[Senate Hearing 118-217]
[From the U.S. Government Publishing Office]


                                                          S. Hrg. 118-217

                HEARING TO CONSIDER PENDING LEGISLATION

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                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________

                             JULY 12, 2023

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
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        Available via the World Wide Web: http://www.govinfo.gov
        
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                 SENATE COMMITTEE ON VETERANS' AFFAIRS

                     Jon Tester, Montana, Chairman
Patty Murray, Washington             Jerry Moran, Kansas, Ranking 
Bernard Sanders, Vermont                 Member
Sherrod Brown, Ohio                  John Boozman, Arkansas
Richard Blumenthal, Connecticut      Bill Cassidy, Louisiana
Mazie K. Hirono, Hawaii              Mike Rounds, South Dakota
Joe Manchin III, West Virginia       Thom Tillis, North Carolina
Kyrsten Sinema, Arizona              Dan Sullivan, Alaska
Margaret Wood Hassan, New Hampshire  Marsha Blackburn, Tennessee
Angus S. King, Jr., Maine            Kevin Cramer, North Dakota
                                     Tommy Tuberville, Alabama
                      Tony McClain, Staff Director
               David Shearman, Republican Staff Director
                            
                            
                            C O N T E N T S

                              ----------                              

                             July 12, 2023

                                SENATORS

                                                                   Page
Hon. Margaret Wood Hassan, U.S. Senator from New Hampshire.......     1
Hon. Jerry Moran, Ranking Member, U.S. Senator from Kansas.......     1
Hon. Tommy Tuberville, U.S. Senator from Alabama.................     6
Hon. Angus S. King, Jr., U.S. Senator from Maine.................     8
Hon. John Boozman, U.S. Senator from Arkansas....................    10
Hon. Jon Tester, Chairman, U.S. Senator from Montana.............    13
Hon. Patty Murray, U.S. Senator from Washington..................    16
Hon. Richard Blumenthal, U.S. Senator from Connecticut...........    20
Hon. Kyrsten Sinema, U.S. Senator from Arizona...................    21

                               WITNESSES
                                Panel I

Miguel LaPuz, MD, Assistant Under Secretary for Health for 
  Integrated Veteran Care, Veterans Health Administration, 
  Department of Veterans Affairs; accompanied by Matthew Miller, 
  PhD, Executive Director, VA Suicide Prevention Program, Office 
  of Mental Health and Suicide Prevention; Cynthia Gantt, PhD, 
  Deputy Director, Office of Patient Centered Care and Cultural 
  Transformation; and Leslie Sofocleous, PhD, Executive Director, 
  Program Management Office, EHRM-Integration Office.............     3

                                Panel II

Jon Retzer, Assistant National Legislative Director, Disabled 
  American Veterans..............................................    11

Meggan Thomas, Associate Director, National Legislative Service, 
  Veterans of Foreign Wars.......................................    13

Jim Lorraine, President and CEO, America's Warrior Partnership...    14

                                APPENDIX
                             Hearing Agenda

List of Pending Bills............................................    31

                          Prepared Statements

Miguel LaPuz, MD, Assistant Under Secretary for Health for 
  Integrated Veteran Care, Veterans Health Administration, 
  Department of Veterans Affairs.................................    35

Jon Retzer, Assistant National Legislative Director, Disabled 
  American Veterans..............................................   100

Meggan Thomas, Associate Director, National Legislative Service, 
  Veterans of Foreign Wars.......................................   116

Jim Lorraine, President and CEO, America's Warrior Partnership...   123

                        Questions for the Record

Department of Veterans Affairs response to questions submitted 
  by:

  Hon. Angus S. King, Jr.........................................   137

                       Statements for the Record

American Optometric Association, Ronald Benner, O.D., President..   141

Coalition letter representing American Seniors Housing 
  Association (ASHA), Argentum, Leading Age, and National Center 
  for Assisted Living (NCAL).....................................   144

D'Aniello Institute for Veterans and Military Families (IVMF) at 
  Syracuse University............................................   147

Lyft, Buck Poropatich, Head of Lyft Healthcare...................   151

Multiple Independent Organizations...............................   154

National Coalition for Homeless Veterans (NCHV)..................   170

New England Center and Home for Veterans (NECHV).................   173

Paralyzed Veterans of America (PVA)..............................   177

 
                      HEARING TO CONSIDER PENDING.
                              LEGISLATION

                              ----------                              


                        WEDNESDAY, JULY 12, 2023

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3 p.m., in Room 
SR-418, Russell Senate Office Building, Hon. Jon Tester, 
Chairman of the Committee, presiding.

    Present: Senators Tester, Murray, Brown, Blumenthal, 
Sinema, Hassan, King, Moran, Boozman, Cassidy, and Tuberville.

                  SENATOR MARGARET WOOD HASSAN

    Senator Hassan [presiding]. This hearing will now come to 
order, and I will now turn the hearing over to Ranking Member 
Moran for his opening remarks, and then we will proceed with 
introduction of witnesses.
    Senator Moran. Already this is moving more smoothly than 
when Senator Tester is here.
    Senator Hassan. This is true.

            OPENING STATEMENT OF SENATOR JERRY MORAN

    Senator Moran. Thank you very much, Senator Hassan, and 
thank you to our panelists, and thank you to Senator Tester for 
calling this meeting. Good afternoon to all of you.
    We have a full list of bills to consider this afternoon, 
and I look forward to hearing about each of them and how they 
will improve the care that veterans receive. I continue to hear 
from veterans in Kansas and across the country who face what 
are unacceptable barriers to accessing timely, quality health 
care that they need.
    For example, we heard from one veteran who called the 
Veteran Crisis Line in 2021, and is still waiting for the VA to 
call him to schedule a follow-up mental health care. We heard 
from another veteran who paid several thousand dollars for 
dental care outside of the VA because the VA dental exam room 
could not accommodate her wheelchair. The VA has refused to 
issue her a Community Care referral. We heard from yet another 
veteran who asked for a referral to a rehab program at a non-VA 
facility in his rural community that had an opening for him but 
was told to wait several weeks for a bed at a VA facility in 
another state, hours away.
    These are just three stories, but they are alarmingly 
common. I have always told people that what I know about what 
is going on at the VA and what is going on in veterans' lives 
is by the conversations I have with Kansas veterans, and these 
are stories that they bring to me.
    I have introduced a couple of bills that are on today's 
agenda as a result of those kind of circumstances. S. 1315, the 
Veterans' Health Empowerment, Access, Leadership, and 
Transparency for our Heroes (HEALTH Act) would codify the 
current Community Care access standards, educate veterans on 
their rights to seek community care, hold the VA accountable 
for providing timely access to care, and help the VA keep pace 
with the best practices for modern medical care in DoD, CMS, 
and the private sector.
    The Veterans HEALTH Act is bipartisan, and I appreciate my 
colleague, Senator Sinema, for working with me on this 
legislation. This bill is also widely supported by veterans' 
organizations including the American Warrior Partnership, and I 
am grateful to Jim Lorraine, who we will hear from on the 
second panel. He is the President and Chief Executive Officer 
of AWP and will testify shortly.
    And because no health care system in the 21st century can 
provide world-class services without a safe top-notch IT 
system, S. 1037, my VA Electronic Health Record Modernization 
Standardization and Accountability Act would establish a clear 
and consistent set of safeguards that must be met before VA can 
move forward with implementing the new Oracle Cerner electronic 
health record. Ultimately, this bill facilitates a more 
thoughtful and evidence-based implementation, increasing the 
likelihood of success, and improve patient outcomes in the long 
run.
    Chairman Tester has bills on today's agenda that are 
similar in certain ways to both of these, the Veteran Health 
Act and the VA Electronic Health Record Modernization Act, 
which suggests to me that we can find a path forward working 
together. I look forward to working together with all my 
colleagues on this Committee and the Senate as we work to 
negotiate a strong bipartisan and fiscally responsible 
legislative package that contains the best of our bills and the 
many others that we will discuss this afternoon.
    And I thank you all for being here, and I yield back.

    [The pending bills referred to by Senator Moran appear on 
page 31 of the Appendix.]

    Senator Hassan. Thank you, Ranking Member Moran, and I will 
note, too, that there is obviously a lot of bipartisanship on 
this Committee, and as we hear about pending legislation today 
I look forward to finding ways we can all work together.
    With that I want to welcome the first panel to today's 
hearing. Dr. Miguel LaPuz, Assistant Under Secretary for Health 
for Integrated Veteran Care, will be VA's lead witness today. 
He is accompanied by Dr. Matthew Miller, Director of Suicide 
Prevention Program, Office of Mental Health and Suicide 
Prevention; Dr. Cynthia Gantt, Deputy Director of the Office of 
Patient Centered Care and Cultural Transformation within 
Patient Care Services; and Dr. Leslie Sofocleous, who is 
Executive Director for the Program Management Office of the 
EHRM-Integration Office.
    Dr. LaPuz, please begin.

