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

                             LEGISLATIVE HEARING ON

                  H.R. 3584; H.R. 3644; H.R. 3649; H.R. 4424;

                  H.R. 5530; H.R. 6324; H.R. 6373; H.R. 7347;

                 H.R. 3225; H.R. 5794; H.R. 3303; AND H.R. 5247

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

                                    HEARING

                                   before the

                             SUBCOMMITTEE ON HEALTH

                                     of the

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED EIGHTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                            THURSDAY, MARCH 21, 2024

                                   __________

                               Serial No. 118-57

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

                        Available via http://govinfo.gov

                               ______

                 U.S. GOVERNMENT PUBLISHING OFFICE
     55-439          WASHINGTON : 2025

                         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

                                  ----------

                            THURSDAY, MARCH 21, 2024

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
    The Honorable Julia Brownley, Ranking Member.....................     4

                             SPEAKING FROM THE DAIS

    The Honorable Jack Bergman, U.S. House of Representatives, (MI-1)     2
    The Honorable Chris Deluzio, U.S. House of Representatives, (PA-
      17)............................................................     5
    The Honorable Mike Bost, U.S. House of Representatives, (IL-12)..     6
    The Honorable Debbie Dingell, U.S. House of Representatives, (MI-
      6).............................................................     7
    The Honorable Derrick Van Orden, U.S. House of Representatives,
      (WI-3).........................................................     8
    The Honorable Lauren Underwood, U.S. House of Representatives,
      (IL-14)........................................................     9
    The Honorable Greg Murphy, U.S. House of Representatives, (NC-3).    10
    The Honorable Nick LaLota, U.S. House of Representatives, (NY-1).    11

                                   WITNESSES
                                    Panel 1

    Dr. Ajit Pai, Executive Director, Office of Rehabilitation and
      Prosthetic Services, Veterans Health Administration, U.S.
      Department of Veterans Affairs.................................    12

            Accompanied by:

        Dr. Michael Brennan, Executive Director, Office of
            Construction and Facilities Management, U.S. Department
            of Veterans Affairs

        Dr. Wendy Tenhula, Deputy Chief Research and Development
            Officer, Office of Research and Development, Veterans
            Health Administration, U.S. Department of Veterans
            Affairs

        Mr. David Perry, Chief Officer, Workforce Management and
            Consulting, Veterans Health Administration, U.S.
            Department of Veterans Affairs

                                    Panel 2

    Mr. Jon Retzer, Assistant National Legislative Director, Disabled
      American Veterans..............................................    18

    Mr. Roscoe Butler, Senior Health Policy Advisor, Paralyzed
      Veterans of America............................................    19

    Ms. Brittany Elliot, Veteran (USMC), Advocate....................    21

    Ms. Melissa Bryant, Chair, Board of Directors, Minority Veterans
      of America.....................................................    23

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Dr. Ajit Pai Prepared Statement..................................    33
    Mr. Jon Retzer Prepared Statement................................    53
    Mr. Roscoe Butler Prepared Statement.............................    58

                              APPENDIX--continued

    Ms. Brittany Elliot Prepared Statement...........................    61
    Ms. Melissa Bryant Prepared Statement............................    65

                           Statements For The Record

    TreatNOW Prepared Statement......................................    77
    The Honorable Matt Cartwright, U.S. House of Representatives,
      (PA-8) Prepared Statement......................................    79
    Wounded Warrior Project Prepared Statement.......................    80
    Association of Air Medical Services Prepared Statement...........    86
    Jewish War Veterans of the USA Prepared Statement................    89
    Military-Veterans Advocacy Prepared Statement....................    93
    American Ambulance Association, International Association of Fire
      Chiefs and National Association of Emergency Medical
      Technicians Prepared Statement.................................    97

                             LEGISLATIVE HEARING ON

                  H.R. 3584; H.R. 3644; H.R. 3649; H.R. 4424;

                  H.R. 5530; H.R. 6324; H.R. 6373; H.R. 7347;

                 H.R. 3225; H.R. 5794; H.R. 3303; AND H.R. 5247

                                  ----------

                            THURSDAY, MARCH 21, 2024

                        Subcommittee on Health,
                        Committee on Veterans' Affairs,
                                 U.S. House of Representatives,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 2:49 p.m., in
    room 360, Cannon House Office Building, Hon. Mariannette
    Miller-Meek [chairwoman of the subcommittee] presiding.
        Present: Representatives Miller-Meeks, Radewagen,
    Rosendale, Murphy, LaLota, Brownley, and Deluzio.
        Also present: Representative Dingell, and Underwood.

       OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

        Ms. Miller-Meeks. The legislative hearing of the
    Subcommittee on Health will now come to order. I want to
    welcome all members of the subcommittee and our witnesses. It
    is a pleasure and a privilege to collaborate once more on
    crucial matters affecting our veterans.
        Today we will be discussing 12 bills, each aimed at
    improving various aspects and critical needs of veterans' whole
    health care. These bills range from increasing the availability
    of assistive mobility devices for veterans living with
    paralysis to guaranteeing appropriate compensation for
    providers of essential transportation services and other
    pressing concerns.
        I would like to discuss my bill, H.R. 3584, the Veterans
    Cannabis Analysis Research and Effectiveness, or CARE Act.
        For years we have heard anecdotal firsthand accounts from
    veterans who have experienced decreased Post-traumatic Stress
    Disorder (PTSD) symptoms and pain through medical cannabis.
        My bill would create a research framework for exploring the
    potential health benefits of cannabis for treating PTSD and
    chronic pain. Through rigorous research the Veterans Health
    Administration (VHA) can explore a new evidence-based treatment
    option that may have the potential to enhance the lives of
    those who have served our Nation and to treat the invisible
    wounds of war.
        My bill also has a commitment to preserving data for future
    research which underscores a long-term vision for evidence-
    based treatment options. It is important not to let old stigmas
    interfere with the healthcare treatment veterans are receiving
    if a therapy is proven to be safe, effective, and improve
    veterans' quality of life. I am proud to introduce this bill so
    that we can gain insight into new therapies that could help
    those who need it most.
        Today we will also discuss Representative Van Orden's bill
    on alternative therapies. H.R. 7347 would direct the Department
    of Veterans Affairs (VA) secretary to report to Congress on
    whether VA will include emerging breakthrough therapy drugs in
    the VA's list of pharmaceuticals after U.S. Food and Drug
    Administration (FDA) approval.
        I look forward to a productive discussion today on my
    legislation, as well as the rest of the bills on today's
    agenda, and the positive impact they promise.
        Thank you to our witnesses and those organizations that
    submitted statements for the record for their thoughtful
    feedback on my bill and the other bills we will discuss today.
        Ensuring the highest standard of care for our veterans is
    more than our responsibility. It is a profound honor. I look
    forward to our discussion on the merits and challenges of all
    the legislation before us today and the impact they could have
    on VA operations and, most importantly, on veterans' lives.
    Thank you again for all being here.
        Because of the interference with votes for our hearing
    today, we will come back to Ranking Member Brownley for her
    opening remarks. We have a full agenda today so I will be
    holding everyone to 3 minutes per bill to get through it in a
    timely manner.
        This morning we are joined by several colleagues who are
    going to testify about their bills. We are extremely grateful
    for their work in serving our Nation's veterans.
        With that, I ask unanimous consent that all non-committee
    members be waived on to speak on their bills from the dais.
    Hearing no objection, we will move forward.
        I now recognize Representative Bergman. You are now
    recognized for 3 minutes.

                       STATEMENT OF JACK BERGMAN

        Mr. Bergman. Thank you, Madam Chair. I would like to start
    by briefly mentioning two bills that the committee will discuss
    today, Congresswoman Dingell's VA Peer Review Neutrality Act,
    which I am proud to be the Republican colleague for and
    Congressman Van Orden's bill to require VA to make a formulary
    determination for psychedelic therapies within 6 months of FDA
    approval. Both are important pieces of legislation. I look
    forward to hearing their sponsors' testimonies.
        I would also like to take a few seconds to show my
    appreciation for one of our witnesses in particular, Ms.
    Brittany Elliot, as well as her full time caregiver and father,
    Morgan Elliot. I have had the opportunity to spend a wonderful
    amount of time with both of them, hear their story, and gain a
    sense of the difficulty that currently exists for our Spinal
    Cord Injury or Disorder (SCI/D) veterans. We will talk about
    that acronym later.
        Brittany is strong, determined, and undaunted by the
    bureaucracy she has been forced to deal with, and as a fellow
    Marine I would expect nothing less. Welcome to both and
    Brittany I look forward to hearing your testimony.
        The Veterans' Spinal Trauma Access to New Devices or
    Veterans STAND Act, takes commensurate steps to improve care
    for veterans with spinal cord injuries or disorders and ensure
    they are assessed for and provided with assistive devices that
    they are already clinically eligible to receive.
        First, the bill would codify the requirement that VHA
    provides an annual spinal health assessment for SCI/D veterans
    and includes specific requirements for proactive outreach to
    those who are eligible.
        Second, the bill takes steps to ensure veterans are
    informed of and assessed for assistive technology that can help
    their independence and mobility. As many veterans will tell
    you, despite both of these measures already existing on paper
    at VA, the actual experience of SCI/D veterans has varied
    widely and in many cases VA has outright failed to meet their
    needs. This is why the bill also takes steps to improve
    transparency and accountability at VA, including by requiring
    the secretary to submit reports to Congress on the extent to
    which veterans are actually being provided with these life-
    changing technologies.
        Finally, the bill would direct VHA to consult with
    veterans' advocates, medical specialists and device experts and
    manufacturers when developing clinical procedure guidelines for
    assistive devices, something that will only become more
    important as the rate of technological advancement continues to
    increase exponentially and new devices enter the marketplace.
    The fact is that we are systematically failing those veterans
    paralyzed from service by denying them simple and rapid access
    to essential assistive technology. Veterans like Brittany who
    have received these devices have often only been able to do so
    through extensive self-advocacy, months of delays, and hundreds
    of miles of travel to find a VA doctor and facility willing to
    meet their needs.
        I am grateful to Chairman Bost, Subcommittee Ranking Member
    Brownley and Congresswoman Dingell for helping me introduce
    this bipartisan bill, as well as the other committee members
    who have joined as co-sponsors. I have also heard that Senators
    Moran and Tester, the ranking member and chairman of the Senate
    VA Committee, have introduced a Senate companion bill today. I
    wholeheartedly welcome any and all constructive input to make
    sure we advance the best possible bill to improve the lives of
    veterans with spinal cord injuries and disorders.
        However, as I hope you learn from Ms. Elliot's testimony,
    our current way of doing things is not working for many
    veterans with spinal cord injuries. That being is unacceptable
    and Congress must act.
        I yield back.
        Ms. Miller-Meeks. Thank you.
        The chair now recognizes Ranking Member Brownley for her
    opening statement.

          OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

        Ms. Brownley. Thank you, Madam Chair, and thank you for
    being patient with me being slightly late. Thank you very much
    for convening today's hearing. I look forward to our discussion
    of the 12 bills on today's agenda. I know many of the sponsors
    of legislation on today's agenda are planning to be here to
    present their bills, and I am eager to hear from our witnesses
    so I will aim to keep these remarks brief and highlight just a
    few of the bills.
        I am pleased we are considering H.R. 6373, the Veterans'
    Spinal Trauma Access to New Devices, or Veterans' STAND Act. I
    am proud to be co-leading this bill with Representative
    Bergman, Bost and Dingell. H.R. 6373 will codify VA's existing
    policy of providing annual preventive health assessments for
    veterans with spinal cord injuries or diseases. These exams are
    vitally important because they can help identify and treat
    health issues before they become too serious.
        Second, our legislation aims to increase veterans' access
    to state-of-the-art assistive technology known as personal
    exoskeletons. Ms. Elliot, a veteran who is testifying on our
    second panel, has a great deal to share about her personal
    experience with this technology and her attempts to access it
    through the VA. We look forward to hearing from her.
        Advancements in technology can provide revolutionary
    options to help paralyzed veterans lead their lives to their
    fullest potential, and the Veterans' STAND Act will help ensure
    VA remains at the forefront of innovation and medical
    treatment,
        I understand that VA has some concerns about the bill, but
    I hope the department will work with us to make those
    improvements.
        I am also pleased that we are considering Representative
    Underwood's bill, H.R. 3303, the Maternal Health for Veterans
    Act. This legislation builds upon the Protecting Moms Who
    Served Act also sponsored by Representative Underwood which was
    enacted in 2021.
        In addition to codifying VA's maternity care coordination
    (MCC) program, the Protecting Moms Who Served Act mandated a
    Government Accountability Office (GAO) report on maternal
    health outcomes among veterans. That report was issued in
    January of this year, and I ask unanimous consent to enter this
    report into the hearing record.
        Ms. Miller-Meeks. No objection.
        Ms. Brownley. GAO analyzed VA data on deaths and severe
    maternal morbidity among pregnant and postpartum veterans from
    fiscal years 2011 through 2020, the most recently available
    data. The findings are concerning. Among other things GAO found
    that the severe maternal morbidity rate among veterans
    increased between 2011 and 2020 and this rate was highest among
    black or African American veterans.
        H.R. 3303, the Maternal Health for Veterans Act, will
    require VA to report annually on activities related to
    maternity care coordination. These reports must include data on
    veterans' maternal health outcomes along with recommendations
    for improving them.
        Further, this bill authorizes funding through Fiscal Year
    2028 for VA's maternity care coordination program. I am pleased
    that Ms. Melissa Bryant of Minority Veterans of America (MVA)
    is here today to testify on this legislation. As you will hear
    from her, there have been many positive outcomes of VA's
    maternity care coordination program since it was established in
    2012, but there are still many areas for improvement.
        Just yesterday I participated in a roundtable with Ms.
    Bryant and other women veterans where we discussed VA's
    implementation of the Deborah Sampson Act, which was signed
    into law just over 3 years ago. While the Deborah Sampson Act
    made significant improvements in the delivery of benefits and
    health care for women veterans, it is clear there is more work
    to do and we need to continue advancing additional legislation
    like Ms. Underwood's bill.
        I understand Representative Deluzio and Ms. Dingell will
    also be here, I see Ms. Dingell right here, in support of their
    bills, H.R. 3225, the Build for Veterans Act and H.R. 5794, the
    VA Peer Review Neutrality Act. I will defer to both of them to
    provide more detailed explanations of their bill, but I want to
    express my support for each.
        I will yield there, Madam Chair.
        Ms. Miller-Meeks. Thank you very much, Ranking Member
    Brownley.
        We are going to go back to presentation. I now recognize
    Representative Deluzio for 3 minutes.

                       STATEMENT OF CHRIS DELUZIO

        Mr. Deluzio. Thank you, Madam Chair. Thank you Ranking
    Member Brownley for the kind words about my bill, the Build,
    Utilize, Invest, Learn, And Deliver for Veterans Act, the BUILD
    for Veterans Act, a common sense piece of legislation to
    modernize and streamline the delivery of VA medical facilities
    and other infrastructure projects, strengthen the workforce,
    save public money by expediting the disposal or repurposing of
    unused or vacant buildings that the VA owns.
        I think it is badly needed. We all know across the country
    in our districts the VA opens lots of new or remodeled
    facilities every year but the need for more modern facilities
    is much greater than its current operational tempo, budget, or
    frankly, infrastructure workforce. Those VA facilities on
    average are around 60 years old and the VA has around 180
    billion in backlogged infrastructure projects, a backlog that
    is growing faster than VA can address them.
        This bill continues to build off historic infrastructure
    investments of Ranking Member Takano's The Sergeant First Class
    Heath Robinson Honoring our Promise to Address Comprehensive
    Toxics (PACT) Act, and I am proud to say there is a companion
    effort in the Senate led by Chairman Tester. Specifically, the
    BUILD for Veterans Act works to tackle workforce issues,
    establishing a staffing model to ensure a base level of capital
    asset staffing through new recruitment and retention incentives
    on infrastructure streamlining.
        The bill requires VA to implement a more concrete schedule
    to eliminate repurposed, unused, or vacant buildings to ensure
    there is an adequate office and staff, or offices, excuse me,
    and staff to efficiently manage capital assets at all levels by
    implementing systems review of the climate resilience of all
    capital assets.
        There is also an oversight section in the bill requiring VA
    to provide an annual budget for Congress to monitor the plan's
    performance data over a 10-year period, requiring a submission
    of a strategic plan that improves VA's delivery and management
    of capital assets and requiring an examination and reporting of
    VA-related capital asset improvement from the VA Inspector
    General.
        The bill is supported by many Veterans Service
    Organizations (VSO), including Veterans of Foreign Wars (VFW),
    Disabled American Veterans (DAV), Paralyzed Veterans of America
    (PVA), the Legion, Iraq and Afghanistan Veterans of America
    (IAVA). I think this is a good bill, one that I hope my
    colleagues will support. The BUILD for Veterans Act strengthens
    VA's capacity to deliver veterans the state-of-the-art care
    that they all have earned and saves public money in the
    process.
        Madam Chair, I yield back. Thank you.
        Ms. Miller-Meeks. Thank you Representative Deluzio.
        I now recognize Representative Bost, Chairman Bost, for 3
    minutes.

                         STATEMENT OF MIKE BOST

        Mr. Bost. Thank you, Madam Chairman. I am glad to be here
    today to speak on my bills, H.R. 5530, and VA Energy
    Transportation Access Act and H.R. 6324, the Fiscal Year 2024
    Veterans Affairs Majority Medical Facility Authorization Act.
        H.R. 5530, the VA Emergency Transportation Access Act,
    would help veterans keep access to emergency transportation
    services. I know firsthand that quick access to emergency
    transportation services can be the difference between life and
    death in rural and remote areas of this United States.
        My commonsense bill would require VA to work with ground
    and air ambulance providers to develop a plan that protects and
    expands rural veterans' access to emergency service first.
        Right now, VA's proposed rule would slash reimbursement for
    good companies that provide vitally important ground and air
    emergency transportation services. VA plans--reverts to the
    outdated medical reimbursement schedule that is based on data
    from 1998 and 2002.
        My bill would ensure that veterans, especially rural
    veterans, have access to transportation for timely medical
    care. It would guarantee that transportation companies are
    reimbursed fairly for their services.
        My bill also would create a simple and sensible process for
    VA to make needed changes in reimbursements. This bill is about
    protecting our veterans so that they have access to care they
    need when they need it.
        Next, I would like to speak about bill, H.R. 6324, the
    Fiscal Year 2024 Veterans Affairs Major Medical Facilities
    Authorization Act. This bill would authorize over $4.6 billion
    in important major medical facilities projects that would
    modernize VA medical facilities across the country, building on
    the personal commitment to bring VA into the--my personal
    commitment to bring VA into the 21st century.
        This legislation would authorize a number of key
    construction projects across country that we know VA medical
    facilities need. These projects range from the construction of
    new healthcare centers to the expansion of mental health
    facilities. My bill would allow VA to replace outdated
    community living centers and update existing facilities with
    the latest earthquake resistant technology.
        By continuing to modernize VA facilities we will ensure
    that the veterans have access to the high quality modern
    medical care that they deserve. It is vitally important that we
    address critical construction projects in a timely and fiscally
    responsible manner. I look forward to ensuring my legislation
    does exactly that.
        Madam Chairman, I yield back.
        Ms. Miller-Meeks. Thank you, Mr. Bost. I was ready,
    willing, and able to yield you another 3 minutes but you spoke
    on both H.R. 5530 and H.R. 6324. Thank you.
        I now recognize Representative Dingell for 3 minutes.

                      STATEMENT OF DEBBIE DINGELL

        Ms. Dingell. Thank you, Madam Chair. I want to start by
    thanking you and the ranking member for including H.R. 5794,
    the VA Peer Review Neutrality Act, as part of today's hearing.
    I am leading this bill alongside my good friend and colleague
    from Michigan, Representative Jack Bergman, and I appreciate
    his support and partnership on this very important issue.
        I care deeply, like all of you do, about our Nation's
    veterans so when they come to me with problems I listen. When I
    started hearing concerns from veterans and employees at the
    John D. Dingell VA Medical Center in Detroit, I knew these
    problems were serious and immediately started sounding the
    alarm.
        I personally went to the Veterans Affairs secretary and I
    want to thank him here for listening. These efforts led to a
    review by the VA Inspector General into allegations of
    misconduct at the Detroit VA Medical Center. Unfortunately, the
    review uncovered findings of misconduct in a pattern of
    substandard surgical care, which included the manipulation of
    external peer reviews.
        The top three administrative leaders at the facility have
    since been removed, and under new leadership the VA has made
    progress in restoring trust and accountability. Still, it is
    critical we never allow this kind of misconduct to happen again
    at any VA hospital across the country, and a Member of Congress
    should not have to go directly to the VA secretary.
        With the VA Peer Neutrality Act we can take concrete steps
    to strengthen accountability and neutrality within the VA's
    peer review process. This bill will codify a VA policy that
    ensures members of a VA facilities peer review committee cannot
    participate in peer reviews of cases they were involved in or
    cases that present a conflict of interest.
        Our veterans deserve the best care and this legislation
    will better strengthen accountability and oversight within the
    VA medical facilities that serve them. I look forward to
    continuing to work with this subcommittee on this very
    important legislation.
        I yield back, Madam Chair.
        Ms. Miller-Meeks. Thank you, Representative Dingell.
        The chair now recognizes Representative Van Orden for 3
    minutes.

                     STATEMENT OF DERRICK VAN ORDEN

        Mr. Van Orden. Thank you, Madam Chair. I am a Navy veteran
    of 26 years and 22 of those were spent as a SEAL. My entire
    adult life has been spent operating next to some of the
    greatest men and women in the world, actually. Although most of
    us have survived combat, many of us come back home and we are
    unable to deal with the issues that presented us in that very
    difficult environment.
        Today, with the passing of a senior chief, to date I have
    had 21 of my friends commit suicide, and we just had another
    Navy SEAL commit suicide 2 weeks ago. These things do not make
    the press, you know, but we have a very tight-knit group of
    folks. His name will never be made public I do not think.
        I did not know him but, you know, who did? His family and
    his teammates, and we do not forget our brothers and sisters
    who, unfortunately, make a permanent decision over a temporary
    problem.
        We have given the Veterans Administration $16.5 billion
    last year and $150 billion since 9/11 for veterans suicide and
    the suicide rate continues to increase. I mean, Dr. Scavella
    here, who has an incredibly impressive academic record and an
    absolutely terrible practical record of preventing veterans
    from committing suicide, so we have to try something different.
    We simply do.
        We have got these incredibly brilliant scientists and
    doctors and all this stuff, and what they are doing is not
    working. We know that because more veterans are committing
    suicide now than they have in the past.
        I have introduced H.R. 7347 and that is to make sure that
    we are able to mandate the Veterans Administration to report
    back to us within 180 days on its plans to incorporate
    psychedelics into treatments upon FDA approval. I will tell you
    what, honestly, I am not 100 percent sold on this. I am not.
        Do you know what? It works for some of our veterans. It
    does. Some of our veterans on this committee actually have done
    psychedelic treatment to prevent or to help them deal with PTS,
    and it worked for them. We are going to be an all-of-the-above
    if it is going to help a single veteran even as a bridging
    mechanism from preventing themselves from committing suicide.
        I am 100 percent sold on faith-based programs because they
    are proven to work also. I am asking everybody, Ms. Brownley
    and Madam Chair, I am asking all to vote for this,
    understanding that it is not a do-all fix-all for everybody but
    it is going to help at least save one veteran's life so that I
    do not have to go to their funeral and get on my knees one more
    time and speak to these fatherless children. Look at their
    widow and try to explain to him why we did not do everything we
    possibly can to prevent their husband from committing suicide.
        I am imploring my colleagues to please vote this. Get it
    through the subcommittee to the full Committee to the House and
    let us actually do what we say we are here to do and that is to
    prevent veteran suicide.
        With that, I yield back, Madam Chair.
        Ms. Miller-Meeks. Thank you Representative Van Orden.
        The chair now recognizes Representative Underwood for 3
    minutes.

                     STATEMENT OF LAUREN UNDERWOOD

        Ms. Underwood. Thank you, Madam Chair. Thank you for
    inviting me to speak today and for considering my legislation,
    the Maternal Health for Veterans Act. While I currently sit on
    the House Appropriations Committee, I previously had the honor
    of serving on House Veterans Affairs in the 116th and 117th
    Congress, and I hope to be back next Congress, but serving
    veterans is one of the greatest privileges we have as Members
    of Congress. I am honored to serve veterans both on and off
    this committee.
        The United States is in the middle of a maternal health
    crisis that is getting worse not better and veteran moms are
    dying. America has the highest pregnancy-related mortality
    ratio of any high income country and significant disparities in
    outcomes. To solve this crisis I introduced the ``Momnibus,'' a
    set of 13 bills including the Maternal Health for Veterans Act
    that comprehensively address our Nation's maternal mortality
    crisis.
        Last Congress we had the first bill from the Momnibus
    enacted, the Protecting Moms Who Served Act which invests in
    world class care, maternity care for our veterans. I was so
    excited to go to the White House and see President Biden sign
    the Protecting Moms Who Served Act into law, but even then I
    knew that the Protecting Moms Who Served Act was only the
    beginning.
        Now earlier this year, the GAO released the report we
    commissioned in the Protecting Moms Who Served Act and their
    findings were devastating, but not surprising. In less than 10
    years the number of veterans suffering severe pregnancy
    complications almost doubled. Pregnant veterans are more likely
    to have physical and mental health conditions that may lead to
    adverse maternal outcomes or complications. For veterans, just
    like the general population, mental health conditions increase
    the risk of severe maternal death complications--I am sorry--
    severe maternal health complications including the risk of
    maternal death by suicide.
        We have a lot more work to do to live up to the promises we
    made to our veteran families. They served our country and our
    job is to serve them, and that is why I introduced the Maternal
    Health for Veterans Act. This legislation builds on our success
    advocating for quality maternal health care for our veterans.
        It authorizes $15 million per year for the next 5 years for
    VA's maternity care programs, and it requires recommendations
    and annual public reporting on maternal health from the VA. Our
    veterans are not just our heroes. As moms they are also the
    heroes of their families.
        During the vulnerable pregnancy and postpartum periods they
    rely on us to ensure that they have access to high quality
    maternity care. We owe them the best. I urge this committee to
    pass the Maternal Health for Veterans Act without delay and
    send it to the House floor this spring. Thank you so much for
    your time and consideration.
        I yield back.
        Ms. Miller-Meeks. Thank you, Representative Underwood.
        The chair now recognizes Dr. Murphy for 3 minutes.

