[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




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                     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

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                              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.
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    \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\
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    \34\ 18 U.S.C. Sec. 930; 38 CFR Sec. 1.218(a)(13).
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    In addition to physical security enhancements, VA police have 
increased their visibility on campuses to which they are assigned. 
Medical Center Police Chiefs, and other appointed personnel, are also 
connected to fusion centers that are located in the corresponding 
geographical area to each respective medical center. These fusion 
centers gather, analyze, and facilitate the sharing of sensitive 
intelligence between Federal, state, tribal, and territorial partners 
which heightens situational awareness and allows VA to make informed 
decisions concerning issues that could impact VA properties.
    The effectiveness of an integrated response to an identified threat 
situation can be enhanced through proper training and preparation. VA 
police undergo substantial and varied training, including continuing 
training at their respective assigned facilities, and have been 
provided with the necessary equipment to appropriately respond to 
violent threat situations. Focused training specific to the facility is 
provided locally and allows for the incorporation of multiple 
variations of site-specific scenarios involving the necessitated 
response to threat incidents involving dangerous weapons or other 
specific threats. VA Police additionally offer training at all VA 
properties to all employees regarding active threat/shooter incidents 
and VA facilities conduct mock and live drills regularly that are 
designed to identify vulnerabilities, inform needed improvements, 
prepare for eventualities, and to prevent violent acts from occurring.
    In addition to the existing mandatory PMDB employee training in VHA 
addressing verbal de-escalation, personal safety, and therapeutic 
containment skills, the Law Enforcement Training Center also offers an 
optional Verbal Defense in Health Care training program, designed for 
employees to use communications skills to de-escalate potential 
incidents that could result in a Veteran, staff, or visitor from 
reacting violently during contact with them.

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

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

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

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

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

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

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

    Question 11. How will the roadmap slated to be created by the task 
force outlined in Executive Order 13861 be different than the already 
existing National Strategy for Veteran Suicide Prevention 2018-2028?
    a. What will become of the National Strategy once the task force's 
roadmap has been completed?
    b. Will progress toward the goals and objectives laid out in the 
National Strategy continue, or be put on hold pending the release of 
the roadmap?
    Response. Influenced by the National Strategy for Preventing 
Veteran Suicide, the Executive Order 13861 (the President's Roadmap to 
Empower Veterans and End a National Tragedy of Suicide, or PREVENTS) 
Roadmap outlines the specific strategies needed to effectively lower 
the rate of Veteran suicide among our Nation's Veterans, analyzing 
opportunities for collaboration within Federal, state, local, tribal, 
and non-government entities. The Roadmap will buildupon the National 
Strategy for Preventing Veteran Suicide as its foundation and is 
currently, through environmental scans, identifying other initiatives 
across governmental agencies and States, counties, and communities 
Nation-wide as potential strategies to include within the roadmap. The 
National Strategy will continue to be the beacon for public health 
strategies across the Nation for Veteran suicide prevention.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Thom Tillis to 
                  U.S. Department of Veterans Affairs
    Question 1. Does VA have a position on S. 1563, the Janey Ensminger 
Act of 2019? Does VA oppose any specific provisions of the Janey 
Ensminger Act? If so, which provisions does VA oppose and why?
    Response. VA is now preparing full views on the Janey Ensminger Act 
of 2019, which will be provided to the Committee separately.

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

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

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

    Question 4a. Does VA currently have the authority to implement such 
a registry, or would it need additional statutory authority to do so?
    Response. VA has authority to initiate such a registry; however, it 
would require extensive coordination with other executive branch 
agencies and additional funding. We do not believe establishment of a 
new registry is necessary. The U.S. Marine Corps already maintains and 
regularly uses an extensive registry database of names and addresses 
for the purpose of notifying Veterans and family members who lived at 
Camp Lejeune during the period of concern.
    We also should note that for the sake of future research, there are 
significant inherent limitations in the use of registries to draw 
inferences regarding the presence or strength of an association between 
an exposure and a health outcome. Recall bias, self-reporting bias, and 
self-selection bias all severely hinder the use of registry data in 
research of this kind. Camp Lejeune Veterans and family members are 
best served in this regard by well-designed, state-of-the-art 
epidemiologic studies.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Patty Murray to 
                  U.S. Department of Veterans Affairs
    Question 1. Please provide and explain VA's cost estimate for 
S. 318, the VA Newborn Emergency Treatment Act, including:

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

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

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

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

                            A P P E N D I X

                              ----------                              


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

    Thank you again to the Chairman and Ranking Member for the 
opportunity to submit written testimony, and I appreciate this 
Committee's consideration of S. 980 and S. 1563. These proposals ensure 
we keep our promise to support the brave men and women who have 
volunteered to protect and served this great Nation. Thank you.
                                 ______
                                 
