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

                              LEGISLATIVE HEARING

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

                                    HEARING

                                   before the

                             SUBCOMMITTEE ON HEALTH

                                     of the

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED EIGHTEENTH CONGRESS

                                 SECOND SESSION

                                   __________

                         WEDNESDAY, SEPTEMBER 11, 2024

                                   __________

                               Serial No. 118-79

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

                     [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                        Available via http://govinfo.gov
                                  ______

                     U.S. GOVERNMENT PUBLISHING OFFICE

    57-073                    WASHINGTON : 2026

                         COMMITTEE ON VETERANS' AFFAIRS

                         MIKE BOST, Illinois, Chairman

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

                           Jon Clark, Staff Director
                      Matt Reel, Democratic Staff Director

                             SUBCOMMITTEE ON HEALTH

                   MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

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

    Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
    hearing records of the Committee on Veterans' Affairs are also
    published in electronic form. The printed hearing record remains the
    official version. Because electronic submissions are used to prepare
    both printed and electronic versions of the hearing record, the process
    of converting between various electronic formats may introduce
    unintentional errors or omissions. Such occurrences are inherent in the
    current publication process and should diminish as the process is
    further refined.

                             C  O  N  T  E  N  T  S

                                  ----------

                         WEDNESDAY, SEPTEMBER 11, 2024

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
    The Honorable Sheila Cherfilus-McCormick, Acting Ranking Member..     2

                             SPEAKING FROM THE DAIS

    The Honorable Morgan Luttrell, U.S. House of Representatives,
      (TX-08)........................................................     3
    The Honorable Scott Franklin, U.S. House of Representatives, (FL-
      18)............................................................     4
    The Honorable Gabriel Vasquez, U.S. House of Representatives,
      (NM-02)........................................................     5
    The Honorable Keith Self, U.S. House of Representatives, (TX-03).     6
    The Honorable Marie Gluesenkamp Perez, U.S. House of
      Representatives, (WA-03).......................................     7
    The Honorable Steve Womack, U.S. House of Representatives, (AR-
      03)............................................................     8
    The Honorable Jill Tokuda, U.S. House of Representatives, (HI-02)     9
    The Honorable Lori Chavez-DeRemer, U.S. House of Representatives,
      (OR-05)........................................................    10

                                   WITNESSES
                                    Panel I

    Dr. Carolyn Clancy, Assistant Undersecretary for Health,
      Discovery, Education, and Affiliate Networks, Veterans Health
      Administration, U.S. Department of Veterans Affairs............    12

            Accompanied by:

        Dr. Matthew Miller, Executive Director, Office of Suicide
            Prevention, Veterans Health Administration, U.S.
            Department of Veterans Affairs

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

        Dr. Ryan Heiman, Acting Director, Member Services, Veterans
            Health Administration, U.S. Department of Veterans
            Affairs

                                    Panel II

    Mr. Brian Dempsey, Director of Government Relations, Wounded
      Warrior Project................................................    20

    Ms. Missy Meyer, Director of Community Integration, America's
      Warrior Partnership............................................    22

    Mr. Clark Pennington, Chief Operating Officer, The Independence
      Fund...........................................................    24

    Mr. Jon Retzer, Deputy National Legislative Director, Disabled
      American Veterans..............................................    26

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Dr. Carolyn Clancy Prepared Statement............................    35
    Mr. Brian Dempsey Prepared Statement.............................    59
    Ms. Missy Meyer Prepared Statement...............................    72
    Mr. Clark Pennington Prepared Statement..........................    74
    Mr. Jon Retzer Prepared Statement................................    77

                           Statements For The Record

    U.S. Office of Government Ethics Prepared Statement..............    83
    American Federation of Government Employees, AFL-CIO Prepared
      Statement......................................................    85
    American Psychological Association, Association of VA
      Psychologist Leaders, Association of VA Social Workers,
      National Association of Veterans Affairs Physicians and
      Dentists, Nurses Organization of Veterans Affairs, Veterans
      Healthcare Policy Institute Prepared Statement.................    87
    The Honorable Jason Crow, U.S. House of Representatives, (CO-06)
      Prepared Statement.............................................    95
    National Association of State Veterans Homes Prepared Statement..    96

                              LEGISLATIVE HEARING

                                  ----------

                         WEDNESDAY, SEPTEMBER 11, 2024

                        Subcommittee on Health,
                        Committee on Veterans' Affairs,
                                 U.S. House of Representatives,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 10 a.m., in
    room 360, Cannon House Office Building, Hon. Mariannette
    Miller-Meek [chairwoman of the subcommittee] presiding.
        Present: Representatives Miller-Meek, Radewagen, Bergman,
    Murphy, Van Orden, Luttrell, Kiggans, Brownley, Levin,
    Budzinski, and Landsman.

       OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

        Ms. Miller-Meeks. I agree with yesterday's hearing that
    members need to be given a map and a watch to be on time to
    hearings. That includes both sides of the aisle. It is not
    directed to one or the other.
        We welcome all members of the subcommittee and our
    witnesses. We look forward to a very productive session today
    on some impactful veterans legislation.
        Before we begin, however, I would like to take a moment to
    remember the nearly 3,000 American lives that were lost 23
    years ago today. Please join me in a moment of silence for the
    9/11 victims and their families. Thank you.
        Today, we will be discussing 16 bills. Each bill would
    attempt to improve the delivery of healthcare to the men and
    women who have served. These bills include creative solutions
    that would seek to address difficult problems, including a
    pilot program to fill vacant shifts, reforms to ensure that the
    U.S. Department of Veterans Affairs (VA) has the authority to
    prescribe medicine, and a study which looks at the mental
    health crisis that affects our veteran community.
        I would now like to take a moment to discuss my bills, H.R.
    9438, the No Wrong Door for Veterans Act and H.R. 9478,
    Veterans Sports Act. H.R. 9438 would seek to reauthorize an
    incredibly important VA mental health program, the Staff
    Sergeant Parker Gordon Fox Suicide Prevention Grant Program.
        The Fox Grant Program is a successful grant program that
    enables the VA to provide grant funding to community-based
    organizations to help organizations in communities where
    veterans live expand the reach of their mental health efforts.
        My bill would reauthorize the Fox Grant Program for an
    additional 3 years until 2028. It would also make changes to
    the administration of the program including improvements to
    coordination of care between VA providers and grantees and the
    standardization of the veteran intake process.
        This program is another avenue for veterans to receive
    brain health support. There should be no wrong door when it
    comes to seeking brain health, and I am proud to have
    introduced this bill to continue and improve this amazing
    program.
        My second bill is H.R. 9478, the Veterans Sports Act. This
    legislation would provide access to adaptive limbs for amputee
    veterans by ensuring that they are able to have the highest
    quality of life that we can provide them.
        This bill would amend existing law to ensure the
    availability of adaptive sports and recreation prostheses limbs
    by recognizing them as medically necessary for veterans living
    with limb loss.
        I think it is critical that we ensure that disabled
    veterans have the equipment and tools they need to live active
    lifestyles as they please in order to allow them to live the
    fullest and make them whole.
        I am proud to introduce these bills and look forward to
    discussing the many others on our agenda.
        I want to again thank our witnesses for being here today
    and those organizations that submitted statements for the
    record. It is a privilege to collaborate on crafting impactful
    legislation for our veterans and to address some critical
    issues facing them.
        I now yield to Representative Cherfilus-McCormick for her
    opening remarks.

    OPENING STATEMENT OF SHEILA CHERFILUS-MCCORMICK, ACTING RANKING
                                 MEMBER

        Ms. Cherfilus-McCormick. Thank you, Chairwoman Miller-
    Meeks.
        Thank you to our witnesses for being here today to discuss
    these bills. I am sitting in for Ranking Member Brownley who,
    unfortunately, could not be here today. I know she is
    disappointed to not be here, especially not to be able to speak
    about her bill, the Have You Served Act, which is on the agenda
    for today.
        I will take the opportunity to recognize her for her work
    on this issue. So often just asking the question have you
    served could make a huge difference in recognizing and
    supporting veterans.
        Helping service providers learn how to appropriately talk
    about veteran status and where to connect them to resources
    will change lives. Representative Brownley's bill will create
    grants to establish ask the question campaign training
    programs, establish key matrices for the training and improving
    outreach about the efforts. I want to thank her for leading
    this effort.
        We will also consider several other bills today sponsored
    by my Democratic colleagues which will increase access to VA
    healthcare, especially for rural veterans. This includes the
    Rural Veterans Transportation to Care Act, which will expand
    the VA's very popular highly rural transportation grant program
    and expand the program to serve veterans in rural in addition
    to highly rural communities.
        It also includes the New Mexico Rural Veterans' Healthcare
    Access Act, which would adjust Veterans Integrated Service
    Network (VISN) lines to ensure veterans in New Mexico can
    easily receive travel reimbursement when accessing care at the
    nearest VA medical facility to them.
        I am also glad we are considering the Veterans Sentinel Act
    legislation to address suicides that occur on VA campuses.
    While these events are rare, they are tragic and devastating
    for VA and to all of the veterans' community.
        Representative Crow's bill would create a task force to
    identify root causes for these events and analyze ways to stop
    further events from happening.
        Finally, we will consider a bill to give co-pay parity to
    veterans that identify as Native Hawaiians and strengthen VA
    coordination with the Native Hawaiians' health care system.
        However, I am disheartened to see so many bills from my
    Republican counterparts on the agenda that focus on diverting
    more care out of VA. We know that VA provides the best care and
    that more often than not veterans want to receive their care
    from the VA.
        Some of these bills, like the Veterans Mental Health Access
    Act and the No Wrong Door for Veterans Act, propose to send
    more money to outside entities creating grant funding giveaways
    with no or very few strings attached.
        These bills lack vital matrices to monitor the performance
    of grantees and ensure these programs are meeting their
    intended purposes.
        I look forward to hearing from our VA witnesses about the
    department's view on all these bills on today's agenda and how
    we can work together to ensure VA can serve veterans to the
    best of their ability.
        I am also looking forward to hearing from our Veterans
    Service Organization (VSO) partners about what these bills
    would mean for their members.
        With that, Madam Chairwoman, I yield back.
        Ms. Miller-Meeks. Thank you, Representative Cherfilus-
    McCormick.
        We have a full agenda today so I will be holding everyone
    to 3 minutes per bill to get through in a timely manner.
        This morning we are joined by several of our colleagues who
    will testify on their bills. We are appreciative of 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 objections, we will move forward.
        I now recognize Representative Luttrell. You are now
    recognized for 3 minutes.

                      STATEMENT OF MORGAN LUTTRELL

        Mr. Luttrell. Thank you, Madam Chairwoman. The Service Dogs
    Assisting Veterans Act, or the SAVES Act, would require the
    secretary to establish a 5-year pilot program that would award
    competitive grants to nonprofit organizations providing service
    dogs to the eligible veterans.
        This bill would ensure that veterans receiving service dogs
    through these grants are not charged fees and are provided with
    a veterinarian insurance policy for their service dogs. The
    bill would also establish a process for granting service dogs
    to veterans with mental health conditions and would authorize
    the secretary to allocate up to $10 million annually for the
    program.
        This builds upon previous legislation, the Puppies
    Assisting Wounded Service Members, or PAWS, for Veterans
    Therapy Act, Public Law 117-37, which expanded efforts to
    support veterans with Post-Traumatic Stress Disorder (PTSD) and
    other service-related injuries with service dogs.
        The VA refers veterans to nonprofit organizations to
    receive these service dogs, but the process can often be
    lengthy and with veterans waiting up to 1 to 3 years, and the
    availability of the of the dogs is extremely limited.
        The SAVES Act aims to address these limitations and wait
    times by expanding the avenues that veterans can receive
    service dogs from VA to nonprofit organizations. Generally,
    nonprofit organizations are expected to provide these service
    dogs quicker than VA due to there being less bureaucracy.
        This legislation also looks at addressing the needs of our
    veterans. Amid that is why it expands the scope of the
    disabilities covered for the veterans who qualify for service
    dogs and will allow veterans who suffer from blindness, visual,
    or mobility impairments, seizures, post-traumatic stress
    disorder, and traumatic brain injuries to qualify as well.
        Veterans face a wide range of issues and there is never a
    one-size-fits-all approach. I am pleased to introduce this
    piece of legislation or this bill and it is bipartisan. It does
    have bipartisan support. Thank you.
        Ms. Miller-Meeks. Thank you, Representative Luttrell.
        Typically, we would go to the Democrat. The Democrat up to
    speak next is not here so we are going to go to Representative
    Franklin. Representative Franklin, I now recognize you for 3
    minutes.

                      STATEMENT OF SCOTT FRANKLIN

        Mr. Franklin. Thank you, Madam Chairman. This is a solemn
    morning, as you noted, as we recognize the 23d anniversary of
    the attacks on 9/11. That evil act of cowardice sent many of
    our sons and daughters to foreign soil to defend our Nation.
        Two decades now and trillions of dollars spent, an entire
    generation at this point of our young men and women who
    answered the call to join our armed forces to defend our great
    Nation, many of them have now joined the ranks of veterans who
    served in previous eras.
        It is the duty of this panel, our primary duty I would
    argue, to ensure that these brave Americans receive the best
    care and the benefits they have earned.
        Despite the sacrifices our veterans and their families have
    made, reports indicate they are being cutoff from certain
    services the VA is obligated to provide them.
        Recently, the VA has been pushing more veterans back into
    VA facilities from community care providers without
    consideration of continuity of care when deciding in a
    veteran's best medical interest. This abruptly cuts off
    veterans from longtime treatment plans and providers they
    trust.
        It is difficult for veterans to build rapport with a
    provider or a counselor and then be forced to find a new one,
    creating gaps in care. These gaps can negatively impact all
    aspects of life for veterans and their families.
        It is unconscionable this would be allowed to even happen
    and that this committee would do so. It is something we must
    stop.
        I am concerned by the comments by members of the committee
    that appear to be in direct opposition to community care. The
    same comments advocate shrinking the funding and size of the
    program.
        The rationale often centers around the VA's recent efforts
    to increase convenience with new clinics and improve care by
    recruiting new specialists. I applaud those efforts, including
    the opening of a fantastic new clinic in my hometown of
    Lakeland, Florida.
        I consider those efforts to be table stakes. The VA can
    always be striving to improve. Excellent care at VA facilities
    and providing flexibility to veterans are not opposing
    missions. VA must continue to improve care and expand
    convenience for our veterans. They deserve nothing less.
        I believe, and I know many of my colleagues here agree,
    veterans should be able to choose the care that works best for
    them, whether that is inside the VA or out, especially for
    those who are already using community care.
        My bill, the Ensuring Continuity in Veterans Health Act,
    protects veterans who have chosen to utilize community care. It
    will also provide clarity for veterans concerned that they will
    lose their provider.
        Specifically, this requires the VA to consider continuity
    of care in determining best medical interest of a veteran. This
    will provide disruption in care for veterans already receiving
    services from community care providers. Most importantly, it
    will allow veterans to continue choosing the most convenient
    care for them.
        I would like to thank the chairman for supporting this
    legislation, and I look forward to working with the committee
    to mark up this bill in the coming days. I urge we take it to
    the House floor for a vote.
        Thank you, Madam Chair, I yield back.
        Ms. Miller-Meeks. Thank you, Representative Franklin.
        I now recognize Representative Vasquez for 3 minutes.

