[Senate Hearing 117-501]
[From the U.S. Government Publishing Office]


                                                        S. Hrg. 117-501

                HEARING TO CONSIDER PENDING LEGISLATION

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED SEVENTEENTH CONGRESS

                             FIRST SESSION
                               __________

                            OCTOBER 20, 2021
                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
       
                  [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]       


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

                    U.S. GOVERNMENT PUBLISHING OFFICE
                    
49-732 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

                              ----------                              

                            OCTOBER 20, 2021
                                SENATORS

                                                                   Page
Tester, Hon. Jon, Chairman, U.S. Senator from Montana............     1
Moran, Hon. Jerry, Ranking Member, U.S. Senator from Kansas......     2
Hassan, Hon. Margaret Wood, U.S. Senator from New Hampshire......     5
Brown, Hon. Sherrod, U.S. Senator from Ohio......................     9
Sullivan, Hon. Dan, U.S. Senator from Alaska.....................    11
Tillis, Hon. Thom, U.S. Senator from North Carolina..............    15
Tuberville, Hon. Tommy, U.S. Senator from Alabama................    17
Blackburn, Hon. Marsha, U.S. Senator from Tennessee..............    19

                               WITNESSES
                                Panel I

Elizabeth Brill, MD, Deputy Assistant Under Secretary for Health 
  for Clinical Services and Deputy Chief Medical Officer, 
  Veterans Health Administration, Department of Veterans Affairs; 
  accompanied by David Carroll, MD, Executive Director, Office of 
  Mental Health and Suicide Prevention, Veterans Health 
  Administration; and Lawrencia Pierce, JD, Assistant Director, 
  Office of Outreach, Transition, and Economic Development, 
  Veterans Benefits Administration...............................     4

                                Panel II

Marquis Barefield, Assistant National Legislative Director, 
  Disabled American Veterans.....................................    21
Thomas Porter, Executive Vice President, Government Affairs, Iraq 
  and Afghanistan Veterans of America............................    23

                                APPENDIX
                             Hearing Agenda

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

                          Prepared Statements

Elizabeth Brill, MD, Deputy Assistant Under Secretary for Health 
  for Clinical Services and Deputy Chief Medical Officer, 
  Veterans Health Administration, Department of Veterans Affairs.    39
Marquis Barefield, Assistant National Legislative Director, 
  Disabled American Veterans.....................................    80
Thomas Porter, Executive Vice President, Government Affairs, Iraq 
  and Afghanistan Veterans of America............................    95

                       Statements for the Record

Hon. Kyrsten Sinema..............................................   105
Wounded Warrior Project..........................................   106
Paralyzed Veterans of America....................................   121

                        Questions for the Record

Department of Veterans Affairs response to questions submitted 
  by:
  Hon. Jon Tester................................................   127
  Hon. Bernard Sanders...........................................   135
  Hon. Richard Blumenthal........................................   137
  Hon. Kyrsten Sinema............................................   143
  Hon. Marsha Blackburn..........................................   145
    Attachment for Question 1: IVC Functional Assessment Report..   147
    Attachment for Questions 2 and 2a: SVAC Legislative Member 
      QFRs.......................................................   163

Disabled American Veterans response to questions submitted by:
  Hon. Kyrsten Sinema............................................   164

 
                      HEARING TO CONSIDER PENDING
                             LEGISLATION

                              ----------                              


                      WEDNESDAY, OCTOBER 20, 2021

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3 p.m., via Webex 
and in Room SR-418, Russell Senate Office Building, Hon. Jon 
Tester, Chairman of the Committee, presiding.
    Present: Senators Tester, Murray, Sanders, Brown, Hirono, 
Manchin, Sinema, Hassan, Moran, Tillis, Sullivan, Blackburn, 
and Tuberville.

              OPENING STATEMENT OF CHAIRMAN TESTER

    Chairman Tester. I call the Committee on Veterans' Affairs 
to order.
    Good afternoon to everybody. I want to thank you for 
joining us here to hear the views from the VA and the Veterans 
Service Organizations on 18 pending bills before this 
Committee.
    In the wake of the U.S. withdrawal from Afghanistan this 
summer, the Veterans Crisis Line saw a sharp increase in calls, 
texts, and chats to hotlines. To the hotline, I mean. The 
Veterans Crisis Line provides a valuable service to veterans in 
crisis or distress and can be a lifeline not only for emergency 
response but for connecting veterans to VA healthcare.
    Due to this increased VCL use and recent disturbing 
oversight reports, today we are going to consider the REACH for 
Veterans Act, a bill that I worked on with Senator Moran, to 
strengthen the Veterans Crisis Line and ensure every veteran 
who calls receives the best possible service. This bill will 
bolster the VCL's staff training, management, and response to 
high risk veteran callers that are at risk of suicide.
    October is Breast Cancer Awareness Month and a good 
reminder that we must provide access to high quality 
mammography and breast cancer care for our veterans. On our 
agenda today is the MAMMO for Veterans Act, a bill I introduced 
with Senator Boozman, Hirono, and Collins. This legislation 
will help improve veterans' access to breast cancer screening 
at the VA and in their communities. It will strengthen 
veterans' access to clinical trials and care through 
partnerships with the National Cancer Institute and the 
Department of Defense.
    Lastly, I want to talk about the military sexual trauma and 
highlight the importance of another bill of mine, the 
Servicemembers and Veterans Empowerment and Support Act, which 
is also on the agenda today. For years, we have been hearing 
from veterans and MST survivors who have not received fair 
consideration from the VBA and are being denied the benefits 
and care they deserve.
    An IG report released this summer found VBA's handling of 
MST claims has actually worsened in recent years. The IG found 
out about 57 percent of denied MST claims were not being 
processed correctly in 2019, and that is an increase from 49 
percent in the 2018 report. That means veterans and MST 
survivors remain at risk of not receiving the benefits and care 
to which they are entitled and of being retraumatized when 
their claims are improperly handled or denied. This is an issue 
that I have worked on in the Senate for almost a decade now, 
with legislation originally titled as the Ruth Moore Act. It is 
long past due for MST survivors to get the benefits and the 
care that they need and that they deserve.
    I want to thank the witnesses. When we get up to the table, 
I will thank you again.
    And with that, I will turn it over to Senator Moran.

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

               OPENING STATEMENT OF SENATOR MORAN

    Senator Moran. Good afternoon, Chairman, and good afternoon 
to Dr. Brill, Dr. Carroll, and to Mrs. Pierce and our VSO 
witnesses here today. I look forward to this hearing, and I am 
glad to see the Committee is moving forward with additional 
pieces of legislation important to members of this Committee 
but important to the veterans that we serve.
    Mr. Chairman, I would tell you that yesterday, Monday in 
fact, I was at a number of memorials to veterans here in 
Washington, DC. And a week ago, another honor flight was here 
that I met at the World War II Memorial, and I was explaining 
to them that this Committee continues to do its work. There is 
a Chairman that is a Democrat and a Ranking Member that is a 
Republican. We have served in opposite capacities in the past. 
And this place continues to be one of the few remaining places 
in which Republicans and Democrats continue to work together on 
behalf of the veterans that I and others were honoring at the 
various memorials across Kansas.
    So I want to thank you for the continued working 
relationship that puts veterans above party politics, and I am 
grateful that today is another example of that.
    We have 18 bills that members of this Committee and others 
in Congress are interested in pursuing. It seems as if this 
Committee has, over the last several years, been able to work 
our way through things that are beneficial to veterans. And 
today, I have no doubt, will continue to be a continuation of 
that bipartisan effort to find good results for those who 
served our Nation.
    I will mention a couple of bills that are important to me, 
and I am anxious to hear comments about all of them. One of 
those includes the Veterans' Prostate Cancer Treatment and 
Research Act, which you, Mr. Chairman, and I are sponsors of, 
the lead sponsors of. This bill creates a standardized system 
of care from early detection to successful treatment for the 
most commonly diagnosed cancers within the VA, affecting over 
489,000 veterans.
    Among the remaining items on today's agenda are such 
critical topics as veteran peer specialists, shared medical 
facilities between the VA and the Department of Defense, and 
the VA's capacity to provide mammography services.
    I am also pleased to join you, Mr. Chairman, in co 
sponsoring the REACH for Veterans Act you mentioned, which will 
build upon our work to improve VA mental health services by 
directing the VA to implement key recommendations of the Office 
of Inspector General, including improved Veterans Crisis Line 
staffing, training, extend the safety planning pilot program, 
and a smooth transition to 988 as the national 3-digit suicide 
crisis hotline for veterans comes into play.
    Mr. Chairman, I was not exactly sure what you said. I 
should have been listening more closely, but I would indicate 
that now is a time in which we cannot turn our backs on those 
veterans suffering from mental health issues or those who are 
contemplating suicide. With the most recent developments in 
Afghanistan, I think the demand for the appropriate services is 
increasing, and I want to make sure that we do everything to 
minimize and to eliminate any death by suicide and improve the 
mental health of our men and women who have served our Nation.
    I look forward to today's testimony. I appreciate, as I 
said earlier, the partnership and working with you and the 
other colleagues on this Committee, again, significantly 
different in many instances than many other committees we all 
serve on, and I am grateful for that.
    I thank you, Mr. Chairman, and I yield back.
    Chairman Tester. I want to let our first witness panel get 
settled. Dr. Elizabeth Brill, Dr. David Carroll, and Ms. 
Lawrencia Pierce, you can go sit.
    I just want to say this to the Ranking Member and my good 
friend, Senator Moran. I have had the incredible privilege on 
this Committee of working with some really good people: Johnny 
Isakson and you, Johnny as Chair of this Committee and myself 
as Ranking Member and now you. And I will tell you that I think 
what allows this Committee to work is respect and respect for 
our opinions even when we differ. And I just want to say 
thanks, it has been a pleasure, and I hope it continues for a 
good number of years, to be able to work with you in this way.
    Senator Moran. Mr. Chairman, I would only point out it 
would work better if you differed with me less often.
    Chairman Tester. Oh, that is true, but you know, what the 
heck. That is life.
    One, two, three, four, five, six, seven, eight, nine.
    Unidentified speaker. We have nine.
    Chairman Tester. We need 10. Brown?
    Unidentified speaker. Ten.
    Chairman Tester. Oh, that is good. So with that, I want to 
recess this hearing momentarily.
    [Recess.]
    Chairman Tester. We will go back to our hearing that we had 
started, and I want to express my appreciation for everybody 
that was here so we could get this done to get these folks into 
the VA.
    Yes?
    Senator Manchin. Mr. Chairman, there is a vote going on so 
we can just come right back [off microphone.]
    Chairman Tester. Yes, we are going to let everybody speak 
but you, Joe. We are just kidding. No, go vote. You come back. 
We are going to be here for the next--it depends on how 
boisterous Dr. Brill is, and then we are going to have another 
panel of VSOs. So we have got--we are going to be here for 
another hour at least. We have had one vote.
    Unidentified speaker. Did you vote on the first one?
    Senator Moran. We had two votes at the beginning.
    Chairman Tester. We had a nom, and then we had a vote on 
the legislation. So . . . Okay? We welcome you back when you 
get back. Everybody.
    So I want to welcome our panel: Dr. Elizabeth Brill, who is 
the Deputy Assistant Under Secretary for Health for Clinical 
Services and the Deputy Chief Medical Officer. She will provide 
the statement on behalf of the VA. She is accompanied by Dr. 
David Carroll, Executive Director, Office of Mental Health and 
Suicide Prevention, VHA, and Ms. Lawrencia Pierce, who is 
Assistant Director, Office of Outreach, Transition, and 
Economic Development of VBA.
    Dr. Brill, welcome, and you may begin.

