[Senate Hearing 118-227]
[From the U.S. Government Publishing Office]



                                                        S. Hrg. 118-227

INVISIBLE WOUNDS OF WAR: IMPROVING MENTAL HEALTH AND SUICIDE PREVENTION 
                   MEASURES FOR OUR NATION'S VETERANS

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED EIGHTEENTH CONGRESS

                             FIRST SESSION

                               __________


                           SEPTEMBER 20, 2023

                               __________

       Printed for the use of the Committee on Veterans' Affairs






                 [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]






        Available via the World Wide Web: http://www.govinfo.gov

                               ______
                                 

                 U.S. GOVERNMENT PUBLISHING OFFICE

54-760 PDF                WASHINGTON : 2024











                 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

                              ----------                              

                           September 20, 2023

                                SENATORS

                                                                   Page
Hon. Jon Tester, Chairman, U.S. Senator from Montana.............     1
Hon. Patty Murray, U.S. Senator from Washington..................     4
Hon. Jerry Moran, Ranking Member, U.S. Senator from Kansas.......     6
Hon. Margaret Wood Hassan, U.S. Senator from New Hampshire.......     8
Hon. Bill Cassidy, U.S. Senator from Louisiana...................    10
Hon. Mazie K. Hirono, U.S. Senator from Hawaii...................    12
Hon. Marsha Blackburn, U.S. Senator from Tennessee...............    14
Hon. Richard Blumenthal, U.S. Senator from Connecticut...........    15
Hon. Thom Tillis, U.S. Senator from North Carolina...............    17
Hon. Angus S. King, Jr., U.S. Senator from Maine.................    19
Hon. John Boozman, U.S. Senator from Arkansas....................    21
Hon. Kyrsten Sinema, U.S. Senator from Arizona...................    22

                               WITNESSES
                                Panel I

Matthew Miller, PhD, MPH, Executive Director for Suicide 
  Prevention, Veterans Health Administration, Department of 
  Veterans Affairs; accompanied by Susan Black, DSW, Suicide 
  Prevention Officer, Outreach, Transition, and Economic 
  Development Service, Veterans Benefits Administration..........     2

                                Panel II

John Eaton, Vice President for Complex Care, Wounded Warrior 
  Project........................................................    29

Gilly Cantor, MPA, Director of Evaluation and Capacity Building, 
  D'Aniello Institute for Veterans and Military Families at 
  Syracuse University............................................    31

                                APPENDIX
                           Closing Statement

Senator Jerry Moran..............................................    27

                          Prepared Statements

Matthew Miller, PhD, MPH, Executive Director for Suicide 
  Prevention, Veterans Health Administration, Department of 
  Veterans Affairs...............................................    45

John Eaton, Vice President for Complex Care, Wounded Warrior 
  Project........................................................    54

Gilly Cantor, MPA, Director of Evaluation and Capacity Building, 
  D'Aniello Institute for Veterans and Military Families at 
  Syracuse University............................................    70

                        Questions for the Record

Department of Veterans Affairs response to questions submitted 
  by:

  Hon. Marsha Blackburn..........................................    75
  Hon. John Boozman..............................................    79

                    Questions for the Record (cont.)

  Hon. Bill Cassidy..............................................    80
  Hon. Kevin Cramer..............................................    82
  Hon. Joe Manchin...............................................    83
  Hon. Kyrsten Sinema............................................    85
  Hon. Thom Tillis...............................................    87
  Hon. Tommy Tuberville..........................................    90

    Attachment--VA response to Question 1: ``Supplemental Online 
      Content: Evaluation of the Recovery Engagement and 
      Coordination for Health''..................................    92

                       Submission for the Record

``Veteran Drug Overdose Mortality, 2010-2019''...................   103

                       Statements for the Record

D'Aniello Institute for Veterans and Military Families (IVMF) at 
  Syracuse University............................................   113

Volunteers of America Northern Rockies, Heath Steel, Executive 
  Vice President and Chief Business Officer......................   118

Western Governors' Association, Jack Waldorf, Executive Director.   120










 
INVISIBLE WOUNDS OF WAR: IMPROVING MENTAL HEALTH AND SUICIDE PREVENTION 
                   MEASURES FOR OUR NATION'S VETERANS

                              ----------                              


                     WEDNESDAY, SEPTEMBER 20, 2023

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 3:41 p.m., in 
Room SR-418, Russell Senate Office Building, Hon. Jon Tester, 
Chairman of the Committee, presiding.

    Present: Senators Tester, Murray, Brown, Blumenthal, 
Hirono, Sinema, Hassan, King, Moran, Boozman, Cassidy, Tillis, 
Sullivan, and Blackburn.

            OPENING STATEMENT OF CHAIRMAN JON TESTER

    Chairman Tester. We call this hearing to order.
    September is Suicide Prevention Month. While we are all 
focusing on this topic today, it must be at the forefront of 
everything of what we do every day. Mental health is one of the 
biggest issues facing our country. It is certainly a big issue 
in my home State of Montana. It is certainly a big issue for 
our veterans.
    That is why it is critically important VA does absolutely 
everything possible to connect more veterans with the mental 
health care and the suicide prevention that they need, 
regardless of where they live.
    The latest data shows that 2020 had the lowest number of 
veteran suicides since 2006. That trend needs to continue. The 
data shows that more than 60 percent of the veterans who died 
by suicide in 2020 had no recent engagement with the Veterans 
Health Administration. That means the VA must work harder to 
get our veterans into the system.
    In recent years, Congress has advanced critical 
legislation. I was proud to champion many of them, including 
the John Scott Hannon Veterans Mental Health Care Bill, 
Veterans Health Healthcare Improvement Act that I did with 
Senator Moran, and the STRONG Veterans Act of 2022.
    These laws have helped the VA's mental health workforce and 
programs, including through alternative and local treatment 
options, but the fact is we have much more to do. That is why I 
recently introduced the Not Just a Number Act to require the 
Department to provide a more fully picture of the factors 
contributing to veterans suicide.
    By making the Community Care for Veterans Act, would also 
strengthen veterans' access to life-saving residential 
treatment programs for mental health and substance abuse 
disorder.
    Congress continues to do its part by giving VA the proper 
funding for mental health, and suicide prevention programs, and 
ensuring it has the tools to meet the veterans' needs. And 
while the VA has made progress, we still have work to do. The 
VA has been too slow in implementing the Hannon Act Telehealth 
Grants that would improve rural veterans' access to mental 
health care by increasing the number of locations that can 
provide VA Telehealth Services.
    That is a particular concern of mine, given Montana has one 
of the highest rates of suicide in the Nation. A nearly 5-year 
implementation timeline is far too long. And I will expect an 
update on that initiative today.
    I am also looking for an update on the Veterans Crisis 
Line. The STRONG Act included my reach for the Veterans Act to 
improve the Veterans Crisis Line oversight.
    Last week, a new IG Report was released, raising more 
concerns about the Veterans Crisis Line. The Veterans Crisis 
Line is a life-saving resource for veterans, and it must be a 
top-performing entity within the VA. But as made clear by 
recent IG reports, it simply is not. I expect an update from 
the VA on how it is implementing the provisions from the STRONG 
Act, and how it is executing the IG's latest recommendations.
    Finally, I was recently informed of the death, by suicide, 
of a longtime VA employee in Montana. That employee, like so 
many at the VA, was a veteran. VA employees deal with stressful 
topics and events each and every day, and they face a lot of 
the same challenges as the veterans they serve.
    As the Department continues to improve its Mental Health 
Service for our veterans, I call on you to redouble efforts to 
care for its workforce across the enterprise. A workforce that 
feels understood and supported will be far better positioned to 
accomplish the mission of delivering vets the care and the 
benefits they have earned.
    Senator Moran is not quite here yet, so we will start with 
the first panel. And then I will yield to him when he gets here 
for his statement, if he so chooses to make it.
    The first panel is: I would like to welcome VA's lead 
witness, Dr. Matthew Miller, the Executive Director of the 
Suicide Prevention at the Veterans Health Administration. He is 
accompanied by Susan Black, a Suicide Prevention Officer at the 
Outreach, Transition, and Economic Development Service of the 
Veterans Benefits Administration.
    So we will start with you, Dr. Miller. You may proceed. You 
have got 5 minutes. Know that your entire written statement 
will be a part of the record.

                            PANEL I

                              ----------                              


                  STATEMENT OF MATTHEW MILLER

    Dr. Miller. Thank you, sir.
    Good afternoon, Chairman Tester, Ranking Member Moran, and 
distinguished Members of the Committee. Thank you for the 
opportunity to discuss the Department's efforts to implement 
legislation related to veterans' mental health care, and 
suicide prevention.
    I want to thank this Committee for its support and 
continued collaboration on reducing veteran suicide. This 
critical relationship is reflected in the resources that the 
Congress has repeatedly secured for VA.
    In 2020, 44,298 adult Americans died by suicide, of those, 
6,146 were veterans. These numbers are more than statistics; 
they reflect veterans' lives prematurely ended, which continue 
to be grieved by family members, loved ones, and the Nation.
    Suicide is a complex problem with multifaceted and 
interweaving contributing factors. Suicide is not just a mental 
health issue, with no single cause; there is no single solution 
to suicide for veterans. Yet, one veteran suicide is one too 
many. VA cannot do this work alone. In order to address 
individual, relational, community, and societal risks, and 
protective factors, VA is collaborating with other Federal 
agencies, public and private partnerships, government at local, 
State, and national levels, veterans service organizations, and 
local communities.
    Together, we are implementing a full-public-health approach 
as outlined in the White House Strategy, and VA's 10-year 
National Strategy for Preventing Veteran Suicide.
    These guiding documents are operationalized through VA 
Suicide Prevention 2.0 Initiative, Suicide Prevention NOW, and 
emerging innovations combined with research and program 
evaluation.
    Further implementation of new laws, including the STRONG 
Act, Hannon Act, COMPACT Act, and the National Suicide Hotline 
Designation Act, are all critical part of these efforts, as 
mentioned by you, sir, at the outset.
    For example, Hannon Act Section 201 established the Staff 
Sergeant Parker Gordon Fox Suicide Prevention Grant Program, 
allowing the VA to provide grants to expand Suicide Prevention 
Services to veterans and their families, to reduce the risk of 
suicide.
    In September 2022, VA awarded $52.5 million to 80 
community-based organizations across 43 States, DC, and 
American Samoa. A second round of grant awards was announced 
today, ensuring reach to veterans across the Nation, not just 
those engaged in VA care or benefits.
    Additionally, the STRONG Act contains more than two dozen 
sections that further support veterans' mental health care and 
suicide prevention, including further strengthening of the 
Veterans Crisis Line.
    In July of 2022, the Veterans Crisis Line rolled out 988-
PRESS-1. VCL prepared for the implementation of 988-PRESS-1, by 
hiring over 900 individuals, responders, to address increased 
demand, and to increase quality assurance, and program 
evaluation efforts.
    Since that launch, VCL has fielded over one million calls, 
texts, and chat messages.
    On that note, and before I close, I want to acknowledge the 
recent OIG Report of a veteran's death by suicide following and 
in the context of a contact with the Veterans Crisis Line.
    We, I, as a veteran, grieve the loss of this veteran. From 
the painful lenses of retrospective review we wish we could 
have done some things differently. It is our earnest desire and 
pledge to apply the wisdom gained through this review to 
strengthen processes as we continue to serve veterans who are 
at the center of all we do, even at this very minute as we 
answer calls.
    Mr. Chairman, this concludes my remarks. My colleague, Dr. 
Black, and I are prepared to address any questions that you may 
have.

    [The prepared statement of Dr. Miller appears on page 45 of 
the Appendix.]

    Chairman Tester. Dr. Miller, thank you for your testimony, 
and thank you for being here.
    I will yield my time to the wily young veteran, former 
Chairman of this Committee, Senator Murray.