                      STATEMENT OF GABRIEL VASQUEZ

        Mr. Vasquez. Thank you, Chairwoman Miller-Meeks and Ranking
    Member Brownley, for allowing me to testify today in support of
    my bill, the New Mexico Rural Veterans Healthcare Access Act.
        Traveling across my district can take up to 9 hours from
    Jal, New Mexico to Zuni Pueblo. That means that nearly 50,000
    veterans who call New Mexico's Second District home have more
    difficulty accessing critical resources, including VA
    healthcare, which is largely contained in two Veteran
    Integrated Service Networks.
        However, in southern New Mexico, the lines do not work and
    veterans suffer. This problem has been occurring for over a
    decade. In fact, I started this fight as a staffer before I
    became a Member of Congress.
        The current lines force veterans in Otero and Edi Counties
    to travel more than 4 hours to Albuquerque instead of nearby El
    Paso less than an hour away for healthcare. Traveling long
    distances for basic care referrals and other appointments
    creates an incredible hardship for those who served our
    country.
        It is not just long distances. It is the dignity of care
    and extended waiting times. The VA will only provide a mileage
    reimbursement to veterans who seek service within their VISN
    lines.
        A veteran in Carlsbad is faced with an unjust choice. Get
    reimbursed for a 9-hour trip to their designated VA hospital in
    Albuquerque or bear the cost themselves for a 4-hour trip to El
    Paso.
        Our veterans opt for the closest VA but are not receiving
    any mileage reimbursement for going outside their VISN lines,
    defeating the purpose of this system.
        I recently met with both the directors of the Albuquerque
    and El Paso VA healthcare systems and brought the ranking
    member of the Veterans Affair Committee to listen directly to
    veterans about the hardships that they face. Everybody in the
    room agreed that the line should be changed.
        As legislators, we cannot leave our rural veterans behind.
    The Veteran Integrated Service Networks were created to make
    sure veterans are organized into a system where they have
    access to what they need, but for the rural veterans in my
    district in southern New Mexico that benefit simply does not
    exist.
        My bill, the New Mexico Rural Veteran Healthcare Access
    Act, would move Edi and Otero Counties in my district into
    Veteran Integrated Service Line 18. This change would give
    these veterans closer access to specialty care and mileage
    reimbursement for the VA hospital trips that they are already
    making.
        To the veterans of New Mexico's Second congressional
    District, know that I am here fighting for you. Whether you are
    in Edi or Otero County, Dona Ana or Bernalillo, you all deserve
    equal access to the benefits that you deserve.
        I urge support for my legislation in this committee, and I
    yield back. Thank you, Mrs. Chairwoman.
        Ms. Miller-Meeks. Thank you, Representative Vasquez.
        I now recognize Representative Self for 3 minutes.

                        STATEMENT OF KEITH SELF

        Mr. Self. Thank you, Chairwoman Miller-Meeks. I am honored
    to introduce H.R. 9485, the Enhancing Faith-Based Support for
    Veterans Act of 2024. This important legislation addresses a
    crucial gap in the spiritual care provided to our veterans.
        Under this bill, VA chaplains would be required to offer
    veterans the option to order their name and contact information
    to be shared with non-VA religious or faith-based organizations
    of their choice. In other words, this option is at the sole
    discretion of the veteran.
        This step will ensure that veterans have access to the
    spiritual care they need and want, regardless of their faith.
        This issue was brought to our attention by a dedicated Army
    veteran who also serves as a Catholic Eucharistic Minister in
    the Dallas Diocese. He learned of the problem through a
    parishioner who had been bringing Catholic communion to the Sam
    Rayburn Memorial Veterans Center and Bonham VA Clinic for many
    years.
        However, 2 years ago, they were informed that due to a
    change in policy access to VA patients had been revoked. H.R.
    9485 aims to fix these issues by allowing veterans to complete
    a privacy release form, similar to what all of our constituents
    have to fill out before opening casework.
        This will enable the VA to connect them with chaplains or
    religious leaders who can offer the specific spiritual support
    they need and want. By passing this bill no veteran would be
    denied the spiritual care they require due to bureaucratic red
    tape.
        I am grateful to my constituent who brought this issue to
    light, and I look forward to working with my colleagues to
    advance this bill through Congress. I yield back.
        Ms. Miller-Meeks. Thank you, Representative Self.
        I now recognize Representative Gluesenkamp Perez for 3
    minutes.

                  STATEMENT OF MARIE GLUESENKAMP PEREZ

        Ms. Gluesenkamp Perez. Thank you to the chairwoman and
    ranking member for the opportunity to testify today about my
    bill, Rural Veterans Transportation to Care Act.
        Almost exactly 1 year ago today I heard from one of my
    counties in my district that they had just received notice from
    the VA that they were no longer eligible for the VA highly
    rural transportation grant program.
        The county had been operating a van for the purposes of
    transporting veterans to the Department of Veterans Affairs
    facilities to receive medical care free of charge since 2014.
        Over the years, this service has proven essential to
    veterans seeking essential care to things like chemotherapy and
    critical surgeries and treatment for heart conditions.
        In 2022 alone, the van made approximately 300 trips and
    transported between 40 and 60 veterans. However, due to the
    definition of eligibility for these grants as set in statute,
    as fewer than seven residents per square mile Skamania County
    learned that due to new Census data and migration changes that
    happened during the pandemic, that our rural county was no
    longer considered rural enough.
        Now we are at 7.15 residents per square mile. With just 1
    week's notice we lost transportation funding.
        I sent a letter to the Secretary of Veterans Affairs
    McDonough in October urging the VA to fill transportation gaps
    for rural veterans and work with Congress to redefine highly
    rural.
        In a reply earlier this year the department expressed
    support for the provision outlined in Rural Transportation to
    Care Act. The bipartisan bill would improve how VA measures
    rurality, helping more veterans living in rural areas get
    transportation to VA or VA-authorized healthcare facilities.
        The bill would also expand eligibility to both rural and
    highly rural counties, as well as tribal organizations.
        Last, the legislation would increase the maximum funding
    amount so transportation services could keep pace with
    inflation.
        It is our responsibility to our Nation's heroes to ensure
    that our Nation's heroes are well supported after returning
    from home and can access the benefits they have earned and
    deserve. Just last week, I was visiting with veterans in
    Pacific County about how vital these kinds of transportation
    services are, and they are literally life or death.
        People who have been waiting for appointments for 18 months
    can lose an appointment if they are just 10 minutes late or 15
    minutes late to their appointment, setting them back 10 months
    to care.
        Access to professional, reliable transportation is critical
    to deliver lifesaving care to our veterans. As veterans across
    my district and the country face dramatic reductions in
    lifesaving services, it is our duty to make sure they are not
    left behind.
        This bipartisan bill will not only restore critical
    healthcare transportation services for Skamania County veterans
    but will also newly expanded eligibility to make sure more
    veterans in rural areas around the country have a safe and
    reliable way to get to their appointments and receive the care
    they deserve.
        I thank you again for the opportunity to testify on this
    bill and I look forward to continuing to work on getting this
    across the finish line.
        Ms. Miller-Meeks. Thank you very much, Ms. Gluesenkamp
    Perez.
        The chair now recognizes Representative Womack for 3
    minutes.

                       STATEMENT OF STEVE WOMACK

        Mr. Womack. I thank the Chairwoman Miller-Meeks and Ranking
    Member Brownley, and distinguished members of the subcommittee.
    I want to thank you for considering my bill, H.R. 9324, the
    Protecting Veteran Access to Telemedicine Services Act of 2024.
        I would also like to express my sincere gratitude for
    allowing me to speak in support of this legislation today. This
    bill seeks to ensure that our Nation's veterans, whether they
    reside in bustling urban centers or in the most remote areas of
    our country, have uninterrupted access to the healthcare
    services they need and deserve.
        As you are aware, the Ryan Hate Online Pharmacy Consumer
    Protection Act was enacted in 2008 to regulate the prescription
    of controlled substances via telemedicine in response to the
    rise in online pharmacies and the potential for misuse.
        This law plays an important role safeguarding public
    health, but also has not been updated to reflect the
    differences between 2024 compared to 2008 and does not
    acknowledge the difference between VA and general civilian
    online pharmacies.
        During the COVID-19 pandemic, requirements under the Ryan
    Hate Act for a patient to meet with a practitioner in person
    for the prescription of a controlled substance were temporarily
    waived.
        The Drug Enforcement Administration (DEA) and U.S.
    Department of Health and Human Services (HHS) announced the
    temporary extension of these flexibilities, but that extension
    expires at the end of this year. My bill, the Protecting
    Veteran Access to Telemedicine Services Act of 2024, would
    permanently extend this exemption to allow healthcare
    professionals employed by the VA to prescribe medically
    necessary controlled substances to veterans via telemedicine
    under certain conditions.
        This exemption has been a lifeline for our Nation's
    veterans and without a permanent exemption, many veterans could
    see their access to vital healthcare services severely
    restricted.
        For our veterans in urban areas, the expiration of this
    exemption would mean longer wait times for in-person
    appointments, further straining an already burdened VA
    healthcare system.
        The situation is even more critical for veterans in rural
    areas. These veterans face unique challenges, including
    geographical isolation and limited access to healthcare
    providers. The Ryan Hate Act exemption has enabled them to
    receive care from VA providers and specialists who may be
    hundreds of miles away without the need for costly and time-
    consuming travel.
        The continuation of this exemption is not just a matter of
    convenience. It is a matter of necessity. It ensures that
    veterans in every corner of this country have equal access to
    the care they so desperately need and they deserve.
        It is an honor to speak in support of my legislation today.
    I urge my colleagues on this subcommittee to support the bill
    and to act swiftly in passing this legislation.
        Our Nation's veterans have sacrificed so much for our
    freedom. It is our duty to ensure they receive the care they
    have earned in a manner that meets their needs in today's
    world.
        With that, Madam Chairwoman, I yield back my time.
        Ms. Miller-Meeks. Thank you very much, Representative
    Womack.
        The chair now recognizes Representative Tokuda for 3
    minutes.

                        STATEMENT OF JILL TOKUDA

        Ms. Tokuda. Thank you, Chairwoman Miller-Meeks,
    Representative Cherfilus-McCormick, and distinguished members
    of the Health Subcommittee, thank you for including my bill,
    H.R. 8562, the Parity for Native Hawaiian Veterans Act, in
    today's legislative hearing and for the opportunity to speak in
    support of this important bill.
        In the United States there are approximately 614,600 Native
    Hawaiian veterans, including nearly 275,000 in my home State of
    Hawaii. According to a May 2022 report by the Veterans Health
    Administration (VHA), Native Hawaiian and other Pacific
    Islander veterans aged 45 and older experienced significantly
    less access to checkups and routine care than their white
    counterparts.
        The report concluded that ``work is needed to improve the
    veteran experience of care among
        [Native Hawaiian and other Pacific Islander] veterans'' and
    better information could be ``helpful in understanding and
    addressing their disparities.''
        They served and sacrificed the same as their fellow
    veterans, yet our country is failing to meet our obligations to
    them. More must be done to eliminate needless barriers to care
    for our Native Hawaiian veterans.
        That is why I have introduced the Parity for Native
    Hawaiian Veterans Act to ensure Native Hawaiian veterans can
    access health care services in a similar manner as their
    American Indian and Alaska Native counterparts.
        To fulfill the Federal Government's trust responsibility to
    the Native Hawaiian community it is vital that Native Hawaiian
    veterans be treated the same as other Native American veterans
    and explicitly included in Federal programs and policies
    supporting other Native veteran populations.
        Currently, the Indian Health Service (IHS), Tribal health
    programs, and IHS-funded urban Indian organizations can seek
    direct reimbursement from the VA for services rendered to
    eligible American Indian and Alaska Native veterans.
        The Parity for Native Hawaiian Veterans Act would codify
    the same reimbursement relationship between VA and the Native
    Hawaiian health care systems that have been authorized by
    Congress to provide comprehensive health promotion and disease
    prevention services, as well as primary health services to our
    Native Hawaiians.
        With more locations near to where Hawaiians live, this is
    about meeting our veterans where they are at and greatly
    increasing their access to care.
        My bill does three things. It updates the definition of
    Native Hawaiian in statutes governing veterans' care and
    benefits. It eliminates co-pays for qualified Native Hawaiian
    veterans. It allows the VA to directly reimburse the Native
    Hawaiian health care systems for care provided to Native
    Hawaiian veterans.
        This bill was developed in consultation with Papa Ola
    Lokahi, which has been authorized by Congress to coordinate and
    assist healthcare programs and services provided to Native
    Hawaiians. The bill also incorporates technical assistance from
    VA and past work by the Office of Hawaiian Affairs.
        Ultimately, the Parity for Native Hawaiian Veterans Act is
    about improving healthcare access and affordability for Native
    Hawaiian veterans and ensuring all veterans are provided the
    care they need and are entitled to as a result of their service
    to our country.
        I look forward to working with members of this committee
    and Senator Hirono, who has introduced identical legislation in
    the Senate, to advance this measure forward in Congress. Mahalo
    and I yield back.
        Ms. Miller-Meeks. Thank you very much, Representative
    Tokuda.
        The chair now recognizes Representative Chavez-DeRemer for
    3 minutes.

                    STATEMENT OF LORI CHAVEZ-DEREMER

        Ms. Chavez-DeRemer. Chairwoman Miller-Meeks and Vice Chair
    Cherfilus-McCormick, thank you for inviting me today to speak
    on behalf of my legislation, the VA Geriatrics and Gerontology
    Advisory Committee Expansion Act.
        This bill is simple. It would include a representative of
    the National Association of State Veterans Homes (NASVH) on the
    Department of Veterans Affairs Geriatrics and Gerontology
    Advisory Committee.
        NASVH has been great partners and supporters of this
    legislation. Their goal as an all-volunteer organization is to
    promote and enhance the quality of care and life for veterans
    and families in their network of homes through education,
    networking, and advocacy.
        There are 169 VA-recognized State Veterans Homes across the
    Nation, including two in Oregon, one in The Dalles, and one in
    my district in Lebanon, Oregon.
        The Geriatrics and Gerontology Advisory Committee was
    authorized in 1991. Its primary role is to advise the VA on
    geriatric research education and assess the demand for long-
    term veteran care and the VA's ability to provide for its plan
    to meet these geriatric services.
        A representative from NASVH having full representation on
    the committee would be able to bring new, unique, and tested
    clinical expertise to strengthen this mission. With over 8
    million living veterans who are aged 65 and older, many still
    from our greatest generation, there is an everlasting need to
    strengthen and expand long-term care options for our veterans.
        The amount of nursing home care offered by the VA is
    currently not meeting the overall number of eligible veterans.
    NASVH will be able to offer nursing home care, experience
    combined with the ability to stretch adequate resources and
    serve as many veterans as possible, including expanding care to
    veterans who can be serviced in their own communities and
    homes.
        With a nationwide network, NASVH has the capabilities to
    understand the changing demographics, needs, and preferences of
    veterans in all areas of the country. I believe State Veterans
    Homes have the full capability to advise the VA on the long
    care options, and I also believe the VA must also make a long-
    term commitment the State Veterans Homes.
        I have appreciated the ongoing support of Chairman Bost and
    the committee here today and thank them for their steadfast
    support and leadership in aiding our Nation's veterans.
        They were kind enough to visit my district back in June to
    tour the Portland VA Medical Center and also help me hosting a
    listening session in Bend, Oregon, where we heard directly from
    local veteran constituents on the issues they face in receiving
    the care they deserve.
        One of the main issues we discussed was long-term and
    community care for the aging veterans. Further, I echoed those
    concerns of Oregonian veterans in writing to Secretary
    McDonough asking the department to respond to a series of
    questions that were raised during that listening session by
    July 31. We have yet to receive that response from the VA.
        I urge Secretary McDonough to respond to these questions
    quickly because they are questions not coming from me. They are
    questions from our veterans, the very ones he was appointed to
    and confirmed to serve.
        Again, I want to thank my colleagues on both sides of the
    dais for their consideration of this legislation, and I urge
    their support. Passing the VA Geriatrics and Gerontology
    Advisory Committee Expansion Act will be a clear win for the
    States Veterans Homes, network, and for our Nation's aging
    veterans.
        With that, Madam Chair, I yield back.
        Ms. Miller-Meeks. Thank you very much, Representative
    Chavez-DeRemer.
        As is our practice, we will forgo a round of questioning
    for those members waiving on to present their bills. They have
    excused themselves or they may now be excused.
        I now invite our first panel to the table. Joining us today
    from the Department of Veterans Affairs is Dr. Carolyn Clancy,
    assistant under secretary for Health, Discovery, Education, and
    Affiliate Networks, Veterans Health Administration.
        She is accompanied by Dr. Matthew Miller, executive
    director, Office of Suicide Prevention, Veterans Health
    Administration, Dr. Ajit Pai, executive director, Office of
    Rehabilitation and Prosthetic Services, Veterans Health
    Administration, and Mr. Ryan Heiman, acting director, Member
    Services, Veterans Health Administration.
        Dr. Clancy, you are now recognized for 5 minutes to present
    the department's testimony.