                            PANEL I

                              ----------                              


          STATEMENT OF ELIZABETH BRILL ACCOMPANIED BY

               DAVID CARROLL AND LAWRENCIA PIERCE

    Dr. Brill. Thank you. Chairman Tester and Ranking Member 
Moran and other members of the Committee, thank you for 
inviting us here today to present our views on several bills 
that would affect VA programs and services.
    VA's views are provided on all the bills in detail in 
written statement, but I will not be able to speak about every 
bill in my opening statement. Therefore, I will only highlight 
some of the bills on the agenda, but please be assured that by 
doing so there is no intent to minimize the importance of any 
bills today.
    VA supports, contingent on funding, the Veterans Preventive 
Health Coverage Fairness Act that would eliminate copayments to 
VA for hospital care, medical services, and medications related 
to preventative healthcare services.
    We are also glad to support a draft bill regarding State 
Veterans Homes that would require State Veterans Homes to have 
a governing body to be responsible for numerous management and 
oversight responsibilities as well as buttress their programs 
for prevention of infections. We believe these changes are in 
the right direction, and VA's written testimony includes other 
suggestions to buttress standardization and expertise in the 
management of State homes.
    We are also glad to support two of the bills today that 
will help VA address its infrastructure needs: the fiscal year 
2022 VA Major Medical Facility Authorization Act and a bill 
designed to facilitate shared medical projects between VA and 
the Department of Defense. We greatly appreciate the 
Committee's interest in this area.
    We also support, with some technical suggestions, the Long 
Term Care Veterans Choice Act. Medical Foster Homes are a way 
to provide veterans, when medically appropriate, with an 
alternative to traditional institutional care that allows them 
to be in the more home-like, less restrictive environment of 
what are called Medical Foster Homes. The bill also actually 
yields net savings to our medical program when traditional 
nursing home care can be avoided while still providing safe, 
quality care for the veteran.
    We are also glad to endorse the draft bill making changes 
regarding VA podiatrists, which includes a pay adjustment and 
certain organizational changes.
    Mr. Chairman, there are other bills on the agenda where we 
wholeheartedly endorse the goals of the bills but cannot offer 
our support on every provision because we believe they 
duplicate current VA efforts and have other technical issues 
that would, in our opinion, make implementation of the bills in 
their current form impractical or counterproductive. One bill 
in that category is the MAMMO for Veterans Act, where there are 
a number of instances of duplication or other issues in 
carrying out the bill as written. We are finalizing the 
strategic plan that we believe meets the spirit of the bill by 
driving toward excellent access and quality in mammography for 
veterans across the Nation.
    Similarly, VA cannot endorse the VA Prostate Cancer 
Treatment and Research Act, which would codify requirements for 
numerous VA actions on early detection, treatment, and 
research. We are very much aligned with the bill's focus on 
prostate cancer, but we believe it is overly prescriptive on 
the details of program implementation, including the internal 
structure of VA and the prostate cancer clinical pathway.
    There are several bills on the agenda that deal with 
critical issues of mental health and suicide prevention and 
military sexual trauma, including the REACH for Veterans Act, 
which concerns the Veterans Crisis Line, and the Servicemembers 
and Veterans Empowerment and Support Act. We support a 
provision in the latter that addresses gaps in health care for 
victims of MST who serve in the Guard and Reserves, with some 
adjustments. VA enthusiastically agrees with the overall goals 
of both pieces of legislation. However, for a number of 
provisions in those multi-part bills, we have serious concerns 
on possible unintended consequences, duplication of existing 
efforts, and other impediments to implementation.
    We welcome further discussion with the Committee on these 
important topics.

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

    Chairman Tester. Appreciate your testimony and we will hear 
questions from the Senators now. I am going to yield my time to 
Senator Hassan.

