    [Senate Hearing 117-231]
    [From the U.S. Government Publishing Office]

                                                            S. Hrg. 117-231

                         HEARING ON PENDING LEGISLATION

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

                                    HEARING

                                   BEFORE THE

                         COMMITTEE ON VETERANS' AFFAIRS
                              UNITED STATES SENATE

                        ONE HUNDRED SEVENTEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                                 JUNE 23, 2021

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

                      [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

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

                                  ___________

                        U.S. GOVERNMENT PUBLISHING OFFICE

    47-277 PDF                WASHINGTON : 2023

                         COMMITTEE ON VETERANS' AFFAIRS

                         Jon Tester, Montana, Chairman
    Patty Murray, Washington             Jerry Moran, Kansas, Ranking
    Bernard Sanders, Vermont                 Member
    Sherrod Brown, Ohio                  John Boozman, Arkansas
    Richard Blumenthal, Connecticut      Bill Cassidy, Louisiana
    Mazie K. Hirono, Hawaii              Mike Rounds, South Dakota
    Joe Manchin III, West Virginia       Thom Tillis, North Carolina
    Kyrsten Sinema, Arizona              Dan Sullivan, Alaska
    Margaret Wood Hassan, New Hampshire  Marsha Blackburn, Tennessee
                                         Kevin Cramer, North Dakota
                                         Tommy Tuberville, Alabama
                          Tony McClain, Staff Director
                     Jon Towers, Republican Staff Director

                                C O N T E N T S

                                  ----------

                                 JUNE 23, 2021
                                    SENATORS

                                                                       Page
    Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
    Tillis, Hon. Thom, U.S. Senator from North Carolina..............     5
    Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire......     8
    Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     9
    Murray, Hon. Patty, U.S. Senator from Washington.................    11
    Brown, Hon. Sherrod, U.S. Senator from Ohio......................    15
    Tuberville, Hon. Tommy, U.S. Senator from Alabama................    16

                                   WITNESSES
                                    Panel I

    Mark Upton, MD, Acting Assistant Under Secretary of Health for
      Community Care, Veterans Health Administration, Department of
      Veterans Affairs
      Accompanied by: Gerard Cox, MD, Assistant Under Secretary for
      Health for Quality & Patient Safety; Clifford Smith, MD, Deputy
      Director, Office of Mental Health Operations; and Theresa
      Gleason, PhD, Director, Clinical Science Research & Development
      Service........................................................     2

                                    Panel II

    Joy Ilem, National Legislative Director, Disabled American
      Veterans.......................................................    17
    Kathryn Monet, Chief Executive Officer, National Coalition for
      Homeless Veterans..............................................    19
    Mario A. Marquez, Director, Veterans Affairs and Rehabilitation
      Division, The American Legion..................................    21

                                    APPENDIX
                                 Hearing Agenda

    List of Pending Bills............................................    35

                              Prepared Statements

    Mark Upton, MD, Acting Assistant Under Secretary of Health for
      Community Care, Veterans Health Administration, Department of
      Veterans Affairs...............................................    39
    Joy Ilem, National Legislative Director, Disabled American
      Veterans.......................................................    80
    Kathryn Monet, Chief Executive Officer, National Coalition for
      Homeless Veterans..............................................   101
    Mario A. Marquez, Director, Veterans Affairs and Rehabilitation
      Division, The American Legion..................................   107

                            Questions for the Record

    Response to questions submitted by:
      Hon. Jerry Moran...............................................   131

                           Statements for the Record

    Tammy Barlet, Associate Director, National Legislative Service,
      Veterans of Foreign Wars of the United States..................   137
    Lisa Robin, Chief Advocacy Officer, Federation of State Medical
      Boards.........................................................   143
    Kate Hendricks Thomas, PhD, Marine Corps veteran, Researcher,
      University of Alabama Center for Evaluation Adjunct Faculty,
      George Mason University's Department of Global and Community
      Health.........................................................   145
    Melissa Jackson, President, National Association of State
      Veterans Homes.................................................   149
    Nursing Community Coalition......................................   154
    David Benton, RGN, PhD, FFNF, FRCN, FAAN, Chief Executive
      Officer, National Council of State Boards of Nursing...........   157
    Paralyzed Veterans of America....................................   160

                         HEARING ON PENDING LEGISLATION

                                  ----------

                            WEDNESDAY, JUNE 23, 2021

                                           U.S. Senate,
                                Committee on Veterans' Affairs,
                                                        Washington, DC.
        The Committee met, pursuant to notice, at 3:19 p.m., in
    Room SR-418, Russell Senate Office Building, Hon. Jon Tester,
    Chairman of the Committee, presiding.
        Present: Tester, Murray, Brown, Blumenthal, Hassan, Moran,
    Tillis, Blackburn, and Tuberville.
        Chairman Tester. I want to call this meeting to order.
        Before we get to my opening statement I just want to make
    one thing really abundantly clear. We have rules in this
    committee, when we want a testimony, we want it in before the
    deadline, not after the deadline. There is a reason for that.
    The reason for that is that both Jerry Moran and myself have
    some really amazing staff members that are able to scrutinize
    that testimony and get some questions driven by what that
    testimony says.
        If the first time we see a testimony is a period not long
    enough for us to look at that testimony, that is a problem.
        Next time, I will be much more pointed and a lot more mad
    if this happens. This is a professional outfit. You are a
    professional outfit. Rules are not made to be broken, in my
    opinion. They are made to be attended to. So I just want to say
    that to begin with. I hope I have made myself clear, thank you,
    and I hope that anybody from the VA that is listening to this,
    I hope I have made myself clear to them too. Okay?
        We want to help you. We cannot help you if we do not know
    what the hell you are thinking. Okay? All right. Thank you very
    much.
        Senator Moran will be here in a few minutes. I am going to
    start with my opening statement, and hopefully he will be here
    by the time I finish.

                  OPENING STATEMENT OF CHAIRMAN TESTER

        Chairman Tester. Good afternoon. I want to thank you all
    for joining us today to hear views from the Department of
    Veterans Affairs and veteran service organizations on 21 bills
    pending before this committee. Even before the pandemic,
    organizations working to support our nation's most vulnerable
    veterans told us they need bigger lifeboats as they could not
    fully support the existing population of veterans experiencing
    homelessness.
        In April, we hosted a roundtable with VSOs on homeless
    veterans advocacy. We heard firsthand about the challenges they
    face in facilitating a productive conversation with VA, HUD,
    Department of Labor about what needs to be done to address
    them. Included on today's agenda is my bill, the Building
    Solutions for Veterans Experiencing Homelessness Act. Every
    section of this legislation came out of a request made during
    that roundtable. This bill makes permanent COVID-related safety
    nets that have become essential to providing the most effective
    care and support to unhoused veterans and their families. These
    requests are not wish list items but concrete changes advocates
    have said are absolutely necessary in the fight to effectively
    end veteran homelessness. In fact, the Department is on record
    requesting some of the items in my bill from Congress.
        Given this, it is disappointing that the VA has not
    provided views on my bill for this hearing, despite having had
    the text since May 24th. My expectation is VA will address this
    delay in views expeditiously.
        Also on our agenda today is S. 1467, the VA Medicinal
    Cannabis Research Act, a bill that I worked on with Senator
    Sullivan that expands the research on alternative treatments
    for veterans who suffer from the seen and unseen wounds of war.
    A survey conducted by the American Legion tells us that 22
    percent of veterans who responded already use cannabis to treat
    a medical condition. Our bill would help the VA get the
    necessary data to fully evaluate this treatment and educate
    veterans on the outcomes of using medicinal cannabis to treat
    certain conditions.
        Once again, I want to thank our witnesses for being here
    today, and I mean that. Thank you. If we work together we can
    fulfill our promise to our veterans. We can reassure them that
    when they fight for us, we are going to fight for them, and
    guarantee they get the benefits that they deserve.
        With that we are going to be in recess until Moran shows
    up.
        [Recess.]

        [The pending bills referred to by Chairman Tester appear on
    page 35 of the Appendix.]

        Chairman Tester. We will just go ahead. You guys start your
    testimony. The rules are that your full written statement will
    be put in the record, so if you can pare that written statement
    down to five minutes I would appreciate it.

