[House Hearing, 116 Congress]
[From the U.S. Government Publishing Office]
H.R. 712; H.R. 1647; H.R. 3083; H.R. 485; DISCUSSION DRAFT, SPECIALLY
ADAPTIVE HOUSING, AND DISCUSSION DRAFT, WORK STUDY
=======================================================================
HEARING
before the
COMMITTEE ON VETERANS' AFFAIRS
U.S. HOUSE OF REPRESENTATIVES
ONE HUNDRED SIXTEENTH CONGRESS
FIRST SESSION
__________
THURSDAY, JUNE 20, 2019
__________
Serial No. 116-21
__________
Printed for the use of the Committee on Veterans' Affairs
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
Available via the World Wide Web: http://www.govinfo.gov
______
U.S. GOVERNMENT PUBLISHING OFFICE
40-822 WASHINGTON : 2021
COMMITTEE ON VETERANS' AFFAIRS
MARK TAKANO, California, Chairman
JULIA BROWNLEY, California DAVID P. ROE, Tenessee, Ranking
KATHLEEN M. RICE, New York Member
CONOR LAMB, Pennsylvania, Vice- GUS M. BILIRAKIS, Florida
Chairman AUMUA AMATA COLEMAN RADEWAGEN,
MIKE LEVIN, California American Samoa
MAX ROSE, New York MIKE BOST, Illinois
CHRIS PAPPAS, New Hampshire NEAL P. DUNN, Florida
ELAINE G. LURIA, Virginia JACK BERGMAN, Michigan
SUSIE LEE, Nevada JIM BANKS, Indiana
JOE CUNNINGHAM, South Carolina ANDY BARR, Kentucky
GILBERT RAY CISNEROS, JR., DANIEL MEUSER, Pennsylvania
California STEVE WATKINS, Kansas
COLLIN C. PETERSON, Minnesota CHIP ROY, Texas
GREGORIO KILILI CAMACHO SABLAN, W. GREGORY STEUBE, Florida
Northern Mariana Islands
COLIN Z. ALLRED, Texas
LAUREN UNDERWOOD, Illinois
ANTHONY BRINDISI, New York
Ray Kelley, Democratic Staff Director
Jon Towers, Republican Staff Director
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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Thursday, June 20, 2019
Page
H.R. 712; H.R. 1647; H.R. 3083; H.R. 485; Discussion Draft,
Specially Adaptive Housing, And Discussion Draft, Work Study... 1
OPENING STATEMENTS
Honorable Mark Takano, Chairman.................................. 1
Honorable David P. Roe, Ranking Member........................... 3
Honorable Luis Correa, U.S. House of Representatives (CA-46)..... 5
Prepared Statement........................................... 41
Honorable Gilbert Ray Cisneros, Jr............................... 7
Honorable Gus M. Bilirakis....................................... 8
WITNESSES
Mr. Adrian M. Atizado, Deputy National Legislative Director,
Disabled American Veterans..................................... 10
Prepared Statement........................................... 41
Mr. Travis Horr, Director, Government Affairs, Iraq and
Afghanistan Veterans of America................................ 11
Prepared Statement........................................... 46
Mr. Carlos Fuentes, Director, National Legislative Service,
Veterans of Foreign Wars....................................... 13
Prepared Statement........................................... 48
Mr. Derek Fronabarger, Director, Government Affairs, Wounded
Warrior Project................................................ 15
Prepared Statement........................................... 52
Dr. Igor Grant, M.D., F.R.C.P.(C), Director, Center for Medicinal
Cannabis Research, University of California.................... 16
Prepared Statement........................................... 55
Larry Mole, BA, PharmD, Chief Consultant, Population Health
Services, Patient Care Services, Veterans Health Administration 32
Prepared Statement........................................... 56
Honorable Scott R. Tipton, U.S. House of Representatives, (CO-
03), prepared statemnt only.................................... 59
Mr. J. David Cox, Sr., National President, American Federation of
Government Employees (AFGE), prepared statemnt only............ 60
Mr. Eric Goepel, Founder & CEO, Veterans Cannabis Coalition
(VCC), prepared statemnt only.................................. 60
Mr. Randy Erwin, National President, National Federation of
Federal Employees (NFFE), prepared statemnt only............... 62
Thelma Roach-Serry, BSN, RN, NE-BC, President, Nurses
