[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]
LEGISLATIVE HEARING ON H.R. 1506, H.R. 2322, H.R. 3832, H.R. 4334 AND
H.R. 4635; VA Medicinal Cannabis Research Act of 2018 and a Draft Bill
To Make Certain Improvements in The Family Caregiver Program
=======================================================================
HEARING
BEFORE THE
SUBCOMMITTEE ON HEALTH
OF THE
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED FIFTEENTH CONGRESS
SECOND SESSION
__________
TUESDAY, APRIL 17, 2018
__________
Serial No. 115-56
__________
Printed for the use of the Committee on Veterans' Affairs
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Available via the World Wide Web: http://www.govinfo.gov
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COMMITTEE ON VETERANS' AFFAIRS
DAVID P. ROE, Tennessee, Chairman
GUS M. BILIRAKIS, Florida, Vice- TIM WALZ, Minnesota, Ranking
Chairman Member
MIKE COFFMAN, Colorado MARK TAKANO, California
BRAD R. WENSTRUP, Ohio JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American ANN M. KUSTER, New Hampshire
Samoa BETO O'ROURKE, Texas
MIKE BOST, Illinois KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine J. LUIS CORREA, California
NEAL DUNN, Florida KILILI SABLAN, Northern Mariana
JODEY ARRINGTON, Texas Islands
JOHN RUTHERFORD, Florida ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto
Rico
Jon Towers, Staff Director
Ray Kelley, Democratic Staff Director
SUBCOMMITTEE ON HEALTH
BRAD WENSTRUP, Ohio, Chairman
GUS BILIRAKIS, Florida JULIA BROWNLEY, California,
AMATA RADEWAGEN, American Samoa Ranking Member
NEAL DUNN, Florida MARK TAKANO, California
JOHN RUTHERFORD, Florida ANN MCLANE KUSTER, New Hampshire
CLAY HIGGINS, Louisiana BETO O'ROURKE, Texas
JENNIFER GONZALEZ-COLON, Puerto LUIS CORREA, California
Rico
Pursuant to clause 2(e)(4) of Rule XI of the Rules of the House, public
hearing records of the Committee on Veterans' Affairs are also
published in electronic form. The printed hearing record remains the
official version. Because electronic submissions are used to prepare
both printed and electronic versions of the hearing record, the process
of converting between various electronic formats may introduce
unintentional errors or omissions. Such occurrences are inherent in the
current publication process and should diminish as the process is
further refined.
C O N T E N T S
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Tuesday, April 17, 2018
Page
LEGISLATIVE HEARING ON H.R. 1506, H.R. 2322, H.R. 3832, H.R. 4334
AND H.R. 4635; VA Medicinal Cannabis Research Act of 2018 and a
Draft Bill To Make Certain Improvements in The Family Caregiver
Program........................................................ 1
OPENING STATEMENTS
Honorable Brad Wenstrup, Chairman................................ 1
Honorable Julia Brownley, Ranking Member......................... 2
Honorable Tim Walz, Ranking Member, Full Committee On Veterans
Affairs........................................................ 3
WITNESSES
The Honorable Beto O'Rourke, Member, U.S. House of
Representatives, 16th District; Texas.......................... 4
Prepared Statement........................................... 29
The Honorable Tim Walberg, Member, U.S. House of Representatives,
7th District; Michigan......................................... 5
Prepared Statement........................................... 30
The Honorable Phil Roe, Chairman, Full Committee On Veterans
Affairs........................................................ 6
The Honorable Neal Dunn, Member, U.S. House of Representatives,
2nd District; Florida.......................................... 8
Prepared Statement........................................... 31
The Honorable Luis Correa, Member, U.S. House of Representatives,
46th District; California...................................... 9
Prepared Statement........................................... 32
The Honorable Mike Coffman, Member, U.S. House of
Representatives, 6th District; Colorado........................ 9
Prepared Statement........................................... 32
Louis J. Celli, Director, National Veterans Affairs and
Rehabilitation Division, The American Legion................... 11
Prepared Statement........................................... 33
Adrian M. Atizado, Deputy National Legislative Director, Disabled
American Veterans.............................................. 13
Prepared Statement........................................... 39
Sarah S. Dean, Associate Legislative Director, Paralyzed Veterans
of America..................................................... 14
Prepared Statement........................................... 44
Kayda Keleher, Associate Director, National Legislative Service,
Veterans of Foreign Wars of the United States.................. 16
Prepared Statement........................................... 47
STATEMENT FOR THE RECORD
Steve Schwab, The Elizabeth Dole Foundation...................... 50
Tom Porter, Iraq and Afghanistan Veterans of America (IAVA)...... 52
Carrie Stead - The Independence Fund............................. 54
Margaret Kabat - The Indepndence Fund............................ 55
Bob Carey - The Independence Fund................................ 58
Veterans Cannabis Coalition (VCC)................................ 61
Veterans Cannabis Project (VCP).................................. 61
Wounded Warrier Project (WWP).................................... 62
LEGISLATIVE HEARING ON H.R. 1506, H.R. 2322, H.R. 3832, H.R. 4334 AND
H.R. 4635; VA Medicinal Cannabis Research Act of 2018 and a Draft Bill
To Make Certain Improvements in The Family Caregiver Program
----------
Tuesday, April 17, 2018
U.S. House of Representatives,
Committee on Veterans' Affairs,
Subcommittee on Health
Washington, D.C.
The Subcommittee met, pursuant to notice, at 3:35 p.m., in
Room 334, Cannon House Office Building, Hon. Brad Wenstrup
[Chairman of the Subcommittee] presiding.
Present: Representatives Bilirakis, Radewagen, Dunn,
Rutherford, Higgins, Gonzalez-Colon, Roe, Coffman, Brownley,
Takano, Kuster, O'Rourke, Correa, Walz.
OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN
Mr. Wenstrup. The Subcommittee will come to order. Before
we begin, I would like to ask unanimous consent for our
colleague and fellow Committee Member, Representative Coffman
from Colorado, to sit on the dais and participate in today's
proceedings. Without objections, so ordered.
Good afternoon, thank you all for joining us. Today we will
be discussing a number of bills that have been referred to the
Subcommittee on Health, as well as two draft proposals that are
sponsored by Chairman Roe and Ranking Member Walz,
respectively. These bills, which are sponsored by Committee
Members and colleagues from both sides of the aisle, would
address some of the most important health care issues facing
our Nation's veterans and the Department of Veterans Affairs.
H.R. 1506, sponsored by Congressman O'Rourke, would address
VA's longstanding recruitment and retention challenges by
increasing the caps for VA's Education Debt Reduction Program.
H.R. 2322, sponsored by Congressman Walberg, would improve
care for injured and amputee veterans, and clarify what those
in need of prosthetic and orthotic care are entitled to from
VA, including access to timely and quality care, either in VA
or in the community, that best meets their needs and goals.
H.R. 3832, sponsored by Dr. Dunn, would help prevent opioid
abuse among veterans by allowing for the greater sharing of
information between VA and state-based prescription drug
monitoring programs.
H.R. 4334, sponsored by Congressman Correa, and H.R. 4635,
sponsored by Congressman Coffman, would improve care for women
veterans by collecting information regarding access to gender-
specific care in the community and environment of care
standards in VA medical facilities, and requiring a sufficient
number of peer-to-peer counselors for women veterans
respectively.
The draft bill, the VA Medicinal Cannabis Research Act of
2018, which is sponsored by Ranking Member Walz with Chairman
Roe and Congressmen Correa as original co-sponsors, would
authorize VA to conduct and support research on the efficacy
and safety of medical marijuana for veterans with chronic pain,
post-traumatic stress disorder, and other conditions.
Finally, the draft bill to make certain improvements in the
Family Caregiver Support Program, which is sponsored by
Chairman Roe, would require the implementation of an
information technology system to support VA's Family Caregiver
Support Program, and then reform and expand that program.
I look forward to learning more about each of these bills
and draft proposals today. I am grateful to each of the bill
sponsors for their leadership on these issues and for being
here to testify on our first panel. I am also grateful to our
veteran service organization partners for being here to provide
their views on these bills on our second panel.
I now yield to Ranking Member Brownley for any opening
statements she may have.
OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER
Ms. Brownley. Thank you, Mr. Chairman and Ranking Member
Walz, for being here and thank you to all of today's witnesses
for participating in our legislative hearing.
I am excited to discuss the legislation on today's agenda.
Each piece of legislation is in response to a serious issue or
concern affecting our veterans' health care. I look forward to
hearing from our witnesses addressing any concerns ahead of a
future markup and moving these important reforms forward.
As a co-sponsor of several of the bills before the
Subcommittee today, I am proud of the work being done within
this Committee and throughout this congress to preserve and
enhance the VA health care so that many veterans utilize,
value, and recommend.
During my time on this Committee, I have made it a special
priority to ensure women veterans have access to high-quality
gender-specific care in a safe and welcoming environment. I
believe that two of the bills on today's agenda will advance
this goal.
The Improving Oversight of Women's Veterans Care Act
requires the VA to practice oversight on the community care
providers that the VA contracts with to provide gender-specific
health care to women veterans. We need to do a better job
tracking the quality of care provided to women veterans and
conduct effective oversight to ensure that they are well served
no matter where they get their care.
I am also excited to lend my support for Congressman
Coffman's legislation to require the VA to ensure that
veterans' peer counseling programs includes enough peer
counselors for women veterans. It is clear that peer-to-peer
counseling is an effective way to reach veterans that may not
be willing to submit to a formal mental health care treatment
plan. Peer-to-peer counseling is meant to be sensitive to the
specific culture of the military and how that culture affects a
veteran's experience.
It is integral that veterans seeking peer-to-peer
counseling are afforded an opportunity to speak with a peer
that they can relate to, and for many women veterans their most
relatable peer will be their fellow women. I appreciate
Congressman Coffman's leadership on this issue and look forward
to further discussions on the merits of his legislation.
Finally, I am eager to hear from the Ranking Member of the
VA Medicinal Cannabis Research Act of 2018. I will leave it to
the Ranking Memberto discuss its merits, but I will say I am
proud to co-sponsor the legislation because I believe the VA
must continue to look at complementary and alternative
treatments, such as cannabis, that can help veterans cope with
the invisible wounds of war.
Thank you also to Congressman O'Rourke and all of our
colleagues for your legislation and your work supporting
veterans. I look forward to your input and recommendations of
our VSO partners. And Mr. Chairman, thank you and I yield back.
Mr. Wenstrup. Thank you, Ms. Brownley. We are honored today
to be joined by Ranking Member Walz who will be speaking about
his respective draft proposal, and I want to thank you for
being here today, and we will recognize you for five minutes
for any comments you may have before we begin.
OPENING STATEMENT OF TIM WALZ, RANKING MEMBER, FULL COMMITTEE
ON VETERANS AFFAIRS
Mr. Walz. Well, thank you Chairman and Ranking Member.
Thank you both for your longstanding bipartisanship and your
ability to bring good solid pieces of legislation forward that
are able to be passed into law. I am grateful to be here with
you.
As a point of personal privilege, I wanted to point out we
are joined today by a non-profit from Minnesota, Wiggle Your
Toes, folks we were just talking to, that mission statement is
pretty clear that they are out here to make sure that folks who
have lost a limb have the capacity to be able to get back the
life that they want, working with our veterans as well as some
of our hero's in the Boston Marathon bombing, appropriate this
week, so thank you for being here. And I will note that at
least one of the Members here today is a fellow alumni of
Minnesota State University Mankato, which the Chairman knows as
the Harvard of the Midwest in its more common name. So just so
you know, but thank you for that.
I appreciate the opportunity to put this forward, and I
want to thank the Chairman of the Full Committee, Dr. Roe, for
working with us on this, and my friend and colleague from
California, Mr. Correa, has been a champion of this. We all
know that the issues that come with pain, whether they be
physical or the mental injuries that come with serving this
Nation, are great. We understand that there are incredibly
powerful drugs that are able to help at times, but we also know
the dangers of the abuses of opioids and other therapies that
we want to try and move folks to.
The VA has always been, since the early 1920s, this
Nation's premier research institution, and they have a cohort
of folks that we owe it to, to get the best possible treatments
to. And one of the things that we are seeing across the country
is veterans understanding that the potential for medicinal
cannabis is great. And what we need to know, and what this Act
does, is very simple. It simply clarifies that the VA has the
capacity and the authority to do research into medicinal
cannabis, and then it asks them to update Congress on where
they are at.
It doesn't mandate that they do it. It doesn't tell them to
do it. It asks us to try and find the data to make sure it is
there. And what this does is clarify because there have been
some confusions, and the VA believes that because of being
labeled a Schedule I drug, that they do not have the capacity
to do this.
They have the largest cohort. We have veterans suffering.
We have the opportunity to do the research, and then find out
once and for all if we can put this in. We have a patchwork
system right now. If you are a veteran in one state you have
access to medicinal cannabis, in another you do not. We don't
have the hard research to show that the best way that we can do
this. I want to give a special thanks to some of the partners
in this, The American Legion, who has come out and asked us to
find out if this works, find out the research, the VFW, and
others.
This is just one of the many things, and I am proud of all
of you who have worked on here. It wasn't that many years ago
when we were talking about acupuncture or yoga being
alternative therapies that couldn't be embraced. Now, we have
those things in the VA. This is the next step of ensuring that
the VA has the best possible research, the best possible data.
And if it is going to provide relief for our veterans, we
should be looking into what is the next step in medicinal
cannabis.
So Mr. Chairman, I thank you for that. I thank you for the
opportunity for introducing this, and again, I want to give a
big thank you to Chairman Roe. We have a lot of medical doctors
on this Committee, and I truly look towards your judgment and
your ability to understand what we need to do to make sure
before we start prescribing these. So thank you.
Mr. Wenstrup. Thank you very much. I now want to introduce
our first panel. It is a pleasure to be joined today by several
of our bill sponsors, and I appreciate you all taking the time
out of your afternoon to be here. With us here today is
Congressman Beto O'Rourke from Texas, Congressman Tim Walberg
from Michigan, Congressman Neal Dunn from Florida, Congressman
Louis Correa from California, and Congressman Mike Coffman from
Colorado.
Mr. O'Rourke, if you are ready, you are now recognized for
five minutes.
STATEMENT OF HONORABLE BETO O'ROURKE
Mr. O'Rourke. Thank you, Mr. Chairman. I wanted to speak a
little bit about H.R. 1506, the VA Healthcare Provider
Education Debt Relief Act of 2017 which I think will help us to
address the crisis and provider shortage that we have in the VA
right now. I think by the last VA Secretary's estimate, we had
at least 30,000 authorized funded, but unhired, clinical
positions in the VA. Every day that goes by without those
positions being hired is another day that we fail to see
veterans honor the commitment they have made with the care that
they need, that they deserve, and that they have earned.
This bill would increase the debt reimbursement available
to providers for their medical school education from $120,000
to $150,000. It would also provide the means in certain
critical shortage areas to waive the cap altogether by working
between the VA and the Department of Health and Human Services.
This bill has support from a number of veteran service
organizations. We have been working with the VA to improve the
bill and I am grateful to have a chance to get feedback from
Members of the Committee and veteran service organizations
today about how we can get this done.
And with that, I yield back. Thanks.
[The prepared statement of Beto O'Rourke appears in the
Appendix]
Mr. Wenstrup. Thank you. Mr. Walberg, you are now
recognized for five minutes.
STATEMENT OF HONORABLE TIM WALBERG
Mr. Walberg. Thank you, Chairman Wenstrup and Ranking
Member Brownley. Thank you as well for giving me the
opportunity to be back in this very special room, dealing with
a very special constituency, that being our veterans. And thank
you for allowing me to be here today to testify on H.R. 2322,
the Injured and Amputee Veterans Bill of Rights.
I would like to start off by thanking the Subcommittee
Members and staff for their time and willingness to work with
me on this very important issue.
I think we can all agree that our veterans have earned the
highest quality possible health care. I understand there are
problems at the Veterans Affairs and that this Committee is
diligently working to address these concerns to ensure our
veterans receive the benefits and care they deserve. I also
know there are great doctors, nurses, and staff that work hard
to make sure our veterans receive timely care.
With that being said, I believe a veteran's health care
decisions are personal choices. We know all too well that the
VA can be an intimidating and hard-to-navigate bureaucracy.
There are layers of paperwork and red tape that can make these
health care decision daunting.
H.R. 2322 moves to empower veterans when it comes to making
their own health care choices, and it does so by ensuring that
injured and amputee veterans know their health care rights.
Years on the battlefield has taken a toll on our war fighters.
Our veterans are younger than before, and transitioning from
active duty can be difficult. We need to ensure that amputee
veterans have the best access to care and the ability to more
easily transition into civilian life. The Injured and Amputee
Veteran Bill of Rights is a bipartisan approach to empowering
injured and amputee veterans in making their health care
choices. This bill simply requires the VA to prominently
display a list of rights in a VA orthotic or prosthetic OMP
clinics, as well as their Web site.
These rights include, and aren't limited to, the right to
access the highest quality and most appropriate OMP care; the
right to select the practitioner of their choice; the right to
consistent and portable health care, including obtaining
comparable services at any VA medical facility; the right to
timely and efficient OMP care; the right to both a primary
prosthesis and orthosis, and functional spare.
Additionally, the VA should be required to educate their
staff, so VA employees can help veterans navigate this process
to make sure veterans are receiving the care they deserve and
need. Our bill also requires the VA to follow up and resolve
any complaints by veterans who believe the VA is not meeting
their OMP needs.
Mr. Chairman, at the end of the day, veterans should
receive the best available and timely care they can get. I know
this is something you and I, and your staff, have worked hard
on and I applaud your unwavering commitment to our veterans. I
am willing to work with you and your Committee in any way to
better this legislation so that we can empower injured and
amputee veterans when they are making their health care
choices.
Thank you for your time today and for the work this
Committee is doing to keep our promises to our Nation's hero's.
Thank you.
[The prepared statement of Tim Walberg appears in the
Appendix]
Mr. Wenstrup. Thank you, Mr. Walberg. We are honored to
have Chairman Roe here with us today, and Dr. Roe, if you would
like to take five minutes to discuss your proposals for the
Family Caregivers Support Program.
STATEMENT OF HONORABLE PHIL ROE, CHAIRMAN, FULL COMMITTEE ON
VETERANS AFFAIRS
Mr. Roe. Thank you, Dr. Wenstrup. It is a pleasure to be
here with the Subcommittee today, and there are a number of
worthy pieces of legislation that we are going to discuss this
afternoon, and I am particularly interested in
Dr. Dunn's bill, the Veterans Opioid Abuse Prevention Act
which would give improvement--would improve the Department of
Veterans Affairs Communication with a state-based prescription
drug monitoring program to help identify and address opioid
addiction among veteran patients.
I am also interested in Representative Walberg's just
presented an Injured and Amputee Veteran Bill of Rights. That
bill was discussed at the Committee's field hearing in
Fayetteville, North Carolina a couple of weeks ago. And when
clarified that those veterans were in need of prosthetic or
orthotic services through VA are entitled to the very best care
at the provider of their choice in light of the unique and
highly individualized needs.
And I am grateful that my draft bill to make certain
improvements in the Department of Veterans Affairs Family
Caregiver Support Program is included on the agenda for today's
hearing. My draft bill would require the VA to implement an IT
system to support the Family Caregiver Program, to use the data
that the system collects to conduct an assessment of the
program, and to use that assessment to identify and implement
needed modifications, and to certify to Congress that the IT
system and modified program are both working.
From there, it would expand eligibility for the program to
pre-9/11 veterans; amend eligibility for the program to
veterans in need of personal care services due to an inability
to perform three or more activities of daily living, ADLs,
rather than the one or more ADL; grant VA the flexibility to
change how the monthly stipends are calculated by removing
certain requirements from the current law and requiring VA to
promulgate regulations regarding stipend determination; require
a primary caregiver to reside or agree to reside in ``close
proximity'' with the veteran he or she is caring for, and
defined close proximity as one that allows regular in-home
management care, supervision, or treatment; require VA to
develop and publish in the Federal Register a plan to
transition those currently approved for the program to the
amended program.
This draft has been in development since the Full Committee
hearing on the program in early February and has been the
subject of multiple round table discussions with VA and veteran
service organization since that time. While this bill remains a
work in progress, I appreciate the thoughtful feedback provided
in those conversations, and look forward to continuing to work
with all interested stakeholders on moving this forward.
I know that there has been much published discussion
recently about a compromise agreement between Senator Isakson,
Senator Tester, and me that would expand eligibility to the
Family Caregiver Program to pre-9/11 veterans without making
any changes to the eligibility criteria or stipend
calculations. Inclusion of that provision was one of the chief
concessions that I made to achieve a compromise agreement. I am
committed to that compromise agreement and hope to see movement
on it in the coming weeks.
That said, negotiations are ongoing. I remain convinced
that should negotiations prove unfruitful, we must have an
honest conversation about the findings of right balance between
clinical appropriateness and the costs within this program, and
make needed changes to ensure it is working as intended for
increasing its participants in such a dramatic fashion.
I also want to mention the draft bill offered by Ranking
Member Walz and myself to authorize VA to conduct research on
the efficacy and safety of medical cannabis. As a medical
doctor, I have written countless prescriptions, but never once
in my life have I prescribed a drug which has not been proven
effective by the FDA. Allowing VA to research medical marijuana
will finally allow us to separate fact from fiction, and
provide a scientific footing on which sound policy may be
built.
As you noted in your testimony, Mr. Celli, 92 percent of
respondents in veteran households' support researching the
effort of medical cannabis for mental and physical conditions.
That is a statistic that should not be ignored. I thank The
American Legion for leading this effort, so we might, at last,
find out if medical marijuana is a viable treatment option for
our Nation's veterans. I look forward to hearing everyone's
comments on legislation today.
With that, I thank you again for allowing me to be here
today, Dr. Wenstrup, and I yield back the balance of my time.
Mr. Wenstrup. Thank you, Dr. Roe. Dr. Dunn, you are now
recognized for five minutes to discuss H.R. 3832.
STATEMENT OF HONORABLE NEAL DUNN
Mr. Dunn. Thank you very much, Chairman Wenstrup, and thank
you, Chairman Roe, for your kind words. And I appreciate the
opportunity today to speak on behalf of H.R. 3832, the Veterans
Opioid Abuse Prevention Act.
According to the Centers for Disease Control, 249 million
prescriptions were written by health care providers in 2013.
The Department of Veterans Affairs Health Care System is the
largest health care provider. Because of this, it is in a
unique position to help curb the opioid epidemic by using every
tool available when a veteran is prescribed an opioid. The
Veterans Opioid Abuse Prevention Act gives the VA health care
providers access to these valuable tools.
H.R. 3832 comes directly from recommendations from the
Nation's top policymakers, the White House Commission on
Combating Drug Addiction, and the Opioid Crisis recommended
last July that the VA lead efforts to have all state and
Federal prescribing drug--or prescription drug monitoring
programs, known as PDMPs, share information.
The interim report cited multiple published best practices
for PDMPs, and has identified interstate data sharing as among
the top priorities to ensure that health care professionals
have a better understanding for prescribing practices for their
patients.
H.R. 3832 directs the VA to have health care providers
participate in the sharing of prescribing data, across a
network of interstate prescription drug monitoring programs.
PDMPs are state-based networks which can access when--which
providers can access when writing or filling prescriptions. And
PDMP data includes the type of the medication, the fill dates,
and the dosage amounts. PDMPs improve a clinician's ability to
follow good prescribing practices for at-risk patients who may
have a pattern of prescription opioid abuse.
In 2011, the National Board of Pharmacy created a national
platform of prescription monitoring programs, PMPs, called PMP
Interconnect, which allows the various states to share the PDMP
data across state lines securely. Today, 44 states and
Washington, D.C., participate in the PMP Interconnect and more
states are adding all the time. My own state, Florida, is
adding now.
I have veterans in my district who are desperate for
opioids because well-meaning but underinformed physicians
repeatedly over-prescribed opioids for them. I can guarantee
everyone sitting on this dais today has veterans back home
suffering for the same reason, and let me be clear, this is not
something that anyone up here on this dais or in this room
should accept as good treatment for veterans. The tragedy in
these situations is that so many of them are preventable just
by giving doctors the right tools and the right information on
how to prescribe these safely to which patients, and we want to
make this a high priority.
H.R. 3832 implements the commission's recommendation by
granting providers the ability to use an interstate PDMP
platform for the betterment of our veterans who are at risk of
opioid abuse. Every doctor has a duty to help the sick, and
according to one's ability and judgment. So as a Committee, we
have a duty to ensure the veterans have access to doctors who
are enabled to make the best clinically informed decision for
the veterans.
I encourage my colleagues to support H.R. 3832, and I yield
my time back, Mr. Chairman.
[The prepared statement of Neal Dunn appears in the
Appendix]
Mr. Wenstrup. Thank you, Dr. Dunn. Mr. Correa, you are now
recognized for five minutes.
STATEMENT OF HONORABLE LUIS CORREA
Mr. Correa. Thank you, Mr. Chairman Wenstrup, Ranking
Member Brownley, and Members of the Subcommittee for the
opportunity to speak on my bipartisan bill H.R. 4334, the
Improving Oversight of Women Veterans Care Act, and I want to
thank my friend and colleague, Ranking Member Brownley, for her
support of this legislation.
Women represent the fastest growing population of veterans
in our society. In 2015, women represented 9.4 percent of the
total veteran population. By 2045, this number is expected to
go above 16 percent. Yet according to the GAO, the Veterans
Health Administration does not have performance measures to
determine women's veteran accessibility to gender-specific
care.
My bill will enhance the monitoring needed for effective
oversight of women's veteran's health by requiring the VA to
submit an annual report on veteran access to gender-specific
care under community care contracts, and quarterly reports on
environment of care standards for women veterans. This will
ensure that we understand women veterans' ability to access
gender-specific health services.