                            PANEL I

                              ----------                              


   STATEMENT OF MIGUEL LAPUZ ACCOMPANIED BY MATTHEW MILLER; 
              CYNTHIA GANTT; AND LESLIE SOFOCLEOUS

    Dr. LaPuz. Good afternoon, Senator Hassan, Ranking Member 
Moran, and members of the Committee. I appreciate the 
opportunity to discuss VA's views on pending legislation 
regarding health care benefits. I am accompanied today by Dr. 
Matthew Miller, Executive Director of VA Suicide Prevention, 
Office of Mental Health and Suicide Prevention; Dr. Cynthia 
Gantt, Deputy Director of Patient Centered Care and Cultural 
Transformation, Office of Patient Care Services; and Dr. Leslie 
Sofocleous, Executive Director, Program Management Office, 
Electronic Health Record Modernization Integration Office.
    There are 19 bills on the agenda today, covering a range of 
issues and programs. My written statement provides more 
detailed information on nearly all of these bills, but I would 
like to take a few moments to raise some issues of general 
applicability to these bills, and particularly for the Veterans 
HEALTH Act and the Making Community Care Work for Veterans Act.
    While we agree with the spirit of improving access and 
delivery of care to all veterans, there are several provisions 
in the aforementioned bills that VA does not support because 
statutorily mandating these efforts would impede VA's ability 
to furnish clinically appropriate and timely care to veterans.
    Nearly 6 years ago, a predecessor of mine sat before this 
Committee and articulated a few principles that VA believed 
should be reflected in legislation that would ultimately become 
the VA MISSION Act of 2018. One of these principles was the 
idea that VA needs to retain flexibility to adjust and adapt to 
an evolving health care landscape. Legislation that is too 
prescriptive in terms of rules, responsibilities, or processes 
can only limit our options in the future, which would lead to 
frustration from our veterans, our community providers, and VA 
employees. We believe that the best legislation would provide 
broad, general authority that VA could define and implement 
through regulations, policies, and contracts.
    These themes still ring true today. The Secretary and Under 
Secretary of Health have made ensuring veterans receive timely, 
appropriate, and accessible care a top priority. Each veteran's 
needs are different, and to best serve veterans we need the 
flexibility to respond to those needs.
    Regarding the two electronic health record modernization 
bills, VA is committed to continued improvement of this 
program, and we are keeping you and your staff and key 
stakeholders informed of these efforts. Health care, and 
particularly health care information technology, is dynamic and 
needs to be responsive to veterans' and clinicians' needs. We 
strongly caution against enacting requirements that may address 
today's situation but could create unintended outcomes in the 
future.
    VA appreciate this Committee's willingness to engage on 
these bills. There are many examples of where these efforts 
have borne fruit, including the Expanding Veterans' Options for 
Long Term Care Act.
    We look forward to discussing VA's perspectives concerning 
the bills on the agenda, and we would welcome the opportunity 
to continue collaborating on how we can improve delivery of 
care and services to our Nation's veterans and their families.
    We thank the Committee for its continued support, and this 
concludes my statement.

    [The prepared statement of Dr. LaPuz appears on page 35 of 
the Appendix.]

    Senator Hassan. Well, thank you very much. I think we can 
proceed to questions from here, and I will go ahead and start 
and then, Senator Moran, you can follow. And I want to again 
thank all of our witnesses not only for being here but for your 
work and for the teams that you lead on behalf of our country's 
veterans.
    Dr. LaPuz, I want to start with a question that highlights 
a Granite State veteran and his service dog, Duchess. Tim 
Carignan of Lyman, New Hampshire, reached out to my office last 
year because he was having difficulty obtaining insurance 
coverage for Duchess, his service dog, through the VA, 
something that the VA does for veterans. My office was able to 
coordinate with local and regional VA representatives to fix 
the problem. The insurance coverage was made possible through 
the Puppies Assisting Wounded Servicemembers for Veterans 
Therapy Act, known as the PAWS Act, a bipartisan bill that I 
co-sponsored and Senator Tillis introduced, that passed into 
law in 2021.
    Now I am joining Senator Tillis and colleagues to support a 
follow-up bill that would further expand access to trained 
service dogs for veterans. Can you talk about how the VA 
coordinates between health care providers and nonprofit 
organizations that train service dogs to ensure that veterans 
who need them can receive service dogs as soon as possible?
    Dr. LaPuz. Ma'am, in reference to the service dogs, we are 
in the process of developing, in VA, the opinion on how we are 
going to proceed with that, so I apologize for not being ready 
to discuss that at this point.
    Senator Hassan. Well, I appreciate that. Let's follow up 
with a conversation because obviously this was passed in 2021. 
We know how useful service dogs can be for our veterans, and 
something like this barrier that prevented requisite insurance 
for the dog made it hard for this particular veteran to get 
that kind of service. And we are seeing more and more training 
efforts to get the dogs to veterans, so I hope you will treat 
it with some urgency, and I would look forward to working with 
you on it.
    Dr. LaPuz. We understand, Senator, and we look forward to 
having a discussion with the Committee.


------------------------------------------------------------------------
 
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VHA Response: Have contacted the Senators office twice to schedule
 briefing. Will continue to work this due-out with the Senators office
 (Melissa Reilly-Diakun).
------------------------------------------------------------------------


    Senator Hassan. Okay. Thank you. Second question for you, 
Doctor. The VA provides veterans with numerous benefits and 
different types of care, but veterans seeking health care may 
not be aware of the other benefits and wraparound services that 
are available to them. These wraparound services could include 
things like transportation, food or housing assistance, and 
various support groups.
    Today I joined Senator Sullivan in introducing the 
bipartisan Leveraging Integrated Networks in Communities for 
Veterans Act, which aims to improve the VA's ability to 
coordinate across these different services. So how can Congress 
and the VA work to facilitate better coordination for getting 
veterans wraparound services?
    Dr. LaPuz. We appreciate your concern, Senator, regarding 
wraparound services, particularly those that will more or less 
address the socioeconomic determinants of health. And we have a 
program in the VA which is already assessing the requirements 
of our veterans in order to ensure that they have services that 
will customarily not be available, and we call that initiative 
ACORN.
    We have already 5,000 veterans that have gone through that 
process, and we can have a conversation with the Committee 
regarding the progress of ACORN. But the reason why we feel 
that this is a redundant legislation, redundant in terms of 
what the VA is already doing, and we are hoping that we can 
share with the Committee the results of these before we 
actually have any legislation.
    So we are looking forward to having a discussion regarding 
the existing programs that already are addressing the 
socioeconomic determinants of health.
    Senator Hassan. Well, I appreciate that, but again, this is 
about getting those full wraparound services that are already 
out there, and making sure that our veterans get them. So I 
would look forward to talking with you more about that, but in 
my experience sometimes until we pass legislation we do not get 
the full scale of services that we are looking for.
    Let me just finish with one more question. Another example 
of the need for that coordination that we were just talking 
about is that often a veteran in New Hampshire, which, as you 
know, does not have a full-service VA hospital, will be seen at 
a local hospital for urgent health concerns, but that hospital 
may not have the experience needed to coordinate care through 
the VA.
    As a result, the Manchester VA Medical Center in New 
Hampshire recently began embedding a VA care navigation team at 
one of the nearby hospitals. I believe this model could help 
other facilities connect veterans with wraparound services as 
well, and the LINC for Veterans Act, the one we just 
referenced, aims to do that.
    How could care navigation teams like the one at Manchester 
help veterans across the country access wraparound services?
    Dr. LaPuz. We have learned from the experience in 
Manchester that you were referring to, Senator, and in fact we 
have several pilots that are mimicking what is happening in 
Manchester, and this is in our coordinating and optimizing 
emergency department care as part of that initiative, which is 
what we refer to as COED initiatives.
    So we are hoping that we are going to learn from all of the 
pilots that are happening across the country because we do have 
several hospitals in Pennsylvania, for example, that are doing 
exactly similar initiatives that you have referred to in 
Manchester. So with that we will learn, in VHA, how to proceed 
to ensure that we do have wraparound services, particularly for 
those who have been admitted to non-VA hospitals.
    Senator Hassan. Well, let's keep working on that together, 
and I appreciate very much the work that you all around doing.
    Senator Moran.
    Senator Moran. Thank you, Senator Hassan. If Senator 
Tuberville would like, I would be happy to yield to him to ask 
questions.