Organization of Veterans Affairs (NOVA), prepared statemnt only 63
STATEMENTS FOR THE RECORD
Paralyzed Veterans Of America (PVA).............................. 64
Veterans Healthcare Policy Institute............................. 65
MATERIALS SUBMITTED FOR THE RECORD (UPON REQUEST)
1. H.R. 2943..................................................... 70
2. H.R. 2942..................................................... 70
3. H.R. 2676..................................................... 70
4. H.R. 2677..................................................... 70
5. H.R. 712...................................................... 70
6. H.R. 1647..................................................... 70
7. H.R. 3083..................................................... 70
8. H.R. 485...................................................... 70
9. Discussion Draft - Specially Adaptive Housing................. 70
10. Discussion Draft - Work Study................................ 70
H.R. 712; H.R. 1647; H.R. 3083; H.R. 485; DISCUSSION DRAFT, SPECIALLY
ADAPTIVE HOUSING, AND DISCUSSION DRAFT, WORK STUDY
----------
Thursday, June 20, 2019
Committee on Veterans' Affairs,
U. S. House of Representatives,
Washington, D.C.
The Committee met, pursuant to notice, at 2:06 p.m., in
Room 210, House Visitors Center, Hon. Mark Takano [Chairman of
the Committee] presiding.
Present: Representatives Takano, Brownley, Rice, Lamb,
Levin, Brindisi, Rose, Pappas, Luria, Lee, Cunningham,
Cisneros, Peterson, Sablan, Allred, Underwood, Roe, Bilirakis,
Radewagen, Bost, Dunn, Bergman, Barr, Meuser, Roy, and Steube.
OPENING STATEMENT OF MARK TAKANO, CHAIRMAN
The Chairman. Good afternoon. I call this hearing to order.
I would like to start by thanking the Veterans Service
Organizations for being here. Without your advocacy, the Blue
Water Navy Vietnam Veterans Act would not be on the President's
desk awaiting his signature.
[Applause.]
The Chairman. Thank you, everybody, actually. Thank
everyone on this Committee. Dr. Roe, thank you especially, and
our Republican colleagues. This is a tremendous accomplishment.
We rely on you, the Veterans Service Organizations, to
provide feedback and expert testimony on legislation affecting
veterans, and today we ask you for the same. The legislation on
the agenda for this hearing covers a range of veterans' issues,
from health care to educational and housing benefits, to
transition assistance. Today, we hope to generate discussion on
each of the agenda items, so we can make informed decisions on
whether the legislation is ready to be considered in markup.
Four agenda items are related to medicinal cannabis. Now, I
believe cannabis must be objective researched, period. Medical
cannabis may have the potential to manage chronic pain better
than opioids and treat PTSD. However, other research shows that
cannabis may significantly affect brain development into early
adult. Young servicemembers enlisting at age 17 or 18 and
separating from the military at age 22 may be particularly
vulnerable to its negative side effects.
I want to make sure that any research legislation this
Committee votes on is not written to achieve one outcome or
used to fast-track treatments for veterans. Clinicians need to
understand the efficacy of this drug and any negative side
effects. In those states that allow medical cannabis, VA
doctors should be able to provide recommendations to veterans
for medical cannabis programs.
I also place H.R. 3083, the AIR Acceleration Act, on the
agenda today, because I have serious concerns about VA's
implementation of the AIR Act. We have received no information
from VA on the market assessments to give this Committee
confidence that the mission when it is scheduled to meet will
actually have the data it needs to make informed decisions. It
is important that we have a public discussion of these concerns
and hear from stakeholders, because I do not believe it makes
sense to speed up this process now. VA's lack of transparency
should be concerning to us all.