                                PANEL I

                                  ----------

                 STATEMENT OF MARK UPTON ACCOMPANIED BY

                    GERARD COX; CLIFFORD SMITH; AND

                            THERESA GLEASON

        Dr. Upton. Thank you, Chairman Tester and Ranking Member
    Moran and members of the committee. We appreciate you inviting
    us here today to present our views on bills covering many
    critical topics. Joining me today, I just would like to say
    thank you to Dr. Gerry Cox, Assistant Under Secretary for
    Health for Quality & Patient Safety; Dr. Clifford Smith,
    Director of Field Support and Analytics, Office of Mental
    Health and Suicide Prevention; and Dr. Theresa Gleason,
    Director of Clinical Science Research & Development Service
    here in the Veterans Health Administration. I would also like
    to thank our VSO colleagues who will be part of the second
    panel. We truly appreciate what you do.
        Mr. Chairman, I would like to start by just acknowledging
    your comments in the beginning. VA apologizes to the committee
    for our late submission of the testimony. We know that you
    depend on VA's views and pledge to work with you during and
    after this hearing to ensure you have the information that you
    need.
        I will not be able to touch on all the bills in the agenda
    during these brief opening remarks, but our written testimony
    contains detailed comments on all but two of them, and I want
    to assure you that VA stands ready to engage with you on all of
    these bills.
        VA has made mental health care and suicide prevention top
    clinical priorities, and we truly appreciate the committee's
    partnership on this important work. VA supports S. 544, that
    would establish an annual Buddy Check program. We appreciate
    the intent but cannot offer our support, however, for S. 613
    and S. 951, both regarding therapeutic use of service dogs, due
    to different but overlapping concerns on both bills that we
    would be happy to discuss today.
        Outreach during the transition to civilian life is
    critical, which is the subject of S. 1198, the Solid Start Act.
    This bill codifies vigorous outreach programs that we are doing
    now on a number of fronts. We do note some issues that are
    shared in our written testimony and certainly would be happy to
    discuss.
        As the number of women veterans enrolling in VA health care
    increases, VA must be prepared to meet their needs. We
    appreciate the inclusion of reproductive health legislation on
    today's agenda. VA supports additional authorities to improve
    and expand these services, and a detailed analysis of S. 1280,
    the Veteran Families Health Services Act, is in our written
    testimony, including technical concerns and open questions, and
    we are eager to work with the committee to go through this in
    detail.
        Let me assure this committee that nothing is as important
    to us as protecting the safety of the veterans who entrust us
    with their care. That must be paramount every hour of every day
    for VA. We support, with some suggestions, S. 539, the VCR Act,
    regarding the use of video cameras to monitor patient safety.
        S. 372, the Ensuring Quality Care for Our Veterans Act,
    involves clinical reviews of the quality of hospital and
    medical services. We appreciate the committee's commitment to
    ensuring that veterans receive the safest and highest quality
    care possible, but do have concerns about the effectiveness of
    layering new requirements on top of existing review processes
    and mechanisms. We are eager to collaborate with the committee,
    however, as partners in patient safety.
        VA remains committed to a strong, thriving, direct health
    care system, augmented by a robust and high-quality Community
    Care Networks. Veterans deserve and demand a strong VA health
    system tailored to their needs and a robust Community Care
    Network to supplement that system. The Guaranteeing Healthcare
    Access to All Personnel Who Served Act would make some
    fundamental changes to VA Community Care authorities, including
    codifying access standards now set by regulation.
        We are concerned that it would eliminate VA's flexibility
    to react to changes in market conditions and other emerging
    issues, as well as preempt VA's ongoing intensive analysis of
    the access standards outlined in the MISSION Act. The bill
    would also directly mandate these access standards in our
    contracts with community providers, and we believe there could
    be disruptive, unintended consequences from that change and
    that network adequacy is an issue that requires the ability to
    adapt to changes in market conditions and emerging needs of our
    veteran population. There are other significant changes that
    would greatly affect VA's delivery of health care that we would
    be happy to discuss with the committee.
        VA supports, with some technical changes, the Veterans'
    Emergency Care Claims Parity Act, and is glad to support S.
    727, the CHAMPVA Children's Care Protection Act.
        Our country's most sacred obligation is to prepare and
    equip the troops we send into harm's way, and to care for them
    and their families when they return home. The Building
    Solutions for Veterans Experiencing Homelessness Act is a
    package of provisions to buttress VA's efforts to support
    veterans in need of assistance. While VA has not been able to
    conclude views on this bill, there are many worthwhile concepts
    in this legislation, and we are eager to work with you, Mr.
    Chairman, and the committee on technical assistance in the
    meantime.
        VA supports the Improving Housing Outcomes for Veterans
    Act, which would help coordinate best practices and other
    information on homelessness programs among homeless providers
    and VA medical center staff. We do note some duplications in
    the bill's provisions, however.
        Finally, VA is glad to support S. 1040, which would expand
    eligibility to VA health care benefits to World War II veterans
    that are not otherwise eligible.
        I want to re-emphasize that we greatly appreciate the
    partnership of this committee and the time to discuss these
    important bills with you today. This concludes my statement,
    and we look forward to your questions.

        [The prepared statement of Dr. Upton appears on page 39 of
    the Appendix.]

        Chairman Tester. I appreciate that. I appreciate your
    comments on the testimony too. We will hold you to it.
        As I pointed out in my testimony, there was no comments
    given on S. 2172, which is a bill that I am particularly fond
    of, but may not be perfect. When can I anticipate your comments
    on that bill?

            Response: Comments were provided to SVAC Majority staff (Tess
            Wrzesinski) during a phone call with VA SMEs on June 30, 2021,
            and will continue with a follow-up call (and/or written TA)
            upon receipt of the revised version of the bill.

        Dr. Upton. Mr. Chairman, first off, as a frontline VA
    health care provider, the work that we do in VA to help
    homeless individuals is so important to me, so I truly
    appreciate that, just at the outset. I think one of the unique
    parts of being a VA provider is when I am taking care of a
    medical issue that is compounded by homelessness we are able to
    help both, which is very, very key.
        In terms of the exact timeline, sir, I know we are actively
    working on that and will certainly be glad to take that for you
    after this hearing today. But you should receive that soon, and
    that is certainly our commitment.
        Chairman Tester. That would be good. Yes, I think it is
    really important.
        Look, I do not want to bring up old issues, but we did a
    hearing on toxic exposure and the VA did not do any comments on
    any of those bills, for whatever reason. And quite frankly, we
    are paying for that right now. We are paying a price for that.
    And so just keep in mind that if there are bills out there, all
    you have got to do is say, ``Yep, I like it,'' or ``No, I
    don't, and here is why.'' That is it, and it is really
    important.
        I have a question for you, Dr. Upton, and it has nothing to
    do with any of the bills. It has to do with the adequacy of our
    dental network in Montana, and I want to thank you for looking
    into that adequacy. My understanding of it is that of the 13
    dental providers in the CCN serving Great Falls, just 7, a
    little over half of the dental providers are willing to make
    appointments for veterans, meaning roughly half of VA's
    directory of dental providers, developed by contractors, was
    unusable for the fourth-largest city in Montana, maybe the
    third.
        Unfortunately, this is not an isolated issue, and one that
    should be reviewed nationwide, so the contractors are
    accountable for network adequacy and veterans are able to know
    what their actual options are for dental or medical care within
    the community.
        What can the VA do to execute better the oversight of these
    networks?
        Dr. Upton. Thank you, Mr. Chairman, and just to echo both
    my role as a frontline doctor, as I mentioned before, as well
    as the head of Community Care in the Veterans Health
    Administration, ensuring that veterans have access to the care
    they need, it is critical. It is personal to me and it is our
    fundamental priority.
        The CCN contracts that you reference are a substantial step
    forward in the care for our veterans and in the work that we do
    with Optum and TriWest, our focus is to get it right the first
    time. But there are certainly some things that we have learned,
    implementing large contracts in the midst of the pandemic, and
    my focus as well as our partners that we work with is when an
    issue gets identified, which I truly appreciate the VA Montana
    staff, your staff, relaying that to us, we take it seriously,
    we acknowledge it, we work to make it better, as well as work
    on large-scale initiatives.
        So a lot of nuances to that, that I am happy to share with
    you, sir, and your committee, but the fundamental answer is I
    hold myself to a very high standard, our office as well as our
    contractors, and we are committed to ensuring that we get this
    right on all fronts, and I am happy to keep you and the
    committee updated on that.
        Chairman Tester. Okay. Thank you. Senator Tillis.

                          SENATOR THOM TILLIS

        Senator Tillis. Thank you, Chairman Tester. Thank you all
    for being here to testify. As you know, Senator Fischer and I
    have been working on complementary legislation that seeks to
    provide veterans with access to proven alternative treatment
    models such as therapeutic training of service dogs, and in
    some instances, pairing veterans with such service dogs.
        I am somewhat disappointed that the VA's testimony today
    raises a number of issues that have already been discussed and
    agreed-upon by the House's unanimous package of Representative
    Stivers' PAWS for Veterans Therapy Act. While I wish the VA
    would have accounted for these changes, which I believe
    resolved the majority of the outstanding concerns, I do want to
    raise a few specific questions that you outlined in your
    testimony. And, Chairman Tester, we got this information, or
    the feedback, just a couple of hours ago.
        So when we have limited time I always hate it when members
    say, ``Give me a yes or no answer,'' but to the extent you can
    give me a yes or no answer on some of these concise questions I
    would appreciate it.
        Your testimony states, ``Although possibly helpful to a
    limited number of veterans, the therapeutic medium of training
    service dogs does not have an adequate basis of evidence.''
    Isn't it true that the VA has already conducted Train the
    Trainer Program at Palo Alto, VA?
        Dr. Smith. Correct. There is a program at Palo Alto.
        Senator Tillis. And isn't it the purpose of vital programs
    to test out these innovative approaches so we, as policymakers,
    can gather additional outcomes and data?
        Dr. Smith. Correct.
        Senator Tillis. And the VA's testimony also casts doubt on
    the efficacy of pairing service dogs with veterans experiencing
    post-traumatic stress, but isn't it true that the VA's own
    study recently found a reduction in severity of PTSD symptoms
    and suicidal ideation and behaviors in veterans paired with
    service dogs?
        Dr. Smith. There is not enough scientific evidence to
    support that broad conclusion.
        Senator Tillis. I will follow up on that with questions for
    the record.
        Moving on to quality standards, which was outlined in the
    PAWS for Veterans Therapy Act that was unanimously passed by
    the House. You raised concerns that the standards and quality
    of partner service dog training organizations, yet isn't it
    true that the VA already has standards for seeing eye dogs?
        Dr. Smith. The VA uses the two accrediting organizations as
    their main bodies, correct.
        Senator Tillis. And isn't it true that those standards are
    defined in regulations and not in statute?
        Dr. Smith. I believe that is correct.
        Senator Tillis. You know, the PAWS for Veterans Therapy
    Act, which unanimously passed the House last month, in a
    cooperation on a bipartisan basis, requires any participating
    organization to be--these are the words--``accredited with
    demonstrated experience, national scope, and recognized
    experience in training of service dogs, as determined by the
    Secretary.'' Are you suggesting that the VA would set standards
    that are inadequate or lesser than those it currently uses?
        Dr. Smith. We would use the standards of the two
    accrediting bodies.
        Senator Tillis. Don't you agree that calling out specific
    accrediting bodies would hamstring the VA's ability to make
    future adjustments to maintain program integrity and quality?
    When I was a coder I called that hard coding. We wanted to give
    the VA flexibility. Would you agree that it would make more
    sense to give the VA flexibility?
        Dr. Smith. Well, we appreciate that intent at flexibility.
    We want to maintain the highest of gold standards, and those
    two organizations are the gold standard.
        Senator Tillis. Isn't it true that the VA worked directly
    with the House sponsors to arrive at a mutually agreeable
    standard in the PAWS for Veterans Act?
        Dr. Smith. Subject matter experts have been working with
    the House, correct.
        Senator Tillis. Now with VA authorities with regards to
    service dog pairing, VA's testimony states that Section 4 of my
    bill was duplicative because VA already has the authority to
    provide a service dog to a veteran, regardless of whether a
    veteran has mobility impairment. Has the VA ever used that
    authority?
        Dr. Smith. I am aware the Secretary has that authority. I
    believe it has been----
        Senator Tillis. They have not used it. I do not believe
    they have, and we can make sure you can submit those
    specifications for the record, at least based on our best
    research.
        Isn't it true the VA's implementing regs are more limiting
    than the underlying statute?
        Dr. Smith. I would have to take that for the record.

