiosk required the user to locate and
    press particular buttons to perform each task. This required a degree
    of accuracy in locating and then pressing each button. Because this
    particular user had no vision, that degree of exactitude was not
    achievable. This is not an accessible kiosk. We should note that VA has
    recently rolled out new software for its kiosks which were supposed to
    improve their accessibility, and this veteran had hoped to have a much
    different experience as a result. Unfortunately, she was disappointed.
    BVA is also disappointed that VA's supposed accessibility improvements
    did not accomplish anything better than this. After four or five years
    of discussions with VA, about how to address these issues, and repeated
    assurances from VA that they would be addressed in the next software
    update, this veteran's report was extremely unsatisfactory. If VA is
    going to truly modernize its IT infrastructure, and expand its use of
    electronic communications to provide access to services, VA must pay
    greater attention to accessibility concerns beginning with the rollout
    phase of devices and software. Each time retrofits or replacements are
    required, there is also unnecessary expenditure of funds; funds that
    could be used to improve services to veterans. Incorporating
    accessibility in the first place is much more cost effective.
        Section 508 of the Rehabilitation Act requires Federal agencies to
    ensure that all electronic and information technologies developed,
    procured, maintained, or used in the Federal environment provide equal
    access for people with disabilities, whether they are Federal employees
    or members of the public. Section 508 implementing regulations,
    together with web accessibility guidelines (WCAG) compiled periodically
    over the years by the Worldwide Web Accessibility Consortium, have
    sought to make it clear to Federal agency personnel how to comply with
    these guidelines and regulations. Unfortunately, our experience
    indicates that while the VA has made significant progress toward
    compliance, the department is a long way from consistent compliance.
    BVA's national officers and staff meet regularly with staff of the
    Section 508 Compliance Office and they are generally responsive to the
    concerns we raise. They address the accessibility barriers we bring to
    their attention promptly. However, all too often, those same barriers,
    are erected again a few months later when websites are updated, or a
    new website is rolled out. The scenario that is most disturbing is when
    accessibility features are put in place, only to be broken the next
    time the site is updated. In fact, any time website administrators add
    tools, redesign features, or update content such alterations can render
    aspects of that site inaccessible, unless the industry standards for
    website accessibility are followed. The same can be said for software
    that is developed for use by VA. Best practices that insure
    accessibility are mature and widely accepted throughout the IT
    industry. VA must be encouraged to incorporate them into all aspects of
    its IT infrastructure sooner rather than later. BVA believes this can
    only be done effectively if the initiative comes from the Department's
    leadership. We urge Congress, therefore, to send a message, through
    passage of S. 746, and its companion bill in the House, that this is a
    priority deserving of leadership's attention.
        Before concluding our discussion of this bill, there is one final
    question we want to raise. What will Congress do with the report called
    for in this legislation? It is our hope that the members of both the
    Senate and House Veterans' Affairs Committees, will exercise greater
    oversight of VA's compliance with accessibility guidelines in the
    future. While the report called for in this legislation can highlight
    what needs to be done, it doesn't make its accomplishment a foregone
    conclusion. We urge Members of this Committee to hold VA accountable
    for addressing the barriers and implementing the plan set forth in any
    report Congress receives on the accessibility of VA's websites and
    other electronic communications to people with disabilities. To that
    end, we urge Members of this Committee to require additional reports
    from VA on their progress toward addressing the accessibility barriers
    that are identified in their initial report to Congress. We recommend
    that VA be required to provide this Committee with updates at least
    every 180 days until all of the issues have been addressed. Further, we
    recommend that the Committee on Veterans Affairs seek regular reports
    from VA on its efforts to incorporate accessibility features into new
    web content, and to insure that updates to existing content are made in
    a manner that allows the content to be accessed by all members of its
    intended audience, regardless of disability. We believe this is a
    necessary step, if Congress wishes to insure that VA plans for
    accessibility when new initiatives are launched, rather than adding
    accessibility features in only after receiving complaints from users.
    It would also give this legislation a greater impact on the
    effectiveness of future communications between VA and our Nation's
    disabled veterans. We urge you to consider amending this legislation to
    include such measures, thereby putting VA on notice that Congress is
    serious about insuring compliance with accessibility guidelines, not
    only for the present, but for the long term.
    III. S. 318, The Newborn Emergency Treatment act
        BVA supports this legislation because it addresses some serious
    needs faced by veterans at a time when they and their families are most
    financially and emotionally vulnerable; the birth of a new child. This
    legislation corrects some unfortunate shortcomings in the coverage VA
    can provide those newborn children under current law. We join with
    other veteran service organizations in urging Congress to approve these
    changes.
    IV. S. 518, The Deborah Sampson Act
        This legislation is long overdue. VA needs to address the practical
    needs of a growing number of women veterans who are enrolled in its
    health care system. We believe that failure to do so now will only
    exacerbate the needs and further alienate the women who have served
    this country. On behalf of the female veterans who have become members
    of our organization, and continue to serve both us and their country
    with distinction, we urge this Committee to approve this legislation.
    V. S. 711, The Care And Readiness Enhancement For Reservists Act
        This legislation provides essential services to reservists who face
    the same challenges and have the same needs for care during their
    transition to civilian life as other veterans do. It is particularly
    imperative that these veterans have access to as many options for
    mental health care as possible, in order to help them deal with the
    stresses associated with this time of transition.
    VI. S. 785, The John Scott Hannon Veterans Mental Health Care
            Improvement Act
        We support this legislation because it takes a comprehensive
    approach to addressing the mental health care needs of our Nation's
    veterans and servicemembers. It also encourages collaboration among all
    of the stakeholders involved in the fight to end suicide within this
    population. Piecemeal approaches that address one issue or fund one
    program at a time, have not worked. If we are to prevent further loss
    of life, we need to martial all available resources and begin thinking
    and acting outside the box. We believe this legislation will help make
    that happen.
    VII. S. 805 The Veteran Debt fairness Act
        The Department of veterans Affairs should never be allowed to make
    veterans pay for its mistakes. If a veteran, or a member of his family,
    knowingly collects benefits or receives services to which they are not
    entitled, it is reasonable for the VA to take steps to recoup its
    losses. However, when the veteran, or his or her beneficiary, is not at
    fault, it is unconscionable for the government of the United States to
    treat that individual as if they had deliberately defrauded the
    Department and seek to remedy their error by demanding repayment. We
    support this legislation, because it makes such principles of fairness
    a part of the law. It also urges VA to address one of the primary
    reasons why mistakes are made by Va, and thereby provides a practical
    means of reducing the problem in the future.
    VIII. S. 857
        A bill to increase the amount of special pension for Medal of Honor
    Recipients, and for other purposes. These veterans have demonstrated by
    their heroic actions and continued service to community and country,
    the need for this legislation. Their family members, who come along
    side them, as they serve, deserve everything we can do to help them
    assist their loved one.
    IX. S. 450, The Veterans Improved Access and Care Act
        We support this legislation because the VA faces a nationwide
    shortage of medical personnel. The current onboarding process is much
    more onerous than any process medical professionals encounter in the
    private sector. As such, it serves to deter, rather than encourage
    prospective employees. If the VA is going to meet its personnel needs,
    VA must find ways to make recruitment and onboarding more efficient.
    This legislation will allow VA to explore the viability of additional
    options for accomplishing this objective.
                                   conclusion
        Thank you, once again, for the opportunity to speak with you about
    the above legislation. If you would like any further information, or
    have questions regarding the above comments, please feel free to
    contact Melanie Brunson, Director of Government Relations, at
    mbrunson@bva.org.
                                     ______

                 Letter from Connecticut Veterans Legal Center

                  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

       Prepared Statement of Adrian Atizado, Deputy National Legislative
                   Director, Disabled American Veterans (DAV)
        Chairman Isakson, Ranking Member Tester, Distinguished Members of
    the Committee: Thank you for inviting DAV (Disabled American Veterans)
    to submit testimony for the record of this legislative hearing of the
    Senate Veterans' Affairs Committee. As you know, DAV is a non-profit
    veterans service organization comprised of more than one million
    wartime service-disabled veterans that is dedicated to a single
    purpose: empowering veterans to lead high-quality lives with respect
    and dignity. DAV is pleased to offer our views on the bills under
    consideration by the Committee.
               s. 123, ensuring quality care for our veterans act
        This bill would require VA to enter into a contract with a third-
    party to conduct clinical peer review to evaluate care provided by VA
    appointed clinicians, whose state license was terminated for cause for
    care rendered in non-VHA facilities. If a determination is made that
    substandard care was provided, VA is to notify such veteran of such
    care.
        In light of the increasing use of non-VA providers under the ``John
    S. McCain III, Daniel K. Akaka, and Samuel R. Johnson VA Maintaining
    Internal Systems and Strengthening Integrated Outside Networks Act of
    2018,'' (Public Law 115-182), we urge the Committee to amend the bill
    to allow such third-party to also conduct clinical peer review to
    evaluate care furnished by non-VA providers that was authorized or
    purchased by VA, and to notify veterans of any substandard care they
    received.
                     s. 221, va provider accountability act
        The measure would require VA to report any adverse actions taken
    against certain providers to be reported to the National Practitioner
    Data Bank and applicable state licensing boards.
        We bring to the Committee's attention the need to further clarify
    the definition of ``major adverse actions,'' without which it may
    inadvertently be more broadly applied than intended as well as specify
    in greater detail to whom the prohibition under Section 2(b) of the
    bill applies.
        DAV is unable to take a position on this bill until further
    clarification is provided on the definition of ``major adverse
    actions,'' which as currently written may inadvertently be applied more
    broadly then intended as well as greater specificity is provided as to
    whom the prohibition under Section 2(b) of the bill applies.
                   s. 318, va newborn emergency treatment act
        S. 318 would allow VA to furnish transportation for newborns of
    women veterans receiving maternity care through VA if a newborn
    requires care that is not available from the facility at which the
    newborn was delivered. The transportation could be for the newborn
    alone or with his or her parents.
        Increasing numbers of women veterans returning from recent
    deployments has spiked the number of veterans seeking maternity care
    from VA. Between 2000 and 2015, the number or women receiving maternity
    care increased more than 14 times (14.4).\1\ Women veterans in
    childbearing years (18-44) are also highly likely to be service-
    connected (73%)\2\ and the growth in women 35 years of age or older
    with obstetric deliveries increased more than 16 times (16.2).\3\
    ---------------------------------------------------------------------------
        \1\ Women's Health Services. Office of Patient Care Services.
    Veterans Health Administration. Department of Veterans Affairs.
    Sourcebook: Women Veterans in the Veterans Health Administration Vol.
    4: Longitudinal Trends in Sociodemographics, Utilization, Health
    Profile, and Geographic Distribution. February 2018. P. 71.
        \2\ Sourcebook. P. 36
        \3\ Sourcebook. P. 72
    ---------------------------------------------------------------------------
        Advanced age and maternal disability are risk factors for adverse
    pregnancy outcomes such as low birth weight or premature birth that
    imperil both women veterans and their newborns. These conditions often
    require specialized care for infants that is not widely available.
    While VA is authorized to provide emergency transportation for women
    veterans, if the infant must travel alone for medically necessary care,
    VA's authority to provide this transportation was unclear. S. 318 would
    provide clear authority for VA to furnish emergency transportation to
    newborn children of women veterans.
        DAV fully supports this bill, in accordance with Resolution No.
    019, which calls for enhanced medical services and benefits for women
    veterans.
             s. 450, veterans improved access and care act of 2019
        This bill would require VA conduct a pilot program across 10
    regionally diverse VA medical facilities to expedite the onboarding
    process of new clinicians to no more than 60 days. A report to Congress
    is required from VA no later than 180 days for a strategy to reduce by
    half the duration of VA's hiring process.
        We support the objectives of this legislation based on DAV
    Resolution 129, which supports a simple-to-administer alternative VHA
    personnel system, in law and regulation, which governs all VHA
    employees, applies best practices from the private sector to human
    capital management, and supports pay and benefits that are competitive
    with the private sector.
                          s. 514, deborah sampson act
        S. 514, the Deborah Sampson Act, a comprehensive measure addressing
    gender disparities, aims to improve and expand VA programs and services
    for women veterans. DAV is pleased to support this important
    legislation, which will achieve many of the objectives DAV first
    identified in our 2014 women veterans report, Women Veterans: The Long
    Journey Home and again in our 2018 follow up report, Women Veterans:
    The Journey Ahead. It is also consistent with DAV Resolution No. 019,
    calling for VA to enhance its programs and services for women veterans.
        Section 101 of the bill would permanently authorize counseling for
    veterans recently separated from military service and accompanying
    family members in group retreat settings, including in women-exclusive
    settings. The social connections, goal-setting and role modeling women
    veterans are exposed to in such retreats have significant and lasting
    effects according to program participants.
        We are pleased to support Section 202, which would extend authority
    and increase funding for families who are precariously housed and live
    at or below the poverty line. This important program has stopped
    thousands of veterans and their family members from becoming homeless.
    It would also earmark $20 million for women veterans. Section 203 would
    require a ``gaps analysis'' of programmatic deficiencies in meeting the
    needs of homeless or precariously housed women veterans, as we
    recommended in Women Veterans: The Journey Ahead.
        Section 301 would extend the number of days, from seven to 14, VA
    may cover the cost of care for newborns of women veterans. As we stated
    in our support of S. 318, women veterans who use VHA have a heavy
    burden of service-connected disability, especially those in
    childbearing years, and are often at advanced age (35 years or older)
    for childbearing, which puts them at risk for adverse birth outcomes.
    Increasing the time VA will reimburse their newborns' care will ensure
    that most of their needs can be addressed before they are discharged.
        Title IV addresses eliminating barriers to access including
    ensuring that environmental care standard deficiencies are addressed
    through adequate retrofitting; that there is at least one designated
    women's health provider in each VA facility; that funds are available
    for training additional primary and emergency providers through VA
    mini-residencies; that training materials are developed for community
    providers in the new Veterans Community Care Program to be launched in
    June 2019; and that VA completes a study to determine the adequacy of
    staffing for Women Veterans Program Managers, determine the need for an
    Ombudsman in each medical center and ensure proper training for the
    individuals in these positions.
        Title V requires VA to conduct a number of studies, including:

         Use of various primary care models serving women veterans;
         Staffing levels of women's health providers including PACT
    team members and gynecologists;
         Data collection and reporting on all VA programs serving
    veterans, by gender and minority status;
         Availability of prosthetics for women veterans; and
         Centralizing all information for women veterans in one
    easily accessible place on VA's website.

        DAV fully supports S. 514 and is eager to work in support of its
    approval.
    s. 524, department of veterans affairs tribal advisory committee act of
                                      2019
        This measure would establish a VA Tribal Advisory Committee to
    better facilitate agreements between VA and other agencies within the
    Federal Government. The Committee would be composed of 15 members,
    including one from each of the 12 Indian Health Service areas.
        We believe this measure would facilitate addressing DAV Resolution
    224 supporting the rights and receipt of benefits earned by service-
    connected Native American or Alaska Native Veterans and look forward to
    its favorable consideration.
       s. 711, care and readiness enhancement for reservists act of 2019
        The Care and Readiness Enhancement for Reservists Act, or CARE for
    Reservists Act of 2019, would allow the Department of Defense to fund
    needed behavioral or mental health care for reservists, regardless of
    whether that servicemember is about to deploy or whether they have
    deployed at all. Currently, members of the National Guard and Reserves
    undergo annual health assessments to identify medical issues that could
    impact their ability to deploy, but any follow-up care must generally
    be pursued at their own expense.
        DAV has no resolution specific to extending mental health care to
    National Guard and reservists, but believes the intent of this
    legislation is in keeping with the goal of ensuring that all
    servicemembers have the health care necessary to readjust successfully
    after deployments. We also recognize that the number of suicides among
    Guard and Reservists who have not been federally activated has grown in
    recent years.\4\ We therefore have no objection to this legislation's
    favorable consideration.
    ---------------------------------------------------------------------------
        \4\ Department of Veterans Affairs. Office of Mental Health and
    Suicide Prevention. VA National Suicide Data Report: 2005-2016.
    September 2018. P. 10.
    ---------------------------------------------------------------------------
      s. 746, department of veterans affairs website accessibility act of
                                      2019
        This bill would require the Secretary of Veterans Affairs to
    examine and report on all websites (including attached files and web-
    based applications) of VA to determine whether such websites are
    accessible to individuals with disabilities in accordance with section
    508 of the Rehabilitation Act of 1973.
        We are troubled by the inability of vision impaired veterans to
    fully access VA websites, thus confounding their ability to claim and
    access their earned benefits. DAV was founded on the principle that
    this Nation's first duty to veterans is the rehabilitation and welfare
    of its wartime disabled and to ensure that all disabled veterans
    receive all benefits they have earned.
        DAV supports S. 746 as it is in accord with DAV Resolution No. 001
    and would help to ensure that all VA websites and associated files are
    accessible by all veterans, especially those with disabilities and
    impairments as noted.
        S. 785, Commander John Scott Hannon Veterans Mental Health Care
    Improvement Act of 2019
        S. 785, the Commander John Scott Hannon Veterans Mental Health Care
    Improvement Act, would improve eligibility and access to transitioning
    servicemembers and veterans to Federal programs such as transitional
    assistance programs and health care, including mental health care, to
    reduce suicide rates and improve mental health among veterans.
        The VA mental health program experienced tremendous growth (86%)
    between 2005 and 2017. Troops returning from deployments in Iraq and
    Afghanistan required mental health care services including treatment
    for Post Traumatic Stress Disorder (PTSD), substance use disorders,
    depression, and anxiety. During this time, VA also identified an upward
    trend in suicides among veterans. Homelessness and unemployment were
    considered contributing factors, particularly for some subgroups in the
    veterans' population such as women and minorities.
        Title I of the bill would improve transition programs for
    servicemembers separating from military service. Research has
    demonstrated that the first three years of readjustment is a time when
    veterans are particularly vulnerable to suicidal ideation.\5\
    ---------------------------------------------------------------------------
        \5\ Ann Epidemiol. 2015 Feb;25(2):96-100.
    ---------------------------------------------------------------------------
        This section would:

         Improve access to transition services for veterans by
    extending VA health care eligibility to a year after discharge from
    military service;
         Create a grant program to help veterans obtain employment
    and help identify the many non-profit programs available to veterans in
    their communities; and
         Require an annual report on utilization of VA medical
    services by veterans with other than honorable discharges.

