[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
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HEARING
before the
SUBCOMMITTEE ON HEALTH
of the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED EIGHTEENTH CONGRESS
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
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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
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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.
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\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.
---------------------------------------------------------------------------
\4\ Traumatic Brain Injury and Hyperbaric Oxygen Therapy: Dawn of a
New Day, APWCA 16th Annual National Clinical Conference, 7-9 September
2017
---------------------------------------------------------------------------
______
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