            Response: The Department does not "place a service dog with a
            Veteran," although VHA Clinical Offices may provide
            recommendations for Veterans with various disabilities as to
            whether or not a service dog is appropriate for them as a
            Veteran seeks to obtain a service dog from a service dog
            provider.

            VHA (Rehabilitation & Prosthetic Services) administers the
            veterinary health benefit for Veterans with approved service
            dogs that have been obtained from Assistance Dogs International
            or International Guide Dog Federation training organizations.
            Currently, this benefit extends to guide dogs (for visual
            impairment), hearing dogs (for deafness), and mobility dogs
            (for mobility disorders due to physical or mental health-
            related disorders).

        Senator Tillis. In our judgment it is. This section simply
    seeks to get VA to update its implementing regulations to
    reflect congressional intent. Unfortunately, the VA has ignored
    this spirit of the law, and instead applied its own narrow
    approach.
        So in my remaining time, you know, here today are a series
    of concerns with respect to how the VA will execute the
    legislation. I firmly believe the VA has the tools and
    authorities necessary to make this program a success, and 435
    of my House colleagues, and I will also say many of my
    colleagues in the Senate, agree. We have waited too long to
    provide the treatment, and I would like to move forward on it.
        Thank you, Mr.--I almost called you Mr. President--thank
    you, Chairman.
        Chairman Tester. I would never forgive you if you did that.
    Thank you, Senator Tillis. Senator Hassan.

                      SENATOR MARGARET WOOD HASSAN

        Senator Hassan. Well, thank you, Chair Tester and Ranking
    Member Moran. Thank you to all of our witnesses for being here
    today and for your service. And I am going to direct these
    questions to you, Dr. Upton, and if you want to ask other
    panelists to chime in, please do.
        Every year, 200,000 servicemembers transition from military
    to civilian life. The majority are in the 18- to 34-year-old
    age range, which also has the highest veteran suicide rate.
    That is why I introduced bipartisan legislation with Senators
    Cramer and Cassidy to strengthen and make permanent the Solid
    Start Program, which as you know, is the VA initiative that
    aims to contact every veteran multiple times by phone in the
    first year after they leave active duty, to check in and help
    connect them to VA programs and benefits.
        So can you please speak to how Solid Start's early and
    consistent contact with new veterans is critical to their well-
    being?
        Dr. Upton. Absolutely, Senator, and we in VA completely
    agree that that transition from active duty service into our
    system is a very important transition period and one that
    should be taken with as much support as possible.
        There are a lot of components to that, that relate to
    mental health, and so I am going to turn to Dr. Smith to touch
    on that quickly.
        Senator Hassan. Yes.
        Dr. Upton. I appreciate that.
        Senator Hassan. Thank you.
        Dr. Smith. Senator, we appreciate that bill and many of the
    aspects within that. I am aware of your commitment for those
    transitioning servicemembers. Broadly, our Solid Start Program
    is already incorporating many of the things you raise in the
    bill. There are some places we would appreciate further
    discussion for clarity. But overall, the current proposal is
    consistent with our implementation of the three phone calls
    within the first year. It is of critical importance to do all
    we can for that engagement of those servicemembers.
        Senator Hassan. Well, I think it will make a real
    difference, as you all have said, to mental health supports for
    our veterans, and that is why I think it should be made
    permanent, and I look forward to continuing to work with you on
    it.
        Let's go on to the Buddy Check program, because veterans
    need outreach in a lot of different ways, and the American
    Legion's Buddy Check volunteer initiative is important because
    it connects veterans directly with other veterans. I introduced
    bipartisan legislation with Senator Ernst to build on the
    American Legion's efforts by directing the VA to designate 1
    week per year as Buddy Check Week, to organize outreach events
    and educate veterans on how to conduct peer wellness checks.
        So, Dr. Upton, and I think probably Dr. Smith too, can you
    please speak to how Buddy Checks, which are volunteer led,
    could complement the VA's efforts to support veterans' mental
    health?
        Dr. Upton. Yes. I will just say thank you for that, and we
    wholeheartedly agree. That bill, and because it is mental
    health specific, I will turn to Dr. Smith, but thank you.
        Dr. Smith. Thank you, Senator. We agree it is a great
    opportunity. We do many outreach activities now, Mental Health
    Month, for example, focusing on communications to not only VA
    enrollees but non-enrollee veterans. Buddy Check is another
    opportunity. I do think it is an opportunity to think broadly.
    It is not just a mental health issue. It is a community issue.
    We should be aware of our buddies. And so that is how we would
    approach it, moving forward, is it is not just a mental health
    focus. It is a veteran focus. It is about community.
        Senator Hassan. Yes, and it is also about different
    veterans with particular different needs or experiences being
    able to find each other----
        Dr. Smith. Absolutely.
        Senator Hassan [continuing]. And that is something I am
    hearing from women veterans, particularly in rural parts of my
    state. So I will look forward to working on that with all of
    you.
        I want to follow up on the line of questioning that Doctor,
    Senator Tillis--I just made you a doctor, Senator--Tillis was
    talking about, because we need innovative solutions to address
    veteran suicide and post-traumatic stress disorder.
        So as you may know, I support legislation like Senator
    Tillis' and like Senator Fischer's PAWS Act, which would
    establish a 3-year program at the VA where the Department would
    provide grants to eligible service dog organizations to pair
    more veterans with service dogs.
        So what I think you are hearing from Senator Tillis, and
    what I would like some commitment on here, is we currently
    understand that the VA, just this morning, indicated it does
    not support these bills, but can we have your commitment that
    the VA will implement it as Congress intends by providing a
    legitimate avenue through the VA to provide service dogs to
    veterans with PTSD?
        Dr. Smith. Thank you, Senator. Absolutely. You know, we are
    aware, and we agree with the deep commitment to intervening in
    veteran suicide. We have to think big, think creatively. It is
    an opportunity to continue thinking big. I know, in addition to
    the two Senate versions there is a House version. We look
    forward to those continued conversations with our subject
    matter experts, staffers and yourself personally. We are
    committed to that.
        Senator Hassan. There are a lot of members of both sides of
    the aisle who are getting a lot of briefings and information
    that indicates that these would be really valuable pairings,
    efforts, and it really does support veterans with PTSD. So what
    you are hearing from us is a real desire, even if you have some
    differences, if it passes, that we get to work and do this in
    the way that Congress intends. Thank you.
        Chairman Tester. Thank you, Senator Hassan. Senator Moran
    for an opening statement.

                   OPENING STATEMENT OF SENATOR MORAN

        Senator Moran. Chairman, thanks for your accommodation.
    There are two hearings that I am the Ranking Member of going on
    at the same time, and a third one that I needed to attend, but
    I think I am with you for the rest of the afternoon, and I am
    not sure that you will find that pleasing but I am here for the
    duration.
        Dr. Upton and our VSO witnesses that are here today, I say
    good afternoon to you and I am looking forward to hearing from
    each of you regarding the legislation before us. Today we have
    22 bills for consideration, with most relating Veterans Health
    Administration. In recent years, Congress has passed
    significant reforms to modernize the system to be more
    effective, streamlined, and most importantly, veteran centered.
    These changes have yielded positive results with more veterans
    having a favorable opinion of VHA.
        Integral to these reforms has been greater choice and
    flexibility among our veterans. Putting greater control into
    the hands of veterans through the VA MISSION Act has helped
    improve the VA and make certain that veterans have timely,
    reliable access to care.
        In addition to the MISSION Act, the Commander John Scott
    Hannon Act, that Chairman Tester and I introduced, is enhancing
    veterans' care by building upon innovative suicide prevention
    services, expanding veterans' access to mental health care,
    bolstering VA's research efforts, and increasing VA
    accountability on all mental health and suicide prevention
    services.
        Despite these recent achievements, gaps remain. My bill,
    Guaranteeing Healthcare Access to Personnel Who Served Act, or
    GHAPs Act, would work to close those gaps by ensuring certain
    and consistent coverage to veterans who get their care through
    the VA.
        When introducing the GHAPs Act it was important to me to
    solicit support from all VSOs and veteran service
    organizations, large and small. Too often, in important
    legislation that impact veterans, only a few select groups are
    given the opportunity to discuss. With the GHAPs Act, my staff
    and I made it a priority to talk with numerous organizations
    which serve veterans across America. I am grateful to have the
    support of larger VSOs, such as the American Legion and Vietnam
    Veterans of America, and the smaller VSOs, such as the Alaska
    Native Veterans Association, the National Association of Black
    Veterans, and the American Ex-POWs, as well as the support of
    important stakeholders such as the American Red Cross and the
    National Association for Rural Mental Health.
        In addition to GHAPs Act, I look forward to discussing my
    VA Supply Chain Resiliency Act, which would address VA's supply
    chain process, particularly during emergency periods. As we saw
    during COVID-19 pandemic, it is crucial that the VA have robust
    plans in place to take into account interdepartmental
    cooperation and to make certain the system has adequate and
    appropriate distributed resources in times of emergency.
        On the remaining legislation on today's agenda there are a
    number of important bills from my colleagues that address
    critical topics such as patient safety at the VA medical
    centers, the VA Solid Start Program, alleviating veteran
    homelessness, and VA provider accountability. On this last
    subject, I am pleased to co-lead the bipartisan effort with
    Senator Manchin to ensure that only verified and credentialed
    providers are permitted to treat our nation's veterans.
        Lastly, I would like to speak to our veterans directly. For
    your service you deserve a system that works for you. Whether
    you live in rural America or urban America, Indian country, or
    overseas, your service to our country must be matched by this
    committee and the Department of Veterans Affairs.
        I look forward to hearing testimony of each of the bills
    today, which I missed hearing it but I have it in writing, and
    I look forward to determining how we can work together to
    better serve our American veterans.
        Mr. Chairman, I will ask my questions at a later time, and
    I yield back.
        Chairman Tester. Thank you, Senator Moran. Senator Murray.