        Title II of the bill would develop community resources for
    addressing suicide prevention. These programs will enhance VA programs
    to prevent suicide and create care outlets for the many veterans (70%)
    who do not use VA health care,\6\ and whose rates of suicide over time
    are surpassing rates of suicide among veterans who use VA.\7\
    ---------------------------------------------------------------------------
        \6\ Department of Veterans Affairs. National Strategy for
    Preventing Veteran Suicide 2018-2028. P. 6.
        \7\ Department of Veterans Affairs. Office of Mental Health and
    Suicide Prevention. VA National Suicide Data Report 2005-2016.
    September 2018. P. 3.
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        Programs developed under this title include:

         Creation of a new suicide prevention program to include
    new grant programs designed to reach veterans at risk of suicide who
    are not obtaining VA mental health care;
         Facilitation of post-traumatic growth services through
    community partners;
         Requirement that VA designate annual Buddy Check Week to
    encourage peer support by organizing education and awareness
    activities;
         Requirement that VA track and report on goals and
    objectives in its suicide prevention plan and direct the Government
    Accountability Office to evaluate VA's case management program for
    veterans at high risk of suicide.

        Title III of the bill addresses programs, studies and guidelines on
    mental health for veterans. These programs include:

         Study of feasibility and advisability of providing access
    to computerized cognitive behavioral therapy to veterans;
         Study of living at high altitude and development of
    suicide risk factors among veterans;
         Requirement for VA to update guidelines on suicide
    prevention including using gender specific risk factors and treatment
    options:

         Establishment of a Precision Medicine Initiative to
    identify and validate brain and mental health biomarkers;
         Creation of VA treatment guidelines for trauma comorbid
    with chronic pain and substance abuse.

        Title IV of the bill would develop a number of oversight vehicles
    to ensure that VA's efforts in mental health care and suicide
    prevention are accessible, effective and on target:

         Require focus group studies of effectiveness of suicide
    prevention and mental health outreach of VA followed by a
    representative survey of the veteran population from focus group
    themes;
         Require VA to develop oversight measures for assessing
    VA's outreach efforts with media;
         Require a report on VA's progress in addressing Executive
    Order 13822 which requires that VA assist servicemembers within the
    first year of separation from armed services;
         Require oversight reports on:

              - VA's mental health and suicide prevention efforts;
              - Integration of mental health into primary care;
              - Joint mental health programs run by VA and the Department
            of Defense including transition assistance programs, centers of
            excellence in Traumatic Brain Injury and Post Traumatic Stress
            Disorder and ancillary programming including employment,
            housing and financial literacy and establish an additional
            Intrepid Spirit Center in a rural area.

        Title V of the bill would make changes to assist VA in developing
    its mental health workforce. Despite VA adding 1000 or more staff to
    aid mental health efforts in recent years, VA's Inspector General (IG)
    continues to identify psychiatrists and psychologists among its
    professions that VA medical centers most frequently identify as being
    in short supply ranking 1 and 4 in the IG's most recent survey.\8\
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        \8\ Statement of Michael J. Missal, Inspector General, Department
    of Veterans Affairs, Before the Subcommittee on Health, Committee on
    Veterans' Affairs, US House of Representatives, More than Just Filling
    Vacancies: A Closer Look at VA Hiring Authorities, Recruiting, and
    Retention.'' June 21, 2018. P. 6 (based upon data from Veterans Health
    Administration's Occupational Staffing Shortages for Fiscal Year 2018.)

         Convert VA psychologists from ``hybrid'' title 38/title 5
    employees to title 38 employees;
         Require VA to develop a staffing improvement plan for
    psychiatrists and psychologists;
         Create occupational series for licensed mental health
    counselors and marriage and family therapists within VA;
         Require staffing improvement plan for peer support
    specialists who are women;
         Create a Readjustment Counseling Service Scholarship
    program;
         Require a report on Readjustment Counseling Service
    regarding the adequacy and types of services provided; efficacy of
    outreach and recommendations for improvements; use of telehealth;
    expanding eligibility and costs of such expansions; use by Reservists;
    use by eligible family members, and assessment of training of group
    therapists.
         Create an annual report from the Readjustment Counseling
    Service looking at resources required to meet needs.
         Create studies of alternative work schedules for VHA
    employees;
         Require one suicide prevention coordinator at each VA
    medical center;
         Create direct hiring authority for certain health care
    positions within VHA.

        While DAV is in favor of most of the provisions within this title,
    we would ask that the Committee give further consideration to Section
    501 which would re-categorize psychologists now under Hybrid Title 5/
    Title 38 authority to Full Title 38 authority. While DAV supports a
    single, simple-to-administer alternative personnel system under DAV
    Resolution No. 129, we are unclear if this measure would improve
    recruitment and retention of psychologists--an occupation that VA's
    Office of Inspector General has identified as having a large staff
    shortfall for the past several years. DAV would instead ask that the
    Committee study both strengths and barriers to using the current system
    and identify benefits within Title 38 and ``Hybrid'' systems that VA
    psychologists value. For example, are practices such as collective
    bargaining, leave policies, pay practices, and retirement benefits
    valued by current employees and job candidates? How would moving from
    one system to another affect such practices and would the change impact
    VHA's ability to recruit or retain these scarce clinical personnel?
        In addition, DAV has some concerns about potentially weakening
    veterans' preference and merit based hiring practices in favor of an
    unproven system that may or may not lead to more expedient hiring
    proposed under Section 521. In DAV's view, it would be more prudent to
    understand barriers to effective use of current hiring flexibilities
    and pay incentives under Title 38.
        Title VI of the bill would improve VA's Telehealth Services.
    Telehealth and other technologies have expanded care options for
    veterans and made care available to populations that might not be
    eligible (such as active-duty veterans, family members, and those with
    less than honorable discharges). VA has apps and web-based curriculum
    that are accessible and effective means of bringing evidence-based
    practices to more individuals in need. Telehealth which is increasingly
    used by VA to distribute scarce health resources (such as specialized
    care) is known to be effective and patients are pleased when seeking
    specialized care does not have to take them far from their homes and
    communities.
        Specifically, the bill would:

         Expand use of telehealth between VHA, other Federal
    agencies and community partners, especially in rural communities by
    offering grants for ``partnerships'' to upgrade hardware,
    infrastructure and security and train staff.
         Implement a national protocol for telehealth security.

        DAV also suggests the addition of a reporting requirement for VHA's
    Special Committee on PTSD. While it is our understanding this group of
    mental health providers and researchers continues to meet and report
    internally, Congress does not benefit from the Committee's guidance and
    recommendations for improving the program in VA.
        The following resolutions lead DAV to strongly support S. 785. DAV
    Resolution No. 293 supports program improvement and enhanced resources
    for VA mental health programs, emphasizing the importance of timely
    access to mental health and readjustment services for transitioning
    servicemembers. DAV Resolution No. 304 urges Congress to monitor
    programs in place to assist those servicemembers transitioning to
    civilian life with access to appropriate Federal programs.
                   s. 805, veteran debt fairness act of 2019
        This legislation would require the VA Secretary to improve the
    processing of veterans benefits, limit the authority of the Secretary
    to recover overpayments and improve the due process accorded veterans
    with respect to such recovery.
        It is a reasonable expectation that recipients of overpayments are
    required to repay the debt; however, the current overpayment and debt
    system allows the VA to collect debts regardless of when or how the
    debt was created. Current debt collections by the VA include complete
    recoupment of the veteran's monthly benefit payments and, in many
    cases, put the veteran at risk of financial hardship. It is important
    to note that additional amounts of debt created by the VA's lack of
    timely action are often added to the debt, thus creating an inequity on
    the veteran.
        S. 805 will allow veterans and beneficiaries to choose how to
    receive debt notification and address several root causes of VA
    overpayments, including:

         Only allowing the VA to collect debts that occur as a
    result of an error or fraud on the part of a veteran or their
    beneficiary;
         Prohibiting VA from deducting more than 25 percent from a
    veteran's monthly payment in order to recoup overpayment or debt. This
    deduction may be further limited if it puts that veteran at risk of
    financial hardship, for example if the veteran is living on a fixed
    income;
         Preventing the VA from collecting debts incurred more than
    five years prior (Currently there is no time limit on how long after a
    payment a veteran can be billed);
         Requiring the VA to provide veterans with a way to update
    their dependency information on their own, eliminating a key processing
    delay for veterans which frequently contributes to the VA making
    overpayments.

        S. 805 will institute common-sense protections for veterans and
    reduce the potential negative financial impact on veterans and their
    families. DAV strongly supports S. 805 as it is in accord with DAV
    Resolution No. 172.
     s. 850, the highly rural veteran transportation program extension act
        The VA Highly Rural Transportation Grants (HRTG) program was
    established to help highly rural veterans travel to VA or VA-authorized
    health care facilities by providing $50,000 grant funding to Veteran
    Service Organizations and State Veterans Service Agencies to provide
    transportation services in eligible counties. The program's authority
    was intended to operate for five fiscal years beginning in 2010, but
    has since been extended five times until 2020.
        DAV understands the importance of transportation to enable veterans
    to access VA health care and benefits. The DAV National Transportation
    Network operates a fleet of vehicles around the country to provide free
    transportation to VA medical facilities for injured and ill veterans.
    We stepped in to help veterans get the care they need when the Federal
    Government terminated its program that helped many of them pay for
    transportation to and from medical facilities. These vans are driven by
    volunteers, and the rides coordinated by more than 178 Hospital Service
    Coordinators around the country.
        DAV Departments and Chapters, along with our long-time partner Ford
    Motor Company, have purchased 3,517 vehicles at a cost of more than
    $80.1 million, which have been donated to VA medical centers nationwide
    since the program began in 1987 to ensure that injured or ill veterans
    are able to get to their medical appointments.
        We recognize HRTG as one of three programs administered by VA's
    Veterans Transportation Program (VTP) to provide veterans little to no-
    cost travel solutions to and from their VA health care facilities. VTP
    also administers the Beneficiary Travel program and the Veterans
    Transportation Service (VTS). Each program, however, has certain
    limitations and areas of concern.
        VTS is intended to provide veterans with convenient and timely
    access to transportation services and to overcome barriers to receiving
    VA health care and services, and in particular to increase
    transportation options for veterans who need specialized forms of
    transportation to VA facilities; however, there is wide variation in
    eligibility for VTS transportation across the VA health care system
    that is not consistent with overcoming barriers to receiving health
    care provided or purchased by the VA to service-connected veterans.
        Beneficiary travel is a critical program, but is not available to
    all service-connected disabled veterans with mobility challenges,
    policies do not comport with VA's current access to care policies, and
    it is a source of confusion among local VA facilities due to vague
    policies for using special-mode transportation, such as a wheelchair
    van, as well as eligibility issues for veterans with visual
    impairments.
        HRTG provides grants to assist only veterans in highly rural areas
    through innovative transportation services to travel to VA medical
    centers.
        While DAV supports enactment of this measure to extend by one year
    HRTG, we urge this Committee to consider addressing the lack of a
    consistent and comprehensive VA transportation policy for all service-
    disabled veterans across all established VA transportation and travel
    programs, benefits and services.
     s. 857, a bill to increase the amount of special pension for medal of
                                honor recipients
        S. 857 would amend 38 U.S.C. Sec. 1562 by increasing the Medal of
    Honor Special Pension from $1000.00 a month to $3,000.00 a month. DAV
    does not have a resolution on this issue; however, we would not oppose
    the enactment of this bill.
                s. 980, homeless veterans prevention act of 2019
        The Homeless Veterans Prevention Act of 2019 authorizes the VA to
    provide per diem payments for furnishing care to the dependents of
    certain homeless veterans, provide for partnerships to provide legal
    services to homeless veterans and those at risk of homelessness, expand
    the VA's authority to provide dental care to homeless veterans, repeal
    the sunset on counseling services for homeless veterans, and extend the
    financial assistance for supportive services for very low-income
    veteran families in permanent housing. In addition, this legislation
    would require the Comptroller General of the United States to study the
    VA's Homeless Veterans Programs and provide an assessment as to whether
    these programs are meeting the needs of the veterans who are eligible
    for assistance.
        DAV supports this legislation in accordance with the following
    resolutions approved by our membership--DAV Resolution No. 291 calling
    for sustained and sufficient funding to improve services for homeless
    veterans; and Resolution No. 173, which supports enactment of
    legislation authorizing VA to provide child care services and
    assistance to veterans attending VA homeless and rehabilitative
    programs.
    s. 1101, better examiner standards and transparency for veterans act of
                                      2019
        The Better Examiner Standards and Transparency Act of 2019, would
    amend title 38, United States Code, section 5101 to prohibit contract
    health care providers who have had their licenses revoked in any state
    to provide VA Compensation and Pension examinations and to ensure that
    only licensed contract health care providers are conducting the
    examinations. S. 1101 would also require the Secretary to submit annual
    reports to Congress addressing both of these concerns.
        A VA examination by an unlicensed health care professional would be
    considered an inadequate VA examination and a violation of VA's duty to
    assist as noted in title 38, United States Code, section 5103A. Under
    the recently implemented Appeals Modernization Act, appeals at the
    Board of Veterans' Appeals will be returned to the agency of original
    jurisdiction for duty to assist errors. Thus, S. 1101 will lessen the
    potential for additional appeals processing by ensuring that all VA
    contract examiners are licensed and not confound the VA's duty to
    assist.
        Veterans' medical disability examinations are incredibly critical
    in ensuring veterans obtain service connection and accurate
    examinations will directly impact disability evaluations. As such, ill
    and injured veterans deserve to have these examinations conducted by
    qualified clinical providers, including those whom VA contracts with to
    provide these important examinations.
        DAV supports S. 1101 as it is in accord with DAV Resolution No.
    001. It is part of DAV's foundation that wartime disabled veterans
    should receive high-quality hospital and medical care from VA as well
    as adequate compensation for the loss resulting from such service-
    connected disabilities.
     s. 1154, the department of veterans affairs electronic health record
                             advisory committee act
        This bill would establish an independent, 11-member Electronic
    Health Record (EHR) Advisory Committee, which would be comprised of
    medical professionals, information technology and interoperability
    specialists, and veterans currently receiving care from the VA. The
    Advisory Committee would, among other things, be required to analyze
    VA's implementation strategy, developing a risk management plan, and
    tour VA facilities as they transition to the new EHR system. The
    Committee would also be required to report to Congress twice a year for
    the first two years of its establishment recommending any
    administrative or legislative action necessary.
        DAV supports the intent of this bill and agrees that the $16
    billion 10-year commitment must not suffer the same setbacks as has
    unfortunately been known to occur with numerous other VA information
    technology projects. We recognize the VA will be going live with
    Cerner's product around March/April 2020 at the Mann-Grandstaff,
    Seattle and American Lake VA medical centers as well as accelerate the
    timetable to complete deployment of a scheduling package across the VA
    health care system in the next five years.
       draft bill, to extend the authority of the secretary of veterans
       affairs to continue to pay educational assistance or subsistence
       allowances to eligible persons when educational institutions are
                               temporarily closed
        This legislation would amend title 38, Section 3680(a) (2) of the
    United States Code to provide continued subsistence allowances to
    eligible veterans who are pursuing a program of education under chapter
    31, 34, or 35 of this title when that educational institution is
    temporarily closed not to exceed a period of eight weeks. Current
    legislation limits the total number of weeks for which allowances may
    be paid over a 12-month period to four weeks.
        While DAV does not have a resolution specific to this issue, we
    support the intent of this legislation and look forward to its
    favorable consideration.
                 discussion draft: janey ensminger act of 2019
        The proposed legislation, consistent with the Comprehensive
    Environmental Response, Compensation, and Liability Act, title 42,
    United States Code, section 9601, directs the Agency of Toxic
    Substances and Disease Registry to provide a report not later than one
    year after the date of enactment and not less frequently than once
    every three years thereafter. The report is to concern:

         Review the scientific literature relevant to the
    relationship between the employment or residence of individuals at Camp
    Lejeune, North Carolina for not fewer than 30 days during the period
    beginning on August 1, 1953, and ending on December 21, 1987, and
    specific illnesses or conditions incurred by those individuals;
         Determine each illness or condition for which there is
    evidence that exposure to a toxic substance at Camp Lejeune;
         With respect to each illness or condition for which a
    determination has been made, categorize the evidence of the connection
    of the illness or condition to exposure described as--

              - ``(i) sufficient to conclude with reasonable confidence
            that the exposure is a cause of the illness or condition;
              - ``(ii) modest supporting causation, but not sufficient to
            conclude with reasonable confidence that exposure is a cause of
            the illness or condition; or
              - ``(iii) no more than limited supporting causation.

        The VA established presumptive diseases recognized as being
    causally linked to the contaminated water at Camp Lejeune from
    August 1, 1953 to December 21, 1987, in title 38, Code of Federal
    Regulations, section 3.309. However, this presumptive is not codified
    nor does it carry a requirement for continuing reports, research and
    diseases noted to be causally linked to said exposure.
        DAV supports this proposed legislation as it is consistent with DAV
    Resolution No. 090 and will provide an avenue to consider additional
    diseases or conditions that can be linked to the contaminated water.
    However, we do seek clarification if the proposed use of three
    categories of evidence would provide any conflict or controversy with
    the National Academy of Sciences, Engineering, and Medicine accepted
    four categories of evidence.

