[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\
---------------------------------------------------------------------------
\1\ https://www.usich.gov/solutions/collaborative-leadership/
mayors-challenge
---------------------------------------------------------------------------
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
[email protected].
______
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.
---------------------------------------------------------------------------
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\
---------------------------------------------------------------------------
\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.
[all]