                          SENATOR PATTY MURRAY

        Senator Murray. Thank you very much, Mr. Chairman. I do
    want to talk a little bit about the two bills that I have on
    the agenda today, which would improve the lives of veterans in
    Washington State and across the country.
        The first one is the Planning for Aging Veterans Act. It
    will require the VA to develop a strategy to address long-term
    care needs of veterans to guide our future investments. The
    bill would make improvements to VA's oversight of State
    Veterans Homes and provide geriatric psychiatric assistance to
    veterans in these facilities, which can improve the lives of
    veterans living with traumatic brain injuries or memory loss.
        The second bill is the Veteran Families Health Services
    Act. It is critical for so many of our veterans with
    infertility, trying to realize their dream of having children.
    I have been fighting for the provisions in this bill to become
    law for almost a decade, because America's veterans deserve
    comprehensive health care benefits from the VA after their
    service to the country, and that includes fertility treatments.
    This legislation is needed because VA's current authority to
    provide fertility treatment, such as IVF, is limited. This bill
    would make VA's authority permanent and expand access to these
    services in a way that would meet the needs of veterans across
    my state and the entire country, and I really appreciate VA's
    technical assistance on this bill. I do have a few questions
    for the witnesses, and Dr. Upton, I want to start with you.
        VA's existing authority to provide IVF is unnecessarily
    restrictive and means that many of our veterans do not have
    access to fertility programs they need to start a family. For
    example, VA's existing IVF policy prohibits the use of donated
    gametes. How common is it for private sector fertility
    providers to allow the use of donors?
        Dr. Upton. Thank you for the question, Senator, and as an
    internist myself and not a women's health expert I am happy to
    take that specific question for the record. But what I can say,
    as someone who executes the IVF contracts in the community as
    well as works closely with their women's health experts, they
    are very appreciative of many aspects of your bill and the need
    to create more of an equitable playing field and align more of
    our care with health care standards. And I think that will
    likely be aligned with that, but we are happy to confirm and
    report back.

            Response: Allowing the use of donated gametes would be a
            standard of in-vitro fertilization practice for private sector
            fertility providers.

        Senator Murray. Well, VA's existing authority to provide
    IVF comes from appropriations that have been enacted by
    Congress each year. How does not having permanent authority
    affect VA's ability to plan ahead, to educate VA providers, and
    make sure there is continuity of care for our veterans?
        Dr. Upton. I will have to take that one for the record as
    well, Senator, but I will say that there are many pieces in the
    bill that we support and very much appreciate.

            Response: Appropriation laws have expirations tied to the
            fiscal year cycle. VA has not been able to assure Veterans that
            the episodes of IVF care they are entering into will be
            authorized beyond a given fiscal cycle. The process of IVF
            treatments can easily require months of examinations,
            medication cycles to enhance ovulation, and specific scheduling
            of retrieval treatment attempts. In addition, Veterans may make
            decisions about pregnancy attempts based on the potential
            expiration of benefits rather than on what timing is best for
            their family.

        Senator Murray. Well, I would say for my colleagues on the
    committee and in the Senate and everywhere else, that if they
    do not have permanent authority then it is very hard to help
    our veterans plan for the families that they deserve. They
    served our country. They were injured, which made limited
    opportunities for them to have children, a dream many people
    ought to have, including our veterans. And so we need to enact
    a full, comprehensive bill here that will allow them to get
    that, and for the people who are providing it to be able to
    give them the kind of education that they need to make sure
    that they can plan for their families.
        Dr. Upton, I have spoken at previous hearings about the
    Planning for Aging Veterans Act and the importance of the VA
    preparing for the future long-term care needs of veterans. As
    the Department makes decisions about infrastructure and
    staffing, the VA has provided a lot of support to State
    Veterans Homes throughout the COVID-19 pandemic, and I hope the
    relationship between State Veterans Homes and the VA remains
    strong. However, the process of entering into sharing
    agreements between medical centers and individual State
    Veterans Homes can differ widely from state to state. Some VA
    medical centers are able to reach an agreement with a state
    home in a timely manner. Others, it takes years to get an
    agreement put together.
        Can you describe for the committee how the lack of a
    standardized process to enter into these agreements can affect
    access for residents to State Veterans Homes?
        Dr. Upton. Thank you, Senator, and I just completely agree
    with the need for an important plan and partnerships as our
    veteran population ages. The partnership we have with our State
    Veterans Homes are critical, and we have certainly worked
    closely with them throughout the pandemic, as you know.
        Our technical experts specifically related to those sharing
    agreements would be happy to comment on that, and I know they
    have in our testimony. But my assumption is they are very
    important and we appreciate your help improving that, and we
    will get you a formal answer as well.

            Response: VA Medical Centers follow an internal VHA Directive
            1660.01, Health Care Resources Sharing Authority--Selling, that
            has the defined process. A selling sharing agreement is used
            when a State Veterans Home (SVH) is required to provide a
            service under the federal regulation and they seek that service
            from the VA Medical Center.

            An agreement does not have any impact on the SVH admission
            process.

        Senator Murray. Thank you very much. I appreciate that.
    Thank you, Mr. Chairman.
        Chairman Tester. Senator Moran.
        Senator Moran. Chairman, thank you again. Dr. Upton, again
    thank you for being here. My staff and I have repeatedly shared
    our concerns with the Department regarding issues for veterans
    in rural and highly rural areas in obtaining high-quality
    virtual care from the VA during the pandemic. The primary
    answer we have received from the VA on that is their solution
    is that the Department is giving 5G-enabled iPads to veterans,
    though connectivity barriers continue to persist for veterans
    in VA care who reside in rural and highly rural areas.
        Do you have anything more besides giving iPads to veterans
    and the ATLAS partnership that you can share with the committee
    on how the VA is trying to find innovative solutions for our
    rural and highly rural veterans?
        Dr. Upton. I appreciate that, Senator, and certainly we
    share the commitment to helping highly rural veterans,
    particularly in Kansas and across the country, who face those
    concerns. As you mentioned, our group who oversees telehealth
    and connected care have been very dedicated to doing that,
    offering 99,000 internet-enabled tablets, cellphones, as well
    as working with major telecommunication companies to help
    address what we call the digital divide, which is very
    critical.
        I think there is still more work to do, both within VA and
    in the private sector, and we would look forward to partnering
    with you, Senator, on additional efforts to bridge that divide.
        Senator Moran. Dr. Upton, thank you. Let me ask about
    access standards. To paraphrase Dr. Matthews' testimony, on
    April 2019, at an SVAC hearing, the VA conducted a broad span
    market analysis of public and private sector plans as well as
    its own data to create access standards. She also testified the
    VA hoped to stick with an industry standard so that veterans
    might have a reasonable expectation of when they could actually
    receive care.
        Do you agree with Dr. Matthews' sentiments, and do you
    still believe the VA did well when crafting access standards?
        Dr. Upton. I appreciate that, Senator, and I worked for Dr.
    Matthews during the time and I know there was a very thoughtful
    review that has been done. I would say that we are very
    committed to implementing the MISSION Act and providing the
    utmost best access to our veterans. We do feel that there needs
    to be a review at this point, as outlined in the MISSION Act,
    to truly understand those impacts. And the honest answer is,
    Senator, that those access standards went live and about 8
    months into that the pandemic hit, and so there is still much
    more to be learned, and we are committed to working with you to
    do that and ensure that access is available to veterans.
        Senator Moran. Doctor, let me go back to what I think is
    the crux of my question. Dr. Matthews outlined the process that
    you went through, that she went through, the Department went
    through, to develop those access standards. The way she
    described it, in my view, was very positive. My question is, do
    you agree that the process that the VA went through was an
    appropriate process to determine the access standards?
        Dr. Upton. Having been a part of that process as well,
    Senator, I think it was very thorough, using the best industry
    information we had at the time. But as I believe Dr. Matthews
    said at the testimony, and elsewhere too, there was still a lot
    to be learned and a lot of parallels in industry for the
    similar standards that we were building. But we did a very
    thoughtful analysis at the time.
        Senator Moran. Thank you for that answer. Dr. Upton, in
    regards to Community Care and the access standards review next
    year, is it possible that a review could result in new access
    standards with longer wait times and drive times than what is
    currently in regulations?
        Dr. Upton. I will say that the Secretary is committed to
    making this the absolute best that it can be for veterans. I
    would not expect that to occur, but we are doing a very
    thoughtful analysis with veteran experience, outcomes, and wait
    times at the center of that, and we will be very transparent
    throughout that process.
        Senator Moran. If that was the outcome, would you consider
    that something that would be negatively affecting veterans?
        Dr. Upton. I would say that we absolutely do not want
    anything that would negatively affect veterans, Senator.
        Senator Moran. Is there anything preventing the VA from
    relaxing access standards as a result of the review?
        Dr. Upton. As I mentioned earlier, we are very committed to
    a transparent process, and in the current process that would
    involve regulation, which involves public comment, VSO comment,
    working with our congressional colleagues, and nothing will
    happen without a very transparent advanced notice, in
    collaboration with important committees like yours, Senator.
        Senator Moran. The possibility then exists for relaxing
    standards that would create longer wait times?
        Dr. Upton. I would say that that would certainly--anything
    that would negatively impact wait times for veterans would
    certainly not be our intent, Senator, and anything that we do
    will be very well thought out, based on evidence, and
    transparent throughout the whole process.
        Senator Moran. Dr. Upton, my staff has repeatedly shared
    our concerns about conflicting access standards and regulations
    and access standards in our CCN contracts. Has the VA modified
    Region 1 for contracts to incorporate MISSION Act access
    standards?
        Dr. Upton. Senator, as I have committed to your staff as
    well as to Senator Tester's staff, my initial focus has been to
    address the needs of highly rural veterans, similar to your
    State, in Kansas, and we are in advanced stages of modifying
    that highly rural drive time standard to substantially reduce
    that, and we would look forward to continue working with you
    and the committee on other potential avenues.
        Senator Moran. That would then be incorporated into the
    existing contracts?
        Dr. Upton. That is correct, sir.
        Senator Moran. Thank you, Dr. Upton. Thank you, Chairman.
        Chairman Tester. Senator Brown.