I would also like to highlight two bills introduced by
Representative Cisneros that I support, H.R. 2942, that
authorizes an existing Air Force Women's Health TAP pilot
program, and H.R. 2943 would codify an existing regulation that
all VA fact sheets be available to veterans in Spanish.
During a recent visit to the VA Medical Center in San Juan,
Puerto Rico, Committee staff saw firsthand why VA should be
mandated by law to provide materials in Spanish. I was shocked
to learn that key letters, fact sheets, and employee training
modules developed to educate veterans and staff on the MISSION
Act were only produced and mailed to veterans in English. In
Puerto Rico, where Spanish is the predominant language, this
means veterans and hospital employees were not notified about
the upcoming changes with the MISSION Act and employees were
not prepared to implement the law on June 6th. Hospital staff
in San Juan, to their credit, translated and reproduced
materials in Spanish on their own, because the translation
provided by a contracted vendor was poor and inadequate.
The Veterans Crisis Line, a lifeline for veterans thinking
about suicide, operates only in English. The Puerto Rico VA
Medical Center established its own local crisis line in
Spanish, but when my staff called the number on several
occasions, no one answered. Well, think about that for a
moment: help is only available at the VA in Puerto Rico if you
understand English.
According to the 2015 census, on average, 73 percent of
Hispanics speak a language other than English at home, and 31
percent of Hispanics state that they are not fluent in English.
VA statistics predict an increase in the Hispanic veteran
population from 7.4 percent in 2017 to 11.2 percent by 2037.
Failing to provide veterans with clear explanations of their
benefits in Spanish means Latin veterans will lose out on GI
Bill benefits, VA home loans, or health care programs like the
MISSION Act. Veterans won't receive their burial benefits if
their surviving family members do not understand English. A
Spanish-speaking veteran's call to the Veterans Crisis Line
would in effect remain unanswered.
So VA should be providing Spanish language materials, but
it is falling short in too many cases. And, when I became
Chairman of this Committee, I committed to you that we would
work to break down barriers for veterans from minority and
under-served communities; Mr. Cisneros' bill is one small step
towards this effort. It is not enough that this is a VA
regulation, we must make this the law and exercise this
Committee's oversight authority to make sure VA is following
it.
So I want to just say this slightly different--
[Speaking Spanish.]
The Chairman. So, that concludes my opening remarks.
Dr. Roe, you are now recognized for 5 minutes to give your
opening statement.
OPENING STATEMENT OF DAVID P. ROE, RANKING MEMBER
Mr. Roe. Thank you, Mr. Chairman. I appreciate you holding
this hearing this afternoon to discuss ten bills, many of which
I support, for and including my bill, H.R. 3083, on today's
agenda.
H.R. 3083, the Asset Infrastructure Review, or AIR,
Acceleration Act would eliminate the requirement in current law
that the AIR Commission meet only in calendar years 2022 and
2023.
The AIR Act was signed into law last year as part of the
MISSION Act. It established a methodical, objective,
transparent process to recommend how the VA health care system
could be realigned and modernized to better meet the needs of
our veterans. That process was developed in response to a
recommendation made in the 2016 Bipartisan Commission on Care,
after finding that VA medical sites on average are five times
older than medical facilities in the private sector, and have
been designed and built to meet markedly different health care
needs in a markedly different health care market than veterans
experience today. That finding was further supported by a 2017
Government Accountability Office report, which found that the
VA health care system is misaligned with the veteran population
and no longer well-suited to providing care in many instances.
VA concurred with the GAO in testimony before this
Committee later that year and further noted that the majority
of VA facilities have outlived their useful life cycle. It is
clear beyond a shadow of a doubt that the AIR Act is necessary
for those and for many other reasons. That is why every major
Veterans Service Organization joined together in support of the
inclusion of the AIR Act in the MISSION Act last year.