                Prepared Statement of Hon. Marco Rubio, 
                       U.S. Senator from Florida
    Chairman Isakson and Ranking Member Tester, thank you for 
scheduling today's hearing, which includes the Better Examiner 
Standards and Transparency for Veterans (BEST for Vets) Act. I am proud 
to have worked with Senator Sinema on this bipartisan legislation, and 
I appreciate your consideration today.
    To determine a veteran's eligibility for disability compensation, 
the Veterans Benefits Administration (VBA) often relies on information 
gathered as part of a medical disability examination (MDE). The VBA has 
increasingly relied on contractors to conduct a large portion of these 
MDEs in an effort to avoid delays in the disability claim process.
    Last year, media reports revealed that contract physicians with 
revoked medical licenses have been performing MDEs on behalf of the 
Department of Veterans Affairs (VA). For example, in my home state of 
Florida, a physician was conducting MDEs on behalf of the VA despite 
the fact that her medical license had been revoked in two other states 
and was on probation in another due to a Federal tax fraud conviction. 
A loophole in current law is allowing this to happen. This is 
unacceptable, and legislation is needed. The BEST for Vets Act would 
address this issue by ensuring only licensed health care providers are 
conducting medical disability examinations on behalf of the VA.
    Health care providers who have had their medical licenses revoked 
have no business conducting MDEs that determine the benefits that our 
Nation's heroes receive. Our veterans not only deserve the highest 
quality care, but they have earned it.
    I would like to thank the Veteran Service Organizations supporting 
this legislation, including Paralyzed Veterans of America, Veterans of 
Foreign Wars, and Disabled American Veterans.
    I appreciate the Committee's consideration of the BEST for Vets Act 
and look forward to working together to pass this important, bipartisan 
bill.
                                 ______
                                 
                Letter from the American Bar Association

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


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

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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

