[House Hearing, 118 Congress]
[From the U.S. Government Publishing Office]


                         LEGISLATIVE HEARING ON
              H.R. 3520; H.R. 1182; H.R. 1774; H.R. 2683;
              H.R. 2768; H.R. 2818; H.R. 3581; H.R. 1278;
                        H.R. 1639; AND H.R. 1815

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                        WEDNESDAY, JUNE 21, 2023

                               __________

                           Serial No. 118-22

                               __________

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


                    Available via http://govinfo.gov
                    
                               __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
53-081                  WASHINGTON : 2024                    
          
-----------------------------------------------------------------------------------     
                   
                     COMMITTEE ON VETERANS' AFFAIRS

                     MIKE BOST, Illinois, Chairman

AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking 
    American Samoa, Vice-Chairwoman      Member
JACK BERGMAN, Michigan               JULIA BROWNLEY, California
NANCY MACE, South Carolina           MIKE LEVIN, California
MATTHEW M. ROSENDALE, SR., Montana   CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa       FRANK J. MRVAN, Indiana
GREGORY F. MURPHY, North Carolina    SHEILA CHERFILUS-MCCORMICK, 
C. SCOTT FRANKLIN, Florida               Florida
DERRICK VAN ORDEN, Wisconsin         CHRISTOPHER R. DELUZIO, 
MORGAN LUTTRELL, Texas                   Pennsylvania
JUAN CISCOMANI, Arizona              MORGAN MCGARVEY, Kentucky
ELIJAH CRANE, Arizona                DELIA C. RAMIREZ, Illinois
KEITH SELF, Texas                    GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

                       Jon Clark, Staff Director
                  Matt Reel, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

               MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

AUMUA AMATA COLEMAN RADEWAGEN,       JULIA BROWNLEY, California, 
    American Samoa                       Ranking Member
JACK BERGMAN, Michigan               MIKE LEVIN, California
GREGORY F. MURPHY, North Carolina    CHRISTOPHER R. DELUZIO, 
DERRICK VAN ORDEN, Wisconsin             Pennsylvania
MORGAN LUTTRELL, Texas               GREG LANDSMAN, Ohio
JENNIFER A. KIGGANS, Virginia        NIKKI BUDZINSKI, Illinois

Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public 
hearing records of the Committee on Veterans' Affairs are also 
published in electronic form. The printed hearing record remains the 
official version. Because electronic submissions are used to prepare 
both printed and electronic versions of the hearing record, the process 
of converting between various electronic formats may introduce 
unintentional errors or omissions. Such occurrences are inherent in the 
current publication process and should diminish as the process is 
further refined.
                         C  O  N  T  E  N  T  S

                              ----------                              

                        WEDNESDAY, JUNE 21, 2023

                                                                   Page

                           OPENING STATEMENTS

The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
The Honorable Julia Brownley, Ranking Member.....................     2

                               WITNESSES
                                Panel 1

The Honorable Jenniffer Gonzalez-Colon, U.S. House of 
  Representatives, District At Large; Puerto Rico................     4

                                Panel 2

Dr. Erica Scavella, M.D., Assistant Under Secretary for Health 
  for Clinical Services, Veterans Health Administration, U.S. 
  Department of Veterans Affairs.................................     5

        Accompanied by:

    Dr. Colleen Richardson, Psy.D., Executive Director, Caregiver 
        Support Program, Veterans Health Administration, U.S. 
        Department of Veterans Affair

    Dr. Scotte Hartronft, M.D., Executive Director, Office of 
        Geriatrics and Extended Care, Veterans Health 
        Administration, U.S. Department of Veterans Affairs

    Dr. Mark Hausman, M.D., Executive Director, Integrated 
        Access, Office of Integrated Veteran Care, Veterans 
        Health Administration, U.S. Department of Veterans 
        Affairs

                                Panel 3

Mr. Jon Retzer, Assistant National Legislative Director, Disabled 
  American Veterans..............................................    14

Ms. Tiffany Ellett, Director, Veterans Affairs and Rehabilitation 
  Division, The American Legion National Headquarters............    15

Mr. Cole Lyle, Executive Director, Mission Roll Call, America's 
  Warrior Partnership............................................    17

                                APPENDIX
                    Prepared Statements Of Witnesses

Dr. Erica Scavella, M.D. Prepared Statement......................    27
Mr. Jon Retzer Prepared Statement................................    41
Ms. Tiffany Ellett Prepared Statement............................    49
Mr. Cole Lyle Prepared Statement.................................    61

                          APPENDIX--continued
                       Statements For The Record

Wounded Warrior Project..........................................    65
The Independence Fund............................................    71
Concerned Veterans for America...................................    75
American Federation of Government Employees......................    79
All Points North.................................................    81
Veterans of Foreign Wars.........................................    84
Paralyzed Veterans of America....................................    87
Argentum.........................................................    90
The Honorable Mark Alford (MO-04)................................    92
The Honorable Susie Lee (NV-03)..................................    92
The Honorable Denis McDonough....................................    94

 
                         LEGISLATIVE HEARING ON
              H.R. 3520; H.R. 1182; H.R. 1774; H.R. 2683;
              H.R. 2768; H.R. 2818; H.R. 3581; H.R. 1278;
                        H.R. 1639; AND H.R. 1815

                              ----------                              


                        WEDNESDAY, JUNE 21, 2023

             U.S. House of Representatives,
                            Subcommittee on Health,
                            Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The subcommittee met, pursuant to notice, at 10:31 a.m., in 
room 360, Cannon House Office Building, Hon. Mariannette 
Miller-Meeks [chairwoman of the subcommittee] presiding.
    Present: Representatives Miller-Meeks, Murphy, Brownley, 
Landsman, and Budzinski.

   OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

    Ms. Miller-Meeks. Good morning. This legislative hearing of 
the Subcommittee on Health will now come to order. I want to 
welcome all the members of the subcommittee and our witnesses 
for attending. Today we will be discussing 10 bills that would 
address issues impacting our veterans and that direct Veterans 
Administration (VA) to initiate fixes. These bills address 
issues raised in subcommittee oversight hearings to ensure 
veterans get timely access to substance use disorder treatment, 
and to help ease Veterans Health Administration (VHA staffing 
shortages. They also enhance peer support networks, explore a 
new long-term care option, boost suicide prevention efforts, 
and even provide flood mitigation solutions.
    I would like to take this time now to speak on my bill, 
H.R. 3520, The Veterans Care Improvement Act of 2023. For 
several years, committee staff and many of the Veterans Service 
Organizations (VSOs) with us here today have heard accounts of 
the VA's unsatisfactory compliance with Mission Act's Community 
Care Guidelines. The partnering of VA care, along with 
community assets has had a demonstrable impact on the quality 
of medical care made available to veterans across the country. 
My bill would continue to make VA healthcare system more 
accessible and accountable to those in need of its services. It 
would codify current access standards, setting a baseline 
expectation for timeliness of care. It would establish a 
defined access standard for the provision of residential 
substance use disorder treatment, recognizing that when a 
veteran decides that help is needed, time is of the essence. It 
requires VA to be more transparent with veterans when they are 
deciding their best options for care, whether in the VA or in 
the community. My bill also creates a pilot program through the 
Center for Innovation to incentivize how community providers 
interact with the VA, creating a more collaborative and value-
based approach, and yes, working to improve several aspects of 
their performance as well.
    The effective partnering of the VA care with community care 
results and more quality care overall. Veterans should have 
full transparency into their eligibility, their options for 
care, reasons for denial, and avenues for appeals. Knowledge is 
power, especially when it comes to making decisions critical to 
your health. I am grateful to our witnesses and those 
organizations that submitted statements for the record for 
their thoughtful feedback on my bill and the other bills on 
today's agenda. I look forward to learning more about each 
piece of legislation being considered today, their merits and 
their challenges, and the impact they could have on the VA 
operations, and most importantly, veterans' lives. Again, thank 
you all for being here. I now yield to Ranking Member Brownley, 
who is also sponsoring H.R. 1278, the Drive Act, for her 
opening remarks.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Chairwoman Miller-Meeks. I 
appreciate it and appreciate you for convening today's hearing. 
I look forward to our discussions of the 10 bills on today's 
agenda, including my bill, H.R. 1278, the Drive Act. This 
legislation will increase the mileage reimbursement rate for 
VA's Beneficiary Travel Program, which helps cover expenses for 
eligible veterans when they must travel to receive treatment 
for a service-connected condition. Specifically, my bill would 
make VA's rate 62.5 cents per mile, equal to the per mile 
reimbursement federal employees receive when driving personally 
owned vehicles for government business. VA's beneficiary travel 
reimbursement rate has not been increased since 2010, when it 
was set at 41 cents per mile. In the meantime, veterans' 
travels costs, including gasoline, vehicle maintenance, tolls, 
auto insurance, etc, have risen steadily.
    I am pleased that VA and many of the organizations 
testifying or submitting statements for the record for today's 
hearing support my bill, which will help ensure veterans can 
travel to receive the care they need, whether it be at a VA 
facility or in the community. I am also pleased that we are 
considering Representative Slotkin's bill, and I know she 
wanted to be here today, H.R. 1815, the Expanding Veterans 
Options for Long Term Care Act. This bill would create a 3-year 
pilot program in six different locations where VA would assess 
the effectiveness of covering assisted living. Typically, 
assisted living is a less intensive and less costly care 
setting for individuals who may otherwise end up admitted to 
nursing homes.
    Veterans' access to long term care has been a long-standing 
interest of mine, and this legislation would explore the 
feasibility and potential cost effectiveness of broadening 
options for veterans. I understand Representative Susie Lee 
will be here today to speak in support of her bill, H.R. 1639, 
the VA Zero Suicide Demonstration Project Act. I will defer to 
her to tell the subcommittee more about it, but I wanted to 
express my support.
    Turning to the other bills on today's agenda, I expect more 
robust discussions of many of the bills and almost all of them 
I am completely in support of. I do have, you know, some 
concerns over the chairwoman's bill, H.R. 3520, the Veterans 
Care Improvement Act of 2025.
    First and foremost, in terms of concerns, I am concerned 
that the bill will lead to a far greater utilization of 
community care among veterans, driving them outside of VA's 
direct care system, where they will receive more costly, less 
timely, and oftentimes lower quality of care that they would 
otherwise receive at VA medical centers. Just last week, a 
national survey published by the Centers for Medicare and 
Medicaid Services found that veterans rated VA hospitals higher 
than private sector facilities in all 10 patient satisfaction 
care categories. At the same time, research shows that access 
to care in the community, particularly in rural areas, is 
actually shrinking and patients wait times are increasing.
    I am concerned that H.R. 3520 would expand veterans' 
eligibility for community care so that there would seldom be a 
situation where a veteran would not be offered community care. 
For example, this bill would allow veterans to obtain community 
care referrals simply by expressing to the VA provider that it 
is their preference to be referred to the community for care. 
It would also bar VA from factoring in the availability of VA 
telehealth appointments when clinically appropriate, when 
making community care eligibility determinations, understanding 
that we are not doing that now, but in the event that we can 
get to a place where we can refer to telehealth appointments, I 
think is important.
    We are, of course, still awaiting a Congress Budget Office 
(CBO) score for this legislation. However, if past experience 
is any indication, H.R. 3520 would drive up VA healthcare 
spending by tens of billions of dollars. Since implementing the 
Mission Act, more than 1/3 of VA's clinical encounters are 
happening in the community. Taxpayer spending on community care 
has far outpaced increases in VA's direct care system. I am 
concerned that this simply is not sustainable in the long run.
    There is one very important area in which I hope we can 
work together to find some common ground. Under the 
chairwoman's bill, veterans needing residential substance use 
disorder treatments would become eligible for community care 
referrals when care at a VA facility is unavailable within 10 
days of the veteran's request or within a 30-minute drive time 
of the veteran's home. Our subcommittee recently held a very 
good oversight hearing on this topic, and I was compelled by 
the testimony of many of the organizations that participated. I 
do think there are opportunities to clarify and streamline 
access standards for residential substance use disorder 
treatment. However, I think we need to think through what the 
drive time requirements should be. I want to work with the 
chairwoman to address this issue and to define access standards 
that we can all agree upon moving forward.
    I hope today's hearing will provide an opportunity for a 
robust discussion of this and other bills on today's agenda. 
With that, Madam Chair, I will yield back.
    Ms. Miller-Meeks. Thank you, Representative Brownley. We 
have a full agenda today, so I will be holding everyone to 3 
minutes per bill so that we can get through them in a timely 
manner. I am honored to be joined this morning by one of our 
colleagues, and we also had colleagues who wanted to be here, 
but unfortunately have been delayed. Representative Kiggans 
wanted to speak on H.R. 3581, the Caregiver Outreach and 
Program Enhancement, or COPE Act, and Representative Lee 
sponsoring H.R. 1639, the VA Zero Suicide Demonstration Project 
Act of 2023. Their work and dedication to helping our veterans 
is very much appreciated. I would now like to recognize 
Representative Jennifer Gonzalez-Colon. You are now recognized 
for 3 minutes.

              STATEMENT OF JENNIFER GONZALEZ-COLON

    Ms. Gonzalez-Colon. Thank you, Madam Chair. I am so happy 
to be back in this committee room. I was a part of this 
committee back when I was first elected to the House of 
Representatives in the 115th Congress. Chairwoman Miller-Meeks 
and Ranking Member Brownley, happy to be here with you. Thank 
you for the opportunity to testify on my bill, H.R. 1182, the 
Veterans Serving Veterans Act of 2023, and for including it in 
today's legislative hearing.
    Maintaining adequate staff levels is essential to the 
quality of services our veterans seek and deserve when in need 
to care from the Department of Veterans Affairs. We have a 
single medical center and a network of clinics serving our 
veterans communities residing in Puerto Rico and in the U.S. 
Virgin Islands. Each of these facilities is important, just as 
the staff who go to work every day and provide direct service 
to the veterans. Yet, like the rest of the country, we see the 
challenges with hiring and retaining our VA staff.
    H.R. 1182 seeks to support staffing levels at the VA by 
increasing the visibility of current vacancies and fostering 
the recruitment of former members of the military to fill these 
positions. The bill will authorize a single searchable data 
base for recruitment within the VA. The platform will include 
the military occupational specialty or skill that corresponds 
to a vacant position, as well as each qualified member of the 
armed services who elects to be listed in the data base and may 
be recruited to fill the position prior to being discharged and 
released from active duty. The Secretary may exercise expedited 
hiring as well as authorize a relocation bonus to a member of 
the armed services who has accepted a position and requires 
this assistance. Last, this bill will establish the 
Intermediate Care Technician Training Program to train and 
certify veterans who serve as basic health care technician 
while in the armed forces to work as an intermediate care 
technician in the VA.
    I trust this bill could facilitate greater collaboration 
between the Department of Defense and the VA and will allow for 
veterans to use their skills and training to serve and work 
with other veterans. This is not the first time this bill has 
been considered. During the 115th Congress, it was passed 
unanimously by the committee as well as the House of 
Representatives. I look forward to receiving any feedback and 
welcome any suggestions from today's panel on ways that we can 
move forward with this legislation. Thank you and I yield back.
    Ms. Miller-Meeks. Thank you, Representative Gonzalez-Colon 
for speaking and sponsoring H.R. 1182. As is our practice, we 
will forego a round of questioning for the members. You are now 
excused.
    I will now invite our second panel to the table. Thank you 
very much. Joining us today from the Department of Veterans 
Affairs is Dr. Erica Scavella, who is the Assistant 
Undersecretary for Health and Clinical Services in the Veterans 
Health Administration. Accompanying Dr. Scavella today are Dr. 
Colleen Richardson, Executive Director of the Caregiver Support 
Program, Dr. Scotte Hartronft, excuse me, Executive Director of 
the Office of Geriatrics and Extended Care, and Dr. Mark 
Hausman, Executive Director for Integrated Access in the 
Integrated Veterans Care Office. Dr. Scavella, you are now 
recognized for 5 minutes to present the Department's testimony.

                  STATEMENT OF ERICA SCAVELLA

    Ms. Scavella. Thank you. Good morning, Chairwoman Miller-
Meeks, Ranking Member Brownley, and members of the 
subcommittee. VA apologizes for its written testimony being 
submitted late. Thank you for the opportunity to discuss the 
Department of Veterans Affairs views on pending legislation 
regarding veterans' health care benefits. I am accompanied 
today by Dr. Colleen Richardson, the Executive Director, 
Caregiver Support program, Dr. Scotte Hartronft, the Executive 
Director of the Office of Geriatrics and Extended Care, and Dr. 
Mark Hausman, Executive Director, Integrated Access.
    My opening remarks will focus on three bills. My written 
statement provides more detailed information on the stated 
bills on today's agenda. The first bill, H.R. 1815, Expanding 
Veterans Options for Long Term Care Act, would require a VA 
beginning not later than 1 year after the date of enactment to 
carry out a 3-year pilot program to assess the effectiveness of 
providing assisted living services to eligible veterans and 
their satisfaction with the pilot program. VA could extend the 
duration of this pilot program for an additional 3 years if VA 
determined it appropriate to do so based on the results of the 
pilot, which will be provided through annual reports to 
Congress and reviewed by the Office of Inspector General.
    With amendments, VA supports this bill subject to the 
availability of appropriations. VA appreciates that the current 
version of this bill has addressed several technical concerns 
identified with similar legislation that has been proposed 
during the prior Congress. VA generally agrees that specific 
authority to furnish assisted living services, particularly 
through a pilot program to assess effectiveness and veteran 
satisfaction, would be a helpful addition to VA's options 
providing long term care services to help veterans and their 
families. It will provide VA with increased options to 
appropriately serve veterans and their family members in the 
appropriate care setting for their specific needs.
    VA supports the protections this bill would include to 
ensure that veterans are receiving appropriate care for their 
needs. While VA appreciates and fully supports the intent of 
this bill, there are recommended amendments that have been 
described in my full written statement.
    I would direct the committee to my written statement 
regarding H.R. 3520, Veteran Care Improvement Act of 2023. VA 
is generally opposed to codification of access standards as it 
removes the ability of the Secretary to develop and publish 
such standards that provide veterans with options to access the 
right care at the right time based on their clinical needs. VA 
cannot support codification of residential treatment and 
rehabilitative services as proposed in this bill. While we 
generally support the establishing of a wait time standard of 
10 or fewer days for the delivery of care, we have significant 
concerns with the 30-minute drive time standard for residential 
treatment program. At this time, it is inconsistent with 
industry standards and the accessible care that is available 
and could result in significantly greater financial costs to VA 
without any guarantee that veterans will receive care that is 
closer to home.
    VA does not support specifically, Section 2 of H.R. 3581 
Caregiver Outreach and Program Enhancement Act, or the COPE 
Act, which would authorize VA to award grants to carry out, 
coordinate, improve, and otherwise enhance mental health 
counseling, treatment, and support to the family caregivers of 
veterans participating in the Program of Comprehensive 
Assistance for Family Caregivers, or PCAFC. VA acknowledges and 
is grateful for the incredible work and sacrifices of family 
caregivers and the sacrifices that they make to take care of 
their loved ones. We have recently begun using regional 
clinical resource hubs, which are staffed by VA specialists 
that can provide direct mental health care to family caregivers 
using telehealth, which is an option for mental health support 
desired by the majority of the PCAFC caregiver respondents in 
previous surveys.
    We believe these efforts will best address the intended 
goal of this section, and we agree that support is needed. As 
utilization of these services through VHA clinical resource 
hubs increases, VA will continue to assess and identify 
opportunities to resource and improve supportive services and 
meet the needs of our family caregivers for veterans. This 
section of the bill, as written, will require significant 
complexities and create significant complexities to administer 
and manage these grants as it is currently written.
    This concludes my statement. We appreciate the committee's 
continued support of the programs that serve the Nation's 
veterans and look forward to working together to further 
enhance the delivery of benefits and services to veterans and 
their families.