                        STATEMENT OF GREG MURPHY

        Mr. Murphy. Thank you, Madam Chair, and I hope everybody
    was listening with what Representative Van Orden just said. It
    was quiet words but extremely powerful.
        I have 3 Marine bases in my district of 21,000 military
    retirees, 50,000 active military family members. I am honored
    today and fully believe in the bill I am introducing today.
        I have supported it since I came to Congress in 2019. I
    have worked on this same issue in the North Carolina State
    House with really good results.
        I have been working for years, despite being a urologist,
    to help find treatments and procedures, et cetera, to help PTSD
    and Traumatic Brain Injury (TBI). This is an absolute criminal
    act by this country that we have an increasing number of
    suicides despite statistical manipulation.
        The Committee knows better than anybody else that a cure
    for PTSD and TBI is elusive. We must examine every treatment
    option that has the potential to help our suffering veterans.
    H.R. 3649, the Veterans National Traumatic Brain Injury Act,
    requires the Department of VA to implement a 5-year pilot
    program to furnish under the Veterans Community Care Program,
    hyperbaric oxygen therapy (HBOT) to veterans with traumatic
    brain injuries, TBI, or traumatic stress disorder, PTSD.
        I strongly recommend that we examine this issue. I am happy
    to say that in the North Carolina House now the legislature has
    funded many veterans to undergo this treatment, and I have seen
    personally, personally, veterans who have been aided with this
    when literally they have hit the wall and nothing else has been
    able available to them.
        I am actually supportive of the hallucenogenics that
    Representative Van Orden was speaking. This must be an all
    hands on deck approach. Just a few weeks ago I was at a large
    gala for this particular issue with Secretary Mike Pompeo. He
    is onboard with this.
        A 2021 report by the North Carolina Community Foundation of
    North Carolina East said to the legislature that there is ``an
    impressive number of successes through the HBOT program and
    treatments in North Carolina veterans.''
        My bill is bipartisan. Don Davis, Marilyn Strickland,
    Representatives Kiggans, Pappas, Duncan, Timmins, Bill,
    Huizenga, Moreland are all co-sponsors, as well are multiple
    other VSOs. My intent is to offer another treatment.
        Reading the response to the VA in the opposition, I am very
    disappointed. It is an absolutely bureaucratic response. All
    hands on deck. All hands on deck to stop this absolute scourge
    which is happening with our veterans. I think the debate on
    risk is absolutely overstated. I have used this as a surgeon
    for close to 30 years and, yes, there are risks with any
    procedures . There are risks with an IV stick. When it has come
    to the end of the road, at the end of the road when our
    veterans have no other option that they choose suicide, all
    hands on deck. Whatever treatment we can as a Veterans
    Administration institution is owed to our veterans. I ask for
    your support.
        Thank you. I yield back.
        Ms. Miller-Meeks. Thank you, Dr. Murphy.
        The chair now recognizes Representative LaLota for 3
    minutes.

                        STATEMENT OF NICK LALOTA

        Mr. LaLota. Thank you, Chairman Miller-Meeks, Ranking
    Member Brownley and members of the Veterans Health Committee
    for hosting this important hearing today and for allowing me to
    waive on.
        Vietnam veterans have a much greater chance of contracting,
    suffering from, and dying from the liver fluke parasite and yet
    the VA does not cover their health-related coverage. The
    correlation between the liver fluke parasite and service in
    Vietnam is obvious.
        In fact, a first of its kind study was conducted back in
    2018 at the Northport VA Medical Center using a 50-veteran
    sample size. The initial results of that study highlighted
    three basic things, the substantial need for greater study of
    the issue, the development of standardized treatment options,
    and broader accessibility of care for veterans at VA facilities
    across the country.
        The VA conducted another study and after years of delays
    that study recently found there was a 30 percent greater risk
    of mortality from this bile duct cancer from Marines who served
    in the Vietnam War as compared to Marines who served elsewhere,
    30 percent. However, the VA still says that the study is not
    enough.
        It is clear to me, a Navy veteran and countless Vietnam
    veterans who have been suffering from and dying from the liver
    fluke parasite, that there should unequivocally be a
    designation of service connection for these veterans. That is
    why I am here today, Madam Chairwoman, to speak in favor of my
    legislation, H.R. 4224, the Liver Fluke Cancer Study Act, which
    would require the VA in conjunction with the Centers for
    Disease Control and Prevention (CDC) to conduct a study to
    determine the prevalence of liver fluke amongst the Vietnam
    veteran population.
        Madam Chairman, our Vietnam veterans are dying every day
    and we do not have the luxury of time. Too much time has passed
    already and we went through a similar terrible situation with
    our Blue Water Navy veterans and Agent Orange. Let us not make
    the same mistake twice.
        I urge all of my colleagues to support this legislation,
    and I want to thank the chairwoman and ranking member again for
    allowing me to testify in front of this committee, and I look
    forward to working with you and this entire committee to see
    this problem solved. Thank you.
        I yield back.
        Ms. Miller-Meeks. Thank you. We also have two additional
    bills that we may hear about today, H.R. 3644, Addressing Care
    Timelines (ACT) for Veterans Act by Representative Latta and
    H.R. 5247, Expedited Hiring for VA Trained Psychiatrist Act of
    2023 by Representative Cartwright. They have both submitted
    statements for the record.
        As is our practice we will forgo a round of questioning for
    the members. I now invite our first panel to the table.
        Thank you. Joining us today from the Department of Veterans
    Affairs is Dr. Ajit Pai, the Executive Director of the Office
    of Rehabilitation and Prosthetic Services at the Veterans
    Health Administration. Accompanying Dr. Pai today are Dr.
    Michael Brennan, Executive Director at the Office of
    Construction and Facilities Management, Veterans Affairs; Dr.
    Wendy Tenhula, Deputy Chief Research and Development Officer,
    Office of Research and Development, Veterans Health
    Administration; and Mr. David Perry, Chief Officer of Workforce
    Management and Consulting, Veterans Health Administration.
        Dr. Pai, you are now recognized for 5 minutes to present
    the Department's testimony.

                         STATEMENT OF AJIT PAI

        Dr. Pai. Good afternoon, Chairwoman Miller-Meeks, Ranking
    Member Brownley, and members of the subcommittee. We are
    grateful for the opportunity to appear before you today to
    discuss this pending legislation. Joining me are Dr. Michael
    Brennan, Executive Director of the Office of Construction and
    Facilities Management; Dr. Wendy Tenhula, Deputy Chief of the
    Office of Research And Development; and Mr. David Perry, Chief
    Officer of Workforce Management and Consulting.
        VA supports several items of proposed legislation before us
    today. While VA's views on all the bills are detailed in my
    written testimony, including areas of concern and support, I
    would like to highlight a few bills that would have profound
    effects on modernizing our delivery of services to veterans,
    their family members, and caregivers.
        First, VA supports, to include with amendments, H.R. 3303,
    the Maternal Health for Veterans Act; H.R. 3584, the Veterans
    CARE Act; H.R. 5794, the VA Peer Neutrality Act of 2023; and
    H.R. 6324, the FY 2024 VA Major Medical Facility Authorization
    Act.
        VA appreciates H.R. 3303 because it aligns with VA's
    current efforts to enhance the health outcomes of pregnant
    veterans. We note there is some ambiguity in the bill text as
    it would require VA to provide data on the maternal health
    outcomes of veterans who receive medical care or services
    furnished by VA when no VA medical facility furnishes maternity
    care.
        Although too prescriptive in its design, H.R. 3584 would
    authorize VA to conduct research in certain forms of cannabis
    on the health outcomes of veterans. I also want to thank the
    subcommittee for their efforts to improve the health outcomes
    of veterans through the introduction of several bills including
    H.R. 4424, the Vietnam Veterans Liver Fluke Cancer Study Act;
    H.R. 5247, the Expedited Hiring of VA Trained Psychiatrists Act
    of 2023; H.R. 7347, the reporting on the determination to
    include newly approved or licensed psychedelic drugs in the VA
    formulary bill; and certain sections in H.R. 3225, the BUILD
    for Veterans Act of 2023.
        I want to emphasize that VA recognizes the congressional
    intent behind these bills, but many of the activities mandated
    are already being carried out or completed.
        For instance, with regards to H.R. 3225, VA is already
    identifying properties annually via the disposal and reuse
    report, providing the total 10-year-long range action plan
    capital requirement and the major construction 5-year
    development plan requirements annually in the President's
    budget request, and incorporating recommendations from the
    Office of the Inspector General (OIG), the Comptroller General,
    and others on how to detect and prevent waste, fraud, and
    abuse.
        With many reporting requirements and provisions in this
    bill, VA is best suited with extended deadlines and
    congressional acknowledgement of staffing needs and the
    availability of appropriations.
        Also, VA is currently conducting research to better
    understand the health risks and conditions of veterans who
    served in combat areas or were otherwise placed at higher risk
    due to do their military service.
        An analysis of Vietnam-era Veterans' deaths from 1979 to
    2019 due to cholangiocarcinoma is in its final stages of
    preparation for submission to a peer-reviewed scientific
    journal. VA fully supports the need to continue conducting
    research in this area, however, we believe the bill's
    requirements are already satisfied.
        Another example is that VA currently has the authority
    proposed in H.R. 5247, to initiate the appointment process for
    psychiatrists before they complete a residency.
        Last, VA would like to address our concerns with H.R. 3649,
    the Veterans National Traumatic Brain Injury Treatment Act, and
    H.R. 6373, the Veterans STAND Act.
        Regarding H.R. 3649, if enacted into law in its current
    form, the bill could have a negative impact on the lives of
    veterans. Extensive research conducted by VA, the Department of
    Defense, and others on the effectiveness of hyperbaric oxygen
    therapy, or HBOT, for traumatic brain injuries has shown no
    significant improvements, especially in cases of mild TBI.
        Studies comparing HBOT to a control intervention reveal
    that HBOT was linked to decreased quality of life during long-
    term follow up at 2 and 3 years. Furthermore, aside from the
    lack of patient improvement, there is insufficient evidence to
    warrant the use of HBOT as a treatment for post-traumatic
    stress.
        We recognize that the advancement of assistive technology
    has significantly enhanced the lives of our Nation's veterans.
    However, H.R. 6373 as currently written, could hinder VA's
    ability to safeguard veterans' well-being and undermine the
    integrity of the clinical decision-making process.
        Additionally, mandatory consultation with specific
    manufacturers or entities could create conflicts of interest
    that might jeopardize patient safety.
        VA providers collaborate closely with veterans to assess
    their needs and suggest the most suitable solution.
    Exoskeletons which can weigh up to 51 pounds are complex
    medical devices. Clinicians trained in exoskeleton use consider
    various factors when prescribing this equipment.
        For safety reasons and due to the device complexity, the
    Food and Drug Administration, FDA mandates that individuals
    using this technology have a companion present. Unfortunately,
    many individuals do not have access to a suitable companion.
        We appreciate the congressional intent and welcome the
    opportunity to work closely with Congress on all of the bills
    on today's agenda. My colleagues and I are happy to respond to
    any questions you may have.

        [The Prepared Statement Of Ajit Pai Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Dr. Pai, for your testimony.
        I now yield myself 5 minutes. Typically I go at the end but
    today is an unusual day. Dr. Pai, the VA's Therapeutic Advisory
    (TA) included the request to initiate additional scientifically
    peer-reviewed clinical trials. Is the authority granted in the
    Veteran CARE Act not broad enough to conduct multiple trials?
        Dr. Pai. Thank you for the question. I would like to defer
    to Dr. Tenhula.
        Dr. Tenhula. Good afternoon. Thank you for the question and
    your interest in this issue. The bill as written, our concern
    is that it is too prescriptive in the framework that is laid
    out. What we would request is to make several amendments and
    work with the committee staff on those.
        Ms. Miller-Meeks. You know, we deliberately tried to make
    it less prescriptive so that the VA could conduct and organize
    trials, given their expertise in that rather than have that be
    directed from Congress, but we would be happy to work with you
    in that endeavor.
        Dr. Pai, what coordination is necessary between the VA and
    other Federal agencies to effectively conduct research under
    the Veteran CARE Act, or maybe Dr. Tenhula?
        Dr. Tenhula. I would be happy to take that question. What
    we would be interested in is working with other Federal
    agencies in developing a plan for an observational study that
    would allow us to understand cannabis use among not only
    veterans but a broader population, and not only veterans that
    seek care in the VA healthcare system.
        Allowing us to work with other Federal agencies on those
    efforts would allow for more unbiased data collection, and
    would provide data that could inform those clinical trials that
    you mentioned and advise us in what direction to go with those
    trials.
        Ms. Miller-Meeks. Is there not already observations? As a
    physician, is there not already observational data that is
    available?
        Dr. Tenhula. There is not adequate observational data that
    has been----
        Ms. Miller-Meeks. Even from overseas?
        Dr. Tenhula. I am not aware of the data from overseas. I
    would take that for the record and get more information.
        Ms. Miller-Meeks. Then either Dr. Pai or Dr. Tenhula, what
    effect will the Medical Marijuana and Cannabidiol (CBD)
    Research Expansion Act have on Veterans CARE Act and VA
    research into CBD and cannabis?
        Dr. Tenhula. That act in particular, as I understand it,
    will not have direct impact on VA's ability to do this
    research. We already have the authorities in place that we need
    to be able to do that work.
        Ms. Miller-Meeks. Thank you very much.
        I now recognize Ranking Member Brownley for any questions
    you may have.
        Ms. Brownley. Thank you, Madam Chair.
        My first question is to Dr. Pai. Thank you for being here.
    I wanted to talk to you about H.R. 6373, the Veterans STAND
    Act. I am frustrated that the VA opposes this bill.
        I suppose I can understand why you might be concerned about
    the provision that would require consultation with the
    manufacturers of assisted technologies and the potential of
    conflict of interest this could raise. I think we could work
    with you on that.
        However, I am confused as to why the Department would
    oppose the rest of the bill to include codification of the
    annual preventive exams that VA should already be providing for
    veterans with spinal cord injuries and disorders.
        The VA also takes issue with the bill's definition of the
    term assistive technology. Could you elaborate on why VA has
    difficulty with our definition and how we could possibly amend
    the bill to address your concerns? Can we also at the end of
    the day have your commitment to working together to get this
    bill on the right path and moving forward?
        Dr. Pai. Thank you, ma'am. To answer your second question
    about the definition of assistive technology, it is an overly
    broad term to be used. Assistive technology is not only for
    mobility devices and technologies for mobility devices but also
    for speech and swallowing, communication.
        In this case specific to this bill it may be more
    appropriate to utilize assistive walking mobility or adaptive
    assisted mobility technologies, something very specific to
    mobility.
        With regards to your first concern or question about annual
    evaluations and codifying them, VA's spinal cord injury and
    disorders system of care looks at the care for veterans with
    spinal cord injuries in a way that they are very committed to
    the comprehensive lifelong care of those veterans from an
    evidence-based manner using innovative and specialized care
    techniques.
        For all veterans with spinal cord injury they highly
    encourage those veterans to participate in annual evaluations.
    It is not a requirement of veterans because we want to make
    sure that we give veterans choice in their care, just as in
    anything else. By codifying the annual evaluations, that can
    create challenges for those specific veterans.
        Ms. Brownley. Well, if we codified it, it must, in what you
    are saying, it must be causing problems right now, right,
    because that is the policy and the directive.
        Dr. Pai. For annual evaluations--
        Ms. Brownley. Yes.
        Dr. Pai. Correct.
        Ms. Brownley. Yes.
        Dr. Pai. They are offered to all veterans with spinal cord
    injuries and disorders.
        Ms. Brownley. Right. Okay, very good.
        Mr. Perry, VA also opposes H.R. 5247, the Expedited Hiring
    For VA Trained Psychiatrists Act. You said in your written
    testimony that it already has the authority to begin the
    appointment process for a psychiatrist prior to completion of
    their residency. Could you please elaborate on this? What
    authority does VA currently use to directly hire psychiatry
    trainees and to what extent can you also use this authority to
    directly hire physicians in other specialties who have trained
    at the VA?
        Mr. Perry. Thank you, Representative Brownley, for that
    question. Yes. We do not support this legislation because, as
    you stated, we have that authority now. Under Title 38 we have
    expedited hiring authority which allows us up to a year to go
    ahead and proactively identify psychiatrists and other medical
    professionals that are in training in residency programs.
        We have the authorities now to do that under our current
    statute, so we really do not see any benefit for adding this
    additional legislation.
        Ms. Brownley. Can you share some data on how many clinical
    trainees convert to VA employment immediately upon completion
    of their residencies?
        Mr. Perry. I would tell you not as many as we would like.
    We absolutely identify that the trainee pipeline is our biggest
    source and conduit that we should be pulling from and so I do
    not have the exact number that we pull from each year, but we
    are aggressively targeting that pipeline for our trainees.
        Ms. Brownley. Can you give me a rough idea? Is it 10
    percent or 20 percent or 50 percent?
        Mr. Perry. I think it varies by year. I do not think it is
    that high. I can tell you we train 70 percent of the residents
    that come through our VA institutions, but yes, we are not
    anywhere close to where we want to be in those targets, so we
    definitely have area for improvement.
        A lot of time our decisions around hiring are budget-driven
    and timing can be a factor as well, but we do like to target as
    advanced out as possible to hire these clinicians.
        Ms. Brownley. Okay. Dr. Brennan, and I understand from your
    testimony that VA is undertaking the creation of facilities
    methodology, but you have concerns with meeting the timeline.
    Do you have a sense of when VA will be able to complete the
    staffing model?
        Dr. Brennan. Good afternoon and thank you for that
    question. You know, if we are referring to Section 101 of the
    bill, in particular, the current organizational structure of VA
    includes staff who are responsible for all the functions that
    are set forth. One of the things we have done in parallel with
    probably the development of this bill has really been focusing
    on the strategy of integration of all the facilities functions
    and personnel that we have across the Department be better
    integrated to gain efficiencies.
        We are undergoing that right now. Along the same pathway,
    VHA is in the early stages of facility staffing methodology
    that will inform by standard performance metrics. They believe
    it will require 450 days to develop a firm model.
        Ms. Brownley. How many days did you say? I did not----
        Dr. Brennan. It may require more than the 450 days to
    develop the model.
        Ms. Brownley. Okay, thank you.
        I yield back.
        Mr. Murphy. [Presiding.] I spoke a little bit earlier about
    my disappointment in the VA's opposition to these and actually
    several of the other bills that we have in present. You know, I
    will be first to say that as a surgeon of now close to 35 years
    I understand the complexities that occur with hyperbaric
    oxygen. I have dealt with it many, many times and I understand
    the complexities here.
        As Representative Van Orden said point blank, we are
    failing our veterans and I see an extremely bureaucratic
    response to this in opposition as with some of these other
    bills as to why it cannot be done.
        Dr. Pai, think this is your area of expertise. I would love
    to hear your comments upon this so that we can have a, you
    know, a respectful discussion in the opposition probably.
        Dr. Pai. Certainly. Completely agree with Representative
    Van Orden with regards to suicidality and suicide being a
    problem, right, a major problem. It is our number one
    healthcare priority.
        With regards to hyperbaric oxygen therapy, it has not been
    shown to decrease suicide ideation from a PTSD standpoint. It
    has not been shown to provide significant improvements. What we
    are really focused on are those treatment options that do treat
    PTSD, prolonged exposure, evidence-based--or eye movement
    desensitization and reprocessing (EMDR).
        , as well as cognitive processing therapy.
        We want to make sure that we are focused on treatments that
    are evidence-based for PTSD and we are not diverting resources
    to interventions that are not proven for PTSD.
        Mr. Murphy. Well, I am going to respectfully disagree
    because in the State of North Carolina now where we are doing
    this, we are seeing tremendous results. We have a huge veteran
    community in eastern North Carolina especially, especially in
    Durham, North Carolina, in the center of the State and in the
    northeast corner with Dr. Moreno. They are seeing tremendous
    results with these.
        You know, again, we are going to get back to where this is
    literally the end of the road for individuals. I was very
    skeptical of psychedelics. Read the literature, very proponent
    of this. I am not a fan of marijuana in a general sense, but I
    am absolutely a fan if it is going to help our veterans, and it
    is very restricted.
        I am just seeing, you know, I am reading in here one of the
    things that might take--veterans may have to travel for this.
    Well, if the option is traveling to a cemetery than traveling
    to a VA to go get this therapy, by God we ought to be knocking
    down the doors of hell to do it. It is critical.
        Yes, I understand that there is discussion about this, but
    we have several different avenues to choose from and I am
    adamant, and I am a scientist at first, at heart, and I am
    adamant that this makes the lives of individuals who are
    hitting the wall.
        I think the Veterans Administration must pursue every
    single opportunity because statistical manipulations in a
    decrease in suicides in this country is not acceptable to
    effectually lowering that number. I would urge you, and it is
    going to maybe have to be in this committee's purview to
    rethink this to literally, as I said, all hands on deck for our
    veterans.
        When they are hitting the wall and they are committing
    suicide we have to open up every door. Any other
    considerations? I will tell you, with Mr. Van Orden and Mr.
    LaLota's bills I am in full support of those things. I hate for
    us to be in an adversarial role here. I think we have good
    individuals. I know your hearts are all in the right place, but
    it is our supervisory role to assist the VA, sometimes
    nudgingly, in what we are doing for our veterans.
        I thank you. This is the end of this subcommittee.
        I want to thank all witnesses for the hearing today. You
    are now excused, and we will wait while the second panel comes
    the witness table.
        Mr. Murphy. Thank you to all members. We would like to
    start our second panel today. On our second panel we have Mr.
    John Retzer, assistant national director for Disabled Veterans,
    Mr. Roscoe Butler, senior health advisor at the Paralyzed
    Veterans of America, Ms. Brittany Elliot, a Marine Corps
    veteran and advocate, and Ms. Melissa Bryant, chair of the
    directors of boards of Minority Veterans of America.
        Mr. Retzer, you are now recognized for 5 minutes. Thank
    you.

                        STATEMENT OF JON RETZER

        Mr. Retzer. Thank you, Chair Murphy, Ranking Member
    Brownley, and members of the subcommittee. Thank you for
    inviting DAV to testify at this legislative hearing. We
    appreciate all the beneficial pieces of proposed legislation on
    agenda today that are focused on improving timely access and
    quality of services for our Nation's veterans, in particular
    service-disabled veterans.
        Throughout the past decade the VA has experienced
    significant growth and difficulty implementing reforms that
    guarantee veterans receive access to quality healthcare. For VA
    to maintain its role as a primary provider of timely and
    quality care, it must address the challenge of an aging
    infrastructure by improving its internal capacity through the
    construction and modernization of facilities.
        Unfortunately, VA facilities have a median age of nearly 60
    years which poses a challenge with renovations. Facilities of
    this era were not designed to accommodate the technological and
    design innovation needs that support a modern healthcare
    system. That is why DAV supports the BUILD for Veterans Act,
    H.R. 3225, which aims to enhance the VA's capital assets
    program by improving planning and oversight, providing more
    consistent funding, and strengthening capability to start and
    complete projects.
        Another key aspect of providing quality care is safe and
    effective innovations and delivery of evidence-based
    treatments. The Veterans Care Act, H.R. 3584, would require the
    VA to conduct and support research on medicinal cannabis for
    treating veterans with PTSD, chronic pain, and other
    conditions.
        While many veterans are currently using cannabis, it is
    important for medical research to continue exploring the safety
    and efficacy of cannabis usage for medical purposes. Despite
    being able to talk about their cannabis use with VA clinicians,
    veterans cannot receive recommendations or prescriptions for
    cannabis from VA clinicians. Our Nation's veterans deserve
    access to the most effective treatments and therapies
    available, including alternative options, which is why DAV
    supports H.R. 3584.
        Now, to address the needs of the fastest growing cohorts of
    veterans using VA healthcare services. There are over 650,000
    women veterans using VA, half of them being childbearing age.
    In fact, since 2014, VA has seen an 80 percent increase in
    maternity care services.
        Last month DAV released our new report, Women Veterans, the
    Journey to Mental Wellness. They found that there can be an
    increased risk for mental health diagnosis and suicidality
    during pregnancy and up to 1 year after giving birth. The
    report emphasized the need for strong support systems and
    coordination during and after pregnancies. For these reasons,
    DAV strongly supports the Maternal Health for Veterans Act,
    H.R. 3303, which addresses the need to strengthen the VA
    oversight and expand funding to coordinate support and
    resources for women veteran mothers.
        To bolster VA mental health staffing to help reduce veteran
    suicide. DAV is pleased to support H.R. 5247, the Expedited
    Hiring for VA Trained Psychiatrists Act. A 2023 VA Inspector
    General report revealed that more than half of VA's 139 medical
    facilities face a severe shortage of psychiatrists. The bill
    aims to reduce wait times for veterans seeking mental health
    care by allowing the VA to fast track the hiring of
    psychiatrists who have completed residency at VA facilities,
        Another bill DAV supports is H.R. 3644, the ACT for
    Veterans Act which would extend the time for veterans to notify
    VA after emergency care at non-VA facilities by an extra 24-
    hour period to ensure coverage under the Veterans Community
    Care Program.
        Currently, VA does not guarantee payment if a veteran does
    not contact the view within 72 hours of receiving non-VA
    emergency care. Veterans suffering medical emergencies should
    not have to worry about whether VA will deny coverage or refuse
    payment because of administrative notification time
    requirements.
        Finally, for far too long, government reimbursement rates
    for emergency transportation have been significantly lower than
    the true cost of providing that service. Earlier this year the
    VA finalized a proposed rule to change, or to change to cut its
    reimbursement rate for emergency air medical transportation.
    During health emergencies this reduction could put an estimated
    4.7 million veterans living in rural and remote communities who
    already struggle to get reliable access to healthcare at even
    greater risk.
        To address this concern, DAV supports H.R. 5530, the VA
    Emergency Transportation Access Act, which would limit VA's
    ability to reduce payment rates for transporting veterans on
    specialized transportation modes.
        Chairman, this concludes my testimony. I am pleased to
    answer your questions you or members of the subcommittee may
    have.

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

        Mr. Murphy. Thank you, Mr. Retzer.
        Mr. Butler, you are now recognized for 5 minutes.