I understand my bill may require technical edits, and I am
open to working with the Committee and others to address those
needed changes. Again, I thank you for the chance to speak
before this Subcommittee.
I yield.
[The prepared statement of Luis Correa appears in the
Appendix]
Mr. Wenstrup. Well, thank you. And Mr. Coffman, you are now
recognized for five minutes.
STATEMENT OF HONORABLE MIKE COFFMAN
Mr. Coffman. Thank you. Chairman Wenstrup and Ranking
Member Brownley, thank you for allowing me to present H.R.
4635, the Peer-to-Peer Counseling Act that I introduce with
Congressman Esty to improve VA counseling afforded to female
veterans. I would also like to thank the Members of the
Subcommittee who co-sponsored H.R. 4635, Ranking Member
Congresswoman Brownley, Representative Bilirakis,
Representative Kuster, Representative Radewagen, Representative
O'Rourke, Representative Rutherford, and Representative
Gonzalez-Colon.
Currently, female veterans make up nearly 10 percent of our
Nation's veteran population, and this population is expected to
grow to 15 percent by 2030. Over the past ten years, the VA has
seen a 45 percent increase in the number of female veterans
using VA benefits, demonstrating that female veterans are
relying more and more on VA services. And as the female veteran
population increases it is critical for VA to meet future
demand.
One area of need among female veterans that warrants our
particular attention is peer-to-peer counseling. Unfortunately,
many female veterans have experienced sexual trauma and PTSD
while serving in the military, and are also suffering from
other mental conditions that put them at risk for homelessness.
Peer counseling can help female veterans who are facing these
critical issues.
The VA's 2016 suicide data report found that the risk of
suicide for female veterans was 2.4 times higher than non-
female adult females, and the rates of suicide increases more
among women than men. The data is disturbing. We owe it to our
female veterans to ensure sufficient resources are available to
assist with gender-specific needs, and that is why I introduce
H.R. 4635, the Peer-to-Peer Counseling Act.
H.R. 4635 enhances the VA's existing peer-to-peer program
which has been successful in providing peer counseling to all
veterans by ensuring the current program has a sufficient
quantity of female peer counselors for female veterans who are
separating, or newly separated, from military service. Ideal
counselors will have expertise in gender-specific issues, VA
services, and benefits focused on women, as well as employment
mentoring.
The Act also would emphasize counseling services for female
veterans who have suffered sexual trauma while serving in the
military, have PTSD, or any other mental health condition, for
our female veterans who are at risk of homelessness.
To ensure these counseling services are not only available
but also known throughout the veteran community, H.R. 4635
directs the VA Secretary to conduct outreach to inform female
veterans about the peer-to-peer program and the services
available to women.
H.R. 4635 authorizes the VA Secretary to facilitate
engagement and coordination with community organizations, state
and local governments, institutions of higher learning, and
local business organizations. With the help from our
communities, we can leverage resources and expertise that exist
within these communities.
Peer-to-Peer counseling. The Peer-to-Peer Counseling Act
ensures VA's peer-to-peer program is better postured to address
the gender-specific needs of women veterans and updates this
vitally important program to better represent the growing
veteran population it serves.
Mr. Chairman, I encourage my colleagues to support this
important legislation and I yield back the remainder of my
time.
[The prepared statement of Mike Coffman appears in the
Appendix]
Mr. Wenstrup. Well, thank you, Mr. Coffman. I thank
everyone from the first panel for being here today, and you are
now excused. I will now welcome our second panel to the witness
table.
Joining us on our second panel is Louis J. Celli, Director
of the National Veterans Affairs and Rehabilitation Division of
The American Legion; Adrian Atizado, the Deputy National
Legislative Director for the Disabled American Veterans; Sarah
S. Dean, Associate Legislative Director for the Paralyzed
Veterans of America, and Kayda Keleher, Associate Director for
the National Legislative Service of the Veterans of Foreign
Wars of the United States.
While VA is unable to be here, I do look forward to
receiving the Department's views for the record, and appreciate
our veteran service organizations for their time and attendance
this afternoon.
Mr. Celli, we will begin with you. If you are ready, you
are recognized for five minutes.
STATEMENT OF LOUIS J. CELLI
Mr. Celli. Tree bark, mold spores, poppy, cocoa,
rhododendrons. There are more than a hundred distinct chemical
substances that are derived from organic plants being used in
pharmacology today. From these organic substances, we enjoy the
benefit of aspirin, a tranquilizer called Rhomitoxin, codeine,
and morphine, and in 1928, a petri dish contaminated with
floating mold spores changed the course of human history by
introducing the first antibiotic, penicillin.
General Wenstrup, Ranking Member Brownley, distinguished
Members of the Subcommittee on Health, on behalf of National
Commander Denise Rohan and The American Legion, I am honored to
be able to testify on the following and pending draft
legislation.
According to The National Institute of Health, cannabis is
a complex plant with over 400 chemical entities, of which more
than 60 of them are cannabinoid compounds. Today, 30 states
have medical cannabis laws that allow patients to use cannabis
for illnesses ranging from inflammation and pain to epilepsy
and cancer, and all 50 states have legalized one of the
chemical derivatives, cannabidiol or CBD, as it is more
commonly known today.
And yet there isn't a single physician who has been
formally trained by an accredited U.S. based medical school on
what this plant can or can't do. There is no education that
discusses medicinal use, drug interaction, placebo effect,
dosage rates, strains, or anything else regarding this plant
because the United States Drug Enforcement Agency continues to
insist that cannabis has, and I quote, ``No currently accepted
medical use, and a high propensity for abuse,'' as opposed to
Schedule IV drugs, like Xanax, Darvon, Valium, Ativan, Ambien,
and Tramadol, which according to the DEA have a low propensity
for abuse and low risk of dependence.
The National Academy of Medicine recently reviewed 10,000
scientific abstracts on the therapeutic value of cannabis and
reached nearly a hundred conclusions in a 2017 report. And yet
the United States continues to lag behind other developed
Nations by restricting scientific research into this drug. The
draft legislation will call on VA to conduct the research
necessary to determine if the cannabis plant, marijuana, has
medical value or not. Our veterans are asking for this
research, and our Nation has an obligation to provide it.
Next, I will address H.R. 1506, the Health Care Debt
Reduction Act. The Department of Veteran Affairs went from
33,000 vacancies in 2016 to 43,000 vacancies today, a 30
percent increase. The Department has been the subject of
intense scrutiny over the past several years, and rightfully
so, but along with that scrutiny comes responsibility, the
responsibility to be fair and balanced. The VA operates the
largest health care network in the country, some say in all the
world, and just like any large organization, VA has a board of
directors, you.
We often compare VA to private industry. We hold them up
against private metrics, quality standards, efficiencies, wait
times, and cost benefit ratios, but we fall short when it comes
time to argue that the employees' pay needs to be competitive
to their non-government peers. H.R. 1506 can help fix that by
making VA a more attractive employment option for our health
care community by offering to pay some of their student debt.
Will this solve the problem? Not entirely, but what it will do
is prove that we are willing to invest in high quality
professionals to care for our wounded and ill veterans.
The Veterans Opioid Abuse Prevention Act will bring VA
online with state-based prescription monitoring programs. This
is in the best interest of patients and helps doctors provide
holistic quality medicine at the Federal level. Patients
commonly have multiple doctors, and it is especially true for
veterans who because of their combat related injuries commonly
suffer more co-morbidities than their civilian counterparts.
In the absence of a single lifetime medical record that can
be accessed and shared among all patients--medical
professionals' participation in a unified database that helps
guard against drug interaction and duplication of prescriptions
is an important step in ensuring veterans receive proper and
accurate care.
Next, peer-to-peer counseling has always been a preferred
counseling medium, long supported by The American Legion. VA's
hundreds of vet centers were built on this very premise, and
The American Legion continues to support this reliable,
individual, peer-to-peer counseling where veterans who have had
similar experiences can share their stories and tactics for
recovery. That said, we support H.R. 4635.
At this time, we are unable to support H.R. 2322, the
Injured Amputee Veterans Bills of Rights Act because it appears
to be missing some language which appears to be a very simple
fix. The American Legion is committed to ensuring that all
veterans, especially those with catastrophic injuries, receive
expert care. We just have to be careful that we don't create a
mechanism whereby VA has no control over how that care is
delivered or how the government will pay for it. We wouldn't
have an issue if the bill contained the passage that is
reflected in the VA Handbook stating, ``Or the veteran's
preferred prosthetist who has agreed to accept the preferred
provider rate,'' which unfortunately, this bill is missing.
Thank you and I look forward to your questions.
[The prepared statement of Luis J. Celli appears in the
Appendix]
Mr. Wenstrup. Well, thank you. Mr. Atizado, you are now
recognized for five minutes.
STATEMENT OF ADRIAN M. ATIZADO
Mr. Atizado. Mr. Chairman, Members of the Subcommittee, I
want to thank you for inviting DAV to testify at this
legislative hearing today. As you know, DAV is a non-profit
service organization. We provide a lifetime of support to all
generation of veterans, and we have been helping more than a
million veterans each and every year to better their lives and
empower them.
I am pleased to offer DAV's views for your consideration on
the bills for today's hearing. I would like to start off with
comments to H.R. 1506. DAV urges the Subcommittee to pass this
bill, The VA Healthcare Provider Education Debt Relief Act of
2017, which would improve VA's ability to compete with other
entities in recruiting and retaining high-quality clinicians to
take care of our Nation's veterans and provide them
comprehensive care.
In our testimony, we make recommendations to improve this
critical piece of legislation and make it stronger. One, we
would like to see the deadline for this program be extended
beyond its current date. Two, we would like to make sure that
there is increased funding for this program. And three, we
would like just the Subcommittee to review the staffing for
this program. According to VA, it requires one staff for any
additional 1,000 participants in the program, and if we want to
consider effective use of monies and keep VA accountable, I
think that is something this Committee should be looking at.
As you are aware, the average debt that a medical student
graduates in 2017 is about $190,000, and the student loan, this
debt, weighs heavily on them when they consider their
employment. And I think EDRP is one of the most successfully
utilized programs that VA has. Combined with the caps that this
Committee had passed and agreed to in 2014, not only has the
number of participants in this program increased, it has also
increased the average amount of award, meaning for the same
amount of money we are having to provide more and more.
Last year GAO found that local facilities depleted their
EDRP budgets early in the physical year. They were not able to
commit to provide debt reduction payments to incoming students
and clinicians because they simply ran out of money. This bill
would also amend the condition in which VA could waive these
authority--these statutory caps. We do ask the Committee review
that this does not--and we know this is not the intent, but we
hope that it doesn't impinge on the ability for local
facilities to use their current statutory authority in light of
the ones that are being proposed now.
DAV strongly supports H.R. 4334, The Improving Oversight of
the Women Veterans Care Act of 2017. This bill would improve
current efforts to ensure access to quality gender-specific
health services provided through community care contracts as
well as highlight VA facilities' performance in meeting
standard that they have agreed to meet with regard to
environment of care.
As this committee knows, women veterans are about 10
percent of the veteran population in total, and it is growing.
We have got 20 percent of new recruits are women veterans, 15
percent of active duty are women veterans, and 18 percent of
Guard and Reserve are women--or are female servicemembers. The
provisions in this bill, Mr. Chairman, are consistent with the
recommendations of DAV's report. We issued that report in 2014.
It is called Women Veterans: A Long Journey Home.
This report spans the breadth and depth of all Federal
assistance that is available to women veterans, and we make
recommendations in every single one of those. We are in the
process of updating this report, and we would be so happy to
brief the Subcommittee as well as the Full Committee on those
findings.
DAV also is pleased to offer its support for H.R. 4635,
which would increase the number of peer-to-peer specialists to
provide women veteran support and counseling tailored to them
and their needs. We recommend the Subcommittee consider adding
funding for this program to ensure peer specialists are given
priority among other critical clinical professional vacancies
that VA has to fill.
Mr. Chairman, VA's existing peer support program has been
shown to be effective in assisting patients to not only become
more active and more engaged in their treatment, but to be
empowered, to be able to advocate for themselves, and it
improves patient satisfaction as well as their quality of life.
Facilities such as West Palm Beach, Chillicothe, Cincinnati,
they have shown that this program is quite effective for their
patient population.
Women peer specialists are available to assist and guide
other women veterans in accessing the services that they need,
which is the bulk of the legislation for today's hearing.
This concludes my statement, Mr. Chairman. I would be happy
and be pleased to answer any questions you or other Members on
the Subcommittee, may have.
[The prepared statement of Adrian M. Atizado appears in the
Appendix]
Mr. Wenstrup. Thank you, very much. Ms. Dean, you are now
recognized for five minutes.
STATEMENT OF SARAH S. DEAN
Ms. Dean. Chairman Wenstrup, Ranking Member Brownley, and
Members of the Subcommittee, Paralyzed Veterans of America
thanks you for the opportunity to present our views on the
legislation before you today.
PVA supports H.R. 3832, the Veterans Opioid Abuse
Prevention Act. Given the specialized needs of veterans, it is
not uncommon for some to travel to different states to receive
their care. And there is no assurance that the prescription
data of a veteran who receives care at an SCI center in
Minneapolis, but lives in Wyoming, can be shared. We urge the
Subcommittee to ensure--to make sure these specialized patient
populations are benefitting from the opioid safety measures in
the same way as non-traveling veterans. H.R. 3832 is the means
to do just that.
PVA strongly supports H.R. 1506, the VA Healthcare Provider
Education Debt Reduction Act of 2017. We believe VA must be
adequately resourced to attract the best and brightest medical
professionals, and the Education Debt Reduction Program has
been a markedly successful means to do just that. As there is a
current and worsening provider shortage in the United States,
VA must be able to insulate, as best as possible, veterans'
care from this trend.
That new residents are hesitant to take a post in an
underserved community should come as no surprise. The cost
burden of their education and training is an overwhelming
prospect, and debt is all but guaranteed. No matter how eager
to serve any resident may be, a career at an understaffed VA
may not be a tenable choice, and loan assistance can cultivate
a culture of commitment from those unburdened by their debt and
revive areas too long stressed by continuous shortages.
PVA appreciates deeply the work of this Committee this year
on behalf of the Caregiver Program. Your staffs have maintained
a thoughtful and open dialogue on the issues of the draft
before us and we thank them for that. The draft addresses, in
part, the greatest malformation of the current program, the
unequal treatment of veterans with the same service-connected
needs. And for eight years, VSOs have asked Congress to reckon
with this unjustice, and we appreciate the Members' commitment
to that goal.
This draft does address it, but does so in a way that
creates a different imbalance. It strikes the date of injury
requirement, but raises the clinical eligibility from one or
more activity of daily living to three. And while this would
make a still imperfect program, it is an imperfection that my
members, veterans with spinal cord injuries, can endure a
little easier knowing that they and their caregivers are
finally receiving the clinical supports and services their
injuries require.
Our support for this draft is not any statement on the work
and sacrifices of those with one or two ADLs. Our position
remains the full expansion of the current program, but my
members can't unhear the ticking clock in their lives, not just
the decades of work their caregivers have done unsupported and
unacknowledged, but the very real sensitivity of the time they
have left to them and their wish to spend that time at home.
We appreciate the cost and quality considerations of the
draft, and while we support it, we do so as a first step
because two activities of daily living due to injury or a
disease are still activities of daily living that a veteran
need someone else to do because they were injured in their
service. PVA's organizational mandate is to expand and improve
the current program to all veterans with catastrophic service-
connected injuries or illnesses, and in this moment in time,
the means to most closely accomplish that mandate is the
negotiated package that was to be included in the omnibus last
month.
That would see that the equal treatment of injured veterans
is done by striking the 9/11 date. This issue is an urgent one,
and aside from any consideration of cost savings, of
institutional care, or the right way to do eligibility, the
majority of veterans today are over 65. And those injured
because they served are having conversations about what the
rest of their lives will look like, and their caregivers are
wondering if they can continue to do this alone. These families
need the financial and clinical supports of this program right
now. We ask the Subcommittee to see that some relief in some
form is finally provided to those who need it most as soon as
possible.
Mr. Chairman, PVA thanks the Subcommittee and I am happy to
answer any questions you may have.
[The prepared statement of Sara S. Dean appears in the
Appendix]
Mr. Wenstrup. Thank you very much.
Ms. Keleher, you are now recognized for 5 minutes.
STATEMENT OF KAYDA KELEHER
Ms. Keleher. Chairman Wenstrup, Ranking Member Brownley,
Members of the Subcommittee, it is my honor to represent the
1.7 million members of the Veterans of Foreign Wars of the
United States and its Auxiliary.
The VFW is pleased to support bills H.R. 4334 and 4635. As
you all know, women veterans are the fastest growing
demographic within the veteran population, and the VFW has
worked hard alongside Congress and VA to make sure they are
able to access the best health care possible. While a lot of
progress has been made, there is still room for improvement.
H.R. 4635 would be an outstanding asset for VA to be able
to increase the number of peer-to-peer counselors for women
veterans who have survived sexual trauma, are diagnosed with
post-traumatic stress disorder, struggle with other behavioral
health conditions, or are deemed at risk for homelessness.
With the hardships faced by these women, including
increased rates of suicide and homelessness, this legislation
would be an invaluable benefit.
H.R. 4334 would be instrumental in providing oversight for
Congress and VA. This bill would provide oversight for women
who choose VA, but must still receive care in the community for
sex-specific appointments. By doing this, we would be assuring
that patients still receive the highest quality of care
possible.
The VFW believes the expansion of VA's Program for
Comprehensive Assistance for Family Caregivers is long overdue
and agrees with the intent of this draft legislation, but has
very serious concerns with it as currently written. The VFW
would oppose setting arbitrary eligibility requirements, such
as increasing the criteria to three activities of daily living
and efforts to lower costs.
The VFW also has concerns with other aspects of this draft
legislation, such as the lack of provisions addressing
caregivers and veterans graduating out of the program.
Currently, when and if a veteran improves and is slated to be
removed from the program, there is a lump-sum totaling three
months of their stipend paid from VA. This abrupt ending has
resulted in financial, emotional, and medical distress of the
veteran and their caregiver.
In addition to this, the VFW believes equity between DoD
and CMS must be provided by including those who are made ill
due to their service.
Moving ahead, the VFW looks forward to continuing to work
with Congress in assuring the package of the Community Care
Package from S. 2193 that includes the expansion of caregivers,
which the VFW supports.
The VFW is happy to support H.R. 5520 for reiterating VA's
current authority for research on medical cannabis. With over
half of the country's states legalizing marijuana, along with
the current opioid epidemic and ongoing Forever War, the VFW
believes it is medically irresponsible for VA providers to be
left in the dark, not knowing about health outcomes and
pharmaceutical interactions associated with medical marijuana.
With veteran patients able to easily access medical marijuana
legally, VA providers must understand the effects associated
with patient's marijuana use. Many states and academic entities
have already conducted research and now is the time for the
next episode of medical cannabis research at the Federal level.
Previous and current studies have found results showcasing
how CBD helps patients with chronic pain and decreases opioid
abuse relapses, an over-represented health struggle for
veterans. While other studies show THC helps with varying
symptoms associated with PTSD and cancer recovery -- also
health concerns either over-represented or of high prevalence
within the veteran community.
This is all in addition to high prescription rates from VA,
though better than those in the private sector, for opioids,
benzodiazepines, and SSRIs, with little to no data showing how
marijuana interacts with these FDA-approved drugs. This is
particularly troubling as the only two drugs FDA approved for
PTSD are SSRIs. Studies published by AMA show SSRIs are no more
effective than placebos for most adult patients, and other
medical research shows that SSRIs are only effective on less
than half the adult population with depressive symptoms, all
while medical providers and researchers scramble with
addressing the highly-addictive negative outcomes that come
with prescribing opioids, benzodiazepines, and other drugs
The VFW knows VA is a leader in medical research. VA
researchers have even won Nobel Peace Prizes in the past. This
is why we believe that VA should lead the way in allowing our
country to better understand medical marijuana for the safety
of our Nation's veterans.
Chairman Wenstrup, thank you again for the opportunity to
present to you today, and I look forward to questions you or
the Subcommittee Members may have.
[The prepared statement of Kayda Keleher appears in the
Appendix]
Mr. Wenstrup. Well, thank you all very much. I appreciate
your testimony here today. True professionals, you all neatly
stay right under 5 minutes, I appreciate that. But I yield
myself 5 minutes for questions.
I want to start with you, Mr. Celli. You were talking about
the draft bill to allow VA research on cannabis. You said in
October 2017 there was a nationwide survey conducted The
American Legion. Can you describe how the survey was conducted
and what your findings were?
Mr. Celli. I can. Thank you, Chairman Wenstrup.
We hired an independent research firm and gave them some
really basic questions, Dear Veteran, and they were responsible
for going out and finding veteran households. They didn't use
our members, some of them may have been coincidentally our
members, but it was completely independent, it was hands-off,
and we just waited for the results. And we asked them a series
of different questions that gauged their interest in if
cannabis should be legal medically, if the Federal Government
should do research, if it should be rescheduled, and we have a
complete printout of all of those results that we are happy to
share with this Committee.
Mr. Wenstrup. What was the response on the research part?
Mr. Celli. The research was overwhelmingly positive in
support of legislation that would allow for not only research,
but also for medical use, overwhelmingly, it was over 90
percent.
Mr. Wenstrup. So from that were you able to be guided in
any way, shape, or form for what type of specific research that
the American Legion may be interested in the VA doing?
Mr. Celli. So there is a host of different illnesses that
the cannabis has been--you know, that our veterans have told us
that cannabis has been successful for. PTSD is certainly one of
them, but so is inflammation, so is pain management, epilepsy.
There is just a variety of different illnesses that this drug,
which it is a drug, has been successful in patients with.
Mr. Wenstrup. Why, thank you. And I appreciate if you would
forward over the results.
Mr. Celli. I am very much happy to do that.
Mr. Wenstrup. That would be very helpful. Thank you for
doing that.
Mr. Atizado, you talked about the family caregivers and the
stipend involved. What do you think is a more appropriate
stipend schedule, what would that look like?
Mr. Atizado. So, Mr. Chairman, before I answer that
question, I just want to give a little bit of background about
the discussion that took place that yielded what we have now.
At the time that the stipend schedule was being discussed
from statute to be made into regulation and implemented as a
program, the idea was the population being served was
undergoing tremendous stress and strain, and the goal of having
what is currently the current schedule is to give them a sense
of stability, that they can count on whatever modest stipend
that they would be receiving would offer them some financial
stability and not add to the stress.
And so the idea that VA decided to use was specifically the
BLS survey of homemaker/home health aide wages, which is
referred to in the statute. Now, the statute and the law didn't
specifically tell them to use that, that is just what the
agency decided to use. And in its regulation, it had noted
there was wide variation in the amount of homemaker/health
wages from any geographic region from one to another and that
has led to these wild deviations from the norm or for the mean.
And so we don't believe that the current issue with the
stipend program being labor-intensive, as well as having such
wide deviations in pay, is necessarily based on statute and we
think VA could regulate themselves out of this mess in using
what this Committee in holding its roundtable, there have been
talk about maybe using a GS schedule which is both
geographically reflective, as well as meeting the intent of the
law of not being any less than what a homemaker/home health
aide would receive pay for.
So there are a number of schedules that VA can use that
meets the intent of the law that doesn't incur this labor-
intensive and this wild deviation of stipends.
Mr. Wenstrup. Thank you.
With that, I will now recognize Ms. Brownley for 5 minutes.
Ms. Brownley. Thank you, Mr. Chairman.
My first question is really to all four of you. And thank
you all for being here, and your constant and steadfast counsel
is very, very helpful. So the question is, how would the lack
of a grandfather clause--this has to do with the caregiver
bill--the lack of a grandfather clause allowing currently
enrolled veterans to continue to participate in the revised
program impact the veteran caregiver community?
In other words, we have got, you know, two different sets
of standards and what do you think the impacts are going to be?
Ms. Keleher. Thank you. The VFW, moving forward, we would
not be in support of having two different standards between
post-9/11 veterans and veterans who did serve beforehand. We do
believe that including a grandfather clause if eligibility
requirements are to change is absolutely necessary. It would
provide clarity to not just the veteran, but to VA as well, for
what the standard for those currently on it are.
If by any means that eligibility requirement did change,
there needs to be something set in stone saying that
individuals who are currently on the program, even if they are
not at the same eligibility requirement or standard moving
forward, saying that they are safe, and they are going to
remain on the program, and continue getting the support and
recognition from VA that they have been receiving.
Ms. Brownley. Any other comments from anyone?
Mr. Celli. The American Legion could never support a bill
that reduces benefits for veterans, just as simple as that.
Ms. Brownley. So PVA has recommended the use of multi-
disciplinary teams in caregiver eligibility assessments in the
past, Ms. Dean, so what disciplines would you like to see
represented on the team?
Ms. Dean. They already are being--that already is the way
that the program is executed is to use multi-disciplinary teams
as a way to sort of not allow for the whole decision to rest on
one doctor at a facility, so that the pressure from the family
or the veteran doesn't influence that one doctor's decision. So
it is a team decision already and I think that should continue.
Ms. Brownley. So, Ms. Keleher, on the medicinal cannabis
issue you stated I think in your testimony it would be
medically unethical for Congress to allow VA providers to stay
in the dark on medicinal cannabis. Could you expand somewhat on
that statement?
Ms. Keleher. Yes. As a non-doctor, doctors are required to
provide ethical treatment that is in the best interest of the
patient. So particularly in the instance of VA, as a Federal
entity and they are in states where it is medically legal, the
VFW views it as being unethical for them not to understand the
science and medical research behind the interactions, whether
it be CBD or THC is actually more valuable than a
pharmaceutical drug, or whether it is that there is an
interaction between one of the pharmaceuticals that they are
taking with their recreational or medical use.
So we view it as being unethical that in a sense VA not
having this research or the lack thereof with Federal research
that these providers just they don't know, they are in the
dark.