    [The Prepared Statement Of Erica Scavella Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you for your testimony, Dr. 
Scavella. I now yield myself 5 minutes. Dr. Scavella, yes or 
no, are veterans ever required to utilize community care should 
that care or service be available at a facility when distance 
or time across standards are not met?
    Ms. Scavella. Thank you for the question, Chairwoman 
Miller-Meeks. Veterans are always given the choice of the care 
that they receive, and they have the opportunity to determine 
with informed decisions whether that care is received within 
the VA system or within the community. There is no requirement 
that they go to the community, just as if we can provide the 
care within VA, we would hope that they would choose to take 
whatever type of care is best for them, whether it is in our 
system or in the community.
    Ms. Miller-Meeks. I am just going to emphasize that. Should 
community care be available, it is not required even under this 
bill, it would not be required for a veteran, even if they met 
the requirements for community care, to obtain community care.
    Ms. Scavella. Correct.
    Ms. Miller-Meeks. Codified access standards would only 
maintain what is currently available as a veteran's option, not 
changing the requirements.
    Ms. Scavella. Our concerns with codifying this particular 
piece of this legislation, we have concerns that in instances 
in rural America, it still may not allow them to receive care 
sooner. That is our concern with relations to particular issue.
    Ms. Miller-Meeks. Well, certainly if there is not care even 
in rural America, since I live in rural America, then a veteran 
would not, you know, preferentially go there for care if there 
is not care available, whether it is codified or not. Yes or 
no, codifying access standards would make that determination 
one aspect of eligibility more transparent--by codifying, would 
it make it more transparent for veterans?
    Ms. Scavella. I think that is a complicated answer, 
Chairwoman Miller-Meeks. I do not think it is a universal yes 
or no answer.
    Ms. Miller-Meeks. Okay. I will accept that. I think that 
that is probably a reflection of reality. Would we in general 
agree that more transparency for veterans for their options 
would be desirable?
    Ms. Scavella. Yes, I will agree that more transparency is 
desired and desirable.
    Ms. Miller-Meeks. Thank you. Dr. Scavella, as several 
witnesses pointedly testified during our substance use disorder 
treatment oversight hearing, VA's determination that inpatient 
residential rehabilitation programs do not fall under the 
mission standards has resulted in delays and significant impact 
in providing access to veterans desperately seeking care. Some 
of the stories we heard were, in fact, heart wrenching, and we 
also know members of our committee have also experienced delays 
through getting care at the VA. In your testimony, you state 
that the VA generally supports establishing a wait time 
standard of 10 or fewer days, but not codifying. Can you 
explain that, please?
    Ms. Scavella. Yes, thank you for the question, Chairwoman 
Miller-Meeks. We obviously understand that when our veterans 
need to come in for a residential treatment program, we want to 
make sure that they have access. We are looking at those, at 
our current ability to meet the needs of our veterans, looking 
at trends from our veterans across this Nation to ensure that 
we understand what are the bottlenecks, what is slowing it 
down. We do have a platform of different forms of care that we 
can provide to include telehealth. In highly rural areas where 
there is not broadband access, telephone care is still possible 
as well.
    We are looking at all of those things, but we do not want 
to lose the flexibilities in identifying how we provide this 
care to our veterans, realizing that we are committed to the 
same goal with getting them in as soon as possible for the care 
they need.
    Ms. Miller-Meeks. As you have already stated, they are not 
required to receive care even in the community. I think for me, 
the standard is veterans getting care when they need it 
especially when it comes to mental health and substance use 
disorder treatment.
    Dr. Scavella, your testimony indicates--I am going to ask 
you about H.R. 1182 in the short time I have left, Veterans 
Serving Veterans Act of 2023. Your testimony indicates that the 
VA already has a transitioning service member data base in use. 
Is that data base fully searchable? If so, how do veterans and 
potential VA employees access this data base?
    Ms. Scavella. Thank you very much for that question, 
Chairwoman Miller-Meeks. We do have a number of resources. The 
one I believe you were referring to that is in my written 
testimony is the Veterans Administration/Department of Defense 
(VA/DoD) Identity Repository, which does allow us to all, 100 
percent of all service members, enter their information into 
that platform. We are able to use that information to search 
and to match people for employment.
    We also have social media outreach, as well as the VA 
careers at VA.gov website to invite our service members to put 
their information there, as well as many other platforms. We do 
have a robust and diverse set of recruitment tools, and we are 
using those. The one that is 100 percent utilized is the VA/DoD 
Identity Repository.
    Ms. Miller-Meeks. I apologize, since my time is finished, 
if you could in writing, submit to the subcommittee how 
veterans can access and the options that you just mentioned for 
VA employees and service members to access the data base, that 
would be appreciated. Thank you.
    I now recognize Ranking Member Brownley for any questions 
she might. Thank you. Ranking Member Brownley, you now have 5 
minutes.
    Ms. Brownley. Thank you, Madam Chair. As I said in my 
opening comments, I really do believe that we need to figure 
out what are the right standards for residential treatment. 
That piece of the bill after our hearing, I think is really 
important. I am wondering from the VA perspective, what you 
think the drive time should be for, you know, for using 
community care for residential treatment. You have stated that 
a 30-minute drive time is not really appropriate, but what do 
you think is appropriate?
    Ms. Scavella. Thank you. I will turn that question over to 
my colleague, Dr. Hausman for a response.
    Mr. Hausman. Thank you Ranking Member Brownley for the 
question. Our experience is that residential treatment 
facilities are just not available in every community. In fact, 
veterans that have accessed these services in the community, 
drive on average about 190 miles to do so. We do not have an 
exact suggestion for drive time standard, but we think 30 
minutes is far too short just given the reality of that these 
facilities are not located in every community. In fact, not in 
most communities.
    Ms. Brownley. Have you looked at, you know, commercial 
Insurers, TRICARE, or Medicaid plans to see if they have 
geographic network adequacy standards for this residential 
treatment care?
    Mr. Hausman. I will have to take that as a follow-up for 
the record. I expect that that work has been done through our 
external networks team within Integrated Veteran Care (IVC), 
and I will follow up with them and get that back.
    Ms. Brownley. Is that something that you would look at in 
terms of making recommendations for what the drive time would 
be?
    Mr. Hausman. Absolutely.
    Ms. Brownley. Okay. You know, I do not want to pick on this 
bill because I really do believe the residential treatment 
piece is important. As I said in my opening comments, I agree 
with some of the VA's concerns with regards to access 
standards. I really believe that the trajectory on cost and 
community care is going in, you know, an absolute upward 
direction. You know, I think if we just open up the access 
standards for anybody to just say this is what I want is to go 
to community care, that that trajectory is only going to 
increase and probably increase pretty substantially. I know I 
mentioned that the CBO has not scored it, but based on our 
experiences, do you have any sense of what the cost might be?
    Mr. Hausman. We do not have a cost estimate worked out yet, 
but as was informed in the testimony, approximately 38 percent 
of VA care is now purchased in the community. That trend has 
been increasing significantly in recent years and at 
significant cost. We will take a specific cost estimate for 
this as a follow-up for the record, please.
    Ms. Brownley. To what extent is VA currently able to inform 
veterans of their expected wait times for community care at the 
time they are deciding whether to opt for VA or community care?
    Mr. Hausman. Thank you for the question. I would say that 
is an important limitation that we have at present. Generally 
speaking, we are able to process a request for care, a 
referral, by first making sure that that request is clinically 
appropriate. From there, we determine veterans' eligibility for 
community care. Often they are asked to make a decision about 
whether they want to stay within VA or go to the community 
without being told the community wait time, what to expect, or 
where the community provider is located. That information is 
generally subsequently communicated at the point of community 
care scheduling. I think it is a limitation right now that we 
are working to resolve, but we are asking veterans to make a 
decision on where to get their care with incomplete information 
a lot of the time at present.
    Ms. Brownley. Thank you. I yield back, Mr. Chairman.
    Mr. Murphy. I practice at a medical center where literally 
there is a VA center not a mile away. They do not have 
admitting privileges at our institution, so I will tell you it 
is in very close proximity. One in seven of my constituents are 
veterans, so it is a big deal for us in eastern North Carolina. 
Thank you again, all for coming.
    I have been made more aware really of the number of 
increasing incidences where VA has not been in compliance with 
the Mission Act requirements and not made aware of their 
eligibility for community care. I am an original cosponsor of 
Dr. Miller-Meek's bill and I believe this will correct and 
codify the current community care access standards.
    I would like to dive down on this because when I was in 
private practice, we had an increasing issue with community 
care. As I said, there are a lot of veterans in my community 
and we were always happy to see them. However, we were always 
happy to see them, but we were always not happy to never be 
paid by the VA. I would like to get to dive down on that in the 
few minutes I have because in our community we have a lot of 
talented surgeons. For our guys, I live in a medical center 
which is halfway between Raleigh in Durham, where our other 
main medical center is, hospital, where most folks get 
referred. I am halfway between Durham and the coast. We have 
veterans that come 2 hours north, 2 hours south, and sometimes 
5 hours east, just to come to Greenville, where I am, much less 
go on another 2 hours, 2-1/2 hours to Durham. Being admitted to 
Durham from 5, 6, 7, 8 hours away is just not a good thing for 
our veterans.
    I would like to find out a little bit more about what your 
percentages for actually paying providers who deliver the care 
and what your backlog is. I will tell you guys, I hear from 
many folks who are trying to run practices, they want to see 
veterans patients, but you cannot see them for free. I would 
like to know about the process we have of actually paying our 
providers. Who can best speak to that?
    Mr. Hausman. Thank you for the question, sir. I can answer 
that one. You are absolutely right. This is a very critical 
issue, and if we do not get this right, veterans are often 
stuck with bills.
    Mr. Murphy. Caught in the middle.
    Mr. Hausman. Yes, caught in the middle of getting bills in 
the mail, which could be very stressful and have an impact to 
their health. We appreciate the importance of this. The data 
you are asking for is gettable, and I will take that as a 
follow-up for the record. I will say directionally, this is 
something we have been following very closely and we are doing 
better. We are not waiting for----
    Mr. Murphy. What does doing better mean? I am sorry, I am a 
surgeon, I am kind of dumb.
    Mr. Hausman. No, I will need to get that for you, sir. I 
know we are in--and I do not want to give you incorrect 
information, so I will take that as an action for the record, 
if you would permit me but----
    Mr. Murphy. Permit me, but you should have that on the top 
of your head because that is an exceedingly important statistic 
for caring for our veterans.
    Mr. Hausman. Yes, absolutely, completely agree. I want to 
say we are in the high 90 percent range. I will get you the 
specific information.
    Mr. Murphy. I want to know this, I want to know, one, are 
claims being paid? Two, how many denials, how many claims? In 
other words, how many times do I have to have somebody in my 
practice call back, go back, go back to the VA. It is worse 
sometimes than banish to say some of the insurance companies 
that love to deny, deny, deny.
    You know, our purpose in providing care to veterans is to 
provide care to those who have sacrificed for our country and 
for us not to be able to do that, you have to pay staff, you 
have to pay the light bill, you have to pay the other things. 
At some point, it gets to be where we give out charity care 
every day. It cannot be charity care to our veterans. They do 
not want charity. They deserve to have their providers cared 
for so that they can do this.
    This is a major item, and I would submit 90 percent is not 
near close from what I hear from our practice manager and from 
other practice managers in this vicinity. That is my main item. 
I am not going to beat on anything else. This is a big deal. We 
need to get the people who care for our veterans outside of the 
VA paid, period. Thank you. I will recognize Ms. Budzinski for 
5 minutes.
    Ms. Budzinski. Thank you, Mr. Chairman, and thank you, 
Ranking Member Brownley. Thank you to the panelists for being 
here. My first question, Dr. Scavella, regarding H.R. 3520, the 
Veterans Health Care Improvement Act, can you elaborate a 
little bit more on the VA's opposition to this provision in the 
bill, Section 2, specifically, that would bar the VA from 
factoring in the availability of telehealth appointments when 
making community care eligibility determinations.
    Ms. Scavella. Thank you for that question. I will also 
refer that to Dr. Hausman.
    Ms. Budzinski. Okay.
    Mr. Hausman. Thank you for the question, ma'am. VA is proud 
of where we have come with telehealth. Last year, we did over 9 
million appointments. We have between an 88 and 90 percent 
trust and satisfaction rate with veterans for telehealth 
appointments. Telehealth has become an important modality for 
healthcare delivery.
    As the secretary mentioned back last fall in September, VA 
is looking at the possibility of incorporating available 
clinically appropriate telehealth appointments into access 
standards. The way we would do this would be through a 
rulemaking process, which would, of course, allow for 
visibility and time for public comment. An additional important 
point as we think about telehealth and veterans is we want to 
preserve a veteran's ability to choose their modality of care. 
In other words, if a veteran is not comfortable with 
telehealth, does not want telehealth, we do not want to force 
that modality. That is another component to how we are thinking 
about this.
    Ms. Budzinski. Thank you for that. I just wanted to 
elaborate on the district that I represent. I, too, come from a 
more rural part of the country. I represent central and 
southern Illinois. I have heard concerns around accessing care 
for too many veterans often have to travel long distances to 
access essential health care. I certainly understand the need 
to get our veterans care as soon as possible, including using 
community care when necessary.
    I am concerned that this provision in H.R. 3520 would 
prevent our rural veterans from having that telehealth option 
that you just spoke about. According to the American Hospital 
Association report, there were over 130 rural hospital closures 
between 2010 and 2021, and the Pandemic has left hundreds of 
other healthcare facilities throughout the country at risk of 
closure. I support community care when needed, but I am worried 
potential closures of these hospitals and facilities may end up 
leading veterans to having to wait just as long or have to 
travel just as far to get to community care. Taking away 
telehealth health options may only really exacerbate that 
issue. That is my real core concern with this.
    If I might follow up with you, Dr. Hausman, on another 
question. Do you believe this provision would hurt our rural 
veterans and or similarly severely limit the access to 
telehealth services and health care just in general?
    Mr. Hausman. Thank you for the question. I will say that we 
want to do everything we can to bring options to veterans, 
including telehealth, which, as I mentioned, is becoming an 
important, an increasingly important modality for care. As we 
are seeing ongoing pressure on rural markets and the loss of 
providers and potentially the loss of hospitals, we do believe 
that telehealth becomes that much more important as a way to 
fill that gap. Anything that would limit our ability to offer 
options to veterans, including telehealth, we would not be in 
favor of.
    Ms. Budzinski. Do you see this provision, though, as being 
something that would do potentially that?
    Mr. Hausman. I think it is a complicated question. I think, 
you know, with this provision in place, ideally, we would still 
offer the VA telehealth option along with the community option. 
I think in practice, in reality, once we determine a veteran is 
community care eligible, oftentimes we schedule in the 
community without taking a hard look at what VA resources are 
available. Now, that is a process that is on us to fix, and we 
are working on it, but I think that is the challenge there.
    Ms. Budzinski. Okay, thank you. I yield back my time.
    Ms. Miller-Meeks. Thank you, Representative Budzinski. The 
chair now recognizes Mr. Landsman for 5 minutes.
    Mr. Landsman. Thank you, Madam Chair. Thank you all for 
being here and the work that you all do on behalf of veterans. 
The concern I have with the bill has to do with diverting 
resources from best practice care that we know veterans get 
from the VA. I am from Cincinnati, southwest Ohio. We have a 
phenomenal facility in Cincinnati. We know that the care is top 
notch. We do not have standards for these community options, so 
we do not know. It is questionable what kind of care our 
veterans are going to get. It is not questionable what kind of 
care they are going to get from the VA.
    The idea that we would divert resources is challenging. 
Obviously, if this had been done in a bipartisan way, which I 
think most things ought to be done, if not everything should be 
done in a bipartisan way, because I think we could have gotten 
and maybe we will ultimately get to a better place in terms of 
ensuring that people have options but they are the highest 
standards, that we are not undermining VA benefits resources 
care.
    You have cited concerns that the VA will no longer be the 
go-to caregiver for many veterans if this were to pass. In your 
view, what do you think that looks like? Why is it so important 
to keep care within the VA?
    Mr. Hausman. Thank you, sir, for that question. I do 
appreciate the statements you made about the quality of care 
that is provided within VA. We are very proud of that. We are 
very proud of our recent Hospital Consumer Assessment of 
Healthcare Providers and Systems (HCAHPS) results with better 
veteran satisfaction across 10 categories compared to the 
community, as well as numerous studies that have come out over 
the last 5 or so years that have shown VA is as good as and 
often better than the community care alternative.
    You know, there are also challenges with community care. We 
had a hearing I think it was a couple of weeks ago, where 
challenges with care coordination have been discussed. You 
know, these are things, again, on us to fix. As things stand 
today, that is the reality. We do not get 100 percent of 
medical information back. We need to fix that. That results in 
challenges with care coordination. We know sometimes when 
veterans get their care in the community, it is likely not as 
high quality. Certainly, veteran centered care is what we can 
provide. We are passionate about providing health care to 
veterans. That is why we do what we do. That is what motivates 
us. It is really inspiring to see that, you know, we are doing 
a great job with veteran perception with our hospitals, as well 
as the quality that has been proven out in several studies.
    Mr. Landsman. Thank you. In your opinion, what would be, I 
mean, because there is an argument, right, that oftentimes in 
certain places, or just based on what a veteran may need, that 
a community provider may be closer, better positioned to 
provide that support. I do not want it to be too leading, but 
my sense is that if there were the same level of standards and 
that there were certain pieces of the agreement, that it could 
be, in fact, beneficial, but there would have to be real 
structure to those partnerships. Do you have an opinion about 
that or what that could look like?
    Mr. Hausman. Yes, sir. Completely agree with that 
assessment. I will share that as those items are being worked 
on, as we are looking at our next generation for our community 
care network, you know, specifically, how do we measure 
quality? How do we then communicate which providers are of 
highest quality to veterans that are community care eligible? 
How do we better facilitate the bidirectional exchange of 
medical information, thereby enhancing care coordination and 
clinical outcomes? All of these are very much in front of us 
and are being actively worked on as we are thinking about the 
next contract for our community care network.
    Mr. Landsman. Thank you so much, and I yield back.
    Ms. Miller-Meeks. Thank you very much, Representative 
Landsman. No one has challenged the quality of care provided at 
the VA, but you can have the best quality of care, but if you 
cannot access it and you commit suicide, you have had no care 
at all. I thank all of our witnesses for giving testimony and 
joining us today on behalf of the subcommittee. Thank you so 
much. You are now excused. We will wait a moment as the third 
panel comes to the witness table. Thank you.
    Welcome everyone and thank you for your participation 
today. On our third panel, we have Mr. John Retzer, Assistant 
National Legislative Director for Disabled American Veterans, 
Ms. Tiffany Ellett, Director, Veterans Affair and 
Rehabilitation Division for the American Legion, and Mr. Cole 
Lyle, Executive Director of Mission Roll Call, a program of 
America's Warrior Partnership. Mr. Retzer, you are now 
recognized for 5 minutes.

                    STATEMENT OF JON RETZER

    Mr. Retzer. Chairwoman Miller-Meeks, Ranking Member 
Brownley, and members of the subcommittee, thank you for 
inviting Disabled American Veterans (DAV) to testify at this 
legislative hearing. I will focus my remarks on the bills under 
consideration today that most affect service-disabled veterans. 
DAV supports H.R. 1182, the Veterans Serving Veterans Act, 
which would require the VA to maintain a data base of vacant 
positions with corresponding military, occupational 
specialties, or skills to recruit qualified members to fill the 
position prior to discharge. VA must aggressively look at all 
means to successfully recruit highly trained, dedicated 
professionals to ensure and deliver sustainable, high-quality 
healthcare.
    We support H.R. 1278, the Drive Act, which would require 
the VA to ensure beneficiary travel reimbursement rate is at 
least equal to the General Services Administration (GSA) 
reimbursement rate of federal employees. This will ensure VA's 
travel reimbursement rates keeps up with the cost of inflation 
and properly accounts for fluctuations in gas prices. Veterans 
should not have to choose between getting care they earned and 
deserve and the rising cost of travel to access their needed 
care.
    Seventeen veterans take their own lives every day, twice 
the rate of nonveteran peers. We must work collectively until 
we get the number down to zero. Losing one service member or 
veteran to suicide is one too many. DAV supports H.R. 1639, the 
VA Zero Suicide Demonstration Project Act. This bipartisan 
legislation would bolster clinical training and resources to 
test the effectiveness of the pilot program and improve the 
quality of the mental healthcare services that our hero 
veterans deserve.
    We support H.R. 1774, the VA Emergency Transportation Act, 
which would provide veterans reimbursement for the cost of 
emergency medical transportation regardless of provider or 
medical facilities.
    DAV supports H.R. 1815, the Expanding Veterans' Option for 
Long Term Care, which would require the VA to carry out a 
program to determine the effectiveness of providing assisted 
living services to eligible veterans who are currently 
receiving nursing home care through the Department to meet the 
increasing demand of long-term care.
    We support H.R. 2768, the Private First Class Joseph P. 
Dwyer Peer Support Program, which would require the VA to 
establish an advisory committee to create standards for grant 
recipients to carry out a program to hire veterans to serve as 
peer specialists to provide veterans nonclinical mental health 
support. Peer specialists would provide unique support to 
veterans by sharing their personal experiences to navigate 
veterans' recovery journey.
    Home improvements and structural alterations rates have not 
changed since Congress last adjusted them in 2010. However, the 
cost of home modifications and labor have risen over 40 
percent. DAV supports H.R. 2818, the Autonomy for Disabled 
Veterans Act. This bipartisan legislation would increase amount 
of funding for VA grants for disabled veterans to make 
necessary modifications to their homes to fit their needs and 
would adjust amount to account for inflation.
    We support H.R. 3581, the COPE Act, which would authorize 
the VA to provide grants to organizations that focus on 
increasing mental healthcare services and resources for 
caregivers. Finally, H.R. 3520, the Veterans Care Improvement 
Act. While DAV strongly supported the Mission Act and creation 
of the Veterans Community Care Program, we have questions and 
concerns about some sections of this legislation. We certainly 
agree that whenever and wherever VA is unable to provide 
timely, accessible, high-quality care to enrolled veterans, VA 
must provide other care treatment options. We believe it is 
critical to strengthen and sustain the VA healthcare system 
that millions of veterans choose and rely on for all or most of 
their healthcare. As studies continue to show, the care 
provided by VA is equal to or better than private care sector 
on average.
    While we support the intention of improving the VA 
community care program, we believe it is essential that VA 
remain the primary provider and coordinator for veterans' 
medical care. Therefore, we ask the subcommittee to consider 
the concerns we outlined in our written statement and that we 
would be pleased to work with you to address them.
    Chairwoman Miller-Meeks this concludes my statement, and I 
am happy to address questions you or members of the 
subcommittee may have.

    [The Prepared Statement Of Jon Retzer Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Mr. Retzer. Ms. Ellett, you 
are now recognized for 5 minutes.

                  STATEMENT OF TIFFANY ELLETT

    Ms. Ellett. Thank you. In April 2020, my friend Greg, a 
government employee on the verge of retiring, died by suicide 
via firearm. Exactly one year later, my friend Carl, a retired 
army veteran--excuse me--and county sheriff suffering from 
Post-Traumatic Stress Disorder (PTSD), died by means of self 
medication. Five months later, a boy like a second son to me 
named Cole, a 21-year-old college senior and son of a Marine 
veteran, died by suicide via firearm. This past February, my 
friend Bruce, an army veteran who served in a special unit in 
Panama, died by suicide via hanging.
    Mental health and suicide does not just affect one 
community in one way. This is a complex problem that needs a 
multifaceted solution. We, as a society need to do better. 
Chairwoman Miller-Meeks, Ranking Member Brownley, and 
distinguished members of the subcommittee, on behalf of our 
national commander, Vincent J. ``Jim'' Troiola, and our more 
than 1.6 million dues paying members, we thank you for inviting 
the American Legion to testify today.
    According to the Substance Abuse and Mental Health Services 
Administration, in 2021, an estimated 12.3 million adults in 
the U.S. seriously considered suicide, 3.5 million planned an 
attempt, and 1.7 million attempted. Veterans Health 
Administration is the largest integrated healthcare network in 
the United States. If any organization has the ability to pull 
together the means to create a multifaceted solution to the 
mental health epidemic plaguing the United States and its 
veterans' population its VA.
    In 2021, the American Legion started its Be the One 
movement to destigmatize and encourage the discussion of mental 
health, suicide, and seeking help. This movement, in 
combination with our Buddy Check program, created in 2019 and 
adopted by VA through 2023 legislation, are examples of the 
American Legion's constant, vigorous support of peer-to-peer 
solutions for veterans' mental health complexities. The 
American Legion strongly supports the VA Zero Suicide 
Initiative pilot and the PFC Joseph P. Dwyer Peer Support 
Programs.
    Mental health struggles or feelings of isolation can be 
exacerbated during transition from service through a veteran's 
perceived loss of identity or mission. One of the solutions for 
this empty space is to immediately provide a mission to the 
veteran. This is just one of the reasons we support the 
Veterans Serving Veterans Act of 2023, which assists in 
building a direct path for exiting service members to feed into 
the VA recruitment pool. Another reason we support this act is 
the direction to train and certify corpsmen or medics to become 
intermediate care technicians, ICTs, augmenting the VA medical 
workforce.
    That being said, we would like to see the Department of 
Homeland Security added in this legislation so that Coast Guard 
health services technicians may be included in the recruitment 
data base. We think the VA ICT program is one that with 
increased use, could not only assist in amplifying personnel 
for our veterans, but could also provide much needed transition 
assistance to those exiting the service by giving them a 
mission to move directly into.
    Separately, I would like to address legislation being 
considered to expand care for our veterans through improving 
long term care, home services, and living conditions, and 
community care. The American Legion believes that veterans and 
their families are best served when their long-term care needs 
are promptly met, while also honoring self-autonomy and giving 
them the choice to remain within their local communities. We 
support the introduced legislation that not only calls for an 
increase in funding to support housing improvements for 
disabled veterans so that they may retain self autonomy in the 
comfort of their own home, but also that which calls for 
codifying community care access standards to ensure veterans 
will receive timely, quality healthcare.
    A final note to mention, the importance of our caregivers 
and their mental health. Often the caregivers of veterans, be 
they spouses, siblings, or even children, carry a burden that 
many of us do not see. They do such a good job of holding up 
the veteran that no one sees the cracks in the foundation. As a 
disabled veteran, the spouse of a disabled veteran, and an 
advocate for our veterans and their families, I have witnessed 
the demons that lay in wait in the dark for each of us. The 
American Legion calls on Congress to pass legislation such as 
those discussed today to assist in involving care and support 
for our Nation's veterans and their families.
    I conclude by thanking Chairwoman Miller-Meeks, Ranking 
Member Brownley, and this subcommittee for your incredible 
leadership and for always putting veterans at the forefront of 
your mission. It is my privilege to represent the American 
Legion before the subcommittee today, and I look forward to 
answering any questions you may have.

    [The Prepared Statement Of Tiffany Ellett Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Ms. Ellett, and on behalf of 
the subcommittee, we are sorry for the loss of your fellow 
service members and friends. Mr. Lyle, you are now recognized 
for 5 minutes.

                     STATEMENT OF COLE LYLE

    Mr. Lyle. Thank you. Chairwoman Miller-Meeks, Ranking 
Member Brownley, and members of the subcommittee, on behalf of 
Mission Royal Call and the roughly 1.4 million veterans and 
supporters in our digital advocacy network, thank you for the 
opportunity to provide their feedback through our remarks on 
pending legislation. While all the proposed bills are worthy of 
discussion and will have impacts on the veteran community, I 
will focus the bulk of my time on the Chairwoman's bill, H.R. 
3520.
    Mission Roll Call strongly supports this legislation as a 
necessity to ensure veterans receive timely access to quality 
care. The Mission Act of 2018 streamlined a congealed process 
that existed via the Choice Act, and Congress's intent with 
Mission was clear, the VA must increase access to private 
doctors when the VHA cannot provide care in a reasonable time, 
distance, or if it was in the best medical interest of the 
veteran.
    In 2021, reports surfaced that VA administrators were 
overruling decisions by VA doctors and patients to keep 
veterans in the system, in some cases cutting off care 
entirely. The article simply confirmed what many VSOs providing 
care coordination and casework already knew that to protect 
VA's parochial interest in some areas of the country, it was 
unnecessarily difficult for veterans to access care in the 
community when it was in their best medical interest. In 2022, 
4 years after Mission was passed, Secretary McDonough testified 
community care now accounts for 1/3 of VA's healthcare budget. 
As a result, the Secretary said the VA would look at changing 
access standards and use telehealth availability to determine 
wait times.
    Using the broad capabilities, we have available, Mission 
Roll Call conducted a poll question on the issue. With over 
6,300 veteran responses across America, 81 percent said 
Congress should codify the access standards. Further, Mission 
Roll Call asked questions on the more general veteran 
experience accessing community care. With an average of 6,200 
responses across seven unique polls, 60 percent of veterans 
said their providers do not make them aware of this option 
after a delay in care. Thirty-seven percent said they had 
experienced a delay or postponement of any healthcare 
appointment at a VA facility. Seventy-one percent said they 
were not referred to the community after a delay in mental 
health or other specialty care at a VA facility. Twenty-two 
percent experienced problems scheduling the care once referred. 
Fourteen percent said their providers referred them to the 
community, but the referral was later denied by the VA upon 
review. Last, 21 percent said their providers scheduled them a 
telehealth visit to access care when they preferred in-person 
visits.
    This clearly indicates an issue simmering beneath the 
surface, but the problem can be found in more than just 
statistics. During Mission Roll Call's geographically diverse 
fact-finding tour last year, meeting with over 5,000 veterans 
individually in California, Texas, Florida, Alaska, Arizona, 
Idaho, Montana and elsewhere, these problems were borne out in 
personal testimonies of countless veterans. While those with 
good experiences at VA mitigated their healthcare issues and 
went on living their lives productively, those with negative 
experiences accessing healthcare in VA or being referred to the 
community, either gave up trying or were not shy telling other 
veterans to stay away from VA. The issues ranged from primary 
care appointments for things like allergies to significant 
mental health issues. A few stark responses from veterans said 
they had peers whose mental health spiralled after being 
frustratingly unable to access mental health care.
    To the best of my knowledge, none of these examples ended 
in suicide. With less than 50 percent of the U.S. Census 
Bureau's estimated 17.4 million veterans in America enrolled in 
VA and even less using it on a regular basis, making it harder 
to access healthcare when needed is counterproductive to the 
VA's interest, regardless of where the care takes place.
    As the VA is the largest healthcare system in the country 
and the second largest Federal agency behind DoD, it is 
understandable why officials sometimes make big decisions with 
respect to workforce recruitment and retention. However, 
Congress must ensure the Agency keeps the veteran, not Agency 
interests, as their North Star and not defer or be unduly 
influenced by workforce considerations when those decisions 
could negatively impact the individual veteran's ability to 
seek healthcare. After all, the VA's core mission is to care 
for those who have borne the battle.
    Mission Roll Call has also supported a similar bill in the 
Senate, the Veterans Health Act. We hope the House and Senate 
pass both bills in a bipartisan manner to pass this urgently 
needed legislation to protect veteran access to timely health 
care, whether that is in a VA facility or not. Madam Chair, 
this concludes my testimony. Mission Roll Call would like to 
thank you and Ranking Member Brownley for the opportunity to 
testify on these important issues, and I am prepared to take 
any questions you or other subcommittee members may have.