At the time, it was expected that the market assessments
that will underlie much of the commission's work could take
many years to complete and, therefore, the commission should
not be allowed to meet until 2022 at the earliest. However, in
the last several months Secretary Wilkie has testified multiple
times before this Committee and before the Senate Committee on
Veterans' Affairs that those market assessments will be
complete next summer. Because of that, the Secretary has urged
Congress to give the AIR Commission the flexibility to begin
their deliberations prior to 2022; the AIR Acceleration Act
would provide that flexibility. This would give the commission
more time to do its work by allowing deliberations to begin
before 2022 and extend after 2023, as needed.
Note that none of the other deadlines including in the AIR
Act deadlines that were carefully coordinated with the Veterans
Service Organizations, who I worked very closely with on every
aspect of this legislation, would be impacted by the AIR
Acceleration Act. I am grateful for the support of the Wounded
Warrior Project, and Iraq and Afghanistan, the IAVA, on this
legislation.
Also, Mr. Chairman, I would appreciate a letter that we
received just yesterday from Concerned Veterans For America
that it be admitted into the record. At the newest--
The Chairman. Without objection, so ordered.
Mr. Roe. Thank you, Mr. Chairman.
As the newest VSO representing the most recent generation
of veterans, IAVA and WWP are perhaps uniquely positioned to
recognize just how critical the AIR Act is to VA's future
success and sustainability, and just how much veterans stand to
lose by waiting to begin the commission's important work while
VA's infrastructure continues to worsen. I thank these VSOs for
their support.
That said, I recognize that VSOs have concerns about the
AIR Acceleration Act, primarily because they fear rushing the
AIR Act process. And while I note that only in government is
the thought that starting something 2 years after it was signed
in law rushing, I still look forward to beginning the dialogue
with them today about that fear and how we can move forward to
address their concerns.
And just off script for a minute. It is not just the VA
health care system; it is the American health care system is
going to have to be re-looked at. Heads in beds actually
maximized in 1981 and 1982; in other words, the number of
people who were in a hospital bed maximized then. The
population has grown 40 percent since that time and we actually
have 10 percent--on any one day, 10 percent less people in a
hospital bed than we did 40 years ago almost. And why? Because
of the changes in medicine, the way we deliver health care, and
I am a perfect example of it. I have had two major operations
in the last 2 years and spent less than 48 hours in the
hospital for both of them.
So it is not just VA and we no longer can support 1100
empty buildings. We need to take those resources and put those
resources where the veterans are, into their health care, into
other benefits for veterans.
The two other bills that I support on the agenda are draft
bills. The first draft bill was sponsored by Representative
Rodney Davis and would improve the payment of work study
benefits to GI Bill beneficiaries. The idea of this bill came
from the student veterans themselves at a GI Bill forum that
Representative Davis hosted in his district last year, which I
was glad to attend that forum with Congressman Davis, and I
commend him for representing the student veterans in his
district so well.
The other draft bill is sponsored by my good friend Gus
Bilirakis, the Ranking member on Economic Opportunity
Subcommittee. It would make needed improvements to the
Specially Adaptive Housing Program to help severely disabled
servicemembers and veterans adapt their homes to meet their
needs.
This afternoon's agenda also includes several bills,
including medical marijuana. One of those bills, 712, the VA
Medicinal Cannabis Research Act, I fully support requiring VA
to conduct research regarding medical marijuana and have said
so for many years. And that is why under my chairmanship last
year this Committee unanimously reported bipartisan legislation
sponsored by then Ranking Member Walz and me that would
authorize VA to research medical cannabis. It is also why I
introduced the same bill, H.R. 747, this year after
strengthening it to not authorize, but require the VA to
conduct research in medicinal cannabis.