                  SENATOR MARGARET WOOD HASSAN

    Senator Hassan. Well, I am very appreciative of that, Mr. 
Chairman and Ranking Member Moran. Thank you as well for this 
hearing and thank you to all of the folks here from the VA for 
your excellent work. We really appreciate it.
    Dr. Brill, I did want to follow up with you on something. 
New Hampshire is home to two VA vet centers, and I often hear 
from veterans about how they wish they could have connected to 
these mental health resources sooner to support their 
adjustment to civilian life. So as I think you know, I have a 
bipartisan bill with Senator Cramer that would require VA vet 
centers to contact recently separated veterans to raise 
awareness about the services available to them. So could you 
please discuss the range of mental health and counseling 
services that VA vet centers offer and why it can benefit 
veterans to learn about these services quickly after separating 
from service.
    Dr. Brill. I will turn to my colleague.
    Senator Hassan. Sure. Thank you.
    Ms. Pierce. Thank you, ma'am. With regards to early 
notification or awareness of the Vet Centers and what they 
offer, that information is robustly covered in the Transition 
Assistance Program, as well as the TAP MLCs. With respect to 
what is covered----
    Senator Hassan. Okay. Can we just start by why is it a 
benefit for veterans to learn about this early?
    Ms. Pierce. Yes. It is a benefit because the Vet Centers 
provide free counseling and support services even while they 
are on active duty, and then they have wraparound care as well 
once the member separates. It is confidential, it is free, and 
it is a community integrator.
    Senator Hassan. And is it fair to say that as veterans 
transition from military to civilian life often they find that 
they may need additional support during that time because it is 
a considerable change?
    Ms. Pierce. Absolutely. Within the first 365 days of 
separation, a critical time period, the Vet Center provides 
support tools along with the services that VHA provides.
    Senator Hassan. Well, thank you for that. I then wanted to 
follow up to get a little bit more specific about the VA's 
position on the bill, and that may be what you were beginning 
to talk about.
    So the bill that Senator Cramer and I have requires the VA 
to electronically alert the vet center nearest to where a 
veteran resides that a veteran has separated from the military. 
And we filed this bill because folks from the VA came and asked 
us to because they said they had difficulty getting information 
from the Department of Defense about when somebody was 
separating and they wanted to be able to do specific outreach. 
And the bill actually not only says DOD has to provide the VA 
this information but then also says that the vet centers have 
to reach out to the veteran within a particular amount of time.
    And I was pleased to get testimony, written testimony, from 
all of you that said you share the goals, but now it seems that 
you are saying you think you can get the information. So I just 
would like to kind of clarify the position of the VA on the 
bill and what we need to do to make sure not only that vet 
centers can get the information in a timely way but that vet 
centers do the outreach in a timely way, too.
    Ms. Pierce. VA's position on the bill, we support the 
intent, but we do feel that with the regulations and the 
processes that are in place currently, there is no need for 
additional legislation. We would be happy to present any 
complications or barriers to accommodating the data sharing 
with the Vet Centers if we approach such. But currently, our 
current process and the data that we get from DOD, we feel that 
we can meet the letter of the law with regards to this bill.
    Senator Hassan. With those guidelines in place right now 
from the DOD and VA, you all can do it. But those could change; 
right? One of the things I am concerned about is different 
administrations, different leadership, different policymakers 
in executive agencies can change the way things work. And I am 
just really wanting to make sure that we all are walking 
together to make sure that VA vet centers can get this 
information in a timely way from DOD so that we are reaching 
out to veterans and then that they know they have an obligation 
to reach out to veterans in a specific amount of time. And are 
you saying that all of the policies and procedures in place 
achieve that goal?
    Ms. Pierce. I would say, yes. Within the TAP, or the 
Transition Assistance Program, governance structure, we have 
work groups and we have the communication with our DOD partner 
as well as VHA to meet the letter of the law.
    There is one item that we would look to have leniency, and 
that would be respect to the seven-day requirement to transfer 
that data over to the Vet Center. We would ask that the seven 
days would begin from the date we receive the data from DOD 
versus once the servicemember separates.
    Senator Hassan. Well, and how long does it take DOD to get 
you the information because if it takes DOD weeks or months 
that is not helpful; right? And then we may need to have this 
law passed to say you have got to get the information to the VA 
and then the vet center.
    I mean, what I am concerned about is the bill also says 
that you all, the vet center, will reach out to the veteran 
within 14 days. And are you telling me that that is a goal you 
currently achieve?
    Ms. Pierce. We can achieve that, yes, ma'am.
    Senator Hassan. Do you currently achieve that?
    Ms. Pierce. So currently, the data transfer requirement 
that is in this bill is not in implementation yet. We receive 
the data from DOD, but the transfer to the Vet Center is the 
part that we are working on. It is in the development phase, 
and we do believe that we can accomplish the same with the 
current infrastructure and the processes that we have in place.
    Senator Hassan. Well, I look forward to following up with 
you. I think I may still think that this legislation is 
necessary because what I would like to do is make sure that 
this is an obligation that you all are required by law to 
follow rather than too much flexibility because, at the end of 
the day, this is about getting veterans the support they need 
and saving lives. Thanks.
    Ms. Pierce. Thank you.
    Chairman Tester. Senator Moran.
    Senator Moran. Chairman, thank you.
    Dr. Brill, my staff and I are confused when we read the 
Department's testimony on S. 2720, the Veterans' Prostate 
Cancer Treatment and Research Act. I know that my Committee 
staff, as well as staff on the House Veterans Affairs' 
Committee, had multiple conversations with relevant program 
offices within the Department and the Office ofCongressional 
and Legislative Affairs to work out issues on the original 
draft text of this bill before it was ever filed. Committee 
staff made several substantial changes to accommodate the 
Department's view. Now we read in your testimony that the VA 
does not support the bill because ``it is overly prescriptive 
in detail of program implementation.''
    Again, we worked out our differences with the VA, and then 
your testimony does not reflect that result. That is confusing 
to us.
    While the VA did develop an initial clinical pathway for 
treatment of prostate cancer, can we all agree that a more 
integrated and streamlined approach, which includes a 
diagnostic component and more collaboration with research 
institutions, would be better care for our veterans? Perhaps I 
will let you respond, and then I may have a few comments to 
respond to your response.
    Dr. Brill. Yes, thank you, sir. So I suspect that what 
occurred is that in the conversations that the entities with 
whom you worked with were talking about the substance of the 
clinical initiatives that they have. And I believe that the 
National Surgery Office and the other interdisciplinary 
services in VA that address prostate cancer do not feel that 
legislation per se is needed in order to achieve these goals 
because they are achieving these goals through the normal 
clinical pathways.
    So in 2021, this year, the VA published a new prostate 
clinical pathway, so already accomplishing that goal, in which 
they worked with DOD experts, interdisciplinary services within 
VA. And they update this regularly, and they are already 
working to integrate this clinical pathway with the new Cerner 
Millennium IT system for EHRM.
    Secondly, in 2019, the Precision Oncology Initiative, which 
is a high reliability, organization-type initiative with a 
learning healthcare model, worked with the Office of Research 
and Development to further cutting-edge and high quality 
technology in order to give veterans the best prostate cancer 
care that is available.
    We also have other services such as genomic profiling, 
tele-oncology, and the availability of decentralized trials for 
veterans to participate in even if they are not immediately 
local to where the trial is being run.
    So fundamentally, I believe that the National Surgery 
Office and the rest of the multidisciplinary team believes that 
they are meeting all of the desires in this Act and do not 
believe that legislation is necessary in order for them to 
provide that level of high quality care.
    Senator Moran. Despite the fact they spent a significant 
amount of time working with us to get the legislation drafted 
in a way that they found acceptable.
    Dr. Carroll, similar to that frustration, it happened again 
in the Department's testimony on S. 2283, the REACH for 
Veterans Act, co-sponsored--both of these bills co-sponsored by 
Chairman Tester and me. This legislation was developed after 
the Office of Inspector General delivered two reports to 
Congress detailing how inadequacies in the Veterans Crisis Line 
resulted in tragic outcomes, including a veteran homicide and a 
veteran suicide. The OIG report also contained recommendations 
for improving these adequacies.
    The testimony submitted by the VA claims that the 
provisions contained within the bill are not necessary because 
``the Department already has sufficient authority in this 
area.'' However, would you agree there were issues with the 
Veterans Crisis Line that resulted in these tragic outcomes 
despite you having sufficient authority in this area and 
significant tragedies for the veterans and their families?
    We understand the VA already has certain policies in place. 
However, I think the main point of this legislation is that the 
Veterans Crisis Line was not adequately following those 
policies. Considering this, why would the Department not want 
to work with Congress to address these issues to ensure that 
these tragic outcomes do not happen again?
    Dr. Carroll. Thank you, Senator. We wholeheartedly agree 
with the intent of this legislation, with the concern of you 
and Chairman Tester. It is a concern that we share, to ensure 
the integrity and high quality of the operations of the 
Veterans Crisis Line. And we appreciate the OIG's report of the 
recent recommendations. All of them have been closed by the 
OIG, except one that requires a few additional months of data 
collection, because we have met or exceeded what they asked us 
to do.
    Our concern with the legislation is not at all about 
intent. We very much appreciate it and take this very 
seriously, but we do not want to be limited by what is written 
into law because we are already meeting and exceeding. We have 
improved several things over the last few months in terms of 
policies, procedures that are put in place, staff training, 
consultation with other organizations. We have seen an increase 
in call and text and chat volume. At the same time, we have 
seen a decrease in our rollover rates. We have accreditation by 
external bodies already.
    We do not want to be--we want to continue to innovate and 
to move forward with our quality improvement process, and we 
are simply asking to be able to do that without being bound by 
what is written in legislation.
    Senator Moran. Dr. Carroll, you said something that I would 
just follow up on. Can you quantify that increase in calls?
    Dr. Carroll. Over the last year, there was about a 2.2 
percent increase in call volume and roughly a 25 percent 
increase, give or take a little, in both chat and text volume.
    Senator Moran. Thank you.
    Dr. Carroll. We are also preparing for the 988 
implementation, which was mentioned earlier, and with 
additional staff at the Veterans Crisis Line.
    Senator Moran. I may come back to process again before the 
hearing is over. Thank you.
    Chairman Tester. Senator Brown.

                     SENATOR SHERROD BROWN

    Senator Brown. Thank you, Chairman Tester and Ranking 
Member Moran.
    Dr. Brill, early in the pandemic, we saw how susceptible 
patients are to infectious diseases in nursing homes and State 
Veterans Homes. In Ohio, as you know, we have two veterans 
homes, one in Georgetown near where you used to live, the other 
in Sandusky in the other end of the State. Too many individuals 
contracted the virus. Too many died. We know the importance of 
public health programs and making sure we have standardization 
of care.
    Senator Warnock has a bill on today's agenda that would 
make improvements to prevent the outbreaks we saw in so many 
State Veterans Homes over the last year. Your testimony has 
some recommendations related to the reporting requirements and 
emergency plan. Walk through for us, if you would, Dr. Brill, 
why hiring infection preventionists and standardizing the 
emergency plan to respond are so important?
    Dr. Brill. Yes, thank you, Senator Brown. So, yes, as you 
know, we fully support this bill and the provisions of 
providing a governing body, infection preventionists, and an 
emergency plan.
    So as you mentioned with the pandemic, you know, many were 
caught off guard with a disease that we had not seen before. We 
did not realize just how virulent it was and in the early days 
what was needed to prevent spread. Obviously, those living in 
nursing homes are highly susceptible to any number of 
infectious diseases, and this has really raised awareness of 
the importance of infection prevention as a full-time role in 
those facilities.
    And so we believe not only should there be an infection 
prevention person in each of those facilities, but there should 
be some standardization around that role so that we can have 
the same standards expected in all of the facilities.
    The same thing with the emergency plan. And the emergency 
plan could deal with things such as pandemics but could also 
deal with the natural disasters of which we have seen, 
unfortunately, far too many this year.
    An infection prevention committee is another recommendation 
that we have, and you know, always in these types of, you know, 
uncertain environments many heads are better than one. And so 
having a committee around infection prevention, treatment, 
mitigation factors, a committee would be very valuable.
    Additionally, we had two other recommendations that all of 
these committees undergo CMS certification, and we recommend 
that the report change from the requirement of annually to 
quarterly, which we believe would allow a better sort of finger 
on the pulse of what is going on in those facilities.
    Senator Brown. Okay. Thank you.
    Ms. Pierce, a question for you. I had a meeting discussion 
today with an Ohio State professor, Ms. Sheftall, and she is--
we talked about suicide rates, and she has issued a paper and 
done a really important study on the alarming increase in young 
black girls, young women, females up to the age of 18, and the 
increasing suicide rates. We are also, of course, seeing rates 
far too high among veterans.
    We have the part of the--you know, where we want to look 
with the Transition Assistance Program is veterans do not 
really know because nobody really knows until they are in that 
situation. They do not know enough about VA services. They do 
not know enough about where they can go if they are having 
thoughts of suicide.
    There is legislation. The Daniel Harvey and Adam Lambert 
Improving Servicemember Transition to Reduce Veterans Suicide 
Act--somebody could have come up with a shorter title than that 
has been introduced. The modified version is included in the 
House bill, in the House version of NDAA. Discuss the 
importance of that, particularly in light of suicide, how we do 
better with transitioning with veterans through these programs.
    Ms. Pierce. Thank you, sir. So with regards to suicide 
prevention or awareness of the resources that VA and community 
partners provide, the Transition Assistance Program has again 
revamped its curriculum to include information along the 
transition journey. And we define that to be 365 days pre 
separation; for retirees, it is two years. And within that 
window, we make sure that there is information about the 
resources that are available to the servicemember that is 
transitioning.
    That can include the crisis hotline. That also includes VA 
Solid Start. If you are not aware, what happens is right after 
the servicemember separates, they receive strategic calls to 
check in with them, and VA Solid Start representatives are 
trained to recognize or handle a crisis with regards to 
transferring them to our VHA partners, to get them expedited 
help in that event of a crisis.
    So I would say that the Transition Assistance Program, 
along with our robust partnership with our VHA partners and 
DOD, is at the ready and provides sufficient resources, 
information, and awareness for those servicemembers who may 
need assistance during that critical transition.
    Senator Brown. It may be at the ready, but it is not 
working as well as it should. But, thank you.
    Ms. Pierce. And that is something that we are looking at 
and will continue to look at. We look at our curriculum on an 
annual basis so that it is ready, and based on servicemembers' 
feedback we make sure that we update accordingly. But we will 
take that for action. Thank you, sir.
    Chairman Tester. Senator Sullivan.