    [The Prepared Statement Of Cole Lyle Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Mr. Lyle, and thanks to all of 
our witnesses today and for their thoughtful inputs. I now 
recognize myself for 5 minutes.
    Mr. Lyle, and you may have answered this, but you listed 
seven unique polls that Mission Roll Call conducted on veterans 
accessing community care. Interestingly enough, they mirror 
what I experience when I talk with veterans within my district, 
and I am a fellow veteran, married to a fellow veteran. You 
also state in your testimony, the data clearly indicates that 
there is a problem simmering under the surface on this issue 
referring to community care. You may have addressed this, but 
could you again briefly expand on this problem?
    Mr. Lyle. Thank you for the question, Madam Chair. You 
know, I think if we look at community care and the program 
since 2018, obviously it has expanded dramatically. By and 
large, the program is working well. I think people that work 
with veterans on the ground, talk to veterans, and get their 
learned experience can tell you that they or someone they know 
has experienced some sort of issue accessing care in the 
community. I myself use the VA full-time for my care, for 
everything, and I have experienced I mean, the vast majority of 
my care has been good, has been excellent, but I still have 
experienced the occasional problem accessing community care.
    Ms. Miller-Meeks. Ms. Ellett, the quality of community care 
is often debated in Congress. In your opinion, can you provide 
an example of a veteran and how community care is safe, 
effective, and timely for veterans seeking to receive care in 
the community?
    Ms. Ellett. Thank you. Thank you, Madam Chair. I think 
that, you know, there are a couple of things that come to mind 
that did not have really good outcomes, because community care, 
there are good and there are bads in community care as well, 
just as well as VA. I know that I myself, I have to drive an 
hour and a half to Richmond to my medical center for some of my 
appointments, and the closest Community Based Outpatient Clinic 
(CBOC) that I have is 45 minutes away.
    I was medically discharged from the army for my back 
issues. I do drive an hour and a half to work every day because 
I love it, but it takes a toll. Driving for another 45 minutes 
to a chiropractor is not very helpful for me. I do use my 
community care in that sense, and it is extremely helpful. It 
is only 10 minutes away. They seem to have a positive 
relationship between VA and the community care there, so that 
is kind of a success story, although we are aware that that is 
not always the case.
    Ms. Miller-Meeks. I think I found that in both instances in 
community care and in VA care, and having been a provider in 
community care, I had excellent ratings as well.
    Mr. Retzer, in your statement you mentioned the DAV 
supports a searchable data base consisting of existing military 
medical personnel for the purposes of recruitment. How 
confident are you in the VA's ability to, one, protect this 
information and maintain privacy, while also being able to 
connect service members to potential opportunities within the 
VA?
    Mr. Retzer. Thank you for that question. I think as far as 
the confidence with electronic data bases that we are 
challenged right now with the VA, I think we can take some lead 
with the Department of Defense, being that this is going to be 
military occupational specialties and skills that are going to 
be listed in the record with individuals' information that have 
served and are serving. I think lessons can be learned as we 
navigate to make those data bases. I think some of the 
confidence levels of maintaining privacy is there because they 
do that with our veteran care information that we have as 
ourselves as veterans. I think they need to be a little bit 
more mindful of the fact that we are literally talking about 
service members putting their data bases into the system. I 
think as we navigate it, they can continue to learn from 
lessons learned in their developments.
    Ms. Miller-Meeks. Ms. Ellett, as you know, the veteran 
population is aging with more senior veterans requiring long 
term care. You note the importance of providing veterans choice 
and care. Do you agree that H.R. 1815 will provide veterans 
with timely care to their long-term care needs while also 
remaining cost effective?
    Ms. Ellett. Yes, we support it, and we think that it will 
be a good supplement, and we are really just looking for 
something to assist VA in taking care of the expanding aging 
network of veterans.
    Ms. Miller-Meeks. Thank you. I yield back. Ranking Member 
Brownley, you are now recognized for 5 minutes.
    Ms. Brownley. Thank you, Madam Chair. I wanted to ask a 
question really of all three of you and get individual answers 
from you. If we codified all of the access standards, including 
I just want to get community care, what do you believe that 
there would be any impact on VA's direct care system at all?
    Mr. Retzer. Thank you for that question. Where DAV is 
concerned with regards to Section 2 of this bill is a 
codifying, is that we feel concerns with the limitation and 
flexibility that the VA would have to ensure that we as 
veterans who are getting the healthcare at the VA, would have 
that option of care for our individual needs. One of the things 
that we see is that the Mission Act already provides the 
guidance for the VA. We just need to ensure that VA is held 
accountable to the access standards and the quality of 
standards. That is the most important thing, is the quality of 
standards. We can have access and timely scheduling, but we 
have to make sure that we have that quality care provided to 
each individual veteran.
    The other thing that we see is that, you know, if we limit 
that access for the VA, individual care out in the community, 
one of the things that they do not have are the same access 
standards or the quality standards. That is one thing that we 
do not have at this time to be able to measure what is really 
happening out there that would be beneficial for our safety and 
quality of our care. Let alone, I think, there is a second 
component there for us to look at is that when we look at 
community care, they do not have the wraparound services that 
veterans need. One of the things that we veterans deserve to 
have are the core values that VA is built on. If I can read 
them off for you, the strengths that they have is system wide 
clinical expertise regarding service-connected conditions and 
disorders. That is one of the things that we veterans walk into 
a community care and VA care system, is that we have multiple 
issues. As many of us suffer from musculoskeletal conditions, 
we also suffer from mental health. Even when we are trying to 
get those resources, we may be seen from medical for the mental 
health, but it is exasperated because of our chronic pains. The 
wraparound services are very important, and that direct care 
handoff, that warm handoff to different departments is 
important.
    Ms. Brownley. Thank you. Ms. Ellett.
    Ms. Ellett. Thank you for that question, Ranking Member 
Brownley. We never want community care to replace VA. I do not 
think that it will be detrimental. I think that it will expand 
or open doors to possibly veterans who are not willing to seek 
VA care. Giving them at least the option. Now, I have 
experienced good VA care. I have also spoken to many veterans 
who have experienced poor VA care. Some of them will choose not 
to get care. That is the last thing that anybody wants. It is 
really just giving them that option, just that window of 
opportunity to get that assistance. We do not think that it is 
going to, you know, kind of privatize VA. We do not believe 
that that is what is going to happen.
    One of the issues is you still have communities out there, 
like the LGBTQ community, who has a hard time going in and 
trusting VA facilities and VA staff. Just even opening up that 
branch to say, hey, if you come in and talk to VA, you get the 
option if you want to come here or go to community care. That 
might do a lot to build a bridge for that community or other 
under representative communities of veterans in order to build 
that trust back up.
    Ms. Brownley. Thank you. Mr. Lyle.
    Mr. Lyle. Thank you, Ranking Member Brownley. I think my 
response would be if the veteran is getting the care they need 
when they need it, then that is not detrimental to anybody, 
including the VA, whose core mission is to take care of the 
individual veteran. If you give them a choice between VA care 
and community providers, if all the studies that VA touts about 
veterans preferring care at VA facilities and that VA care is 
demonstrably better, then why have we seen the explosion we 
have seen in the last 4 years? That is a question that the VA 
has got to answer. Why are they meeting so many of the access 
standards requirements currently? Let us look at the VA 
experience and see how we can improve that if the goal is to 
get the veteran the best care possible when they need it.
    Ms. Brownley. Very good. I mean, I agree, really with all 
of your answers and responses. I just still sort of maintain 
the concern that the trajectory of community health care, you 
know, is just continuing to rise. We do not have an endless 
bank account in some sense. I do not want to, you know, put a 
bank account against the care of our veterans by any stretch of 
the imagination. I think the data shows that the veterans 
prefer healthcare inside the VA, assuming it is good health 
care and they can have access to it and it is quality care. I 
just worry about losing resources to continue to, you know, to 
continually improve upon the VA healthcare services itself.
    You know, I do not know where the sweet spot is and where 
it is a delicate balance, and I am not sure where it is, and we 
have got to figure that out. I do agree that the VA has to 
answer for why, you know, the demand on community care 
continues to go up. Oh, am I overtime already? I apologize. I 
yield back.
    Ms. Miller-Meeks. Thank you, Ms. Brownley. The chair now 
recognizes Mr. Landsman for 5 minutes.
    Mr. Landsman. Thank you, Madam Chair. I have just a 
question about Congresswoman Lee could not be here, but in her 
bill, she calls for this VA Zero Suicide Demonstration Project, 
which creates a program that implements the curriculum of the 
Zero Suicide Institute of the Education Development Center. I 
just wanted to know if you guys were familiar with the 
curriculum, thoughts on the bill, or the need for that kind of 
support within the VA. Any of you can answer that. Just wanted 
to get your perspective.
    Mr. Lyle. Thank you, sir, for the question. I think when we 
look at suicide, veteran suicide broadly, you know, I support 
any effort to improve training and care within VA facilities to 
try to expand outreach and prevention. Again, with less than 50 
percent of veterans utilizing enrolled in VA care, VA has to do 
more. I think less than 1/10 of 1 percent of their annual 
budget goes to suicide prevention initiatives, and that 
includes Fox grants. It would be my opinion that a more far-
reaching way to fight this problem would be to expand Fox 
grants for community providers that have touch points with 
veterans that the VA will just frankly, never have.
    Mr. Landsman. Yes, thank you. One of the things that we 
talked about with the administration were the partnerships with 
these community providers and getting to a point where there 
are agreements around sharing medical records, around the 
standard of care, and, you know, being able to increase those 
grants along with those partnerships. Without those 
partnerships, we could be sending folks into pretty 
questionable situations. Do you comment on that? Do you agree 
with that----
    Mr. Lyle. I think----
    Mr. Landsman [continuing]. do you feel differently?
    Mr. Lyle [continuing]. I mean, I think anytime that 
Congress mandates the VA enter partnerships with community 
providers, usually there is some prescription of rules 
guaranteeing, you know, certain ethical and programmatic 
standards that these programs have to adhere to. In many cases, 
with the Fox grants, the requirement to submit programmatic 
data back to VA requires a full-time employee. It is not a 
small job. I would just say that I do not think under current 
conditions for these types of programs, that that would be a 
huge issue.
    Mr. Landsman. Just and also a question for any of you or 
all of you. One of the issues that we have, so I am from 
Cincinnati, southwest Ohio, and we have a VA, a great VA. One 
big issue we have as I talk to veterans is those who are 
struggling, really struggling, obviously are isolated. Being 
able to connect with somebody is the biggest issue. Whether 
they get the care at the VA or somewhere else, it is getting 
connected. One of the, you know, issues or things I have been 
trying to understand better is what we do well in terms of 
outreach, where we could do outreach better. Let us just put 
aside the question of whether you get the care at the VA or a 
community provider. I still think there is this big question, I 
could be wrong, this big question as to whether or not we are 
really going out of our way, like going to meet veterans where 
they are? If so, what does that look like? What is best 
practice outreach so that we can get folks start to build those 
relationships and then get them the care that they need?
    Mr. Retzer. I will share with my experience as almost 20 
years of advocacy with the DAV advocating for our veterans' 
benefits and healthcare. DAV prides themselves on providing 
information seminars where we actually do these information 
seminars talking about VA benefits and navigating the 
healthcare system and partnering with the VA for the homeless 
programs and also with employment opportunities. It is one of 
these things that we use as peer specialists. Peer specialist 
concept with the DAV is not new because our national service 
officers are wartime service, injured, and ill veterans who 
serve veterans to help veterans navigate VA system and to build 
that confidence.
    I think that is one of the things that we as a panel has 
already expressed our experience with our service and what we 
do as advocates to be able to build that confidence and build 
the relationships with VA and our veteran community to have 
more reassurance that they are not alone in their journey, as I 
had stated earlier.
    Mr. Landsman. Thank you.
    Ms. Ellett. Just a quick comment, so----
    Mr. Landsman. My time is up.
    Ms. Ellett. Oh, Okay.
    Mr. Landsman. I apologize, but we will circle back 
afterwards. I apologize----
    Ms. Ellett. All right.
    Mr. Landsman [continuing]. Madam Chair.
    Ms. Ellett. Thank you.
    Mr. Landsman. I yield back, sorry.
    Ms. Miller-Meeks. Thank you. I was waiting for you to yield 
back. Thank you very much. Ranking Member Brownley, would you 
like to make any closing remarks?
    Ms. Brownley. Not really. I appreciate you having this 
hearing and bringing these bills forward, and I look forward to 
the next steps in terms of markup and moving the bills along.
    Ms. Miller-Meeks. Well, I just want to thank my colleagues 
on both sides of the aisle, the Department, our VSOs, members 
who presented to us today in addressing the issues that we 
discussed. I appreciate your feedback and we will look into 
that. As both a veteran, a doctor, and a former nurse married 
to a veteran who is a nurse, I think what is most important is 
that we take into consideration those veterans who are not 
receiving care in a timely fashion. It does not matter if you 
have the best quality care in the world if you cannot access 
that care by not getting an appointment. One of the first 
things that I did as a new Member of Congress when I was 
elected in 2020, in 2021, was to work in a bipartisan fashion 
to pass a bill because a service member from 60 miles away went 
to the VA in Iowa City for mental healthcare, was denied care, 
and 5 hours later committed suicide. It was the first bill I 
was on and was signed by President Biden.
    That is why this is an important issue. Codifying community 
care and especially access to care in the community for 
substance use disorder or severe mental health disorder does 
not mandate that care has to be provided in the community. 
Codifying only means that the VA understands that it is their 
duty and their mission to make sure that care is accessed. No 
one wants to divert from best practices, and there are 
parameters that we can put in place. I am a staunch supporter 
of telehealth and had bills on telehealth immediately when I 
came into Congress to make the waiver permanent that had 
occurred.
    Care coordination is at the behest of the VA. Yes, we did 
hear about care coordination. For those, you know, I was a 
nurse at Walter Reed taking care of spinal cord injury 
patients. Flipped a lot of strikers in my time, suctioned a lot 
of patients that were managing on ventilators. I know that care 
coordination is important, but that is at the behest of the VA 
to improve their practices.
    I think for all of us here on the committee, what we are 
most concerned about is that veterans have access to care. Of 
course, we want it to be high quality care, and we want it to 
be timely. So, I look forward to working with all of you. The 
complete written statements of today's witnesses will be 
entered into the hearing record. I ask unanimous consent that 
all members have 5 legislative days to revise and extend their 
remarks and to include extraneous material. Hearing no 
objections, so ordered. I thank the members and the witnesses 
for their attendance and participation today. This hearing is 
now adjourned.
    [Whereupon, at 11:53 p.m., the subcommittee was adjourned.]
    
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                         A  P  P  E  N  D  I  X

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                    Prepared Statement of Witnesses

                              ----------                              


                  Prepared Statement of Erica Scavella

    Good morning, Chairwoman Miller-Meeks, Ranking Member Brownley, and 
Members of the Subcommittee. I appreciate the opportunity to discuss 
the Department of Veterans Affairs' (VA) views on pending legislation 
regarding health care benefits. We are unable to provide views today on 
H.R. 2683, the VA Flood Preparedness Act. We will provide those views 
in a follow-up views letter. I am accompanied today by Dr. Colleen 
Richardson, Executive Director, Caregiver Support Program, Dr. Scotte 
Hartronft, Executive Director, Office of Geriatrics and Extended Care, 
and Dr. Mark Hausman, Executive Director, Integrated Access.

H.R. 1182 Veterans Serving Veterans Act of 2023

    Section 2(a) of H.R. 1182 would amend section 208 of Public Law 
115-46 in a number of ways. VA would be required to establish and 
maintain a single searchable data base (known as the Departments of 
Defense and Veterans Affairs Recruitment Data base) that also includes 
the military occupational specialty or skill that corresponds to each 
vacant position and each qualified member of the Armed Forces who may 
be recruited to fill the position before such qualified member has been 
discharged and released from active duty. VA would have to hire 
qualified members of the Armed Forces who apply for vacant positions 
without regard to the provisions of subchapter I of chapter 33 of title 
5, United States Code (U.S.C.). VA could authorize a relocation bonus 
in an amount determined appropriate (subject to certain limitations) to 
any qualified member of the Armed Forces who has accepted a position 
listed in the data base. The term ``qualified member of the Armed 
Forces'' would mean a member of the Armed Forces described in 10 U.S.C. 
Sec.  1142(a), who elects to be listed in the data base, and who VA has 
determined, in consultation with the Department of Defense (DoD) to 
have a military occupational specialty that corresponds to a vacant 
position described in section 208(a).
    Section 3 of the bill would require VA to implement a program to 
train and certify covered Veterans to work in VA as intermediate care 
technicians (ICT). VA would have to establish centers at VA medical 
facilities selected by VA for the purposes of this program. The term 
``covered veteran'' would mean a Veteran whom VA determines served as a 
basic health care technician while serving in the Armed Forces.
    Section 4 would prohibit any additional funds from being 
appropriated to carry out these provisions.

Position: VA does not support

    This bill duplicates multiple existing efforts already underway in 
VA to identify, engage, and recruit transitioning military personnel 
for employment at VA. Principally, section 5127 of the National Defense 
Authorization Act for Fiscal Year 2023 (the NDAA, Public Law 117-263), 
already addresses the elements of this bill.
    Regarding section 2(a), several efforts are already underway to 
target transitioning military members for mission critical and 
difficult to fill positions by utilizing the occupational and personal 
contact data contained in the Veterans Affairs/Department of Defense 
Identity Repository (VADIR) data base. The VADIR data base includes 
information on all Service members projected to transition from the 
military. Using data from VADIR allows VA to target Service members for 
recruitment at a time prior to, during, or immediately upon their 
transition.
    Additionally, the USA Jobs Agency Talent Portal (ATP) allows VA 
recruitment professionals to mine searchable job seekers who are 
eligible and well-suited for VA job opportunities. In addition, the 
Transitioning Military Program (TMP) marketing plan includes publishing 
a quarterly VA News blog and conducting outreach via VA Careers social 
media channels; these efforts combined yield more than half a million 
impressions per quarter.
    Finally, section 5127(a) of the NDAA allows Veterans who served in 
a medical occupation while serving in the Armed Forces to provide a 
history of their medical experience and competencies to facilitate 
civilian medical credentialing and hiring opportunities for Veterans 
seeking to respond to a national emergency. VA activated this portal on 
the VA Careers website May 1, 2023, and transitioning military 
personnel with relevant medical experiences can already self register.
    Regarding section 3 of the bill, section 5127(b) of the NDAA 
requires VA to establish a program to train, certify, and employ 
covered Veterans as ICTs. The VA has already implemented a program to 
train, certify, and employ covered Veterans as ICTs. The VA ICT 
training program launched as a pilot in December 2012 and transitioned 
to an established national program in 2014.

H.R. 1278 Driver Reimbursement Increase for Veteran Equity Act (DRIVE 
Act)

    H.R. 1278 would amend subsection (g) of 38 U.S.C. Sec.  111 to 
require VA to ensure that the mileage rate paid under subsection (a) is 
equal to or greater than the mileage reimbursement rate established by 
the General Services Administration (GSA) for the use of privately 
owned vehicles by Government employees on official business when no 
Government vehicle is available. The bill would also remove the mileage 
rate in subsection (a), which is currently $0.415 per mile, and instead 
specify that the mileage rate would be determined in accordance with 
subsection (g).

Position: VA supports, subject to the availability of appropriations

    The current GSA reimbursement rate is authorized if no Government-
furnished vehicle is available and a privately owned vehicle is 
authorized; the rate is $0.655 per mile, which is greater than the 
current mileage reimbursement rate under VA's beneficiary travel 
program of $0.415 per mile. The current rate was established in law 
more than 13 years ago, and transportation costs have increased for 
Veterans since that time. VA sees benefit in ensuring that this rate is 
updated and continues to adjust in future years, as appropriate, to 
reflect rising costs for transportation.
    Discretionary (for the Veterans Health Administration, or VHA) and 
mandatory costs (for the Veterans Benefits Administration, or VBA) 
would be associated with this section. The mandatory costs for VBA 
would increase by approximately $43.5 million in fiscal year (FY) 2024, 
$184.1 million over five years, and $349.1 million over 10 years. 
Additional mandatory costs would be associated with future rate 
increases published by GSA. VHA estimates that increased reimbursement 
rates at $0.655 per mile would result in an additional $337.7 million 
in FY 2024, $1.866 billion over 5 years, and $4.248 billion over 10 
years. VA estimates a portion of the VHA costs would be allocated to 
the Cost of War Toxic Exposures Fund (TEF), consistent with the 
methodology used to develop the TEF request in the 2024 Budget.

H.R. 1639 VA Zero Suicide Demonstration Project Act of 2023

    Section 2 of H.R. 1639 would require VA, not later than 180 days 
after the date of enactment, to establish a pilot program called the 
Zero Suicide Initiative (hereafter, the Program). The Program would 
have to implement the curriculum of the Zero Suicide Institute of the 
Education Development Center (the Institute) to improve safety and 
suicide care for Veterans. VA would develop the Program in consultation 
with the Secretary of the Department of Health and Human Services; the 
National Institutes of Health; public and private institutions of 
higher education; educators; experts in suicide assessment, treatment 
and management; Veterans Service Organizations; and professional 
associations VA determines relevant to the purposes of the Program.
    The Program would generally terminate after 5 years, but VA could 
extend the Program for not more than 2 years if VA notified Congress.

Position: VA does not support the bill as written

    VA does not support this current bill for clinical, fiscal, 
empirical, contractual, and technical, and empirical reasons which are 
elaborated in this following response.
    Clinically, existing suicide prevention efforts and strategies are 
more robust than what would be required by this bill. VA's current 
efforts incorporate all foundations within the Institute's Program and 
offers surveillance, prevention and intervention strategies that exceed 
the Institute's Program. We welcome an opportunity to provide a 
briefing to the Committee comparing VA's comprehensive approach and 
programs within suicide prevention to that of the Institute's Program.
    VA has made suicide prevention is a top clinical priority and is VA 
implements a implementing a comprehensive public health approach to 
with the goal of reaching all Veterans within and outside the 
healthcare system. This approach is in full alignment with the 
President's new White House Strategy for Reducing Military and Veteran 
Suicide, advancing a comprehensive, cross-sector, evidence-informed 
public health approach with focal areas in lethal means safety, crisis 
care and care transition enhancements, increased access to effective 
care (consistent with the VA/DoD Clinical Practice Guideline for the 
Assessment and Management of Patients at Risk for Suicide), addressing 
upstream risk and protective factors and enhanced research 
coordination, data sharing and program evaluation efforts. The FY 2023 
Budget and the FY 2024 Budget request sufficiently supports VA's system 
of comprehensive treatments and services to meet the needs of each 
Veteran and the family members involved in the Veteran's care.
    In August 2020, VA funded and completed a pilot, through the 
execution of a one-year contract awarded to the Education Development 
Center, for the development and implementation of a Zero Suicide 
Initiative at the Manchester (New Hampshire) VA Medical Center (VAMC). 
The Manchester VAMC, with the support of the New Hampshire State 
Suicide Prevention Council, engaged key community agencies across the 
State in a 9-month online community of practice (CoP). They also 
engaged in facility level organizational culture and performance 
related suicide prevention improvement efforts. A technical review of 
the Manchester VAMC pilot found that the facility did report 
qualitative improvements. However, when comparing suicide prevention 
outcomes and suicide prevention key performance indicators, there were 
no measurable improvements that could be directly attributed to the 
Zero Suicide processes (and some key performance indicators worsened). 
Therefore, further resource allocation to advance Zero Suicide was not 
supported at that time. This conclusion was drawn by both reviewing the 
performance across several suicide prevention domains and considering 
other performance improvement supports provided by VHA's public health 
approach.
    Fiscally, the bill's requirements would come at unknown and 
unaccounted for cost to VA, which would likely require VA to divert 
resources from other suicide prevention programs and initiatives 
demonstrating solid, empirical evidence of progress. We welcome a 
conversation on the Institute's total costs of the Program to comply 
with the requirements in the bill prior to further action by the 
Committee. VA would then need adequate time to review and calculate 
indirect and opportunity costs associated with all phases of program 
implementation and with costs and cost parameters or assumptions 
provided by the Institute.
    Contractually, the bill would direct VA to form a legally binding 
monetary agreement with a specific entity, seemingly violating Federal 
acquisition and procurement principles of open and fair competition. 
This could result in a greater cost to the Department than we might 
otherwise incur through full and open competition.
    VA is concerned about legislating a specific model using specific 
entities when defining clinical operations. Suicide prevention is a 
dynamic field informed by evidence, and VA believes the best approach 
is to allow VA to continue to adopt a public health model based on 
proven clinical interventions, established business practices and 
equitable and transparent exchange of relevant data, rather than 
prescribing a single approach which predominantly focuses 
implementation within healthcare settings.
    VA has several technical concerns regarding the bill. First, the 
stated goal of the implementation of the Institute's curriculum is to 
``improve safety and suicide care'' for Veterans, but it is not clear 
how this would be defined, measured and reported, and over what course 
of time. Second, the eight metrics VA would have to use to compare the 
suicide-related outcomes at program sites and other VA medical centers 
would not be a methodologically valid or statistically valid study 
design. There are numerous and complex correlated, moderating, 
mediating, and confounding variables to include or statistically 
control if valid and reliable comparisons are going to be made 
isolating the impact of the Program. We could see value in a 
comparative study of different programs, but the evaluation would need 
to be carefully reviewed, constructed and implemented by appropriate 
data analytics and research design subject matter experts.
    Finally, as written, the bill would require development and 
consultation with various stakeholders. This activity may invoke the 
Federal Advisory Committee Act and require VA to form multiple new 
Federal Advisory groups. VA recommends amending the bill's language to 
clarify that consultation activities are exempt from the Federal 
Advisory Committee Act. In the alternative, the consultation 
requirements could be removed, which would also address this concern. 
However, we again emphasize that even with these changes, VA would not 
support this bill.
    VA does not know what the Institute would charge in terms of access 
to its materials and training resources or the direct and indirect 
costs to VA associated with implementation and training.

H.R. 1774 VA Emergency Transportation Act

    H.R. 1774 would amend 38 U.S.C. Sec.  1725 by replacing the term 
``emergency treatment'' as used throughout the section with the term 
``emergency services'' along with other conforming amendments. The bill 
would also define the term ``emergency services'' to include both 
emergency treatment and emergency transportation. The term ``emergency 
transportation'' would be defined as transportation of a Veteran by 
ambulance or air ambulance by a non-VA provider to a facility for 
emergency treatment or from a non-Department facility where a Veteran 
received emergency treatment, to a VA or other Federal facility and 
subject to existing limitations on the duration of emergency treatment.

Position: VA supports, if amended, and subject to the availability of 
appropriations

    This bill is intended to clarify VA's existing authority to pay for 
ambulance and air ambulance transportation to a facility that provides 
emergency treatment to an eligible Veteran; it also would require that 
VA pay or reimburse under 38 U.S.C. Sec.  1725 for ambulance or air 
ambulance transportation from the non-VA facility where the eligible 
Veteran received emergency treatment to a VA or other Federal facility. 
VA already pays for ambulance or air ambulance transportation when 
payment or reimbursement is authorized under 38 U.S.C. Sec.  1725 (or 
would have been in certain cases) for emergency treatment provided at a 
non-VA facility. VA would continue to do so under this bill; however, 
by defining emergency transportation to include ambulance and air 
ambulance transportation to a facility for ``emergency treatment'' in 
proposed section 1725(h)(2)(A), this bill could be interpreted to also 
authorize ambulance and air ambulance reimbursement so long as the 
purpose of the transportation was ``for'' emergency treatment, even if 
emergency treatment was not provided. While VA has interpreted current 
section 1725 to authorize payment for transportation when ``emergency 
treatment'' could not be provided due to the death of the patient, it 
is not clear if the bill is intended to cover the emergency 
transportation in other scenarios as well.
    VA recommends several amendments to this bill. First, section 
2(a)(8) of the bill would amend 38 U.S.C. Sec.  1725(a)(2)(A) to 
replace the phrase ``health care provider that furnished the 
treatment'' with ``provider that furnished such emergency services''; 
however, section 2(a)(5) would have already amended this provision to 
read ``health care provider that furnished such emergency services'', 
so the phrase that section 2(a)(8) would amend would not exist. VA 
recommends section 2(a)(8) strike the phrase ``health care''. Second, 
in section 2(a)(11)(B), the use of the phrase ``was furnished'', should 
instead be ``were furnished''.
    VA recommends section 1725(h)(2)(B)(i), as well as redesignated 
(h)(3)(C), include non-Department facilities. VA may be able to 
interpret the phrase ``to a Department...facility'' to include a non-
Department facility authorized to furnish services by VA, but we 
believe a clear statement by Congress would make this simpler. This 
amendment would address situations where, for example, a Veteran has 
reached the point of stability and no longer requires emergency 
treatment but needs continued care (e.g., inpatient care) or needs a 
higher level of care not available at the first facility. With this 
proposed change, if the Veteran is eligible to elect to receive such 
care through the Veterans Community Care Program and chooses to do so, 
under 38 U.S.C. Sec.  1725, VA could reimburse for the Veteran's 
transport by ambulance or air ambulance from the non-Department 
facility that furnished emergency treatment to another non-Department 
facility that would furnish inpatient care, for example. The proposed 
change would clarify VA's authority to pay for emergency transportation 
under 38 U.S.C. Sec.  1725 in the case of such a transfer.
    We also note for awareness that this bill would not fill the gap in 
VA's authority to reimburse for transportation of a Veteran by 
ambulance or air ambulance to a VA facility for emergency treatment in 
cases where the Veteran is not eligible for such transportation under 
38 U.S.C. Sec.  111. The term ``emergency transportation'' would be 
defined to mean transport of a Veteran by ambulance or air ambulance by 
a non-VA provider ``to a facility for emergency treatment'' (proposed 
section 1725(h)(2)(A)). However, the term ``emergency treatment'' would 
be defined to only apply to ``medical care or services furnished in a 
non-Department facility'' (proposed section 1725(h)(3)). This would 
categorically exclude care or services furnished in a Department 
facility. If the Committee intended to ensure that Veterans' ambulance 
transportation costs to both VA and non-VA facilities are covered, 
further amendments would be needed to achieve that goal. VA can provide 
technical assistance if desired, to achieve this goal.
    Forecasting costs for this section would require additional data 
gathering and analysis from VA's community care and beneficiary travel 
programs. VA is working to assemble the necessary data, but VA does not 
have a cost estimate for this bill at this time.

H.R. 1815 Expanding Veterans' Options for Long Term Care Act

    This bill would require VA, beginning not later than 1 year after 
the date of enactment, to carry out a 3-year pilot program to assess 
the effectiveness of providing assisted living services to eligible 
Veterans (at their election) and the satisfaction with the pilot 
program of the Veterans participating in the program. VA could extend 
the duration of the pilot program for an additional 3 years if VA 
determined it was appropriate to do so based on the result of annual 
reports to Congress and a report by the IG on the pilot program.
    In carrying out the pilot program, VA could enter into agreements 
for the provision of assisted living services on behalf of eligible 
Veterans with a provider participating under a State plan or waiver 
under title XIX of the Social Security Act (42 U.S.C. Sec.  1396 et 
seq.) or a State home recognized and certified under 38 C.F.R. part 51, 
subpart B. VA could not place, transfer, or admit a Veteran to any 
facility for assisted living services under the pilot program unless it 
determined that the facility met the standards for community 
residential care established in 38 C.F.R. Sec. Sec.  17.61 - 17.72 and 
any additional standards of care VA may specify. State homes would have 
to meet such standards of care VA may specify. VA would pay to a State 
home a per diem for each Veteran participating in the pilot program at 
the State home at a rate agreed to by VA and the State home. In the 
case of a facility that is a community assisted living facility, VA 
would pay to the facility an amount that is less than the average rate 
paid by VA for placement in a community nursing home in the same VISN 
and would re-evaluate payment rates annually to account for current 
economic conditions and current costs of assisted living services. Upon 
termination of the pilot program, VA would have to provide to all 
Veterans participating in the pilot program at the time of the 
termination of the pilot program the option to continue to receive 
assisted living services at the site they were assigned, at VA expense, 
and for such Veterans who do not opt to continue to receive such 
services,
    The term ``assisted living services'' would be defined to mean 
services of a facility in providing room, board, and personal care for 
and supervision of residents for the health, safety, and welfare. 
Eligible Veterans would be defined to mean Veterans who are already 
receiving nursing home level care paid for by VA, are eligible to 
receive nursing home level care paid for by VA pursuant to 38 U.S.C. 
Sec.  1710A, or requires a higher level of care than domiciliary care 
provided by VA but does not meet the requirements for nursing home 
level care provided by VA, and are eligible for assisted living 
services, as determined by VA or meets such additional criteria for 
eligibility as VA may establish.

Position: VA supports, if amended, and subject to the availability of 
appropriations

    We appreciate that the current version of this bill has addressed a 
number of the technical concerns we identified with similar legislation 
in the prior Congress. VA generally agrees that specific authority, 
particularly in the form of a pilot program, to furnish assisted living 
services would be a helpful addition to VA's options for long-term 
care. VA has encountered difficulties within its current authorities in 
appropriately placing Veterans who may only require assisted living 
services because these Veterans do not qualify for nursing home care. 
Moreover, due to shifts in the industry to an assisted living model of 
care, particularly for patients with dementia, Alzheimer's, or other 
memory deficits, VA's lack of authority to furnish assisted living 
services means they have no appropriate option. The pilot authority 
would allow VA to determine how best to develop a program to support 
these Veterans' needs. VA supports the protections this bill would 
include to ensure that Veterans are protected and receiving safe and 
appropriate care.
    While VA supports the intent of this bill, VA recommends several 
amendments. First, the implementation timeline of 1 year from bill 
enactment is untenable. VA would need to issue regulations, hire staff, 
draft and enter into new agreements, and likely develop new systems or 
processes to support successful implementation. VA recommends providing 
2 years from enactment and will require timely and sufficient resources 
to support the program.
    Second, VA seeks clarification in the application of section 
2(b)(2)(B). As written, it is unclear whether this section applies to 
the pilot program as a whole or to each participating VISN. VA cautions 
that requiring each VISN to meet the provisions of section 2(b)(2)(B) 
would severely complicate implementation and increase costs as well.
    Third, the bill needs to clarify whether the other requirements in 
38 U.S.C. Sec. Sec.  1741 1745 and in VA regulations should apply if 
the payments to State homes are intended to be accomplished by a grant 
program. VA has been working to implement section 3007 of the Johnny 
Isakson and David P. Roe, M.D., Veterans Health Care and Benefits 
Improvement Act of 2020 (Public Law 116-315) related to per diem 
payments for Veterans who do not meet all the requirements for per diem 
payments for domiciliary care in 38 CFR part 51; we recommend the bill 
be amended to allow for, but not require (at least not initially) 
participation of State homes to ensure that the existing efforts to 
comply with section 3007 are not delayed or interrupted by 
implementation of this new authority. We further note that selecting a 
State home for a location could present other issues, as VA does not 
manage or control State homes. Presumably, VA would need to establish 
standards and parameters for a program that a Sate home could then opt 
into or apply to furnish.
    Fourth, VA recommends more specificity in section 2(d)(2)(B) in the 
definition and scope of benefits and participants under this program. 
As written, section 2(d)(2)(B) would require VA to ``enroll'' Veterans 
who no longer wish to participate in the pilot program in other 
extended care services based on their preference and best medical 
interest, but VA does not have an enrollment requirement for most VA 
extended care. It is unclear if the intent of this subparagraph is to 
require VA to enroll and pay for these Veterans' care in non-VA 
programs, to establish an enrollment requirement for VA extended care 
programs, or simply to provide VA care through other means.
    Finally, VA seeks clarity regarding part of the definition of 
``eligible veteran'' in section 2(i)(2)(B)(i). In this section, the 
term ``eligible veteran'' is defined to mean, in pertinent part, 
Veterans who are ``eligible for assisted living services, as determined 
by the Secretary.'' The intent of this provision is unclear and could 
be interpreted various ways that could create significant and 
potentially costly implementation challenges. VA would appreciate the 
opportunity to discuss these technical issues in detail with the 
Committee.
    VA estimates this bill would cost $60.309 million in FY 2024, 
$62.551 million in FY 2025, $188.195 million over 5 years, and $188.195 
million over 10 years. The costs are the same for the 5 and 10-year 
estimates because this is only a 3-year pilot.