                       STATEMENT OF ROSCOE BUTLER

        Mr. Butler. Chairman, Ranking Member Brownley, and members
    of the subcommittee, Paralyzed Veterans of America would like
    to thank you for this opportunity to present our views on some
    of the legislation that the subcommittee will be examining
    today.
        PVA strongly supports the BUILD Act, which seeks to improve
    staffing to manage construction of VA assets and ensure that
    there are concrete plans to improve the planning, management,
    and budgeting of VA construction and capital asset programs.
        Among its many provisions, the BUILD Act requires the VA to
    implement a more concrete schedule to eliminate or repurpose
    unused and vacant buildings, develop and execute a plan to hire
    construction personnel, examine infrastructure budgeting
    strategies, and identify required reforms and provide annual
    budget requirements over a 10-year period.
        It also directs the VA to report to Congress on the
    Department's current and future anticipated long-term care
    needs and models of care for women veterans, veterans with
    spinal cord injuries and disorders, and other veteran
    population with unique needs. This is particularly important to
    paralyzed veterans as VA's current number of long-term care
    beds for veterans with SCI/D is woefully inadequate for an
    aging veteran population where care needs are not readily met
    in the community.
        As of January, only 169 of VA's 181 SCI/D long-term care
    beds were actually available, and only one of VA's six
    specialized long-term care facility lies west of the
    Mississippi River. Until construction projects at the Dallas
    and San Diego VA medical centers are completed, only 12 long-
    term care beds are available for the thousands of SCI/D
    veterans that reside in this area of the country. We urge
    Congress to pass this bill as soon as possible.
        PVA also supports the Expedited Hiring for VA Trained
    Psychiatrists Act, which would help VA fill critical
    psychiatrist vacancies sooner. Many SCI/D centers lack the
    direct support of a psychiatrist, forcing the staff to submit
    intra and inter-facility consults for all veterans with SCI/D
    requiring psychiatric care. The response time to these consults
    are lengthy, delaying essential psychiatric care and services
    for these veterans. We believe the change authorized by this
    legislation could help veterans receive the essential
    psychiatric care they need sooner.
        Last year VA announced a proposed final rule establishing a
    new payment methodology which would dramatically lower ground
    and air ambulance reimbursement rates. Part of the problem is
    that proposed rule relies on outdated data for air and ground
    transportation. PVA supports the VA Emergency Transportation
    Access Act because it would help ensure changes in
    reimbursement rates do not adversely impact veterans.
        Finally, we support the STAND Act, which would first ensure
    that veterans with SCI/Ds are offered an annual medical
    examination. These annual assessments are important because it
    allows the veteran's physician to identify and treat health
    issues before they worsen, review any changes that have
    occurred over the last year, and identify risk factors that
    could lead to future health problems, and offer expert advice
    on how to mitigate them.
        Some VA facilities do not--some VA facilities do an
    excellent job reaching out to SCI/D veterans to offer them an
    annual assessment, but not all. There is room for improvement
    in this area. The bill also directs the VA to ensure veterans
    are assessed for and briefed on the types of assistive
    technologies that they may be eligible for during these annual
    exams.
        Advancement in technology could provide life-changing
    options for veterans with SCI/Ds so it is extremely important
    that they are made aware of anything that could improve their
    mobility, functionality, or independence.
        Thank you again for this opportunity to share our views on
    some of the legislation being reviewed today. I would be happy
    to answer any questions you may have.

        [The Prepared Statement Of Roscoe Butler Appears In The
    Appendix]

        Ms. Miller-Meeks. [Presiding.] Thank you.
        Ms. Elliot, you are now recognized for 5 minutes.

                      STATEMENT OF BRITTANY ELLIOT

        Ms. Elliot. Madam Chairwoman Miller-Meeks, Ranking Member
    Brownley, and distinguished members of this subcommittee, my
    name is Brittany Elliot and I am a medically retired U.S.
    Marine Corps veteran. I am honored to join you today to discuss
    the critical importance of H.R. 6373, the VA Spinal Trauma
    Access to New Devices Act, or the STAND Act. I am joined here
    today by my father, full-time caregiver, and exoskeleton
    companion Morgan Elliot.
        By way of background I am a medically eligible veteran in
    terms of VA healthcare and I am fully paralyzed from my chest
    down as a result of a head-on collision with a drunk driver on
    July 3, 2015 and was placed in a wheelchair. Since you have my
    longer history in my written testimony I will skip forward to
    2017 when I was introduced through social media and other
    means, not by the VA, to a device that I thought may have some
    utility for me if I were to ever regain the ability to stand
    and walk, the ReWalk personal powered exoskeleton.
        I approached my care providers at the Memphis VA and
    started pushing to gain access to this technology. After
    significant hesitation by my local providers, I was finally
    able to get them to agree to enroll me in the VA's landmark
    study on the technology.
        The VA co-op study was being undertaken at several VA
    facilities across the country but not in Memphis, so I was
    forced to travel on my own resources to the St. Louis VA
    Medical Center at Jefferson Barracks. I spent 3 weeks
    undergoing intensive training on the device. I might add this
    is an 8-week process but I am a Marine after all, and
    successfully completed this trial, at which point I was able to
    take the device home and start using it.
        I took it everywhere. Unfortunately, my story does not end
    there. When I returned to the St. Louis VA in 2018, my
    provider, the very same provider who entered me into the trial,
    informed me that she would not support my continued use of this
    device and to this day has failed to provide sufficient
    rationale for that decision.
        The device was returned to the VA and I was left in a
    chair. I was also told you should get used to it because that
    is all you can expect. Well, as a trained warfighter that is
    simply not good enough.
        For the next 4 years, that is right, a 4-year battle with--
    I was engaged with a battle and a local and regional battle to
    regain access to the device that had already so profoundly
    changed my life.
        Finally and thanks to a forward-thinking and supportive
    clinician at the Sonny Montgomery VA Medical Center in Jackson,
    Mississippi, I was seen, reevaluated over the course of weeks,
    again on my own dime, and ultimately provided a new device
    which I still have and use every day of my life.
        I am eternally grateful to this provider as his disposition
    was not one that lent itself to the bureaucracy, but one that
    carefully considered the entirety of the evidence and the
    utility of this device for me, a young, vibrant, and motivated
    Marine. This fight never needed to happen, but the system in
    many cases it seems to me is built to protect itself instead of
    the veterans it serves.
        I am so grateful to General Bergman for his authoring, and
    I want to personally thank Chairman Bost, Ranking Member
    Brownley, and Congresswoman Dingell for their willingness to
    co-lead this effort. I would also personally like to thank
    Senators Tester and Moran for their companion bill that was
    introduced this morning.
        My thanks as well to those who have agreed and continue to
    agree to co-sponsor the STAND Act. In my view, this bill is
    critical for a few reasons. As you all know, this bill seeks to
    codify what the VA is already supposed to be doing in the way
    of performing annual examinations . I can tell you with
    certainty they are not. I have had five exams over the last 8
    years and had to push for several of those myself.
        Additionally, I think it is imperative that VA assess the
    viability of assistive technologies for all veterans with SCI,
    not simply forcing them to stay in chairs if they are
    clinically eligible for other devices is simply not good
    enough. The STAND Act mandates this type of assessment.
        One thing I have learned over my years of fighting the VA
    is that clinical behavior is often very difficult to change.
    One way to accomplish change, however, is to demand
    accountability for those responsible for making clinical
    decisions. This bill seeks to accomplish this by two means,
    make the VA reportable to Congress on their success against the
    metrics I mentioned and hold Veterans Integrated Services
    Networks (VISN) leadership accountable through their annual
    performance evaluations on these same metrics.
        In conclusion, Madam Chairwoman, Ranking Member Brownley,
    and members of this subcommittee, I am very thankful to you and
    to all those who have supported this bill as it can be truly
    life-changing for those like me who have faithfully served
    their Nation. A lack of system capacity and widespread
    unwillingness of VA clinical leadership to allow veterans to
    enter the community for training and just flat out bureaucratic
    red tape continue to hamper other veterans' ability to gain
    access to these important technologies that can be truly life-
    changing.
        I can proudly stand in strong support of this bill and I
    believe its impact can be truly immeasurable for those who are
    simply trying to rebuild their lives and who are seeking the
    VA's support to get them there. With your collective help, this
    will be an easier path. I truly appreciate the opportunity to
    appear before you today and I am happy to respond to any
    questions you may have.

        [The Prepared Statement Of Brittany Elliot Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Ms. Elliot.
        Ms. Bryant, you are now recognized for 5 minutes.

                      STATEMENT OF MELISSA BRYANT

        Ms. Bryant. Chairwoman Miller-Meeks, Ranking Member
    Brownley, and distinguished members of the subcommittee, I am
    Melissa Bryant and I am honored to appear before you today on
    behalf of Minority Veterans of America where I serve as the
    chair of the board of directors .
        As an organization dedicated to advocating for the unique
    needs of minority veteran service members and their families,
    we appreciate the opportunity to provide testimony and to
    contribute the unique perspectives of those we serve to today's
    discussion. The focus of today's testimony will be on H.R.
    3303, the Maternal Health for Veterans Act.
        MVA is dedicated to creating belonging and advancing equity
    and justice for our Nation's historically marginalized and
    underserved veterans, racial and ethnic, gender, sexual,
    religious and non-religious minorities. MVA works on behalf of
    more than 10.2 million minority veterans, and through our suite
    of programs directly serve thousands of veteran service members
    and their families each year.
        Of MVA members 52 percent identify as women, 7 percent as
    gender diverse, 60 percent are traditional reproductive ages of
    18 to 45, and 30 percent are survivors of military sexual
    trauma. As a former Army officer I have witnessed firsthand the
    challenges of pregnancy for soldiers as a carryover for those
    soldiers when they become veterans, especially those who had to
    be administratively separated from active duty due to those
    challenges.
        We are grateful to be here today to represent their unique
    lived experiences and perspectives, stories highlighted within
    my written testimony of Dez Lincoln, Khadija Smith, Gracie
    Mangual, and others.
        Maternal health for veterans is a critical aspect of care
    that addresses the unique needs of veterans who are navigating
    pregnancy, childbirth, and postpartum care. Veterans who use VA
    for care faced obstacles in accessing timely and appropriate
    maternal care due to the limited availability of onsite
    obstetric services and poor care coordination between VA and
    community-based providers.
        Those challenges are compounded by the unique health issues
    veterans face, including physical and mental health conditions
    resulting from their service which can impact their pregnancy
    and birth experiences. Complexities such as traumatic brain
    injury or even musculoskeletal injuries, mental health
    conditions like PTS and depression, and even toxic exposures
    have been shown to have long-term consequences that impact
    reproductive health and pregnancy.
        The challenges minority veterans face are rooted in
    systemic inequities such as poverty, structural racism,
    implicit bias, and language and cultural barriers that impede
    access to essential prenatal, labor, delivery, and postpartum
    care. Minority veterans often contend with higher rates of
    comorbidities like hypertension, diabetes, and mental health
    disorders, complicating their pregnancy and childbirth
    experiences and contributing to disparities in maternal health
    outcomes.
        These historical contexts and associated social
    determinants of health can significantly impact access and
    utilization of maternal health services within VA. As Ms.
    Brownley mentioned in her opening statement, GAO recently found
    that severe maternal mortality rate was highest amongst black
    veterans, highlighting pronounced disparities in maternal
    health outcomes.
        LGBTQ plus veterans also face additional hurdles and access
    and maternal health services within the VA system, including
    harassment and systemic discrimination in care settings, in
    addition to disparate discharge statuses under policies like do
    not ask, do not tell, which impede VA access to care or access
    to VA care, further exacerbating disparities in maternal health
    experiences and outcomes.
        The MCC program has served a pivotal role in enhancing
    access to comprehensive maternal care services, improving the
    care experience for pregnant and postpartum veterans and
    addressing the unique healthcare needs of this population
    within the VA healthcare system.
        High utilization rates, its critical role in pregnancy
    care, a centralized telehealth program at the VISN level, and
    enhanced mental health support are among the key successes of
    the MCC program, but several areas for improvement remain,
    including remedy and limited access to comprehensive maternity
    care, the lack of specialty care providers, fragmented care
    coordination, inadequate screening and risk assessment, limited
    mental health support, insufficient data collection and
    analysis, barriers to minority and rural veterans, and limited
    support for postpartum care.
        Issues unique to minority veterans include persistent
    racial inequities and insufficient training for LGBTQ plus
    support, requiring targeted interventions and outreach to
    address these disparities.
        MVA strongly supports H.R. 3303, recognizing its potential
    to significantly enhanced maternity care coordination for
    veterans throughout pregnancy and 1 year postpartum within VA
    services. We urge Congress to strengthen this legislation by
    improving provisions specifically targeting the unique needs of
    minority veterans accessing maternal health services within the
    VA healthcare system.
        MVA also recommends enhancing cultural competency training,
    enhancing data collection analysis, strengthening community
    partnerships, improving language access services, and expanding
    access to doulas and culturally competent midwives, as doulas
    can provide care services that include offering emotional
    support to pregnant veterans through childbirth and enhance
    their agency and self-advocacy and have shown to mitigate
    preventative causes of maternal morbidity as doulas can also
    uniquely provide trauma-informed care to our most vulnerable
    pregnant veterans.
        Addressing maternal health disparities among veterans is
    paramount for future generations who will return from service
    to start families. Again, we wholeheartedly support this bill.
    We thank you for the opportunity to testify today and I look
    forward to any questions you all may have.

        [The Prepared Statement Of Melissa Bryant Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Ms. Bryant, and I would like
    to thank all of our witnesses for their very thoughtful input.
        As is my practice, I will recognize myself at the end of
    questioning. Ranking Member Brownley, you are now recognized
    for 5 minutes.
        Ms. Brownley. Thank you, Madam Chair.
        My first question is to Ms. Bryant. In your testimony you
    shared some very poignant stories from your members about their
    need for more support during and after their pregnancy, and
    certainly I am excited about H.R. 3303 as I know you are. I
    know that there is so much more that the needs to be done to
    support our veterans who are pregnant or who have given birth.
        In your mind is there a theme to the support needed in
    these stories that we should focus on to make sure these
    veterans get the support that they need?
        Ms. Bryant. Yes, Ranking Member Brownley. I believe that
    the through line that was really identified and outlined
    throughout our testimony is that the wraparound services need
    to be there and they need to be culturally competent, whether
    it is for someone who cannot access care because they need an
    interpreter or whether it is someone who just needs that
    assistance in self-advocacy we have now seen.
        We have data. We have the GAO report on top of VA, excuse
    me, VA's own data that show when you give those wraparound
    services, especially for those of us who are vulnerable, who
    are facing mental health challenges that will mitigate very
    preventable issues that could happen when you are experiencing
    issues in accessing care within VA. That can assist in your
    childbirth outcomes.
        Ms. Brownley. Very good. What is a wraparound? What does
    wraparound services look like? Just----
        Ms. Bryant. Wraparound services should address the social
    determinants of health. As you saw from some of our member
    stories within our testimony, they are experiencing financial
    instability. They are experiencing----
        Ms. Brownley. Got it.
        Ms. Bryant [continuing]. housing insecurity. Those are the
    types of things that we should include within our wraparound
    services.
        Ms. Brownley. They are all interconnected?
        Ms. Bryant. It is all inextricably linked.
        Ms. Brownley. Yes, yep, yep. Thank you for that.
        Ms. Elliot, it is very nice to have you here with us today
    and I certainly want to applaud your father as your caregiver.
    I have a caregiver bill going through Congress right now and
    hopefully we can bring more veterans to get their healthcare
    needs, disabled and aging veterans to get their healthcare in
    their homes and to also provide help and support to the
    caregivers who are taking care of our Nation's veterans.
    Wherever your father is, I applaud you.
        It is a challenging and rewarding job, but it is a job I
    think where sometimes the caregiver needs to have a little rest
    himself or herself so, but I really thank you, Ms. Elliot, for
    being here.
        I was really looking forward to seeing you and your
    exoskeleton because I have never seen it before. Alexis just
    showed me some pictures so I sort of have an idea, but I was
    really looking forward to it. I understand that got damaged by
    the airlines flying here.
        Ms. Elliot. It got damaged in transit, yes, ma'am. I was
    looking forward to presenting it today to you and to the rest
    of the subcommittee but it was, unfortunately, damaged to a
    point that we could not utilize it today.
        Ms. Brownley. Yes, that is really too bad. I also have a
    bill. I sit on the Transportation Committee and I also have a
    bill to try to address this problem where so many people who
    have any kind of medical device, I am sure they have not seen
    many exoskeletons but, you know, wheelchairs, motorized
    wheelchairs, and so forth that get damaged too frequently on
    airplanes and people are lost with without their devices.
        Ms. Elliot. Yes, ma'am. I have personally also experienced
    those type of losses through an airline with my travel, so I do
    completely understand that.
        Ms. Brownley. Very good. I think, you know, I think I am
    happy that you are here to, you know, support the STAND Act.
    Can you just expand on why annual exams for veterans with
    spinal cord injuries are so crucial and actually need to be
    codified in this line? I mean, I am sure you heard the VA
    testify that they wanted to make it a choice, but can you
    expand on that?
        Ms. Elliot. For me that is the only way I can get, you
    know, issues with my chair resolved or issues, other unresolved
    health issues sometimes is through my annual exam. Those are
    crucially important in things like wheelchair maintenance and
    also just various health needs that the spinal cord injury and
    disease veterans face that are specific to our needs.
        Those are crucially important as part of longevity of life
    and ease of life. I mean, if my chair is broken for, you know,
    6 months out of the year and I cannot get into an appointment
    that is a big inconvenience.
        Ms. Brownley. You mentioned in your testimony, too, that
    you have had five out of eight of your annual appointments?
        Ms. Elliot. Right.
        Ms. Brownley. Did I understand that correctly? That you
    said you had to really, kind of, push to get some of those
    appointments?
        Ms. Elliot. Yes, ma'am.
        Ms. Brownley. Does that mean three times you were
    unsuccessful in getting your appointment?
        Ms. Elliot. Yes, ma'am, and it is not COVID's fault that I
    could not get all those appointments. I did have one virtual
    through COVID so that was not the reason that I did not have
    all of the appointments that was necessary.
        Ms. Brownley. These annual appointments, when you leave an
    annual appointment there is not the next annual appointment
    scheduled for you?
        Ms. Elliot. No, not usually.
        Ms. Brownley. I see that my time is up and the chair is
    anxious and so I will yield my time back. Thank you.
        Ms. Miller-Meeks. Thank you very much, Ranking Member
    Brownley.
        The chair now recognizes Representative Bergman for 5
    minutes.
        Mr. Bergman. Thank you, Madam Chair.
        I want to first thank our witnesses from Paralyzed Veterans
    of America and Disabled American Veterans for being here today.
    Your presence makes a big difference.
        I know that you have worked with my office as we developed
    the Veterans STAND Act, and I was grateful to be able to
    discuss it with PVA President Thomas when he testified during
    our joint VSO hearing over at the Senate a few weeks ago. In
    that same vein, I am going to take advantage of the opportunity
    to talk directly with Ms. Elliot while she is here today in
    that same vein as I spoke with PVA President Thomas.
        Ms. Elliot, I am very familiar with your long-term struggle
    with dealing with the VA over your device. Given your role as
    an advocate and your routine interactions with folks can you,
    the VA folks, can you share with the committee the experience
    of other veterans who are currently in similar circumstances?
    We have heard yours but have you got any other stories to share
    with us?
        Ms. Elliot. I actually do. Thank you for the question, Mr.
    Bergman. I have actually been working with a veteran as I also
    ski, and so I take my exoskeleton to the winter sports clinic.
    I actually had a veteran personally reach out to me while I was
    walking my device and he goes, can you help me? I said, what do
    you need help with, my friend? He said, I have been fighting
    the Richmond VA for years to get access to the ReWalk and I
    have only been given one option and that is not that one and I
    just need help. I need help with this bureaucratic tape that I
    am facing. I said, I wish I could.
        I find that some of our veterans that I have worked very
    closely with they are all fighting Richmond VA for that same
    access, but they are not the only VA. I have had veterans that
    come to me personally and say, you know, I have been fighting
    this war for years. Is there any advice that you have? I said
    just do not give up. I will fight any way that it can to help
    you, but it is going to be a war because they would rather give
    you another chair than give you access to technologies that can
    truly change your life.
        I stand by these guys. Most of them are young men, but I
    stand by these guys and offer support when they do get
    discouraged.
        Mr. Bergman. Thank you. Do you know, do you think there are
    others or do you know personally of any others who may be
    clinically eligible already for the device but are simply being
    told no? Do you have any specifics there?
        Ms. Elliot. Yes. Actually the one that was--he was
    clinically eligible for exoskeletons but they are only giving
    him one option, and he does not feel that that is the best
    option for his life. He intends to use it a whole lot more than
    just inside his house.
        Veterans are acknowledging there is more than one
    technology available and want access to all the technologies,
    not just one that the VA specifically has decided to work
    beside for each VA center.
        Mr. Bergman. Okay. Do you think that the Veterans
    Administration's resistance to using this device is an issue of
    local medical center capacity or, you know, who is passing the
    buck to who here? Any thoughts?
        Ms. Elliot. That is where the community care network would
    be crucial to veterans like myself. I traveled 10 hours to get
    access to the technology on my dime and for most veterans that
    is just not that is not possible. They cannot give up that kind
    of time away from their families and in their homes in order to
    get access to technology, but that is where a community care
    network would be crucially important in getting veteran access
    to the technologies and the training closer to home, not having
    to travel hours upon hours away from home and family to get
    access to this technology.
        Mr. Bergman. You know, I think I saw a statement where the
    VA stated that the reporting requirements loaded on them will
    disallow them from doing their daily work with SCI veterans, so
    they are even currently meeting the mark in terms of the
    current workload.
        There is kind of a workload balance here. They are claiming
    they have got too much so they cannot do this with that. If
    not, are there any professional resource centers available in
    the community, because you have referenced community care, that
    could be used to train veterans on this device so, you know,
    different entities?
        Ms. Elliot. Even I personally trained with a community care
    provider in my own community post injury because it was so
    inconvenient for me to go to outpatient VA. Any outpatient VA
    center that--or outpatient community care provider who has
    already been deemed eligible to get community care services for
    veterans would be eligible to teach veterans how to use this
    technology.
        Mr. Bergman. Okay. I see my time is just about up. I am not
    putting words in the mouth of Secretary McDonough, but when we
    traveled up in the Upper Peninsula of Michigan together in
    December and he spoke to VA hospital and a couple of clinics,
    he made it very clear that whatever the Veterans Administration
    did the veterans should not have to wait because the
    bureaucracy was doing its thing and not prioritizing the
    veteran. That was his intent.
        Secretary McDonough is a man of his word and I, you know,
    he knows that he has got his hands full just like we have hands
    full. Thank you for the indulgence, Madam Chair.
        Ms. Miller-Meeks. You are welcome. Thank you very much.
        I now recognize myself for 5 minutes. It is interesting
    listening to all of your testimony, and I am going to deviate
    from my questions. I will ask the question, one of the
    questions I planned to ask but then I am going to deviate.
        Mr. Butler and Mr. Retzer, can share what you have heard
    from your members about their experiences with therapeutic
    medicinal use of cannabis or cannabis-derived products?
        Mr. Butler. We have not really received any information
    from our members directly about the product. We are interested
    in seeing the research go forward and the evidence that it
    provides efficacy to meet the clinical needs of veterans so
    that they can sustain their lives more. We are hopeful that the
    evidence will prove that it has efficacy in the support of
    clinical needs for the veterans.
        Ms. Miller-Meeks. Mr. Retzer.
        Mr. Retzer. Thank you for that question. Our membership
    actually has a resolution, as a resolution-based organization,
    where we call for the research of medical efficacy of cannabis
    for service-connected disabled veterans so it is very important
    to us.
        We have also published multiple articles with regards to
    the cannabis studies and the innovations in the direction for
    needs for options for our veterans.
        Ms. Miller-Meeks. I hear similar things from the veterans
    in my community as well.
        Ms. Bryant, this is not necessarily a question. While I am
    not opposed to Representative Underwood's bill, it seems like
    we have a tremendous amount of data both with veterans and non-
    veterans. As a physician and former director of public health
    this is not an area that is unfamiliar to me.
        It also seems like we have recommendations for how to
    reduce maternal morbidity and mortality. Do we really need
    another report to Congress or is it better that we utilize the
    money to implement practices and evidence-based practices that
    we feel will be effective?
        Ms. Bryant. In order to address the epidemic, as you
    stated, Chairwoman, that we are facing in this country, we have
    to have that information from VA as the representative of the
    largest integrated healthcare system in our country to
    contribute to the whole within our healthcare system.
        Having regularly reported data, being able to see the
    intersectionality and the impact of intersectionality within
    maternal healthcare will be a boon for the rest of the entire
    industry in being able to address a lot of the issues that
    veterans face and all women face.
        Ms. Miller-Meeks. Thank you.
        Then where I am going to deviate is this. Ms. Elliot, I
    started my career in the military. I did medical surgical
    nursing and I did emergency room nursing and then I got
    assigned to Walter Reed Army Medical Center as a young
    lieutenant and I was assigned to neurosurgery at Ward 10 of
    Walter Reed. We did traumatic brain injuries which were not
    called that at the time. I flipped many of the Stryker frame.
    Both my husband and I did care after our time, so this is
    taking me back to my very early days as a nurse, although I did
    not do neurosurgery as a physician.
        It is appalling to me that you were told to just get used
    to it. The VA is probably one of the premier institutions for
    prosthetic devices, and why we do not consider an exoskeleton
    or other devices to help our veterans become ambulatory, become
    independent, is hard for me to fathom. I am going to look at
    this as a physician and what are the consequences of being in a
    wheelchair when you could be somewhat ambulatory or upright?
        I apologize for those of you who are not medical because
    some of this is rather, I do not consider it gross, but
    pressure sores, debridement of pressure sores, the cost of
    hospitalization, the cost of being bedridden, the cost of
    urinary tract infections, catheterization, the cost of
    impaction, all of those--and then not to count what it does to
    the veteran's individual mental health and that of their
    families when they could be productive and have active, engaged
    minds. I still visit and take care of people who have spinal
    cord injuries in the civilian world as well.
        Thank you for mentioning the community care network and how
    crucially necessary it is. To me, given the VA's track record
    on prosthetic devices and helping our military and veterans be
    whole, it is unfortunate that we would have to consider
    legislation for the VA to bring veterans back to a livelihood,
    a production, care for their families, interactions in their
    communities. I know I am pontificating, but I cannot thank you
    enough for being here today and for your testimony.
        Ms. Elliot. Thank you, Madam Chairwoman.
        Ms. Miller-Meeks. With that, that concludes our second
    panel.
        Ranking Member Brownley, would you like to make any closing
    remarks?
        Ms. Brownley. I do not. I do not, but I just want to thank
    the panelists who are here today, and I think we have got a lot
    of good bills here that I hope we can move along and move over
    to the Senate.
        Ms. Miller-Meeks. Well, on behalf of the committee I would
    extend my thanks to all of the witnesses today. I look forward
    to working with the stakeholders, my colleagues at the
    Department of Veterans Affairs to address the issues we
    discussed today.
        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
    objection, so ordered.
        I thank the members and the witnesses for their attendance
    and participation today. This hearing is now adjourned.
        [Whereupon, at 4:22 p.m., the subcommittee was adjourned.]

    ?

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                             A  P  P  E  N  D  I  X

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                        Prepared Statements of Witnesses

                                  ----------

                         Prepared Statement of Ajit Pai

        Good afternoon, Madam Chair, Ranking Member Brownley, and other
    Members of the Subcommittee, thank you for inviting us here today to
    present our views on several bills that would affect VA programs and
    services. Joining me today is Dr. Michael Brennan, Executive Director,
    Office of Construction and Facilities Management, Dr. Wendy Tenhula,
    Deputy Chief Research and Development Officer, Office of Research and
    Development, VHA, and Mr. David Perry, Chief Officer, Workforce
    Management and Consulting, VHA.