                      SENATOR DAN SULLIVAN

    Senator Sullivan. Thank you, Mr. Chairman.
    And I want to thank the witnesses, sincerely thank the 
witnesses, Dr. Brill and your team. You know, you guys come in 
here; you take a lot of incoming in these hearings. And we know 
that your heart is in the right place in terms of taking care 
of our veterans, and that is a noble service. So thank you for 
that.
    Now I am going to give you a lot of incoming. No, I am just 
kidding. Actually, I want to thank you.
    S. 2526, which, Dr. Brill, you mentioned in your written 
statement--in your opening statement, is a bill that I have 
been working on with a number of Senators, what I think is a 
really common-sense bill because it would do things that you do 
not often see in the Federal Government. It would save money. 
It would help train our active duty, DOD, and VA medical 
professionals. It would expand services for medical services to 
our vets. It would increase the readiness of our military. And 
it would apply to all kinds of states that have this 
opportunity.
    In essence, Mr. Chairman and Senator Moran, this is the 
bill that authorizes the Secretary of Defense and the Secretary 
of the VA to enter into agreements for the planning, design, 
construction of facilities to be operated at a shared medical 
facility.
    So, Dr. Brill, I am glad that you have endorsed this. Part 
of the reason, I am sure, is because we worked really closely 
with you and your staff on it in addition to the Pentagon. But 
can you expand more on why this kind of collaboration between 
VHA, DHA, and this joint planning would be a good thing?
    Some of the things I listed in terms of cost savings, but 
this is really about service to veterans in addition to 
training up our DOD docs. I would like a little more detail 
because this is a top priority of mine. I think it should be a 
top priority of the Committee's. It is already having success 
on the DOD SASC side, but I would like to get your more 
detailed views.
    Dr. Brill. Yes, thank you, Senator. So as you noted, we 
fully support this bill, and as you mentioned, there are 
certainly cost savings and ease of planning.
    I can share my personal experience of when I was training 
as a resident at William Beaumont Hospital in El Paso, Texas, 
in the Army. The VA facility was co-located with us, and so it 
gave us the ability to sort of wheel a patient across the 
hall----
    Senator Sullivan. Oh.
    Dr. Brill [continuing]. And to take them directly to VA.
    Senator Sullivan. Oh, so you have actually experienced this 
idea.
    Dr. Brill. Experienced it, yes, sir.
    Senator Sullivan. And you were an active duty doc at the 
time?
    Dr. Brill. Yes.
    Senator Sullivan. Great. So you got to work on, say for 
example, you know, elderly patients that you would not see in 
the active force.
    Dr. Brill. Correct.
    Senator Sullivan. One example.
    Dr. Brill. I think, you know, even more so today, you know, 
as we saw with the pandemic and you never know where you are 
going to see peaks and valleys of need, the ability to share 
staff, to share facilities, to share equipment across 
geographies and then across the DOD and VA is very helpful. And 
then of course, also in times of conflict, when our, you know, 
DOD counterparts are deployed, then again you know, the ability 
of VA and DOD to work collaboratively back here in the States 
allows us to give great care to our patients.
    Senator Sullivan. So the surge capacity on either side, 
depending on where the demand signal is, is obviously enhanced.
    Dr. Brill. Correct.
    Senator Sullivan. What about service to veterans 
themselves, which of course, is of high priority to this 
Committee?
    Dr. Brill. So, service to veterans. So first of all, again 
from a geographical perspective, not every facility is in every 
geography. And so by having more facilities available net-net, 
I think that gives veterans more options of where to receive 
care. And it does--also, as we move much more into telemedicine 
and teleconsultation, it allows tapping into experts that may 
be in one geography but not another. And so really, the more 
that we can collaborate across VA and DOD, the more options we 
have to serve our veterans.
    Senator Sullivan. Good. Well, Mr. Chairman, you know, this 
is a bill I think that makes sense whether you are from 
Alabama, North Carolina, Montana, Alaska, because we all have 
significant vet populations, significant DOD centers. This is 
very important for my State. As you know, we do not even have a 
full-service VA hospital in the whole State and we are, you 
know, six times bigger than Montana; right?
    So I hope that we can move this in a bipartisan way because 
for all the reasons Dr. Brill mentioned and it saves money, and 
there is not a lot of legislation that comes out of this 
Committee that we know is going to save money. So I appreciate 
the VA's support, and I look forward to working with the 
Committee on moving this. Thank you.
    Chairman Tester. Thank you, Senator Sullivan. Just so you 
know, we are working to annex North Dakota, South Dakota, 
Wyoming, Nebraska, Iowa, Arkansas, and Louisiana.
    Senator Sullivan. I am sorry.
    Chairman Tester. It is all right. This is an ongoing thing.
    So first of all, I want to thank all three of you to be 
here today. I will tell you that I feel a little beat up this 
afternoon. I mean, the bills that the good Ranking Member and 
Chairman have on this docket are not exactly embraced, and so I 
want to flesh that out a little more if I might because I think 
if I got the list right from you, Dr. Brill, at the very end of 
your testimony, you had problems with the MAMMO Act, you had 
problems with the Prostate Cancer Act, you had problems with 
the REACH for Veterans Act, the MST bill. Is that pretty 
accurate?
    Dr. Brill [No audible response.]
    Chairman Tester. Okay. So I am just going to ask right off 
the top, kind of going off of Senator Moran's questions, and I 
think it goes to you, Dr. Carroll. You said that you are taking 
care of the problem. You are taking care of the problem that 
the REACH Act is trying to address with the Veterans Crisis 
Line already and that, I believe your words were--and do not 
let me put words in your mouth--that if we pass legislation 
that would kind of limit your ability to do stuff.
    Dr. Carroll. That was not my intention, sir, at all.
    Chairman Tester. So tell me what you said.
    Dr. Carroll. I said that we did not want to be held to a 
lower standard in legislation than we are already meeting, and 
that was----
    Chairman Tester. Okay. So what you are saying is you think 
that the REACH Act is a step backward from where you are at 
now?
    Dr. Carroll. We think we are meeting what is in the REACH 
Act right now.
    Chairman Tester. So you have data to show that you are 
meeting or exceeding the expectations in the volume, including 
the increased volume?
    Dr. Carroll. We would be happy to go through the data with 
you, sir.
    Chairman Tester. Do you have it?
    Dr. Carroll. We do. I think we can talk through our 
training standards.
    Chairman Tester. Yes.
    Dr. Carroll. The legislation talks about two monitors per 
month. We are already doing three.
    Chairman Tester. I am going to task my staff----
    Dr. Carroll. Okay.
    Chairman Tester [continuing]. And the Ranking Member's 
staff, too, if they so choose, to go over that information with 
you.
    Dr. Carroll. Sure.
    Chairman Tester. And I will tell you why this kind of 
concerns me. I want to work with the Department to make sure we 
have a bill that is workable. If it is not workable, you cannot 
implement it, and it is unfair to do that.
    On the same side of the coin, our job is to make sure there 
is oversight that you are doing the job. And I could be wrong 
on this, but I can tell you that we can have oversight over 
rules that you guys pass; we also can have oversight over the 
legislation, much more direct oversight. In fact, we do in 
every meeting almost.
    And so the goal here--and it is the same goal you have, Dr. 
Carroll--is to make sure that if a vet is in crisis that stuff 
happens and that it happens and we do not lose these people. I 
do not need to tell you the statistics; you should be able to 
repeat them to me, about how many veterans we are losing per 
day. It is not acceptable. It has been that way since I have 
been on this Committee.
    And so when the IG report comes out with a report and says, 
you know, your Veterans Crisis Line, which is pretty 
foundational to healthcare, is not doing the job, then you guys 
are going to have to show us the data that shows you are doing 
the job now because if you are not we are going to bring you 
back up and we are going to do it again.
    Now let us talk about the Prostate Cancer Act that Senator 
Moran also talked about, and the question I have for you, Dr. 
Brill, is that: We worked with the VA, but we did not work with 
the right people in the VA; is that what you were saying?
    Dr. Brill. Sorry. I am not sure if that would be the right 
answer, and I will be happy to circle back with those that you 
worked with to see what kind of communication they had with 
your team. I think, you know, if their feeling was that what we 
are doing clinically through our development of guidelines, 
through our development of relationships, through our 
development of, you know, cutting-edge technologies, using 
telemedicine, tele-oncology, et cetera, precluded the need for 
legislation, then I think that they should have been more 
forthcoming of that opinion during the working sessions that 
they had with your team.
    Chairman Tester. So this is basically the same thought as 
with the REACH Act, that you were already meeting the needs and 
you do not need legislation to do it? I do not want to put 
words in your mouth. I am just kind of repeating what I heard.
    Dr. Brill. Well, so yes and no. I would say, yes, but also 
because the nature of medicine and development of clinical 
guidelines and keeping up to date, as you could certainly see 
from the pandemic, can be sometimes slow-moving but sometimes 
very rapidly moving. And when the clinical community comes 
together through research, collaboration, work with academic 
affiliations, you know, they should be able to move as quickly 
as they need to, to respond clinically to a----
    Chairman Tester. And do you think that they have moved as 
quickly as they have needed to, to address prostate cancer?
    Dr. Brill. Well, I do believe that prostate cancer is very 
high on the VA's list because of the number of veterans that we 
have that fall into the age group and gender that are impacted 
by prostate, and it is a very high priority.
    Chairman Tester. I think that is true, as veteran suicide 
is a very high priority, but we have not found out what we need 
to do to solve that yet either.
    And so what I would say is this: We are going to take 
another run at this on all five or six of these bills, and I 
will tell you--and I did not even get into military sexual 
trauma, which is--I mean, it is a massive issue within the VA. 
Okay? It is.
    And I will tell you that I worked with the members on this 
Committee, including the Ranking Member, on all these bills. 
And if they put you in a bad situation, where it is going to 
limit your ability to provide benefits to veterans, we do not 
want to do that. What we do want to do, though, is hold you 
accountable so you make sure that you are going to continue to 
be the leader in healthcare for veterans in this Nation. No 
ifs, ands, or buts, about it.
    And if you are not, then we are going to bring you in front 
of the Committee and Tillis is going to rail on you. Okay? Or I 
am going to rail on you, or somebody is going to rail on you. 
Okay?
    So we will go back. We will have a discussion about these 
bills. We tend to--I will just be honest with you. We tend to 
do what the VSOs ask us to do in this Committee, and I do not 
think these bills came about because of my staff working in a 
vacuum. So we will continue to work with that.
    With that, I will turn it over to Senator Tuberville unless 
you were second to Tillis, which I can certainly make a mistake 
on that.
    Senator Tuberville. I was courteous. I did not elbow him 
when we were in the doors.
    Chairman Tester. Oh, well, in that case, look--no, it is 
age before beauty, Tuberville.
    Senator Tillis.

