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




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