    H.R. 3225 Build, Utilize, Invest, Learn, and Deliver (BUILD) for
    Veterans Act of 2023

        The BUILD for Veterans Act of 2023 would support improvements of
    VA's capital asset programs' management and performance to better serve
    Veterans, their families, caregivers, and survivors. However, VA cites
    concerns with this bill.
        Section 101(a)(1) of the bill would require VA, not later than 540
    days from the date of enactment, to ensure that VA has dedicated
    offices or entities and sufficient staff, including at each VA medical
    center (VAMC), to conduct relevant critical responsibilities for the
    life cycle of capital asset management at the local, regional, and VA
    central office level. This could include ensuring such mix as VA
    considers appropriate of personnel with duties in the following
    categories: facility planning; long-range capital planning; management
    of certain projects and capital assets; property disposal or transfer,
    environmental remediation, and historic preservation; engineering,
    maintenance, and repair; the collection of views of Veterans and VA
    employees to understand VA's capital asset needs; and other relevant
    functions. VA would have to ensure, to the greatest extent possible,
    that these requirements would be assigned to a different individual or
    group of individuals so as to organize common work in a cohesive manner
    and not overburden a small number of staff. Within 180 days of
    enactment, VA would have to: designate and notify appropriate
    congressional committees one individual as the lead senior official
    responsible for the integration and coordination of, and accountability
    for, the evaluation of VA's capital asset workforce needs; a required
    staffing model; and the ongoing implementation and monitoring of
    actions to ensure adequate capital asset staffing across VA, including
    those at the field, regional, and central offices of VHA, the National
    Cemetery Administration, the Veterans Benefits Administration, and the
    Office of Acquisition, Logistics, and Construction (OALC). Within one
    year of enactment, VA would have to establish a staffing model for the
    relevant Administrations, Staff Offices, and other elements to carry
    out paragraph (1) that ensures a minimum base level of capital asset
    staffing and is adjusted based on the volume and complexity of capital
    asset work of a particular facility, catchment area, region, or central
    office responsibility. VA would have to update this staffing model
    regularly. In a State or territory where VA does not operate a full-
    service VAMC, VA would have to ensure, to the greatest extent
    practicable, that VA has a dedicated office or entity and sufficient
    staff at the largest VA medical facility in the State or territory.
        Section 101(a)(6) would state that the purpose of this subsection
    is to ensure that field, regional, and central offices of VA have an
    appropriately sized and credentialed capital asset workforce to allow
    for efficient and effective execution of their relevant segment of
    capital asset work. It would further clarify that nothing in this
    section would be intended to mandate a realignment of capital asset
    workforce roles, responsibilities, and reporting structures.
        Under section 101(b), VA would have to ensure that appropriate
    professional certifications, educational background, and other
    qualifications were in effect for individuals employed in a position at
    a required dedicated office or entity to manage the duties under
    subsection (a)(1).
        Section 101(c) would define the duties of the dedicated offices or
    entities at VAMCs. Duties of offices or entities required at a VAMC
    could include the following, as VA considers appropriate to achieve
    efficient and effective capital asset management and performance as it
    pertains to relevant activities at the field level: developing,
    monitoring, and implementing capital asset objectives in the area;
    coordinating capital asset management and planning with others in VA;
    delivering effectively capital asset projects; maintaining and
    repairing existing infrastructure; conducting capital asset disposal or
    transfer, environmental remediation, and historic preservation;
    monitoring regularly state-of-the-art best practices in health care
    capital asset delivery and management; monitoring constantly the needs
    of Veterans and employees for medical space and services including
    views and expectations expressed by relevant local or national Veterans
    Service Organizations (VSO); understanding and implementing capital
    asset policies; providing feedback to improve these policies; and
    understanding the importance of collaboration and coordination within
    VA to achieve success in all phases of capital asset management. VA
    would have to collect views and expectations through multiple channels,
    allow for anonymous and confidential submission of views, include
    diverse viewpoints, coordinate with existing VA efforts, and use these
    views and expectations to inform VA offices and leadership in the
    development of capital asset improvement.
        Section 101(d) would require VA to develop a standardized process
    to solicit feedback regularly from VA employees on ways to improve VA's
    capital asset management program. To the degree practicable, VA would
    have to align this process with the performance of market area
    assessments under 38 U.S.C. Sec.  7330C(a).
        Under section 101(e), VA would have to use the results of the
    report required under section 202 of the BUILD for Veterans Act in
    establishing offices, entities, or organizational structures required
    under subsection (a) and carrying out the requirements of this section.

        Position: VA does not support section 101. In general, throughout
    this bill, OALC should be corrected to read the Office of Construction
    and Facilities Management (CFM). Currently, 38 U.S.C. Sec.  312A gives
    the Executive Director of CFM authorities and responsibilities
    pertinent to this bill.
        VA does not support section 101. Current organizational structure
    within VA includes staff who are responsible for the functions set
    forth in the section. This would require extensive analysis and
    clarification on the specific goal. VHA is in the early stages of a
    facilities staffing methodology that will be informed by standard
    performance metrics, and this may require more than 540 days to develop
    a firm model. VA does not support subsection (c), which would define
    specific duties for offices or entities at VAMCs and would locate the
    management outside of the program office in certain circumstances.
    Given that subsection (a) already sets forth more general (and less
    prescriptive) requirements, subsection (c) is unnecessary and would
    make implementation more difficult. VA also does not support subsection
    (d), which would require a standardized process for soliciting
    feedback. VA is improving and standardizing planning processes that
    should satisfy the intent of this section without detailing specific
    requirements or parameters in statute. Allowing VA to define these
    requirements will ensure VA is responsive to and able to adapt to
    changing circumstances. VA will be transparent on how we are organizing
    to support improvements of VA's capital asset programs management and
    performance to better serve Veterans, their families, caregivers, and
    survivors.
        Section 102 would require VA, within 1 year of enactment, to
    develop goals and metrics to assess and monitor the performance of VA's
    capital asset management programs, including those carried out by a
    non-VA entity under 38 U.S.C. Sec.  8103(e)(1), to make sound decisions
    regarding infrastructure decisions in alignment with VA's mission and
    budget. VA would have to develop an internal dashboard or other tool to
    monitor progress toward meeting those goals, establish and implement
    governance processes to direct necessary changes to improve performance
    and achievement of those goals, and submit to Congress a report on the
    development of those goals and metrics, the implementation of the
    internal dashboard, and the internal governance process.

        Position: VA has no objection to section 102. VA supports section
    102, and VA has developed actionable capital program and asset goals
    and metrics that will help inform VA capital decisions and enhance
    long-term improvement of VA's capital efforts. VA will continue to
    assess whether additional measures would be helpful as the effort
    continues. There are no costs associated with section 102.
        Section 103 would require, within 180 days of enactment, VA and the
    Department of Defense (DoD) to add representatives from the Indian
    Health Service (IHS) and the Department of Health and Human Services
    (HHS) to the Capital Asset Planning Committee (CAPC) to facilitate
    Federal health infrastructure planning, coordination, and investment.

        Position: VA supports section 103. VA supports section 103 but
    defers to IHS and HHS. There are no costs associated with section 103.
        Section 201 would require VA to conduct a comprehensive review of
    the climate resilience of facilities, land, and other relevant capital
    assets that may be at risk due to changes in the climate. Within 540
    days of enactment, VA would have to submit to Congress a report with
    respect to mission critical VA capital assets and the actions VA will
    take in response to the findings of such review. Within 1 year of
    submitting this report, VA would have to submit an additional report to
    Congress detailing the results of this review for all VA capital assets
    and the actions VA will take in response to the findings of such
    review. VA would have to provide an update to this report to Congress
    at least once every 5 years after the submission of the additional
    report described above.

        Position: VA has no objection, if section 201 is amended, and
    subject to the availability of appropriations. VA supports the overall
    objectives of this section but would require an initial reporting
    deadline of 2 years (rather than 540 days) to allow VA sufficient time
    to develop requirements for the comprehensive assessment, conduct the
    assessment, and generate the recommendations for action as outlined in
    the bill. VA appreciates that the initial report in this version of the
    bill would be limited to assessing mission critical assets, which would
    still be a significant undertaking. VA would require additional
    staffing to meet these requirements. VA also recommends amending
    subsection (c)(2), which would require a report on all VA capital
    assets. VA recommends limiting this to only assets involving land in
    excess of 10 acres and buildings greater than 25,000 gross square feet
    under operation, ownership, and control by VA. The current language is
    very broad and would create requirements that are not feasible. Leases
    should be excluded if they are executed contracts that VA does not have
    unilateral ability to modify without reopening contract negotiations.
    VA estimates that the study of 152 VAMCs and 155 National Cemeteries
    will cost $134,510,000; owned assets only.
        Section 202(a) would require VA, within 1 year of enactment, to
    submit to Congress a strategic plan (a ``Strategic Plan to Improve VA's
    Delivery and Management of Capital Assets'') to improve the planning,
    management, budgeting, staffing, capacity, and performance by VA
    related to capital assets. This plan would have to consist of at least
    two parts: the first focused on the human capital needs for VA's
    capital asset and related areas workforce, and the second covering the
    methods undertaken by VA to accomplish changes to improve the planning,
    execution, and delivery of VA's capital asset projects. Section 202(b)
    would require VA to submit subsequently two additional reports 3 years
    apart providing updates on changes, actions taken, and other plans.

        Position: VA would have no objection, if section 202 is amended,
    and subject to the availability of appropriations. VA does not support
    the proposed Part 1 of the plan. VA is focused on the strategic
    initiatives needed to improve capital asset management, so redirecting
    that focus to reporting on individual positions would redirect
    resources allotted to the larger tasks at hand. While not in the detail
    requested, VA provides staffing figures in the organizational budget
    chapters within the President's Budget submission. We recommend Part 1
    of the plan be removed.
        VA does not object to the intent of the proposed Part 2 of the
    plan. VA is in the process of improving the planning, execution, and
    delivery of capital asset projects. VA submitted a report to the
    Subcommittees on Military Construction, Veterans Affairs, and Related
    Agencies of the Committees on Appropriations of the House of
    Representatives and the Senate in response to a request associated with
    the Fiscal Year (FY) 2020 appropriations act; we ask that the proposed
    Part 2 be revised to request an update to that plan with the same
    timeframe (1 year from enactment). VA believes these actions would
    require time to plan, program, and resource to meet this requirement.
    We also recommend removal of the subsequent reporting requirements
    under section 202(b). If these changes are made, VA would support this
    section. VA estimates Part 2 of the plan will cost $1.5 million.
        Section 203(a) would require VA, within 1 year of enactment and to
    the greatest extent practicable, to centralize and consolidate the
    management and oversight of all disposal and reuse activities within
    one office or suboffice of VA which have the sole focus of property
    disposal, including reuse, transfer, and demolition. The office or
    suboffice would have to focus on developing and implementing a
    measurable plan with yearly goals to dispose of, reuse, or transfer
    relevant capital assets. To the greatest extent practicable, VA would
    have to consolidate the functions and employees of the office or
    suboffice within one organization element of VA so as to improve
    effectiveness, efficiency, and accountability. Within 1 year of
    enactment, VA would have to submit to Congress a report on its actions
    to carry out this subsection.
        Section 203(b) would require VA to include as part of its annual
    budget submission a report containing a specific timeline to accomplish
    the disposal and reuse actions VA included in the disposal and reuse
    reports in the annual budget request. Among other elements, VA would
    have to consider the need for a dedicated fund to handle these vacant
    or unused properties.
        Section 203(c) would require VA, on an annual basis as part of its
    budget justification, to include a report on actions described in
    subsection (b).

        Position: VA does not support section 203. VA does not support the
    overall objectives of this section. As the bill itself acknowledges, VA
    already identifies properties annually via the Disposal and Reuse
    Report. Challenges with vacant and underutilized property, such as the
    historic nature, the location potentially within a campus, and limited
    funding make additional requirements for vacant property overly
    rigorous. This section would create unfunded requirements that would
    detract from other VA capital asset management efforts. The proposed
    organizational alignment would not provide any efficiencies or change
    internally who works together on these projects. The reporting
    requirements would be contingent on multiple factors, many of which are
    not in VA's control, and which could jeopardize VA's ability to submit
    the reports, as required.
        Section 204 would require VA to submit to Congress a report, not
    later than 180 days from the date of enactment, on potential options
    and alternatives to improve, reform, and provide more flexibility to
    VA's minor construction activities to increase effectiveness in
    commencing and delivering minor construction capital asset projects.

        Position: VA has no objection, if section 204 is amended, and
    subject to the availability of appropriations. VA supports, if amended.
    Section 204(c) needs to be updated to reflect the $30,000,000 threshold
    for major medical facility projects/minor construction limitation as
    adjusted in section 5001 of the National Defense Authorization Act for
    Fiscal Year 2024 (P.L. 118-31).
        Section 205 would require VA, not later than 180 days from the date
    of enactment, to report on any potential improvements to the alignment
    of funding for information technology to facilitate more effective and
    efficient activation of medical and other relevant space.

        Position: VA has no objection, if section 205 is amended, and
    subject to the availability of appropriations. VA is working on
    improvement plans. VA would require an initial reporting deadline of 1
    year, however, to allow sufficient time to complete the internal work
    and prepare a report. VA estimates this provision to include resources
    to cost $2 million.
        Section 206 would amend 38 U.S.C. Sec.  8120 to require VA to
    report, not later than 30 days after the end of the Fiscal Year and
    every 60 days thereafter through the fiscal year, detailed information
    on completed and planned key capital asset investments, including major
    construction, minor construction, non-recurring maintenance, leases, or
    other categories. VA would also be required to report on the same
    schedule described above, on the super construction projects carried
    out by the appropriate non-VA entity described in 38 U.S.C. Sec.
    8103(e)(1) during the year.

        Position: VA has no objection to section 206, subject to the
    availability of appropriations. VA supports parts of section 206. VA
    provides information on planned major construction, minor construction,
    major leases, minor leases, and non-recurring maintenance projects in
    Volume IV of its annual budget. Data on future awards for major
    construction and leases is provided in the individual project
    prospectuses and status summaries. Due to the planning and execution
    cycles for minor construction, minor leases, and non-recurring
    maintenance projects, reporting would be limited to projects scheduled
    to be awarded in the current budget year. VA also does not support the
    proposed section 8120(a)(2)(A)(ix); the observations of best practices,
    impediments, and accomplishments would be addressed in the report VA
    has suggested in response to section 202. The frequency of the
    reporting requirements for this section would be onerous and
    inconsistent with reporting substantial progress on a large
    construction project; VA suggests a biannual frequency (every 180 days)
    instead. VA believes these actions would require time to plan, program,
    and resource to meet these requirements. VA has other clarifying
    technical assistance it can provide on this section as well. For the
    part the VA supports, VA estimates a cost of $1 million.
        Section 207 would require VA, within 180 days of enactment and as
    part of its annual budget submission, to submit to Congress a report
    summarizing the projected amount of funding for infrastructure and
    capital assets needed over 10 fiscal years.

        Position: VA does not support section 207. VA does not support
    section 207. VA already provides the total 10-year, long range action
    plan capital requirement and the major construction 5-Year Development
    Plan (FYDP) requirements annually in the President's Budget request,
    Volume IV. The FYDP identifies major construction projects on which VA
    has begun active planning and could require additional funding in the
    next 5 budget years. The FYDP provides appropriate rigor to the
    planning process to ensure that proposed major construction projects
    make the best case possible for why they should receive funding, and
    the requested funding is a valid estimate of the actual cost to
    complete the identified projects. The long-range action plan also
    consists of new (not funded or partially funded) investments and
    includes individual capital projects and lump sum resource requirements
    over a 10-year planning horizon focused on reducing gaps, increasing
    efficiencies, and providing better services to Veterans. VA does not
    support breaking down the long-range plan into individual annual
    capital program requirements beyond the budget year request. Project
    cost estimates include acquisition costs only, which will likely change
    as projects move through the investment process, and requirements
    become more refined. Long range action plan projects in years 2 through
    10 and lump sum requirements are considered potential future year
    needs, and most cannot be credibly assigned a specific funding year
    while they are still being developed and prioritized.
        Section 208 would require the Office of Inspector General (OIG),
    not later than 3 years after enactment and at least twice during the
    following 6-year period, to submit to Congress a report examining the
    management and performance of relevant VA capital asset projects.

        Position: VA defers section 208 to OIG.
        Section 209 would require the Comptroller General to report to
    Congress, not later than 3 years after the date of enactment and
    triennially thereafter until the date that is 9 years after the date of
    enactment, on VA's progress toward meeting VA's goals, metrics, and
    other plans under this Act, particularly under sections 101, 102, and
    202.

        Position: VA defers section 209 to the Comptroller General.
        Section 210 would require VA, not later than 1 year after the date
    of enactment, to submit to Congress a report, disaggregated by VAMC or
    other relevant health care facility, on the physical infrastructure
    needed to provide dental services to eligible Veterans and the project-
    by-project cost and total cost to establish this physical
    infrastructure and an estimated timeline to complete such projects upon
    receipt of appropriate funding.

        Position: VA does not support section 210. VA already provides much
    of the information required by this section through the Strategic
    Capital Investment Planning (SCIP) process. An additional report would
    be redundant.
        Sections 210, 211, 213, and 214 would require a focused investment
    plan aligned to one single program area (dental, long-term care,
    women's health, and research); however, VA is working toward more
    comprehensive capital plans and strategies that include these areas. In
    some markets, VA may need to establish a new hospital, and in that
    capital strategy, dental, long-term care, women's health, and research
    would all be components of that larger plan, but costs for each would
    not be identifiable because they would be tied to a larger investment.
    Further, through VA's market area assessments and development of high-
    performing integrated health care networks, VA does not plan or assess
    individual components or programs like this. These sections aim to
    carve out distinct program areas and require development of capital
    investment needs focused on them, but these needs must be coordinated
    with the total market needs, larger facility master plans, and other
    development work. It is not feasible to provide the costs for specific
    components when these would be furnished as part of an integrated,
    larger, multi-focused capital plan.
        Section 211(a) would require VA, not later than 1 year after the
    date of enactment, to submit to Congress a report, disaggregated by
    VAMC or other relevant health care facility, on the physical
    infrastructure needed to support current and future anticipated long-
    term care needs and models of care for Veterans, including
    infrastructure needed to support the delivery of long-term care for
    women Veterans, Veterans with spinal cord injuries and diseases (SCI/
    D), Veterans with traumatic brain injury (TBI), Veterans with unique
    behavioral health needs, Veterans with memory loss, and other
    population groups with unique needs or projected future needs. VA would
    also need to include information regarding VA's plans to provide such
    care as VA builds internal capacity, but space is not yet available to
    meet the demand for such care, and with respect to any projects
    specified, the estimated individual project cost and total cost to
    accomplish those projects and the estimated individual project timeline
    to accomplish each such project upon receipt of appropriate funding.
        Section 211(b) would require VA to include in the report required
    under subsection (a) information on how VA's infrastructure
    prioritization processes, such as the SCIP process, could be modified
    to include higher prioritization of projects that support the provision
    of a health care service that is not widely available, or is not
    available in compliance with appropriate quality or access standards,
    from non-VA providers.
        Section 211(c) would further require VA, in developing the report
    under subsection (a), to consult with relevant regional and national
    program offices in VHA with responsibility to manage the various health
    care services covered by the report, including long-term care and care
    relating to SCI/D, to ensure the report contains a holistic,
    comprehensive, and integrated plan to address the capital asset and
    other space needs for this population.
        Section 211(d) would require VA, in the report under subsection
    (a), to indicate the projects that can be most efficiently and
    effectively accomplished through smaller individual infrastructure
    projects or through a larger medical facility replacement or new site
    of care.

        Position: VA does not support section 211. VA does not support
    section 211 for reasons set forth above in discussion of section 210.
    VA already provides much of the information required by this section
    through both the SCIP process and various reports to Congress. An
    additional report would be redundant.
        Section 212 would require VA to provide a report on the feasibility
    and advisability of requesting that Congress create a dedicated budget
    account from which VA would request funds based on relevant
    methodology, formulas, and percentages tied to the existing and future
    capital asset needs of VA, and if such funds are provided, to draw upon
    them to pay for maintenance, preventative maintenance, and repair of
    capital assets.

        Position: VA does not support section 212. VA does not support
    section 212. The Medical Facilities account supports the maintenance,
    preventative maintenance, and repair of VHA real property capital
    assets and related personal services costs. This account includes 1,717
    leases and is used to keep 5,598 owned buildings, parking lots, roads
    and walkways, and vehicles in good working condition, as well as
    maintaining a clean environment, linens, and medical equipment at all
    VHA facilities. Creation of a separate account would jeopardize the
    flexibility within the existing account to respond to changing workload
    demand requirements during the fiscal year.
        Section 213 would require VA to continue submitting to Congress a
    report on an annual basis for a 10-year period (or until all projects
    have been completed) on the Women Veterans Retrofit Initiative, as
    initially required under section 5102 of the Deborah Sampson Act of
    2020 (title V of P.L. 116-315; 38 U.S.C. Sec.  8110 note). The report
    would require identification of funding provided specifically to
    support the retrofitting requirements under section 5102 (Women's
    Health), which segregates these improvements from a facility integrated
    master plan.

        Position: VA does not support section 213. VA does not support this
    section for reasons set forth above in discussion of section 210. As
    part of the report required by section 5102, VA provides a list of
    projects to be funded in a given fiscal year, the status of those
    projects, and provides a 5-year plan that represents the items
    requested in subsection C that is being added. This section does not
    appear to expand beyond what is already provided and is duplicative.
        To date, no additional funds have been provided so reporting has
    been limited to planned projects, but VA anticipates funding from
    normal appropriations. Expansion of reporting and more focused
    management on prioritization of these investments would require
    significant resources to fulfill this recurring requirement.
        Section 214 would require VA, not later than 1 year after the date
    of enactment, to submit to Congress a report on the capital asset and
    information technology needs of VA's research and development
    facilities.

        Position: VA does not support section 214. VA does not support
    section 214 for reasons set forth above in discussion of section 210.
    VA already provides much of the information required by section 214
    through reports on facility infrastructure needs for research and
    development through the SCIP process, which is submitted to Congress
    annually. An additional report would be redundant.
        Section 215 would require VA to review all relevant authorities,
    including those in 38 U.S.C. Sec.  312A to determine whether the
    provisions of such authority are still meaningful, relevant, and
    reflect the current operational needs, organizational structure, and
    all other requirements for the full life-cycle of effective and
    efficient management of capital assets. VA would have to report to
    Congress, not later than 270 days after the date of enactment, on
    whether these authorities should be revised to align more closely with
    current and future projected operational needs.

        Position: VA has no objection, if section 215 is amended, and
    subject to the availability of appropriations. VA supports the overall
    objectives of this section but recommends the reporting timeframe be
    adjusted until after the implementation of the efforts currently
    underway and otherwise proposed in this legislation. If the due date
    were moved to 18 months from the date of enactment, this would allow VA
    time to continue enhancing enterprise integration and fully address any
    gaps in the legislation. VA believes these actions would require time
    to plan, program, and resource to meet these requirements. VA estimates
    this provision will cost $2 million.
        Section 216 would require VA to submit to Congress a report, within
    1 year of enactment, on actions VA is taking or plans to take to
    enhance VA's ability to prevent, detect, and report waste, fraud, and
    abuse occurring in capital asset projects. The report would have to
    include an assessment of whether new training or enhancements to
    existing training should be undertaken and recommendations for such
    legislative and administrative action as VA determines appropriate. In
    carrying out this section, VA would have to consult with OIG and the
    Comptroller General on matters relating to best practices and
    strategies to improve detection and prevention by VA of waste, fraud,
    and abuse in capital asset projects and management, and VA could
    consult with such other persons and entities as VA considers
    appropriate.

        Position: VA does not support section 216. While VA agrees with the
    need to eliminate waste, fraud, and abuse in all VA programs and
    operations, including those involving capital asset projects, this
    section would provide VA no additional authority to handle such issues;
    portions of this section are also vague and unclear as to what would be
    within the scope of this section. VA already incorporates
    recommendations from OIG, the Comptroller General, and others on how to
    detect and prevent waste, fraud, and abuse, so it is unlikely that this
    section would result in any substantive improvements to VA's systems
    and processes. If Congress chooses to retain this section, VA
    recommends at least that the report be due not later than 1 year after
    submission of the OIG report required by section 208.

    H.R. 3303 Maternal Health for Veterans Act

        Section 2(a) of H.R. 3303 would require VA, not later than 1 year
    after the date of the enactment of this Act, and annually thereafter
    until September 30, 2028, to submit to Congress a report that contains
    a summary of the activities carried out by VA relating to the
    coordination of maternity health care, data on the maternal health
    outcomes of Veterans who receive VA care (whether in a VA facility or
    through the Veterans Community Care Program (VCCP), and recommendations
    to improve the maternal health outcomes of Veterans, with a particular
    focus on Veterans from demographic groups with elevated rates of
    maternal mortality, severe maternal morbidity, maternal health
    disparities, or other adverse perinatal or childbirth outcomes.
        Section 2(b) of the bill would authorize to be appropriated $15
    million for each of FYs 2024-2028 for VA programs relating to the
    coordination of maternity health care, including the maternity care
    coordination program described in VHA Directive 1330.03; Maternity
    Health Care and Coordination. Amounts authorized would be in addition
    to any other amounts authorized for the coordination of VA maternity
    health care.

        Position: VA supports, if amended, and subject to the provision of
    appropriations. Section 2 is in alignment with many of VA's current
    efforts to enhance health and health outcomes for pregnant Veterans,
    where we are gathering and analyzing data and focusing on high-risk
    groups. VA is disaggregating data on severe maternal morbidity (SMM) by
    Veterans' race and ethnicity, age, and residence (urban or rural area)
    on a quarterly basis and will evaluate trends over time; the first
    quarterly data was available for review in February 2024. This month,
    VA will finish developing and implementing a systematic process to
    compile and review data on VA Maternity Care Coordinators' (MCC)
    required completion of mental health screening and screening results.
        VA is tracking severe maternal morbidity and mortality and has
    improved its data collection efforts to support real-time tracking of
    conditions and health outcomes. We recognize the critical importance of
    maternity care and have taken significant steps to improve the delivery
    of such care to Veterans. Every VHA facility offers maternity care
    coordination. VA MCCs understand the needs of Veterans and support them
    through every stage of pregnancy and the postpartum period. Beginning
    October 1, 2023, VA expanded the national MCC Program to include follow
    up of postpartum Veterans for 12 months after delivery, and VA
    increased the number of contacts with Veterans from 4 to 8 during this
    period. Through these contacts, MCCs screen pregnant and postpartum
    Veterans for social determinants of health, mental health risk factors,
    relationship health and safety, and health risks (such as gestational
    diabetes and hypertensive disorders of pregnancy). Identifying these
    maternal risk factors allows VA MCCs to connect pregnant and postpartum
    Veterans with VA health care providers and resources, ensuring access
    to care and follow-up screening. This follow up has proven necessary
    because of the significant proportion of poor maternal outcomes that
    can happen in the late postpartum period.
        VA has tremendous resources to offer pregnant and postpartum
    Veterans, including primary care, mental health care, treatment for
    substance use disorder, intimate partner violence assistance, housing
    assistance, and resources to address food insecurity. VA also
    identifies peri-pregnancy Veterans at increased risk to offer clinical
    intervention, connect them with resources, provide care, and reduce
    pregnancy-associated morbidity and death.
        VA has also created a training module for community health care
    providers to establish a basic understanding of mental and physical
    health diagnoses common in Veterans, military culture, trauma-sensitive
    care principles, and suicide awareness and prevention. This web-based
    course is available 24 hours a day, 7 days a week, and offers a variety
    of accreditations to multiple health care disciplines.
        Regarding the bill's specific requirements, VA can and does provide
    data requested by Congress, so an additional reporting requirement in
    statute is not technically necessary. We note there is some ambiguity
    in the bill text, as it would require VA to provide ``data on the
    maternal health outcomes of Veterans who receive medical care or
    services'' furnished by VA (whether in VA facilities or through VCCP).
    This language is not limited to Veterans who receive maternity care
    furnished by VA (we note for clarity that currently, no VA medical
    facility furnishes maternity care; all maternity care for eligible
    Veterans is authorized under VCCP). Instead, VA would be required to
    report on maternal health outcomes for any Veteran who receives any
    care from VA. VA would not have this data available unless it had
    authorized maternity care. In this light, the bill may be improved by
    amending this to refer to ``data on the maternal health outcomes of
    Veterans who receive maternity care services furnished...'' by VA. VA
    would be able to provide this information.
        Regarding section 2(b), VA believes that its Fiscal Year 2024
    President's Budget request is sufficient to implement its current
    authorities and programs without any additional funding. We would
    recommend the bill be updated to refer to Fiscal Year 2025-2029, as FY
    2024 is already underway, and VA would face challenges in allocating
    any additional funds, even if appropriated, within this period of time
    to implement this bill. If this bill were to be enacted without
    updating to Fiscal Year 2025a, this would require a shift in resources
    from other programs to support these initiatives. This could entail the
    reallocation of funds from other high-priority efforts. VA estimates a
    total 5-year cost of $1.9 million to carry out this report.