                         SENATOR SHERROD BROWN

        Senator Brown. Thank you, Mr. Chairman and Ranking Member
    Moran, for the good work you do together in running this
    committee. We have worked for years to strengthen veterans'
    health care, both in the VA and in the community. Young adults,
    as you know, age out of CHAMPVA coverage at 18, and if they are
    a student they age out at 23, understanding that ACA, people
    age out at 26 for private sector health care insurance plans.
        We are recovering from the worst pandemic in 100 years. Now
    is the time to right the wrong and correct this oversight from
    10 years ago. We made the change for TRICARE. We should do the
    same for CHAMPVA, which is what my CHAMPVA Children's Care
    Protection Act of 2021 would do. No parent or child should face
    the additional mental burden of worrying about their health
    care coverage.
        Dr. Upton, from watching your head nod I assume you agree
    that CHAMPVA beneficiaries should have parity with TRICARE
    beneficiaries?
        Dr. Upton. Senator, I know we have many bills on the docket
    today. This is an area that I directly oversee and concur. And
    I will just say, very briefly, that the CHAMPVA program, the
    children that you are speaking of are children of
    servicemembers who either are severely disabled from war or who
    lost their parents, and they deserve to be treated equitably,
    similar to the other health plans that are out there. And so we
    are very supportive of this bill, in making that change, and I
    appreciate you raising that.
        Senator Brown. We will continue to work with you to make
    sure that it is enacted and carried out. Thank you.
        I was glad to see that Senator Murray's bill, Veterans
    Family Health Services Act, that she was talking about when I
    entered the room, is on the agenda. I am a co-sponsor, as many
    are on this committee. It is beyond shameful we have not acted
    to make this change, this benefit permanent. I urge my
    committee colleagues to support this. This is a move forward,
    so that wounded veterans receive comprehensive health care
    benefits, including fertility treatments and counseling, to
    enable them to have families. I just wanted to concur with
    Senator Murray's very lucid comments.
        I will end with one question for Dr. Smith, if I could. I
    have worked on a bill to improve mental health connections for
    transitioning servicemembers. It is not on today's agenda. My
    job is to convince the Chairman and the Ranking Member that it
    be. It is the Daniel Harvey and Adam Lambert Improving
    Servicemember Transition to Reduce Veteran Suicide Act. It
    would create a pilot program to counsel servicemembers about
    mental health, the challenges they might face during transition
    to civilian life and how that might affect their mental health,
    and the services available to them at their local VA medical
    facility, in the 90 days post transition.
        A social worker or mental health professional from the
    local VA would call the servicemember to set up an appointment.
    We, I think, are increasingly conscious, as a society, as
    members of the Senate, reflecting much of the time that society
    we have simply not done what's needed to do for mental health
    services throughout our government, throughout our society. No
    excuses for not doing it at the VA.
        So Dr. Smith, talk to me, if you would, for a moment, about
    the value for veterans knowing that mental health programs are
    available to them at their local, very trustworthy in their
    minds, VA, and having that, shall we say, warm handoff back to
    civilian life.
        Dr. Smith. Thank you, Senator. We look forward to being
    able to review that and provide technical assistant as that is
    developed.
        It is a critical time period. Transitions for any adult is
    critical. It is a critical time for an individual who is
    committed to serving in the military, and that may be the only
    job, profession, role that they are familiar with, coming right
    out of high school. So this is something new for them, and
    there are a lot of stresses during that time.
        So you bring up excellent points. It has to be a seamless
    handoff, as much as we can be doing. The Hannon Act covers
    this, with Section 101, and what we can be doing for services
    in that first year. Solid Start is another addition to that.
    All of these should be working together, in union, to address
    the transition process, to make it as smooth as possible, as
    seamless as possible, and to encourage our servicemembers to
    make that transition.
        Senator Brown. Thanks. Mr. Chairman, thank you.
        Chairman Tester. Senator Tuberville.

                        SENATOR TOMMY TUBERVILLE

        Senator Tuberville. Thank you, Mr. Chairman. I feel like I
    am on the committee down here, on the end. You put me all of
    the way at the end of that. It is good.
        Thank you all for being here. Like many Americans over the
    last year, Alabama's veterans took advantage of telehealth
    services to meet their doctors. The total number of telehealth
    visits for the VA-enrolled veterans in Alabama increased 886
    percent in 2020, compared to 2019. I am an original co-sponsor
    of S. 1863, Guaranteeing Healthcare Access to Personnel Who
    Served Act, the GHAPs Act, which requires the Secretary of
    Veterans Affairs to develop a strategic plan to ensure the
    effectiveness of telehealth technologies.
        Dr. Upton, given the astronomical increase in telehealth
    appointments, what changes do you believe need to be made to
    ensure quality of care for veterans who choose telehealth?
        Dr. Upton. I appreciate that question, Senator, and
    certainly telehealth has been one of the areas of the new
    normal in health care that we are all adapting to, both
    patients and providers, as a result of the pandemic, and VA has
    been a leader in telehealth. It is something we believe very
    strongly in.
        And to address questioning that came up earlier about the
    digital divide, I think ensuring that veterans have the
    technology and the tools available to access telehealth is very
    critical, and VA, under the leadership of my colleague, Dr.
    Cox, does extensive work in quality monitoring and monitoring
    of patient safety, and certainly we would be happy to work
    together with you to share how we navigate that in the
    telehealth space as well.
        Senator Tuberville. Thank you. Anybody else want to comment
    on telehealth?
        Dr. Smith. I will just comment briefly, Senator, because I
    was the one that helped pull some of that data for you. Just
    looking at mental health, in 2019 there was about 2,000
    encounters for a veteran having an appointment where they
    choose, be it their home, a parking lot, the VFW, wherever. In
    fiscal year 2020, the next year, there were over 11,000, a
    substantial increase.
        We need, in mental health, it is highly efficacious. We
    know research supports it. But we have to do all we can to make
    that process smooth. It is not always smooth, right. There are
    IT difficulties. There are button difficulties. There are
    connectivity challenges. Dr. Upton spoke to some of that. We
    are committed to continuing to improve that process, because it
    is a critical avenue within mental health to provide access to
    care.
        Senator Tuberville. Thank you. Does the VA intend to
    include all the criteria listed in Section 201 of the GHAPs Act
    as part of the strategic review?
        Dr. Upton. Senator, our subject matter experts have
    reviewed that, in the telehealth world, and they have some
    technical comments that are outlined in our response to the
    legislation, and we would be happy to work with you and your
    staff to address that. I know you received it earlier today, so
    you have our commitment to be a partner to address that as we
    go forward.
        Senator Tuberville. Thank you. Thank you, Mr. Chairman.
        Chairman Tester. Thanks for being so efficient, Senator
    Tuberville. I appreciate that. We are going to go to the next
    panel. Doctor, Doctor, Doctor, Doctor, thank you all for being
    here today, and we will move on to the second panel, which will
    consist of veterans' advocates, and I will introduce them as
    they are getting sat down.
        First we have Ms. Joy Ilem, National Legislative Director
    for Disabled American Veterans. Next we have Ms. Kathryn Monet,
    Chief Executive Officer of the National Coalition for Homeless
    Veterans. And last but not least we have Mr. Mario Marquez,
    Director of the Veterans Affairs and Rehabilitation Division,
    The American Legion.
        Thank you all for being here. We appreciate your advocacy
    and we appreciate your testimony. As with the previous panel,
    know that your full written testimony will be a part of the
    record. If you can keep your verbal comments to five minutes it
    would be very appreciated. We still start with you, Joy.

                                PANEL II

                                  ----------

                         STATEMENT OF JOY ILEM

        Ms. Ilem. Thank you, Mr. Chairman. DAV appreciates being
    invited to provide our views on the bills that are under
    consideration by the committee today. My written statement
    details our position on all of the legislation on the agenda.
    However, I will focus on my oral remarks on only eight of the
    bills.
        Reducing veteran suicide and ensuring access to quality
    mental health care are key priorities for DAV. We know that
    peer-to-peer programs are effective in getting at-risk veterans
    the mental health services they need. Therefore, we support S.
    544, which calls for an outreach and training initiative for
    peer-supported wellness checks, to increase the number of
    trained peers available to assist veterans in crisis.
        DAV is also pleased to support S. 796, the Protecting Moms
    Who Served Act, legislation that would increase support for
    VA's maternity care coordination activities and improve
    services for women veterans who are often at higher risk of
    adverse birth and health outcomes.
        Likewise, we offer support for S. 2102, the SERVICE Act.
    This bill would revise the VA standards for mammography
    screening for women veterans who served near burn pits and
    ensure early access to these critical services that can save
    veterans' lives.
        DAV is also pleased to support S. 1280, the Veteran
    Families Health Services Act. This legislation would improve
    reproductive services and facilitate research for veterans with
    genitourinary disabilities. It also adds access to fertility
    services for enrolled veterans who are unable to conceive or
    safely carry a pregnancy to term. Importantly, the bill would
    correct existing inequities by allowing veterans access to this
    benefit regardless of their marital status, gender identity, or
    sexual orientation.
        DAV also offers our support for S. 1467, the Cannabis
    Research Act, which requires comprehensive research by VA into
    the therapeutic benefits and risks of cannabis as a possible
    treatment option for common conditions affecting service-
    disabled veterans with chronic pain and PTSD.
        DAV also supports S. 1319, which would require VA
    facilities to disclose wait times, staffing levels, and
    information about safety, quality of care, and health outcome
    measures on the Department's Access to Care website. Public
    availability of this data will enhance veterans' ability to
    make more fully informed decisions about their care.
        Mr. Chairman, a constant concern for seriously disabled
    veterans as they age is what will happen when their spouse or
    family caregiver is no longer able to provide a level of
    support needed for them to remain in their home. With more than
    half of the veteran population age 65 or older, a range of
    effective, long-term care options is required. We are therefore
    pleased to support S. 1965, the Planning for Aging Veterans
    Act, which would require VA to develop a strategic, long-term
    care plan for providing both institutional and non-
    institutional care through home and community-based services.
        DAV supports a number of provisions in S. 1863, the GHAPs
    Act, including Sections 201 and 203, that would require VA to
    study the efficacy of, and develop a strategic plan for the use
    of telehealth services. Section 202 of the bill would require
    GAO to assess VA's third-party transportation program for rural
    veterans. As you know, DAV operates a large transportation
    network program, providing hundreds of thousands of veterans
    free rides to VA medical appointments each year. We recognize,
    though, that there are still parts of the country that are
    difficult to reach, and we agree that exploring additional
    modes of transportation could improve veterans' access to care.
        DAV is unable to support Section 101 of the bill, to codify
    health care access standards promulgated by regulation in 2019.
    Last November, VA reported to Congress that neither VA nor the
    Community Care Networks were able to fully meet these access
    standards. Since the MISSION Act already requires VA to provide
    a report with recommendations for changes by next June, we
    believe it would be premature to make these access standards
    permanent now without sufficient evidence that doing so would
    improve access and quality of care to enrolled veterans.