H.R. 2768 PFC Joseph P. Dwyer Peer Support Program Act

    H.R. 2768 would require VA to establish a grant program, known as 
the PFC Joseph P. Dwyer Peer Support Program, under which VA would make 
grants to eligible entities for the purpose of establishing peer-to-
peer mental health programs for Veterans. Eligible entities would be 
non-profit organizations that have historically served Veterans' mental 
health needs, congressionally chartered Veterans Service Organizations 
(VSO), and State, local, or Tribal Veterans service agencies, 
directors, or commissioners that submit an application to VA containing 
such information and assurances as VA may require. Grant recipients 
could receive a grant in an amount not to exceed $250,000. Grantees 
would be required to use funds to hire Veterans to serve as peer 
specialists to host group and individual meetings with Veterans seeking 
non-clinical support, provide mental health support to Veterans 24 
hours a day, seven days a week, hire staff to support the program, and 
carry out a program that meets appropriate standards (including initial 
and continued training for Veteran peer volunteers, administrative 
staffing needs, and best practices for addressing the needs of each 
Veteran served) created by an advisory committee. VA could not require 
grantees to maintain records on Veterans seeking support or to report 
any personally identifiable information directly or indirectly to VA 
about such Veterans. The bill would authorize $25,000,000 to carry out 
this section during the 3-year period beginning on the date of 
enactment of this bill.

Position: VA opposes

    While VA supports the broad goals of this bill, VA does not believe 
this bill is necessary and could prove problematic. VA already has the 
authority to appoint peer specialists at VA medical centers. As of May 
2023, VA has more than 1,350 peer specialists working in mental health 
programs across the Nation, and VA also maintains peer support services 
through the Veterans Crisis Line that makes peer support services 
available to Veterans across the country. The proposed bill would place 
VA in competition with grantees in recruiting and retaining peer 
specialists and thus frustrate the purposes of already enacted 
statutory requirements.
    VA is already working to comply with requirements under section 401 
of the STRONG Veterans Act (Division V of Public Law 117-328) and 
section 5206 of the Deborah Sampson Act (Title V of Public Law 116-315) 
to increase staffing for VA peer specialists. In implementing section 
506 of the VA MISSION Act of 2018 (P.L. 115-182), VA found that 
expanding peer specialist services in patient-aligned care teams 
benefited Veterans and was associated with increased participation and 
engagement in care. As stated in VA's final report to Congress on its 
implementation of section 506 of the VA MISSION Act of 2018, peer 
specialists were highly beneficial to Veterans.
    In addition to the conflict this proposed bill would create, we 
oppose the provision that would prohibit grantees from maintaining 
records or sharing information with VA as it is contrary to efforts in 
a number of other grant programs, such as the Staff Sergeant Parker 
Gordon Fox Suicide Prevention Grant Program, which is designed to 
facilitate bringing Veterans into VA care. By prohibiting grantees from 
sharing information with VA, efforts to furnish VA care would be 
hindered, and such prohibitions would significantly impede any 
oversight and accountability efforts by VA to ensure the proper use of 
Federal funds.
    VA believes this bill is overly prescriptive in some elements 
(establishing a cap on the amount of grant awards, defining narrowly 
the authorized uses of grant funds, requiring an advisory committee to 
establish standards, etc.) and very vague in others (the term 
``historically served veterans' mental health needs'' is undefined, 
there are no requirements for grantees specifically enumerated, there 
is no requirement to provide data on the use of funds for oversight 
purposes, etc.). The bill is also unclear as to the duration of the 
program and other key parameters. We object to the unnecessary 
specificity included in the bill and would note that further detail 
would be needed to ensure VA could implement this consistent with 
Congressional intent. While the bill would authorize appropriations 
beginning on the date of enactment for a 3-year period, VA would be 
unable to implement this authority on such date, as it would need to 
engage in rulemaking (which can take approximately 24 months). 
Consequently, the authorization of appropriations under the bill would 
expire approximately 1 year after VA could begin implementing the 
program.
    Finally, the bill would require VA to create an advisory committee 
subject to the Federal Advisory Committee Act, the National Records 
Act, the Privacy Act, the Freedom of Information Act, and the 
Government in the Sunshine Act. However, the bill does not provide 
sufficient guidance to VA to establish, manage, or terminate this 
committee. The bill would need to include an official name for the 
committee, the mission authority of the committee, the substantive 
objectives and scope for the committee, the size of the committee, the 
official to whom the committee would report, the reporting requirements 
for the committee, the meeting frequency of the committee, the 
qualifications for committee members, the types of committee members 
and their term limits, whether the committee is authorized to have 
subcommittees, the funding for the committee, and the record keeping 
requirements of the committee. Alternatively, the bill could strike the 
requirement to establish an advisory committee and avoid these issues 
altogether.

H.R. 2818 Autonomy for Disabled Veterans Act

    Section 2(a) of H.R. 2818 would amend 38 U.S.C. Sec.  1717 to 
increase the amount available to eligible Veterans for improvements and 
structural alterations furnished as part of home health services. In 
the case of medical services furnished under section 1710(a)(1) or for 
a disability described in section 1710(a)(2)(C), the amount available 
for improvements and structural alterations would be increased from 
$6,800 to $10,000.For all other enrolled Veterans, this amount would be 
increased from $2,000 to $5,000. Section 2(b) would make this change 
effective for Veterans who first apply for such benefits on or after 
the date of enactment. Section 2(c) would provide that a Veteran who 
exhausts his or her eligibility for benefits under section 1717(a)(2) 
before the date of enactment would not be entitled to additional 
benefits by reason of these amendments. Section 3 of the bill would 
further amend section 1717 to include a new subsection (a)(4) that 
would require VA to increase on an annual basis the dollar amount in 
effect under subsection (a)(2) by a percentage equal to the percentage 
by which the Consumer Price Index (CPI) for all urban consumers (United 
States city average) increased during the 12-month period ending with 
the last month for which the CPI data is available. In the event the 
CPI did not increase during such period, VA would maintain the dollar 
amount in effect during the previous fiscal year.

Position: VA supports, if amended, and subject to the availability of 
appropriations

    VA recommends the bill remove the distinction between the levels of 
benefits available to Veterans with a service-connected disability and 
those without by making all eligible Veterans able to receive a 
lifetime benefit up to $9,000. The $9,000 amount is appropriate because 
the most common home improvement and structural alteration to 
accommodate a disability involves renovation of a bathroom, and the 
national average cost for a bathroom modification is $9,000. Further, 
VA recommends an index, such as one focused on construction costs, for 
determining cost index. VA further notes it is unclear how the 
adjustment for inflation that would occur as a result of section 3 
would affect Veterans who have used but not exhausted their benefits as 
of the day before the date of enactment, as described in section 2(c) 
of the proposed bill. VA recommends the bill include limitations on the 
number of times a Veteran could use this benefit to ensure appropriate 
administration of this program, proper use of Federal resources and to 
avoid disparate effects on similarly situated Veterans. While the 
benefit is a ``lifetime'' benefit, VA believes a limited number of 
disbursements would provide a more equitable program that would also be 
easier to administer. VA welcomes the opportunity to work with the 
Committee on language to address these concerns.
    The cost for this bill, as written, is estimated to be $33.0 
million in FY 2024 of which $4.3 million would be allocated to the TEF, 
$231.3 million over 5 years of which $40.7 million would be allocated 
to TEF, and $720.7 million over 10 years of which $40.7 million would 
be allocated to the TEF.
    We estimate the bill, if amended, would costs $29.5 million in FY 
2024 of which $3.8 million would be allocated to the TEF, $206.0 
million over 5 years of which $36.3 million would be allocated to the 
TEF, and $640.3 million over 10 years of which $156 million would be 
allocated to the TEF. For all estimates, TEF allocations are consistent 
with the methodology used to develop the TEF request in the 2024 
Budget.

H.R. 3520 Veteran Care Improvement Act of 2023

    Section 2(a) of H.R. 3520 would amend 38 U.S.C. 1703B regarding 
VA's access standards to expand and codify VA's existing access 
standards established in regulation at 38 C.F.R. Sec.  17.4040. 
Specifically, it would create a new section 1703B(a) that would provide 
that covered Veterans could receive hospital care, medical services, or 
extended care services under section 1703(d)(1)(D) (the eligibility 
criterion for the Veterans Community Care Program based on VA's 
designated access standards) if VA determined, with respect to primary 
care, mental health care, or extended care services, VA could not 
schedule an in-person appointment for the covered Veteran with a VA 
health care provider at a facility that is located less than a 30-
minute drive time from the Veteran's residence or during the 20-day 
period after the date on which the Veteran requests such appointment. 
With respect to specialty care, covered Veterans could elect to receive 
community care if VA could not schedule an in-person appointment with a 
VA health care provider at a facility that is located less than a 60-
minute drive from the Veteran's residence or during the 28-day period 
after the date on which the Veteran requests such appointment. With 
respect to residential treatment and rehabilitative services for 
alcohol or drug dependence, covered Veterans could elect to receive 
community care if VA could not schedule an in-person appointment with a 
VA health care provider at a facility that is located less than a 30-
minute drive from the Veteran's residence or during the 10-day period 
after the date on which the Veteran requests such appointment. VA could 
prescribe regulations that establish a shorter drive or time period 
than those otherwise described above. Covered Veterans could consent to 
longer drive or time periods, but if they did, VA would have to 
document such consent in the Veteran's electronic health record and 
provide the Veteran a copy of that documentation in writing or 
electronically. In making determinations about scheduling appointments, 
VA could not consider a telehealth appointment or the cancellation of 
an appointment unless such cancellation was at the request of the 
Veteran.
    Proposed section 1703B(b) would require VA to ensure that these 
access standards apply to all care and services (except nursing home 
care) within the medical benefits package to which a covered Veteran is 
eligible under section 1703 and to all covered Veterans.
    Proposed section 1703B(c) would require VA to review, at least once 
every three years, the access standards established under the revised 
section 1703B(a) with Federal entities VA determines appropriate, other 
entities that are not part of the Federal Government, and entities and 
individuals in the private sector (including Veterans who receive VA 
care, VSOs, and health care providers participating in the Veterans 
Community Care Program (VCCP)). This subsection would also strike 
section 1703B(g), which allows VA to establish through regulation 
designated access standards for purposes of VCCP eligibility, as well 
as other conforming amendments.

Position: VA opposes Section 2

    VA is opposed to codification of access standards. Removing the 
ability of the Secretary to develop and publish such standards for VA 
diminishes the Secretary's authority to ensure Veterans receive the 
right care, at the right time. This bill fails to consider other market 
forces that also impact access to care outside of VA and would not 
allow VA to consider and incorporate those forces to meet Veterans' 
needs for timely, high quality care. Moreover, VA cannot support 
codification of residential treatment and rehabilitative services as 
proposed in this bill. VA generally supports establishing a wait-time 
standard of 10 or fewer days for the delivery of care, although we 
oppose codifying this in law.
    We do, though, have significant concerns with and oppose the 30-
minute drive time standard for residential treatment programs, which is 
inconsistent with industry standards in terms of accessible care. 
Although we do not have a cost estimate at this time, this standard 
could result in significantly greater financial costs to VA without any 
guarantee that Veterans would actually receive care that is closer to 
home. While Veterans are not eligible to elect to receive care in the 
community based on the designated access standards, they may be 
eligible on another basis (such as best medical interest, which can 
consider distance) and can elect to receive community care. When they 
do so, current data indicate that Veterans receiving community 
residential treatment care are traveling 189 miles on average to access 
such care.
    Further, VA operates several different types of residential 
treatment programs beyond just alcohol and drug dependence (such as 
programs for posttraumatic stress disorder). It is unclear which, if 
any, standards established under this section would apply to these 
other residential treatment programs. Additionally, the exception to 
nursing home care under proposed subsection (b), which defines the 
applicability of the standards, creates confusion as to whether there 
are standards for nursing home care and they are simply not applicable 
or whether there is no requirement to establish standards for nursing 
home care. We are unclear as to the intended effect of this change but 
believe it could simply create more confusion for Veterans and staff 
alike.
    The references to drive times refer only to drive times, not 
``average driving time'', which is the current designated access 
standard in 38 C.F.R. Sec.  17.4040. It is unclear whether this section 
is intended to retain that ``average driving time'' element or if it is 
intended to establish a requirement that VA calculate actual drive 
time. We caution that such an approach would be effectively impossible 
to implement, as actual drive times vary day-by-day and minute-by-
minute, and VA must determine eligibility for community care now for an 
appointment in the future. It is unclear how VA would determine actual 
drive time in the future. This would represent a step backward for VA 
in terms of being responsive to Veterans' needs.
    VA opposes the provision that, in making determinations about 
scheduling appointments, prohibits consideration of a telehealth 
appointment or the cancellation of an appointment unless such 
cancellation was at the request of the Veteran. VA will take into 
consideration a Veteran's preference for in-person care as it develops 
any .
    Finally, VA notes that section 2 would require VA to engage in 
consultation with various stakeholders; this could invoke the Federal 
Advisory Committee Act and require VA to form multiple new Federal 
Advisory committees. VA recommends amending the bill's language to 
clarify that consultation activities are exempt from the Federal 
Advisory Committee Act. In the alternative, the consultation 
requirements could be removed, which would also address this concern.

_______________________________________________________________________

    Section 3 of the bill would amend 38 U.S.C. Sec.  1703(a) by adding 
a new paragraph (5) that would require VA to notify a covered Veteran 
in writing of the eligibility of the Veteran for care or services under 
this section within two business days of the date on which the Veteran 
seeks care or services under chapter 17 and VA determines the Veteran 
is a covered Veteran. VA could provide covered Veterans with a periodic 
notification of Veterans' eligibility, and notice could be provided 
electronically.

Position: VA does not support Section 3

    While VA agrees that timely eligibility notification is an integral 
component of VA's ability to provide Veterans quality care, a 
statutorily prescribed two-business day notification deadline would be 
administratively burdensome, especially in cases where notification by 
telephone or electronic communication is unavailable or in instances of 
walk-in emergency care. VA personnel would face administrative burdens 
if they were responsible for making notifications, which would come at 
additional cost to VA.
    It is also unclear what is anticipated as the penalty for non-
compliance in any situation where VA was unable to meet this 
requirement. VA welcomes the opportunity to work with the Committee to 
modify the process for notifying eligible Veterans to ensure they are 
notified in the timeliest fashion possible while avoiding some of the 
barriers that would be created by this section as written.

_______________________________________________________________________

    Section 4 of the bill would amend 38 U.S.C. Sec.  1703(d)(2) by 
adding new subparagraphs (F) and (G). These amendments would require VA 
to ensure that criteria developed to determine whether it would be in 
the best medical interest of a covered Veteran to receive care in the 
community the preference of the Veteran regarding where, when, and how 
to seek care and services and whether the covered Veteran requests or 
requires the assistance of a caregiver or attendant when seeking care 
or services.

Position: VA does not support Section 4

    While this section purports to include additional factors that 
would be considered by VA clinicians and Veterans when determining 
whether receiving care in the community is in the Veteran's best 
medical interest, the wording of these changes create ambiguity and may 
shift this decision-making from a joint decision to a unilateral one by 
the Veteran. Specifically, it is unclear whether the ``preference of 
the covered veteran regarding where, when, and how to seek hospital 
care, medical services, or extended care services'' would allow a 
Veteran unilaterally to determine his or her eligibility for community 
care if the Veteran stated a preference for community care. If the 
Veteran can choose to be seen in the community based on this 
preference, even if the provider did not agree, then by definition, the 
Veteran would be choosing to receive care that was not in the Veteran's 
best medical interest (in the judgment of the clinician). If, on the 
other hand, the Veteran's referring clinician only needed to 
``consider'' the Veteran's preference, but the preference was not 
determinative, it is not clear that this would have any effect on 
operations or eligibility, and thus would seem unnecessary. 
Determinations regarding a Veteran's best medical interest already 
considers the distance between a provider and the Veteran, the nature 
of the care or services required, the frequency of the care or 
services, the timeliness of available appointments, the potential for 
improved continuity of care, the quality of care, and whether the 
Veteran would face an unusual or excessive burden in accessing VA 
facilities.
    Further, by including ``whether the covered veteran requests or 
requires the assistance of a caregiver or attendant'' as a factor for 
determining whether it is in the Veteran's best medical interest to 
receive community, this similarly creates confusion as to how this 
factor would work in practice. VA agrees that a Veteran's need for an 
attendant or caregiver is relevant when making a determination as to 
whether receiving community care is in the best medical interest of the 
Veteran, and VA already considers this today (see 38 C.F.R. Sec.  
17.4010(a)(5)(vii)(E)). However, a Veteran's ``request'' for a 
caregiver or attendant does not establish need. The bill language would 
potentially allow Veterans who may not medically require a caregiver or 
attendant, but who request one for personal reasons, to qualify for 
community care.
    Ultimately, we do not believe the proposed changes could be 
implemented as written without fundamentally altering the process for 
making determinations about Veterans' best medical interest.

_______________________________________________________________________

    Section 5 of the bill would amend 38 U.S.C. Sec.  1703 by adding a 
new subsection (o) that would require VA, if a request for care or 
services under the VCCP is denied, to notify the Veteran in writing as 
soon as possible, but not later than two business days, after the 
denial is made of the reason for the denial and how to appeal such 
denial using VHA's clinical appeals process. If a denial were made 
because VA determined the access standards under section 1703B(a) were 
not met, the notice would have to include an explanation of the 
determination. Notice could be provided electronically.

Position: VA does not support Section 5

    Similar to section 3, VA is concerned that a statutorily prescribed 
two-business day notification deadline would be administratively 
burdensome, especially in cases where notification by telephone or 
electronic communication is unavailable. It is also unclear what is 
anticipated as the penalty for non-compliance in any situation where VA 
was unable to meet this requirement. As written, section 5 includes a 
paradox, proposed 38 U.S.C. Sec.  1703(o)(2) would State that if VA 
denied a request by a Veteran for care or services through the VCCP 
because the access standards are not met, VA would have to provide 
notice and an explanation of the determination. However, if VA was 
unable to schedule an appointment that met the designated access 
standards, then the Veteran would be eligible, so there would be no 
denial. We believe this was intended to apply when VA has determined 
that the access standards are met, and when a covered Veteran is 
ineligible for community care, rather than when the access standards 
are not met. We further note that the language would only apply to 
eligibility determinations regarding the access standards and would not 
apply to determinations regarding any other eligibility criteria.
    VA recommends modifying the process for notifying Veterans that VA 
has determined they are not eligible for community care to ensure they 
are notified in the timeliest fashion possible while avoiding some of 
the barriers that would be created by this section as written.

_______________________________________________________________________

    Section 6 of the bill would amend 38 U.S.C. Sec.  1703 by adding a 
new subsection (p) that would require VA to ensure that Veterans were 
informed that they could elect to seek care or services via telehealth, 
either through a VA medical facility or through the VCCP, if a health 
care provider in the VCCP provides such care or services via telehealth 
and VA determined that telehealth was appropriate for the type of care 
or service the Veteran seeks.

Position: VA supports section 6, with amendments

    As written, the bill would only require that ``a'' health care 
provider in the VCCP provide such care or services via telehealth, not 
necessarily that a provider who actually would furnish the care or 
services to the Veteran could do so via telehealth. We do not believe 
this result was the intended result, unless the language is 
specifically intended only to determine whether a Veteran would be 
willing to accept telehealth in general. It is unclear whether the bill 
is intended to ensure that a Veteran who, upon being informed of the 
option to receive care via telehealth declines to receive such care via 
telehealth, does not subsequently receive telehealth through the VCCP. 
If that is the case, that could result in additional costs to VA and 
could create network adequacy issues, as VA currently allows Veterans 
who decline VA-administered telehealth to receive telehealth from a 
community provider. VA welcomes the opportunity to discuss recommended 
amendments to this section with the Committee. We also would be happy 
to discuss the potential cost estimates with the Committee and others 
as needed.

_______________________________________________________________________

    Section 7 of the bill would amend 38 U.S.C. Sec.  1703 by adding a 
new subsection (q) that would prohibit VA from overriding an agreement 
between covered Veterans and their referring providers regarding the 
best medical interest of the Veteran to receive care in the community 
unless VA notified the Veteran and the referring provider in writing 
that VA could not provide the care or services described in the 
agreement.

Position: VA does not support Section 7

    Referring providers may not always have the specific information 
needed to know whether receiving community care is in the best medical 
interest of the Veteran. This section would prohibit reviews or 
corrections of erroneous use of the best medical interest criterion and 
would not be appropriate if there are clinical or other changes that 
might require changes to use of the best medical interest criterion. 
For example, a referring provider may be unaware of a Veteran's other 
conditions (such as when test results are pending or a referral with 
another is still pending) before agreeing that community care would be 
in the Veteran's best medical interest; other conditions may also arise 
during the course of treatment that would affect the best medical 
interest determination for a Veteran.
    Moreover, this bill would prevent the reconsideration of a best 
medical interest determination once it has been made and could 
consequently negatively impact the course of treatment based on these 
other factors.
    VA is concerned that this section could complicate determinations 
VA must make on whether the care is necessary and appropriate. This 
determination must occur prior to determining whether receiving care in 
the community would be in the Veteran's best medical interest. For 
example, VA currently requires that any Veteran that is potentially in 
need of a transplant be entered into the VA TRACER system for 
evaluation before a determination is made about the provision of the 
transplant. It is not clear whether this language would impact these 
determinations, but VA is concerned that it could be interpreted to 
prevent this type of clinical review.

_______________________________________________________________________

    Section 8 of the bill would amend 38 U.S.C. Sec.  1703 by adding a 
new subsection (r) that would require VA to conduct outreach to inform 
Veterans of the conditions for care or services under section 1703(d) 
and (e), how to request such care or services, and how to appeal a 
denial of a request for such care or services using VHA's clinical 
appeals process. VA would have to inform Veterans upon their enrollment 
in VA care, and not less frequently than every two years thereafter, 
about this information, and VA would have to ensure that this 
information is displayed publicly in each VA medical facility, 
prominently displayed on a VA website, and included in other outreach 
campaigns and activities conducted by VA. Section 8(b) would also amend 
38 U.S.C. Sec.  6320(a)(2)(A) would be amended to require VA, as part 
of the Solid Start program, to proactively reach out to newly separated 
Veterans to inform them of their eligibility for programs of and 
benefits provided by VA, including how to enroll in the system of 
annual patient enrollment under section 1705 and the ability to seek 
care and services under sections 1703 and 1710.

Position: VA does not support Section 8

    The provisions of section 8 are already common practice in the VA 
enrollment process as enrollment prompts automated communications with 
information about the benefits available to them.
    Under the VA Solid Start (VASS) program, VA conducts individualized 
conversations tailored to the needs of recently separated Service 
members to increase awareness and utilization of VA benefits and 
services. VASS calls are not scripted and are driven solely by the 
needs of the individual at the time of each interaction. Employees 
supporting VASS have the necessary training and resources to provide 
information about how to enroll in health care and seek community care 
for interested Veterans.
    As VASS contacts all recently separated Service members, regardless 
of their character of discharge, some VASS-eligible individuals may not 
be eligible for VHA benefits, including VCCP. Requiring VASS to discuss 
these benefits with all
    VASS-eligible individuals may create concern or frustration for 
those recently separated Service members who are not eligible for VHA 
benefits due to their character of discharge.
    VBA must allocate resources to allow for the extended time it would 
take to discuss these services with each VASS-eligible individual, 
which may negatively impact the overall program's successful connection 
rate. VA would require additional funding to support implementation and 
maintenance of this section.

_______________________________________________________________________

    Section 9 of the bill would amend 38 U.S.C. Sec.  1703(i)(5) to 
require VA to incorporate, to the extent practicable, the use of value-
based reimbursement models to promote the provision of high-quality 
care. It would further require VA to negotiate with third party 
administrators (TPA) to establish the use of value-based reimbursement 
models under the VCCP.

Position: VA supports Section 9

    VA currently has efforts underway to incorporate value-based care 
to improve outcomes and care coordination while lowering costs. 
However, generally speaking, any negotiations with TPAs or others who 
have existing contracts or agreements with VA would be subject to 
bilateral agreement on such terms. While VA may seek to incorporate 
such changes through negotiation, there is no guarantee that the non-VA 
party would agree to such terms.
    VA does not have a cost estimate at this time because the specific 
terms and parameters surrounding value-based reimbursement are subject 
to contract negotiations, and VA cannot predict what reimbursement 
models would be adopted through such negotiations. We would be happy to 
discuss the potential cost estimates with the Committee and others as 
needed.

_______________________________________________________________________

    Section 10 of the bill would amend 38 U.S.C. Sec.  1703D to extend 
from 180 days to one year the time period for health care entities and 
providers to submit claims to VA for payment for furnishing hospital 
care, medical services, or extended care services.

Position: VA does not support Section 10

    VA's contracts for community care generally include a 180-day 
timely filing requirement. Providers are aware of the 180-day timely 
filing requirement when agreeing to the contracts. Additionally, 
section 142 of the recently enacted Cleland-Dole Act amended 38 U.S.C. 
Sec.  1725 to require 180 days for timely filing, which is consistent 
with current section 1703D. VA believes the 180-day time limit is 
appropriate and ensures predictability and more accurate claims 
processing.
    We note, though, at present, claims for service-connected emergency 
care under 38 U.S.C. Sec.  1728 must be filed within two years of the 
date of service (see 38 C.F.R.Sec.  17.126), and claims under the 
Civilian Health and Medical Program of the Department of Veterans 
Affairs (CHAMPVA) must be filed within one year of the date of service 
(see 38 C.F.R. Sec.  17.276). CHAMPVA claims are generally processed 
separately, and claims under section 1728 represent a relatively 
smaller number of claims processed by VA. Further, because claims under 
section 1728 are claims for service-connected care, a longer filing 
period helps ensure more Veterans receive benefits under this 
authority, which seems justified based on their service-connected 
disabilities.
    In general, VA believes that a single, consistent filing timeline 
would make administration easier and more accurate and is concerned 
about the inconsistency this bill would create between sections 1703D 
and 1725.

_______________________________________________________________________

    Section 11 of the bill would amend 38 U.S.C. Sec.  1720A to require 
VA to determine whether a Veteran who requests residential treatment 
and rehabilitative services for alcohol or drug dependence under 
section 1720A requires such services not later than 72 hours after 
receipt of such request.

Position: VA does not support Section 11

    VA does not support a statutory requirement in this area. As 
written, the language is ambiguous as to whether a screening is 
required within 72-hours or whether care would need to be delivered 
within the 72-hour period. VA is already moving in the direction of 
conducting screening within 48-hours of a request of presentation of a 
need for care. We caution that a hard line in statute can prove 
difficult to administer in complicated cases (such as when a Veteran is 
known to need care but is not medically stable, as in the case of a 
recovering overdose), and the consequences of failure to meet the 72-
hour standard are not defined. Further, it is not clear if this is 
intended to establish eligibility for community care, and if so, how 
this is reconcilable with the changes proposed to section 1703B under 
section 2 of this bill.

_______________________________________________________________________

    Section 12 would require VA, acting through the Center for 
Innovation for Care and Payment, to seek to develop and implement a 
plan with a TPA to provide incentives to a covered health care provider 
(defined as a health care provider under section 1703(c) that furnishes 
care or services under the VCCP and that is served by a TPA), pursuant 
to an agreement with such TPA, (1) to allow VA and the TPA to see the 
scheduling system of the provider, to assess the availability of (and 
to assist in scheduling appointments for) Veterans under the VCCP, 
including through synchronous, asynchronous, and asynchronous assisted 
digital scheduling; (2) to complete continuing professional education 
(CPE) training regarding Veteran cultural competency and other subjects 
determined appropriate by VA; (3) to improve the rate of the timely 
return to VA of medical record documentation for care or services 
provided under the VCCP; (4) to improve the timeliness and quality of 
the delivery of care and services to Veterans under such program; and 
(5) to achieve other objectives determined appropriate by VA in 
consultation with TPAs. The plan would also need to decrease the rate 
of no-show appointments under the VCCP and consider the feasibility and 
advisability of appropriately compensating such providers for no-show 
appointments under the VCCP, and it would need to, within each region 
in which the VCCP is carried out, to assess needed specialties and to 
provide incentives to community providers in such specialties to 
participate in the VCCP.