                    SENATOR TOMMY TUBERVILLE

    Senator Tuberville. Let's do it. Thank you. Thank you to 
the witnesses for being here today to talk about this pending 
legislation. It is very important for veterans all across the 
country.
    Dr. LaPuz, I co-sponsored Senator Blackburn's Veterans 
Health Care Freedom Act because I support veterans accessing 
the doctor of their choice, whether a doctor is at the VA or in 
their community. I understand frequently the veterans enrolled 
in the VA health care are not educated on access to care in the 
community. While the VA has taken the position to oppose this 
legislation, the fact remains that the MISSION Act gives 
eligible veterans the right to access community care.
    Doctor, what trainings have the VA providers undergone to 
ensure they are open with the veterans on their eligibility for 
community care? Any training that has gone on?
    Dr. LaPuz. Yes, Senator. We have trained every one of our 
schedulers--it is a rather extensive training--to ensure that 
the schedulers have a good understanding of the eligibility for 
community care. So we have extensive training for that, 
Senator.
    Senator Tuberville. Are you getting good feedback from 
that, do you know?
    Dr. LaPuz. Generally. Our schedulers are able to perform 
quite well in their jobs. We do have a lot of dedicated 
employees that are performing to the best of their ability, and 
the majority of the time they are able to inform veterans 
regarding eligibility and community care appropriately.
    Senator Tuberville. Do you know of any post-appointment 
surveys that we do to get their feedback from the veterans 
after they have been to the VAs?
    Dr. LaPuz. Not to that question, Senator, but we have V-
Signals, which is like a survey after a veteran has visited our 
clinic as well as after a veteran has visited community care 
clinics. So we do have the feedback regarding the care that 
they have received, whether that is in-house or in the 
community care.
    Senator Tuberville. Yes. And that is the best way to get 
better is find out what you did right and what you did wrong.
    Dr. LaPuz. Yes, sir.
    Senator Tuberville. Dr. Miller, as you know, Operation Deep 
Dive, conducted by Duke University and America's Warrior 
Partnership, requires information from the VA that is vital to 
their analysis on veteran suicide rates across the country. 
What information has the VA provided to America's Warrior 
Partnership so far, and what additional data does the VA plan 
to provide?
    Dr. Miller. Thanks for the question. There has been a 
rather extensive history of correspondence and dialogue with 
AWP and Operation Deep Dive regarding this issue. I would be 
happy to present the full history, documentation to you, 
including present state and planned future state.


------------------------------------------------------------------------
 
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VHA Response: Briefing on Operation Deep Dive scheduled for August 29th
 1-2 PM. (Riley Hambrick & Kaitlin Stoddard).
------------------------------------------------------------------------


    Senator Tuberville. Do you think it is working, you know, 
getting that data? Is it helping? Are we learning from it, do 
you know of?
    Dr. Miller. I think what we are learning, and this gets to 
the More than Just the Number Act, I think that what we are 
learning is there is room for improvement in terms of data 
validity and speed coming from states and coming into the 
Federal network. And, therefore, you will see us supporting 
stipulations within the More than Just the Number Act.
    Senator Tuberville. Does the VA have concerns about sharing 
this data with other people? Are there concerns?
    Dr. Miller. By ``this data'' I would probably need more 
specifics, to answer that specifically. However, we do protect 
veteran data to the fullest extent possible for the benefit of 
veterans and for the mission. Now within that, then, we also 
seek to be as transparent as possible to promote the mission, 
which includes partnerships with other collaborators such as 
AWP.
    Senator Tuberville. Thank you. Dr. LaPuz, among many 
things, the HEALTH Act will allow veterans experiencing 
substance use disorder to access care in the community without 
first receiving a referral from the VA. Testimony states that 
the VA cannot support codification of residential treatment and 
rehabilitation services as proposed in this bill, and that the 
VA generally supports establishing a wait time standard of 10 
or fewer days for the delivery of such treatment and services, 
although the VA opposes codifying this timeline into law.
    Given that veterans experiencing substance use disorder 
require help immediately, why does the VA want to keep 
bureaucratic red tape in place before a veteran can get help?
    Dr. LaPuz. So, Senator, just like any other treatment 
modality there is a requirement to fully assess the veteran and 
have an idea of how you are going to meet the veteran's need, 
and this is just part of the clinical requirements. So we would 
like to make sure that we have a very good assessment of the 
veteran's needs before we actually have a remedy for that kind 
of condition, and that includes substance use disorder.
    So in our minds, we would prefer for the VA to actually 
maintain that flexibility so then we can make sure that there 
is appropriate clinical determination of the veteran's needs.
    Senator Tuberville. Why is the VA opposed to codifying a 
wait time standard for rehabilitation services? Why are we 
opposed to that?
    Dr. LaPuz. Codifying the standards really limits the 
authority of the Secretary to determine what is required for 
veterans' care. And we all know that the health care landscape 
changes, and it is important to the VA for the Secretary to 
maintain that authority, to make a determination on what will 
be needed in order to take care of veterans' needs at that 
particular point in time.
    Senator Tuberville. Thank you. I apologize, Madam Chair, 
for going a little long. Thank you.
    Senator Hassan. Thank you. Senator King.

                   SENATOR ANGUS S. KING, JR.

    Senator King. Thank you, Madam Chair.
    One of the bills before the Committee today involves 
reimbursement for domiciliary care for veterans with dementia, 
and this is something that Maine veterans' homes undertook. On 
January 5, 2021, the President signed the Johnny Isakson and 
David P. Rowe Veterans Health Care Act. It had, in Section 
3007, ``the VA to allow a waiver for eligible veterans to 
receive per diem payments for domiciliary care.'' So far, so 
good. January 5, 2021.
    As of today, no rules have been issued by the Veterans 
Administration to implement this law. This was not a suggestion 
from the United States Congress. This was a law, and we are 
still waiting.
    So I have a bill in before this Committee that would 
mandate that the rules be issued. The Veterans Administration, 
for reasons that escape me, are opposing this rule. That takes 
a lot of nerve. Just issue the damn rule. And if you are going 
to issue the rule, do it. Otherwise, we are going to pass this 
bill. But it is a damn shame that we have to pass a second bill 
to implement a bill that we already passed. So what is the 
problem here?
    Dr. Gantt. Senator, VA is not supporting this bill because 
we are actively, as you mentioned, working on regulations----
    Senator King. Define ``active.'' It was 2021. Let's see. We 
are 2 \1/2\ years later. That is not very active.
    Dr. Gantt. And----
    Senator King. Eisenhower retook Europe in 11 months.
    Dr. Gantt. Yes, sir.
    Senator King. So active? Are you active? Give me a date.
    Dr. Gantt. I cannot----
    Senator King. August 1st?
    Dr. Gantt. I cannot give you a date today.
    Senator King. September 1st? Well, I guess we are going to 
have to pass the bill.
    Dr. Gantt. I will say, Senator, we are continuing to 
coordinate with this, as you know, the state veterans' homes 
also, to make sure that piece--and we absolutely do support 
this type of care, making sure that we have this, and we have 
the coordination that is required with the state veterans' 
homes.
    Senator King. Well, I am delighted to hear that, and I am 
delighted to hear about the coordination, but the veterans' 
homes, the DAV, the VFW, all support the bill that I am talking 
about, in order to move your agency to issue the rules so that 
we can give the veterans the care that they deserve. So as you 
can tell, this is not acceptable. So you said ``actively,'' I 
will take you at your word and consider that a commitment to 
move on this matter in the immediate future, and that means in 
the next several months.
    Dr. Gantt. Yes, sir.
    Senator King. Agreed?
    Dr. Gantt. Yes, sir.
    Senator King. Thank you. Thank you, Madam Chair.
    Senator Hassan. Thank you, Senator King.
    Senator Moran.
    Senator Moran. Thank you, Senator Hassan. Thank you, 
Senator King, for highlighting the challenge that we have, even 
when we do pass laws. And Dr. LaPuz, I had not planned on 
speaking about anybody else's legislation, but the suggestion 
that we do not want law because it changes so quickly, you 
could say the same thing. You do not want rules because 
tomorrow may be different.
    Congress has a responsibility to give direction to the VA. 
We do it based upon our best abilities and the information that 
we have. And I find it--``offensive'' is not the right word, 
but it saddens me that a bill that, even if you support it you 
do not want the Congress to be giving you directions. It is a 
significant part of our responsibility on behalf of those we 
serve.
    Let me ask you, Doctor, I heard a lot recently from the VA 
about the need for timely medical documentation from community 
care providers. I could not agree more about the importance of 
that, and there are challenges with how we communicate between 
a community care provider and the VA.
    I want to highlight an issue that just arose yesterday. My 
staff spoke to a longtime VA community care partner in 
Pennsylvania who has repeatedly been advised by the VA to send 
medical records information to a fax machine. It turns out that 
that fax machine is not monitored. This provider at the VA's 
instruction is sending medical documentation containing 
personal health information over and over again because there 
is no one else on the other end of the line. And, in addition, 
those documentations--let me just first say I would like for 
you to commit that you will work with my staff to solve this 
issue.
    Dr. LaPuz. Yes, sir, absolutely.
    Senator Moran. Thank you. This provider is also being told 
that the VA will not send subsequent referrals to them because 
they are not returning medical documentation in time, and the 
VA is actually calling veterans who are actively receiving care 
from this provider to advise them to stop going, to stop 
obtaining their ongoing treatment and to use VA telehealth 
services instead.
    More concerning, the same provider shared documentation of 
a VA employee sending personally identifiable information, 
including dates of birth and full Social Security numbers, for 
veterans via unencrypted mail without taking even the basic 
steps to protect that information from disclosure. If a 
community provider had done this it would have been grounds to 
remove that community provider from the network, and lots of 
other serious repercussions.
    Again, the Veterans HEALTH Act that I described in my 
opening remarks is trying to put a stop to this kind of conduct 
by improving how community care programs are administered. Will 
you assure me that the behavior that I described does not align 
with the standard of practice, and work with my staff to look 
into these allegations and see if we cannot put an end to them?
    Dr. LaPuz. Yes, sir. We will work with your staff in order 
to look into this circumstance.
    Senator Moran. Thank you very much. I yield.
    Senator Hassan. Senator Boozman.

