    [House Hearing, 119 Congress]
    [From the U.S. Government Publishing Office]

                              LEGISLATIVE HEARING

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

                                    HEARING

                                   BEFORE THE

                             SUBCOMMITTEE ON HEALTH

                                     OF THE

                         COMMITTEE ON VETERANS' AFFAIRS

                         U.S. HOUSE OF REPRESENTATIVES

                        ONE HUNDRED NINETEENTH CONGRESS

                                 FIRST SESSION

                                   __________

                            TUESDAY, MARCH 11, 2025

                                   __________

                               Serial No. 119-10

                                   __________

           Printed for the use of the Committee on Veterans' Affairs

    [GRAPHIC NOT AVAILABLE IN TIFF FORMAT]

                        Available via http://govinfo.gov

                                    __________

                       U.S. GOVERNMENT PUBLISHING OFFICE
    60-671                  WASHINGTON : 2025

    -----------------------------------------------------------------------------------

                         COMMITTEE ON VETERANS' AFFAIRS

                         MIKE BOST, Illinois, Chairman

    AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking
        American Samoa, Vice-Chairwoman      Member
    JACK BERGMAN, Michigan               JULIA BROWNLEY, California
    NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire
    MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK,
    GREGORY F. MURPHY, North Carolina        Florida
    DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky
    MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois
    JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois
    KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York
    JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon
    ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey
    KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota
        Mariana Islands
    TOM BARRETT, Michigan

                           Jon Clark, Staff Director
                      Matt Reel, Democratic Staff Director

                             SUBCOMMITTEE ON HEALTH

                   MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

    JACK BERGMAN, Michigan               JULIA BROWNLEY, California,
    GREGORY F. MURPHY, North Carolina        Ranking Member
    DERRICK VAN ORDEN, Wisconsin         SHEILA CHERFILUS-MCCORMICK,
    JEN KIGGANS, Virginia                    Florida
    ABE HAMADEH, Arizona                 MAXINE DEXTER, Oregon
    KIMBERLYN KING-HINDS, Northern       HERB CONAWAY, New Jersey
        Mariana Islands                  KELLY MORRISON, Minnesota

    Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
    hearing records of the Committee on Veterans' Affairs are also
    published in electronic form. The printed hearing record remains the
    official version. Because electronic submissions are used to prepare
    both printed and electronic versions of the hearing record, the process
    of converting between various electronic formats may introduce
    unintentional errors or omissions. Such occurrences are inherent in the
    current publication process and should diminish as the process is
    further refined.
                             C  O  N  T  E  N  T  S

                                  ----------

                            TUESDAY, MARCH 11, 2025

                                                                       Page

                               OPENING STATEMENTS

    The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
    The Honorable Julia Brownley, Ranking Member.....................     2

                             SPEAKING FROM THE DAIS

    The Honorable Steve Womack, U.S. House of Representatives, (AR-3)     4
    The Honorable Sylvia Garcia, U.S. House of Representatives, (TX-
      29)............................................................     5
    The Honorable Greg Murphy, U.S. House of Representatives, (NC-3).     6
    The Honorable Chris Deluzio, U.S. House of Representatives, (PA-
      17)............................................................     6
    The Honorable Lauren Underwood, U.S. House of Representatives,
      (IL-14)........................................................     7
    The Honorable Don Bacon, U.S. House of Representatives, (NE-2)...    11

                                   WITNESSES
                                    Panel I

    Dr. Thomas O'Toole, Deputy Assistant Under Secretary for Health
      for Clinical Services, Quality and Field Operations, Veterans
      Health Administration, U.S. Department of Veterans Affairs.....     8

            Accompanied by:

        Dr. Antoinette Shappell, Deputy Assistant Under Secretary for
            Health for Patient Services, Veterans Health
            Administration, U.S. Department of Veterans Affairs

        Dr. Thomas Emmendorfer, Executive Director, Pharmacy Benefits
            Management, Veterans Health Administration, U.S.
            Department of Veterans Affairs

    Dr. Jeffrey Gold, President, University of Nebraska System.......    10

                                    Panel II

    Ms. Sue Morris, President, Veterans Trust........................    23

    Mr. Brian Dempsey, Director of Government Affairs, Wounded
      Warrior Project................................................    24

    Dr. Andrew Kozminski, Medical Director of Hyperbaric Medicine,
      University of Iowa Health Care.................................    26

    Mr. Ed Harries, President, National Association of State Veterans
      Homes..........................................................    27

    Mr. Jon Retzer, Deputy National Legislative Director for Health,
      Disabled American Veterans.....................................    29

                                    APPENDIX
                        Prepared Statements Of Witnesses

    Dr. Thomas O'Toole Prepared Statement............................    43
    Dr. Jeffrey Gold Prepared Statement..............................    62
    Ms. Sue Morris Prepared Statement................................    74

                              APPENDIX--continued

    Mr. Brian Dempsey Prepared Statement.............................    75
    Dr. Andrew Kozminski Prepared Statement..........................    81
    Mr. Ed Harries Prepared Statement................................    89
    Mr. Jon Retzer Prepared Statement................................    96

                           Statements For The Record

    Veterans Healthcare Policy Institute Prepared Statement..........   103
    American Association for Marriage and Family Therapy and
      California Association of Marriage and Family Therapists
      Prepared Statement.............................................   105
    Paralyzed Veterans of America Prepared Statement.................   107
    American Federation of Government Employees, AFL-CIO Prepared
      Statement......................................................   111
    Trajector Medical Prepared Statement.............................   112
    Document for the Record Submitted by Greg Murphy.................   123

                              LEGISLATIVE HEARING

                                  ----------

                            TUESDAY, MARCH 11, 2025

                        Subcommittee on Health,
                        Committee on Veterans' Affairs,
                                 U.S. House of Representatives,
                                                        Washington, DC.
        The subcommittee met, pursuant to notice, at 2:15 p.m., in
    room 360, Cannon House Office Building, Hon. Mariannette
    Miller-Meek [chairwoman of the subcommittee] presiding.
        Present: Representatives Miller-Meek, Murphy, Hamadah,
    King-Hinds, Brownley, Cherfilus-McCormick, Dexter, Conaway, and
    Morrison.
        Also present: Representatives Deluzio, Womack, Underwood,
    Garcia, and Bacon.

       OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

        Ms. Miller-Meeks. The legislative hearing of the
    Subcommittee on Health will now come to order. I would like to
    welcome all members and witnesses for today's hearing. We look
    forward to a very productive discussion on some impactful
    veterans legislation.
        Today we will discuss 12 bills, including bills which would
    enable the U.S. Department of Veterans Affairs (VA) to enter
    into innovative public-private partnerships, research cutting-
    edge hyperbaric oxygen therapy, and provide some long overdue
    oversight of the VA's budget management. Also on today's agenda
    are four bills I have had the pleasure of introducing.
        Before I discuss my bills, I would like to thank our
    witnesses again for being here today. I would like to
    especially thank Dr. Andrew Kozminski, who is the medical
    director of the Hyperbaric Medicine at my beloved University of
    Iowa. I had the pleasure of touring Dr. Kozminski's office a
    few months ago and learned about the incredible healing
    properties that hyperbaric oxygen therapies can provide. Dr.
    Kozminski, welcome to my office and I would like to look
    forward to hearing your thoughts about Dr. Murphy's bill, the
    Veterans National Traumatic Brain Injury Treatment Act.
        Now to my bills. First, the Supporting Prosthetics
    Opportunities an Recreational Therapy (SPORT) Act. The SPORT
    Act would make sure athletic prosthetics are defined as
    medically necessary for amputee veterans. Every year in my
    district, severely disabled veterans gather to play golf. I am
    not a golfer except for miniature golf, but it is amazing to
    see how many sports, even golf can improve veterans' mental and
    physical well-being. I think all veterans should be able to
    enjoy the benefits and camaraderie sports provide, and my
    legislation would achieve just that.
        I am also proud to introduce the No Wrong Door for Veterans
    Act. This bill would reauthorize VA's successful Fox grant
    Program. Fox grants enable community organizations to provide
    services to veterans, screen them for suicidal ideation, and
    connect them with the VA so they can receive the mental health
    support that meets their individual needs. My bill would ensure
    organizations who have been successful in our mission to expand
    mental health can receive additional funds by partnering with
    the VA to reach even more veterans. The Fox Grant Program is a
    great example of public-private partnerships working for the
    better. House Republicans will continue to push the needle and
    protect programs like this one.
        Next, I am proud to lead the Providing Veterans Essential
    Medications Act. This bill would allow the VA to provide very
    high-cost medications to severely disabled veterans receiving
    care at State veterans homes. VA pays for these medications for
    all other veteran patients, but antiquated laws require VA to
    pay State veterans home a fixed per diem, limiting their
    ability to provide for veterans who desperately need these
    medications while residing at a veterans home. Unfortunately,
    these high-cost medications can cost as much as $1,000 per day,
    meaning State veterans homes are not able to house many of our
    most deserving veterans. My bill would fix this clear mistake
    and ensure veterans with complex needs are cared for.
        Ironically, the last bill I would like to mention is the
    Standardizing Treatment and Referral Times (START) Act. Far too
    often our veterans receive community care referrals that are
    only valid for a fixed period of time, but due to provider
    shortages and bureaucratic delays, veterans might not even get
    in until halfway through the authorized time period. My START
    Act addresses this issue by ensuring that the validity of the
    referral begins only once a veteran has attended their initial
    appointment. It is pretty common sense.
        It is a privilege to collaborate on crafting impactful
    legislation for our veterans and to address critical issues in
    the delivery of their healthcare.
        I would now like to turn to Representative Brownley for any
    opening remarks she may have. Representative Brownley, you are
    now recognized.

          OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

        Ms. Brownley. Thank you, Madam Chair.
        At the outset, I have to say I find it a bit crazy that we
    are having a legislative hearing today rather than an oversight
    hearing. The Trump administration's executive orders, mass
    firings of VA employees, reckless contract terminations, and $1
    spending limit on purchase cards are causing significant
    upheaval within the Veterans Health Administration (VHA). That
    we are here today proceeding to consider new legislation as if
    these changes are not already significantly impacting veterans
    access to care is absurd.
        Our time today would be much better spent examining the
    administration's plan to gut VA's workforce by 80,000 employees
    before September. This would be in addition to the 2,400 or
    more VA employees who have already been terminated. Committee
    Democrats have already heard a multitude of instances of these
    terminations negatively impacting patient care, despite
    Secretary Collins insisting that they are not. The terminations
    that have already occurred include positions like procurement
    professionals who play a critical role in purchasing
    prosthetics and medical devices veterans need. We are aware of
    numerous VA medical facilities where such terminations have
    occurred.
        Supply chain staff who are responsible for equipping
    surgical suites with necessary supplies, the committee has
    heard from several supply chain professionals who were
    terminated from the VA facilities in Florida, Texas, Oklahoma,
    and in California. Human resources professionals who are
    necessary for filling clinical staff vacancies. While clinical
    staff have largely been exempted from the Trump
    administration's hiring freeze, VA cannot efficiently fill
    clinical positions without human resources professionals.
    Psychology technicians at the Cleveland Veterans Affairs
    Medical Center (VAMC), who perform neuropsychological tests for
    individuals with neurological conditions, like strokes,
    Traumatic Brain Injury (TBI), Post-Traumatic Stress Disorder
    (PTSD), and concussions. Staff that perform, manage, and
    analyze mammogram results at the Hampton VAMC. One veteran
    whose mammogram was canceled due to a staffing shortage at the
    Hampton VAMC just found out the earliest she could reschedule
    her appointment elsewhere is June, 4 months from now. These are
    just a few examples that the committee has heard about from
    across the Nation.
        Unfortunately, none of the bills we are considering today
    will address the very real threat to VA healthcare access,
    quality, and safety that veterans are facing. In just the last
    few days, my Democratic colleagues and I have received tens of
    thousands of emails from veterans across the country asking
    that we do all we can to stop the VA workforce cuts and
    eliminations of crucial contracts. I certainly hope that our
    Republican colleagues are receiving the same messages.
        Veterans do not support these cuts. I would encourage the
    witnesses and members here today to keep in mind that if we
    continue to see efforts to dismantle VA by firing hardworking
    employees, canceling vital research, terminating healthcare
    contracts, and eroding veterans' trust in VA, it will not
    matter what excellent legislation we put forth. There will not
    be employees or even an infrastructure left at VA to implement
    these bills, and veterans' care will suffer because of it.
        I would hope the chair shares these same concerns and I
    understand that we must protect the many VA employees that
    provide critical care to our Nation's veterans. However, I
    understand that despite what I have laid out today, we are here
    to consider legislation today on this committee.
        I am pleased today's agenda includes my VA Marriage and
    Family Therapist Equity Act. I am also glad that a bill I am
    coleading with my friend from Texas, Congresswoman Garcia, the
    Women Veterans Cancer Care Coordination Act, is on the agenda.
    I look forward to hearing from our witnesses on all of the
    bills on today's agenda.
        With that, Madam Chair, I will yield back.
        Ms. Miller-Meeks. Thank you very much, Ranking Member
    Brownley.
        We have a full agenda today, so I will be holding everyone
    to 3 minutes per bill to ensure we can move in a timely manner.
        This morning we are joined by several of our colleagues who
    will speak in support of their bills. We appreciate the
    dedication to serving our Nation's veterans. With that, I ask
    unanimous consent that all non-subcommittee members be waived
    on to speak on their bills from the dais. Hearing no objection,
    we will move forward.
        I now recognize Representative Womack for 3 minutes.

                       STATEMENT OF STEVE WOMACK

        Mr. Womack. I thank the chairwoman.
        Chairwoman Miller-Meeks, Ranking Member Brownley, and
    distinguished members of this subcommittee thank you for
    considering my bill, H.R. 1107, Protecting Veteran Access to
    Telemedicine Services Act of 2025. I also want to express my
    sincere gratitude for allowing me to speak in support of this
    legislation.
        This bill aims to guarantee that our Nation's veterans,
    whether in bustling cities or remote rural areas, have
    continuous access to the healthcare services they need and
    deserve. The Ryan Haight Online Pharmacy Consumer Protection
    Act, enacted in 2008, was designed to regulate the prescription
    of controlled substances via telemedicine in response to the
    rise of online pharmacies and the risk of misuse. While this
    law plays a crucial role in protecting public health, it has
    not been updated to reflect the realities of 2025, nor does it
    account for the fundamental differences between the VA and
    civilian online pharmacies.
        During the COVID-19 pandemic, the Ryan Haight Act's in-
    person consultation requirement for prescribing controlled
    substances was temporarily waived. The Drug Enforcement (DEA)
    and U.S. Department of Health and Human Services (HHS) later
    extended these flexibilities through the end of this year. My
    bill, the Protecting Veteran Access to Telemedicine Services
    Act of 2025, would make this exemption permanent for the VA,
    allowing VA healthcare professionals to prescribe medically
    necessary controlled substances via telemedicine under specific
    conditions. This exemption has been a lifeline for our
    veterans. Without it, many will face severe restrictions in
    accessing vital healthcare.
        For veterans in urban areas, letting this exemption expire
    would mean longer wait times for in-person appointments,
    further straining an already overburdened VA healthcare system.
    The impact is even greater for veterans in rural communities
    where geographic isolation and limited healthcare providers
    create significant barriers. The exemption has allowed them to
    receive care from VA specialists hundreds of miles away without
    the burden of costly and time-consuming travel.
        Continuing this exemption is not just a matter of
    convenience, it is a necessity. It ensures that every veteran,
    no matter where they live, has equal access to the care they
    have earned and deserve. I am honored to speak in support of
    this legislation today. I urge my colleagues to act swiftly in
    passing the bill. Our veterans have sacrificed so much for all
    of us. It is our duty to ensure they receive the care they need
    in a way that meets the demands of today's world.
        Madam Chairwoman, thank you for the time and a yield back
    my balance.
        Ms. Miller-Meeks. Thank you very much. Representative
    Womack.
        The chair now recognizes Representative Garcia for 3
    minutes.

                       STATEMENT OF SYLVIA GARCIA

        Ms. Garcia. Thank you, Madam Chair. Thank you to the
    ranking member for giving me a few minutes to talk about my
    bill, the Women Veterans Cancer Care Coordinator Act. I am
    pleased to lead this bill with Ranking Member Brownley to
    improve the breast and gynecological cancer care that the VA
    provides to our heroines.
        Every day, more and more American women sign up to serve in
    these U.S. military. As women sign up, the women veteran
    community also grows. In Fiscal Year 2000, women veterans made
    up just about 4 percent of all the veteran population. Today,
    they rank at about 11.3 percent, over 2.1 million women
    veterans nationwide. However, as the women veteran community
    ages, breast and gynecological care rates in this population
    will also increase. The VA responded to this need by
    establishing the Breast and Gynecological Oncology System of
    Excellence in late 2020, a program that ensures women veterans
    are getting the appropriate cancer care they deserve.
        The VA also partners with community care providers to treat
    these veterans when the VA does not have the means to provide
    care. Now, that sounds great, but the system that we set up for
    women is not entirely working as it should. Veterans must
    navigate multiple facilities alone and ensure that providers
    communicate with the VA. The lack of coordination between both
    the VA and these providers lead to treatment delays,
    miscommunication, and unnecessary stress. Without a well-
    coordinated care team, a lot can go wrong. No veteran fighting
    cancer should struggle with red tape. They should be focused on
    getting better.
        My bill will effectively address these challenges by
    creating dedicated regional cancer care coordinators at the VA.
    These professionals would guide veterans through their
    treatment journey, improve communication between the VA and
    community care providers, track patient progress, and address
    the existing delays in their care. These coordinators would
    also provide veterans with emergency health information and
    mental health resources to support their well-being.
        I firmly believe that a grateful nation shows its gratitude
    in the care and benefits we provide to our heroines. Supporting
    our veterans is one of the solemn promises we have made, and it
    is a promise we must keep.
        Thank you again, Madam Chairwoman, and, of course, to
    Ranking Member Brownley for support on this issue. I yield
    back.
        Ms. Miller-Meeks. Thank you very much, Representative
    Garcia.
        The chair now recognizes representative Dr. Murphy for 3
    minutes.

                        STATEMENT OF GREG MURPHY

        Mr. Murphy. Thank you, Madam Chair. Thank you, Ranking
    Member Brownley.
        Delighted for the second time to introduce my bipartisan
    bill, H.R. 1336, the Veterans National Traumatic Brain Injury
    Treatment Act, being discussed here today. It is long overdue
    that we do something further for our veterans who suffer from
    PTSD and TBI. Sadly enough, we lose 17, up to 22 veterans a day
    due to suicide, many who are suffering from TBI and PTSD.
        I am a big fan and have been for over 30 years of the
    treatments of hyperbaric oxygen therapy. We have used this in
    surgical wounds for wounds that will not heal. It has enjoyed
    great success amongst many different maladies. It has been my
    own experience now in exploring this issue for TBI and PTSD
    that this is not only a viable but a very, very successful
    intervention.
        I am going to introduce into the record a meta analysis
    study from National Institutes of Health (NIH). This was done
    in January to March 2020, which is an exhaustive list of mostly
    randomized double-blind control studies which shows great
    objective improvement for those veterans who have suffered from
    TBI and PTSD, not only in cognitive function but mood disorder.
    I ask this be submitted for the record.
        This organization now, HBOT4Heroes in North Carolina, has
    successfully treated over 200 veterans who suffer from TBI and
    PTSD. We had a witness here before the executive director, Mr.
    Ed Di Girolamo, who gave very compelling testimony at a
    roundtable concerning alternative therapy specifically for
    Hyperbaric Oxygen Therapy (HBOT). My bipartisan bill sets up a
    pilot program for 5 years at three veterans service networks.
    Costs are borne by donations, not to the taxpayer, but by
    donations. The veterans service organizations are supportive,
    multiple, and listed here. We also have expert witness from Dr.
    Andrew Kozminski, an M.D. from the great University of Iowa, I
    think somebody went there or knows there, who is a Hyperbaric
    Oxygen (HBO) medicine specialist.
        I have thought this through and through. I believe it is
    sad that we get our veterans when they hit the wall, when there
    is literally nothing else that the VA can offer that we are not
    offering this therapy to them. It is a proven alternative and a
    successful alternative. I will say it again, and I have said
    this before, I believe it is medical malpractice that is not
    being offered to our veterans at this point in time.
        I thank you for your support. I would ask that this
    committee at some point review this favorably, bring this to
    the floor so that we can get our veterans the care that they
    need.
        Thank you Madam Chairman. I will yield back.
        Ms. Miller-Meeks. The chair now recognizes Representative
    Deluzio for 3 minutes.

                       STATEMENT OF CHRIS DELUZIO

        Mr. Deluzio. Thank you, Chairman Miller-Meeks, Ranking
    Member Brownley, and members of the Health Subcommittee. It is
    great to be back with all of you and appreciate your
    flexibility working with me and my team on my bill, considering
    this important measure to reduce veteran suicide, Saving Our
    Veterans Lives Act of 2025. It is H.R. 1987.
        I am proud to say this has been a bipartisan effort from
    the start. Although they are not here, I commend
    Representatives Fitzpatrick, James, and Landsman, alongside
    Senators King and Sheehy, and a wide variety of organizations
    who have come together and worked with me and others on such an
    important issue of veteran suicide.
        This bill will create a program at VA to provide and
    distribute gun lockboxes to veterans, including those who are
    not enrolled with the Veterans Health Administration. This
    aspect of the bill is very important. Cited in VA's 2024
    National Veterans Suicide Prevention Annual Report, the rate of
    veteran suicide is about 17-1/2 per day, and the majority of
    those come, those terrible deaths, from veterans outside of
    VHA. We have got to do a better job at reaching these veterans
    and connecting them with resources that could make a difference
    in their lives, and this bill will help bridge that gap.
        That said, I have read the VA's testimony. I know VA
    recommends some changes in the bill text. I welcome amendments
    and working with the subcommittee and its members to make this
    legislation stronger so we can save more of my fellow veterans'
    lives from the scourge of veteran suicide.
        Madam Chairwoman, thank you for your time and engagement. I
    yield back.
        Ms. Miller-Meeks. Thank you very much, Representative
    Deluzio.
        The chair now recognizes Representative Underwood for 3
    minutes.