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

    Chairman Isakson, Ranking Member Tester, and Members of the 
Committee: Thank you for the opportunity to provide testimony today on 
several pieces of proposed legislation that offer the potential to have 
a tremendous impact on our Nation's veterans. I am Tim McClain and have 
had the honor of serving our country on active duty for more than 20 
years as a Navy Surface Warfare Officer and JAG Corps Officer, and the 
privilege of serving as a former General Counsel for the U.S. 
Department of Veterans Affairs (VA).
    I am currently the Chairman of the Board of Directors of America's 
Warrior Partnership, a nonprofit organization serving veterans and 
their families. Our mission at America's Warrior Partnership is to 
empower communities to empower veterans. Our approach to the mission 
takes many forms, but it starts with connecting community organizations 
with local veterans to understand their unique needs and situations. 
After gaining this knowledge, we connect local veteran-serving 
organizations with the appropriate resources, services, and partners 
that the veteran requires. Our ultimate goal is to create a better 
quality of life for all veterans.
    Our Community Integration model provides the framework for 
organizations to conduct proactive outreach to veterans and 
holistically serve all of their needs. We have seen incredible results 
from this model, which has established relationships with more than 
48,000 veterans since February 2014 in our eight Affiliate Communities 
across the country. Proactive outreach is having a tremendous impact on 
these veterans. More than 90% of our veterans self-report that 
America's Warrior Partnership's proactive engagement and support give 
them a greater level of overall satisfaction, and they believe their 
community cares about their well-being. America's Warrior Partnership's 
Community Integration model works.
    Providing testimony with me today is the president and CEO of 
America's Warrior Partnership, Mr. Jim Lorraine, who is also a veteran 
of our great country having served for 22 years as an Air Force Officer 
and Flight Nurse. Before founding America's Warrior Partnership, Mr. 
Lorraine served as the founding director of the United States Special 
Operations Command Care Coalition, a wounded warrior advocacy 
organization recognized as the gold standard in supporting more than 
4,000 special operations force wounded, ill, or injured and their 
families. He has also served as Special Assistant for Warrior and 
Family Support to the Chairman, Joint Chiefs of Staff, during which 
time he transformed the Chairman's ``Sea of Goodwill'' concept into a 
strategy. Mr. Lorraine will provide America's Warrior Partnership's 
testimony regarding four pieces of proposed legislation.
    Thank you, Mr. McClain. In my testimony today, I will address a 
number of the draft legislative proposals related to our work at 
America's Warrior Partnership. As an organization that has developed, 
operated, and replicated community-based veteran serving programs 
throughout the Nation we recognize the positive impact a community 
integration approach has on the hopefulness and improved quality of 
life for the veterans, their families, and their communities. To help 
frame our testimony related to the legislation you are considering I 
would like to share what we've learned from veterans across the 
country. Every month we measure the services being sought and 
successfully provided to over 48,000 veterans across the Nation 
additionally, through our annual survey of the same population we 
correlate the holistic services they are seeking with their level of 
hopefulness or hopelessness. We've learned that 49.7% of veterans 
surveyed are seeking greater opportunities for recreation or sports, 
45% are seeking networking with other veterans, and 35% are seeking 
volunteer opportunities. Additionally, access to Veterans Affairs 
benefits and better employment opportunities round out the top 5 
opportunities that veterans are seeking.
    When looking at the veteran's level of hope our research indicates 
that 56% of veterans are very hopeful or what we call ``thriving,'' 
with 32% hopeful or what we call ``in transition,'' and 13% of veterans 
as hopeless or ``stuck.'' This 13% is consistent across our communities 
regarding the percentage of veterans who are seeking critical life 
services. In our research, we correlate the veterans level of hope with 
the services they are seeking. Those that are thriving are seeking 
networking with other veterans, better employment, and improved 
education. Those in transition are seeking short term financial 
assistance, legal support, and housing. While those veterans who are 
struggling are seeking access to transportation, short-term financial 
assistance, spiritual support and legal assistance. To summarize our 
research, those who have access to transportation are 22% more hopeful 
than those who do not. Those veterans with self-sustained housing are 
13% more hopeful than those who do not have stable housing. Those 
veterans with a Bachelor's Degree or higher are 10% more hopeful than 
those without a college degree. And those with access to healthcare 
(86.4% of veterans surveyed have health insurance) are 13% more hopeful 
than those without health insurance.
    I provide this information to the Committee to frame America's 
Warrior Partnership's support of legislation that builds stronger more 
collaborative communities around veteran employment as captured in 
S. 785 but would suggest we look beyond encouraging community-based 
collaboration around a single issue and rather focus on holistically 
improving veterans hope and quality of life. We strongly support 
legislation that builds on a plan to improve the quality of life for 
all veterans and their families through alternative care, recreational 
therapy, and engagement outside of the Veterans Affairs services.
    We feel that changing the eligibility criteria for Veterans Affairs 
care for Dishonorable and Other Than Honorable as written in S. 785, 
Section 104 would help those with this characterization of discharge, 
but should be re-thought due to the fact that millions of honorably 
discharged veterans who served without adverse impact are not eligible 
for Veteran's Affairs care and should be first for eligibility 
modification.
    While we agree with the services outlined in S. 785, Section 102 
for transition services we feel that without corporate and educational 
institutions acknowledging the skills acquired within the military the 
services that are outlined do not fully meet the transition needs of 
the veterans.
    Last, we completely support both the S. 857 A bill to amend title 
38, United States Code, to increase the amount of special pension for 
Medal of Honor recipients, and for other purposes and a bill to amend 
title 38, United States Code, to extend the authority of the Secretary 
of Veterans Affairs to continue to pay educational assistance or 
subsistence allowances to eligible persons when educational 
institutions are temporarily closed, and for other purposes. It is 
vital that we support those we recognize as providing the greatest 
sacrifice to our Nation. We also must recognize that those using their 
GI Bill must have the stability of income during the most trying 
periods of natural disaster or government shut-down that are beyond 
their control or ability to plan.
    I appreciate the opportunity to comment on these critical areas and 
will now let Mr. McClain conclude our testimony.
    Thank you, Mr. Lorraine. Chairman Isakson, thank you for inviting 
us to provide testimony today. We are both honored and pleased to have 
this opportunity. Our mission is the same as the mission of this 
Committee: to ensure that all veterans are taken care of and provided 
the benefits that they have rightfully earned through their service to 
our country. There is much work to be done, and we look forward to 
continuing collaborating with the Department of Veterans Affairs and 
our partners across the country to empower veterans from all walks of 
life as they transition to civilian life. Thank you again for the 
invitation to share our testimony today.
                                 ______
                                 