        Mr. Chairman, this concludes DAV's testimony. Thank you for
    inviting DAV to submit testimony for the record of today's hearing. I
    would be pleased to address any questions related to the bills being
    discussed in my testimony.
                                     ______

     Prepared Statement from Daniel Elkins, Legislative Director, Enlisted
    Association of the National Guard of the United States and the Veterans
                               Education Project
                 s. 123: ensuring quality care for veterans act
        The Enlisted Association of the National of the United States
    (EANGUS) supports S. 123, Ensuring Quality Care for Veterans Act, which
    provides additional oversight over Veterans Health Administration's
    (VHA) appointees.
        The Department of Veterans Affairs is one of the largest Federal
    agencies, and VHA's task is monumental in scope and need. We are
    therefore supportive of providing a contracted third party, independent
    of the Federal Government, to review VHA appointees who have had their
    license terminated for cause by a State licensing board for care or
    services rendered at non-VHA hospitals, and to review the quality of
    care provided to Veterans by such individuals. If it is found that the
    quality of care or services provided to Veterans fell below the
    standards of care, EANGUS agrees that such Veterans should be notified
    by the Secretary of VA.
       s. 221: department of veterans affairs provider accountability act
        The Enlisted Association of the National Guard of the United States
    is supportive of S. 221, Department of Veterans Affairs Provider
    Accountability Act.
        Providing additional accountability to section 7401(1) employees
    will improve quality of care for Veterans, as current accountability
    measures do not go far enough to curb inadmissible conduct and poor
    performance of appointed employees. EANGUS believes VHA should have
    more power to discipline unacceptable behavior of 7401(1) employees,
    and extending additional recourses such as reporting to the National
    Practitioner Data Bank and State Licensing Boards will strengthen the
    accountability necessary to ensure quality of care for our Veterans.
                   s. 318: va newborn emergency treatment act
        The Enlisted Association of the National Guard of the United States
    currently does not have a stance on S. 318, VA Newborn Emergency
    Treatment Act.
             s. 450: veterans improved access and care act of 2019
        The Enlisted Association of the National Guard of the United States
    is supportive of S. 450, Veterans Improved Access and Care Act of 2019.
        Currently, there are not enough VHA providers to care for our
    Nation's Veterans, and VHA providers are not yet geographically diverse
    enough for Veterans to receive appropriate care. The creation of a
    pilot program to expedite the hiring process of new providers to no
    longer than 60 days, and for this pilot program to focus on
    geographically diverse regions that face hiring shortages of providers,
    will do much to meet the medical needs of Veterans. EANGUS believes
    this expedited onboarding process can be accomplished without
    compromising on necessary procedures, such as certifying the medical
    provider's credentials, performing a background check, assessing their
    health status, and other necessary actions that ensure these medical
    providers will provide the best care to Veterans.
                          s. 514: deborah sampson act
        The Enlisted Association of the National Guard of the United States
    is supportive of S. 514, the Deborah Sampson Act.
        Women Veterans are a growing population, and currently VA
    facilities and staff are not equipped to provide quality care necessary
    for women Veterans. This legislation plans to improve women Veterans
    transition and care in commonsense ways, like providing additional
    legal counsel, improved VA care and updated facilities, and better data
    tracking and analysis. EANGUS applauds that this legislation provides
    preventative measures against homelessness, unemployment, and lack of
    health care with expanded transition programs, and plans to implement
    specialized program managers for women Veterans at VA facilities.
    s. 524: department of veterans affairs tribal advisory committee act of
                                      2019
        The Enlisted Association of the National Guard of the United States
    does not have a stance on S. 524, Department of Veterans Affairs Tribal
    Advisory Committee Act of 2019.
        s. 711: care and readiness enhancement for reservist act of 2019
        The Enlisted Association of the National Guard of the United States
    is highly supportive of S. 711, the Care and Readiness Enhancement for
    Reservist Act of 2019.
        Of the nearly 20 Veteran suicides daily, on average five are from
    the Reserve components, and three have never been federally activated,
    and are ineligible to receive VA mental health care. EANGUS is
    currently in the process of finalizing a Memorandum of Agreement with
    VHA to combat suicide in the National Guard and Reserve components, and
    we recognize that mental health care must be made available to these
    Servicemembers, regardless of their Veteran status. The Care and
    Readiness Enhancement for Reservist Act of 2019 provides the
    legislative fix necessary to care for these overlooked Servicemembers
    who are currently unable to receive the mental health care they
    deserve.
      s. 746: department of veterans affairs website accessibility act of
                                      2019
        The Enlisted Association of the National Guard of the United States
    is generally supportive of S. 746, Department of Veterans Affairs
    Website Accessibility Act of 2019.
        It is important that disabled Veterans be able to navigate the
    various websites of the Department of Veterans Affairs and be able to
    access the information they need. However, we believe that VA should
    consult with various Veteran Service Organizations while updating their
    websites, and should not neglect the vast amount of expertise these
    organizations can provide VA in order to make sure these updates do not
    create new problems for Servicemembers and Veterans.
        s. 785: commander john scott hannon veterans mental health care
                            improvement act of 2019
        The Enlisted Association of the National Guard of the United States
    is generally supportive of S. 785, Commander John Scott Hannon Veterans
    Mental Health Care Improvement Act of 2019.
        EANGUS encourages the exploration of alternative treatment options
    and partnering with non-VA mental health providers, but desire to see
    these treatments and care extended to National Guard and Reserve
    members who have never been federally activated.
        Section 101, Expansion of Health Care Coverage for Veterans, uses
    the limiting term of ``active service,'' that only applies to active
    duty or full-time National Guard duty. We ask that the Committee change
    the proposed insert to Section 101, ``(B) to any veteran during the
    one-year period following the discharge or release of the veteran from
    active military, naval, or air service; and'' be changed to insert
    after the word service ``and active status; and'' which would include
    reserve component members leaving a participating reserve position as
    defined by Title 10, Section 101.
        We are highly supportive of tracking suicide-related data, and
    disaggregating data by potential contributing factors, such as
    Traumatic Brain Injury and anxiety. Additionally, we support this
    legislation's aim to increase mental health assessments, but desire to
    see mental health assessments provided during MEPS pre-examinations in
    order to identify at-risk applicants, and screen out high-risk
    applicants.
        EANGUS supports this legislation, but we are concerned with the
    feasibility of its implementation. We suggest that it be implemented in
    incremental, achievable measures to evaluate its efficacy.
                   s. 805: veteran debt fairness act of 2019
        The Enlisted Association of the National Guard of the United States
    is supportive of S. 805, the Veteran Debt Fairness Act of 2019.
        For a variety of reasons, including delays in processing dependency
    changes, and communication errors between IT systems, VA sometimes
    makes overpayments to Veterans. Because these payments are automatic
    and monthly, these overpayments add up significantly over time, and
    they are not the fault of the Veteran. The Veteran Debt Fairness Act of
    2019 will limit VA's ability to recoup overpayments only when it is the
    fault of the Veteran, and VA may withhold no more than 25 percent of a
    Veteran's monthly benefit check--as opposed to withholding entire
    monthly checks from Veterans on fixed incomes. This provision
    safeguards Veterans and their families who depend upon their monthly
    benefits, while incentivizing VA to fix their erroneous data systems.
    Further, we support that this legislation requires VA to perform yearly
    audits in order to eliminate the systematic errors that cause
    overpayments.
       s. 850: highly rural veteran transportation program extension act
        The Enlisted Association of the National Guard of the United States
    currently does not have a stance on S. 850, the Highly Rural Veteran
    Transportation Program Extension Act.
       s. 857: increase special provisions for medal of honor recipients
        The Enlisted Association of the National Guard of the United States
    is highly supportive of S. 857, Increase Special Provisions for Medal
    of Honor Recipients. These heroes deserve all the recognition and
    support we can give, and increasing their monthly pensions to $3,000
    monthly will do much to alleviate undue economic stress.
                s. 980: homeless veterans prevention act of 2019
        The Enlisted Association of the National Guard of the United States
    is supportive of S. 980, the Homeless Veterans Prevention Act of 2019.
        Alleviating economic stress for homeless Veterans and their
    dependents via Per Diem support allows for the exploration of permanent
    solutions, and ensures these Veterans have the ability to seek and
    access to further resources--whether that is mental, physical, or legal
    help. Private and public partnerships to provide legal counsel to
    homeless Veterans and their families provides another means of
    protection and stability, and will potentially prevent further
    homelessness among at-risk Veterans in the midst of financial or
    marital distress.
        EANGUS recommends that National Guard and members of the Reserve
    components be disaggregated in collected data, as the nature of their
    homelessness differs from the active duty population. Understanding the
    differences between active duty population and the Reserve Component
    population will enable us to determine correlative factors that
    contribute to each population's homelessness, and to draft better
    legislation to strengthen preventative measures.
    s. 1101: better examiner standards and transparency for veterans act of
                                      2019
        The Enlisted Association of the National Guard of the United States
    supports S. 1101, Better Examiner Standards and Transparency for
    Veterans Act of 2019.
        When evaluated for disability ratings, Veterans should be confident
    their examiner is a licensed health care provider that is
    professionally qualified to conduct an accurate analysis and give
    trustworthy recommendations. Anything less would be an insult to these
    Veterans.
       s. 1154: department of veterans affairs electronic health record
                             advisory committee act
        The Enlisted Association of the National Guard is generally
    supportive of S. 1154, the Department of Veterans Affairs Electronic
    Health Record Advisory Committee Act.
        Generally, members of the National Guard are not seen at military
    facilities, and it becomes incumbent on National Guard members to
    ensure their medical records from civilian providers are placed in
    their military medical records--something rarely done. Our
    understanding is that, as GENESIS matures, the plan is for it to
    include the EHR from several private commercial health plans for even
    more access to civilian medical records by DOD and VA. It must include
    Guard and Reserve members to be effective. EANGUS therefore recommends
    that National Guard and Reserve Component be represented on the EHR
    advisory committee to ensure that our members' medical records are
    properly integrated.
                      s. ___: janey ensminger act of 2019
        The Enlisted Association of the National Guard of the United States
    does not have a stance on the Janey Ensminger Act of 2019.
                    s. ___: pay educational assistance etc.
        The Enlisted Association of the National Guard of the United States
    is highly supportive of this yet untitled bill submitted by Senator
    Cassidy.
        In the wake of multiple closures of institutions of higher
    education, Student Veterans have had no recourse for reimbursement, nor
    the necessary benefits to transition into another program. This piece
    of legislation will empower the Secretary of VA to continue to pay
    subsistence allowances and educational assistance for up to eight
    weeks, greatly aiding Student Veterans to weather temporary closures,
    or provide them the resources necessary to transition and persist at
    another institution of higher education.
                                     ______

     Letter from Carol Wild Scott, Esq., Legislative and Veterans Affairs
        Chair, Veterans & Military Law Section, Federal Bar Association

                                       Federal Bar Association.
    Hon. Johnny Isakson, Chairman,
    Hon. Jon Tester, Ranking Member,
    Committee on Veterans' Affairs,
    U.S. Senate, Washington, DC.
                             Re: Comments on S. 785
        Dear Chairman Isakson and Ranking Member Tester: The Veterans &
    Military Law Section (V&MLS) of the Federal Bar Association
    respectfully submits the following comments for the record on this
    important legislation addressing the improvement of mental health care
    provided by the Department of Veterans Affairs (VA). V&MLS asks the
    Senate Committee on Veterans' Affairs to review and then respond to our
    carefully crafted recommendations to improve and enhance S. 785, a bill
    V&MLS strongly supports.
        For several years, V&MLS has brought our concerns to Congress
    regarding the diminished availability of VA programs, benefits, and
    health care to Native American veterans, particularly those located on
    or near tribal lands in rural areas. We are pleased to see the
    inclusion of Native American veterans in S. 785.
        V&MLS recommends the inclusion of Native Americans should be
    specific in several provisions of the legislation. This is of paramount
    importance because veteran suicide in Indian Country is largely
    unidentified. V&MLS understands that VA keeps no record of Native
    American veteran suicides. As a result, this vital information is not
    included in VA's national statistics. We believe that tracking mental
    health care and suicide among Native American veterans, including for
    those with other than honorable discharges is crucial, as they appear
    to be more prevalent among Native American veterans.
        We also believe that it is essential for VA to do much more than VA
    currently does to provide prompt access as well as to furnish
    culturally competent health and mental health care to this underserved
    segment of the veteran community. Thus, V&MLS recommends the following
    changes to the bill, as shown in italics:
                           comments for titles i-iv:
    Title I, Sec. 104(c)(iv) (Add: ``including identified tribal
            reservations;''
    Title II, Sec. 1720J(b)(4) (Add: ``(v) to coordinate and tailor
            culturally competent mental health needs of Native American
            veterans.
    Title II, Sec. 204(a) (Add a provision that requires the development,
            in partnership with Indian Health Service, Tribal Health
            Systems and Bureau of Indian Affairs metrics for identifying
            and tracking Native American veteran suicide on tribal lands.)
    Title II, Sec. 205(b) [Renumber (5) as (6) and insert (5) Traditional
            Native American healing.]
    Title II, Sec. 206(c)(2) [Add: ``(3) or has received health care
            through IHS or a Tribal Health System (THS) during the two year
            period preceding the initial participation of the veteran in
            the program'']
    Title III Sec. 301(b) [Add: ``(3) or has received health care from IHS,
            a THS during the two-year period preceding the initial
            participation of the veteran in the program]
    Title III Sec. 304(b)(1) [Add: ``(E) Ethnic gender-specific risk
            factors for suicide and suicide ideation; (F) Ethnic gender-
            specific treatment efficacy for depression and suicide
            prevention; (G) Gender-specific efficacy of Native American
            traditional healing when provided for Native American veterans]
    Title III Sec. 304(b)(2)(A) [Renumber (x) as (xi) and insert: (x)
            Traditional Healing for Native American veterans.]
    Title IV Sec. 401(b)(2) [Add: to (A): `` . . . including Native
            American tribal lands.'']
    Title IV Sec. 405(b) (1) (Add: ``and culturally competent tradition-
            based mental health care.'')
    Title IV Sec. 405(b)(2)(D) (Add: ``and culturally competent tradition-
            based mental health care.'') with conforming additions to
            (D)(i) and (ii). Include as well the addition of ``culturally
            competent tradition-based'' to (E)-(G).
    Title IV Sec. 406(a)(2)(B)(iv) (Add: `` . . . including those of Native
            American servicemembers.'') with conforming addition to
            (a)(2)(C)(iv).
    Title IV Sec. 406(a)(2)(E) (Add: ``including Native Americans.''
                             comments for title v:
        V&MLS believes the single greatest barrier to mental health care
    for Native American veterans is the nearly total lack of mental health
    professionals capable of delivering culturally competent mental health
    care on or near tribal lands. According to VA data, there are only 12
    Native American psychologists employed by VA. V&MLS was unable to
    obtain data on the number of psychiatrists employed by VA. The majority
    of Native Americans, veterans or not, often seek care from traditional
    healers. However, VA medical providers and claims adjudicators do not
    recognize traditional care. It is critical to this population of
    veterans that VA actively recruit Native American mental health
    providers at all levels of licensure and recognize traditional healers
    and healing for both treatment and disability claim decisions.

    Title V Sec. 502(a). (Add: `` . . .  a plan to address staffing
            shortages of psychiatrists and psychologists, including Native
            American psychologists and psychiatrists . . . '')
    Title V Sec. 504(a)(2)(B) (Add: ``to include Native American women'')
    Title V Sec. 504(a)(2)(C) (Add: ``The number and proportion of women
            peer specialists to include Native American women peer
            specialists . . . '')
    Title V Sec. 504(c)(1) (Add: `` . . . to hire additional qualified peer
            specialists who are women, to include Native American women . .
            . ''
    Sec. 7699(a) (Add: ``In General-An individual, including a Native
            American . . . ''
    Title V Sec. 506(b)(1) (Add: `` . . . other services provided at Vet
            Centers, including those located on or mobile to tribal lands .
            . . ''
    Title V Sec. 506(b)(2) (Add: `` . . . for how outreach efforts can be
            improved, including such efforts on tribal lands.''
    Title V Sec. 506(b)(7) (Add: `` . . . how better to reach those family
            members, including those on tribal lands.''
    Title V Sec. 507:

              The reporting requirements on Readjustment Counseling
            Services (RCS) should include requirements for detailed
            accounts of efforts made to bring RCS treatment to tribal
            lands. V&MLS was present at Pine Ridge Reservation in May 2018,
            meeting with the Tribal Veteran Service Officer (TVSO) and
            local veterans when a mobile Vet Center vehicle arrived along
            with representatives from other VA programs and services. No
            one on the Reservation had ever seen any of these people or
            these VA programs before.
              The poverty on or near many reservations and tribal lands
            because of the lack of a viable economy presents significant
            barriers to the ability to purchase fuel or even borrow
            transportation for a Native American Veteran to travel from the
            reservation to a VA facility for health care. With Vet Centers,
            it is possible to provide mental health care on tribal lands in
            settings comfortable for veterans who by and large do not trust
            U.S. Government. The Vet Centers should be staffed with those
            able to provide culturally competent counseling and provide an
            opportunity for interface with Traditional Healers, which
            requires recruiting counselors with cultural skills.