                      SENATOR JOHN BOOZMAN

    Senator Boozman. Thank you, Madam Chair.
    Dr. Miller, veteran suicide prevention continues to be my 
number one priority, and I think that is true of a lot of 
people on this Committee. I believe that the issue is more 
complex than just viewing it from a clinical perspective. There 
are other root causes of suicide we need to be looking at, such 
as food insecurity, lack of housing, and financial strain.
    That is why Senator Tester and I teamed up to introduce the 
Not Just a Number Act, which would allow us to study this issue 
from a holistic standpoint in order to better understand why 
veterans are taking their lives.
    Dr. Miller, do you think that it would be helpful to move 
the Suicide Prevention Office from VHA to the enterprise level 
at VA to allow for better communication and data-sharing 
between VHA and VBA?
    Dr. Miller. Thank you, and I am happy to answer this 
question and also I want to express appreciation from the 
perspective of the suicide prevention team for your advocacy 
for veteran suicide prevention.
    What I think that you have done through this bill is you 
have demonstrated the importance, as you stated, of including 
important information and data within the analysis of veteran 
suicide. You have also further, I think, highlighted that that 
is going to require a deeper and broader level of cooperation 
and collaboration between VBA, VHA, NCA, and other Federal 
agencies, as well as states. I 100 percent agree with you on 
that level.
    You then bring that into a conclusion, in Section 5, saying 
is suicide prevention organizationally placed well to implement 
Sections 2 and 3 in the manner that we are outlining here, and 
we believe need to move. We think it is a fair question, we 
think it is a good question, and therefore we 100 percent 
support the feasibility and advisability analysis that you have 
requested.
    Senator Boozman. Very good. Dr. LaPuz, you mentioned in 
your testimony that suicide is rare event with no single cause, 
which leads me to believe that you would agree that there is no 
single cause to suicide. I am sorry. What I am saying is, you 
know, is that there is no single cause to suicide, and there is 
no single solution as well. You go on to state in your 
testimony that the analysis required by this bill would only 
identify correlations and not causations.
    Would you not agree that understanding the correlation 
between the VBA programs that prevent veterans from taking 
their lives is a good thing to know?
    Dr. LaPuz. Senator, I will defer to our expert, Dr. Miller, 
to respond to that question.
    Dr. Miller. Thanks. I appreciate the question, and the 
answer to the question is yes, it is important to study VBA-
based efforts as well as VHA efforts, and efforts that go into 
our community-based interventions program, do what we can to 
validly study relationships between them, and move the field 
and the VA closer to understanding what works, what does not 
work, as well, and what is worth investing in, from a program 
perspective.
    Senator Boozman. So again, that is exactly what we would 
like to do. In this bill with Senator Tester our intent is to 
identify the programs that are working in order to better 
resource them, and identify the programs that do not work, so 
that we can modify them and be more supportive of veterans in 
need. So are we on the same page?
    Dr. Miller. We are 100 percent on the same page, sir. I 
think the spirit of that particular feedback was not to 
indicate we are on a different page with you on this. It was 
more to indicate there are some complexities with 
relationships, and we will move together with you to explore 
those.
    Senator Boozman. Good. Thank you. Thank you all for all of 
your hard work. We appreciate you.
    Senator Hassan. Well, thank you very much. Seeing no other 
questions for this panel, thank you all very much for your 
testimony and for your work. And I will welcome the second 
panel to the witness table.
    [Pause.]
    Senator Hassan. Well, good afternoon to our second panel. 
It is good to see you all. We have Jon Retzer, Assistant 
National Legislative Director for the Disabled American 
Veterans; Meggan Thomas, Associate Director, National 
Legislative Service, Veterans of Foreign Wars; and Jim 
Lorraine, President and CEO of the America's Warrior 
Partnership. We are very grateful that you are all here today, 
and we look forward to your testimony on this pending 
legislation.
    Mr. Retzer, why don't we start with you.

                            PANEL II

                              ----------                              


                    STATEMENT OF JON RETZER

    Mr. Retzer. Madam Chair Hassan, Ranking Member Moran, and 
other members of the Committee, thank you for inviting DAV to 
testify at this legislative hearing. We appreciate the many 
beneficial pieces of proposed legislation on agenda today to 
improve services for our Nation's veterans, in particular, our 
service-disabled veterans. My oral remarks will focus on the 
community care bills under consideration by the Committee.
    Both S. 1315 and the HEALTH Act, the draft bill, Making 
Community Care Work for Veterans Act make enormous changes to 
VA's current community care program. DAV supported the VA 
MISSION Act after working with the Committee and others to 
carefully craft a compromise to improve access, quality, and 
veteran-centric care, particularly those living in rural and 
remote areas, focusing on key principles, first ensuring VA 
would continue to be the primary provider and coordinator of 
veterans' care; increasing VA's internal capacity through 
investments in staffing, infrastructure, and IT to meet the 
rising demand for care; establishing access and quality 
standards, taking into account wait time and travel distance to 
care; and finally, requiring community care providers meet the 
same access and quality standards as well as training and 
certification requirements as VA clinicians.
    Both bills would codify the existing VA access standards 
for wait and travel times and would limit VA's ability to 
modify those access standards in response to changing 
conditions. DAV supports responsible efforts to lower wait and 
travel times for care. However, codifying access standards by 
itself will not improve veterans' access to care, lower wait 
time, improve quality, or produce better health outcomes. We 
believe investing in the VA health care infrastructure, 
staffing, and IT would achieve these important goals.
    Furthermore, studies continue to confirm that VA health 
care is equal to or better than private sector care, on 
average, and a robust VA health care system provides vital 
research, training, and emergency preparedness for veterans and 
the Nation, furthermore justifying such investments.
    We have questions and concerns about the provision in both 
bills that would restrict the ability of the Secretary to 
review the ``best medical interest'' decisions between veterans 
and their referring physicians, which would limit VA's role in 
overseeing and meeting VA's quality care guidelines versus 
veterans' preference.
    DAV supports provisions in Making Community Care Work for 
Veterans Act, which seeks to expand VA capacity by increasing 
recruitment and retention programs for critical health care 
provisions. We support provisions seeking to increase training 
and compliance by community care providers. However, we 
strongly believe they should be required to meet all the same 
training requirements as VA providers. We also support the 
provisions to expand reporting of quality matrix by community 
care providers. However, the Secretary should set those 
standards. Further, we support the provisions to ensure 
community care appointments are scheduled more timely.
    DAV has questions with the provision in S. 1315, to mandate 
the conversation of VA health care into a value-based care 
model. Given the medical complexity and the needs of the VA 
patient population, we recommend further studies, including 
eliciting an opinion from the Secretary's Special Medical 
Advisory Group regarding the use of a value-based care model in 
the VA health care system. DAV welcomes the opportunity to work 
with the Committee to address concerns raised in these two 
bills and to develop a balanced, bipartisan package to improve 
access and quality health care for all enrolled veterans.
    Our final comments are on S. 1545, the Veterans Health Care 
Freedom Act. DAV opposes this legislation, as it would unravel 
the MISSION Act by completely eliminating access standards for 
community care eligibility. Although similar bills in recent 
years have been scored by CBO to cost billions of dollars, this 
legislation would provide no additional funding and would 
weaken the VA's internal capacity to care for enrolled 
veterans. Ultimately, it would threaten the viability of VA 
health care, and more importantly, severely limit options of 
millions of veterans who have chosen and rely upon VA for care.
    VA is unique health care system serving millions of ill, 
injured, and disabled veterans every year. We must ensure we 
continue to fulfill the mission in the years ahead, and we look 
forward to working with the Committee to find solutions that 
will improve access, particularly for rural veterans, while 
maintaining quality. We also believe the community care 
framework establish by the MISSION Act is the optimal path 
forward to achieve those goals.
    And now that Chairman Tester is here, Chairman Tester, this 
concludes my statement, and I am happy to address questions you 
or members of the Committee may have.