                      STATEMENT OF CAROLYN CLANCY

        Dr. Clancy. Well, good morning, Chairwoman Miller-Meeks and
    acting Ranking Member Cherfilus-McCormick, and members of the
    subcommittee. Thank you for the invitation to present our views
    on several bills that would affect VA programs and services.
        I am not sure if we have name tags so we will just point
    out Dr. Matthew Miller, Dr. Ajit Pai, and Mr. Ryan Heiman, who
    are with me here today.
        Today's date, as noted by you earlier, Madam Chair, holds
    profound significance in our Nation's history and for VA.
    Twenty-three years ago our Nation was under attack, and in the
    aftermath many brave Americans honorably answered the call to
    serve, creating a new generation veterans, each with unique
    challenges and healthcare needs for nearly 2 decades of
    conflict.
        Our solemn duty is to ensure that all veterans receive the
    exceptional care and respect they deserve. The sacrifices and
    those of their families underpin our unwavering commitment to
    VA's noble mission.
        While we are prepared to discuss all proposed legislation,
    I will highlight a few bills in these opening remarks. The No
    Wrong Door for Veterans Act proposes changes to VA's Staff
    Sergeant Parker Gordon Fox Suicide Prevention Grant Program.
        Key provisions extend this program's duration, modify the
    definition of emergency treatment, and require baseline mental
    health screening for grantees using the Columbia-Suicide
    Severity Rating Scale, also known as the C-SSRS. The bill also
    requires annual briefings between grantees and VA Medical
    Center personnel.
        We support the bill's intent but have concerns. We are
    opposed to codifying C-SSRS use as this could prevent adapting
    more effective future tools.
        Additionally, we recommend extending the pilot to allow the
    program to run a full 8-year period and also recommend
    increasing authorized appropriations to reflect the extended
    program duration and allow nationwide scaling.
        Our teams are prepared to collaborate with your offices to
    incorporate these recommendations and others noted in the
    written statement.
        Next, H.R. 6291, Have You Served Act, provides a grant
    program encouraging human services professionals. State and
    local governments. and community providers to inquire about
    military service.
        This bill would authorize VA to make up to 25 grants
    annually not exceeding $200,000, each to eligible entities for
    developing or expanding ask the question campaigns. These
    campaigns are crucial to identifying and supporting veterans in
    various community settings.
        We support the bill's intent but recommend technical and
    clarifying edits for successful implementation, including
    expanding the scope of eligibility and supported services and
    other amendments would just be needed to provide VA with some
    flexibility in program administration.
        With respect to H.R. 6330, the Veterans' Sentinel Act,
    Section 2(a) would require VA to establish a pilot program for
    a working group to collect and analyze data regarding on-campus
    suicides and attempted suicides.
        We support this section but recommend technical edits to
    ensure optimal use of resources for preventing veteran suicide.
        We recommend that Congress avoid legislating a specific
    methodology or evaluation approach, allowing VA the flexibility
    to determine the best strategies and apply innovative solutions
    to address this critical issue. As written, we anticipate
    significant implementation costs.
        Section 2(b) would require VA to annually evaluate
    statistical trends of suicides and attempted suicides by
    veterans that occur on VA property and determine
    recommendations for prevention, and we support this section,
    recognizing the need for timely and useful surveillance efforts
    to end veteran suicides.
        We defer to the Comptroller General regarding Section 2(c).
        Finally, we appreciate the committee's interest in two
    bills resembling legislative proposals in fiscal years 2024 and
    2025 Presidential budgets, H.R. 7504 and H.R. 9324, which would
    both make important progress in reducing barriers
    disproportionately affecting rural and otherwise underserved
    veterans.
        We support both bills, however, several technical and
    clarifying edits technically are needed to fully address the
    intended problems.
        Thank you for your ongoing support of programs supporting
    our Nation's veterans. Your dedication has improved the lives
    of those who have served our country, and we look forward to
    working together with you to develop innovative solutions and
    develop emerging challenges to meet veterans' evolving needs.
    Your partnership is absolutely invaluable.
        Madam Chair, Ranking Member, this concludes my statement
    and we are happy to answer questions.

        [The Prepared Statement Of Carolyn Clancy Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you very much, Dr. Clancy.
    Typically I will reserve my questions until the end so that
    other members can go prior to me, so Representative Cherfilus-
    McCormick, I now recognize you for 5 minutes.
        Ms. Cherfilus-McCormick. Thank you, Madam Chair.
        Dr. Clancy, in your testimony you suggest that
    Representative Brownley's bill be modified to provide greater
    clarity in terms of how the grant program would be administered
    to include the application process, the award of grants, and
    requirements for applications.
        Could you elaborate on this? What kind of requirements for
    applicants would be most helpful to ensure grants are awarded
    to appropriate entities?
        Dr. Miller. Thank you for the question. As we have
    indicated, we fully support the spirit and the intention of the
    Have You Served as to the question of legislation.
        This is in direct reinforcement of Governor's Challenge
    goal number one, which is to better identify veteran service
    members, family members in the community, and in turn, connect
    them to care.
        I think the increased clarity that is requested around the
    application process, applicant requirements, awarding of
    grants, and use of grant funds can relatively easily and in a
    straightforward manner be worked through within the markup
    process. Our team stands by ready to offer suggestions therein.
        Ms. Cherfilus-McCormick. Thank you.
        My next question is for Dr. Clancy, but I guess you are
    directed to who can best answer it. As written, Representative
    Brownley's Have You Served Act is pretty deferential to the
    secretary on the topic of what VA resource grantees should
    connect veterans to.
        In your written testimony, you recommend that the bill be
    amended to be more specific about the array of VA services and
    benefits to which grantees should connect with veterans. Can
    you expand on how you believe those services should be
    identified and why more prescriptive language would be helpful
    to VA in ensuring veterans can be connected with those
    programs?
        Dr. Clancy. Great questions, thank you. Also for Dr.
    Miller.
        Dr. Miller. I think that that is our--I think it is a
    really good question. It is always a fine line between writing
    this in a way that is broad versus overly prescriptive to find
    the right balance and mix.
        I think the right subject matter expertise teams between
    the Veteran Experience Office and our Partnerships Office would
    happily sit down and talk about the specifics to strike that
    balance in a way that most fully supports the spirit and the
    intention of this bill.
        Ms. Cherfilus-McCormick. Thank you. I think this question
    is going to be for you also, Dr. Miller. I appreciate the VA's
    testimony on the Have You Served Act and the recommendation
    that the scope of eligible entities that can apply for these
    grants to be expanded.
        Can you speak to some of the work that the community
    partnership in the VA, in the Vet Resource Community Network
    and the VHA National Center for Healthcare Advancement and
    Partnership that this bill might be able to help and support it
    becoming law?
        Dr. Miller. This bill as it is currently written speaks
    very directly and I must say, from my perspective, I appreciate
    it as such to the efforts being conducted through the
    Governor's Challenge. It highlights efforts that eight states
    and one U.S. territory are currently engaged in with ask the
    question and seeks to expand those efforts.
        In the spirit of expansion, it also looks at and offers to
    look at other partnerships, such as those that are engaged and
    structured through the Veterans Experience Office (VEO) and
    through the National Center for Healthcare Advancement and
    Partnerships (HAP). It is opening the door to other
    partnerships beyond Governor's Challenge and drawing them in.
        Ms. Cherfilus-McCormick. Well, I have a quick question. I
    wanted to shift toward Veterans Sentinel Act. Dr. Miller. I was
    glad to learn from your testimony that VA established an
    interagency workgroup to address the U.S. Government
    Accountability Office's (GAO) recommendations regarding on-
    campus suicides.
        Can you share what the VA's existing interagency workgroup
    has done to improve VA's response to on-campus suicide,
    particularly in improving processes?
        How long does VA intend to continue convening the working
    group and would codify the working group help ensure this work
    continues?
        Dr. Miller. Three improvements stand out to me to offer to
    you in response to your question. Improvement number one from
    the interagency workgroup is we have improved the process of
    the informational briefing system such that we have
    standardized the process across VHA, Veterans Benefits
    Administration (VBA), and National Cemetery Administration
    (NCA) so that standardized information is included.
        Number two, we have included in the process very specific
    checkpoints for asking was an Root Cause Analysis (RCA)
    conducted? Was a peer review conducted? Creating hard stops
    with those questions.
        Three, we have addressed direct needs that have been
    identified, parking lot signs being one. We in Fiscal Year 2023
    provided parking lot signs to 100 percent of VA facilities. In
    Fiscal Year 2024 we are offering 7,000 additional parking lot
    signs with the Veterans Crisis Line (VCL) number and 988
    updates.
        Ms. Cherfilus-McCormick. Thank you. I yield back.
        Ms. Miller-Meeks. Thank you very much.
        The chair now recognizes herself for 5 minutes. Dr. Clancy,
    the VA's testimony request for moving the statutory cap on Fox
    Grant amounts, VA has not properly managed grant funds within
    the first 2 years of the program, given that some organizations
    are receiving the full grant the amount and serving less than
    20 veterans a year.
        How do you justify removing the cap when the VA is not
    properly overseeing these funds?
        Dr. Miller. I am happy to take that question, ma'am. As the
    program that administers the Staff Sergeant Gordon Parker Fox
    Grant Program, I appreciate your question. I thank you for it.
        The request to adjust the cap is in response to adjustments
    to something we all have been talking about, inflation so that
    the awards as it continues are reinforcing of current costs and
    adjust to current costs.
        I think panel two members noted the advantage of this as
    well within their written statements.
        Ms. Miller-Meeks. Thank you.
        Dr. Clancy, given the significant, and I realize that you
    may refer this, given the significant physical and mental
    health benefits of adaptive prostheses and terminal devices for
    sports and recreational activities, why does the VA not support
    including these devices in the definition of medical services
    under Title 38?
        Dr. Clancy. This is Dr. Pai, who is the expert here.
    Thanks.
        Dr. Pai. Good morning, Chairman. We already include that
    definition of adaptive sports devices in our regulations and
    our clinicians are prescribing them.
        Ms. Miller-Meeks. You said you include a definition but
    does that definition mean that they are--it does not mean that
    they are medically necessary?
        Dr. Pai. Correct. With adaptive sports and let me say that
    we really appreciate the intent and the spirit of this
    legislation. These devices are highly complex, right? An
    individual with an amputation has to go through weeks, months,
    sometimes years of rehabilitation and their medical
    comorbidities can impact their ability to utilize that device.
        You know, we just have had the Paris Paralympics and we are
    really proud of our 13 veterans that we support over there.
    What we see is that the rehabilitation for this type of journey
    can take even longer than just that initial phase.
        We really want to make sure that a veteran has consistent
    and constant participation in that activity so that they can
    really benefit with lifelong care.
        Ms. Miller-Meeks. I just want to make sure I understand
    this correctly. You support the current regulatory framework.
    You are not opposed to these devices being utilized. Is the
    problem with codifying these provisions into law problematic
    because you are afraid veterans will not get the rehabilitative
    services that they need?
        Dr. Pai. No, ma'am. We just feel that the legislation is
    redundant because we are already doing that. We understand that
    there are veterans out there that are having challenges, and we
    really want to make sure that we are hearing from those
    veterans, from those districts, from yourself and other
    Congress persons to make sure that we are caring for those
    veterans.
        I understand that there is a question of will one clinician
    prescribe something that another clinician may not prescribe?
    We are really putting in efforts to educate our clinicians.
        Ms. Miller-Meeks. Right, thank you, which is why we need to
    have it codified into law. Thank you for that.
        I had another question in regards to the Have You Served
    Act, Dr. Clancy. Rather than setting up a new program, why
    cannot grants be utilized for those entities that are already
    doing this?
        In Iowa we have veteran service organizations in every
    single county. Why could not these grants go to them or why
    could not these grants go to our, you know, our great veteran
    service organizations, such as the Legion, Disabled American
    Veterans (DAV), Wounded Warrior Project, Purple Heart, Veterans
    of Foreign Wars of the United States (VFW).
        There are too many. If I left you I do apologize.
        Why not give the grants to existing organizations who
    already work with veterans and are adept at that?
        Dr. Clancy. I think the short answer is we could certainly
    do that and happy to work with your staff on that. At the same
    time, we would also like to recognize that there are places
    that are beyond the reach even of those phenomenal
    organizations and not preclude their contributions as well.
        Ms. Miller-Meeks. Oh, interesting. The smallest town in
    Iowa of 200 people has a VSO but thank you so much for that.
        I am seeing no other members. I think this round of
    questioning is over. Our second round of questions, do you have
    a second round of questions?
        Ms. Cherfilus-McCormick. Yes.
        Ms. Miller-Meeks. The chair now recognizes Representative
    Cherfilus-McCormick.
        Ms. Cherfilus-McCormick. Thank you.
        I appreciate your testimony points. I appreciate that your
    testimony points out that while on-campus deaths by suicide are
    tragic, they are relatively rare among all suicide deaths.
        However, we have no way of knowing how many veteran deaths
    by suicide may be occurring at community care facilities or
    their root causes.
        Would VA be able to apply the same investigation method in
    this bill, which is the Veterans Sentinel Act, to suicide
    deaths that occur at community care facilities if we were to
    amend the bill to include that?
        Dr. Miller. Happy to answer that question. There have been
    20 on-campus suicides to the present day this fiscal year.
    Adding information from non-VA sites applicable to veterans, I
    think, would be value added to our awareness and surveillance
    process.
        We would be very happy to take a look at what would be
    needed to engage that process with our community partners, yes.
        Ms. Cherfilus-McCormick. Thank you. I want to also talk
    briefly about the New Mexico Rural Veterans' Healthcare Access
    Act.
        Dr. Clancy, in your testimony regarding the New Mexico
    Rural Veterans Healthcare Access Act, you mentioned that VA is
    taking action to address this issue. However, there are
    veterans currently electing to receive their care on the El
    Paso VA healthcare system because it is closer to them.
        However, in VA's eyes they live within the catchment area
    of the Albuquerque VA and are therefore officially assigned to
    that facility and only receiving travel reimbursement when they
    travel to that facility.
        What actions, if any, can the VA take right now to address
    this without requiring VISN lines to be redrawn to ensure that
    veterans who are already doing this are able to get their
    transportation reimbursed?
        Dr. Clancy. Great question. Mr. Heiman.
        Dr. Heiman. Sure. Thank you, Ranking Member Cherfilus-
    McCormick and also thank you to Representative Vasquez for his
    testimony earlier.
        We agree with the interest of examining the particular
    lines. That is something that we do not feel we need a law to
    actually accommodate, and as such, we are currently looking
    into everything from referral patterns to transportation
    reimbursement, as you mentioned and as Representative Vasquez
    mentioned.
        We are committed to this and we intend to brief the
    committee as well as local delegations of these efforts in and
    around the end of the calendar year.
        Ms. Cherfilus-McCormick. Does VA have any plans to adjust
    the VISN boundaries to account for these veterans? If so, what
    is keeping the VA from doing this as expeditiously as possible?
        Dr. Heiman. Thank you for the question. We are actively
    looking into what those boundaries could be, and I think
    certainly redistricting or reapplying the VISN structure and
    boundaries is something that is within our control and
    something that we are actively working at between VISN 22 and
    VISN 17.
        Ms. Cherfilus-McCormick. Dr. Clancy, I understand that your
    testimony that the SAVES Act, which would create a 5-year pilot
    grant program for nonprofit organizations to provide service
    dogs to veterans, would likely require new staff in a dedicated
    office.
        Do you have an idea of how many additional staffs would be
    needed to administer this program and within which program
    office with VHA would you house this program?
        Dr. Clancy. I will need to take that for the record,
    Congresswoman. I do not think it would be an enormous lift in
    terms of the number of staff, and I am guessing it would
    probably come under prosthetics but I do not want to speak for
    my colleague here. We will get back to you on that. He was
    about to say no.
        Ms. Cherfilus-McCormick. Dr. Miller, can you explain more
    about why VA is concerned about the No Wrong Door Act codifying
    the Columbia-Suicide Severity Rate Scale as the only tool Fox
    Grant recipients may use to complete baseline mental health
    screenings?
        What is the current practice? What are some other possible
    tools that could be used, and how would limiting the program to
    Columbia-Suicide Severity Rating Scale affect grantees and
    outcomes?
        Dr. Miller. Thank you for the question and let me be clear
    that the Suicide Prevention Program Office supports the
    Columbia as a scale from a validity and reliability perspective
    and sees the value of its role.
        I think our concern can best be summarized in terms of
    codifying it as the tool to use. If a more effective tool
    arises in the next 2 to 3 years we want to be able to flexibly
    adjust to that and our current bylaws allow for that rather
    than an act of Congress, literally, to adjust from the Columbia
    to a different measure.
        Ms. Cherfilus-McCormick. Thank you very much.
        I yield back.
        Ms. Miller-Meeks. Thank you very much, Representative
    Cherfilus-McCormick.
        The chair now recognizes Ranking Member Takano for 5
    minutes if he has questions.
        Mr. Takano. Thank you, Chair Miller-Meeks.
        Dr. Miller, we received VA's interim report on the Fox
    Grant Program that included some limited data on the
    effectiveness of the program so far, and we appreciate that VA
    anticipates having additional data in its final report and
    believe these data will help Congress and VA evaluate whether
    the program is working as intended.
        Do you believe that limiting grantees to the Columbia-
    Suicide Severity Rating Scale would impair the level of data
    that grantees can collect and therefore limit our ability to
    assess the effectiveness of the program if we reauthorize it?
        Dr. Miller. Thank you for your question, sir, good to see
    you. Yes. We do believe that limiting to the Columbia would
    impact the reliability and the validity of outcome evaluation
    of the Fox Program.
        With that said, we do not necessarily read in the
    legislation that outcome data is restricted to the Columbia
    necessarily as there are other measures and broader measures of
    well-being, mental health, financial status that will also be
    included in the outcome measures as part of the Fox Grant
    Program.
        Mr. Takano. Okay. Well, I want to, kind of, switch gears
    here and talk about H.R. 9426 to carry out a pilot program
    under the secretary under which the secretary may fill vacant
    shifts at medical facilities of the Department of Veterans
    Affairs with non-departmental healthcare providers.
        While I appreciate my majority counterpart's intent in
    putting forth a bill that would allow VA to use contractors to
    cover vacant shifts at VA medical facilities, I share VA's
    concern that key aspects of the bill are not clearly defined
    and the implementation would be difficult.
        However, knowing that staffing shortages are often a
    concern for medical centers, I am glad to hear that our VISNs
    are already offering clinical resource hubs to ensure staffing
    needs are met in times of vacancies.
        Can you expand on how that is activated and if it has so
    far been sufficient to address shortages?
        Dr. Clancy. I will give you a couple of examples. The
    notion is if a veteran, for example, is seen at Detroit and by
    a primary care clinician who then believes that that clinician
    needs a specialist but that specialist is not available or they
    do not have the capacity to see that veteran in a timely way at
    that facility, through this clinical resource hub they can
    identify another facility in the network where the veteran
    could get that care.
        This has worked extremely well, as I understand it, in VISN
    23, you know, which is Minnesota, Iowa, South Dakota, and North
    Dakota. It has allowed them to bring much more of the
    cardiology care back into VA.
        Obviously, in areas in all of those states where there are
    not cardiologists everywhere. It also works very well on a
    number of other networks, but that is the intent of it.
        In other words, the VISN is more than just a silent
    overseer, if you will, of multiple freestanding facilities but
    really is leveraging their capability as a system within a
    system, if that makes sense?
        Mr. Takano. Dr. Clancy, are these, in this example you
    gave, would the cardiologist, would that be a VA doctor or
    maybe potentially a contract doctor?
        Dr. Clancy. A VA doctor.
        Mr. Takano. Okay. That is through, so it is called a
    clinical resource hub?
        Dr. Clancy. Yes.
        Mr. Takano. How does VA currently decide how and when to
    activate contracts with temporary help service firms?
        Dr. Clancy. We have put together a new contract, I think a
    year and a half ago, the interim critical staffing program
    where we can hire a whole array of medical, nursing, and other
    healthcare specialties as needed.
        That would be activated by individual facilities. It can
    also activate administrative and managerial support as needed
    as well.
        Mr. Takano. To what extent are these already in use?
        Dr. Clancy. I would have to take that for the record and
    get back to you, sir, because it became live shortly before we
    realized that we needed to be more strategic with hiring and so
    forth.
        Mr. Takano. Madam Chair, I have a couple more just odd
    questions or do you want to just, kind of, stop now for now?
    Okay. All right. All right that is fine. I will yield back.
        Mr. Takano. Thank you very much, Ranking Member Takano.
        On behalf of the subcommittee, seeing that no other members
    are here, I wanted to thank all of you for your testimony and
    for joining us here today. You are now excused, and we will
    wait for a moment as the second panel comes to the witness
    table.
        Dr. Clancy. Madam Chair, I had one quick question.
    Representative Tokuda from Hawaii made a point today which
    clarified an issue for us which may require a correction or
    addendum to the written statement. Is that feasible?
        Ms. Miller-Meeks. I think that you can submit that for the
    record.
        Dr. Clancy. Perfect, thank you.
        Ms. Miller-Meeks. Welcome, everyone, and thank you for your
    participation today. On our second panel we have Mr. Brian
    Dempsey, director of Government Relations for the Wounded
    Warrior Project, Ms. Missy Meyer director of Community
    Integration at America's Warrior Partnership (AWP), Mr. Clark
    Pennington, chief operating officer at the Independence Fund,
    and Mr. Jon Retzer, deputy national legislative director for
    health at Disabled American Veterans.
        Mr. Dempsey, you are now recognized for 5 minutes.