Ms. Brownley. So, and to anyone who would like to answer,
this particular legislation allows the VA to do research and I
think that kind of codifies what the VA can already do, it is
my understanding, but don't you believe that we should have a
bill that says, you know, the VA should and must do the
research in this area?
Mr. Celli. Well, you know, I think that VA has really
stepped up to the plate. Former Secretary David Shulkin had
issued a memo stating that primary care physicians would have
these conversations with their patients and in good faith, and
would record that conversation in their medical records.
Unfortunately, you know, to VFW's point, right now physicians
don't have the clinical training because there is no research
that the Federal Government supports that they can learn from.
You know, it is a vicious cycle.
We definitely think that the VA should do the research, but
we also understand, you know, VA's apprehension of wanting to
be at cross purposes with Federal law and their boss. So, you
know, legislation is what they need, I think that is what we
are here for today, and we support that.
Ms. Brownley. Thank you very much.
I have no more questions. I yield back.
Mr. Wenstrup. Mr. Higgins, you are now recognized for 5
minutes.
Mr. Higgins. Thank you, Mr. Chairman.
Mr. Celli, regarding your organization's position on
medical marijuana, cannabis research, there have been thousands
of studies around the world on this subject already.
Mr. Celli. There are and, you know, the nice thing about
having those studies already at the Federal Government's
disposal is that, once they make a decision to study cannabis
and take it off of Schedule I, put it down into, you know, a
schedule that will allow medical institutions, allow colleges,
allow the Federal Government to study it, they can then absorb
those existing research studies. So they wouldn't have to start
from ground zero, so it is very beneficial.
Mr. Higgins. So isn't it, specifically regarding the VA,
let's stay away from society in general for the moment, much to
the chagrin of my friend at the rear of the room, let's focus
on veterans, for a Federal program, wouldn't there have to be a
federally mandated standard of THC within the cannabis?
And hasn't this always been the difficulty amongst the
thousands of surveys and studies that have been done around the
world is not the question of whether or not cannabis has
medicinal value, certainly I don't question it and I support
it, by the way, but our challenge, isn't it to actually
introduce cannabis medicinally into the Federal system, the VHA
system, doesn't that challenge come down to the THC content and
how to regulate that? We are talking about growing a plant. Or
does the Legion support synthetic production of a medicinal
equivalent?
And just share with us what your thoughts are on that,
please.
Mr. Celli. Congressman Higgins, that is an excellent point,
and what the Legion supports right now is research specifically
to answer those very questions that you have. There is no
standard dosage, there is no standard efficacy, there is no
standard strength, and just like with an opiate, you wouldn't
just randomly take a poppy plant, grind it up, and create your
own opiates and decide that--
Mr. Higgins. Exactly.
Mr. Celli [continued]. --you are going to self-medicate.
So the research absolutely needs to be done; it needs to be
done professionally by scientists, it needs to be validated by
the Federal Government, and then they can turn around and take
this drug and they can distill it into whatever media or
whatever delivery method that is appropriate for the patient
based on the illness, and then they can deliver it that way.
Mr. Higgins. Thank you for your clarification and you have
just very eloquently explained why I support this draft
legislation.
Mr. Atizado, I believe we should support veterans if they
would like to look outside the VA for their prosthetics.
Reasonable accommodations should always be made to ensure that
veterans receive the best care available according to that
veteran's unique needs.
Is it your understanding that the VA's policy pertaining to
prosthetic or orthotics and other rehabilitative services have
effectively changed, and are veterans now experiencing more
difficulty or less getting the authorizations they need for the
life-changing items when they use providers outside of the VA?
Just share with the Committee, please, your feelings on it.
Mr. Atizado. Thank you for that question, Congressman
Higgins.
So we, a lot of our members use VA's prosthetics and
sensory-aid service by virtue of who our organization
representations and are trying to serve. So, over the years the
program, the service has actually changed, and because
fundamental aspects of that program has changed over years it
has impacted service delivery, but there is a catch. The change
is supposed to have yielded some positive results, which we are
still trying to engage VA to make sure that has happened,
because there has been some problems getting the care and
services and the items in a timely manner.
We are very appreciative of VA actually creating my
understanding is a complaint line that patients can actually
call and get their attention, and get the leadership of the
program's attention to address those situations in a more
timely manner that has been occurring lately.
And so to your question, it has had some growing pains,
that it has adversely impacted patients who need this service,
but we are working very closely with VA to improve them,
because we hear from our members and other patients about these
programs and we can identify possibly policy issues or
statutory limitations to just make it work better for veterans.
Mr. Higgins. Thank you for your answer, sir, very thorough.
Mr. Chairman, I yield back, my time has expired.
Mr. Wenstrup. Mr. Takano, you are now recognized for 5
minutes.
Mr. Takano. Thank you, Mr. Chairman.
I want to just echo Ranking Member Brownley's comments
about the Family Caregivers Program and I would like to back
the sentiments of The American Legion that I would not support
anything that would diminish the benefits for any veteran, and
that I prefer what I see occurring with the Senate bill, which
is to expand the current program to veterans to all eras is our
best option. And so I just want to make sure we get that on the
record now.
But I want to move on to H.R. 1506, which has been the VA
Care Provider Education Debt Relief Act of 2017, which has been
offered by my colleague Mr. O'Rourke. How can Congress ensure
that the authority granted under this legislation to increase
the caps for educational debt is properly implemented and
utilized following enactment?
Mr. Atizado. Thank you for that question, Mr. Takano. I
would have to direct you to VA and, unfortunately, they are not
here to answer this question, but the EDRP program is well
tracked by VA. They can project with a good amount of certainty
the number of new applicants that will be coming into the
program, as well as how many are currently in and how long they
will be in.
And so I think if you work with the department, with that
agency, in identifying what they believe will be the new demand
because of these new caps, I think you will get a very
respectful answer as far as funding levels moving forward.
Mr. Takano. Well, Mr. Atizado, in your written testimony
you highlight the fact that the Education Debt Reduction
Program is set to expire at the end of next year. What impact
would that have on VA's ability to recruit and retain medical
providers?
Mr. Atizado. Well, so it would be quite devastating for
these medical graduates, these clinicians. The award under this
program is usually a multi-year award, and so what you will get
is a number of current participants who probably, you know, are
serving as clinicians in the VA health care system with an
agreement that VA may not need. And so they will be saddled
with these student debts that they thought would otherwise be
taken care of, at least in part or if not in whole by the VA,
suddenly find themselves having to repay those because of the
extinguishment of this program, not to mention the number, the
thousands of vacancies that are out there that facilities won't
be able to fill simply because they don't have this as a tool
at their disposal.
Mr. Takano. So you are saying it is a very important tool
to be able to bring medical professionals into our health care
system, that without it these positions will continue to be
vacant or we could see more vacancies occur as people leave the
VA through separations or retirements.
Mr. Atizado. Well, yes, sir. So that is actually a very
good point. If this were to expire and they have these loans
that they need to pay, they are likely going to get released
from the agreement and probably seek employment elsewhere where
they can have those debts extinguished.
But to the point, you know, facilities use this program,
the Education Debt Reduction Program, as well as another
program called the Relocation, Recruitment, and Retention
Program, the RRR Program. That program actually suffers from a
cap as well, much like this. And so those two are actually very
important tools that local facilities use to recruit new
medical graduates, as well as retain high quality health
professionals within the health care system, and because those
two are under stress now, to us, we understand why VA's
vacancies remain as high as they are.
Mr. Takano. Well, I hadn't heard about the caps on this
other program. What is the program called again, the RRR you
said?
Mr. Atizado. So it stands for Recruitment, Relocation and
Retention. It got swept into the VA Choice bill that was
enacted back in 2014 and it was swept into the cap for bonuses
being paid.
So we actually supported the idea of limiting bonuses being
paid to clinicians because of poor performance, right? But the
RRR is not a performance-based, it is actually a recruitment
and retention instrument, but it somehow got pulled into those
caps. And we have been working very closely with not only the
Full Committee, but the Senate VA Committee to address that
issue as well.
Mr. Takano. All right. Well, thank you very much.
My time is up. I'm sorry I went over, Mr. Chairman, and I
yield back.
Mr. Wenstrup. Mr. Rutherford, you are now recognized for 5
minutes.
Mr. Rutherford. Thank you, Mr. Chairman.
First, I would like to say that I am a strong supporter of
improving and expanding the loan-repayment program at VHA and
that is why I offered my VA Physician Recruitment Act, which
includes that loan repayment, as an amendment to the Choice
legislation that the Committee agreed to and moved earlier last
year.
Everything Mr. O'Rourke said highlights the fact that we
have got to get this right and we have got to get it right
soon, because half of all providers in VA are eligible for
retirement within the next 10 years. That is a scary thought.
And what is even scarier is the Senate Choice Act, their
proposal still extends the Graduate Medical Education Program
as a way to bring more doctors into the system. However, in
hearings that we have had with the previous Secretary and Dr.
Clancy, we have learned that, number one, this is more
expensive, less effective, and potentially brings in less
qualified physicians to care for our veterans, where loan
repayment provides VA with more flexibility to recruit the most
qualified candidates.
And so, Mr. Atizado, can you give me your perspective on
the GME versus the loan repayment? The GME as it still remains
in the Senate Choice Act.
Mr. Atizado. So, Congressman Rutherford, I first have to
let you know that I think we do support the GME proposal. We
think VA frankly needs every tool in the bucket that they can
have in there. Certainly, GME has its own purpose and it is
successful in its own way, but I don't believe the two should
be seen as a competition. I think they both work in different
ways to enhance the local facility, fill a critical need.
I think GME works in areas where there are facilities who
have very strong affiliate relationships where they have that
pool of talent that comes in to help care for veterans, both in
the academic institution as well as in the VA facilities, and I
think that program works very well, but not all facilities have
that kind of relationship with an affiliate. And so these other
tools, these financial-incentive tools, become more important
for those other facilities.
So I think those two are good programs and each--
Mr. Rutherford. Complementary?
Mr. Atizado. I believe so, yes, sir, for the whole system
as a whole to address its workforce shortage issues.
Mr. Rutherford. Okay. Anybody else want to comment on that,
GME vs. loan repayment? Okay.
Let me share this experience too. Mr. Chairman, when I was
sheriff in Florida, I had an opportunity, I was a legislative
chairman for the Florida Sheriffs Association. When we actually
as an association of 67 sheriffs advocated for Charlotte's Web,
which is an extract of cannabis, very high in CBDs, but low in
THC, and I have seen, I can tell you firsthand the results of
Charlotte's Web on a little girl who was around eight or nine
years old suffering a tremendous number of seizures every day.
Her legs, she couldn't get out of bed, her legs had atrophied.
With Charlotte's Web, a year later, that girl was up walking
around.
That is why I support this idea that we have to look at
this drug, see what we can do to help individuals with a drug
that I think for too long we have just mischaracterized--well,
I don't want to--I am not defending marijuana, but I am saying
there is a medicinal purpose and efficacy there that I would
like to see studied.
And so with that, Mr. Chairman, I will yield back.
Mr. Wenstrup. Mr. O'Rourke, you are now recognized for 5
minutes.
Mr. O'Rourke. Thank you, Mr. Chairman.
Mr. Chairman, I have got to say I really appreciate the
conversation today and the fact that on almost every one of
these bills there seems to be bipartisan agreement on what it
is we are trying to do here, and very helpful feedback from the
panel, some constructive criticism that on at least the bill
that we have authored, H.R. 1506, will incorporate into the
changes that we will propose.
And I agree with some of the panelists that perhaps the
only complaint I have is that some of these bills do not go far
enough. And I love what the Chairman is doing on the Family
Caregiver Program, but I want to make sure, as one of the
panelists said, that this is just a first step, it doesn't get
us to where we are.
And I think implied in some of the questions about medical
cannabis is how much more study do we need to do for something
that is legal in 29 states, that doctors are already
prescribing. That veterans in Texas at least come up to me at
town hall meetings and say this is the only thing that I can
take that makes life livable for me, but I am treated as a
criminal under the law in this state. How screwed up is that?
And if we are going to wait for study upon study upon study for
veterans to get the care they need, especially if it is an
alternative to opioids, from which veterans are dying today.
I had a town hall meeting in El Paso, a veteran came
forward and he said, listen, the VA cut off my opioid
prescription and I understand why the VA is doing this, but
they didn't provide an alternative in its place and I am--and
he said this in front of 200 people at the town hall--I am
buying heroin on the street right now because this is how I can
take care of this issue.
I think we have got to go, you know, within the bounds of
reason and medicine and science as quickly as we can to making
sure that doctors can prescribe what they think is in the best
interest of their patients, including cannabis or marijuana. I
think we are there. And just given the number of states who are
there, the number of countries who are there, the number of
veterans who need it, I mean, let's get there.
On the debt repayment issue--and we authored it--I don't
think it goes far enough. I mean, that is my complaint. We
should be much more aggressive in raising the caps, and if we
have got between 30 and 40,000 vacancies, let's be aggressive
on that. I mean, there are people literally dying right now
because they cannot get in to see an appointment. We still have
a crisis in veteran suicide, though the last Secretary made it
his number one clinical priority.
And so I think, especially in those under-served, in-demand
professions I think of psychiatry, and the need for those who
treat traumatic brain injury and post-traumatic stress
disorder, let's make it as easy as possible to make the choice
to practice medicine in the Veterans Health Administration or
to stay there, if you are already there. And I think everyone
is on the same page, it is just I want us to be as aggressive
as possible. And so your comments about making sure that this
is funded, that we get past the sunset, and that we do
everything within our power to make this attractive hit home,
and I will do everything that I can.
And I just, I think within the context of $1.4 trillion in
outstanding student loan debt, why do we make it so hard for
people to better themselves, so that they can do better for
their fellow Americans, especially in the VA. This is an
investment this country absolutely should make. And so I hope
there is bipartisan commitment to actually fund what we are
proposing to authorize.
So I don't really have a question. I think you all did such
a great job in providing your feedback and we are taking notes
on all this, and just I want to tell you that we are grateful
for that.
And I will yield back to the Chairman.
Mr. Wenstrup. Thank you.
Dr. Dunn, you are now recognized for 5 minutes.
Mr. Dunn. Thank you, Chairman Wenstrup.
My principal interest today has been the Veterans Opioid
Abuse Prevention Act, one of the bills we are considering here.
I don't have the sense, as Mr. O'Rourke said, I don't have the
sense of any pushback from anybody, but I want to poll you
explicitly. Do you have the sense in any of the VSOs that there
is opposition to this prescription database sharing plan? Any
of you or all of you.
Mr. Celli. So based on the feedback from our veterans, it
is not that there would be opposition to it, it is that there
has been such a pendulum swing of, you know, the opioid crisis
with veterans who are in chronic pain and on systemic lifelong
opioid prescriptions, they are very concerned that their
prescriptions will be reduced and that they will not be able to
perform the daily functions that they are currently able to
enjoy now.
So any time there is legislation, legislative efforts, or
efforts by our Federal Government to try to curtail the abuse,
the patients who are taking this as prescribed get very
nervous. So that would be the only thing.
And the only other thing that I would add to that is, if we
had the lifetime electronic medical record, we wouldn't need
additional legislation specifically to track prescriptions. So
I think that we have work to do in both of those areas.
Mr. Dunn. So I appreciate that comment as a surgeon myself
and I don't look forward to having my hands tied on how long I
can prescribe a medicine for. I don't know that I can say that
that won't happen, honestly, because as you have hinted at, you
know, the Government tends to overreact when they react. So,
you know, buckle up, it could be a bumpy ride, but I do agree
with that.
I do also want to make one more comment about the cannabis
research. You know, we have a form of legal cannabis now that
really has no abuse history at all, very effective. It is
actually tetrahydrocannabinol, the stuff that makes you high in
cannabis. And I just looked it, because I want to be sure I was
right, it is a Schedule III drug. So it should be very easy to
do research on, at least that form or that cannabinoid, which
is just one of dozens to hundreds of cannabinoids in a
marijuana plant and it is different than the cannabinoid that
Congressman Sheriff Rutherford mentioned, which I am familiar
with and is effective against, you know, seizure disorders in
some children, and certainly want to make that available, it is
available in Florida to children. I don't see a lot of veterans
with that particular affliction, because it affects infant
children.
But, you know, I think we could study the THC in the
Marinol, the generic name is Dronabinol and it is just
tetrahydrocannabinol. So I don't know if you have any comment
on that, but it is available, and it actually would be pretty
easy to do research on a Schedule III drug, I think.
Any thoughts?
Mr. Celli. Well, the only thing that I would add to that,
and I am not a scientist, but I do know that there are
components within that tetra cannabinol that are in the
Schedule IV--or in Schedule I, rather, that prohibits the
Federal Government from authorizing--
Mr. Dunn. Well, so that is a marijuana plant. So I am just
saying--
Mr. Celli. Correct, that is right.
Mr. Dunn [continued]. --if you want to do research on THC,
tetrahydrocannabinol, you can go at it all day long and it is
not even a particularly controlled drug. I have prescribed it
and it is only used currently for anorexia, and for pain
potentiation in typically terminal patients, but, you know, it
is a very available drug and I have never seen it abused, I
have never seen it stolen, I have never heard of it, you know,
walking out of a pharmacy. I wish Buddy Carter were here. But I
think it is a pretty, you know, available drug for study right
now.
I have no other questions, Mr. Chairman, and I am happy to
yield back.
Mr. Wenstrup. Ms. Kuster, you are now recognized for 5
minutes.
Ms. Kuster. Thank you very much, Mr. Chairman, and thank
you to all of you for being with us. I just want to join my
colleagues that these are predominantly bipartisan bills and it
is great to make progress here in the Veterans' Affairs
Committee, and I have joined as a cosponsor on most of the
bills.
I want to direct some of my concerns. I appreciate the
efforts that Dr. Roe has made to come up with a bipartisan
compromise on the benefits for family caregivers, but I still
am concerned about the policy proposed and the fact that it
doesn't really resolve the fundamental lack of fairness between
our post-9/11 and pre-9/11 veterans.
This is just directed at any of the VSO witnesses. Besides
increased cost to the VA, is there any other reason not to
expand the program to include all veterans of all eras that
require home caregivers?
Mr. Celli. We believe it is only a cost issue.
Ms. Keleher. Yes. The VFW doesn't see any reason to not
expand to everybody as is. We do understand there is constant
concern and some criticisms on VA for the way the current
program has been implemented and road bumps that they have
undoubtedly had along the way. But, again, VFW doesn't look at
that as a reason to not expand for all eras of veterans.
Ms. Kuster. I mean, sometimes, this is just my impression,
I think we spend a whole lot of money trying to limit care and
determine who is eligible for what, and I really like the way
you said it that, you know, being unable to do two activities
of daily living is a major constrain on someone's life that you
need help with.
So could the VSOs explain some of the potential unintended
consequences of expanding benefits to only those with three or
more activities of daily living? So, just briefly, examples of
how that would be a problem.
Ms. Dean. I think we have seen it the last 8 years of the
program as is. This inherent unfairness about people who need
these services, but are not allowed because of an arbitrary
date. We are picking a new lucky cohort, essentially.
Ms. Kuster. Well, now we're not only having an arbitrary
date, but now we're having an arbitrary number of issues that
you might have, which I can't imagine medically that has any
basis in reality.
And then could you give us some examples of veterans that
would not qualify for expanded benefits, but reasonably might
need additional help? Does anybody have an example of what this
might look like?
Mr. Atizado. So, in the current program now, you would have
a significant majority who would fall under the one and two ADL
who would have to be transitioned out and I can't even imagine
the impact on their lives, not only on the veteran's, but the
caregiver's and their families as well if that were to happen.
I do want to make sure we understand, though, you know, the
intent of the legislation is to operate to expand the program,
within certain constraints, and so we appreciate that work. We
very much appreciate the work that Congressman Roe has done,
his staff has done to talk to us about how to do this within
these constraints, and we appreciate that. But to echo my
colleague's comments, we have an opportunity, we have an
historic opportunity before us, before this Committee and the
Senate and Congress, to actually not even have to talk about
the proposed draft bill, because we are talking about actually
expanding the current program to all eras. And I really have
been thankful of my colleagues' support and all the Members'
support to try and make that a reality this year. And so I
would prefer we actually focus on making that a reality and
then pick up, if that in case doesn't happen, then perhaps take
up this conversation after.
Ms. Kuster. Well, I would love to work with you on that,
and I certainly think that is the direction we want to go.
Otherwise, I just want to join my colleagues, anything that
we can do to improve access to care for women veterans and also
the veteran opioid abuse prevention, this is something that I
have dedicated the past five years of my life. We have a
bipartisan task force with 105 Members, Republicans and
Democrats, trying to tackle the opioid epidemic all across our
country. And I think the VA is where a lot of the innovative
solutions will come from, both to lower the rate of opioid
prescriptions by using alternative pain management, and also to
help with this prescription monitoring program, and help with
more efficient and effective methods for treatment and long-
term recovery.
And I yield back.
Mr. Wenstrup. I want to thank everyone once again. Thank
you all for being here. I appreciate all the input you provided
with us today and the second panel is now excused.
And I ask unanimous consent that all Members have 5
legislative days to revise and extend their remarks and include
extraneous material.
Without objection, so ordered.
I would like to once again thank all of you, our witnesses
and audience members, for joining us this afternoon. The
hearing is now adjourned.
[Whereupon, at 5:04 p.m., the Subcommittee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Honorable Beto O'Rourke
Chairman Wenstrup, Ranking Member Brownley, honorable Members of
the Committee it is my pleasure today to present to the House Committee
on Veterans Affairs Subcommittee on Health H.R. 1506 -VA Health Care
Provider Education Debt Relief Act of 2017. Thank you for this
opportunity. I introduced H.R. 1506 on March 10, 2017 to address
serious staffing shortages throughout the Department of Veterans
Affairs (VA) and to increase the VA's recruitment and retention
capacity for high need and difficult to fill medical provider
positions. It is my hope we can work together to ensure talented
medical professional remain in the VA to deliver quality care to our
veterans.
H.R. 1506 increases the maximum amount of education debt reduction
available for health care professionals employed by the Veterans Health
Administration (VHA) participating in certain education reimbursement
programs. The bill also makes clear the definition of a provider
shortage so that VA facilities can better address their efforts to fill
the highest need provider positions.
Colleagues, you are well aware of the enduring provider shortage at
the VA. When this bill was introduced, the VA reported a shortage of
43,000 medical providers nationally. This number remains in the tens of
thousands. Last week, VA spokesman, Mark Cashour, reported, as of early
March 2018, there are more than 33,000 full-time vacancies at the VA.
\1\ At the February 15th Full Committee VA budget hearing, we learned
from then Secretary Shulkin that the VA has approximately 2,800 vacant
mental health provider positions. These are positions critical for
ensuring veterans get the care they need - care they have earned
through their service - in a timely fashion.
---------------------------------------------------------------------------
\1\ Washington Post, 10 April 2018.
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In many cases, timely care can save lives. Currently, veterans are
waiting approximately four days for primary care and mental health care
appointment. In some regions, this can be upwards of 7-10 days. \2\ A
2016 report from the RAND Corporation states ``only about half of
veterans reported getting care ``as soon as needed.'''' \3\ Today,
mental health care providers at the VA are doing their best to serve
veterans, however, their case loads are much too large and they report
``burn out'' and frustration.
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\2\ VA, Report: Pending Appointments as of 1 April 2018.
\3\ ``Balancing Demand and Supply for Veterans' Health Care,'' RAND
Corporation, 2016, pg. 9.
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Staffing shortages also hurt retention. Medical providers,
specifically, mental health care providers cite being overworked and
underpaid as one of the top reasons they seek positions in the private
sector. In February, I met with a nurse from the Houston VA who shared
his experience in this kind of work environment; he also impressed upon
me the importance of recruitment and retention efforts focused on
specialty providers. This reinforces the importance of H.R. 1506.
According to the 2016 Commission on Care Report, medical providers at
the VA make an average $74,631 less than those in the private sector,
while the long-term earning potential differential at the top of the
salary range can be as much as $310,000. Furthermore, the report
explains, ``lower salaries reduce VHA's competitive edge [.] when
trying to attract top talent.'' \4\
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\4\ Commission on Care Report, 2016, VA.
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H.R. 1506 bill seeks to make the VA a more attractive employer by
increasing the benefit available for a VA medical professional who is
part of the Education Debt Reduction Program (EDRP). The EDRP is a
student loan reimbursement program for employees with qualifying
student loans in provider positions that are difficult to recruit and
retain as determined by each VHA facility. \5\ The VA estimated there
are about 3,000 medical professionals participating in this program. In
accordance with 38 U.S. Code Section 7683(d) and under the
EDRP, an employee with student loans for a degree program that
qualified the individual for their position at the VA is eligible for a
maximum benefit of $120,000 over the course of five years as
reimbursement for their proven student loan payments.
---------------------------------------------------------------------------
\5\ VA, Education Debt Reduction Program (EDRP).
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H.R. 1506 increases the total amount of reimbursement eligible from
$120,000 to $150,000 keeping in place the five year time frame.
Accordingly, the bill would increase the total amount of debt reduction
possible per year from $24,000 to $30,000. Keeping in mind the average
long-term earning difference between medical professional at the VHA
and their counterparts in the private sector is estimated at $74,631,
this bill provides a modest increase in the benefit available for a VA
professional by $30,000.
H.R. 1506 is both relevant and important. At a time when the
collective student debt held by Americans is around $1.3 trillion
dollars, \6\ making loan repayment possible for those who serve in high
need and critical public service positions could not be more important.
For the 2017-2018 academic year, the Association of American Medical
Colleges (AAMC) reports the average cost of attendance (tuition fees,
and health insurance) for an in-state student at a public medical
school was $53,327 per year, while the average cost per year for a
private medical school (all nonresident) was about $67,000 per year.
\7\ The cost of attendance estimates show a 3.5% increase from 2016. At
the least, H.R. 1506 will provide additional support for the rising
cost of attendance for medical school. And, I hope this bill will help
further recruitment and retention for critical medical professional and
specialists at VA.