                     STATEMENT OF LAUREN UNDERWOOD

        Ms. Underwood. Thank you, Madam Chair. As a nurse, I am
    really proud to be here to testify before you today on one of
    the first bills that I introduced in Congress with my friend
    Senator Duckworth, the Copay Fairness for Veterans Act.
        While I currently sit on the Appropriations Committee, I
    have the honor of serving on the House of Veterans' Affairs
    Committee in the 116th and 117th Congresses. Our veterans are
    heroes who have given so much to our country, and serving
    veterans and their families is one of the greatest privileges
    we have as Members of Congress. At a time where research shows
    us that veterans face worse health outcomes than the general
    public and have higher burden of chronic diseases, no veteran
    should go without the ready access to preventive healthcare
    services that can improve their healthcare and quality of life.
    That is why my legislation would eliminate, once and for all,
    all of the financial barriers that could prevent veterans from
    accessing basic care.
        Under the Affordable Care Act (ACA), almost all private
    health insurance plans are required to provide coverage of
    preventive services without charging copays. However, while
    most civilians have been able to access preventive services
    without copays for nearly 15 years thanks to the ACA, this same
    guarantee does not exist for our veterans, at least who get
    their healthcare through the VA. Despite their sacrifices and
    commitment to our country, veterans are still at risk of being
    charged out-of-pocket costs for services like cancer
    screenings, mammograms, diabetes care, and screenings for
    depression and anxiety. That is just unfair. Luckily, friends,
    we can fix it.
        My Copay Fairness for Veterans Act rights this wrong by
    eliminating out-of-pocket costs for veterans seeking the
    preventive services that they need and deserve at the VA. My
    bill will ensure that veterans are not charged copays for basic
    essential care, such as screenings for cancer, depression,
    anxiety, diabetes, and other diseases; interventions to prevent
    and treat heart disease; maternal healthcare and breastfeeding
    support for new moms; help with alcohol and tobacco abuse; well
    woman visits; and other critical healthcare services for
    veterans and their families.
        I am proud to say that this bill is endorsed by the
    Disabled American Veterans (DAV) and the Minority Veterans of
    America, among others. Our veterans have earned the best, and I
    urge my colleagues on both sides of the aisle to support this
    critically important legislation.
        Thank you, Madam Chair, for including this bill in today's
    legislative hearing. Thank you to our witnesses for being here.
    I yield back.
        Ms. Miller-Meeks. Thank you, Representative Underwood.
        As is our practice, we will forego a round of questioning
    for the members. For those off committee members, you may stay
    around to ask questions of the witnesses if you have time.
        Our first panel is already at the table. Thank you. Joining
    us from the Department of Veterans Affairs is Dr. Thomas
    O'Toole, the VA's deputy assistant under secretary for Health
    and Clinical Services for Quality and Field Operations. He is
    accompanied by Dr. Antoinette Shappell, VA's deputy assistant
    undersecretary for Health and Patient Care Services, and Dr.
    Thomas Emmendorfer, VA's executive director of Pharmacy
    Benefits Managers. Also on our first panel, we have Dr. Jeffrey
    Gold, president of the University of Nebraska System. Welcome,
    Dr. Gold.
        Dr. O'Toole, you are now recognized for 5 minutes to
    present the Department's testimony.

                      STATEMENT OF THOMAS O'TOOLE

        Dr. O'Toole. Great. Thank you and good afternoon,
    Chairwoman Miller-Meeks, Ranking Member Brownley, and members
    of the subcommittee. Thank you for inviting us here today to
    present our views on several bills that will affect Department
    of Veterans Affairs' programs and services. Joining me today
    are Dr. Antoinette Shappell, deputy assistant undersecretary
    for Health for Patient Care Services, and Dr. Thomas
    Emmendorfer, executive director of Pharmacy Benefits
    Management.
        I joined the VA 19 years ago, leaving a senior position at
    a large academic health center to work at the VA Hospital in
    Providence, Rhode Island. The surge in deployments needed for
    the Iraq War was underway. We were seeing more and more
    veterans returning from the war needing our help, and it is a
    decision I have never regretted. I have been incredibly proud
    to work in the VA. Our commitment to mission, the
    professionalism and dedication of my colleagues, and the
    excellence in care and quality that VA provides to our Nation's
    veterans defines us as an agency. Much of this has come from
    the strong partnership, guidance, and oversight we receive from
    Congress, and the thoughtfulness and intent of the legislation
    being discussed today reflects that. While the Department views
    are provided in detail in written testimony, I would like to
    highlight several bills in my opening remarks.
        The No Wrong Door for Veterans Act makes several amendments
    to the Staff Sergeant Parker Gordon Fox Suicide Prevention
    Grant Program. VA strongly supports the intent in some of the
    amendments the bill would make, particularly extending the
    program through Fiscal Year 2028 and requiring grantees to
    inform individuals about emergent suicide care. However, we do
    have concerns about some of the bill's amendments and look
    forward to working with the subcommittee to address those
    further. This bill aligns with the Department's priority of
    reaching veterans at risk for suicide.
        VA also supports the Standardizing Treatment and Referrals
    Act, or START Act. This bill ensures that the referral period
    for care from a non-VA provider begins on the date of the first
    appointment. VA supports this bill. However, we would like the
    opportunity to work with the subcommittee to ensure the text is
    clear and does not result in any unintended consequences.
        VA strongly supports, we all support efforts to reduce
    veteran suicide. However, in its current writing, we do not
    support the Saving Our Veterans Lives Act. As written, the bill
    is overly broad and the resources needed to implement would
    significantly exceed the authorized appropriation of $5 million
    per year.
        VA supports with amendments the Women Veterans Cancer Care
    Coordination Act and the Veterans Supporting Prosthetics
    Opportunities and Recreation Therapy Act. VA supports H.R. 217,
    the Communities Helping Invest through Property and Improvement
    Needs (CHIP IN) for Veteran Acts, which would allow VA to
    modernize infrastructure more efficiently and cost effectively.
    VA supports efforts to ensure veteran State homes are
    adequately supported in covering the costs of care for
    veterans.
        Though we do not support the Providing Veterans Essential
    Medications Act, we would appreciate the opportunity to discuss
    this bill and VA's concerns with the committee. VA supports the
    Copayment Fairness for Veterans Act with amendments and subject
    to appropriations.
        Regarding the Veterans National TBI Treatment Act, this
    bill requires VA to implement a pilot program for hyperbaric
    oxygen therapy, or HBOT, for veterans with TBI or PTSD. VA does
    not support this bill due to the lack of scientific evidence
    supporting HBOT for these conditions and we have concerns about
    the proposed funding mechanism. VA does not support H.R. 658,
    qualifications for marriage and family therapists. We defer to
    the Comptroller General regarding H.R. 1823, directing VA and
    the Comptroller General to report on certain funding shortfalls
    in VA.
        Finally, VA does not have views on H.R. 1107, Protecting
    Veteran Access to Telemedicine Services of 2025, and we will
    provide these views in a letter to the subcommittee after the
    hearing.
        This concludes my statement. We appreciate the continued
    support and oversight of the committee. My colleagues and I are
    prepared to respond to any questions you or other members of
    the subcommittee may have about the legislation before us.
    Thank you.

        [The Prepared Statement Of Thomas O'Toole Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Dr. O'Toole.
        The chair now recognizes Dr. Gold for 5 minutes.

                       STATEMENT OF JEFFREY GOLD

        Dr. Gold. Thank you and good afternoon, Chairwoman Miller-
    Meeks, Ranking Member Brownley, and other members of the
    committee and Congressman Bacon. I am Dr. Jeff Gold and I have
    the distinct privilege of serving as the president of the
    University of Nebraska System, which has campuses in Lincoln,
    Omaha, and Kearney, as well as a top-ranked academic medical
    center in Omaha. We educate approximately 50,000 students, do
    approximately $700 million in peer-reviewed medical research. I
    myself am a recovering pediatric heart surgeon by training, but
    for the last 10 years, prior to my current position, I had the
    privilege of serving as the chancellor of the University of
    Nebraska Medical Center.
        For many decades, UNMC, University of Nebraska Medical
    Center, has had a broad and deep relationship with civilian and
    military Federal departments focused on training, research, and
    quality clinical care. However, over the past decade there has
    been intense multi-departmental focus with key partnerships in
    civilian and military Chemical, Biological, Radiological,
    Nuclear, and High-yield Explosives (CBRNE) global health
    security challenges.
        Thank you for the opportunity to testify today to support
    Congressman Bacon's H.R. 217, which seeks to make permanent the
    CHIP IN for Veterans Act. This bill supports our service
    members through innovative and productive approaches to develop
    and finance VA facilities through public-private partnerships.
        In 2016, Congressman Brad Ashford of Nebraska and Senator
    Deb Fischer were instrumental in passing this new legislation
    creating a unique pilot program that allowed public-private
    partnerships with the VA. This opportunity led to remarkable
    improvement in care for local veterans in our community,
    including the construction of a new ambulatory center that
    today serves as a key resource for outpatient diagnostic,
    procedural, and interventional veterans care services in the
    Nebraska Western Iowa region. This project was funded through
    Federal dollars and private philanthropic support, and has been
    recognized nationally as a true pillar of success.
        However, at this time, the University of Nebraska Medical
    Center, one key of the University of Nebraska system, has
    identified a significant need to replace several of our own
    aging academic facilities on the Omaha campus, and among these
    projects is a forthcoming $2.19 billion project known as
    ``Project Health''. This will serve as a state-of-the-art
    medical facility with unique training opportunities focused on
    meeting Nebraska's growing need for medical professionals. This
    project will also provide access to high-quality advanced
    medical care, a unique interprofessional multidisciplinary
    learning environment, and access to life-saving clinical trials
    for patients across the State and in the region. Project HEALTH
    is a collaboration of the State of Nebraska, the city of Omaha,
    the University of Nebraska, the Academic Medical Center and, of
    course, extensive participation by Nebraska's philanthropic
    community.
        Therefore, we have proposed that the much needed
    replacement local VA hospital now be repositioned on the UNMC
    campus to better meet the needs of veterans in Nebraska and
    Western Iowa. This would be constructed to replace the aging
    facility currently in use on the VA campus. This new
    freestanding facility would be branded, staffed, and operated
    by the VA with physical connectivity to Project Health for
    potentially shared diagnostic, interventional, laboratory, and
    support services. This would also provide proximity for
    university clinicians and learners from UNMC and also remain
    open to staffing and training for other public and private
    academic medical center professional staff.
        Leveraging private construction and adjacent resources
    significantly creates more cost-effective facilities and
    opportunities for renovating and replacing the existing VA
    hospital that was opened in 1950. Our approach is not only
    cost-effective, but also ensures that veterans will receive the
    highest standard of care by utilizing private sector
    construction efficiencies and philanthropic support. We can
    significantly reduce construction timelines and costs, ensuring
    timely delivery of quality services to those that have served
    our country.
        Our community has demonstrated the potential of highly
    successful public-private partnerships, the Veterans Health
    Care and the CHIP IN Act born in your committee. This is just
    one example of proven success. By effecting the proposed
    partnership in Omaha, we together can set the standard for
    future care for those that have worn the cloth of our Nation
    and protected our freedom.
        I thank you for your time and look forward to your
    question.

        [The Prepared Statement Of Jeffrey Gold Appears In The
    Appendix]

        Ms. Miller-Meeks. Thank you, Dr. Gold.
        The chair now recognizes General Bacon for 3 minutes to
    speak on his bill H.R. 217.