        Our recommendations are worthy of the Committee's attention because
    they impact hundreds of thousands of Native American Veterans. In 2017,
    VA's ``Vantage Blog'' noted that, ``Native Americans serve in the
    military among the highest rate, per capita, compared to other groups .
    . . .'' According to the 2010 Census, there were more than 150,000
    American Indian and Alaska Native Veterans (Kevin Gover, Director,
    Smithsonian National Museum of the American Indian, Huffington Post,
    May 22, 2015).
        The Veterans & Military Law Section of the Federal Bar Association
    is honored to provide the Committee with our comments on this vital
    legislation. The recommendations are the product of V&MLS only. In
    summary, we believe S. 785 provides a meaningful opportunity to provide
    for the development of culturally competent mental health care to
    Native American veterans who have earned VA care through their
    sacrifice and service to our country.
                Respectfully submitted,
                                         Carol Wild Scott, Esq.
                                Legislative and Veterans Affairs Chair,
                                       Veterans & Military Law Section.
                                     ______

          Letter from Federation of State Medical Boards Submitted by
                 Hon. Cory Gardner, U.S. Senator from Colorado

                  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

       Letter from Alie Muolo, Staff Attorney and Michele Levy, Managing
                      Attorney, Homeless Advocacy Project

                  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

     Prepared Statement of The Institute for Veterans & Military Families
                       Syracuse University, Syracuse, NY
        The Institute for Veterans and Military Families (IVMF) at Syracuse
    University is grateful to Chairman Isakson, Ranking Member Tester, and
    the Members of the Committee for the opportunity to submit written
    testimony on the subject of S. 785 or, be it enacted, the Commander
    John Scott Hannon Veterans Mental Health Care Improvement Act of 2019.
        Over the past decade, the research and programmatic efforts of the
    IVMF have generated actionable insights into the social and economic
    determinants of veteran health and wellness, particularly as impacted
    by the servicemember's lived experience navigating the transition from
    military to civilian life. For that reason, it is our position that
    those insights are uniquely positioned to inform the focus and
    substance of the Act as currently proposed. It is our hope that this
    testimony contributes to your ongoing efforts to meaningfully address
    the critically important issues impacting the transition from military
    to civilian life--and by doing so, advance the mental and physical
    well-being of our Nation's veterans.
        Today the IVMF operates vocational and community coordination
    programs across the United States, designed to complement public-sector
    efforts in support of a holistic transition from military to civilian
    life for our servicemembers, veterans, and their families. Each year
    more than 25,000 servicemembers, veterans, and their families leverage
    IVMF programs as a means to navigate the transition out of uniform and
    toward civilian careers, schools, and communities. Those programs
    include interventions designed to support business ownership, career
    preparation, vocational skills training, and also the effective and
    efficient provision of social services within the communities our
    veterans call home.
        Importantly, all IVMF programs are available to servicemembers,
    veterans, and their families without any financial barriers to access.
    It is through the generosity of the IVMF's corporate and foundation
    partners--such as JPMorgan Chase, the Schultz Family Foundation, First
    Data, Walmart, USAA, and many others--that we're able to design and
    deliver our vocational and community coordination programs without any
    cost to those who benefit.
        Most simply, acting on the opportunity to enhance and improve the
    transition experience for servicemembers and their families is the
    mission of the IVMF. For that reason, we have leveraged the academic
    resources of Syracuse University and other partners, to conduct
    extensive research related to the social, cultural, and economic
    factors that impede or enhance the transition from military to civilian
    life.
        One consistent finding from that research is a clear and enduring
    linkage between the lived transition experience of servicemembers and
    their families, and the overall mental and physical health of the
    veteran, both during and long-after transition.
        For example, recent findings from the annual Blue Star Families
    Military Family Lifestyle Survey, conducted in partnership with the
    IVMF, suggests a strong relationship between transition experience,
    preparation for transition, and stress. Specifically, this research
    illustrates a strong correlation between the transition experience and
    mental distress (i.e. stress), which is heightened in instances where
    planning and time pressures are compressed. High levels of stress, in
    turn, significantly compromise mental health. This is likely why
    complementary research demonstrates higher rates of suicidal ideation
    among veterans within five years of military separation, as compared to
    populations five or more years removed from the transition experience.
        In short, our research--and related research conducted by others--
    demonstrates clearly that `getting transition right' is central to
    mitigating those factors likely to otherwise compromise long-term
    wellness and mental health among veterans. Alternatively, a negative
    transition experience is highly likely to set a veteran (and the
    veteran's family) on a trajectory of compromised wellness and mental
    health, from which it is often exceedingly difficult to recover.\1\
    ---------------------------------------------------------------------------
        \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
    ---------------------------------------------------------------------------
        For this reason, it is our position that the substance and intent
    of the proposed legislation must be framed in the context of the lived
    transition experiences of veterans and military families. Such a
    framework is most likely to generate actionable strategies, best
    positioned to positively impact long-term mental health outcomes for
    our community.
        Accordingly, our programmatic and research experiences suggest
    three areas of focus most strongly aligned with enhancing the
    transition experience, in a way that powerfully undercuts the social
    and economic factors demonstrated by research to erode the mental
    health of transitioning servicemembers and veterans. Those three areas
    of focus, we suggest to be critical to consider relative to the intent
    and administration of S. 785 as proposed, are as follows:

        1. Support for effective and efficient navigation--by or on behalf
    of the veteran--to public and private sector resources positioned to
    bolster the economic and social determinants of wellness and mental
    health.
        2. Enhanced access to educational and vocational services and
    supports--before, during, and after transition--most strongly aligned
    with post-service job and career opportunity.
        3. Purposeful and robust pathways connecting veterans and their
    families to the communities in which they live, work, and raise their
    families.

        In what follows we address each area of focus, and the associated
    implications for S. 785 or, be it enacted, the Commander John Scott
    Hannon Veterans Mental Health Care Improvement Act of 2019.
                                 issue area 1:
    Support for effective and efficient navigation to public and private
            sector resources, positioned to bolster the economic and social
            determinants of wellness and mental health.
        A major study conducted by the IVMF and focused on the transition
    experiences of more than 8,000 servicemembers, found that effective and
    efficient navigation of available services, resources, and benefits to
    be the most commonly cited challenge associated with the transition
    from military to civilian life.\2\ Further, robust data generated by
    the IVMF's AmericaServes initiative highlights that nearly half of
    those who transition experience co-occurring needs for transition
    support--needs that typically require assistance from multiple
    providers and across multiple sectors and domains (e.g. employment and
    education; health and transportation).
    ---------------------------------------------------------------------------
        \2\ Maury, R. & Zoli, C. (November 18, 2015). Missing perspectives:
    servicemembers' transition from service to civilian life. The Institute
    for Veterans and Military Families. Retrieved May 17, 2019 from https:/
    /ivmf.syracuse.edu/article/missing-perspectives-servicemembers-
    transition-from-service-to-civilian-life/
    ---------------------------------------------------------------------------
        The issue of co-occurrence is critically important to acknowledge
    and understand in the context of any legislation proposed for the
    purpose of enhancing mental health outcomes for veterans and their
    families. This is because any clinical mental health intervention is
    most effective when aligned with quality housing, financial stability,
    social connectivity, and employment supports.\3\ Importantly, it is
    often the case that such complementary services and supports are
    already funded and in place within the communities our veterans call
    home, however those resources are too often unknown or inaccessible to
    veterans.
    ---------------------------------------------------------------------------
        \3\ The Institute for Veterans and Military Families. (December
    2018). A case for patient philanthropy, supporting jobs and careers for
    military-connected americans. Retrieved May 17, 2019 from https://
    ivmf.syracuse.edu/wp- content/uploads/2019/02/Schultz-Report_A-Case-
    for-Patient-Philanthropy-1.31.19.pdf
    ---------------------------------------------------------------------------
        In fact, this insight represents the seminal premise of the IVMF's
    AmericaServes program; that is, the recognition that the physical and
    mental health of our veterans is impacted in ways that go beyond
    clinical care, but extends to the many social determinants of health
    and mental well-being. These social determinants include meeting basic
    needs (food, shelter), vocational success and fulfillment, and
    regaining positive connections with family, friends, and the broader
    community, among others.
        Importantly, acknowledging these co-occurring needs is, by itself,
    insufficient.
        Instead, government, industry, and non-profit partners must act
    with intent to support effective and efficient navigation to public and
    private sector resources, positioned to bolster the economic and social
    determinants of health and mental well-being. The IVMF's AmericaServes
    program, and other initiatives like AmericaServes, represent practical
    validation of this premise.
        Today, in 17 communities across the U.S.--including New York City,
    Pittsburgh, Charlotte, San Antonio, and Dallas--AmericaServes provider
    networks represents the backbone infrastructure supporting effective
    and efficient navigation to public and private sector resources aligned
    to advance social, economic, and wellness outcomes for veterans and
    their families. To date, more than 25,000 veterans have registered more
    than 52,000 requests for community-connected, human service support
    (spanning 20 health and human service categories) through the
    navigation and care coordination infrastructure provided by the
    AmericaServes network.
        All of this is to assert that, for the intent of the proposed
    legislation to be realized, it is critical to consider the means and
    mechanisms appropriate to empower those veterans seeking care and
    services, to efficiently and effectively navigate the full complement
    of services and supports available to them.
        Summary Conclusion: As drafted, S. 785 includes (Title II) funding
    for robust and meaningful tools that undercut the crisis of veteran
    suicide, such as grants to local providers, feasibility studies related
    to complementary mental health services, and new interventions
    including outdoor therapy. Yet, as currently drafted, S. 785 could
    include a greater acknowledgement--and therefore practical focus--
    related to the persistent challenges cited by veterans associated with
    navigation and coordination, in the context of the holistic provision
    of wellness, mental health, and associated social services.
        Most simply, to maximize the efficacy and impact of the investments
    detailed in S. 785 as currently drafted, our research and practical
    experience suggest that it is imperative to engage local community and
    government organizations, capable and willing to provide care
    coordination and navigation services at the community level. The
    objective of such a focus should be to transparently connect veterans
    experiencing compromised mental health, to local providers representing
    the full spectrum of human service categories. Examples of how this
    engagement could proceed include incorporating specific grant funding
    to support care coordination and navigation services in local
    communities; making funding accessible to local government to support
    city and or county-level care coordination; and funding for community-
    level resource mapping, aligned with the objective of enhancing
    information available to veterans related to the full spectrum of
    public, private, and non-profit providers of social and human services
    within a given community.
                                 issue area 2:
    Enhanced access to educational and vocational services--before, during,
            and after transition--aligned with post-service jobs and
            careers
        Another opportunity, often less understood in the context of
    efforts to enhance mental health outcomes for veterans, relates to the
    importance of employment and associated vocational training at the time
    of transition. The consequences of unemployment and under-employment
    for the veteran and his or her family, particularly immediately
    following the transition to civilian life, are profound and well-
    documented.
        For example, unemployment or underemployment at the time of
    transition has been demonstrated to undermine the long-term financial
    health of the family unit, contribute to marginalized health outcomes,
    and has even been linked to an increased rate of suicidal ideation
    among veterans.\4\ \5\ The IVMF's research has contributed to this
    strongly supported finding, particularly as situated in the post-9/11
    generation of veterans and military-connected families.
    ---------------------------------------------------------------------------
        \4\ Ibid.
        \5\ Kline, A., Ciccone, D., Falca-Dodson, M., Black, C. & Losonczy,
    M. (December 2011). Suicidal ideation among national guard troops
    deployed to iraq: the association with postdeployment readjustment
    problems. The Journal of Nervous and Mental Disease. Volume 199 Issue
    12 pp. 914-920. Retrieved May 17, 2019 from https://journals.lww.com/
    jonmd/Abstract/2011/12000/
    Suicidal_Ideation_Among_National_Guard_Troops.4.aspx
    ---------------------------------------------------------------------------
        For example, research conducted jointly between Blue Star Families
    and the IVMF recently found that 16% of veteran respondents who were
    not currently working, but were seeking employment, reported (serious)
    suicidal ideations in the past year. This compares to 7% of those who
    were currently working full-time (who seriously considered suicide in
    the past year), 8% of those working part time, 9% of those who were not
    currently working and not seeking employment, and 7% of those who were
    retired.\6\
    ---------------------------------------------------------------------------
        \6\ 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
    ---------------------------------------------------------------------------
        Veteran unemployment is low, but some research suggests that the
    economic and financial gains of military families may be slowing.\7\ In
    fact, employment data alone reveals very little about the nature of the
    employment secured by those veterans who are successful finding work
    after service. In truth, a great many veterans find themselves
    underemployed with respect to their level of skill, experience, and
    education.\8\ Further, recent studies reveal that more than 50% of
    veterans leave their first job after the military within a year,
    suggesting a sub-optimal employment transition with regard to issues of
    `fit.' \9\
    ---------------------------------------------------------------------------
        \7\ Hosek, J. & Wadsworth, S. (Fall 2013). Economic conditions of
    military families. The Future of Children. Retrieved May 17, 2019 from
    https://www.questia.com/read/1G1-349721081/economic-conditions-of-
    military-families
        \8\ Barerra, Cathy and Phillip Carter. Challenges on the Home
    Front: Underemployment Hits Veterans Hard. Santa Monica, CA: The Call
    of Duty Endowment, 2017. Retrieved at https://
    d3n8a8pro7vhmx.cloudfront.net/callofduty/pages/1236/attachments/
    original/1510192920/ZipCODE_Vet_Report_FINAL.pdf?1510192920.
        \9\ Maury, Rosalinda V., Brad M. Stone, Deborah A. Bradbard,
    Nicholas J. Armstrong, and J. Michael Haynie. Workforce Readiness
    Alignment: The Relationship Between Job Preferences, Retention, and
    Earnings. (Workforce Readiness Briefs, Paper No. 3). Syracuse, NY:
    Institute for Veterans and Military Families, Syracuse University,
    August 2016. Retrieved at https://ivmf.syracuse.edu/wp-content/uploads/
    2016/08/USAA_paper3_8.30.16_REVISED_digtial.pdf.
    ---------------------------------------------------------------------------
        Given the compelling relationship between employment and mental
    health, it is imperative that we remain focused on the importance of
    employment and associated vocational training at the point of
    transition. While approximately 65% of veterans report participating in
    the Transition GPS or some type of government- sponsored transition
    programming, only half (50%) of those who attended felt that the
    programming prepared them to successfully transition from active duty
    to civilian life.\10\
    ---------------------------------------------------------------------------
        \10\ 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
    ---------------------------------------------------------------------------
        The IVMF's Onward to Opportunity (O2O) represents a blueprint for
    what is possible when public-private partnership is positioned to
    address the relationship between post-service jobs and careers, and
    veteran health and well-being.
        The O2O program is a first-of-its-kind transition initiative, built
    to support a holistic approach to post-service career preparation,
    search, and placement. The O2O model supports participant access to
    specialized training and certification opportunities--both in-residence
    at 18 military installations, and online--representing 32 in-demand
    learning pathways, and a network of more than 800 post-training
    partners and employers across the United States and the globe. Today
    the O2O program represents the largest national footprint among the DOD
    approved Career Skills Programs. Specifically, since the program's
    inception in 2015, the O2O program has served as a pathway to jobs and
    careers for more than 13,000 veterans, transitioning servicemembers,
    and spouses, and supported thousands more to higher-education and
    vocational training.
        Most simply, the intent of the O2O program is to complement TAP
    GPS, in a way that is aimed at improving the long term career
    trajectory of our veterans. Certifications like project management,
    cybersecurity and IT provide participants with actionable skills
    training that will improve their immediate job marketability and set
    them up for long term employment success.
        A long-term focus on employability at transition--made possible by
    programs such as Onward to Opportunity--is critically important both
    for the veteran, and for all Americans.
        Current projections related to the costs associated with veteran's
    benefits--to include unemployment compensation--are expected to exceed
    $1 trillion.\11\ Moreover, given the strong linkage between employment
    and wellbeing, this estimate would trend significantly higher in the
    face of any extended period of economic depression, which would in turn
    create an additional financial burden on the Department of Veterans
    Affairs, private health care systems, and on other Federal supportive
    services.
    ---------------------------------------------------------------------------
        \11\ Bilmes, Linda J. (2016). A Trust Fund for Veterans. Democracy
    39, no. 16 (2016).
    ---------------------------------------------------------------------------
        Most simply, sustained and meaningful employment represents a
    seminal building block supporting a happy and healthy post-service
    life. Given purposeful efforts to address moralized mental health and
    suicide among veterans, it is therefore important to assume a broad
    view of the means and mechanisms positioned to bolster mental health
    outcomes associated with the veterans' community.
        That broad view must include enhanced access to educational and
    vocational services aligned with post-service jobs, careers, and long-
    term employability. Without qualification, employment represents a
    central pillar supporting the foundation of mental wellness during and
    after the transition to civilian life.
        Summary Conclusion: Title I of this Act, focused on improvement of
    transition experience for veterans, offers an opportunity to draw a
    legislatively mandated connection between improved mental health and
    quality employment transition programs. Our experiences have shown us
    that quality employment programs are also suicide prevention programs.
    As drafted, section 103 calls for a study of community-based transition
    programs. While this is an important step, the opportunity for more
    immediate action is real and should be considered by the Committee.
        Mental health related dollars would be best directed for impact, in
    those instances where funding is aligned with complementary efforts to
    support long-term employability of veterans, in the face of a rapidly
    changing workforce. We emphasize the role of non-public organizations
    because government services can be even more effective when enhanced
    and supplemented by the ecosystem of other service providers.
        Specifically, the Committee should explore opportunities to work
    with the Committee on Armed Services to assess and, where appropriate,
    expand the current SkillBridge authority as a strategy to enhance
    connections between veterans, employers, and those non-public entities
    already equipped to deliver employment services to veterans and their
    families; create new and enhanced access to TAP GPS for the Nation's
    employers; incorporate grant opportunities to expand the scale and
    scope of those non-public entities already equipped to deliver
    employment services to veterans and their families; and mandate and
    fund a longitudinal study focused on informing the relationship between
    TAP GPS and related access to employment programs, and the long-term
    mental health situation of veterans and their families.
                                 issue area 3:
    Purposeful and robust pathways connecting veterans and their families
            to the communities where they live, work, and raise their
            families
        Less acknowledged in the context of both veterans policy and public
    discourse, is the fact that our post-9/11 wars are the first in the
    Nation's history to be shouldered by a military composed entirely of
    volunteers. One consequence of that fact is a real and significant
    social and cultural divide, present between those who have served, and
    those who have not. This ``civilian-military divide'' serves to, in
    insidious ways, foster among some veterans a feeling of social
    isolation and disconnectedness. Social disconnectedness, in turn, is
    powerfully and directly linked to compromised mental health and suicide
    among veterans.
        Decades of scholarly research highlight how and why enhancing
    social connectedness--for all people--correlates directly to enhanced
    mental and even physical health. Research specifically situated in the
    veterans' community demonstrates that social and community
    connectedness during transition is strongly associated with the quality
    of a veteran's mental health. This is true even among servicemembers
    long out of the military, indicating that transition experiences,
    particularly tied to one's sense of belonging to broader community,
    have a long-term impact on health and well-being.\12\
    ---------------------------------------------------------------------------
        \12\ Ibid.
    ---------------------------------------------------------------------------
        Too often, well-intentioned policy fails to leverage opportunities
    to purposefully engage the community of non-public sector providers,
    for the specific purpose of `building community' in a way that fosters
    social and community connectedness among veterans. With approximately
    45,000 nonprofit organizations serving veterans and military families--
    and tens of thousands more providing social services to the general
    public--a tremendous opportunity exists for the private and independent
    sectors to work in partnership with government on the issue of
    enhancing social connectedness in support of the wellness needs of
    veterans and their families.\13\
    ---------------------------------------------------------------------------
        \13\ Government Accountability Office. (April 2014). 2014 annual
    report: additional opportunities to reduce fragmentation, overlap and
    duplication and achieve other financial barriers. GAO-14-343. Retrieved
    May 17, 2019 from https://www.gao.gov/assets/670/662327.pdf
    ---------------------------------------------------------------------------
        For veterans, effective interventions supporting social
    connectedness must be rooted in their communities, alongside an
    integrated continuum of supportive services. Yet, we know from research
    and practice that these and other services are often fragmented and
    siloed. We also know that many community-based organizations and
    service providers lack the ability to offer culturally competent care
    to veterans in their community, simply because the opportunity to learn
    and understand the military service experience isn't broadly available
    to many of those who would otherwise act in support of this community.
        Any and all efforts to improve transition--and to improve veteran
    mental health outcomes--must be foundationally grounded in support for
    community-based organizations and service providers, so as to enable
    those organizations and providers to offer culturally competent care
    and better integrate and coordinate their activities across a
    culturally competent continuum of supportive services in the places
    where our veterans live, work, and raise their families. When providers
    and communities are able to create a culturally competent continuum of
    supportive services, such action fosters trust, connectedness, and
    enhanced mental and physical health.
        Summary Conclusion: There is an extensive ecosystem of providers
    across the country equipped to serve veterans and improve their mental
    wellness. As drafted, this legislation makes considerable investment in
    new public sector programs, delivered through the VA, and developing
    the workforce needed to deliver them. While this enhanced support is
    needed and appropriate, it must be paired with focused effort to
    leverage and maximize existing capacities of local providers across the
    country.
        It is our recommendation that investment focused toward enhancing
    the clinical workforce equipped to deliver service through the VA,
    should be complemented with investments positioned to educate and
    engage non-public sector providers--specifically those entities and
    organizations who offer services and supports positioned to foster
    social and community connectedness among veterans. Doing so would prove
    cost effective over the long-term, and generate enduring gains related
    to the mental health of our veterans.
        In practice, this suggests the current legislation should consider
    mechanisms to incentivize local providers to bridge there services and
    supports to veterans in their community; enhanced opportunity for
    community organizations and non-profit providers to access military
    cultural competency training; enhanced opportunity for employers and
    educational institutions to engage veterans and their families prior to
    and during the transition to civilian life; a purposeful public
    information campaign, targeted toward human service providers and local
    governments, focused on the opportunities associated engaging veterans
    across the spectrum of community issues and concerns.
                                   conclusion
        In conclusion, on behalf of the veterans and military-connected
    families we serve in partnership with this Committee, thank you for the
    opportunity to provide written testimony on S. 785, be it enacted, the
    Commander John Scott Hannon Veterans Mental Health Care Improvement Act
    of 2019.
        Our testimony reflects the accumulated insights of our research and
    programmatic experience, supporting the transition experience of
    veterans and their families over the past decade. Those learnings
    suggest that central to any holistic strategy positioned to support the
    overall mental wellbeing of our veterans, are effective and efficient
    navigation to community-connected wellness and mental health resources,
    enhanced access to educational and vocational services and supports,
    and accessible pathways connecting veterans and their families to their
    communities.
        To that end, grant-making represents a powerful mechanism of the
    Federal Government related to driving community action on an issue such
    as mental health and suicide prevention. Federal grants like Supportive
    Services for Veteran Families (SSVF) can serve as a model for how
    Federal action can empower communities to act--with intent and
    accountability--related to impacting this nationally important issue.
        In that vein, we respectfully suggest that S. 875 can be further
    enhanced by grant funding opportunities beyond clinical interventions,
    to include expanded access to complementary human services and
    vocational supports, and also innovations enhancing community-connected
    care coordination and navigation. An investment of this type will
    enhance and extend the impact of funds directed to clinical mental
    health interventions, and most importantly best serve the enduring
    health and wellness concerns of our veterans and their families.