                       STATEMENT OF BRIAN DEMPSEY

        Mr. Dempsey. Thank you. Chairwoman Miller-Meeks, Ranking
    Member Takano, and distinguished health subcommittee members,
    thank you for inviting Wounded Warrior Project to testify at
    this morning's hearing to discuss legislation intended to
    improve VA's ability to provide better access to care and
    ensure better health outcomes for our Nation's veterans.
        Honoring and empowering wounded warriors has been at the
    heart of our mission since 2003. Meeting the needs of those who
    volunteered to serve our Nation and protect the freedoms we
    enjoy as Americans is not only a solemn obligation but a
    national priority.
        Our written statement reflects our views on several of the
    bills before you, but for today's hearing on the anniversary of
    the September 11th attacks that led to our founding, I am going
    to focus on legislation that we believe will be most impactful
    on the lives of the post-911 wounded, ill, and injured warriors
    that we serve.
        First, we support H.R. 9438, the No Wrong Door Act, which
    would reauthorize the Staff Sergeant Parker Gordon Fox Suicide
    Prevention Grant Program through 2027 and extend an important
    tool for VA to provide upstream suicide prevention services in
    communities around the country.
        We remain hopeful that the Fox Grant Program becomes a
    permanent fixture in VA's public health strategy, however, we
    believe that attention should be given to how service
    eligibility determinations are made and how clinical care can
    be responsibly provided before the program is made permanent.
        To that end, we support adoption of the Columbia protocol
    for baseline mental health screenings, which were used at
    Wounded Warrior Project for the same purpose.
        Second, we support H.R. 9427, legislation that would allow
    VA to provide grants to nonprofit organizations to provide
    outpatient mental health treatment services to veterans. While
    we appreciate the need to keep VA as a coordinator of
    unfragmented clinical care, we believe that embracing grants to
    direct care programs is a commitment most consistent with
    putting the needs of the veteran first, particularly when
    skepticism toward VA in the veteran community is an unfortunate
    reality for some.
        We believe this legislation can be thoughtfully
    incorporated into the No Wrong Door Act so that grants are
    carefully coordinated with other community-based efforts to
    help serve an overarching intent to connect veterans to the
    care and support they need now, but also foster a healthier
    awareness of and trust in the VA services that are available.
        Third, we support draft legislation to include a
    representative of the National Association of State Veterans
    Homes on the Geriatrics and Gerontology Advisory Committee of
    the Department of Veterans Affairs.
        VA's long-term support services reached just over a half a
    million veterans last year and 30 percent were under the age of
    65.
        While we do not have figures to definitively state how many
    of these younger veterans served after 9/11, one of Wounded
    Warrior Project's most significant programs, the independence
    program, supports warriors with moderate and severe traumatic
    brain injury symptoms or other debilitating injuries or
    illnesses for whom independent living may be far from assured
    in both the near and long term.
        We need to plan for their futures and the present needs of
    aging veterans is more important than ever. We need to ensure
    that critical stakeholders in VA's long-term support service
    portfolio have a voice in that planning.
        Shifting attention to veterans whose injuries may be more
    evident, we are proud to support H.R. 9478, the Veterans
    Supporting Prosthetics Opportunities and Recreational Therapy
    Act. This bill would raise adaptive prostheses and terminal
    devices for sports and other recreational activities to the
    same level as wheelchairs, artificial limbs, and special
    clothing as far as how VA is prepared to assist veterans on
    their path to a new normal.
        Under current law, VA will not provide adaptive recreation
    equipment to a veteran unless it is part of a medical or
    rehabilitative treatment plan. This legislation would
    effectively remove this barrier between the veteran and the
    support they may need to pursue activities like biking,
    swimming, or weightlifting that can be every bit as beneficial
    to mobility and mental well-being as clinical or guided
    rehabilitative care.
        We are proud to support this legislation because we have
    seen firsthand the positive and life-changing effects of
    adaptive equipment on a veteran's quality of life and mental
    health.
        Last, I would also highlight the needs of post-911 veterans
    with traumatic brain injury as a basis for our support for H.R.
    7504, the Rural Veterans Transportation to Care Act. Traumatic
    brain injuries and related neurocognitive impairment can
    challenge, if not totally eliminate, a veteran's ability to
    travel to and from VA medical appointments. Some may rely on
    caregivers but extensive commutes can add to the stress of
    caring for a loved one.
        Others may rely on public transportation, which can be very
    tedious and time consuming, if it is even available in the
    rural areas where they live. The Rural Veterans Transportation
    to Care Act would expand access to VA's highly rural
    transportation grants to veterans residing in rural areas.
        This VA grant-based program currently only helps veterans
    in highly rural areas travel to VA or VA-authorized health care
    facilities, but there are clearly many more who could benefit
    from this critical service.
        Ladies and gentlemen, it is my distinct honor to be here to
    represent our Nation's wounded warriors and their families.
    Thank you for letting us do our part to keep the promise.
        This concludes my testimony and I look forward to your
    questions. Thank you.

        [The Prepared Statement Of Brian Dempsey Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Mr. Dempsey.
        Ms. Meyer, you are now recognized for 5 minutes.

                        STATEMENT OF MISSY MEYER

        Ms. Meyer. Chairwoman Miller-Meeks, Ranking Member Takano
    thank you so much for the privilege of being here today to
    testify. There are two bills that I would like to discuss
    today.
        First, America's Warrior Partnership is in support of H.R.
    9427 introduced by Chairman Bost to carry out the pilot program
    to provide grants to outpatient mental health facilities. The
    more our Nation can expand access to mental health care for
    veterans the better, but it must be done with a holistic
    approach.
        Every veteran is unique. Offering counseling is wonderful.
    Additional choices such as outpatient facilities for mental
    health, access to traumatic brain injury treatments, since it
    is often concurrent with mental health crisis, and post-
    traumatic growth training can expand the resources that are
    available.
        The main focus of my testimony today is going to be on the
    No Wrong Door for Veterans Act. AWP is focused on outreach to
    all veterans and as we told the committee last year, the
    original idea of the SSG Fox Grant had a singular goal, find
    veterans in the community that need help and help them.
        To reach that goal, Congress needs to implement reforms
    that specifically bring back outreach as the singular focus,
    streamline the intake into the VA for eligible Fox
    participants, and hold organizations accountable.
        We are thankful for the committee's hard work on this
    program, and we offer a few observations and suggestions. As
    one of 80 grantees we have done a significant amount of
    outreach since Fox inception.
        Currently we have screened 1,917 warriors for the risk of
    suicide using the Columbia-Suicide Severity Rating Scale, or
    the C-SSRS. 370 of those warriors discussed and disclosed some
    level of suicide risk or a previous attempt. That is 19
    percent.
        Ninety-four percent of the warriors that have turned to AWP
    with their thoughts and trusted us with the risk of suicide,
    were not seeking assistance for a mental health-related issue.
    The SSG Fox Program is working. Relationships are being built
    and connections to resources are made.
        The Fox Grant is a success story and asking the question
    works. AWP, the VA, and Congress have all played an integral
    part in saving the lives of these warriors, but there is more
    to do.
        First, we are thankful for the inclusion of language that
    directs briefings for VA employees in regard to the SSG Fox
    Program and ensuring a bi-direction, solid, working
    relationship with local VA staff is essential.
        It is more important than ever that we have education for
    frontline staff at the VAs to understand this program and its
    purpose.
        While the legislation mandates the C-SSRS as the only
    required screening protocol, AWP recommends also adding
    language that would make the additional baseline assessments
    discussed earlier as optional.
        Rarely do veterans in our program complete all five of the
    additional baseline assessments and very rarely do they
    complete them twice as required. The assessments have been
    described as both triggering and redundant by both our staff
    and the warriors that they are being administered to.
        Third, the emergent care section is very helpful. AWP
    recommends adding a section that clearly lays out expectations
    for the program and identifies boundaries for both the VA and
    the grantees.
        The SSG Fox Grant Program is about outreach, however, the
    line has become muddied and expectations can be unclear. To fix
    this it would be helpful to add a section that requires a
    specific program on-ramp for veterans identified as eligible
    and in need of VA care.
        The process does not need to be complex. It does not need
    to be burdensome. It can be done through the 988 crisis line.
    It can be done through local Veterans Affairs Medical Centers
    (VAMC) with expedited care or even a dedicated line for
    grantees to call when we have an eligible participant.
        The key here is expedited. If we are going to ask the
    question we need to have a plan for the answer.
        Fourth is accountability. The Fox Grant Program is working
    and to keep the program successful Congress and the VA must
    hold organizations accountable with verifiable metrics.
        AWP recommends adding a section requiring the VA to develop
    accountability metrics in regard to outreach, screenings,
    eligible participants identified in the course of the program,
    referrals, et cetera and then require regular reports back to
    Congress.
        While accountability and metrics are vital, the data
    collection tool implemented by the VA at the end of 2023 has
    had the opposite of its intended effect. The Fox Grant
    Program's assessments are meant to be anonymous but currently
    the tool requires a Social Security number and a date of birth
    to enter any data into the tool.
        This has caused AWP to go from reporting nearly 100 percent
    of our data to less than 5 percent. AWP has suggested returning
    to the original anonymous participant identification numbers
    instead of requiring our warriors to provide personal health
    information to be in the program.
        Finally, the only limitation AWP has on being more
    successful is funding. If the ceiling on grants was doubled
    tomorrow so would our outreach efforts. For these suggestions,
    please see our written statement that we have submitted.
        Thank you for the opportunity to testify, and I look
    forward to any questions you may have.

        [The Prepared Statement Of Missy Meyer Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Ms. Meyer.
        The chair now recognizes Mr. Pennington for 5 minutes.

                     STATEMENT OF CLARK PENNINGTON

        Mr. Pennington. Chairwoman Miller-Meeks, Ranking Member
    Takano, and distinguished members of the subcommittee, on
    behalf of Sarah Verardo, Chief Executive Office (CEO) of the
    Independence Fund, thank you for the opportunity to testify
    before you today.
        The Independence Fund was founded in the halls of Walter
    Reed to serve catastrophically wounded veterans, their
    caregivers, and their families. While the Independence Fund
    submitted written testimony on most of the bills before the
    subcommittee, I will limit my remarks to two pieces of
    legislation that impact our constituency the most.
        In 2017, VA promulgated a regulation entitled,
    ``Prosthetics and Rehabilitative Items and Services'' under 38
    CFR, Part 17 that specifies when adaptive creative recreation
    equipment within prosthetics may be approved.
        The regulation cites, ``An item that is designed to
    compensate for or that may by design compensate for loss of
    physical, sensory, or cognitive function and is necessary for a
    veteran to actively and regularly participate in a sport,
    recreation, or leisure activity to achieve the veteran's
    rehabilitative goals.''
        This definition appears to cover items like a running
    blade, climbing blade, a swimming or diving prosthetic, among
    others. However, the regulation potentially limits VA's
    approval at a local level of such an item for a veteran unless
    it is part of a medically necessary rehabilitation plan to meet
    a medical goal and not for a long-term life or health plan and
    a routine solitary or group activity for what VA states is only
    for personal enjoyment.
        The wording of that regulation has the potential to bias VA
    practitioners and VA employees in the prosthetics approval
    chain from allowing these devices to be approved, ordered,
    manufactured, or provided to veterans who seek to remain active
    throughout their lives beyond the rehabilitation phase.
        The very nature of this regulation appears to be at odds
    with VA's often invoked philosophy around whole health of the
    veteran and the VA's implied mission to help veterans heal and
    incrementally or ultimately achieve some degree of self-
    actualization and self worth despite their medical history.
        The idea of using whole health approach to medicine is an
    important aspect of improving mental health and reducing
    suicide. Because of the disparity between VA's whole health
    philosophy and the regulation it imposes, limiting when
    veterans can obtain adaptive prosthetics, the Independence Fund
    is pleased to support Chairwoman Miller-Meeks' legislation that
    will amend Section 1702, Subparagraph 6 to specifically include
    adaptive prosthesis and terminal devices for sports and other
    recreational activities to the list of medical services VA must
    provide.
        This legislation will ensure veterans seeking to enjoy and
    benefit from physical and psychological aspects of recreational
    activities will now be guaranteed access to the prosthetics
    they need to thrive. The Independence Fund encourages the
    committee to quickly pass this legislation.
        Suicide prevention is one of VA's stated healthcare
    priorities. In 2020, Congress passed into law Commander John
    Scott Hannon Veteran Mental Health Care Improvement Act.
    Included in that act is the staff Sergeant Parker Gordon Fox
    Suicide Prevention Grant, which provides grant recipients the
    means and authority to evaluate suicidality through a mental
    health assessment.
        In the case the veteran is deemed to need access to
    immediate higher level mental health care due to acute suicidal
    crisis, the statute requires the secretary to furnish that
    care. What is missing from the statute is the time requirement
    in which that care must be placed.
        Along with reauthorizing the grant program, the No Wrong
    Door for Veteran Act mandates that if the secretary cannot
    provide the emergent care within 72 hours, the veteran will be
    deemed eligible for emergent suicide care under Paragraph 1720J
    of Title 38.
        This is a much-needed provision. Veterans who are in acute
    crisis do not have days or weeks to be placed in a care setting
    that can address the crisis. This legislation will ensure that
    every care option is used so veterans are not left on their own
    while they are in the greatest period of need.
        The Independence Fund fully supports the enactment of this
    legislation. This concludes my testimony and I am happy to
    answer questions.