                         STATEMENT OF DON BACON

        Mr. Bacon. Thank you, Madam Chair. I appreciate the
    opportunity to advocate on this bill in the subcommittee and
    the bill is H.R. 217, Communities Helping Invest through
    Property and Improvements Needed for Veterans Act, otherwise
    known as the CHIP IN for Veterans Act.
        This bill will make the current pilot program a permanent
    site. Chairman Bost has been out to our district and seen the
    new facility. I appreciate that Chairwoman Miller-Meeks has
    been out there. I invite the ranking member and, frankly,
    anybody that wants to go to Omaha to see literally one of the
    most beautiful VA facilities in the country, and it was done
    through this bill that was temporary that we would like to make
    permanent.
        I also want to thank President Gold for being here and Ms.
    Sue Morris, who helps manage the philanthropic operation here
    to make this possible.
        The CHIP IN for Veterans Act enables communities to take
    the lead, contribute resources, and complete VA construction
    projects on time and in a cost-efficient manner, benefiting
    taxpayers, the communities, and, most importantly, our
    veterans. The Ambulatory Care Center in Omaha, Nebraska, was
    the first public-private partnership project for the VA. Now, I
    would like to get your attention on this because this is what
    makes this so important. The VA had budgeted this for $135
    million. That was going to be the cost. The community doing
    with State and local financing and philanthropic, plus Federal,
    was able to do this for $85 million. Right away we saved $50
    million for the taxpayer.
        It gets even better. Out of that $85 million, $35 million
    came from not Federal sources; philanthropic, State, and local.
    In other words, this cost went from $135 million for the VA
    down to approximately $50 million. This is why this bill is so
    important. We can do this all over the country where folks want
    to donate and contribute and where states, local governments
    want to help.
        Since the doors opened in August 2020, the Ambulatory Care
    Center has provided--cares for 31,744 patients and over 261,000
    visits. Now, we want to replace the inpatient facility now. We
    already have approximately $100 million outside of the VA ready
    to invest in this facility. It will be a great deal for the VA.
        Look forward to working with the committee to enact this
    legislation and with the Department of VA and the philanthropic
    community to bring this to fruition. Another innovative
    facility for the benefit of veterans across the country.
        I yield back.
        Ms. Miller-Meeks. Thank you, Representative Bacon.
        As is my typical practice, I will reserve my time until all
    other members have had a chance to ask their questions.
        I now recognize Ranking Member Brownley for 5 minutes for
    any questions she may have.
        Ms. Brownley. Thank you, Madam Chair.
        Dr. O'Toole, I am disappointed that the VA is opposing my
    bill, the VA Marriage and Family Therapist Equity Act. You
    know, VA is an outlier among its peers, including TRICARE, in
    terms of requiring licensed marriage and family therapists to
    have graduated from a Commission on Accreditation for Marriage
    and Family Therapy (MFT) Education program in order to be
    promoted within the VA. MFTs are among the occupations for
    which VA has been developing national standards of practice for
    the last several years. Perhaps you can reconsider this
    standard as part of that effort if it is still underway under
    the new administration. Can you share any updates on the
    National Standards of Practice Initiative?
        Dr. O'Toole. Thank you, Chair--thank you, Congresswoman.
    The national standards work is ongoing. The intent behind that
    effort is to ensure that there is minimized variance across
    states in terms of accreditation and licensure.
        The VA is very supportive of position of marriage and
    family therapists. We see it as an integral part of the VA. Our
    primary concern with this is that there are currently no
    statutory requirements for supervisorial roles in any of our
    Title 38 positions and our concerns with State variances that
    currently exist and how those supervisorial roles are
    supported. We are very open and would be happy to work with the
    subcommittee further to, you know, further advance this
    legislation in a way that would work or that our rules would
    work.
        Ms. Brownley. Thank you for that. I mean, I just believe
    that this kind of clinician is so critically important to the
    veteran community. You know, for a while, we did not even
    accept marriage and family therapists. Now we do. In order to
    keep them, they have to have a road of opportunity to be
    promoted. I just think it is so many other states, TRICARE, so
    forth, does not require this. It requires another accreditation
    and it works pretty well. Anyway, I hope that you will continue
    to consider it because I think it is really, really important.
        Next question I had is I wanted to talk a little bit about
    the VA and its undertaking to expand access to lockboxes and
    other suicide prevention tools for veterans. You know, I think
    Mr. Deluzio's bill is a good one, and I think we need to
    strengthen those efforts. Can you sort of expand on the lockbox
    distribution program that you are already providing?
        Dr. O'Toole. Thank you, Congresswoman. To begin, we very
    much share the concerns about the need and the essential
    capacity of we have to be there to reduce veteran suicides. I
    can speak personally to having had patients who have died by
    suicide. I think all of us know, sadly, individuals who have
    family members who have friends who have died by suicide. This
    is an emergency.
        Currently, the VA does have a lockbox program that began
    last year. It is run jointly between our Office of Suicide
    Prevention and the Prosthetics Department to provide lockboxes
    for veterans identified as part of a clinical encounter and
    clinical screening who are determined to have risk for suicide,
    moderate to high risk; who have access to firearms or
    peripheral access to firearms, meaning a member of the family
    or household has access to firearms. In which case they are
    provided a lockbox, which is a proven method of trying to
    create space between the impulsivity of wanting to commit
    suicide and having access to a lethal means.
        Our concern with this bill is that----
        Ms. Brownley. I am not asking about the bill. I am asking
    about the program and what you are doing.
        I want to know, it is my understanding that under the
    current program, lockboxes have to be requested by their
    provider. How would a veteran or their provider know this
    program is available?
        Dr. O'Toole. Thank you, ma'am. We have an extensive
    education experience both to the veteran as well as to the
    provider to promote this program to both groups to try to, you
    know, encourage its application and use.
        Ms. Brownley. Okay. We know it is a good program. You have
    already said that it is a good program. I just, you know, it
    seems to me that making sure that any veteran who wanted a
    lockbox should receive a lockbox because there are many
    veterans out there where we might not know their situation or
    their vulnerabilities. I think it is important to do that.
        I guess what kind of--oh, I have run out of time. I yield
    back, Madam Chair.
        Ms. Miller-Meeks. Thank you, Representative Brownley.
        The chair now recognizes Representative Hamadeh for 5
    minutes.
        Mr. Hamadeh. Thank you, Chairwoman.
        As an Army intelligence officer who served overseas, I
    understand firsthand the obligation we have to the those who
    wore our uniform. Our veterans deserve more than gratitude.
    They deserve action. That is why I am proud to support several
    of the bills before us today that will directly improve
    healthcare access and quality of life for veterans all across
    Arizona and our country.
        My first question is for Dr. O'Toole. The alleged budget
    shortfall within the VA raises serious concerns about your
    organization's financial planning and resource allocation. Do
    you believe the VA should undergo an annual forensic audit?
        Dr. Emmendorfer. Thank you, Congressman. First, I just
    wanted to say thank you for your service in the military as
    well as here with us today.
        On this particular bill, we do defer to the Comptroller
    General.
        Mr. Hamadeh. What is their recommendation?
        Dr. Emmendorfer. By deferring, we are deferring to the
    Comptroller General on the forensic audit.
        Mr. Hamadeh. Do you believe that having a forensic audit
    would give confidence to veterans and the taxpayers that their
    money is being spent wisely?
        Dr. Emmendorfer. I do appreciate the question, Congressman,
    but we would defer to the Comptroller General.
        Mr. Hamadeh. Dr. O'Toole, the Parker Gordon Fox Suicide
    Prevention Grant Program has helped expand access to mental
    healthcare for veterans. In what ways has the program been most
    effective and how can it be further improved to ensure veterans
    and crisis receive timely mental healthcare?
        Dr. O'Toole. Thank you, Congressman. This act has been
    serving our veterans very well, and we support many of the
    amendments, several of the amendments that are in the bill. The
    grant program in particular, we have found very helpful and has
    been very supportive. Four of the amendments in particular we
    are supportive of, including the extending the duration of the
    pilot program because of its successes; requiring grantees to
    inform individuals about their ability to receive emergency
    suicide care, which we currently do, but I think codifying it
    is going to be a strength; ensuring that eligible entities have
    provided mental healthcare and support for veterans over the--
    excuse me, support services in the U.S. for the previous 2
    years, we feel strengthens it. There is some technical
    corrections as well we support.
        The concern we have with this bill is the $500,000 cap and
    the $10,000 per grantee additional payment, which we think
    would be difficult logistically to manage in the context of how
    Federal grants are currently managed with providers in that
    form.
        Mr. Hamadeh. Thank you. Going off of Congressman Bacon's
    comments earlier, it is a very impressive facility from what I
    see and I would like to visit that, Congressman.
        My first question--or third question is to Dr. Gold. What
    were the biggest advantages of using the public-private
    partnership for the Omaha center project and how can this model
    be replicated across the country?
        Dr. Gold. Thank you for asking, sir. Of course, thank you
    for your service.
        There are so many different advantages. One was to, of
    course, save a lot of money. What would have cost the VA $136
    million ended up costing $56 million out of the VA budget.
        Second was this project was finished not only exactly on
    budget, but ahead of schedule, which does not always happen in
    large Federal construction projects. At least that has been my
    multidecade experience. It also was able to bring to bear the
    experience that our university had with being part of this
    small, but very effective 501(c)(3) corporation, in that we
    have built lots of different healthcare facilities, ambulatory
    care centers, ambulatory surgery centers, and many other
    inpatient and out patient health care facilities, women's
    health centers, imaging centers, et cetera. Being able to bring
    all that to bear with the architects, the engineers, and with
    the construction contractors allowed us to accelerate the
    planning for the process in partnership with the local VA and
    deliver it on time and on budget.
        Mr. Hamadeh. A truly, truly impressive project.
        Dr. Gold. It is a beautiful facility, an award-winning
    facility.
        Mr. Hamadeh. Right. On time and under budget. That is
    pretty rare for the Federal Government.
        I yield back.
        Mr. Bacon. Like $85 million under budget.
        Ms. Miller-Meeks. Thank you very much, Representative
    Hamadeh.
        The chair now recognizes Representative Cherfilus-McCormick
    for 5 minutes.
        Ms. Cherfilus-McCormick. Thank you so much. I would first
    like to say thank you to our panelists for testifying today.
    Thank you for your dedication and service.
        Dr. O'Toole, Representative Garcia's Women Veterans Cancer
    Care Coordination Act identifies the difficulties veterans face
    in navigating transitions to and from community care. For
    instance, I have heard of cases where medical records from
    community providers took weeks to return, delaying crucial
    treatment and causing unnecessary stress for the veterans and
    their families. No veteran should navigate their battle with
    cancer alone.
        Dr. O'Toole, do you have--Dr. O'Toole, do VA hospitals need
    dedicated community care coordinators, teams, to help veterans
    navigate and keep contractors accountable?
        Dr. O'Toole. Thank you, Congresswoman. First, we agree with
    you absolutely that no veteran, no person, should have to
    navigate the management of cancer by themselves. We strongly
    support the role of care coordinators in helping them both
    navigate the care within the VA and navigating the care in the
    community.
        Ms. Cherfilus-McCormick. What is the impact to the
    veteran's care when there is not a seamless through line
    between community care and the VA?
        Dr. O'Toole. The biggest challenge, Congresswoman. I think,
    as we would all acknowledge, is the concern about care falling
    through the cracks, not being communicated well to different
    providers who were involved in that care for the veteran, not
    knowing what was going on with their care. These are things
    that nobody should have to experience in their care journey.
        Ms. Cherfilus-McCormick. Dr. O'Toole, my second question,
    having a regional breast and gynecological care cancer care
    coordinator for each Veterans Integrated Service Network (VISN)
    has the potential to save many lives if Representative Garcia's
    bill were to become law. However, I have deep concerns that
    Department of Government Efficiency (DOGE) may work to stop
    this position from being in existence. Over the weekend, the
    New York Times uncovered a horrifying consequence of DOGE's
    indiscriminate workforce cuts. The VA hospital employees
    responsible for enrolling veterans with throat cancer in an NIH
    clinical trial was fired. As a result, the clinical trial was
    put on hold and veterans with cancer were left without access
    to potential life-saving medication.
        Dr. Gold, should we exempt clinical trial coordinators and
    the coordinator position established by the Women Veterans
    Cancer Care Coordination Act from DOGE's indiscriminate firing?
        Dr. Gold. There is no question that access to clinical
    trials is life-saving, particularly in cancer, but also in end
    stage congestive heart failure, in neurodegenerative diseases,
    and so many others. Our veterans should be afforded the very
    best quality care that our Nation can provide, which means they
    need to have access to all of those trials. In order to do
    that, we must have qualified personnel to enroll and to perform
    those trials and to monitor them.
        Ms. Cherfilus-McCormick. You would recommend expanding the
    exemption to other areas and other positions, also?
        Dr. Gold. Access to clinical trials is absolutely state-of-
    the-art care and needs to be available to all patients in our
    Nation.
        Ms. Cherfilus-McCormick. Do you believe VA's plan to lay
    off 83,000 workers will help facilitate veterans access to
    cancer care?
        Dr. Gold. I know that the staffing of any medical center,
    large or small, is what makes it work. Buildings are beautiful,
    the coffee shops are important, but at the end of the day, it
    is the doctors, the nurses, the pharmacists, and the therapists
    that make it all work. I also know that you need a critical
    mass of that workforce to make it successful.
        Ms. Cherfilus-McCormick. Is that a yes or a no?
        Dr. Gold. Do you mind repeating your question?
        Ms. Cherfilus-McCormick. Do you believe that VA's plan to
    lay off 83,000 workers will help facilitate the VA's access to
    cancer care?
        Dr. Gold. Without understanding the details of which 83,000
    workers will be laid off, it is difficult to give you a
    specific answer. Anything that materially reduces the workforce
    will materially reduce access to care and quality of care.
        Ms. Cherfilus-McCormick. I will take that as a yes. Well,
    thank you.
        I would like to know that the VA research has led to the
    best treatment in the world when it comes to prosthetics,
    spinal cord injuries, and TBI. In addition, VA researchers also
    brought use of the pacemaker, nicotine patches, and aspirin as
    a method to preventing heart attacks. Attacks on these
    healthcare researchers and the VA affects every veteran in
    America, not just the veterans who are presently receiving
    care.
        Thank you so much for your time. I yield back.
        Ms. Miller-Meeks. Thank you very much, Representative
    Cherfilus-McCormick.
        The chair now recognizes Representative King-Hinds for 5
    minutes.
        Ms. King-Hinds. Thank you, Madam Chair.
        My question is to Dr. O'Toole. I come from the territories
    and I just wanted to get your thoughts. Given that the Parker
    Gordon Fox Suicide Prevention Grant Program is designed to
    reach veterans who may not necessarily be engaged with the VA,
    how is the program ensuring that the resources are effectively
    reaching veterans in remote or underserved areas, such as U.S.
    territories, like the Commonwealth of the Northern Mariana
    Islands (CNMI)?
        Dr. O'Toole. Thank you, Congresswoman. That is obviously of
    great importance. I think the intent and design of the grantee
    process is critical to that, to ensuring and both also our
    monitoring of grantees to ensure that that is appropriately
    managed and distributed to every veteran no matter where they
    live.
        Ms. King-Hinds. Okay. Then, in addition to that question,
    what strategies are in place to support community-based
    organizations in these areas that may lack the infrastructure
    or capacity to apply for and manage these grants effectively so
    that we do meet the mission of certain serving our veterans,
    especially in underserved, remote areas?
        Dr. O'Toole. Thank you, ma'am. I would have to take the
    specifics of that response on the record and defer to our
    subject matter experts in that program. It is something,
    though, we fully agree with in terms of its importance.
        Ms. King-Hinds. Thank you, I appreciate that. I yield my
    time, Madam Chair.
        Ms. Miller-Meeks. Thank you very much, Representative King-
    Hinds.
        The chair now recognizes Dr. Dexter for 5 minutes.
        Ms. Dexter. Thank you, Chairwoman Miller-Meeks, and thank
    you to our witnesses for being here today and for your service
    to our veterans.
        Although I am very grateful for the opportunity to consider
    this legislation before us today, I have to state the obvious.
    We are proceeding with business as usual when nothing about
    what is happening in the world is business as usual. In a
    matter of hours, everyone on this dais will leave this room to
    vote on legislation put forth by my Republican colleagues to
    cut nearly $23 billion in advance funding to ensure we can care
    for our veterans exposed to toxic chemicals in the line of
    duty. If that were not bad enough, that vote comes just days
    after we found out that Trump's team will fire an additional
    83,000 VA workers on top of the 2,400 they have already
    stripped of their jobs, and return us to the staffing levels we
    saw before implementation of the Sergeant First Class Heath
    Robinson Honoring our Promise to Address Comprehensive Toxics
    (PACT) Act, the biggest expansion of veterans' benefits in
    generations.
        Make no mistake, these firings are as good as a cut for
    veterans. Without those dedicated workers, our veterans will
    absolutely have trouble accessing the care and benefits they
    have earned, waiting longer for their claims to be processed,
    or, worse, not being able to access new benefits at all. Look,
    I built a track record at the State level for being able to
    reach across the aisle. I absolutely want to get things done.
    Several of the bills before us--and several of the bills before
    us are good policy, whether it is ensuring veterans have access
    to essential medicines regardless of where they are cared for,
    improving care coordination for women veterans, or advancing
    cost-effective gun safety measures. I have serious doubts about
    our ability to implement any of these policies if the VA does
    not have the staffing or the funding that it needs.
        I spent much of my professional career practicing as a
    physician at Kaiser Permanente in Oregon and served first as a
    board member and then as chair of the board. I understand
    intimately the challenges of running a large medical system.
        I simply have a--I have a simple question for you, I hope,
    Dr. O'Toole. First, would it make it easier or harder to
    implement a new initiative at the VA if it were uncertain that
    the VA would be provided with the funding required to do so?
        Dr. O'Toole. Thank you, Congresswoman. I am, you know,
    trying to fully, I guess, understand the question. Obviously,
    any bill that comes through, it helps to have the
    authorizations associated with that bill to be able to
    implement it.
        Ms. Dexter. Okay, thank you. Would it make it easier or
    harder to implement a new initiative at the VA if there were no
    staff to do so?
        Dr. O'Toole. Thank you, Congresswoman. Again, you know, I
    think in--I am not--I would have to take for the record
    specifics related to, you know, current issues related to
    staffing and the staffing proposals underway. I think, in
    general, though, I think your question is rather self obvious.
        Ms. Dexter. Thank you. Following up on my colleague's
    questions regarding care coordination, do you have objective
    reasons to believe that care coordination within the VAMC,
    especially around cancer care, is superior to care outside
    coordination with our community care systems?
        Dr. O'Toole. I would need to defer to our subject matter
    experts who have spent, you know, many of them have spent their
    careers studying differences in quality between the VA and care
    outside the VA. I have been very proud to be a clinician in the
    VA system and very proud of the care that we provide and the
    outcomes we provide. You know, it is not to say we could never
    do better. We always can. I think the role of care
    coordination, particularly in complex care that involves
    multiple providers, it has been well proven to be an important
    element of that care.
        Ms. Dexter. I absolutely agree with you having had access
    to care coordinators throughout my practice as well on lung
    cancer treatment.
        I am going to ask, Madam Chair, if we can submit some
    studies for the record looking at the comparison of outside
    versus inside care, one of which is titled, ``VA Delivered or
    VA Purchased Care: Important Factors for Veterans Navigating
    Care Decisions.''
        Ms. Miller-Meeks. No objection.
        Ms. Dexter. Thank you.
        I just urge my colleagues to keep in mind the importance of
    this legislation. I certainly appreciate the work that folks
    are doing, but that we cannot expect better care when we gut
    the system that has to deliver it.
        With that, I yield back, Madam Chair.
        Ms. Miller-Meeks. Thank you very much, Dr. Dexter.
        The chair now recognizes Dr. Conaway for 5 minutes.
        Mr. Conaway. Thank you, Madam Chair, and thank you, thanks
    to our witnesses for presenting themselves to us today and
    offering information on the bills at hand.
        Mr. O'Toole, this question is, I think, directed at you.
    You are taking most of the incoming now, it seems. In the last
    Congress, the No Wrong Door Act was introduced to demonstrate
    improvements in veterans' mental health, a very critical issue.
    We are seeing, sadly, the number of suicides among that cohort
    going up. The updated version has changed that requirement that
    now grantees must show that funds are being used to assist a
    significant number of veterans. My concern is it went from
    showing that you have good outcomes to showing that you have,
    quote, unquote, ``significant numbers of veterans'' who are
    receiving assistance.
        The question is, what does ``significant'' mean in that
    context? How do we measure it? When do people meet the bar?
        Dr. O'Toole. Thank you, sir. That reflects similar concerns
    that we have to the construct of this bill. Absolutely, these
    pilot programs have made a difference and we are strong
    supporters of them. The bill as drafted and changing from the
    $750,000 grant amount to $500,000 with an additional $10,000
    per individual served, we feel would create challenges and
    logistics to both how the grant would be administered, but also
    challenges to how we would be assessing performance of those
    grants.
        We stand very much in support of this legislation and the
    intent of it. You know, I think we share the subcommittee's
    concerns and try to make sure we have the best bill going
    forward.
        Mr. Conaway. I agree that the effort is more than
    worthwhile, the concerns that we are seeing among the veterans
    community and indeed mental health more broadly, and certainly
    would have a particular need and duty to provide that care to
    those who have given so much to our country.
        Next, I want to address H.R. 1336, the Veterans National
    Traumatic Brain Injury Treatment Act. This bill aims to direct
    the Secretary of Veterans Affairs to establish a pilot program
    to provide hyperbaric oxygen therapy to veterans suffering from
    traumatic brain injuries or post-traumatic stress disorder.
    Indeed, we have seen studies in the traumatic brain injury
    space which suggests that the use of hyperbaric oxygen therapy
    would be really quite beneficial.
        The VA conducted its own study and which showed, you know,
    great promise. Does the VA have any reservations regarding this
    pilot program and the potential impact of this therapy on
    veterans?
        Dr. Shappell. Thank you. Thank you for your question. VA
    shares your concerns. Mental health and suicide preventions are
    huge priorities for VA. We do not support this bill.
        Our VA subject matter experts are continuously reviewing
    scientific literature and updating and publishing our clinical
    practice guidelines. Published results of the scientific
    rigorous research that has been done by VA and U.S. Department
    of Defense (DOD) repeatedly they have shown hyperbaric oxygen
    therapy has the same impact as a placebo.
        Mr. Conaway. What is that? If you would speak into the mic,
    it would be very helpful.
        Dr. Shappell. Published studies----
        Mr. Conaway. There you go.
        Dr. Shappell. Published results of the scientifically
    rigorous research that has been done by both VA and DOD has
    shown repeatedly that hyperbaric oxygen therapy has the same
    impact as placebo. There is no scientific basis to support the
    use of hyperbaric oxygen therapy for PTSD. There is strong
    scientific basis that hyperbaric oxygen therapy is not
    recommended for traumatic brain injury.
        Mr. Conaway. We are looking at a study here on our desk
    that would suggest otherwise. It is an NIH study and certainly
    we do want to look at the preponderance of evidence across
    multiple studies. They are done, hopefully, according to the
    most rigorous standards. Therefore, if you do not like the
    hyperbaric oxygen as a treatment, could you suggest alternate
    therapies that--alternative therapies that we are perhaps not
    using now that ought to be deployed deal with these important
    conditions?
        Dr. Shappell. Thank you. As I mentioned, our subject matter
    experts are continuously reviewing scientific literature. I
    would be happy to provide you a review of other alternate
    therapies that we are currently considering.
        Mr. Conaway. Great. Thank you, Madam Chair.
        Ms. Miller-Meeks. Thank you, Dr. Conaway.
        I now recognize General Bacon for 5 minutes for any
    questions you may have.
        Mr. Bacon. Thank you, Madam Chair, for the opportunity to
    be part of your subcommittee today. I would like to follow up
    with President Gold and some of his comments on the numbers
    because I think they are worthy of repeating.
        What he said is that the VA--we saved the VA, or the
    Federal Government, approximately $80 million. What was going
    to cost the VA $135 million ended up costing the Federal
    Government $56 million. I think I got the numbers that you said
    right there.
        President Gold, could you lay out what can we expect for
    the inpatient hospital, rough numbers? Like, what does the
    Federal Government or the VA think it is going to cost versus
    what we can probably build it at versus how much State and
    local philanthropic money we may get? We just want to show the
    benefit of this for our future facility.
        Dr. Gold. A great deal would depend upon how much shared
    services we are talking about. Certainly replacing inpatient
    med surg, critical care, and other bed space would be
    essentially at the standard construction rates for large, high-
    quality academic medical centers. However, a lot of the cost of
    construction in healthcare now really is not on the inpatient
    bed space, but it is in the extremely expensive equipment
    including diagnostics, procedural, and interventional space.
    Biplane fluoroscopy, for instance, some of the modern
    laparoscopic and endoscopic operating rooms, et cetera. Even in
    the ophthalmology world, the equipment has gotten incredibly
    expensive with the operating microscopes interventional
    technology.
        To the extent that some of that diagnostic and procedural
    space could be shared, some of the clinical and anatomic
    pathologies space, some of the imaging space, some of the--even
    some of the central sterile supply space that would need to be
    connected, shared parking, shared logistics, and
    infrastructure. Right now, the project is on the VA
    construction priority list, as, I believe, the number two
    priority for 2029 and, if I am correct, at $1.56 billion. I
    would estimate based on discussions with the local VA and VISN
    leadership, that we could probably save the Federal Government
    if we did this in a shared fashion and shared these types of
    resources, we estimate you could save a half a billion dollars
    to the taxpayers.
        Mr. Bacon. That is what I was waiting to hear.
        Dr. Gold. Well, it all depends on how much you saved due to
    shared very expensive space and equipment.
        Mr. Bacon. That is the savings right there. If I may ask
    our VA representatives, and I will defer to which one, could
    you talk about what this CHIP IN bill has done, what it means
    to you? I would love to get your perspective on this.
        Dr. O'Toole. Thank you, Congressman. I think we are adding
    to the chorus, VA supports this bill. As you know, we were
    authorized as part of the pilot for up to five projects. Two
    have been undertaken, one completed in Omaha, as you have
    heard, and the hospital in Oklahoma is currently under
    construction. We do support this legislation.
        Mr. Bacon. With that, Madam Chair, I yield back.
        Ms. Miller-Meeks. Thank you very much, General Bacon.
        I now yield myself 5 minutes.
        I am going to follow up on something Dr. Gold said, which
    is carrying the public-private partnership even beyond, i.e.,
    sharing facilities, especially those expensive facilities, and
    sharing parking, and some people may be aghast at that. Dr.
    O'Toole, do not many VA hospitals, are not they staffed by
    people that have dual appointment between a medical center and
    a VA center?
        Dr. O'Toole. Thank you, Congressman. Yes, actually we have
    a very deep academic partnership and footprint and particularly
    in our level 1A, 1B, and C facilities. I would note that 70
    percent of doctors practicing in the United States all went
    through a veteran hospital as part of their training.
        Ms. Miller-Meeks. As did I. Dr. Gold, the Omaha VA
    Ambulatory Care Center was completed a year ahead of schedule
    and over $40 million under budget thanks to the CHIP IN for
    Veterans pilot program. How did the VA's CHIP IN authorities
    foster such a successful public-private partnership?
        Dr. Gold. Thank you for the question. One of the biggest
    advantages that we shared was that we were able to plan this
    the way we would plan a commercial, large academic medical
    center clinic and then deliver it on a schedule that we would
    normally do it. Over my decade of leadership at the University
    of Nebraska Medical Center, we have done over a billion dollars
    of healthcare and academic construction and have never exceeded
    the budget and really never significantly exceeded the
    timeline, except minimally during the early months of the
    COVID-19 pandemic.
        The construction standards are absolutely critical because
    of the penalties associated with going over budget and going
    over timeline. Anybody that has been involved with large
    academic medical centers understands that, that time is money
    for all of these types of projects. That type of precision was
    used through the 501(c)(3) and you will hear from Sue Morris in
    a little bit of how that actually worked. That type of
    precision was used in a very, very careful way to ensure we
    delivered this project.
        Ms. Miller-Meeks. Thank you. It is one of the reasons we
    are hoping to make this permanent. For those who are
    interested, there is a pamphlet here that shows that clinic. It
    is quite outstanding.
        Dr. O'Toole, the Parker Gordon Fox Suicide Prevention Grant
    has made tremendous progress in connecting veterans with timely
    mental healthcare in their communities. Why is it vital that we
    quit quickly reauthorize the program?
        Dr. O'Toole. Excuse me while I catch up to my notes here on
    this. Thank you. Yes, we fully endorse the importance of this.
        My understanding is that the concern is obviously being
    able to reauthorize it before the pilot project expires, which
    my understanding is September 30, 2028. We strongly endorse
    this legislation as an important armament in our effort to
    reduce veteran suicide. Thank Congress definitely for all of
    your work and support on this effort.
        Ms. Miller-Meeks. Then again, Dr. O'Toole, the START Act
    would ensure community care referrals remain valid through the
    veterans standard episode of care. Would this help veterans
    receive all the care that the VA has determined necessary?
        Dr. O'Toole. We think so, ma'am. I think this is an
    important element where this legislation will help the VA
    practice to its policy. Obviously, our intent is obviously
    ensuring that it is not just the episode of care or the first
    appointment, but rather the episode of care, which can be up to
    1 year and renewable beyond that. More importantly, it is about
    helping the VA, I think, you know, shore up its practices to
    ensure that we are doing a better job of ensuring that that is
    actually what we are practicing, too.
        Ms. Miller-Meeks. I think, Dr. Gold, you were asked a
    question that may be difficult for you to answer, was in
    letting people go and managing a very large healthcare
    facility. Let me just say that if you were given an increase in
    your budget by 126 million over a 4-year period, and over that
    same past 4 years, you had an increase in full-time employees
    of 60,000 and part-time employees for 23,000 and you were
    looking at 80,000 employees, exempting hiring of nurses and
    doctors, would you consider that gutting a program?
        Dr. Gold. It would depend on the role of those individuals
    employees. You know, having been a pediatric heart surgeon for
    over two decades of my life, it is not just the person that
    stands at the operating room or over the ether screen, but it
    is the person that mops the floors and stocks the supply
    cabinets and does so much else in our system.
        Ms. Miller-Meeks. You would need to know----
        Dr. Gold. I would need to know.
        Ms. Miller-Meeks [continuing]. what those positions are.
    Thank you so much. With that, I yield back.
        I am going to ask if we would have our--on behalf of the
    subcommittee, I want to thank all of our witnesses for their
    testimony and joining us. You are now excused. We are going to
    wait a moment while the second panel comes to the witness
    table.
        Welcome, everyone, and I thank you for your participation
    today.
        On our second panel we have Ms. Sue Morris, president and
    CEO of Veterans Trust; Mr. Brian Dempsey, director of
    Government Affairs for Wounded Warrior Project; Dr. Andrew
    Kozminski, medical director of hyperbaric medicine for the
    University of Iowa Healthcare; Mr. Ed Harries, president of the
    National Association of State Veterans Homes; and Jon Retzer,
    deputy national legislative director for Health, Disabled
    American Veterans.
        Ms. Morris, you are now recognized for 5 minutes.

                        STATEMENT OF SUE MORRIS

        Ms. Morris. Good afternoon, Chairman Miller-Meeks, Ranking
    Member Brownley, and members of the Health Subcommittee. My
    name is Sue Morris. I am the president of Veterans Trust, the
    nonprofit philanthropic entity that partnered with the
    Department of Veterans Affairs under the CHIP IN Act to
    construct VA's Ambulatory Care center in Omaha, Nebraska,
    serving Western Nebraska and Western Iowa.
        Our nationally award-winning ambulatory care center project
    was completed and donated to Veterans Affairs in July 2020 as
    the first public-private partnership to be completed under the
    CHIP IN Act. The project received several national awards for
    healthcare design and construction. I am here today to speak in
    favor of taking the pilot program authorized under the CHIP IN
    Act and making it permanent, as H.R. 217 would do. Our project
    showed how VA, in partnership with the private sector,
    delivered a truly superb facility in a cost-effective and
    efficient manner.
        What allowed the Omaha project to be successful? First, the
    project was owned by Veterans Trust during the development and
    construction phases and then donated to Veterans Affairs upon
    completion. While there was very close coordination and
    cooperation between Veterans Trust and VA officials at both the
    national and local levels, it was not a government construction
    project. This structure allowed Veterans Trust, whose
    leadership had a history of facilitating or over a billion
    dollars on local projects, to use local vendors and suppliers
    in its procurement of services and materials, leveraging
    demonstrated relationships for best pricing. We were able to
    tell our partners in design and construction that they will
    make money on the project, but not a lot of money, as this is a
    community project to serve our veterans.
        Second was a strong commitment from Veterans Affairs'
    senior leadership. We met regularly at VA headquarters,
    including three meetings directly with the Secretary, to ensure
    project milestones were achieved. There was zero scope creep,
    which helped the project to be delivered on time and on budget.
        One key factor in this regard was Veterans Affairs'
    willingness to review VA's normally applicable construction and
    physical security standards. We were able to come to agreement
    on which of those standards made sense, resulting in value
    engineered savings of $23 million. In the end we delivered the
    facility for a total of $86 million when it was originally
    budgeted at $135 million, saving the taxpayers $50 million. In
    addition, the private philanthropic contribution to the project
    was $30 million.
        Based upon our experience and success with this effort, we
    recommend that H.R. 217 go further than simply making CHIP IN
    permanent to also consider other changes. In particular, we
    suggest the following. Add the option to construct facilities
    on land leased to VA, not just owned or donated real property.
    Add the ability to use the program for minor construction, not
    just major projects, and make clear that the act applies to
    more than just healthcare, but also to construction projects
    providing other types of facilities to veterans, such as
    housing and community centers.
        In amending the act itself, we suggest the subcommittee and
    staff engage a small group of VA leadership and private sector
    representatives to recommend forward-looking best practices and
    new models for public-private partnerships. My team and board
    would be pleased to have been included in this effort.
        In summary, we wholeheartedly support the effort to make
    CHIP IN a permanent tool to deliver state-of-the-art
    facilities. The act allows Veterans Affairs the ability to
    leverage advantages of private sector construction processes to
    deliver significant cost savings. We are tremendously proud of
    our role in helping lead in this effort to deliver a world
    class facility to our veterans and cost savings to our
    taxpayers.
        I want to add one final point. As Dr. Gold mentioned, there
    is no doubt that a new inpatient facility to replace Omaha's
    aging VA hospital is sorely needed. Veterans Trust stands ready
    to partner with Veterans Affairs and the University of Nebraska
    Medical Center to assist in developing a new, state-of-the-art,
    inpatient facility that will better serve the veteran
    community.
        I am happy to answer any questions that you might have.
    Thank you for including me today.

