[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
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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
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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
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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
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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
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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.
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\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.
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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.
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\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).
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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.
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\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.
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\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.
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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.
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\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.
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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.
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\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\
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\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).
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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.
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\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.
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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
---------------------------------------------------------------------------
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
[GRAPHICS NOT AVAILABLE IN TIFF FORMAT]
______
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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