    H.R. 3584 Veterans Cannabis Analysis, Research, and Effectiveness
    (CARE) Act

        Section 2(a) of the bill would require VA, in carrying out
    responsibilities under 38 U.S.C. Sec.  7303, to conduct and support
    research relating to the efficacy and safety of certain forms of
    cannabis on the health outcomes of Veterans enrolled in VA care who are
    diagnosed with chronic pain, PTSD, and other conditions determined
    appropriate by VA. VA would have to ensure that such research is
    conducted in accordance with applicable regulations relating to the
    oversight of research, including regulations prescribed by VA's Office
    of Research and Development, HHS through the National Institute on Drug
    Abuse (NIDA), the Food and Drug Administration (FDA), the Drug
    Enforcement Administration, and the National Institutes of Health.
        Section 2(b) would require that this research include a mechanism
    to ensure the preservation of all data, including all data sets
    collected or used for this research, in a manner that will facilitate
    further research.
        Section 2(c) would define the forms of cannabis to be evaluated in
    the research required by subsection (a). Specifically, this would
    include varying forms of cannabis, including full plants and extracts,
    at least three different strains of cannabis with significant variants
    in phenotypic traits and various ratios of tetrahydrocannabinol (THC)
    and cannabidiol (CBD) in chemical composition, and other chemical
    analogs of THC. This would also include varying methods of cannabis
    delivery, including topical application, combustible and non-
    combustible inhalation, and ingestion.
        Section 2(d) would require VA, before conducting and supporting
    such research, to submit a plan to Congress and to issue any requests
    for proposals VA determines appropriate for implementation.
        Section 2(e) would require VA to submit annual reports to Congress
    during the 5-year period beginning on the date of the enactment of this
    Act on the implementation of this section.
        Section 2(f) would define the term ``covered veteran'' to mean
    Veterans enrolled in VA health care.

        Position: VA supports, if amended, and subject to the availability
    of appropriations. We are concerned that, as drafted, the bill is too
    prescriptive in its design. In particular, section 2(c) raises concerns
    as full plant products contain high levels of THC as well as other
    molecules that have undetermined therapeutic benefit or harmful
    effects.
        VA generally supports efforts to study the effects of cannabis
    products on the health outcomes of users of such products to determine
    whether the use of such products can benefit Veterans who have been
    diagnosed with PTSD and who are experiencing chronic pain or other
    conditions as deemed appropriate by VA. We recommend extensive
    amendments to this bill, though, to ensure that its requirements would
    yield scientifically and clinically valid results. VA recommends
    convening subject matter experts from within VA and from other Federal
    entities (e.g., NIDA, FDA) to develop and implement a plan for an
    observational study on the effects of cannabis products on the health
    outcomes of users of such products, including but not limited to
    covered Veterans. Enabling VA to coordinate with other agencies would
    result in unbiased data collection and the ability to focus on specific
    methods and dosages of those cannabis compounds that may be more
    beneficial to health outcomes. Further, the data that result from the
    collaborative, retrospective analysis would be robust and would likely
    allow VA to render a determination as to the advisability of proceeding
    with additional clinical trials.
        VA also recommends that it be charged with determining the
    feasibility and advisability of establishing patient registries to
    support research to provide insight into how cannabis products are used
    and associated with medical outcomes. This would be methodologically
    sound and would buildupon existing efforts and research to inform
    conclusions based on the latest, evidence-based work. It would also
    support the goal of section 2(b) by ensuring that this work would
    support future efforts as well.
        VA further recommends that, as it determines necessary, it be
    required to initiate additional scientifically peer-reviewed clinical
    trials to determine the safety and efficacy of cannabis-derived
    pharmaceutical products or cannabinoid pharmaceutical products. Section
    2(c) of the bill recognizes that variations in dosages of cannabis and
    their effects on either chronic pain or PTSD could result in different
    outcomes due to variations in cannabinoids and variations in potencies
    that arise from different methods of administration (e.g., smoking,
    edible, transdermal). If VA conducted additional clinical trials, it
    could control for these variables to determine if specific methods of
    administration or specific dosages were more effective than others. VA
    also could carry out additional scientifically peer-reviewed clinical
    trials, as appropriate, to determine whether the reported benefits of
    the use of cannabis-derived pharmaceutical products or cannabinoid
    pharmaceutical products in the general population could be replicated
    in the population of covered Veterans.
        We further recommend that any agency or Department of the Federal
    Government be exempt from the Paperwork Reduction Act in terms of the
    voluntary collection of information during the conduct of research
    engaged in or supported under this section. This would remove a
    potential barrier to collaborations with other Federal agencies, and
    this language would mirror the authority recently granted to VA through
    38 U.S.C. Sec.  7330D (as added by section 181 of the Joseph Maxwell
    Cleland and Robert Joseph Dole Memorial Veterans Benefits and Health
    Care Improvement Act of 2022 (Division U of P.L. 117-328)).
        VA is already conducting clinical trials related to cannabis and
    would use existing criteria applicable to those studies for the purpose
    of assessing the feasibility of future clinical trials. VA has utilized
    the scientific peer review system and is currently supporting a
    clinical trial of CBD prescribed at a fixed dosage, not the entire
    plant, titled ``Cannabidiol as an Adjunctive to Prolonged Exposure for
    the Treatment of PTSD'' to treat PTSD where CBD is used as an add-on
    treatment to standard of care psychotherapy. This study was recently
    extended, until December 2024, and results will be available after the
    study's completion.
        VA proposes clarifying that the eligibility or entitlement of a
    covered Veteran to any other benefit under law would not be affected by
    the Veteran's participation in any research or trial under this
    section. VA also recommends including a provision stating that nothing
    in this section would affect or modify other specific laws or
    authorities affecting other Federal agencies.
        VA also proposes a new section 3 that would authorize to be
    appropriated additional funds to the Medical and Prosthetic Research
    account and the Information Technology Systems account for purposes of
    carrying out these provisions. Appropriated funds would remain
    available until expended. This would ensure that sufficient resources
    could be made available to support both research and necessary
    information technology projects to implement these requirements.
        Finally, we note that Congress recently enacted the Medical
    Marijuana and Cannabidiol Research Expansion Act (P.L. 117-215), which
    established new provisions of law and amended various provisions in
    titles 21 and 42 of the United States Code regarding research on CBD
    and marijuana. While this law does not provide a needed authority to
    VA, given that VA already funds clinical trials that include medical
    uses of marijuana for conditions that impact Veterans, we do note that
    it may enable VA and other parties to conduct research on medical
    marijuana more easily. However, the Department of Justice and HHS have
    primary responsibility for implementing the provisions of this new Act,
    and until those Departments have issued guidance or regulations to
    implement these new authorities, it may be premature to begin new
    research under processes that may be outdated. The proposed amendments
    described above would provide these agencies time to issue guidance or
    regulations, and the coordination requirements in the proposed
    amendments would ensure VA's efforts are aligned with other Federal
    agencies. We also suggest that the Subcommittee solicit HHS for its
    views on this bill.
        VA would be happy to provide specific amendments to the bill text
    and to discuss our recommendations further with the Committee.

    H.R. 3644 Addressing Care Timelines (ACT) for Veterans Act

        Section 2(a) of the bill would amend 38 U.S.C. Sec.  1703(a)(3),
    which generally limits VA to furnishing care or services under VCCP to
    care or services authorized by the Secretary. The bill would amend this
    authority to provide that, in the case of emergency treatment furnished
    to a covered Veteran by an eligible entity or provider in the course of
    authorized care or services, VA could deem such emergency treatment to
    be authorized if the covered Veteran (or someone acting on the
    Veteran's behalf) or the eligible entity or provider submitted notice
    to VA in such form and containing such information as VA may determine
    appropriate. VA could not require such notification to be submitted
    earlier than 96 hours after the date on which such eligible entity or
    provider furnishes such emergency treatment to a covered Veteran. The
    term ``emergency treatment'' would have the same meaning given that
    term in 38 U.S.C. Sec.  1725.
        Section 2(b) of the bill would provide that these amendments would
    take effect on the date that is 1 year after the date of the enactment
    of this Act.

        Position: VA does not support. VA currently authorizes emergency
    care furnished by an authorized entity or provider if VA is notified
    within 72 hours of the start of such care for covered veterans. VA has
    been reviewing the existing ``72-hour rule'' under 38 C.F.R. 17.4020(c)
    to determine whether changes are appropriate, including whether
    reliance on other statutory authorities (such as 38 U.S.C. Sec. Sec.
    1725 and 1728) might be more appropriate. VA would welcome the
    opportunity to discuss potentially broader reforms regarding
    eligibility for and administration of emergency care benefits to
    simplify the process for Veterans and VA.
        The bill would generally expand VA's current 72-hour rule, which
    allows VA to authorize under the VCCP emergency care or services when
    VA is notified of such care within 72 hours of that care beginning. The
    bill, however, would extend this period to 96 hours, and it would
    potentially extend this even further. Current regulations provide that
    notice must be provided ``within 72 hours of the beginning of such
    treatment,'' while the bill would refer to ``after the date on which
    such health care provider furnishes such emergency treatment.'' In this
    context, the bill's language could mean that the 96-hour notice period
    would not begin until 12:01 a.m. of the date after care begins. VA is
    unclear whether this is the intent, but we recommend clarifying this
    language. If this is the intent and result, this would require systems
    and process changes to ensure accurate adjudication.
        Additionally, we note that the phrase ``in the course of care or
    services authorized under subparagraph (A)'' could unintentionally
    narrow the scope of this text. As written, it would seem the authority
    to deem emergency treatment as authorized would only apply in
    situations where that emergency treatment was furnished during the
    delivery of other care or services. In other words, if a Veteran had
    been authorized by VA to see an orthopedist for a hip injury, and if
    during an appointment with the orthopedist, the Veteran had a heart
    attack that required emergency treatment, VA could deem that emergency
    treatment as covered. Currently, under VA's 72-hour rule, any emergency
    treatment, whether furnished ``in the course of care or services
    authorized'' by VA or not, that is furnished by an eligible entity or
    provider to a covered Veteran can be authorized within 72 hours of the
    emergency care or services being furnished. See 38 C.F.R.
    17.4020(c)(2). In this context, if the bill is interpreted to override
    VA's discretionary authority under the 72-hour rule, the resulting
    benefit may be significantly narrower than VA's current authority.
        Although section 2(b) of the bill would make the amendments
    effective 1 year from the date of the enactment of this Act, this could
    still present complications and could be a difficult timeline to meet.
    VA would need to update its regulations to reflect this change (which
    would normally take more than 1 year to complete), making this timeline
    unrealistic. Separately, but related, VA would need different
    contractual terms than are currently in place to give effect to this
    change; that would either require a modification of current contracts
    or inclusion of these terms in future contracts. VA's efforts to
    develop the next generation of Community Care Network (CCN) contracts
    are already underway, so attempting to modify current contracts would
    likely not be feasible or advisable. If VA attempted to include this in
    the next generation contracts, this could delay the award of such
    contracts, and if these delays resulted in a gap between the expiration
    of the existing contracts and the award of the next contract, this gap
    could have significant consequences in terms of Veterans' access to
    community care.
        We appreciate that this bill reflects and incorporated most of the
    technical assistance VA provided on an earlier draft of this bill.
    These changes improved the clarity of the bill in several ways from the
    prior draft.

    H.R. 3649 Veterans National Traumatic Brain Injury Treatment Act

        Section 2(a) of the bill would require VA to implement a pilot
    program to furnish hyperbaric oxygen therapy (HBOT) to Veterans with
    TBI or PTSD through health care providers who are not VA employees,
    Medicare providers, DoD, IHS, or federally qualified health centers.
        Section 2(b) would require VA to select three Veterans Integrated
    Service Networks (VISN) in which to operate the pilot program.
        Section 2(c) would establish in the general fund of the Treasury
    the VA HBOT Fund; the sole source of moneys for the Fund would be from
    donations received by VA for the express purposes of the Fund. Amounts
    in the Fund would be available without fiscal year limitation to pay
    for HBOT, and the Fund would terminate on the day that is 5 years after
    the date of the enactment of this Act (as established by section 2(d)).
        Section 2(e) would define HBOT to mean hyperbaric oxygen therapy
    with a medical device either approved by the FDA or issued an
    investigational device exemption by the FDA.

        Position: VA strongly opposes. VA, DoD, and others have conducted
    extensive research on the efficacy of HBOT on TBI, and the research has
    found no support for this as an effective treatment (particularly for
    mild TBI). In fact, there is a strong clinical basis that HBOT is not
    recommended for treating TBI. There is no evidence to support a
    sufficient basis for HBOT as a treatment for PTSD either. In this
    context, we are concerned that this bill could result in adverse health
    outcomes for participating Veterans; there is also little ability to
    monitor performance with definitive, evidence-based metrics. The bill
    also would result in significant burdens on Veterans in terms of the
    time commitment involved in treatment and potential personal liability
    for portions of treatment that are not covered by VA (such as travel or
    room and board, if applicable). Further, the resources associated with
    providing this treatment in terms of clinical and administrative time
    would mean fewer resources for evidence-based therapies for Veterans.
        In 2017, VA initiated a clinical (non-research) program to evaluate
    the feasibility of referring Veterans diagnosed with PTSD (with or
    without a history of mild TBI) for HBOT treatment provided by DoD or
    community providers. This clinical program evaluation was designed to
    better understand the treatment protocol requirements and burdens on
    Veterans and VA in the context of PTSD treatment. The evaluation was
    not designed to examine or measure the efficacy of HBOT as a treatment
    for PTSD, TBI, or any other indication. VA proactively began the
    clinical program evaluation to understand the logistical and
    administrative requirements and barriers for providing this treatment
    for these indications, which are considered ``off-label'' because they
    have not been approved by FDA. VA's clinical program evaluation found
    that fewer than half of the Veterans referred completed the full course
    of HBOT treatment. Some Veterans were not interested in engaging or
    continuing treatment due to the treatment schedule (appointments are
    scheduled for 1-2 hours per day, 5 days a week, for 4-8 weeks) and the
    need to travel or because of the availability of evidence-based
    treatment alternatives. We anticipate that similar results could occur
    if this bill were enacted, in which case Veterans would be delayed in
    receiving evidence-based care to treat their conditions.
        VA and DoD have developed evidence-based clinical practice
    guidelines (CPG) for both TBI and PTSD; the most recent update for the
    TBI CPGs was completed in June 2021, while the most recent update for
    the PTSD CPGs was completed in June 2023. The CPGs for PTSD found there
    is insufficient evidence to recommend for or against HBOT as a
    treatment for PTSD. The CPGs for TBI strongly recommend against the use
    of HBOT for the treatment of patients with symptoms attributed to mild
    TBI. Reviews of available research found no evidence of improved
    symptom severity and only a mixed effect on quality of life. When HBOT
    was compared to a sham intervention (effectively, a placebo treatment),
    HBOT actually was associated with decreased quality of life at long-
    term follow up at 2 and 3 years. In addition to the lack of patient
    improvement, the use of HBOT after mild TBI may have harmful impacts,
    including seizures. Emerging treatments are often marketed to patients
    struggling with chronic symptoms, and providers need to understand the
    potential negative impacts that referrals for unfounded treatments can
    have on the provider-patient relationship. The CPGs explain that when
    treatments do not work, it may lead to disappointment, damage to a
    patient's trust, an increase in the likelihood of the patient taking on
    a ``sick role,'' and even harm to the patient. Given the evidence of
    harm in the literature and FDA's findings, the CPGs conclude that HBOT
    is not currently identified as a safe or effective treatment after mild
    TBI.
        VA also has procedural concerns with this bill. Initially, the bill
    seems to establish a parallel program to VCCP for HBOT. Congress
    enacted VCCP to consolidate the various community care programs and to
    simplify eligibility by establishing a common set of criteria to
    determine when Veterans would qualify for community care. This bill
    appears to require VA to furnish this care exclusively through non-VA
    providers regardless of whether VA could furnish treatment for PTSD or
    TBI. The bill expressly excludes VA, Medicare, DoD, and IHS providers,
    as well as federally qualified health centers. Given this narrow range
    of potentially eligible entities, it is not clear that VA would have
    any means to verify the quality of those providers or the quality of
    services they would furnish under this bill. Additionally, this narrow
    scope of eligible providers could both limit Veterans' access to timely
    care and would very likely increase costs to VA as there would likely
    need to be a separate referral, scheduling, and follow-up process
    created for this authority. We recognize that there is a limited number
    of providers and HBOT treatment centers, but imposing additional
    restrictions would seem to make implementation more difficult and
    costly. Further, given that multiple treatments are often required and
    the limited number of providers, the likelihood that Veterans would
    need to travel to receive this care is high. This may be inconvenient
    and place a significant financial burden on patients.
        The bill does not define which Veterans could receive care under
    this authority; it is unclear whether this is limited to enrolled
    Veterans or if another population would apply. Additionally, there are
    no criteria set forth in the bill to determine when HBOT would be
    offered to Veterans--whether this would be required to be a treatment
    of first resort or last resort, purely at the Veteran's election, or as
    otherwise clinically indicated. We emphasize that providers must
    determine that care is medically necessary and in the best interest of
    the patient to furnish it in accordance with current legal and ethical
    standards. We would infer these requirements would continue to apply if
    this legislation were to become law in the absence of specific language
    to this effect, but we recommend the bill include such requirements to
    reduce the potential for confusion. Given the CPGs described above
    strongly recommend against the use of HBOT for the treatment of
    patients with symptoms attributed to mild TBI, it is not clear that VA
    actually could refer such patients for treatment.
        The funding mechanism proposed in this bill also raises significant
    questions and concerns. No other VA program operates under such
    parameters as proposed by this bill, so VA would need to develop new
    procedures and requirements to govern the use of an account like this.
    It is unclear whether there would be sufficient funds donated to VA to
    cover the costs of treatment. VA would need to wait until there were
    sufficient resources in the new HBOT Fund to support the delivery of
    care, which could delay VA's implementation of this (potentially by
    months or years). VA would need to develop new processes and procedures
    to determine who would manage these funds in VA and how the funding
    would be distributed. It is also unclear whether a new administrative
    office would be needed to handle the financial aspects that are unique
    to this arrangement. This could result in additional oversight costs
    that would divert funds from Veterans care.
        In general, if Congress proposes to require VA to operate a new
    program, conventional appropriations measures would make it more
    feasible to carry out. This both ensures accountability for Congress
    (by ensuring Congress is responsible for funding these programs
    appropriately) and reliability for VA (by ensuring that there is a
    clear and dedicated resource pool for different programs).
        The bill also lacks critical elements, such as a clear termination
    date--the bill only refers to the termination of the HBOT Fund, not the
    program authority in the first place, which would seemingly require VA
    to continue the program after the termination of the HBOT Fund (meaning
    within current appropriations accounts). In the absence of further
    clarity, VA would likely have challenges with implementing this bill,
    and this could further increase administrative expenses that would
    divert funds from other evidence-based care.

    H.R. 4424 Vietnam Veterans Liver Fluke Cancer Study Act

        Section 2(a) of the bill would require VA, not later than 120 days
    after the date of the enactment of this Act, in consultation with the
    Director of the Centers for Disease Control and Prevention (CDC), to
    commence an epidemiological study on the prevalence of
    cholangiocarcinoma in covered Veterans of the Vietnam era. This study
    would need to use data from the VA Central Cancer Registry and the
    National Program of Cancer Registries. The study would have to identify
    the rate of incidence of cholangiocarcinoma in covered Veterans in the
    Vietnam era and in residents of the United States (U.S.) from the
    beginning of the Vietnam era to the date of the enactment of this Act.
    For each of these two groups, the study would have to identify the
    percentage of individuals with cholangiocarcinoma by various
    demographic characteristics, including age, gender, race, ethnicity,
    and the geographic location of the patient at the time of diagnosis.
        Section 2(b) would require VA, within 1 year of completing this
    study, to submit to Congress a report that contains the results of the
    study and recommendations for administrative or legislative actions
    required to address issues identified in the study.
        Section 2(c) would require VA to track the prevalence of
    cholangiocarcinoma in covered Veterans of the Vietnam era using the VA
    Central Cancer Registry and provide such information to Congress in
    periodic follow-up reports (as required by section 2(d)).
        Section 2(e) would define the term ``covered veterans of the
    Vietnam era'' to mean Veterans who served in the Vietnam theater of
    operations during the Vietnam era.

        Position: VA does not support. VA fully supports the need to
    conduct research to understand the health risks and conditions of
    Veterans who served in combat areas or were otherwise placed at higher
    risk due to their military service; however, the bill's requirements
    would not be as useful to VA as VA's current efforts. For nearly a
    century, VA research and development has been improving the lives of
    Veterans and all Americans through health care discovery and
    innovation. Congress' generous support of more than $900 million for VA
    research supports more than 7,000 active research projects designed to
    enhance the delivery of care for Veterans and others.
        Cholangiocarcinoma is a rare cancer of the biliary tract, which is
    comprised of the gallbladder and bile ducts. Liver fluke infection is a
    type of parasitic infection that is prevalent in Southeast Asia and is
    acquired from the ingestion of raw or poorly cooked freshwater fish
    infected by this parasite. Liver fluke infection is a well-recognized
    risk factor for the development of cholangiocarcinoma. Liver flukes can
    survive in human bile ducts for decades and can cause a state of
    inflammation that can lead to cholangiocarcinoma, a cancer that is
    diagnosed far more commonly in countries like Thailand and Vietnam than
    in the U.S. Vietnam War Veterans have been concerned about exposure to
    liver flukes during deployment and subsequent development of
    cholangiocarcinoma.
        Other risk factors for cholangiocarcinoma are biliary tract
    diseases such as primary sclerosing cholangitis (an autoimmune
    disease), chronic cholelithiasis (bile duct stones), cirrhosis (liver
    scarring from several causes), and infections such as Hepatitis B or C.
    An evaluation of VA health records in 2018 indicated that Vietnam
    Veterans who receive VA health care have similar or lower age-adjusted
    incidence rates of cholangiocarcinoma when compared with the U.S.
    population in most age categories (fewer than the U.S. rate of 1.6
    cases/100,000 persons/year). VA does recommend that all Veterans who
    have not been tested for Hepatitis B or C in the past obtain those
    tests, as there is definitive treatment available to clear most
    Hepatitis B and C viral infections.
        VA also has a current research study on rates and causes of
    mortality in Vietnam era Veterans. An analysis of deaths from 1979-2019
    from cholangiocarcinoma is in final stages of preparation for
    submission to a peer-reviewed scientific journal. This analysis
    compares deaths from cholangiocarcinoma between all Veterans who served
    in the Southeast Asia theater of operations and all of those Veterans
    who served elsewhere in the world during the Vietnam War era. Because
    cholangiocarcinoma has a very high mortality rate, comparing death
    rates is an accurate way of counting cases and comparing incidence of
    this unfortunate cancer. VA's mortality study is very likely the most
    definitive way that the real incidence of cholangiocarcinoma can be
    measured because counting cases of Veterans who receive health care in
    VA does not include all Vietnam-era Veterans nor all diagnoses of
    cholangiocarcinoma as Veterans receive care outside VA. VA designed
    this study in collaboration with scientists from the Uniformed Services
    University of the Health Sciences. The VA mortality study shows that
    there is no difference in mortality rates from cholangiocarcinoma among
    all Vietnam-War deployed Veterans compared to all Veterans who served
    elsewhere in the world during the era, except for Marines. Vietnam War-
    deployed Marines appear to have a higher rate of death from
    cholangiocarcinoma compared to non-deployed Marine Vietnam Veterans.
    The reasons for this cannot be definitively determined; data to compare
    risk factors (including exposure to undercooked fish and diagnoses of
    liver fluke infections) are not available. It is possible that Marine
    deployment locations or experiences resulted in greater exposure to
    liver fluke infections, but other risk factors could explain this
    outcome as well. These research results, once peer reviewed, will be
    communicated to Veterans and clinicians to be watchful for signs and
    symptoms of cholangiocarcinoma.
        Given VA's observations with existing studies, the bill's
    requirements would not be as useful to the agency as VA's current
    efforts at this time. Any additional epidemiological study would face
    significant hurdles in counting cases because of the lack of available
    and comprehensive health care data (such as cancer diagnoses and risk
    factors) on the entire population of Vietnam-era Veterans over the
    years since the war, whereas VA has conducted this mortality study by
    compiling a roster of all Vietnam Veterans along with a data base of
    their death dates and causes. For example, reliable health care
    encounter data are available only from 2000 forward for both DoD and
    VA. Thus, there is at minimum a 25-year gap (1975 to 2000) where we
    would be unable to ascertain cholangiocarcinoma incidence. As noted
    earlier, given the high mortality of cholangiocarcinoma, using
    cholangiocarcinoma mortality as the primary outcome in the Vietnam-era
    Mortality Study provides the most robust epidemiologic assessment of
    this condition in Vietnam-era Veterans. We do not believe the bill
    would provide additional information that would justify the resources
    needed for implementation.
        Further, section 505 of the Sergeant First Class Heath Robinson
    Honoring our Promise to Address Comprehensive Toxics (PACT) Act of 2022
    (P.L. 117-168) requires a review of cancer rates among Veterans. In
    implementing this requirement, VA has developed a bilateral agreement
    with State tumor cancer registries, which have accurate current data on
    cancer diagnoses and which could be leveraged to further the work this
    bill proposes to undertake. In this regard, VA is effectively already
    meeting the requirements of this bill. VA also suggest that the
    Subcommittee solicit HHS for its views on this bill.