                                     ______

     Letter from Neal Loidolt, President/CEO, Minnesota Assistance Council
                                  for Veterans

                  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

            Statement from Military Officers Association of America
        Chairman Isakson, Ranking Member Tester, and Members of the Senate
    Committee on Veterans' Affair, The Military Officers Association of
    America (MOAA) is pleased to submit its views on pending veterans'
    legislation under consideration.
        MOAA does not receive any grants or contracts from the Federal
    government.
                               executive summary
        On behalf of the 350,000 members of the Military Officers
    Association of America, the largest military service organization
    representing the seven uniformed services, including active duty and
    Guard and Reserve members, retirees, veterans, and survivors and their
    families, thank you for holding this hearing and for your continued
    commitment to the Department of Veterans Affairs (VA) and support to
    our Nation's servicemembers and veterans and their families.
        MOAA offers our position on the following bills:

         S. 318, VA Newborn Emergency Treatment Act
         S. 514, Deborah Sampson Act
         S. 711, Care and Readiness Enhancement for Reservists Act
    of 2019
         S. 746, Department of Veterans Affairs Website
    Accessibility Act of 2019
         S. 785, Commander John Scott Hannon Veterans Mental Health
    Care Improvement Act of 2019
         S. 850, Highly Rural Veteran Transportation Program
    Extension Act
         S. 1154, Department of Veterans Affairs Electronic Health
    Record Advisory Committee Act
         DRAFT Bill, Janey Ensminger Act of 2019

        The association recommends funding be appropriated to support any
    legislative provisions directing expansion of VA programs or services
    in the bills listed above, where funding has not been identified but
    will be required, or for the establishment of new programs and services
    not already provided for in VA's current and advance budget
    authorities.
        MOAA takes no position on: S. 123, Ensuring Quality Care for Our
    Veterans Act; S. 221, Department of Veterans Affairs Provider
    Accountability Act; S. 450, Veterans Improved Access and Care Act of
    2019; S. 524, Department of Veterans Affairs Tribal Advisory Committee
    Act of 2019; S. 805, Veteran Debt Fairness Act of 2019; S. 857, A bill
    to amend title 38, United States Code, to increase the amount of
    special pension for Medal of Honor recipients, and for other purposes;
    S. 980, Homeless Veterans Prevention Act of 2019; S. 1101, Better
    Examiner Standards and Transparency for Veterans Act of 2019; and,
    Draft Bill, A bill to amend title 38, United States Code, to extend the
    authority of the Secretary of Veterans Affairs to continue to pay
    educational assistance or subsistence allowances to eligible persons
    when educational institutions are temporarily closed, and for other
    purposes. These bills are outside of our scope of expertise or
    familiarity with the current state of the issues.
                              pending legislation
    S. 318, VA Newborn Emergency Treatment Act (Senator Patty Murray, D-
            Wash.)
        MOAA supports the legislation.
        The association has long supported legislation to extend health
    care coverage to newborn children of women veterans. This bill would:

         allow VA to furnish medically necessary transportation for
    newborns,
         provide a waiver process for the extension of that care if
    there is a medical need,
         allow the Secretary to waive the current seven-day
    restriction on health care coverage, and
         close an existing gap to allow newborn coverage for
    mothers who delivered before they reached the hospital, who would
    otherwise qualify for the coverage.

        MOAA is appreciative of the Committee's work in recent years to
    provide care and services for a growing population of women veterans
    who are of child-bearing age. This bill is not only critical to the
    long-term health of both the child and mother, but also will help new
    parents avoid the hardships and significant costs associated with
    delivery under emergency conditions.
        The association would respectfully request the Committee consider
    adding to the bill an extension of care from the mandatory seven days
    to 14 days to cover all newborns. This change would align with S. 514,
    the Deborah Sampson Act, under consideration by the Committee today and
    supported by MOAA and other veterans' organizations during the last two
    congressional sessions.
    S. 514, Deborah Sampson Act (Senator Jon Tester, D-Mont.)
        MOAA supports the legislation as we endorsed in the 115th Congress.
        The measure would improve a number of services and benefits
    provided by VA to women veterans. Generally it would:

         expand group counseling and the department's women
    veterans call center capabilities,
         expand the number of days of maternity care, including
    newborn care, from seven to 14 days,
         increase staffing of gender-specific health care providers
    and training to non-VA community providers,
         retrofit existing medical facilities to improve privacy
    and environmental care conditions for women veterans, and
         increase grants for organizations supporting low-income
    women veterans, including legal services and additional resources for
    homeless women and their families.

        While VA has worked hard in recent years to get ahead of the
    growing demand of women seeking health care in the department's medical
    facilities (at higher rates than their male peers), barriers still
    exist preventing women from accessing medical care or feeling welcomed
    and safe.
        Eliminating these barriers will require additional funding and
    resources to implement massive system improvements and services in
    order to meet the current and future needs of women veterans. MOAA is
    pleased the Committee and VA continue to work hard to provide the
    authorizations and appropriations necessary to help the department
    succeed. This legislation starts to put in place the parameters and
    governance needed to monitor and evaluate VA's progress in addressing
    the needs of this unique veteran population.
    S. 711, Care and Readiness Enhancement for Reservists Act of 2019
            (Senator Jon Tester, D-Mont.)
        MOAA supports the legislation.
        The bill would expand eligibility for mental health services in VA
    for reservists of the Armed Forces. In consultation with the Department
    of Defense (DOD), the VA may furnish a comprehensive assessment and
    counseling to any member of the reserve components who has a behavioral
    health condition or psychological trauma. DOD may fund the needed care
    regardless of whether the reservist is within his or her pre-deployment
    window.
        Guard and Reserve members also may access confidential VA
    readjustment counseling services, known as ``Vet Centers,'' for mental
    health screening and counseling, employment assessments, education
    training, and other services to help them transition successfully back
    to civilian life.
        MOAA considers this legislation critical and timely to addressing
    the mental health needs of the total force and not just active duty
    servicemembers. However, MOAA urges the Committee to expand the
    legislation to include servicemembers of all the uniformed services, as
    the U.S. Public Health Service and the National Oceanic and Atmospheric
    Administration Commissioned Corps also play a vital role in national
    security and emergency response efforts.
        This legislation will complement VA's current efforts aimed at
    improving mental health care and support to Guard and Reserve members
    and help mitigate the rising rates of mental health conditions and
    suicides being reported in the reserve components.
    S. 746, Department of Veterans Affairs Website Accessibility Act of
            2019 (Senator Robert Casey, D-PA.)
        MOAA supports the legislation.
        The measure would require the Secretary to conduct a study of the
    accessibility of VA websites to individuals with disabilities.
        MOAA and veterans service organizations (VSOs) continue to hear
    from veterans with disabilities, particularly those with hearing or
    visual impairments, about their difficulty accessing information,
    products, and services in a manner that helps them effectively
    communicate with VA in appropriate accessible formats. Accessing VA
    website information has frequently been a source of frustration to this
    population of veterans, who believe VA has not been able to keep up
    with the technological changes and/or has not devoted adequate
    resources to ensure compliance with Section 508 of the Rehabilitation
    Act of 1973, 29 U.S.C. 794d, which ``applies to all Federal agencies
    when developing, procuring, maintaining, or using electronic and
    information technology. Under Section 508, agencies must give disabled
    employees and members of the public access to information comparable to
    the access available to others.''
        The department would be required to conduct a study of all websites
    within 180 days after enactment of the Act and to submit a report to
    both the Senate and House Veterans' Affairs Committees, to include a
    list of websites not accessible to individuals with disabilities and a
    plan for bringing the sites into compliance or identifying barriers
    preventing VA from meeting the requirements of Section 508.
    S. 785, Commander John Scott Hannon Veterans Mental Health Care
            Improvement Act of 2019 (Senator Jon Tester, D-Mont., and
            Senator Jerry Moran, R-Kan.)
        MOAA supports the legislation.
        The association is grateful for this comprehensive and innovative
    piece of legislation aimed at improving mental health care delivered in
    the VA health system by:

         providing care for transitioning servicemembers,
         providing suicide prevention resources,
         launching programs and studies on mental health,
         increasing oversight of mental health care and suicide
    prevention efforts, and
         enhancing medical workforce and telehealth services.

        MOAA is particularly pleased to see the incorporation of a variety
    of ideas and contributions from multiple stakeholders, including
    veterans' organization like ours, mental health awareness groups, and
    other advocacy organizations to produce this landmark bill.
        As stated in our testimony at the Senate and House Veterans'
    Affairs Committee Hearing March 12, 2019, there is no doubt VA has made
    great strides in expanding its health care services to help veterans
    with mental health conditions. However, these efforts aren't enough to
    address the growing demand for mental health services and the
    frightening statistics related to veteran suicides.
        This legislation is exactly what is needed to close existing gaps
    so VA can deliver the kind of wrap-around services and continuity of
    care so desperately needed by veterans suffering from mental health or
    traumatic conditions.
    S. 850, Highly Rural Veteran Transportation Program Extension Act
            (Senator Dan Sullivan, R-Ark.)
        MOAA supports the legislation.
        This legislation would extend VA's authority to award grants to
    VSOs who provide transportation to veterans in highly rural areas.
        Extending the program helps ensure coverage of underserved
    populations, including American Indians and Alaska Natives.
        Additionally, transportation for aging veterans and those with
    disabilities continue to be a barrier to accessing care in VA. This
    legislation not only builds on the existing work the VA has undertaken
    to improve access for Native Americans and rural veterans but also
    supports the larger and growing population of aging veterans who not
    only have mobility issues but also are at or below poverty level or
    live on fixed incomes, preventing them from seeking critical health
    care services.
        Currently, VA covers travel expenses for care at VA medical centers
    and community-based outpatient clinics. Vet Centers provide a critical
    capability within VA's health system, thus inclusion of these
    facilities for purposes of payment for beneficiary travel and
    allowances should also be a covered benefit for consistency and
    continuity of care throughout the system.
        MOAA recommends funds be appropriated to support the extension of
    the program to continue providing grants to VSOs to help augment VA's
    current efforts to provide transportation to this unique population of
    highly rural veterans with special needs. We believe medical care and
    services, including associated travel expenses and allowances, are
    central components to opening up access and delivering high-quality
    health care to our veterans.
    S. 1154, Department of Veterans Affairs Electronic Health Record
            Advisory Committee Act (Senator Jon Tester, D-Mont.)
        MOAA supports the legislation.
        This bill would require the establishment of an advisory committee
    to provide guidance to the Secretary and Congress on the implementation
    of the electronic health record (EHR) and the department's transition
    to the new system. Duties of the advisory committee include touring VA
    facilities as those medical centers begin using the electronic health
    record to analyze implementation and to solicit feedback from
    employees. MOAA believes it is important to ensure the voices of
    stakeholders, veterans, and other participants in the transition
    process of moving to a new EHR are heard and elevated to leadership.
        We are encouraged and view this legislation as a positive step
    toward providing better accountability through enhanced stakeholder
    representation, which importantly includes clinical and technical
    expertise, as well as key VSOs. It is important to have a committed
    external audience reviewing the EHR implementation actions to help
    identify and mitigate risks for veterans.
        MOAA believes successful transformation to a more veteran-centric
    health care system will only occur once VA fully implements and
    achieves an integrated, interoperable EHR system--something MOAA,
    Congress, and other veterans stakeholders have been pressing hard to
    achieve for two decades.
    Draft Bill, Janey Ensminger Act of 2019 (Senator Richard Burr, R-N.C.)
        MOAA supports the legislation.
        This measure would require the VA to provide medical care for all
    diseases scientifically associated with exposure to toxic chemicals
    found at Camp Lejeune, N.C. The bill also requires the Agency for Toxic
    Substances and Disease Registry, an agency within the Centers for
    Disease Control and Prevention, to review all significant scientific
    literature every three years to determine if links have been found
    between toxic exposures found at Camp Lejeune and additional diseases
    and conditions.
        Establishing a national center for research on the diagnosis and
    treatment of health conditions of the descendants of individuals
    exposed to toxic substances during service is a reasonable manner in
    which to collect information related to the long-term health effects of
    these exposures. An advisory board taking responsibility for advising
    the national center, determining health conditions that result from
    toxic exposure, and studying and evaluating cases of exposure is also a
    reasonable mechanism to ensure VA weighs the relevant evidence and
    information in its implementation and continued engagement.
                                   conclusion
        MOAA greatly appreciates the hard work of the Committee in holding
    this hearing. We are especially grateful for your efforts in bringing
    forward legislation from previous years for consideration, and for
    introducing new bills--all aimed at improving the health and well-being
    of our uniformed servicemembers, veterans, and their family members.
    The association looks forward to working with the Committee to ensure
    swift passage of the bills through Congress.
                                     ______

      Letter from John P. Moser, MSgt USAF (Ret.) to Hon. Sherrod Brown,
                             U.S. Senator from Ohio
        Senator Brown, I wish to convey to you my personal interest in
    Veteran's Debt Fairness Bill.
        My interest in this bill stems from 10 years of over payments by
    the VA totaling some $26,000. These over payments were the result of
    negligence by the VA regarding adjusting compensation due to concurrent
    receipt of Air Force Reserve Drill Pay and VA Compensation. I received
    the notices each year from Defense Manpower stating that I had served
    so many days and did I wish to waive my drill pay or my VA Comp. Each
    year I waived comp as it was considerably less than my reserve pay.
    Each year nothing would happen. The compensation was never adjusted and
    the VA never sent any notices stating they were going to adjust for
    concurrent receipt. After several years, multiple phone calls, etc., I
    gave up. I noticed on the ``notice of concurrent receipt,'' a
    statement, which I took to heart. It stated, '' Should we not receive
    your waiver request, we will assume you waive your VA compensation for
    the year and days indicated.'' It was then I decided that I do not need
    to waste my time, my commander's time, effort, etc. if the compensation
    was to be waived anyway. The compensation was never adjusted.
        I retired in September 2015. After 23 years of faithful and
    honorable service, some 11 deployments (that I can remember), 50 combat
    and combat support missions in the Middle East, the VA determined that
    it was time to collect for every year I received concurrent benefits,
    2005-2015. The debts/overpayments totaled some $26,000. $3000 or so was
    the result of an education benefit error on my part, which I accepted
    responsibility for and paid. In September 2016, the VA took my entire
    monthly benefit. I counted on that compensation for car payments. I had
    received a couple of letters/notices in the mail stating the benefit
    would be reduced and that I had an overpayment. Each notice of
    overpayment/debt was very confusing and difficult to understand. When I
    called the VA Regional office, they were of no help. I only grew more
    confused. In January 2018, I finally have a payment plan in place with
    Debt Management. It only took some 18 months to settle and the burden
    of proof was 100% on me. Ironically, it only took the VA less than 60
    days to start garnishing my compensation once they found the
    overpayment. I currently have an active waiver claim on file with the
    VA and process can take 3-7 years. Is this fair to our Nation's
    veterans?
        Sir, it is my belief that the Veteran's Debt Fairness Bill would
    prevent this from happening to future veterans and maybe even help
    current ones as well. It states in the proposed legislation that if
    there is no fault of the veteran then the VA can do nothing about that
    over payment. The VA also has no timetable to recoup these over
    payments. The bill would limit their time to 5 years if my
    understanding is correct. It is also my understanding and experience
    that the VA can withhold a veteran's entire benefit until debts are
    recovered. I ask you Sir, is this fair? What if that veteran's only
    income was VA compensation? What if he/she was already dealing with a
    failed marriage, PTSD, struggling to reintegrate to society after
    serving, or homeless? What then Sir? This bill would limit the amount
    the VA can garnish to 25% of the veteran's compensation.
        The VA is in dire need of reform. I truly believe this bill is an
    excellent start.
        I would be willing to testify before your committee about my
    experiences and tribulations with the VA and its debt collection
    practices to support this bill.
        I have been involved with many veterans who share my experiences.
    In 2016 alone, some 200,000 over payments totaling over $1.06 trillion
    dollars were sent to veterans. These over payments can not all be the
    fault of the veteran. Let's change this!
        Thank you for your attention in this matter and for your
    considerations of my testifying in support of Veteran's Debt Fairness
    Bill. Our veterans deserve it!
                Sincerely,
                                                          John P Moser,
                                                          MSgt USAF (Ret.).
                                     ______