        [The prepared statement of Ms. Ilem appears on page 80 of
    the Appendix.]

        Mr. Chairman, that completes my statement, and I am pleased
    to answer any questions you or members may have. Thank you.
        Chairman Tester. Thank you, Ms. Ilem. Kathryn, you may
    proceed.

                       STATEMENT OF KATHRYN MONET

        Ms. Monet. Chairman Tester, Ranking Member Moran, and
    distinguished members of the committee, thank you for the
    opportunity to join you today. Last week, NCHV presented
    testimony before the HVAC Economic Opportunity Subcommittee on
    veteran homelessness in the wake of COVID-19, and our testimony
    touched on many things, most important among them that the need
    for sufficient funding must be incorporated into non-emergency
    appropriations and authorizations as we move away from COVID-
    specific emergency funding for homeless veterans.
        It is my pleasure to let you know, Chairman Tester, that
    you will be awarded, NCHV's 2021 Policy Award in conjunction
    with our annual conference that is currently ongoing this week.
    We really appreciate everything that you did in terms of
    introducing the GRACE Act, and your team has been wonderful to
    work with, truly wonderful.
        Chairman Tester. Kathryn, thank you but I have just got to
    tell you, this is a joint effort, both sides of the aisle,
    everybody on this committee, so thank you.
        Ms. Monet. I hear you. Well, I will share comments on a
    couple of bills. We do not oppose legislation that is not
    included in our views, but we have abstained from offering
    comments on legislation that is outside the scope of our
    expertise.
        We appreciate, Chairman Tester, your legislation, Building
    Solutions for Veterans Experiencing homelessness. We appreciate
    everything that Congress did to make it easier for current
    grantees to take advantage of GPD capital grants to
    decongregate their facilities, and we have requested future
    rounds of capital grants in regular, non-emergency funding to
    allow time for appropriate planning and construction. This will
    allow our remaining congregate shelter providers opportunity to
    reconfigure their facilities, and they all will benefit from
    continued waivers of real property disposition and matching
    requirements.
        Certain restrictions in the most recent capital grant NFO
    prevented certain grantees from making full use of this
    opportunity, including the availability of sufficient per diem
    funding to support 24/7 staffing operations and multiple sites,
    particularly for providers who were not able to decongregate
    their facility without adding to their physical footprint,
    meaning that they would need an extra building and a whole
    other set of staff. Grantees have found that current rates have
    been insufficient to run these programs well before COVID-
    related restrictions and the push to decongregate made that
    even more complicated. We do request that the per diem rate be
    maintained at 300 percent post-emergency, and we also ask that
    you require VA to identify a way to decouple payments to GPD
    operators from the state home per diem rate.
        A key item to note here is that while the CDC has relaxed
    masking guidelines for many activities and types of locations,
    its guidelines for congregate shelter remain unchanged. They
    continue to recommend decongregating, keeping isolation and
    quarantine beds available, and continued social distancing,
    even as much of the country goes back to normal operations. So
    while certain bed models will continue to run deficits on a
    regional basis, the bill's proposed 200 percent rate of per
    diem is a first step toward funding providers for the level of
    care that is expected and the level of care that veterans
    deserve.
        We support language in the bill that offers additional
    technical assistance and training, as the amount provided for
    those types of activities has not changed since programs have
    started, and we also support the additional flexibilities for
    transportation assistance.
        We do anticipate that economic recovery will take time and
    that payments made for rent in arrears could potentially move
    veterans off of assistance before they have truly stabilized.
    So to that end, reemployment and reintegration efforts will be
    really critical through an expanded homelessness veteran
    reintegration program.
        While we support your expansion of the program, because
    there are still a handful of states, including Kansas, who do
    not have any HVRP grantees, the program has really outstanding
    outcomes. Fifty-three percent of HVRP participants were placed
    in a job paying more than $15 per hour, and the economic crisis
    will continue to deepen when unemployment benefits sunset. We
    hope that adequate funding for programs that prevent
    homelessness and lift up veterans through quality employment
    are a direct result of this legislation.
        We do support the intent of S. 612, and we recommend some
    technical changes to this legislation. We ask that you require
    HUD and VA to jointly develop a mechanism for effectively
    sharing and reporting data between HUD's HMIS systems and VA's
    HOMES system. We further recommend that additional funding be
    appropriated to VA's Health Care for Homeless Veterans Program
    to enhance coordinated entry specialist support at each medical
    center. Medical center catchment areas often overlay multiple
    HUD continuums of care, meaning that some VA coordinator entry
    specialists are responsible for maintaining partnerships with
    multiple, multiple--many--COCs, and that is a challenge with
    the staffing that they have got right now.
        In closing, I do appreciate the opportunity to share views
    with you today, and it is a privilege to work with all of you
    to ensure that every veteran facing a housing crisis has access
    to safe, decent, and affordable housing, paired with the
    supportive services they need to remain stably housed. Thank
    you.

        [The prepared statement of Ms. Monet appears on page 101 of
    the Appendix.]

        Chairman Tester. Thanks, Ms. Monet. Mario, you are up.

                     STATEMENT OF MARIO A. MARQUEZ

        Mr. Marquez. Thank you, Mr. Chairman. Good afternoon. Robin
    Olson, a retired Navy chief petty officer, honorably served our
    nation for 20 years. He has been diagnosed with the mental
    health conditions of anxiety and depression. He is 100
    permanent and totally disabled and does not qualify for VA's
    service dog veterinary health benefit. After taking three years
    of finding a nonprofit organization who was willing to take his
    case, a subsequent 14-month application and interview process,
    involving psychiatrists and psychologists, multiple meetings
    with dogs, home visits and training for him and his dog, Robin
    was finally paired with his service dog, Doc. This grueling
    effort was accomplished at Robin's own personal expense.
        Chairman Tester, Ranking Member Moran, and distinguished
    members of the committee, on behalf of National Commander James
    ``Bill'' Oxford, representing almost 2 million dues-paying
    members, it is my duty and honor to present the American
    Legion's position on pending legislation being discussed here
    today.
        Currently, Robin's service dog, Doc, knows more than 100
    purpose-driven commands. He helps Robin adjust to the real
    world, in situations where Robin may otherwise be in danger to
    himself or others. The value that Doc has provided Robin's
    quality of life is immeasurable, a monetary price that Robin,
    and his family, are willing to pay out of pocket again. But
    they should not have to. No veteran should.
        Robin's story is one example of the difficulties veterans
    face while transitioning from service in the military,
    difficulties that often lead to a feeling of helplessness or
    incapacitation, and can result in suicidal behavior. The
    pandemic exacerbated veteran suicide, and CDC statistics show
    that reports of anxiety and depression have tripled, and in
    some cases quadrupled, since 2019.
        To combat this, the American Legion implemented Buddy Check
    Weeks, where veterans call veterans to create a space, and open
    and candid dialog with a veteran peer who has had similar
    experiences, and potentially make them aware of resources at VA
    or in the community.
        S. 544 makes such suicide prevention efforts permanent by
    directing VA to designate one week annually as Buddy Check
    Week, for the purposes of encouraging outreach and peer
    wellness checks by veterans to other veterans. This week will
    be a VA-led but not VA-coordinated event. The success of Buddy
    Check Week will be reliant on grassroots efforts by veterans
    reaching out to veterans they served with, and letting them
    know they are part of a community that cares about them. A VA-
    led national Buddy Check Week will reach, support, and aid
    significantly more veterans. Getting this bill signed into law
    remains one of our top legislative priorities.
        Shifting topics, and of urgent significance, is duly
    honoring our Greatest Generation by awarding them VA health
    care benefits while a fraction of the 16 million who fought and
    served are still alive. VA regulations determine a veteran's
    eligibility for health care benefits on factors related to
    income, disability rating, and military service history. As a
    result, World War II veterans are not exempted from means tests
    required to enter VA health care system.
        S. 1040 would fix this problem by extending automatic
    eligibility to World War II veterans so those who currently do
    not qualify for health care will have access to VA hospital
    care, medical services, and nursing home care. We have done
    this in the past for veterans of the Spanish-American War and
    World War I, and it is time to do this for our Greatest
    Generation. World War II veterans are dying by the day, and
    there is no more time to wait. It is unacceptable that some of
    our veterans from the Greatest Generation do not have access to
    benefits they earned due to restrictions in eligibility for VA
    health care. This legislation is vital for the welfare of our
    World War II veterans, and we stand ready to assist Secretary
    McDonough in doing what is best for America's veterans.
        We thank Chairman Tester and Ranking Member Moran for their
    incredible leadership and for always keeping veterans at the
    core of their mission. It is my privilege to represent the
    American Legion before this committee. I look forward to
    answering any questions you may have. Thank you.

        [The prepared statement of Mr. Marquez appears on page 107
    of the Appendix.]