However, H.R. 712 includes numerous restrictions regarding
what the research VA must conduct on medicinal cannabis should
look like. According to VA, those restrictions are inconsistent
with the standards and practices of scientific research. It is
wholly inappropriate for members of Congress to dictate the
research that scientists are being asked to perform and,
therefore, I oppose H.R. 712 and express disappointment that,
despite my request, H.R. 747 was not included on today's
agenda, so that we could have an open discussion about which
approach this important issue is most likely to benefit our
Nation's veterans.
With that, I thank the witnesses for being here, and I
yield back.
The Chairman. Thank you, Chairman Roe. And we will discuss
this more, but I recognize your--I think you have raised some
very valid points about the research.
I would now like to welcome non-committee members to our
first panel. I see that we have the Honorable Lou Correa, Luis
Correa, a Member of Congress from my own home state,
California, California's 46th District. We have two other
Members, but they are not here, and I will introduce them as
they arrive.
So, Mr. Correa, you are recognized for 5 minutes. Go ahead.
OPENING STATEMENT OF LUIS CORREA
Mr. Correa. Thank you, Mr. Chairman, Chairman Takano and
Ranking Member Roe, for inviting me to speak on my bipartisan
bill, H.R. 712, the VA Medicinal Cannabis Research Act. I
appreciate the chance to return to the VA Affairs Committee
where I served in the last Congress to speak on this very
important issue on the need of research on medical cannabis as
a possible treatment option for our Nation's veterans.
The U.S. Department of Veterans Affairs is in a unique
position to pursue necessary research in what cannabis can and
cannot do for our veterans.
Our brave men and women return from military service from
Iraq and Afghanistan, and many times with both visible and
invisible wounds sustained in battle.
Unfortunately, for many of these veterans with PTSD and
chronic pain, the use of prescription opioids has been
ineffective in providing relief. And, even worse, the use of
prescription opioids has led to addiction and even death.
Tragically, VA patients are almost twice as likely to die
from accidental opioid overdose than non-veterans.
In California, I have met with many veterans who use
medical cannabis as an alternative to prescription opioids and
other medical treatment options, and all of them vouch for the
therapeutic benefits of medical cannabis and support further
research into this issue.
In fact, according to the Iraq and Afghanistan Veterans of
America, over 90 percent of their members support medical
cannabis research. And more veterans use cannabis for medical
purposes, and it is important that doctors be able to fully
advise on the potential benefits and effectiveness of medical
cannabis.
Presently, VA doctors can discuss cannabis usage with their
patients, but they have very limited federally approved
research on which to base recommendations or clinical options.
For that reason, with my colleague and friend Congressman
Clay Higgins of Louisiana, we have introduced the VA Medicinal
Cannabis Research Act.
The bill requires the U.S. Department of VA to conduct
double-blind clinical studies on the safety and effectiveness
of medical cannabis. Let me repeat: this bill requires the VA
conduct double-blind clinical study on the safety and
effectiveness of medical cannabis. The legislation provides a
framework for that research to ensure that scientifically-sound
studies are conducted on this issue.
And, finally, let me thank the Iraq and Afghanistan
Veterans of America, Veterans of Foreign Wars, Disabled
American Veterans, and many others for their support of this
bill. And I look forward to working with you on this most
important piece of legislation.
And, if I may, Dr. Roe, I just wanted to address some of
your concerns with this legislation.
I know last year we worked together on some of this
legislation and I understand your concern that we are mandating
to the VA how to conduct scientific research. Yet, I have to
tell you, over the last 2 years and dealing with the VA, they
have told us different opinions as to what they can and can't
do at the VA. First, they said, we don't have the authority to
do the research; then they said, we have the authority to do
research.
I am not quite sure who is telling us the truth, where
there is a truth, but what we are simply doing with this bill
is assuring that there is no bias in the research of medical
cannabis, there is no bias on the part of the researchers or on
the individuals that are actually being researched. That is
what this bill is about, making sure we get good data for our
veterans.
Thank you very much.
The Chairman. Thank you, Mr. Correa, for your testimony.
I now would like to recognize Dr. Roe for 5 minutes to
speak about his bill.