     Prepared Statement of Angela Kimball, Acting Chief Executive Officer,
                      National Alliance on Mental Illness
        Chairman Isakson and Ranking Member Tester, on behalf of the
    National Alliance on Mental Illness (NAMI), I am pleased to offer our
    organization's strong support for the Commander John Scott Hannon
    Veterans Mental Health Care Improvement Act of 2019 (S. 785). NAMI
    urges this Committee to advance this important bipartisan effort to
    reduce veteran suicide and improve mental health outcomes through
    expanded access to care, better diagnostic tools, and increased
    oversight of U.S. Department of Veterans Affairs (VA) programs.
        NAMI is the Nation's largest grassroots mental health organization,
    dedicated to building better lives for the millions of Americans
    affected by mental illness. NAMI envisions a world where all people
    affected by mental illness experience resiliency, recovery, and
    wellness.
        NAMI commends both you, Senator Tester, and your colleague Senator
    Moran for introducing S. 785. We are proud to join you in celebrating
    the legacy of retired Navy SEAL Commander John Scott Hannon, who served
    for 23 years and fought a courageous battle with post-traumatic stress,
    Traumatic Brain Injury, and bipolar disorder. CDR Hannon embodies the
    strength of veterans living with mental health conditions, and this
    bill exemplifies his passion and efforts to improve access to veterans'
    mental health care as a member of NAMI Montana.
        NAMI is proud to have worked with a bipartisan group of legislators
    on key components of the bill, including increasing access and
    continuity of care for veterans in need of coordinated support. NAMI
    advocates for improving mental health and brain condition diagnostics
    because an accurate, quick, and early diagnosis has the potential to
    save countless lives and is a critical step to effective care. We are
    dedicated to working with the VA, legislators, and researchers to
    improve the process and get veterans the treatment and care they need
    for their recovery.
        As NAMI Montana Executive Director Matt Kuntz has noted about his
    friend CDR Hannon, ``He was a long-time mental health advocate for
    America's veterans and believed strongly that the VA mental health care
    system, like every system, needs to take concrete steps to improve its
    ability to conduct its mission.'' This bill is a tangible step in the
    right direction to ensure that every veteran has the right care
    available to them at the right time.
        S. 785 seeks to improve veterans' mental health outcomes by
    increasing veterans' access to mental health care, particularly during
    transition, supporting innovative suicide prevention initiatives,
    launching programs and studies on mental health, increasing oversight
    of VA's mental health care and suicide prevention efforts, and
    enhancing VA's medical workforce and telehealth services. This
    legislation builds upon the President's Executive Order Number 13822
    and recommendations from mental health organizations, Veterans Service
    Organizations, the U.S. Government Accountability Office, and VA
    Advisory Committees.
        This bill aims to make improvements to VA mental health care that
    will have a lasting effect on the future of the diagnosis and treatment
    for mental health conditions. Among the many important provisions in
    this bill, NAMI is particularly grateful for the inclusion of the
    following in S. 785:

         Extending VA health care eligibility to veterans for a
    full year after transitioning from the Armed Forces and requiring the
    promotion of this eligibility during the Transition Assistance Program
    (TAP) and on VA's website.
         Directing the VA to conduct a computerized Cognitive
    Behavioral Therapy (CBT) program as a supplement to VA mental health
    care and carry out a study of veterans living at high altitudes who
    might be at an increased risk for dying by suicide.
         Creating the Precision Medicine for Veterans Initiative,
    modeled after the National Institutes of Health's All of Us program, in
    order to identify and validate brain and mental health biomarkers, with
    a focus on Post Traumatic Stress Disorder, Traumatic Brain Injury,
    depression, and severe anxiety disorders.
         Directing the GAO to conduct a management review of the
    Office of Mental Health and Suicide Prevention, report on how VA
    manages patients at high-risk for suicide, and report on the
    effectiveness of VA's efforts to integrate mental health care into a
    primary care setting, both within VA and between VA and community-based
    providers.
         Providing $10 million in funding to increase the number of
    locations for VA telehealth care.

        Mr. Chairman, NAMI is grateful to this Committee for the continued
    focus on ending veteran suicide and improving the lives and care of
    America's veterans. We wish to express our gratitude to the Committee
    for the invitation to submit a statement for the record on S. 785. It
    is a devastating tragedy that our Nation continues to lose an average
    of 20 veterans each day to suicide. We continue to commit our
    organization to working shoulder-to-shoulder with Congress, VA, the
    Department of Defense, and our advocacy partners to achieve our shared
    goal of the reduction, and eventual elimination, of suicide among
    veterans in America.
        NAMI congratulates Senators Tester and Moran for bringing forward
    this important legislation. We urge swift passage of S. 785 to improve
    mental health care among our Nation's veterans and advance the
    important cause of suicide prevention.
                                     ______

        Prepared Statement of the National Congress of American Indians
                                  introduction
        On behalf of the National Congress of American Indians (NCAI),
    thank you for holding this hearing on legislation to support veterans.
    Founded in 1944, NCAI is the oldest and largest representative
    organization serving the broad interests of tribal nations and
    communities. Tribal leaders created NCAI in 1944 in response to
    termination and assimilation policies that threatened the existence of
    American Indian and Alaska Native (AI/AN) tribal nations. Since then,
    NCAI has fought to preserve the treaty and sovereign rights of tribal
    nations, advance the government-to-government relationship, and remove
    historic structural impediments to tribal self-determination.
        NCAI is grateful for the Committee's consideration of legislation
    intended to better fulfill the Federal Government's commitment to
    providing for the wellbeing of Native veterans when they return home.
    S. 524, the Department of Veterans Affairs Tribal Advisory Committee
            Act of 2019
        Tribal nations have always held tribal citizens that serve in all
    branches of the U.S. Armed Forces in the highest esteem. Per capita,
    American Indians and Alaska Natives (AI/ANs) serve at a higher rate
    than any other group of Americans and have served in all of the
    Nation's wars since the Revolutionary War. Despite this long history of
    service, too often Native veterans have difficulty accessing the
    benefits they earned through their military service.
        S. 524, the Department of Veterans Affairs Tribal Advisory
    Committee Act of 2019, would begin to help address the challenges faced
    by Native veterans. This legislation establishes the Veterans Affairs
    Tribal Advisory Committee (VATAC), which would provide vital
    opportunities for collaboration, communication, and coordination
    between the Department of Veterans Affairs (VA) and tribal nations.
    Specifically, the VATAC would advise the Secretary on how to improve
    programs and services for Native veterans, identify timely issues
    related to Department programs, propose solutions to identified issues,
    provide a forum for discussion, and help facilitate getting useful
    feedback from across Indian Country.
        Building a strong relationship between the VA and tribal nations
    will increase awareness and understanding across the VA of the unique
    issues affecting Native veterans in tribal communities. This awareness,
    paired with more direct interaction with tribal leaders who regularly
    hear from Native veteran constituents will ultimately produce faster
    solutions and better services for AI/ANs that have served this country.
        Accordingly, NCAI supports the immediate passage of S. 524.
    S. 785 and S. 980
        NCAI would also like to provide testimony on two other bills:
    S. 785, the Commander John Scott Hannon Veterans Mental Health Care
    Improvement Act of 2019; and S. 980, the Homeless Veterans Prevention
    Act of 2019. Although not tribal-specific, each of these bills includes
    provisions that would help address significant issues impacting Native
    veterans across the United States.
        American Indians and Alaska Natives experience high rates of
    depression and psychological distress, which contributes to Native
    people having the highest suicide rate of any group in the United
    States.\1\ Suicide continues to be a major concern for AI/AN veterans.
    S. 785 includes provisions that could support mental health wellness
    services to Native veterans who face barriers in accessing mental
    health care services directly from the VA. Building capacity and
    increasing accessible mental health care services for Native veterans
    is a positive step toward ending this epidemic and ensuring a healthy
    future for tribal citizens that served this country. NCAI would like to
    work with the Committee to ensure that the provisions of this
    legislation will significantly reduce suicide rates among Native
    veterans.
    ---------------------------------------------------------------------------
        \1\ Leavitt RA, Ertl A, Sheats K, Petrosky E, Ivey-Stephenson A,
    Fowler KA. Suicides Among American Indian/Alaska Natives--National
    Violent Death Reporting System, 18 States, 2003-2014. MMWR Morb Mortal
    Wkly Rep 2018; 67:237--242. DOI: http://dx.doi.org/10.15585/
    mmwr.mm6708a1
    ---------------------------------------------------------------------------
        Additionally, when Native veterans return home from their military
    service, it is all too common that they face barriers to reestablishing
    themselves in civilian life, especially when it comes to obtaining safe
    and affordable housing. S. 980 would help eliminate those barriers by
    expanding access to legal assistance for housing and other purposes.
    Creating partnerships to increase access to legal services for Native
    veterans who are homeless or at risk of being homeless will help ensure
    that Native veterans can find housing and utilize other benefits
    provided through the VA.
                                   conclusion
        Thank you for the opportunity to provide testimony on this
    legislation, and we greatly appreciate the work of this Committee to
    address the many challenges and barriers faced by Native veterans. We
    look forward to working with this Committee to pass S. 524 and advance
    other Federal policies that support those who have served our Country.
                                     ______

               Letter from David C. Benton, RGN, PhD, FRCN, FAAN,
      Chief Executive Officer, National Council of State Boards of Nursing

                  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

              Prepared Statement of Paralyzed Veterans of America
        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee, Paralyzed Veterans of America (PVA) would like to thank you
    for the opportunity to submit our views on the broad array of pending
    legislation impacting the Department of Veterans Affairs (VA) that is
    before the Committee. No group of veterans understand the full scope of
    care provided by the VA better than PVA's members--veterans who have
    incurred a spinal cord injury or disorder. Most PVA members depend on
    VA for 100 percent of their care and are the most vulnerable when
    access and quality of care is threatened. Several of these bills will
    help to ensure veterans receive timely, quality care and services.
           s. 123, the ``ensuring quality care for our veterans act''
        PVA supports S. 123. This legislation requires VA to establish a
    third party process for the review of any instance in which a veteran
    has been treated by a VA provider later found to have a revoked
    license. It also requires VA to notify veterans if it is determined
    that an episode of care or services they received was below established
    levels for acceptable care. PVA supports this common sense approach to
    help protect the health and well-being of our Nation's veterans.
     s. 221, the ``department of veterans affairs provider accountability
                                     act''
        PVA supports S. 221, which requires VA to report major adverse
    personnel actions involving certain health care employees to the
    National Practitioner Data Bank and to applicable state licensing
    boards. We believe the key to providing exceptional health care to
    veterans starts with quality providers. If those providers have major
    adverse personnel actions, they should be reported to the proper
    licensing authorities to ensure they are unable to practice elsewhere
    within the VA health care system.
               s. 318, the ``va newborn emergency treatment act''
        PVA strongly supports S. 318. This legislation would correct a
    cruel oversight in newborn care furnished by VA. While women veterans'
    newborns may receive health care coverage up to seven days after birth,
    VA is not authorized to pay for any emergency transportation that a
    newborn may require to reach a different medical facility. Currently,
    veterans must pay the full cost of any ambulance or helicopter
    transportation needed to transport their newborns for emergency medical
    care. This legislation will ensure no veteran receives bills for this
    type of care again. Additionally, this legislation would waive any
    outstanding debts associated with medically-necessary emergency
    transportation services for a newborn. It would also expand the seven
    days of VA provided coverage through a waiver process for medically
    necessary care. We urge Congress to move quickly to advance this
    crucial legislation.
         s. 450, the ``veterans improved access and care act of 2019''
        PVA supports many efforts to bolster staffing levels at VA
    facilities, particularly within the Spinal Cord Injury System of Care,
    which historical data shows is one of the most difficult areas to
    recruit and retain nursing staff. S. 450 would create a limited pilot
    project to expedite the onboarding process for new medical providers.
    PVA agrees with this legislation's intent, but believes a pilot program
    unnecessarily delays this critical need at a time when Congress should
    be enacting legislation that directs VA to expedite its hiring
    processes department-wide.
                      s. 514, the ``deborah sampson act''
        PVA supports S. 514, which helps address some of the quality of
    care barriers that are unique to women veterans. From transition
    services, to health care access, to the availability of prosthetics,
    this bill is a critical and timely step to enhancing the health and
    well-being of women veterans and their families. As women veterans are
    the fastest growing population of veterans, we urge Congress to enable
    VA to fully meet the need for specialized services for women.
        This bill would initiate a program for peer-to-peer counseling for
    women veterans transitioning out of the military and make permanent the
    availability of readjustment counseling services in group retreat
    settings. Of the existing readjustment counseling retreats provided
    through VA, participants consistently showed better understanding of
    how to develop support systems and to access resources at VA and in
    their communities. They work with counselors and peers, building on
    existing support.
        If needed, there is financial and occupational counseling. These
    programs are marked successes and the feedback is overwhelmingly
    positive for women veterans, who show consistent reductions in stress
    symptoms as a result of their participation. Other long lasting
    improvements included increased coping skills. It is essential for
    women veterans that Congress make this program permanent. We believe
    the value and efficacy is undeniable.
        Importantly, the bill would also authorize hospital stays of up to
    14 days for newborns under VA care. VA currently allows a maximum stay
    of seven days. As the average stay for a healthy newborn is two days,
    any newborn needing additional coverage is likely to be facing
    complications immediate after birth or a severe infant illness. The
    current seven day coverage is in a non-department facility for eligible
    women veterans who are receiving VA maternity care. Beyond the seven
    days, the cost of care is the responsibility of the veteran and not VA,
    even if complications require continued care beyond the coverage
    period. Post-natal health is critical to newborn health which directly
    impacts the lives and well-being of veterans and their families. PVA is
    particularly concerned about those veterans with catastrophic
    disabilities that can cause high-risk pregnancies or pre-term
    deliveries. A seven day limit arguably impacts veterans with
    disabilities at a greater rate than other veterans. Extending newborn
    coverage to 14 days is the right thing to do.
        The legislation also aims to eliminate barriers to care. For
    example, it would ensure that every facility has at least one full-time
    or part-time women's health provider. Furthermore, an additional $20
    million would be authorized to carry out the retrofitting of existing
    facilities to improve privacy, safety, and environmental needs for
    women veterans. Finally, the bill would require data collection and
    reporting by gender and minority status on VA programs serving veterans
    and a reporting requirement on prosthetic availability for women
    veterans.
        This bipartisan legislation ensures women veterans receive the care
    and benefits they earned and we support its swift passage.
    s. 524, the ``department of veterans affairs tribal advisory committee
                                 act of 2019''
        PVA supports S. 524 which seeks to establish a VA Advisory
    Committee on Tribal and Indian Affairs. This advisory committee would
    help to foster better communication and understanding between VA and
    Tribal governments. The result will be improved access to VA health
    care programs, benefits, and services for Native American veterans.
      s. 711, the ``care and readiness enhancement for reservists act of
                                     2019''
        PVA supports S. 711, which allows the Department of Defense (DOD)
    to fund behavioral or mental health care for reservists, regardless of
    whether they are within the 180 day pre-deployment window, or have
    never deployed. It also directs VA to furnish mental health services
    for members of the National Guard and Reserves, and allows them to
    access veteran centers for mental health screening and counseling,
    employment assessments, education training, and other services to help
    them successfully transition to civilian life.
        Access to mental health services is a universal issue and we need
    to make certain that everyone who is serving or has served in uniform
    has access to the behavioral health services needed to help ensure no
    veteran is lost to suicide. This legislation compliments existing
    efforts to reduce this unnecessary loss of life by ensuring all members
    of the Reserve components have access to needed care.
    s. 746, the ``department of veterans affairs website accessibility act
                                   of 2019''
        PVA supports S. 746, which directs VA to study the accessibility of
    its website and related resources for veterans with disabilities and
    provide a report of its findings to Congress. Following the study, VA
    would be required to identify applications that are not accessible to
    such individuals and VA's plan to make each of them accessible.
        Section 508 of the Rehabilitation Act of 1973 requires Federal
    Government agencies to develop and maintain information and
    communication technology that is accessible to persons with
    disabilities. A formal review of VA's website and related resources to
    ensure compliance with the law is appropriate.
     s. 785, the ``commander john scott hannon veterans mental health care
                           improvement act of 2019''
        PVA supports S. 785, which seeks to strengthen and improve VA's
    mental health care services. Passage of this bill would enable VA's
    mental health workforce to serve more veterans by giving VA direct
    hiring authority for more mental health professions, offering
    scholarships to mental health professionals to work at Vet Centers, and
    placing at least one Suicide Prevention Coordinator in every VA medical
    center. It also improves rural veterans' access to mental health care
    by increasing the number of locations at which veterans can access VA
    telehealth services and offer grants to non-VA organizations that
    provide mental health services or alternative treatment to veterans.
        This legislation also provides greater support and assistance to
    servicemembers transitioning out of the military by giving them a full
    year of VA health care when they leave the military and improves
    services that connect transitioning veterans with career and education
    opportunities. We are further pleased that it expands veterans' access
    to animal, outdoor, or agri-therapy, yoga, meditation, and acupuncture,
    and investing in VA mental health research. Most importantly, it
    includes a host of studies and resources provisions specially targeted
    toward evaluating and improving VA mental health care programs and
    service with the goal of reducing veteran suicides in mind.
        We lose too many veterans each day to suicide and a concerted
    approach to reducing these numbers is badly needed. S. 785 offers a
    comprehensive approach toward improving the diagnosis and treatment for
    mental health conditions which, in the long term, will undoubtedly save
    lives.
               s. 805, the ``veteran debt fairness act of 2019''
        PVA supports S. 805. Failure to resolve debt issues in a timely
    manner can have a lasting, catastrophic impact on a veteran. If the
    Veterans Benefits Administration (VBA) sends out a notice of an
    overpayment of benefits, or some other circumstance producing a debt
    owed by the veteran, it is essential that VBA know whether that notice
    actually reached the veteran prior to the veteran going into default.
    Unfortunately, it is not uncommon for veterans to find that one part of
    VA has updated their contact information, while other parts of VA have
    not.
        We understand and support the Secretary's need to recover on debts,
    however, it must be done in a manner that maintains due process rights
    and is not unduly detrimental to the veteran. It is important to ensure
    that veterans are not going into default for lack of notice, especially
    in circumstances where the debt itself is a product of VA's mistakes
    and overpayments.
      s. 850, the ``highly rural veteran transportation program extension
                                     act''
        PVA supports extending the authorization of appropriations to VA
    for purposes of awarding grants to veterans service organizations for
    the transportation of highly rural veterans. Access to transportation
    is critical to ensuring that veterans receive the health care that they
    need in a timely manner.
       s. 857, a bill to increase the special pension for medal of honor
                                   recipients
        PVA supports S. 857. It has been close to fifteen years since the
    pension amount for Medal of Honor recipients was increased. With the
    great honor of this award comes a responsibility from them to share
    their stories and inspire their fellow citizens. Often times, this
    requires traveling and participating in events around the country. This
    responsibility should never become a financial burden on those who have
    already sacrificed so much. We support this bill which more than
    doubles the current pension amount to $3,000.00 per month.
            s. 980, the ``homeless veterans prevention act of 2019''
        PVA generally supports S. 980. Specifically, we support the
    provisions in this bill that would help keep veteran families together
    by allowing VA to house the children of homeless veterans in
    transitional housing programs; direct VA partnerships with public and
    private entities to provide legal services for homeless veterans and
    veterans at risk of becoming homeless; and grant VA the authority to
    provide dental care to homeless veterans.
        However, we do not support the provision allowing VA to stop
    reporting annually on its assistance programs for homeless veterans.
    The most recent figures show that 38,000 veterans across the country
    are without stable housing on any given night in America. Congress
    needs to continue to hold VA accountable, and require them to report on
    what programs are being provided.
    s. 1101, the ``better examiner standards and transparency for veterans
                                 act of 2019''
        PVA supports S. 1101, which would ensure that only licensed health
    care providers are conducting medical disability examinations on behalf
    of VA. Veterans must be able to receive their disability examinations
    from providers they can trust. We support its swift passage.
    s. 1154, the ``department of veterans affairs electronic health record
                            advisory committee act''
        S. 1154 creates an additional layer of accountability and oversight
    to ensure the development and roll out of the new Electronic Health
    Record (EHR) goes smoothly. The 11-member Committee would operate
    separately from VA and DOD and would be made up of medical
    professionals, Information Technology and interoperability specialists,
    and veterans currently receiving care from the VA. The Committee will
    analyze the VA's strategy for implementation; develop a risk management
    plan; tour VA facilities as they transition to the new system; and
    ensure veterans, VA employees and medical staff, and other participants
    have a voice in the process.
        The development of an integrated DOD/VA electronic health record
    has been beset with problems for years. We support the intent of
    S. 1154 because it is a positive step forward. We suspect, however, the
    Committee's efforts will only be successful if they are given equal
    latitude to work with, evaluate, and advise DOD on its portion of the
    EHR as well.
                  s. ___, the ``janey ensminger act of 2019''
        PVA understands and supports the intent of the draft legislation
    known as the ``Janey Ensminger Act of 2019.'' This legislation would
    amend the Public Health Service Act with respect to the Agency for
    Toxic Substances and Disease Registry's (ATSDR) review and publication
    of illnesses and conditions relating to veterans stationed at Camp
    Lejeune, North Carolina, and their families. The bill would require the
    ATSDR Administrator to review the scientific data pertaining to the
    relationship between individuals at Camp Lejeune and the suspected
    resulting illness or condition. The ATSDR Administrator would be
    required to determine each condition that may be caused by toxic
    exposure, categorize the level of evidence for these conditions into
    three categories: sufficient with reasonable confidence that the
    exposure is a cause of the illness or condition, modest supporting
    causation, or no more than limited supporting causation. This
    information would then be published and continually updated on the
    Department of Health and Human Services' website. Newly registered
    veterans and family members would receive care based on the list
    provided by the ATSDR Administrator.
        Research regarding toxic exposures and the subsequent credibility
    of presumptive conditions has traditionally been the charge of the
    Institute of Medicine (IOM). The bill does not discuss the processes
    that should be implemented if the ATSDR conflicts with the findings of
    the IOM and we hope you will consider this in your deliberations on
    this measure. That aside, PVA supports this effort to ensure periodic
    literature reviews of the existing body of research on the relationship
    between toxic exposures at Camp Lejeune and adverse health conditions.
      s. ___, a bill to amend title 38, united states code, to extend the
       authority of the secretary of veterans affairs to continue to pay
     educational assistance or subsistence allowances to eligible persons
      when educational institutions are temporarily closed, and for other
                                   purposes.
        PVA generally supports this draft language which would extend
    educational assistance or subsistence allowances for a brief period of
    up to two months to ensure stability of Forever GI Bill users when
    their educational institution closes unexpectedly.
        PVA would once again like to thank the Committee for the
    opportunity to submit our views on the legislation considered today.
    Enactment of much of this proposed legislation will significantly
    enhance the health care services and benefits available to veterans,
    servicemembers, and their families. We look forward to working with the
    Committee on their passage, and would be happy to take any questions
    you have for the record.
                                     ______