        Chairman Tester. Thank you, Mr. Marquez. I appreciate your
    testimony. I appreciate the testimony of all three of you.
        Just for a real quick update, and I do not know if you are
    going to be sticking around or not, Senator Tillis, but Senator
    Moran and I myself have a conversation with the CBO at 4:30. If
    you would be willing to chair the committee in our absence, I
    would appreciate that.
        Senator Tillis. Does that allow me to do a UC in the
    absence of any other members?
        Chairman Tester. You can do--well, Tuberville is here. He
    will object to everything you do. And Maggie is here, but
    Maggie is going to leave. Sorry.
        I have a couple of questions, and I want to thank you all
    for your testimony, and as I said in the opening, your
    advocacy. This is for you, Ms. Monet.
        After the pandemic-related flexibility ceases, the current
    maximum grant per diem rate will drop from 300 percent to 115
    percent. This is less than one-fifth of the current guarantee,
    our operating within the 115 percent maximum. The bill that I
    have is going to permanently that maximum of 200 percent. Ms.
    Monet, what will be the impact on GPD recipients and the
    veterans that they serve when the emergency declaration is over
    and the maximum rate drops to 115 percent?
        Ms. Monet. Well, I think the impacts will be dire on
    veterans. I think one of the challenges that providers often
    have is that the rate historically has not been enough to
    provide the level of services that they need, so many of the
    grantees spend a good chunk of time private fundraising,
    finding other options to fill gaps, and that is time that could
    be spent actually caring for veterans.
        I do also think, to some degree, that we have been pushing,
    and VA has also been pushing, facilities to decongregate, so to
    space people out better, to improve facilities for veterans, to
    give them the dignity that they need. Because I think one of
    the things that is often unnoticed is that the homelessness
    population is aging, so these are veterans who are in their
    60s, 70s, in some places sleeping on cots or in bunk beds, and
    that is certainly not something that I would want for my 70-
    year-old grandfather, right?
        And so we have been pushing for them to improve facilities
    and offer higher quality care, but they cannot do that at 115
    percent. It is impossible. So if they go to decongregate now
    and they have got to have 24/7 staffing in two or three
    buildings, you are now doubling your staff costs with less
    funding. It just makes it very hard to provide that level of
    care.
        Chairman Tester. There are currently few, if any, options
    for veterans with significant medical needs, especially elderly
    veterans, to escape chronic homelessness. Traditional
    transitioning housing facilities do not have the staff or the
    authority to provide assistance with activities of daily
    living, medication management, or medical crisis care. As such,
    these veterans often find themselves bouncing between
    facilities, ER waiting rooms, and the street.
        The bill that I am sponsoring would allow transitional
    housing facilities to hire the nursing staff necessary to
    attend to the needs of these veterans and house them while they
    wait for open spots in long-term care facilities. Ms. Monet,
    can you explain how this provision would help connect these
    veterans to options for permanent housing?
        Ms. Monet. Well, I think one of the challenges that, you
    know, we do not talk about a lot is that some veterans have
    care needs that are too acute to remain in shelter but are not
    acute enough to enter into long-term care. And when that
    happens there is nowhere really for them to go. And so we do
    hear from certain communities and certain providers where, you
    know, they are struggling because their liaison will not let
    them admit someone because they cannot provide the level of
    care, but the local nursing home is not willing to take them,
    so the person just ends up outside, back at square one, while
    people try to find other solutions. And I do not think that is
    something that anybody here supports.
        Chairman Tester. Thank you. Senator Moran.
        Senator Moran. Chairman, thank you. Thank you all three for
    being with us this afternoon. In the past 15 months, in the
    pandemic, there is a lot of light that has been brought to some
    gaps in the American health care system, and VHA is no
    exception to that. Persistent gaps in the VA health care system
    continue to hamper our veterans in obtaining the care they
    deserve, particularly in rural, highly rural, and medically
    underserved parts of the country.
        Mr. Marquez, we appreciated the strong support of The
    American Legion for the Commander John Hannon Act, which was
    signed into law last October. Building on that legislation, and
    understanding your organization knows first-hand the importance
    of peer support, can you speak how increased peer support can
    help veterans find and stay on the road to recovery?
        Mr. Marquez. Thank you, Senator. First, before I begin, on
    behalf of The American Legion we would like to thank you for
    your support recently when one of our posts in your state was
    devastated by a flood, which caused the loss of over 300 flags
    that you were able to replace, and that was detrimental to the
    events that we had planned, and we were appreciative of your
    efforts in that. So thank you very much.
        The American Legion believes that peer support approach to
    mental health and suicide prevention is instrumental to
    anything that we do when it comes to our efforts and getting
    after, hopefully one day, figuring out this devastating issue
    of suicide. As a result, as you know, The American Legion has
    led into our own efforts by conducting Buddy Check Week. We
    believe that Buddy Check Week is a grassroots, boots-on-the-
    ground, in-your-face, veterans getting after veterans.
        Something I learned in the military, Senator, as a sergeant
    major, it was devastating every time that I lost a marine while
    I was on active duty, but it was even more difficult dealing
    with the veteran that had already gotten out, and I just felt
    helpless in trying to reach and assist them. And the efforts
    that I believe we can achieve with peer-to-peer efforts at
    getting after suicide prevention I believe will be instrumental
    with the Buddy Check bill, and I hope that we can continue to
    get this legislation through and passed and into action
    immediately.
        Senator Moran. Thank you for that answer. Mr. Marquez, what
    are you hearing from your veteran members concerning current
    access standards? What would be the advantage of codifying the
    current standards, and what impact would a negative change to
    the access standards have on veterans?
        Mr. Marquez. Thank you, Senator. The American Legion
    believes that access standards are crucial to the success of
    the MISSION Act. If applied uniformly by VA and TPA networks,
    which are currently not being done, we believe it would
    facilitate access across the board in a fair standard.
        Region 5, as you know, has a set of standards that we
    believe our veterans, and our members believe are the standard,
    but we also believe that is the minimum standard that we should
    strive for and improve from that. Having said that, The
    American Legion also believes that patient-centered access
    standards should not be altered in any form that places any
    more burden or reduce access on any veteran.
        And finally, I do not foresee any scenario where adjusting
    access standards to put a greater burden on the veteran, by
    either expanding wait times or longer driving distances, would
    be advisable. The access standards that I talk about now are
    the bare minimum standards, and they should be codified as
    such.
        Senator Moran. Ms. Ilem, I appreciate the service DAV
    provides, particularly to our rural and highly rural veterans
    in regard to third-party transportation. Can you share with us,
    the committee, how you feel Section 202 of the GHAPs Act would
    assist Congress in filling those remaining gaps in rural
    transportation services? You mentioned it in your testimony,
    and I am not sure what--I want to just flesh out what you think
    is there that would be helpful.
        Ms. Ilem. I think just having a report and looking at the
    full scope of what is available for veterans. I mean, we know
    DAV's transportation network, very busy, and, you know, being
    able to provide services across the country. But with the
    pandemic and everything that happened, there are a lot of
    changes that have occurred. We want to make sure that veterans
    have access to the transportation they need to get to their
    appointments. We do not want it to be a barrier to care. So
    looking at all options is, I think, going to be really
    critical. Where are those specific gaps and where are they in
    the country, and what can be done to make other plans in those
    areas?
        Senator Moran. Thank you. Ms. Monet, you caught my
    attention. Apparently the Chairman is not going to give me time
    to ask a question, but the lack of Kansas participating in a
    program regarding homelessness veterans has caught my
    attention, and we will figure out what is going on. Thank you.
        Chairman Tester. Thank you, Senator Moran. I will recognize
    Senator Hassan and I will turn the gavel over to Senator
    Tillis.
        Senator Hassan. Well, thank you very much, Mr. Chairman and
    Ranking Member Moran, again, for this hearing, and to the three
    panelists, thank you, not only for your service but what you do
    for our veterans.
        I want to just ask two very brief questions, and then you
    will see me dart out, so I apologize. But Mr. Marquez, you have
    testified about the Buddy Check program and the bill, something
    that Senator Ernst and I have sponsored. And I just wanted to
    get you to elaborate a little bit more. Can you please speak to
    how this Buddy Check Week initiative, how having a specific
    week for this would help veterans and how we can support these
    efforts through the VA, how we could reach more veterans?
        Mr. Marquez. Yes, ma'am. First of all, I would like to
    thank you for sponsoring this bill. Although it has not passed
    yet, it is a great victory in our effort to get after suicide
    and suicide prevention.
        VA has a lot of great programs that they work on
    continuously to get after suicide and suicide prevention, and
    we applaud every one of their efforts. We think they are vital
    and they are important. However, the Buddy Check bill is
    complementary to everything that VA already does, and as I
    alluded to earlier, and something that I would like to
    emphasize, we like to talk about, unfortunately, that we were
    able to count the number of suicides. But what we cannot count,
    and something that I would love to be challenged with to count,
    is the number of wins and lives we have saved. That is the
    measure we need to achieve. How do we get after suicide
    prevention is trying to measure the number of lives we saved by
    engaging veterans in peer-to-peer efforts.
        Senator Hassan. Right. And if we focus a week on it I think
    it adds particular outreach and focus at a critical time. Thank
    you to The Legion for leading on this.
        Mr. Marquez. Yes, ma'am. Thank you.
        Senator Hassan. And Ms. Ilem, I wanted to thank you for
    your written testimony supporting the bipartisan legislation
    that I am leading on the Solid Start Act. That would focus on
    strengthening outreach to servicemembers in the first year
    after they separate from the military, and it makes permanent
    and bolsters Solid Start by prioritizing outreach to veterans
    who accessed mental health resources prior to transitioning to
    civilian life and ensuring that calls are tailored to the needs
    of each veteran.
        I have heard from New Hampshire veterans about the
    importance of this type of outreach, including specifically
    from women veterans who can face additional barriers to service
    and to support. So how would servicemembers transitioning from
    military to civilian life benefit from this tailored approach,
    and specifically, how would women veterans benefit?
        Ms. Ilem. Thank you for the question. I think it is a great
    program, we agree, and we are pleased to support the bill. And
    I think with regard to women veterans, again, you have put your
    finger right on it, that sometimes there are some really
    tailored needs for women veterans or women that are
    experiencing certain barriers. So having that personal contact,
    especially if there are mental health challenges, like you
    said, someone that you know you can assist and maybe answer
    some of their questions right up front for them, make sure they
    know somebody is knowledgeable about what is helpful to them
    and trying to really connect them with the programs and
    services they need.
        Senator Hassan. Thank you very much. Thank you, Senator
    Tillis.
        Senator Tillis. [Presiding.] Senator Hassan, before you go,
    Senator Tuberville, I am going to let you ask questions next,
    but I thank you for your comments on service dogs. One thing I
    am going to ask the first panel to do is get back, and maybe as
    a starting point, since we have done a lot of work here, is to
    take a look at the bill that passed on the suspension calendar.