        [The Prepared Statement Of Clark Pennington Appears In The
    Appendix]

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

                        STATEMENT OF JON RETZER

        Mr. Retzer. Chairwoman Miller-Meeks, Ranking Member Takano
    and Member Bergman, thank you for inviting DAV to offer our
    views on the veterans' healthcare bills being considered by the
    subcommittee today.
        Many veterans do not recognize their veteran status and are
    not receiving care and benefits through the Veterans Health and
    Benefits Administration and community services.
        By asking have you served healthcare providers and
    community partners can identify veterans who might otherwise go
    unnoticed and ensure they receive tailored healthcare, access
    to benefits, and community services. For this reason, DAV is
    pleased to support H.R. 6291, Have You Served.
        Data is essential for preventing veteran suicide by
    identifying at-risk individuals, tailoring their interventions,
    and monitoring trends. Leveraging data enables VA to comprehend
    veteran suicide complexities, devise effective prevention
    strategies, and ultimately save lives.
        Therefore, DAV supports H.R. 6330, the Veteran Sentinel
    Act, but recommends expanding its scope to also include
    collecting suicide data for veterans using the veterans
    community care program.
        2.7 million rural and highly rural veterans confront unique
    obstacles in accessing VA's top-notch healthcare services. DAV
    supports H.R. 7504, the Rural Veterans Transportation to Care
    Act that would modify the existing transportation grant program
    to improve access to healthcare for rural veterans.
        H.R. 9324, the Protecting Veteran Access to Telemedicine
    Service Act, would enhance telehealth care accessibility for
    veterans in remote or underserved areas by eliminating the in-
    person visit, a requirement for prescribing certain controlled
    medications.
        DAV supports this bill as it would guarantee continuous
    medication access for veterans, regardless of their ability to
    physically go to a VA facility.
        H.R. 9427 would direct the VA to carry out a pilot grant
    program for non-VA outpatient mental health facilities to
    ensure the delivery of culturally competent, evidence-based
    mental health care for veterans.
        Rather than creating a parallel system with little
    oversight and potential lower standards of care, we recommend
    increasing the number of VA mental health clinicians to reduce
    the wait times for mental health care in VA and veteran
    community care program settings.
        The recent VA Red Team report emphasized the need to expand
    the use of VA direct healthcare and balance the use of
    community healthcare services to prevent the erosion of the VA
    healthcare system.
        Madam Chair, H.R. 9438, and No Wrong Door for Veterans Act,
    would amend and reauthorize the VA Staff Sergeant Parker Gordon
    Fox Suicide Prevention Grant Program. DAV has no concerns about
    the provision to reauthorize the Fox Grant Program for an
    additional 3 years.
        However, the bill would also establish a new access
    standard mandating a 72-hour deadline for the VA to provide
    services after a veteran is referred to non-suicidal mental or
    behavioral health follow-up care.
        Although we prioritize timely access to mental health
    services for veterans, this provision may risk disconnecting
    them from VA and other necessary support services. For these
    reasons we do not support this provision of the bill.
        DAV supports H.R. 9478 to include adaptive prosthesis and
    terminal devices for sports and other recreational activities
    in VA's medical service package. These devices will help to
    promote physical activity and overall well-being among
    veterans, allowing them to engage in sports and recreational
    activities that they need and enjoy.
        DAV supports the Safeguarding VA's Healthcare Workforce Act
    which would allow VA to bring in outside healthcare providers
    when they need to fill vacant shifts, ensuring enrolled
    veterans have timely access to care.
        However, we highly recommend VA prioritize its efforts to
    maintain proper hiring and retention practices, strengthen
    internal staffing levels, and remain the primary provider and
    coordinator of care while effectively utilizing community care
    networks.
        Finally, DAV supports the Service Dogs Assisting Veterans,
    SAVES, Act that would establish a pilot program to award grants
    to nonprofit organizations to assist in providing service dogs
    to eligible veterans.
        This bill would also ensure prescribed service dogs are
    provided at no cost, that there is reimbursement for any
    required follow-up training, and as well as coverage of
    veterinary benefits for the life of the service dog.
        Chairwoman Miller-Meeks, this concludes my testimony and I
    am pleased to answer questions you or members of the committee
    may have.

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

        Ms. Miller-Meeks. Thank you very much.
        Thanks to all of you for your thoughtful comments.
        I now recognize general Bergman for 5 minutes.
        Mr. Bergman. Thank you, Madam Chair.
        Thanks to all of you for being here today and your
    thoughtful, articulate, and timely testimony, not only timely
    in the subject at hand, but maintaining yourself within the
    standards of time. You know, you did not waste any time. You
    got right to the point.
        I would like to focus on two important bills that will help
    improve veterans' access to mental health care and suicide
    prevention programs. First, the No Wrong Door for Veterans Act,
    which I joined Chairwoman Miller-Meeks in introducing last
    month. Despite spending more and more money each year on VA
    suicide prevention programs, more and more veterans continue to
    take their lives every day.
        There is a--it leaves a hole not only, I think, I know in
    the family's heart, but it leaves a hole in those of us, and
    you included, trying to do the right thing for the right
    reasons for our veterans. It takes a little bit out of you
    every day knowing that we are still dealing with this.
        The Fox Grant Program, which I helped to champion during
    the 116th Congress, complements VA's existing suicide
    prevention efforts by targeting veterans outside of the VA
    system and ensuring that those in need are able to receive
    evidence-based care.
        The No Wrong Door for Veterans Act will reauthorize and
    improve the Fox Grant Program so that more veterans can
    continue to receive the suicide prevention that they need,
    prevention and care that is, not just prevention.
        Second, I would like to highlight Chairman Bost's Veterans
    Mental Health Access Act which would create a pilot program to
    increase veterans' access to behavioral health care in the
    community. Both of these bills would make real changes to
    address the veteran mental health and suicide epidemic while
    protecting and complementing the important work of the VA.
        Now for questions. Ms. Meyer, could you speak to the
    bureaucratic barriers at VA that might prevent a veteran from
    receiving mental health or suicide prevention care?
        Ms. Meyer. Thank you for the question. The barriers tend to
    be twofold, one of them being the requirements of the program
    to be enrolled, participating in the lengthy and sometimes,
    well, most of the time redundant baseline mental health
    screenings.
        We may have a veteran that is qualified based on the C-
    SSRS, however, they do not want to participate in four or five
    other baseline assessments, so they are now ineligible so they
    would not be then enrolled in the Fox Grant Program. AWP will
    still refer them to the VA.
        Mr. Bergman. Okay. Do you think that the bills like
    Chairman Bost's Veterans Mental Health Access Act will give
    more options to veterans who need mental health care?
        Ms. Meyer. We hope so.
        Mr. Bergman. Okay.
        Mr. Pennington, how has the Fox Grant Program improved
    veteran access to suicide prevention care?
        Mr. Pennington. Well, I would say that the Fox Grant is
    obviously an opportunity for organizations to capitalize on
    that funding to move their programs forward.
        At the Independence Fund we do not typically take part in
    that in our suicide prevention. Our operation resiliency
    program is a program that is funded through 100 percent
    donations.
        The Fox Grant is enabling us to also reach out to
    organizations like law enforcement and using that opportunity
    to educate law enforcement, who is typically our first
    responders onsite with somebody who is in crisis. That is a
    huge opportunity for us under the Fox Grant.
        Mr. Bergman. Okay. I am going to interpret, but what you
    said is that the reforms to the Fox Grant Program included in
    H.R. 9438 will actually improve in broad-based, you know, more
    broad basing of these efforts and hopefully targeted to
    appropriate and much in need veterans.
        Mr. Pennington. Yes, sir.
        Mr. Bergman. Okay.
        Well, then with that, Madam Chair, I know there was a
    couple of hearings ago I went over my time so I am going to
    yield back 35 seconds.
        Ms. Miller-Meeks. Thank you very much, General Bergman.
        I now recognize myself for 5 minutes. Mr. Dempsey, can you
    elaborate on the benefits of requiring the baseline screening
    to be conducted using the Columbia protocol in terms of
    streamlining intake and standardizing data collection as
    specified in the reauthorization of the Fox Grant Program?
        Mr. Dempsey. Of course. Thank you, Madam Chair. Our
    perspective on that bill in using the Columbia protocol is very
    much rooted in our own personal experience at Wounded Warrior
    Project where our largest programming investment has been in
    the delivery of mental health support and related care.
        We recently established a triage team to help assign
    veterans to several programs within a continuum of support. The
    Columbia protocol has allowed us to quickly and effectively
    screen veterans for their risk of suicide and help assign them
    to the appropriate level of care.
        I think it is the efficiency that you can move through and
    screen that has been the most beneficial aspect of us, but I
    would be happy to follow up with colleagues of mine who work
    with warriors directly and then we can, perhaps, provide some
    more insight on just how effective that has been for our
    organization. Thank you.
        Ms. Miller-Meeks. Thank you.
        Ms. Meyer, as you know, many VA medical facilities are not
    aware of the Fox Grant Program. Can you tell me why you think
    the quarterly briefings in this bill would build partnerships
    between the community and the VA, as well as increase care
    coordination and ultimately provide better care to our
    veterans?
        Ms. Meyer. Yes, ma'am. Thank you for your question. I think
    that the quarterly briefings would be successful. When you
    become a grantee you are required to reach out to all the
    suicide prevention coordinators within your community and so we
    have done that.
        Then the gap so far has been that then the frontline staff
    answering the phone has no idea when I call and say, hi, I am a
    Fox Grantee and I am a Fox participant. They do not even know
    what that is.
        Making sure that they understand, knowing who we are when
    we make the phone call, knowing why we are calling to serve
    that veteran immediately would just, I think it could change
    the intake process completely.
        Ms. Miller-Meeks. Thank you.
        Mr. Retzer, the H.R. 9324, Protecting Veteran Access to
    Telemedicine Services Act of 2024, how do you believe this bill
    would better serve rural veterans who may not have a VA
    provider within a reasonable driving distance?
        Mr. Retzer. Thank you for that question, very good
    question. We look at this situation as our veterans that are in
    challenges with barriers for geographical location or even
    climate, they may not be able to make their way VA all the
    time.
        That brings a risk when there is a deadline to get their
    medications on time. Many other medications that they are
    taking actually are much needed for lifesaving purposes and
    actually have some risky side effects if they do not have that
    continuity of care from their medication. That is one of the
    things that we see in the advancement in the use of
    telemedicine to be able to facilitate that gap and barrier.
        Ms. Miller-Meeks. Thank you very much.
        Mr. Pennington, in regards to H.R. 9478, the Veterans
    Sports Act, you have noted concerns about VA's policy of not
    providing adaptive recreation equipment such as adaptive
    prostheses or terminal devices when the equipment is intended
    solely for recreation.
        How many veterans have you heard from who were denied such
    equipment due to this policy and could you provide any specific
    examples of veterans who are affected by this limitation and
    the impact it had on their physical, and even more importantly,
    their mental or emotional well-being?
        Mr. Pennington. Yes, ma'am, thank you. In reference to
    that, I mean, you can look back to a survey that we conducted
    in 2021 where we reached out to a significant population within
    our constituency that is seeing a significant reduction in the
    opportunity for recreational prosthetics.
        I can bring two examples to you right now that we are
    currently working with the VA on that has specifically
    requested swimming blades, specifically requested opportunities
    to continue recreational opportunities and activities that they
    did prior to their injury that they no longer can do because of
    their injury and therefore is impacting their mental health.
        Because of some of the restrictions in not just the fitting
    of a prosthetic to the individual initially, then the
    opportunity to have access to recreational prosthesis is not a
    significant mental health barrier for them.
        We saw a significant decline in both of these that we have
    access to and that we presented to the committee before in the
    past that we really believe that this opportunity improves
    their mental health.
        I did hear from the VA during their testimony here today
    that they believe this is already part of their process. I
    would say that the information coming from that level down to
    the practitioners inside of those VISNs is not happening
    because they are being denied access to these recreational
    prosthetics that ultimately go to mental health improvement.
        Ms. Miller-Meeks. Thank you very much.
        As a doctor and veteran I can certainly testify to the need
    for making people whole, similar to what their lives were
    before their injuries.
        Seeing that no other members are here, I would recognize
    the ranking member for closing remarks but he is not here.
        On behalf of the subcommittee I want to thank you all, all
    of the witnesses for being here today. I look forward to
    working with you and with the VA to address some of the issues
    facing our veterans and some of the points brought up today in
    testimony.
        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 include extraneous material. Hearing no
    objection, so ordered.
        I want to thank the members and witnesses for their
    participation today. This hearing is now adjourned.
        [Whereupon, at 11:30 a.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 Carolyn Clancy

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                      Prepared Statement of Brian Dempsey

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                       Prepared Statement of Missy Meyer

        Chairwoman Miller-Meeks, Ranking Member Brownley, and other
    honorable members of the Subcommittee

        Thank you for the honor to testify before the House Veterans
    Affairs Subcommittee on Health. There are many bills up for discussion
    today, but my testimony will primarily focus on one: The No Wrong Door
    for Veterans Act, which reauthorizes the SSG Parker Gordon Fox Suicide
    Prevention Grant Program.
        However, before I discuss the bill, I wanted to mention America's
    Warrior Partnership's support for another bill being discussed today,
    H.R. 9427, introduced by Chairman Bost, to carry out a pilot program to
    provide grants to outpatient mental health facilities for the provision
    of culturally competent, evidence-based mental health care for
    veterans.
        At AWP, one of the most common requests for health care services is
    related to mental health. The more our Nation can expand access to
    mental health care for veterans, the better. But it must be done with a
    holistic approach. Counseling is a great tool, but every veteran is
    unique. Offering additional choices, such as outpatient facilities for
    mental health, access to Traumatic Brain Injury (TBI) treatment (since
    it is often concurrent with mental health crisis), and Post-Traumatic
    Growth (PTG) training (both pre-and post-crisis) can expand the
    resources available.
        That being said, AWP is focused on outreach to all veterans. Since
    I was last before the Subcommittee to discuss the SSG Fox Grant last
    December, much has changed and much has been accomplished. AWP is one
    of the most successful recipients of funding from the SSG Parker Gordon
    Fox Suicide Prevention Grant Program (aka SSG Fox Grant).
        As we told the Committee last year, the original idea of the SSG
    Fox Grant had a singular goal: find veterans in the community that are
    in need and help them.
        However, as the program was implemented by the VA and put into
    practice by organizations across the country, part of this goal has
    been diluted and lost. To reach that goal, Congress needs to implement
    reforms that specifically bring back outreach as the singular focus,
    streamline the intake into the VA for eligible Fox veterans, and hold
    organizations accountable.
        We are very thankful for all your hard work on this program,
    Chairwoman Miller-Meeks, Ranking Member Brownley. The introduced
    legislation, H.R. 9438, to reauthorize the SSG Fox Grant, is a terrific
    start, and AWP is grateful for your efforts to continue this successful
    program. To help improve the SSG Fox Grant program, we offer a few
    observations and suggestions:

        Program Overview

        As one of 80 SSG Fox Grant recipients, we have done a significant
    amount of outreach with the program since its inception. From October
    2023 to July 2024, AWP produced results:

            -1,818 warriors screened for suicidal ideation using the
            Columbia-Suicide Severity Rating Scale

            -13 percent disclosed some level (low, moderate, high) of
            suicide risk (235)

        This rate of outreach, screening, and eligibility is consistent
    with past years.
        The SSG Fox Grant Program is working. Veterans who are both inside
    and outside the VA and VSO system and in need of assistance are being
    identified.
        Relationships are being built and connections with resources made.
    Since Fox Grant Inception, 370 veterans have trusted AWP with their
    thoughts of suicide while only 6 percent of those warriors were seeking
    assistance for a mental health related issue to begin with. This is a
    success story and asking ``the question'' works. AWP, the VA, and
    Congress have all played an integral part in saving these veterans, but
    there is more that can be done.