                      SENATOR PATTY MURRAY

    Senator Murray. Thank you very much, Mr. Chairman.
    Let me just, first of all, thank you both for being here. 
But the fact that nearly a third of women veterans experience 
sexual assault or harassment while serving our country in 
uniform is really staggering. And unsurprisingly, we know that 
military sexual trauma is a significant cause of mental health 
issues for these women.
    In fact, women who are survivors of military sexual trauma 
are nine times more likely to develop PTSD than other women 
veterans. There was a 2018 VHA directive that requires all VA 
facilities to have a designated coordinator to help veteran 
survivors of military sexual trauma access mental health care 
and other resources.
    But in my home State of Washington, the Puget Sound VA, 
which treats, by the way, more than 65,000 veterans, doesn't, 
does not have a full-time person in this position, which seems 
notable for a facility of that size, and a position that is so 
important.
    So Dr. Miller, I want to ask you, what steps is VA doing 
and taking to make sure that all VA facilities, including Puget 
Sound VA, have enough resources to assist and reach out to 
survivors of military sexual trauma?
    Dr. Miller. Thank you for the question, Senator. I agree 
with you 100 percent, as does the VA and Suicide Prevention, 
that addressing military sexual trauma is critically important 
and a key component of suicide prevention. Exactly what you 
have said, there is increased risk with regard to suicide in 
this area.
    We, at the national level, have a policy in place, 
requirements at the local level regarding the very points of 
contact that you mentioned. We receive regular reports on a 
quarterly basis regarding staffing, and then we work with local 
facilities through the VISN with regard to gaps or according--
--
    Senator Murray. So is my VA facility going to get a 
coordinator or not?
    Dr. Miller. Your VA facility should be receiving a message 
stating, ``Tell us what the plan is to fulfill this FTE 1.0.''
    Senator Murray. When will that occur?
    Dr. Miller. I don't know the exact timing of that vis-a-vis 
the current date. I would imagine by the end of the quarter. or 
the start of the quarter, but I would be happy to check on this 
and then send this----
    Senator Murray. If you can get back to me and tell me 
specifically when that is going to happen, I would appreciate 
it.
    Dr. Miller. Yes, ma'am.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: Per VHA Directive 1115 Military Sexual Trauma (MST)
 Program, each facility must have a designated MST Coordinator who is
 typically given at least 0.2 FTE of time specifically dedicated to the
 administrative responsibilities of the role. VA Puget Sound Health Care
 System has 2 MST Coordinators labor mapped 0.3 and 0.2 FTE; the current
 MST Coordinators' start dates were March 20, 2020 and July 19, 2021.
------------------------------------------------------------------------


    Senator Murray. Thank you. Let me ask about homelessness. 
There are 33,000 veterans experiencing homelessness in the 
U.S., 1,500 of them in my State, veterans who have experienced 
homelessness are four times more likely than other veterans to 
attempt suicide. And I know the VA has made progress in 
reducing the number of veterans who lack housing, but we also 
need to make sure that we are utilizing our knowledge of risk 
factors and engaging with these veterans to help prevent them 
from experiencing homelessness in the first place.
    So Dr. Miller, what is the VA doing right now to reach out 
to veterans who are experiencing homelessness, and provide them 
with the mental health services that they need?
    Dr. Miller. I think that the answer to that question, 
ma'am, starts with identifying where are veterans at the 
highest risk for suicide within that particular situation. And 
what we have learned is that veterans are at the highest risk 
for suicide 30 to 60 days prior to homelessness status or 
losing their home. So a big part of the issue for us is 
identifying veterans who are at high risk.
    Senator Murray. How do you do that?
    Dr. Miller. I think that it is an issue of measuring and 
monitoring through the Homeless Program Office at the local 
level, up to the national level.
    Senator Murray. Is that happening?
    Dr. Miller. It is happening. I don't think that it is 
perfect, because it is very difficult to identify, 100 percent, 
who is at risk within 30 to 60 days. We had a situation that we 
faced this week where I assisted, along with some other 
colleagues, a veteran and his spouse who found out within 5 
days that they were losing their home. We put them in direct 
contact with resources and assistance, but the timing can be 
very short. There are areas for improvement there, and we are 
committed to working on them.
    Senator Murray. Okay. Well, Congress and the VA have been 
putting a lot of effort into reaching out to veterans with the 
message that it is okay for them to ask for help.
    Dr. Miller. Mm-hmm.
    Senator Murray. That when they are feeling alone, when they 
are feeling depressed, there is people and resources available 
for them. So it is really concerning to see on the VA's website 
that the wait time for a mental health appointment at the Puget 
Sound VA Medical Center is over a month long. I have personally 
had veterans tell me that they have had to wait as long as 3 
months just to get an appointment.
    I know it is challenging. I know it is complicated. But 
what is the VA doing to make sure that veterans who are 
experiencing a mental health crisis access the care they need 
when they need it?
    Dr. Miller. Same-day access is the first step that should 
be in place at every local facility regarding this, following 
same-day access, attending to staffing, and ensuring that staff 
can accommodate the demand.
    Senator Murray. Okay, but it is not happening. So what do 
we do?
    Dr. Miller. Then we, from a national level, we consult, we 
offer consultation to the local level regarding where they are 
seeing barriers, where they are seeing impediments to access, 
and assisting them with constructing a plan, an action plan for 
following through and making improvements.
    Senator Murray. Okay, can I get you to get in touch with 
the Puget Sound VA Medical Center and find out why these wait 
times are so long, and follow up on what we are going to do to 
fix it?
    Dr. Miller. Absolutely.
    Senator Murray. Thank you.


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response:
 
Current Average Wait Times for a New Mental Health Individual
 Appointment
 
  Includes appointments scheduled in advance over the past 30
 days, including telephone appointments; however, does not include
 appointments made the same day
      Seattle VA Medical Center-37 days
      American Lake campus-11 days
 
  Includes all scheduled appointments, including those scheduled
 the same day, over the past 6 months; however, does not include
 telephone appointments
      Seattle VA Medical Center-20.2 days
      American Lake campus-22.5 days
 
Note: All eligible Veterans have same-day mental-health access at the
 American Lake and Seattle clinics with no pre-scheduled appointment
 necessary.
------------------------------------------------------------------------


    Chairman Tester. Senator Moran.

                      SENATOR JERRY MORAN

    Senator Moran. Chairman, thank you. I will forego my 
opening statement and maybe make a few comments at the end. But 
let me ask questions of Dr. Miller.
    Dr. Miller, the Office Inspector General published a report 
last Thursday, September 14th, detailing deficiencies at the 
Veterans Crisis Line and how the Crisis Line staff failed to 
take appropriate action with the veteran who died by suicide 
that same night, the night that he contacted the crisis line. 
The report also details significant issues with the Veteran 
Crisis Line leadership and some staff. What are you doing, 
personally, to make certain that the deficiencies detailed in 
the Inspector General's Report are fixed quickly?
    Dr. Miller. Thank you for the question, Senator. We are 
better than what was depicted in that report. And we have to do 
better than what was depicted in that report. Personally, since 
you asked for that particular perspective, when I was first 
presented with the situation, with a call from OIG, directly, 
telling me about their concerns, I enacted pulling the 
responder from responder duties and initiating a full review of 
the work.
    That became what you see with Responder 2 and 3 in the 
review and the report. From that time, we have been working 
very aggressively to make changes. Such that, to the point 
right now, there is 11 recommendations specific to the Veterans 
Crisis Line in this report. We have made significant progress 
on eight of the eleven. There are two that involve close 
collaboration with the Office of Information and Technology. 
There is one that involves new information from a personnel 
perspective that we are pursuing.
    Senator Moran. Dr. Miller, what would be your--why does it 
take an Inspector General Report for this to be addressed? What 
is not taking place at the VA to get this solved before this 
particular veteran committed suicide?
    Dr. Miller. There are aspects of this situation that 
involve standards and expectations that are new to the field of 
crisis call; for example, text retention. Text retention is not 
a standard for the National Suicide Prevention Lifeline, nor is 
it known how many even in the Lifeline engage in text 
retention. It also has significant challenges, from an OIT 
perspective, balancing privacy, security with retention.
    We have been engaging for the last 2 years, even prior, to 
this particular situation, in what we would need to do to 
change our text platform to allow us retention. This report is 
not the first time we have thought about this and tried to move 
to this. The issue is finding a platform that OIT approves of 
that does not jeopardize veteran safety.
    Senator Moran. As you might expect, I think my staff and I 
will have additional questions, perhaps in writing, and maybe 
in a conversation.
    Dr. Miller, let me follow on a different topic, within the 
John Hannon Act, there is the Staff Sergeant Fox program, it 
seems to be overly administratively burdensome and has 
significant, what I would call, excessive restrictions on the 
use of funding. Do you disagree with those broad conclusions? 
And what changes would you expect to alleviate--make to 
alleviate the concerns that I am raising, or the concerns that 
have been raised to me?
    Dr. Miller. Yes. Thank you, Senator. I appreciate that. We, 
as you are, are proud of the Fox Grant Program. I do not 
disagree, however, with your statement. I think that this is a 
developmental process. This is the first time that we have 
engaged in grants, and we are learning to walk that fine line 
between too much and too little, in terms of requirements and 
measurements.
    I think that there is at least three things that I would be 
happy to talk with you at greater depth, that we are learning 
along the way about walking that proverbial fine line. But we 
are committed to learning, growing, adapting as we move 
forward.
    Senator Moran. There is a lot of things that are really 
pleasing to me in this legislation, and this grant program is 
one of them that I think gives an opportunity for community and 
personal engagement in veterans' lives.
    Dr. Miller. Yes.
    Senator Moran. That I think is really, really important, 
and I want to see it succeed. And if there is something, I 
would like to have the conversation, but also if there is 
something that is missing legislatively, congressionally, 
please make sure that I know that.
    Dr. Miller. I appreciate that. We will do so, sir.
    Senator Moran. Thank you.
    Chairman Tester. Senator Hassan.

                  SENATOR MARGARET WOOD HASSAN

    Senator Hassan. Thank you, Mr. Chair, and Ranking Member 
Moran for the hearing. And Dr. Miller and Ms. Black, thank you 
as well for being here.
    I was really glad to see that the VA has chosen a week next 
month, October 16th to 20th, to designate as the first official 
Buddy Check Week in which veterans conduct peer-to-peer 
wellness checks. As you know, Senator Ernst and I introduced 
and passed into law the bill to make this happen, our 
bipartisan legislation required the VA to build on what the 
American Legion had already started with the Buddy Check Week, 
by making it a nationwide VA initiative.
    Can you talk about how the VA plans on conducting outreach 
to maximize the impact of the first nationwide VA Buddy Check 
Week?
    Dr. Miller. Yes, thank you for the question. We are really 
looking forward to the first Buddy Check Week; that is 
scheduled for October 16th to initiate. We are also hoping to, 
and targeting, pairing the release of our annual report with 
the initiation of Buddy Check Week as a call to action. We are 
currently engaged in the process of talking with our close 
partners, the VSOs, regarding Buddy Check Week and 
implementation.
    One of the biggest concerns that we have with 
implementation is, making sure veterans feel equipped to engage 
in it constructively and helpfully. We have completed training, 
therefore, for Buddy Check Week, and we will be rolling that 
out within the next week.
    Senator Hassan. Great, thank you for that. I wanted to 
follow on Senator Murray's lead to talk a little bit about 
women veterans right now. Women veterans face unique hurdles to 
accessing VA health care and benefits, even though more than 30 
percent of new VA health care users are women, and there have 
been--there has been a threefold increase in the number of 
women veterans accessing VA mental health services since 2005.
    So I want to help raise awareness among women veterans 
about the Women Veterans Network, or WoVeN Program, which aims 
to develop peer support networks that are specific to the 
unique needs of this growing population of women veterans. What 
steps has the VA taken to address the unique mental health 
challenges that women veterans face? And how has the WoVeN 
Program been developed to help improve outcomes for the women 
who participate in it?
    Dr. Miller. Yes. Thanks for that question. And thanks for 
highlighting this as an example of an important program for 
women veterans. I agree with you. It absolutely is. What we are 
doing at the outset, in terms of broad messaging, is talking 
about the point that you made: that women veterans have unique 
risk factors, they have unique protective factors, and we need 
to be able to address those in a tailored way.
    In terms of WoVeN--pardon me--in terms of WoVeN, we have 
made some significant, I think, program evaluation observations 
and adjustments after the initial implementation. I think two 
examples serve as important to know for that. Number one, we 
have developed a Train the Trainer Program. Number two, we have 
learned that we can go from a co-lead paradigm to a single 
individual leading. These two lessons learned and the 
implementation plan will, exponentially, increase in the next 
year our ability to implement more of these groups and 
opportunities.
    Senator Hassan. Okay. That would be really excellent. One 
of the things I continue to hear, especially in rural areas in 
New Hampshire, from women veterans, is how hard it is for them 
to know where the other women veterans are and to provide the 
kind of peer-to-peer support that is so important. So I would 
look forward to continuing to work with you on that.
    A last question is about something I worked with Senator 
Cramer on: The bipartisan and bicameral push to enact the Solid 
Start Program. That directs the VA, as you know, to contact 
every veteran at least three times by phone in the first year 
after they leave active duty service, to check in and help 
connect them to the VA programs and benefits that they have 
earned and deserve. Last month alone, the VA contacted 23,479 
veterans through the Solid Start Program. How does the VA 
tailor outreach through the Solid Start Program to veterans 
with mental health care concerns, and what have you done to 
ensure that those mental health concerns are being addressed as 
quickly and effectively as possible?
    Dr. Miller. Great question, not to be punny, but VBA is 
taking the lead on doing solid work in this. I defer to Dr. 
Black.
    Dr. Black. Yes. And thank you for that question. So when 
you look at the Solid Start Program, that is one of the primary 
focuses, is ensuring that when we are making those contact with 
the veteran, that we are asking those questions. So all of our 
Solid Start representatives, they are trained in suicide 
prevention awareness; so when they are on those calls that is 
one of the topics that is discussed, that is a topic that is 
discussed.
    And not only that, our Solid Start makes a priority for any 
veteran who was seen in mental health the year prior to 
separating from the service. We make that a priority, and we 
engage those individuals as far as suicide prevention and 
mental health topics. About 80 percent of those priority 
veterans, we have made those successful connections with, so 
that is definitely a priority.
    Senator Hassan. Okay, that is really, really helpful 
because obviously if they had had a mental health consult or 
issue during service, the confusion or unease during 
transition, which is just, from what veterans tell me, it can 
be a pretty confusing time, makes them even that much more 
vulnerable, right?
    Dr. Black. Yes, and ensuring that we have--make that warm 
handoff from care to care is vital.
    Senator Hassan. Excellent. Well, thank you, Dr. Black and 
Dr. Miller.
    Chairman Tester. Dr. Cassidy.