    I am convinced we can make progress. Senator Tuberville?
        Senator Tuberville. Thank you very much. Thanks for being
    here today. Mr. Marquez and Ms. Ilem, in both The American
    Legion and DAV testimony you note that your organizations
    support legislation such as PAWS for Veterans Therapy Act,
    because it allows for an alternative form of treatment for
    veterans suffering from TBI and PTSD. I agree with allowing
    alternative forms for treatment and I believe it is incumbent
    upon us to make available every treatment option for veterans
    available, suffering from any condition.
        Today I introduced a bill that gives veterans suffering
    from TBI and PTSD the right to hyperbaric oxygen therapy. Just
    a question. Given your commitment to alternative, non-invasive
    treatment options for TBI and PTSD, would you commit to
    reviewing my legislation, which was out today, and work with my
    staff on a way forward where you can support this bill? I would
    appreciate that.
        Mr. Marquez. Yes, sir, we can.
        Senator Tuberville. Does anybody have any experience with
    hyperbaric treatment, with any veterans?
        Mr. Marquez. The American Legion does, Senator, but I would
    have to go back and do a little bit of research, and we can
    follow up with you and your staff as we do have some
    resolutions that address this matter.
        Senator Tuberville. Okay. Thank you.
        Ms. Ilem. We are happy to work and review the legislation
    and provide any feedback. You know, we have been hearing about
    this for some time now, and again, I know some veterans have
    indicated they benefit from it, and we want to make sure that
    veterans have access to any treatments and services that may be
    helpful to them.
        Senator Tuberville. Anything we can do to help? You know,
    we are having way too many suicides, and I have some experience
    with some veterans that say it helps. And being a former
    football coach, we had a lot of head injuries, and we used
    that, and we made progress. It is something you cannot see, you
    know, PTSD, you can't look at it, but we have got to find some
    way to treat it. We just been through two wars and millions of
    veterans coming back, and they all have problems, to some form.
        Mr. Marquez. Senator, if I may, The American Legion, as you
    may be aware, has a TBI, PTSD, and Suicide Prevention
    committee. I can get this in front of my leadership and in
    front of the committee and the commission, and we can do a
    little bit more research and get you some information that I
    think we will find to be valuable.
        Senator Tuberville. Thank you.
        Mr. Marquez. Yes sir.
        Senator Tuberville. You probably heard my question earlier.
    Any experience, any feedback on telehealth during the pandemic?
        Ms. Ilem. We have heard from some DAV members that, you
    know, they really liked it, I mean, for certain things. They
    felt that they were being cared for throughout the pandemic.
    They got their needs met, basic medications, that type of
    thing. And we know that VA was open and available for seeing
    veterans that needed to be seen in the facility. So I think
    people appreciated it. It was new. It is a little bit
    different. But I think for elderly veterans we need to make
    sure, and that is why studying it would be important, about,
    you know, if there is technology or a barrier for somebody who
    is not used to doing something remotely, on their own, and do
    they just forego care if they didn't know how to use the
    computer or be able to do that. So that will be important to
    look at and help outcomes.
        Senator Tuberville. We had huge benefits in rural areas
    from veterans. Ms. Monet, do you want to chime in on that?
        Ms. Monet. Actually, I think telehealth was a really good-
    news story for veterans experiencing homelessness. Some of the
    provisions that you all enacted enabled VA to purchase
    telehealth equipment for veterans experiencing homelessness,
    and I believe that what we saw was that telehealth visits
    really increased and really helped. HUD-VASH case managers
    could case manage veterans remotely. And it was not a perfect
    system but it really helped veterans get through the pandemic.
    And so I do think we support further expansion of telehealth
    and some of the authorities that are in Chairman Tester's bill,
    to make permanent some of the things.
        Senator Tuberville. Thank you. Through The American Legion
    did you have any feedback on telehealth?
        Mr. Marquez. We did. Recently I spoke to my commission
    chairman and one of the things he reminded me of is although
    telehealth has been a great convenience in many ways, as I said
    in my opening remarks there is a little bit of a limitation
    there. Some of it is connectivity, but also there is a matter
    and a concern of privacy. Not all veterans have the privacy,
    even if they have access to telehealth, whether it is at home
    or in the office, or sexual assault we mentioned earlier, a
    parking lot. A lot of times that may not be the right situation
    for a veteran to then drive themselves if they are not in the
    right mental state to properly finish whatever they just went
    through.
        And so the concerns with privacy, we are looking at it. It
    is something we are researching in The American Legion, and we
    would like to look into it further.
        Senator Tuberville. Real quick, vaccines. How are we doing
    with veterans, in your eyes?
        Ms. Ilem. I think VA has done a great job in terms of
    outreach and trying to make sure that all veterans know they
    have access. At first there was a big clamoring and lots of
    people coming in to get them, and I know VA is wanting to make
    sure that every veteran who wants to get a vaccine is able to
    get one.
        Senator Tuberville. Ms. Monet?
        Ms. Monet. I would agree. I think they are doing a lot
    better at connecting with homeless shelters and permanent
    supportive housing providers to do more mass vaccination
    efforts, where that was really spotty and challenging at the
    start of the pandemic.
        Mr. Marquez. Senator, VA has done a great job in really
    getting after vaccine hesitancy. Our organization, The American
    Legion, does the same. We have published, on our websites,
    every possible manner, down through the chain of command,
    through the different posts. And as you may be aware, we also
    recently had the Secretary down in Alabama, and our Executive
    Director for Government Affairs was down with our National
    Commander as well.
        So we are putting it down at the grassroots level,
    originating at the posts, and host any shot access that we can
    get done, vaccine opportunities, and just offering it up. Even
    if we do not get large numbers we are still continuing to see
    people slowly getting back into a little bit of trust and
    confidence with the vaccine. Because people want to get back to
    normal life, and they know that they are probably hampering
    that from happening in its totality.
        Senator Tuberville. Thank you. Thanks for being here today.
    Thank you.
        Senator Tillis. Well, thank you all. Mr. Marquez, thank you
    for your past and continued service to our nation and our
    veterans.
        Mr. Marquez. Thank you, Senator.
        Senator Tillis. You did a great job in your opening
    statement about Buddy Check Week. I am a co-sponsor. I think it
    is very important. I was just at an event that was hosted by
    the Independence Fund, called Operation Resiliency, where they
    are bringing units back. This unit had served in Iraq in 2011,
    bringing them together. And that connection, is something that
    is very important, so thank you for your support of that bill.
        You also mentioned, in your opening, before you started the
    formal opening statement, the story of the journey of a veteran
    at his own expense for getting a service dog. How is that
    veteran doing now?
        Mr. Marquez. He is doing great, Senator. The only thing is
    that he is fighting for advocacy, so that other veterans do not
    have to pay. And I realize there is a very strict and
    regimented qualification process for that, and so in speaking
    to him he asked me that we do what we can to pass legislation
    to offer as many veterans. He is more concerned about other
    veterans than he is himself, because his exact words, ``I could
    afford this. My family could afford this. We would do this
    again. But there are many veterans out there that they cannot
    afford this.''
        Senator Tillis. Well, it just so happens I have a personal
    interest in this, and that is why my questions--I want to
    really get to a good place. I think most people know, in my six
    and a half years on the committee, I have maintained a very
    positive relationship with the VA. I know they have a complex
    task and I want to get through it.
        Ms. Ilem, I know that the DAV expressed some concerns, I
    think, with the Senate version of the bill. I have been
    tracking very closely the compromise bill that passed on the
    suspension calendar in the House. Have you had an opportunity
    to take a look at that and take a position or express any
    concerns on it?
        Ms. Ilem. I have not seen specifically that, but in
    comparing that to the Senate version, I mean, I think there
    were some changes to the bill when I did compare what I had
    availability to see, and I think, you know, there was certainly
    an effort to try to address some of those things that
    originally came up.
        Our point is, I think, just as Mario has said, we want to
    make sure that this is an equitable benefit that veterans are
    going to have, that there is some standardized way to make sure
    service dogs are available. And as you heard from the VA, it is
    very limited ability to get a service dog. And while we are
    appreciative of these types of initiatives, we just want to see
    some standardized way, make sure there is an equity in this
    benefit, and the veterans that really need it can get access to
    a service dog.
        Senator Tillis. Could I get your commitment to take a look
    at--you know, in Washington, on our best day, it is hard to get
    435 people to agree to something. And the fact that it passed
    out of suspension calendar I think is an indication that
    members who had similar but different bills were not out a
    compromise, that in many respects, I believe, represent a
    bridging of the gap between a couple of the bills that are in
    the Senate.
        So I would like for you to take a look at that, because in
    good faith I would like to get with the VA and see if we can
    get to a good place on the legislation, ideally what passed out
    of the House. And I would appreciate the VA also providing us
    feedback on where they think that bill may still fall short,
    and work in good faith to resolve our difference. I would
    appreciate that.
        Ms. Monet, I appreciate your commitment to the homeless
    vets. It is something else I have worked quite a bit on in
    North Carolina. We just stood up a new Veterans Life Center,
    which was, I think, going to be something that can be scaled
    across the country. It is extraordinary.
        You mentioned that the VA should maintain 300 percent GDP
    rate post pandemic, and I know you probably understand the VA
    has still not spent much of the supplemental funding, and will
    not award GPD this year. So what should the VA be doing to
    serve as many homeless vets as possible? New GDP awards? Other
    ideas?
        Ms. Monet. So in regards to what they have spent, I think
    75 percent of what has been allocated to HPO has already been
    spent. GDP is a little bit different because providers have to
    spend the money and then go back and seek reimbursement. So I
    do not know that I have any doubts that they will not spend
    their money by the end of the fiscal year. I mean, I think VA
    is probably in a better position to answer that question, but I
    think what I heard from the program office last week is that
    they will, in fact, spend all those funds.
        I think that there are a lot of things that they can do in
    other programs to enhance the way that they serve veterans, so
    thinking about ways that they can increase HUD-VASH case
    management staffing, thinking about ways that they can
    coordinate better between programs, or that they can tie HVRP
    programs more closely to SSVF and the shallow subsidies. There
    is a lot that can be done, and that, I think, is in the works.
        Senator Tillis. Thank you. I know a lot of my members, we
    have several committees or subcommittees going on, so a lot of
    my members were not able to make it. But this is one of the
    great committees where we work together and try to produce a
    good bipartisan outcome, under Chairman Tester's leadership.
        I want to thank you all for participating today, both the
    VA and the veteran service organizations. You have shared
    valuable insight, but you know that a lot of the good stuff
    happens when you come to our office and we work out differences
    and get to a good place. I welcome you all to continue to come
    to my office, and I am sure I speak for all my members, on
    bills that you are not there yet, that we would like to get to.
        So we will keep the record open for a week, and thank you
    all for participating. The hearing is adjourned.
        [Whereupon, at 4:47 p.m., the Committee was adjourned.]

                                A P P E N D I X

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