    Coordination:

        AWP is thankful for the inclusion of language that directs
    briefings for VA employees about the SSG Fox Grant program. It's
    important for organizations in the community and the VA to all
    coordinate together. It is our hope that grant recipients will be
    invited to these briefings and work together to improve communication
    and ``warm hand-offs'' of individual cases as they arise. Previously,
    many VA staff members had no idea what the Fox Grant is or why grantees
    were calling asking for assistance with a ``Fox Participant.'' Ensuring
    a bi-direction, solid working relationship with local Suicide
    Prevention Coordinators and VA staff is essential, as is more education
    to frontline staff on the SSG Fox Grant. Accordingly, as an advocate
    for veterans who trust us, it is essential for the VA to communicate
    back to grantees their plan and status of that veteran.

    Screening Questionnaires:

        Next, AWP is very grateful for the inclusion of language in H.R.
    9438 that eliminates some of the redundancies and bureaucracy of the
    screening questions. As AWP mentioned in previous testimony in December
    2023, rarely did veterans make it through all the questionnaires, and
    the Columbia Protocol (C-SSRS) has proven to be the most inclusive and
    comprehensive set of questions needed to ensure those at risk are
    identified quickly and easily.
        While the legislation mandates C-SSRS as the only required
    screening protocol, AWP recommends adding language that would make the
    five follow-on assessments optional. Rarely do veterans make it through
    all five of the VA-mandated assessment questionnaires, and it has
    become burdensome on staff as well. Instead, the focus should be on
    ensuring the veterans have access to resources and not focusing on
    answering redundant questions.

    Crisis Intervention:

        In H.R. 9438, the section on ``Emergent Suicide Care'' is a strong
    addition. In many instances, AWP has used the 988-emergency crisis line
    to help veterans identified through Fox Grant outreach. This language
    helps codify support and resources available to those who are unable to
    obtain services in the crucial 72-hr window after first contact.

    Clearly Defined Pathway for Eligible Individuals:

        The addition of the Emergent Care section in H.R. 9438 is very
    helpful. However, AWP recommends adding a section that clearly lays out
    the expectations for the program itself and identifies boundaries for
    the VA and organizations. While AWP does all it can to provide
    connections to referrals and resources, AWP is not a direct service
    provider. It is clearly outlined in the scope of the grant proposal.
    However, the line has become muddied and expectations are often
    unclear.
        To fix this, it would be helpful to add a section that requires a
    specific program ``on-ramp'' for veterans identified by grant
    recipients that need VA care. The process does not need to be complex
    or burdensome. Since grant recipients have already asked the required
    questions and processed the information, passing along the information
    to the VA without burdening the veterans themselves again with tiring,
    frustrating, redundant questions (which sometimes involve discussing
    traumatic experiences) would dramatically increase the success rate of
    the program as well as assist the veteran more efficiently.
        This can be done in several ways. For example, requiring that after
    grantees go through the required screening procedures, eligible
    veterans must be connected with the 988-crisis line or their local VAMC
    for expedited care when necessary. In addition, Congress could also
    mandate that the VA create a dedicated phone line for intakes from
    grantees that would offer expedited care.

    Accountability:

        The SSG Parker Gordon Fox Suicide Prevention Grant Program is
    working. To keep the program successful, we need to ensure all
    organizations that are receiving grants in the program are held to
    account. The $750,000 grants come from the trust Congress and the
    American taxpayers have in our organizations, and AWP holds that trust
    in the highest regard. Accordingly, AWP holds itself to account
    regularly with audits and reviews, and we work hard to ensure these
    funds are maximized efficiently to find veterans in the community and
    serve them.
        At AWP, we hope all other grantees are holding themselves
    accountable with the same high standards. However, Congress and the VA
    must also hold organizations accountable with verifiable metrics. AWP
    recommends adding a section requiring the VA develop accountability
    metrics that report outreach, referrals, etc--and then require regular
    reports to Congress. It is the only way to find if some organizations
    are not fulfilling their responsibility under the program.
        For the metrics themselves, it's hard to identify specific keys to
    success. However, AWP believes the best way to look at program success
    is to measure the number of screened individuals and the number of
    eligible veterans, in addition to outreach completed to document
    efforts toward identifying those in need.
        While accountability and metrics are vital, the Data Collection
    Tool (DCT) implemented by the VA at the end of 2023 has had the
    opposite of its intended effect. While developed to streamline data
    submission previously completed in thousands of pdf documents, the
    result has been a standstill in reporting for many grantees. The SSG
    Fox Grant Program assessments are meant to be anonymous. The DCT now
    requires a participant's Date of Birth and Social Security Number to
    enter any data shared in the DCT. AWP has gone from reporting nearly
    all data to less than 5 percent. Previously, the program was hindered
    by the redundancy of assessments and lack of incentive to complete them
    multiple times. Now that is compounded by the obvious lack of anonymity
    that comes with providing your PHI to the VA for an ``anonymous
    program.'' AWP hoped the DCT would save both AWP staff and clients from
    repetitive and exhausting data reporting, but unfortunately it has only
    diminished any data collection the VA hoped to gain through this grant.
        In February 2024, the VA asked for suggestions on how to remedy
    this issue. AWP has suggested returning to participant identification
    numbers that were previously used to report data (created and tracked
    only by the reporting agency) rather than PHI of participants. This
    issue remains despite repeated acknowledgements by VA staff that data
    is not being adequately captured with the DCT as it is.

    Grantee Funding:

        For AWP, the only limitation in being more successful with the
    program is funding. If the ceiling on the grants was doubled overnight,
    so would AWP's outreach efforts.
        Accordingly, while $750,000 has been the limit on SSG Fox Grants to
    date, there are organizations, like AWP, who have successfully utilized
    the grant and could do more with more. While not for all organizations,
    raising the ceiling could be beneficial if done correctly. Again, it
    would require metrics and reporting.
        Members of the Subcommittee, thank you again for the opportunity to
    testify today. We look forward to our continued work together and would
    like to thank each of you for all your hard work and dedication to
    those who served in our Nation's armed forces.

                     Prepared Statement of Clark Pennington

        The Independence Fund was established in 2007 to empower our
    Nation's catastrophically wounded, injured, or ill Veterans, by helping
    them cope with and overcome the physical, mental, and emotional wounds
    sustained in service. The Fund is dedicated to improving the lives of
    Veterans and their families through a range of programs including
    Mobility, Caregiver Support, Advocacy, Casework, Operation RESILIENCE,
    Independence@Home, and other Family oriented initiatives, The
    Independence Fund strives to bridge the gaps in care across all these
    areas and offers comprehensive support to Veterans and their families
    in need by working with the Department of Veterans Affairs, Department
    of Defense Health Agency, State level agencies, non-profit entities,
    and private mental health professionals.
        The Independence Fund is honored to present its views on the
    legislation that impacts catastrophically disabled veterans and their
    caregivers.

    Draft Legislation to amend title 38, United States Code, to include a
    representative of the National Association of State Veterans Homes to
    the Geriatrics and Gerontology Advisory Committee of the Department of
    Veterans Affairs.

        This bill amends section 7315(a) of title 38, USC, requiring the
    Under Secretary of Health to consult with the President of the National
    Association of State Veterans Homes (NASVA) when selecting members for
    appointment to the Geriatrics and Gerontology Advisory Committee. This
    legislation will also require that the Committee include one
    representative who holds a professional license in nursing home
    administration and is a member of the National Association of State
    Veterans Homes.
        The Independence Fund supports this legislation. No other
    association is more qualified at understanding the needs of aging
    veterans than members of NASVH, and as such, their participation will
    be an invaluable in advising the Under Secretary of Health and
    assessing the capabilities and needs of VA's obligation to care for our
    aging veteran population.

    Draft Legislation to direct the Secretary of Veterans Affairs to carry
    out a pilot program to provide grants to outpatient mental health
    facilities for the provision of culturally competent, evidence-based
    mental health care for veterans, and for other purposes.

        The Independence Fund holds no position on this legislation.

    Draft Legislation to amend title 38, United States Code, to require
    that non-citizen appointees to positions in the Veterans Health
    Administration are subjected to background investigations prior to
    employment.

        The Independence Fund holds no position on this legislation.

    Draft legislation to amend title 38, United States Code, to permit the
    voluntary transmission of patient contact information to certain
    religious or faith-based organizations by chaplains employed by the
    Department of Veterans Affairs, and other purposes.

        The Independence Fund holds no position on this legislation.

    H.R. 9438, a bill to amend and reauthorize the Staff Sergeant Parker
    Gordon Fox Suicide Prevention Grant Program of the Department of
    Veterans Affairs.

        This legislation includes four main provisions. First, the bill
    limits the amount of the grant that can be used on food and non-
    alcoholic drinks. This is a commonsense amendment that ensures grant
    recipients are using the bulk of the funding to provide services.
    Second, the bill requires quarterly updates to VA personnel on grant
    recipients that are within 100 miles of the VAMC to better educate and
    coordinate available services the grant recipients provide. Third, this
    bill requires VA to refer a veteran who needs emergent suicide care to
    the community if VA cannot provide that care within 72 hours. Last,
    this legislation will extend the program until September 30, 2027.
    Veterans who are in crisis cannot wait for care. The Independence Fund
    fully supports this legislation.

        H.R. 9324, a bill that amends title 38, United States Code, to
    authorize certain health care professionals employed by the Department
    of Veterans Affairs to deliver, distribute, or dispense to veterans
    certain controlled medications via telemedicine under certain
    conditions, and of other purposes.

        The Independence Fund supports this legislation. VA is a leader in
    the use of telemedicine, working to improve access to care regardless
    of where veterans live or their preferred mode of receiving care should
    continue to be a priority. A gap in current law, that has been
    temporarily lifted in response to COVID-19 and is set to expire on
    December 31, 2024, prevents VA providers from prescribing controlled
    substances without an in-person medical examination. This legislation
    will make this authority permanent to VA providers, allowing for
    increased access and functionality to VA's robust telehealth
    capabilities.

    Draft legislation that directs the Secretary of Veterans Affairs to
    carry out a pilot program under which the Secretary may fill vacant
    shifts at medical facilities of the Department of Veterans Affairs with
    non-Department health care providers.

        The VA currently is under a 5-year, indefinite delivery/indefinite
    quantity contract with the medical staffing company, Aptive, to provide
    staffing services for all levels of clinical care and administrative
    support. If this contract is insufficient to fulfil VA's needs, The
    Independence Fund recommends modifying the current contract.

    H.R. 9478, a bill to amend title 38, United States Code, to include
    adaptive prostheses and terminal devices for sports and other
    recreational activities in the medical services furnished to eligible
    veterans by the Secretary of Veterans Affairs.

        The Independence Fund fully supports this much needed amendment to
    law. VA currently applies a 2017 regulation ``Prosthetic and
    Rehabilitative Items and Services, 38 CFR Part 17 that specifies when
    ``adaptive recreation equipment'' within prosthetics may be approved,
    allowing for ``an item that is designed to compensate for, or that, by
    design compensates for, loss of physical, sensory, or cognitive
    function and is necessary for a veteran to actively and regularly
    participate in a sport, recreation, or leisure activity to achieve the
    veteran's rehabilitative goals.'' This language limits approval of
    these adaptive and recreational prosthetics when they are specifically
    part of a medical goal, and not for long term life and health goals
    that are described as ``for personal enjoyment.'' This regulation
    ignores VA's philosophy of ``whole health.'' Veterans who have lost a
    limb and what to begin, return to, or maintain an activity that keeps
    them active improve social engagement and psychological and physical
    health and should not have to be subject to specific medical goals.

    Draft legislation to require the Secretary of Veterans Affairs to award
    grants to nonprofit organizations to assist such organizations in
    carrying out programs to provide service dogs to eligible veterans, and
    for other purposes.

        Research studies have found that veterans who have PTSD see a 66
    percent reduction in symptoms within 3 months of being paired with a
    service dog. This research found that the presence of the service dog
    lowers anxiety and depression, improves social functioning and
    relationship health, and interrupts panic attacks. Unfortunately, the
    capability of organizations to train and provide service dogs does not
    meet the demand. This legislation will provide grants to nonprofit
    organizations to increase the number of dogs that can be trained to be
    service animals. This is a small investment to increase access to a
    clinically proven method of improving veterans' mental health. The
    Independence Fund is proud to support this legislation.

    H.R. 9146, a bill to amend title 38, United States Code, to require the
    consideration of continuity of health care in determining best medical
    interest under the Veterans Community Care Program, and for other
    purposes.

        This legislation amends Section 1703(d)(2) of title 38 to include
    continuity of care as a consideration for referral to community care.
    1703 (a)(2)(B) requires the Secretary of Veterans Affairs to ``ensure
    continuity of care and services'' when coordinating non-VA hospital
    care. However, under subparagraph (d) ``Conditions Under Which Care Is
    Required To Be Furnished Through Non-Department Providers'' there is no
    mention of continuity of care as a factor for consideration in
    determining the bast medical interest for when and where a veteran
    receives care. This legislation includes continuity of care in the list
    of considerations a provider can use to ensure veterans get non-
    disrupted care. The Independence Fund suggests that the bill be amended
    to include guidelines that will prevent CCN providers from requesting
    additional authorization of care without that care being approved by
    the PCP or the VA provider who initially authorized the care.

    Draft legislation to amend title 38, United States Code, to make
    improvements relating to conflicts of interest for certain Department
    of Veterans Affairs employees, and for other purposes.

        The Independence Fund does not hold a position on this legislation.

    H.R. 9301, a bill to direct the Secretary of Veterans Affairs to
    include two counties in New Mexico in a certain Veteran Integrated
    Service Network.

        The Independence Fund does not hold a position on this legislation.

    H.R. 6291, the ``Have You Served Act''

        Many State and local governments and community organizations
    provide benefits and services to military veterans and their families,
    but all too often veterans are unaware of the benefits. This grant
    program provides funds to human resource offices in these agencies and
    organizations to train frontline employees on how to ask about military
    service as well as build campaigns to proactively inform the veteran
    community of the programs and services that are unique to that
    community. The Independence Fund fully supports this legislation.

    H.R. 6330, the ``Veterans' Sentinel Act''

        Every effort must be taken to understand and mitigate the
    circumstances that lead to suicide. It is particularly disturbing when
    a veteran dies by suicide on a VA campus. This should signal to VA and
    advocates alike that the system designed to provide mental health care
    is inadequate. The Veterans' Sentinel Act call on the Secretary to
    establish a pilot that would form a working group to collect and
    analyze data regarding on-campus attempted and completed death by
    suicide. Importantly, this legislation requires the working group,
    through the Secretary, to send a report to the House and Senate
    Committees on Veterans Affairs that outlines any recommendations that
    can lead to the reduction of suicide attempts on VA campuses. The
    Independence Fund fully supports this legislation.

    H.R. 7504, the ``Rural Veterans Transportation to Care Act''

        H.R. 7504, the ``Rural Veterans Transportation to Care Act'' amends
    current law, allowing transportation grants to include rural regions,
    which account for 2.7 million enrolled veterans. By expanding access to
    this population, veterans will have easier access to VA's direct care
    services. Additionally, this bill will increase the grant amount to
    modify vehicles to comply with ADA requirements. Both of these
    provisions are necessary to care for veterans who are catastrophically
    disabled.

    H.R. 8562, the ``Parity for Native Hawaiian Veterans Act of 2024''

        The Independence Fund holds no position on this legislation.

                        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 nearly 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. 6291, the Have You Served Act

        H.R. 6291, the Have you Served Act, would require the Department of
    Veterans Affairs (VA) to provide grants to eligible organizations for
    the purpose of conducting ``Ask the Question Campaigns'' encouraging
    human services professionals, State and local governments and community
    providers to ask whether someone has served in the military. By
    promoting the question ``have you served?'', the bill seeks to raise
    awareness about veteran status among health care providers, social
    service agencies, and the general public. Improved identification of
    veterans can lead to better access to VA benefits and services and
    addressing unmet needs within the veteran community.
        While DAV does not have a specific resolution on this matter, the
    bill could potentially get veterans who are unaware of their veteran
    status access to earned benefits and health care services. For these
    reasons DAV supports H.R. 6291, in accordance with our Statement of
    Policy, which calls for enhanced outreach to ensure that all disabled
    veterans receive the benefits they have earned through their military
    service.