Position: VA does not support Section 12

    VA does not support section 12 for several reasons. First, we do 
not believe it is necessary to specify the organization, the Center for 
Innovation for Care and Payment, that would carry out this effort. 
Second, and related, the Center for Innovation for Care and Payment was 
established pursuant to 38 U.S.C. Sec.  1703E, which defines specific 
conditions and parameters associated with some of the work of the 
Center. Specifically, when the Center carries out a pilot program that 
requires a waiver approved by Congress, there are limitations in terms 
of the number of projects, the funding, and specific reporting 
requirements that attach to such an effort. It does not appear that 
section 12 would require a waiver proposal, but we believe clarifying 
this would be important.
    Third, VA already has the authority to engage in efforts to support 
patient scheduling with community providers; indeed, sections 131-134 
of the Cleland-Dole Act requires VA to commence a pilot program under 
which covered Veterans eligible for care through the VCCP may use a 
technology that has the capabilities specified in section 133(a) to 
schedule and confirm medical appointments with health care providers 
participating in the VCCP. Fourth, given the contractual requirements 
that would be necessary to implement this section, the timeline 
(submitting a plan within 180 days) would be unrealistic. Fifth, we are 
concerned that the bill would prohibit VA from penalizing a health care 
provider or TPA for not carrying out any part of the plan; to the 
extent the plan is reflected in contract terms, this would seemingly 
preclude VA's ability to enforce contractual terms. Finally, VA is 
concerned with the way the specific parameters of this proposal could 
create contractual relationships between VA and VCCP providers who are 
part of a TPA's network. Currently, VA has contracts with TPAs, and the 
TPAs have contracts with individual providers. There is no privity of 
contract between VA and the TPA's providers, which means these 
providers are not subject to other requirements associated with Federal 
contractors. If the intent of the proposed changes is for VA to 
establish a direct contractual relationship with these providers, or if 
a relationship was imputed, this could change the obligations imposed 
upon these providers. There is also the potential that any contractual 
or other obligations between the provider and VA could conflict with 
requirements in the contract between the provider and the TPA. We 
recommend against creating a situation where providers could have 
conflicting requirements.

_______________________________________________________________________

    Finally, section 13 of the bill would require VA's Office of 
Inspector General (OIG), as OIG determines appropriate, to assess the 
performance of each VAMC in appropriately identifying Veterans eligible 
to elect to receive care through the VCCP; informing Veterans of their 
eligibility for care and services, including, if appropriate and 
applicable, the availability of such care and services via telehealth; 
delivering such care and services in a timely manner; and appropriately 
coordinating such care and services. OIG would have to commence the 
initial assessment within one year of enactment.

Position: VA has no objection, defers to OIG.

H.R. 3581 Caregiver Outreach and Program Enhancement Act (COPE Act)

    Section 2 of the draft bill would create a new 38 U.S.C. Sec.  
1720K, which would authorize VA to award grants to carry out, 
coordinate, improve, or otherwise enhance mental health counseling, 
treatment, or support to the Family Caregivers of Veterans 
participating in the Program of Comprehensive Assistance for Family 
Caregivers (PCAFC). VA would have to seek to ensure that grants awarded 
under this section were equitably distributed among entities located in 
States with varying levels of urbanization. VA would have to prioritize 
awarding grants that would serve areas with high rates of Veterans 
enrolled in PCAFC, as well as areas with high rates of suicide among 
Veterans or referrals to the Veterans Crisis Line (VCL). Grants would 
have to be used to expand existing programs, activities and services; 
establish new or additional programs, activities, and services; or for 
travel and transportation to facilitate carrying out existing or new 
programs described above. Grant amounts awarded could not exceed 10 
percent of amounts made available for grants under this section for the 
fiscal year in which the grant was awarded. Amounts necessary to 
support VA's activities under this section would have to be budgeted 
and appropriated through a separate appropriation account, and VA would 
have, in the budget justification materials submitted to Congress, have 
to include a separate statement of the amount requested to be 
appropriated for that fiscal year for this new separate account. There 
would be authorized to be appropriated $50 million for each of fiscal 
years 2023 through 2025 to carry out this section.

Position: VA does not support Section 2

    This section, while discretionary, would, if implemented, require 
significant additional administrative staff and resources to implement 
and manage these grants. Further, VA has recently begun using clinical 
resource hubs to provide direct mental health support to Family 
Caregivers using telehealth (which was an option for mental health 
support desired by a majority of PCAFC caregiver respondents in 
previous surveys), and we believe these efforts will help address the 
intended goal of this section, which is the provision of mental health 
support to Family Caregivers participating in PCAFC. As utilization of 
these services through the clinical resource hubs increases, we will 
continue to identify opportunities to expand (either programmatically 
or geographically) to address those needs. Further, VA medical centers 
continue to offer mental health support to Family Caregivers. In the 
context of existing initiatives, the proposed section 1720K would 
authorize grants that would supplement existing efforts and would not 
create new benefits entirely.
    VA has several technical concerns with the language in proposed 
section 1720K. The proposed distribution requirement, specifically 
requiring VA to ``seek to ensure that grants awarded under this section 
are equitably distributed among entities located in States with varying 
levels of urbanization'', is unclear and would be difficult to 
operationalize. Effectively every State has varying levels of 
urbanization as every State has both urban and rural areas, so the 
distribution requirement would seem to have no particular effect. If 
there is an intended outcome--other grant programs, for example, 
require VA to prioritize the award of grants to States with rural or 
highly rural populations or to territories or Tribal lands--we 
recommend this language be revised to State that intent clearly. 
Otherwise, we recommend its removal. The cap on grant amounts is also 
unclear, but seems intended to ensure that a single grant does not 
represent a disproportionate amount of the total grant funds awarded. 
VA has not had a similar issue with other grant programs and does not 
believe such a limitation is necessary. Also, the bill would set forth 
that activities would be budgeted and appropriated through a separate 
appropriation account. We note that no other VA grant program has a 
dedicated appropriations account, and it is unclear what would make 
this grant program unique in this regard. Additionally, the 
authorization of appropriations, as drafted, only applies to fiscal 
years 2023 through 2025, which would likely have elapsed by the time VA 
was ready to implement this authority. Finally, we recommend replacing 
the term ``enrolled'' in proposed section 1720K(d)(1) with the term 
``participating''.
    Section 3 would require the Comptroller General, within one year of 
enactment, to submit to Congress a report on the provision of mental 
health support to caregivers of Veterans. The report would have to 
include, for caregivers participating in VA's caregiver programs under 
38 U.S.C. Sec.  1720G(a) and (b), an assessment of the need for mental 
health support; an assessment of the options for mental health support 
in VA facilities and in the community; an assessment of the 
availability and accessibility of mental health support in VA 
facilities and in the community; an assessment of the awareness among 
caregivers of the availability of mental health support in VA 
facilities and in the community; and an assessment of barriers to 
mental health support in VA facilities and in the community.

Position: VA has no objection on Section 3, defers to the Comptroller 
General

    While VA generally defers to the Comptroller General on this 
section, we do note, however, that it is unclear whether the 
Comptroller General would be able to gather and analyze information to 
conduct the assessments that would be required by this section. We 
believe that reframing the assessments to focus on when, where, and why 
Family Caregivers use mental health support would be more effective and 
produce more meaningful results.

Conclusion

    This concludes my statement. We appreciate the Committee's 
continued support of programs that serve the Nation's Veterans and look 
forward to working together to further enhance the delivery of benefits 
and services to Veterans and their families.
                                 ______
                                 

                    Prepared Statement of Jon Retzer

    Chairwoman Miller-Meeks, Ranking Member Brownley and Members of the 
Subcommittee:
    Thank you for inviting DAV (Disabled American Veterans) to testify 
at today's legislative hearing of the Subcommittee on Health. DAV is a 
congressionally chartered non-profit veterans service organization 
(VSO) comprised of more than one million wartime service-disabled 
veterans that is dedicated to a single purpose: empowering veterans to 
lead high-quality lives with respect and dignity. DAV is pleased to 
offer our views on the bills under consideration today by the 
Subcommittee.

          H.R. 1182, the Veterans Serving Veterans Act of 2023

    H.R. 1182, the Veterans Serving Veterans Act of 2023, would amend 
the Department of Veterans Affairs (VA) Choice and Quality Employment 
Act and direct the Secretary of Veterans Affairs to establish a vacancy 
and recruitment database to facilitate the recruitment of certain 
members of the Armed Forces to satisfy the occupational needs of the VA 
to establish and implement a training and certification program for 
intermediate care technicians within the Department.
    Specifically, this legislation would amend Section 208 of the VA 
Choice and Quality Employment Act (Public Law 115-46; 38 U.S.C. 701 
note); the VA Secretary shall establish and maintain a single 
searchable data base (to be known as the Departments of Defense and 
Veterans Affairs Recruitment Data base) and that with respect to each 
vacant position, the military occupational specialty or skill that 
corresponds to the position, as determined by the VA Secretary, in 
consultation with the Secretary of Defense; and each qualified member 
of the Armed Forces who may be recruited to fill the position before 
such qualified member of the Armed Forces has been discharged and 
released from active duty.
    The database established regarding each qualified member of the 
Armed Forces would contain the following information:

      The name and contact information of the qualified member 
of the Armed Forces;

      The date on which the qualified member of the Armed 
Forces is expected to be discharged and released from active duty; and

      Each military occupational specialty currently or 
previously assigned to the qualified member of the Armed Forces.

    Information in the data base shall be available to VA offices, 
officials, and employees to the extent the VA Secretary determines 
appropriate. The VA Secretary shall hire qualified members of the Armed 
Forces who apply for vacant positions listed in the database and may 
authorize a relocation bonus, in an amount determined appropriate by 
the VA Secretary to any qualified member of the Armed Forces who has 
accepted a position listed in the database.
    The VA Secretary shall implement a program to train and certify 
covered veterans to work as intermediate care technicians in the 
department. The VA Secretary shall establish centers at medical 
facilities selected by the VA Secretary for carrying out the program.
    The Veterans Health Administration (VHA) faces rising challenges to 
meet the needs of a rapidly growing and changing health care system, 
which is plagued with staffing shortages to provide much needed 
veteran-centric health care needs. For VHA, this data base and list of 
potential qualified candidates from the ranks of the Department of 
Defense would provide another selection pool of qualified and 
potentially peer support clinical specialists and providers. VHA must 
be able to not only retain their highly trained staff but aggressively 
look at all means to successfully recruit highly trained and dedicated 
professionals to ensure and deliver sustainable quality health care and 
continual performance improvement for the Nation's veterans.
    DAV supports H.R. 1182, in accordance with DAV Resolution No. 056, 
as it supports a simple-to-administer alternative VHA personnel system, 
in law and regulation, which governs all VHA employees, applies best 
practices from the private sector to human capital management, and 
supports pay and benefits that compete with the private sector and 
urges VA to consider campaigns to target service members in health care 
and other appropriate occupations separating from the military and 
develop systems for expedited hiring and credentialing to onboard them.

                        H.R. 1278, the DRIVE Act

    H.R. 1278, the Driver Reimbursement Increase for Veteran Equity 
(DRIVE) Act, would increase the mileage reimbursement rate for veterans 
receiving health care from the Department of Veterans Affairs (VA).
    Congress passed legislation in 2010 to set the mileage 
reimbursement rate at a minimum of $0.41 per mile, which was comparable 
at the time to rates federal employees were reimbursed for work-related 
travel. This law also gave the VA Secretary the authority to increase 
rates going forward to be consistent with the mileage rate for federal 
employees for the use of their private vehicles on official business, 
as established by the Administrator of the General Services 
Administration (GSA). Since the enactment of this law, the VA travel 
mileage reimbursement rate has not kept pace with increasing gas prices 
and costs of auto maintenance and insurance, which have significantly 
increased in the most recent years. Meanwhile, the GSA rate has 
increased over time to $0.655 per mile.
    According to the U.S. Department of Energy (DOE), the average price 
for a gallon of regular gas during the week of March 1, 2010, when VA's 
mileage rate was last increased, was $2.671 per gallon. During the week 
of February 13, 2023, the average was $3.390 per gallon, and on the 
West Coast, it was $4.106 per gallon.
    The DRIVE Act would require the VA to ensure the Beneficiary Travel 
reimbursement rate is at least equal to the GSA reimbursement rate for 
federal employees. This will ensure VA's reimbursement rates keep up 
with the cost of inflation and properly account for fluctuations in gas 
prices over time.
    Veterans who are seeking care for service-connected conditions or 
veterans with service-connected conditions rated at least 30 percent 
are among veterans who are eligible for beneficiary travel pay--which 
may include reimbursement for mileage, tolls and additional expenses, 
such as meals or lodging.
    Unfortunately, the current mileage rates for beneficiary travel do 
not always cover the actual expenses for gas and the associated costs 
of using a personal vehicle. The difference in the current mileage rate 
for reimbursement for veterans (41.5 cents) compared to federal 
employees using personal vehicles for business (65.5 cents) highlights 
the inadequacy of the rate for veterans' travel. Such expenses may 
serve as a barrier to care, especially when gas prices are high. 
However, the DRIVE Act would tie veterans' mileage reimbursement to the 
rate of government employees receive for using their personal vehicles 
for government business.
    Veterans should not have to choose between getting the care they've 
earned and deserve, and the rising cost of travel to access their 
needed care. This legislation would provide much needed improvement by 
ensuring that veterans are not burdened with travel expenses, in 
particular low-income veterans and rural area veterans who heavily 
depend on VA's travel reimbursement program.
    DAV supports H.R. 1278, the DRIVE Act, in accordance with 
Resolution No. 432, which calls for adopting the General Services 
Administration increased mileage rate for veterans' beneficiary travel.

    H.R. 1639, the VA Zero Suicide Demonstration Project Act of 2023

    H.R. 1639, the VA Zero Suicide Demonstration Project Act of 2023, 
would improve suicide and mental health care for veterans by launching 
the Zero Suicide Initiative Pilot Program at the Department of Veterans 
Affairs (VA).
    In 2019, there was an average of more than 17 U.S. veterans dying 
from suicide per day at a rate 52.3 percent higher than non-veterans. 
40 percent of veteran suicides were among active VA patients. For 
veterans who have served since September 11, 2001, the rate is even 
more alarming, with 30,117 active-duty service members and veterans 
dying by suicide, over four times the number of combat deaths over the 
past two decades. These statistics support the need to pilot 
alternative intervention methods at VA facilities to improve veteran 
care, diminish the risk of suicide, and help keep safe those who have 
sacrificed to serve our Nation.
    Congress and the VA must do everything in their power and authority 
to address the epidemic of veteran suicide. Every day, 17 veterans take 
their own lives, and we must work collectively until we get that number 
down to zero. Our nation has an obligation to ensure that our veterans 
get the health care, including mental health care, they need.
    This legislation would initiate pilot program to implement the Zero 
Suicide Institute curriculum to improve veteran safety and suicide care 
that stems from the Henry Ford Health Care System, built on the belief 
that all suicides are preventable through proper care, patient safety, 
and system-wide efforts. The model has delivered clear decreases in 
suicide rates through innovative care pathways to assess and diminish 
suicide risk for patients across care systems. In consultation with 
experts and veteran service organizations, the VA Secretary would 
select five medical centers to receive training and support under the 
pilot program to demonstrate the effectiveness of the Zero Suicide 
Framework to better combat suicides across the entire VA.
    The VA Zero Suicide Demonstration Project Act would bolster 
clinical training, assessments, and resources to test the effectiveness 
of implementing the Zero Suicide Model at five VA centers. This model 
has proven successful in decreasing suicide rates in other health care 
settings through innovative care pathways, as noted in the Henry Ford 
Zero Suicide Prevention Guidelines.
    Losing one service member or veteran to suicide is one too many. 
Our veterans have served our Nation, and they have earned the right to 
affordable, accessible and high-quality VA mental health care. This 
bipartisan legislation will take a positive step by establishing the 
Zero Suicide Initiative Pilot Program and bolstering the mental health 
care services that our hero veterans receive.
    DAV supports H.R. 1639, the VA Zero Suicide Demonstration Project 
Act of 2023, in accordance with DAV Resolution No. 059, which calls for 
legislation to support program improvements, data collection and 
reporting on suicide rates among service members and veterans; improved 
outreach through general media for stigma reduction and suicide 
prevention; sufficient staffing to meet demand for mental health 
services; and enhanced resources for VA mental health programs.

             H.R. 1774, the VA Emergency Transportation Act

    H.R. 1774, VA Emergency Transportation Act, would reimburse 
veterans for the cost of emergency medical transportation to a federal 
facility.
    The Veterans Transportation Service (VTS) provides safe and 
reliable transportation to veterans who require assistance traveling to 
and from VA health care facilities and authorized non-VA health care 
appointments. This program offers these services at little or no cost 
to eligible veterans.
    VA's Beneficiary Travel (BT) program reimburses eligible veterans 
for costs incurred while traveling to and from VA health care 
facilities. The BT program may also provide pre-approved transportation 
solutions and arrange special mode transportation (SMT) at the request 
of VA. Veterans may be eligible for common carrier transportation (such 
as bus, taxi, airline or train) under certain conditions.
    The Highly Rural Transportation Grants (HRTG) program provides 
grants to VSOs and State veteran service agencies. The grantees provide 
transportation services to veterans seeking VA and non-VA approved care 
in highly rural areas.
    Since 1987, DAV has donated 3,665 vehicles to VA and Ford Motor Co. 
has donated 256 vehicles at a cost of more than $92 million. DAV 
operates a fleet of vehicles around the country to provide free 
transportation to VA medical facilities for injured and ill veterans. 
DAV stepped in to help veterans get the care they need when the federal 
government terminated its program that helped many of them pay for 
transportation to and from medical facilities. The vans are driven by 
volunteers, and the rides coordinated by more than 156 DAV Hospital 
Service Coordinators around the country.
    However, none of the above transportation services address the 
needs during a medical emergency to seeking immediate medical attention 
that was reasonably expected to be hazardous to life and health.
    This legislation would amend Section 1725 of title 38, United 
States Code by redefining emergency treatment as services and that such 
services include emergency treatment and emergency transportation. The 
bill would codify emergency transportation to mean transportation of a 
veteran by ambulance or air ambulance by a non-Department provider to a 
facility for emergency treatment; or from a non-Department facility 
where such veteran received emergency treatment to a Department or 
other federal facility, which would expand access and eligibility to 
much needed service for reimbursement of emergency care related to 
ambulance transportation.
    DAV supports H.R. 1774, in accordance with DAV Resolution No. 148, 
which supports legislation to simplify the eligibility for urgent and 
emergency care services paid for by the VA and urges the Department to 
provide a more liberal and consistent interpretation of the law 
governing payment for urgent and emergency care and reimbursement to 
veterans who have received emergency care at non-VA facilities.

   H.R. 1815, the Expanding Veterans' Options for Long Term Care Act

    H.R. 1815, the Expanding Veterans' Options for Long Term Care Act, 
would require the Secretary of Veterans Affairs to carry out a pilot 
program to provide assisted living services to rapidly growing 
population of aging or disabled veterans who are not able to live at 
home.
    This legislation would require the Secretary of Veterans Affairs to 
carry out a three-year pilot program to assess the effectiveness of 
providing assisted living services to eligible veterans who are 
currently receiving nursing home care through the department in not 
fewer than six VA Veterans Integrated Service Networks.
    Title 38, United States Code, subsection 1720C(a)(1), (2) notes 
that ``the Secretary may furnish medical, rehabilitative, and health-
related services in noninstitutional settings for veterans who are 
eligible under this chapter for, and are in need of, nursing home care 
for veterans who are in receipt of, or are in need of, nursing home 
care primarily for the treatment of a service-connected disability; or 
have a service-connected disability rated at 50 percent or more.''
    Over the next two decades, an aging veteran population, including a 
growing number of service-disabled veterans with specialized care 
needs, will require long-term care (LTC). While the overall veteran 
population is decreasing, the number of veterans in the oldest age 
cohorts with the highest use of LTC services is increasing 
significantly. For example, the number of veterans with disability 
ratings of 70 percent or higher, which guarantees mandatory LTC 
eligibility, and who are at least 85 years old is expected to grow by 
almost 600 percent--therefore, costs for LTC services and supports will 
need to double by 2037 just to maintain current services.
    In order to meet the exploding demand for LTC for veterans in the 
years ahead, Congress must provide VA the resources to significantly 
expand home-and community-based programs, while also modernizing and 
expanding facilities that provide institutional care. The VA must focus 
on addressing staffing and infrastructure gaps in order to maintain 
excellence in skilled nursing care. The VA also needs to expand access 
nationwide to innovative and cost-effective home-and community-based 
programs, such as veteran-directed care and medical foster home care. 
Unfortunately, funding for home-and community-based services in recent 
years has not kept pace with population growth, demand for services or 
inflation. For noninstitutional care to work effectively, these 
programs must focus on prevention and engage veterans before they have 
a devastating health crisis that requires more intensive institutional 
care.
    DAV supports H.R. 1815, in accordance with DAV Resolution No. 016, 
which supports legislation to improve the VA's program of long-term 
services and supports for service-connected disabled veterans 
irrespective of their disability ratings, and urges the Department to 
ensure each VA medical facility is able to provide service-connected 
disabled veterans timely access to both institutional and 
noninstitutional long-term services and supports.

                H.R. 2683, the VA Flood Preparedness Act

    H.R. 2683, the VA Flood Preparedness Act, would authorize the 
Secretary of Veterans Affairs to make certain contributions to local 
authorities to mitigate the risk of flooding on local property adjacent 
to VA medical facilities.
    This legislation would amend Section 8108 of title 38, United 
States Code, by adding language to mitigate the risk of flooding, 
including the risk of flooding associated with rising sea levels 
adjacent to VA medical facilities.
    The bill would require the VA Secretary to submit to the House and 
Senate Veterans' Affairs Committees a report that includes an 
assessment of the extent to which each medical facility is at risk of 
flooding, including the risk of flooding associated with rising sea 
levels; and whether additional resources are necessary to address the 
risk of flooding at each such facility.
    DAV does not have a specific resolution to authorize the VA 
Secretary to make certain contributions to local authorities to 
mitigate the risk of flooding on local property adjacent to medical 
facilities of the VA as outlined in H.R. 2683 and takes no formal 
position on this bill.

      H.R. 2768, the PFC Joseph P. Dwyer Peer Support Program Act

    H.R. 2768, the PFC Joseph P. Dwyer Peer Support Program Act would 
require the Secretary of Veterans Affairs (VA) to establish a grant 
program to be known as the ``PFC Joseph P. Dwyer Peer Support Program'' 
under which the Department shall make grants to eligible nonprofit 
organization having historically served veterans' mental health needs, 
congressionally chartered veterans service organization and state, 
local, or tribal veteran service agency, director, or commissioner for 
the purpose of establishing peer-to-peer mental health programs for 
veterans.
    The recipient of a grant would receive an amount that does not 
exceed $250,000 and would be required to carry out a program that meets 
the standards to hire veterans to serve as peer specialists to host 
group and individual meetings with veterans seeking nonclinical 
support; provide mental health support to veterans 24 hours each day, 
seven days each week; and hire staff to support the program.
    The VA Secretary would be required to establish an advisory 
committee for the purpose of creating appropriate standards applicable 
to programs established using grants under this section. The standards 
would include initial and continued training for veteran peer 
volunteers, administrative staffing needs, and best practices for 
addressing the needs of each veteran served, with an authorized 
appropriation of $25,000,000 to carry out the program during the 3-year 
period.
    Over a century of service, DAV's main goal has been to provide the 
best, most professional claims representation to all injured and ill 
veterans and their families and survivors. An integral part of that 
goal is fielding a knowledgeable, well-trained nationwide corps of 
national and transition service officers who can extend our advocacy 
and outreach to those who need our services not only as fellow veterans 
but also injured/ill veterans who have navigated and use the VA. This 
has provided an opportunity to build trust in not only the benefits 
claims/appeals process but also the confidence of the quality of care 
VHA provides to include mental health care, through our own personal 
experiences we share as veterans through our advocacy of being service 
officers. This relationship of veterans serving veterans has assisted 
in bridging the complexity and bureaucracy of the VA benefits and 
health care systems for fellow veterans to know they are not alone with 
their VA journey.
    Expanding peer specialist support through to eligible nonprofit 
organization having historically served veterans' mental health needs, 
congressionally chartered veteran service organization and state, 
local, or tribal veteran service agency, director, or commissioner can 
be of great support to the veterans and to the VA.
    Trained peer specialists can help veterans to reach identified 
personal goals for their recovery and wellness. Peer specialists serve 
as role models to veterans. And can share their personal recovery 
stories, model skills that help recovery, help with personal goal 
setting and problem solving, help learn new coping strategies and 
improve their self-management over their mental health problems.
    DAV supports H.R. 2768, in accordance with DAV Resolution No. 059, 
which calls for legislation to support mental health program 
improvements, data collection and reporting on suicide rates among 
service members and veterans.

           H.R. 2818, the Autonomy for Disabled Veterans Act

    H.R. 2818, the Autonomy for Disabled Veterans Act, would increase 
the amount of funding available to disabled veterans for improvements 
and structural alterations provided to them by the VA for home 
improvements related to their disability.
    Veterans who need and receive Home Improvements and Structural 
Alterations (HISA) grants because of a service-connected disability 
receive up to $6,800 and those who are rated 50 percent service 
connected or greater may receive the same amount even if a modification 
is needed because of a nonservice-connected disability. Veterans who 
are not service connected but are enrolled in the VA health care system 
can receive up to $2,000 for needed home modification. These are the 
maximum amounts an eligible veteran can receive in their lifetime. HISA 
rates have not changed since Congress last adjusted them in 2010. 
However, the cost of home modifications and labor has risen more than 
40 percent during the same timeframe.
    This bipartisan legislation would increase the amount of funding 
for VA grants for disabled veterans to make necessary modifications to 
their homes to fit their needs, including wheelchair ramps, structural 
changes, medical equipment, and would adjust the amount to account for 
inflation.
    Veterans have made incredible sacrifices for our nation's freedom 
and bear the scars of their service every day. Therefore, it is only 
fitting that this Nation, Congress and VA keep the promise to ensuring 
that they are adequately provided for and to ensuring that they can all 
lead high quality lives.
    DAV supports H.R. 2818, in accordance with DAV Resolution No. 326, 
which calls for a reasonable increase in HISA benefits for veterans.

          H.R. 3520, the Veterans Care Improvement Act of 2023

    H.R. 3520, the Veterans Care Improvement Act of 2023, would make 
numerous changes to the Veterans Community Care Program that offers 
veterans the option to use non-VA health care providers when VA is 
unable to provide medically necessary care in a timely or accessible 
manner.
    Section 2 of the bill would codify current access standards that VA 
adopted via regulation as required by the VA MISSION Act of 2018. 
Current access standards for primary care, mental health care, and 
extended care are 20 days waiting time or 30 minutes driving time; 
access standards for specialty care are 28 days waiting time or 60 
minutes driving time. As required by the VA MISSION Act, the department 
reviewed those access standards in 2021 and made no changes to them.
    This section would add a new access standard for residential 
treatment and rehabilitative services for alcohol or drug dependence: 
10 days waiting time or 30 minute driving time.
    As history has shown, establishing arbitrary or unachievable access 
standards does not improve health outcomes. We are not convinced that 
codifying already existing access standards, and creating new ones for 
drug and alcohol treatment, while at the same time limiting future 
regulatory flexibility to adjust them, will lead to better health 
outcomes.
    In addition, this section would remove the requirement that VA 
provide veterans with, ``...relevant comparative information that is 
clear, useful, and timely, so that covered veterans can make informed 
decisions regarding their health care.''
    DAV believes that providing comparative information about the 
quality and timeliness of care is critical for veterans to make truly 
informed decisions about where to receive their care.
    Section 3 would add a new requirement that VA provide written 
notification of community care eligibility to all veterans who seek 
care from VA or who VA determines are eligible for care from VA. We 
have concerns about the cost and administrative burden for this 
requirement.
    Section 4 would add a new provision to require the VA to give 
consideration to the preference of each veteran seeking community care. 
It also requires VA to give consideration to whether a veteran has a 
caregiver when determining eligibility for community care. It is not 
clear how or why VA would consider a caregiver in determining community 
care eligibility.
    Section 5 would require VA to provide formal notification in 
writing within 2 days of every determination that a veteran is not 
eligible for community care.
    Section 6 would require VA to inform veterans eligible for 
community care of options for telehealth care, when considered 
medically appropriate, both from VA and from community care providers.
    Section 7 would mandate that a ``best medical interest'' 
determination by a veteran and their referring physician to provide 
that veteran medical care through a community provider cannot be 
overridden by any VA official, unless VA is legally prohibited from 
providing that care.
    Section 8 would create new outreach requirements for VA to notify 
all enrolled veterans of how to request community care and how to file 
clinical appeals if they are not found eligible for community care. 
Along with public outreach efforts, VA would have to repeat its direct 
outreach to all veterans every two years.
    Section 9 would mandate that VA begin using value-based 
reimbursement models in the Veterans Community Care Program.
    Section 10 would extend the length of time community providers are 
allowed to submit claims to VA for payment from six months to one year 
following the date they provided care to a veteran.
    Section 11 would require that VA determinations about whether 
veterans requesting residential treatment or rehabilitative services 
for alcohol or drug dependence be made within 72 hours after receiving 
such a request.
    Section 12 would create a pilot program to provide incentives to 
community care providers who commit to meeting certain objectives to 
increase their participation in the community care program. However, VA 
would be prohibited from penalizing a participating provider, or third 
party administrator overseeing the provider, if they fail to meet the 
objectives of the pilot program.
    Section 13 would require an assessment by the VA Inspector General 
three years after enactment of the law to assess the performance of 
each VA medical center in identifying and informing veterans eligible 
for the community care program, including telehealth, as well as 
delivering and coordinating such care.
    While DAV strongly supported the VA MISSION Act and the creation of 
the Veterans Community Care Program, we have questions and concerns 
about some sections of this legislation.
    The new notification and outreach requirements in the bill could 
add significant administrative burden and expense to VA's health care 
providers and place additional strain on VA's health care budget absent 
new and dedicated resources for those purposes. We also have serious 
concerns about whether a value-based reimbursement model for community 
care would improve the quality of care; particularly since VA has never 
been able to establish quality standards for private sector health care 
providers.
    We certainly agree that whenever and wherever VA is unable to 
provide timely, accessible, and high-quality care to enrolled veterans, 
VA must provide other health care treatment options. At the same time, 
we believe it is critical to strengthen and sustain the VA health care 
system that millions of veterans choose and rely on for all or most of 
their care. As numerous studies continue to show, the care provided by 
VA is equal to or better than private sector care on average. For this 
reason, VA must remain the primary provider and coordinator for 
enrolled veterans' medical care. While we support the intention of 
improving the VA community care program, we do not support moving this 
legislation forward at this time.