        [The Prepared Statement Of Sue Morris Appears In The
    Appendix]

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

                       STATEMENT OF BRIAN DEMPSEY

        Mr. Dempsey. Chairwoman Miller-Meeks, Ranking Member
    Brownley, and distinguished Health Subcommittee members, thank
    you for inviting Wounded Warrior Project to testify on
    legislation intended to improve VA's ability to provide better
    access to care and ensure better health outcomes for our
    Nation's veterans.
        Over 20 years ago, when the first wounded servicemembers
    returned from the battlefields of Iraq and Afghanistan, the
    founders of our organization made a promise: to be there for
    these warriors no matter what. In the years since, our
    organization has grown to provide more than a dozen programs
    and services to more than 227,000 veterans and servicemembers,
    and our reach continues to grow by the day. These programs and
    the relationships we have built with warriors along the way are
    what inform our advocacy before Congress. Today, I am pleased
    to speak on three bills from the agenda that we believe will
    have the biggest impact on those who serve.
        First, we strongly support the Veterans Support Act. This
    bill would amend VA's legal definition of medical services to
    clarify that the agency's existing ability to provide
    artificial limbs includes the authority to provide adaptive
    prosthesis and terminal devices for sports and other
    recreational activities. If you are unfamiliar with what an
    adaptive prosthesis or terminal device is, think of the curved-
    shaped blades you might see on someone who has lost a lower
    limb or a waterproof fin that allows someone with an upper body
    prosthetic to swim in a pool. Now think about stress relief you
    may know from running, the community you found playing in a
    local softball league, or the body transformation you may have
    seen from lifting heavy weights. Participating in activities
    like these should be simple, but for veterans who use VA for
    prosthesis, it can be a challenge.
        Under current law and stated as simply as possible,
    veterans often struggle to get this kind of prosthetic support
    if they are not actively pursuing a rehabilitation plan, even
    if they have completed one in the past and are very familiar
    with what they need to do what they want. These regulations
    focus on the clinical need for adaptive prosthetics, but
    disregard their potential to improve a veteran's quality of
    life. If a clinical need cannot be found, providers cannot
    offer the equipment.
        The Veterans Support Act would help these veterans by
    effectively removing the requirement that they be enrolled in a
    VA rehabilitative program in order to receive the adaptive
    prosthetics for sports and recreation. The current population
    of post 9-11 veterans as young, young, mobile and energetic. We
    believe that VA should be building an ecosystem of care that
    encourages an active lifestyle and makes it easier to
    experience the profound health benefits, both mental and
    physical provided by sports and other recreational activities.
        Second, we support efforts to renew the Staff Sergeant
    Parker Gordon Fox Suicide Prevention Grant pilot program,
    including the No Wrong Door for Veterans Act. Our
    organization's approach to mental healthcare appreciates that
    no one organization and no single agency can fully meet all
    veterans' needs. Evidence-based mental health treatment
    absolutely works when available and when pursued, but the best
    results will be found by incorporating a public health approach
    focused on increasing resilience and psychological well-being.
    This kind of suicide prevention strategy embraces upstream
    prevention efforts, like helping with case management, peer
    support, work outreach, and establishing financial wellness,
    all of which are recognized as suicide prevention services
    through the Fox Grant Pilot program. Each year since the Fox
    Grant Pilot was launched, VA has discussed it as a key
    initiative for helping prevent suicide in its National Suicide
    Data Report.
        Previous congressional oversight and legislative hearings
    have revealed that the pilot program is not perfect, but we
    appreciate efforts like the No Wrong Door Act that would
    continue to refine the pilot's operation and foster community
    collaboration in ways tailored to local needs. We hope that
    this legislation can be prioritized as a vehicle for
    bipartisan, bicameral action to renew this program in time and
    disperse grants in Fiscal Year 2025.
        Third and finally, we support the Protecting Veteran Access
    to Telemedicine Services Act. This legislation would extend a
    COVID-19 era waiver from a law that requires patients to
    complete at least one in-person visit with a healthcare
    provider before that provider can prescribe them a controlled
    substance. If the waiver expires as planned in December 2025,
    rural veterans who do not live near VA or community healthcare
    facilities, who rely primarily on telehealth services, likely
    will be negatively impacted. Appointment coordination
    challenges and travel logistics may lead to interruptions in
    their care or lapses in prescriptions. The list of controlled
    substances contains not only pain medications, but also
    multiple mental health drugs that are important parts of
    treatment plans for many veterans dealing with mental health
    issues and for whom an in-person appointment may present
    additional challenges.
        Members of the committee, it is my distinct honor to be
    here on behalf of Wounded Warrior Project to speak to the needs
    of our Nation's wounded warriors and their families. Thank you
    for letting us do our part to keep the promise. This concludes
    my testimony and I look forward to your questions.

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

        Ms. Miller-Meeks. Thank you.
        Dr. Kozminski, you are now recognized for 5 minutes.

                     STATEMENT OF ANDREW KOZMINSKI

        Dr. Kozminski. Good afternoon, Chairwoman Dr. Miller-Meeks,
    Ranking Member Brownley, and members of the subcommittee. Thank
    you for inviting me to participate in this hearing to discuss
    H.R. 1336, the Veterans National Traumatic Brain Injury
    Treatment Act.
        I am Dr. Andrew Kozminski, an emergency medicine physician
    with a specialization in undersea and hyperbaric medicine. I am
    the current medical director for Hyperbaric Medicine at
    University of Iowa Healthcare and medical director for the
    United Hospital Center (UHC) Wound Center.
        This legislation aims to improve the health of our
    veterans, establishing a pilot program for the implementation
    of hyperbaric oxygen therapy for veterans with traumatic brain
    injury or post-traumatic stress disorder. As an emergency
    medicine physician, I have cared for numerous veterans
    suffering from TBIs and PTSD. With my experience in hyperbaric
    medicine, I think the implementation of hyperbaric oxygen for
    these ailments would be uncomplicated. Veterans already use
    this therapy through their VA insurance for currently approved
    HBO indications. Consequently, HBO, hyperbaric oxygen, has
    proven its safety after many decades of use by the medical
    community. For these reasons, this legislation has been
    potential to help improve the lives of our friends, families,
    and neighbors.
        I want to comment on the potential for an increased
    likelihood of oxygen toxicity seizures in this patient
    population as 1 in 50 TBI patients develop post-traumatic
    epilepsy. However, an oxygen toxicity seizure is a complication
    that trained hyperbaric medicine professionals are well versed
    in how to manage and should be able to ensure continued patient
    safety throughout a treatment course. Clinical trials, I will
    mention, even utilize a protective pressure of 1.5 Atmospheres
    Absolute (ATA), which should reduce the likelihood of this
    complication. However, this is an important reason to create a
    pilot program through the VA Health System, as this would
    provide a safe option for patients seeking treatment for what
    is currently an off-label indication. Without this program,
    desperate patients may find themselves at the mercy of popular
    health spas. Businesses that might not have adequately trained
    staff may use incorrect treatment profiles and at times pose
    serious risk to their patients or their clients.
        The research that investigators in my field have completed
    on the utility of HBO for TBI and PTSD shows promise for
    improving health outcomes in these patient populations. For
    chronic TBI cases, HBO has been found to improve cellular
    metabolism, reduce cell death and oxidative stress, and enhance
    mitochondrial function. These mechanisms aim to promote
    neuronal repair and regeneration. The Brain Injury and
    Mechanism of Action, BIMA, trial published in 2016 demonstrated
    improved post-concussive symptoms, PTSD, cognitive processing
    speed, sleep quality, and balance function by 13 weeks after 40
    60-minute HBO sessions at 1.5 ATA.
        Unfortunately, these improvements did not persist beyond
    that 6-month follow up. In February 2025, however, just last
    month Dr. Lindell Weaver, a leader in my field, and his team
    published their most recent study a double-blind randomized
    trial of hyperbaric oxygen for persistent symptoms after brain
    injury. This study showed similar results to what was observed
    in the BIMA trial for both sham and HBO groups at 13 weeks,
    with the HBO treatment group maintaining the neuropsychiatric
    benefits at 6 months.
        A second phase within the trial offered another 40 HBO
    sessions to all participants. Final follow up 3 months after
    the last of the second round of HBO treatments were given,
    patients who received 80 HBO treatments had greater
    neuropsychiatric improvement compared to their results after 40
    sessions. Patients who received a maximum of 40 treatments also
    showed neuropsychiatric improvements compared to their baseline
    scores, but less improvement than their counterparts received
    80 treatments.
        In conclusion, I find the outcomes of these clinical trials
    seem promising. Establishing a pilot program for the VA to
    offer HBO therapy for veterans with TBIs and PTSD could help
    improve these patients' quality of life, provide access to safe
    healthcare environments in which to receive these treatments,
    and continue to build insight on how best to construct and
    administer treatment courses in the future. Thank you.

        [The Prepared Statement Of Andrew Kozminiski Appears In The
    Appendix]

        Ms. King-Hinds. [Presiding.] Mr. Harries, you are
    recognized for 5 minutes.

                        STATEMENT OF ED HARRIES

        Mr. Harries. Members of the subcommittee, as president of
    the National Association of State Veterans Homes, thank you for
    the opportunity to testify today and offer our strong support
    for the Providing Veterans Essential Medications Act. This
    legislation would remove an inequity in the law concerning
    high-cost medication for veterans that are preventing many of
    them from living in State veterans homes.
        As you know, State veterans homes are not able to receive
    reimbursement from the VA for high-cost medications provided to
    seriously disabled veterans, even though private nursing homes
    that contract with the VA can. As a result, many State homes
    are losing hundreds of thousands of dollars every year that
    could be used to improve the lives of aging and disabled
    veterans.
        For example, at the Iowa State Veterans Home they are
    caring for a 55-year-old service-connected Air Force veteran
    who suffers from Crohn's disease. Fortunately, a drug called
    Stelara can help control his symptoms. However, this medication
    costs about $20,000 a month, which is more than the full cost
    of care prevailing rate the VA pays the home. Despite the
    financial burden, the Iowa State Home decided to care for this
    veteran at a significant operating loss. However, that likely
    means that they will have to cut costs elsewhere, perhaps
    admitting fewer veterans, spouses, or Gold Star parents, or
    maybe cutting back on social, recreational, or other nonmedical
    services.
        The same situation is occurring at State veterans homes
    across the country. At an Idaho State Veterans Home, a 63-year-
    old service-connected Army veteran is receiving a medication
    called Duopa for Parkinson's disease, which costs the home
    about $16,000 a month. The prevailing rate that Idaho receives
    for this veteran does not fully cover the cost of this one
    medication, let alone the cost of all the other care provided.
    Unfortunately, due to the financial strain from high-cost
    medications, some State homes can only afford to care for a
    limited number of such veterans who need these medications.
        For example, a 76-year-old 100 percent service-connected
    Air Force veteran living in a VA contracted community nursing
    home in Idaho was taking a special medication called Promacta.
    The cost of that drug was $18,000 a month. The VA was providing
    this medication to the veteran's spouse, who took it to the
    private nursing home where they would administer it to him.
    Although the private nursing home was receiving a prevailing
    rate for the full cost of care, just like the State homes do,
    their contract included a provision for them to receive or be
    reimbursed for these high-cost medications. The veteran wanted
    to move into the State veterans home and his spouse asked if
    she could continue to pick up the medication and bring it to
    the home. The VA told her that by law they could not allow it,
    effectively denying this veteran the ability to live in State
    veterans home, which was his choice.
        There are also cases where this inequity in the law is
    literally throwing away money that could be used to improve the
    care of veterans. In Wisconsin, a 76-year-old veteran who 100
    percent service-connected veteran, a Marine sharpshooter, was
    admitted to the State veterans home while receiving
    chemotherapy medication free of charge through an Astellas
    Patient Assistance Program. After the veteran moved to the
    State veterans home, his wife brought the medication so that it
    could be administered to him. However, according to the VA's
    rules, they could not use the free medication. Instead, the
    facility itself incurred a cost of $12,000.
        Wisconsin also had a service-connected army veteran living
    in one of their homes who was prescribed a chemotherapy drug by
    his VA oncologist, which was shipped directly from the VA
    pharmacy to the State home. When the medication arrived, the
    home contacted the VA, aware knew that it could not utilize the
    drug because they had not purchased it themselves under the
    program. When inquiring how to avoid wasting the $20,000
    medication, the VA told them it could not be returned even
    though it was in its original sealed packaging and to dispose
    of it.
        Madam Chairwoman, the Providing Veterans Essential
    Medication Act would require VA to furnish or reimburse State
    veterans homes for these high-cost medications, just like they
    are doing for the private homes. This would ensure that
    veterans could choose where they want to spend their twilight
    years without illogical statutes and regulations limiting their
    choices.
        That concludes my statement and I will be pleased to answer
    any questions that you or the members of the subcommittee may
    have.

        [The Prepared Statement Of Ed Harries Appears In The
    Appendix]

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

                        STATEMENT OF JON RETZER

        Mr. Retzer. Chairwoman Miller-Meeks, Ranking Member
    Brownley, and members of the subcommittee, thank you for
    inviting DAV to testify at today's legislative hearing. DAV is
    pleased to support the following bills.
        The SPORT Act seeks to include adaptive prosthesis terminal
    devices for sports and other recreational activities and the
    medical services provided to eligible veterans of the VA. DAV
    has long recognized and continues to support the importance of
    adaptive sports through our involvement with the National
    Disabled Veterans Winter Sports and Golf Clinics, which helps
    veterans improve their physical and mental health by overcoming
    limitations and challenge their perceived disabilities.
        The Saving Our Veterans Lives Act aims to tackle the
    devastating issue of veteran suicide by providing secure
    firearm storage. Firearms are involved in nearly 72 percent of
    veteran suicides and offering lockboxes creates time and space,
    reducing access to lethal means during moments of crisis,
    allowing veterans to reconsider their actions and seek help.
        The Marriage and Family Therapist Qualification of Veterans
    Health Administration Act aims to ensure that veterans receive
    care for high qualified marriage and family therapists through
    effective supervision and improved therapeutic practices.
    Incorporating family and relationships into mental health
    treatment can result in more effective outcomes, reinforcing
    coping strategies and provide a sense of belonging and
    stability.
        The Protecting Veterans Access to Telemedicine Service Act
    would ensure veterans can access controlled medications and
    consultations remotely, enabling convenience scheduling and
    thus improving treatment adherence and health outcomes. It
    breaks down barriers, such as distance, mobility challenges,
    and transportation limitations, particularly for those in
    underserved areas.
        The Women Veterans Cancer Care Coordination Act aims to
    ensure that women veterans diagnosed with breast and
    gynecological cancers receive seamless and tailored support
    through regional care coordinators. This would ensure veterans
    receive timely and appropriate care.
        The START Act aims to streamline the referral process for
    veterans receiving community care, ensuring smoother
    transitions and reducing administrative barriers. By
    establishing a clear referral period, it would ensure better
    care coordination.
        The Providing Veterans Essential Medication Act aims to
    address the financial burdens faced by safe veterans homes,
    ensuring veterans have access to high cost medications without
    added strain to the facilities. The bill guarantees continued
    high-quality care for veterans in long-term care, reflecting
    our commitment to their well-being.
        The Copay Fairness for Veterans Act aims to eliminate
    copayments for medications and preventive health services
    provided by the VA. Removing financial barriers will encourage
    routine checkups and screenings, leading to better overall
    health management and fewer emergency medical situations. We
    commend the thoughtful intent beyond the next two bills and
    encourage incorporating our recommendations to enhance their
    effectiveness.
        The No Wrong Door for Veterans Act reauthorizing and
    extending the Staff Sergeant Gordon Fox Grant Program,
    providing ongoing support for community-based mental health
    services. To enhance its impact, DAV recommends reiterating the
    importance of the original requirements of baseline mental
    health screening, using validating tools, and measuring the
    effectiveness of suicide prevention services with pre and post
    evaluations.
        Furthermore, funding criteria should focus on improvements
    in veterans' well-being rather than the number of participants
    served. Payment structure should be clearly defined to avoid
    overcompensation for minimal services. An annual renewal
    process is recommended until comprehensive data confirms the
    program's efficacy and identifies the most effective services
    in reducing suicide risk among veterans.
        The Veterans National Traumatic Brain Injury Treatment Act
    aims to establish a pilot program to provide hyperbaric oxygen
    therapy for veterans whose PTSD and TBI symptoms have not
    responded to traditional therapies. While initial research
    shows promise, researchers suggest further rigorous studies are
    necessary to validate its efficacy and safety. DVA recommends
    amending the bill to prioritize research along treatment axis
    to ensure veterans receive care that is both effective and
    evidence based.
        In conclusion, these legislative bills represent a
    comprehensive approach to addressing the urgent needs of our
    veterans to receive the services and healthcare that they have
    earned. This concludes my testimony on behalf of DAV and I am
    pleased to answer questions you subcommittee may have.