    [The prepared statement of Mr. Retzer appears on page 100 
of the Appendix.]

                      CHAIRMAN JON TESTER

    Chairman Tester [presiding]. And there will be questions, 
and thank you for your testimony, Jon, on behalf of the 
Disabled American Veterans. We appreciate always what you have 
to add to this Committee.
    Next is Meggan Thomas, who is Associate Director of 
National Legislative Service of the Veterans of Foreign Wars, 
otherwise known as VFW. The floor is yours, Meggan.

                   STATEMENT OF MEGGAN THOMAS

    Ms. Thomas. Thank you, sir. Good afternoon, Chairman 
Tester, Ranking Member Moran, and members of the Senate 
Committee on Veterans' Affairs. On behalf of the VFW and its 
auxiliary, thank you for the opportunity to provide our 
insights on this proposed legislation.
    The VFW strongly supports S. 928, that incorporates VBA 
data into its suicide prevention efforts. It is one of our top 
legislative priorities for this Congress. VA's suicide 
prevention efforts should include full information on 
disability compensation, use of education, employment, and home 
loan benefits; foreclosure assistance; and participation in 
housing and food insecurity programs.
    VA has recently begun reporting on the convergence of VA 
benefits and veteran suicide, but not in any substantial 
manner. We must identify, study, and utilize information 
regarding economic opportunity benefits, and leverage that 
information to successfully prevent suicide among veterans.
    All veteran economic programs are administered by VBA, but 
the Office of Suicide Prevention is operated out of the VHA. We 
strongly support this proposal to begin actively incorporating 
data and benefit usage into overall suicide prevention efforts 
within VA. We also believe this should be a program under the 
Office of Secretary, that would elevate suicide prevention as a 
top priority across the entire Department and not only within 
VHA.
    VA's focus should remain on how veterans can receive the 
care they need, whether it is inside or outside of its 
facilities, which is why we support both Senator Tester' and 
Senator Moran's community care proposals presented here today. 
The VFW sees many important provisions in both the Veterans 
HEALTH Act and Making Community Care Work for Veterans Act, 
that would both benefit the Community Care Network. We 
encourage the Committee to work in a bipartisan manner to take 
the best parts of both bills and combine them into a 
comprehensive community care bill that provides improvements 
that will help VA and the veterans that it serves.
    That said, there is one part of S. 1315 we believe should 
be clarified. Section 103 may provide contradictory guidance to 
patients or clinicians regarding a veteran's preference for 
care. Currently, if a patient and the referring clinician agree 
that receiving care and services through a non-VA entity or 
provider would be in the best interest of the veteran, then 
they are referred to community care. We are concerned this 
proposed section has the potential to allow contradictory 
guidance with the veteran's preference and the best medical 
interests.
    And there are certain sections of the Making Community Care 
Work for Veterans Act of 2023 we would like to see highlight as 
critical improvements and other sections we believe could 
benefit from additional improvements. In Section 107, the VFW 
understands the need for self-referrals for services that going 
to remain constant for the veteran. We would like to see 
additional services added to this list to include podiatry, 
prosthetics, laboratory services, dermatology, and the diabetes 
clinic. Services that are part of a veteran's treatment plan 
should not have to be reauthorized if it is for chronic care 
and often utilized.
    In Section 112, the VFW supports a feasibility study to 
consider if Community Care Network is a viable option for care 
in the Philippines. However, veterans in that area currently 
utilize the Foreign Medical Program, which is in dire need of 
improvement. The FMP has no formal means through which either 
veterans or providers can receive consistent reimbursement. We 
recommend providing structure to the FMP, like VBA's 
Compensation and Pension overseas examination contracts and 
TRICARE Overseas, to include electronic reimbursement for care.
    Finally, an issue we would like to see addressed is 
veterans who are referred to residential treatment via 
Community Care Network are mostly only able to access programs 
that are physically located within their respective 
jurisdictions, each of which is managed by either Optum Serve 
or TriWest. Arbitrarily restricting the program access based on 
administrative network boundaries limit's VA's ability to 
coordinate timely and appropriate residential mental health and 
substance abuse care for veterans.
    Chairman Tester, Ranking Member Moran, this concludes my 
testimony, and I am prepared to answer any questions you may 
have. Thank you.

    [The prepared statement of Ms. Thomas appears on page 116 
of the Appendix.]

    Chairman Tester. Thank you for your testimony, Meggan. I 
appreciate it. It is always good to have VFW's perspective 
here.
    Next we have Jim Lorraine, who is the President and CEO of 
America's Warrior Partnership. The floor is yours, Jim.

                   STATEMENT OF JIM LORRAINE

    Mr. Lorraine. Chairman Tester, Ranking Member Moran, and 
members of the Committee, thank you for the opportunity to 
testify before you today.
    For nearly a decade, community care has grown in veteran 
preference and size. Its positive impact for the veteran 
community has been extraordinarily important and lifesaving. 
Access to community care is critical to America's Warrior 
Partnership and our rural community programs, where we advocate 
for veterans and their families.
    The VA Secretary testified last year that the community 
care had grown so successfully that the cost may require 
limiting its growth. It is troubling that when the VA has a 
successful community care program that is working the instinct 
is to trim it back. A small number of individuals and 
organizations believe that if veterans are given the choice or 
allowed to manage their own care, the VA will cease to 
function. In fact, it is the contrary. Ensuring the VA has 
strong, effective community partnerships helps safeguard the 
VA's health care system and keeps it strong for future 
generations of veterans. We have seen veteran enrollees 
increase as the door to community care opens, as veterans 
return to the VA to get care.
    But important elements of community care must be made 
permanent, including access standards. Mission Roll Call 
conducted a series of poll questions on these issues, with over 
6,300 veteran responses across the United States. Over 81 
percent said Congress should codify the community access 
standards. Seventy-one percent said they were not referred to a 
community care after a delay in mental health or other 
specialty care at a VA facility. This clearly indicates a 
problem.
    The VA must not only provide community care but actively 
educate veterans that they have a choice. Accordingly, AWP was 
proud to support the access standards 2 years ago when 
introduced by Ranking Member Moran, and again proud to support 
the HEALTH Act, introduced by Ranking Member Moran and Senator 
Sinema. The HEALTH Act codifies the access standards and 
applies them to nearly all types of care. It also addresses the 
unacceptable practice of restarting the wait clock when the VA 
cancels or reschedules an appointment or refers to a 
telemedicine appointment instead.
    Chairman Tester, AWP supports Making Community Care Work 
legislation, which is similar to the HEALTH Act in many ways. 
In fact, we support that this bill creates a program for 
veterans to begin self-referral for some services, such as 
vaccinations, vision, or other hearing services, but feels 
substance abuse and mental health should be added to the self-
referral program, and I would argue that what the VFW said is 
much further, that that should be included also.
    AWP recommends including provisions for value-based care 
already used by Medicare to advance the quadruple aim of 
providing better care to individuals, improving population 
health management strategies, improving the work quality of 
health care providers, and reducing health care costs. Along 
these lines, as a nurse and a leader, I strongly encourage the 
Committee to consider continuity of care, which has been 
repeatedly documented to improve outcomes as a measure of 
criteria equal to the time and distance of an appointment.
    AWP hopes this Committee can compromise on the best of both 
of these proposals and pass the legislation quickly.
    Chairman Tester and Senator Boozman, regarding the Not Just 
a Number Act, AWP is supportive of the intent of the 
legislation. However, the suicide and premature non-natural 
death is too complex from one perspective, and this Committee 
should request an outside view related to VA reporting. We 
suggest this Committee request transparency, not necessarily 
additional data. In fact, the data requested in the legislation 
is exactly what is missing from Operation Deep Dive, and we 
look forward to working with the VA in the future to fill that 
gap.
    We are very grateful for the inclusion of some of the 
Operation Deep Dive interim summary recommendations in this 
legislation. Providing a tool for coroners and state medical 
officials to help verify veteran status quickly and accurately, 
and evaluating the VA Suicide Prevention Office to the 
Secretary level is long overdue.
    Again, thank you for the opportunity, sir.