                      SENATOR THOM TILLIS

    Senator Tillis. Thank you, Senator Tuberville,
    Chairman, Ranking Member. And I want to thank you all for 
being here. We made a comment about bipartisan collaboration 
among the members. But I have been here for six and a half 
years, and I have seen transitions of Democrat and Republican 
administrations, and I think there has been a smooth transition 
there. So, look forward to working with you all and the work 
that you have done in the past.
    I want to get to Senator Sanders's bill. I think it is a 
well-intentioned bill. However, in your opening testimony, I 
think one of the statements you made, VA's existing resources 
to provide dental care are at or near full capacity, and then 
you say, with regional variances. In North Carolina, in our 
VA--or I am sorry, our Fayetteville service area, we are only 
meeting the needs of about 20 percent of the currently eligible 
population. And we are adding dental treatment rooms, but I do 
not believe that the additional dental treatment rooms will be 
sufficient for current capacity. And we are talking about a 
State that has got one of the fastest growing populations.
    And so Senator Tester, in reference to another bill, made 
the comment, it is not workable if you cannot implement it. I 
think if we were to implement this until we were able to fully 
achieve, across all regions, capacity for those currently 
eligible, that it would not be workable and put us further away 
from providing quality care for those who have it. So, not 
opposed to the intent, but I do think it could create a lot of 
disruptions.
    So with that said, do you support--I know that you, in your 
opening testimony, made reference to a couple of sessions. But 
do you support the bill? I mean, can it be made right now given 
the challenges you have with the current unmet need?
    Dr. Brill. So, Senator Tillis, you bring up a very good 
point, and what we noticed--so before I was in this role, I was 
the Chief Medical Officer for the Office of Community Care. And 
so what we noticed with the MISSION Act is when eligibility was 
increased in terms of distance and wait time that there was a 
tremendous upsurge in the seeking of dental care in the 
community, which showed that even for the eligible veterans, 
which is only 15 percent of our veteran population, even for 
those eligible veterans, we were not meeting their needs. And 
so the cost went up significantly for community care. But what 
it does signify is that were we to increase eligibility to all 
veterans, you know, it is such a far road to travel from 15 
percent to 100 percent.
    A few things that make it challenging in particular is, as 
you point out, we do not have the infrastructure to handle it 
internally at all. So, immediately would have to go the 
community, which would be okay except the way that the dental 
benefit is written it is very comprehensive and does not have a 
lot of sort of guard rails around it and could be really 
prohibitive from a cost perspective. The projection for five 
years is $34 billion. Billion.
    And so I think conversations that----
    Senator Tillis. I saw a 10-year projection of $109 billion.
    Dr. Brill. Yes. Correct.
    Senator Tillis. Yes.
    Dr. Brill. And that is because over that period of time 
that would be when we would be building more dental clinics, 
hiring more staff, and the early days would really just be 
paying for community care.
    So one of the things I think we need to consider, 
collectively, is: Should the coverage be so comprehensive? You 
know, should we cover all people perhaps with fewer benefits 
rather than fewer people with more benefits?
    So I think that would be one thing to consider in order to 
limit the total cost and then really plan a stepped-out 
approach to the segueing from community care, which would be 
our first--you know, sort of our first step, and then really 
timing out the building of facilities and recruitment of 
dentists. And there is some concern from the Office of 
Dentistry as to the availability of dental providers throughout 
the country to recruit.
    So I think we could do it, but it will be very expensive, 
and it needs to be very carefully stepped out over time.
    Senator Tillis. Yes, I think your point over the--I think 
it was in the past, just when related to Sections 3 and 4 of 
the bill, that even if you built it, not enough dentists or 
dental professionals would come because this is not only a 
problem in our VA population in North Carolina, where half of 
our State is rural, but we are struggling to find basic dental 
services for the broader population.
    So again, I think I would rather our focus be on the 
immediate challenge, which is not serving the population who 
already is eligible, dealing with the geographic disparities, 
and then figure out how we can incrementally build a wider net 
and, as you said, maybe fewer services to more people or 
whatever mix makes sense. So I think for that reason I share, I 
think word for word, your concerns that were expressed in the 
bill.
    Thank you, Mr. Chair.
    Chairman Tester. Senator Tuberville.

                    SENATOR TOMMY TUBERVILLE

    Senator Tuberville. Thank you, Mr. Chairman.
    Thank you all for what you all do for our veterans. It is a 
hard job, going to get harder. That is the reason we are here, 
to help.
    Ms. Pierce, I want to follow up on Senator Hassan's 
question on Vet Centers earlier. Can you talk about S. 1944, 
the Vet Center Improvement Act, especially the requirements of 
productivity evaluation of counselors. What are vet centers 
doing to support transitioning veterans, and how can 
productivity evaluations bring more assistance to veterans in 
crisis?
    Dr. Brill. So I will take that one if that is okay with 
you, Senator.
    Senator Tuberville. Go ahead.
    Dr. Brill. So essentially, there was a GAO report in 2021 
which identified some issues with productivity, with staffing, 
and recommended feedback from vet center counselors, from 
staff, and from veterans, et cetera, some standardization 
around position descriptions, some hiring--you know, some 
hiring initiatives.
    So I think with regards to the bill itself the vet centers 
are achieving all of the goals that were stated for them from 
the GAO report, and the VA's position is that the bill is not 
necessary because they are already taking those actions to 
address those issues.
    I would focus on Section 8, which relates to food, and just 
quickly say that we do support the issue of dealing with food 
insecurity and veterans and that portion of the bill we would 
like to have some more conversation about as to how we can do 
that more comprehensively. We do not have an appropriation to 
purchase food for veterans at this point in time, and so we 
would like to explore ways of how we can help with food 
insecurity.
    We would ask, though--the GAO is doing a review of food 
insecurity for VA and also for USDA. So we would like to ask 
that after that review is completed then looking at what the 
recommendation are.
    And I would say that, differentiating the recommendations 
around food versus the recommendations around staffing and 
productivity, we have the internal capacity, and have already 
addressed the staffing and productivity issues. That is within 
our bailiwick, if you will. But the food piece, particularly 
the ability to purchase food, they may need other 
appropriations or certain things that could only be legislated 
in order for us to support the food insecurity piece. And so we 
would like to work with you on that.
    Senator Tuberville. Thank you. I am going to ask you this 
one, too, Dr. Brill. S. 2386, the Veteran Peer Specialist Act, 
would require the VA to expand the Peer Specialist Support 
Program at 25 VA medical centers. Can you describe, you know, 
how the expansion would be implemented, number one, and what 
benefits this expansion would bring to our veterans?
    Dr. Brill. So I am going to defer that one over to Dr. 
Carroll.
    Senator Tuberville. Nobody likes my questions. Go ahead.
    Dr. Carroll. Thank you, Senator, and thanks, Dr. Brill. The 
peer support within VA has been one of the most transformative 
things that has happened with the support of Congress, this 
Committee, over the last several years, and it makes an 
incredible difference for veterans to connect with other 
veterans who can help them connect to resources in the 
community, help walk them through mental health treatment. And 
we are continually looking for ways to expand peer support 
within our own structure. We currently have almost 1,200 peer 
support specialists employed in VA right now and are looking to 
expand that and also working with our community partners around 
Peer Support.
    This legislation would ask us to move forward on additional 
peer support specialists within our primary care clinics in 
particular. We have had good experience with that. We feel we 
are ready to do that. We have the technical assistance, the 
lessons learned from a previous implementation, that we are 
very ready to share with facilities that want to do this.
    We feel that they need to look at their staffing within 
primary care and have the flexibility to, you know, perhaps 
this month they could hire a peer specialist, but maybe the 
next opportunity they need to look at provider staffing or 
nurse staffing within their primary care clinic. So we think 
having--allowing facilities to flexibly hire is important.
    This year, we are looking to--we are expanding peer support 
in our substance use disorder clinics, in our women's mental 
health programs as well.
    And so I think it is a constant area for us, but we feel 
that we currently have the authorities necessary to move 
forward with this.
    Senator Tuberville. Are you asking for volunteers, or how 
are you doing this selection process for the 25?
    Dr. Carroll. We would ask for volunteers to move forward 
with it. So . . .
    Senator Tuberville. Okay. Thank you all. Thank you for your 
support. Thank you.
    Thank you, Mr. Chairman.
    Chairman Tester. I believe we have Senator Blackburn, 
virtually. Senator Blackburn, you are up.