                      H.R. 6330, the Veterans Sentinel Act

        H.R. 6330, the Veterans Sentinel Act, would address the issue of
    veteran suicides on VA property by implementing a pilot program within
    the VA.
        This bill would require the VA to set up a working group within the
    Office of Mental Health and Suicide Prevention for the purpose of
    gathering and analyzing data on veteran suicides and attempted suicides
    that occur on VA property. The working group would unify disparate
    sources of data related to on-campus suicides to improve the accuracy
    and comprehensiveness of the information collected. Furthermore, the VA
    would analyze the statistical trends of suicides and attempted suicides
    at VA facilities annually and be required to report on policies,
    staffing and resource levels and suggest preventive actions for these
    incidents.
        DAV supports H.R. 6330, the Veterans Sentinel Act, in accordance
    with DAV Resolution No. 224, which supports program improvement and
    enhanced resources for VA mental health programs and suicide prevention
    efforts. We do however, suggest the bill be amended across all veteran
    care settings to include gathering information on suicide attempts and
    deaths within the Veterans Community Care Program (VCCP) as well. This
    expanded study should encompass onsite VCCP suicides and any suicides
    occurring within 24 hours of Community Care Network (CCN) contact. This
    timeframe aligns with the VA's current practice for root cause
    analyses, a standard not yet adopted by the VCCP.

            H.R. 7504, the Rural Veterans Transportation to Care Act

        The goal of H.R. 7504, the Rural Veterans Transportation to Care
    Act, is to improve veterans transportation options to VA medical
    facilities for veterans living in rural areas.
        Veterans living in rural areas can face challenges that lead to
    disparities in access and quality of health care compared with their
    urban counterparts. This bipartisan bill would expand eligibility to
    the VA's Highly Rural Transportation Grant Program, which provides
    grant funding for veteran service organizations and State veterans
    service agencies to provide veterans transportation in eligible
    counties by increasing the maximum amount of funding granted to
    purchase an ADA-compliant vehicle.
        The bill would also modify the existing grant program to include
    both rural and highly rural counties, by redefining ``rural'' and
    ``highly rural'' using Rural-Urban Commuting Area (RUCA) designations
    to better account for population density, urbanization, and commuting
    patterns.
        Our nation's 2.4 million veterans living in rural areas often face
    unique difficulties accessing VA health care that those living in urban
    and suburban areas do not. Chief among them is transportation to VA
    medical facilities. The nearly 300,000 veterans living in areas
    considered highly rural face even greater obstacles and deserve
    increased attention to assistance in accessing VA's high-quality health
    care.
        DAV is proud to support H.R. 7504, the Rural Veterans
    Transportation to Care Act, in accordance with DAV Resolution No. 42,
    which calls for ensuring sufficient access to care to meet the health
    needs of veterans residing in rural or remote areas. This bill would
    help the VA provide more rural veterans better access to health care
    and help ensure our Nation keeps its promises to America's veterans.

         H.R. 8562, the Parity for Native Hawaiian Veterans Act of 2024

        H.R. 8562, the Parity for Native Hawaiian Veterans Act of 2024,
    would amend title 38, United States Code, and make modifications to the
    program for direct housing loans and medical care services from the
    Department of Veterans Affairs for Native Hawaiians.
        The bill would modify the definition of Native Hawaiian veterans
    and aims to improve access to medical care for Native Hawaiian veterans
    by eliminating copays for services received through the VA, and
    enabling the Native Hawaiian Health Care System to seek direct
    reimbursement for certain costs from the VA.
        DAV has no resolution on this issue and takes no position on the
    bill.

           H.R. 9146, the Ensuring Continuity in Veterans Health Act

        H.R. 9146, the Ensuring Continuity in Veterans Health Act, would
    ensure that continuity of health care is considered when determining
    the best medical interest under the Veterans Community Care Program
    (VCCP).
        The proposed legislation would amend title 38, United States Code,
    to ensure that continuity of health care is a factor considered in
    determining the best medical interest for veterans using the VCCP. This
    would be achieved by adding a new subparagraph to Section 1703(d)(2) of
    title 38, which explicitly includes continuity of care as a
    consideration. The amendment does not specify the definition of
    continuity of care or its requirements. The focus is solely on
    expanding the criteria used by a provider to evaluate the best medical
    interests of a veteran within the existing framework of the VCCP when
    VA services are not readily available.
        It appears the bill aims to ensure that veterans are able to
    maintain consistent relationships with their health care providers and/
    or complete an episode of care when referred to care in the community.
    We agree it is important that VA maintain quality and consistency of
    health care services provided to veterans and believe VA already has
    the authority to consider continuity of care as a factor under the
    existing statute. At the same time, it is important to point out that
    numerous research studies have shown that care provided by the VA
    direct care system is of comparable and often superior quality to that
    provided by private sector providers and may have other advantages from
    coordination and continuity of care perspectives.

           H.R. 9301, New Mexico Rural Veteran Health Care Access Act

        H.R. 9301, the New Mexico Rural Veteran Health Care Access Act,
    would add two new counties in New Mexico as part of the VA's Veterans
    Integrated Service Network (VISN) 17. The new areas to be included in
    the VISN would be Eddy and Otero counties.
        Currently, Eddy and Otero counties are part of VISN 22, which
    covers most of the State of New Mexico. VISN 17 covers all of Texas and
    small portion of eastern and southeastern New Mexico. This legislation
    would bring together the final two counties in the southeastern portion
    of New Mexico and include them in VISN 17.
        DAV does not have a resolution specific to VA's VISN system;
    however, we do not have an objection to the bill's intent to address
    regional disparities in access to veterans' health services.

       H.R. 9324, Protecting Veteran Access to Telemedicine Services Act

        This bill aims to permanently extend a pandemic-related exemption
    that allows VA health care professionals to deliver, distribute, and
    dispense medically necessary controlled substances to veterans via
    telemedicine, even if they have not conducted the in-person medical
    examination.
        By removing the requirement for an in-person visit, the bill aims
    to make health care more accessible for veterans who reside in remote
    or underserved areas. Last, this bill would ensure that veterans can
    continue to receive their medications without interruption, even if
    they cannot physically visit a VA facility.
        DAV supports H.R. 9324, in accordance with DAV Resolution No. 42,
    which supports the right of rural veterans to be served by the VA to
    the maximum extent practicable and calls for the VA to overcome
    barriers to care for rural veterans by continuing to improve access to
    telehealth care initiatives.

     H.R. 9427, to direct the VA Secretary to carry out a pilot program to
    provide grants to outpatient mental health facilities for the provision
    of culturally competent, evidence-based mental health care for veterans

        H.R. 9427 would direct the Secretary of Veterans Affairs to carry
    out a pilot program to provide grants to non-VA outpatient mental
    health facilities to ensure the delivery of culturally competent,
    evidence-based mental health care for veterans.
        This bill recognizes the importance and expertise VA provides in
    the delivery of specialized mental health services to veterans. In
    doing so, it highlights the need to ensure high-quality, evidence-based
    care when a veteran is referred to the community for services.
        Although DAV Resolution 224 calls to support program improvement
    and enhanced resources for VA mental health programs and suicide
    prevention to address the mental health needs of veterans and ensure
    they receive high-quality, accessible care, we have concerns with this
    bill. Specifically, that it could potentially weaken the VA's
    integrated health care system, which conflicts with DAV Resolution 403,
    calling for strengthening and protecting the VA health care system.
        Veterans in need of mental health care are eligible for care via
    the Veterans Community Care Program (VCCP) if the VA cannot provide it
    within 20 days or 30 minutes of drive time. This bill would create a
    system parallel to the existing VCCP and introduces a new structure
    with competing eligibility rules. For veterans receiving care through
    the MISSION Act, VA serves as the authorizer of community care when a
    veteran is eligible. For veterans receiving care through the grant,
    VA's role in authorizing community care would be bypassed, which
    eliminates VA as the default provider of care when available in a
    timely and convenient manner. Under this bill, even when VA services
    are readily available, a veteran would be entitled to obtain outside
    care.
        This approach sets a precedent that could extend beyond mental
    health care, potentially leading to a system that is the exact opposite
    of what MISSION intended, i.e., to rely on community resources to
    supplement and not supplant VA care.
        The recent VA Red Team Report strongly advised for VA to expand
    direct-delivered care and reduce community-delivered health care to
    prevent the VA system's collapse. This bill would potentially move in
    the opposite direction.
        If the goal is to reduce wait times for mental health care access
    in VA and VCCP settings, the most effective solution would be to
    increase the number of VA mental health clinicians rather than create a
    parallel system with little oversight and potentially lower standards
    of care. Medical facilities that are not currently participating in the
    VCCP who wish to furnish mental health care to veterans should be
    actively invited to join the VCCP.

                   H.R. 9438, No Wrong Door for Veterans Act

        H.R. 9438, the No Wrong Door for Veterans Act, would amend and
    reauthorize the VA Staff Sergeant Parker Gordon Fox Suicide Prevention
    Grant Program (SSG PGFSP), which supports nonprofit community
    organizations and government agencies working to serve veterans at risk
    of suicide. This grant program utilizes a public health approach and
    combines clinical and community-based interventions with a goal of
    preventing suicide for veterans inside and outside of the VA health
    care system.
        The Fox Grant Program allowed VA to implement a comprehensive
    mental health screening for grantees to measure the effectiveness of
    services. In order to combat veteran suicide and assess program
    outcomes, it is vital to examine data on specific interventions.
        The March 2024 congressionally mandated report, An Interim Report
    on the Provision of Grants through the Staff Sergeant Parker Gordon Fox
    Suicide Prevention Grant Program (SSG Fox SPGP), noted under
    ``Measurement Outcomes'' that grantees spent much of the first year,
    since January 2023, building and staffing their programs before
    starting to provide services and screening potential eligible
    individuals.
        Although limited, the data collected from SSG Fox SFGP grantees was
    considered to be beneficial for reporting, program management, and
    evaluation. VA indicated it is using the initial year's program data to
    assess the suitability of benchmarks for future performance standards.
    Over time, VA predicts an increase in available data and the potential
    for more program graduates. The final report will better assess the
    effectiveness, capacity, and the feasibility of expanding grant
    provisions.
        The No Wrong Door for Veterans Act would appear to limit VA in its
    ability to measure Fox Grant recipients who currently evaluate
    participants using both pre and post measurements across relevant
    metrics. Data collection and assessment will help VA make better
    decisions regarding program effectiveness and the needs for future
    resource allocation and we believe it is critical to maintain a robust
    set of metrics and evaluation tools, particularly during the early
    phase of this program.
        The No Wrong Door bill would also implement new access standards
    that enforce a 72-hour deadline for the VA to deliver services after a
    veteran is referred for follow-up care for non-suicidal, non-emergency
    mental or behavioral health. This provision dramatically shortens the
    timeliness standard for VA mental health care for Fox Grantee veterans
    from the current 20-day standard to a mere 72 hours. If the VA fails to
    meet this timeline, the veteran would automatically become eligible for
    non-VA care, even outside of the Veterans Community Care Program, in
    line with the COMPACT Act standard, which ensures that mental health
    care is available anywhere for veterans who are in mental health crisis
    and at imminent risk for suicide. We are concerned that this
    unrealistic and unworkable new standard could undermine VA's efforts to
    provide coordinated mental health care to veterans.
        This provision has the potential to negatively affect the VA health
    care system and the veterans it serves.

     Draft bill to include a representative of the National Association of
      State Veterans Homes on the VA Geriatrics and Gerontology Advisory
                                   Committee

        This draft legislation would require the VA to include a
    representative from the National Association of State Veterans Homes,
    who holds a professional license in nursing home administration, on its
    Geriatrics and Gerontology Advisory Committee (GGAC).
        The VA's GGAC was created in 1980 to address challenges VA faced
    related to caring for a large influx of aging World War II veterans.
    One of the committee's main duties is to assess the capabilities of
    VA's health care facilities to respond with effective and appropriate
    care and services to address the medical, psychological, and social
    needs of older/aging veterans.
        DAV has no specific resolution that addresses who should be
    appointed as a member of the VA's GGAC; however, the experience and
    expertise of a representative from the National Association of State
    Veterans Homes could be beneficial to the Committee's work and we have
    no objection to this draft bill moving forward.

     Draft bill to require that non-citizen appointees to positions in the
          Veterans Health Administration are subjected to background
                       investigations prior to employment

        This draft legislation would require that non-citizen appointees
    undergo a background investigation prior to their employment with the
    VA. Currently, a non-citizen appointee may be hired by VA on a
    temporary basis under title 38, United State Code.
        While DAV has no resolution that addresses VA hiring practices for
    non-citizen appointees, according to VA, these appointees are subject
    to background investigations. Furthermore, as part of VA's Personnel
    Security and Suitability Program, all employees, including non-
    citizens, are required to meet the necessary security and suitability
    standards before being hired by VA.

         Draft bill, the Enhancing Faith-Based Support for Veterans Act

        This draft legislation would allow a VA chaplain to send a
    veteran's contact information to a non-VA religious or faith-based
    organization. Once the VA chaplain has completed a spiritual
    assessment, the veteran must approve/elect to have their contact
    information shared with a non-VA religious or faith-based organization.
    The spiritual assessment includes the medical treatment plan of the
    veteran as well as their personal spiritual information.
        While DAV has no resolution that addresses this matter, we have no
    objection to ensure that veterans have access to a wide range of
    supportive services, including those offered by faith-based
    organizations.

             Draft bill, Safeguarding VA's Healthcare Workforce Act

        This draft bill would establish a 3-year pilot program that allows
    the VA to fill vacant shifts at its medical facilities with non-
    Department health care providers once the number of vacant shifts
    reaches a minimum threshold, predetermined by the Secretary.
        This initiative could help address staffing shortages and ensure
    that veterans receive timely and quality care. By leveraging non-
    Department health care providers, this program could improve veterans'
    access to care, especially in underserved areas.
        That said, it is important that VA continue to work diligently to
    ensure appropriate hiring and retention practices are exercised and
    that internal VA staffing levels continue to be strengthened.
        DAV supports this draft bill in accordance with DAV Resolution No.
    403, which calls for VA to provide timely and convenient access to care
    for enrolled veterans, and for VA to remain the primary provider and
    the coordinator of care, while continuing to optimize the use of
    community care networks to fill in gaps, particularly in rural and
    remote areas.

      Draft bill, to include adaptive prostheses and terminal devices for
       sports and other recreational activities in the medical services
      furnished to eligible veterans by the Secretary of Veterans Affairs

        This draft bill would include adaptive prostheses and terminal
    devices for sports and other recreational activities in the medical
    services furnished to eligible veterans by the Secretary of Veterans
    Affairs. A terminal prosthetic device is one that works by means of
    cables to create voluntary opening and closing for managing a grip.
        Amending current medical-services law would be a significant step
    in enhancing the quality of life for many veterans. The proposed
    amendment would ensure that veterans have access to adaptive prostheses
    specifically designed for sports and recreational activities. This can
    include specialized limbs for running, swimming, cycling, and other
    activities. By providing these adaptive devices, the amendment aims to
    promote physical activity and overall well-being among ill and injured
    veterans, helping them to engage in sports and recreational activities
    that they enjoy and need to maintain their fitness and independence.
        The amendment would establish guidelines for veterans to be
    eligible for these devices, guaranteeing access through the VA for
    those in need. VA would not only provide such devices, but also offer
    training and support to help veterans effectively use their new
    prostheses. Furthermore, the amendment could stimulate the exploration
    and creation of new adaptive technologies, guaranteeing veterans have
    access to state-of-the-art prosthetic and adaptive devices.
        DAV supports this draft bill in accordance with DAV Resolution No.
    429, which supports sufficient funding for VA prosthetics and sensory
    aids service and timely delivery of prosthetic items, promoting
    physical activity and overall well-being among veterans, helping them
    to engage in sports and recreational activities that they enjoy.

          Draft bill, Service Dogs Assisting Veterans Act (SAVES Act)

        The SAVES Act would establish a 5-year pilot program to require the
    Secretary of Veterans Affairs to award grants to nonprofit
    organizations, accredited by Assistance Dogs International or the
    International Guide Dog Federation, to assist in providing service dogs
    to eligible veterans. The bill would also provide for the training of
    the dogs to assist veterans with various mental health and physical
    conditions. This bill would also provide each veteran who receives a
    dog through the grant program a commercially available veterinary
    insurance policy for the service dog.
        DAV supports this draft bill in accordance with DAV Resolution No.
    590, which supports a consistent benefit for service dogs, to include
    that any veteran for whom a service dog is prescribed receives the dog
    at no cost; there is reimbursement for any follow-up training deemed
    appropriate; and a veterinary benefit provided for the life of that
    service dog.