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

        Ms. Miller-Meeks. Thank you very much.
        Ranking Member Brownley, you are now recognized for 5
    minutes.
        Ms. Brownley. Thank you, Madam Chair.
        Mr. Retzer, thank you for your testimony and I certainly
    appreciate DAV's support of the VA Marriage and Family
    Therapists Equity Act as well as your support for the Women
    Veterans Cancer Care Coordination Act, which I am coleading
    with Representative Garcia. On the Cancer Care Coordination
    bill, can you sort of elaborate a little bit more? I know you
    did somewhat in your testimony, but can you elaborate a little
    bit more on why this legislation would be beneficial,
    especially in the light of previously enacted legislation, like
    the Making Advances in Mammography and Medical Options for
    Veterans (MAMMO) Act, which expanded veterans' access to high-
    quality breast imaging services, and the Service Act and the
    PACT Act, which expanded access to screening and made breast
    cancer a presumptive condition for veterans who were exposed to
    toxins during their military service?
        Mr. Retzer. This bill is very important to us on a couple
    different facets. As in our written testimony, we outline the
    importance for our women veterans to get specialized care. The
    coordination of care is so important and the challenges that VA
    has with addressing women veterans' special needs, especially
    when we look at, for example, breast cancer prevention. We need
    to ensure that VA, being that their infrastructure is not built
    to sustain all women veterans care at every VA facility, we
    rely on partnerships and affiliates to be able to supply the
    technical and lab work requirements plus the clinical
    specialists that are out there to provide that care.
        Another thing that we saw that was really meaningful in
    this bill with regards to the care coordinators is the impact
    it has with honoring our PACT Act. Now that we have found that
    male veterans who have been exposed to toxic exposures can also
    be, unfortunately, suffering from the same illness of breast
    cancer, we feel that this piece of legislation will open up the
    door to developing good care coordination not only for women
    veterans who suffer with breast cancer, but also for our male
    veterans who have been exposed to toxic exposures. We feel it
    is very important with the research and the clinical findings
    that they work with.
        Ms. Brownley. Thank you for that. Speaking of the PACT Act,
    I mean, I have to ask you with 83,000 folks being laid off or
    fired in the VA and significant cuts to the PACT Act, what
    impacts--I think it is 23 billion cuts to the PACT Act. What
    are the implications?
        Mr. Retzer. What we are hoping for that the administration
    and VA and Congress itself work together in a bipartisan manner
    to ensure that these bills, and they are very thoughtful bills,
    continue to strengthen the VA system and that is the
    infrastructure, staffing, and technology.
        Ms. Brownley. Thank you. Dr. Kozminski, in your testimony
    you briefly discussed the importance of sufficient training and
    strict safety standards and the potential risks faced by
    patients who are seeking hyperbaric oxygen treatment for off-
    label indications, like TBI and PTSD, at health spas. You also
    mentioned the recent tragic explosion of a hyperbaric chamber
    at a facility in Michigan, which killed a 5-year-old child. Dr.
    Murphy's legislation, H.R. 1336, does not seem to include any
    limitations or guardrails on which types of providers veterans
    with TBI or PTSD could receive treatment from under this
    proposed pilot program.
        Do you think we should consider amending it to include
    safeguards such as ensuring that veterans would go to
    institutions that have been accredited by the Undersea and
    Hyperbaric Medical Society or another body? Would you recommend
    other safeguards? The bill literally is like two pages, maybe
    two and a half pages. It is just about funding and having the
    program and starting the program, but no safeguards whatsoever.
        Dr. Kozminski. Frankly, I mean, I do agree that it would be
    best to make sure that whatever treatment they receive, what
    our veterans receive, is done at an accredited facility.
    Amending the bill for that would be probably best for patient
    safety.
        Ms. Brownley. That is it?
        Dr. Kozminski. I am good.
        Ms. Brownley. Thank you. I will yield back.
        Ms. Miller-Meeks. Thank you very much.
        The chair now recognizes Representative King-Hinds for 5
    minutes.
        Ms. King-Hinds. More along the lines of this traumatic
    brain injury treatment option. I guess this is a question for
    Dr. Retzer because it is a policy conversation. Right?
        What additional research or oversight do you suggest or
    recommend is needed basically, that one we could actually
    explore this type of treatment, right, that a lot of folks
    support? How do we ensure balancing the safety of our veterans?
        Mr. Retzer. I think as we see all the research that we see
    and what VA is doing and what NIH is doing, and also the
    Journal of Medicine, we are seeing all these factors that have
    progressed throughout the year, showing from a point of where
    there was an imbalance, where it was not positive, that age
    HBOT was reducing outcomes for traumatic brain injury and PTSD.
    As we started to move through the years, we started to see some
    progress and that is the promise that we are hearing, that we
    are wanting to see that more research. As a resolution-based
    organization, we support research, strongly support
    continuation of VA's research, and also the research partners
    and affiliates out there to ensure that they are looking at
    safe clinical practices, evidence-based methods to ensuring
    that we are providing alternative options of care for our
    veterans.
        Ms. King-Hinds. Okay. Thank you for that. This question is
    also for you. Given the importance of telemedicine in providing
    timely care to veterans, especially those who live in remote
    and underserved communities, like mine, the CNMI, what specific
    safeguards are being considered to ensure that prescriptions
    for controlled substances via telehealth are both safe and
    effective?
        Mr. Retzer. Thank you for that question. With
    pharmaceutical care and trying to address the issues of mental
    health and suicide prevention along with substance use abuse,
    there is a responsibility on VA to ensure when they are
    providing patient care in direct environment or in the
    community care, that there are direct communication, clear
    communications on the treatment processes and what medications
    are given so that the veterans themselves understand being
    informed what those interactions are and what the risk factors
    are and, at the same time, that VA and community are speaking
    directly with themselves.
        For example, my time when I was stationed up in Alaska,
    very remote area, it is very difficult to find clinicians in
    every part of it. When you are dealing with the VA and
    community care and you look at their infrastructure up there,
    it is not built to communicate very directly or well. We hope
    that as we continue with the modernization of electronic health
    record modernization, that is something that will be worked
    very robustly into the system of the pharmaceutical safety
    measures and making sure that patient safety is paramount
    throughout the whole development.
        Ms. King-Hinds. All right, thank you. I yield my time
        Ms. Miller-Meeks. Thank you. The chair now recognizes Dr.
    Morrison for 5 minutes.
        Ms. Morrison. Thank you, Madam Chair. It has been my
    distinct privilege to join in the work that this committee
    leads, ensuring that VA is meeting veterans diverse and
    evolving needs. As a physician myself, I have been part of
    teams that work together to help patients receive the highest
    quality of care and have witnessed firsthand the impact,
    positive impact of building comprehensive care coordination
    that enables effective communication and supports patients
    through their care. With the number of women veterans expected
    to continue growing, obviously we should be proactive in our
    efforts to coordinate care for one of the most pressing health
    issues women veterans face.
        Mr. Retzer, you answered ranking member Brownley's
    question. I am going to direct it to you now, Mr. Dempsey, if I
    may, and thank you for being here today. We have highlighted
    that breast cancer is the most diagnosed cancer for women
    within VA and that we will likely see a rise in the volume of
    cancer care that veterans need. Can you expand a little bit on
    the importance of care coordination for improving health
    outcomes and women veterans overall VA experience?
        Mr. Dempsey. Of course and thank you for the question.
    Thank you additionally for pointing out that breast cancer
    ranks as the second most common cancer among women in the U.S.
    and within VA, it is the most diagnosed cancer. I think for any
    veteran coming through the VA health system, in this case the
    increased volume of female patients that VA sees, it is
    important that patients feel supported with cancer care. In
    particular, where a lot of that care is received in the
    community, it is critically important to make sure that there
    is good coordination between the VA direct care system and
    those community providers. There is no gap in service, whether
    it be transfer of records back and forth, communication between
    the providers to make sure there is gaps in care. I think
    overall just creating a culture where veteran patients feel
    supported by their care providers.
        Ms. Morrison. Thank you. Appreciate that answer. I would
    also like to highlight another health issue that we have
    discussed that affects veterans at 1.5 times greater than
    nonveterans. Suicide rates among servicemembers have risen
    gradually over the decade, with veterans experiencing an
    alarmingly disproportionate rate of suicide by firearm. As the
    wife of a veteran, I find this absolutely heartbreaking.
        While we understand that mental health issues facing our
    veterans do not stem from a single cause, of course, it is
    important that we take any and every path to prevent these
    tragedies and empower veterans to address their mental health
    conditions. Safe firearm storage, education, and resources are
    integral to addressing the elevated risk veterans face for
    firearm suicide.
        With firearms reported to be involved in up to 72 percent
    of veteran suicides, as you noted, Mr. Retzer, the evidence for
    continued support of intervention programs that promote
    potentially life-saving time delays is clear.
        Mr. Retzer, in your testimony you do discuss time and space
    as critical components in preventing suicides. Why is
    approaching suicide prevention through safe firearm storage
    particularly impactful for veterans and their families?
        Mr. Retzer. I can speak as a veteran who owns firearms and
    who suffers with mental health. It is very meaningful to have
    this conversation because it is a responsibility not just of
    the veterans, but to the clinicians and the families integrated
    to understand how to save the veteran and themselves. In our
    testimony we wrote about the community being safe, and that is
    the end goal is to make that community safe, but where it
    starts is that veteran is safe.
        I have gone through the VA process of the clinical side,
    and I wish I was offered a lockbox. I was not. I met all the
    criteria that were actually testified, and I was not given an
    option for the lockbox. The good thing is that VA, throughout
    the process, has been doing and taking steps to ensuring that
    they offer these security measures to our veterans.
        Ms. Morrison. Thank you. The Saving Our Veterans Lives Act
    considered by the committee today includes an education
    element. How do you anticipate the educational component of the
    initiative will work with the resource component of the bill?
        Mr. Retzer. That is a great question and education is
    always very important. That is something we, the veterans, have
    to also own for ourselves, for our responsibilities, something
    that we come from. We come from an environment of being
    educated on how to handle firearms in the military. Hopefully
    that VA will build upon that knowledge that we have and the way
    that we are taught those, so that it relates to us in a manner
    that is meaningful and it also has highlights the importance.
    Education, I think, is going to be very important because it is
    going to open up the dialog for us to talk about something that
    is not always easy to talk about.
        Ms. Morrison. Thank you, Mr. Retzer. The legislative
    efforts considered in today's hearing demonstrate critical
    steps toward delivering the quality care that VHA should
    continuously pursue. I sincerely believe that finding common
    ground on ways to improve VA is a goal that is shared by all of
    my colleagues that sit on this committee.
        In recent weeks, there is been a lot of conversation about
    ramping up efficiency in our government. Every single one of
    the bills we have discussed today would require implementation
    actions that are the responsibility of VA employees. We cannot
    hope to continue to deliver care to our veterans if we throw
    the folks responsible for its delivery into instability and
    uncertainty. We cannot wish for improved access to care if we
    allow the disruption of essential food functions in our VA
    hospitals and facilities. We cannot tell our servicemembers we
    value their well being if we permit critical contracts and
    research initiatives to be slashed.
        I urge my colleagues, particularly those that have
    presented their bills before the committee today, to recognize
    the importance----
        Ms. Miller-Meeks. Your time has expired. I am sorry. We
    have votes that are coming up----
        Ms. Morrison [continuing]. of supporting the workforce.
        Thank you, Madam Chair. I yield back.
        Ms. Miller-Meeks [continuing]. so please wrap-up your time.
        The chair now recognizes Dr. Dexter for 5 minutes.
        Ms. Dexter. Thank you, Madam Chair. Again, thank you to our
    panelists for being here and for the work that you do with our
    veterans.
        As I alluded to earlier, I spent my career in a
    comprehensive coordinated care system very similar to the VA,
    and so I appreciate the ability to really embrace our veterans
    within the system and deliver care. I know that these systems
    work for patients, as you have spoken to, and we have clear
    data that we will submit for the record showing that care
    outcomes and satisfaction for care received inside of the VA is
    superior to outside. We also want to make clear that our
    veterans have access to care and mitigate the need for our
    veterans to be able to access care and have that intervention
    at the moment of impulsivity and despair for our veterans at
    high risk for suicide is critical. Thank you for your support
    for the lockbox display policy. I think that is proven very
    high yield and critical.
        It also is critical that our veterans have time to talk
    with a provider, be able to reach out when they are feeling
    most impulsive and desperate. I believe that is the intention
    with the No Wrong Door Act is to be able to help people at that
    moment. However, I am concerned about our requirement for in-
    person care delivery for mental healthcare and the fact that we
    are not going to allow telemedicine mental health any longer,
    that everyone is going to have to be in person because an
    established care provider is trusted and certainly preferable
    having worked in an emergency room to walking into an emergency
    room and expecting high-quality personalized care.
        Despite the good intentions of the Wrong Door Act, it seems
    to run counter to the principles of a capitated inclusive body.
    I also have concerns about the reauthorization of a program for
    which we have collected good outcome data for only 4 percent of
    the participants.
        I wonder, Mr. Retzer, if you would be willing to share your
    thoughts on when VA led interventions are looking to be most
    impactful for our high-risk suicide patients, do you feel like
    we have sufficient data to be confident that the No Wrong Door
    Act is actually saving lives more than further investing in VA
    comprehensive care and even telehealth mental healthcare?
        Mr. Retzer. Thank you for that question. That is such an
    important issue that we have No Wrong Door Act really addresses
    alternative options where VA cannot do it by themselves. That
    is something that we are very realistic to. With having over 9
    million veterans enrolled in the VA healthcare system and you
    have 2.7 million in the rural, we have to be able to provide
    that type of a resource. When the Compact Act came out and that
    was a great win for Congress and for American veterans to be
    able to get healthcare when they were in acute crisis, that is
    another tool. The No Wrong Door has the potential to do what we
    need to do to provide alternative resources and clinical
    support out in the community where veterans may not be enrolled
    in the healthcare system. I think that is the most Important
    thing is that we do not shut the door on this.
        We continue to see what we can do with this. That is why we
    recommended our recommendations and testimony to be fiscally
    responsible, to make sure that it is not participants that are
    being gauged, and we are not a production of veterans going
    through the shop. We want quality care, the same kind of care
    that we get within the VA system and the wraparound services
    that were actually noted in the bill with regards to ensuring
    that they are going back to VA and being informed about how to
    utilize VA.
        We see promise in there, but we are waiting for the report
    and we hope to see the final report and become public for us to
    be able to make a determination.
        Ms. Dexter. I absolutely share the intentions and the
    suppositions of the bill. I just am concerned about only 4
    percent of output being really looked at for the outcomes. It
    is not a question, it is just I think that compelling data
    before we invest when we have so modest resources available to
    us is important.
        What do you think Congress can be doing better to bolster
    interventions to help prevent suicide, which is at a critical
    crisis point for our veterans right now?
        Mr. Retzer. Thank you for that question. I think like I
    said earlier, it is multifaceted. We have to look at every
    avenue directly within the VA healthcare system, making sure we
    have proper staffing. We have clinical psychologists,
    psychiatry shortages in staffing, but also to support them, we
    have to ensure that the VA staffing itself in general is on
    par.
        For example, if we go to the phone call for the crisis
    line, someone has to be manning that line. If we go to the
    phone to call the public contact office, someone has to be
    there. If we go into a VA medical center, the facility has to
    be cleaned where we have our people who are custodians that
    they are working. All the employees that support their VA, it
    is very important that we look at it.
        The other thing is we need more peer-to-peer. Our veterans
    who work within the VA system, they themselves know what the
    life is like and they have the experience to become peer-to-
    peer counselors or peer-to-peer to be able to mentor through
    us.
        Ms. Dexter. I recognize that I am over time, so thank you
    for your tolerance, Madam Chair. I thank you for your
    testimony.
        Ms. Miller-Meeks. Thank you. The gentlewoman yields.
        The chair now recognizes herself. I was going to recognize
    Dr. Conaway, but he slipped out. Thank you very much.
        Ms. Morris, were there difficulties executing the
    construction of the VA clinic in Omaha, Nebraska, in
    coordination with the VA? If you could improve the CHIP IN
    authorities, what would you suggest if there, in fact, were
    difficulties?
        Ms. Morris. Really did not experience a lot of difficulties
    in construction. If you remember, probably the biggest
    challenge was the last 4 months. COVID hit March 2020, and we
    needed to finish up the project by the end of July in order to
    do the transfer in August. Our construction team and our design
    team worked diligently to be able to get that done on time,
    which is really kind of amazing that that was able to happen at
    that period.
        Ms. Miller-Meeks. Were there certain waivers or exemptions
    that you sought from the VA in order to get construction done
    under budget and under time?
        Ms. Morris. Well, certainly I referenced the construction
    manuals and the security manuals. Those were critical. We
    actually spent a 2-day time period in Omaha, Nebraska, where
    about 15, 20 VA employees came out. We went through those
    manuals with great precision and, at that point in time, we
    were able to have value engineering of about $23 million.
        Ms. Miller-Meeks. Thank you. Dr. Kozminski, many aging
    veterans and those suffering from diabetes-related
    complications sadly receive amputations due to chronic limb
    ischemia. Could HBOT therapies be potential preventive
    treatment for our veterans suffering from those conditions?
        Dr. Kozminski. Just to clarify, so preventative in the
    sense of preventing those infections or preventing----
        Ms. Miller-Meeks. Amputations.
        Dr. Kozminski. Yes. I do think that hyperbaric oxygen
    therapy has been a fairly well proven implementation for
    salvage therapy in those cases for sure.
        Ms. Miller-Meeks. Thank you so much for coming in. Go Hogs.
        Mr. Harries, I understand the difficulties your members are
    experiencing as a result of the VA's inability to reimburse for
    high-cost medications that the patient may have been on prior
    to coming to a facility. VA testified the status quo is okay.
    Do you agree?
        Mr. Harries. No, we do not. The costs of these drugs that
    are coming in are climbing rapidly. The other thing that is
    happening, with the exposure to toxic chemicals that our
    veterans are having, we are having more and more cancer
    diagnoses. Some of these high-cost drugs, or a good portion of
    them, are related to chemotherapy.
        Ms. Miller-Meeks. They, in fact, cover these drugs if the
    patient was at a different facility or at their home.
        Mr. Harries. Correct. You know, looking at it from a cost
    perspective, the average institutional per diem is $262 for
    State veterans home, whereas with the community homes, it is
    $424. If you looked at balancing that out, it may be a net
    neutral event.
        Ms. Miller-Meeks. Thank you. Mr. Dempsey, how could the
    SPORT Act assist post 9-11 veterans?
        Mr. Dempsey. Thank you for the question. The SPORT Act
    would, I think, do a tremendous job of reforming the way that
    amputee veterans engage with the VA prosthetic department.
    Currently, with the limitation that adaptive and support-
    related prosthetics only be provided as part of a clinical
    program, expediting that process and getting these into a
    veteran's life is a great way to re-engage in the community,
    whether it just be participating in athletics, whether it be
    involved in community outings, golf, running, any number of
    activities I think a lot of people take for granted, but which
    could be greatly danced by better access to these prosthetics.
        Ms. Miller-Meeks. Does it seem to you that the VA's current
    status and parameters are geared toward elderly veterans who
    perhaps have amputations from medical conditions, such as
    diabetes, rather than to our younger, much more active post 9-
    11 veterans?
        Mr. Dempsey. Well, thank you for the question. To be
    honest, I do not know that I could speak to that. I would say
    that most of the voices that come to our post 9-11 serving
    generation are those who were injured in the early 2000's for
    whom, you know, getting adaptive prosthetics became part of
    their post-injury life very early. They have become familiar
    with how to use them, how they want them, and so ensuring that
    the process works a bit more smoothly for them is the priority
    here.
        Ms. Miller-Meeks. Thank you. I yield my time.
        Thank you to all of you. Thank you to our witnesses and for
    all your thoughtful input.
        Ranking Member Brownley, I am going to ask if you have any
    closing remarks.
        Ms. Brownley. Thank you, Madam Chair. I just wanted to
    associate myself with Representatives Dexter and Morrison and
    their comments that they have made today. I will just repeat
    what I said in my opening remarks and that I find it a bit
    crazy that we are having a legislative hearing today rather
    than an oversight hearing while the Trump administration's
    careless executive orders, mass firings of VA employees, and
    reckless contract terminations are causing significant upheaval
    within the Veterans Health Administration. As I said earlier,
    none of these bills we are considering today will address the
    very real threat to VA healthcare, to VA access to healthcare,
    quality, and safety that our Nation's veterans are facing
    today.
        Veterans do not support these proposed cuts, nor do they
    support cutting 83,000 employees within the VA. If we continue
    to see efforts to dismantle the VA by firing hardworking
    employees, canceling vital research, terminating healthcare
    contracts, and eroding veterans' trust in VA, it will not
    matter what excellent legislation we put forth. There will not
    be employees or even an infrastructure left at VA to implement
    these bills and veterans care will suffer because of it. We can
    do better than that.
        I yield back.
        Ms. Miller-Meeks. Thank you very much.
        Perhaps it is because I am a physician and a 24-year
    military veteran, married to a 30-year military veteran, that I
    find it completely plausible that we as Members of Congress can
    actually make legislation, go through legislation, in addition
    to respond to things that are happening through other parts of
    the Federal Government as well.
        Let me also say that I just need to address some
    misinformation I have heard here today. Whether it is
    intentional or unintentional, there is a $6 billion increase to
    the Toxic Exposure Fund, not a decrease. Let me repeat that.
    The Toxic Exposure Fund in the Continuing Resolution that we
    may be voting on has a $6 billion increase.
        Let me also say that over the past 4 years the VA's budget
    has increased $240 billion--or has increased from $243 billion
    to $369 billion, an over $126 billion increase, while
    nationally the level of veterans seeking care is level. Is
    level. Of that, in the past 4 years an increase of 60,000 full-
    time employees and 23,000 part-time employees.
        Given my time in the military, I remember as an Operating
    Room (OR) nurse, I will not say what facility I was in, it was
    1:30 in the afternoon. All of the staff, with the exception of
    three of us, and I can see Dr. Kozminski smiling because he
    knows what I am going to say, three of us were back putting
    together the instruments and putting up our instrument sets.
    Everybody else was in the break room. I would say to look at
    how we spend money in the Federal Government, so precisely what
    Ranking Member Brownley has said, so that we can continue to
    have the funds to deliver high-quality care to our veterans in
    a timely fashion, be it at the VA or in community care, is a
    priority for all of us. None of this dismantles or guts or
    defunds the VA or the Toxic Exposure Fund.
        I want to thank our witnesses who have been here today. I
    appreciate your coming and testifying. I want to thank our
    veterans, most importantly who give us the opportunity to be
    here and to vote this afternoon. On behalf of the subcommittee,
    I want to thank you all again, the witnesses, members who are
    here today. I am looking forward to working with you to address
    the issues facing our veterans.
        The complete written statement of today's witnesses will be
    entered into the hearing record. I ask unanimous consent that
    all members have 5 legislative days to revise and extend their
    remarks and include extraneous material. Hearing no objection,
    so ordered.
        This hearing is now adjourned.
        [Whereupon, at 4:20 p.m., the subcommittee was adjourned.]

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

                             A  P  P  E  N  D  I  X

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

                        Prepared Statements of Witnesses

                                  ----------

                      Prepared Statement of Thomas O'Toole
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                       Prepared Statement of Jeffrey Gold
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                        Prepared Statement of Sue Morris

        Good afternoon, Chairwoman Miller-Meeks, Ranking Member Brownley,
    Members of the Health Subcommittee.
        My name is Sue Morris. I am the President of Veterans Trust,
    formerly known as Veterans Ambulatory Center Development Corporation,
    the nonprofit philanthropic entity that partnered with the Department
    of Veterans Affairs under the CHIP-IN Act to construct VA's ambulatory
    care center in Omaha, Nebraska, serving Western Iowa and Nebraska. I
    want to note first that our non-profit entity is led by Veterans. Our
    Chairman, John Henderson, is a retired Army Colonel and our Secretary,
    Mike Pallesen who is with me today, is a retired Navy Commander.
        Our nationally award-winning Ambulatory Care Center project was
    completed and donated to Veterans Affairs in July 2020 as the first
    public-private partnership to be completed under the CHIP-In Act. The
    project received several national awards for health care design and
    construction.
        I am here today to speak in favor of taking the pilot program
    authorized under the CHIP-In Act and making it permanent, as H.R. 217
    would do. Our project showed how VA, in partnership with the private
    sector, can deliver a truly superb facility, in a cost-effective and
    efficient manner.
        What allowed the Omaha project to be successful? First, the project
    was ``owned'' by Veterans Trust during the development and construction
    phases and donated to Veterans Affairs upon completion. While there was
    very close coordination and cooperation between Veterans Trust and VA
    officials at both the national and local levels, it was not a
    ``government construction project''. This structure allowed Veterans
    Trust, whose leadership had a history of facilitating $1 billion on
    local projects, to use local vendors and suppliers in its procurement
    of services and materials, leveraging demonstrated relationships for
    best pricing. We were able to tell our partners in design and
    construction that they will make money on the project, but not a lot of
    money, as this is a community project for the Veterans.
        Second, was a strong commitment from Veterans Affairs senior
    leadership. We met regularly at VA's headquarters, including three
    meetings directly with the Secretary, to ensure project milestones were
    achieved. There was zero scope creep which helped the project to be
    delivered on-time and on-budget. One key factor in this regard was
    Veterans Affairs' willingness to review VA's normally applicable
    construction and physical security standards. We were able to come to
    agreement on which of those standards made sense, resulting in value
    engineered savings of over $23 million.
        In the end, we delivered a facility for a total of $86 million when
    it was originally budgeted at $135 million, saving the taxpayers $50
    million. The private philanthropic contribution to the project was $30
    million.
        Based upon our experience and success with this effort, we
    recommend that H.R. 217 go further than simply making CHIP-In permanent
    but to also consider other changes that will allow the public-private
    partnership structure to provide even greater opportunities to deliver
    best in class facilities to our Veterans while doing so in a way that
    saves taxpayer dollars. In particular, we suggest the following:

          Add the option to construct facilities on land leased to
    VA, not just owned or donated real property.

          Add the ability to use the program for minor
    construction, not just major projects.

          Make clear that the Act applies to more than just
    healthcare but also to construction projects providing other types of
    facilities to Veterans such as housing and community centers.

        In addition to amending the Act itself, we suggest that the
    Subcommittee and staff engage a small group of VA leadership and
    private sector representatives to recommend forward-looking best
    practices and new models for public--private partnerships. My team and
    Board would be pleased to be included in this effort.
        In summary, we wholeheartedly support the effort to make CHIP-In a
    permanent tool to deliver state-of-the-art facilities. The Act allows
    Veterans Affairs the ability to leverage the advantages of private
    sector construction processes to deliver significant cost-savings.
        Thank you again for the opportunity to express our support for H.R.
    217 and further expansion of the CHIP-In Act. We are tremendously proud
    of our role in helping lead in this nationally groundbreaking effort to
    deliver a world-class facility to our Veterans and cost-savings to
    taxpayers.
        I want to add one final point. As Dr. Gold mentioned, there is no
    doubt that a new in-patient facility to replace Omaha's ageing VA
    hospital is sorely needed. Veterans Trust stands ready to partner with
    Veterans Affairs and the University of Nebraska Medical Center to
    assist in designing and constructing a new state-of-the-art facility
    that will better serve the Veteran community in Nebraska and Western
    Iowa while taking advantage of the public-private partnership model
    offered by the CHIP-In Act.
        I am happy to answer any questions that you might have.

                      Prepared Statement of Brian Dempsey

        Chairwoman Miller-Meeks, Ranking Member Brownley, and distinguished
    members of the House Committee on Veterans' Affairs, Subcommittee on
    Health - thank you for the opportunity to submit Wounded Warrior
    Project's views on pending legislation.
        Wounded Warrior Project (WWP) was founded to connect, serve, and
    empower our Nation's wounded, ill, and injured veterans, Service
    members, and their families and caregivers. We are fulfilling this
    mission by providing life-changing programs and services to more than
    227,000 registered post-9/11 warriors and 56,000 of their family
    support members, continually engaging with those we serve, and
    capturing an informed assessment of the challenges this community
    faces. We are pleased to share that perspective for this hearing on
    pending legislation that would likely have a direct impact on many we
    serve.

    Draft legislation: No Wrong Door for Veterans Act

        Launched in 2022, the Department of Veterans' Affairs (VA) Staff
    Sergeant Parker Gordon Fox Suicide Prevention Grant (``Fox Grant'')
    Program is a groundbreaking initiative that empowers community-based
    organizations to provide targeted mental health and crisis intervention
    services to veterans. The program was established through the Commander
    John Scott Hannon Veterans Mental Health Care Improvement Act (P.L.
    116-171 Sec.  201) and facilitated VA's financial support to more than
    80 organizations in Fiscal Year 2024 to provide or coordinate a range
    of suicide prevention programs for veterans and their families.\1\ In
    each year since its implementation, the program has been discussed as a
    key initiative for helping prevent suicide in VA's national suicide
    data report.
    ---------------------------------------------------------------------------
        \1\ Press Release, U.S. Dep't of Vet. Aff., VA Awards $52.5 Million
    in Veteran Suicide Prevention Grants, Announces Key Updates in the
    Fight to End Veteran Suicide (Sep. 2023), https://news.va.gov/press-
    room/va-awards-veteran-suicide-prevention-grants/.
    ---------------------------------------------------------------------------
        The No Wrong Door Act is one of several legislative initiatives to
    renew the Fox Grant pilot program (see S. 2793; S. 5210 (118th Cong.)).
    This specific effort reflects the most comprehensive legislative effort
    to extend the current Fox Grant pilot and includes provisions to make
    clear that prior grant recipients shall not receive preference from VA
    for future grants; to require prior grantees to include evidence of
    services delivered to a ``significant number'' of veterans in
    applications for future Fox grants; to require that VA brief
    ``appropriate personnel'' of each VA medical center within 100 miles of
    a Fox grantee about the Fox grant program in an effort to improve
    coordination; to require Fox grantees to inform veterans receiving Fox
    grant services that they may receive emergent suicide care through VA;
    and to require Fox grantees to use a VA-selected screening protocol
    when using Fox grant funding to provide baseline mental health
    screening.
        The changes outlined above would be welcomed; however, WWP
    encourages the Subcommittee to consider amendments that would lead to
    bipartisan, bicameral support to extend the Fox Grant program with
    enough time to allow for grants to continue to be dispersed to
    community-based grantees at the start of the next fiscal year. We would
    also encourage adoption of language from S. 793 focused on measures and
    metrics.