    H.R. 5247 Expedited Hiring for VA Trained Psychiatrists Act of 2023

        H.R. 5247 would add a new section 7406A to title 38, United States
    Code, to allow VA to begin the process of appointing a psychiatrist
    before the psychiatrist completes a residency sponsored by or
    affiliated with VA, provided the individual meets the requirements in
    the VA qualification standards for psychiatrists. VA could appoint a
    psychiatrist under the proposed section 7406A(a) if the position
    remained unfilled for at least 35 days or more.

        Position: VA does not support. VA does not support this bill
    because it is redundant given existing policy and authorities. VA
    currently has authority to begin the appointment process for
    psychiatrists prior to their completion of a residency contingent upon
    them meeting the qualification requirements by the time of appointment.
    VA focuses on expediting the hiring of both current and former trainees
    based on their qualifications.

    H.R. 5530 VA Emergency Transportation Access Act

        Section 2(a) of the bill would provide that VA may not change the
    rate of payment or reimbursement provided for the transportation of a
    Veteran or other eligible individual on a special mode of
    transportation, as in effect on January 1, 2023, unless such change
    would increase the rate of such payment or reimbursement or, before the
    effective date of such change, VA: (1) conducted a thorough review and
    analysis of the effects of the change on VA, industry, and Veterans;
    (2) developed a formal process to ensure any changes made to such rate
    would not reduce Veterans' access to care; and (3) ensured the new rate
    reflects, at a minimum, the actual cost of such transportation.
        Section 2(b) would require VA, in carrying out any such review and
    developing any process, to consult with a committee made up of relevant
    industry experts, representatives from the Centers for Medicare and
    Medicaid Services (CMS), VA employees with subject matter expertise in
    various areas (transportation, access to care, integrated Veteran care,
    rural Veterans, Native American Veterans, and other matters determined
    appropriate), and representatives of VSOs.
        Section 2(c) would require that, not later than 2 years before the
    effective date of any change made to the rate of payment or
    reimbursement for special mode transportation that affects the payable
    rate under any contract, VA would have to establish a template and a
    standardized process for entering into and making changes to rates in
    effect under such contract, issue guidance about the use of such
    template and process within VA and across the industry associated with
    special mode transportation, and submit a report to Congress that
    includes a description of the template and process.
        Section 2(d) would define the term ``special mode of
    transportation'' to mean an ambulance, ambulette, air ambulance,
    wheelchair van, or other mode of transportation specially designed to
    transport disabled persons. The term would not include a mode of
    transportation not specifically designed to transport disabled persons
    (such as buses, subways, taxis, trains, or airplanes) or a modified,
    privately owned vehicle with special adaptive equipment or that is
    capable of transporting disabled persons.

        Position: VA does not support. In 2011, Congress authorized VA to
    pay to providers of transportation the lesser of the actual charges for
    transportation or the amount determined by CMS, unless VA has entered
    into a contract for that transportation with the provider.
        In 2020, VA proposed to put in place the very change Congress had
    authorized. VA's publication of a proposed rule triggered a comment
    period, during which VA received five substantive comments. VA
    responded to these comments in a final rule, known as the Change in
    Rates Rule, which was published in the Federal Register on February 16,
    2023. VA stated in the final rule that we would delay the effective
    date of the final rule by 1 year (to be February 16, 2024) to ensure
    that ambulance providers had adequate time to adjust to VA's new
    methodology for calculating ambulance rates (88 FR 10035). We further
    stated in the final rule that such adjustment could include ambulance
    providers entering negotiations with VA to contract for payment rates
    different than those under the CMS ambulance fee schedule, as
    contemplated in the final rule. Congress granted VA the discretion in
    38 U.S.C. Sec.  111(b)(3)(C) to use the CMS ambulance fee schedule as
    part of VA's methodology to calculate ambulance payments, ostensibly
    finding such schedule to be sufficient. VA cannot modify or increase
    the CMS ambulance fee schedule rates.
        After publication of the final rule, however, VA received feedback
    from both internal and external stakeholders, including VA employees,
    ambulance providers, and industry experts, that more time was necessary
    for successful implementation of the rule. Specifically, the delay of
    the effective date was necessary to accommodate unforeseen difficulties
    in air ambulance broker contracting. These difficulties relate to air
    ambulance brokers requiring a contract or subcontract in place with all
    potential air ambulance providers that covers emergency, non-VA
    initiated trips. Based on this feedback and evaluation of the continued
    effort that would be required by air ambulance brokers to negotiate and
    enter into contracts before February 16, 2024, we delayed the effective
    date of the regulation by 1 year (to be February 16, 2025). VA
    understands the Committee is specifically concerned about the effect
    these proposed rules would have on unauthorized emergency
    transportation, and VA is exploring options to try to address this
    concern. We would welcome the opportunity to discuss this further with
    the Committee.
        VA's regulations, as proposed for 38 C.F.R. Sec.  70.30(a)(4),
    would allow VA to enter into a contract with a vendor of special mode
    transportation (including air ambulance transport), and the terms of
    that contract would govern the payment rates for such transport. Such
    contracts could provide for a different rate as agreed, in the event
    that VA determined it may be justified based on local considerations,
    such as for rural areas.
        VA has other concerns with the bill beyond its apparent retreat
    from prior congressional intent. The bill is unclear in several
    critical respects. For example, the bill refers to a ``rate'' of
    payment throughout the text, but there is not a singular rate for
    transportation given the variability in geography, type of vehicle or
    conveyance (ambulance versus helicopter, for example), and type of
    service furnished. Other Federal agencies, particularly CMS, have
    established rates for ambulance services that reflect appropriate
    charges for such transportation, which do not reflect billed charges.
    VA's pending regulatory changes would give effect to the discretion
    Congress provided to VA to align its payment structures with these
    other Federal agencies (including CMS). By referring to special mode
    transportation of Veterans or other eligible individuals, this would
    also apply to health care programs for family members (such as the
    Civilian Health and Medical Program of VA (CHAMPVA) or the Children of
    Women Vietnam Veterans). VA currently pays for special mode
    transportation for eligible individuals under these programs consistent
    with the CMS ambulance fee schedule. It is unclear whether this was the
    intent of the bill.
        Subsection (a)(2) would require VA to conduct thorough analyses of
    the proposed changes to rates for special mode transportation, but
    these would largely duplicate the requirements associated with a
    regulatory impact analysis, which VA already provided. In this context,
    these requirements would be duplicative and unnecessary.
        Further, under subsection (a)(2)(B), VA would have to develop a
    formal process to ensure that any change made to such rate does not
    reduce the access to care for Veterans. It is unclear how VA would be
    able to determine whether any changes would affect access to care;
    access is influenced by many different variables, some of which are
    completely outside of VA's control (principally, the decision of
    private providers to offer services in the marketplace in the first
    instance). In this context, VA could likely never develop a process,
    formal or otherwise, that would ensure that rate changes do not reduce
    access to care.
        We are also concerned about the language in subsection (a)(2)(C),
    which would direct VA to ensure that ``the new rate reflects, at a
    minimum, the actual cost of such transportation.'' It is unclear what
    ``the actual cost'' is intended to mean, but we infer that the intent
    is to ensure that VA always pays, at a minimum, the billed charges for
    transportation. However, the billed charges do not reflect the ``actual
    cost of such transportation,'' as billed charges also include profit
    margins and administrative expenses beyond the cost of the
    transportation. To the extent the bill is intended to require VA to pay
    billed charges, this would effectively allow private entities without a
    contract with VA to charge any amount, and VA would be obligated to pay
    this amount. This would seriously undermine VA's efforts to establish a
    contracted network of providers, which could increase both the
    predictability and accessibility of services while also providing cost
    assurances for the Government and taxpayers. Requiring VA, by statute,
    to pay no less than the billed charges would make budgeting and
    accountability impossible. It also raises questions about whether this
    would effectively allow private entities to determine Federal
    obligations of appropriated funds.
        Subsection (b) of the bill would require VA to consult with various
    entities, including non-Governmental entities. The bill text appears to
    direct VA to establish a committee composed of relevant industry
    experts and representatives of VSOs, but this would seemingly require
    this to be a Federal Advisory Committee subject to the Federal Advisory
    Committee Act (FACA). There is no further discussion of this
    requirement or explicit authorization pursuant to FACA, and there is no
    express waiver of the need to comply with FACA. We recommend the
    drafters clarify the intent of this provision and whether this
    committee would be subject to FACA. We do not believe this provision is
    necessary as the consultation requirements would largely duplicate the
    public comment period that was previously available for VA's proposed
    regulations.
        Subsection (c) of the bill would prohibit rate changes until a 2-
    year period elapsed from the time that a template and standardized
    process for entering into and making changes to rates and guidance
    about the template and process was issued with VA and across the
    industry. This would ultimately make entering into contracts at set
    rates more difficult, which appears antithetical to Congress' goal of
    ensuring accountability and predictability for the costs of these
    services. We are also concerned that the 2-year delay for the effective
    date of any change would result in VA paying greater costs for that
    entire period of time.
        We understand the Committee's concerns regarding transportation
    access, and we would welcome the opportunity to discuss these in more
    detail.

    H.R. 5794 VA Peer Review Neutrality Act

        H.R. 5794 would add a new 38 U.S.C. Sec.  7311B; the proposed
    subsection (a)(1) would require peer review committee members to
    withdraw from participation if the individual has direct involvement
    with the care under review, or the individual is unable to conduct an
    objective, impartial, accurate, and informed review. In addition, under
    the proposed subsection (a)(2), VA would have to conduct an additional
    review by a neutral peer review committee at another VA facility for
    quality management reviews conducted with respect to care provided by a
    peer review committee member. Under the proposed subsection (b)(1),
    individuals with knowledge of confidential quality assurance
    information regarding a matter under investigation could not serve as a
    factfinder or member of an administrative investigation board (AIB)
    examining such matter, nor disclose confidential quality assurance
    information to an AIB or factfinder. Under the proposed subsection
    (b)(2), VA would be required to ensure a member of an AIB or a
    factfinder does not: (1) have any personal interest or other bias
    concerning the investigation being conducted, (2) have direct
    involvement in matters being investigated, and (3) have a supervisory
    or personal relationship with the subject of the investigation. Any
    individuals with any of the three identified relationships or personal
    interest or bias would have to inform the authority responsible for the
    investigation and recuse themselves.

        Position: VA supports, if amended. VA supports the underlying
    premises in the bill, such as maintaining the integrity of peer
    reviews, protecting confidential quality assurance information, and
    ensuring investigations are free of bias and potential investigatory
    conflicts of interest that would compromise the integrity of the
    investigation. However, significant amendments to the bill's language
    would be needed to align these common interests for VA's support. The
    bill appears to overlook major components of existing statute and VA's
    existing processes for peer review, investigating patient care matters,
    protecting quality assurance information, and conducting impartial
    investigations.
        VA has no concerns with the proposed section 7311B(a)(1), which is
    in line with current VA guidelines. Similarly, VA has no concerns with
    the proposed section 7311B(a)(2), which is also in line with current VA
    guidelines.
        However, VA recommends that the proposed section 7311B(b)(1) be
    removed. VA has existing investigation formats for patient care
    concerns that comply with 38 U.S.C. Sec.  5705, which deals with
    confidentiality of medical quality assurance records. Some
    investigations are confidential quality assurance reviews, but some are
    purposefully not covered by 38 U.S.C. Sec.  5705, namely Focused
    Professional Practice Evaluations for Cause and Focused Clinical Care
    Reviews, fact findings, and AIBs. These reviews are critical for
    addressing concerns regarding substandard care that may be detrimental
    to Veterans because they are administrative investigations that provide
    a mechanism for information to be discovered, and in turn, utilized for
    administrative action if necessary. The non-disclosure element of the
    proposed provision extends provisions of 38 U.S.C. Sec.  5705(b)(1),
    which already defines rules for release of information. VA agrees that
    employees who have knowledge of events being investigated because of
    their role in the quality review process cannot be a factfinder or
    member of an AIB. However, the vague language of the bill may preclude
    an employee from testifying or providing information obtained through
    the individual's role in an event or their appropriate peripheral
    involvement in an event. To ensure appropriate administrative action
    can be taken in response to misconduct, the discoverable investigatory
    processes must be able to collect information from all sources related
    to an event and not protected under 38 U.S.C. Sec.  5705. VA can
    provide narrative examples of how these concerns could arise to the
    Committee upon request. If the proposed paragraph (b)(1) is not struck
    in its entirety, VA at least recommends removing the prohibition on
    disclosing information in at least some situations. Further, any
    clarifications should be included as an amendment to 38 U.S.C. Sec.
    5705, rather than as part of the proposed section 7311B, to avoid
    confusion and creating multiple statutes covering the same matter. VA
    can provide further technical assistance on this issue if needed.
        VA also recommends amending the proposed section 7311B(b)(2). VA
    takes seriously the administrative investigation process and the
    impartiality of those conducting investigations. VA Directive 0700,
    Administrative Investigation Boards and Factfindings, and VA Handbook
    0700, Administrative Investigation Boards and Factfindings, provide the
    framework for VA's general administrative investigations and include a
    specific requirement for those participating in fact findings and AIBs
    to undergo training. In 2021, VA updated these policies and training to
    emphasize the avoidance of potential investigatory conflicts of
    interest. VA policy requires that authorities responsible for
    investigations ensure that members of AIBs and factfinders are free
    from such conflicts. VA AIB members and factfinders are already
    required to be objective, impartial, and free from personal interests,
    bias, or involvement in the matter. AIB Members and factfinders also
    are already required to recuse themselves if they do not meet these
    standards.
        VA supports the assurances that investigators do not have potential
    investigatory conflicts of interest or personal relationships impacting
    their objectivity regarding the incidents they are investigating. VA is
    concerned that moving these requirements from policy to statute will
    increase the likelihood and weight of employees challenging
    disciplinary actions by arguing that the underlying investigation
    violated the statute and constituted harmful procedural error. To
    mitigate this risk, VA recommends that the bill simply state that VA
    will ensure that its investigators are impartial and that VA must
    include appropriate measures in policy. This would allow VA to tailor
    and monitor the issue in light of the complexities and unique
    requirements of its administrative investigation structure.
        Investigations within VA vary in severity and response, from every
    day information gathering where a supervisor asks an employee about
    minor infractions (e.g., being late to work) all the way to an AIB,
    which may investigate much more severe misconduct such as inappropriate
    conduct of a sexual nature or inappropriately striking a patient. Per
    VA policy, AIB members are not permitted to have a supervisory
    relationship with the subject of the investigation. The same rule was
    intentionally not applied to factfindings, as they are intended to
    provide an investigative process for, among other things, first-line
    supervisors to address issues within their office of business unit. It
    is imperative that supervisors maintain their authority to conduct
    investigations, when appropriate. A first-line supervisor is the
    appropriate individual to inquire into the routine misconduct issues
    that surface every day within VA (e.g., tardiness, customer service
    complaints, observing suspected impairment, etc.). To ensure optimal
    operations, proposed subsection (b)(2)(B) would need to be amended to
    remove the provision disallowing this practice to allow routine
    exercises of supervisory authority. The bill could include further
    language clarifying that subordinates should not investigate an issue
    in which their supervisor has a significant interest (e.g., the
    supervisor is the subject of a related investigation). VA also supports
    adding explicit safeguards that preclude supervisors from completing an
    investigation when they are implicated in the misconduct under review.
    There would be no costs associated with this bill.

    H.R. 6324 Fiscal Year 2024 Veterans Affairs Major Medical Facility
    Authorization Act

        This bill would authorize major medical facility projects in
    American Lake, WA; Dallas, TX; El Paso, TX; Perry Point, MD; Portland,
    OR; Reno, NV; San Diego, CA; San Francisco, CA; San Juan, PR; St.
    Louis, MO; and West Haven, CT. It would authorize to be appropriated in
    Fiscal Year 2024, or the year in which funds are appropriated for VA's
    major construction account, $4,603,129,000 for these projects.

        Position: VA supports, if amended. VA supports the authorization of
    the projects identified in this bill. VA has previously provided and is
    requesting an amendment regarding the authorization for the San Diego,
    CA project. VA recommends the bill also authorize ``central utility
    plant upgrades'' and the seismic retrofit of the existing spinal cord
    injury building 11 at the VA San Diego Healthcare System. VA can
    provide technical assistance on this language if needed.

    H.R. 6373 Veterans Spinal Trauma Access to New Devices (STAND) Act

        Section 2 of the bill would amend 38 U.S.C. Sec.  1706 by adding a
    new subsection (d). The proposed subsection (d)(1) would require VA, in
    managing the provision of hospital care and medical services, to
    furnish (through direct provision of service, referral, or a VA
    telehealth program) a preventative health evaluation annually to any
    Veteran with an SCI/D who elects to undergo the evaluation. The
    proposed paragraph (2) would require that the evaluation include an
    assessment of any circumstance or condition the Veteran is experiencing
    that indicates a risk for any health complication related to the SCI/D,
    chronic pain and its management, dietary management and weight
    management, prosthetic equipment, and the provision of any assistive
    technology that could help maximize the independence and mobility of
    the Veteran.
        Proposed paragraph (3) would require VA, in maintaining,
    prescribing, or amending any guidance, rules, or regulations issued by
    VA regarding the requirements in the new subsection (d), to consult
    with VA's SCI/D program managers, VA clinicians employed as specialists
    in SCI/D, and organizations named in or approved under 38 U.S.C. Sec.
    5902 (generally, organizations that prepare, present, and prosecute
    claims for VA benefits). Before issuing any guidance, rules, or
    regulations regarding the requirements set forth in this new
    subsection, VA would have to consult with manufacturers of assistive
    technologies and other entities relevant to the provision of assistive
    technologies if the guidance, rules, or regulations would directly
    affect such manufacturers or entities. VA would have to ensure, to the
    extent possible, that any Veteran known by VA to have an SCI/D receive
    information annually about the annual evaluation and the benefits to
    undergoing this evaluation.
        Proposed paragraph (4) would require VA, within 1 year of the
    enactment of this Act and every 2 years thereafter, to submit to
    Congress a report on the number of Veterans who received medical care
    or hospital services from VA and used an assistive technology, received
    VA care or services and were assessed for the provision of an assistive
    technology, and received VA care or services and were prescribed an
    assistive technology. VA would also need to report the year-to-year
    change in the percent of Veterans with an SCI/D who received an
    evaluation described above.
        Proposed paragraph (5) would require VA, in evaluating the
    performance metrics of a VISN for any year beginning after the date
    that is 1 year after the date of the enactment of this Act, to consider
    the provision of the preventative health evaluations described above.
        Proposed paragraph (6) would define the term ``assistive
    technology'' to mean a powered medical device or electronic tool used
    to treat or alleviate symptoms or conditions caused by an SCI/D,
    including a personal mobility device (including a powered exoskeleton
    device) and a speech-generating device.
        Position: VA opposes. VA is committed to providing comprehensive,
    lifelong, innovative, and specialized care that is safe and evidence-
    based for Veterans with SCI/D. VA opposes this bill because it would
    reduce VA's ability to ensure the safety of Veterans and would
    compromise the integrity of the clinical decision-making process. It
    would also increase administrative costs to VA, burden clinicians'
    time, and ultimately result in reduced access to clinically appropriate
    care.
        In particular, VA is opposed to proposed subsection (d)(3), which
    would require VA to consult with the manufacturers of assistive
    technologies ``and other entities relevant to the provision of
    assistive technologies'' if VA's guidance, rules, or regulations
    ``would directly affect such manufacturers or entities.'' Mandatory
    consultation with such entities in the development of clinical guidance
    would introduce a conflict of interest that could easily compromise
    patient safety. This would not only set a concerning precedent, but it
    would contradict best practice for the development of clinical
    protocols in health care settings. Research indicates that increased
    stakeholder involvement in the development of clinical protocols or
    clinical practice guidelines can result in poor quality protocols that
    fail to ensure safety and do not meet the needs of clinicians in
    guiding best care for patients. The recommended course of action for
    the development of high-quality clinical protocols is to utilize
    research and subject matter experts from a range of settings and
    expertise. VA's assessment and procurement of assistive technologies is
    consistent with the standard practice of care for Veterans with SCI/D.
        Additionally, the provisions in proposed subsection (d)(4), which
    would require detailed reports from VA, would consume clinicians' and
    administrators' time without apparent value; this additional burden
    would reduce the ability to see more Veterans in clinical appointments
    and to process requests for assistive technology and other devices,
    ultimately reducing Veterans' access to timely and appropriate care.
    VA's current data systems capture when assistive technology is
    procured, but the other data elements in the bill are not available.
    VA's systems are not able to capture instances where Veterans are
    evaluated, but not found suitable, for assistive technology, or
    Veterans who decline assistive technology.
        VA is also concerned about the breadth of the definition of the
    term ``assistive technology'' in the bill. The term would mean a
    powered medical device or electrical tool used to treat or alleviate
    symptoms or conditions caused by an SCI/D, including a personal
    mobility device (including a powered exoskeleton device) and a speech
    generating device. Given the breadth of this term, the associated
    procedural requirements would apply in multiple instances; this would
    make practical implementation very difficult, if not impossible.
        The provisions of this bill that would not result in these outcomes
    are unnecessary because VA is already meeting those requirements. For
    example, VA already provides annual evaluation for Veterans with SCI/D,
    and these requirements meet or exceed all elements of the bill in this
    regard. Furthermore, explicitly prioritizing powered assistive
    technology during annual evaluations diminishes the value all other
    aspects of the comprehensive medical and functional evaluation that is
    performed. While assistive technology is seen as a critical component
    of the evaluation, it is not weighted above other interventions or
    considerations in providing Veteran-centered care.
        To the extent the bill is concerned that Veterans do not have an
    opportunity to determine which assistive technologies would be best for
    them, VA providers work closely with Veterans to identify their needs
    and recommend the best solutions for them. When devices like
    exoskeletons are identified, VA allows Veterans to try these devices
    for up to 90 days to determine whether these are appropriate for them.
    Recent data indicate that nearly 40 percent of Veterans who use an
    exoskeleton during this trial period decide against using it beyond the
    trial period. This approach ensures Veterans receive the device or
    technology that best meets their functional needs while avoiding waste
    that could otherwise result if these technologies were furnished
    without personal experience. This reflects VA's commitment to both
    clinically appropriate care as well as accountable fiscal stewardship.
        Additionally, it is critical to ensure that Veterans can safely use
    any devices they are prescribed. VA was an early adopter of exoskeleton
    technology, and powered exoskeletons have been provided to Veterans
    with SCI/D since 2015, shortly after the FDA first approved powered
    exoskeletons for home use. To provide guidance and ensure consistency
    in screening, evaluation, and training, VA developed a rigorous
    clinical protocol, which was shared with VA facilities in December
    2015. This clinical protocol was updated in 2018, reflecting additional
    exoskeleton products that received FDA clearance for personal use in
    the community.
        Further demonstrating VA's commitment to supporting exoskeletons
    and innovative technology, VA performed one of the largest national
    randomized, controlled multi-center exoskeleton research studies,
    investigating home/community use, efficacy, and safety of powered
    exoskeletons in Veterans with SCI/D. Powered exoskeletons can lead to
    assisted ambulation in individuals with SCI/D, yet they require careful
    evaluation of potential users, extensive training, inclusion of a
    companion for safe use, extensive clinician experience, and specific
    manufacturer training and expertise by staff for safe and effective use
    by individuals with SCI/D. Notably, the criteria for each device are
    largely based on FDA specifications. VA has taken an individualized
    approach to Veterans' exoskeleton training to minimize the burden on
    Veterans who are interested in and are evaluated for clinical
    appropriateness to utilize this technology.
        After a Veteran is determined to be clinically appropriate for an
    exoskeleton device, training with the device can occur at a VA SCI/D
    Center or at a facility that provides equivalent certified exoskeleton
    training. Training typically requires 20-30 visits over a series of
    months to achieve proficiency with the device. Device issuance is
    considered when all critical skills are safely demonstrated by the
    Veteran and their companion(s). Clinical training and home trials must
    occur before a device can be purchased to ensure that the device meets
    the needs of the Veteran and is safe in the home environment.
        Exoskeletons are complicated medical devices, and exoskeleton-
    trained clinicians must consider a number of factors when issuing this
    equipment. Factors include but are not limited to: level of spinal cord
    injury, height, weight, hip and leg length measures, joint range of
    motion (flexibility), skin integrity, spasticity, arm/hand strength,
    bone density, history of fractures, blood pressure, autonomic
    dysreflexia, cardiovascular health, cognition, environments of intended
    use, Veteran's goals for use of the device, vision, and the ability to
    develop the skill needed to operate this equipment. Due to the
    complexity of the devices, a large number of Veterans who are
    interested in exoskeletons are not appropriate for the use of these
    devices. Additionally, for safety reasons, the devices currently
    available in the U.S. require a companion to be present when an
    individual is utilizing this technology. Many individuals lack access
    to an appropriate companion to help with management of the device,
    which can weigh up to 51 lbs. Requiring the presence of a companion
    while utilizing the device can result in the perception of decreased
    independence to users who are fully independent when using a
    wheelchair. The involvement of a companion also prolongs the training
    period and requires a significant commitment from both the Veteran and
    companion.
        Exoskeletons have been studied in a number of settings, and there
    are many potential benefits, such as standing, walking, cardiovascular
    response, spasticity management, weight loss, bowel function, and bone
    density. Evidence of adverse events, including fractures, falls, skin
    breakdown, autonomic dysreflexia, and soft tissue injuries have been
    reported across subjects, studies, and devices. Currently, there are no
    established CPGs regarding the use of exoskeletons. For each
    individual, it is still largely unknown if the benefits outweigh the
    risks and how to identify candidates who will most likely benefit from
    the technology. Therefore, VA has developed a clinical protocol that
    emphasizes patient preference and safety. Importantly, through safe,
    evidence-based services and devices, VA will continue its ongoing
    efforts to support Veterans with SCI/D in their goals of optimizing
    their health, functional mobility, and independence. Those efforts
    include the careful evaluation and when appropriate, provision of
    assistive technology devices including powered exoskeletons.
        VA is focused on ensuring Veterans have access to and can use
    specialized technology to address their needs. A new Office of Advanced
    Manufacturing is focused on these efforts specifically in the context
    of assistive technology. VA is continually reviewing current clinical
    protocols to ensure Veterans can receive timely, high-quality, and
    evidence-based care and technology.