  H.R. 3581, the Caregiver Outreach and Program Enhancement (COPE) Act

    H.R. 3581, the Caregiver Outreach and Program Enhancement (COPE) 
Act, would increase mental health resources available to caregivers who 
care for our nation's veterans.
    Currently, the VA Program of General Caregiver Support Services 
(PGCSS) and the Program of Comprehensive Assistance for Family 
Caregivers (PCAFC) provide certifications and resources to veterans' 
caregivers.
    Under PGCSS, general caregivers are defined as any person who 
provides personal care services to a veteran enrolled in VA health care 
who needs assistance with one or more activities of daily living and 
needs supervision or protection based on symptoms or residuals of 
neurological impairment or other impairment or injury.
    General caregivers have access to training and support through 
online, in-person, and telehealth sessions; skills training focused on 
caregiving for a veteran's unique needs; individual counseling related 
to the care of the veteran; and respite care, giving caregivers short 
breaks.
    The PFCAC program specifically targets family members or close 
friends who decide to take on caregiver responsibility for veterans. 
While its requirements are more stringent, the PFCAC provides stipends 
to caregivers that meet these requirements (in addition to the 
resources given to general caregivers).
    The COPE Act would authorize the VA to provide grants to 
organizations whose mission is focused on the mental health care of 
participants in the PFCAC. This legislation would increase mental 
health resources available to caregivers through grant programs for 
entities that support caregiver mental health and well-being. 
Additionally, it requires that the VA must provide outreach to 
registered caregivers, as well as provide specific directives for 
meeting the needs of underserved populations.
    DAV supports H.R. 3581, in accordance with DAV Resolution No.082, 
which calls for legislation to support mental health programs to 
provide psychological and mental health counseling services to family 
members of veterans suffering from post-deployment mental health 
challenges or other service-connected conditions.
    This concludes my testimony on behalf of the DAV.
                                 ______
                                 

                  Prepared Statement of Tiffany Ellett
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 

                    Prepared Statement of Cole Lyle

    Chairwoman Miller-Meeks, Ranking Member Brownley, and members of 
the subcommittee, on behalf of Mission Roll Call, a non-partisan 
program of America's Warrior Partnership, and the roughly 1.4 million 
veterans and supporters who have opted-in to our digital advocacy 
network, thank you for the opportunity to provide their feedback 
through our remarks on pending legislation. While all the proposed 
bills are worthy of discussion and will have impacts on the veteran 
community, MRC's three main priorities are veteran suicide prevention, 
access to healthcare and benefits, and amplifying the voices of 
traditionally underserved populations. For this reason, in our 
testimony, MRC will focus on four specific bills on the docket for 
which we have polling data or learned in-person veteran experiences.

H.R. 3520, Veteran Care Improvement Act of 2023

    MRC strongly supports this legislation as a necessity to ensure 
veterans receive timely access to quality care. The MISSION Act of 2018 
was a bipartisan effort to improve accessibility to healthcare for 
veterans by streamlining the congealed process that existed via the 
CHOICE Act. Congress' intent with MISSION was clear: the VA must 
increase access to private doctors when the Veterans Health 
Administration couldn't provide care in a reasonable time and/or 
distance, or if access to an outside provider was in the best medical 
interest of the veteran.
    In 2021, reports surfaced that VA administrators were overruling 
decisions by VA doctors and patients to keep veterans in the system, in 
some cases cutting off care entirely. The article confirmed what many 
veteran service organizations providing care coordination and casework 
already knew: that to protect VA's parochial interests, it was 
unnecessarily difficult for veterans to access care in the community 
when it was in their best medical interest. In 2022, 4 years after 
MISSION passed, Secretary McDonough testified community care now 
accounted for one-third of VA's healthcare budget. As a result, the 
Secretary said the VA would look at changing access standards and use 
telehealth availability to determine wait times. In response, MRC 
conducted a poll on the issue, and with over 6,300 veteran responses 
across America, 81 percent said Congress should codify the access 
standards.

      Further, MRC asked questions on the more general veteran 
experience accessing community care. With an average of 6,200 responses 
across 7 unique polls:

        60 percent of veterans said their providers don't make them 
        aware of this option after a delay in care;

      37 percent said they had experienced a delay or 
postponement of any healthcare appointment at a VA facility;

      71 percent said they were not referred to the community 
after a delay in mental health or other specialty care at a VA 
facility;

      22 percent experienced problems scheduling the care once 
referred; 14 percent said their providers referred them to the 
community but the referral was later denied by the VA upon review;

      21 percent said their providers scheduled them a 
telehealth to access their healthcare when they preferred in-person 
visits.

    This data clearly indicates there is a problem simmering under the 
surface on this issue.
    But this problem can be found in more than just statistics. During 
MRC's geographically and demographically diverse fact-finding tour last 
year, meeting with over 5,000 veterans individually in California, 
Texas, Florida, Alaska, Arizona, Idaho, Montana, and elsewhere, these 
problems were borne out in more than just statistics. While veterans 
who had good experiences at the VA mitigated their issues and went on 
living their lives productively, those with negative experiences 
accessing healthcare at VA facilities or with referrals to community 
care either gave up trying or were not shy to tell other veterans they 
should stay away from VA. These issues ranged from simple primary care 
appointments for things like allergies, to significant mental health 
issues. A few stark responses from veterans said they knew peers whose 
mental health spiraled after being frustratingly unable to access 
mental healthcare when and where they needed it. To the best of my 
knowledge, luckily none of these examples ended with a suicide attempt. 
But with less than 50 percent of the U.S. Census Bureau's estimated 
17.4 million veterans in America enrolled in VA, and even less using it 
on a regular basis, making it harder to access healthcare when needed 
is counterproductive to the VA's interest, regardless where the care 
takes place.
    As the VA is the largest health care system in the country and the 
second-largest Federal agency behind the Department of Defense, it's 
understandable why officials sometimes make big decisions with respect 
to workforce recruitment and retention. However, Congress must ensure 
the agency keeps the veteran, not agency interests, as their North 
Star, and not defer or be unduly influenced by workforce considerations 
when those decisions could negatively impact the individual veterans' 
ability to seek healthcare. After all, the VA's core mission is to care 
for those who have borne the battle.
    MRC is a successful program of America's Warrior Partnership, which 
has also supported a similar bill in the Senate, the Veteran's HEALTH 
Act. We hope the House and Senate can pass both bills and come together 
on a bipartisan basis to pass this urgently needed legislation to 
protect veteran access to timely healthcare, whether that is in a VA 
facility or not.

H.R. 2768, PFC Joseph P. Dwyer Peer Support Program

    MRC supports this legislation that would require the Secretary to 
establish a grant program to benefit eligible entities for the purposes 
of establishing peer-to-peer mental health programs for veterans.
    Recently, MRC conducted a poll that asked if former service members 
with mental health challenges should be able to access the provider of 
their choice, regardless of whether the care was in a VA facility or in 
the community. With 7,200 responses, 94 percent said yes. With less 
than 50 percent of the estimated 17.4 million U.S. veterans enrolled in 
VA care, the Department must expand its use of grant funding to local 
organizations with touchpoints in the veteran community the VA simply 
does not have. Integrating local, non-governmental resources into a web 
of connectivity for veteran care is crucial in our fight against 
veteran suicide.
    Successful peer-to-peer programs, whether through VA facilities 
like Vet Centers, community programs of America's Warrior Partnership 
across the country, resources like the Vets4Warriors line, or Boulder 
Crest Foundation events, show remarkable results where evidenced-based 
treatments fail. No one can better understand the struggles a veteran 
may be going through than another veteran. These resources provide 
confidential and free support through programs, case coordination, and 
conversations which help veterans in crisis or dealing with a non-
crisis issue that may or may not be mental health related.
    However, given the short window of applications for a similar grant 
program which negatively affected smaller organizations the program was 
intended to assist, MRC has concerns that if VA is not given a mandate 
to provide a reasonable window of time, history will repeat itself. The 
organizations on the ground doing this work must be laser-focused on 
programmatic activity and may not have a full-time employee whose job 
is to apply for grants and follow-up on government reporting 
requirements.

H.R. 1639, VA Zero Suicide Demonstration Project Act of 2023

    MRC supports this legislation that would require the Secretary to 
establish a pilot program to institute the ``Zero Suicide Initiative,'' 
which seeks to improve safety and suicide care for veterans at select 
VA facilities.
    VA providers, generally, understand the unique traumas of veterans 
in crisis. However, according to the VA's treatment decision guide for 
mental health issues, the effectiveness of evidenced-based treatments--
talk therapy and pharmacology--have variable success rates of 53 
percent and 40 percent, respectively. Providing VA clinicians with 
another resource to improve their ability to handle veterans in crisis 
and refer them for ``comprehensive assessment of suicidality'' would 
bolster the VA's ability to refer and treat veterans with the 
appropriate resource they require, whether that is evidenced-based 
treatment or a more holistic approach to suicide prevention.
    The VA is not going to counsel or prescribe its way out of a mental 
health crisis. Every veteran is different and needs a holistic 
approach.

H.R. 1774, VA Emergency Transportation Act

    Under current law, VA only covers emergency travel to hospitals 
within their network. If a veteran seeks care for an emergent health 
issue at a non-VA facility, reimbursed by VA under current law and 
regulation, that veteran could still be hit with an expensive, surprise 
bill for ambulatory care. Given that acute financial stress is a major 
driver of suicide, MRC supports this legislation that would require the 
Secretary to reimburse veterans for the cost of emergency medical 
transportation to a healthcare facility. If a veteran requires care 
that the VA provides, either at a VA facility or community provider, it 
makes sense that the VA should cover the cost of that entire episode of 
care, from the moment a veteran requires assistance to complete 
convalescence.
    Chairwoman Miller-Meeks, this concludes my testimony. Mission Roll 
Call would like to thank you and Ranking Member Brownley for the 
opportunity to testify on these important issues before this 
subcommittee. I am prepared to take any questions you or the 
subcommittee members may have.

                       Statements for the Record

                              ----------                              


             Prepared Statement of Wounded Warrior Project

    Chairwoman Miller-Meeks, Ranking Member Brownley, and distinguished 
members of the House Committee on Veterans' Affairs, Subcommittee on 
Health - thank you for the opportunity to submit Wounded Warrior 
Project's views on pending legislation.
    Wounded Warrior Project (WWP) was founded to connect, serve, and 
empower our nation's wounded, ill, and injured veterans, Service 
members, and their families and caregivers. We are fulfilling this 
mission by providing more than 20 life-changing programs and services 
to more than 190,000 registered post-9/11 warriors and 48,000 of their 
family support members, continually engaging with those we serve, and 
capturing an informed assessment of the challenges this community 
faces. We are pleased to share that perspective for this hearing on 
pending legislation that would likely have a direct impact on many we 
serve.

H.R. 3520, the Veterans Care Improvement Act

    Opioid and substance use disorders (SUDs) continue to rank as one 
of the top self--reported - and objectively verified - health 
challenges faced by those who complete WWP's Annual Warrior Survey. In 
our 2022 report \1\, more than two in five responding warriors screened 
positive for potentially hazardous drinking or alcohol use disorders 
(43.5 percent) and over 6 percent showed a moderate to severe level of 
problems related to drug abuse. VA estimates that among veterans that 
served in Iraq and Afghanistan, about 1 in 10 have a problem with 
alcohol or drugs. Unfortunately, many of these veterans face 
difficulties when attempting to get treatment for substance use issues.
---------------------------------------------------------------------------
    \1\ Our Annual Warrior Survey reference corresponds to the 
thirteenth edition of the survey, which was published in 2023 and 
reflects data gathered in 2022. To learn more, please visit https://
www.woundedwarriorproject.org/mission/annual-warrior-survey.
---------------------------------------------------------------------------
    Mental Health Residential Rehabilitation Treatment Programs (MH 
RRTPs) represent the most intensive level of care for veterans with 
SUDs and other conditions, like PTSD, military sexual trauma (MST) and 
serious mental illness (SMI) at the Department of Veterans Affairs 
(VA). The VA MISSION Act (P.L. 115-182 Sec.  104) required VA to 
establish access standards for community care and in 2019, VA announced 
those access standards for primary care, mental health, specialty care, 
and non-institutional extended care services. However, VA did not 
include a specific access standard for residential care. Instead, VA 
relies on VHA Directive 1162.02 to establish when a veteran is eligible 
for residential treatment in the community. The Directive states that 
veterans requiring priority admission must be admitted within 72 hours. 
For all other veterans, they must be admitted as soon as possible after 
a decision has been made. If they cannot be admitted within 30 days, 
they must be offered treatment at a residential program within the 
community.
    Unfortunately, this is often not the reality on the ground. WWP has 
frequently ran into issues when trying to place veterans into suitable 
residential care programs outside VA when local VA facilities have 
reached their capacity. These issues are similar to experiences in a 
recent report from the VA's Office of Inspector General (OIG) that 
found that staff at VA North Texas placed patients on waitlists for two 
to three months, while failing to offer referrals for community based 
residential care in 2020 and 2021.\2\ This type of experience can have 
devastating consequences for veterans that are reaching out for help. 
Extended wait times for treatment increase the risk of losing contact 
with a veteran or the veteran changing their willingness to enter 
treatment or further engage with VA.
---------------------------------------------------------------------------
    \2\ OFF. OF INSP. GENERAL, U.S. DEP'T OF VET. AFFAIRS, 
NONCOMPLIANCE WITH COMMUNITY CARE REFERRALS FOR SUBSTANCE ABUSE 
RESIDENTIAL TREATMENT AT THE VA NORTH TEXAS HEALTH CARE SYSTEM (Jan. 
2023).

---------------------------------------------------------------------------
    H.R. 3520 seeks to address this issue and others by:

      Codifying current community care access standards and 
giving the Secretary the option to shorten the distance or time access 
standards through regulation.

      Establishing an access standard for the provision of 
residential treatment and rehabilitative services for alcohol or drug 
dependency.

      Requiring that veterans seeking residential treatment for 
alcohol or drug dependence are evaluated no later than 72 hours after 
VA receives the request.

      Ensuring that access standards apply to all VA care, 
except for nursing home care.

      Prohibiting VA from considering the availability of a 
telehealth appointment as satisfying the access standards.

      Requiring that the calculation of a veteran's wait time 
for the purposes of determining community care eligibility starts on 
the date of request for the appointment, in the case that a veteran's 
appointment is canceled by VA.

      Requiring VA to inform veterans of their eligibility for 
community care.

      Requiring VA to take into consideration a veteran's 
preference for when, where, and how to seek care, as well as their need 
or desire for a caregiver, when determining if it is in the best 
medical interest of a veteran to receive care in the community.

      Requiring VA to provide a veteran with the reason for 
their denial for community care and instructions for how to appeal the 
decision.

      Requiring that a determination for eligibility for 
community care not be overturned without notification in writing to the 
veteran and their provider.

      Requiring outreach from VA to inform veterans of their 
ability to seek community care, how to request community care, and how 
to appeal a denial of a request for community care.

      Requiring VA to conduct public outreach regarding care 
and services under Veterans Community Care Program, including through 
the Solid Start Program and on VA's webpages.

      Requiring VA to develop a pilot program to improve 
administration of care under the Veterans Community Care Program 
through the Center for Innovation for Care and Payment, including by 
providing incentives to community care network providers to allow 
visibility into their scheduling systems, improving the rate of timely 
medical documentation return and improving the timeliness and quality 
of care in the community.

      Requiring the VA OIG to assess the implementation of the 
Veterans Community Care Program at each VA Medical Center on a regular 
basis.

      Requiring VA to incorporate the use of value-based 
reimbursement models and report to Congress on these efforts.

    Veterans in need of inpatient residential care must be able to 
access it in a timely and efficient manner. With an established access 
standard for MH RRTPs, veterans will receive more consistent, quality, 
and timely care. For these reasons, Wounded Warrior Project supports 
H.R. 3520 but would respectfully ask the Committee to consider 
expanding the terms in Section 2 to include other varieties of RRTP 
care, including its specialty tracks for PTSD, MST, and SMI. We would 
like to thank Chairwoman Miller-Meeks for her introduction of this 
legislation and her attention to this issue.

H.R. 1182, the Veterans Serving Veterans Act

    Despite sustained efforts, VA continues to face a workforce 
shortage and high turnover rates, resulting in longer wait times and 
disjointed care for veterans. According to its own June 2022 report 
\3\, VA experienced a 20-year high in its VHA staff turnover rate (9.9 
percent) in FY 2021 partly due to higher wages and bonuses offered by 
private health care systems, COVID-19 pressures, and burnout. These 
shortages can be aggravated by a slow and complicated hiring process 
used by the Veterans Health Administration (VHA).\4\ Furthermore, 
thousands of former military health care providers from all branches of 
the Armed Services separate from the military and, despite their 
training and experience, do not possess a civilian certificate allowing 
them to continue in the occupations for which they were trained.
---------------------------------------------------------------------------
    \3\ U.S. DEP'T OF VET. AFFAIRS, ANNUAL REPORT ON THE STEPS TAKEN TO 
ACHIEVE FULL STAFFING CAPACITY 3 (June 2022), available at https://
www.va.gov/EMPLOYEE/docs/Section-505-Annual-Report-2022.pdf.
    \4\ U.S. GOV'T ACCOUNTABILITY OFF., STAFFING CHALLENGES PERSIST FOR 
FULLY INTEGRATING MENTAL HEALTH AND PRIMARY CARE SERVICES (Dec. 2022).
---------------------------------------------------------------------------
    Congress has given VA tools to address these issues. The RAISE Act 
(P.L. 117-103, Div. S Sec.  102) increased the pay limitation on 
salaries for nurses, advanced practice registered nurses, and physician 
assistants within VA. The STRONG Veterans Act (P.L. 117-328, Div. V) 
includes provisions that will expand the Vet Center workforce (Sec.  
102), create more paid trainee positions in mental health disciplines 
(Sec.  103), and offer more scholarship and loan repayment 
opportunities for those pursuing degrees or training in mental health 
fields (Sec.  104). Clearly, however, more can be done.
    The Veterans Serving Veterans Act would serve a dual purpose of 
increasing veteran employment and addressing VA health workforce 
shortages by requiring VA to identify the health care related military 
occupation specialties (MOS) that relate to similar job openings within 
VA. VA would accomplish this by establishing a vacancy and recruitment 
data base that would be used to identify VA's occupational needs and 
transitioning Service members (job candidates) to fill those needs. VA 
would also deploy direct hiring and appointment systems for vacant data 
base positions and may approve relocation bonuses. Finally, the bill 
requires VA to train and certify veterans who worked as basic health 
care technicians in the U.S. military to function as VA intermediate 
care technicians.
    In addition, WWP believes veterans may be better served by fellow 
veterans who understand their needs and concerns. WWP supports this 
legislation because it is a welcomed initiative to address the 
workforce shortage VA is currently facing and can provide economic 
opportunities for our warriors. We thank Resident Commissioner 
Jenniffer Gonzalez-Colon (R-PR-At Large) for introducing this 
legislation.

H.R. 1774, the VA Emergency Transportation Act

    The Department of Veterans Affairs currently reimburses veterans 
for ambulance transportation to non-VA facilities during an emergency. 
However, if these veteran patients require ambulance transportation to 
a VA medical facility for further treatment, the agency is not required 
to pay for that subsequent transportation, leading to significant 
ambulance bills for veterans.
    The VA Emergency Transportation Act would amend 38 U.S.C. Sec.  
1727 to address reimbursement rates for emergency medical 
transportation to a federal facility. Specifically, VA would be 
required to reimburse a veteran for transportation by a non-VA provider 
(1) to a facility for emergency treatment, or (2) from a non-VA 
facility where the veteran was treated to a VA or other federal 
facility for additional care.
    This legislation would help ensure veterans are not paying out-of-
pocket for necessary emergency transportation to facilities outside of 
VA's network and are not limited in their ability to receive high 
quality treatment. WWP is pleased to support the VA Emergency 
Transportation Act. We thank Rep. Mark Alford (R-MO-04) for introducing 
this bill, and we urge Congress to pass this legislation to help 
address transportation costs for veterans in need of emergency medical 
care.

H.R. 2683, the VA Flood Preparedness Act

    Currently law is unclear about whether VA can support flood 
mitigation projects that decrease the possibility of washed-out streets 
or other flooded infrastructure impeding access to its facilities. 
Under this legislation, 38 U.S.C. Sec.  8108 would be amended to 
clarify that VA can contribute funding to assist local authorities 
mitigate the risk of flooding on properties neighboring VA medical 
facilities. Additionally, this bill would require VA to present a 
report to Congress detailing the extent to which VA medical facilities 
are at risk of flooding. This report must also inform on whether 
additional resources are needed to mitigate the risk of flooding at 
said facilities.
    Wounded Warrior Project supports this legislation because it would 
empower VA to work directly with local authorities on flood mitigation 
initiatives that ensure safe and reliable access to essential care 
facilities. We thank Rep. Nancy Mace (R-SC-01) for introducing this 
legislation.

H.R. 2768, the PFC Joseph P. Dwyer Peer Support Program Act

    Peer support is a critical tool for many veterans facing stress, 
emotional challenges, and mental health concerns. WWP's most recent 
Annual Warrior Survey showed that 18.5 percent of responding warriors 
have used support groups, including peer-to-peer counseling, to help 
them face these challenges. Over 30 percent of responding warriors have 
had difficulty getting physical health care, put off getting physical 
health care, or did not get the physical health care they thought they 
needed because no peer support was available. To help address this 
need, one of the programs that WWP offers is our Veteran Peer Support 
Groups, held monthly at locations across the country. Last year, WWP 
facilitated over 1,200 Peer Support Groups, giving us firsthand insight 
into the life changing impacts of peer support. These Peer Support 
Groups are small, Warrior-led groups that allow veterans to connect 
with each other, discuss shared challenges, and support one another in 
their communities.
    The Joseph P. Dwyer Veteran Peer Support Program is a peer-to-peer 
program for veterans facing challenges related to post-traumatic stress 
disorder (PTSD) and traumatic brain injury (TBI) in New York State. 
Established in 2012, its focus on addressing loneliness and creating 
communities of healing appears prescient in 2023 after U.S. Surgeon 
General Vivek Murthy's recent advisory about the epidemic of loneliness 
and isolation in our country. This bill would create a grant program 
for state and local entities to receive up to $250,000 to establish 
similar peer-to-peer mental health programs for veterans. These state 
and local entities would include nonprofit organizations that have 
historically served veterans' mental health needs, congressionally 
chartered veteran service organizations, or a state, local, or tribal 
veteran service agencies.
    As an organization that embraces the power of peer support, WWP 
supports this legislation. The expansion of peer support programs like 
the Joseph P. Dwyer Peer Support Program will give more veterans the 
opportunity to use peer connection to address their challenges and 
embark on their path to healing. We urge Congress to pass this 
legislation and would like to thank Rep. Nick LaLota (NY-01) for its 
introduction.

H.R. 2818, the Autonomy for Disabled Veterans Act

    Wounded Warrior Project's 2022 Annual Warrior Survey reported that 
nearly half of responding warriors indicate that they live paycheck-to-
paycheck and 43.2 percent say they have little to no confidence that 
they could find the money to cover a $1,000 emergency expense. Many of 
these veterans, either due to their service-connected disabilities or 
other medical conditions, find themselves needing special home 
alterations and adaptations for them to live comfortably in their own 
home.
    The VA Home Improvements and Structural Alterations (HISA) benefit 
helps disabled veterans by providing a grant to offset the cost 
associated with making medically necessary improvements and structural 
alterations to a veteran's primary residence. However, the lifetime 
benefit is only $6,800 for veterans with a service-connected disability 
and $2,000 for those with disabilities that are not service-connected. 
As prices and inflation have risen over the last few years, the amount 
that disabled veterans are eligible for has not.
    The Autonomy for Disabled Veterans Act increases the amount 
available to disabled veterans for improvements and structural 
alterations to their homes related to their disability, through the 
HISA grant program. The bill increases the amount to $10,000 for 
veterans with a service-connected disability and $5,000 for those with 
disabilities that are not service-connected. The bill also requires VA 
to increase the amount of the grant in accordance with inflation as 
determined by the Consumer Price Index.
    Wounded Warrior Project supports this bill that would help disabled 
veterans fund modifications and alterations that are medically 
necessary to update their homes. We believe that these alterations are 
crucial to a warrior's quality of life and should be increased 
periodically to keep up with inflation. We thank Rep. Don Bacon (R-NE-
2) and Rep. Chris Pappas (D-NH-1) for introducing this legislation.

H.R. 3581, the Caregiver Outreach and Program Enhancement (COPE) Act

    Caregivers of post-9/11 veterans tend to be younger than those of 
other generations. The number of post-9/11 military veteran caregivers 
who were aged 30 years or younger (37 percent) is higher than pre-9/11 
military veteran caregivers (11 percent) or civilian caregivers (16 
percent).\5\ Therefore, post-9/11 veteran caregivers may serve as 
caregivers for a greater period of time. For example, 30 percent of 
veteran caregivers reported they had been caregiving for 10 years or 
more compared to 15 percent of civilian caregivers.\6\ Military 
caregivers were also found to have greater levels of caregiver burden 
and stress compared to nonmilitary caregivers.
---------------------------------------------------------------------------
    \5\ RAJEEV RAMCHAND ET AL., HIDDEN HEROES: AMERICA'S MILITARY 
CAREGIVERS 81 (RAND Corp., 2014), available at https://www.rand.org/
pubs/research_reports/RR499.html.
    \6\ NAT'L ALLIANCE FOR CAREGIVING, CAREGIVERS OF VETERANS - SERVING 
ON THE HOMEFRONT (Nov. 2010), available at https://
www.unitedhealthgroup.com/content/dam/UHG/PDF/uhf/caregivers-of-
veterans-study.pdf.
---------------------------------------------------------------------------
    Over time, the stress of caring for another person can lead to 
``compassion fatigue.'' This is a common condition that can make 
caregivers feel irritable, isolated, depressed, angry, or anxious. 
Additional symptoms include exhaustion, impaired judgment, decreased 
sense of accomplishment, and sleep disturbances. Military and veteran 
caregivers may require increased access to mental health care because 
many of these stressors can contribute to the development of 
conditions, such as depression, anxiety, or substance use disorders.
    The COPE Act would authorize VA to award grants to carry out, 
coordinate, improve, or otherwise enhance mental health counseling, 
treatment, and support for caregivers in VA's Program of Comprehensive 
Assistance for Family Caregivers (PCAFC) program. To apply for a grant, 
entities must submit an application with a detailed plan for the use of 
the grant and, if selected, must meet outcome measures developed by VA. 
At least once a year, VA would review the performance of entities who 
have received a grant to ensure that they are meeting outcome measures; 
those who are not would be required to submit a remediation plan and 
will not be eligible for a subsequent grant until the remediation plan 
is approved.
    This legislation would authorize $50 million for a three-year 
period and would require that funding be distributed equitably among 
states. Grant selection would prioritize areas with high rates of 
veterans enrolled in PCAFC, high rates of suicide among veterans, or 
high rates of referrals to the Veterans Crisis Line. Finally, the COPE 
Act requires VA and the Government Accountability Office (GAO) to 
conduct studies to report to Congress on the program and its outcomes.
    As an organization committed to supporting veteran caregivers, WWP 
supports the intent of the COPE Act and thanks Rep. Jennifer Kiggans 
(R-VA-02) for introducing this bill. While we appreciate the 
description of the application process that would be involved for grant 
selection, we would invite the Committee to consider amending this 
legislation to include a definition of the word ``entity'' to further 
clarify who is eligible for such a grant (i.e., state government, local 
government, tribal governments, nonprofit organizations, etc.) and 
whether there would be any limitations on such groups to be eligible 
for application.