    Draft legislation: Providing Veterans Essential Medications Act

        State Veterans Homes (SVHs) - state-owned and--operated facilities
    that work in tandem with VA - play an important role in meeting the
    nursing home, domiciliary, and adult day health care needs of veterans
    across the country. While SVHs primarily serve an elderly population,
    the future long-term care needs of post-9/11 veterans can be mitigated
    by addressing critical priorities today. Part of that effort includes
    ensuring that veterans residing in SVHs receive the medical care they
    deserve, particularly access to life-saving and high-cost medications.
        Under current law, VA provides per diem payments to SVHs for each
    eligible veteran receiving nursing home, domiciliary, or adult day
    health care.\2\ For veterans with service-connected disabilities rated
    50 percent or greater, the law requires VA to cover the cost of all
    medications administered by SVHs. However, if the veteran has service-
    connected disabilities rated 70 percent or greater, VA pays a higher
    ``prevailing rate'' to the SVH, but does not pay for any medications,
    even high-cost drugs that can cost upwards of $20,000 a month. These
    medications would otherwise be covered by VA when a veteran is not
    being cared for at an SVH. For example, existing law permits private
    nursing homes to receive VA reimbursement for high-cost medications.
    ---------------------------------------------------------------------------
        \2\ JARED SUSSMAN, CONG. RSCH. SERV., IF11656, STATE VETERANS HOMES
    (2020).
    ---------------------------------------------------------------------------
        The Providing Veterans Essential Medications Act seeks to amend 38
    U.S.C.Sec.  1745(a)(3) to direct VA to either reimburse SVHs for the
    cost of expensive medications or directly provide these medications to
    the facilities. As defined in this bill, medications would be
    considered ``costly'' if their average wholesale price for a 1-month
    supply, plus a 3 percent transaction fee, exceeds 8.5 percent of VA's
    monthly payment to the SVH for the care of the veteran receiving the
    medication.
        Wounded Warrior Project supports the Providing Veterans Essential
    Medications Act. By requiring VA to either reimburse or directly
    provide these essential medications, this legislation would help
    alleviate the financial strain on SVHs, ensuring they can continue to
    offer quality care without risk of budget constraints that limit
    veterans' access to necessary treatments.

    Draft legislation: Veterans Supporting Prosthetics Opportunities and
    Recreational Therapy Act, or Veterans SPORT Act

        The highest priority for amputees requiring prosthetics should be
    improved quality of life. In addition to enabling veterans to live more
    independently and complete activities of daily living, adaptive
    prosthetic devices and equipment can have positive and life-changing
    impacts on a warrior's life through exercise and recreation. WWP has
    witnessed this when assisting warriors through our Adaptive Sports and
    Soldier Ride programs. Adaptive sports equipment empowers warriors to
    engage in modified athletic opportunities designed for their individual
    abilities, resulting in profound improvements to physical and mental
    health.
        VA's current definition of ``medical services'' includes
    ``wheelchairs, artificial limbs, trusses, and similar appliances,'' \3\
    but does not include adaptive prostheses or terminal devices. Although
    VA clinicians work with veterans to identify recreation activities and
    needed adaptive recreation equipment to support a veteran's
    rehabilitation goals, VA will not provide adaptive recreation equipment
    if the purpose of the equipment is to support the veteran's
    participation in an activity for personal enjoyment. Specifically, VA
    regulations only provide adaptive prosthetics and terminal devices for
    sports and other recreational activities for veterans if the device (1)
    is needed to promote, preserve or restore the health of the veteran;
    (2) serves as a direct and active component of the veteran's medical
    treatment and rehabilitation; and (3) does not solely support the
    comfort or convenience of the veteran.\4\ These regulations focus on
    the clinical need for adaptive prosthetics but disregard their
    potential to improve veterans' quality of life.
    ---------------------------------------------------------------------------
        \3\ 38 U.S.C. Sec.  1701(6)(F)(i).
        \4\ 38 C.F.R. Sec.  17.3230(a)(1).
    ---------------------------------------------------------------------------
        If a veteran is interested in adaptive recreation equipment, VA
    regulations require that he or she must use it to support
    rehabilitation goals and, accordingly, must be enrolled in a VA
    rehabilitation program. The necessity to participate in such
    rehabilitation programs can be a deterrent for some veterans who may
    not be able to travel or devote the time required. These programs are
    also repetitive as they require that veterans be retrained to use
    replacement adaptive equipment for which veterans completed
    rehabilitation training in the past. For these reasons, some veterans
    may choose not to obtain or replace adaptive recreation equipment,
    hindering a veteran's ability to maintain an active and healthy
    lifestyle.
        Wounded Warrior Project supports the Veterans SPORT Act, which
    would amend 38 U.S.C. Sec.  1701 to add adaptive prostheses and
    terminal devices for sports and other recreational activities to VA's
    definition of ``medical services.'' The current population of post-9/11
    veterans is young, mobile, and energetic. WWP believes that VA should
    be building an ecosystem of care that is encouraging of such an active
    lifestyle. We recommend that VA authorize adaptive equipment for
    amputees without requiring that they be enrolled in a VA rehabilitative
    program for the profound benefits provided by sports and other
    recreational activities.

    Draft legislation: To direct the Secretary of Veterans Affairs and the
    Comptroller General of the United States to report on certain funding
    shortfalls in the Department of Veterans Affairs

        In July 2024, VA notified Congress about a forecasted $2.8 billion
    shortfall that would prevent the agency from delivering VA benefits to
    veterans at the start of Fiscal Year 2025 (October 1, 2024). VA also
    reported a potential 2025 shortfall of approximately $12 billion for
    its health care system. Those estimates have since been adjusted, as
    the Veterans Benefits Administration (VBA) reported a $5.1 billion
    surplus from Fiscal Year 2024, and the Veterans Health Administration
    (VHA) more recently estimated its 2025 shortfall to be $6.6 billion.
        Wounded Warrior Project is grateful for Congress's action to take
    precautionary steps when it passed the Veterans Benefits Continuity and
    Accountability Supplemental Appropriations Act (P.L. 118-82) to avoid
    any potential harm to veterans through VBA funding challenges. As a new
    budget cycle begins, we appreciate congressional commitment to ensure
    that VHA can meet its solemn obligation to deliver high-quality, timey
    care to veterans throughout 2025 and beyond.

    H.R. 217: CHIP IN for Veterans Act

        In 2016, the Communities Helping Invest through Property and
    Improvements Needed (CHIP IN) for Veterans Act of 2016 (P.L. 114-294)
    became law. It authorized VA to carry out a 5-year pilot program to
    improve and expand its medical facilities by allowing private donors,
    local governments, and other organizations to contribute funding or
    property for VA construction projects. The bill was designed to address
    VA's backlog of construction needs - without solely relying on Federal
    funding - by leveraging community involvement to improve veterans'
    healthcare facilities more efficiently.
        The VA Omaha Ambulatory Care Center was the first project completed
    under the CHIP IN Act for Veterans Act of 2016. The facility, which
    opened in 2020, was successfully built using $56 million in Federal
    funding and $30 million in private donations.\5\ In 2021, the CHIP IN
    pilot program was extended for an additional 5 years through the
    Department of Veterans Affairs Expiring Authorities Act of 2021 (P.L.
    117-42). As of today, many VA construction projects continue to face
    delays and budget challenges. VA's Fiscal Year 2024 Budget in Brief
    estimates that between $106 billion and $129 billion will be needed
    over the next 10 years to maintain and enhance VA infrastructure.
    ---------------------------------------------------------------------------
        \5\ Marc Thomas, U.S. Dep't of Vet. Aff., Redefining Healthcare
    Spaces: The ACC Wins the AIA National Design Award (Nov. 29, 2023),
    https://www.va.gov/nebraska-western-iowa-health-care/stories/
    redefining-healthcare-spaces-the-acc-wins-the-aia-national-design-
    award/.
    ---------------------------------------------------------------------------
        The CHIP IN for Veterans Act would permanently authorize the
    program, allowing VA to accept private donations to help fund new
    construction and facility improvements. It would also remove the limit
    on the number of donations that VA may accept under the program. The
    CHIP IN for Veterans Act would expand the ability of local communities
    and organizations to invest in and directly support VA medical center
    projects to accelerate the development of VA infrastructure, make these
    projects more affordable, and increase transparency.
        Wounded Warrior Project supports the CHIP IN for Veterans Act.

    H.R. 1107: Protecting Veteran Access to Telemedicine Services Act of
    2025

        In 2008, the Ryan Haight Online Pharmacy Consumer Protection Act
    (P.L. 110-425) became law and required patients to complete at least
    one in-person visit with a health care provider before that provider
    could prescribe them a controlled substance. In consideration of the
    COVID-19 public health emergency, this requirement was temporarily
    suspended in March 2020. In November 2024, both the Drug Enforcement
    Agency (DEA) as well as the Department of Health and Human Services
    (HHS) agreed to continue this temporary suspension until December 31,
    2025.\6\ The Protecting Veteran Access to Telemedicine Services Act of
    2025 would make this exemption permanent for veterans and VA providers
    by authorizing the delivery, distribution, and dispensing of controlled
    substances to veterans from VA providers without requiring an in-person
    appointment.
    ---------------------------------------------------------------------------
        \6\ Third Temporary Extension of COVID-19 Telemedicine
    Flexibilities for Prescription of Controlled Medications, 89 Fed. Reg.
    91,253 (Nov. 19, 2024) (codified at 21 C.F.R. pt. 1307).
    ---------------------------------------------------------------------------
        If the current COVID-era extension expires, rural veterans who do
    not live near VA or community health care facilities - and who rely
    primarily on telehealth services - would likely be negatively impacted.
    Appointment coordination challenges and travel logistics may lead to
    interruptions in their care or lapses in prescriptions. The list of
    controlled substances contains not only pain medications, but also
    multiple mental health drugs that are important parts of treatment
    plans for many veterans dealing with mental health issues and for whom
    an in-person appointment may present additional challenges.
        Many veterans who began treatment plans that included controlled
    substance prescriptions during the period of this exemption may not be
    aware of, or prepared for, the potential interruptions of their care
    plan. For instance, the PACT Act (P.L. 117-168), the most comprehensive
    authorization of VA benefits in recent history, became law in August
    2022 while this exemption was in place. More than 1.5 million PACT Act-
    related claims have since been granted by VA,\7\ meaning that none of
    those veterans have been subject to pre-exemption requirements. This
    dramatically increases the number of veterans who could have their
    current treatment plan impacted by the expiration of this exemption.
    ---------------------------------------------------------------------------
        \7\ U.S. DEP'T OF VET. AFF., PACT ACT PERFORMANCE DASHBOARD (Feb.
    21, 2025), https://department.va.gov/pactdata/interactive-dashboard/.
    ---------------------------------------------------------------------------
        Wounded Warrior Project supports this bill in its current form;
    however, we recognize that laws surrounding in-person visits may be
    brought back to scale as we move further away from the COVID-19 public
    health emergency. In such a case, we would also support a modified
    version of this legislation that would authorize the renewal of
    controlled substance prescriptions written for veterans when the
    exemption was in place - and who are still seeing the same provider who
    issued the prescription - to help prevent unexpected disruptions of
    veteran treatment plans.

    H.R. 1336: Veterans National Traumatic Brain Injury Treatment Act

        The prevalence of PTSD and TBI among post-9/11 veterans remains
    alarmingly high. WWP's 2025 Warrior Survey \8\ revealed that more than
    3 in 4 responding warriors (76.5 percent) self-reported having PTSD and
    approximately half (52.3 percent) of those respondents screened
    positive for PTSD symptoms using the PCL-5 test.\9\ Another 35.2
    percent self-reported a TBI incurred during military service. As we
    continue to learn more about these invisible wounds and their
    prognosis, investments in research and treatment now and into the
    future must embrace innovation - and VA has an important role in
    leading those efforts.
    ---------------------------------------------------------------------------
        \8\ To review WWP's Warrior Survey in more detail, please visit
    https://www.woundedwarriorproject.org/mission/warrior-survey.
        \9\ The PCL-5 is a validated tool used by VA that assesses symptoms
    over the past month.
    ---------------------------------------------------------------------------
        Hyperbaric oxygen therapy treatments involve a patient entering a
    special chamber where they breathe pure oxygen in air pressure levels
    1.5 to 3 times higher than average. This helps fill the blood with
    enough oxygen to repair brain tissue and restore normal body function.
    Currently this treatment is approved by the Food and Drug
    Administration (FDA) for treatment of inflammation in the body, and
    some doctors believe that both TBI and PTSD are the result of brain
    inflammation due to trauma. While some research recommends caution when
    administering HBOT treatment to individuals with PTSD, results are
    generally encouraging. \10\
    ---------------------------------------------------------------------------
        \10\ Keren Doenyas-Barak et al., The Use of Hyperbaric Oxygen for
    Veterans with PTSD: Basic Physiology and Current Available Clinical
    Data, FRONT NEUROSCI.(Oct. 2023), available at https://
    www.frontiersin.org/journals/neuroscience/articles/10.3389/
    fnins.2023.1259473/full.
    ---------------------------------------------------------------------------
        The Veterans National Traumatic Brain Injury Treatment Act would
    establish a 5-year pilot program at VA to supply hyperbaric oxygen
    therapy (HBOT) to veterans with traumatic brain injuries (TBI) or post-
    traumatic stress disorder (PTSD). The pilot program would be funded
    through a general fund of the Treasury, known as the ``VA HBOT Fund''
    that is supplied solely by donations received for express purposes of
    the Fund. The effort would be implemented in three Veteran Integrated
    Service Networks (VISNs).
        Given these early signs of promise and frequent requests heard from
    warriors for access to HBOT, WWP supports the Veterans National
    Traumatic Brain Injury Treatment Act. If expanded to include reporting
    requirements on clinical outcomes and impact on health care access, we
    believe that this pilot has potential to contribute to the growing body
    of research and longitudinal studies on innovative treatments for TBI
    and PTSD.

    Draft legislation: Saving Our Veterans Lives Act

        Gun lockers, also known as firearm storage safes or cabinets, can
    play a significant role in reducing the risk of suicide by limiting
    access to firearms, particularly in moments of crisis. Increasing space
    and time between an individual and lethal means can create
    opportunities for interventions by another or through personally driven
    changes in thought. Many empirical studies have demonstrated that
    creating time and space between an individual and lethal means is
    effective in preventing suicide, and although some individuals might
    seek other methods, many do not.\11\ In such cases, the means chosen
    are often less lethal and are associated with fewer deaths than when
    more dangerous ones are available. In a veterans context, research like
    this helped drive the PREVENTS Task Force to recommend ``increase[d]
    implementation of programs focused on lethal means safety (e.g.,
    voluntary reduction of access to lethal means by individuals in crisis,
    free/inexpensive and easy/safe storage options).'' \12\
    ---------------------------------------------------------------------------
        \11\ See, e.g., Paul Yip et al., Means Restriction for Suicide
    Prevention, 379(9834) THE LANCET 2,393-99 (June 2012), available at
    https://www.thelancet.com/journals/lancet/article/PIIS0140-
    6736(12)60521-2/abstract.
        \12\ PREVENTS TASK FORCE, PREVENTS: THE PRESIDENT'S ROADMAP TO
    EMPOWER VETERANS AND END A NATIONAL TRAGEDY OF VETERAN SUICIDE (June
    2020), available at https://www.va.gov/PREVENTS/docs/PRE-007-The-
    PREVENTS-Roadmap-1-2_508.pdf.
    ---------------------------------------------------------------------------
        The Saving Our Veterans Lives Act would create a new program to
    provide veterans with lock boxes intended for the secure storage of a
    firearm. It would authorize $5 million per year over a 10-year period
    for VA to carry out this program while also requiring an annual report
    that addresses topics including compliance with the new statute,
    outreach to veterans, obstacles with implementation, and how many lock
    boxes were distributed. The bill makes clear that VA would not be
    permitted to collect personally identifiable information on veterans
    who request a lockbox under the program, require mandatory storage,
    require firearm registration, or prohibit participating veterans from
    purchasing, owning, or possessing a firearm.
        This effort would build upon existing efforts at VA to distribute
    free firearm cable locks to any veteran who requests one, as well as
    more limited availability of gun lockers. As our Nation continues to
    explore new investments and opportunities to end veteran suicide, WWP
    supports the Saving Our Veterans Lives Act.

    Draft legislation: Women Veterans Cancer Care Coordination Act

        Breast cancer ranks as the second most common cancer among women in
    the U.S., and within VA, it is the most diagnosed cancer for women.\13\
    The trend may continue as the recently passed Dr. Kate Hendricks Thomas
    SERVICE Act (P.L. 117-133) allows veterans who served in certain combat
    locations and periods to receive services to check their risk of breast
    cancer and get a screening mammogram if needed. And as the number of
    women veterans continues to increase \14\, VA will likely see a rise in
    the number of female veterans needing cancer care in the coming years.
    ---------------------------------------------------------------------------
        \13\  How Common is Breast Cancer?, AM. CANCER SOC'Y, https://
    www.cancer.org/cancer/types/breast-cancer/about/how-common-is-breast-
    cancer.html (last visited Mar. 7, 2025).
        \14\ Katherine Schaeffer, The Changing Face of America's Veteran
    Population, PEW RESEARCH CTR. (Nov. 8, 2023), https://
    www.pewresearch.org/short-reads/2023/11/08/the-changing-face-of-
    americas-veteran-population/.
    ---------------------------------------------------------------------------
        In its most recent annual budget submission to Congress \15\, VA
    stated that its ``policy requires that facilities have personnel
    assigned to breast and cervical cancer care coordination. To ensure
    accuracy, timeliness and reliability, VA tracks the provision of breast
    and cervical cancer screening and the availability of breast and
    cervical cancer care coordinators across the system.'' The submission
    further elaborated that ``[t]he Breast and Gynecologic Cancer System of
    Excellence is providing state-of-the-art breast and gynecologic cancer
    care and care coordination across the system through VA's tele-oncology
    program.''
    ---------------------------------------------------------------------------
        \15\ U.S. DEP'T OF VET. AFF., Fiscal Year 2025 BUDGET SUBMISSION -
    MEDICAL PROGRAMS, VOL. 2 OF 5 at VHA-23.
    ---------------------------------------------------------------------------
        The Women Veterans Cancer Care Coordination Act would build upon
    this foundation by requiring VA to appoint a Regional Breast Cancer and
    Gynecologic Cancer Care Coordinator in each Veterans Integrated
    Services Network (VISN). These coordinators will report directly to the
    Director of the Breast and Gynecologic Oncology System of Excellence.
    The bill sets eligibility standards for patients to receive care
    coordination through a Regional Coordinator and sets several
    responsibilities for those coordinators including ensuring seamless
    care coordination between VA clinicians and community care providers
    specializing in breast and gynecologic cancers and maintaining regular
    contact with veterans based on individual medical needs during
    community care treatments. Notably, the bill would also require VA to
    submit a report to Congress comparing health outcomes between veterans
    receiving cancer care at VA facilities and those treated by non-VA
    providers, evaluating necessary changes or resources to improve cancer
    care coordination, and addressing any other relevant matters.
        Wounded Warrior Project is pleased to support the Women Veterans
    Cancer Care Coordination Act; however, we look forward to increased
    dialog among stakeholders to ensure that existing efforts at VA are
    enhanced and not duplicated.

    Agenda items not addressed in this Statement for the Record

          Draft legislation: Standardizing Treatment and Referral
    Times Act

          Draft legislation: Copay Fairness for Veterans Act

          H.R. 658: To amend title 38, United States Code, to
    establish qualifications for the appointment of a person as a marriage
    and family therapist, qualified to provide clinical supervision, in the
    Veterans Health Administration

    Concluding Remarks

        Wounded Warrior Project once again extends our thanks to the
    Subcommittee on Health for its continued dedication to our Nation's
    veterans. Our commitment to keeping the promise by rebuilding the lives
    of warriors impacted by war and military service remains as strong as
    ever, and we are honored to contribute our voice to your discussion
    about pending legislation. As your partner in advocating for these and
    other critical issues, we stand ready to assist and look forward to our
    continued collaboration.

                     Prepared Statement of Andrew Kozminski
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                        Prepared Statement of Ed Harries
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                        Prepared Statement of Jon Retzer

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

        Thank you for inviting DAV (Disabled American Veterans) to testify
    at today's legislative hearing of the Subcommittee on Health. DAV is a
    congressionally chartered non-profit veterans service organization
    composed of nearly one million wartime service-disabled veterans. Our
    single purpose is to empower veterans to lead high-quality lives with
    respect and dignity.
        It is crucial to provide timely, coordinated, and comprehensive
    health care tailored to meet the diverse needs of veterans. DAV is
    pleased to offer our views on the bills under consideration today by
    the Subcommittee. These bills address the necessity for timely access
    to medical services, infrastructure improvements, the removal of
    financial barriers, better understanding of health outcomes, the
    incorporation of adaptive sports prosthetics, hyperbaric oxygen
    therapy, secure firearm storage programs and effective care
    coordination.

         H.R. 217, the Communities Helping Invest through Property and
                Improvements Needed or CHIP IN for Veterans Act

        The CHIP IN for Veterans Act includes provisions that would make
    permanent a pilot program that authorized the Department of Veterans
    Affairs (VA) to accept donated facilities or donations to make facility
    infrastructure improvements. This legislation would eliminate the cap
    on the number of projects allowed in the pilot program and enhance the
    quality and availability of veteran services without additional Federal
    costs. For example, in Omaha, Nebraska, there was a project/donation
    for construction of an ambulatory care center and in Tulsa, Oklahoma a
    project/donation to construct an inpatient facility and parking garage
    to support the Muskogee Veterans Affairs Medical Center (VAMC). In
    2021, VA received $120 million for a capital contribution to execute
    the Muskogee plan. These collaborations lead to improved access to care
    and services for veterans, while fostering community support and
    involvement.
        We support the CHIP IN for Veterans Act in accordance with DAV
    Resolution No. 193, urging necessary infrastructure funding and
    exploring new funding models.