                      SENATOR BILL CASSIDY

    Senator Cassidy. Hello. This is an incredibly damning OIG 
Report, incredibly damning. And I am struck that the executive 
director, who apparently interfered with the OIG Report, was 
not fired. She is reassigned, I presume still getting a 
paycheck; I assume she is still building a pension, having 
demonstrated her lack of truthfulness in conversation with the 
OIG.
    I am told that the Director of Quality and Training, or 
Training and Quality, is in the same position as this person 
was before. Now, we have passed accountability measures for 
people who don't do their job, and it sounds like interfering 
with an investigation of a suicide, which may have been 
inappropriately handled on a Veterans Crisis Line, is 
incompetence.
    So it may be a decision above your pay grade, but can you 
tell us why the only accountability that has been had so far is 
that somebody moved over to the Secretary's Office?
    Dr. Miller. Dr. Cassidy, we agree 100 percent with the 
necessity of accountability and holding our staff and team 
members to the highest level of standards when it comes to 
serving our veterans. The Executive Director that you mentioned 
is not named in ``interference'', to use the term that you 
used; the individual who was listed as Director of Quality is 
discussed in that, the information that we had to that effect 
is new from the OIG evaluation in their review. It is not 
uncommon to receive new information----
    Senator Cassidy. Well, then maybe, ``The Executive 
Director,'' I am quoting, ``Reported that after completion of a 
quality assurance review, it was decided there is,'' quote, 
``Insufficient information for us to really move forward on a 
root cause analysis; however, leaders initiated the root cause 
analysis after the OIG notification of the inspection, although 
the text conversation had not been obtained.''
    Now, it sounds like somebody is asleep at the wheel, and 
the question is, was it just incompetence, or was it just a 
cover up? So is anything being done about it? What is this 
person earning? Are they earning less than they were before?
    Dr. Miller. No, sir. What you are referring to is an RCA in 
the context of reviewing the text exchange; this gets to the 
text retention issue.
    Senator Cassidy. Stop. I am not asking text retention. I am 
asking, were the people responsible for the failure of this 
system, and who did not initiate the appropriate follow-up, 
and/or apparently tampered with people, responder number one, 
have said things which may have influenced the way they 
responded to the OIG; how are they being held accountable?
    Dr. Miller. They are under review using an appropriate 
personnel, guidance policy, and subject matter experts.
    Senator Cassidy. And the person who was transferred, did 
they get a cut in pay? Are they making the same money; or are 
they making more?
    Dr. Miller. I am not aware of a person transferred, sir.
    Senator Cassidy. I thought somebody was transferred to the 
Secretary's Office out of the position they had. Am I right on 
that? That is correct. I am told that is correct.
    Dr. Miller. There is an individual who took a different 
job; there was not an individual that was transferred.
    Senator Cassidy. Okay, took a different job. Just 
voluntarily took it and everybody said, incredibly well 
qualified, and no stains upon the record?
    Dr. Miller. I can't speak to the hiring process that was 
engaged, sir.
    Senator Cassidy. And when did the process of review begin 
for each of these two individuals?
    Dr. Miller. The process of review began for the first 
situation with responder one, that is mentioned in the report, 
immediately. The process of review----
    Senator Cassidy. I am sorry. What is the date on that?
    Dr. Miller. The date would be November----
    Senator Cassidy. And I am sorry. And I don't mean of the 
root cause analysis.
    Dr. Miller. Oh.
    Senator Cassidy. I mean of the apparent attempt to 
influence how the OIG was spoken with.
    Dr. Miller. Right. We did not--we did not become aware of 
that till OIG gave us feedback to that effect, which was about 
a year after the answer----
    Senator Cassidy. And how long ago was that?
    Dr. Miller. That would have been in the spring of 2021--I 
am sorry, '22.
    Senator Cassidy. And so the spring of 2021, and so a person 
has been--'22, has been under review since then; has anything 
resulted from that review?
    Dr. Miller. That is different, sir. You are talking about 
the review with regard to responder one.
    Senator Cassidy. Mr. Miller, I feel like you know what I am 
asking, but you are deliberately dodging the question. I want 
to know when did the review begin, of the two people whom this 
report alleges interfered with the investigation and/or told 
folks how to respond differently than what apparently was the 
truth?
    Dr. Miller. The answers to your question, sir, require 
technical responses----
    Senator Cassidy. Okay. But tell me what day--what month did 
those investigations, of those two people began, by the VA?
    Dr. Miller. The investigation with responder one 
initiated----
    Senator Cassidy. And again, I am not speaking of the fact 
that the veteran died. I am speaking of the fact that the 
supervisor, apparently, shall we say, misbehaved. When did the 
supervisor's misbehavior begin to be investigated?
    Dr. Miller. That began when we learned of----
    Senator Cassidy. And what was the date of that?
    Dr. Miller. The draft report was received by the OIG, I 
want to say, maybe two, three months ago; that is when we first 
came to the information of the----
    Senator Cassidy. And so how long will this investigation 
take to still hold them accountable, if indeed, the OIG is 
correct, that their actions were as you described?
    Dr. Miller. I can't answer that question for you.
    Senator Cassidy. That veteran was ill-served, and there--as 
best as I can tell, an attempt not to hold people accountable. 
And my, gosh, that is a pattern. Thank you.
    Chairman Tester. Thank you, Senator. There is no doubt your 
line of questioning is appropriate. And your disgust with the 
situation is entirely appropriate. I think that we demand 
excellence from the people in the VA, and people need to be 
held accountable, and we are going to ensure that--I am going 
to be following up with the IG on this issue tomorrow, and I 
will download with you from his perspective.
    With that, Senator Hirono.

                    SENATOR MAZIE K. HIRONO

    Senator Hirono. Thank you, Mr. Chairman.
    I noted that Senator Murray, my colleague, mentioned the 
high incidence of military sexual trauma experienced 
particularly by women. Dr. Miller, would you consider that a 
factor? Experiencing sexual trauma in the military a factor in 
suicide?
    Dr. Miller. Absolutely, it is a risk factor, yes.
    Senator Hirono. So I would say that, as I read your 
testimony, and you know these various risk factors, I would 
suggest to you that you include sexual military trauma in this 
list that you have. I think that is really important to call it 
out because of the high incidents of women who experience MST. 
So in noting the number of--by the way, would you start doing 
that as you prepare testimony for these kinds of hearings?
    Dr. Miller. Are you are referring to the written 
testimony----
    Senator Hirono. Well, that you should put in that military 
sexual trauma is a factor in suicide.
    Dr. Miller. Yes.
    Senator Hirono. So when we look at the numbers that you 
noted in 2020, that seems to be the most recent numbers we 
have. I hope those numbers are relatively accurate and not 
vastly undercounted. But 6,146 were veterans who committed 
suicide. Do you know how many of this number were women?
    Dr. Miller. Yes, that is available within our report.
    Senator Hirono. What is it?
    Dr. Miller. Off the top of my head; I am sorry, I don't 
know. It is by count much lower than men. It is by rate, 
rising, and higher.
    Senator Hirono. I think that is what should concern us 
because as more and more women enter the service, their suicide 
numbers, sadly, are going up. And do you know how many of these 
suicides had--was associated with opioids?
    Dr. Miller. In terms of opioid overdose or prescribing----
    Senator Hirono. Yes. I would start that, opioid overdoses?
    Dr. Miller. Yes. We do have a report that is available for 
opioid deaths, overdose that is separate from suicide 
reporting.
    Senator Hirono. Oh. Thank you. So what would that number 
be?
    Dr. Miller. That is a report that is generated by the 
Substance Use Disorder Program Office within the Office of 
Mental Health. There is also a publication from 2019 that 
updates that information, but we can take that back.

    [The publication referred to by Dr. Miller appears on page 
103 of the Appendix.]


------------------------------------------------------------------------
 
-------------------------------------------------------------------------
VA Response: VA's most recent reporting regarding Veteran overdose
 mortality is available in the following publication:
 
Begley MR, Ravindran C, Peltzman T, Morley SW, Stephens BM, Ashrafioun
 L, McCarthy JF. 2022. Veteran Drug Overdose Mortality, 2010-2019. Drug
 and Alcohol Dependence. 233:109296. doi: 10.1016/
 j.drugalcdep.2022.109296. Epub 2022 Jan 12. https://
 pubmed.ncbi.nlm.nih.gov/35219064/ PDF also attached.
 
Per Table 3, in 2019, there were 229 opioid overdose deaths among women
 Veterans, and there were 3,197 opioid overdose deaths among all
 Veterans.
 
Per the Begley et al. paper, attached, which includes the following
 information:
------------------------------------------------------------------------

Table 3

                 Veteran Drug Overdose Mortality Counts 2010-2019, Overall and by Drug Category
----------------------------------------------------------------------------------------------------------------
                                 Overall Drug Overdose          Opioid Overdose           Stimulant Overdose
                             -----------------------------------------------------------------------------------
                               2010 Deaths   2019 Deaths   2010 Deaths   2019 Deaths   2010 Deaths   2019 Deaths
----------------------------------------------------------------------------------------------------------------
All Veterans                         3669          4865          1891          3197           612          2172
Sex
  Female                              356           372           172           229            35           102
  Male                               3313          4493          1719          2968           577          2070
----------------------------------------------------------------------------------------------------------------


    Senator Hirono. So would you say that that is a significant 
number of opioid overdoses that involve veterans?
    Dr. Miller. Yes. Yes. That is a significant issue.
    Senator Hirono. So thank you for telling us that opioid 
overdoses are not counted as suicides, because I think that it 
would be enlightening. I would have thought that it would be a 
part of that information.
    Dr. Miller. May I add--may I add one caveat to that?
    Senator Hirono. Yes.
    Dr. Miller. It depends on what the medical examiner puts on 
the death certificate. If the opioid overdose is viewed as an 
accident, it is not a suicide.
    Senator Hirono. It is not. I understand. I do have a 
question about some of the categories or the--some specific 
populations that have a higher incidence of suicides. And in 
one of your reports, I noted that the rate of suicides among 
Asian-American, Native Hawaiian, and Pacific Islander veterans 
is higher. And as a part of a response to a question that I had 
asked of Secretary McDonough, he noted that there were 
demonstration projects related to tailored mental health 
outreach for specified veteran populations, including AANH 
veterans and women veterans.
    So can you describe what you would consider a tailored 
outreach for women veterans? And a tailored outreach for AANHPI 
veterans?
    Dr. Miller. Yes. We have been working on this, and happy to 
talk about it. We have developed a partnership with the Rocky 
Mountain MIRECC to study suicide prevention in this particular 
area, and specifically dedicated upon it. One publication has 
thus far emerged from that on geospatial considerations and how 
it impacts our knowledge of this population and in turn our 
programs. And they are currently in active recruitment for 
individuals to participate in the next phase of research.
    Simultaneously, we spent a couple of weeks this summer 
traveling to Guam and to the Mariana Islands to talk firsthand 
with important points of contact there, including Governor's 
Challenge teams.
    Senator Hirono. You are telling me, then, that you are 
specifically focusing on certain ideations relating to AANHPI 
veterans?
    Dr. Miller. Yes.
    Senator Hirono. I would like to find out more about what 
you are doing, what you are learning, and whether that informs 
some of the resources that you are providing toward outreach to 
these populations.
    Dr. Miller. Yes.
    Senator Hirono. And I am particularly interested also in 
your outreach to women veterans.
    Thank you, Mr. Chairman.
    Chairman Tester. Senator Blackburn.