H.R. 1278, the DRIVE Act

    According to our latest Annual Warrior Survey, a total of 15.6 
percent of responding warriors cited distance from the VA as a 
significant barrier to accessing VA care. While there are other factors 
aside from fuel costs associated with these long commutes, the VA 
Travel Beneficiary Program provides reimbursement for mileage and other 
expenses incurred while traveling to and from their VA health care 
appointments to help alleviate some of the financial burden. Under the 
current policy (which was enacted in 2010), reimbursements are 
calculated based on a mileage rate of 41.5 cents per mile and have not 
been adjusted to reflect the rising cost of fuel and other expenses 
impacted by inflation. These costs negatively impact warriors who live 
further from VA medical facilities, especially those who must travel 
from rural areas.
    The DRIVE Act would allow for an increase in reimbursement rates 
for health care related travel by striking the rate of 41.5 cents per 
mile and adjusting the rate to be equal or greater than the mileage 
reimbursement rate for government employees who use private vehicles 
for official purposes, which is currently 65.5 cents per mile.\7\ In 
addition, this bill would require VA to ensure the Beneficiary Travel 
reimbursement rate is equal to the General Services Administration 
reimbursement rate for federal employees moving forward. This will 
ensure that these rates keep up with the cost of inflation and properly 
account for fluctuations in gas prices over time.
---------------------------------------------------------------------------
    \7\  U.S. GOV'T SERVS. ADMIN., PRIVATELY OWNED VEHICLE (POV) 
MILEAGE REIMBURSEMENT RATES, available at https://www.gsa.gov/travel/
plan-book/transportation-airfare-pov-etc/privately owned-vehicle-
mileage-rates.
---------------------------------------------------------------------------
    Wounded Warrior Project supports this legislation that would help 
ease the financial burden of medically necessary travel expenses and 
make health care and benefits more accessible to the veterans who need 
them, and we thank Rep. Julia Brownley (D-CA-26) for introducing this 
legislation.

H.R. 1639, the VA Zero Suicide Demonstration Project Act

    Tragically, veteran suicide continues to be a national public 
health crisis that requires coordinated action from all levels of 
government, as well as public-private partnerships. In 2020, there were 
6,166 veteran deaths by suicide according to VA's 2022 National Veteran 
Suicide Prevention Annual Report. Our Annual Warrior Survey data found 
that nearly one in five responding warriors reported an attempted 
suicide at some point in their lives, and nearly 30 percent have had 
suicidal thoughts in the past 12 months. Thankfully, some progress has 
been made on this front in recent years. Fewer veterans died by suicide 
in 2020 than the year before and 2020 had the lowest number of veteran 
suicides since 2006. However, there is still significant work that must 
be done to address this crisis and prevent veteran suicide.
    This legislation would establish a five-year Zero Suicide 
Initiative pilot program at five VA medical centers across the country, 
including one that must serve primarily veterans who live in rural 
areas. The pilot program would implement the curriculum of the Zero 
Suicide Institute of the Education Development Center to improve safety 
and suicide care for veterans and reduce veteran suicide. The bill 
requires VA to submit an annual report to Congress that includes a 
comparison of suicide-related outcomes at program sites and those of 
other VA medical centers. The report would also assess whether the 
policies and procedures implemented at each site align with the 
standards of the Zero Suicide Institute in several areas, including 
suicide screening, lethal means counseling, and outreach to high-risk 
patients. VA may choose to extend the pilot program for up to two 
additional years.
    While we agree with the unobjectionable intent of ending veteran 
suicide, WWP is concerned about the collateral impact of this 
legislation. Currently, suicide prevention is VA's top priority and 
they have implemented a comprehensive public health approach to address 
the issue that extends beyond what is required by this legislation. 
Implementing this new pilot program would require VA to redirect an 
unknown number of resources that are currently being used for suicide 
prevention efforts that have shown signs of progress over recent years. 
Additionally, the legislation requires VA to enter into a legally 
binding financial agreement with a specified non-profit organization to 
implement their curriculum. We agree with VA's assessment \8\ that they 
should have the ability to evolve and adapt their suicide prevention 
efforts based on proven clinical interventions, established business 
practices, and an exchange of relevant data, as opposed to legislation 
requiring them to adapt a single model. While we support the intent of 
this bill, WWP has concerns with the current legislative language, but 
looks forward to working with the Committee and VA to continue our 
shared goal of preventing veteran suicide.
---------------------------------------------------------------------------
    \8\ Legislative Hearing on: H.R. 291, the COST SAVINGS Enhancement 
Act; H.R. 345, the Reproductive Health Information for Veterans Act; 
H.R. 1216, the Modernizing Veterans' Health Care Eligibility Act; H.R. 
1957, the Veterans Infertility Treatment Act of 2021; H.R. 6273, the VA 
Zero Suicide Demonstration Project Act of 2021; H.R. 7589, the REMOVE 
Copays Act before the House Committee on Veterans Affairs Subcommittee 
on Health, 117th Congress. 9-12, 2022 (statement of Matthew A. Miller, 
Ph.D., MPH, Executive Director, Suicide Prevention Program, Office of 
Mental Health and Suicide Prevention, Veterans Health Administration 
(VHA), Department of Veterans Affairs (VA).

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H.R. 1815, the Expanding Veterans' Options for Long Term Care Act

    A September 2021 report to Congress by VA found that the percent of 
veterans who are 85 or older that are eligible for nursing home care 
will increase 61,000 to 387,000 over the next 20 years, a nearly 535 
percent increase. However, of the veterans currently living in 
Community Nursing Homes (CNHs) at VA's expense, approximately five 
percent do not require the daily skilled nursing interventions provided 
and would be better served by assisted living, which would allow them 
to live more independently. In fiscal year (FY) 2020, the annual cost 
of a CNH placement was $120,701, while the annual cost of an Assisted 
Living Placement was $51,600.\9\
---------------------------------------------------------------------------
    \9\  Letter from the American Seniors Housing Association et al., 
to U.S. Senators Jon Tester, Jerry Moran, and Patty Murray (June 13, 
2022) (available at https://www.argentum.org/wp-content/uploads/2022/
06/FinalVAcoaltionltrSENATESponsors.pdf).
---------------------------------------------------------------------------
    Currently, VA can refer veterans to assisted living facilities but 
is restricted from paying room and board fees; this policy precludes 
many veterans from utilizing this long-term care option because they 
cannot afford it. The Expanding Veterans' Options for Long Term Care 
Act would create a pilot program for eligible veterans to receive 
assisted living care paid for by VA. The 3-year pilot program would be 
conducted at six Veterans Integrated Services Networks (VISNs) 
nationwide, including at least two program sites located in rural or 
highly rural areas and two State Veterans Homes. Veterans may be 
eligible for this program if they are already receiving nursing home 
level care paid for by VA; are eligible to receive nursing home level 
care paid for by VA; or require a higher level of care than the 
domiciliary care provided by VA but do not meet the requirements for 
nursing home level care. To qualify, veterans must also be eligible for 
assisted living services or meet additional eligibility criteria that 
may be established.
    Establishing a pilot program for veterans to receive assisted 
living care paid for by VA would not only allow aging veterans to live 
more independently but would also help save taxpayer dollars. This bill 
would provide veterans whose conditions do not rise to the level of 
requiring nursing home care with more appropriate long-term care 
options based on their preferences and in their best medical interests. 
In particular, the focus on rural veterans would help those who face 
greater challenges accessing Veterans Homes in their states. Further, 
for each veteran who is placed in an assisted living community for 
their supportive care services, VA would realize a potential nursing 
home savings of approximately $69,101 per placement per year. An annual 
report on the pilot program would study several factors, including 
aggregated feedback from participants in the pilot program and an 
analysis of cost savings by VA.
    Traditionally, VA programming does not provide veterans with 
housing. One notable exception was VA's pilot program, the Assisted 
Living for Veterans with Traumatic Brain Injury (AL-TBI) Program, which 
demonstrated a demand for providing increased housing options for 
younger veterans with difficulty with independent living. This program 
provided residential care and neurobehavioral rehabilitation to 
eligible veterans with traumatic brain injuries to enhance their 
quality of life and community integration. Veterans were eligible for 
VA's AL-TBI pilot program if they were enrolled in VA's patient 
enrollment system; had received VA hospital care or medical services 
for a TBI; were unable to manage routine activities of daily living 
without supervision and assistance; and could reasonably be expected to 
receive ongoing services after the end of the pilot program under 
another Federal program or through other means. (P.L. 110-181 Sec. 
1705.) Through VA's AL-TBI program, veterans received care and support 
in specialized assisted living facilities; these facilities provided 
assistance with activities of daily living, including meal preparation, 
bathing, dressing, grooming, and medication management. Although this 
pilot lasted for nearly a decade before sunsetting in 2018, its utility 
has not been replicated despite ongoing need.
    Expanding veterans' access to assisted living services is a WWP 
priority. The Expanding Veterans' Options for Long Term Care Act would 
help VA provide access to a greater range of long-term care options and 
prepare to care for the ever-increasing population of aging veterans. 
WWP urges Congress to pass this legislation, and we appreciate Rep. 
Elissa Slotkin (D-MI-08) for its introduction. We would recommend that 
the Committee broaden the eligibility criteria by incorporating 
eligibility criteria - similar to that used for the expired AL-TBI 
pilot - that would accommodate veterans with TBI symptoms that 
challenge their ability to live without supervision. The need for 
residential support and services remains while access to appropriate 
facilities covered by VA is limited mostly to nursing homes where aging 
populations often are a poor fit for a younger person with TBI or other 
long-term care needs.

CONCLUSION

    Wounded Warrior Project once again extends our thanks to the 
Subcommittee on Health for its continued dedication to our Nation's 
veterans. We are honored to contribute our voice to your discussion 
about pending legislation, and we are proud to support many of the 
initiatives under consideration that would enhance veterans' access to 
care and support. As your partner in advocating for these and other 
critical issues, we stand ready to assist and look forward to our 
continued collaboration.
                                 ______
                                 

              Prepared Statement of The Independence Fund

    Chairwoman Miller-Meeks, Ranking Member Brownley and distinguished 
Members of the Subcommittee:
    Thank you for your kind invitation to The Independence Fund and me 
to testify before today's legislative hearing.
    The Independence Fund (TIF) serves catastrophically wounded 
Veterans and their Caregivers so much of the legislation before the 
Subcommittee holds particular relevance for our community.
    As we outlined in our testimony at the April 18, 2023 Subcommittee 
on Health hearing, ``Combating a Crisis: Providing Veterans Access to 
Life-saving Substance Abuse Disorder Treatment,'' too many Veterans are 
being denied the critical, often life-saving treatment they require 
because of an unclear, poorly implemented policy for Mental Health 
Residential Rehabilitation Treatment Programs (MH RRTP). Our 
Caseworkers have uncovered a seemingly widespread access to care and 
care coordination problem within the Veterans Health Administration 
(VHA) and it is particularly acute with Substance Use Disorder (SUD) 
treatment. TIF supports efforts to codify and expand access standards 
to include all extended care services including MH RRTP. We also 
support ensuring that the calculation of wait times is consistent and 
clearly communicated to VHA clinical and administrative staff, as well 
as Veterans, and allowing the Secretary of the Department of Veterans 
Affairs (VA) the flexibility to reduce wait and drive times. Veterans 
who need residential support should not be forced to wait beyond 30 
days or more and not be offered or denied Care in the Community (CITC). 
These Veterans who require immediate care for SUD or risk suicidality 
do not have 30 days to wait. For substance abusers, time is the enemy. 
The longer a Veteran waits, the less likely he/she will follow through 
with treatment. Studies show there is a 48-hour window which substance 
users must receive treatment before they return to using.
    Further, industry standards for SUD detoxification and treatment 
include residential, inpatient care immediately following (bed-to-bed 
transfer) detoxification, however VA practices often do not align with 
those standards. Many VA facilities refer SUD Veteran patients to a 
community provider for ``detox'' then send them home without critical 
follow-up residential care or put Veterans in an intensive outpatient 
program (IOP) which is against the standards set by industry 
professionals. This gap in residential services sets Veterans up for 
failure as they are forced to return to unhealthy or enabling 
environments leading them back to substance use and causing Veterans to 
repeat the cycle of ``detox'' with no rehabilitation. Veterans are 
being discharged from ``detox'' with no indication of when treatment 
will start or referred to an outpatient program which has little chance 
of success. This pattern of providing a lower level of care following 
``detox'' is harming our Veterans and is contrary to best practices for 
providing appropriate clinical care. Legislation is needed to ensure 
Veterans' access to residential care is based on a defined set of 
standards to be applied at all Veteran Affairs Medical Centers (VAMCs).
    We have seen too often the stalemate that occurs when a provider 
and Veteran believe it is in the best medical interest of the Veteran 
to be referred to CITC, however the CITC team denies the referral 
without taking the wishes and best interests of the Veteran into 
consideration as a determining factor. TIF believes the preference and 
interest of the Veteran must be a priority when making such decisions 
and supports expanding the decision to include the Veteran's 
preference.
    Ensuring timely information about CITC approval and denial, and how 
to appeal a denial, is critically important for Veterans. Establishing 
a standard for notification will provide clear direction and eliminate 
ambiguity in whether a Veteran can access a CITC provider. However, we 
question the ability for the VA to reasonably implement a two-day, 
written response given staff shortages and other limitations. We also 
question when the clock starts on the two-days.
    Telehealth has been a game-changer for many Veterans. It is useful 
for Veterans in rural areas without close access to a VAMC for many 
appointments such as primary care. But telehealth is no substitute for 
intensive, in-patient treatment for SUD or other mental conditions. We 
support excluding the availability of telehealth as acceptably meeting 
the access standards and allowing Veterans to choose CITC and support 
the availability of telehealth to Veterans to choose for their care.
    As previously stated, once a Veteran presents themselves for SUD 
assessment, the window of time is short to identify and provide the 
care they seek. A 72-hour timeframe to assess alcohol or drug 
dependence from the time the VA receives the request is appropriate in 
our opinion, however we would expand the 72-hour rule to include other, 
urgent mental health conditions.
    We support strengthening accountability for CITC and would advocate 
for additional measures as outlined in Title II, Sections 205 and 206 
of S. 1315, the Veterans' Health Empowerment, Access, Leadership, and 
Transparency for our Heroes (HEALTH) Act of 2023.
    TIF supports the codification and expansion of access standards, 
inclusion of a Veteran's preference in CITC, timely disclosure of CITC 
information and 72-hour turnaround for SUD and other mental condition 
assessment. While not addressed in this hearing, we also recommend 
ensuring the transition from ``detox'' to residential treatment is a 
seamless one, without harmful gaps or delays.
    TIF supports the intent behind H.R. 3520, however we are 
disappointed there is not yet bipartisan support for the measure, and 
we encourage both sides of the Committee to work together to ensure 
that our veterans receive the high quality and timely care they need.

H.R. 1182, the Veterans Serving Veterans Act of 2023

    In recent years, the VA has experienced significant labor 
shortages. H.R. 1182, Veterans Serving Veterans Act of 2023 would 
create a pipeline between the Department of Defense (DoD) and VA to 
create a data base of prospective workers to fill empty VA positions 
and expedite hiring for qualified members of the Armed Forces. The 
legislation would also implement a program to train and certify covered 
veterans to work as intermediate care technicians in VAMCs. TIF 
supports this bill.

H.R. 2768, the PFC Joseph P. Dwyer Peer Support Program Act

    Roughly nine percent of TIF's casework in 2023 has been mental 
health related. This is the highest concentration behind benefits, 
housing, and income. Our Casework Team remains largely effective in 
serving over 900 constituents with complex and challenging issues due 
to the rapport built on peer support. Named to honor the memory of an 
Iraq war hero, the Joseph P. Dwyer Veteran Peer Support Project is a 
peer-to-peer program for Veterans facing the challenges of Post-
Traumatic Stress Disorder (PTSD) and Traumatic Brain Injury (TBI). H.R. 
2768, PFC Joseph P. Dwyer Peer Support Program Act would expand a 
successful, local pilot partnership by establishing a grant program to 
create peer-to-peer mental health programs for veterans. TIF would like 
to note the important role that many non-congressionally chartered 
Veteran Service Organizations (VSOs) play in executing programs such as 
these. We support the intent of this legislation but recommend H.R. 
2768 be amended to allow non-congressionally Chartered VSOs to 
participate in this grant program.

H.R. 2818, the Autonomy for Disabled Veterans Act

    TIF's original mission was to support catastrophically wounded 
post-9/11 Veterans gain the mobility and freedom to have a meaningful 
quality of life. We have donated over 2,500 all-terrain track chairs to 
Veterans of all eras and know these devices are life changing. H.R. 
2818, the Autonomy for Disabled Veterans Act, provides a much-needed 
raise in the Home Improvements and Structural Alterations (HISA) grant 
by increasing the maximum amount authorized from $6,800 to $10,000 for 
veterans with a service-connected disability and $2,000 to $5,000 for 
those with disabilities that are not service-connected. These grants 
allow Veterans the opportunity to improve or enhance their homes to 
make the necessary accommodations for daily living. We support our 
disabled Veterans and support H.R. 2818.

H.R. 3581, the Caregiver Outreach and Program Enhancement Act or COPE 
Act

    As a VSO with Caregivers as the CEO and on staff, we understand the 
toll caregiving can have on the mental health of the Caregiver. We have 
helped over 2,000 Caregivers through our Caregiver Retreats and 
continue to support them and their children today. Caregivers sacrifice 
so much to care for their Veterans and often ignore or dismiss their 
own mental health needs. H.R. 3581, the Caregiver Outreach and Program 
Enhancement Act'' or ``COPE Act'' would provide grant funding to 
organizations to provide much-needed mental health services to 
Caregivers without the fear they are taking away VA benefits from their 
Veterans. We fully support our Nation's Caregivers and support H.R. 
3581.

H.R. 1278, the Driver Reimbursement Increase for Veteran Equity Act or 
DRIVE Act

    Transportation costs are up. From gas to insurance, our Veterans 
are paying more to travel to their VAMC appointments. Additionally, the 
Beneficiary Travel mileage reimbursement rate, which pays eligible 
Veterans and caregivers back for mileage and other travel expenses to 
and from approved health care appointments, has not been adjusted in 
over a decade. H.R. 1278 will update the Beneficiary Travel mileage 
reimbursement rate as well as ensure VA's mileage reimbursement rates 
keep up with current prices. It is long overdue to make these changes 
to ease the financial burden of Veterans and Caregivers traveling to 
and from their VAMC appointments. TIF supports this bill.

H.R. 1639, VA Zero Suicide Demonstration Project Act of 2023

    Veteran suicide is an epidemic facing our country. For Post-9/11 
Veterans, this epidemic is even more acute and devastating. Some 
reports say about 17 Veterans die by suicide a day, however others 
indicate the number is even higher. Several factors are known to 
increase suicidality in Veterans including feelings of loneliness, 
isolation, and stress. The Zero Suicide Initiative was developed by 
Henry Ford Behavioral Health who was the first to pioneer and 
conceptualize ``zero suicides'' as a goal and develop a care pathway to 
assess and modify suicide risk for patients with depression. This 
approach proved groundbreaking in terms of suicide-prevention. The Zero 
Suicide pilot program would build on the VA's suicide prevention 
efforts by implementing more comprehensive, systems focused Zero 
Suicide efforts in five VAMCs, including one that serves Veterans in 
rural or remote areas. As a VSO which engages in suicide-prevention 
initiatives with Post-9/11 combat Veterans, TIF supports H.R. 1639 and 
will closely monitor the progress of the chosen VAMCs to observe the 
success and learn from other suicide-prevention modalities.

H.R. 1815, Expanding Veterans' Options for Long Term Care Act

    Long-term care projections outlined in a September 2021 report from 
the VA to Congress indicated veterans over age 85 were the fastest 
growing veteran population in VA's health care system. Over the next 20 
years, the number of veterans in that age group eligible for nursing 
home care will increase from 61,000 to 387,000, nearly a 535 percent 
jump. While this statistic is alarming, not all senior Veterans require 
or desire the comprehensive care provided by nursing homes. Assisted 
living may be an appropriate alternative which would allow Veterans to 
live independently. However, the VA is prohibited from covering costs 
associated with assisted living facilities. H.R. 1815, the Expanding 
Veterans' Options for Long Term Care Act creates a three-year pilot 
program for eligible veterans to receive assisted living care paid for 
by the VA which would help senior Veterans to live more self-
sufficiently while reducing costs for the VA. Nursing home fees average 
nearly $121,000 per year, while assisted living facilities cost only a 
little more than $51,000 per year. For example, from TIFs case files, 
Vietnam Combat Veteran ``T.K'' from Knoxville, TN currently desires 
assisted living services and is unable to use a Veterans home due to 
not needing a ``skilled-care'' level. If eligible for this program, 
Veterans like him who need a moderate level of support could receive 
services. TIF Supports this legislation which will help thousands of 
senior Veterans.
    On behalf of The Independence Fund, we thank you again for the 
opportunity to provide testimony in response to the above legislation. 
Each bill moves us closer to fully meeting the obligation our Nation 
carries to support and care for our heroes when they return home. Our 
Veterans deserve what they were promised when they put on the uniform 
to serve our country, and our Caregivers deserve the support necessary 
to care for their Veterans. Please contact our team if you have any 
questions about this testimony or other that we can work together to 
assist our community.
                                 ______
                                 

          Prepared Statement of Concerned Veterans for America
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 

   Prepared Statement of American Federation of Government Employees
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 

                 Prepared Statement of All Points North

    We are grateful for the opportunity to submit written testimony 
about the need to expand access to community care under the MISSION Act 
for Veterans and their loved-ones suffering with mental health and 
substance use disorders.
    It is estimated that since 2008, more than 70,000 veterans have 
died by suicide - more than the total number of deaths from combat 
during the Vietnam War and the Global War on Terrorism combined. Risk 
of suicide is significantly higher among Veterans who have a mental 
health and/or substance use disorder.\1\ More than 18 percent of all 
Veterans say they experience high levels of difficulty when 
transitioning to civilian life. Amongst combat Veterans, over 45 
percent describe a difficult transition.\2\ After service, many 
Veterans describe a sense of loss of the camaraderie, honor, duty, and 
service that inspired them for years or even decades, leaving them 
alone and without purpose. This serves as a stark reminder that many of 
America's warriors need mental health and addiction treatment on this 
side of the uniform.
---------------------------------------------------------------------------
    \1\ Tanielian, Terri, et al. Invisible Wounds: Mental Health and 
Cognitive Care Needs of America's Returning Veterans. RAND Corporation, 
2008.
    \2\ Parker, Kim, et al. The American Veteran Experience and the 
Post-9/11 Generation. Pew Research Center, 10 Sept. 2019.
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    Approved, in-network community care providers have immediate 
capacity, expertise, experience, and resources to rapidly and 
effectively provide medical and clinical care for anxiety, depression, 
substance misuse, and other known drivers of suicide among Veterans.
    For example, All Points North (APN) is an approved substance misuse 
and behavioral health treatment provider for Veterans with TriWest. 
With 77 residential beds, APN combines innovative neurotechnology and 
interventional psychiatry - such as Hyperbaric Oxygen Therapy (HBOT), 
Deep Transcranial Magnetic Stimulation (dTMS), Stellate Ganglion Block 
(SGB), Neurofeedback, and Ketamine-assisted treatment - with proven 
talk and experiential PTSD treatment modalities, extensive group 
therapy, individual therapy, and medically assisted treatment for 
substance use disorders, anxiety, and depression. APN's specific 
Veterans' treatment track creates a safe and specialized environment 
for Veterans with significant mental health, trauma and substance use 
disorders. To further support Veterans in an acute condition, APN also 
has walk-in detox and behavioral health assessment and stabilization 
facilities in Colorado and California with more facilities opening soon 
in Texas and Florida.
    Because APN focuses on outcomes and transparency, it participates 
in the ACORN collaboration, a large data base of psychotherapy 
treatment outcomes. ACORN measures APN's client outcomes against 3,000 
other providers and 3 million other patients. APN is in the top 5 
percent of provider outcomes, with six-times better client engagement 
and only 7.3 percent of clients returning for additional care post-
treatment. ACORN categorizes APN's Change in Patient Condition as 
``Significantly Improved''.
    APN is the only community care provider of its kind for the 
approximately one million Veterans who live in the VA Rocky Mountain 
Network (VISN 19), a 10-state region covering Montana, Wyoming, Utah, 
Colorado, Oklahoma, and portions of North Dakota, Nebraska, Kansas, 
Nevada, and Idaho.
    Despite its innovative services and excellent outcomes, the VA has 
rarely referred a Veteran to APN for community care under the MISSION 
Act. Instead, the VA consistently delays approval for Veterans who meet 
the Eligibility Standards for Access to Community Care under the 
MISSION Act and ask to be treated at APN. Instead of efficiently and 
quickly approving a Veteran for life-saving community care, the VA 
makes them wait for authorization, leaving them to languish in a 
dangerous ``VA decision-limbo'' for many weeks and even months without 
treatment.
    To further delay a Veteran's access to community care, the VA often 
rejects the diagnosis and level of care recommended for a Veteran by a 
non-VA licensed clinical or medical professional. Instead of accepting 
the assessment and recommended treatment plan of a licensed clinical or 
medical professional, who is a specialist trained to diagnose and treat 
mental health and substance use disorders, Veterans are instead 
required by VA policy to first see a Primary Care Physician (PCP). This 
step alone oftentimes and tragically results in the Veteran giving up 
seeking treatment altogether, putting the Veteran at high risk of 
suicide or overdose.
    Rather than turn them away, APN has consistently admitted and 
treated any Veteran at risk of suicide or overdose and provided 
anywhere from thirty to sixty days of intensive, residential care, free 
of charge. Currently, seven combat Veterans are receiving care at APN's 
residential facility. Their diagnoses range from severe PTSD and opioid 
dependence to anxiety and depressive disorders. Less than half of the 
seven at APN have currently been approved by the VA for community care 
under the MISSION Act.
    Changing the culture of resistance to community care within the VA 
ranks remains the largest and most time-sensitive challenge to ending 
Veteran suicide and overdose. A hand-in-hand partnership with its in-
network community care providers is something Congress has encouraged, 
authorized, and advocated through multiple statutory and budget 
approvals. After nearly a decade of efforts, starting with the Veterans 
Choice Program, the tools are in place for the VA to engage community 
care providers as a much-needed extension of mental health and 
addiction treatment in the life-saving care of Veterans and their 
families.

Community Care Under the MISSION Act of 2018

    Under the MISSION Act of 2018, Veterans may request, and are 
eligible for, community care when they meet one or more of the MISSION 
Act Eligibility Standards for Access to Community Care. These 
eligibility standards were intentionally designed by Congress to 
accelerate care for Veterans whose condition would otherwise worsen 
unless treated quickly, and when a Veteran needs a service not 
available at a nearby VA medical center; a Veteran lives more than a 30 
minute drive to their nearest VA medical center; a VA medical center 
cannot schedule an appointment for the Veteran within 20 days; a 
Veteran determines that community care is in their best interest; or a 
Veteran does not feel they are receiving the best care they need at the 
VA.
    For Veterans seeking treatment for a mental health and/or substance 
use disorder, these access standards rightly prioritize the urgent 
conditions under which community care treatment services are needed to 
prevent another Veteran suicide or overdose.
    Considering the shocking reality that we are now in our 20th 
consecutive year with 6,000 or more Veteran suicides per year, there is 
no rational or humane justification to delay or deny an eligible 
Veteran efficient and effective mental health and substance use 
disorder treatment by an approved community care provider.
    Community care under the 2018 MISSION Act should be a seamless 
alternative for Veterans who can't quickly or easily access care at a 
VA medical center. Unfortunately, there are currently significant 
obstacles to overcome in order to ensure Veterans can access community 
care under the law.

The VA's Own Guidance Has Dissuaded Veterans from Community Care 
Options.

    The Americans for Prosperity Foundation (AFPF) has reported 
extensively on documents obtained under the Freedom of Information Act 
about the VA's willingness and efficiency in approving Veterans for 
community care. According to the AFPF, the VA regularly fails to refer, 
while delaying and denying eligible Veterans for community care under 
the MISSION Act and its own regulatory requirements.\3\
---------------------------------------------------------------------------
    \3\ ``More Evidence the VA Is Improperly Delaying or Denying 
Community Care to Eligible Veterans.'' Americans for Prosperity, AFPF, 
28 Jan. 2022.
---------------------------------------------------------------------------
    According to AFPF, the VA Veterans Health Administration's own 
Referral Coordination Initiative Implementation Guidebook (Updated: 
October 28, 2021) describes the VA's strategy to reduce utilization of 
community care because of ``more Veterans being referred to the 
community than expected.'' \4\ The VA's solution to the higher-than-
expected access to community care among Veterans was to shift the 
responsibility of referring to community care from health care 
providers to ``dedicated clinical and administrative staff'' who the VA 
calls ``Referral Coordination Teams.'' This additional process of 
decision-making was implemented in part because ``Veteran feedback 
suggests many Veterans prefer to receive internal/direct VA care.'' \5\ 
The AFPF also uncovered a VA training document that creates an 
additional barrier for a Veteran already eligible for community care. 
It states, ``After eligibility has been confirmed, clinical review is 
performed to determine if the requested services are clinically 
appropriate to be authorized for delivery in the community.'' This 
extra step is not required in the MISSION Act or implementing 
regulations, but it could lead to longer wait times or denial of 
community care.\6\
---------------------------------------------------------------------------
    \4\ ``Veterans Health Administration: Referral Coordination 
Initiative Implementation Guidebook.'' U.S. Department of Veterans 
Affairs, 28 Oct. 2021, pp. 92.
    \5\ Veterans Health Administration: Referral Coordination 
Initiative Implementation Guidebook.'' U.S. Department of Veterans 
Affairs, 28 Oct. 2021, pp. 90.
    \6\ ``More Evidence the VA Is Improperly Delaying or Denying 
Community Care to Eligible Veterans.'' Americans for Prosperity, AFPF, 
28 Jan. 2022.
---------------------------------------------------------------------------
    Sadly, some may think that these VA cost-saving measures are 
justified for fiscal reasons. However, in the face of a two-decades-
long suicide crisis, these decision delays leave Veterans languishing 
in ``VA decision-limbo'', putting them a grave risk of suicide and 
overdose. Delaying an eligible Veteran from receiving community care 
for mental health and/or addiction treatment it's nothing short of 
inhumane, not to mention, unlawful.