     H.R. 658, to establish qualifications for the appointment of a person
       as a marriage and family therapist, qualified to provide clinical
               supervision, in the Veterans Health Administration

        H.R. 658 seeks to establish qualifications for marriage and family
    therapists (MFTs) providing clinical supervision within the Veterans
    Health Administration (VHA). The bill aims to enhance mental health
    services for veterans and maintain consistent care across VHA
    facilities by ensuring that MFTs are highly qualified and recognized by
    reputable organizations like the American Association for Marriage and
    Family Therapy.
        Veterans face numerous mental health challenges, including post-
    traumatic stress disorder (PTSD), depression, anxiety, substance use
    disorders, and traumatic brain injuries (TBI). Qualified MFTs can
    significantly improve mental health outcomes by providing effective
    supervision and promoting better therapeutic practices, potentially
    reducing the incidence of suicide among veterans. Including family and
    relationships in mental health treatment is crucial for the holistic
    well-being of veterans. Many veterans have found that involving their
    loved ones in therapy sessions helps create a better support system,
    and fosters improved understanding and communication. This approach can
    lead to more effective treatment, as the support from family members
    can reinforce coping strategies and provide a sense of belonging and
    stability.
        We support this bill in accordance with DAV Resolution No. 224,
    which calls for program improvements, sufficient staffing, and enhanced
    resources for VA mental health services.

     H.R. 1107, the Protecting Veteran Access to Telemedicine Services Act
                                    of 2025

        The Protecting Veteran Access to Telemedicine Services Act is a
    crucial step toward ensuring that veterans receive the high-quality,
    accessible health care they earned. Many veterans face challenges in
    accessing timely and consistent medical care, particularly in rural and
    underserved areas. This legislation addresses these challenges by
    leveraging the power of telemedicine to provide controlled medications
    to veterans without the need for in-person medical visits.
        Telemedicine bridges the gap for veterans living in remote
    locations, allowing them to receive necessary medications and
    consultations from home. This convenience is particularly beneficial
    for those with mobility issues or limited transportation options.
    Additionally, the flexibility of telemedicine allows veterans to
    schedule appointments that fit their busy lives, leading to better
    adherence to treatment plans and improved health outcomes. The bill
    would ensure that health care providers can maintain regular contact
    with patients, providing continuous care and preventing interruptions
    in treatment, which is vital for managing chronic conditions.
    Telemedicine is also a game-changer for mental health services, helping
    to reduce the stigma and barriers often associated with seeking help by
    providing therapy and support remotely. Finally, the bill includes
    robust guidelines and processes to ensure that the delivery and
    dispensing of controlled substances via telemedicine is safe and legal,
    maintains integrity of the health care system and patient safety while
    expanding access to care for veteran patients.
        We support this bill in accordance with DAV Resolution No. 342,
    which urges the VA to enhance its national pain management program
    using patient-centered, interdisciplinary, and holistic approaches,
    ensuring timely medication delivery and humane alternatives to
    controlled substances. It also encourages the VA to regularly update
    its clinical guidance and policies to comply with Federal law and best
    practices for prescribing and dispensing controlled substances. By
    harnessing the power of telemedicine, we can provide veterans with the
    accessible, efficient, and high-quality care they deserve.

     H.R. 1336, the Veterans National Traumatic Brain Injury Treatment Act

        The Veterans National Traumatic Brain Injury Treatment Act would
    require the VA to establish a pilot program to provide hyperbaric
    oxygen therapy (HBOT) to veterans suffering from TBI or PTSD.
        Veterans with TBI and PTSD face significant challenges, and
    traditional treatments have proven ineffective for some. Studies have
    shown that HBOT, which involves breathing pure oxygen in a pressurized
    chamber, can enhance the body's natural healing processes. This
    therapy, traditionally used for treating severe wounds that won't heal,
    has been found to promote the growth of new blood vessels, reduce
    inflammation, and improve oxygen delivery to injured tissues. One small
    clinical trial, published in the Journal of Clinical Psychiatry (JCP)
    in 2024, has also demonstrated improvements in PTSD symptoms and brain
    function among veterans undergoing HBOT.
        However, despite these promising findings, more comprehensive
    research is necessary to fully understand the efficacy and safety of
    HBOT for patients with TBI and PTSD. According to the VA, the
    scientific evidence is currently mixed, and rigorous, larger-scale
    studies are recommended to validate the initial positive outcomes noted
    in the 2024 JCP study and to address any potential risks. A 2018 report
    by the VA's Evidence Synthesis Program found that large treatment
    benefits demonstrated in uncontrolled case series have not been easily
    replicated in well-controlled randomized controlled trials (RCTs). The
    report suggests that the potential benefits of HBOT may be subtle and
    require larger RCTs to demonstrate significant effects.
        Currently, the VA offers HBOT as a treatment option for a small
    number of veterans with persistent PTSD symptoms that are resistant to
    standard treatments. This treatment is provided through partnerships
    with HBOT providers at select VA health care systems and medical
    centers. The VA is also conducting a multisite research study to
    examine the use of HBOT for patients diagnosed with PTSD.
        While HBOT shows promise, we must remain committed to a
    comprehensive and evidence-based approach. By supporting further
    research and careful evaluation, we can better ensure that our veterans
    receive the best possible and most effective care for TBI and PTSD. We
    therefore recommend the Subcommittee include provisions in this bill to
    prioritize rigorous research alongside providing veterans access to
    HBOT. It is important to thoroughly validate and understand the
    efficacy and risks of this therapy as an alternative treatment option
    for PTSD and TBI before it is more broadly implemented.

                 H.R. 1644, the Copay Fairness for Veterans Act

        The Copay Fairness for Veterans Act aims to eliminate copayments
    for medications and preventive health services provided by the VA. It
    would enhance access to these services by removing financial barriers
    that can discourage veterans from seeking essential care. Preventive
    services are critical for early detection and management of certain
    health issues, leading to improved health outcomes. The bill also
    includes provisions for women veterans to ensure they receive
    preventative care services, screenings and contraceptives as outlined
    in the Health Resources and Services Administration Preventative
    Services Guidelines.
        By removing financial barriers, the bill encourages routine check-
    ups, vaccinations and critical screenings, leading to better overall
    health management and fewer emergency medical situations. Many
    veterans, especially those on fixed incomes, struggle with copayments
    for health services and medication. By removing required copayments,
    the bill provides much-needed financial relief, ensuring that veterans
    can access the care they need without worrying about additional costs.
    Moreover, promoting preventive care can lead to long-term cost savings
    for both veterans and the health care system by reducing the need for
    more expensive treatments and hospitalizations. Preventive services
    with an ``A'' or ``B'' rating from the United States Preventive
    Services Task Force and immunizations recommended by the Advisory
    Committee on Immunization Practices are essential components of this
    approach.
        We support this bill in accordance with DAV Resolution No. 246,
    which calls for legislation to eliminate or reduce VA and DOD health
    care out-of-pocket costs for service-connected disabled veterans to
    improve health care access, provide financial relief, enhance health
    equity and encourage routine care. This bill reflects our Nation's
    commitment to supporting our veterans and ensuring they receive the
    care they earned.

     H.R. 1823, to direct the VA Secretary and the Comptroller General of
      the United States to report on certain funding shortfalls in the VA

        This bill seeks to address funding shortfalls in the VA by
    directing the VA Secretary and the Comptroller General of the United
    States to conduct thorough reviews and report on funding shortfalls.
        The bill specifically mandates a review by the Comptroller General
    to investigate the circumstances and causes of funding shortfalls in
    the Veterans Benefits Administration (VBA) for Fiscal Year 2024 and the
    VHA for Fiscal Year 2025. The review must include a comparison of
    monthly obligations and expenditures against the spending plan, an
    analysis of any transfers between accounts, an evaluation of reasons
    for significant diversions from the spending plan, an assessment of the
    accuracy of projections and estimates, and recommendations for remedial
    actions to improve accuracy and prevent future shortfalls. The
    Comptroller General would be required to submit a report to the VA
    Secretary, who will then submit the report to the specified
    congressional committees.
        By identifying and addressing funding shortfalls, the bill aims to
    improve the financial management of the VBA and VHA and establish more
    efficient use of resources and better allocation of funds to critical
    services. The goal of the bill is to improve financial management,
    enhance accountability, establish preventive measures, and ensure more
    timely reporting of projected budget shortfalls. The bill also requires
    thorough reviews and reports aimed at increasing accountability within
    the VA and promoting more transparent and responsible budget management
    practices. The identification of remedial actions may help prevent
    future funding shortfalls, ensuring uninterrupted services for
    veterans.
        We support this bill in accordance with DAV Resolutions Nos. 23 and
    403, advocating for consistent VA funding, full implementation of
    existing laws, and protection of veterans' services and health care
    from budget caps.

           H.R. 1860, the Women Veterans Cancer Care Coordination Act

        The Women Veterans Cancer Care Coordination Act seeks to
    revolutionize cancer care for women veterans by establishing a
    comprehensive support system. The bill mandates the designation of
    Regional Breast and Gynecologic Cancer Care Coordinators within each
    Veteran Integrated Services Network (VISN). These coordinators would be
    tasked with ensuring seamless communication and coordination between VA
    clinicians and community cancer care providers.
        Eligibility for care coordination would be extended to veterans
    diagnosed with breast or gynecologic cancer or those identified with
    precancerous conditions, provided they qualify for health care through
    the Veterans Community Care Program (VCCP). Additionally, the bill
    would require the establishment of regions for care coordination, to
    determine the specific needs of veterans in different areas, including
    rural communities. This regional approach aims to provide tailored
    support, ensuring that veterans receive timely and appropriate care
    regardless of their location.
        The prescribed duties of the Regional Breast and Gynecologic Cancer
    Care Coordinators are multifaceted. They would facilitate the
    coordination of care between VA clinicians and community care
    providers, ensuring that veterans receive consistent and comprehensive
    treatment. They would be responsible for monitoring the services
    provided, tracking health outcomes, and maintaining data on cancer
    care. This data--driven approach will help identify trends, measure
    effectiveness, and guide future improvements in care delivery.
        A significant component of the bill is the requirement for the VA
    Secretary to submit a detailed report to Congress within 3 years of
    enactment. This report would compare health outcomes between veterans
    treated at VA facilities and those treated by community providers. It
    would assess the timeliness, safety, and quality of care, and identify
    any necessary changes or additional resources needed to enhance cancer
    care for women veterans. By establishing dedicated coordinators,
    focusing on data-driven care, and providing essential information and
    support, the bill strives to improve health outcomes and quality of
    life for these veterans and to ensure they receive coordinated,
    comprehensive, and compassionate care.
        The bill would also help to ensure that male veterans who suffer
    from breast cancer due to toxic exposures receive the same specialized
    care as their female counterparts. The Honoring our PACT Act, signed
    into law in August 2022 (P.L. 117-168), expands and extends eligibility
    for VA health care for veterans with toxic exposures. This includes
    male veterans who have been diagnosed with breast cancer.
        The VA has recognized the need to address the health effects of
    toxic exposures and has included male breast cancer in the list of
    conditions presumed to be caused by military service. Male veterans who
    have been exposed to toxic substances during their service and have
    developed breast cancer are eligible for the same benefits and
    specialized care as female veterans.
        We support this bill in accordance with DAV Resolution 39, which
    calls for ensuring that the VA provides health care services and
    specialized programs, including gender-specific services, to eligible
    women veterans at the same degree and extent as services provided to
    male veterans. It also emphasizes improving women's health programs and
    finding innovative methods to address care barriers, ensuring women
    veterans receive quality treatment and specialized services.

             Draft Bill, the Saving Our Veterans Lives Act of 2025

        The Saving Our Veterans Lives Act of 2025 aims to prevent veteran
    suicide by providing eligible veterans with secure firearm storage
    items upon request. The alarming rate of veteran suicide is a stark
    reminder of the urgent need for comprehensive measures to protect those
    who have sacrificed so much for our country. According to the VA 2024
    National Veteran Suicide Prevention Annual Report, there were 6,407
    suicides among veterans in 2022, with firearms being involved in 72
    percent of these cases. Firearms are the primary method of suicide
    among veterans, and by providing secure storage options for firearms--
    such as a lockbox or safe, this Act aims to reduce access to lethal
    means during moments of crisis, potentially saving countless lives.
        Creating time and space is a critical component of this Act's
    strategy to reduce veteran suicides. Providing veterans with secure
    firearm storage can create a critical time delay, allowing them to
    reconsider their actions and seek help during moments of crisis. This
    additional time can be a lifesaving interval, as it provides a window
    of opportunity for the veteran to reach out for support, contact the
    crisis hotline, or have a moment of reflection. The VA's 2024 suicide
    prevention report highlighted a reduction in suicide rates among
    veterans with VHA mental health diagnoses, underscoring the
    effectiveness of targeted suicide prevention efforts. By delaying
    access to firearms during a crisis period, the Act empowers veterans to
    make safer choices and access the help they need.
        The Act includes an educational component that would help inform
    veterans about the benefits of secure firearm lock box storage with a
    goal of more responsible firearm handling and storage practices. The
    development of informational videos would help ensure that veterans
    receive the necessary guidance on secure storage as a suicide
    prevention strategy. Proper firearm storage not only protects veterans
    but also their families, reducing the risk of accidental discharges and
    unauthorized access by children or other household members. This
    program aims to promote a culture of safety within the veteran's
    community, fostering a secure environment for all.
        We support this bill in accordance with DAV Resolution No. 224,
    which calls for mental health and suicide prevention program
    improvements to include suicide rate data collection and reporting,
    improved outreach for stigma reduction, sufficient mental health
    staffing, and enhanced resources for VA mental health programs.

                 Draft Bill, the No Wrong Door for Veterans Act

        The No Wrong Door for Veterans Act would reauthorize and extend the
    Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program
    through September 30, 2028, ensuring that community-based suicide
    prevention initiatives and mental health services will continue to be
    available to veterans.
        By adjusting the grant amount and clarifying the criteria for
    eligible entities, the bill promotes equitable distribution of funds
    and aims to ensure that qualified organizations can provide high-
    quality mental health services to veterans. Moreover, the bill's
    emphasis on improved coordination and communication between grantees
    and VA medical centers is a significant enhancement. Quarterly
    briefings for local VA medical center personnel will help facilitate
    better collaboration and information sharing, hopefully leading to more
    efficient and effective delivery of mental health services. This
    improved coordination is crucial for creating a seamless support
    network for veterans in crisis.
        Another critical provision in the legislation is the bill's
    requirement that grantees notify eligible individuals about emergent
    suicide care options and report requests for such care to the VA.
    Increased awareness and utilization of suicide prevention resources can
    lead to more timely intervention and potentially save lives. By
    requiring the use of screening protocols selected by the Secretary, the
    bill also ensures that veterans receive consistent and standardized
    care, further enhancing the quality of mental health services.
        While the intent of extending the Fox Suicide Prevention Grant
    Program is commendable, DAV recommends strengthening the proposed
    legislation to ensure it meets its primary objective--reducing risk of
    suicide in this population. We recommend the bill reiterate the
    standard of baseline mental health screening that all grantees must
    provide or coordinate the provision of a baseline mental health
    screening to all eligible individuals they serve at the time those
    services begin. This mental health screening must be provided using a
    validated screening tool that assesses suicide risk and mental and
    behavioral health conditions. Applicants or partner organizations must
    measure the effectiveness of suicide prevention services provided to
    eligible individuals and their families using pre-and post-evaluations
    that employ validated measures of suicide risk and mood-related
    symptoms.
        Additionally, funding criteria in the bill is associated with the
    number of participants served rather than prioritizing demonstrated
    improvements in veterans' well-being (i.e., reduction in suicide risk
    factors). We want to ensure that resources are directed to programs
    that achieve measurable outcomes. Finally, we suggest the payment
    structure be more clearly defined to prevent overcompensation for
    minimal services.
        Given that the funding renewal for this initiative was supposed to
    be based on demonstrated improvements in veterans evaluation measures,
    we recommend a cautious, annual renewal process until comprehensive
    data confirms the program's overall efficacy and specifically, which
    services are most effective in reducing suicide risk in the veteran
    population. These changes are essential to maximize the program's
    potential and truly support at-risk veterans.

          Draft Bill, the Providing Veterans Essential Medications Act

        The Providing Veterans Essential Medications Act would amend title
    38, United States Code, to ensure that veterans receiving nursing home
    care in State homes have access to necessary, yet costly, medications.
        Under this bill, the VA Secretary is directed to either reimburse
    State homes for these high-cost medications or furnish them directly,
    at the election of the State home. The bill defines ``costly
    medication'' as any drug or medicine whose average wholesale price for
    a 1-month supply, plus a transaction fee, exceeds 8.5 percent of the
    payment made by the Secretary for the veteran's care. This amendment
    seeks to alleviate the financial burden on State homes and ensure that
    veterans continue to receive appropriate and comprehensive care without
    the added stress of high medication costs.
        The cost of high-cost medications, such as revolutionary cancer
    drugs, can often exceed $1,000 a day. This bill will ensure that State
    homes are not financially strained by these costs. VA providing these
    types of medications also incentivizes more State homes to provide care
    for severely disabled veterans and increases the availability of high-
    quality long-term care services across the country. The PACT Act has
    led to an increase in veterans adjudicated as severely disabled due to
    toxic exposure. This rise will more likely than not necessitate State
    Veterans Homes to provide high-cost medications to more veterans. As
    the number of veterans requiring specialized and expensive medications
    grows, State Veterans Homes will face increased financial strain. It is
    essential to ensure that these homes receive adequate funding and
    support to meet the rising demand for care. This bill will help address
    the growing demand for high-cost medications in State homes and ensure
    that all veterans receive the health care they earned.
        We support this bill in accordance with DAV Resolution No. 227,
    which calls on Congress and the VA to provide sufficient funding to
    support State Veterans Homes, including adequate per diem payments for
    skilled nursing care, domiciliary care and adult day health care, which
    properly support different levels of care within each program.

      Draft Bill, to establish the period during which the referral of a
     veteran, made by a health care provider of the Department of Veterans
    Affairs, to a non-Department provider, for care under the VA Community
                          Care Program, remains valid.

        This bill seeks to streamline the referral process for community
    services, reduce administrative barriers, and improve access to care.
    The bill's primary objective is to establish the period during which a
    referral of a veteran, made by a health care provider of the VA, to a
    non-Department provider remains valid under the VCCP. The bill
    specifies that this period begins on the day the covered veteran has
    their first appointment with the non-Department provider. This
    provision would ensure veterans referred to non-Department providers
    have a clear referral validity period, facilitating smoother
    transitions.
        We support this bill in accordance to DAV Resolution No. 18, which
    supports legislation that establishes clearly defined VA health care
    services for enrolled veterans.

       Draft Bill, the Veterans Supporting Prosthetics Opportunities and
                       Recreational Therapy or SPORT Act

        The DAV has long recognized the importance of adaptive sports in
    the rehabilitation and well-being of veterans through our involvement
    with events like the National Disabled Veterans Winter Sports Clinic,
    and the National Disabled Veterans Golf Clinic. These recreational
    therapy programs help veterans improve their physical and mental health
    through sports and activities tailored to their abilities, while
    connecting them with other veterans and a community to help overcome
    limitations and challenge their perceived disabilities.
        The Veterans SPORT Act seeks to include adaptive prostheses and
    terminal devices, for participation in sports and other recreational
    activities, in the medical services provided by VA to eligible
    veterans. Including adaptive sports devices is congruent with VA's
    holistic approach to veteran care, which includes the physical,
    psychological and social aspects of rehabilitation. This legislation
    aims to enhance the quality of life for our Nation's ill and injured
    veterans by providing them with the necessary adaptive devices to
    participate in various sports and recreational activities, which plays
    a vital role in their overall physical and mental well-being. These
    devices enable service-disabled veterans to engage in a wide range of
    activities, including Paralympic sports like track and field, swimming,
    and wheelchair basketball; archery with adaptive equipment; cycling
    with hand cycles and adaptive bicycles; skiing with adaptive equipment;
    hunting with specialized devices; rock climbing with modified safety
    equipment; skydiving with adaptive gear; golf with adaptive golf
    equipment; and various water sports like paddle boarding, kayaking,
    pedal boating, and canoeing.
        We support this bill in accordance with DAV Resolution No. 429,
    which urges the VA to keep centralized funding for Prosthetics and
    Sensory Aids Service to provide high-quality prosthetic items and train
    veterans on their use and care. By supporting this bill, we honor the
    sacrifices of our most severely disabled veterans and promote their
    overall well-being by providing them with the necessary adaptive
    devices to once again engage in sports and recreational activities.
        In closing, the proposed bills under consideration by the
    Subcommittee today represent a comprehensive and multifaceted approach
    to addressing the urgent needs of our veterans. By prioritizing timely
    access to care, effective care coordination, and comprehensive,
    individualized health care options, these bills aim to enhance the
    quality of life for our veterans, who have bravely served our Nation.
        This concludes my testimony on behalf of DAV. I am pleased to
    answer questions you or members of the Subcommittee may have.

                           Statements for the Record

                                  ----------

                      Veterans Healthcare Policy Institute

        Chairwoman Miller-Meeks, Ranking Member Brownley, and distinguished
    members of the subcommittee:

        On behalf of the Veterans Healthcare Policy Institute, we thank you
    for inviting us to submit a statement for the record for today's
    hearing on improving the health care and services for veterans. Many
    members of our organization are veterans or have family members who are
    veterans. Many of us have had long careers serving veterans, published
    papers on veterans' healthcare in peer-reviewed journals, or presented
    congressional testimony. In today's statement, we wish to convey our
    appreciation for your leadership and commitment to ensuring that
    veterans receive the highest level of health care within the Veterans
    Health Administration (VHA) and supplementary care in the private
    sector when it's both needed and authorized by the VHA.
        While today's hearing considers 12 bills, we limit our comments to
    only one of them--The No Wrong Door for Veterans Act.

    Background

        The No Wrong Door for Veterans Act proposes to renew and modify the
    Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program. This
    pilot initiative allocated $174 million over 3 years to a diverse array
    of private and government community entities to supplement VA efforts,
    including veterans' associations, social service agencies, and tribal
    nations that partnered with the VHA at the local level.
        Under the Fox Grant Program, 80 grantees receive up to $750,000
    annually. Their primary role is to identify and engage veterans
    exhibiting one or more of 14 defined suicide risk factors. Once
    identified, these at-risk veterans and their families are provided with
    peer support, case management, benefits navigation assistance and/or
    other targeted services aimed at reducing suicide risk factors before
    they escalate into crises.

    The Importance of the Fox Grant Program's Use of Outcome Measurement

        The original Fox Grant law vastly improved the use of comprehensive
    outcome data to be able to discern which community programs effectively
    enhanced veterans' lives and reduced long-term suicide risk. As
    Congressman Jack Bergman, the bill's co-author, emphasized: ``This bill
    would develop measurement tools to track the effectiveness of these
    community-level programs in order to address the suicide crisis and its
    impact on Veterans.''
        The law authorized the VA to establish and apply a comprehensive
    baseline mental health screening for outcome metrics. Five well-
    validated measures were identified for grantees to administer at the
    beginning and end of participants' involvement. These additional
    measures are crucial, given that the programs are not clinical and are
    expected to impact suicidality downstream. The VA was expected to
    analyze changes in these scores to direct renewal funding to the
    interventions that demonstrated improvement in these instrument scores.
        Senator John Boozman (R-AR) hailed the Fox Grant Program for
    establishing ``a common tool to measure the effectiveness of our
    programs and promote better information sharing, data collection, and
    continual feedback in order to identify what services are having the
    most impact.''