    [The prepared statement of Mr. Lorraine appears on page 123 
of the Appendix.]

    Chairman Tester. Thank you for your testimony, Jim. I 
appreciate it. I am going to use my privilege as Chairman of 
this Committee to turn it over to the old-timer on this 
Committee, Senator Murray.

                      SENATOR PATTY MURRAY

    Senator Murray. The youngest old-timer ever. Thank you so 
much, Mr. Chairman, and thank you to all the Committee members. 
I really appreciate you holding this hearing to look at some of 
the really important legislation coming before this Committee, 
including the EHR Program RESET Act, which we introduced 
earlier this year with Senator Brown.
    I, as you know, have been raising concerns about VA's 
implementation of EHR from the start, and when I say ``start'' 
I mean before the ink was even dry on the contract between 
Oracle Cerner and the Trump administration was signed. And the 
criteria for success is pretty straightforward to me--Does it 
work for our providers? Does it work for our patients? Are we 
helping veterans get the care that they deserve?--Which is what 
I am focused on when I talk to our veterans back in Spokane and 
Walla Walla.
    Unfortunately, it was pretty clear early on that this new 
system was missing that mark in a lot of ways, whether it is 
the providers in Spokane who are really burnt out just trying 
to navigate the broken interface or the patients who are unable 
to get the medicine they rely on because of the system 
malfunctions. And as we all know, a flawed system can be fatal, 
and I have previously discussed here about a constituent of 
mine who received a late cancer diagnosis because the system 
did not work the way it was supposed to. So it is painfully, 
devastatingly clear to me this system has been not working for 
our veterans or our providers and was broken.
    So the reset VA announced this year was really badly 
needed, but we do need more than a reset. We need reforms that 
make sure the problems with EHR are not just fixed but do not 
ever happen again in the future. Many of those problems stem 
from the deeply flawed single-source contract the Trump 
administration agreed to back in 2018--I think we should all 
agree on that--and regardless, we should be doing everything we 
possibly can to make sure we have a VA where veterans can get 
the highest quality of care they deserve.
    So I look forward to our witnesses and appreciate all of 
you being here. And let me just start, for the whole panel, and 
ask you what gaps do you see in VA's current contracting 
process, and what else can VA be doing to make sure that in the 
future it does not face the same issues that we had with this 
contract?
    Chairman Tester. You get to go first, Jon.
    Mr. Retzer. Thank you, Senator. A great question and 
obviously the EHR, we also resonate your concern. DAV is quite 
concerned with the progress of where EHR was and the safety 
issues that were brought up.
    With regards to the contract, DAV's position is that we 
feel very strongly that our veterans deserve a modernization to 
ensure that they have the resources that are there to apply 
quality health issues and needs. But at the same time, we want 
to ensure the providers have that infrastructure that works for 
them to provide safe care.
    With regards to now the contract, DAV does not have a 
position where we care who has that contract as long as the 
contract and the VA's relationship of governance over that 
contract has the authority to ensure that they are doing it 
right and they are overseeing, with good, strong oversight, to 
ensure VA is held accountable and so is the contract being 
accountable to fulfilling the contract and its obligations to 
the veterans, taxpayers, and this Nation.
    So that is where we are sitting at this time, is we just 
want to ensure that VA knows what they are doing and does it 
with the right partners say will get it done for them.
    Senator Murray. Ms. Thomas, Mr. Lorraine, do you have any 
comments about the contracting process?
    Ms. Thomas. Good afternoon. At this time I do not have any 
comments in regard to the contracting.
    Senator Murray. Mr. Lorraine?
    Mr. Lorraine. Yes, ma'am. In terms of the contracting I do 
not have comments, but I would echo what DAV is saying, that it 
is critical that we have to get it done. I served on a Senior 
Oversight Committee at the Department of Defense back in 2008, 
and this was an issue then. That was in 2008, and it needs to 
get done. I am a victim of it myself, and it needs to get 
fixed.
    Senator Murray. Okay. Thank you.
    And let me quickly ask about the Expanding Veterans' 
Options for Long Term Care Act. Our population of veterans is 
aging, and we have to make sure that there are long-term care 
options available for them. So that is exactly why I joined 
Chair Tester and Ranking Member Moran in introducing the 
bipartisan Expanding Veterans' Options for Long Term Care Act, 
creating a pilot program for our veterans to get assisted 
living care.
    Just real quickly, any of you, can you talk a little bit 
about what some of our veterans are facing in our rural areas 
in terms of long-term care? Ms. Thomas?
    Ms. Thomas. Thank you for that question. So when we deal 
with long-term care options, especially in the rural areas, we 
already have limited access to care. We actually see this 
program, this pilot, as a good opportunity to provide the 
care--it is like that middle care. They are not sick enough for 
nursing home care, and they are not able to be on their own. I 
believe this opportunity for assisted living in rural areas 
would actually allow for the veterans to get the care they need 
without having to worry about the financial burden, and I think 
that is one of the biggest factors to look at.
    Senator Murray. Okay. The Chairman has been generous, 
allowing me to speak, and I am out of time. But if any of you 
could give me written comments back I would really appreciate 
it. Thank you.
    Chairman Tester. Thank you, Senator Murray. Senator Moran.
    Senator Moran. Chairman, thank you. Ms. Thomas, I am 
grateful to you for your support of the Veterans HEALTH Act, 
and I am glad to have VFW and a diverse group of growing VSOs 
and other veteran service nonprofits supporting this 
legislation.
    Can you elaborate on why the VFW supports Veterans HEALTH 
Act and how enacting it would align, not compete, with the VA's 
efforts to focus on improving wait times, embracing whole 
health, and preventing suicide?
    Ms. Thomas. Thank you for that question. The VFW definitely 
supports improving community care. We understand that patients 
in our care should be a priority. Value-based care focuses on 
prevention, which reduces illness and suicide, which is a top 
priority for all of us.
    I would have to say that one section that we were looking 
into was Section 103, to clarity the best interest in veteran's 
preference versus a veteran's preference. We want to ensure 
that we are not pushing all veterans to go outside the care of 
the VA, which VA provides better than most outside areas.
    Senator Moran. Mr. Lorraine and Ms. Thomas, the VA opposes 
Section 103, that was just mentioned, of the Veterans HEALTH 
Act, which would require VA's criteria on how a veteran and 
their provider can reach a mutual decision about a veteran's 
best medical interest to include the consideration of a 
veteran's preference. So what I am saying is that the VA 
opposes the consideration of what the veteran, what they want 
to see.
    To be clear, this section does not stipulate that a 
veteran's preference is the outcome of the decision. This 
section would not stipulate that a veteran is entitled to care 
in the community just because they express a preference for it, 
nor would it alter the current statutory requirement, put in 
the MISSION Act, that best medical interest be determined 
between the veteran and their clinician.
    As you know, health care is a highly personal issue. Why do 
you think it is important that decisions about a veteran's care 
take into account personal preference for when, where, and how 
they seek care? Mr. Lorraine?
    Mr. Lorraine. Thank you for the question. You know, I think 
when it comes to health care it is a personal choice, and I 
think because you are veteran you should not have your choices 
foregone. You should have a say in the health care that you 
receive and where you receive it, no matter where you live in 
the country. And I think your point, and the point between the 
physician and the patient has to be the decision. It cannot be 
a bureaucratic decision that breaks the 30 days, that breaks 
the distance, that breaks all the continuity. It needs to be 
between the physician and the patient.
    Senator Moran. Thank you. And let me ask just a broader 
question about this topic. Mr. Retzer, I understand the DAV's 
concern about preserving the primary role that the VA plays in 
providing coordinated care for veterans who are enrolled in the 
VA health care system. To that end, as Senator Tester and I 
perhaps join forces to craft a compromise bill that draws on 
the best of both of our separate bills, would DAV support the 
inclusion of language reasserting that role for the VA, even as 
access is expanded under certain circumstances into the 
community?
    Mr. Retzer. Thank you, Senator, for asking that question, 
and where DAV stands with this is we appreciate both the bills, 
and we have provisions that we appreciate and that we 
understand where they are coming from, especially as you are 
trying to address your constituents' needs in Kansas and 
Montana. You have very dynamic, in Kansas, dynamic populations 
that are very sparse and that VA does not have the 
infrastructure to support that population. Not only in Montana 
do we have that same situation but geographical constraints 
that hurt that situation, along with the individual veterans' 
preference issues that may cause them not to.
    Now we definitely invite, just as we had said in our 
testimony and also in my oral statement, I would welcome the 
opportunity to work with you and your staff to draw a nice 
piece of legislation that is bipartisan, and I think we can get 
there. We do understand what your intent is, and we just do not 
want to take away the authority from the VA as the primary. 
Because one of the concerns that we have with the VA is that 
they provide so many significant wraparound services.
    Like myself, I use the VA health care system 100 percent. I 
am very fortunate to be 25 miles from D.C. and 25 miles from 
Baltimore, but you also know that navigating Baltimore and D.C. 
is not always easy. There will be veterans who cannot do that, 
so that would be maybe a foreseeable reason that is realistic. 
But I have the fortunateness of having a CBOC, not like your 
constituents. They may not have either of them.
    So we do understand, and we did support the MISSION Act, 
and we did support the community care program. We just want to 
ensure that when we look at legislation it is very well thought 
out, and we think there is a special need for our rural 
veterans that are in a very unique situation.
    Senator Moran. Jon, my intent of that question was to 
suggest to you that I might be willing to again reassert--I was 
fully engaged in the MISSION Act, so the language that is in 
there is language that I participated in creating, and language 
that I voted for and support. And my point in asking that 
question is that I may be willing to reassert that role for the 
VA, but there still may be instances in which, in my view, we 
need to expand access to community care. Does that trouble you?
    Mr. Retzer. We understand that initially when the MISSION 
Act was looked at, and we were compromising and looking at 
crafting it, the terminology of a supplement versus a plan. And 
we want to continue to supplement the community care. We know 
it is needed, and the VA system is weakened and is struggling. 
And that is why we want the investments, and both of you have 
provided legislation to strengthen the VA's infrastructure.
    So we think that just putting everything together and 
working together and discussing the provisions that we have 
concerns and how to clean it up a little bit easier for our 
veteran community to make a seamless system so that they are 
not navigating a bureaucracy, or they are not navigating red 
tape, but it gives authority to the Secretary to do the right 
things when the time is needed.
    We really do want that warm handoff for our veteran 
community because the fact is our veterans--typically, if I go 
to general care and community care I have more than five issues 
that the general physician has to deal with. That physician may 
only be able to identify one issue or address one issue. Then 
they want me to do a lab for some reference. Now there are more 
referrals. So that is why we want to ensure the best medical 
practices and the best medical interests are applied 
accordingly.
    Senator Moran. Jon, Meggan, and Jim, thank you.
    Chairman Tester. Senator Blumenthal.