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\6\ ``Student Loan Debt In 2017, A$1.3 Trillion Crisis,'' Forbes,
21 February 2017.
\7\ Association of American Medical Colleges, ``Tuition and Student
Fees for First-Year Students,'' 2017-2018.
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Finally, this bill more clearly defines what it means to have a
provider shortage, thus allowing for the waiver of reimbursement caps
for certain positions at VA facilities in Health Professional Shortage
Areas (HPSA) set annually by the Department of Health and Human
Services (HHS). This bill would encourage the Secretary of Veterans
Affairs to exercise the authority to waive provider education debt
reimbursement limits to fill provider vacancies with a focus on
geographic locations as having shortage areas in primary care.
I remain dedicated to ensuring the brave men and women who have
served this country receive excellent care. To do this, we must provide
the VA resources necessary to recruit and retain the best and the
brightest in the field of medicine. I look forward to working with my
colleagues to ensure the VA is equipped with the resources needed to
take care of our nation's heroes. Again, it is my pleasure to lead on
this legislation and look forward to working with everyone here to
close the provider gap, retain talented and motivated VA professions,
and, most importantly, care for our veterans. Thank you to all Members
of the Committee, Ranking Member Brownley, and Chairman Wenstrup for
your time and attention.
Prepared Statement of Honorable Walberg
VA Committee Hearing on H.R. 2322 Testimony
Chairman Wenstrup and Ranking Member Brownley, thank you for
allowing me to be here today to testify on H.R. 2322, The Injured and
Amputee Veterans Bill of Rights. I would like to start off by thanking
the Subcommittee members and staff for their time and willingness to
work with me on this important topic.
I think we can all agree that our veterans have earned the highest
quality possible health care. I understand there are problems at the
Veterans Affairs and that this committee is diligently working to
address these concerns to ensure our veterans receive the benefits and
care they deserve. I also know there are great doctors, nurses and
staff that work hard to make sure our veterans receive timely care.
With that being said, I believe a veteran's healthcare decisions
are personal choices. We know all too well that the VA can be an
intimidating and hard to navigate bureaucracy. There are layers of
paperwork and red tape that can make these healthcare decisions
daunting. H.R. 2322 moves to empower veterans when it comes to making
their own healthcare choices and it does so by ensuring injured and
amputee veterans know their healthcare rights.
Years on the battlefield has taken a toll on our war fighters. Our
veterans are younger than before and transitioning from active duty can
be difficult. We need to ensure that amputee veterans have the best
access to care and ability to more easily transition into civilian
life.
The Injured and Amputee Veterans Bill of Rights is a bipartisan
approach to empower injured and amputee veterans in making their
healthcare choices. This bill simply requires the VA to prominently
display a list of ``rights'' in VA Orthotic and Prosthetic (O&P)
clinics as well as on their website.
These rights include:
1. The right to access the highest quality and most appropriate O&P
care
2. The right to continuity of care during their transition
3. The right to select the practitioner of their choice
4. The right to consistent and portable healthcare, including
obtaining comparable services at any VA medical facility
5. The right to timely and efficient O&P care
6. The right to play a meaningful role in their rehabilitation
process and a second medical opinion
7. The right to both a primary prosthesis and orthosis and a
functional spare
8. The right to be treated with respect and dignity during and
after their rehabilitation
9. The right to transition and readjust to civilian life in an
honorable manner
Additionally, the VA would be required to educate their staff so VA
employees can help veterans navigate this process.
To make sure veterans are receiving the care they deserve and need,
our bill also requires the VA to follow up and resolve any complaints
by veterans who believe the VA is not meeting their O&P needs.
Mr. Chairman, at the end of the day, veterans should receive the
best available and timely care they can get. I know this is something
you and your staff have worked hard on and I applaud your unwavering
commitment to our veterans.
I am willing to work with you and your committee in any way to
better this legislation so that we can empower injured and amputee
veterans when they are making their healthcare choices.
Thank you for your time today and for the work this committee is
doing to keep our promise to our nation's heroes.
Prepared Statement of Honorable Rep. Neal P Dunn, M.D.
Statement for the Record - H.R. 3832, ``Veteran's Opioid Abuse
Prevention Act''
Mr. Chairman, thank you for the opportunity to speak today on
behalf of H.R. 3832, the ``Veterans Opioid Abuse Prevention Act.''
According to the Centers for Disease Control, 249 million
prescriptions were written by healthcare providers in 2013. The
Department of Veterans' Affairs healthcare system is the nation's
largest healthcare provider, and because of this, is in a unique
position to help curb the opioid epidemic by using every tool available
when a veteran is prescribed an opioid. The ``Veterans Opioid Abuse
Prevention Act'' gives VA health care providers access to these
valuable tools.
H.R. 3832 comes directly from recommendations from the nation's top
policy makers. The White House's Commission on Combatting Drug
Addiction and the Opioid Crisis recommended last July that the VA lead
efforts to have all state and Federal Prescription Drug Monitoring
Programs - known as PDMPs - share information. The interim report cited
multiple published best practices for PDMPs, and has identified
interstate data sharing among PDMPs as a ``top priority'' to ensure
that healthcare professionals have a better understanding for
prescribing practices for their patients.
H.R. 3832 directs the VA to have healthcare providers participate
in sharing prescribing data across a network of interstate prescription
drug monitoring programs. PDMPs are state-based networks which
healthcare providers and pharmacists can access when writing or filling
a prescription. PDMP data includes types of medications dispensed, fill
dates, and dosage amounts. PDMPs improve a clinician's ability to
follow good prescribing practices for at-risk patients who may have a
pattern of prescription opioid abuse. In 2011, the National Board of
Pharmacy created a national platform of Prescription Monitoring
Programs - or PMPs - called ``PMP Interconnect'' - which allows states
to share PDMP data across state lines securely. Today, 44 states and
Washington D.C. participate in PMP Interconnect, with more soon to
follow suit.
I have veterans in my district who are desperate for opioids
because well-meaning but underinformed doctors have time and time again
have overprescribed opioids for them. I can guarantee everyone sitting
on this dais today has veterans back home suffering for the same
reason. And let me be clear - this is not something anyone up here on
this dais or in this room should accept as good treatment for our
veterans. The tragedy in these situations is that so many of them are
preventable by just giving doctors the right tools to decide on how to
prescribe an opioid safely. We must make sure this is a priority.
H.R. 3832 implements the Commission's recommendation by granting
providers the ability to use an interstate PDMP platform for the
betterment of our veterans who are at risk of opioid abuse. Every
doctor has a duty to help the sick according to one's own ability and
judgment, and we as a Committee have a duty to ensure veterans have
access to doctors who are enabled to make the best clinically-informed
judgments for veterans.
I encourage my colleagues to support H.R. 3832, and I yield my time
back to the Chairman. Thank you.
Prepared Statement of Honorable Congressman J. Luis Correa
H.R. 4334 - Improving Oversight of Women Veterans' Care Act
Thank you, Chairman Wenstrup, Ranking Member Brownley, and Members
of the Subcommittee. I appreciate the opportunity to speak on my
bipartisan legislation today: H.R. 4334, the Improving Oversight of
Women Veterans' Care Act. I am particularly grateful to my friend and
colleague Ranking Member Brownley for her support of the bill.
Women represent the fastest growing population in the veteran
community. According to the Department of Veterans Affairs, there are
about two million women veterans today. That number is expected to
increase at an average rate of about 18,000 women per year for the next
ten years. It is important that we ensure that women veterans receive
quality care in a safe and dignified environment, as well as in a
timely manner.
According to the Government Accountability Office, the Veterans
Health Administration does not have performance measures to determine
women veterans' accessibility to gender-specific care delivered through
certain community care programs despite having such metrics for
Patient-Centered Community Care (PC3). Additionally, GAO reports that
the Veterans Health Administration does not have accurate or complete
data regarding VA medical centers' compliance with environment of care
standards for women veterans. Currently, medical centers must conduct
regular inspections and report instances of noncompliance, but
sometimes these cases are not reported to VHA.
My legislation will enhance the monitoring needed for effective
oversight of women veterans' by requiring VA to submit an annual report
on veteran access to gender-specific care under community care
contracts and quarterly reports on environment of care standards for
women veterans. This will ensure we understand women veterans' ability
to access gender-specific health services.
I understand the legislation may require technical edits and I am
open to working together with my colleagues to address those needed
changes. Again, thank you for the chance to speak before the
Subcommittee.
Prepared Statement of Honorable Mike Coffman
Chairman Wenstrup and Ranking Member Brownley, thank you for
allowing me to present H.R. 4635, The Peer-2-Peer Counseling Act that I
introduced with Congresswoman Esty to improve VA counseling afforded to
female veterans. I would also like to thank the members of the
Subcommittee who co-sponsored H.R. 4635 - Rep Bilirakis, Rep Radewagen,
Rep O'Rourke, Rep Rutherford, and Rep Gonzalez-Colon.
Currently, female Veterans make up 10% of our nation's veteran
population and this population is expected to grow to 15% by 2030. Over
the past 10 years, the VA has seen a 45% increase in the number of
female veterans using VA benefits, demonstrating that female veterans
are relying more and more on VA services. As the female veteran
population increases, it is critical for VA to meet future demand.
One area of need among female veterans that warrants our particular
attention is peer-to-peer counseling. Unfortunately, many female
veterans have experienced sexual trauma and PTSD while serving in the
military and are also suffering from other mental conditions that put
them at risk for homelessness. Peer counseling can help female veterans
who are facing these critical issues.
The VA's 2016 suicide data report found that the risk of suicide
for female veterans was 2.4 times higher than non-veteran adult females
and the rates of suicide increase more among women than men. This data
is disturbing. We owe it to our female veterans to ensure sufficient
resources are available to assist with gender-specific needs and that
is why I introduced H.R. 4635, The Peer-2-Peer Counseling Act.
H.R. 4635 enhances the VA's existing Peer-to-Peer program, which
has been successful in providing peer counseling to all veterans, by
ensuring the current program has a sufficient quantity of female peer
counselors for female veterans who are separating or newly separated
from military service. Ideal counselors will have expertise in gender-
specific issues, VA services and benefits focused on women, as well as
employment mentoring.
The act would also emphasize counseling services for female
veterans who have suffered sexual trauma while serving in the military,
have PTSD or any other mental health condition, or female veterans who
are at risk for homelessness.
To ensure these counseling services are not only available but also
known throughout the veteran community, H.R. 4635 directs the VA
Secretary to conduct outreach to inform female veterans about the peer-
to-peer program and the services available to women.
Finally, H.R. 4635 authorizes the VA Secretary to facilitate
engagement and coordination with community organizations, state and
local governments, institutions of higher learning, and local business
organizations. With the help from our communities, we can leverage
resources and expertise that exists within our communities.
The Peer-2-Peer Counseling Act ensures VA's peer-to-peer program is
better postured to address the gender-specific needs of women veterans
and updates this vitally important program to better represent the
growing veteran population it serves.
Mr. Chairman, I encourage my colleagues to support this important
legislation and I yield back the remainder of my time.
Prepared Statement of Louis J. Celli Jr.
Chairman Wenstrup, Ranking Member Brownley and distinguished
members of the Subcommittee on Health; on behalf of National Commander
Denise H. Rohan and The American Legion, the country's largest
patriotic wartime veterans service organization, comprising over 2
million members and serving every man and woman who has worn the
uniform for this country, we thank you for the opportunity to testify
on behalf of The American Legion's positions on the following pending
and draft legislation.
H.R. 1506 - VA Health Care Provider Education Debt Relief Act of 2017
To amend Title 38, United States Code, to increase the maximum
amount of education debt reduction available for health care
professionals employed by the Veterans Health Administration, and for
other purposes
The American Legion is deeply troubled by the Department of
Veterans Affairs (VA) leadership, physicians and medical specialist
staffing shortages within the Veterans Health Administration (VHA).
Since the inception of our System Worth Saving program in 2003, The
American Legion has identified, and reported staffing shortages at
every VA medical facility and reported these critical deficiencies to
Congress, the VA Central Office (VACO), and the President of the United
States.
Currently, there are 43,000 vacancies throughout the VA in primary
care, mental health care and dental care providers. Moreover, the June
2016 Commission on Care report has concluded that, ``in the area of
educational debt repayment relief, VHA lags behind other federal and
state agencies that use such programs to fill critical physician
shortages in medically under-served areas.'' \1\
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\1\ Commission on Care Final Report, June 30, 2016, page 145
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This bill provides an incentive to attract qualified providers to
fill the above noted vacancies by increasing total educational loan
repayment amounts from $120,000 to $150,000 and annual debt repayment
amounts from $24,000 to $30,000.
During testimony before the joint House and Senate Veterans'
Affairs Committees this February, our National Commander called for
raising the ceiling of the VA Debt Relief Reduction program to $200,000
to increase VA probability of attracting high-quality talent in its
recruitment efforts. \2\
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\2\ https://www.veterans.senate.gov/hearings/legislative-
presentation-of-the-american-legion--02282018
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In VA's Office of Inspector General (VAOIG) September 27, 2017
report entitled ``Veterans Health Administration's Occupational
Staffing Shortages,'' VAOIG determined based on data provided by VHA
that the largest critical need occupations were Medical Officers,
Nurses, Psychologists, Physician Assistants, and Medical Technologists.
\3\
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\3\ VAOIG Report 17-00936-835
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One medical center interviewed by VAOIG reported encountering
recruitment challenges generally related to ``extreme competition'' for
quality healthcare professionals. The facility further stated that it
made use of multiple recruitment endeavors such as special salary
rates, incentives (for recruitment, relocation, and retention), and an
education debt reduction program.
During The American Legion May 2017 System Worth Saving site visit
to the Alaska VA Healthcare System, medical center personnel voiced
concerns that community hospitals are offering to repay a provider's
debt in exchange for them coming to work at their hospital. While VA
has a debt reduction program, VA does not forgive provider's debt in
exchange for acceptance of a position at a particular VAMC. \4\
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\4\ 2017 Alaska VA Healthcare System Worth Saving Site visit
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A common theme our System Worth Saving team hears from VHA medical
center human resource staff and physicians is VA's debt reduction
program is not adequately funded and the amount VA can offer to a VA
provider is not in keeping with what local community hospitals can pay.
Under current law, the amount of education debt reduction payments
made to or for a participant under VA's Education Debt Reduction
Program may not exceed $120,000 over a total of five years of
participation in the Program, of which not more than $24,000 of such
payments may be made in each year of participation in the Program.
According to the Association of American Medical Colleges, the
average medical school debt balance for graduating physicians in 2015
was $183,000, and is no doubt higher today. Add that burden to their
average undergraduate balance of $24,000 and the total average student
loan balance for a doctor is $207,000. \5\ Once interest is factored
in, repayment amounts can range from $329,000 to $480,000. \6\
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\5\ Gitlen, Jeff. Average Medical School Debt, LendEDU, Feb. 15,
2017, lendedu.com/blog/average-medical-school-debt/
\6\ Marquit, Miranda. Is Medical School Worth It? 4 Questions to
Ask Before Deciding, Student Loan Hero, Feb. 9, 2018,
studentloanhero.com/featured/cost-of-medical-school-worth-it/
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Through The American Legion Resolution No. 377, Support for Veteran
Quality of Life, we support any legislation and programs within the VA
that will enhance, promote, restore or preserve benefits for veterans
and their dependents, including, but not limited to, the following:
timely access to quality VA health care, timely decisions on claims and
receipt of earned benefits, and final resting places in national
shrines and with lasting tributes that commemorates their service. \7\
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\7\ The American Legion Resolution No. 377 (2016): Support for
Veteran Quality of Life
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The VA Health Care Provider Education Debt Relief Act will grant
this nation's veterans better access to care by increasing the number
of doctors available to be seen and will improve the overall quality of
care that the VA is able to provide.
The American Legion supports H.R. 1506.
H.R. 2322 - Injured and Amputee Veterans Bill of Rights
To direct the Secretary of Veterans Affairs to educate certain
staff of the Department of Veterans Affairs and to inform veterans
about the Injured and Amputee Veterans Bill of Rights, and for other
purposes
The American Legion has long opposed the privatization of the
Department of Veterans Affairs (VA.) Though we understand the intention
of HR 2322, which is to highlight and provide more and better benefits
and educations as to the rights of those who have lost a limb in
service of this nation, the VA in concert with the veteran patient,
must determine when the veteran should seek and obtain care outside the
community. In order for the VA to remain an organization that is there
to serve the 9 million currently enrolled veterans, and those in the
future, the VA must have the final approval on when a veteran is
approved for outside care.
Allowing veterans to elect when the VA pays more for outside care,
especially when they may have the internal ability, will destroy the
VA, leaving a dilapidated system.
H.R. 2322, calls for a veteran to have the right to select a
practitioner that best meets their orthotic and prosthetic needs,
whether or not that practitioner is an employee of the VA, a private
practitioner who has entered into a contact with the VA, or even a
private practitioner with specialized expertise. Allowing veterans to
simply dictate when they government spends money is a dangerous slope
that will turn the robust VA system into nothing more than an over-
paying insurance system.
Through American Legion Resolution No. 372: Oppose Closing or
Privatization of Department of Veterans Affairs Health Care System,
passed in 2016, The American Legion opposes any legislation or effort
to close or privatize the Department of Veterans Affairs healthcare
system.
The American Legion Opposes H.R. 2322.
H.R 3832 - Veterans Opioid Abuse Prevention Act
To direct the Secretary of Veterans Affairs to enter into a
memorandum of understanding with the executive director of a national
network of State-based prescription monitoring programs under which
Department of Veterans Affairs health care providers shall query such
network, and for other purposes
America continues to be in the throes of an opioid addiction
crisis, including an epidemic of overdose deaths, affecting veterans
and non-veterans alike. \8\ H.R. 3832 directs the Department of
Veterans Affairs (VA) to connect VA health care providers to a national
network of state-based prescription drug monitoring programs (PDMPs),
databases which track controlled substance prescriptions. PDMPs ensure
health care providers do not accidently prescribe dangerous and
potentially lethal combinations of drugs to patients who also see other
healthcare providers. These state programs also have been proven to
curb ``doctor shopping'' whereby people visit multiple health care
providers to solicit more prescription medications than their original
doctor has agreed to prescribe.
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\8\ http://thehill.com/blogs/congress-blog/healthcare/241243-a-
national-prescription-drug-database-to-combat-opioid
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Currently, VA doctors are required to consult state-based PDMPs
before prescribing potentially dangerous pain medications to veterans.
VA doctors, however, lack the ability to consult a national network of
state-based PDMPs that can identify someone from another state who is
at high risk for abuse, overdose, and death.
H.R. 3832 would help overcome this lack by directing VA to enter
into a memorandum of understanding with the executive director of a
national network of state-based prescription drug monitoring programs
under which VA health care providers shall query such a network to
support the safe and effective prescribing of controlled substances to
covered patients. Under such memorandum of understanding:
(1) Department health care providers practicing in a state that
participates in such network shall query such network in accordance
with the agreement between that state's prescription drug monitoring
program and such network in accordance with applicable Veterans Health
Administration policies; and
(2) Department health care providers practicing in states that do
not participate in such network shall query such network through the
drug monitoring program of the participating State that is in closest
proximity to the State where the provider is practicing.
Because prescription abuse, misuse, and diversion is a nationwide
issue, it is vital that VA and states work together to share PDMP data
and provide a national solution to prescription abuse issues. \9\ The
President's Commission on Combating Drug Addiction and the Opioid
Crisis issued a preliminary report in July 2017 that cited the lack of
cross-state interoperability as one significant shortcoming of state
PDMPs. The Commission recommended ``enhancing interstate data sharing
among state-based prescription drug monitoring programs.'' \10\
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\9\ https://www.pharmacist.com/sites/default/files/files/
Prescription%20Drug%20Monitoring%20Programs.pdf
\10\ https://www.whitehouse.gov/ondcp/presidents-commission/
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Through The American Legion Resolution No. 83: Virtual Lifetime
Electronic Record, we support the use of Electronic Health Records as a
method of coordinating care provided to veterans inside and outside VA
medical facilities and the controlled but widespread sharing of
electronic medical records so that veterans can receive the highest
possible quality healthcare available. \11\
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\11\ American Legion Resolution No. 83 (Sept. 2106): Virtual
Lifetime Electronic Record
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The American Legion supports H.R. 3832.
H.R. 4334 - Improving Oversight of Women Veterans' Care Act of 2017
To provide for certain reporting requirements relating to medical
care for women veterans provided by the Department of Veterans Affairs
and through contracts entered into by the Secretary of Veterans Affairs
with non-Department medical providers, and for other purposes
H.R. 4334 would enhance the monitoring needed for effective
oversight of women veterans' healthcare in the Department of Veterans'
Affairs (VA) and community care programs.
According to a December 2016 Government Accountability Office (GAO)
report, the Veterans Health Administration (VHA) does not have data and
performance measures to determine women veterans' accessibility to
gender-specific care delivered through the Veterans Choice Program, a
community care program. VHA does, however, already collect data to
evaluate women veterans' access to gender-specific care received
through PC3 - a different community care program. \12\
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\12\ Improved Monitoring Needed for Effective Oversight of Care for
Women Veterans. GAO-17-52: Published: Dec 2, 2016
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The GAO report also found that VHA does not have accurate or
complete data regarding medical centers' compliance with environment of
care standards for women veterans. Medical centers must conduct regular
inspections and report instances of noncompliance, however sometimes
instances of noncompliance are not reported to VHA.
This legislation would require VA to report to Congress women
veterans' accessibility to gender-specific healthcare in any community
of care program. The report must include the average waiting period
between the veteran's preferred appointment date and the date on which
the appointment is completed, and driving time required for veterans to
attend their appointments. The bill would also require VA medical
facilities to report to the Secretary the compliance and noncompliance
of the facility to ensure they meet quality care standards for women
veterans. Evidence gathered from the reports could potentially help the
VA enhance and preserve the benefits and the medical care for women
veterans while providing timely access to care.
Through The American Legion Resolution No. 377, Support for Veteran
Quality of Life, we support any legislation and programs within the VA
that will enhance, promote, restore or preserve benefits for veterans
and their dependents, including, but not limited to, the following:
timely access to quality VA health care, timely decisions on claims and
receipt of earned benefits, and final resting places in national
shrines and with lasting tributes that commemorates their service. \13\
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\13\ The American Legion Resolution No. 377 (2016): Support for
Veteran Quality of Life
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The American Legion supports H.R. 4334.
H.R. 4635
To direct the Secretary of Veterans Affairs to increase the number
of peer-to-peer counselors providing counseling for women veterans, and
for other purposes.
H.R. 4635 would help ensure that the Department of Veterans'
Affairs (VA) existing peer-to-peer counseling program has sufficient
female peer counselors for female veterans who are separating or newly
separated from military service.
This bill, as written, would also emphasize counseling for women
who suffered sexual trauma while serving, have PTSD or another mental
health condition, or are at risk of becoming homeless. The American
Legion supports the goal of this legislation recognizing the risk of
suicide is 2.4 times higher among female veterans when compared to
their civilian counterparts. The American Legions also recognizes
existing peer-to-peer counseling programs have been successful and this
bill creates a more representative program for the veteran population.
Peer counselors are veterans themselves and can relate in profound ways
to the mental health challenges facing fellow veterans. By connecting
female veterans with one another, peer-to-peer assistance can empower
female veterans to connect with each other and their communities.
Through The American Legion Resolution No. 364, Department of
Veterans Affairs to Develop Outreach and Peer to Peer Programs for
Rehabilitation, we continues to exert maximum effort to ensure that the
Secretary of Veterans Affairs utilizes returning servicemembers for
positions as peer support specialists in the effort to provide
treatment, support services and readjustment counseling for those
veterans requiring these services \14\.
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\14\ The American Legion Resolution No. 364 (2016) Department of
Veterans Affairs to Develop Outreach and Peer to Peer Programs for
Rehabilitation
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The American Legion supports H.R. 4635.
Draft Bill
To authorize the Secretary of Veterans Affairs to use the authority
of the Secretary to conduct and support research on the efficacy and
safety of medicinal cannabis
The federal government continues to list cannabis as a Schedule I
drug - the most addictive and dangerous - although its addiction rates
are lower than alcohol, and the less-restrictive Schedule II
classification that applies to opioids, which kill 91 Americans every
day.
Medical schools offer limited formal education in the human
endocannabinoid system, or the impact of cannabinoids on the human
body. Every day, thousands of citizens ingest cannabis but have no
federally certified doctor to turn to for accredited consultation. In
response to this dire need, medical education must be updated, as well.
By continuing to consider accumulating evidence of the efficacy of
cannabis-based medicines, the federal schedule fails patients fighting
debilitating conditions, including PTSD and potentially lethal opioid
addiction. The American Legion fully supports research for potential
medicinal use of cannabis and responsible action in the interest of
advancing medicine, particularly for veterans who report relief from
service-connected conditions, thanks to this important drug.
For over two years now, The American Legion has called on the
federal government to support and enable scientific research to
clinically confirm the medicinal value of cannabis. The National
Academies of Science, Engineering, and Medicine recently reviewed
10,000 scientific abstracts on the therapeutic value of cannabis and
reached nearly 100 conclusions in a 2017 report. As a two million
member strong veteran service organization, our primary interest and
advocacy is grounded in the wellbeing and improved health of our
veterans, and specifically our service disabled veterans.
The American Legion is a strong, vocal proponent of the Department
of Veterans Affairs (VA) and has published several books, pamphlets,
and magazines that help showcase VA's value to The United States of
America. Our members have long been ferocious advocate's for evidence-
based, complementary and alternative medicines and therapies. For
decades, we have supported increased funding and research in such
therapies as hyperbaric oxygen therapy, Quantitative
Electroencephalography (QEEG), animal therapy, recreational therapy,
meditation, and mindfulness therapies, just to name a few, to improve
outcomes for veterans confronted with PTSD and other combat related
illnesses and injuries.