Delays to Access Community Care

    Long delays veterans face when attempting to access life-saving 
mental or behavioral health care through the Veterans Administration 
(VA) betrays America's Promise by Abraham Lincoln ``To care for him who 
shall have borne the battle, and for this widow and his orphan.'' 
According to the VA's own internal data, veterans waited an average of 
41.9 days for an appointment, starting from the time he or she 
requested an appointment until the date they actually were seen by the 
VA.
    Outside audits of appointment delays at the VA are far more 
damning. On July 24, 2019, Debra Draper, Director of Health Care at the 
United States Government Accountability Office (GAO), delivered 
shocking testimony before the House Committee on Veterans' Affairs. 
When considering all factors, veterans are typically waiting up to 70 
days for an appointment for care at the VA.
    This limbo period, between when a veteran in a mental health or 
behavioral health crisis first asks for help, and the moment they 
access care, has become a ``Valley of Death.'' Consequently, many 
veterans lose hope, give up, and tragically take their own lives or 
suffer a lethal overdose.
    It is acutely problematic when a veteran seeks non-VA ``Community 
Care'' under the MISSION Act of 2018. There are two primary VA policies 
that create delays which can contribute to suicides for veterans 
seeking Community Care.
    First, veterans are required by VA policy to first see a VA Primary 
Care Physician (PCP) prior to accessing community care. If and when the 
veteran finally sees their PCP, many weeks or months later, and secures 
a referral for Community Care, the VA often overturns the PCP referral 
and requires the veteran to be treated within the VA's own health care 
system. More appointments are then required, and the process starts all 
over again.
    Second, the VA often rejects the diagnosis and level of care 
recommended for a Veteran by a non-VA licensed clinical or medical 
professional. Instead of accepting the psychiatric assessment, 
diagnosis, and recommended treatment plan from a licensed clinical or 
medical professional, who is a specialist trained to diagnose and treat 
mental health and substance use disorders, the VA requires the veteran 
to be assessed by their physician.
    These steps and delays don't make clinical or economic sense for 
someone with any other life-threating condition such as cancer, heart 
disease, or a severe allergy. Why then is it acceptable to slow-play 
and disregard veterans who need immediate intervention and treatment 
for depression, anxiety, post-traumatic stress, or addiction? Have we 
not learned anything from the now two-decade-long veteran suicide 
crisis where we have lost over 6,000 Veterans year over year? The 
solution is simple. Veterans must have the same rights and access to 
life-saving mental health and behavioral health care that every other 
insured American is afforded.

Mental and Behavioral Health Treatment for Non-Veterans

    The Paul Wellstone and Pete Domenici Mental Health Parity and 
Addiction Equity Act of 2018 (a.k.a., mental health parity law or 
Federal parity law) requires any insurance company to treat mental and 
behavioral health and substance use disorder coverage equal to, or 
better than medical/surgical coverage. The law also requires that 
insurers treat financial requirements equally and lift all limits on 
the number of mental health visits allowed by an insurance company per 
year.
    The federal parity law applies to all employer-sponsored health 
coverage, for companies with 50 or more employees, coverage purchased 
through health insurance. It also applies to exchanges that were 
created under the Affordable Care Act, the Children's Health Insurance 
Program (CHIP), and most Medicaid programs.
    Unlike the delays a Veteran has to endure with VA care, under 
commercial PPO health insurance coverage in the United States, an 
individual can walk into any in-or out-of-network provider and receive 
treatment for a mental or behavioral health disorder. Under even the 
most basic HMO plan, the policy-holder can typically get an appointment 
and referral from their PCP in less than a week. In the case of a 
mental or behavioral health referral, approvals are oftentimes 
expedited due to the emergent nature of the diagnosis and the liability 
the PCP shoulders if they delay getting their patient into the proper 
level of care.
    Furthermore, under commercial insurance plans, the insurer accepts 
the psychiatric assessment and diagnosis, performed by the patient's 
chosen healthcare provider.

Policy Recommendations

    Therefore, to eliminate delays in life-saving services and to 
reduce Veteran suicide and overdose:

1) Congress should ensure that all Veterans who meet one or more of the 
MISSION Act Eligibility Standards for Access to Community Care should 
be afforded both the same choice of when and where they receive 
treatment that is given under the Urgent Care exception in the MISSION 
Act and the same choice afforded to every American under the Paul 
Wellstone and Pete Domenici Mental Health Parity and Addiction Equity 
Act (MHPAEA) of 2008.

2) Congress should ensure that all Veterans who self-refer to Community 
Care, and who meet one or more of the MISSION Act Eligibility Standards 
for Access to Community Care, are quickly assessed by a licensed 
clinical or medical Community Care professional, and promptly approved 
for the indicated level of care by the VA, without the requirement that 
a Veteran must first see their Primary Care Physician. Congress should 
consider imposing a 7-day maximum waiting period for mental health care 
attendant to a finding of suicidal crisis/ideation or any assessment 
that is deemed life-threatening.

3) Congress should ensure that diagnostic assessments conducted by any 
licensed clinical or medical professional (whether at the VA or in the 
community) are the standard for diagnosis and level of care placement 
for Veterans.

4) Congress should pass H.R. 3520 the Veteran Care Improvement Act of 
2023 as it addresses barriers that are preventing access to mental 
health care via Community Care for veterans in crisis and recognizes 
the difficulties that veterans and clinicians are facing in rapidly 
providing assessment and care to prevent suicide.

5) Congress should pass H.R. 3554, the Protecting Veteran Community 
Care Act as it provides much needed reforms to the Community Care 
program at VA specific to mental health and can make a measurable 
difference in preventing veteran suicide.

About the Author

    West Huddleston has been advocating for and helping Veterans who 
have substance misuse and/or behavioral health treatment needs for 30 
years. As the former CEO of the Washington, DC-based National 
Association of Drug Court Professionals (NADCP) and founder and 
Executive Director of Justice For Vets, he led the only national 
organization dedicated to transforming the way the justice system 
identifies, assesses, and treats justice-involved Veterans. Due in part 
to his effort, there are now over 700 Veterans Treatment Courts across 
the United States, significant federal and State funding, as well as 
engagement by the VA, national and state Veteran Service Organizations, 
and a vast network of volunteer Veteran Mentors. West is on the 
Advisory Boards of the Harvard Medical School CHA Division on Addiction 
and All Points North (APN). He is the former Vice Chairman of the Board 
of The Independence Fund, granting mobility to our Nation's 
catastrophically wounded combat Veterans and the proud dad of an 
Active-Duty son in the United States Armed Forces.
                                 ______
                                 

             Prepared Statement of Veterans of Foreign Wars

    Chairwoman Miller-Meeks, Ranking Member Brownley, and members of 
the subcommittee, on behalf of the men and women of the Veterans of 
Foreign Wars of the United States (VFW) and its Auxiliary, thank you 
for the opportunity to provide our remarks on these important pieces of 
legislation pending before this subcommittee.

H.R. 1182, Veterans Serving Veterans Act of 2023

    The VFW supports this legislation that would amend the VA Choice 
and Quality Employment Act of 2017  (P.L. 115-46) to direct the 
Secretary of Veterans Affairs (VA) to establish a vacancy data base to 
facilitate the recruitment of certain members of the armed forces to 
satisfy the occupational needs of VA, and to establish and implement a 
training and certification program for intermediate care technicians. 
The VFW recognizes the skill sets that veterans obtain from their time 
in service and the need for those skills in our workforce. Providing 
training and certifications would help veterans obtain employment, and 
also aid VA with hiring the qualified employees it desperately needs to 
fill its vacancies. This would be beneficial to both transitioning 
service members and to veterans receiving care at VA facilities.

H.R. 1278, DRIVE Act

    The VFW supports this legislation that would increase the rate of 
reimbursement payments provided by VA for beneficiary travel. The VFW 
agrees that beneficiary travel rates should be at least equal to those 
for government employees. The inflation of automotive fuel cost has 
made it more financially difficult for veterans to travel to their 
appointments. Prices have risen but the travel beneficiary has remained 
the same, causing hardship for some veterans. This proposed increase 
would equalize VA with all other government agencies. Veterans should 
receive reimbursement payments at a rate that enables them to afford 
the cost of travel to health care appointments.

H.R. 1639, VA Zero Suicide Demonstration Project Act of 2023

    The VFW supports this legislation that would establish the Zero 
Suicide Initiative pilot program of VA. Reducing the number of service 
members and veterans who die by suicide has been a priority for the VFW 
and will remain so until it is no longer needed. This multi-layered 
approach consists of continuous suicide screening at all health care 
touchpoints, creating a crisis plan, and maintaining consistent 
communication with veterans. Removing the stigma of discussing suicide 
and fostering healthy conversation will help in reaching the goal of 
zero suicides. The Veterans Health Administration has the opportunity 
to support all VA providers with the tools and knowledge to screen 
their patients for suicide at every appointment.

H.R. 1774, VA Emergency Transportation Act

    The VFW supports this legislation to reimburse a veteran for the 
reasonable cost of emergency medical transportation by a non-VA 
provider to a facility for emergency treatment, or from a non-VA 
facility to a VA or other federal facility for additional care. A 
veteran should not be burdened with the transportation cost component 
of receiving critical medical attention.

H.R. 1815, Expanding Veterans' Options for Long Term Care Act

    The VFW supports this legislation that would require VA to carry 
out a three-year pilot program to assess the effectiveness of providing 
assisted living services to eligible veterans. Assisted living 
facilities are needed when a veteran does not require nursing home care 
but cannot live alone. This program would allow veterans to receive 
needed services without being financially responsible for the cost, 
thereby reducing or eliminating the burden on family members who may 
not be able to provide round-the-clock care. This option for long-term 
care has great potential for veterans to still have some independence 
while being cared for at facilities that are authorized and inspected 
by VA.

H.R. 2683, VA Flood Preparedness Act

    The VFW knows this proposal has a worthy goal, but cannot support 
it at this time. The Ralph H. Johnson VA Medical Center is located in a 
highly flood-prone area that can cause life-threatening conditions for 
patients during flood emergencies, which of course is a major concern. 
However, VA's current authority to make contributions to local 
authorities was meant to help patients safely ingress and egress 
facilities. We believe making contributions to local authorities for 
major infrastructure work would be outside of the intent of Section 
8108, Title 38, United States Code. Additionally, the VFW believes VA 
infrastructure is already underfunded and does not have sufficient 
personnel to oversee its own backlog of necessary infrastructure work. 
Rather than routing VA funds to local communities to combat the effects 
of rising sea levels, we recommend adding funds for the U.S. Army Corps 
of Engineers to incorporate this problem or to prioritize it in 
existing projects.

H.R. 2768, PFC Joseph P. Dwyer Peer Support Program Act

    The VFW supports this legislation that would make grants to State 
and local entities to carry out peer-to-peer mental health programs. 
The VFW recognizes that all veterans do not utilize VA facilities to 
obtain mental health services or the support of peer-to-peer 
specialists. This grant would enable eligible entities to establish 
peer-to-peer mental health programs for veterans. We understand there 
is a demand for more mental health services, and would particularly 
like to see additional services in rural areas.

H.R. 2818, Autonomy for Disabled Veterans Act

    The VFW supports this legislation that would increase the amount 
paid by VA to veterans for medically necessary improvements and 
structural alterations furnished as part of home health services. As 
veterans age their mobility may decrease, which may make navigating 
their surroundings and accomplishing daily tasks increasingly 
difficult. Having a resource for improvements or alterations creates 
more accessible, safer homes, and better quality of life for these 
veterans.

H.R. 3520, Veteran Care Improvement Act of 2023

    The VFW supports this legislation that would improve the provision 
of care and services under the Veterans Community Care Program of VA. 
We understand this program is essential as it provides services for 
veterans who live too far from a VA facility or in the event a 
requested appointment is not available in an acceptable timeframe. VA's 
focus should remain on how veterans can receive the care they need, 
whether it is inside or outside of its facilities.
    Adapting a value-based health care model allows for a patient-
centered system that aligns with VA's whole health care approach. 
Value-based care programs focus on prevention efforts to reduce 
illnesses and suicide, which is a top priority of VA. The VFW also 
supports the continuation of the Electronic Health Record Modernization 
program as it is needed to work in conjunction with the value-based 
program.
    The VFW agrees the ability to access the scheduling system would 
help improve the timeliness of appointments and/or allow veterans to 
obtain care at non-VA facilities. Medical record documentation needs a 
timely return to allow VA providers to access treatments received and 
determine if additional follow-up would be appropriate. The VFW 
understands the need for VA to explore a value-based reimbursement plan 
to determine and implement a more holistic system.
    There are two parts of this proposal we believe should be 
clarified. Section 4 may provide contradictory guidance to patients or 
clinicians regarding a veteran's preference for care. Currently, if a 
veteran and the veteran's referring clinician agree that receiving care 
and services through a non-VA entity or provider would be in the best 
medical interests of the veteran, then the veteran is referred to 
community care. We are concerned this proposed section has the 
potential to allow for conflicts with the veteran's preference and the 
best medical interest of the veteran. We would like to see this 
clarified.
    Additionally, the VFW questions if the telehealth provisions in 
Section 2 and Section 6 are in conflict with each other. Telehealth is 
a critical tool for VA to deliver care for veterans. Veterans should 
not have telehealth appointments scheduled for them if that is not 
their request or preference. However, we do believe they should be an 
option if appropriate to patients' wants and needs. We look forward to 
working with the committee to ensure the best outcomes are available 
for veterans.

    H.R. 3581, Caregiver Outreach and Program Enhancement (COPE) Act

    The VFW supports this legislation that would modify the family 
caregiver program of VA to include services related to mental health 
and neurological disorders. However, we would like clarification on the 
neurological disorders referred to in this bill. Caring for our 
nation's veterans is not an easy task. The diverse and often complex 
issues our veterans face require the care and support of well-trained 
caregivers. Balancing everyday life with the health care needs of a 
veteran can cause mental, emotional, and physical distress for the 
caregiver. The VFW believes that caregivers need support to ensure they 
are healthy enough to be of service.
    Chairwoman Miller-Meeks, Ranking Member Brownley, this concludes my 
testimony. I am prepared to answer any questions you or the 
subcommittee members may have.

 Information Required by Rule XI2(g)(4) of the House of Representatives

Pursuant to Rule XI2(g)(4) of the House of Representatives, the VFW has 
not received any federal grants in Fiscal Year 2023, nor has it 
received any federal grants in the two previous Fiscal Years.

The VFW has not received payments or contracts from any foreign 
governments in the current year or preceding two calendar years.
                                 ______
                                 

          Prepared Statement of Paralyzed Veterans of America

    Chairwoman Miller-Meeks, Ranking Member Brownley, and members of 
the Subcommittee, Paralyzed Veterans of America (PVA) would like to 
thank you for the opportunity to submit our views on pending 
legislation impacting the Department of Veterans Affairs (VA) that is 
before the Subcommittee. No group of veterans understand the full scope 
of benefits and care provided by VA better than PVA members--veterans 
who have incurred a spinal cord injury or disorder (SCI/D). Several of 
these bills will help to ensure veterans receive much needed aid and 
support. PVA provides comment on the following bills included in 
today's hearing.

H.R. 3520, the Veteran Care Improvement Act of 2023

    PVA has concerns about how this bill would affect care for veterans 
with the greatest support needs. First, care in the community should 
only be offered when it is unavailable at VA facilities, or when it is 
based on sound medical judgment in the best interest of the veteran. 
Section 4 expands the criteria VA must consider when authorizing 
community care, and the additional variables could eventually cause VA 
to circumvent these important tenants of the community care program and 
eventually harm VA's ability to provide the care. Second, Section 9 
allows VA to negotiate with third party administrators to establish the 
use of value-based reimbursement models under the Veterans Community 
Care Program. Value-based models were designed for the ``for profit'' 
healthcare sector and are often not suitable for the management of 
complex medical conditions. We have concerns about how VA might 
implement such a model.

H.R. 3581, the Cope Act

    The Cope Act seeks to help veterans' caregivers by authorizing the 
VA to provide grants to organizations whose mission is focused on the 
mental healthcare of participants in its Program of Comprehensive 
Assistance for Family Caregivers. It also requires the Department to 
provide outreach to registered caregivers. Veterans' caregivers are 
often isolated, forced to give up careers or lifestyles to provide 
around-the-clock medical and emotional support for their loved one. 
They are normally so focused on the needs of their veterans that they 
will put their own well-being on the backburner. PVA supports this 
bill, which would help caregivers meet their emotional needs, so they 
can continue to support their veterans.

H.R. 1182, the Veterans Serving Veterans Act

    The Veterans Service Veterans Act establishes a vacancy and 
recruitment data base to facilitate the recruitment of soon to separate 
members of the Armed Forces in order to fill vacant positions at VA. To 
do so, it requires DOD to provide the names and contact information of 
every member of the Armed Forces whose military occupational specialty 
or skill corresponds to an employment vacancy at the VA. We are 
unconvinced the current employment data bases are so insufficient that 
it justifies this degree of interagency investment and upkeep. Most 
concerning, this data base of DOD information, to be maintained by VA, 
would automatically submit service members' information and require one 
to opt-out, rather than opt-in, in writing. PVA commends the intent of 
this legislation, to fill vacancies and provide suitable employment to 
newly separated service members, but we recommend the privacy and 
efficiency concerns be addressed.

H.R. 1278, the Drive Act

    The Drive Act increases the mileage reimbursement rate available to 
beneficiaries for travel to or from VA facilities in connection with 
vocational rehabilitation; required counseling; or for the purpose of 
examination, treatment, or care. Specifically, the bill makes the 
reimbursement rate for such travel equal to or greater than the mileage 
reimbursement rate for government employees using private vehicles when 
no government vehicle is available. Government employees travel rates 
are adjusted annually but reimbursement rates for veterans are not. 
Under current regulations, VA reimburses veterans when traveling for a 
VA health care appointment at a rate of 41.5 cents per mile, which is 
far less than what government employees receive. PVA endorses this 
bill, because veterans should not be subject to a lower reimbursement 
rate.

H.R. 1639, the VA Zero Suicide Demonstration Project Act of 2023

    PVA supports this measure, which directs the VA to establish the 
Zero Suicide Initiative pilot program at five VA medical centers across 
the country. This proposed pilot program would help the VA identify 
gaps in care and create a multi-layered approach with evidence-based 
interventions to ensure veterans at risk of suicide do not slip through 
the cracks and transform the culture around suicide prevention. The 
pilot program would require the VA to consult with several outside 
stakeholders and agencies such as the National Institutes of Health, 
the Department of Health and Human Services, and different offices 
within the VA.
    According to a recent VA Office of Inspector General report, 
approximately 163,000 veterans were referred to a Suicide Prevention 
Coordinator between March 2019 and June 2020.\1\ This statistic paints 
a stark picture for veterans. The current system needs strengthening. 
The Zero Suicide Institute has seen impressive results from its quality 
improvement model, transforming system-wide suicide prevention and care 
to save lives. They report a reduction in suicide deaths and 
hospitalizations, an increase in quality and continuity of care, 
improvements in post-discharge follow-up visits, and improvements in 
screening rates.\2\ Implementing a similar project through the VA could 
reduce veteran suicides and should be pursued.
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    \1\ VAOIG Report 20-02186-78, Suicide Prevention Coordinators Need 
Improved Training, Guidance, and Oversight
    \2\ Zero Suicide Results; the Zero Suicide Institute

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H.R. 1774, the VA Emergency Transportation Act

    PVA supports this bill, which requires the VA to properly reimburse 
veterans for the cost of emergency transportation by a non-VA provider 
to a facility for emergency treatment, or from a non-VA facility where 
the veteran was being treated to a VA or other federal facility for 
additional care. We feel this commonsense legislation will decrease 
veterans' worries about the cost of emergency transportation by 
eliminating this financial burden.

H.R. 1815, the Expanding Veterans' Options for Long Term Care Act

    Currently, the VA can refer veterans to assisted living facilities, 
but it cannot directly pay for that care. PVA strongly supports the 
Expanding Veterans' Options for Long Term Care Act, which would create 
a three-year pilot program at six VISNs, including at least two program 
sites in rural areas and two in state veterans homes to test the 
benefit of having VA pay for this care. Veterans eligible for the pilot 
would include those already receiving nursing home-level care paid for 
by the VA and those who are eligible to receive assisted living 
services or nursing home care. At the conclusion of the pilot program, 
participating veterans will be given the option to continue receiving 
assisted living services at their assigned site, paid for by the VA. We 
believe this would help veterans and the VA alike by giving greater 
access to assisted living and reducing costs for long-term care, 
allowing more veterans to receive needed assistance.

H.R. 2818, the Autonomy for Disabled Veterans Act

    Improvements are long overdue for VA's Home Improvements and 
Structural Alterations (HISA) grant program. As the name suggests, HISA 
grants help fund improvements and changes to an eligible veteran's 
home. Examples of qualifying improvements include improving the 
entrance or exit from their homes, restoring access to the kitchen or 
bathroom by lowering counters and sinks, and making necessary repairs 
or upgrades to plumbing or electrical systems due to installation of 
home medical equipment.
    A lifetime HISA benefit is worth up to $6,800 for veterans who need 
a housing modification due to a service-connected condition. Veterans 
who rate 50 percent service-connected may receive the same amount even 
if a modification is needed due to a non-service-connected disability. 
Veterans who are not service-connected but are enrolled in the VA 
healthcare system can receive up to $2,000. These rates have not 
changed since 2010 even though the cost of home modifications and labor 
has risen at least 50 percent during the same timeframe. As a result, 
the latter figure has become so insufficient it barely covers the cost 
of installing safety bars inside a veteran's bathroom.
    In the past, our service officers reported having veterans who had 
used the HISA grant more than once because the remainder of the one-
time amount would cover at least part of a second project. Today, they 
rarely have veterans with remaining balances because veterans' entire 
allowance coupled with their own money is needed to complete one 
project. This should not be happening.
    PVA strongly supports this legislation, but believes it could be 
made even better by adjusting the text so it offers a single rate of 
$10,000 for all veterans and ties future increases to the same index VA 
uses for its other home modification programs. The most commonly 
requested HISA grant alteration is to renovate a bathroom. Nationwide, 
it costs about $10,000 to modify an average size bathroom.
    Increasing the grant amount to $10,000 for all enrolled veterans 
would allow for this critical modification. We also believe the 
relevance of the grant program would be better sustained if it used a 
formula like the Turner Building Index which calculates the actual 
costs of home modifications. HISA grants were intended to serve injured 
and aging veterans at a time in their lives when they need it the most, 
and we appreciate the effort to restore this grant program to its 
originally intended strength.
    PVA would once again like to thank the Subcommittee for the 
opportunity to submit our views on some of the bills being considered 
today. We look forward to working with the Subcommittee on this 
legislation and would be happy to take any questions for the record.

  Information Required by Rule XI 2(g) of the House of Representatives

Pursuant to Rule XI 2(g) of the House of Representatives, the following 
information is provided regarding federal grants and contracts.

                            Fiscal Year 2023

Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events----
Grant to support rehabilitation sports activities--$479,000.

                            Fiscal Year 2022

Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events----
Grant to support rehabilitation sports activities--$ 437,745.

                            Fiscal Year 2021

Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events----
Grant to support rehabilitation sports activities--$455,700.

                     Disclosure of Foreign Payments

Paralyzed Veterans of America is largely supported by donations from 
the general public. However, in some very rare cases we receive direct 
donations from foreign nationals. In addition, we receive funding from 
corporations and foundations which in some cases are U.S. subsidiaries 
of non-U.S. companies.
                                 ______
                                 

                     Prepared Statement of Argentum
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        Prepared Statement of The Honorable Mark Alford (MO-04)

    Chairwoman Mariannette Miller-Meeks and Ranking Member Julia 
Brownley, thank you for the opportunity to submit a statement as the 
Subcommittee considers H.R. 1774, the VA Emergency Transportation Act.
    H.R. 1774 replaces the term ``emergency treatment'' with 
``emergency services'' and defines ``emergency services'' to include 
both emergency treatment and transportation. If enacted, this bill 
would cover emergency transportation to a non-Veterans' Affairs (VA) 
facility for treatment.
    Under current law, the VA only covers emergency transportation 
within the VA network. While veterans can always file a claim with the 
VA for reimbursement, there is no guarantee their costs for emergency 
transportation outside the VA network will be covered.
    What is a veteran to do if they experience an emergency and require 
emergency transportation outside of the VA network? This is not a 
concern men and women who selflessly gave everything to serve this 
country should have to deal with.
    Missouri's Fourth congressional District is proudly home to two 
prestigious military installations, Whiteman Air Force Base and Fort 
Leonard Wood. These bases generate a significant military population to 
our district, including a substantial number of veterans. Our veterans 
made the decision to put their life on the line to defend our country 
and it is our duty to support their health and prosperity in civilian 
life.
    Once again, I would like to thank the Veterans' Affairs 
Subcommittee on Health, Chairwoman Mariannette Miller-Meeks, and 
Ranking Member Julia Brownley for this opportunity. I appreciate the 
committee holding this important hearing and hope this bill passes with 
overwhelming support.
                                 ______
                                 

         Prepared Statement of The Honorable Susie Lee (NV-03)

    Chair Miller-Meeks, Ranking Member Brownley, and Members of the 
Subcommittee, thank you for this opportunity to share my strong support 
for passage of a bipartisan bill I introduced earlier this year, H.R. 
1639, the VA Zero Suicide Demonstration Project Act of 2023.
    As members of the House Committee on Veterans Affairs, you are far 
too familiar with the fact that suicide is a serious, devastating issue 
in the United States, especially for our veterans and their families.
    The suicide rate for veterans is one and a half times higher than 
that of the general population, with an average of 17 veterans dying by 
suicide each day. Many veterans in southern Nevada have told me they 
think the number is even higher. Of those 17 veterans a day, 40 percent 
of them are actively seen at the VA, which means we lose approximately 
seven veterans a day to suicide who receive VA care. These numbers are 
simply unacceptable.
    Given the unique stressors and risk factors we know veterans face, 
Congress needs to do more to ensure those who served our country are 
effectively, consistently supported through their worst moments.
    We need to do more to advance suicide prevention efforts among 
veterans across our communities--keeping in mind the truth that even 
one suicide is too many. We need to change our mindset and do 
everything in our power to bring the number of veteran suicides to 
zero.
    That's why I reintroduced the VA Zero Suicide Demonstration Project 
Act in March 2023, alongside my colleague, Representative Tony 
Gonzales. Building on VA's existing suicide prevention efforts, this 
bipartisan, bicameral bill would stand up a Zero Suicide Initiative 
pilot program at the VA.
    Developed in Michigan's Henry Ford Health Care System, this program 
is rooted in the belief that all suicides are preventable through 
proper care, patient safety, and system-wide planning. This model 
trains and empowers clinicians to assess for suicide risks at every 
encounter with patients, identifying risk factors as well as 
interventions, self-management tools, and other effective suicide 
prevention techniques.
    This Zero Suicide approach has delivered statistically significant 
results across diverse health system, including a notable 18-month 
period without a single suicide. We owe it to veterans to ensure they 
have access to this proven approach to suicide prevention.
    This bill will ensure veterans have the care and support they 
deserve, by implementing a pilot program across five VA medical centers 
and offering them Zero Suicide Initiative training and support. It's 
all about changing mindsets and rearranging priorities with a 
commitment to getting to zero suicides a day.
    The bill does not authorize any new spending, and it has been 
endorsed by many leading VSOs and national mental health 
organizations--some of which have submitted letters of support for this 
hearing.
    Last Congress, this bill saw robust bipartisan support through a 
successful legislative hearing and passage by voice vote through this 
committee. While the bill did not come up for vote before the full 
House during the 117th, I am glad to return to the committee and to 
urge my colleagues to do all we can to see it through this Congress. 
Thank you for the committee's attention to and support for this 
critical piece of legislation. I look forward to working with you all 
to pass the VA Zero Suicide Demonstration Project Act into law, and to 
take a critical step in preventing veteran suicide.
                                 ______
                                 

          Prepared Statement of The Honorable Denis McDonough
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