                Letter from James Powers, Veteran, Columbus, OH
       statement of support for s. 805 veteran debt fairness act of 2019
        Here we are, 18 months after I came before this Committee and gave
    a veteran's perspective of VA services in Ohio. Never did I expect that
    elements of my field hearing on a November day in Columbus, Ohio would
    find their way into purposeful legislation to prevent unnecessary
    hardship for Veterans.
        S. 805 puts measures into place to prevent financial hardship on
    Veterans that incur from an overpayment of benefits. The current
    policies in place provide little protection the Veteran. The appeals
    process is one-sided, and the collection processes is a nightmare. In
    my own case that I spoke of in my testimony, had an audit process been
    in place my debt far more easily could have resolved itself. If the
    VA's IT systems allowed for a veteran to make dependency changes that
    immediately updated benefit amounts, many of these overpayments could
    be avoided. This bill is as much about helping Veterans as it is about
    improving the agency that is here to serve Veterans. It is common sense
    to want a government agency to do a better job handling this country's
    money. Especially when it is for our Veterans. Error or not, government
    money should not be able to cause a hardship. The VA is currently doing
    just that by not automatically capping monthly repayment at 25%. Had
    the VA followed their normal debt collection method in my case, I would
    have gone 3+ months with no benefits payments. This easily would have
    caused me to need emergency financial assistance. That assistance would
    have come from state and local resources--resources that could be
    better appropriated to helping veteran homelessness, suicide
    prevention, and outreach. But, instead, it gets used to pay rent or
    utility bills for the Veteran who is getting all of his disability
    compensation garnished. It seems counterproductive when you look at it
    like that. Especially when the solution is right here in this bill.
        Section 3 of this bill builds on a practice already in place to
    prevent overpayment of DOD and VA benefits. Currently, when a
    servicemember retires the DOD automatically verifies VA compensation
    amounts to prevent overpayment of retirement benefits. With this bill,
    the DOD would quarterly verify Drill pay for guard/reservist to the VA.
    This simple reconciliation would remove the reporting/recording issue
    facing the Veteran/VA. No longer would the VA find itself recouping
    benefits that occurred over a long period of time.
        Many of these policies are not new to the Federal Government. They
    exist in similar context within the Social Security Administration.
    Many of these debt collection practices also come straight from similar
    protections a Veteran may find when dealing with a private debt and the
    CFPB.
        So, I ask this Committee to continue ``to not let my words fall
    upon deaf ears'' as I said in my previous testimony, but to work toward
    making S. 805 Veteran Debt Fairness Act of 2019 the next law showing
    this country's continued commitment to honor, care for, and in this
    case, protect its Veterans.
        Previous Committee testimony: https://www.veterans.senate.gov/
    download/powers-testimony_11212017
                Signed,
                                                          James Powers.
                                     ______

               Prepared Statement of Student Veterans of America
        Chairman Isakson, Ranking Member Tester and Members of the
    Committee: Thank you for inviting Student Veterans of America (SVA) to
    submit our testimony on pending legislation before the Committee.
        Established in 2008, SVA is a national nonprofit founded to empower
    student veterans as they transition to civilian life by providing them
    with the resources, network support, and advocacy needed to succeed in
    higher education. With over 1,500 Campus Chapters across the U.S. and
    in four countries overseas, serving 750,000 student veterans, SVA
    establishes a lifelong commitment to each student's success, from
    campus life to employment, through local leadership workshops, national
    conferences, and top-tier employer relations. As the largest chapter-
    based student organization in America, we are a force and voice for the
    interests of veterans in higher education, and SVA places the student
    veteran at the top of our organizational pyramid.
        Edward Everett, our Nation's 20th Secretary of State, and the
    former President of Harvard University was famously quoted as stating,
    ``Education is a better safeguard of liberty than a standing army.''
    While we have the finest military that the world has ever known, the
    sentiment remains; the importance of education to our Nation's national
    security continues to be critical and we thank the Committee for
    putting forth thoughtful legislation that speaks to this importance.
                   s. 805, veteran debt fairness act of 2019
        The Veteran Debt Fairness Act of 2019 would make certain
    improvements to the Department of Veterans Affairs (VA) debt collection
    process and limit the authority of VA to recover overpayments made to
    veterans due to VA accounting errors.
        VA sends out up to 200,000 overpayment notices to veterans every
    year.\1\ Most are health-related, but based 2015 GAO study, roughly one
    out of every four veterans using the Post-9/11 GI Bill also received an
    overpayment notice.\2\ These notices demand the debt--a number we have
    seen reach as high as $75,000--be repaid in full within thirty days or
    the veteran's benefits will be withheld.\3\ This short window of time
    to respond to a wholly unexpected and life-changing letter can be a
    challenge for veterans on its own, but is also further reduced by VA's
    outdated and disconnected address databases and years-long reliance on
    physical mail, meaning many veterans have not received these
    notifications in time to engage in their appeals or repayment
    options.\4\
    ---------------------------------------------------------------------------
        \1\ Senator Sherrod Brown. (March 2019). Brown, Tester, Boozman
    Work to Stop Veterans from Being Punished for VA's Miscalculations.
    https://www.brown.senate.gov/newsroom/press/release/brown-tester-
    boozman-work-to-stop-veterans-from-being-punished-for-vas-
    miscalculations
        \2\ U.S. Government Accountability Office (October 2015).
    Additional Actions Needed to Help Reduce Overpayments and Increase
    Collections. https://www.gao.gov/products/GAO-16-42
        \3\ Horne, Chris. (May 2019). VA overpayment puts Marine vet, Navy
    officer on hook for $75,000. https://www.wavy.com/news/military/navy/
    va-overpayment-puts-marine-vet-navy-officer-on-hook-for-75-000/
    1995067521
        \4\ Office of Servicemembers' Affairs, Consumer Finance Protection
    Bureau. (January 2019). 2018 Annual Report. https://
    files.consumerfinance.gov/f/documents/cfpb_osa_annual-report_ 2018.pdf
    ---------------------------------------------------------------------------
        The causes of overpayments and poor dissemination of these notices
    due to inadequate infrastructure is a well-worn discussion, but in some
    cases the root issue is not related to IT but VA's internal processes.
    The VA's Office of the Inspector General released a report in December
    of last year regarding 1,300 disabled veterans receiving Dependent's
    Educational Assistance (DEA) overpayment notices totaling $4.5
    million--an average of $3,400 each.\5\ The report found that 25 of the
    58 regional VA offices had roughly 4,600 unread emails in their
    respective DEA inboxes dating back to August 2016, sixty-seven percent
    of which (3,100) were about DEA benefits.\6\ \7\ Seven of the offices
    reported not checking those inboxes at all because there was no VBA
    standard in place.\8\
    ---------------------------------------------------------------------------
        \5\ VA OIG (December 2018). Delays in the Processing of Survivors'
    and Dependents' Educational Assistance Program Benefits Led to
    Duplicate Payments. https://www.va.gov/oig/ publications/report-
    summary.asp?id=4601
        \6\ Ibid.
        \7\ Ibid.
        \8\ Ibid.
    ---------------------------------------------------------------------------
        With overpayment letters on the rise--nearly tripling from 2013 to
    2017--an ever-increasing number of our veterans and families are being
    threatened with or experience financial harm.\9\ The serious nature of
    these notices and the impact they can have on families requires that
    stronger guardrails be placed around the processes that enable them.
    This bill is a step in that direction.
    ---------------------------------------------------------------------------
        \9\ Jerving, Sara. VICE (March 2017). Indebted. https://
    news.vice.com/en_ca/article/ywn9xb/va-veterans-overpayment
    ---------------------------------------------------------------------------
        SVA strongly supports the bill's language on limiting VA's
    recoupment of debts to only those made by errors from the veteran or
    beneficiary, capping the benefit deduction at 25%, and only those debts
    that were incurred in the last five years.
        SVA also supports the requirement that the VA provide veterans with
    the ability to update their dependency information online, which
    eliminates a potential processing delay and cause of overpayments. We
    continue to emphasize VA's need to improve and modernize its IT
    infrastructure and see this as another opportunity to provide greater
    service to our veterans.
    draft legislation, to amend title 38, united states code, to extend the
       authority of the secretary of veterans affairs to continue to pay
     educational assistance or subsistence allowances to eligible persons
             when educational institutions are temporarily closed.
        This legislation would extend the period that VA is able to
    continue paying housing allowances during a school's temporary closure
    due to an Executive order of the President or because of an emergency
    situation from four weeks to eight.
        As has been made all too clear in the past few years, natural
    disasters dramatically impact the lives of students and the communities
    that surround them. In 2017 and 2018, we saw at least 43 separate
    college and university closures of over 10 days. In Georgia, those
    included Albany Technical College, East Georgia State College, Georgia
    Southern University-Armstrong, and the Savannah School of Art and
    Design. In North Carolina, Fayetteville Technical Community College and
    Craven Community College temporarily shuttered. And some, like Lone
    Star College's Kingwood and Atascocita campuses, closed for a full
    month. When schools close in the aftermath of a catastrophic event,
    student veterans must navigate their own recovery while the ticking
    clock of the four-week benefits extension hangs over their head.
        It is important to understand that significant disaster events are
    occurring more frequently and more intensely than ever before. Since
    1980, the United States has faced an average of six billion-dollar
    storms in a given year.\10\ In the past 5 years, however, we have faced
    an average of thirteen.\11\ It is clear our students face a growing
    threat from the environment and we believe that preparing policy to
    more adequately, and proactively, address these issues is the best
    option. We should not wait until our veterans are suffering to enact
    this positive change.
    ---------------------------------------------------------------------------
        \10\ Stein, Jeff; Van Dam, Andrew. Washington Post. (April 22).
    Taxpayer spending on U.S. disaster fund explodes amid climate change,
    population trends. https://www.washingtonpost.com/us-policy/2019/04/22/
    taxpayer-spending-us-disaster-fund-explodes-amid-climate-change-
    population-trends/?noredirect=on&utm_term=.2b49a5ca45db
        \11\ Ibid.
    ---------------------------------------------------------------------------
        SVA strongly supports giving VA the authority to extend the current
    timeframe when natural disasters are so severe an institution needs
    more than a month to reopen campus. We believe this is a common-sense,
    proactive policy change providing student veterans more than a few
    weeks' time to figure out a new plan when facing catastrophes.
        If the Committee would like to continue the conversation on ways to
    better serve our student veterans responding to natural disasters, one
    area that students still need relief is with post-disaster relocation.
    If a student must relocate due to a natural disaster and cannot
    immediately return to school upon reopening, VA is unable to continue
    making payments to them or assist with relocation needs. This compounds
    the student's existing problems and causes undue hardship.
        We would also like to encourage the Committee to consider ways to
    provide assurances for housing allowances in the wake of natural
    disasters without having to lose a month or more of educational
    assistance eligibility due to circumstances beyond students' control.
        We applaud Congress' efforts thus far to provide common-sense
    relief to our student veterans who are impacted by natural disasters.
    With each proactive step, Congress sends a powerful message to our
    veterans that our country is committed to serving them when they need
    help the most.
        In addition to the legislation listed above, SVA also supports
    S. 785, the Commander John Scott Hannon Veterans Mental Health Care Act
    of 2019, which makes continued improvements to the Transition
    Assistance Program and authorizes a scholarship program for veterans
    seeking certain degrees.
        The success of veterans in higher education is no mistake or
    coincidence. Research consistently demonstrates this unique population
    of non-traditional students is far outpacing their peers in many
    measures of academic performance.\12\ Further, this success in higher
    education begets success in careers, in communities, and promotes
    family financial stability, holistic well-being, and provides the all-
    volunteer force with powerful tools for recruitment and retention when
    recruits know military service prepares them for success after service.
    ---------------------------------------------------------------------------
        \12\ Cate, C.A., Lyon, J.S., Schmeling, J., & Bogue, B.Y. (2017).
    National Veteran Education Success Tracker: A Report on the Academic
    Success of Student Veterans Using the Post-9/11 GI Bill. Student
    Veterans of America, Washington, DC, http://nvest.studentveterans.org/
    wp-content/uploads/2017/03/NVEST-Report_FINAL.pdf.
    ---------------------------------------------------------------------------
        We thank the Chairman, Ranking Member, and the Subcommittee Members
    for your time, attention, and devotion to the cause of veterans in
    higher education. As always, we welcome your feedback and questions,
    and we look forward to continuing to work with this Committee, the
    Senate Veterans' Affairs Committee, and the whole of Congress to ensure
    the success of all generations of veterans through education.
                                     ______