The American Legion supports VA's statutory medical research
mission and has donated millions of dollars toward expanding their
scientific research. VA innovation is widely championed for their
breakthrough discoveries in medicine and has been recognized over the
years with several Nobel Prizes for scientific work that has benefited
the world over.
The opioid crisis in America is having a disproportionate impact on
our veterans, according to a 2011 study of the VA system, as they
contend with the facts that poorly-treated chronic pain increases
suicide risk, and veterans are twice as likely to succumb to accidental
opioid overdoses. Traumatic brain injury and PTSD remain leading causes
of death and disability within the veteran community.
VA officials report that about 60 percent of veterans returning
from combat deployments and 50 percent of older veterans suffer from
chronic pain compared to 30 percent of Americans nationwide. Many
veterans suffering from post-traumatic stress disorder and chronic pain
- especially those of the Iraq and Afghanistan generation - have told
The American Legion that they have achieved improved health care
outcomes by foregoing VA-prescribed opioids in favor of medical
cannabis.
While the stories of these wartime veterans are compelling, more
research must be done in order to enable lawmakers to have a fact-based
debate on future drug policy. As a scientific research leader in this
country with a statutory obligation to care for and improve the lives
of our nation's veterans, The American Legion supports the draft bill
``VA Medicinal Cannabis Research Act of 2018'' co-sponsored by Chairman
Roe and Ranking Member Walz, that will continue to put VA at the
forefront of national cutting edge research.
The American Legion calls for immediate reclassification of
cannabis from Schedule I to Schedule III on the DEA Controlled
Substance Act Schedule to allow research into its potential for medical
application. We call on Congress to conduct oversight hearings and
support legislation that enables research on cannabis, and the medical
impact it could have for Americans suffering from; opioid over-
prescription, pain, depression and a host of other known ailments, and
direct departments and agencies within the administration to fully
cooperate in all federally authorized scientific research and offer
assistance as needed to authorize extensive research.
In October 2017, The American Legion conducted a nationwide survey
of veterans. \15\ The results are significant and reinforce The
American Legion's continued efforts, under Resolution 11, to urge
Congress to amend legislation to remove marijuana from Schedule I of
the Controlled Substances Act and reclassify it, at a minimum, as a
drug with potential medical value.
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\15\ https://www.legion.org/documents/legion/pdf/medical--
cannabis--study.pdf
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According to the survey - which included more than 1,300
respondents and achieved a +/- 3.5 percent margin of error at a 95
percent confidence level - 92 percent of veteran households support
research into the efficacy of medical cannabis for mental and physical
conditions.
Eighty-three percent of veteran households surveyed indicated that
they believe the federal government should legalize medical cannabis
nationwide; \16\
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\16\ https://www.legion.org/sites/legion.org/files/legion/
documents/Veterans%20and%20Medical%20Cannabis.pdf
82 percent said they wanted cannabis as a federally legal
treatment option.
Only 40 percent lived in states with medical marijuana
laws.
Over 60 percent were 60 and older, the largest cohort of
veterans committing suicide.
22 percent of veterans are currently using cannabis to
treat a medical condition.
And as former Speaker of the House John Boehner revealed in his
official statement when he joined the Board of Advisors for one of the
nation's largest, multi-state actively-managed cannabis corporations
last week, ``We need to look no further than our nation's 20 million
veterans, 20 percent of whom, according to a 2017 American Legion
survey, reportedly use cannabis to self-treat PTSD, chronic pain and
other ailments.'' \17\
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\17\ https://www.acreageholdings.com/news-release-board-of-
advisors-appointment
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Based on The American Legions extensive advocacy, The Department of
Veterans Affairs' recently issued updated guidance on medical marijuana
that urges government doctors to discuss medical marijuana use with
veterans, due to its clinical relevance to patient care, and discuss
marijuana use with any veterans requesting information about marijuana.
Because marijuana is a Schedule I controlled substance, VA doctors
cannot prescribe, recommend, or assist patients with getting it.
Following the VA's announcement, American Legion National Commander
Rohan issued the following statement, ``I applaud the VA in taking this
bold move toward treating veterans and also fulfilling resolutions
passed by The American Legion. We do not support recreational use of
drugs, but we do think the medicinal possibilities of cannabis should
not be ignored by the VA. We are all about putting the health of
veterans first.''
Over the course of the past two years, The American Legion has
passed two resolutions, testified on the necessity for additional
research into the effectiveness of medical cannabis, and has held a
press conference right here in this very room. We have received
thousands of comments and interactions on this issue through our
website, social media, as well as letters, phone calls, and personal
interactions around the country, and the support we receive is
overwhelmingly positive.
For more information on this research, please visit www.Legion.org/
mmjresearch
American Legion Resolution No. 11, passed in 2016, titled, Medical
Marijuana Research, The American Legion calls on the Drug Enforcement
Agency to license privately funded medical marijuana production
operations in the United States to enable safe and efficient cannabis
drug development research; and urging Congress to remove marijuana from
Schedule I and reclassify it in a category that, at a minimum, will
recognize cannabis as a drug with potential medical value. \18\
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\18\ https://archive.legion.org/bitstream/handle/20.500.12203/5763/
2016N011.pdf?sequence=4&isAllowed=y
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The American Legion supports the Draft Bill.
Draft Bill
To make certain improvements in the family caregiver support program of
the Department of Veterans Affairs
The American Legion advocates for equal benefits for all veterans
regardless of period of service, and will never support a reduction in
benefits. This bill reduces benefits to the existing caregiver program.
The American Legion opposes this bill.
The American Legion Opposes this Draft Bill.
Conclusion
As always, The American Legion thanks this Subcommittee for the
opportunity to elucidate the position of the over 2 million veteran
members of this organization. For additional information regarding this
testimony, please contact Assistant Director of the Legislative
Division, Jeff Steele, at (202) 861-2700 or [email protected].
Prepared Statement of Adrian M. Atizado
Mr. Chairman and Members of the Subcommittee:
Thank you for inviting DAV (Disabled American Veterans) to testify
at this legislative hearing of the Subcommittee on Health of the House
Veterans' Affairs Committee. As you know, DAV is a non-profit veterans
service organization comprised of more than one million wartime
service-disabled veterans that is dedicated to a single purpose:
empowering veterans to lead high-quality lives with respect and
dignity. DAV is pleased to offer our views on the bills under
consideration by the Committee.
H.R. 1506, the VA Health Care Provider Education Debt Relief Act of
2017
DAV supports passage of this important legislation based on DAV
Resolution 128, calling for enabling the Department of Veterans Affairs
(VA) to compete for, recruit and retain the types and quality of VA
employees needed to provide comprehensive health care services to sick
and disabled veterans.
We recommend the Education Debt Reduction Program be extended
beyond the current December 31, 2019 deadline, the baseline funding be
increased to achieve the intent of this measure, and that additional
program staff may be needed for successful implementation.
To recruit and retain health professionals to work at VA to meet
the health care needs of over 6 million ill and injured veterans, VA
provides financial incentives under four broad categories to improve on
the rigid government pay scales that has less room for growth than in
private practice: market-based salaries, recruitment, retention, and
relocation incentives (3Rs), Continuing Medical Education funds (CME),
and Health Professionals Educational Assistance Program (HPEAP).
This bill seeks to improve HPEAP, which includes other critical
recruitment and retention programs such as the Education Debt Reduction
Program (EDRP). EDRP is one of the most utilized programs and allows
the Veterans Health Administration (VHA) to reimburse qualifying
education loan debt for employees, including physicians, in hard-to
recruit positions. Physicians apply directly to the VA medical center,
and applications are approved by VHA to repay student loans for up to
five years.
Section 302 of Public Law 113-146, the Veterans' Access to Care
through Choice, Accountability, and Transparency Act of 2014 (VACAA)
made improvements to EDRP by increasing the monthly and annual caps on
debt reduction payments to an individual participant from $12,000 to
$24,000 and from $60,000 to $120,000, respectively. As a result, both
the number of new EDRP awards are increasing, the current active
participants increased by 45 percent and the current average award has
increased by more than 40 percent.
This measure seeks to build on the success of EDRP due to the VACAA
cap increases by increasing the current annual cap of $24,000 and five-
year cap of $120,000 to $30,000 and $150,000 respectively.
As this Subcommittee is aware, the Government Accountability Office
(GAO) October 19, 2017 reported, based on conversations with VA medical
center officials, that their EDRP program funding was insufficient,
given that both the number of applicants and the amount awarded to
individual physicians increased significantly, and that they depleted
their EDRP budgets early in the fiscal year. As a result, some
facilities GAO reviewed would not commit to providing EDRP during the
recruitment process. Instead, officials routinely told candidates that
they would consider EDRP eligibility if funding was available.
The bill would also amend the conditions under which VA could waive
such caps. Currently, the caps could be waived if the health
professional is serving in a position for which there is a shortage of
qualified employees, by reason of either location or requirements of
the position. If enacted, the bill would change the waiver criteria to
apply to health professionals working in a geographical area designated
by the Department of Health and Human Services as a health professional
shortage area with respect to such participant's specialty or
assignment. Because of the difference between these two definitions, we
urge the Subcommittee to ensure this change does not adversely impact
the ability for local VA medical centers to use EDRP in meeting their
staffing needs.
H.R. 2322, the Injured and Amputee Veterans Bill of Rights
This bill would require the Secretary of Veterans Affairs to ensure
that the ``Injured and Amputee Veterans Bill of Rights'' (hereafter
referred to as the Amputee Bill of Rights) is posted on signage and
displayed prominently in each prosthetics and orthotic clinic of the
VA. The measure includes provisions for targeted outreach to notify
veterans and veterans service organizations of the Amputee Bill of
Rights, including placement on the Department's website. H.R. 2322 also
requires VA employees working in prosthetic and orthotic clinics,
federal recovery coordinators, case managers, and those working as
patient advocates to receive training on the Amputee Bill of Rights.
The bill includes provisions mandating that each fiscal quarter
patient advocates and veterans' liaisons collect information related to
complaints and alleged mistreatment from veteran patients and report it
to the VA's Chief Consultant of Prosthetics and Sensory Aids. The Chief
Consultant would then be required to address and investigate
allegations and complaints in accordance with the Amputee Bill of
Rights.
Based on the bill, injured and amputee veterans would have the
right to:
access prosthetic and orthotic devices of the highest
quality, and appropriate technology, while receiving care from the best
qualified practitioners;
continuity of care between VA and DoD by including
comparable benefits relating to prosthetic and orthotic services;
select the practitioner that best meets a veteran's needs
regardless of the practitioner's Department affiliation (VA/DoD), to
include private practitioners that have entered into contracts with the
VA Secretary;
comparable services and technology at any VA medical
facility;
timely and efficient orthotic care, including a speedy
authorization process with expedited authorization for veterans
visiting from another area of the country;
be included in rehabilitation decisions and have the
ability to get a second opinion regarding their prosthetic and orthotic
treatment and needs;
receive a primary and functional spare prosthetic or
orthotic device;
access to VA vocational rehabilitation, employment
programs, and housing assistance; and
be treated with respect and dignity.
DAV does not have a resolution that specifically calls for an
Amputee Bill of Rights; however, DAV Resolution No. 178 calls for
sufficient funding for the Prosthetic and Sensory Aid Service and
timely delivery of prosthetic items. It also urges VA to rededicate
itself to becoming a leader in prosthetic care by providing cutting-
edge services and items to help injured, ill and wounded veterans fully
regain mobility and achieve maximum independence in their activities of
daily living, and in sports activities such as running, cycling,
skiing, rock climbing and other physical exercises if they so choose.
For the reasons mentioned above, we have no opposition to the enactment
of this legislation.
H.R. 3832, the Veterans Opioid Abuse Prevention Act
The Veterans Opioid Abuse Prevention Act requires the Secretary of
Veterans Affairs to enter into a memorandum of understanding with the
executive director of the national network of state prescription drug
monitoring programs. The purpose of this agreement would be to allow VA
to submit queries on veterans who are longer-term users of controlled
substances to such programs in the states in which the clinicians
practice, or for non-participating states, the nearest state with a
monitoring program. Submitting these veterans to these monitoring
programs would enhance the safety and effectiveness of prescribing
controlled substances to certain veterans who are prescribed such
substances for more than 90 days by ensuring they are not receiving the
same prescribed drugs from different clinicians.
DAV does not have a resolution calling for support of VA's
participation in state prescription drug monitoring programs. However,
we believe this enhances patient safety in prescribing controlled
substances with many known adverse effects, including addiction and
overdose, to veteran patients therefore; we have no objection to its
enactment.
DAV also urges Congress to ensure that VA redoubles its efforts to
conduct a uniform national pain management program to ensure that
veterans with chronic pain who have been prescribed pain medications
over long periods of time are managed in a patient-centered
environment, with balanced regard for both patient safety and provided
humane alternatives to the use of controlled substances. Additionally,
while under VA care veterans should be confident they will receive
their prescribed medications in a timely fashion to relieve unnecessary
pain or anxiety. We urge VA to monitor pain management efforts and
resolve any conflicts between the effects of the Controlled Substances
Act of 1970 and its prescribing policies and procedures to ensure the
Department is compliant with its own national pain management policy
and guidelines and comport with its stated goals of patient-centered,
safe care that offers appropriate alternatives and carefully monitors
withdrawal from controlled substances for veterans who have been long-
term users of such medications.
H.R. 4334, the Improving Oversight of Women Veterans' Care Act of 2017
DAV strongly supports H.R. 4334, in accordance with DAV Resolution
No. 225, which calls for support for enhanced medical services and
benefits for women veterans. This resolution seeks to ensure that
health care services and specialized programs provided by VA to
eligible women veterans are provided to the same degree and extent that
services are provided to eligible male veterans, inclusive of
counseling and/or psychological services incident to combat exposure or
sexual trauma.
DAV urges VA to strictly adhere to stated policies regarding
privacy and safety issues relating to the treatment of women veterans
and to proactively conduct research and health studies as appropriate,
periodically review, adjust and improve its women's health programs,
and seek innovative methods to address barriers to care, thereby better
ensuring women veterans receive the quality treatment and specialized
services they so rightly deserve.
H.R. 4334, the Improving Oversight of Women Veterans' Care Act of
2017, would require the VA Secretary to submit an annual report to
Congress on women veterans' access to covered sex-specific services
under community care contracts including the average wait time for
appointments, the veteran's driving time to the appointment and reasons
why appointments could not be scheduled with non-Departmental medical
providers.
The bill would also require each VA medical facility to submit
quarterly reports on compliance with environment of care standards to
the VA Secretary and to develop a plan within 180 days of enactment for
strengthening the process to verify non-compliance data is accurate and
complete; that all patient care areas are inspected; and to include the
list of inspected items to align with those outlined in the Women
Veterans Program Manager's Handbook.
The provisions in this bill are also consistent with
recommendations in DAV's 2014 report, Women Veterans: The Long Journey
Home. I am pleased to report that DAV will be releasing an update to
that report in the near future and we look forward to sharing our
findings and recommendations with the Subcommittee.
H.R. 4635, to increase the number of peer-to-peer counselors providing
counseling for women veterans
DAV is pleased to offer its support for H.R. 4635, legislation
calling for an increase in the number of peer-to-peer specialists to
provide support and counseling specific to women veterans. This bill is
consistent with DAV Resolution No. 225, calling for enhanced health
care services and benefits to meet the unique needs of women veterans.
If enacted, this bill would require the Secretary of Veterans
Affairs to ensure the Department has a sufficient number of peer
counselors for women veterans. These counselors may be employees of VA
and have expertise in gender-specific issues and services, employment
mentoring, service and benefits provided by the Secretary. The bill
would also require the Secretary to emphasize facilitation of peer-to-
peer counseling for women veterans who have experienced military sexual
trauma (MST), have post-traumatic stress disorder (PTSD), or other
mental health conditions, or are at risk of becoming homeless.
The Secretary would be required to conduct outreach to inform women
about the peer-to-peer program, and facilitate engagement and
coordination with community organizations, state and local governments,
institutions of higher education, chambers of commerce, local business
organizations, and organizations that provide legal assistance to
facilitate the transition of women veterans. The bill would require the
Secretary to use existing funds to carry out the mandates and
provisions in H.R. 4635.
Women comprise a small, but growing portion of the veteran
population using VA services. Many service-disabled women veterans face
challenges reintegrating into their communities following military
service. Researchers have found that women veterans often lack a
supportive social network during the transition period and that they
face a number of barriers to accessing the care and benefits they need.
Women veterans often do not self-identify as veterans and seek benefits
at lower rates than their male peers. Lack of child care services is
frequently noted as a barrier to accessing post-deployment mental
health readjustment counseling. Exposure to military sexual trauma and
abuse of alcohol are complicating factors among this population that
also make them more prone to homelessness and suicide.
Peer specialists have been shown to be especially effective in
engaging VA users in accessing needed mental health services. Ensuring
that women peer specialists are available to assist and guide other
women veterans with accessing the services they need, such as mental
health care, child care, legal assistance and assistance with job
placement or training and in identifying appropriate resources within
and outside of VA, will lead to a more successful transition and better
health outcomes for this population.
DAV supports using peer specialists as a means of expanding VA's
workforce and providing additional support to veterans with complex and
comorbid conditions such as PTSD, substance-use disorders and traumatic
brain injury. However, we are concerned that other priorities such as
filling critical health occupation vacancies within the Veterans Health
Administration (VHA) such as physicians, nurses, psychologists, and
other credentialed professionals may hamper VHA's ability to hire more
women peer specialists. For these reasons, we recommend the
Subcommittee consider adding funding for this important program.
It is critical that these peer specialists are available to provide
culturally competent and gender-sensitive assistance in navigating the
many federal government programs available to meet women veterans'
needs. VA's existing peer support program has been shown to enhance
patient engagement, increase veterans self-advocacy skills, increase
quality of life and patient satisfaction and ensure more appropriate
use of services.
Draft Bill, the VA Medicinal Cannabis Research Act of 2018
The VA Medicinal Cannabis Research Act of 2018 would allow the
Secretary of VA to engage in research on the safety and efficacy of
medicinal cannabis use on health outcomes for veterans with chronic
pain, post-traumatic stress disorder (PTSD) and other conditions the
Secretary deems appropriate. The bill would require that VA include
certain forms of cannabis in addition to different delivery methods for
using cannabis products in its research and develop a means of
preserving data for future studies. It further requires that VA develop
a five-year implementation plan for conducting such research, including
issuance of requests for proposal, within 180 days of enactment.
Finally, the bill would require VA to submit progress reports to
Congress not less frequently than annually.
DAV understands that use of cannabis for medicinal purposes is now
legal in 29 States and the District of Columbia. However, we note there
have been no changes made to federal law regarding use of these
products for any purpose. We further understand that, while the medical
literature has been inconclusive about the effectiveness of marijuana
for improving symptoms of chronic pain and PTSD, noting both risks and,
in some cases, benefits, many veterans report the use of cannabis for
these purposes is beneficial.
While DAV has no specific resolution calling for VA to conduct
research on the safety and efficacy of medicinal cannabis for veterans
with chronic pain or PTSD, DAV Resolution No. 129 notes strong support
for VA research on common conditions related to military service and
effective treatments to help veterans recover, rehabilitate and improve
the overall quality of their lives. We must ensure that any
intervention for treatment of chronic pain and PTSD is both safe and
effective for veteran patients especially veterans with clinically
complex comorbid conditions such as traumatic brain injury, PTSD and
chronic pain from amputations and other war-related injuries. For these
reasons we have no objection to passage of this bill.
Discussion Draft, to make certain improvements in the family caregiver
support program of the Department of Veterans Affairs
Public Law 111-163, the ``Caregivers and Veterans Omnibus Health
Services Act of 2010,'' established the Program of General Caregiver
Support Services and the Program of Comprehensive Assistance for Family
Caregivers. The Program of Comprehensive Assistance for Family
Caregivers (the Comprehensive Program) provides additional support
services to caregivers beyond what is provided through the Program of
General Caregiver Support Services, including a modest monthly
financial stipend, health care coverage through CHAMPVA, counseling and
mental health services, respite care, and technical assistance.
However, the Program is only available to veterans who have serious
injuries (including traumatic brain injury, psychological trauma, or
other mental disorder) incurred or aggravated in the line of duty in
the active military, naval, or air service on or after September 11,
2001 (post-9/11).
We are encouraged the program is working as intended based on
comments from a qualitative online survey conducted by DAV, which
received 1,833 validated responses from veterans and caregivers. This
is described in greater detail in our testimony before the full
Committee during its oversight hearing on February 6, 2018. But our
members recognize there is always room for improvement.
Since the program's enactment, DAV has fought for legislation that
improves the program and provides family caregivers and veterans
severely ill and injured before September 11, 2001 (pre-9/11) equitable
access to comprehensive caregiver support services.
During the February 6, 2018 oversight hearing, DAV, along with
virtually all of our VSO colleagues, called on the full Committee to
take bold and decisive actions, similar to what the Senate Veterans'
Affairs Committee did last fall, and pass legislation extending
eligibility for the full array of caregiver support services to
veterans from all eras.
As such, we continue to advocate that the most equitable solution
is for Congress to amend existing statute by removing ``on or after
September 11, 2001'' so that all veterans and caregivers have equal
access to the Program. Furthermore, Congress should amend the statute
by including provisions allowing severely ill veterans and their family
caregivers to be eligible for the Program.
DAV, along with our VSO colleagues, has been working with both the
House and Senate Veterans' Affairs Committees to come to an agreement
and pass a legislative package, which includes extending the current
eligibility criteria for the Comprehensive Program to family caregivers
of veterans severely injured pre-9/11; requires the implementation and
certification of an information technology system to assess, support,
and improve the family caregiver support program, and modifies the
annual evaluation report of the program.
In light of current circumstances, DAV has grave concerns regarding
Section 3 of this draft measure, which proposes to address the
unfairness of excluding pre-9/11 veterans from the Comprehensive
Program by raising the bar for eligibility on both pre- and post-9/11
veterans. We could not support limiting or restricting eligibility to
the Comprehensive Program for family caregivers and veterans when a
more supportive and equitable caregiver policy has already tentatively
been agreed to and is under active consideration by Congress.
We urge the Subcommittee to amend and reconsider the provision in
this draft bill that would amend paragraph (3)(C) of section 1720G(a).
The original intent of this paragraph remains sound and is an important
one, which is to mitigate the financial impact of caregiving, by
providing caregivers a modest stipend that would not be less than the
amount a commercial home health entity would pay an individual in the
geographic area of the veteran to provide equivalent personal care
services. We believe the source of the issues surrounding both the
labor intensive process in calculating local stipend rates and the
resulting outlier stipend rates are more the result of the Department's
regulatory decision to calculate such rates by using the Bureau of
Labor Statistics hourly wage for home health aides in a geographic
area. \1\
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\1\ 38 C.F.R. 71.40(c)(4)(v)
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This draft measure could better address the disadvantages of this
particular regulation by assisting VA in establishing a more
appropriate stipend schedule that does not erode current benefits while
addressing program inefficiencies. We urge the Subcommittee to work
with VA in crafting more suitable language to accomplish the desired
intent and for VA to make improvements through regulatory action.
There is also a conditional effective date for the sections in
draft bill amending title 38, United States Code, section 1720G. Rather
than leaving the effective date open ended, we recommend a date certain
be included in Section 3 of this bill to ensure program improvements
contemplated in such section is realized and not left to uncertainty.
Finally, we urge the Subcommittee to consider additional provisions
such as integrating a research component to VA's caregiver support
program, which could help find answers such as how to most effectively
support family caregivers of severely ill and injured veterans in a
cost-effective manner and could better inform program managers, policy
makers and the public. In addition, because the success of the Program
and the quality of life of severely ill and injured veterans relies
heavily on the ability for VA to provide in-home assistance, and based
on DAV's report ``American's Unsung Heroes: Challenges and Inequities
Facing Veteran Caregivers,'' which found that family caregivers of
severely ill and injured veterans often do not get the support they
need, such as financial assistance, respite care, medical training or
home health aide services, we urge the Subcommittee to include a
provision that would instruct the Government Accountability Office to
update its 2003 report on veterans' access to non-institutional/home-
and community-based care.
In reviewing Section 2 of this draft bill, we believe it is
intended to address the recommendations in GAO's September 2014 report
on VA's caregiver support program that VA ``expedite the process for
identifying and implementing an [IT] system that fully supports the
program and will enable [VHA] program officials to comprehensively
monitor the program's workload, including data on the status of
applications, appeals, home visits, and the use of other support
services, such as respite care,'' and that VA ``use data from the IT
system, once implemented, as well as other relevant data to formally
reassess how key aspects of the program are structured and to identify
and implement modifications as needed to ensure that the program is
functioning as envisioned so that caregivers can receive the services
they need in a timely manner.''
DAV continues to press VA to ensure it meets the GAO's
recommendations to implement an IT system that fully supports the
program. We are encouraged that VA's long-term IT solution for the
caregiver program is due to be delivered by the end of September. We
urge this Subcommittee to use its oversight powers to ensure progress
in its development is maintained to meet the delivery date.
This concludes my testimony, Mr. Chairman. DAV would be pleased to
respond for the record to any questions from you or the Subcommittee
Members concerning our views on these bills.
Prepared Statement of Sarah S. Dean
Chairman Wenstrup, Ranking Member Brownley, and members of the
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank
you for the opportunity to present our views on the broad array of
pending legislation impacting the Department of Veterans Affairs (VA)
that is before the Subcommittee. No group of veterans understand the
full scope of care provided by the VA better than PVA's members-
veterans who have incurred a spinal cord injury or disease. Most PVA
members depend on VA for 100 percent of their care and are the most
vulnerable when access and quality of care is threatened. Several of
these bills will help to ensure veterans receive timely, quality care
and services.
H.R. 1506, the ``VA Health Care Provider Education Debt Relief Act of
2017"
PVA supports H.R. 1506, the ``VA Health Care Provider Education
Debt Reduction Act of 2017.'' This legislation would increase the
maximum amount of education debt reduction available for health care
professionals employed by the Veterans Health Administration (VHA).