                    SENATOR MARSHA BLACKBURN

    Senator Blackburn. Thank you, Mr. Chairman, and thank you 
for being here. This is an area that we all have concerns about 
in Tennessee, with our clinics, with our large veteran's 
population that is there. We do hear a good bit about this. I 
want to ask you all this: If I were a veteran in crisis and I 
reached out on the 988 right now and asked to be seen by the 
VA, how long would my wait be?
    Dr. Miller. So--I want to give you a technical answer, but 
you don't want a technical answer. The real answer to that is, 
it depends on the local facility that you would be referred to 
through the----
    Senator Blackburn. All right; I pulled some numbers.
    Dr. Miller. Yes.
    Senator Blackburn. Out of our region 32 of the 33 VAs in 
our region, the wait time would be longer than a week. And the 
reason I looked at that is because we looked at the National 
Library of Medicine Study that goes in and they do the surveys 
on those that are hospitalized because they attempted suicide. 
They did not succeed. Forty-eight percent of them said, within 
10 minutes, from the time they thought about it to the time 
they made the attempt, that that was the amount of lapsed time.
    Dr. Miller. Yes.
    Senator Blackburn. Now, if you want to look at some of 
these numbers. And this is what startled me, because these are 
individuals that are in crisis, we, as a Nation, a government, 
have promised these veterans healthcare. And then if you look 
at the--one of the clinics in Nashville, it is a seven-day 
wait; the Alvin C. York Veterans' Hospital over in 
Murfreesboro, eight days; sixty-six days at the Cookeville 
Clinic.
    Dr. Black, you have been to UT, you know where that clinic 
is.
    And you know the Chattanooga Clinic, seventy-one days; 
Campbell County Clinic, ninety-six days. So this access issue 
is one that we have got to solve.
    I want to switch topics to an IG report on a patient 
suicide following mismanagement of the Veterans Crisis Line, 
and it was on the 14th of September. I found it interesting 
that the Director of the Veterans Crisis Line did not define 
the patient's death as a ``sentinel event''. So what is the VA 
definition of a ``sentinel event''? Because I would think that 
that mismanagement and that death would be classified as a 
``sentinel event''.
    Dr. Miller. Yes. According to policy, and I feel badly, 
talking about policy and technical things in the context of a 
veteran who is--who is not with us and died by suicide. 
According to policy a ``sentinel event'' is defined as a death 
or near death, and can be reasonably associated with, from a 
causal perspective, to action or non-action on the part of last 
contact.
    Senator Blackburn. Okay. But he committed--he took his life 
within 30 minutes of speaking to somebody on that line.
    Dr. Miller. Mm-hmm.
    Senator Blackburn. And if someone were to text, how long 
does it take you to respond? What is the amount of time on the 
text? That it would take----
    Dr. Miller. Our response if someone text us, is immediate.
    Senator Blackburn. Immediate?
    Dr. Miller. Yes. Now, the individual that we are texting 
with, it is not uncommon that their response is not immediate. 
There could be 15, there could be 20 minutes lag.
    Senator Blackburn. Do they ever call that number that they 
are getting the text from, to make that personal contact? Or do 
they just sit there and text it?
    Dr. Miller. Yes. Our policy is that if the risk assessment 
indicates, we need to switch them to phone from text, and that 
was one of our--that was one of the things that we did wrong in 
this situation.
    Senator Blackburn. Okay. I do have some additional 
questions. My time is running out, but I am wanting to look at 
your staffing levels--I will submit this to each of you for 
writing--and the way that you are utilizing community care to 
help ease the burden on that staffing. I also want to know what 
kind of training you are doing to individuals that are Crisis 
Line responders; what kind of training they are receiving?
    Thank you, Mr. Chairman.
    Chairman Tester. So Senator Blackburn, we will put that 
into the record, and get a response for those. So thank you.
    Senator Blackburn. Yes.
    Chairman Tester. Senator Blumenthal.

                   SENATOR RICHARD BLUMENTHAL

    Senator Blumenthal. Thanks, Mr. Chairman.
    I want to just return to the exchange you had with Senator 
Hirono on drug overdoses.
    Dr. Miller. Mm-hmm.
    Senator Blumenthal. Those are not counted as suicide?
    Dr. Miller. Drug overdoses that the coroner, or the medical 
examiner determines on the death certificates are accidental, 
are not the official CDC definition of suicide, so they are not 
coded as a suicide. Those do not come to us for the suicide 
report.
    Senator Blumenthal. So it depends on the local coroner?
    Dr. Miller. Yes.
    Senator Blumenthal. So the definition that you gave me 
earlier, or you gave to Senator Blackburn, or you gave us 
earlier, about in effect, the causal link, how does that factor 
into what you count as a suicide by overdose?
    Dr. Miller. You know, that is getting into a question of--
it is more in the areas of the medical examiner or the coroner. 
Usually, and very generally speaking, there needs to be 
indication of motive. Motive can be indicated by the means, 
motive can be indicated by a letter, or artifacts left behind, 
as two examples.
    Senator Blumenthal. I think what you are telling us is that 
the numbers of suicide may, in fact, be far greater than what 
you have tabulated, and what you have given to Congress year 
after year, because this local coroner, I mean, I am a former 
State official, lots of coroners have different definitions, 
different way of applying that, what you called a technical 
definition.
    And I am a lawyer and I can't repeat the way you put it, 
essentially, it is causal connection. And I don't know how a 
coroner makes that determination, which then determines the VAs 
reporting to the United States Congress. I think those numbers 
are probably tremendously incomplete.
    Let me ask you a more general question. You know, according 
to you: Suicide is a complex problem with a multifaceted 
interweaving of potential contributing factors; that is true. 
Would you say that we have really made significant progress 
over the last 10 years?
    Dr. Miller. I think there the two areas that my mind would 
go to, to answer that question. Two questions really, have we 
advanced on understanding and treating or improving the 
``why''? And have we advanced on improving the ``how''?
    Senator Blumenthal. Well, have we advanced on the numbers?
    Dr. Miller. We have not advanced on the numbers.
    Senator Blumenthal. We have not advanced on the numbers, so 
I don't know how you could tell me we have made progress on 
this problem. If the same numbers are dying, if the rate of 
suicide is 1 in 17, 1 in 20, 1 in 21; I don't even know the 
most current figure, how it depends on the numbers of veterans, 
not the numbers of suicides, but the numbers of suicides are 
basically unchanged. How could you tell us that we have made 
progress?
    Dr. Miller. Because we have seen certain areas of higher 
risks or risk where we have seen improvements and decreases; 
for example, veterans who are in VHA care and diagnosed with 
PTSD, there has been a 30 percent reduction in suicide rate 
over the last 20 years. Veterans in VHA care diagnosed with a 
depressive disorder, there has been a greater than 20 percent 
reduction.
    Senator Blumenthal. Well, those are veterans in VHA care?
    Dr. Miller. Mm-hmm. And veterans----
    Senator Blumenthal. What about the total number?
    Dr. Miller. And veterans not in the----
    Senator Blumenthal. I think our Nation is judged, not by 
the numbers who are in VHA care, they are bound to be lower, I 
would hope they would be lower, but the numbers overall. If you 
were judging our Nation, those numbers are unchanged. I mean, I 
think we need to face the fact, and I am encountering 
constituents every day who say: Why can't we make progress?
    Dr. Miller. My answer to that sir, it is the ``how'', 70 
percent of veterans die by firearms. That is the number that 
hasn't changed, and has only gone up. And until we make a 
significant improvement in that area, we probably will not see 
a significant decrease in veteran suicide.
    Senator Blumenthal. So my time is expiring, but have you 
advised the leadership of the VA that it should issue a warning 
to veterans and their families that firearms should be removed 
from their homes. And they should support red-flag statutes, 
and emergency risk protection orders in States where they are 
not now? And I have been probably one of the leading advocates 
in the Senate for separating people from guns when they say 
they are going to kill themselves and kill others? Shouldn't 
the VA be much more aggressive in advocating for those 
statutes?
    Dr. Miller. We provide technical consultation on everything 
that comes our way from you and back up through the chain. I 
just flew here from Denver where I was partnered with someone 
from your State, sir, and the President of NSSF, to address 
firearm manufacturing industry regarding what we can do 
together and collaboratively, to message exactly what you are 
saying.
    Senator Blumenthal. My time has expired. Thank you, 
Chairman.
    Chairman Tester. Yes. Thank you. Before I get to Senator 
Tillis, I would just say that, I believe you are on Armed 
Services, I think Senator King is Armed Services, and Senator 
King knows this because we have talked about it, the transition 
between active military and the VA, we need to do some work on, 
because I really think that is a huge driver for the suicides.
    Senator Tillis.

                      SENATOR THOM TILLIS

    Senator Tillis. Yes, starting with the fact that two-thirds 
of those who are taking their lives every day are not connected 
to the VA, we have got to figure out a way to get them better 
connected.
    Dr. Miller, and Dr. Black, thank you both for being here. 
You know, the exchange that you had with Senator Cassidy about, 
maybe a mistake, and it may very well be that somebody who was 
in a position to where they could have gotten the consult done, 
intervene, save a life. But it could have also, and more likely 
be related to a breakdown of a process and staffing, and a 
number of other things. I just can't imagine that somebody 
working in that position would actually not care about trying 
to save that veteran's life.
    Dr. Miller. Senator----
    Senator Tillis. But it is what it is. And to the extent 
that they failed to follow processes they obviously need to be 
disciplined.
    Dr. Miller. Yes, sir.
    Senator Tillis. I just believe in my heart of hearts it has 
got to be something more fundamental. The OIG analyzed, I 
guess, the analysis of consults for PTSD, military sexual 
trauma, or couples therapy, submitted from November 1st, 2020, 
through June 2022. They found 39.3 percent of psychotherapy, 
39.5 percent of PTSD, 27 percent of military sexual assault, 
and 67, almost 68 percent of couples therapy consults, did not 
meet the required time of 30 days from the patient indicated 
date.
    This sounds to me like a--and I guess as a part of the OIG 
Report, they said it looked like staffing issues, backlogs, the 
Clinical Research Hub no longer available to Hub staffing 
concerns. Do you agree with the OIG's assessment, or the 
information they receive from mental health leaders that you do 
have staffing backlog issues that are a problem? And if you do, 
how are they being addressed?
    Dr. Miller. Yes, sir. To answer your question accurately, 
to make sure I am thinking of the same OIG Report, are you 
referring to the one from North Carolina and Asheville?
    Senator Tillis. Yes.
    Dr. Miller. Yes. Okay. Yes. From my review of what I know 
of that OIG Report, there was concurrence to all the 
recommendations that were provided. I also believe that if we 
were to look at it today, that that facility has made some 
meaningful progress regarding mental health hiring. I do know 
that the Chief of Mental Health is today sitting at a training 
program for BHIP, which was also mentioned in that particular 
report, so they are making advancements on that as well.
    Senator Tillis. Just moving on to other information that 
was included in the OIG Report, one thing that stuck out at me 
is--look, I know I talk with a lot of veterans, I talk with a 
lot of veterans service organizations, and they all like the 
brick-and-mortar presence of the VA, about when they can get an 
appointment, and when they can get the care they need. In the 
behavioral health space, we do not have enough in the VA or in 
the general community of the general population.
    But can you speak to some of the passages in the OIG Report 
that said that people within the VA were really discouraging 
community care referrals for behavioral health; why they would 
do that?
    Dr. Miller. So I think that from that, and specific to the 
situation, from my understanding of it, there were discussions 
about exactly what we have said in here, which is VA care 
works, and let us capture as much of that as we can through 
appropriate mental health staffing. I think that there may have 
been interpretations of that that led to then believing that it 
was a black and white and then discouraging community 
referrals. I believe in the response to that OIG, the facility 
attempted to clarify that, and one of the recommendations that 
they are engaging is staff-wide training on that very issue, 
sir.
    Senator Tillis. Yes. I think it is critically important----
    Dr. Miller. Yes.
    Senator Tillis [continuing]. For anyone in the VA. And I am 
a big supporter of the VA. I like to think of myself as a 
cheerleader, I very seldom flog you all in these open hearings 
but--very seldom--but for something like this, we have got to 
have balance. This is about providing care.
    Dr. Miller. Mm-hmm.
    Senator Tillis. And unless you think you are knowingly 
providing a community care referral to somebody who is not 
competent to provide the care, refer the case.
    Dr. Miller. Yes.
    Senator Tillis. And then build a capability and serve more 
within the VA, but that particularly in behavioral health 
crisis situations, days and minutes matter.
    Dr. Miller. Yes.
    Senator Tillis. And I think that anyone who, in the VA, is 
guilty of saying: Well, you know, we just need to keep them in 
the mix, a few more days, a few more weeks. First, you are 
playing, potentially, with somebody's life, and you are--the 
person who is saying that is running counter to what I have 
heard from everybody in the VA: Get the care, quality care as 
quickly as possible, in the VA if possible, but in the 
community when necessary.
    Dr. Miller. That is all that matters. I agree with you 100 
percent. You would know this better than I do, sir, but I 
believe specific to that region and your constituents, 
community care, mental health care is in short supply. It seems 
difficult to come by.
    Senator Tillis. It is, and that is why we are--And Mr. 
Chair, I just want to mention this for future consideration. I 
met with Secretary McDonough when he was in Charlotte, about a 
month ago, and I was talking to him about the Bipartisan Safer 
Communities Act, and so it made me think about it when Senator 
Blumenthal spoke up, that is one of the single largest 
investments in behavioral health that this Congress has made in 
modern history.
    One of the things I asked Secretary McDonough is, have we 
tuned it right to where--if you think about Eastern North 
Carolina, think about between Fort Bragg and Camp Lejeune, is 
there someplace down there where maybe we have something that 
we haven't had before? Collaboration with the VA, collaboration 
with the Army, collaboration with the private sector, to stand 
up a behavioral health capability that does really exist, it is 
scaled down in that area.
    So I would like for us, if we could, I have talked to Denis 
about it, but I would like to see if the plain text as we 
passed it, facilitates that sort of thinking. Or if we need to 
open it up and potentially consider that in areas where I think 
it could be helpful.
    Dr. Miller. And improve telehealth in those areas. Yes, 
sir.
    Senator Tillis. Yes. Thank you. Thank you, Mr. Chair.
    Chairman Tester. Senator King.