                Letter from James Craig, J.D., Ed.D, President,
                  United Veterans Committee of Colorado (UVCC)

                  [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     ______

     Prepared Statement of Carlos Fuentes, Director, National Legislative
             Service, Veterans of Foreign Wars of The United States
        Chairman Isakson, Ranking Member Tester, and Members of the
    Committee, On behalf of the men and women of the Veterans of Foreign
    Wars of the United States (VFW) and its Auxiliary, thank you for the
    opportunity to offer our views on legislation pending before the
    Committee.
               s. 123, ensuring quality care for our veterans act
        The VFW supports this legislation which would require the
    Department of Veterans Affairs (VA) to conduct a clinical review of
    care furnished by VA health care professionals who had their licenses
    to practice terminated for cause.
        It is unacceptable to endanger the lives of our Nation's veterans
    by hiring health care professionals with suspended licenses. There have
    been several egregious examples of VA doctors who commit malpractice
    under VA's watch, but should never have been allowed to provide care to
    veterans. This bill would rightfully ensure VA health care
    professionals who had their licenses terminated in the past and are
    currently employed by VA are providing high-quality care. If not, VA
    would be required to provide a clinical disclosure of adverse events to
    impacted patients. Doing so would ensure patients know their rights and
    options for recourse.
       s. 221, department of veterans affairs provider accountability act
        The VFW supports the intent of this legislation, which would codify
    VA's reporting requirements to the National Practitioner Data Bank and
    state licensing boards, and has suggestions to improve it.
        Several instances of VA medical errors have been made public in the
    past couple of years, where VA health care providers have been held
    accountable or fired, but the instances were never reported to state
    licensing boards or the National Practitioner Data Bank. This
    legislation would ensure such providers are not allowed to continue to
    endanger the lives of their patients, whether it is at VA or outside of
    VA, by requiring VA to report all major adverse actions to the National
    Practitioner Data Bank within 30 days of such actions. This legislation
    would also prohibit VA from purging negative records from personnel
    files except in situations where the record is found not to be
    legitimate by the Office of Accountability and Whistleblower
    Protection.
        The VFW urges the Committee to amend the legislation to require VA
    to report incidents VA is investigating. It is common practice for
    private sector health care facilities to report incidents to state
    boards when the facility begins a medical error investigation and when
    adverse actions have been carried out. This legislation only requires
    VA to report medical errors after the adverse actions have taken place.
    This is a particular concern in instances where a provider may choose
    to retire before an adverse action is carried out. In such instances,
    the state medical board where the provider is licensed may investigate
    and discipline the provider even though VA has lost its opportunity to
    do so.
                   s. 318, va newborn emergency treatment act
        The VFW supports this legislation which would expand VA's current
    authority to cover the cost of emergency transportation for eligible
    newborn babies. Under current law VA is authorized to provide seven
    days of medical coverage for newborn children, but that coverage does
    not include emergency transportation.
        The VFW has long supported expanding the length of time a veteran's
    newborn child is provided medical coverage by VA, and believes also
    expanding current legislation to include emergency transportation is
    common sense. If a veteran gives birth to a child who then has an
    emergency medical situation which the birthing facility is unable to
    address, VA must be able to cover the cost of transporting such newborn
    to a facility that can provide the required care. Veterans in this
    situation are already under a great deal of stress, and it is unjust to
    then add the burden of emergency transportation costs.
        During the first seven days, the transportation must be covered as
    it is part of the treatment. Medical services and surveillance would be
    needed during the transport as a matter of life or death to the infant.
    This legislation provides Congress with an easy way to increase the
    quality of care women veterans rightfully deserve. The VFW urges the
    Committee to swiftly pass this bill.
             s. 450, veterans improved access and care act of 2019
        The VFW supports this legislation to require VA to assess the
    feasibility of expediting the process of onboarding new medical
    providers and require VA to create a plan to reduce the hiring process
    for health care professionals.
        The VFW continues to hear that VA's licensing and credentialing
    process is excessively long and should be modified to make certain VA
    is able to hire high-quality doctors on a timely basis. The VFW has
    also heard from providers who work at VA that they face delays
    transferring to underserved areas because they are required to undergo
    burdensome onboarding processes again, even though VA policy authorizes
    streamlined transfers between VA medical facilities. Veterans want more
    doctors at their VA medical facilities. Requiring doctors who want to
    serve veterans to jump through hoops deters them from doing so.
                          s. 514, deborah sampson act
        The VFW supports this legislation to improve VA benefits and
    services for women veterans. The VFW has adamantly worked alongside
    Congress and VA to improve access, care, and benefits to women
    veterans. This legislation would address issues and concerns regarding
    access to care, recognition, and homelessness which the VFW has
    identified in direct feedback from women veterans.
        As the women veteran population continues to grow, VA must ensure
    it provides care and services tailored to their unique health care
    needs. Women veterans deserve access to the best treatment and care
    this Nation has to offer. That is why it is crucial VA outfit existing
    facilities with basic necessities, such as curtains for privacy in
    women's clinics. These clinics also need to maintain at least one
    primary care provider with expertise in women's health who is able to
    train others. However, the VFW recommends removing the option of one
    part-time provider. A part-time provider would limit access to care for
    women veterans and decrease the provider's ability to maintain gender-
    specific expertise.
        For women veterans who rely on VA for postnatal care, the VFW urges
    Congress to extend the number of days newborn care is covered by VA.
    Currently, VA only covers newborn care for seven days. One week is not
    enough to provide coverage for critical care that may be necessary in
    the first weeks of a child's life--especially in the relatively common
    instance of false-positive newborn disease testing--nor is it enough to
    ease the new mother of unnecessary stress. The VFW supports the
    provision of this bill which would expand newborn coverage for veterans
    who use VA while receiving maternity care.
        In addition, this legislation would provide many other improvements
    to women veterans' needs within VA. Some of these improvements include
    analysis of staffing needs, the establishment of a women veteran
    training module for non-VA health care providers, expansion of legal
    services for women veterans, and information to be added to the VA
    website relating to women veteran programs.
       s. 711, care and readiness enhancement for reservists act of 2019
        The VFW supports this legislation to expand eligibility for VA Vet
    Centers for members of the reserve component of the U.S. Armed Forces.
        According the Department of Defense Suicide Events Report, members
    of the reserve component have higher rates of suicide than active duty
    servicemembers. Lack of access to mental health care and possible
    impact on career are common reasons reserve component servicemembers do
    not receive the care they need to cope with mental health conditions,
    despite their high frequency of deployment. This bill would ensure they
    have access to the high-quality and confidential care provided by VA's
    more than 300 Vet Centers around the country.
      s. 746, department of veterans affairs website accessibility act of
                                      2019
        The VFW supports this legislation which would require VA to ensure
    its websites and kiosks meet accessibility requirements. With VA's
    increased reliance on websites to communicate with veterans, and kiosks
    at VA medical centers to check in for appointments, VA must ensure all
    veterans have the ability to utilize such modalities.
        s. 785, commander john scott hannon veterans mental health care
                            improvement act of 2019
        The VFW supports this comprehensive legislation which would
    significantly improve VA's suicide prevention efforts.
        Eliminating suicide among our Nation's veterans continues to be a
    top priority for the VFW. The most recent analysis of veteran suicide
    data from 2016 found suicide has remained fairly consistent within the
    veteran community in recent years. An average of 20 veterans and
    servicemembers die by suicide every day. While this number must be
    reduced to zero, it is worth noting that the number of veterans who die
    by suicide has remained consistent in recent years, while non-veteran
    suicides have continued to increase.
        The Office of Inspector General report determining Veterans Health
    Administration staffing shortages continues to list psychiatry clinics
    as having the most need, with the fourth being psychology. Out of 141
    facilities surveyed, 98 had a shortage for psychiatrists and 58 had a
    shortage for psychologists. By not adequately staffing VA, the capacity
    to serve veterans and provide the necessary access to mental health
    care needed by so many will continue to be limited. With the entire
    nation experiencing a critical shortage of mental health care
    providers, such need cannot be sufficiently addressed by simply
    increasing use of community care. This legislation would make
    improvements to VA's mental health care workforce to ensure veterans
    with mental health care concerns have timely access to high-quality
    care.
        The VFW is proud to be part of the solution. Through Project
    Advancing Telehealth through Local Access Stations (ATLAS), the VFW has
    worked with VA and Philips to leverage VA's anywhere to anywhere
    authority to expand telehealth options for veterans who live in rural
    areas. In this partnership, VA has identified highly rural areas where
    veterans must travel far distances to receive VA health care. The VFW
    identifies posts in those areas to serve as access points for VA health
    care. Once the post is modified to VA's specifications, it is equipped
    with Philips-donated telehealth technology to provide veterans access
    to VA health care at a convenient veteran-centric location. More than
    20 VFW posts have been identified as possible telehealth centers. The
    primary use for the first Project ATLAS site in Eureka, Montana, will
    be for mental health care. Veterans in Eureka must travel more than 70
    miles to the nearest VA clinic for mental health care. The VFW is glad
    this legislation would expand such opportunities through a grant
    program. Doing so would provide veterans the ability to receive VA
    health care closer to home.
        VA is making concerted efforts to ensure it appropriately uses
    pharmaceutical treatments when providing mental health care. Under the
    Opioid Safety Initiative, VA has reduced the number of patients to whom
    it prescribes opioids. Prescribed use of opioids for chronic pain
    management has unfortunately led to addiction to these drugs for many
    veterans, as well as for many other Americans. VA uses evidence-based
    clinical guidelines to manage pharmacological treatment of Post
    Traumatic Stress Disorder and substance use disorder to ensure better
    health outcomes. However, many veterans report being abruptly taken off
    opioids they have relied on for years to cope with their pain
    management, without a proper treatment plan to transition them to
    alternative therapies. Doing so leads veterans to seek alternatives
    outside of VA or to self-medicate. VA must continue to expand research
    of non-traditional medical treatments, such as medical cannabis and
    other holistic approaches, for mental health care conditions. This bill
    would require VA to expand access to such therapies to ensure veterans
    are able to access care that works best for them.
                   s. 805, veteran debt fairness act of 2019
        The VFW supports this legislation which would improve the
    processing of veterans benefits by VA, limit the authority of the
    Secretary of Veterans Affairs to recover overpayments made by the
    Department and other amounts owed by veterans to the United States, and
    improve the due process afforded veterans with respect to such
    recovery.
        While the VFW understands that overpayments must be recouped in
    order for benefit programs to work efficiently, it is important for
    debt notices to be clear and provide concise information regarding what
    steps veterans must take in order to resolve any outstanding debts as
    soon as possible. Ultimately, a veteran should be responsible for
    repaying the overpayment, if it is indeed legitimate. Due to the
    inconsistencies regarding communication of overpayments from VA, as
    well as the general lack of information regarding the nature of such
    debt, many veterans are simply unable to meet the deadline imposed on
    them by VA. To further complicate things, the VFW's interaction with
    VA's Debt Management Center personnel has made it very clear that VA
    employees lack a proper understanding of VA policy and procedures
    regarding debt recoupment. The VFW believes this legislation would
    address these concerns, and strongly urge Members of this Committee to
    support its passage.
       s. 850, highly rural veteran transportation program extension act
        The VFW strongly supports this legislation, which would expand the
    authority for VA to partner with veterans service organizations and
    state veterans agencies to provide transportation services for veterans
    in rural areas.
        Lack of transportation is a significant barrier to accessing health
    care for veterans who live in rural and remote areas. Such veterans
    often do not have the opportunity to use public transportation like
    their fellow veterans who live in urban areas. While VA provides
    benefits for veterans who travel long distances for care, veterans may
    not have the resources to pay for the cost of travel up front. VFW
    posts and departments in North Dakota, Maine, California, and Texas
    have partnered with VA through the Highly Rural Transportation Grants
    to eliminate this barrier for veterans. The VFW supports a one-year
    expansion of this important program, but urges this Committee to make
    it permanent.
             s. 857, to increase the amount of special pension for
                           medal of honor recipients
        This legislation would increase the Medal of Honor pension. The VFW
    supports this legislation and has a recommendation to improve it.
        Veterans who have been awarded the Medal of Honor have made
    extraordinary sacrifices for our country and are rightfully awarded a
    special pension for those heroic acts. The special pension for Medal of
    Honor recipients has been increased to adjust to cost of living
    increases, but has not been significantly increased since 2002. The VFW
    agrees that it is time to update this modest benefit for America's most
    cherished heroes.
        The loved ones of our most honored heroes often forgo careers to
    become full time caregivers. This means they become dependent on the
    Medal of Honor pension to make ends meet. However, the Medal of Honor
    pension ends with the death of the recipient and their spouses often do
    not qualify for VA benefits upon that death. Our nation has continued
    pensions for surviving spouses in the past, such as pensions for
    members of the Grand Army of the Republic. It is fitting that our Medal
    of Honor veterans' spouses should continue to receive Medal of Honor
    pensions until their remarriage or death. The VFW recommends this
    Committee authorize the continuation of the pension for the Medal of
    Honor recipient's surviving spouse until the surviving spouse remarries
    or dies.
                s. 980, homeless veterans prevention act of 2019
        This legislation would improve benefits afforded to homeless
    veterans. The VFW supports this legislation and would like to offer a
    suggestion to strengthen section 3.
        The VFW firmly believes that no veteran who has honorably served
    this Nation should have to suffer the indignity of living on the
    streets. We praise the great progress that has been made in reducing
    veterans' homelessness in recent years as a direct result of
    coordinated efforts across multiple government agencies to provide
    transitional housing, rapid rehousing, and employment programs for
    veterans in need.
        The VFW generally supports section 3 of the bill which would allow
    the Secretary to enter into partnerships with public or private
    entities to fund a portion of certain legal services for homeless
    veterans. While the VFW recognizes that legal issues are often a
    significant barrier to homeless reintegration and must be addressed, we
    are concerned that some for-profit legal entities would view this
    program as an opportunity to exploit the availability of government
    resources in exchange for poor or inadequate services. For this reason,
    we suggest that the language in this section be changed to allow VA to
    enter into partnerships with only public or non-profit private legal
    entities that provide services to homeless veterans.
    s. 1101, better examiner standards and transparency for veterans act of
                                      2019
        The VFW supports this legislation which would require VA to ensure
    contracted health care providers who perform VA compensation and
    pension examinations are qualified to conduct such important
    examinations.
        Veterans are dependent on the medical opinion of contract
    physicians who perform their disability evaluations to access their
    earned VA care and benefits. To maximize the effectiveness of the
    contracted compensation and pension examinations, Congress authorized a
    national license to practice for such providers, similar to VA health
    care providers. This means contracted providers may perform an
    examination in a state other than the one where they are licensed. This
    legislation would rightfully prohibit health care providers who have
    their licenses revoked in any state from conducting important
    compensation and pension examinations for veterans. Doing so would
    ensure veterans do not receive inaccurate examinations, which could
    lead to the wrongful denial of much-needed benefits.
       s. 1154, department of veterans affairs electronic health record
                             advisory committee act
        The VFW supports this legislation, which would establish an
    Electronic Health Record Advisory Committee to oversee VA's Electronic
    Health Records Modernization.
        This bill would authorize the advisory committee to conduct
    periodic risk assessments and evaluations, and develop recommendations
    to mitigate prominent risks. It would also require the Committee to
    submit annual reports to the Secretary of Veterans Affairs and the
    House and Senate Committees on Veterans' Affairs. These would contain
    recommendations for legislative actions as they see appropriate. This
    legislation would also provide the ability for impacted stakeholders to
    participate in oversight of the implementation VA electronic health
    record modernization.
                 draft legislation, janey ensminger act of 2019
        This legislation would require the Agency for Toxic Substances and
    Disease Registry (ATSDR) to conduct periodic literature reviews of the
    existing research regarding the relationship between exposure to toxic
    water at Camp Lejeune and adverse health conditions. The VFW supports
    the intent of this legislation, but has a serious concern with the
    threshold it sets for medical research, which we hope this Committee
    will address before advancing this legislation.
        The approximately 650,000 veterans and family members who served on
    Camp Lejeune between 1953 and 1987 deserve to know if their health
    conditions are related to water they drank that was contaminated with
    trichloroethylene, tetrachloroethylene, vinyl chloride, and other
    toxins. That is why the VFW fully supports periodic literature reviews
    of the existing body of research on the relationship between
    contaminated water at Camp Lejeune and the health conditions prevalent
    among veterans and family members exposed to such toxic substances.
        However, this legislation would require the ATSDR to evaluate
    whether a health condition is caused by exposure to contaminated Camp
    Lejeune water, which is an unreasonably high bar for determining a
    relationship between adverse health conditions and toxic exposure. This
    legislation would require the ATSDR to place related health care
    conditions into three categories: sufficient with reasonable confidence
    that the exposure is a cause of the illness or condition; modest
    supporting causation; or no more than limited supporting causation.
    This would mean that the majority of the health conditions the ATSDR
    considers to be associated with exposure to trichloroethylene,
    tetrachloroethylene and vinyl chloride in drinking water would fail to
    meet this threshold.
        Research regarding toxic exposures has traditionally used the
    Institute of Medicine's (IOM) six categories of associations:
    sufficient evidence of a causal relationship; sufficient evidence of an
    association; limited/suggestive evidence of an association;
    insufficient evidence to determine whether an association exists;
    inadequate/insufficient evidence; and limited/suggestive evidence of no
    association. These six categories are aligned with the nature of
    epidemiological research and can be used to guide future research. The
    VFW strongly urges this Committee to reduce the threshold from
    causation to IOM's six categories of association.

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