                   SENATOR RICHARD BLUMENTHAL

    Senator Blumenthal. Thanks very much, Mr. Chairman. Thank 
you for being here today.
    Ms. Thomas, you have had very extensive experience as a 
caregiver, as a medic, and also as a caseworker, so I would 
like to ask you about a problem which may not be reflected 
extensively in the legislation. There is one piece of 
legislation dealing with veteran suicide. But perhaps you could 
give us your assessment as to what more we can and should be 
doing, ``we'' meaning not only the VA but also Congress. Like 
others on the Committee, I have worked extensively for 
legislation for more resources. I have been critical of past VA 
administrations because of the failure to do more outreach, for 
example, using the resources that have been available. But 
maybe you could talk a little bit about veteran suicide and 
what we ought to be doing.
    Ms. Thomas. Thank you for that, sir. One of the things that 
the VFW looks at--and I want to just speak a little bit on 
Senator Tester's bill, but not just the Number Act. We 
understand that the data that is received from the VBA is 
important. We know it coincides because it is not one thing 
that causes suicide. Having food to eat, having a roof over 
your head, having money in your pocket, or having a job are 
factors, and if those needs are not met, that puts a person in 
a position to want to commit suicide.
    This actually brings me back to prevention methods that 
could be used. We actually currently have one that we could 
actually be using right now, and I just wanted to highlight the 
TAP Program. The TAP Program is actually given for 
servicemembers who are exiting out of the service. We need 
accredited service representatives to actually assist those 
with filing claims. We need those services at the TAP Program 
to actually talk about educational benefits, talks about 
housing options, talks about things that they are going to need 
to be able to get out, so they will not be able to walk out of 
the military and have nothing to look at.
    So I think really looking into the TAP Program and how we 
better enhance the TAP Program, and how we make sure that our 
servicemembers are being able to utilize that program is going 
to be key for what we need to do going forward in the veteran 
realm.
    Senator Blumenthal. Would you recommend any particular 
legislative initiatives to that end?
    Ms. Thomas. I would recommend the Not Just a Number Act. I 
think the VBA data is essential to get a whole view on barriers 
that could lead to suicide.
    Senator Blumenthal. I noticed that in your testimony, S. 
1040, prohibiting smoking on the premises of any veterans 
facility, VHA facility, you recommend against our approving. 
Could you explain a little bit more why you are against 
prohibiting smoking on VA facilities? I know that you say that 
having a specific area where smoking may be permitted is a 
middle ground, but it would seem to me that smoking is 
certainly a detriment to health and permitting it anywhere on a 
VA facility sends a message of acceptability that the VA ought 
to avoid. Do you differ?
    Ms. Thomas. So with that being said, sir, and thank you for 
that, the VFW understands that there are barriers out there. 
What we do not want to see is, we do not want to see smoking as 
a barrier for veterans not going to get the care that they 
need. Also, when you are looking at the staff that works at the 
facilities, if they cannot smoke they may not want to work 
there. The VA is already behind when it comes to employment. So 
we do not want to have any barriers, and that is the reason why 
we are choosing against the bill.
    Senator Blumenthal. Thank you. I do not know the answer to 
this question. Maybe some of you do. Does the VA have smoking 
cessation programs as part of what it offers? I am seeing some 
heads nodding. I have not asked this question before so forgive 
my ignorance. And how widely are they offered? To any member of 
the panel.
    Mr. Lorraine. I will. From personal experience, every time 
I go to the VA I am asked whether I smoke or whether I consume 
alcohol, and they always have a program that is available. It 
is literature in the pamphlets and whatnot. There are a number 
of programs in the facility in Augusta that I attend.
    Senator Blumenthal. I am wondering how strongly they urge 
or recommend these programs, beyond saying it is available.
    Mr. Lorraine. I could just speak to my experience, but 
additionally, Senator Blumenthal, with our Operation Deep Dive 
study, we have also seen not just non-natural deaths, but we 
see natural death and a differentiation amongst cancer-related, 
that would be lung cancer-related premature early deaths 
amongst veterans. It is not a bad thing to stop smoking.
    Senator Blumenthal. Thank you all for being here. Thanks, 
Mr. Chairman.
    Chairman Tester. Senator Sinema.