      Prepared Statement of Ken Falke, Chairman, Boulder Crest & 
                         EOD Warrior Foundation
    May is Mental Health Awareness Month, an opportunity to raise 
awareness of the millions of veterans--and Americans--battling mental 
health challenges, and perhaps more importantly, to discuss what should 
be done to ensure these men and women can live great lives--filled with 
meaning, purpose, connection, and growth.
    When it comes to the subject of mental health and veterans, there 
is no doubt that much is done to raise awareness of their plight. 
However, far too little is done when it comes to talking about and 
taking action on the second part of the story--the journey from 
struggle to strength, pain to purpose, tragedy to triumph.
    As a 21-year US Navy service-disabled combat veteran, and the 
Chairman of the EOD Warrior Foundation and Boulder Crest, which owns 
and operates two privately-funded wellness centers--Boulder Crest 
Retreat Virginia and Boulder Crest Retreat Arizona--as well as the 
Boulder Crest Institute for Posttraumatic Growth, I have a unique 
perspective, from considerable personal and professional experience, on 
the struggles of veterans and their family members, and on their 
opportunities to grow in the aftermath of trauma.
    In March 1989, I was severely injured in a military parachuting 
operation. I broke my back in two places, dislocated my shoulder, and 
was knocked unconscious, suffering a severe concussion. I was told that 
my military career was over. In December of the same year, I was back 
to full active duty primarily thanks to my personal motivation and a 
private medical resource--a chiropractor. You see, the Navy assigned me 
an E-3 physical therapist and bottles of pain killers and Motrin 800 
mg. I am convinced that if I would have stuck to the Navy's regime, I 
would have been discharged. I went on to do a full 21-year career and 
ultimately retired as a Master Chief Petty Officer, the Navy' s senior 
enlisted rank.
    In 1989, Chiropractors were looked upon as ``witch doctors.'' This 
is not the case today. My hope is that we can transform the mental 
health community like we have physical therapy and pain management and 
further hope that it doesn't take 30 years!
    On that front, I am heartened by the language included in S. 785 
related to Posttraumatic Growth, and I am grateful for the opportunity 
to share some of what we are learning on our journey.
                     boulder crest retreat virginia
    In September 2013, we opened Boulder Crest Retreat Virginia--the 
Nation's first privately- funded wellness center dedicated exclusively 
to combat veterans and their families. Our vision was to create a 
place--and programs--where servicemembers and veterans could transform 
struggle into strength and growth and receive what they required to be 
as productive at home as they were on the battlefield. For our first 
nine months, we invited innovative nonprofits to use Boulder Crest 
Retreat Virginia, for free, as a platform to deliver their programs. 
These programs ran the gamut--from 1-15 days, clinical to non-clinical, 
focused on everything from Military Sexual Trauma (MST) and 
Posttraumatic Stress Disorder (PTSD) to relationship and familial 
challenges.
    It soon became clear to us that these programs would not be 
sufficient to allow us to achieve our ambitious vision. Every program 
we witnessed struggled with four key challenges:

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

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

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

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

    The military does a tremendous job when it comes to bringing people 
into the service in a relatively short period of time. The Marine Corps 
Museum boasts of how the Corps ``transforms ordinary civilians into 
Marines.'' When it comes time for the transition, we subject our 
transitioning servicemembers to a week of ``death by PowerPoint.''
    We have had countless instances of a veteran who has transitioned 
poorly, self-medicated in response, damaged relationships in the 
process, and found themselves in a mental health office. They are then 
mis-diagnosed with PTSD, medicated, turn to disability payments, and 
become unproductive, unfulfilled, unworthy, and suicidal. What was a 
temporary issue of adjustment became a permanent diagnosis. We can and 
must do better to prepare transitioning servicemembers not just for a 
post-military job; we must prepare them for a post- military life. 
Critical elements of our program, particularly focused on education, 
could be used to that end, and a clear-eyed look of how transition goes 
wrong is critical to understanding how veterans end up at the brink of 
suicide.
    In short, we cannot simply wait for veterans to get to the point of 
crisis or fail to acknowledge what the data and the veteran are telling 
us--whether you served for four years or forty, getting out is hard. We 
must do a better job of getting ``left of boom.''
                               conclusion
    As a retired disabled combat veteran and a retired CEO, I know the 
power of military experience and the challenges associated with combat 
experiences and long deployments. I also know that I am the man I am 
because of the United States Navy. More than two thousand years ago, 
the Athenian general and philosopher Thucydides said it best: ``We must 
remember that one man is much the same as another, and that he is best 
who is trained in the severest school.''
    Rather than focusing on suicide prevention and more of the same in 
terms of mental health services, we should be focused on ensuring 
veterans can live great lives at home--lives filled with joy, passion, 
love, service, and purpose. We should ensure my fellow veterans can use 
the great military training they receive as a launching pad for a 
productive and purposeful life as a Warrior at home. We must ensure 
that, to paraphrase the words of a good friend and USMC General 
officer, their time in the service cannot be the greatest 
accomplishment of their lives. Doing so requires an integrated and 
collaborative approach, and we look forward to being a part of the 
solution and any questions that arise from this written testimony.
                                 ______
                                 