     Draft bill to make improvements relating to conflicts of interest for
                certain Department of Veterans Affairs employees

        This draft bill seeks to make improvements relating to conflicts of
    interest for certain VA employees.
        Currently, title 18, United States Code, Sec.  208 addresses
    conflicts of interest for Federal employees, including those at the VA.
    This law prohibits Federal employees from participating personally and
    substantially in any government matter that could affect their own
    financial interests or those of their family members, business
    partners, or organizations they are affiliated with. This law ensures
    that Federal employees, including VA researchers, maintain the highest
    standards of integrity and avoid any actions that could compromise
    their objectivity.
        In the past, researchers could freely discuss the science with both
    VA and their academic affiliate without conflict, except for the
    funding and research agreement. Recognizing their erroneous historical
    interpretation and the potential legal risks, the VA Office of General
    Counsel (OGC) concluded that science, funding, and research agreements
    are all crucial aspects of the matter. Due to this OGC decision,
    employees working on the matter or research topic must secure a waiver
    prior to proceeding.
        Initially planned for March, the policy's enforcement was deferred
    by VA until at least September 30, 2024. The absence of a policy for
    pursuing waivers at VA significantly impacts thousands of researchers
    by substantially delaying approval of research projects, as they
    require approval from both OGC and local VAMCs.
        Although DAV does not have a resolution specifically addressing
    conflict of interest matters for Federal/VA employees, research is a
    critical part of VA's mission of serving our Nation's ill and injured
    veterans. For these reasons, we suggest that measures taken to address
    this issue should focus on maintaining quality researchers and
    employees. VA must ensure that their work can continue without undue
    administrative burdens.
        This concludes my testimony on behalf of DAV. I am pleased to
    answer questions you or members of the Subcommittee may have.

                           Statements for the Record

                                  ----------

             Prepared Statement of U.S. Office of Government Ethics

        The U.S. Office of Government Ethics (OGE) is pleased to provide
    its views on proposed legislation to amend title 38, U.S. Code, to
    provide exceptions to the criminal conflict of interest laws, 18 U.S.C.
    Sec. Sec.  203, 205, and 208, for employees of the Department of
    Veterans Affairs (VA) who concurrently hold outside positions with
    certain outside employers. OGE has not reviewed and takes no position
    on other pending legislation being considered at this hearing.
        OGE appreciates VA's and the Subcommittee's ongoing work to address
    the complex balance between recruitment and retention of qualified VA
    medical personnel and the need to protect government processes from
    abuse and conflicts of interest. OGE is concerned, however, that the
    draft legislation does not effectively balance these competing
    equities. As written, the draft legislation would disturb the carefully
    balanced conflict of interest program that has existed for the past 60
    years by providing overly broad exemptive relief, reducing oversight
    and transparency in the process of waiving the conflict of interest
    laws, and creating inconsistent treatment between dually appointed VA
    scientists and other scientists. More importantly, OGE believes that
    the existing legal framework is flexible enough to provide exemptive
    relief in many cases in which there is a legitimately low risk of an
    actual conflict of interest.

    I. Current Law and Effect of Proposed Legislation

        Congress enacted 18 U.S.C. Sec. Sec.  203, 205, and 208 as part of
    omnibus legislation updating the Federal bribery, conflict of interest,
    and graft laws in 1962.\1\ These laws were promulgated carefully, with
    the goals of not only strengthening limitations on conflicts but also
    ensuring that the government could access qualified experts from
    outside government, particularly scientists.\2\
    ---------------------------------------------------------------------------
        \1\ Modern Bribery, Graft and Conflict of Interest Law, P.L. 87-
    849, 76 Stat. 1119 (1962). Additional conflict of interest laws are
    found in chapter 11, title 18, of the United States Code. Employees of
    the executive branch are also covered by comprehensive standards of
    conduct found in 5 C.F.R. part 2635.
        \2\ H. Rep. 748, 87th Cong., 1st Sess. 4 (1961); S. Rep. No. 2213,
    87th Cong., 2d Sess. (1962).
    ---------------------------------------------------------------------------
        Section 208 provides that an employee may not participate in any
    particular matter in which, to the employee's knowledge, the employee,
    a spouse, minor child, general partner, or any ``organization in which
    [the employee] is serving as officer, director, trustee, general
    partner or employee, or any person or organization with whom [the
    employee] is negotiating or has any arrangement concerning prospective
    employment'' has a financial interest.\3\ While the prohibition is
    broad, it provides several authorities that allow OGE or an agency to
    waive insubstantial conflicts of interest. These authorities include
    personalized waivers\4\ and regulatory exemptions.\5\ The draft
    legislation would change this framework by creating two special
    exemptions at 38 U.S.C. Sec. Sec.  7302(f)(1) and 7303(e)(1) that would
    allow dually appointed VA employees to participate in health profession
    education and research particular matters affecting the financial
    interests of their outside employers--so long as they do not make a
    final, binding determination related to that matter--notwithstanding 18
    U.S.C. Sec.  208(a).
    ---------------------------------------------------------------------------
        \3\ 18 U.S.C. Sec.  208(a). For OGE regulations interpreting and
    providing guidance on Sec.  208, see 5 C.F.R. pt. 2640.
        \4\ 18 U.S.C. Sec.  208(b)(1). Agencies must confer with OGE prior
    to issuance of an individualized waiver whenever practicable, provide
    OGE with a copy of each executed waiver, and make each executed waiver
    available to the public upon request. OGE is committed to reviewing
    waivers as fast as possible while meeting its responsibility to
    objectively review the facts of each case to ensure the statutory
    standard is met.
        \5\ 18 U.S.C. Sec.  208(b)(2).
    ---------------------------------------------------------------------------
        Section 205 provides that an employee may not represent an outside
    party before the Federal Government in relation to any particular
    matter in which the United States has a direct and substantial
    interest.\6\ Section 203 provides that an employee may not receive any
    compensation for representational services provided by themselves or
    another person in any particular matter in which the United States has
    a direct and substantial interest.\7\ Although these two laws apply to
    all government employees, there are several exemptions, including
    exemptions for intermittent and temporary appointees.\8\ These
    exemptions balance the need for specialized expertise from outside the
    government with the need to prevent these employees from using their
    positions to unfairly advantage their outside employer. The draft
    legislation would change this framework by creating two special
    exemptions at 38 U.S.C. Sec. Sec.  7302(f)(2) and 7303(e)(2), allowing
    dually appointed VA employees to lobby the government on behalf of
    their outside employers on health profession education and research
    matters, as well as receive compensation for those communications,
    notwithstanding 18 U.S.C. Sec. Sec.  203 and 205.
    ---------------------------------------------------------------------------
        \6\ 18 U.S.C. Sec.  205(a)(2).
        \7\ 18 U.S.C. Sec.  203(a).
        \8\ 18 U.S.C. Sec. Sec.  203(c), (e); 18 U.S.C. Sec. Sec.  205(c),
    (f).

    ---------------------------------------------------------------------------
    II. Concerns Regarding Proposed Legislation

        OGE is concerned that the draft legislative exemptions to 18 U.S.C.
    Sec. Sec.  203, 205, and 208 are overbroad and lack the necessary
    protections against substantial conflicts of interest found in current
    law. Unlike current exemptions to 18 U.S.C. Sec.  208, which are only
    available when a conflict of interest is insubstantial, remote, or
    inconsequential,\9\ the proposed legislation would allow an employee to
    participate in any health profession education or research particular
    matter regardless of how substantial the potential financial gain to
    their home institution--potentially including multi-million-dollar
    contracts, grants, cooperative agreements, and other financial
    assistance arrangements. In addition, by enacting exemptions to 18
    U.S.C. Sec. Sec.  203 and 205, dually appointed VA employees would be
    free to both lobby for benefits on behalf of their outside employer and
    participate in the decision to grant those same benefits in their
    official role, so long as they were not the final signatory. Without
    necessary safeguards, dually appointed VA researchers could be placed
    in the position of making decisions not because it is the right thing
    to do, but because it advantages their home institution.
    ---------------------------------------------------------------------------
        \9\ See 18 U.S.C. Sec.  208(b)(1)-(2).
    ---------------------------------------------------------------------------
        OGE is also concerned that the draft legislation would remove
    important checks and balances that ensure that waivers and exemptions
    are done in an accountable and transparent way. For example, agencies
    are currently required to consult with OGE prior to issuing individual
    waivers when practicable and must make those waivers public upon
    request.\10\ Likewise, OGE provides centralized review and issuance of
    regulatory exemptions to 18 U.S.C. Sec.  208.\11\ OGE's involvement
    ensures that those waivers and exemptions are consistent with the
    statutory criteria and that these authorities are not subject to abuse.
    The proposed legislation does not contain similar checks and balances
    as the existing conflicts of interest statutes.
    ---------------------------------------------------------------------------
        \10\ 18 U.S.C. Sec.  208(d)(1).
        \11\ 18 U.S.C. Sec.  208(b)(2).
    ---------------------------------------------------------------------------
        OGE is likewise concerned that the draft legislation would treat
    dually appointed VA researchers differently than other VA employees and
    other scientists and medical professionals that work for other
    agencies.\12\ Avoiding inconsistent treatment and a proliferation of
    ``nonuniform ad hoc exemptions'' was one of the principal reasons
    Congress established a single, uniform set of conflict of interest
    rules.\13\
    ---------------------------------------------------------------------------
        \12\ Congress recently enacted a limited exemption to 18 U.S.C.
    Sec.  209 for dually appointed VA researchers. See Consolidated
    Appropriations Act, 2023, P.L. 117-328, Sec.  182, 136 Stat. 5436
    (2023) (codified at 38 U.S.C. Sec.  7382(b)). While that provision has
    no effect on the views in this statement, OGE notes that there are more
    safeguards that apply to that provision than are found in this draft
    legislation, including a requirement that the Secretary authorize use
    of the exemption in writing.
        \13\ H. Rep. No. 748 at 14.
    ---------------------------------------------------------------------------
        Finally, OGE believes that the legislation may be unnecessary. In
    instances in which a conflict of interest arising from a health
    professional education or research particular matter is insubstantial,
    remote, or inconsequential, the VA can issue an individualized waiver
    or may be able to work with OGE to promulgate an appropriately scoped
    regulatory exemption. Likewise, dually appointed VA employees serving
    only intermittently with the government may be able to rely on a pre-
    existing exemption or receive an individualized waiver of 18 U.S.C.
    Sec. Sec.  203 and 205 to communicate on a grant or contract with the
    United States if the VA Secretary has determined it is in the public
    interest.
        OGE thanks the Subcommittee for the opportunity to present views
    related to this draft legislation. OGE stands ready to work with the
    Subcommittee and with VA to identify and implement procedures that
    ensure the VA can continue to retain qualified VA researchers, while
    also limiting the influence of conflicts of interest in the research
    and education process. We believe that an approach is possible that
    will appropriately balance the needs to secure qualified medical
    professionals while protecting Government processes from abuse and
    conflicts of interest.
        Please do not hesitate to contact us if we may be of additional
    assistance.

    Prepared Statement of American Federation of Government Employees, AFL-
                                      CIO

        Chairwoman Miller-Meeks, Ranking Member Brownley, and Members of
    the Subcommittee:

        The American Federation of Government Employees, AFL-CIO (AFGE) and
    its National Veterans Affairs Council (NVAC) appreciate the opportunity
    to submit a statement for the record for the September 11 House
    Veterans' Affairs Health subcommittee legislative hearing. AFGE
    represents more than 750,000 Federal and District of Columbia
    government employees, 304,000 of whom are Department of Veterans
    Affairs (VA) employees. AFGE's positions on several of the bills being
    considered are below:

    H.R. 9146, Ensuring Continuity in Veterans Health Act (Rep. Franklin)

        H.R. 9146 requires the Secretary to include ``continuity of care''
    as one of the criteria used to determine when private care would be in
    the best medical interest (BMI) of a veteran. We oppose this provision
    because it will make it harder for VA to bring veterans back to VA from
    private care in instances when private care is no longer in the best
    interest of the veteran by requiring that continuity of care in the
    community be considered as a criterion in determining medical best
    interest. This would hamper VA's efforts to reverse excessive
    privatization by bringing back more veterans to direct care after
    receiving private for-profit care. VA already has flexibility under the
    current statute to consider continuity of care if it is in the best
    interest of the veteran. But adding it as a required criterion in
    determining best interest would limit VA's ability to decide that
    transferring a veteran back to the VA from private care is truly in the
    best interest of that veteran. This would particularly impact the VA's
    ability to rein in costly private care following emergency care by
    transferring veterans to VA hospitals after a veteran has been
    stabilized. In a recent Hospital Consumer Assessment of Healthcare
    Providers and Systems (HCAHPS) survey conducted by the Centers for
    Medicare & Medicaid Services, nearly 80 percent of VA medical
    facilities received a four or five-star rating compared to only 40
    percent of non--VA hospitals. This only adds to an already large body
    of evidence that VA provides higher quality care to veterans than
    private providers. It therefore is neither in the best interest of the
    veteran nor the taxpayer to legislate keeping veterans out of VA where
    they receive high-quality care specifically targeted to their needs at
    lower cost than private for-profit care.

    H.R. 6330, the Veterans Sentinel Act

        H.R. 6330 establishes an Office of Mental Health and Suicide
    Prevention, a pilot program under which the Secretary establishes a
    working group to collect and analyze data regarding on-campus suicides
    and on-campus attempted suicides. AFGE supports efforts to improve
    suicide prevention by collecting data on direct care suicides and
    conducting root cause analysis. However, the bill should be amended to
    include parallel data collection and analysis for suicides that happen
    when veterans are served at non-VA facilities.

    Pilot program to fill vacancies with non-departmental staff

        This bill creates a pilot program under which the Secretary would
    contract out to fill vacancies at a medical facility with non-
    department health care providers. This would create a new program that
    fills vacancies with non-department health care workers in addition to
    the Integrated Critical Staffing Program (ICSP) for temporary
    contractors, which the VA already has in place. The ICSP has already
    created a troubling precedent for outsourcing hiring at the expense of
    permanent staff. In recent months, VA directed medical centers to
    remain FTE-neutral, a policy it applied to permanent workers but not to
    contractors. VA has admitted that it needs an additional 5,000 FTE in
    Fiscal Year 2025 to meet its direct care needs. If VA continues rely on
    this privatization accounting scheme to hire contractors to meet these
    needs and not permanent workers, contract workers will effectively
    crowd out funding for permanent FTE. Rather than further expanding
    costly temporary staffing, the VA should pass a comprehensive
    recruitment and retention bill that addresses problematic hiring and
    compensation policies.

    Veterans' Mental Health Access Act (Chairman Bost)

        The Veterans' Mental Health Access Act would create a pilot for a
    new program to create non-VA outpatient mental health. This program
    would provide grants to nonprofit organizations that have operated at
    least one outpatient mental health facility in the United States for a
    continuous period of at least 3 years. AFGE opposes creating a parallel
    private mental health program that supplants VA's direct care system
    rather than supplement it when veterans cannot reasonably access VA
    care. Veterans are already eligible for private care if the VA cannot
    provide it within 20 days or 30 minutes of drive time. VA, however,
    must authorize this care. This bill would undermine the direct care
    system by creating a parallel private program that veterans would
    access without VA authorization. This would erode the integrity of the
    VA's integrated delivery system which depends on VA to coordinate
    veterans' care. Finally, the bill does not include quality or licensing
    standards for these providers. Rather than create a private, standard-
    free program for mental health outpatient treatment, Congress should
    invest in direct care mental health by funding additional VA mental
    health providers.

    H.R. 9438, the No Wrong Door for Veterans Act,

        H.R. 9438 would amend and reauthorize the VA Staff Sergeant Parker
    Gordon Fox Suicide Prevention Grant Program which supports nonprofit
    community organizations and government agencies that identify at-risk
    veterans and provide an array of suicide prevention interventions such
    as suicide risk education and peer support services. The focus of the
    program is on supplementing VA's clinical program with community-based
    prevention programs.
        H.R. 9438 introduces a new 72-hour deadline for the VA to provide
    services after a veteran is referred for follow-up care. If the VA
    can't meet this deadline, the veteran becomes eligible for private
    care. This drastically reduces the wait time for VA mental health care
    from the current 20 days (under the MISSION Act) to just 3 days. This
    new standard is impossible for the VA to consistently meet. We have
    opposed other provisions like this. Again, Congress should instead fund
    additional VA mental health providers.
        AFGE looks forward to working with members of the health
    subcommittee to advance legislation that strengthens the VA workforce
    to improve veteran care.

     Prepared Statement of American Psychological Association, Association
    of VA Psychologist Leaders, Association of VA Social Workers, National
        Association of Veterans Affairs Physicians and Dentists, Nurses
     Organization of Veterans Affairs, Veterans Healthcare Policy Institute

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                        Prepared Statement of Jason Crow

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

       Prepared Statement of National Association of State Veterans Homes

    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                     [all]