                   SENATOR ANGUS S. KING, JR.

    Senator King. Thank you, Mr. Chairman.
    Dr. Miller, nice to see you in person, we talked last week. 
One of the main issues that seem to be motivating suicides is 
financial, and financial distress, and I think the data is four 
times--veterans with incomes below $50,000 who have financial 
problems are four times as likely to have ideation of suicide. 
What about a pilot in the helpline, of the Crisis Line, of 
having some financial expertise that could be referred? Are you 
having a financial problem, here is somebody you can talk to.
    Dr. Miller. Yes.
    Senator King. Is that something we could work on?
    Dr. Miller. Yes, is the short answer. What you are getting 
at though, sir, is an important point in terms of instead of 
having maybe the referral from the Veterans Crisis Line go to 
mental health, maybe it would be more appropriate for it to go 
to a financial counselor, in which case then there is a ripple 
effect in capacity with mental health. You save by putting 
people in the right place at the right time. Yes.
    Senator King. So is this something that you don't need 
legislation; is this something you could pilot for, in one 
VISN, for example?
    Dr. Miller. Yes. What we can pilot is, we are starting a 
new Veteran Center for Financial Empowerment. That center will 
offer, through VBA, and services that are available with VBA, 
referral to free consultation for financial issues. That will 
allow us to get some initial data on demand and need and be 
able to report that back to you for next steps.
    Senator King. I would appreciate it. I think that is an 
important step. Let us see what the data shows us because it 
does appear to be one of the causation factors. Workforce, it 
seems like every hearing that we are at, we talk about 
workforce, and I keep hearing about the difficulty of 
onboarding people.
    For example, if you want to bring on a new therapist, it 
may be a therapist, it may be a clinical social worker, it may 
be a psychologist, you have got to do three different--three 
different job descriptions and go through a long process. And 
in fact, I have heard of mental health directors who are 
spending 20 hours a week on administrative functions of 
onboarding people. How do we crack that problem? It just seems 
to be a problem throughout the agency.
    Dr. Miller. Yes. I feel your pain and theirs. We hired 900 
Veterans Crisis Line responders in the last year, a-year-and-a-
half, and a significant portion of my time is paperwork to help 
move those issues in hirings along. I think that we are taking 
a good step in this area through the Under Secretary's 
initiatives that are informally called ``Tiger Teams''. There 
are at least six key areas, suicide prevention is one, but 
another one is hiring and retention and workforce management 
optimization. Watching how that group is able to progress with 
the targeted goals and outcomes will be important.
    Senator King. Well, I would hope something, and this isn't 
for you necessarily, but for the VA generally, instead of this 
iron hand of control from Washington, why shouldn't the local 
VA facility be able to hire the people they need? Washington 
can give them guidelines; here are the standards, here are the 
minimum standards, and those kinds of things. But somebody in 
Maine, if they need somebody, they ought to be able to reach 
out into the community and try to find them, and not go through 
all the steps that appear to be in this process.
    I don't expect you to answer that, but I think that is 
something, Mr. Chairman, we ought to talk to the Agency about. 
There are just--I keep hearing about the administrative burden 
of bringing people on board, and then we just--we need them.
    Final question, I think it was the Chairman who used the 
term ``better connected'', about getting people connected into 
the system. One of the ideas that I am working on is that an 
active-duty service member can pre-enroll in the VA while still 
in active duty as part of the TAP process. Do you have a 
reaction to that?
    Dr. Miller. Yes. I think that would--personally, I think 
that would be extremely helpful in terms of streamlining the 
process. Currently, what can be done is a transitioning service 
member can preregister; they cannot pre-enroll. The reason why 
they cannot pre-enroll is because, by law, they have to be a 
veteran by the legal definition of a veteran to enroll.
    Senator King. Fortunately, laws are the business that we 
are in here.
    Dr. Miller. Yes, sir.
    Senator King. Great. Well, I think that is something I 
would like to see us work on. Thank you, Mr. Chairman.
    Chairman Tester. Senator Boozman.

                      SENATOR JOHN BOOZMAN

    Senator Boozman. Thank you, Mr. Chairman. And thank you and 
Senator Moran for having such an important hearing. You know, 
with all the rancor that is going on around here, but this 
Committee really does work in a very, very bipartisan way, and 
because of that, in the last couple of congresses we got an 
awful lot done.
    We all know that suicide is really complex; it is a 
complicated crisis, there is no single solution. We also know 
that if people are in the VA system, they are less likely to 
commit suicide. Most of the people that are committing suicide 
are outside of the system.
    So one of the things that we have worked on, and most of 
the Committee has worked on, is trying to make it such that we 
could capture those folks that are outside of the system, get 
them some help in the community, and then ultimately bring them 
into the VA where they can get even additional help.
    Dr. Miller. Mm-hmm.
    Senator Boozman. Dr. Miller, I appreciate you highlighting 
the Staff Sergeant Parker Gordon Fox Suicide Grant Program in 
your testimony. When we wrote the grant program, we intended to 
provide Federal resources to organizations in the community 
that coordinate Suicide Prevention Services outside of a 
clinical setting. I have met with many grant recipients and 
heard incredibly positive feedback on the program.
    After one year of this program being in effect, what are 
the biggest lessons that you have learned? And have you 
identified ways to improve for the future? So this has been 
going on for a while; you have got these grant programs out 
there. What are you finding with them?
    Dr. Miller. Yes. I think one thing that we are learning is, 
it is written into the law the importance of screening for 
risk, and ensuring that the services are going to those who are 
at higher risk. But we are learning, as part of that process, 
that one of the many beauties of this grant is the services 
that a lot of the grantees are providing, are what we may call 
``upstream'' in nature. So it is a bit contradictory for them 
to be, necessarily, screening for risk, and screening out those 
who aren't high risk, when a lot of the work they are doing is 
moving upstream before these individuals become high risk.
    So resolving that I think--discrepancy, I think is a 
challenge for us that we are committed to working with you and 
this Committee together. I think the second thing I would say 
is we are learning a lot about how to screen for risk in ways 
when you are not a licensed mental health professional, and it 
just feels out of your normal flow of what you do to pull out a 
survey, a questionnaire, and say: I have some questions here 
that I need to ask you.
    So I think we are taking a close look at the screener tool 
that we have implemented as part of this, and wanting to take a 
look at: is there a better way to meet the requirements of the 
screen without necessarily asking grantees to slip into a role 
that feels very unnatural for them as part of their service.
    Senator Boozman. Yes. And this follows up on your comments, 
and then question--comments that Senator Moran had, but it does 
appear that when you visit with people, you know, that are 
involved, that there is just something about government that 
makes things pretty complex. And I am part of government; I 
understand that. But, you know, providing increased flexibility 
in that area, and, you know, the whole process, I think, would 
really be helpful.
    Dr. Miller. Absolutely; I think that would--I would want 
that to be an open discussion between us, because how I may 
define increased flexibility, I may have a blind spot then in 
terms of what you were intending with the law and the 
applications of the law. So I think it is really important we 
continue our open and collaborative dialogue so that we are 
fully capturing your intentions with the law.
    Senator Boozman. No. I agree, and I think something would 
be helpful if we could discuss with you, but also get some 
providers in, you know, to help us realize some of the 
unintended consequences. We all want the same thing.
    Dr. Miller. Mm-hmm.
    Senator Boozman. That may be, you know, a requirement, or 
whatever; just makes it a little bit more difficult.
    Dr. Miller. Yes. I am looking forward to Panel Two. I think 
it will give us some good insights and steps forward.
    Senator Boozman. Thank you.
    Dr. Miller. Thank you.
    Chairman Tester. Senator Sinema.