         Prepared Statement of The Blinded Veterans Association
                              introduction
    Thank you, Chairman Isakson, Ranking Member Tester, and 
distinguished members of the Senate Committee On Veterans Affairs, for 
giving the Blinded Veterans Association this opportunity to comment on 
the legislation under consideration by this Committee. BVA is the only 
congressionally chartered Veterans Service Organization that is 
exclusively dedicated to serving the needs of blinded veterans and 
their families. On behalf of our members and their families, we are 
pleased to support several of the bills under consideration by this 
Committee. Congressional approval of two of these bills is of the 
highest priority to our membership. These include S. 850, The Highly 
Rural Veterans Transportation Program Extension Act, and S. 746, The 
Department of Veterans Affairs Website Accessibility Act. We will 
comment on these in detail in the following paragraphs. We will also 
outline our reasons for supporting the following bills: S. 318, the VA 
Newborn Emergency Treatment Act; S. 514, the Deborah Sampson Act; 
S. 711, the Care and Readiness Enhancement for Reservists Act; S. 785, 
the Commander John Scott Hannon Veterans Mental Health Care Improvement 
Act; S. 805, the Veteran Debt Fairness Act; S. 857, a bill to increase 
the amount of special pension for Medal of Honor Recipients; and 
S. 450; The Veterans Improved Access and Care Act. Our organization has 
not yet taken positions on the other bills that are under consideration 
at this hearing.
I. S. 850, The Highly Rural Veteran Transportation Program Extension 
        Act
    BVA is very pleased to support this legislation, because 
transportation is the most significant, and sometimes insurmountable, 
barrier that stands between our members and their healthcare. When 
veterans lose their eyesight, they also lose their ability to drive. 
When that happens, they do not automatically acquire the assistance of 
another person who will drive them to the places they need to go. 
Efforts to locate such assistance are especially problematic in rural 
areas, where public transit options are few or nonexistent, and 
alternative services are either excessively expensive or unavailable. 
We believe that it is absolutely imperative that Congress provide the 
Department of Veterans Affairs with both the incentive and the 
resources to address this barrier. This legislation will go a long way 
toward this goal by encouraging the development of additional 
transportation options for veterans, but the provision that we are 
particularly pleased to see is the permanent authorization of the 
Veterans Transportation Program. This is long overdue. The current 
situation makes participation in this program by VA medical centers too 
precarious and burdensome, and this fact has harmful consequences for 
the veterans they serve. Having said that, we would be even happier 
with this bill if it provided that once the program is permanently 
authorized, participation by VA medical centers is mandatory, at least 
in rural areas. For veterans with catastrophic disabilities that 
prevent them from driving, lack of transportation can force them to 
choose between health care and food, or to delay getting care, thus 
risking worsened medical conditions that would have been treatable if 
cared for earlier. It is not uncommon for veterans, faced with the 
prospect of paying $100 each way for a trip to their doctor's office, 
to decide to forego treatment because getting to it is too costly. This 
is an unnecessarily harsh situation to put some of our Nation's most 
vulnerable veterans in, and it is avoidable. Avoiding it can begin with 
passage of S. 850.
II. S. 746, The Department of veterans Affairs Website Accessibility 
        Act
    The VA currently faces myriad challenges on multiple fronts, and 
many issues compete for the attention of its leaders. Not the least of 
these concerns the capacity of VA's IT infrastructure to meet the 
demands resulting from ever-changing expectations regarding 
communications between Federal Government agencies and those who 
utilize their programs and services. Federal agencies are now expected 
to make ever-increasing amounts of information accessible through a 
rapidly growing number of media and devices, and VA has struggled to 
keep up with these demands. One area where VA has struggled the most is 
the area of compliance with accessibility guidelines for the design and 
dissemination of electronic information. We believe that this struggle 
will continue unless and until the issue of accessible communications 
becomes a priority of VA's senior leadership. We believe that by 
directing the VA Secretary to evaluate and report to Congress on the 
accessibility of VA's electronic communications, S. 746 will provide an 
impetus for VA's leadership to make the commitment that is needed to 
insure these issues will be addressed in a meaningful manner.
                       why accessibility matters
    Statistics indicate that our Nation's veteran population contains a 
growing number of individuals who have visual impairments. Studies 
conducted by the Veterans Health Administration in 2018 estimated that 
there were 131,580 legally blind veterans in the U.S. Just over 42,000 
of these veterans had cases open with a visual impairment services team 
coordinator at that time. Further, these numbers are expected to grow 
as the U.S. population, including its veterans, ages over the next 20 
years. Veterans who experience vision loss will want and need to access 
VA's websites, apps, kiosks, tele-health tools, claims process, and 
other benefits, programs, and services administered by the VA, both now 
and for the foreseeable future. Already, since many veterans are 
comfortable with today's myriad technologies, they want access to all 
of the communications options the VA offers to other veterans. 
Therefore, when concerns about the accessibility of websites, 
documents, and other equipment and media used to communicate with 
veterans are minimized or ignored, some of our Nation's most vulnerable 
veterans, those with catastrophic disabilities, are left behind. 
Furthermore, when these veterans are denied access to information and 
services, there is a risk that they will suffer serious consequences, 
such as further aggravation of their disabilities, and in some cases, 
suicide. The longer we wait, the greater this risk.
                          what is the problem?
    In the following paragraphs, we will discuss some of the most 
common, and most serious, accessibility barriers that both blind 
veterans, and VA employees who have visual impairments, face on a 
regular basis. Before doing so, we do need to acknowledge that BVA has 
appreciated the efforts of VA's Section 508 compliance Office to 
correct problems promptly, particularly as they relate to VA websites. 
Both the staff, and contractors who work with them, are responsive when 
we alert them to the existence of accessibility barriers. Additionally, 
thanks to the involvement of that office and its contractors, most of 
the applications VA makes available to veterans at this time are 
accessible to and usable by veterans who use adaptive software on their 
computers and smart devices. The problems veterans face in accessing 
VA's new websites have decreased in number as well, though 
unfortunately, website access continues to be a major challenge.
    VA's websites are generally the first point of contact veterans 
have with the Department. Therefore, the layout and content of those 
sites necessarily changes frequently. As a result, there are lots of 
occasions when things can go wrong. It is not uncommon for veterans to 
find that a web page that was easily accessed one day cannot be read or 
navigated during the next visit to the site. Some of the reasons this 
happens include:

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

    With regard to documents circulated by the VA, there has been some 
recent improvement, as VA now generally posts accessible Pdf documents 
on their public-facing websites. However, individuals, such as Veteran 
Service officers who assist veterans with claims, and VA employees, who 
need access to VA's internal documents, are not nearly so fortunate. VA 
still continues to utilize inaccessible PDF formats for much of its 
internal communications. This practice makes it very difficult for 
individuals who have disabilities that require them to use screen-
readers to do their jobs and serve our veterans.
    In our testimony at the joint hearing held by the full House and 
Senate Committees on Veterans Affairs earlier this year, we highlighted 
another long-standing access issue related to a vital VA website used 
by Veteran Service Officers. The TRIP Training site is itself compliant 
with accessibility guidelines. However, it is off limits to anyone who 
uses adaptive software because it must be entered through a portal that 
does not follow those guidelines. There is, as of this writing, no 
indication that this situation will be corrected any time soon.
    In addition to website accessibility barriers, the kiosks VA has 
deployed at medical facilities nationwide present major access barriers 
for visually impaired veterans. These devices are supposed to be used 
by veterans to check in when they arrive for appointments, so they 
serve as the veteran's first introduction to the facility. A 
complicated or unsuccessful check-in process can impact the remainder 
of the veteran's experience. For a blind veteran, kiosks are, by their 
very nature, at best intimidating, and frequently unusable, due to 
their perfectly flat screens, and the absence of any tactile or audible 
features to give the potential user an idea of how to make them 
operate. Fortunately, such flat screens are becoming fairly common, and 
as they have been incorporated into other devices, such as ATM machines 
and voting machines at some polling places, industry has developed 
standards and best practices that make them accessible to people who 
have reading disabilities. To begin with, such kiosks generally have a 
3.5mm headphone jack located in a prominent place on the machine, and 
insertion of a headphone into this jack activates an audio feature, 
which speaks information into the user's ear about where to touch on 
the screen in order to make it function. Such instructions often begin 
with a brief orientation to the screen and a brief tutorial on what to 
expect while using the machine. Repeat users can skip such introductory 
material if desired, and all users can adjust things like speaking rate 
and volume. Further, instructions for performing various tasks are also 
read out loud to the person wearing the headset. The machines also 
provide audible feedback whenever the user attempts to perform those 
functions, to indicate whether or not the attempt was successful. 
Therefore, since kiosks can be quite usable, and they do serve a 
beneficial purpose for VA, we don't necessarily object to their 
deployment. What we object to is that the kiosks in use at VA medical 
centers do not comply with the industry standard accessibility 
guidelines described above.
    As recently as April, 2019, BVA received a complaint about the 
accessibility of the kiosk in the Washington D.C. VA Medical Center. 
First, plugging in a headset did not activate any audio features. 
Instead, the veteran who was attempting to use the machine stated that 
a sighted bystander told her that a notice had appeared on the screen 
which said, ``If you are blind, press this button.'' One wonders how a 
``blind'' person is supposed to know this information was visible on 
the screen. Once the person who did see it had pressed the appropriate 
button, the instructions did begin and they were audible through the 
veteran's headset. However, the veteran continued to encounter 
problems, because unlike other similar devices, which require users to 
touch a particular area of the screen, such as the bottom right corner, 
the top left corner, or the center, in order to make selections or move 
through various functions, this kiosk required the user to locate and 
press particular buttons to perform each task. This required a degree 
of accuracy in locating and then pressing each button. Because this 
particular user had no vision, that degree of exactitude was not 
achievable. This is not an accessible kiosk. We should note that VA has 
recently rolled out new software for its kiosks which were supposed to 
improve their accessibility, and this veteran had hoped to have a much 
different experience as a result. Unfortunately, she was disappointed. 
BVA is also disappointed that VA's supposed accessibility improvements 
did not accomplish anything better than this. After four or five years 
of discussions with VA, about how to address these issues, and repeated 
assurances from VA that they would be addressed in the next software 
update, this veteran's report was extremely unsatisfactory. If VA is 
going to truly modernize its IT infrastructure, and expand its use of 
electronic communications to provide access to services, VA must pay 
greater attention to accessibility concerns beginning with the rollout 
phase of devices and software. Each time retrofits or replacements are 
required, there is also unnecessary expenditure of funds; funds that 
could be used to improve services to veterans. Incorporating 
accessibility in the first place is much more cost effective.
    Section 508 of the Rehabilitation Act requires Federal agencies to 
ensure that all electronic and information technologies developed, 
procured, maintained, or used in the Federal environment provide equal 
access for people with disabilities, whether they are Federal employees 