    H.R. 7347 Reporting on Determination to Include Newly Approved or
    Licensed Psychedelic Drugs in the VA Formulary

        This bill would add a new section 8125A to title 38, United States
    Code, that would require VA, not later than 180 days after a
    psychedelic drug is approved under 21 U.S.C. Sec.  355 or licensed
    under 42 U.S.C. Sec.  262, to submit to Congress a report regarding
    such drug that includes VA's determination whether to include the drug
    in VA's formulary and VA's justification for that determination.
        Position: VA does not support. VA does not support this bill
    because it is unnecessary. VA already has processes in place where
    formulary decisions regarding inclusion or exclusion of a drug are
    released publicly. In this context, the bill would include additional
    administrative burden without any increase in transparency or
    accountability. VA publicly lists changes to the formulary (see https:/
    /www.va.gov/formularyadvisor/), and any of the documents that VA
    reviewed and influenced VA's decision are publicly available (see
    https://www.pbm.va.gov/PBM/NationalFormulary.asp). We are also
    concerned about the precedent this could set; further reporting would
    only delay actions that would improve Veterans' access to new drugs and
    treatments. VA makes decisions regarding which drugs to include in the
    formulary in consideration of the best clinical outcomes of Veterans;
    if the FDA approves any psychedelic drugs, VA will review these drugs
    using the same process as any other drug or medication. If or when FDA
    approves any psychedelic medications, we anticipate such drugs would be
    prescribed in combination with evidence-based psychotherapy or other
    psychosocial support as directed in the FDA approval. In this context,
    the existence of a drug on VA's formulary would not necessarily
    guarantee Veterans access to these drugs, in VA or in non-VA
    facilities, if the related therapy or psychosocial support is not
    available at a given facility.
        These concerns are hypothetical at this point, though, as no
    psychedelic drugs have been approved by FDA yet. VA is developing plans
    to respond in the event such drugs are approved. All drugs that are
    approved by the FDA are available to Veterans with clinical need,
    regardless of whether the drug is available on the formulary.
        VA has supported and is supporting three main efforts to ensure
    that Veterans will have access to safe and effective treatments,
    including psychedelics, when approved. VA co-hosted a State-of-the-Art
    Conference in September 2023 to address two major objectives: first, to
    better understand the current state of scientific evidence and to
    identify a strategic framework to consider future psychedelic treatment
    research for select mental health conditions; and second, to determine
    the necessary next steps for potential VA system-wide clinical
    implementation for psychedelic compounds for potential future use.
    Additionally, VA issued a request for applications for proposals from
    its network of VA researchers (in collaboration with academic
    institutions) to study the use of certain psychedelic compounds in
    treating PTSD and depression. Finally, VA is establishing a workgroup
    to develop plans for potential future clinical deployment, provider
    training, evaluation, and further research. We would be pleased to
    brief the Committee in more detail on these efforts. Additionally, we
    request that the Subcommittee solicit HHS for its views on this bill.

    Conclusion

        This concludes my statement. We appreciate the Subcommittee'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, a
    congressionally chartered non-profit veterans service organization
    (VSO), is comprised of over one million wartime service-disabled
    veterans. Its single purpose is to empower 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. 3225, BUILD for Veterans Act

                                      and

    H.R. 6324, Fiscal Year 2024 VA Major Medical Facility Authorization Act

        Over the past decade, the Department of Veterans Affairs (VA)
    Veterans Health Administration (VHA) has experienced significant growth
    and stress while implementing reforms to help ensure veterans receive
    timely access to quality health care. For the VA to remain the primary
    provider of care, the VA must tackle an aging infrastructure to improve
    its capacity.
        The VA states that private sector health facilities have a median
    age of around 13 years. In contrast, VA facilities have a median age of
    nearly 60 years and suffer from a lack of resiliency and long-term
    sustainability. Facilities of this era, which were not designed to
    accommodate the technological and design innovations that support
    modern health care delivery, pose a challenge with renovation. For the
    VA to continue being the primary health care provider and care
    coordinator of choice for veterans, the VA must focus on improving its
    internal capacity by building and modernizing facilities. Up to date
    and modern facilities will ensure that the VA can effectively meet the
    needs of both current and future veterans, offering a broad range of
    primary and specialized care options.

        The Build, Utilize, Invest, Learn, and Deliver (BUILD) for Veterans
    Act, H.R. 3225, seeks to improve the management and performance of the
    VA's capital asset programs to better serve veterans, their families,
    caregivers, and survivors.
        The BUILD Act would help provide the VA with a clear roadmap by
    identifying internal capacity needs and consistent funding for
    infrastructure needs, as well as strengthen the VA's capabilities to
    start and complete projects.
        This bill would require the VA to develop plans to identify
    infrastructure needs and improve workforce hiring strategies. It would
    also examine capital asset budgeting strategies and identify potential
    reforms based on industry best practices. VA would also be required to
    forecast annual budget requirements over a 10-year period and lay out a
    concrete schedule to dispose of, or repurpose, unused buildings.
        Furthermore, the bill mandates the VA Inspector General to assess
    and report on the management and performance of relevant VA capital
    asset projects, ensuring greater accountability. In addition, the
    Government Accountability Office would review and report on the VA's
    progress toward achieving the goals, metrics, and other plans specified
    in this bill.
        We support H.R. 3225, in accordance with DAV Resolution No. 247,
    calling for modernization of the VA health care infrastructure to
    provide veterans with the quality care and benefits they deserve.

        The Fiscal Year 2024 VA Major Medical Facility Authorization Act,
    H.R. 6324, would grant authorization for 11 major medical facility
    projects for the VA in Fiscal Year 2024, to include construction of new
    and renovation of existing medical specialty health care centers,
    parking facilities, clinical space expansions, replacement of community
    living centers, seismic retrofitting, and new research facilities.
        Although DAV does not have a resolution calling for funding
    specific VA construction projects, DAV strongly supports increasing VA
    infrastructure funding to accelerate the expansion and the
    modernization of the VA health care system.

                          H.R. 3584, Veterans Care Act

                                      and

      H.R. 7347, to direct the Secretary of Veterans Affairs to report on
      whether the Secretary will include certain psychedelic drugs in the
                              formulary of the VA.

        DAV supports research to develop new, safe, and effective
    treatments and therapies for veterans, particularly when seeking relief
    from hard-to-treat injuries and illnesses. Our Nation's veterans
    deserve access to the most effective treatments and therapies
    available, including alternative options available under the law. It is
    important that Congress and VA support safe and effective innovations
    in delivering evidence-based treatments to improve veterans' health and
    quality of life.
        The Veterans Care Act, H.R. 3584, would direct the VA to conduct
    and support research on the efficacy and safety of medicinal cannabis
    and promote medical research by VA on the use of medicinal cannabis to
    explore alternate means of treating veterans with post traumatic stress
    disorder (PTSD), chronic pain, and other illnesses and injuries. VA
    would be required to submit an implementation plan to Congress and
    report annually on its progress.
        Many veterans are currently using cannabis, and it is important for
    medical research to continue exploring the safety and efficacy of
    cannabis usage for medical purposes. It is crucial for clinicians to be
    able to offer veterans with PTSD and chronic pain appropriate guidance
    on the potential impacts, harms, and benefits of cannabis use to
    provide comprehensive support.
        Today there are 39 states and the District of Columbia that allow
    medical cannabis, with wide variations in how each regulates its
    production, distribution, and use. However, even in states where
    cannabis is legal, veterans may still be in violation of Federal laws
    due to its classification as a Schedule I drug by the Federal
    Government.
        While VA policy encourages veterans to discuss their marijuana use
    with their VA health care providers, VA clinicians are not allowed to
    recommend or prescribe cannabis, and veterans who possess it while on
    VA grounds are violating Federal law.
        We support H.R. 3584, in accordance with DAV Resolution No. 203,
    which calls for research into the medical efficacy of cannabis for
    service-connected disabled veterans.
        H.R. 7347 directs the VA to make a determination on whether to add
    psychedelic drugs to the Department's formulary no later than 6 months
    after a psychedelic drug is approved by the Food and Drug
    Administration (FDA) or licensed for use by the Department of Health
    and Human Services (HHS).
        At present, no psychedelic drugs are federally approved for
    prescription as medicine. The FDA has granted breakthrough status to
    two psychedelic compounds. When used in conjunction with existing
    psychotherapies, both Methylenedioxymethamphetamine (MDMA), and
    psilocybin, the active compound in psychedelic mushrooms, have shown to
    be safe and effective in treating PTSD and treatment-resistant
    depression, respectively.
        Although psychedelics are tightly regulated as controlled
    substances under Federal law, research can still be conducted with
    proper regulatory approvals. These approvals must be obtained from the
    FDA and Drug Enforcement Administration. The promising yet preliminary
    research evidence points to the potential healing power of
    psychedelics.
        In collaboration with academic institutions, the VA issued a
    request for applications for proposals from its network of researchers,
    which aims to study the use of certain psychedelic compounds in
    treating PTSD and depression. This is the first time since the 1960's
    that VA will study psychedelics.
        VA's research involves studying psychedelic compounds, including
    MDMA and psilocybin use alongside psychotherapy for treating veterans
    with PTSD and depression. To properly inform veterans about the effects
    of psychedelics on conditions like PTSD and depression, ongoing medical
    research is vital to assess their safety and effectiveness.
        DAV does not have a specific resolution on what drugs should be
    included in VA's formulary; however, we believe that once adequate
    clinical research has determined a new drug or therapy is both safe and
    effective, VA should consider whether to begin using it, particularly
    if there are no better alternatives.
        This bill does not require VA to add psychedelics, but only
    requires a determination about adding them to VA's formulary after
    another Federal agency (FDA or HHS) has approved their use. We support
    this legislation, in accordance with DAV Resolution No. 535, which
    calls for increased medical research to develop new treatments for
    wounded and injured veterans.

                  H.R. 3303: Maternal Health for Veterans Act

        The Maternal Health for Veterans Act, H.R. 3303, would provide
    additional support for VA programs coordinating maternity health care
    by authorizing $15 million per year for 5 years. It would also require
    the VA to report to Congress on its activities related to coordination
    of maternity health care, including data on outcomes and services
    provided by VA and non-VA providers, as well as make recommendations to
    improve the maternal health outcomes of veterans, particularly veterans
    from demographic groups with higher rates of maternal mortality, severe
    maternal morbidity, maternal health disparities, or adverse perinatal
    or childbirth outcomes.
        This bill would strengthen VA oversight and expand VA funding for
    women veterans' maternity care. Currently, there are over 650,000 women
    veterans who receive health care services from the VA, and half of them
    are of childbearing age. Since 2014, there has been an almost 80
    percent increase in the number of pregnancies among women receiving VA
    care.
        Last month, DAV released our new report ``Women Veterans: The
    Journey to Mental Wellness.'' Research findings note that hormonal
    shifts and changes women experience during pregnancy, birth, and post-
    pregnancy put women at higher risk for suicide. The report emphasized
    the need for strong support systems during and after pregnancy. Because
    most maternity care is provided through community partners, the VA has
    worked hard to create a supportive maternity experience for women
    veterans.
        Previously set at 8 months, the cutoff date for post-partum care
    has been extended to 12 months for women veterans. This means that they
    now have access to maternity care coordinators from the start of their
    pregnancy until a year after giving birth. These coordinators assist
    veterans in navigating health care inside and outside of VA, connecting
    veterans with care after delivery, ensuring access to follow-up
    screenings, and more. This bill would help ensure that all new mothers
    will have the support and resources they need from VA.
        We support H.R. 3303, as it aligns with DAV Resolution No. 027
    calling for improved medical services and benefits for women veterans.

                        H.R. 3644, ACT for Veterans Act

        H.R. 3644, the Addressing Care Timelines (ACT) for Veterans Act,
    would extend the time that veterans have to notify VA after receiving
    emergency care at non-VA medical facilities to ensure that the care is
    covered under VA's Veterans Community Care Program.
        Currently, a veteran must contact the VA within 72 hours of
    receiving non-VA emergency care, otherwise VA may deny payment even if
    the veteran is eligible for treatment. The ACT for Veterans Act would
    provide an additional 24-hour period for veterans to inform the VA when
    receiving care at a non-VA facility.
        The last thing veterans suffering medical emergencies should have
    to worry about is whether VA will deny coverage or refuse payment
    because of administrative barriers.
        We support H.R. 3644, in accordance with DAV Resolution No. 205,
    which calls for the improvement of urgent and emergency care benefits
    for service-connected veterans.

       H.R. 3649, Veterans National Traumatic Brain Injury Treatment Act

        The Veterans National Traumatic Brain Injury Treatment Act, H.R.
    3649, would establish a pilot program to offer Hyperbaric Oxygen
    Therapy (HBOT) to veterans who have Traumatic Brain Injury (TBI) or
    PTSD.
        In clinical practice, HBOT has been employed and approved to treat
    different physical injuries, including non-healing wounds. When
    administered by a trained professional medical team, HBOT is deemed
    safe and any potential side effects are generally resolved without
    requiring additional treatment. In pre-clinical and clinical trials, it
    has been shown that HBOT can also enhance the clinical outcomes of
    veterans with treatment-resistant PTSD.
        Military clinical trials, which focused on evaluating HBOT effects
    on post-concussion syndrome, a condition commonly accompanied by PTSD,
    demonstrated improvements in post-traumatic symptoms, potentially
    indicating a role in alleviating post-concussion symptoms.
        Congress and VA have a responsibility to explore safe and effective
    alternative options for veterans who are not helped by VA's existing
    treatments and therapies for PTSD or TBI, which should include HBOT.
        We support H.R. 3649, in line with DAV Resolution No. 013, which
    calls for well-designed studies to assess the effectiveness of
    hyperbaric oxygen therapy on treatment resistant TBI and PTSD. We would
    also recommend that the legislation include a provision requiring a
    report on the pilot program, which should include an assessment of the
    health outcomes from HBOT, as well as a recommendation on whether to
    extend the pilot program to all enrolled veterans.

            H.R. 4424, Vietnam Veterans Liver Fluke Cancer Study Act

        The Vietnam Veterans Liver Fluke Cancer Study Act, H.R. 4424,
    directs the VA to examine and document the occurrence of bile duct
    cancer in Vietnam veterans.
        An aggressive disease, bile duct cancer (Cholangiocarcinoma)
    attacks the gallbladder, bile ducts, and liver, and it has been
    connected to infection by parasitic worms known as liver flukes.
    Vietnam veterans who consumed raw or undercooked fish during their
    service in Southeast Asia may have been at risk of infection due to
    common parasites in the region's fresh waters.
        In a research study conducted by the VA at Northport, NY, it was
    discovered that one in four of the 50 Vietnam veterans tested had
    positive results for exposure to the liver fluke parasite.
        According to the Cholangiocarcinoma Foundation, this type of cancer
    can develop over the course of 30 to 40 years while remaining
    asymptomatic. While there is no scientific consensus that consuming
    certain raw or undercooked fish causes liver cancer, the VA has granted
    some direct service connection claims for bile duct cancer, but it is
    not currently recognized as a presumptive illness for Vietnam veterans.
        Given that many Vietnam veterans could have unknowingly been
    exposed to environmental conditions that resulted in bile duct cancer
    from their service in Southeast Asia, it is imperative that we make
    every effort to guarantee they receive the necessary care and benefits
    for their service-related injuries and illnesses.
        We support H.R. 4424, in accordance with DAV Resolution No. 214,
    which calls for providing service connection for disabling conditions
    resulting from toxic and environmental exposure.

      H.R. 5247, Expedited Hiring for VA Trained Psychiatrists Act of 2023

        H.R. 5247, the Expedited Hiring for VA Trained Psychiatrists Act of
    2023, aims to reduce wait times for veterans seeking mental health care
    by allowing the VA to establish a fast-track process for hiring
    psychiatrists.
        This bill would allow the VA to directly hire psychiatrists who
    have completed residency at a VA facility, bypassing civil service or
    classification laws that can cause delays. Psychiatrists would still
    need to fulfill all educational requirements and obtain all necessary
    credentials to be hired.
        The VA continues to struggle with recruiting and hiring mental
    health specialists, which hinders its ability to support the growing
    number of veterans seeking help. A 2023 VA Inspector General report
    (23-00659-186) revealed that 91 out of 139 VA facilities faced a severe
    shortage of psychologists, while 73 facilities had a severe shortage of
    psychiatrists.
        The VA has stated that almost a third of veterans within its health
    care system suffer from PTSD. In 2021, there was an increase of 114
    suicides from 2020, resulting in 6,392 veterans dying by suicide. These
    numbers, reflecting veterans' lives prematurely ended, are more than
    statistics, as they are still mourned by family members, loved ones,
    and the Nation. This bill could create a more efficient hiring process
    for psychiatrists trained by the VA, who are already culturally
    competent, to provide immediate clinical lifesaving services, including
    VA suicide prevention and lethal means safety counseling to veterans in
    need.
        We support H.R. 5247, in accordance with DAV Resolution No. 250,
    which calls for effective recruitment, retention, and development of
    the VA health care system workforce.

               H.R. 5530, VA Emergency Transportation Access Act

        The VA Emergency Transportation Access Act, H.R. 5530, limits the
    VA's ability to change payment rates for transporting veterans and
    eligible individuals on specialized transportation modes.
        The VA finalized a proposed rule change to cut its reimbursement
    rate for emergency air medical services earlier this year. By reducing
    the VA's reimbursement rate to the Medicare rate, which currently
    reimburses providers at less than 50 percent of transport costs puts
    the estimated 4.7 million veterans living in rural and underserved
    communities, who need reliable access to quality care, at even greater
    risk during emergencies, despite the existing barriers to health care
    they already face.
        The VA's proposed reimbursement rate cut would also put additional
    strain on air medical bases, particularly in rural areas where there
    are high concentrations of veterans and a significant need for
    transportation to health care facilities.
        For far too long, government reimbursement rates have been
    significantly lower than the true costs of providing service. If this
    trend continues and the VA lowers its reimbursement rate, air medical
    bases will be challenged, limiting emergency care access for rural
    veterans. Additionally, compounding this issue is the potential closure
    of approximately 600 rural hospitals, which would leave communities
    without local lifesaving care and long distances from the closest
    medical center.
        We support H.R. 5530, in accordance with DAV Resolution No. 323,
    which calls for ensuring easy and equitable access to VA transportation
    benefits and services.

                         H.R. 6373, Veterans STAND Act

        The Veterans Spinal Trauma Access to New Devices (STAND) Act, H.R.
    6373, seeks to enhance health care for veterans with spinal cord
    injuries by mandating that VA offer them annual yearly preventative
    health evaluations and improve accessibility to assistive technologies
    that could help maximize the independence and mobility of the veteran.
        The STAND Act is focused on improving access to and coverage of new
    and emerging technologies. For example, exoskeletons are wearable
    assistive technology devices that can empower certain individuals with
    spinal cord injury (SCI) to stand, walk, turn, and navigate stairs,
    which can enhance socialization, independence, and participation in
    community activities. According to the VA, there are around 42,000
    veterans with SCIs, and the VA Spinal Cord Injuries/Disorders network
    provides care to over 27,000 individuals annually.
        By offering yearly preventative health evaluation, assessments and
    making new assistive technologies accessible, VA can further improve
    the quality of life for veterans who meet the clinical eligibility
    criteria. Extensive clinical training and expertise are necessary to
    evaluate and assess veterans with SCI for the use of powered
    exoskeletons safely and effectively.
        We support H.R. 6373, in accordance with DAV Resolution No. 286,
    which calls for improvement in the provision of comprehensive VA health
    care services to enrolled veterans. It is critical to ensure that SCI
    veterans have access to and coverage of these life-changing
    technologies.

                    H.R. 5794, VA Peer Review Neutrality Act

        The VA Peer Review Neutrality Act, H.R. 5794, aims to eliminate
    conflicts of interest in the conduct of quality management and
    administrative investigations by the VHA.
        For VA to ensure the quality of health care provided, it conducts a
    comprehensive monitoring and evaluation program. This program includes
    assessing significant deviations in mortality and morbidity for
    surgical procedures and evaluating deficiencies in overall health care
    quality. VHA employees may submit confidential reports on matters
    relating to quality of care in VHA facilities to the quality management
    officers for peer review.
        Currently, the initial review involves one peer reviewer, followed
    by a broader peer review committee within the same facility that
    evaluates and discusses their assessment of the care provided by the
    facility.
        The VA Peer Review Neutrality Act would require that local peer
    reviewers withdraw from cases involving conflicts of interest and would
    require that neutral assessments of initial peer reviews be conducted
    by a peer review committee from a different VHA facility.
        To eliminate conflicts of interest, it is critical for the VHA to
    continue to review and update guidance, procedures and responsibilities
    at its medical centers while conducting quality management and
    administrative investigations.
        We support H.R. 5794, in accordance with DAV Resolution No. 512,
    which calls for meaningful accountability measures, while ensuring due
    process for employees of the VA.
        This concludes my testimony on behalf of DAV. I am pleased to
    answer questions you or members of the Subcommittee may have.
                                     ______

                      Prepared Statement of Roscoe Butler

        Chairwoman Miller-Meeks, Ranking Member Brownley, and members of
    the subcommittee, Paralyzed Veterans of America (PVA) would like to
    thank you for this opportunity to present 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 the VA better than PVA members--
    veterans who have incurred a spinal cord injury or disorder (SCI/D).
    PVA provides comment on the following bills included in today's
    hearing.

    H.R. 3225, the BUILD for Veterans Act

        The Build for Veterans Act seeks to improve staffing to manage
    construction of VA assets and ensure that there are concrete plans to
    improve the planning, management, and budgeting of VA construction and
    capital asset programs. Currently, the VA has nearly $180 billion in
    backlogged infrastructure projects, and the backlog is growing every
    day. Also, it is important to note that this estimate is a snapshot in
    time and is based on current market conditions, a baseline capital
    portfolio, demographic data, and projected needs. The department's real
    needs are likely to be higher because its Strategic Capital Investment
    Planning list also does not include projects identified in the Asset
    and Infrastructure Review Commission needed to meet veterans' care
    needs.
        In Fiscal Year (FY) 2025, the department is requesting a total of
    $2.8 billion for the entire infrastructure account. However, VA Capital
    Infrastructure's backlog of projects continues to grow faster than VA
    can address them. In addition to the lack of funding, neither VA's
    Office of Construction and Facilities Management nor the individual VA
    facilities have the staff to oversee the amount of work necessary to
    keep up with the growing backlog, much less decrease it. To overcome
    VA's infrastructure challenges, Congress must not only provide
    significantly increased funding to fully address these long-standing
    issues, but also enact comprehensive planning, budgeting, management,
    and oversight reforms to ensure more effective use of those funds.
        Infrastructure is a top priority for PVA and we fully support this
    bill. VA's current number of long-term care beds for veterans with SCI/
    D is woefully inadequate for an aging veteran population with care
    needs not readily met in the community. As of January, only 169 of VA's
    181 SCI/D Long-Term Care beds were actually available, and only one of
    VA's six specialized long-term care facilities lies west of the
    Mississippi River. Until construction projects at the Dallas and San
    Diego VA Medical Centers are completed, only 12 long-term care beds are
    available for the thousands of SCI/D veterans that reside in this area
    of the country. VA desperately needs to increase its SCI/D Long-Term
    Care capacity. Among its many provisions, the BUILD Act directs the VA
    to report to Congress on the department's current and future
    anticipated long-term care needs and models of care for women veterans,
    veterans with SCI/D, traumatic brain injury, and other veteran
    populations with unique needs. It also requires VA to implement a more
    concrete schedule to eliminate or repurpose unused and vacant
    buildings, develop and execute a plan to hire construction personnel,
    examine infrastructure budgeting strategies and identify required
    reforms, and provide annual budget requirements over a 10-year period.

    H.R. 3303, the Maternal Health for Veterans Act

        More women are choosing VA healthcare than ever before with women
    veterans accounting for over 30 percent of the increase in enrolled
    veterans over the past 5 years. PVA supports this legislation which
    strengthens oversight of VA's maternity care coordination while
    authorizing new funding to make sure the department has what it needs
    to provide more women veterans with access to the maternal care they've
    earned through their service. Additionally, this legislation will
    require the VA to provide an annual report to Congress that would track
    maternal health outcomes as well as information pertaining to services
    provided by the Maternal Health coordinators. With a growing number of
    women veterans using the VA who are of child bearing age, the
    department needs to be prepared to fully support them. Congress must
    take its oversight seriously to ensure the health and welfare of women
    veterans and their families.

    H.R. 3584, the Veterans Care Act

        There is a growing body of evidence that cannabinoids are effective
    for treating conditions like chronic pain, chemotherapy induced nausea
    and vomiting, sleep disturbances related to obstructive sleep apnea,
    multiple sclerosis spasticity symptoms, and fibromyalgia. The Veterans
    Care Act directs the VA to conduct and support research on the efficacy
    and safety of certain forms of cannabis and cannabis delivery for
    veterans enrolled in the VA health care system and diagnosed with
    conditions such as chronic pain or post-traumatic stress disorder. PVA
    supports evidence-based alternative treatments, including research into
    the efficacy of medical cannabis. A series of clinical trials on the
    use of medicinal cannabis may help determine if it could provide any
    medical benefits for veterans.

    H.R. 3644, the Act for Veterans Act

        Veterans eligible for VA healthcare experiencing a medical
    emergency are allowed to seek medical attention immediately from the
    nearest emergency medical facility, even if it is not at a VA Medical
    Center. However, if they are suffering from an eligible condition that
    prevents them from physically contacting the VA within 72-hours, the VA
    may still deny payment. PVA supports the Act for Veterans Act which
    allows the VA to give veterans an additional 24-hour period, at a
    minimum, to notify the VA when receiving care at a non-VA facility. The
    additional time will allow for flexibility if a veteran needs
    additional time to recover from a severe medical condition or if they
    are experiencing other challenges.

    H.R. 3649, the Veterans National Traumatic Brain Injury Treatment Act

        Hyperbaric Oxygen Therapy (HBOT) is a well-established treatment
    for a variety of conditions including decompression illness, carbon
    monoxide poisoning, or compromised skin grafts and flaps. However, its
    safety and efficacy to treat Traumatic Brain Injury or Post Traumatic
    Stress Disorder is unclear. PVA has no objections to this legislation
    which seeks to establish a pilot program at the VA to furnish HBOT to
    veterans with these conditions.

    H.R. 4424, the Vietnam Veterans Liver Fluke Cancer Study Act

        PVA supports this bill which directs VA, with the assistance of the
    Centers for Disease Control, to determine the prevalence of
    cholangiocarcinoma (bile duct cancer) in Vietnam era veterans. Bile
    duct cancer is an aggressive disease that attacks the gallbladder, bile
    ducts, and liver and has been linked to infections by parasitic worms
    known as liver flukes, which are common in Asia. The study would
    identify the rate of incidence of cholangiocarcinoma in covered
    veterans of the Vietnam era and in residents of the United States, from
    the beginning of the Vietnam era to the date of enactment of this Act.
    It also requires the VA to track and report on the prevalence of
    cholangiocarcinoma using the VA Central Cancer Registry.

    H.R. 5247, the Expedited Hiring for VA Trained Psychiatrists Act of
        2023

        PVA supports this legislation which authorizes the VA to appoint a
    psychiatrist who completes a residency at a Veterans Health
    Administration (VHA) facility to a VHA health care position immediately
    after such residency, without regard to civil service or classification
    laws, if (1) the psychiatrist meets the qualifications established in
    regulations prescribed for the position, and (2) the position has been
    unfilled for at least 35 days. The critical shortage of psychiatrists
    within the VA is well documented and extends wait times for veterans
    seeking this level of mental health care. Passage of this bill would
    help ensure some of them receive needed care sooner.
        Many SCI/D Centers lack the direct support of a psychiatrist. This
    forces other members of the care team (psychologists, social workers,
    and other SCI/D staff) to submit an Intra Facility Consult--and in some
    cases, an Inter Facility Consult for all veterans with SCI/D requiring
    psychiatric care. The response time to these consults are lengthy,
    delaying essential psychiatric care and services for these veterans.
    The dedicated SCI/D psychologists provide crucial mental health
    services; however, many veterans require specialized services only a
    psychiatrist can deliver. The change authorized by this legislation may
    help alleviate shortages like these, enabling SCI/D veterans to receive
    the essential psychiatric care they need in a timely manner.