                     SENATOR KYRSTEN SINEMA

    Senator Sinema. Well, thank you, Chairman Tester, for 
holding this hearing. And thank you to our panelists for being 
here, and for the critical services you provide for America's 
veterans. I will focus my questions on mental health resilience 
for veterans and for their community. But first I want to 
address a time-sensitive issue.
    Much of what we discussed today centers around access to 
care for veterans, and part of that access is transportation to 
the point of care, like a VA hospital or a clinic. The VA is 
currently implementing a rule that decreases veterans' access 
to ambulance services, particularly in rural parts of the 
country, like Northern Arizona.
    So I commend Senators Tester and Moran for their quick 
bipartisan work drafting and introducing the VA Emergency 
Transportation Access Act to address this issue, as well as a 
related amendment to the appropriations bill that I hope to 
vote on in the near future. I look forward to working with the 
Committee and the VA to protect veterans' access to life-saving 
ambulance services.
    Since coming to the Senate, I have led bipartisan efforts 
to help service members and veterans build supportive resilient 
communities; first, by earning broad support and passing my 
Sergeant Daniel Somers Veterans Network Act into law, and more 
recently by introducing the Military Suicide Prevention in the 
21st Century Act. As we know, networks of support for our 
veterans are vital to their well-being.
    So my first question is for you, Director Miller. National 
Community Health Partners, which is based in Southern Arizona, 
has recently launched a project called ``The Best Is Yet to 
Come'' funded through the Staff Sergeant Parker Gordon Fox 
Suicide Prevention Grant Program; one of three such grantees in 
Arizona. Can you speak to the importance of these grants to 
community organizations?
    Dr. Miller. Yes. Absolutely, I think there is a few things 
that come together under the heading of our community-based 
Suicide Prevention Plan that reinforce your points exactly. The 
community-based Suicide Prevention Plan focuses on the fact 
that suicide prevention is not just clinical; it does not just 
occur in the room between a patient and provider, it occurs in 
the community. And as such, we have the Governor's Challenge, 
we have the development of community coalitions and 
collaborations, and then we have the Fox Grants.
    Arizona is leaning forward in each of these areas, and what 
we have seen out of States like, and such as Arizona is the 
importance of, at the State level, at the county level, forming 
veteran suicide prevention plans for the community that are 
informed and built by the community. And then we are able to 
come in and support, through the Governor's Challenge, we are 
able to come in and support through the Fox Grants. The fact 
that you see that with the Fox Grants is evidence of the 
strength of that in Arizona.
    Senator Sinema. Mm-hmm. Thank you. I still hear from my 
Veterans Advisory Committee in Arizona that the lack of a 
cohesive network creates challenges for veterans. So what 
additional resources do veterans have to find a community after 
their service?
    Dr. Miller. I think that that is a critically important 
consideration because one thing that we know, and I think we 
are going to see this more and more in the data, there is a 
relationship between connection, lack of connection, and 
suicide, particularly for veterans. So in terms of creating a 
community, I think one important step is the Solid Start. To 
that I will defer to Dr. Black.
    Dr. Black. And thank you, Senator. Yes, the Solid Start 
Program is that first critical year after separation from the 
Military. So those calls at 90, 180, and 365 days it is helping 
to connect to the community, so when our Solid Start 
representatives are making that call that is some of those 
questions as asked, and helping connect them to their local 
VSOs, is one of the things that they will do.
    If that is something that is an issue for the veteran it is 
based--those calls are based on the veteran need. So if they 
are saying: Yes, I am having a hard time, you know, finding 
community connections. That is something that will be addressed 
in those calls.
    Senator Sinema. And are there any metrics that we can use 
to gauge the growth and strength of these types of support 
networks?
    Dr. Miller. I think that the metrics that are associated--
the first thing that comes to mind is the metrics that are 
associated with the Governor's challenge and the work that we 
are doing there. So the practical application of that would be: 
What is Arizona seeing in terms of the number of community 
collaborations that have been built, implemented, maintained. 
That would be an important indicator. Nationwide we just 
reached 1,500. How is that relative in Arizona? Is it growing? 
What lessons are we learning?
    Senator Sinema. I see my time has expired. Thank you, Mr. 
Chairman, for holding this hearing on such an important topic.
    Chairman Tester. Thank you, Senator Sinema.
    So you heard my opening statement, and I think you are 
fully aware that 60 percent of the veterans who commit suicide 
don't have any engagement with the VA. Senator King has a bill 
that will enroll the service member before they get out of the 
service, in the VA. I want your opinion. Is that a solution?
    Dr. Miller. So there is the answer that I could give which 
is, we will review that through our Technical Consultation Team 
and experts and we would happy----
    Chairman Tester. Except I want your opinion.
    Dr. Miller. My opinion is that when you look at engaging 
preregistration, and the percent that we are able to do with 
that, and then you look at how that converts to pre--or how 
that converts to enroll enrollment, there is a gap. So the 
short answer is, if you can cut that gap down between 
preregistration and enrollment, and make it all the same, that 
just makes sense to me. But that is just Matt Miller talking.
    Chairman Tester. Well that is right--we are in front of 
this Committee though. Okay? If you were a ``nobody'' you 
wouldn't be here, all right. So Dr. Miller the STRONG Veterans 
Act includes the silent monitoring requirements of the Veterans 
Crisis lines.
    Dr. Miller. Yes.
    Chairman Tester. The IG was critical of that too in his 
report. What assurances can the VA--can you provide--can the VA 
provide to this Committee that Veterans Crisis Line responders 
are receiving the appropriate amount of silent monitoring 
today?
    Dr. Miller. Yes. A few things; and I think that is really 
important, because that is one of the keys to rebuilding trust, 
I think, in this situation. Number one, if you look at our 
staffing levels in January of '21 when this tragedy occurred, 
we were about 550 responders. We have since added 900-plus 
responders.
    Why does that matter? That matters because the context of 
this situation is we were using someone in an overtime role who 
wasn't regularly a responder. My point is, we don't have to do 
that anymore to answer any call. So that is one step that has 
been necessary here.
    The second step is, two forms of silent monitoring that 
must occur on a monthly base and be reported, 90 percent 
supervision, or supervisor performance monitoring, 80 percent 
silent monitoring. We report that on a monthly basis, as I 
said, and as part of the OIG recommendations we are going to be 
reporting that and our progress to OIG. We will not be able to 
close that recommendation until we reach a level that they are 
satisfied with.
    That said, I know for a fact, because I looked at it today, 
we are at over 90 percent for both the supervision silent 
monitoring, and the silent monitor silent monitoring, two 
forms.
    Chairman Tester. All right; you answered my second question 
with that answer. So in Section 701 of the Hannon Act, and by 
the way this law was passed--was signed in a law in 2020; it 
implements new telehealth access grants, the VA doesn't expect 
to be able to give awards out until 2025, not to beat this, but 
2020 is when it was signed into law, we are not going to get 
any grants after 2025, telehealth is really important in a 
rural State, I think it is important in an urban State too, 
quite frankly. What can you guys do to expedite that roll out? 
Or are you happy with that timeline?
    Dr. Miller. We are not happy with that timeline.
    Chairman Tester. Okay.
    Dr. Miller. I think that in talking to those who are 
leading this particular effort my understanding and perception 
is that we are not happy, we have looked at options to 
expedite, there has been some consultation that is needed to 
occur with OGC, and OGC has found themselves needing to fill in 
some details toward enactment. And the impression that I got in 
talking with them is, it is better to measure twice, cut once, 
than to do it wrongly, legally.
    Chairman Tester. I got it.
    Senator King [continuing]. In months.
    Chairman Tester. Yes.
    Senator King. That is a standard I----
    Chairman Tester. That is a very good point, Senator King. I 
would also point out that that we are--if it takes us 5 years 
to do a telehealth grant to get them out the door, we have got 
no hope to ever get electronic medical records done. We have 
just got no hope.
    Dr. Miller. We were, I think, very quick and efficient with 
Staff Sergeant Parker Gordon Fox, so I think there is hope.
    Chairman Tester. Okay. The last question, because we have 
got another panel, though I will defer to the Ranking Member if 
he has another question; and maybe even to Senator King, but it 
had better be a damn good one.
    Recently, we introduced the bipartisan Not Just a Number 
Act, Senator Boozman was just here, we introduced it together, 
it requires a VA to examine association between veterans' use 
of VA benefits and suicide. I think you could also bring in the 
point that Senator King talked about, about financial 
difficulties.
    Dr. Miller. Mm-hmm.
    Chairman Tester. Dr. Miller, how could Outreach do an 
analysis of veterans who use VBA programs help? Do you think it 
would?
    Dr. Miller. Let me give you----
    Chairman Tester. Do you think it would be worth the time 
spent to look at them?
    Dr. Miller. Yes, sir. Let me give you an example to 
illustrate. REACH VET is considered a leader, nationwide and 
internationally, in risk prediction for suicide. REACH VET is 
based primarily on clinical factors pulled from the medical 
chart. We know that from looking at the data the majority of 
veterans who die by suicide by firearm don't show up in the top 
50 percent of risk for REACH VET. They show up in other areas 
that are outside of the clinical. So then the short answer 
founded upon that is, yes, sir.
    Chairman Tester. Okay. Senator Moran.
    Senator Moran. Thank you, Chairman. I will use my time of 
my opening statement that I didn't give, to just ask a couple 
of clarifying questions. First of all, Senator Tillis, in 
Asheville, your answer to him involved that--and the question 
that I want to raise is about the lack of suggestion, or 
recommendation, or appointment to community care. And your 
answer was that we think that there was a policy in place that 
we were trying to keep our patients within the VA, we believe 
we provide better service. And you indicated, I think, Dr. 
Miller, that the Asheville staff was being retrained or trained 
to get this right; is that--did I make that up, or that is what 
you said?
    Dr. Miller. I think the only thing that I would suggest 
modification on, is I don't know that there was a policy in 
place. I think that there was a communication about the general 
spirit of VA provides great care, let us provide great care.
    Senator Moran. And the point I was--that is what you said. 
The point I want to make is that the directions, though, were 
given to the hospital at Asheville, not more broadly within the 
VA?
    Dr. Miller. Yes. In this particular OIG, all----
    Senator Moran. Because OIG pointed this out?
    Dr. Miller. Yes.
    Senator Moran. I would say that it is happening across the 
country, that that is not a policy, but this belief that the VA 
provides the best service, and therefore community care is 
often not suggested to a veteran. I hear about it consistently 
at home, I hear about it from my colleagues, and it is not what 
the MISSION Act says. The issue there is that you can have 
community care, if your wait time is too long, or if it is in 
the best interest of the patient, the veteran, determined not 
by the VA, but by the veteran and his or her provider.
    Dr. Miller. Yes. Well----
    Senator Moran. I am restating what the law is, but it is 
not, ever been clear to me that the VA is interested in making 
community care that widely available, and I think it is 
particular important in this hearing, where mental health 
services are rare, hard to find, within the VA, and sometimes 
outside the VA, we don't have enough providers anyplace. But it 
is also important because it can be a life and death 
circumstances, and the failure to suggest community care is one 
of those life and death circumstances.
    It, again, is not in compliance with the law as we wrote it 
and I wish that your answer would have been, the VA is now 
providing direction to all VAs, all VISNs, all hospitals, all 
providers that community care is an option in the circumstance, 
particularly when a veteran cannot get an appointment within 
the VA.
    Let me ask a more technical question. I think you have said 
that if you are suggesting ideation of suicide, you can get an 
appointment within 24 hours; did I hear that? Or is that true?
    Dr. Miller. That is not what I meant to say in that 
particular context. What I think I was talking about was same-
day access that any veteran should be able to request and there 
should be an option for it at the VA facility, or the 
community-based outpatient clinic. Now, with that said, yes, 
there should be immediate access for any veteran who is 
experiencing suicidal thoughts.
    Senator Moran. The point I want to try to make sure I 
understand is, I think you said: we could get an appointment 
within that time frame. And does ``get an appointment'' mean 
you are seen by a provider? Or does ``get an appointment'' mean 
you are scheduled to be seen by a provider?
    Dr. Miller. No. In this case, in a crisis, if we are 
talking about--and we are not even talking about an 
appointment; let us say we are talking about an encounter, an 
engagement, you go and do the appointment after the fact, just 
to make sure that it is logged into the system. That is what 
should occur with same-day access, and with the certain----
    Senator Moran. Same-day access is different than getting an 
appointment. Same-day access is same day access, getting an 
appointment is something that is written on a piece of paper 
and----
    Dr. Miller. Yes.
    Senator Moran. All right.
    Dr. Miller. What you are highlighting is a nuance that I 
think is important, and that is that there are different 
dimensions of access. There is emergency access, there is 
routine first appointment, and there is follow-up episode of 
care. What we need to do in the VA, is be carefully watching, 
providing for, and monitoring all three types of access.
    Senator Moran. You are talking VA health care broadly; or 
VA health care as it relates to mental health and suicide?
    Dr. Miller. Well, I would argue broadly. However, mental 
health specifically is unique somewhat in that you commonly see 
the need for emergency first appointment routine follow-for 
episode of care.

            CLOSING STATEMENT OF SENATOR JERRY MORAN

    Senator Moran. And now for my closing statement Mr. 
President--Mr. Chairman, which was the opening statement: I had 
a veteran from Kansas visit my office today, this morning, and 
this is her story, she shared that after the beginning of 
mental health treatment at a Kansas VA Medical Center. She was 
referred to a local Vet Center because of staffing shortages at 
the VA Health Center. When she reached out for an initial 
appointment with the counselor at the Vet Center she was told 
their case load was already full, unless she was experiencing 
suicide ideation they would not be able to prioritize her.
    Six weeks later the veteran received a follow-up call from 
the Vet Center saying: We will not be able to help you at all. 
We don't have the staff. I think was the point. That is now 
months ago, and she has had no follow up, no effort to re-
engage, never met with a counselor.
    And unfortunately, I don't think this is an isolated 
circumstance. And so this is an example, and I heard this with 
Senator Murray in her conversations about the number of days. I 
heard it with Senator Blackwell. And the number of days for 
care and treatment for an appointment, for attention for--and 
so the other point that I make is not one time, this veteran 
said, did she ever hear anything about the possibility of going 
to the community, because both the hospital and the Vet Center 
failed her for lack of capability of seeing her due to staffing 
shortages.
    It is why my support for community care is not at all based 
upon any bias against the VA, it is that too many veterans fall 
through the cracks when there is, the reason that we created 
community care in the MISSION Act, was a result of their lack 
of capabilities of a hospital in Phoenix meeting the needs of 
our veterans, and so we gave all--initially Choice and then the 
MISSION Act, we gave an option to try to solve the staffing 
shortages.
    They still exist, and the law says a veteran is entitled 
to, in many circumstances, care in the community but they don't 
know it if the VA doesn't tell them, and if the VA doesn't make 
it available for them. What am I missing?
    Dr. Miller. Nothing, sir. Message heard.
    Senator Moran. Thank you.
    Chairman Tester. And that was at a CBOC in Wichita?
    Senator Moran. It was at a hospital in Kansas.
    Chairman Tester. A VA hospital?
    Senator Moran. A VA hospital in Kansas.
    Chairman Tester. Okay. Yes. Look, thank you guys very, very 
much. I appreciate you being here Dr. Miller. I wished to let 
Dr. Black speak more, but you did--you did a fine job answering 
the questions. We appreciate you both being here.
    I think as the Ranking Member said to me a bit ago, we have 
had so damn many hearings on mental health, and it doesn't seem 
like anything has changed. And there is no doubt in my mind 
that you want to do the best for our veterans, and you are 
trying to do the best for your veterans, and this was really 
frustrating for me to say, but we have got to do better. We 
have just got to do better.
    This is just--this isn't saleable. It is keeping people out 
of our military when we need more people in our military. It is 
ruining lives. It is ruining families. And so we all need to 
work together to make sure this happens, and please know that 
this Committee would probably give you anything you ask for 
when it comes to mental health. We just need to make sure that 
what you are asking for is something that actually will make a 
difference. Thank you.
    Senator Moran. Mr. Chairman, the legislation that we are 
talking about, John Hannon----
    Chairman Tester. Yes.
    Senator Moran [continuing]. It is a result of your 
leadership. I chaired the Committee when this legislation was 
passed. It was your piece of legislation named after a veteran 
in Montana.
    Chairman Tester. That is correct.
    Senator Moran. This matters to you, it matters to me.
    Chairman Tester. Yes.
    Senator Moran. And I want to be helpful to you. This 
Committee does want to work together with the Department of 
Veterans Affairs to save lives.
    Chairman Tester. Yes. Amen. And so we are all on the same 
page here. Okay. Thank you for your time. We are going to get 
the next panel going. Thank you.
    I will start by welcoming our witnesses to the second 
panel. First up is going to be John Eaton, who is the Vice 
President of Complex Care at the Wounded Warrior Project.
    John, I will tell you, earlier today I got to meet with 
some women from the Wounded Warrior's Project, and I will tell 
you that it was enlightening and beneficial for me, and I am 
glad you sent them over, if you did, or somebody did, but it 
was a nice conversation.
    Then we are going to hear from Gilly Cantor. And I am going 
to tell you, Gilly, you are the first ``Gilly'' I ever met. 
Okay. And it is good to have you here. You are the Director of 
Evaluation and Capacity Building for the D--D'Anielo--better 
yet--Institute for Veterans and Military Families, at the great 
University of New York, Syracuse. And it is good to have you 
here.
    I would ask you to keep your comments to 5 minutes as with 
the previous panel. Please know that you are full written 
statement will be a part of the record.
    We will start with you Mr. Eaton.