                     SENATOR KYRSTEN SINEMA

    Senator Sinema. Thank you, Chairman Tester, for holding 
this hearing, and thank you to our witnesses for being here 
today.
    With over 500,000 veterans calling Arizona home, 
conversations around accessibility of veteran-specific health 
care are critical to ensuring the welfare of our state. Access 
to veteran health care services in rural areas is often 
limited, and it is necessary to come up with ways to keep our 
veterans from going without services simply because they cannot 
reach the facilities that are able to provide them with care.
    In circumstances where non-VA emergency medical care 
results in saving these veterans' lives, they should not have 
to jump through hoops to get reimbursed. And that is why I, 
with Senator Braun, introduced the RELIEVE Act to expand the 
eligibility for veterans to access emergency care from a 
provider outside the VA. I have also joined with Senator Moran, 
our Ranking Member, in introducing the HEALTH Act, to ensure 
Arizona veterans retain the ability to make their own decisions 
around their health care, while also making much needed 
improvements to the quality of care provided. And I look 
forward to working with both Senator Moran and Chairman Tester 
to continue to improve options for community care.
    My first question is for you, Ms. Thomas. Nearly every day 
my staff helps Arizona veterans navigate an unexpected VA 
medical bill. What efforts should the VA implement to ensure 
that staff and community emergency departments are aware of the 
new eligibility criteria to prevent the veteran from 
experiencing issues or reimbursement delays, and do you believe 
legislation like the RELIEVE Act will help address the problem?
    Ms. Thomas. Thank you for the question. I do believe that 
the legislation, the RELIEVE Act legislation, will definitely 
impact those veterans, definitely understanding that when a 
veteran needs to receive emergency care they need to receive 
emergency care. They should not be burdened by the fact that 
they did not get their initial visit at the VA to get that 
care.
    Senator Sinema. Thank you.
    Mr. Retzer, Arizona has many veterans living in 
geographically isolated areas, like Show Low or Pinetop, where 
it can be harder to access care due to the lack of community 
providers or outreach or communication. Have your organizations 
raised similar concerns with the VA to ensure that these 
veterans are informed of their eligibility and have access to 
the care that they have earned?
    Mr. Retzer. Senator, thank you for that question. That is 
actually a question that is asked to our national service 
officers out in the field. That is one of the things that I 
spent 14 years advocating out there and spent 20 years with the 
DAV trying to navigate this issue and trying to influence VA to 
ensure that they are doing proper training of the patient 
advocates, their staff, and to ensure that they are sharing 
that education and knowledge to the veterans on what they are 
eligible for.
    So when we look at VA's infrastructure, it is very 
difficult for them. So we continue to speak with the VA and 
collaborate with them, where their shortcomings are, where 
there are more improvements, to improve the veteran's 
experience in both the benefit side and the health side.
    Senator Sinema. And as a follow-up, what steps could the 
organizations here or our congressional offices take to ensure 
that veterans in Native American communities, for us 
particularly the Navajo Nation, receive the same or better 
outreach?
    Mr. Retzer. Thank you for that question too, and I think 
one of the things that we are seeing in the legislation here, 
it is very thoughtful in the way that we are looking out for 
our rural veterans or veterans in remote areas, and it comes 
with collaborating with the VA to do outreach. For example, the 
direct health care system of having direct connect to our 
homeless veterans, for example, could be the same application 
to our Native Americans who are needing that assistance, who 
have those barriers, and who may also have some issues or 
cultural issues with working with the VA system.
    So we need to be able to ensure that we open the doors and 
start to communicate and show the communities what they are 
entitled to and make a warm entrance into it by making sure we 
have partners on both sides that are being trained equally, the 
same way, and that understand the system.
    Senator Sinema. Thank you.
    Mr. Lorraine, my office also hears from Arizona's veterans 
about the cumbersome community care referral process, which can 
negatively impact continuity of care. One issue my HEALTH Act 
bill is trying to address is to ensure that veterans who are 
seeking mental health care or treatment for substance abuse can 
self-refer to get the help they need when they need it.
    What improvements to the referral process should be made to 
make it work better, and of course, without delay for patients 
and caregivers?
    Mr. Lorraine. Yes, I think especially those two areas that 
you just talked about, they are stigma ridden, and I think if 
the veteran can have the ability to directly seek out care, 
whether it is mental health or substance abuse, that is 
important.
    America's Warrior Partnership, one of our programs is the 
Dine Naazbaa Partnership. It is Navajo women veterans that are 
employed by us that work up in Show Low. They are up in Chimney 
Rock or Window Rock, and Shiprock. We see it all the time. We 
hear from them. Their goal is to go find and develop a 
relationship with veterans. Their biggest issue is that there 
are facilities that are local that they could use, but there is 
no mechanism to go use those. They either have to go to Gallup, 
as you know, or go down to Phoenix, which is a pretty arduous 
trip.
    So between the Alaska Warrior Partnership and our work in 
the Navajo Nation, we have extensive experience.
    I would just also--and I know I am running over--I would 
also say that the thought that we are going to call these 
veterans when they barely have electricity, they barely have 
water, and a phone is something that is far beyond that. I 
think that it is a personal relationship, especially within the 
culture of the Navajo.
    Senator Sinema. Yes. Thank you. Thank you all for taking 
the time to be here today, and my team is going to continue 
working with all of you. Mr. Chairman, thank you for the 
hearing.
    Chairman Tester. You bet. Thank you.
    Senator Murray brought up Expanding Veterans Option for 
Long Term Care Act, a bill that I have got, and she talked 
about the number of veterans who are over the age of 85, which 
I think is going to increase by over 500 percent in the next 20 
years.
    Right now the VA is prevented from paying veterans to 
receive assisted living services. This bill would help address 
that. For you, Mr. Retzer, can you explain how allowing the VA 
to pay for assisted living would help address the needs of this 
growing population?
    Mr. Retzer. Thank you, Chairman Tester. Well, at DAV we 
actually support this piece of legislation. We really 
appreciate the thoughtfulness of expanding options, not just 
for our long-term care but our seriously injured veterans. As 
we see even our younger veterans who have serious injuries or 
illnesses, they do need care that extends beyond skilled 
nursing care. So we appreciate the fact that there is a piece 
of legislation here that would create a little bit of 
seamlessness for a veteran who needs that extra care, to be 
able to have VA provide that resource.
    Chairman Tester. I am going to stick with you, Jon. The 
CHARGE Act makes permanent essential programs that expired in 
May. It is also a bill that I have authored. These programs 
serve homeless veterans and caregivers who assist at state 
veteran homes dealing with staffing shortages. Does DAV support 
this legislation?
    Mr. Retzer. Yes, we do, and this is a very thoughtful piece 
of legislation to address the safety and survival issues and 
needs of our homeless veterans. We definitely support the issue 
of having direct services with our homeless veterans to provide 
not only the survival items of food, shelter, and clothing, but 
to also extend that service to the transportation to medical 
appointments, and also then keeping them connected with 
technologies of like tablets or even mobile phones.
    Chairman Tester. You answered my second question.
    Last year the VFW came to our Committee with the idea to 
make VA's annual Suicide Prevention Report go beyond just 
health care so we could better understand what we can do to 
help prevent veteran suicide. Senator Boozman and I have the 
Not Just a Number Act, to require the VA to make a more 
comprehensive look at veteran suicide including the use of VA 
benefits.
    For Ms. Thomas, can you speak to the importance of this 
bill for VFW and how it would be useful in improving veteran 
suicide prevention efforts?
    Ms. Thomas. Thank you, sir. So this bill would allow, from 
VBA's data, to be used in regards identifying the barriers that 
cause suicide. The additional data going into the annual VBA 
report would actually provide some clarity and actually start 
conversations about what preventive methods can we use to 
actually help the veterans to limit their chances of wanting to 
commit suicide.
    Chairman Tester. Secretary Elnahal was in front of this 
Committee before the 4th of July break and talked about self-
referral as a potential option that he is working on, which I 
see some real potential for. Dr. Senator Cassidy brought up the 
point of oversubscribing and how do you prevent that. Our 
community care went by a little over $5 billion, with a B, last 
year, as far as a budget line item.
    Look, Senator Moran and myself come from places where 
health care is hard to find if you are in the VA, or if you are 
not in the VA it is hard to find. So giving these folks the 
ability to go out and get health care is really important in 
the community. You do not want them driving 100 miles, and the 
nearest big hospital, to me--and I actually live in a place 
that is not the end of the earth--is 75 miles, so 150-mile 
round trip.
    But oversubscription issue is not something that we have 
talked about a lot. How do we control that, assuming there is 
going to be some, and you can live with some, but how do we 
control that? Anybody can answer that question if you have a 
thought. Jim, go ahead. You have not spoken yet, at least not 
in my questioning.
    Mr. Lorraine. Yes, so as a health care provider I would 
tell you that oversubscription, you are going to get it, but I 
think that the point of sale or the point of dispensary is 
probably the best place to address oversubscription. The 
pharmacies are linked.
    Chairman Tester. Oversubscription--and maybe I used the 
wrong word----
    Mr. Lorraine. Yes, maybe.
    Chairman Tester [continuing]. From a health care 
standpoint. So if somebody has a sprained finger, it really 
does not need to be looked at but what the hell. It is free so 
I am going to go do it.
    Mr. Lorraine. Right. You know, I think in terms of, so like 
overuse of the----
    Chairman Tester. Yes, overuse of the system overall, not 
only prescriptions but overall use.
    Mr. Lorraine. Yes, no problem. You know, I think, as I 
said, I think in terms of reducing that oversubscription you 
are going to have it whether it is in the VA or whether it is 
in the civilian community. The civilian community, on the 
billing, you are going to see it, and I think it is something 
that you address on a case-by-case basis. You know, I always 
say that 90 percent of the rules are meant for 10 percent of 
the people.
    Chairman Tester. That is a fact.
    Mr. Lorraine. And there is probably a group of people that 
are going to overuse it. But I would rather address that than 
take it away from the 90 percent.
    Chairman Tester. Yes. I do not think it is the intent of 
anybody on this Committee, and I do not want to speak for 
everybody, that we are going to take away community care by any 
stretch of the imagination. But it is a pitfall that I never 
thought about. Cassidy is a doctor. He has probably seen it, 
and that is why he brought it up, and I appreciate it.
    I want to thank you all for being here. I appreciate your 
perspective. I want to apologize to the first panel--hopefully 
they are still here--for missing theirs. I had a water compact 
in Indian Affairs that I have been working on for 12 years, 
actually longer than that, that I had to introduce, so that is 
my excuse. But thank you all for being here.
    Look, we are going to continue to work together to figure 
out ways we can get health care to our veterans in the best way 
so that we keep them healthy forever because they have earned 
that. Thank you all very much.
    [Whereupon, at 4:21 p.m., the hearing was adjourned.]

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