Currently, the total amount VA may provide for debt reduction of a
provider is $120,000 over a five year period, provided the amount does
not exceed more than $24,000 per year. This legislation would increase
the maximum amount to $150,000 and $30,000, respectively, in order to
match education debt average.
If the Secretary determines there is a particular shortage in an
area or specialty, VA currently has the authority to waive the maximum
amount of debt, and pay the principal plus interest of a provider's
loans. This proposal would specify shortages and adopt the Department
of Health and Human Services' definition of Health Professional
Shortage Areas.
PVA believes VA must be adequately resourced to attract the best
and brightest medical professionals. The Education Debt Reduction
program has been a markedly successful means to do just that. There is
a current and worsening provider shortage in the United States. VA must
be able to see that veterans are insulated from this trend. That new
residents are hesitant to take a post in an underserved community,
should come as no surprise. The cost burden of their education and
training is an overwhelming prospect and debt is all but guaranteed. No
matter how eager to serve, or desirous of giving back to veterans a new
resident may be, a career at an understaffed VA may not be a tenable
choice. Loan assistance can cultivate a culture of commitment from
those unburdened by their debt and revive areas too long stressed by
continuous shortages.
H.R. 2322, the ``Injured and Amputee Veterans Bill of Rights''
PVA supports H.R. 2322, the ``Injured and Amputee Veterans Bill of
Rights'' to better educate injured and amputee veterans on their rights
and the requirement that VA staff who work at prosthetics and orthotics
clinics or who work as patient advocates for veterans understand these
rights as well. This bill would ensure that VA prosthetics clinics
around the country prominently display the ``Injured and Amputee
Veterans Bill of Rights'' and, ideally, that VA employees understand
it. This reaffirms the idea that a veteran in need of an assistive
device or prosthetic gets the highest quality item available and in a
timely manner. PVA is concerned, however, that the language ignores
veterans who are in need of special equipment because of a specific
disease and not a physical injury. Further, we remain concerned VA is
not sufficiently resourced to procure prosthetics for veterans in a
manner that is timely and clinically precise.
H.R. 3832, the ``Veterans Opioid Abuse Prevention Act''
PVA supports H.R. 3832, the ``Veterans Opioid Abuse Prevention
Act.'' This legislation would direct the Secretary to enter into a
memorandum of understanding with the executive director of a national
network of state-based prescription drug monitoring programs (PDMP) in
order to assess if opioids have been accessed in other states.
Currently, VA doctors cannot consult a national network of state-based
PDMPs in order to identify those at high risk for abuse. A July report
from the President's Commission on Combating Drug Addiction and the
Opioid Crisis said the lack of cross-state interoperability is a
shortcoming of state PDMPs and recommended ``enhancing interstate data
sharing among state-based prescription drug monitoring programs.''
In 2016, Public Law 114-198, the ``Comprehensive Addiction and
Recovery Act'' (CARA), required providers at the VHA to participate in
their respective state's PDMP. Prescribers must check patient records
in the state databases before prescribing pain killers. The pharmacists
are responsible for recording when they fill those prescriptions.
The United States is in the midst of an opioid epidemic and PDMPs
are a critical tool for safe prescribing practices by providers. VA has
been authorized to share prescription data with PDMPs since 2011 and
last year, CARA required VHA to participate. The effectiveness of
Opioid Safety Initiatives is dependent on the availability of all
prescription data and the ability to see it across state lines. This
loophole allows for veterans to `doctor shop' across states with
neither entity the wiser. These veterans suffering from chemical
dependency must have the safety protections we can reasonably provide.
This bill ensures VA can better mitigate the potential consequences of
opioid use.
Given the specialized needs of veterans, it is not uncommon for
veterans to travel to different states to receive their care. Each VA
Medical Center (VAMC) only shares prescription data to the state PDMP
in which the VAMC is located. Some have established regional Memoranda
of Understanding, communicating information only with neighboring
states. But there are veterans, particularly veterans with a spinal
cord injury or disease (SCI/D) who regularly travel across multiple
state lines to one of the 24 SCI Centers across the country. There is
no assurance that the prescription data of an SCI/D veteran who
receives care at an SCI/D center in Minneapolis, but lives in Wyoming,
can be shared. We urge the Committee to make sure these specialized
patient populations are benefiting from the opioid safety measures in
the same way as non-traveling veterans. H.R. 3832 is the means to do
just that.
H.R. 4334, the ``Improving Oversight of Women Veterans' Care Act of
2017"
PVA supports H.R. 4334, the ``Improving Oversight of Women
Veterans' Care Act of 2017.'' This legislation would require the
Undersecretary of VHA to submit to Congress an annual report on the
ability of women veterans to access gender specific care in the
community. It would also require each medical facility to report to the
Secretary, on a quarterly basis, the compliance and noncompliance of
the facility with the environment care standards for women veterans, as
defined in VHA Directive 1330.01(1). Each report is to name the person
at each facility who is responsible for compliance and the facility
plan to strengthen environment of care standards.
According to GAO report 17-52 from December 2016, VHA does not have
data and performance measures for women veterans' accessibility to
gender-specific care delivered through the Veterans Choice Program.
However, VHA does collect data to evaluate women veterans' access to
gender-specific care received through PC3 - a different community care
program. The report also found VHA does not have accurate or complete
data regarding medical centers' compliance with environment of care
standards for women veterans, allowing for instances of noncompliance
not reported to VHA.
H.R. 4334 would require VA to report to Congress accessibility to
gender-specific health care in any community of care program; and
include the average waiting period between the veteran's preferred
appointment date and the date on which the appointment is completed,
reasons VA could not fulfill the appointment, and driving time required
for appointments.
If VA cannot meet the needs of women veterans and refers them to
providers in the community, then VA must still ensure that care is the
quality, appropriate care that best meets the veterans' needs. Holding
VA and community care providers to different standards while the
taxpayer pays for both is unacceptable. VA must be able to ensure the
care a veteran receives in and outside its walls is the best clinical
option available. As such, Congress must have the data to conduct the
appropriate oversight on that care.
H.R. 4635, to direct the secretary of Veterans Affairs to increase
the number of peer-to-peer counselors providing counseling for women
veterans, and for other purposes.
PVA supports H.R. 4635, to ``direct the secretary of Veterans
Affairs to increase the number of peer-to-peer counselors providing
counseling for women veterans, and for other purposes.'' This
legislation would require VA to employ sufficient numbers of peer
counselors to meet the needs of women veterans, particularly to address
military sexual trauma, post-traumatic stress, and those at risk of
homelessness.
For those veterans who have been able to access peer-to-peer
counseling or retreats for women provided through VA, participants
report a better understanding of how to develop support systems and to
access resources at VA and in their communities. Peer counseling
programs have been a marked success for most veterans who show
consistent reductions in stress symptoms and increased coping skills.
It is essential for the life and wellbeing of women veterans that
Congress make their needs a priority. By hiring peer counselors
familiar with issues specific to women veterans' experiences we can
move a step closer to meeting those needs.
A draft bill to authorize VA to conduct and support research on the
efficacy and safety on medicinal cannabis
PVA has no position on the drafted legislation at this time.
A draft bill to make certain improvements in the Family Caregiver
Program
Established by Public Law 111-163, the ``Caregivers and Veterans
Omnibus Health Services Act of 2010,'' the Program of Comprehensive
Assistance for Family Caregivers provides caregivers of post-9/11
service-connected, injured veterans with support services. These
include a modest monthly financial stipend, health care through
CHAMPVA, mental health services, and respite care.
For those PVA members able to access the program, it has made all
the difference in their lives. For eight years, PVA, along with nearly
all VSOs, has ardently advocated the program be made accessible to
those injured before 9/11 and to those made ill as a result of service
in any era.
During the February 6, 2018, full committee hearing, PVA, DAV, and
the Elizabeth Dole Foundation asked the House Committee to be as bold
as the Senate Committee was last November and pass an expansion effort
that treats all veterans the same, regardless of date of injury. This
remains our chief legislative priority for the 115th Congress.
PVA's organizational mandate is to expand and improve the Caregiver
Program. In this moment in time, the means to most closely accomplish
that mandate is the negotiated package that was to be included in the
omnibus last month. This legislative package would eliminate the date
of injury requirement for the Comprehensive Program; require the
implementation and certification of an information technology system to
assess, support, and improve the program; and modify the annual
evaluation report. While this effort was not actualized in the omnibus,
it is our intention to see such a deal, both bipartisan and bicameral,
passed as soon as may be accomplished. It is with this in mind that we
provide our views on the draft legislation.
As this proposal would make eligible veterans with catastrophic
injuries of all eras, PVA would support it as a first step to full
expansion. This proposal would achieve what former Secretary Shulkin
desired; serve those with a particular high need, while at the same
time, simplify the program structure to be more efficiently
implemented. A clearly understood eligibility, and efficient
assessment, implemented nationwide, would greatly enhance this vital
program. In order to accomplish both aims, this draft adopts a
restrictive criteria for all future participants to require assistance
with three Activities of Daily Living (ADLs).
If the committee moves forward with this restricted eligibility, we
strongly encourage VA be enabled to develop or adopt a validated
instrument to measure needs and caregiver burden. The current clinical
assessment tool of ADLs and tiers can be unnecessarily confusing and
does not clearly capture need. Tightening eligibility under the same
structure ensures the same concerns of inconsistency, espoused over the
years by this Committee, continue. Because the participation is
dependent on ADLs and their ongoing clinical assessment, variability is
innate to each clinical team's opinion. Using a standardized assessment
tool, such as the United Kingdom's Functional Assessment Measurement
and Functional Independence Measurement (FAM & FIM), may help to
clearly delineate the level of care required to accomplish ADLs and
Instrumental Activities of Daily Living (IADL). Such an approach could
help to make clear to families the means by which their loved ones
needs, both physical and psychological, are measured.
As expressed in the February hearing on caregivers, we encourage
the Subcommittee to advance provisions that support research into how
to best support family caregivers of veterans with catastrophic
disabilities and how to delay the costs of institutional long term
care. We also encourage the draft include a GAO report on VA's Home and
Community Based Services. It has been nearly a decade since such a
study was conducted and would illustrate the needs of pre-9/11
caregivers today.
PVA would once again like to thank the Subcommittee for the
opportunity to submit our views on the programs affecting veterans and
their caregivers. We look forward to working with you to ensure our
catastrophically disabled veterans and their families receive the
medical services and supports they need.
Prepared Statement of Kayda Keleher
Chairman Wenstrup, Ranking Member Brownley and members of the
Subcommittee, on behalf of the women and men of the Veterans of Foreign
Wars of the United States (VFW) and its Auxiliary, thank you for the
opportunity to provide our remarks on legislation pending before this
Subcommittee.
H.R. 1506, VA Health Care Provider Education Debt Relief Act of 2017
The VFW supports this legislation which would increase the maximum
amount of education debt reduction available for health care
professionals who work at the Department of Veterans Affairs (VA)
Veterans Health Administration (VHA).
With over 35,000 current job vacancies, VA must be provided all
tools necessary to address personnel shortages. This is particularly
worrisome for VHA, where provider shortages result in access issues and
insufficient wait times for veterans needing to receive treatments they
have earned.
To address these personnel shortages, this legislation would
authorize VA to work alongside the Department of Health and Human
Services to identify areas with increased health professional
shortages. Where these shortages are found to exist, VA would then be
able to aggressively use their authority to provide new hires with
educational debt reduction at increased cap rates.
Congress and VA must assure that funding appropriated for
educational debt reduction is properly disbursed. The VFW has received
feedback from multiple locations that VA facilities are only receiving
the capped rate equivalent to what the maximum would be for one
employee. For this authority to be effective in recruiting and
retaining employees at VA, it must be properly implemented and
utilized.
H.R. 2322, Injured and Amputee Veterans Bill of Rights
The VFW believes this legislation would unintentionally establish
an unattainable expectation for VA. Therefore, the VFW cannot support
this bill.
This legislation would require VA to display what would become the
``Veterans Bill of Rights'' throughout all VA prosthetics and orthotics
clinics as a means of outreach for education. The VFW fully supports VA
outreach campaigns to educate and connect with veterans, and believes
that this legislation would be better routed as an outreach campaign to
veterans who were injured and/or are amputees.
With this said, the VFW has concerns with some of the verbiage used
in what would be the Bill of Rights. In the third subparagraph of these
rights, it would be publicly shared and expressed that a veteran would
have the right to see a private practitioner entered into a community
care contract with VA, or the veteran would be able to access a
practitioner with specialized expertise. This language may stand to be
interpreted that if a veteran opts to see a specialized practitioner
who has not entered into contract with VA, that the veteran would still
have the right to see the practitioner. The VFW opposes veterans having
the ability to see any provider outside VA of their choosing and VA
then paying for the appointment without coordinating the care. Keeping
VA as the coordinator of care not only provides assurance that patients
are seeing quality doctors for appointments they need, but it also
provides quality assurance and oversight for the patient as well as VA
appropriations. It is also worth noting that this legislation would
build expectations going beyond current law, without amending what is
currently in statute. For example, the Bill of Rights would establish
that all amputees are eligible for a backup prosthetic, but that would
not align with current eligibility requirements.
The VFW also believes the quarterly reporting requirement would be
over legislating. This report would require every medical center within
VA to submit a report for each fiscal quarter containing all
information related to alleged mistreatment of injured and amputee
veterans. Each of these allegations would then receive a full
investigation. The VFW believes this is something VA already does and
should be doing, making these provisions unnecessary.
H.R. 3832, Veterans Opioid Abuse Prevention Act
The VFW supports this legislation which would direct VA to enter
into a memorandum of understanding (MOU) with the executive director of
a national network of state-based prescription monitoring programs. By
entering into this MOU, providers within VA will be able to access data
regarding controlled substance prescriptions for patients regardless of
which state they are in, so long as that state has entered into an MOU
as well.
There are currently 43 states and the District of Columbia that
have entered into an MOU with the National Association of Boards of
Pharmacy for the association's prescription monitoring program (PMP)
InterConnect. This allows participating states' PMPs across the entire
country to be linked regardless of state lines, and provides an
effective means of combating drug diversion and/or abuse. Data is
shared and collected through a secure communications platform that
transmits PMP data to authorized requestors, while the state's
individual data access rules and laws are enforced. PMP InterConnect
also does not house any data itself.
Having access to this data and being able to share with the states
already entered into an MOU would benefit VA. VA would be more easily
able to access prescription data for patients across state lines, such
as winter snowbirds, while also making sure patients' information is
shared with the private sector--providing great potential to identify
and prevent prescription drug abuse and fraud.
H.R. 4334, Improving Oversight of Women Veterans' Care Act of 2017
The VFW supports this legislation which would require reporting
associated with medical care for women veterans provided by VA and
through non-VA providers entered into contract agreements with VA.
Assuring veterans who receive care from non-VA providers receive the
same high-quality standard of care, or above, that they would receive
at VA is critical.
Not all appointments can be fulfilled by VA, and this is especially
true for certain specialized services such as sex-specific treatments.
Whether there is a shortage of gynecologists, or not enough women
veteran patients to meet annual certification requirements for
mammogram technicians, there is the need at times for women veterans to
receive sex-specific health care in the community. For this reason, the
VFW is pleased to see the reporting requirements this legislation would
put into law.
To improve women veterans' health care within VA, it is also
important for VA to keep up to date on where facilities need to
improve, as well as for Congress to be aware of these needs. This is
why the VFW is pleased to see the reporting requirements for the
environment of care standards within VA facilities.
H.R 4635, to direct the Secretary of Veterans Affairs to increase the
number of peer-to-peer counselors providing counseling for women
veterans
The VFW supports this legislation which would increase the number
of peer-to-peer counselors for women veterans within VA. This
legislation would also emphasize the demand for peer-to-peer support
specialists for women veterans who have survived sexual trauma during
their time in service, have post-traumatic stress disorder (PTSD), any
other mental health condition, or are in other ways at risk of becoming
homeless. This would be particularly useful as ***40 percent of women
veterans who participated in the VFW's women veterans' survey either
currently use or have previously used VA for mental health services.
This legislation would also coordinate assistance for women
veterans under the Department of Defense's employment, job training and
transitional assistance programs with the Department of Labor to help
women veterans identify employment and training opportunities, as well
as how to obtain these necessities and other related information and
services. The VFW is pleased to see this in the legislation, as
addressing mental health care needs and avoiding homelessness must be
addressed with a holistic approach. To do this, veterans must have
assurance and a sense of self-worth and meaningfulness through their
work, as well as a means to provide food and shelter for themselves and
their families.
Draft legislation, VA Medicinal Cannabis Research Act of 2018
The VFW supports this draft legislation which would direct VA to
use its authority to conduct and support medical research on the
effects and safety of medicinal cannabis.
The VFW supports expanding research of non-traditional medical
treatments for alternative therapies and less harmful ways of
addressing health care issues for veterans within VA. With the ongoing
opioid epidemic, an increase in veterans who suffer from chronic pain,
the constant co-morbidity of chronic pain with PTSD and a continuing
list of other health ailments--all while VA is under constant scrutiny
for over-prescribing pharmaceuticals, while still managing to prescribe
opioids at nearly half the rate of the private sector, VA must be
proactive in finding solutions to responsibly treat veterans.
There are currently 30 states and the District of Columbia that
have passed legislation legalizing medical or recreational marijuana.
This means veterans are able to legally obtain marijuana for medical
purposes in over half the country. Some may see a private sector
provider about using medical marijuana, while others may self-prescribe
without a health care provider's guidance. Regardless of how veterans
in the majority of the country choose to obtain medical marijuana, they
are doing this without the medical understanding or proper guidance
from their coordinators of care at VA. This is not to say VA providers
are opting to ignore this medical treatment, but that there is
currently a lack of federal research and understanding of how medical
marijuana may or may not treat certain illnesses, injuries, and the way
it interacts with other drugs. Due to this, the VFW believes it is
medically unethical for Congress to allow VA providers to stay in the
dark. VA must conduct research on medical marijuana to determine what
is in the best interest of veteran patients.
This draft legislation would reiterate VA's current authority to
conduct schedule one research for ailments ranging from physical injury
to behavioral health. Three different strain variants consisting of
differing ranges of phenotypical traits as well as ratios of
tetrahydrocannabinol (THC) and cannabidiol (CBD) compositions must be
researched in the study. The VFW believes it is important to test at
minimum three strains, which can vary in strength such as when
pharmaceuticals study dosing variations of both major chemical
components found in marijuana. It is also important to test varying
ratios of THC and CBD, as scientists know these chemicals affect
different receptors in the human body. For example, in some studies,
patients with PTSD or who are recovering from cancer have been found to
benefit from THC. Meanwhile, other studies have found that patients
struggling with chronic pain have been found to benefit from CBD.
Participants in the study would use the marijuana in varying ways,
subject to VA's decision on how to break up participant groups.
To assure the research study would be implemented as intended, VA
would report to Congress 180 days from the date of enactment with a
plan moving forward. At this time VA would then also make requests for
anything needed to carry on with the study. After this initial report,
VA would then be required over a five-year period to submit a report at
a minimum of once per year to Congress.
The VFW is pleased to see bipartisan support for this very
important issue for our nation's veterans, and looks forward to
continuing to work on medical cannabis research with Congress and VA.
Draft legislation, to make certain improvements in the Family Caregiver
Program
The VFW agrees with the intent of this draft legislation but has
serious concerns with it as written. Since the Program for
Comprehensive Assistance for Family Caregivers was first discussed, the
VFW has urged Congress to expand eligibility to those caring for
veterans who served before Sept. 11, 2001. The VFW strongly believes
the contributions of family caregivers cannot be overstated, and our
nation owes them the support they need and deserve. Regrettably, the
program is unjustly limited to caregivers of severely wounded post-9/11
veterans. Severely wounded and ill veterans of all conflicts have made
incredible sacrifices, and all family members who care for them are
equally deserving of our recognition and support. The fact that
caregivers of previous era veterans are currently barred from the
program implies that their service and sacrifices are not as
significant, and we believe this is wrong.
The VFW currently supports H.R. 1472 and S. 591, as well as S.
2193, which includes the expansion of VA's caregiver program. The VFW
has been pleased to see the committee's willingness to evaluate and
advance a bill to expand this important program.
As currently written, this draft would increase the eligibility
requirements from the current requisite of assistance for one or more
activities of daily living (ADL) to a minimum of three ADLs. The VFW
opposes setting arbitrary eligibility requirements and urges the
committee to evaluate other means of accurately determining who should
and should not be in the program. The VFW believes that eligibility
determination must be clinically made by VA, and not restricted by
arbitrary thresholds. There must also be an inclusion of instrumental
activities of daily living (IADL), so the program does not disregard
those in need for cognitive purposes. Moving forward, discussions of
eligibility for the program should focus around accountability and
rehabilitation, rather than limiting the program in efforts to save
money as well as prevent fraud and abuse. This is particularly
pertinent as VA has consistently provided feedback that less than one
percent of those who have been removed from the program were removed
for reasons at cause, which includes fraud. The VFW would also oppose
any restrictive changes in program eligibility that does not provide a
grandfather clause for current program recipients. This current draft
would not only restrict eligibility, but would not offer a grandfather
clause for those currently in the program. To draft a grandfather
clause, technical assistance must be given by VA.
The VFW also believes that moving forward with new legislation,
there must be an inclusion of veterans who were made ill. This would
provide equity between caregivers to align more with caregiver programs
in Titles 10 and 42, as well as assure equity between service members
and veterans. For a veteran who is ill and unable to take care of
herself or himself without the assistance of a caregiver, the VFW finds
no just reason to continue not defining them as eligible for VA's
caregiver program. This is particularly true for veterans who are ill
from diseases undoubtingly linked to their service, such as non-
Hodgkin's lymphoma.
Caregivers must be capable of providing care that is in the best
interest of the veteran, and in a clinically timely manner determined
by the veteran's VA provider in accordance with their treatment plan.
The VFW believes the language within the draft for caregiver criteria
living proximity requirements is moving in the right direction, but
must be better defined to avoid inconsistent implementation.
Finally, the VFW believes any legislation amending the caregiver
program must include provisions for caregivers and veterans who are
graduating out of the program. Currently, when a veteran improves and
is slated to be removed from the program, a lump sum of three months
stipend is paid out for financial assistance. This has resulted in
financial, emotional, and health distress of the veterans and their
caregivers. The VFW urges this Subcommittee to amend this legislation
to establish new off-ramp requirements which would remove the lump sum
payment, continue a monthly stipend and insurance coverage for a
reasonable amount of time, and provide employment training and
assistance to the caregiver from the caregiver program coordinator they
have worked with through their time in the program. This is imperative
to the veteran and caregiver's success out of the program, as well as
the well-being both physically and mentally of these highly regarded
patriots.
In conclusion, the VFW supports expanding the caregiver program to
veterans who served before 9/11, but opposes reducing eligibility
requirements simply to lower cost.
Mr. Chairman, this concludes my testimony. I am prepared to take
any questions you or the Subcommittee members may have.
Statements For The Record
STEVE SCHWAB
UNITED STATES HOUSE OF REPRESENTATIVES ON ``A DRAFT BILL TO MAKE
CERTAIN IMPROVEMENTS IN THE FAMILY CAREGIVER PROGRAM''
Chairman Roe, Ranking Member Walz, and Members of the Committee,
the Elizabeth Dole Foundation is pleased to present its views on the
House Committee on Veteran Affairs' draft legislation, which makes
modifications to the Program of Comprehensive Assistance for Family
Caregivers (PCAFC).
We thank the Committee for its continued leadership to support more
than 5.5 million military and veteran caregivers serving across the
nation. The PCAFC is a critical program that provides comprehensive
caregiver support, helps offset the cost of income lost from caregiving
responsibilities, and recognizes the service they provide to our
nation's wounded warriors. As the preeminent organization empowering,
supporting, and honoring our nation's military caregivers, the
Elizabeth Dole Foundation seeks to strengthen and empower American
military and veteran caregivers and their families by raising public
awareness, driving research, championing policy, and leading
collaborations that make a significant impact on their lives. We
appreciate that the Committee has made this legislation a priority and
has conducted an open process by convening focused discussions on this
draft legislation with VSOs and caregiver support organizations and
incorporating feedback into modifications to the draft legislation.
Expanding the Program to Pre-9/11 Veterans
We are pleased that the Committee has put forward legislation that
addresses what the Foundation has felt is the most significant deficit
in the PCAFC; that only a limited scope of veterans and their
caregivers are eligible under the current law. It is unfair that since
the Program's enactment, pre-9/11 caregivers - who make up 80 percent
of our nation's 5.5 million veteran and military caregivers - are
arbitrarily barred from accessing the PCAFC because of their veterans'
era of service or diagnosis with a service-connected illness. We
appreciate that the Committee has demonstrated its intent to correct
this injustice, and we are wholly supportive of expansion.
While the expansion of the program in the draft legislation
represents a momentous victory for the caregiver community, it comes
with some significant trade-offs. The Committee's bill proposes more
restrictive thresholds for eligibility to the program, including that a
caregiver provide support with an increased number of activities of
daily living. This provision will drastically reduce the number of
eligible veterans and demonstrate a considerable tightening of the
Program's criteria. We understand that the Committee has proposed this
provision to reduce the overall cost of the program and ensure that the
program is in place to serve those who need it most. However, the
Foundation strongly recommends that the Committee eliminate, make
modifications to, or adjust this eligibility-reducing provision - as it
may be detrimental to current and future generations of veteran
caregivers.
Activities of Daily Living
The Foundation is a strong proponent of expansion with unaltered
eligibility requirements, as proposed in the Senate's Caring for Our
Veterans Act, which passed the Senate Veterans Affairs Committee with
overwhelming bipartisan support in November 2017. However, we recognize
that the Committee would like to explore different options related to
eligibility and standardization of the program.