    Concerns with the No Wrong Door for Veterans Act

        As the 3-year pilot comes up for reauthorization, the proposed ``No
    Wrong Door for Veterans Act'' contains several concerning elements that
    significantly undermine the Fox Grant program. Amendments are needed to
    remedy these shortcomings.

    1. Eliminating Demonstrated Effectiveness as a Criterion for Continued
    Funding

        The bill explicitly states that previously funded entities need
    only demonstrate ``serving a significant number of veterans'' to
    qualify for continued funding. That eliminates the core feature of the
    Fox Grant program to utilize participants' pre-post changes for
    decisions about continued funding. Grant recipients would only need to
    demonstrate throughput, not a track record of any successful
    improvements, leaving open the strong possibility that taxpayer funds
    would be misdirected into programs without proven effectiveness.

    2. Ambiguous Language About Screening Requirements

        As noted above, the original Fox program required grantees to
    screen for acute suicide risk and collect pre/post measurements of five
    psychosocial suicide risk factors.
        The language in the No Wrong Door legislation is unclear whether
    both types of screening remain mandatory. At a HVAC hearing last
    December, testimony suggested the new bill might eliminate pre/post
    screening requirements. Without these crucial evaluation metrics, it
    will be challenging to accurately assess any program's success in
    addressing the issues surrounding veteran suicide prevention.
        The bill also explicitly permits grantees to use their own
    protocols to screen for risk, undermining the ability to make apples-
    to-apples comparisons or aggregate data reporting, which require
    uniform protocols.

    3. Insufficient Safeguards on Overpayment to Grantees

        The bill provides $500,000 per grantee ``plus $10,000 per eligible
    individual who receives suicide prevention services provided or
    coordinated by such grantee.'' This ambiguous wording could allow a
    grantee to be reimbursed $10,000 for nominal activities. For example, a
    grantee could be reimbursed for:

          Providing services to an individual that another funder
    is already fully covering

          Conducting a screening with no follow-up services

          Giving a pamphlet to an individual at an outreach event

        There needs to be far more explicit definitions for what
    constitutes reimbursable ``suicide prevention services provided or
    coordinated by such grantee.''

    4. Premature Extension of an Unproven Program

        The bill calls for a 3-year extension through 2028 despite the lack
    of a proven track record. Yet, the Interim Report on the Fox Suicide
    Prevention Grant Program revealed extremely significant gaps:

          Of the 80 grantees, 55 failed to report any post-service
    outcome measurements

          The remaining 25 grantees had only 196 participants total
    who completed services and underwent some degree of pre/post
    measurement

          27 percent of eligible participants did not complete even
    one instrument upon entering their program

          23 percent of grantees served fewer than ten veterans/
    family members in their first year

          80 percent of grantees had less than fifty participants

        Thus, as of today, grantee effectiveness has been impossible to
    ascertain--either at the disaggregated grantee level or even at the Fox
    Grant program level--as required by law. The purpose of requiring both
    internal VA and external MITRE program evaluations of the pilot is to
    determine whether the Fox Grant program is effective for its intended
    purpose of reducing suicide risk factors. The program should not be
    extended carte blanche for three more years until its effectiveness is,
    as Bergman and Boozman intended, identified by data.

    Recommendations:

            1. Tie funding to demonstrated effectiveness: Add language
            specifying that reauthorizing an entity's funds is based on it
            serving a significant number of veterans and demonstrated
            improvements in participant outcomes on the mandated well-being
            measures.

            2. Strengthen outcome measurement requirements: The Act must
            explicitly reinforce the requirement that Fox Grant recipients
            conduct pre-and post-intervention assessments across all
            relevant metrics. This ensures robust data collection that
            shows how veterans' scores on the five key measures improve
            after participating in each grantee's services. All grantees
            should use the identical measures.

            3. Clarify payment structure: Tighten language to ensure that
            entities are paid $10,000 per enrollee only for a defined and
            substantial amount of provided services, not nominal
            interventions.

            4. Implement a 1-year renewal before blindly funding a long-
            term commitment: Until there is concrete proof of the Fox Grant
            program's effectiveness, and until the congressionally mandated
            MITRE Corporation 18-month and 3-year evaluations show
            systematic success, renewal should proceed on a year-to-year
            basis rather than a multi-year extension.

        While leveraging non-clinical community organizations is a crucial
    component of an effective upstream public health approach to suicide
    prevention, rigorous evaluation must be maintained to ensure these
    programs truly benefit veterans and represent good stewardship of
    taxpayer dollars.
        We respectfully thank you for the opportunity to provide our
    perspectives on these essential matters. We look forward to working
    with the committee to ensure that veterans can receive timely, high-
    quality compassionate care in the VHA and the community now and in the
    future.

      Prepared Statement of American Association for Marriage and Family
      Therapy and California Association of Marriage and Family Therapists

        Dear Chairwoman Miller-Meeks and Ranking Member Brownley:

        We are writing on behalf of the American Association for Marriage
    and Family Therapy (``AAMFT'') and the California Association of
    Marriage and Family Therapists (``CAMFT''), organizations that
    represent the professional interests of more than 81,000 licensed
    marriage and family therapists (``MFTs'') who provide individual,
    family, and group psychotherapy services throughout the United States.
    Thank you for providing AAMFT and CAMFT with an opportunity to comment
    in response to legislation considered on March 11, 2025 by the
    Committee on Veterans' Affairs Subcommittee on Health.
        We are commenting in support of H.R. 658, legislation introduced by
    Ranking Member Julia Brownley to correct a problem that impacts care
    and treatment for Veterans. AAMFT and CAMFT would like to thank Ranking
    Member Brownley for sponsoring this legislation. H.R. 658 seeks to
    expand access to licensed MFTs for Veterans and their families by
    removing unnecessary guidelines and policies that currently restrict
    the promotion of many VA MFT employees to supervisory positions,
    resulting in barriers to a qualified mental health workforce and
    barriers to timely access to care. H.R 658 would allow MFTs in the VA
    who are authorized to provide clinical supervision under State law to
    be eligible to provide clinical supervision in the VA.

    Background

        In 2006, the Veterans Benefits, Health Care, and Information
    Technology Act of 2006 (P.L. 109-461) was signed into law. This
    legislation established MFTs as recognized professionals within the VA.
    The VA started hiring MFTs in 2010 after the adoption of the first
    qualification standard for MFTs.\1\ In 2018, the VA issued its second
    and current qualification standard for MFTs.\2\ This 2018 standard
    added a new requirement that all MFTs in the VA who are supervising or
    who want to serve at a supervisory or managerial level and above
    designation must first have obtained the AAMFT Approved Supervisor
    designation in order to supervise.\3\ This requirement prevents well-
    trained and highly qualified MFTs who are serving in the VA at the GS-
    11 full performance level from advancing within the VA into a
    supervisory role. In addition, no such requirement exists in almost all
    other employment settings, and a similar requirement in the VA does not
    exist for psychologists, clinical social workers, or professional
    mental health counselors.
    ---------------------------------------------------------------------------
        \1\ VA Handbook 5005/41, Part II, Appendix G42
        \2\ VA Handbook 5005/101, Part II, Appendix G44
        \3\ The VA does allow MFTs to are working to obtain the AAMFT
    Approved Supervisor designation to serve as supervisors in the VA.
    These providers have 2 years from the date of placement to obtain the
    AAMFT Approved Supervisor designation.
    ---------------------------------------------------------------------------
        Currently, the VA requires that MFTs must hold the AAMFT Approved
    Supervisor designation to be promoted to supervisory positions. While
    AAMFT is proud of its high caliber supervisory designation, the AAMFT
    Approved Supervisor designation is not intended to be the only pathway
    for an MFT to become a clinical supervisor in the VA or in other
    settings. The VA does not require that licensed professional mental
    health counselors (``LPMHCs''), licensed clinical social workers
    (``LCSWs'') or other clinicians obtain a designation from a private
    organization in order to serve as a clinical supervisor in the VA.

    The Current MFT Supervisor Requirement is an Unnecessary Barrier

        The current MFT supervisor requirement is not necessary, and serves
    as a barrier for providers and Veterans. This requirement places MFTs
    at a disadvantage when it comes to the retention and promotion of MFTs
    within the VA. There are thousands of MFTs who are recognized as state-
    approved supervisors, yet they are not able to supervise within the VA
    because they do not have the AAMFT Approved Supervisor designation. We
    are aware of MFTs who have left VA employment because of this
    restriction, including MFTs that are Veterans themselves. We have heard
    that some hiring authorities within the VA are reluctant to hire MFTs
    for entry level positions due to the shortage of MFTs eligible to
    supervise in the VA, thus unnecessarily increasing workforce shortages
    and hampering Veteran's timely access to care.

    The Current MFT Supervisor Requirement Does Not Align with State
        Requirements

        The VA's current MFT supervisor requirement is not in alignment
    with State law. All 50 states and the District of Columbia license
    MFTs. States require that in order to become a licensed MFT, an
    applicant must hold a master's degree or doctoral degree in marriage
    and family therapy or a related field, have 2 years of clinical
    supervised experience, and pass a clinical exam. All states have
    requirements for MFTs who want to provide clinical supervision.
        Based upon a review of the licensure laws governing MFTs in all 50
    states and the District of Columbia, only two states--North Carolina
    and Tennessee--require that clinical supervisors providing supervision
    for MFT licensure must be AAMFT Approved Supervisors. In all 48 other
    states, a clinical supervisor of a candidate for licensure as an MFT
    does not need to be an AAMFT Approved Supervisor. Instead, these 48
    states allow MFTs who have experience and/or training in supervision to
    obtain a State MFT supervisor designation or otherwise legally provide
    supervision to supervisees in those states. For example, under Texas
    law, a person can become a Texas MFT supervisor if have either
    successfully completed a 3-semester hour course in MFT supervision,
    completed a 40-hour continuing education course in clinical
    supervision, or completed a supervision course approved by AAMFT.\4\
    ---------------------------------------------------------------------------
        \4\ 22 TX Admin Code Sec. 801.143. In addition, all candidates for
    the MFT supervisor status in Texas must document the completion of
    3,000 hours of MFT practice over a minimum of 3 years.
    ---------------------------------------------------------------------------
        In many states, the supervisor requirements for MFTs are identical
    to, or closely similar to, the State supervisor requirements for other
    mental health professionals. For example, in Iowa, the requirements to
    be an eligible supervisor for MFTs and LPMHCs are identical: hold an
    active license, have a minimum of 3 years of independent practice
    experience, complete at least a 6-hour continuing education course in
    supervisor or one graduate-level course in supervision, and knowledge
    of the law and ethics rules governing supervisees in Iowa.\5\
    ---------------------------------------------------------------------------
        \5\ Iowa Admin Code r. 481.891.7
    ---------------------------------------------------------------------------
        The VA's current additional MFT supervisor requirement does not
    align with the VA's own clinical supervisor requirements for other
    healthcare professionals. The VA generally recognizes clinical
    providers in the VA as eligible to supervise if State law allows them
    to supervise. For example, within the mental health professions, LPMHCs
    and LCSWs can provide clinical supervision if they are licensed to
    provide clinical supervision under State law or otherwise can legally
    provide supervision for licensure under State law.\6\ Instead of
    following clinical supervisor requirements under State law, the VA MFT
    supervisor requirement is unique in requiring those applying for a
    supervisory position or having the ability to supervise trainees to
    obtain a supervision designation from a nongovernmental organization.
    Since the VA generally defers to State law pertaining to the minimum
    standards necessary to work in the VA, such as meeting a state's
    requirements for licensure in a recognized healthcare profession, the
    VA should allow MFTs who are authorized to provide clinical supervision
    under State law to be eligible to provide clinical supervision in the
    VA.
    ---------------------------------------------------------------------------
        \6\ VA Handbook 5005/106, Part II, Appendix G43 (LPMHCs) & VA
    Handbook 5005/120, Part II, Appendix G39 (LCSWs)

    HR 658 Would Increase the Number of MFT Supervisors While Providing the
    ---------------------------------------------------------------------------
    Best Quality of Care to Veterans

        HR 658 would expand access to licensed MFTs for Veterans and their
    families by removing unnecessary regulations that currently prohibit
    many MFTs employed by the VA from being promoted to supervisory
    positions. This legislation would significantly increase the number of
    current MFTs in the VA who would be eligible to provide clinical
    supervision. By increasing the pool of MFTs eligible to become clinical
    supervisors and be promoted within the VA, this bill would increase the
    retention of MFTs within the VA. Increasing the number of supervisors
    and improving retention of MFTs within the VA will also improve access
    to care in a timely manner for Veterans. H.R 658 protects Veterans by
    requiring that all MFT supervisors must be an AAMFT Approved Supervisor
    or authorized by a State to provide clinical supervisor. As with all
    clinical supervisors of any profession within the VA, under this bill,
    the VA would still retain the ability to manage VA employees,
    investigate supervisors, and take any action against employees who are
    not providing the best care for Veterans.
        We would like to thank the Committee for the opportunity to submit
    comments in support of H.R. 658. AAMFT and CAMFT look forward to
    working with the Committee on this legislation.

              Prepared Statement of Paralyzed Veterans of America

        Chairman Bost, Ranking Member Takano, and members of the committee,
    Paralyzed Veterans of America (PVA) would like to thank you for the
    opportunity to submit our views on some of the pending legislation
    impacting the Department of Veterans Affairs (VA) that is before the
    committee. No group of veterans understand the full scope of benefits
    and care provided by the VA better than PVA members--veterans who have
    incurred a spinal cord injury or disorder (SCI/D). We appreciate the
    opportunity to offer our observations on some of the bills being
    discussed during today's hearing.

    H.R. 217, the Communities Helping Invest through Property and
    Improvements Needed or CHIP IN for Veterans Act

        The Communities Helping Invest through Property and Improvements
    Needed for Veterans Act of 2016 (P.L. 114-294), often referred to as
    the ``CHIP IN'' Act, authorized the VA to carry out a pilot program
    under which it may accept up to five donations from nonfederal entities
    of existing facilities, land, or a facility to be constructed by the
    donor on real property of the VA. Increasing investment in VA's
    infrastructure, particularly facilities that support specialized health
    care services, is a crucial priority for veterans with SCI/D. PVA
    supports this bill, which would make the CHIP IN pilot program
    permanent, thus, increasing the availability of health care services to
    veterans.

    H.R. 658, to establish qualifications for the appointment of a person
    as a marriage and family therapist, qualified to provide clinical
    supervision, in the Veterans Health Administration

        PVA supports this legislation, which would establish qualifications
    for the appointment of a person as a marriage and family therapist,
    qualified to provide clinical supervision in the Veterans Health
    Administration (VHA). Veterans who have developed mental health issues
    often find it difficult to resume daily activities, which creates
    stress and anxiety. Well trained marriage and family therapists have
    helped thousands of veterans become productive citizens and improve
    their family relationships. Removing current restrictions that limit
    the growth potential for marriage and family therapists within the VA
    will increase retention of these professionals and improve access to
    the care they provide.

    H.R. 1107, the Protecting Veteran Access to Telemedicine Services Act
    of 2025

        PVA supports this legislation, which would permanently extend a
    pandemic-related exemption that allows VA health care providers to
    prescribe certain medications via telemedicine to their veteran
    patients. Specifically, it would authorize a covered health care
    professional to use telemedicine to deliver, distribute, or dispense to
    veterans certain controlled medications via telemedicine under specific
    conditions as determined under the Federal Food, Drug, and Cosmetic Act
    (21 U.S.C. 301 et seq.). Veterans who live in rural communities often
    do not have easy access to a VA health care facility, and telemedicine
    is often the most convenient way to provide essential care. Using
    technology to increase access to care within VA is an important way to
    provide care to better meet veterans' needs, ensuring they receive
    their medications without interruption.

    H.R. 1336, the Veterans National Traumatic Brain Injury Treatment Act

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

    H.R. 1644, the Copay Fairness for Veterans Act

        PVA supports this legislation, which would eliminate copayments for
    medications and preventive health services provided by the VA. While
    the VA charges copays to certain veterans for hospital and medical
    care, veterans should not be subject to copays for preventive services.
    These services are essential for management and early detection of
    health issues, that if left untreated, could lead to more serious
    illnesses or conditions. Ending copays for preventative care will also
    ensure parity for veterans with most other Americans who have no copays
    when accessing this type of care.

    H.R. 1823, to direct the VA Secretary and the Comptroller General of
    the United States to report on certain funding shortfalls in the VA.

        In July 2024, the Veterans Benefits Administration (VBA) projected
    a $2.88 billion budget shortfall for the remainder of Fiscal Year (FY)
    2024 and VHA projected a $12 billion shortfall for Fiscal Year 2025.
    Toward the end of September 2024, Congress approved H.R. 9468, the
    Veterans Benefits Continuity and Accountability Supplemental
    Appropriations Act of 2024 (P.L. 118-82), which gave VBA an additional
    $2.9 billion to pay veterans' pension and disability benefits for
    Fiscal Year 2024.
        On November 1, 2024, VBA revealed that it carried over
    approximately $5.1 billion from Fiscal Year 2024 to Fiscal Year 2025,
    meaning it did not need the additional funding approved by Congress.
    Also, at the end of November, the VA announced that it only needed $6.6
    billion, not $12 billion, to cover existing shortfalls in the VHA
    budget for Fiscal Year 2025. The lack of clarity on what VA's true
    financial needs are has been a concern for all interested parties, and
    to date, sparse details have been provided about VA's inability to
    track and project its funding. PVA strongly supports this legislation,
    which requires the Comptroller General to investigate the circumstances
    surrounding the reported funding shortfalls for the VHA and VBA in
    Fiscal Year 2024 and Fiscal Year 2025.

    Discussion Draft, to establish the period during which the referral of
    a veteran, made by a health care provider of the Department of Veterans
    Affairs, to a non-Department provider, for care or services under the
    Community Care Program of such Department, remains valid.

        PVA supports this draft legislation, which would establish the
    valid time frame for a referral from a VA health care provider to a
    non-VA Community provider under the Community Care Program. As written,
    ``valid time'' begins the day a covered veteran has their first
    appointment with the community care provider. This would ensure
    veterans referred to community care providers meet all of VA's
    authorization requirements, allowing the provider to focus on
    delivering appropriate care to a veteran without delay.

    Discussion Draft, the Providing Veterans Essential Medications Act

        PVA supports this draft bill, which would ensure that veterans
    receiving nursing home care in State Veterans Homes have access to
    high-cost medications, as needed. Currently, the VA does not pay State
    homes for high-cost medications for veterans. This bill would require
    the VA Secretary to either reimburse State homes for costly medications
    or furnish them directly, which would eliminate financial burdens on
    these long-term care facilities and increase veterans' access to care.

    Discussion Draft, The Veterans Supporting Prosthetics Opportunities and
    Recreational Therapy (``SPORT'') Act.

        PVA strongly supports this draft bill, which would provide VA
    coverage of prosthetic limbs that veterans with limb loss use to
    participate in sports and other recreational activities. Specifically,
    this bill would add ``adaptive prostheses and terminal devices for
    sports and other recreational activities'' to the statute governing
    which equipment and aids that the VA is allowed to grant veterans.
    Adaptive equipment is intended to promote and support holistic healthy
    lifestyles for amputees. But occasionally, VA's own internal policies
    create unnecessary barriers for veterans with disabilities. For this
    reason, we highly recommend that VA provide these kinds of adaptive
    equipment for amputees without requiring that the veteran be enrolled
    in a VA rehabilitative program.

    Discussion Draft, the Saving Our Veterans Lives Act

        Firearms are the most common method of suicide in the US, with
    veterans representing slightly more than 69 percent of cases.\1\ More
    than 70 percent of male veteran suicide deaths and 50 percent of female
    veteran suicide deaths are the result of firearms, and these rates
    greatly exceed those of non-veterans. Fifty-one percent of veterans
    report owning one or more personal firearms, and of those, over half
    report storing firearms that are loaded and/or unsecured. Many of the
    veterans who store their firearms loaded and unlocked don't even own a
    lockbox or safe. PVA supports this effort to make it easier for
    veterans to access secure firearm storage devices and raise awareness
    about the importance of lethal means safety to help prevent firearm
    suicide among veterans and their families.
    ---------------------------------------------------------------------------
        \1\ Firearm suicide risk and prevention in service members--
    ScienceDirect

    ---------------------------------------------------------------------------
    Discussion Draft, the Women Veterans Cancer Care Coordination Act

        The Women Veterans Cancer Care Coordination Act would require the
    VA to hire or designate a Regional Breast Cancer and Gynecologic Cancer
    Care Coordinator at each Veterans Integrated Services Network (VISN).
    While PVA supports the intent of this draft bill, some changes are
    needed to make it stronger. The National Women Veterans Oncology System
    of Excellence was established in 2020 to offer increased attention and
    collaborative treatment plans for women experiencing breast or
    gynecological cancers. Their work has led to improved early detection,
    coordinated treatment of cancers, and provided increased trust in VA
    among women veterans. However, the National Women Veterans Oncology
    System of Excellence is not protected in statute. PVA recommends adding
    a provision within the legislation that secures the National Women
    Veterans Oncology System of Excellence to ensure the great work VA is
    doing on behalf of women veterans living with cancer. Additionally,
    cancer care coordination is disparate across the system, and while PVA
    supports additional focus and attention on the needs of women veterans,
    we believe having someone within each VISN to focus on all cancers,
    regardless of gender, should be prioritized.
        PVA would once again like to thank the committee for the
    opportunity to submit our views on some of the bills being considered
    today. We look forward to working with you on this legislation and
    would be happy to take any questions for the record.

      Information Required by Rule XI 2(g) of the House of Representatives

    Pursuant to Rule XI 2(g) of the House of Representatives, the following
    information is provided regarding Federal grants and contracts.

                                Fiscal Year 2025

    Department of Veterans Affairs, Office of National Veterans Sports
    Programs & Special Events----Grant to support rehabilitation sports
    activities--$502,000.

                                Fiscal Year 2023

    Department of Veterans Affairs, Office of National Veterans Sports
    Programs & Special Events----Grant to support rehabilitation sports
    activities--$479,000.

                                Fiscal Year 2022

        Department of Veterans Affairs, Office of National Veterans Sports
    Programs & Special Events----Grant to support rehabilitation sports
    activities--$ 437,745.

                         Disclosure of Foreign Payments

    Paralyzed Veterans of America is largely supported by donations from
    the general public. However, in some very rare cases we receive direct
    donations from foreign nationals. In addition, we receive funding from
    corporations and foundations which in some cases are U.S. subsidiaries
    of non-U.S. companies.

    Prepared Statement of American Federation of Government Employees, AFL-
                                      CIO
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                    Prepared Statement of Trajector Medical
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                Document for the Record Submitted by Greg Murphy
    [GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

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