                    SENATOR MARSHA BLACKBURN

    Senator Blackburn. Yes, Mr. Chairman. Thank you so much and 
thank you for this hearing and for allowing us to come in 
virtually when we are trying to do too many things at one time. 
So I appreciate that.
    Dr. Brill, I would like to come to you if I may. I am a big 
believer in veterans deserve choice, flexibility. They want 
options when it comes to how they use the benefits that they 
have earned.
    We have a lot of veterans in Tennessee. Tennessee does not 
have a State income tax. We have a lot of people that have 
served for Fort Campbell, or they have been at Arnold 
Engineering, or they have been at the naval station in 
Millington over by Memphis, and they choose to retire in 
Tennessee. So we do have very high numbers of veterans that 
live there, and having more flexibility, not less, is what they 
are looking for.
    This is why Senator Sinema and I did the Long-Term Care 
Act, and we are grateful that this was on the markup calendar 
for today because it increases access to Medical Foster Homes 
as an alternative to nursing homes. That is the kind of thing 
that veterans are wanting to see.
    And I also hear from veterans in Tennessee that they prefer 
to get their care in the community, that local community where 
they live, seeing a doctor there in that community, many times 
going to a hospital there in their local community. And I have 
concerns that the VA has begun to restrict access to community 
care. And the press release that the VA sent out October 5th 
announced that they were decommissioning the Office of 
Community Care and noted that VHA conducted a functional 
assessment in the fall of 2020 to reach this decision.
    So, Dr. Brill, you may not be able to speak directly on 
this issue, but I want to get your commitment that the VA will 
work with my office and work with this Committee to provide 
answers so that we can continue to conduct proper oversight. 
And can you please provide the Committee and my office a copy 
of that functional assessment report?
    Dr. Brill. Senator Blackburn, thank you. I will address 
both of the issues that you brought up. So first of all, VA is 
very supportive of the Long-Term Care Veterans Choice Act. 
Medical Foster Home, as you know, provides an option for 
veterans to be in a non-institutional environment, in someone's 
home as a Medical Foster Home. And right now they have to pay 
out of their own pocket to be in those settings, and this bill 
would allow some subsidizing of those veterans so that they 
would not necessarily need to pay for that setting. So we are 
very supportive of that. It would be a net savings to our 
program. So it really benefits everyone, not just the veterans, 
but also the VA. And so that is what I will say about Medical 
Foster Home.
    And then as far as the Office of Community Care, so first 
of all, I was a chief medical officer for the Office of 
Community Care right before taking this role. And what I will 
tell you is, first of all, the MISSION Act standards have not 
changed at all. Those are by statute. And so the wait times, 
the travel distances, et cetera, the lack of facilities in a 
State, those sort of statutes, they still hold, and the 
eligibility is in no way changed because of this kind of 
bringing together of the Office of Access for Care and the 
Office of Community Care.
    So I will just explain the goal of that joining of those 
two offices. So the Office of Community Care was stood up in 
short order due to Choice Act and other legislation that 
increased choice for veterans to be seen in a community with 
less hassle, less wait, and less travel time. The Office of 
Access for Care is working on access inside of the VA 
facilities to make sure that clinics are available and, if not, 
that patients are getting sent to the community.
    What veterans were then experiencing is this bifurcated 
relationship with their healthcare providers. These offices 
were not always working completely in synchrony, and really, 
the veteran should have a seamless experience. If they want 
care, it should not really matter how we are working behind the 
scenes making the sausage for them to get care. They should be 
able to get the kind of care that they want, that they are 
eligible for. And so by bringing these two offices together, we 
are attacking access, quality, and service collaboratively and 
uniformly, whether or not the patient goes to the community or 
stays in VA.
    And we will be happy to provide those documents to your 
office.
    Senator Blackburn. Thank you. I know I am out of time, but 
I would also like for you to provide me a list of completed 
appointments through community care, those community care 
completed appointments in 2019, '20, and '21, so that we can 
see how many have been completed, not scheduled, but completed. 
That would be helpful.
    I have a couple of other questions for you that I will 
submit for the record, but thank you so much for your time.
    Chairman Tester. Senator Moran.
    Senator Moran. Chairman, thank you. Just a couple of things 
to wrap up. I do not think there is a question here but just a 
statement on my part.
    First of all, legislation, in my view, should not be 
opposed because you are exceeding its requirements. It is 
appropriate for us to establish legislation. We often look at 
what the VA is doing now and put into statute that standard so 
that you do not ever go beneath what you are already doing. And 
so the idea that a bill is less demanding of what you are 
already doing, I hope that you always look for ways to do 
better than what even the statute or the law says. And so I do 
not know that is a good explanation for opposition to a bill. 
Creating a floor, not a ceiling, is what I think we are all 
about.
    And then I wanted to highlight the Veterans Health Care Act 
of 1992. I have indicated this to the Secretary, and I indicate 
it again to you to make certain that it is heard within the VA 
leadership. That Act, 1992, unequivocally prohibited the VA 
from performing and providing abortions. However, after writing 
to the Secretary to remind him of this prohibition, he 
responded by describing the VA's prohibition as a policy 
decision, quote unquote, rather than a statutory one. This is a 
departure from the VA's previous position that it cannot, by 
law, provide abortion services. That is what the VA has said 
publically on its website.
    I raise this today not because any bill that we are 
considering on the agenda touches upon on this issue, 
specifically, but because the VA's argument is that despite 
congressional authorization and prohibitions on what it can and 
cannot do it has generally treatment authority to override 
those decisions made by Congress.
    I would like to use this as an opportunity based upon the 
discussion that we have had regarding a number of the bills 
that Senator Tester and I have sponsored. I would like to 
reiterate to our witnesses here today that we do not hold 
hearings like this before passing legislation just so that 
those laws will ultimately end up being mere suggestions to the 
VA on how they operate. We expect, I expect, the VA to abide by 
these laws, including the statutory prohibition on abortion.
    Mr. Chairman, thank you.
    Chairman Tester. Thank you, Senator Moran. I would just 
tell you there is 18 bills on the [off microphone.] In the end, 
I want you guys on board or tell us why you cannot get on 
board. Okay?
    Thank you for that. The first panel is released.
    And we will hear from the second panel which are our 
veterans' advocates. We have Marquis Barefield, who is 
Assistant National Legislative Director for the Disabled 
American Veterans. And we have Tom Porter, and Tom is the 
Executive Vice President, Government Affairs of the Iraq and 
Afghanistan Veterans of America. We will get you guys seated, 
and then we will hear your testimony and then open up for 
questions and answers. So take your seats if you might.
    Welcome, gentlemen. It is great to have you back in front 
of the Committee, and we will start with you, Mr. Barefield.

                            PANEL II

                              ----------                              


                 STATEMENT OF MARQUIS BAREFIELD

    Mr. Barefield. Thank you, Mr. Chairman. Chairman Tester, 
Ranking Member Moran, and members of the Committee, DAV is 
pleased to offer our views on the bills that impact service-
disabled veterans and the programs administered by the VA that 
are under consideration by the Committee. My full written 
statement covers all the legislation, but I would just 
highlight a few bills in my oral remarks.
    DAV strongly supports the Servicemembers and Veterans 
Empowerment and Support Act of 2021. This legislation would 
address existing shortfalls in the military sexual trauma 
claims process to help ensure that veterans are aware of, and 
have adequate access to, care and services for conditions 
related to their trauma and that they do not face unnecessary 
hardships throughout the claims process. This bill stands as a 
much needed compilation of provisions that address many of the 
longstanding issues DAV has noted within the claims process for 
MST-related conditions.
    We support changing the evidentiary standard for MST cases 
more closely in line with what is currently required for combat 
veterans. It is also important to protect the integrity of the 
claims process and prioritize the best interest of veterans by 
putting accuracy before speed. We strongly recommend veterans 
complete the full claims development process prior to 
undergoing any exams to ensure they are presenting the 
strongest and most thorough for VA evaluations and 
adjudication. It is very important to get this first step right 
to avoid possible premature denials and putting veterans in the 
position of undue emotional stress.
    We support automatic written communications providing 
information on resources for MST coordinators in both VBA and 
VHA. DAV believes this is a positive step forward in 
synchronizing efforts between the two administrations and 
keeping the veterans more informed.
    DAV also supports studies on staff training for claims 
processors and studies on access to inpatient mental health 
care and the pilot program on interim access to more intensive 
outpatient care. This bill will help ensure that all MST 
survivors gain access to specialized treatment programs and 
services they need to fully recover and that VA conducts 
vigorous oversight of claims adjudication personnel and review 
of data to ensure the policies for processing claims for 
conditions due to MST are standardized in all VA regional 
offices.
    DAV also strongly supports the Veterans Dental Care 
Eligibility Expansion and Enhancement Act. The bill would 
authorize dental services in a phased approach beginning with 
veterans that are service-connected at 30 percent or greater. 
We believe the phase-in implementation outlined in the bill 
would allow VA the appropriate time to develop program 
capacity, to include the hiring of dental staff or to contract 
with community dentists for such services.
    Oral health is integral to overall general health and well 
being. Veterans who are medically compromised or who have 
chronic disabilities can be at greater risk for oral diseases, 
which has the potential to jeopardize the overall health and 
quality of life. DAV supports this draft legislation which 
recognizes the importance of oral health as part of basic 
healthcare and authorizes VA to provide comprehensive dental 
care to all enrolled veterans.
    DAV is also pleased to support the following bills:
    S. 2283, the REACH Act for Veterans, which would improve 
training protocols for Veterans Crisis Line responders, 
including enhanced guidance for managing callers with substance 
use disorder or at risk of overdosing, which would strengthen 
the overall quality of the program.
    S. 2386, the Veteran Peer Specialist Act of 2021, which 
seeks to expand the peer specialist program. DAV recommends the 
Committee work closely with the VA to address some of the 
concerns it raised in testimony about its companion bill about 
implementing this program.
    Finally, DAV is pleased to support both vet center bills, 
S. 1944, the Vet Center Improvement Act of 2021, and S. 2924, 
the Vet Center Outreach Act of 2021. Vet centers have proven to 
be an effective resource to assist veterans of all eras, who 
seek care for issues associated with exposure to traumatic 
combat situations, military sexual trauma, and challenges 
reintegrating into families and communities.
    Mr. Chairman, this concludes my remarks, and I welcome any 
questions that you or members of the Committee may have.