or members of the public. Section 508 implementing regulations, 
together with web accessibility guidelines (WCAG) compiled periodically 
over the years by the Worldwide Web Accessibility Consortium, have 
sought to make it clear to Federal agency personnel how to comply with 
these guidelines and regulations. Unfortunately, our experience 
indicates that while the VA has made significant progress toward 
compliance, the department is a long way from consistent compliance. 
BVA's national officers and staff meet regularly with staff of the 
Section 508 Compliance Office and they are generally responsive to the 
concerns we raise. They address the accessibility barriers we bring to 
their attention promptly. However, all too often, those same barriers, 
are erected again a few months later when websites are updated, or a 
new website is rolled out. The scenario that is most disturbing is when 
accessibility features are put in place, only to be broken the next 
time the site is updated. In fact, any time website administrators add 
tools, redesign features, or update content such alterations can render 
aspects of that site inaccessible, unless the industry standards for 
website accessibility are followed. The same can be said for software 
that is developed for use by VA. Best practices that insure 
accessibility are mature and widely accepted throughout the IT 
industry. VA must be encouraged to incorporate them into all aspects of 
its IT infrastructure sooner rather than later. BVA believes this can 
only be done effectively if the initiative comes from the Department's 
leadership. We urge Congress, therefore, to send a message, through 
passage of S. 746, and its companion bill in the House, that this is a 
priority deserving of leadership's attention.
    Before concluding our discussion of this bill, there is one final 
question we want to raise. What will Congress do with the report called 
for in this legislation? It is our hope that the members of both the 
Senate and House Veterans' Affairs Committees, will exercise greater 
oversight of VA's compliance with accessibility guidelines in the 
future. While the report called for in this legislation can highlight 
what needs to be done, it doesn't make its accomplishment a foregone 
conclusion. We urge Members of this Committee to hold VA accountable 
for addressing the barriers and implementing the plan set forth in any 
report Congress receives on the accessibility of VA's websites and 
other electronic communications to people with disabilities. To that 
end, we urge Members of this Committee to require additional reports 
from VA on their progress toward addressing the accessibility barriers 
that are identified in their initial report to Congress. We recommend 
that VA be required to provide this Committee with updates at least 
every 180 days until all of the issues have been addressed. Further, we 
recommend that the Committee on Veterans Affairs seek regular reports 
from VA on its efforts to incorporate accessibility features into new 
web content, and to insure that updates to existing content are made in 
a manner that allows the content to be accessed by all members of its 
intended audience, regardless of disability. We believe this is a 
necessary step, if Congress wishes to insure that VA plans for 
accessibility when new initiatives are launched, rather than adding 
accessibility features in only after receiving complaints from users. 
It would also give this legislation a greater impact on the 
effectiveness of future communications between VA and our Nation's 
disabled veterans. We urge you to consider amending this legislation to 
include such measures, thereby putting VA on notice that Congress is 
serious about insuring compliance with accessibility guidelines, not 
only for the present, but for the long term.
III. S. 318, The Newborn Emergency Treatment act
    BVA supports this legislation because it addresses some serious 
needs faced by veterans at a time when they and their families are most 
financially and emotionally vulnerable; the birth of a new child. This 
legislation corrects some unfortunate shortcomings in the coverage VA 
can provide those newborn children under current law. We join with 
other veteran service organizations in urging Congress to approve these 
changes.
IV. S. 518, The Deborah Sampson Act
    This legislation is long overdue. VA needs to address the practical 
needs of a growing number of women veterans who are enrolled in its 
health care system. We believe that failure to do so now will only 
exacerbate the needs and further alienate the women who have served 
this country. On behalf of the female veterans who have become members 
of our organization, and continue to serve both us and their country 
with distinction, we urge this Committee to approve this legislation.
V. S. 711, The Care And Readiness Enhancement For Reservists Act
    This legislation provides essential services to reservists who face 
the same challenges and have the same needs for care during their 
transition to civilian life as other veterans do. It is particularly 
imperative that these veterans have access to as many options for 
mental health care as possible, in order to help them deal with the 
stresses associated with this time of transition.
VI. S. 785, The John Scott Hannon Veterans Mental Health Care 
        Improvement Act
    We support this legislation because it takes a comprehensive 
approach to addressing the mental health care needs of our Nation's 
veterans and servicemembers. It also encourages collaboration among all 
of the stakeholders involved in the fight to end suicide within this 
population. Piecemeal approaches that address one issue or fund one 
program at a time, have not worked. If we are to prevent further loss 
of life, we need to martial all available resources and begin thinking 