                            PANEL II

                              ----------                              


                    STATEMENT OF JOHN EATON

    Mr. Eaton. Thank you, Chairman Tester, Ranking Member 
Moran, and the distinguished Committee members, for this 
opportunity to speak.
    Since 2003, Wounded Warrior Project has been working to 
transform the way America's injured Post-9/11 veterans are 
empowered, employed, and engaged in their communities. For the 
past 20 years, we have supported warriors through and beyond 
their transition to civilian life with services in mental 
health, physical health, peer connection, career counseling, 
and financial wellness. We currently offer these services to 
over 195,000 veterans across the country, and we are welcoming 
hundreds more every month.
    Our vision to foster the most successful, well-adjusted 
generation of wounded service members in our Nation's history 
brings with it the responsibility to identify, address, and 
serve the mental health needs of the veterans who reach out for 
help. In our 2022 Annual Warrior Survey, nearly all respondents 
reported experiencing post-traumatic stress, traumatic brain 
injury, or other mental health injuries during their military 
service, 83 percent reported experiencing more than one.
    Outreach and awareness-building have been critical parts of 
our mission because, sadly, many veterans don't seek the help 
they need due to fear of being negatively labeled, or they 
don't know the programs and services that are available to 
them. Wounded Warrior Project is here to help them, at no cost, 
get the specific type of mental health help they need to take 
the next step on their journeys to recovery.
    Of course, we believe no single organization can meet the 
needs of our injured veterans. We also believe that evidence-
based mental health treatment works when it is available and 
when it is pursued. However, the best results will be found 
when we embrace a public health approach focused on increasing 
resilience, improving psychological well-being, and building an 
aggressive prevention strategy. VA is our biggest and most 
important partner in that pursuit, and it is critical that we 
give them the tools they need to succeed.
    Our written statement outlines several ways that Congress 
can help. But this afternoon, I will focus on five important 
steps that this Committee can take to help take the veterans 
suffering from the invisible wounds related to their service of 
our Nation.
    First, we have to reduce wait times for accessing mental 
health. VA's access standard is reasonable on paper, but the 
practical experience for many veterans who ultimately seek care 
through Wounded Warrior Project indicates that many of them are 
being offered appointments well beyond the target, without any 
clear discussion with their provider about how care may be 
found more quickly in the community.
    In addition, the lack of a consistently applied access 
standard for residential rehabilitation care for mental health, 
has essentially resulted in no true access standard for care. 
Fortunately, both the Making Community Care Work for Veterans 
Act, and the Veterans Health Act offer solutions to both of 
these problems and improvements over the status quo.
    Second, we have to acknowledge and respond to the fact that 
access to care issues at the VA are a symptom of a larger 
challenge of needing more mental health providers. Recent HHS 
research indicates that 164 million Americans live in areas 
with mental health professional shortages, and so it is no 
surprise that VA is facing several shortages in psychology, 
psychiatry, and social work in many of its facilities.
    To address these problems, we call on Congress to pass the 
VA Careers Act and the Mental Health Professionals Workforce 
Shortage Loan Repayment Act, the first of which would help VA 
recruit and retain more mental health providers, while the 
latter would address the fact that mental health isn't just a 
veteran problem; it is an American problem, and we simply need 
to get more providers in the field.
    Third, we should to continue encouraging VA to leverage 
telehealth as a means of making care more accessible. Veterans 
who share their stories with us through surveys and action, 
often prefer telehealth for its convenience; however, those 
preferences should not be assumed, and veterans should be 
provided with clarity and transparency when telehealth is 
available as an alternative to in-person care. We believe that 
telehealth should satisfy access standards only when a veteran 
has agreed to it, with a clear understanding of their options.
    Fourth, we continue to support investment in VA grants and 
partnerships within the community to provide upstream suicide 
prevention services. We remain hopeful that the Fox Grant 
Program will become 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.
    Fifth, and finally, we encourage this Committee to take 
care in understanding that brain health is not always 
synonymous with mental health, and that there are steps we can 
take to improve the quality of life and mitigate factors for 
suicide among those who have suffered traumatic brain injury. A 
growing body of research is showing a greater association 
between TBI and suicide. And while TBI often co-occurs with a 
mental health diagnosis, we encourage stronger support and 
long-term care to address the care and financial stressors that 
can affect those with moderate to severe TBI.
    To that end, we urge Congress to pass the Elizabeth Dole 
Home Care Act, and Expanding Veterans' Options for Long-Term 
Care Act, which would collectively serve the long-term needs of 
younger veterans who need this care earlier in life.
    In closing, I want to thank this Committee for the 
invitation to testify. And welcome your questions.

    [The prepared statement of Mr. Eaton appears on page 54 of 
the Appendix.]

    Senator Moran. Thank you. Gilly Cantor.

                   STATEMENT OF GILLY CANTOR

    Ms. Cantor. Thank you, Mr. Chairman, Ranking Member Moran, 
and Members of the Committee. Thank you for this opportunity to 
testify.
    I am Gilly Cantor. I serve as the Director of Evaluation 
and Capacity Building at the D'Aniello Institute for Veterans 
and Military Families at Syracuse University.
    Our contribution to this conversation is rooted in upstream 
approaches to suicide prevention. For 10 years, we played a key 
role in building and evaluating networks of health and 
community-based social service organizations, originally those 
are part of our AmericaServes Initiative, which is in 18 
communities across the country.
    These collaborative models have demonstrated that helping 
veterans navigate to the full scope of services and resources 
they need beyond clinical interventions alone is an integral 
component of suicide prevention. At the same time, we have 
witnessed unprecedented effort from this Committee, and 
Congress, and the VA, to better integrate communities into 
suicide prevention strategies. It is the strong belief of the 
IVMF, and on behalf of our partners, that we must not give up 
on the promise of these efforts, but rather ensure that they 
live up to their potential.
    So today, I would like to reinforce why communities remain 
essential to effective suicide prevention, and I would like to 
demonstrate that establishing transparency and accountability 
between the VA and communities, at scale, is both achievable 
and necessary.
    There are three findings I want to highlight from a study 
that we did with the VA Center for Health Equity Research and 
Promotion. We looked at collaboration between AmericaServes 
networks, and VA medical centers and their communities.
    First, we found high overlap between AmericaServes and VA 
data, even in communities with low levels of partnership. In 
other words, many veterans enrolled at the VA are, 
unquestionably, also receiving services in their communities.
    Second, veterans served by both the VA and the community 
were comparatively younger. They included more Black, Hispanic, 
and women veterans, and they had more health-related social 
needs, like housing and food security. So in other words, 
communities are reaching the most marginalized veterans 
experiencing the most hardship.
    And third, when partnerships were strong, veterans 
receiving healthcare from the VA and services in the community, 
were more likely to have those needs successfully met. So when 
we work together, the stressors impacting veterans' well-being 
can be more effectively addressed.
    Broader research shows, and this was talked about earlier, 
that these economic, social, and interpersonal circumstances 
increase the risk of suicide. Imagine what more we could do if 
non-health data like this was examined regularly and shared. We 
must support legislation like the Not Just a Number Act, and 
bring all the data the VA and communities have to bear on this 
issue.
    Additionally, we know from our own evaluation of 
AmericaServes in Pittsburgh, that hundreds of veterans are 
formally referred between the VA and the community each year, 
because this data is meticulously tracked, the VA has full 
access to this information. This level of transparency is also 
happening in other places, such as North Carolina and Texas, 
but it is not happening everywhere.
    Finally, I would like to share opposing accounts we heard 
during our roundtable with 11 of our partners who are 
recipients of the Staff Sergeant Fox Suicide Prevention Grant 
Program. In one community, the Suicide prevention coordinator 
sat shoulder-to-shoulder with the grantee. They streamlined 
enrollment into the VA for those who screened eligible due to 
the risk.
    In other communities, suicide prevention coordinators were 
hardly aware of the program, and the ability to facilitate that 
enrollment was not happening. We need to make these successful 
communities the rule and not the exception.
    We have submitted a full brief as a statement for the 
record on that roundtable, and encourage the Committee and the 
VA to consider its findings. And we are happy to talk about it 
as much as they would like.
    If there is one message that I would like to leave you 
with, in light of some of the tragic things that have happened, 
again, focusing upstream, it is this: We think there is more to 
be hopeful about than there is to criticize. We are all here 
because the stakes remain high and the consequences of failure 
are quite, literally, existential. But we have collectively 
taken meaningful action and effective steps toward our shared 
goal.
    We simply need to monitor our progress and have the courage 
to adjust course along the way if necessary. Thank you.

    [The prepared statement of Ms. Cantor appears on page 70 of 
the Appendix.]