    [The prepared statement of Mr. Barefield appears on page 80 
of the Appendix.]

    Chairman Tester. Thank you, Mr. Barefield.
    Mr. Porter.

                   STATEMENT OF THOMAS PORTER

    Mr. Porter. Thank you, Mr. Chairman, Ranking Member Moran, 
and members of the Committee for having us here to provide our 
views. Our full testimony is submitted for the record. I will 
highlight a few of the bills that we have here today.
    I am glad you brought up the military sexual trauma issues. 
It is an issue that is really, really important to us. It is a 
near crisis situation, and IAVA is attacking this from all 
angles. So we actually support--and it is a big priority of 
ours--legislation on the front end on DOD, with Senator 
Gillibrand and Senator Ernst over on the DOD side. And I am 
glad that we are doing this on the VA side as well because, as 
you probably know, 1 in 4 women veterans and 1 in 100 males 
report experiencing military sexual trauma.
    For years, the claims process has been criticized for the 
lengths veterans must endure to approve their MST claims. And 
in August, the VA OIG reported the VA potentially denied 
thousands of veterans benefits related to their MST claims due 
to errors in processing. The report also found the VA failed to 
implement recommendations made by OIG back in 2018 that 
resulted in similar issues. The lack of implementation resulted 
in an increase from 49 percent of claims being improperly 
processed to 57 percent. The VA must make veterans feel safe as 
they embark on the difficult process of filing their claim.
    So IAVA strongly supports Senator Tester's draft 
Servicemembers and Veterans Empowerment and Support Act to 
improve the MST claims process and adjust the standard of proof 
a veteran has to provide, lessening the potential for 
retraumatizing veterans.
    Suicide prevention is always a top IAVA priority. In the 
last year, IAVA worked to pass legislation to establish a 
national suicide hotline, 988, to ensure that all Americans, 
including veterans, have easier access in times of crisis and 
mental health and suicide prevention resources.
    The VCL is invaluable resource, but it is not without 
fault. The data has shown, when the VA OIG reported last year, 
that VCL mishandled several high risk callers. That is why IAVA 
supports the Revising and Expediting Actions for the Crisis 
Hotline, the REACH Act. This bill would implement many OIG 
recommendations, as you know, such as retraining for VCL 
employees and other improvements. It also would have the VCL 
consult with VSOs in implementing the new 988 number, so we 
appreciate that.
    Veterans, as you know, have been very, very stressed over 
the last few weeks, couple months, during the withdrawal from 
Afghanistan. Our data has shown that in the amount of veterans 
that have called in for help from us. So this is a timely 
discussion on this bill. So, appreciate it.
    There is much uncertainty around the decision to leave the 
military, and according to a Pew Research study veterans are at 
highest risk for dying by suicide in the first three months 
after their transition. And vet centers offer a community-based 
touch point that could be used to proactively reach out to 
veterans soon after they separate from the military. So vet 
centers are very, very valuable to us and to our community. 
They are an innovative response to a lot of needs and emerging 
needs in the veteran community.
    So for these reasons, we support both of the vet center 
bills, Senator Tester, the one you have with Chairman Reed, the 
Vet Center Improvement Act, and then Senators Hassan and Cramer 
have the Vet Center Outreach Act. So those are both bills that 
we support.
    The MISSION Act established a peer support program that 
empowers veteran peer specialists to apply their own 
experiences to help others navigate the VA system and access 
services while teaching them about positive, health-reaffirming 
behaviors. The Veteran Peer Specialist Act expands the 
successful peer specialist program to all VA medical centers, 
and it would prioritize expansion to rural areas and ensure 
peer specialists reflect population diversity.
    We know there is a connection between Agent Orange and 
prostate cancer. There has been research to back that up. So we 
support the Veterans' Prostate Cancer Treatment and Research 
Act. That is important to us to be able to improve ways to 
treat it.
    And then our women veterans are always a top priority for 
us. They are the fastest growing segment of the military 
veteran population. Veterans' services have improved greatly in 
recent years at the VA. There is still more work to do. One of 
the piece of legislation that highlights--that we want to focus 
on is the MAMMO for Veterans Act. I think the more that we can 
improve the ability, especially in rural areas where women 
veterans and all veterans lack a lot of services, that we can 
deliver mammogram services, upgrading their abilities to seek 
treatment.
    So thank you for having us here today. Happy to answer any 
questions, Mr. Chairman.

    [The prepared statement of Mr. Porter appears on page 95 of 
the Appendix.]