Under current law, participants must be in need of personal care
services due to - among other criteria - the inability to perform one
or more activities of daily living (ADLs). The Committee's draft
increases the threshold to three or more ADLs. In 2012, the Foundation
commissioned the RAND Corporation to conduct a study on military and
veteran caregiving; the findings of which are detailed in a 2014 report
``Hidden Heroes: America's Military Caregivers.'' The report found
that, on average, post-9/11 caregivers help with 1.0 ADL, while pre-9/
11 caregivers help with 1.3 ADLs (and instead help with an increased
level of safety and supervisory assistance). The research did not
provide analysis as to how many caregivers help with three or more
ADLs. We believe that the proposed increased threshold may be too high
and would severely limit the effectiveness of the PCAFC in supporting
those who need the program most.
There is a lack of available information on the number of veterans
potentially affected by the proposed increase to the activities of
daily living. Therefore, the Foundation recommends that the Committee
either consider eliminating this provision entirely or allow the
Secretary of Veterans Affairs to make any eligibility-restricting
determination only after conducting a comprehensive impact analysis and
following the appropriate rule-making process.
Addition of Service-Connected Illnesses
The Foundation urges the Committee to consider expansion of the
program to service-connected illnesses, not just injuries from all eras
of service. The way the bill is written today, it still does not
include service-connected illnesses, such as ALS or the hundreds of
other illnesses included in the VA's Presumptive Disease List. That is
unjust. We believe for this program to be genuinely inclusive of our
nation's veterans and their caregivers, it must not exclude those with
service-connected illnesses.
The Inclusion of the Financial Planning Services
The 2014 RAND report examined characteristics of military and
veteran caregivers and services available to them. The report indicated
that, of the military caregiver-specific programs, few provide long-
term planning assistance, including financial planning, for military
caregivers.
The Senate's Caring for Our Veterans Act includes a provision which
would require the VA to include financial planning and legal services
related to the needs of injured veterans and their caregivers as a
service provided to caregivers. The bill language makes clear that VA
should provide these services through the use of contracts with or the
provision of grants to public or private entities. The Senate Committee
intends that VA and VA employees not provide these services, but
instead partner with public or private entities.
We believe the financial planning services would be a critical
improvement to the PCAFC program. We are also supportive of offering
legal services to caregivers, but sympathetic to the VA's concerns that
this might pose a conflict of interest. We urge the Committee to
consider the inclusion of financial planning services to caregivers in
the PCAFC.
Grandfathering Current Program Participants
The Foundation appreciates that Committee has added additional
language to its current draft legislation to address what happens to
current program participants who will be no longer eligible under the
new criteria. However, we are concerned that the language allowing the
Secretary of Veterans Affairs to develop a transition plan is too
broad, creates further program uncertainty, and places the thousands of
current program participants at potential risk of losing their
caregiver benefits. The Foundation believes the legislation should
explicitly protect current program participants from losing support as
a result of these legislative changes.
Thank you again for this opportunity to submit our comments on the
Committee's draft legislation. We look forward to continuing to work
with the Committee to ensure support for our nation's military and
veteran caregivers.
TOM PORTER
Chairman Wenstrup, Ranking Member Brownley, and Members of the
Subcommittee:
On behalf of Iraq and Afghanistan Veterans of America (IAVA) and
our more than 425,000 members and supporters, thank you for the
opportunity to share our views on the legislation being discussed
today.
VA Medicinal Cannabis Research Act of 2018
IAVA is proud to express our support for the VA Medicinal Cannabis
Research Act of 2018 and I would like to commend Chairman Roe and
Ranking Member Walz for working in a bipartisan manner to develop the
measure and hold this hearing to underscore the importance of getting
this research right for our veterans at the VA.
IAVA veterans have made it clear that 2018 is the year we will be
heard on the important and emerging health issue of utilizing cannabis
to treat injuries of war. Veterans consistently and passionately have
communicated that cannabis offers effective help in tackling some of
the most pressing injuries we face when returning from war.
In our latest Member Survey, 63% supported and only 15% opposed
legalization for the medical use of cannabis. The youngest of the Post-
9/11 generation are most supportive; with about three-fourths of IAVA
members under 35 supporting the allowance of medical cannabis.
Medical cannabis is rapidly gaining support across party lines in
Congress and across the country. Yet our national policies are
outdated, research is lacking, and stigma persists. In 2018, IAVA
members will set out to change that and launch a national conversation
underscoring the need for bipartisan, data-based, common-sense
solutions that can bring relief to millions, save taxpayers billions,
and create thousands of jobs for veterans nationwide. Those solutions
must include the approval of medical cannabis for every veteran in
America who needs it.
Our nation is rapidly moving toward legalizing cannabis, and twenty
nine states plus the District of Columbia now permit medical cannabis.
Yet, as with many innovative solutions to veteran needs, progress on
this issue within the VA has been slow and incremental--and lags behind
the needs of veterans and the changing reality of state-level laws.
There has been marginal progress, as in late 2017, when the
Veterans Health Administration issued a policy change which urged
patients to discuss medical cannabis use with their doctors. This
policy change alleviates previous concern that admitting to cannabis
use could jeopardize VA benefits, a policy recommendation noted in
IAVA's Policy Agenda. But VA physicians still cannot refer patients to
legally sanctioned state medical cannabis programs because of the
federal prohibition. Moreover, patients are not allowed to have any
cannabis on VA property, even if it is medically recommended to them
and the state they are living in allows it. And VA employees are still
barred from using any form of cannabis, including medical cannabis,
while roughly one-third of VA employees are veterans and may want
access to cannabis as a treatment option.
Further, in opposition to strong and rising popular opinion across
the veterans community, the VA Secretary announced in early 2018 that
the VA will not conduct research into whether medical cannabis could
help veterans suffering from PTSD and chronic pain. This is despite
protest from many in the VSO community who posit medical cannabis could
serve as an alternative to opioids and antidepressants. A January 2017
National Academy of Sciences study that stated: there was ``conclusive
or substantial'' evidence that cannabis is effective in treating
chronic pain, moderate evidence that cannabis helps with sleep (which
may impact other mental and physical health conditions), limited
evidence in improving anxiety symptoms, and limited evidence in
improving PTSD symptoms.
It is important to note that in our most recent member survey, 46%
report suffering from PTSD, 38% report suffering from chronic pain, and
almost 40% report depression and anxiety. These service-connected
injuries are hard to treat, and if there is any possibility that
cannabis can be used as an effective treatment, we should be willing to
do the research to explore that opportunity.
Again, thank you for allowing IAVA to share our views. We thank
Chairman Roe and Ranking Member Walz for taking this valuable step in
moving forward with such a significant piece of legislation. We need
the definitive research to be conducted on the efficacy and safety of
medical cannabis use by veterans - and it is long past the time for the
VA to have taken this up.
Congress must prioritize passage of this legislation this year.
Discussion Draft, to make certain improvements in the family caregiver
support program of the Department of Veterans Affairs
IAVA opposes this draft bill as it raises the bar of eligibility
for the post-9/11 veterans currently eligible for the Caregiver
Program, as well as for pre-9/11 veterans that would gain eligibility
under this draft.
IAVA has consistently supported expanding the Caregiver Program to
all generations of veterans, but we cannot support legislation that
reduces benefits by raising the eligibility bar for program
beneficiaries.
The Improving Oversight of Women Veterans' Care Act of 2017 (H.R.
4334) and Legislation (H.R. 4635) to ``direct the secretary of Veterans
Affairs to increase the number of peer-to-peer counselors providing
counseling for women veterans, and for other purposes.''
IAVA thanks the sponsors for putting forth H.R. 4334 and H.R. 4635,
as they are consistent with our She Who Borne The Battle campaign in
the 115th Congress to close gaps in care for women veterans.
H.R. 4334 would require the Undersecretary of the Veterans Health
Administration to submit to Congress an annual report on the ability of
women veterans to access gender specific non-VA medical care in the
community, including the average wait time between the veteran's
preferred appointment date and the date on which the appointment is
completed, driving time required for veterans to attend appointments,
and reasons why appointments could not be scheduled. The bill would
also require each VA medical facility to submit a quarterly report to
the VA Secretary on the compliance and noncompliance of the facility
with the environment of care standards for women veterans.
H.R. 4635 would increase number of peer-to-peer counselors
providing counseling for women veterans, with an emphasis on treating
women veterans who suffered military sexual trauma, suffer from PTSD or
other mental health conditions, or are at risk of becoming homeless.
IAVA remains focused on the centerpiece of our She Who Borne The
Battle campaign, the bipartisan Deborah Sampson Act (H.R. 2452), the
most comprehensive legislation this Congress that addresses shortages
in care for female veterans. H.R. 2452 establishes peer-to-peer
assistance, makes permanent programs to provide counseling in retreat
settings, provides legal and support services, doubles the newborn care
at the VA, funds retrofits at VA facilities to improve privacy,
requires the VA to collect gender-specific data on all veterans
programs, and expresses a sense of Congress that the VA motto should be
more inclusive, among other initiatives.
On this last provision, our campaign has had an impact, as we know
that VA leadership had taken recent, concrete steps to make motto
changes more welcoming to our transitioning women warriors, but
partisan infighting at the VA derailed those steps from moving forward.
IAVA encourages this committee to support a greater level of
progress on making VA care more reflective of the growing numbers of
women serving in uniform and move to enact the Deborah Sampson Act and
other legislation that shares this spirit.
Thank you for allowing IAVA to share our views.
CARRIE STEAD
Chairwoman Dole, Members of the Committee, thank you for the
opportunity to comment on the future of the Program of Comprehensive
Assistance for Family Caregivers (PCAFC). I am Carrie Stead, Director
of Programs for The Independence Fund, and am a caregiver myself.
The Independence Fund, founded 10 years ago, has provided more than
$50 million in adaptive equipment and support services for
catastrophically wounded and seriously disabled Veterans, as well as
Caregiver support services for the Caregivers of those wounded and
disabled veterans.
Overall, The Independence Fund's greatest concern with the PCAFC
program is the apparent lack of standardization throughout the program.
We see wide variation not only across Veterans Intergrated Service
Networks (VISNs), but even across VA facilities within a VISN, or even
a single VA facility itself.
This lack of standardization leads to wide variation in tier
classification for similar cases; for what services and support
individual Veterans and Caregivers are eligible; and even whether the
Caregiver will be allowed to stay in the program or be ``graduated.''
Because of that lack of standardization, we see VA officials
improperly apply the Caregiver eligibility standards, such as they
exist, especially in cases of spouse or other family caregivers. VA
officials apply improper ``rules'' in ways like telling Caregivers they
cannot have outside employment. We also see it where individual
veterans are forced by reviewing VA officials, without warning, to
prove they cannot do certain activities, even where an occupational
therapy order has not been issued.
The result is a pervasive and underlying presumption on the part of
the medical administrators that Veterans or Caregivers are frauds, and
need to be ``tricked'' into displaying their actual, greater,
capabilities. Shame on the VA for such tactics.
While not the topic of today's hearing, this Committee is charged
with making recommendations on other VA benefits and services that
impact families and caregivers. Given that, the single biggest issue
raised by the severely disabled Veterans and Caregivers we serve is the
lack of access to timely and quality medical care. While we are
uniformly told the clinicians that serve our clients, especially the
doctors, are first rate, the medical administration staff that is
supposed to support the Veteran in gaining access to that medical care,
instead seem to consistently and uniformly act to block timely access.
We've received hundreds of complaints from our clients detailing
the bureaucratic roadblocks; local ``policies'' and ``guidance'' not
based on law, regulation, or printed VA directive; or simply what
appears to be simple indifference on the part of the medical
administration staff; which hinder, if not stop, Veteran access to the
care they need. We've received numerous reports of medical providers
repeatedly directing care outside the VA, or not in accordance with
current standards of care or formularies, only to be repeatedly denied
by the medical administration staff, often without justification or
explanation.
Ultimately, this comes down to who is in charge of a Veteran's
medical care decisions: the Veteran and his family, or the VA
bureaucracy? Our experience is that the individual Veteran and his or
her family are consistently denied the opportunity to make that choice
themselves. In fact, we often experience an underlying, if unspoken,
attitude the Veteran is incompetent to make such medical care
decisions. This condescension towards the Veteran is unfortunately
shared by many of the largest, and oldest, Veteran service
organizations.
We believe the vast majority of Veterans are competent to make
medical care decisions, just as they would if they were being served by
Medicare or Tricare instead of the VA. We are heartened by the
commitment President Trump made to that Veteran empowerment in the
campaign. Therefore, we implore this Committee to recommend to the
Secretary that he fully support a Veteran's ability to choose his or
her health care provider, whether within the VA or in the community. Of
note, in the current debate underway in Congress, neither the House or
the Senate Veterans Affairs Committee passed bills come close to
providing the real healthcare choice the President promised.
Finally, the VA issued a Request for Comments on the Caregiver
program, with those comments due last month. The Independence Fund
responded to that Request with its own recommendations for further
refining the Caregiver program. In the interest of time, I request the
attached copy of that Response be included in the record today.
Thank you for the opportunity to discuss this with you today.
MARGARET KABAT
Margaret Kabat
National Director
Caregiver Support Program (10P4C)
Veterans Health Administration
Department of Veterans Affairs
810 Vermont Ave., NW
Washington, DC 20420
Dear Ms. Kabat:
Thank you for the opportunity to comment on the future of the
Program of Comprehensive Assistance for Family Caregivers (PCAFC). The
Independence Fund, founded 10 years ago, has provided more than $40
million in adaptive equipment and support services for catastrophically
wounded and seriously disabled veterans, as well as caregiver support
services for the caregivers of those wounded and disabled veterans. Our
Executive Director and our Director of Programs are both caregivers to
catastrophically wounded veterans. As well, most of our employees are
either disabled Veterans or Caregivers themselves.
Overall, The Independence Fund's greatest concern with the PCAFC
program is the apparent lack of standardization for large segments of
the program, from initial eligibility to program execution and
classification standards, not only across Veterans Intergrated Service
Networks (VISNs), but even across VA facilities within a VISN, and even
a single VA facility itself. While we understand the need for a
clinical determination to establish individualized eligibility based on
the need for assistance with activities of daily living, such clinical
determination appears to justify not pursuing any type of national
standardization for assessment or continuing eligibility standards for
the program, essentially leaving those decisions to be implemented
arbitrarily by the personal fiat of individual clinicians and VA
medical administrators throughout the country.
Because of that, The Independence Fund regularly sees wide
variation in the Caregiver tier classification determined for
individually similar cases, for what services and support individual
Veterans and Caregivers are eligible, and even whether the Caregiver
will be allowed to stay in the program or be ``graduated.'' Given the
close similarities we see in these underlying cases with vastly
different results, this broad variation across regions and even
facilities appears to be an arbitrary execution of the law within the
Department.
Further The Independence Fund receives numerous anecdotal
complaints of VA officials improperly applying the Caregiver
eligibility standards, such as they exist, especially with spouse or
other family caregivers. One of the most commonly heard improper
``rules'' is that Caregiver scannot have outside employment besides
serving as a Caregiver. Considering the Caregiver stipend is based upon
40 hours per week of Caregiver assistance (even for the most
catastrophically wounded, or the barely conscious Veterans), those
Administrators who do try to tell Caregivers that they cannot work
outside their Caregiver assistance must believe these Caregivers do not
provide any additional Caregiver assistance outside normal working
hours. That's outrageous, as is VA officials wrongly telling Caregivers
they cannot work outside the caregiving assistance they provide. The
regulations regarding PCAFC should specifically state Caregivers can
have outside employment beyond the Caregiver assistance they provide.
Within that framework, below are our answers to the specific
Request for Comments.
1. Should VA change how ``serious injury' is defined for the purpose of
eligibility?
Yes.
Per the authorizing legislation, the Secretary is authorized to
expand eligibility for PCAFC to an individual's need for personal care
services of, ``.such matters as the Secretary considers appropriate (38
USC 1720G(a)(2)(A)-(B)). While there are obviously 100% disabled
veterans who do not need and should not qualify for Caregiver support
(which would seem to call into question why such a Veteran would be
awarded a 100% disability rating), we do believe certain disability
ratings, such as Special Medical Compensation rating R1 or R2, should
carry with it a presumption of eligilibity for the PCAFC program. We
believe the Secretary should use that special authority referenced
above to establish such a presumption.
A: Should the severity of injury be considered in determining
eligibility to ensure VA is supporting family caregivers of
Veterans most in need? If so, how should the level of severity be
determined?
This question is confusing in its sentence structure. The program
was, in our estimation, established on a clear standard of the Veteran
not being able to complete activities of daily living. Congressional
intent would appear clear that those Veterans are already considered
most in need of Caregiver support?
If the Department is asking whether it should further limit access
to the Caregiver program beyond the standard already established by
Congress, then the answer is categorically no.No.
The question appears to imply the Department wishes to prioritize
eligibility in order to ration access, something which The Independence
Fund categorically rejects. The PCAFC program should be administered in
a way that any Veteran qualified for the program gains immediate access
to it.
However, establishing national eligibility standards would, in our
estimation, reduce much of the variability across Caregiver eligibility
described above, and would, in our opinion, reduce the need to even
conduct such prioritization by providing bright line standards for
clinicians and administrators to follow.
C. Should eligibility be limited to only those Veterans who without a
family caregiver providing personal care services would otherwise
require institutionalization?
Absolutely not.
The paltry stipend paid to current caregivers, and the presumption
apparently applied by many of the VA eligibility gatekeepers that
family caregivers should automatically be assisting Veterans with
activities of daily living (including eating, mobility, hygiene and
toileting) without compensation is insulting and atrocious.
Essentially, considering to limit the Caregiver program to only those
Veterans without a family caregiver available is to leverage the love
families have for their disabled Veterans to provide the care the
Department would otherwise provide, but at a far cheaper rate.
Essentially, the US Government is leveraging that familial love for the
Veteran against the family in order to save the US Government money.
Considering to further limit eligibility to only those without a family
caregiver available is, in our opinion, unconscionable.
2.To be eligible for the program, participation must be determined to
be `in the best interest' of the Veteran. How should `best
interest' be defined.
The way ``best interest'' is currently implemented perpetuates a
paternalistic and condescending approach of how the Department should
provide care to Veterans, assuming a Veteran is incapable of
understanding what health care is and is not in their best interest.
Such a ``Big Brother'' approach to health care decisions implies that
the Veteran is incapable of making his or her own health care
decisions.
Instead, The Independence Fund believes if a Veteran applies for
Caregiver assistance, it should automatically be presumed that such
assistance is in the best interest of the Veteran. Given the law
requires a ``Best Interest'' determination by the Secretary, The
Independence Fund recommends the ``Best Interest'' determination be
changed to a negative only determination: Unless the Department
specifically determines it is not in the best interest of the Veteran
to participate in the program, the ``Best Interest'' test should be
presumed to be met by the Veteran's application.
A. How can VA improve consistency in `best interest' determinations for
participation in the program?
By changing the ``Best Interest'' determination into a negative
determination: Unless the Department specifically determines it is not
in the best interest of the Veteran to participate in the program, the
``Best Interest'' test should be presumed to be met by the Veteran's
application.
B. Are there any conditions under which participation would not be in a
Veterans best interest?
The Independence Fund cannot think of any except where the
Caregiver is abusing or taking financial advantage the Veteran, and
where ending eligibility is the only way the Department would have to
end the abuse.
4. Once approved for the PCAFC should the Veterans eligibility be
reassessed at specific time intervals or based on clinical
indicators?
Many Veterans assisted by PCAFC are catastrophically, permanently
and totally disabled, and as such, their disability ratings are set at
that minimum level with no future downgrading allowed. Similarly, The
Independence Fund points out the Caregivers for these permanently and
totally disabled veterans are, absent a miracle, going to be Caregivers
for the rest of that Veteran's life. Requiring periodic reevaluations,
especially at the current 90 day interval, is insulting to the Veteran,
introduces uneccessary stress and disruption for both the Veteran and
the Caregiver, and completely unnecessary. The Independence Fund
recommends reassessment be eliminated for the Caregivers of permanently
and totally disabled Veterans enrolled in the program, who are also
rated R1 or R2 under the Special Medical Compensation program.
b.1. Should reassessments be standard for every participant?
No.
The Independence Fund recommends reassessment be eliminated for the
Caregivers of permanently and totally disabled Veterans enrolled in the
program, who are also rated R1 or R2 under the Special Medical
Compensation program.
b.2. Are there conditions under which continued eligibility should be
presumed and a reassessment not needed?
Yes.
b.3. If so, what would these conditions be?
For the Permanently and Totally Disabled, who are also rated R1 or
R2 under the Special Medical Compensation program.
6.b. Under what circumstances should the family caregiver benefits be
continued after revocation?...How long should the benefits be
continued under such circumstances?
Many caregivers give up careers and all outside employment to care
for wounded and disabled veterans. The Caregiver stipend, completely
insufficient though it is, is often the only income that Caregiver
family has outside the Veteran's VA compensation. When the Veteran
dies, that family loses a huge portion of their income, compounded by
the fact the Veteran's Caregiver could very well have been out of the
workforce for years. Further, the Caregiver loses health insurance
coverage they receive under CHAMPVA.
Therefore, The Independence Fund recommends Caregiver stipends and
CHAMPVA coverage be continued for at least a year after the death of
the enrolled Veteran.
7. How should VA calculate stipends?
The Caregiver stipend rate is an embarrassment for our country.
With a maximum weekly stipend of 40 times the rate for personal care
assistance in that geographical region, for the most catastrophically
wounded veteran who nevertheless provide round the clock care, such a
paltry sum is an insult to the care Veterans' Caregivers provide. If
that family caregiver were not available, the institutionalization of
the Veteran would cost the Department far more, likely somewhere in the
$7,500 to $10,000 per month range, under the best of circumstances.
Further, basing the stipend on the presumption the family Caregiver
will only provide 40 hours per week for the Veteran is fanciful, and
seems to be chosen to save the government money, not properly
compensate the Caregiver for his or her services.
Therefore, The Independence Fund recommends the stipend by
calculated by what home care licensed vocational nurse care of that
Veteran would cost the US Government, times 80 hours per week.
a.Should VA use one BLS rate per state?
No. Costs of living can vary greatly within a State, and varying
stipends based on those costs of living.is reasonable.
8.b. A Veteran is assigned a stipend tier based on the amount and
degree of personal care services provided. How should VA assess and
determine the amount and degree of personal care services provided
to the Veteran by the family caregiver?
While much of the PCAFC program eligibility is related to needs
regarding activities of daily living, given the well established
disability rating program the Department already executes, both with
the standard disability rating system and the Special Medical
Compensation ratings, it should rely upon those standards to the extent
that it can, regardless of the underlying activities of daily living
standard, as there is likely a strong correlation between the two, and
using such ratings would bring much greater transparency and uniformity
to the Caregiver tier and compensation systems.
Thank you for the opportunity to submit these comments. If you need
further clarification or if you wish to discuss further, I can be
reached at [email protected] or 202-779-1598.
Very Respectfully,
Bob Carey
Director, Policy & Advocacy
BOB CAREY
Dear Chairman Wenstrup, Representative Brownley, and Members of the
Subcommittee, thank you very much for inviting The Independence Fund to
testify before your Subcommittee today. I am Bob Carey, Director of
Policy & Advocacy of The Independence Fund, headquartered in Charlotte,
North Carolina, with additional offices in Washington, DC and San
Antonio, TX.
Only 10 years old, we were founded in 2007 with the very specific
purpose of assisting the most catastrophically wounded veterans from
the Iraq and Afghanistan with adaptive mobility devices, and returning
to them, at least in part, their independence. Since those humble
beginnings, The Independence Fund's grown to also provide assistance
for the caregivers of the catastrophically wounded and disabled,
assistance to adaptive athletes and teams, wellness programs to combat
the scourge of veteran suicide and post-traumatic stress disorder,
veteran service programs to navigate the overly complex VA health care
and benefit systems, advocacy programs to change the laws and
regulations that unnecessarily limit veterans access to their earned
benefits, and our newest program, Heroes at Home, which will assist the
children of the catastrophically wounded and disabled.
To date, The Independence Fund's provided more than $50 million in
assistance to the catastrophically wounded and disabled and their
Caregivers. This includes more than 2,200 motorized cross-country
wheelchairs, 1,500 adaptive bicycles, and more than 150 Caregiver
support retreats.
Overall Issues and Compromise Legislation
Mr. Chairman, we would be remiss if we did not discuss the failed
opportunity to bring widespread reform to the VA system with the
recently considered compromise VA Choice, Caregiver expansion, and
capital asset review legislation that was proposed to include on the
Comprehensive Appropriations Act for FY 2018, recently passed by
Congress. The Independence Fund supported this compromise legislation,
as we believe most every other major veteran service organization did.
We do not believe a single veteran service organization opposed the
compromise legislation. That is why we joined our VSO colleagues in our
disappointment it was not included in the final omnibus legislative
package.
That said, it is not too late to enact this groundbreaking
legislation. With the VA Choice program projected to run out of money
by late May or early June, some type of legislative action will be
needed very soon. The Independence Fund believes that original
compromise legislation, without amendment, is our best chance to break
ourselves from this endless cycle of budgetary brinksmanship with the
VA Choice program, to bring meaningful and real choice to the VA health
care system, to expand the caregiver program, and to analyze
deliberatively and rigorously the real capital asset requirements of
the VA.
While we share the Chairman's and the prior Secretary's concerns
expanding the VA Caregiver program without revising the eligibility
criteria may swamp the program so completely that current caregivers
are denied the support they need, the need for expanding choice in the
VA health care system is so severe, we are willing to take that risk
with the Caregiver program as part of a broad legislative compromise
proposal.
Therefore, Mr. Chairman and members of the Subcommittee, The
Independence Fund strongly recommends the proposed omnibus legislative
compromise language, with all three pieces major reform - VA health
care choice expansion and community care consolidation; VA Caregiver
expansion, and the capital asset review - be pursued in their entirety,
and without further amendment, before alternative texts are considered.