and acting outside the box. We believe this legislation will help make 
that happen.
VII. S. 805 The Veteran Debt fairness Act
    The Department of veterans Affairs should never be allowed to make 
veterans pay for its mistakes. If a veteran, or a member of his family, 
knowingly collects benefits or receives services to which they are not 
entitled, it is reasonable for the VA to take steps to recoup its 
losses. However, when the veteran, or his or her beneficiary, is not at 
fault, it is unconscionable for the government of the United States to 
treat that individual as if they had deliberately defrauded the 
Department and seek to remedy their error by demanding repayment. We 
support this legislation, because it makes such principles of fairness 
a part of the law. It also urges VA to address one of the primary 
reasons why mistakes are made by Va, and thereby provides a practical 
means of reducing the problem in the future.
VIII. S. 857
    A bill to increase the amount of special pension for Medal of Honor 
Recipients, and for other purposes. These veterans have demonstrated by 
their heroic actions and continued service to community and country, 
the need for this legislation. Their family members, who come along 
side them, as they serve, deserve everything we can do to help them 
assist their loved one.
IX. S. 450, The Veterans Improved Access and Care Act
    We support this legislation because the VA faces a nationwide 
shortage of medical personnel. The current onboarding process is much 
more onerous than any process medical professionals encounter in the 
private sector. As such, it serves to deter, rather than encourage 
prospective employees. If the VA is going to meet its personnel needs, 
VA must find ways to make recruitment and onboarding more efficient. 
This legislation will allow VA to explore the viability of additional 
options for accomplishing this objective.
                               conclusion
    Thank you, once again, for the opportunity to speak with you about 
the above legislation. If you would like any further information, or 
have questions regarding the above comments, please feel free to 
contact Melanie Brunson, Director of Government Relations, at 
[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
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    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.
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    SVA strongly supports giving VA the authority to extend the current 
timeframe when natural disasters are so severe an institution needs 
more than a month to reopen campus. We believe this is a common-sense, 
proactive policy change providing student veterans more than a few 
weeks' time to figure out a new plan when facing catastrophes.
    If the Committee would like to continue the conversation on ways to 
better serve our student veterans responding to natural disasters, one 
area that students still need relief is with post-disaster relocation. 
If a student must relocate due to a natural disaster and cannot 
immediately return to school upon reopening, VA is unable to continue 
making payments to them or assist with relocation needs. This compounds 
the student's existing problems and causes undue hardship.
    We would also like to encourage the Committee to consider ways to 
provide assurances for housing allowances in the wake of natural 
disasters without having to lose a month or more of educational 
assistance eligibility due to circumstances beyond students' control.
    We applaud Congress' efforts thus far to provide common-sense 
relief to our student veterans who are impacted by natural disasters. 
With each proactive step, Congress sends a powerful message to our 
veterans that our country is committed to serving them when they need 
help the most.
    In addition to the legislation listed above, SVA also supports 
S. 785, the Commander John Scott Hannon Veterans Mental Health Care Act 
of 2019, which makes continued improvements to the Transition 
Assistance Program and authorizes a scholarship program for veterans 
seeking certain degrees.
    The success of veterans in higher education is no mistake or 
coincidence. Research consistently demonstrates this unique population 
of non-traditional students is far outpacing their peers in many 
measures of academic performance.\12\ Further, this success in higher 
education begets success in careers, in communities, and promotes 
family financial stability, holistic well-being, and provides the all-
volunteer force with powerful tools for recruitment and retention when 
recruits know military service prepares them for success after service.
---------------------------------------------------------------------------
    \12\ Cate, C.A., Lyon, J.S., Schmeling, J., & Bogue, B.Y. (2017). 
National Veteran Education Success Tracker: A Report on the Academic 
Success of Student Veterans Using the Post-9/11 GI Bill. Student 
Veterans of America, Washington, DC, http://nvest.studentveterans.org/
wp-content/uploads/2017/03/NVEST-Report_FINAL.pdf.
---------------------------------------------------------------------------
    We thank the Chairman, Ranking Member, and the Subcommittee Members 
for your time, attention, and devotion to the cause of veterans in 
higher education. As always, we welcome your feedback and questions, 
and we look forward to continuing to work with this Committee, the 
Senate Veterans' Affairs Committee, and the whole of Congress to ensure 
the success of all generations of veterans through education.
                                 ______
                                 
            Letter from James Craig, J.D., Ed.D, President, 
              United Veterans Committee of Colorado (UVCC)

              [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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

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