    Chairman Tester. Appreciate you both being here. Appreciate 
your testimony. This question is for both of you. Have either 
you or your organizations had a chance to look at all 18 bills?
    Mr. Porter. I can say, Mr. Chairman, not in as much detail 
as we would like. We noted the ones that I have testified on 
today in my oral statement that we dug a bit deeper on, but we 
have taken a look at almost all of them. A couple of the 
offices did not respond, so we could not look at all of them.
    Chairman Tester. Okay.
    Mr. Porter. But . . .
    Chairman Tester. Mr. Barefield?
    Mr. Barefield. Yes, we have had an opportunity to review 
all 18 bills.
    Chairman Tester. And we will go with you, Mr. Barefield. 
Are there any of the bills that you oppose of the 18?
    Mr. Barefield. Of the 18, there are 5 bills that we do not 
have a position on based on the fact there are no resolutions 
that the Disabled American Veterans have for those particular 
pieces of legislation.
    Chairman Tester. Okay. Mr. Porter?
    Mr. Porter. Mr. Chairman, the legislation on the chaplains, 
to reorganize that, it seems to make sense on the front end to 
us, but we would like to hear more from the VA to see what 
their reaction is, want to see what there is more to do discuss 
on this, hear more about that.
    I think that the National Green Alert Act, we cannot 
support that bill at this time. There is still a stigma in 
seeking out help on this issue. I have concerns about some 
privacy, possible privacy concerns about this, and I want to 
hear what VA and proponents of the legislation have to say 
about that.
    Chairman Tester. Okay. So as I requested of the VA, I will 
make the same request of you guys. If there are ways we can 
work with you to make sure we address those concerns, I think 
that is critically important moving forward. And if there is 
information that you need that you cannot get that you want, we 
will do our best to get it for you. And so that is where we are 
at.
    I want to talk a little bit about where you left off, Tom, 
and that is with the breast cancer screening and care, 
especially as it applies to rural and remote areas and the 
challenges accessing healthcare there. Almost the entire 
Mountain West and Pacific Northwest do not have an onsite VA 
mammography, and there is a lot of rural veterans in that 
region that do not live near a National Cancer Institute-
designated cancer center.
    So, Mr. Barefield, can you speak to the necessity of 
assessing mammography and coordinating cancer care for 
veterans, especially in the rural areas?
    Mr. Barefield. Thank you for the question, Chairman. Yes, 
it is very important, very important that women's health is put 
in the forefront. And when it comes to the mammography bill, 
since as you mentioned in your area there is not enough or 
there is a lack of VA facilities to be able to provide those 
services, then that is where the relationship in the community 
should be looked to and grown. That way, the needs of women 
veterans, especially for mammography services, can be sent out 
to community providers to help fill in the gap that the VA 
cannot fill.
    Chairman Tester. Okay. Thank you.
    Mr. Porter, I do not need to explain to you that the 
women's population I believe it continues to be the fastest 
growing population within the VA for services. Can you talk 
about the importance of the VA establishing a strategic plan 
when it comes to mammography?
    Mr. Porter. Well, that can go for treating women veterans, 
Mr. Chairman.
    Chairman Tester. That is true.
    Mr. Porter. And that is why we helped develop the Deborah 
Sampson Act with you, and that is one of our top priorities, is 
seeing that implemented. And that goes a long way to look at it 
strategically, to look at all services. There is a lot more 
that we can do. So, yes, we need to look at the more targeted 
approaches on mammograms and getting rural veterans access to 
those, but we want to keep going and look at everything that we 
could possibly do.
    Chairman Tester. Appreciate that. Look, the Veterans Crisis 
Line was brought up with the last panel. You guys were here. 
You heard the conversation around it. I mean, from a veteran's 
standpoint, Tom, can you explain the importance of the Veterans 
Crisis Line as a resource to veterans?
    Mr. Porter. Well, as we all know, suicide amongst the 
veteran and military community remains a crisis. And we keep 
saying that over and over and over again, but it remains to be 
true. But at no time have we felt it more critical--and I 
cannot underscore it enough--than over the last couple of 
months as we withdrew from Afghanistan.
    I knew veterans, military members around the clock like 
desperate to get people they knew out of Afghanistan or that 
felt that their service suddenly did not matter anymore. The 
deployments over the last 20 years, why did we go? Spouses 
saying, why do we do this?
    And so we surveyed our members. The survey is out right 
now, but we have preliminary data that is out that shows 
exactly how it impacts the community. And this has not been 
released yet, publically yet, but 63 percent of our members 
supported withdrawing troops from Afghanistan, but 56 percent 
strongly disagreed with the way that the administration 
withdrew the troops. Another 10 percent agreed, simply agreed. 
So about 66 percent disagree with the way they were withdrawn. 
And then even greater, 85 percent, that more should have been 
done to help our Afghan partners get out.
    So that just proves that there is an enormous amount of 
stress in the community, and then that goes to the 80 percent 
increase of callers to our call center that we maintain that 
refer for mental health referral. So, 80 percent increase just 
in August.
    Chairman Tester. Okay.
    Mr. Porter. So there is an answer just from our community.
    Chairman Tester. Yes. Thank you.
    I am way out of time or I would have asked you the same 
question, Marquis, but we will go down that line a bit later.
    Senator Moran.
    Senator Moran. Thank you, Chairman.
    Tell me, Mr. Porter, about 988. What is the status of its 
implementation, and what, if anything, still needs to be 
accomplished to see that it is functioning well?
    Mr. Porter. Well, I have not talked to VA about the exact 
state of it, but I know from working with the House and Senate 
energy committees in developing it, it is a lot more 
complicated than people think. They think we just establish the 
three numbers, and then you implement it. You have to go to 
each of the States, and you have to get all of the right, 
qualified personnel. You have to get the funding, the 
authorizations. There is a lot to do. We are here to help, but 
I have not heard anything that needs our help at this point.
    Senator Moran. Okay. Your testimony, Mr. Porter, about S. 
2720, the Veterans' Prostate Cancer Treatment Act, what do you 
regard as important in this legislation? What outcome will we 
achieve with its passage and rightful implementation?
    Mr. Porter. Well, I think, first off, it is always a 
priority for us to address the broader picture of toxic 
exposures, and Agent Orange is something that we have worked 
with the older groups to address. And we know that there is a 
tie to, because of research, from Agent Orange to prostate 
cancer. So if we would know more about the disease, we would 
know more about how to address that, and then we could address 
it better. And then that also tells us that we need to address 
the broader issue of toxic exposures.
    Senator Moran. Thank you.
    Mr. Barefield, DOD and VA constantly communicate, yet still 
have difficulties in forecasting and planning future medical 
facility needs. The passage of 2526, Senate Bill 2526, that we 
are having a hearing on today, how does it allow the 
departments to behave differently or to get a better result?
    Mr. Barefield. Thank you for the question. This particular 
bill would allow the two departments to get along and be able 
to have facilities that they can coexist in. And hopefully, as 
they coexist in these facilities, they would be able to develop 
relationships where not only the clients that they serve can 
have better quality service and healthcare, but they can see 
that these two organizations can work together. And as it was 
mentioned earlier during the questioning of the first panel, 
anything that can save money would be a very integral thing.
    Senator Moran. Thank you for that answer.
    Mr. Porter, let me come back to you for my final question. 
Women veterans' health. What do you think the priority should 
be, and how do the bills that we are talking about today 
address those priorities?
    Mr. Porter. Well, I mean, all of these affect women 
veterans. But women veterans also want equal care, and 
sometimes that means there are gaps in care that we need to 
fill. And so that does not mean that we are providing special 
treatment for women veterans. So when veterans need mammograms 
in rural areas and they cannot get to them, we need to be able 
to fill those gaps and get them what they need.
    Senator Moran. Let me ask this question. Would you consider 
that the MISSION Act and community care that is authorized by 
the MISSION Act, in fact, required by the MISSION Act, would be 
a further step in meeting the needs of particularly women 
veterans, rural or otherwise?
    Mr. Porter. Absolutely. IAVA was a supporter of the MISSION 
Act because the VA cannot be everywhere. So the private sector 
has a role in that, that VA cannot be everywhere the veterans 
are. So that is why we supported that is because especially in 
the rural areas where you cannot have an appointment as quickly 
as you would like to, if the private sector can fill that gap, 
then that is what they are there for, and we support that.
    Senator Moran. I agree with that. I would say that in 
addition to that, I mean in addition to the community care, the 
MISSION Act community care providing needs for rural veterans, 
women are a larger percentage of the population than they are 
of the VA at the moment. That number continues to grow. The 
percentage of women who are veterans. And we know that women 
are being treated in our medical communities, in communities, 
in community care, in the places they would normally go.
    So my point is that there would be availability of care for 
women more readily perhaps outside the VA until we catch up 
with the general medical care provided in a community; right? I 
mean, so community care becomes more important as the VA works 
to get more care for women. We are not there yet?
    Mr. Porter. Absolutely. No, I would be happy to work with 
you.
    Senator Moran. I did not say that very well, but I think 
that the concept is right. Women are being provided care in the 
normal healthcare setting outside the VA. This gives the VA a 
chance to provide those services in the community while the VA 
continues to increase the availability of care for women today.
    Mr. Porter. Right.
    Senator Moran. Makes sense?
    Mr. Porter. Yep. Absolutely, sir.
    Senator Moran. Okay. Chairman, thank you.
    Chairman Tester. Yep. Senator Tuberville.
    Senator Tuberville. Thank you, Mr. Chairman.
    Thanks for being here. Off the subject a little bit, how 
are veterans dealing with COVID that you know of?
    Mr. Porter. We see a lot of veterans, sir, that really are 
taking advantage of the vaccine, and we encourage them all to 
get vaccine. And we are actually partnering with some other 
VSOs to encourage veterans and servicemembers to go out there 
and get it. We support efforts by DOD to require that amongst 
the Services. Seeing a lot of great results on that. We just 
think we need to do more.
    Senator Tuberville. Yes. Our DAVs, with COVID, how are we 
doing?
    Mr. Barefield. Our position is that we are encouraging 
veterans to go out and get vaccinated. A lot of our membership, 
of course, are over the age of 50. So of course, we are pushing 
to make sure that they know about where they go and get the 
vaccines, and vaccine shots are available to them.
    I, myself being a veteran, of course, myself and my wife 
were able to get vaccinated at our local community-based 
outpatient clinic. So as soon as the shots were available, we 
signed up, and we went right ahead and got our vaccine.
    So we are doing what we can to help spread the word that it 
is very important to become vaccinated.
    Senator Tuberville. Yes. I hope the boosters are available 
soon. Have you all seen any availability yet for our veterans? 
The boosters?
    Mr. Porter. They are available for everybody that is 
suggested that they get it.
    Senator Tuberville. Yes.
    Mr. Porter. At the right amount of time.
    Senator Tuberville. Yes. Okay. Mr. Barefield, many of the 
bills on today's agenda address mental health and wellness of 
veterans. What VA resources, such as vet centers, have you 
found the DAV members leverage the most?
    Mr. Barefield. Our membership, they respect and use all of 
the services, so to include the vet centers and the mental 
health services that are at the VA medical centers as well. We 
understand that the VA has high quality care when it comes down 
to mental health services. So we encourage our members to make 
sure that if there are issues that they have, that they seek 
out going to their closest either VA medical center or vet 
center, if they meet the qualifications to go to the vet 
center, to make sure that they go there and get the required 
mental health services that they need.
    Senator Tuberville. Did you see anything in this 
legislation, our list here, that you would most emphasize?
    Mr. Barefield. Well, I think all of the bills that deal 
with the mental health and suicide prevention efforts that are 
on discussion today are important. So I would not say singling 
out one more than another. But if I did have to pick one, the 
Servicemembers and Veterans Empowerment and Support Act is very 
key because along with just the regular mental health services 
that it discusses it also talks about the MST and being--and 
offering available mental health services for those veterans 
who suffer from MST incidents.
    Senator Tuberville. Yes. Thank you.
    Mr. Porter, in your testimony, you mentioned that based on 
some preliminary data from a recent Iraq and Afghanistan 
Veterans of America survey 77 percent of members had some or 
many challenges upon transitioning from active duty to the 
civilian world; 34 percent stated they were not prepared to 
manage their finances immediately after the military. Based off 
your experience, can you ballpark what percentage of 
transitioning servicemembers have leveraged VA resources, you 
know, to get through this situation?
    Mr. Porter. I do not have the numbers in front of me, but a 
great deal, a vast majority of our members, I believe around 
three-quarters at least of our members are enrolled with the 
VA.
    Senator Tuberville. Really?
    Mr. Porter. So they are heavily invested in the VA. They 
depend on the VA. They need VA to work better for them. So they 
are pleased with it.
    Senator Tuberville. Do you find they are successful? Are 
they successful?
    Mr. Porter. There is a big challenge a lot of times with 
veterans trying to get into the care, but the studies that we 
have seen show that once they are actually in then they highly 
value the VA care once they get in.
    Senator Tuberville. So how do you foresee legislation such 
as S. 2924, the Vet Center Outreach Act, complementing the 
opportunity for, you know, people to use all of our resources? 
Have you looked at that one?
    Mr. Porter. I looked at both of the bills that deal with 
the vet centers. They both add to the capability of the vet 
centers and enable them to be more--be supportive of the 
community, like the one with the outreach that requires them on 
a timeline to reach out to veterans when they leave the 
service, when they transition. Those are all good. I mean, 
these reforms are good. They increase the capabilities of the 
vet centers.
    Senator Tuberville. Thank you.
    Thank you, Mr. Chairman.
    Chairman Tester. Thank you, Senator Tuberville.
    I want to thank you fellows for your testimony. I want to 
thank you for being here and representing the organizations you 
represent. Very thankful for having you folks at the table.
    And I want to thank the VA for coming in and testifying. I 
want to also thank the VA for sticking around for the second 
panel. I think that is really important, and so thank you.
    I think both panels today shared valuable insight, and we 
will use that insight as we move forward on these 18 bills.
    We will keep the record open for a week, and with that, 
this hearing is adjourned.
    [Whereupon, at 4:33 p.m., the Committee was adjourned.]



                            A P P E N D I X

                             Hearing Agenda


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    


                          Prepared Statements


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



                       Statements for the Record


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                        Questions for the Record


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
    
  

                                  [all]