    Chairman Tester. I want to thank you both for your 
testimony, and I want to start by commending you both for the 
work that you and your organizations do. I will tell you, I 
like the optimism of saying that we have more to be thankful 
for than we do to be critical of. You know, if this was an easy 
issue, we would have had it settled a long, long time ago. The 
human mind is a hard thing to try to figure out how it works, 
and there is proof around this place all the time, so it is an 
interesting situation.
    I am going to start with you, Mr. Eaton. As I indicated in 
my introduction of you, this morning some women from the 
Wounded Warrior's Project came to my office, and I talked about 
a lot of things, including a survey that Wounded Warrior's 
Project just did about women veterans. Could you give me an 
idea on what that survey said about mental health, if it said 
any--I haven't had a chance to read the documents they gave me, 
okay, but if it said anything about mental health, could you 
talk about that? And if there are solutions, talk about those 
too?
    Mr. Eaton. Yes, thank you, Mr. Chairman. And thank you for 
meeting with the women warriors from Wounded Warrior Project. 
Just yesterday, we released the report, so the 2023 Women's 
Warrior Report; and it was based on surveys, as you mentioned, 
from 5,000 women warriors from our alumni, as well as in-person 
focus groups across the country, to really collect qualitative 
and quantitative data.
    The findings across multiple areas, you know. To name a 
few: access to care, transition from military to civilian life, 
as well as financial wellness. With respect to the mental 
health area, anxiety and depression were the top two health 
challenges reported by women warriors. And research shows that 
women are more likely to show moderate to severe symptoms, as 
well as PTSD symptoms, than our male warriors.
    Also, a higher percentage experienced loneliness and 
isolation compared to men as well, which is hugely detrimental, 
as we know and have discussed today, to our overall mental 
health.
    There is good news that came out, one of which women were 
found to score higher on resiliency measures, and eight out of 
ten women warriors reported--have accessing professional help 
at least 12 times over the last year. So we are, as a 
population, very resilient and engaged in their mental health 
and wellness, which is a really good finding.
    And so what can we do? You know, what we have taken away is 
really the opportunity to focus on transition, and how do we 
ease the stress and foster better connections to other veterans 
and support networks and after service, as well as making the 
VA a more desirable place for care by making it easier to 
access with appointment times and gender-specific care; and 
finally, additional research that can be done to understand the 
whys behind how men and women are experiencing trauma, and 
thus, seeing the results of the survey.
    Chairman Tester. Was there any sort of conversation around 
how well the VA is doing?
    Mr. Eaton. So that is a topic we discussed with veterans 
across all of our alumni, and over 90 percent of our alumni 
report using the VA for their services. When we think about 
access to care, we hear the same feedback from our female 
warriors as we do male warriors, and you know, long wait times 
perhaps, and how that affects, you know, it is really important 
when we are at the moment of readiness to really capture that 
momentum, and oftentimes without that, we are seeing poor 
health outcomes, both mental, physical, family, and relational 
issues as well.
    Chairman Tester. So Gilly, this next question is for you. 
The Not Just a Number Act is a bill that we have--and Senator 
Boozman, I appreciate your mention of it--because I think 
suicide goes way beyond just mental health practices. This bill 
would also look at things like disability compensation, 
education, employment benefits, home loans, foreclosure 
assistance, housing assistance programs.
    From your seat, how could you--from your seat, tell me your 
analysis of veterans who use VBA programs and how this bill 
could improve VA suicide prevention efforts?
    Ms. Cantor. Sure, I don't know a lot about exact 
likelihoods, or things like that, but I do know of a recent 
Brown University Study that looked at Vietnam veterans, 
specifically, and their usage of disability compensation, and 
it was directly associated with certain improved health 
outcomes, which just tells you that there is a lot more to look 
at there.
    And I think that if we can't look at that data regularly, 
then we are doing something wrong. And I think that in order to 
make that possible, it wouldn't surprise me if it there is sort 
of some underlying infrastructure problems, technology-wise, 
and gets into the weeds, and it is boring data stuff. But I 
really think that part of it has to do with how different 
agencies, including within the VA, track data, and it doesn't 
line up.
    We have seen it between DoD and VA, it is even within VBA 
to VHA. It is really hard to match things up and to look at 
things really clearly and get an understanding of what is going 
on without taking years to do a research project. And that is a 
problem.
    Chairman Tester. Okay. Thank you both very, very much.
    Senator Moran.
    Senator Moran. Senator King, I would be happy if you would 
like to go next.
    Senator King. I will go after you.
    Senator Moran. Let me start with you, Mr. Eaton. Thank you 
very much for being here today. Thank you for your work on 
behalf of Wounded Warrior's Project. I appreciate very much 
your remarks in your testimony, and your written testimony 
about the Veterans Health Act. It reflects an effort by Senator 
Sinema and I on a topic that we have been trying to be 
prevalent on and relevant on today.
    Could you discuss in detail, more detail how the VA's 
current misinterpretation of access standards set forth in the 
MISSION Act are having a consequence on veterans' access to 
care?
    Mr. Eaton. Yes. And thank you for the question. You know, 
we discussed in our written statement, so the VA's MISSION Act, 
you know, standards that do not exist around the critical 
mental health rehabilitation programs. So instead, veterans and 
advocates are left to really interpret that VHA directive, and 
in our experience, it provides little predictability on 
acceptance of referrals, length until a decision; and other 
really important factors when we know that time is of the 
essence.
    What we are seeing in our C3, our Complex Case Coordination 
Program, works with the most in-need warriors who are 
experiencing mental health concerns, and oftentimes an RRTP is 
an indicator for their care. And so what we are seeing, though, 
you know, local policy variations that are, again, 
unpredictable referrals, lengthy wait times, and really not a 
formally calculated way to be consistent about how we are 
understanding those options so we can advocate for the veteran. 
And what also comes as a result is that alternative treatment 
options that could result in a community referral or an inter-
VA referral aren't taking place.
    And so, you know, in totality, that really just shows that, 
you know, what we are seeing is veterans are not accessing the 
care they need when they need it, and delays in finding that 
appropriate care really enable our opportunity to capitalize on 
the momentum and the willingness to get that treatment, which 
oftentimes is years in the making and really important.
    Senator Moran. Mr. Eaton, from time to time I am told that 
the reason that the VA is not making referrals for community 
care is the lengthy wait times in the community. Is that 
anything that you hear, and what is the reality there when we 
know there are wait times also at the VA?
    Mr. Eaton. Sure. And that is a great point. I think as we 
talk about mental health shortage, it is obviously something 
that is not only seen within the VA. And so it is very 
regional-specific, and that is why our team looks at all 
options, the primary, working with the VA within that program 
to establish their holistic care within that system of care. 
What I know is that we have a very cultivated group of partners 
from RRTP programs that are part of the Community Care Network, 
and it would be our experience that we have very quick response 
times for when those needs arise.
    For example, we serve over 6,000 warriors a year with 
outpatient mental health services, with wait times less than 14 
days for a first appointment, and generally in most cases. And 
so I think, depending on the region, it could be a better 
choice, whether it is VA or a Community Care Network. But 
ultimately, we really feel the veteran should have more 
visibility into that conversation.
    Senator Moran. Thank you for that answer.
    Ms. Cantor, you, in your testimony, talk about the recent 
convening of 11 organizations who are Hannon Fox grantees. This 
takes me back to my first question earlier: Would you elaborate 
on the need for the VA? You talk about the screening issues 
remain a barrier, elaborate on the need, or what the VA could 
do to open up the eligibility standards to meet the needs of 
veterans who we are trying to reach and better serve.
    Ms. Cantor. Sure. So one of the issues that came up was 
around who is eligible, and then also on which services are 
eligible at which points. And I really appreciated how Dr. 
Miller described the tension that is going on between trying to 
get it to be the right people and the right things. And I think 
that what we are seeing and what the communities are saying is 
that depending on which screeners--individuals screen for risk, 
some, not others, and it depends on the person, that that can 
cause people to screen ineligible.
    And so they are looking for more flexibility in which 
screeners they use, or the possibility of making sure that as 
long as they are screening on one, even if not the other, that 
that constitutes enough of a risk for someone to get--to be 
eligible to be enrolled. They are also hoping that they can 
increase which services are eligible for coverage under the 
program so that they can try to do better outreach and get more 
people in the door in the first place, access to 
transportation, being able to provide food, making it a more 
welcoming environment for people to come in and connect with 
others, and address isolation, and then hopefully ask for help.
    Senator Moran. Any ways for the screening--to streamline 
the screening and make it more friendly?
    Ms. Cantor. They expressed a need to make it more 
conversational, that was one thing that came up repeatedly, and 
that the forms that accompany the screeners that they have to 
fill out would also need to be tailored to accommodate that 
style where, right now, it is difficult for them to do those 
intake screenings and then have to populate other things. And 
so there is sort of this extra barrier during the screening 
process, just for them to make sure that those conversations 
Dr. Miller referred to, as trying to ensure that they are not 
clinical conversations because the goal of this is to take the 
clinical element out and get more people, get more of the ten 
people who die by suicide that are not connected to the VA, 
comfortable, screened, and connected.
    Senator Moran. Any suggestion that this help from these 
organizations that receive the Hannon Fox grants that that 
would help us get to those who are not engaged with the VA?
    Ms. Cantor. I think--this is me speaking--I think it would. 
I think that most of them--you know, I mentioned the study we 
did, 70 percent of this doesn't apply to all those partners, 
but for those that it does apply to, 70 percent of the people 
that are veterans that they work with showed up in VA data. But 
that means that 30 percent didn't. And that is just from the 
veterans, they also serve family members, they also serve 
caregivers, et cetera. So there is--I see at least a 30 percent 
opportunity there for people that they are talking to every 
single day.
    Senator Moran. Ms. Cantor, I never thought about, when we 
wrote the Hannon Act that these grants to community 
organizations might increase the population of who is served. 
But your testimony, your conversation with me, that kind of a 
light bulb went off that, I don't know whether it is true, but 
it sure seems kind of commonsense to me that one way to serve 
more veterans, those veterans who are not engaged in the VA 
today, can be through a community organization.
    Ms. Cantor. Thank you for that comment. I fully agree.
    Senator Moran. Okay. Senator King.
    Senator King. I want to start with two general comments. 
Number one, you may wonder where everybody is. At this very 
moment; there is a Classified All-Senators Briefing on the 
conflict in Ukraine. And that this is one of the most dedicated 
committees in the Senate. But I just want you to understand 
that sometimes we have these inevitable conflicts in terms of 
time. So that is what--that is where everybody is right now.
    Senator Moran. Senator King is pointing out that he and I 
are supposed to go as well.
    [Laughter.]
    Senator King. Yes. Yes. Okay, second, in these hearings we 
always are talking about how we can improve things, we can do 
better, and they often turn into somewhat negative about the 
VA. I think I can tell you from the point of view of what I 
hear from my veterans in Maine, they really like the care that 
they are getting from the VA. They are impressed by the 
personal qualities of the people that they meet with, and they 
get--they get great care.
    Now, one of the issues is access. The question is when do 
you get the care? And that is a larger issue. We have got an 
enormous shortage in this country of mental health 
professionals. In fact, we have got an enormous shortage of 
just about everything. One of our major hospitals just told me 
recently they are short 800 nurses. I mean, that is what we are 
up against.
    So I think we need to understand that it is not for lack of 
trying that the VA is short-staffed, that this is a nationwide 
problem, in and around the VA, but just generally.
    So the question is, I think, what tools can we provide to 
the VA that they can more effectively compete in the workforce 
market? And I don't expect you to answer that, but if you have 
any thoughts, Ms. Cantor? I want to get this----
    Ms. Cantor. That is a really--no, that is a really hard--I 
mean, that is a great, that is a great idea, Senator. I think 
one of the things that this is not necessarily helping with 
mental health specifically, but it is a model that could be 
applied. There is a great program out of New York City called 
``PROVE'', that is a peer-to-peer model, and they train their 
social workers in their social work program through--to work 
with veterans. And thereby, in addition to helping a peer-to-
peer model, which can, again, be upstream from other challenges 
and help people feel connected on campuses.
    It is training a new workforce of culturally competent 
social workers. And I think that models like that could be 
applied outside of the social work space. It is something that 
could be done. I know that--I don't know the number, but it is 
my understanding that a huge percentage of physicians are 
partially trained at the VA because of the high-quality care 
that--and program and education that can be offered there.
    It is surprising to me that it is not a more competitive 
and interest--and place to work that people would be interested 
in working.
    Senator King. Well, I do think this is something we need to 
think about.
    Ms. Cantor. Yes.
    Senator King. If this is a competitive marketplace, we are 
going to have to--for example, I learned recently, no one in 
the Federal Government is allowed to be paid more than the 
President. That is $400,000 a year. Try hiring a cardiologist 
for $400,000. I mean, that is the kind of thing that we need to 
discuss, we need to talk about waivers, and to be sure that we 
have access to the professionals that we need.
    Telehealth, Mr. Eaton, you mentioned that, and I don't know 
if you are aware of the answer to this question. I probably 
should have asked it of the prior panel, but do we have 
licensure issues with telehealth? If you have got a VA facility 
in Augusta, Maine, can a veteran go there and get counseling 
from a counselor in Kentucky? Do you know?
    Mr. Eaton. I am not aware of the VA's approach and what 
they are able to do across State lines, but I do know through 
PSYPACT, there is a growing number, an overwhelming majority of 
States that are able to have cross-state service through 
psychology. And we leverage that within our Warrior Care 
Network as well as our outpatient.
    Senator King. Clearly, that is something we need to do. And 
in my talking with veterans and others, mental health, and 
behavioral health lends itself to telehealth. A lot of people 
are even more comfortable talking to a screen, and they don't 
have to wait in a doctor's office and worry about stigma, and 
who is in the--who is sitting in the chair next to them. And 
you mentioned they have got to understand their options, but I 
think telehealth is an opportunity to provide the care 
nationwide that perhaps might not be available, particularly in 
a rural area.
    Mr. Eaton. Well, a hundred percent agree. And that is what 
we have seen, you know, when we----
    Senator King. I like that on the record. ``A hundred 
percent agree.'' I appreciate that.
    Mr. Eaton. During our survey with our warriors, of those 
that were offered telehealth services, 90 percent accepted 
that. And those that were not offered, only 40 percent said 
that if they were offered, they would not have elected that 
service. So we see it as, again, increasing access, increasing 
capacity, and it is a positive experience for veterans.
    Senator King. And one of the other, in terms of the 
providers, what I am told is, there is a much lower level of 
missed appointments; there is a better--they are getting to the 
appointments, which is better for the providers. So I do think 
that is something that we have got to--we have got to work on.
    Ms. Cantor, your thoughts on telehealth?
    Ms. Cantor. I agree. I think that it makes sense for many 
people. I think that, similar to what we were talking about 
with community care, that it comes down to patient choice; and 
that if that is something that they are willing to do, that 
that makes a lot of sense. And I think, missed appointments, in 
particular, is a missed opportunity, and it also, with 
telehealth, addresses the transportation problem that is a huge 
cause of that for in-person visits.
    Senator King. Particularly in rural areas?
    Ms. Cantor. Particularly in the rural areas.
    Senator King. Great. Well, thank you all very much for your 
testimony, and I appreciate the work that you are doing. And we 
are in a learning mode here, so if there are suggestions, 
ideas, that is what we want to hear, ways that we can try to 
fix things, whether it is--it could be a law change, but it 
could also be something that we can work with the VA 
administratively, that doesn't involve a law change.
    If there are things, and we have talked about earlier, you 
heard us talking about the onboarding, and the barriers to 
bringing new people in. So share your thoughts; we are in the 
idea business around here. Thank you.
    Thank you, Mr. Chairman.
    Senator Moran. Senator King, thank you. Thank you for your 
full, lengthy participation today.
    Senator King. Sure.
    Senator Moran. Mr. Eaton, Ms. Cantor, thank you very much 
for your testimony. Thanks for joining us today.
    The Members of the Committee will have one week to submit 
written questions, and we would ask the witnesses to respond to 
them as quickly as possible.
    The Committee is now adjourned.
    [Whereupon, at 5:42 p.m., the hearing was adjourned.]






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