It is in this compromise language that our community finds its best
hope for passage. With the universal VSO support, if any part of the
original omnibus language were reopened, we would demand, as we believe
many other VSOs would demand, for additional reforms of other parts of
that omnibus package. In our case, it would be further expansion of
access to non-VA care and refinement and national standardization of
the Caregiver program. But such renegotiation of the language would
likely delay consideration to after the deadline for funding VA Choice,
and with that, the best legislative vehicle for enacting such laws.
HR 2322
Mr. Chairman, with The Independence Fund's focus on reforming VA
health care, especially for the catastrophically disabled, and for
supporting the caregivers and families of those catastrophically
disabled, we will only comment on HR 2322, HR 4334, and the Revised
Draft to Make Certain Improvements in the Family Caregiver Support
Program.
Which brings us to the specific issue of wheelchairs and
prosthetics. Our Executive Director, Sarah Verardo, is Caregiver to her
husband SGT Michael Verardo, USA (Ret), catastrophically wounded in
Southern Afghanistan in 2010. Mike regularly talks about how his
biggest battle was not on the battlefield, nor in the immediate
recovery before his medical retirement from the military in 2013. Mike
and Sarah's biggest battle is with a VA health care system unresponsive
to their unique health care needs, and apparently either unwilling or
unable to make the changes necessary to optimize the care for the
catastrophically disabled. Their personal experience, and the
experience of hundreds of our clients served through the years, is that
the VA cannot deliver wheelchair and prosthetic repairs and
replacements in a timely manner.
For example, when Mike was retired from the military and we moved
back to Rhode Island, his prosthetic leg was damaged, but we had to
wait 57 days for a VA medical administrator to sign a form authorizing
the repair of the prosthetic. Eventually, the prosthetic vendor grew
disgusted with the VA and provided a new prosthetic without
authorization, risking non-payment. In the meantime, Sarah was forced
to duct tape Mike's leg to keep it even somewhat operational. More
recently when Sarah requested a wheelchair repair or replacement from
VA, sheI was told that the VA needed to evaluate if Mike still had
injuries that required wheelchair use. Apparently the VA did not
realized limb loss is permanent.
The Independence Fund's made eliminating the requirement to see a
Primary Care Physician first when seeking prosthetics or wheelchair
repairs one of its type priorities, meeting with the White House, the
prior Secretary, Congress (including this Subcommittee), and the
leadership of the Rehabilitation, Wheelchair, and Prosthetics
departments at the VA. And that is why we are so encouraged by VA's
announcement week before last eliminating that requirement, allowing
the Veteran to go directly to the wheelchair and prosthetics offices to
seek assistance.
But that, Mr. Chairman, is not enough. The VA Inspector General
released a report last month detailing the myriad problems with
wheelchair and prosthetic repairs in VISN 7, which we believe apply
nationwide. The first remarkable item in this report is that the VA
apparently has no standard for how long it should take to repair
wheelchairs and scooters. Second, the VA IG found the average wait time
was 99 days. Some of the Veterans researched in this study were
bedridden for more than 100 days while their wheelchairs were being
repaired. We believe such wait times are similar for prosthetics as
well.
Lastly, the VA IG detailed the repair administrative process. That
process seems incredibly complex and unnecessarily duplicative. A
simple process review would likely be able to trim substantial time and
steps from this process. The Independence Fund recently met with the
Central Office Prosthetics and Wheelchairs Department, and we are
hoping to enter some Memorandum of Understanding with the VA to help
them improve those processes. We request your support with the VA to
enter into such an agreement with us.
But again, Mr. Chairman, we do not believe there are any
circumstances where the VA will be able to adequately respond to
Veterans' prosthetic and wheelchair repair and replacement needs.
Having to wait until the point of failure for the VA to even initiate
repair or replacement action and having no spares available for the
Veteran to use in the interim, highlights a system unresponsive to the
basic needs of disabled Veterans. Even the 30-day repair standard the
VA IG arbitrarily applied in their report (since the VA does not have
its own repair/replacement standard), is unacceptably long. Therefore,
we recommend Veterans be allowed immediate access to non-VA care for
the repair or replacement of prosthetics, wheelchairs, and scooters.
With regards to HR 2322, we believe additions and revisions to the
bill will help address these problems, and we look forward to working
with the sponsors of the legislation and the Subcommittee to revise it.
But spefically, we believe the following recommendations will help
improve the legislation:
-Specifically add language for wheelchairs. While many amputees are
able to use their prosthetics for many hours throughout the day, many
others are more limited in that use, relying on wheelchairs for the
other times. Further, administratively, the wheelchair programs and
prosthetic programs are run by the same offices in the VA, and the
procedures are developed by the same personnel.
-Required the VA to develop realistic repair and replacement
timelines. As the VA IG report highlighted, the VA currently has not
standards for how long it can take to repair or replace a wheelchair or
prosthetic device. The VA IG used 30 days as an arbitrary standard, but
even then, we believe that is unreasonably long. Further, the VA has no
preventive maintenance programs, or backup/loaner programs, even for
manual wheelchairs. We believe the Bill of Rights must include timely
access to repairs and replacements, loaners and backups provided by the
VA within days of the Veteran contacting VA, and immediate direct
access to the vendor by the Veteran, rather than having to go through
the Byzantine VA bureaucracy.
HR 4334
Mr. Chairman, The Independence Fund salutes the Subcommittee's
commitment to serving our female Veterans and specifically addressing
their unique needs. We also believe the bill's focus on exploring non-
VA care options is wise. While female veterans make up an increasing
portion of the VA health care population, they are still a significant
minority. We are concerned, at least in some regions, there will never
be enough of a female patient density to justify unique female programs
at local VA facilities, and that the unique needs of female Veterans
are such that the VA will never be able to recruit enough specialists
to provide adequate VA care to that population at the local level.
Further, we do not believe regional or national specialist clinics,
to which female Veterans would travel, are a reasonable way to provide
the care. It forces sick Veterans to travel long distances, forces them
inappropriately into inpatient care settings, and takes them away from
their primary family and local support systems. Therefore, Mr.
Chairman, The Independence Fund recommends the language regarding
female Veteran access to non-VA care by strengthened and expanded. We
look forward to working with the bill sponsors and the Subcommittee on
those recommendations.
Caregiver Support Programs
Mr. Chairman, as The Independence Fund's noted many times in the
past, we share your concern expanding the Caregiver program without
also refining it may so swamp the VA Caregiver infrastructure that
current Caregivers are denied the support they need. And in another
time and another place, we would be excited to help the Subcommittee
with such refinements. However, our fellow VSOs have made it clear, in
no uncertain terms, that only absolute expansion of the program, under
current eligibility rules, to pre-9/11 Veterans, is acceptable to them
as part of the broader omnibus appropriations compromise legislation.
Any change to that current language will trigger their opposition to
the entire package. Therefore, we are concerned consideration of this
legislation at today's hearing may endanger Congress' ability to get
not only VA Caregiver expansion enacted, but VA Choice expansion as
well.
The Independence Fund's attached it's response to the February 2018
Federal Register request for comments on the current Caregiver program,
as well as our testimony before the VA's Caregiver and Military Family
Advisory Committee, in order to provide the Subcommittee with the
background on our overall concerns with the program.
If Congress is unable to pass the omnibus appropriations compromise
VA reform legislation, and the entire gamut of issues is reopened for
legislative consideration, The Independence Fund looks forward to
working with the Subcommittee then on the new Caregiver expansion and
reform legislation.
Thank you again, Mr. Chairman, for the opportunity to appear before
this Subcommittee today. I look forward to answering any questions you
may have.
THE VETERANS CANNABIS COALITION
Chairman Wenstrup, Ranking Member Brownley, Members of the
Subcommittee, on behalf of the Veterans Cannabis Coalition (VCC), we
thank you for the invitation to submit our remarks to authorize the
U.S. Department of Veterans Affairs (VA) to conduct and support
research of medicinal cannabis. We believe that the VA Medicinal
Cannabis Act of 2018 is a positive first step toward putting the
incredible research capacity of the Department of Veteran Affairs to
work investigating the medical value of cannabis.
The Veterans Cannabis Coalition appreciates the Committee for
having listened to the concerns of millions of veterans and identified
the immediate need for more high-quality research into the efficacy of
cannabis through the Department of Veteran Affairs. The untold number
of veterans, whom are suffering from a lack of effective treatments for
their service-connected injuries, need options. Based on current and
existing research and anecdotal testimonies, we recognize the immense
potential of cannabis to treat some of the most persistent health
issues facing veterans today, particularly traumatic brain injury
(TBI), post-traumatic stress disorder (PTSD), and the pernicious effect
of chronic pain.
The comorbidity of these conditions in many veterans returning home
from Iraq and Afghanistan over the last 17 years has led to a modality
within the Veterans Health Administration to focus on pharmacology.
Doctors throughout the VA health system have consistently prescribed
risky combinations of incredibly powerful drugs in order to manage the
symptoms of the veterans under their care. These drugs include opioids,
benzodiazepines, stimulants, sedatives, anti-depressants, anti-
psychotics, and more, and are often taken in conjunction.
Veterans report that this commonly prescribed drug regimen,
nicknamed the `combat cocktail', negatively impacts their interpersonal
relationships and employment, destroys their quality of life, and has
led many to unsuccessfully attempting to take their own life while
under the influence of the very same medications prescribed by the VA.
There are thousands of others, driven by desperation and unable to find
relief through the only treatments offered, who were successful. The
veteran suicide and overdose rates reflect this reality.
As Congress and the public have begun to grapple with the fact that
millions of Americans-from valedictorians to professional athletes to
service members-struggle with opioid use disorders, the reaction from
health systems has been to taper or cut opioid prescriptions for
patients. The VA has touted their reduction and shift toward other
therapies and holistic treatments like acupuncture and yoga. Scaling
such therapies, however, presents massive challenges, while using non-
narcotic medications like non-steroidal anti-inflammatory drugs
(NSAIDs) carries other long-term risks such as kidney damage. Cannabis
has no known toxicity, low rates of misuse and abuse, and its use as a
medication is associated with marked improvements in dozens of
different conditions, ranging from insomnia to anxiety, PTSD to pain
management.
The Veterans Cannabis Coalition recognizes the VA Medicinal
Cannabis Research Act of 2018 as an opportunity for Congress to
decidedly address this crisis. Establishing the medical merit of
cannabis through Department of Veterans Affairs guided and funded
research will provide immeasurable public good, one that we hope both
parties will fully support. We look forward to working with your
offices and Committee staff as we aim to educate and build support for
this effort in the weeks and months ahead.
For additional information, please contact Eric Goepel, Founder &
CEO of the Veterans Cannabis Coalition at (213) 986-8139 or
[email protected].
THE VETERANS CANNABIS PROJECT
``TO AUTHORIZE THE DEPARTMENT OF VETERANS AFFAIRS TO CONDUCT AND
SUPPORT RESEARCH ON THE EFFICACY AND SAFETY OF MEDICINAL CANNABIS''
APRIL 17, 2018
Chairman Wenstrup, Ranking Member Brownley, Members of the
Subcommittee, on behalf of the Veterans Cannabis Project (VCP), we
thank you for the invitation to submit our remarks to authorize the
U.S. Department of Veterans Affairs (VA) to conduct and support
research of medicinal cannabis. It is imperative that Congress pass the
VA Medicinal Cannabis Research Act of 2018 to provide the VA the
resources to effectively and comprehensively treat the complexity of
every veteran's mental and physical wounds.
The internal wounds of military veterans have become a costly
nationwide epidemic. Upwards of 20 percent of the 2.7 million Iraq and
Afghanistan veterans will experience post-traumatic stress or
depression, according to the VA.
Veterans are often placated with ``cocktails'' of prescription
drugs, including powerful and addictive opiates. The current
arrangement is not meeting veterans' healthcare needs. Recent research
at the VA indicates a link between increased opioid dosages and suicide
among veterans. Federal data shows veterans are twice as likely as non-
veterans to die from an accidental overdose of highly addictive
prescription drugs.
Medical cannabis is a proven, safe and common-sense personal health
management option, free of the devastating side effects of opiate-based
drugs. It is now legal in 30 states and is recognized by experts such
as the American College of Physicians, the American Public Health
Association and the American Nurses Association as a safer alternative
to many legal treatments. Medicinal cannabis is an incredibly effective
tool for veterans challenged with managing the symptoms of their
wounds.
Furthermore, in states where medical cannabis is now legal,
veterans are stuck in a ``catch-22'' situation if they elect to obtain
a medical cannabis recommendation: the VA is a federal healthcare
system, which ignores state cannabis laws, leaving veterans unable to
openly discuss the issue with their primary care providers and at risk
of losing hard-earned benefits. Regardless of the legal status of
cannabis in a state, Veterans Health Administration physicians are
prohibited from recommending cannabis as a treatment option for their
Veteran patients.
The VA Medicinal Cannabis Research Act of 2018 will elevate
cannabis as a health policy issue and lay the foundation for veterans
to legally access an effective healthcare treatment. While data already
exists proving medical cannabis' positive effects, federal research is
needed to afford the VA the ability to treat cannabis as medicine. We
owe those who served, currently serve, and will serve our nation access
to every medically proven healthcare treatment, including medical
cannabis.
The Veterans Cannabis Project was founded by veterans, for
veterans, to create an improved quality of life through the opportunity
of cannabis. The Veterans Cannabis Project team is comprised of veteran
leaders and their families through meaningful career progression after
the military. We thank the Subcommittee for holding this important
hearing and for the opportunity to explain the views of the Veterans
Cannabis Project.
For additional information, please contact Nick Etten, Founder &
CEO of the Veterans Cannabis Project at (512) 992-7567 or
[email protected].
WOUNDED WARRIOR PROJECT
Chairman Wenstrup, Ranking Member Brownley, and distinguished
members of the Subcommittee on Health - thank you for inviting Wounded
Warrior Project (WWP) to provide this statement for the record for
today's legislative hearing on pending health legislation. More than
113,000 wounded warriors are registered to receive WWP's free direct
programs and services, and thus far in Fiscal Year 2018, WWP is
registering an average of more than 1,200 new warriors per month.
Based on these figures and our own observations and experiences
working with wounded warriors and their families around the country, we
believe that the need for strong, sensible, and sustainable veteran-
centric health care laws is great and growing. We are pleased to
provide the following positions on legislation before the Subcommittee.
H.R.--: A draft bill to make certain improvements in the Family
Caregiver Program
As a crucial component of delivering on our mission to honor and
empower wounded warriors, WWP has been proud to advocate for benefits
for seriously injured post-9/11 veterans' caregivers. In addition to
organizing in support of enacting the Caregivers and Veterans Omnibus
Health Services Act of 2010, WWP has worked closely with the Department
of Veterans Affairs (VA) to ensure that the Program of Comprehensive
Assistance for Family Caregivers (the Program) is carried out as
effectively as possible.
Wounded Warrior Project believes the Program should be available to
all generations with appropriate funding and without a reduction in
benefits for post-9/11 warriors. While WWP's mission focuses on family
caregivers of veterans and service members who have been wounded, ill,
or injured since September 11, 2001, we appreciate that the
Subcommittee has acknowledged that all generations should receive the
benefits that have been such a crucial resource for post-9/11
caregivers over the last seven years.
In this context, WWP does not support the current draft legislation
because its proposed improvements do not outweigh the associated
detriments to the current program. WWP supports the information
technology provisions in Section 1; however Section 2 creates concerns
that overshadow the desired goal of expanding the Program to all
generations. Specifically, raising the threshold for eligibility based
on activities of daily living would result in the ability to serve
fewer veterans whose best clinical interest can and should be served by
participating in the Program.
Section 2 also proposes to ``transition'' current program
participants - whose current eligibility may not be sufficient for
participation under new criteria - to the new program. While WWP has
concerns about the VA's ability to administer a bifurcated Program with
different eligibility standards, WWP is strongly opposed to
implementing a new, single program that holds potential to remove
current, deserving beneficiaries to accommodate new participants.
Moreover, it has been approximately one year since VA froze Program
revocations due, in part, to complaints from veterans who lost access
to the Program even though their conditions had not improved \1\.
Anecdotally, WWP has seen such revocations from veterans utilizing our
Benefits Services program, and in our experience, successful appeals
are extremely rare. By ordaining a transition process that could
potentially remove thousands of veterans from the Program, this draft
bill would amplify these issues even further. Removing current
participants who have been clinically approved to participate and who
maintain a severe level of disability is an unacceptable approach to
realizing the greater community's dream of bringing the Program within
the reach of other veteran caregivers who are no more or less deserving
of its critical resources.
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\1\ Quil Lawrence, Some VAs are Dropping Veteran Caregivers from
their Rolls, NPR (April 5, 2017) (available at https://www.npr.org/
2017/04/05/522690583/caregivers-for-veterans-dropped-from-va-plan).
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In sum, WWP believes that those who cannot participate in the
Program now (and all who could potentially participate in the future)
should have access to the same benefits offered to those currently in
the Program. Such an expansion can and should be achieved with careful
management and appropriate funding, and without diminishing the quality
of the Program for those currently-eligible or those who may become
eligible in the future. As the current draft proposal does not meet
these criteria, WWP respectfully opposes the current draft proposal.
WWP also fully supports S. 2193 Caring for our Veterans Act of 2017,
which offers full expansion of the Caregiver Program to all generations
without diminishing the quality of the Program, and WWP will
aggressively pursue its passage through the House and Senate.
H.R.--: A draft bill to authorize VA to conduct and support research on
the efficacy and safety of medicinal cannabis
Wounded Warrior Project's mission to honor and empower wounded
warriors drives us to foster the most successful, well-adjusted
generation of injured veterans in our nation's history. The warriors,
caregivers, and family members we serve are at the center of every
decision we make. Several emerging and alternative therapies have
demonstrated some initial promising results for the management and
treatment of the invisible wounds of war, including post-traumatic
stress disorder (PTSD) and traumatic brain injury (TBI). Lately, there
has been much debate surrounding veterans' rights to access medical
cannabis as an alternative therapy.
At WWP, we believe that choosing a treatment method, whether
alternative or empirically supported, is a personal decision that
should be made between each warrior, his or her family, and his or her
medical team. WWP encourages warriors to make informed decisions in
pursuing the treatment options that are most relevant to their
circumstances with the guidance of their health care providers. While
WWP does not have an official stance on the use of medical cannabis,
WWP is supportive of evidence-based and evidence-informed therapies, as
well as complementary and alternative therapies that have been
empirically demonstrated and validated through research to be
successful in rehabilitation and recovery.
For these reasons, Wounded Warrior Project supports research and
investments with potential to expand the number of evidence-based and
evidence-informed therapies available to treat both the visible and
invisible wounds of war affecting post-9/11 veterans. As any research
plan developed by VA to investigate potential uses of medical cannabis
under this proposal would be subject to additional review by Congress,
this proposal permits future oversight of potential concerns regarding
employment constraints and other ramifications of those selected to
participate. In this context, WWP is pleased to support this draft
proposal.
H.R. 1506: VA Health Care Provider Education Debt Relief Act of 2017
Recent work to improve and consolidate VA's community care programs
has provided an opportunity for WWP and others in the veterans policy
community to highlight a corresponding need to ensure that VA is given
the tools and resources necessary to grow and strengthen as it
struggles to meet the increased demand for services for our nation's
heroes. Of particular note, VA must be able to recruit, hire, and
retain high-quality medical professionals.
WWP views the Health Care Provider Education Debt Relief Act of
2017 as a way to attract quality personnel to the VA, and with the rise
of education debt, an opportunity to give VA a competitive advantage to
hire and retain those best qualified to deliver care to veterans. In
its Determination of VHA Occupational Staffing Shortages FY 2017
report, VA's Office of Inspector General found that the largest
critical need occupations were Medical Officers, Nurses, Psychologist,
Physician Assistants, and Medical Technologists \2\. In the past four
years, Medical Officers and Nurses have been the top two critical need
occupations. Given the amount of cost it requires to obtain a degree in
one of these two fields, H.R. 1506 would constitute an effective tool
to attract these critically needed specialists to VHA. For these
reasons, WWP is pleased to support the Health Care Provider Education
Debt Relief Act of 2017.
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\2\ https://www.va.gov/oig/pubs/VAOIG-17-00936-385.pdf
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H.R. 2322: Injured and Amputee Veterans Bill of Rights
While the past several years have seen increased focus on the
mental health needs of post-9/11 veterans, WWP remains vigilant in
addressing the needs of those with severe physical injuries. From
January 1, 2001, through December 31, 2016, 1,710 service members
sustained at least one conflict-related amputation (excluding fingers,
thumbs, or toes) \3\. This group is just a small segment of a larger
population. The total number of Veterans with amputations being seen at
VA facilities increased 325 percent, from 25,000 in FY 2000 to almost
90,000 in FY 2016 \4\. These figures reflect the need to help ensure
veterans with injuries and amputations have access to high quality
prosthetic limb and orthotic care.
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\3\ VA/DoD Clinical Practice Guidelines for Rehabilitation of
Individuals with Lower Limb Amputation. The Rehabilitation of
Individuals with Lower Amputation Working group; Version 2.0 - 2017;
pg. 10.
\4\ Id. at 10.
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Although not all amputees elect to wear a prosthesis, the vast
majority do. The ultimate goal for a prosthesis is to achieve the most
function and mobility possible, leading to an active and fulfilling
lifestyle. To achieve that goal, an amputee must work closely with a
prosthetist who understands their unique needs, such as residual limb
size, type of amputation, gender- and age-related issues, and activity
levels.
The proposed Injured and Amputee Veterans Bill of Rights would
affirm a commitment to ensuring these veterans have access to timely,
high quality, and patient-centered care. WWP believes the nine-line
Bill of Rights in Section 2(d) are all reasonable and non-controversial
policy statements, including the right to have access to high-quality
care, the most appropriate prosthesis and orthosis, the most
appropriate technology, and the best-qualified practitioners, whether
or not that practitioner is an employee of the VA. A requirement to
prominently post these rights at each VA prosthetics and orthotics
clinic, as well as on the VA website, would help ensure they are known
and understood by both veterans and health practitioners.
Additionally, with the increasing number of amputees relying on the
VA for prostheses, WWP supports the reporting requirements for the VA
to establish transparency of allegations of mistreatment of injured and
amputee veterans. The educational component of this legislation would
ensure that VA employees who work at prosthetics and orthotics clinics
or as a patient advocate for amputees, receive training on such Bill of
Rights.
For these reasons, WWP is pleased to support the Injured and
Amputee Veterans Bill of Rights.
H.R. 4334: Improving Oversight of Women Veterans' Care Act of 2017
H.R. 4635: To direct the Secretary of Veterans Affairs to increase the
number of peer-to-peer counselors providing counseling for women
veterans, and for other purposes
Women comprise 8.7 percent of the veteran population and are the
fastest-growing demographic in the military \5\. At WWP, nearly 16
percent of our registered alumni are women and as an organization
dedicated to honoring and empowering wounded veterans and service
members who have been injured in both mind and body since 9/11, we
particularly aware of the growing contributions of women in our armed
services - and the need for programs and services tailored to their
needs.
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\5\ Source: National Center for Veterans Analysis and Statistics:
Profile of Veterans: 2016: Data from the American Community Survey.
2016.
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The Department of Veterans Affairs has expanded its care options
and outreach to women veterans, but there is still room for
improvement. VA offers primary and specialty care to support women at
every stage of their life - including women's services such as family
planning, infertility services, menstrual and menopausal management -
but accessibility in a community-based settings is not fully captured
and compliance with environment of care standards for women in VA-based
settings is not fully monitored. The Improving Oversight of Women
Veterans' Care Act of 2017 aims to correct these deficiencies, and
women veterans stand to benefit.
One particular area where women veterans are finding satisfaction
is peer support. In our experience, peer-to-peer support is critical to
recovery for many warriors. According to the 2017 Wounded Warrior
Project Survey, more than half of those surveyed, or 51.6 percent, used
talking with another Operation Enduring Freedom, Operation Iraqi
Freedom, or Operation New Dawn veteran as a resource to address mental
health issues. The only more frequently utilized resource was VA
Medical Centers.
Within the context of female veterans, peer-to-peer support is a
particularly important tool to break through seclusion and isolation.
As the Subcommittee is aware, shifts in perception of military
demographics are slow-moving, and many on either side of the civilian-
military divide still think of members of the Armed Forces as male.
Particularly when combined with injuries to mental health sustained in
service, these preconceived notions can be harmful to reintegration and
recovery. VA's 2016 suicide data report found that the risk of suicide
was 2.5 times higher among female veterans when compared with civilian
adult females \6\. By connecting female veterans with one another,
peer-to-peer assistance can empower female veterans to connect with
each other and their communities. At WWP, we've increased our
commitment to offering more all-female peer support groups and all-
female alumni workshops based on demand and overall satisfaction.
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\6\ Source: Office of Suicide Prevention, Department of Veterans
Affairs, Suicide Among Veterans and Other Americans 2001-2014, 4
(August 2016).
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Wounded Warrior Project is committed to improving health options
and outcomes for women veterans as both a program provider and an
advocate for those receiving care and services through VA. Both H.R.
4334 and H.R. 4635 are consistent with our commitment to achieving
these goals, and WWP is pleased to provide its support for both
proposals.
H.R. 3832: Veterans Opioid Abuse Prevention Act
Wounded Warrior Project does not take a position on this bill at
this time.
CONCLUSION:
Wounded Warrior Project thanks the Subcommittee on Health, its
distinguished members, and all who have contributed to the policy
discussions surrounding the bills under consideration at today's
hearing. We share a sacred obligation to serve our nation's veterans,
and WWP appreciates the Subcommittee's effort to identify and address
the issues that challenge our ability to carry out that obligation as
effectively as possible. We are thankful for the invitation to submit
this statement for record and stand ready to assist when needed on
these issues and any others that may arise.
Sincerely,
Rene C. Bardorf
Senior Vice President of Government and Community Relations
[all]