    H.R. 5530, the VA Emergency Transportation Access Act

        The VA Emergency Transportation Access Act would bar the VA from
    reducing rates of pay and reimbursement for special mode transportation
    providers, including ground and air ambulances, unless the department
    meets certain requirements that ensure rate changes will not reduce
    veterans' access to this essential service. Specifically, it requires
    the VA to conduct a thorough review of the impact a change in rates
    would have on veterans' access to care; consult industry experts,
    Centers for Medicare and Medicaid Services, appropriate VA subject
    matter experts, and veterans service organizations when conducting the
    review; and develop a formal process of updating the rates that
    protects or expands veterans' current access to emergency
    transportation. Most importantly, it ensures the new rates reflect the
    actual costs of transportation. Having access to VA's Special Mode of
    Transportation is the only way many veterans can safely get to their VA
    and authorized non-VA medical appointments. PVA supports this
    legislation, because it helps ensure changes in reimbursement rates do
    not adversely impact veterans.

    H.R. 6324, the Fiscal Year 2024 VA Major Medical Facility Authorization
    Act

        PVA wholeheartedly supports this bill which authorizes the VA to
    carry out 11 major medical facility projects during Fiscal Year 2024
    and sets maximum spending amounts for each one of them. This includes
    more than $300 million to support the ongoing construction of a new
    SCI/D Acute and Long-Term Care Center and related facilities at the San
    Diego VA Medical Center.
        In addition to meeting the acute care needs of veterans with SCI/
    Ds, the new facility would house 20 new, desperately needed long-term
    care beds. Currently, only 12 long-term care beds are available for the
    thousands of SCI/D veterans that reside in this area of the country, so
    completion of this project is extremely important to PVA members. We
    urge you to pass this important legislation as quickly as possible.

    H.R. 6373, the Veterans STAND Act

        Veterans with SCI/Ds rely heavily on the use of assistive
    technologies to increase their independence and enhance participation
    in work, their families, and communities. These range from a simple
    cane to complex systems that allow the veteran to stand and move at eye
    level. In recent years, the neuroscience and biomedical communities
    have made great strides in developing new technologies to help restore
    mobility for people with SCI/Ds. Many of the newest and more complex
    technologies are limited to those with specific physical and mental
    capabilities amongst other factors. Still, PVA wishes to ensure those
    who meet the appropriate clinical criteria are considered for emerging
    assistive technologies.
        We support the STAND Act which would first ensure that veterans
    with SCI/Ds are offered an annual medical exam. These annual
    assessments are important because it allows the veterans physician to
    identify and treat health issues before they worsen; review any changes
    that have occurred over the last year; and identify risk factors that
    could lead to future health problems and offer expert advice on how to
    mitigate them. Some VA facilities do an excellent job reaching out to
    SCI/D veterans to offer them an annual assessment--but not all, so
    there is room for improvement in this area. Second, the bill directs
    the VA to ensure veterans are assessed for, and briefed on the types of
    assistive technologies they may be eligible for during these annual
    evaluations. Advancements in technology could provide life-changing
    options for veterans with SCI/Ds, so it is extremely important that
    they are made aware of anything that could improve their mobility,
    functionality, or independence.
        We would like to note that we do have a minor concern with the
    requirement under Section 2 (3)(B) for the VA to consult with the
    manufacturers of assistive technologies. Veterans are determined to be
    qualified candidates to use complex assistive technologies like
    exoskeletons based on clinical criteria. VA should work with industry,
    as appropriate, but we are concerned about such collaboration being
    required. Thus, the language should be modified as appropriate.
        PVA would once again like to thank the subcommittee for the
    opportunity to discuss 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 answer any questions.

      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.

                         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 Brittany Elliot

    Introduction

        Madam Chairwoman Miller-Meeks, Ranking Member Brownley and
    distinguished members of the subcommittee.
        My name is Brittany Elliott and I am a medically retired United
    States Marine Corps Veteran. I am honored to join you today to discuss
    the critical importance of H.R. 6373, the VA Spinal Trauma Access to
    New Devices Act, or the STAND Act. I am joined here today by my father,
    full-time caregiver and exoskeleton companion, Morgan Elliott.

    Background

        By way of background, I am a medically eligible Veteran in terms of
    VA healthcare and I am fully paralyzed from my chest down as a result
    of a head-on collision with a drunk driver on July 3, 2015.
        As you can imagine, our journey to date has been a long one: One
    filled with great personal successes, but also great frustration and
    disappointment as it relates to the bureaucratic obstacles we have
    witnessed over the course of our VA journey.
        I want to be clear: I am thankful that I, like many of my military
    brothers and sisters, have access to VA healthcare as it is
    indispensable to me and my family as a resource. Having said that, I am
    very concerned that many Spinal Cord Injury (SCI) Veterans like me
    continue to be effectively ignored when it comes to legitimately
    assessing their overall healthcare needs and the types of technologies
    that can assist them in regaining a sense of normalcy.
        My story, is exactly mine, but many others with whom I routinely
    interact, share similar concerns and encounter many of the same
    obstacles while seeking care at the VA.
        For the subcommittee's background, I was injured in 2015. After a
    month of intensive hospitalization, I was mistakenly sent home for a
    short period of time by my private sector providers. Due to ongoing and
    lasting issues, associated with the trauma, I was forced to return to
    the hospital, this time the Lt. Col. Luke Weathers, Jr. VA Medical
    Center in Memphis Tennessee, where I stayed for an additional five
    weeks of intensive treatment and rehabilitation. That time was followed
    by nearly three very tough years re-entering life in a wheelchair at my
    home outside of Nashville, Tennessee.
        In late 2017 I was introduced, through social media and other
    means--NOT THE VA, to a device that I thought may have some utility for
    me if I were to ever regain the ability to stand and walk--The ReWalk
    personal powered exoskeleton. I approached my care providers at the
    Memphis VA and started pushing to gain access to the technology. After
    significant hesitation by my local providers, I was finally able to get
    them to agree to enroll me in VA's landmark study on the device, but
    that came at a significant cost to me and my family, especially my Dad
    as my full-time care-giver.
        The VA Co-Op study was being undertaken at several VA facilities
    across the country, but not in Memphis. So, I was forced to travel,
    using my own limited resources, to the St. Louis, Missouri VA Medical
    Center at Jefferson Barracks. While there, I spent 3 weeks undergoing
    intensive training on the device (I might add this is normally an 8-
    week process, but I am a Marine, after all, and was able to power
    through the training at a faster pace) and successfully completed the
    trial. At which point, I was able to take the device home and start
    using it. I took it everywhere: Disney World, Sea World, Bush Gardens
    and multiple county fairs. It very quickly became an integral part of
    my new life and provided me opportunities otherwise unavailable to
    those in wheelchairs.
        Unfortunately, the story doesn't end there. When I returned to my
    new home VA, the St. Louis VA in 2018, my provider (the VERY SAME
    PROVIDER who entered me into the trial) informed me that she would not
    support my continued use of the device AND TO THIS DAY has failed to
    provide any substantive rationale for that decision. As a result, the
    device was promptly returned to the VA and I was left in a chair and
    told ``you should get used to it because that's all you can expect.''
    Well, as a trained U.S. warfighter, THAT'S SIMPLY NOT GOOD ENOUGH,
    especially in light of all the training I had already successfully
    completed with the device and given how it had effectively changed my
    life over the course of its use.
        For the next four (4) years, yes, that's right, four (4) years, I
    was engaged in a local and regional battle to regain access to the
    device that had already begun to change my life. Unfortunately, the VA
    bureaucracy is extremely strong and literally no one would stand up
    clinically and advocate on my behalf, even in light of my having
    successfully completed VA's own study on the device!
        Finally, and thanks to a forward-thinking and supportive clinician
    at the Sonny Montgomery VA Medical Center in Jackson, MS, I was seen,
    re-evaluated over the course of weeks, AGAIN ON MY OWN DIME, and
    ultimately provided a new device which I still have today and use every
    day of my life. I am eternally grateful to this provider as his
    disposition was not one that lent itself to the institutional
    bureaucracy, but one that carefully considered the entirety of the
    evidence and the utility of this device for me--a young, vibrant, and
    motivated Marine.
        I am confident this fight never needed to happen, but the system in
    many cases, it seems to me, is built to protect itself instead of the
    Veterans it serves.
        While many of you saw me walk in here today, and while standing and
    walking are clearly critical elements of this device, it's what you
    don't see that may be the most life-changing for me. For instance:

          My bone density has returned to almost normal levels as a
    function of me standing and bearing weight that I would not be able to
    accomplish in a chair;

          My core strength has been improved and sustained allowing
    me to sit upright, which is not a given, considering my level of
    injury;

          While in a chair, I was having several urinary tract
    infections (UTIs) every month that were becoming increasingly difficult
    to combat with antibiotics and serious infections were causing serious
    challenges. Using this device, my UTIs have now decreased to around 2
    per year--A DRAMATIC AND POTENTIALLY LIFE-SAVING REDUCTION;

          I have lost weight, which in a chair is nearly an
    impossibility due to the lack of mobility or activity overall; and

          My mental health has dramatically improved. When I stand,
    I get to look people in the eye, shake their hand properly and be
    addressed as a person, not simply patted on the back and often
    overlooked altogether--this is HUGE for a Marine like me!

        Even in light of the well-recognized health-related advantages to
    standing and being ambulatory, VA often relies on the fact that
    sufficient capacity in the various SCI centers and related ``hubs''
    nationally, does not exist to do the extensive training associated with
    the device. At the same time, however, they seem equally unwilling to
    send Veterans into the community, through the existing and expanding
    Community Care Networks (CCN), for training by those who have already
    been professionally trained on the devices. It seems to me, you can't
    have it both ways... You either treat those who are clinically
    eligible, or follow the law and send them into the community.
    Unfortunately, this is rarely the case.

    STAND Act

        I am aware that we are here to discuss the STAND Act, but I wanted
    to ensure that my interest in this legislation was explicitly clear and
    I am confident my experience lends itself to this critical effort.
        With regard to the bill, I am so grateful to General Bergman and
    his staff for his authoring, and I also want to personally thank
    Chairman Bost, Ranking Member of the subcommittee Brownley and
    Congresswoman Dingell for their willingness to co-lead this effort. My
    thanks as well to those who have agreed, and continue to agree, to co-
    sponsor the STAND Act.
        Equally important, I am supremely thankful for the public support
    that has been provided by the Paralyzed Veterans of America (PVA), the
    Disabled American Veterans (DAV) and the Reserve Organization of
    America (ROA) and the Independence Through Enhancement of Medicare and
    Medicaid, or ITEM Coalition, a coalition of industry and non-profit
    organizations supporting assistive technologies, generally.
        In my view, the bill is critical for a few reasons, and I will
    relate them to my personal experience and to those with whom I
    routinely interact across the VA SCI spectrum:

          As you all know, the bill seeks to codify what VA is
    already supposed to be doing in the way of performing annual
    examinations--I can tell you with certainty, they are not. I have had 5
    exams over the last eight (8) years and I had to push for several of
    those myself. So, the requirement for VA to proactively solicit
    participation in annual examinations from enrolled SCI Veterans is not
    only important as it relates to assistive technologies like mine, but
    to the overall health and well-being of this important population. It's
    VERY hard for me to hear VA claim to be the best at SCI care in the
    world, and at the same time know that many Veterans who need routine
    care simply are not getting it;

          Additionally, like me, I think it's imperative that VA
    assess the viability of assistive technologies for ALL Veterans with
    SCI as simply allowing them to stay in chairs, if they are clinically
    eligible for other devices, is just simply not good enough. The STAND
    Act mandates this type of assessment;

          One thing I've learned over my years of fighting the VA
    is that clinical behavior is very difficult to change. One way to
    accomplish change however, is to demand accountability for those
    responsible for making clinical decisions. This bill seeks to
    accomplish this by two means:

              Make the VA reportable to Congress on their success
            against the metrics I mentioned; and

              Hold VISN leadership accountable, through their
            annual performance evaluations for these same metrics;

              Institutional change doesn't come easy, but it seems
            to comes easier if those in charge are held accountable and
            understand that some level of oversight is effectively in
            place.

          Finally, and I think this is important, VA failing to
    consult Veterans about the opportunities that exist for them is one
    thing, but their continued unwillingness to engage the manufacturers of
    these technologies when considering how the technologies can work for
    Veterans is disturbing. I know, based on my own experience, they will
    fall on their ``objectivity sword'' all day long, but the manufacturers
    and scientist who build these technologies possess the technical
    information that can truly assist in informing these types of important
    decisions for SCI Veterans.

    Conclusion

        Madam Chairwoman, Ranking Member Brownley and members of this
    subcommittee I am very thankful to you and all those who have supported
    this bill as it can be truly life-changing for those like me, who have
    faithfully served their nation. But lack of system capacity, an
    unwillingness for VA leadership to allow Veterans to enter the
    community for training and just flat-out bureaucratic red-tape continue
    to hamper other Veterans' ability to gain access to these important
    technologies that are truly life-changing.
        As I have already stated, ensuring others have access to
    technologies like mine is indeed my new mission in life and with your
    continued support I am confident more Veterans will be able to reclaim
    their lives and fulfill their ongoing obligations to family, community
    and country. I proudly stand, AND I MEAN STAND, in strong support of
    this bill as its importance can be truly immeasurable for those who are
    simply trying to rebuild their lives and who are seeking the VA's
    support to get them there. With your collective help this will be an
    easier path for others who are currently waiting and those who will
    inevitably follow.
        I truly appreciate the opportunity to appear before you today and I
    am happy to respond to any question you may have.
                                     ______

                      Prepared Statement of Melissa Bryant

                           Statements for the Record

                                  ----------

                         Prepared Statement of TreatNOW

        US House Committee on Veterans' Affairs Members,

        EXECUTIVE SUMMARY: The TreatNOW Coalition supports H.R. 3649. We
    are dedicated to ending service member suicides (now over 146,000)
    through the use of Hyperbaric Oxygen Therapy (HBOT) and adjunct
    therapies. In over 150 Coalition clinics in the last 12 years, HBOT is
    proven to heal wounds of all types, especially including brain wounds
    caused by BLAST/TBI/PTSD/Concussion/Friendly fire. Over twenty-one
    clinical trials--including the US Government's own trials--demonstrate
    safety and effectiveness of using HBOT for mild Traumatic Brain Injury
    persistent post concussive syndrome. Ten State legislatures have
    already passed legislation mirroring H.R. 3649, and five have
    appropriated over $30 million to treat Veterans still suffering from
    ineffectively treated brain wounds. Over 31,000 patients with brain
    wounds, including over 12,500 active duty and Veteran service members
    have been restored to a Quality of Life denied them by lack of insured
    access to HBOT. It is unfortunate that neither the VA nor DoD are
    practicing the standard of care as laid out in 1990 in the Textbook of
    Military Medicine.\1\ It is long past time that both the DoD and the VA
    insure HBOT coverage, beginning with immediate ``informed consent'' to
    all invisible brain wounded service members about the availability of
    HBOT. Federal funds should cover the use of public and private HBOT
    clinics to treat the brain wounded.
    ---------------------------------------------------------------------------
        \1\ Conventional Warfare: Ballistic, Blast, and Burn Injuries,
    Textbook of Military Medicine Series on Combat Casualty Care, Part 1,
    Volume 5, 1990, Pages 311-316, Chart Page 313, Office of Surgeon
    General, Department of Army. See attached protocol.
    ---------------------------------------------------------------------------
        Our military has been exposed to blast force waves since the Civil
    War. The results: TBIs to our servicemen and woman. Labels came and
    went. In the Civil War, combat could lead to ``soldier's heart'' and
    ``railway spine'', \2\ in World War I it was ``Shell Shock;'', in World
    War II it was ``Battle Fatigue'' or ``War Neurosis;'' in Korea it was
    ``Combat Stress/Fatigue;'' in Vietnam it was originally called ``Post-
    Vietnam War Syndrome'' which later migrated to PTSD, and now in the
    ensuing Gulf War Era and the preceding decades fighting terrorism,
    medicine has settled on TBI and or PTSD. A full 150 years of
    misdiagnosis of this same issue has deepened reliance on prescription
    drugs, leading in too many cases to drug and alcohol addictions,
    homelessness, unemployment, incarcerations, and suicides. Along the
    way, an array of varying drugs, and self-awareness education and
    calming protocols have done little to combat the ``invisible physical
    wounds'' to the brain.
    ---------------------------------------------------------------------------
        \2\ See, for example, U.S. Government Printing Office. The Medical
    and Surgical History of the War of the Rebellion, 1861-65. Part I,
    Volume II: Surgical History (1870). Prepared, under the direction of
    Joseph K. Barnes, Surgeon General United States Army, by George A.
    Otis, Assistant Surgeon, United States Army. Covers wounds and injuries
    of the head, face, neck, spine, and chest; and Howard H. Kaufman M.D.,
    ``Treatment of head injuries in the American Civil War,'' Journal of
    Neurosurgery, May 1993
    ---------------------------------------------------------------------------
        The DoD has established a process and culture that punishes service
    members for their combat wounds versus treating the ``physical brain
    wound similar to a gunshot wound.'' This has resulted in the current
    suicide (146,000+) and opioid (109,000) epidemics besieging our Veteran
    community. Over 255,000 Veterans have already succumbed to their
    invisible wounds because our government is unwilling to accept modern
    medical science. The 255,000 combined deaths represent 41 percent of
    all the U.S. troops KIA since the beginning of WW I (623,718).
    Hyperbaric Oxygen Therapy (HBOT) is proven safe and effective in
    treating and healing wounds of all types, including a portion of the
    877,450+ brain wounds caused by 70,000+ IEDs, BLAST, 155mm Howitzers,
    dangerous close explosions, RPGs, and friendly fire. Twenty-one
    clinical IRB trials completed since 2007--including the US Government's
    own trials--demonstrate safety and efficacy of using HBOT for mild
    Traumatic Brain Injury persistent post concussive syndrome.
        Ten State Governors (OK, TX, IN, AZ, KY, FL, NC, WY, MD, VA) have
    enacted legislation and appropriated more than $30 million for
    treatments using HBOT. Why are individual states having to pay for
    effective medical treatment for invisible brain wounded Veterans? The
    DoD and the VA must insure HBOT coverage, beginning with immediate
    ``informed consent'' to all wounded service members about the
    availability of HBOT, and its use in public and private HBOT hospitals
    (1,156) and clinics (200+). Using independent scientific methods to
    collect and report on data aimed at more proof of the safety and
    effectiveness of HBOT is costing Veteran lives. The 3.75 million
    members of The American Legion, DAV, AMVETS, AFSA, and Vietnam Veterans
    of America, have endorsed their support for HBOT in the treatment of
    mild TBI/PTSD Veterans (see attached). Over a hundred TBI/PTSD Veteran
    video testimonials from the 12,500+ HBOT treated attest to the safe and
    effective results of HBOT treatment. See https://www.youtube.com/
    @treatnowdotorg/videos
        The Army and Marines have sustained the majority of TBIs, 53 and 18
    percent respectively, across all the service branches or 71 percent of
    the total because of their missions of boots on the ground. The Spec
    Ops groups have high TBI numbers but are in a smaller demographic
    population and largely go unreported for fear of punishment and or
    banishment from their military career. Clearly, the data reveals the
    current strategy and medical approach to mitigating TBIs--whether from
    blast overpressure force, IEDs, howitzer artillery rounds, rocket
    firing, etc.--has failed. The 2014 congressional testimony before the
    House Armed Services Committee by Marine Commandant Conway and Navy
    Chief of Naval Operations Admiral Roughead advocated HBOT be used to
    treat TBI/PTSD Veterans because in their words, ``it can only help.''
    What can we do? What is TreatNOW doing?
        Through a national network of 150+ private HBOT treatment clinics
    and non-profits across the country, the TreatNOW Coalition has treated
    and healed thousands of TBI Veterans and civilians alike. Hyperbaric
    Oxygen Therapy of Arizona, LLC (3,600 civilians/900 TBI Vets), Rocky
    Mountain Hyperbaric Institute, Colorado (1255/477), Extivita in North
    Carolina (3,500/3,150), The Patriot Clinics, Oklahoma (2,800/2,650),
    Tier 1 Therapy Centers, Virginia (800/572), America's Mighty Warriors,
    Arizona (600+ Navy SEALS) are examples of the network contributing to
    the estimated 12,500 TBI Veterans treated and healed to date.
        We conservatively estimate over 877,450 TBI/PTSD PHYSICALLY brain
    wounded Veterans with an economic impact estimated at $118.1 billion
    annually, $4.7 trillion over 40-year lifespan. There is not a single
    FDA approved drug for TBIs, yet they are widely and routinely
    prescribed, along with a multitude of other off-label interventions.
    There were over 847 million opioid pills prescribed between 2006 to
    2014 by the VA (DEA.gov) decimating our physical invisible brain
    wounded Veterans. From 2008 to 2020, VA mental health budget has
    tripled, totaling $86.1 billion. The medical research budget totals
    $7.7 billion during the same period without any change in the TBI/PTSD
    suicide rate. The VA estimated from 2020 to 2029 a $2.4 billion budget
    to treat TBI wounded Veterans.
        Today, America continues to fail our veterans, contrary to
    Lincoln's promise, and the avowed Mission of the Veterans
    Administration. The failure is not for trying, it is for staying too
    long on afailed path to the exclusion of proven alternatives. Veterans
    continue to commit suicide at an epidemic rate. We need bold new action
    supported by medical data and demonstrated results which is exactly
    what we are offering. Dr Paul G. Harch's HBOT meta-analysis of 11 of
    the 21 clinical trials, and their positive results, highlights the
    safety and efficacy of HBOT for mTBI.
        Some of you will have heard that HBOT is unproven in treating TBI.
    The gold standard of Hyperbaric medicine, the Undersea & Hyperbaric
    Medical Society (UHMS) last year revised its definition of hyperbaric
    medicine in line with current known laws of physics. This redefinition
    categorically proves that the Government studies, in line with the
    worldwide scientific evidence, demonstrate safety and efficacy of HBOT
    for TBI. The controversy was settled by scientific evidence in the last
    decade. HBOT has been a standard of care for TBI Israeli Veterans for
    over a decade; they ``have the third lowest suicide rate amongst males
    compared to 27 countries worldwide'' \3\ How are they achieving these
    results?
    ---------------------------------------------------------------------------
        \3\ State of Israel Ministry of Health Report, August 2020, https:/
    /www.health.gov.il/English/News_and_Events/Spokespersons_Messages/
    Pages/09082020_01.aspx
    ---------------------------------------------------------------------------
        Given the published scientific evidence, clinical results,
    continuing suicide rate, and the needless suffering of untreated brain
    wounds, it is past time to use HBOT for TBI as part of military
    medicine's tool bag. Dr George Wolf, the Principal Investigator of the
    first government study, has said ``Hyperbaric oxygen therapy for mild
    traumatic brain injury and PTSD should be considered a legitimate
    adjunct therapy...'' \4\ . We ask for your leadership in helping us
    migrate HBOT forward as a standard of care for our invisible wounded
    warriors as did the Israeli government. At a minimum, use Emergency Use
    Authorization, fund treatments in the ten states which have enacted
    HBOT legislation and help us help save the remaining 877,450 invisible
    wounded warriors from suicide and or opioid addiction.
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        \4\ Traumatic Brain Injury and Hyperbaric Oxygen Therapy: Dawn of a
    New Day, APWCA 16th Annual National Clinical Conference, 7-9 September
    2017
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                                     ______

                     Prepared Statement of Matt Cartwright

        Thank you, Chairwoman Miller-Meeks, Ranking Member Brownley, and
    members of the House Veterans' Affairs Subcommittee on Health, for
    allowing me to submit a statement in support of critical legislation
    that would benefit our Nation's Veterans. I write today in support of
    my bipartisan bill, H.R. 5247, the Expedited Hiring for VA Trained
    Psychiatrists Act, which would increase access to mental health
    services for our Veterans--to whom we owe a great debt.
        The Department of Veterans Affairs (VA) psychiatrists diagnose
    mental, emotional, and behavioral conditions, and provide treatment to
    our Nation's heroes after they've answered the call to uniformed
    service. Everyone knows the sobering statistic that the rate of suicide
    among veterans is almost 60 percent higher than that of civilians.
    Whether a Veteran is struggling with the aftereffects of military
    combat, adjusting to civilian life, or facing a mental illness such as
    PTSD, having access to a psychiatrist at a VA facility could make a
    world of difference in a Veteran's journey to mental health and well-
    being.
        While the VA has prioritized hiring new medical staff at an
    unprecedented rate, it is still difficult to hire and retain
    psychiatrists at a level sufficient to meet the needs of our Veterans.
    The Government Accountability Office (GAO) has previously found that
    the VA does not have proper staff levels for its suicide prevention
    teams, and efforts to fill these vacancies have been significantly
    hampered by a long recruitment and hiring process. Furthermore, the GAO
    has repeatedly reported that demand for Veterans mental health services
    will only increase, exacerbating staffing shortages.
        The practical impacts of understaffing include excessive wait
    times, lack of proper follow-up care, and Veterans' inability to
    schedule appointments in a timely manner. These unnecessary hurdles to
    accessible, reliable care and treatment can have terrible consequences.
        The Expedited Hiring for VA Trained Psychiatrists Act would tackle
    the VA understaffing problem by codifying the VA Secretary's ability to
    hire psychiatrists who have completed their residency at a VA facility
    if a position has gone unfilled for at least thirty-five days.
        Many aspiring psychiatrists do at least part of their residency in
    a VA facility. These trainees gain valuable experience working with
    Veterans and are already familiar with the issues specific to this
    community. By giving the Secretary the ability to directly convert
    psychiatric residents to full employment with the VA - pending
    satisfactory completion of both the residency and all credentialing
    requirements - Congress can help make the VA a more attractive place
    for these residents to begin their careers. By reducing the time it
    takes to fill critical psychiatrist positions, my bill would reduce the
    wait times for Veterans seeking to access mental health services.
        Ensuring timely access to quality mental health care for all
    Veterans should be a priority for everyone, regardless of party. The
    Expedited Hiring for VA Trained Psychiatrists Act is commonsense,
    bipartisan legislation that would provide a fast track hiring process
    for qualified psychiatrists who train at VA facilities. I am grateful
    to my colleagues on both sides of the aisle for their support of this
    important legislation.
        Chairwoman Miller-Meeks, Ranking Member Brownley, and members of
    the Health Subcommittee, I offer my sincere thanks for your consistent
    prioritization of the issue of Veteran mental health.

                 Prepared Statement of Wounded Warrior Project

           Prepared Statement of Association of Air Medical Services

              Prepared Statement of Jewish War Veterans of the USA

                Prepared Statement of Military-Veterans Advocacy

             Prepared Statement of American Ambulance Association,

     International Association of Fire Chiefs and National Association of
                         Emergency Medical Technicians