Mr. Roe. Thank you. And, Mr. Correa, thank you for your 2
years of service on this Committee and your service in
California for veterans there. And I know of no one who has the
interests of veterans any more than you do. You and I are good
friends, and I respect you and respect what you want to do. And
we authorized, Congressman Walz and I, last year the VA to do
the studies; they didn't do it.
My concern is just this, is that we don't need to be
prescribing from on the high here in Washington how to carry on
clinical research. We need to make sure that they do--that the
VA not authorizes, but has to study either chronic pain or
opioid, a substitute for opioids, or PTSD treatment. And I have
read this morning probably a dozen articles on various research
that is done around the country. I just don't think that--I
know, as a scientist, we shouldn't as politicians be telling
the scientists how to design their studies.
I agree with everything you said and your bill and would
support it, if it just allowed VA the ability to be able to
design their trials based on what they think are the best ways
to do it and not how we think are the best ways. And that is
all my bill said was that, look, you have to do the studies,
but let the scientists at Yale or wherever they are, at
whichever medical center or multiple medical centers that are
done, that are able to do it.
And, with that, I yield back.
The Chairman. Okay. I now would like to recognize Mr.
Cisneros, Congressman Cisneros, you are recognized for 5
minutes.
OPENING STATEMENT OF GILBERT CISNEROS
Mr. Cisneros. Thank you, Chairman Takano and Ranking Member
Roe. I really appreciate the opportunity to testify about my
bill, the Providing Benefits Information in Spanish for
Veterans and Families Act.
This legislation would direct the Secretary of Veterans
Affairs to make all Department of Veterans Affairs fact sheets
available in English and Spanish.
According to the U.S. Census, as of July 1st, 2017, the
U.S. Hispanic population is approximately 58.9 million,
constituting 18.1 percent of the Nation's total population,
making people of Hispanic origin the Nation's largest ethnic
and racial minority.
With the changing demographic of the U.S. population
overall trending towards a more racially and ethnically diverse
majority, the veteran population is diversifying at similar
rates. The share of veterans who are Hispanic is expected to
double from 7 to 13 percent, according to the Pew Research
Center.
With Spanish as the first language of an increasing number
of veterans and their families, it is important that the facts
sheet offered by the VA are made available. This bill would
serve as an important first marker in ensuring veterans and
their families with limited English proficiency have full
access and information on VA services without burden or
barriers, benefits they have rightfully earned.
Additionally, I have been informed by Representatives from
this Committee that this issue is of particular importance to
veterans in Puerto Rico, in which approximately 300,000
veterans live.
I urge you to join me in support of this legislation, H.R.
2943.
I yield back the balance of my time.
The Chairman. Mr. Cisneros, thank you for your testimony on
your bill.
I understand you have a second piece of legislation that
you would like to discuss, so I recognize you for 5 minutes to
discuss your second bill.
Mr. Cisneros. Yes. Thank you again, Mr. Chairman, and thank
you again, Ranking Member Roe.
This bill is H.R. 2942, Health for Women Veterans Act. I
really appreciate the opportunity to testify about my bill
helping to expand and launch Transitional Health--or Health for
Women Veterans Act, introduced with my distinguished colleague
and fellow vet Congresswoman Chrissy Houlahan.
As a veteran myself, one of my top priorities is ensuring
active servicemembers who are transitioning into the civilian
world who are connected to the VA system--well, to make sure
that they are connected to the VA and provided with the best
education and tools needed to succeed as civilians.
Despite being the fastest-growing cohort in our military
community, many servicewomen face unique challenges related to
their transition into civilian life. Too often, women veterans
report not feeling comfortable seeking woman-specific care in
the male-dominant VA health system.
Studies have shown that women veterans do not connect with
the VA until approximately 2.7 years post-military service on
average or until health issues have manifested, contributing to
higher rates of mental health issues. In fact, over 60 percent
of servicewomen report that military service has negatively
affected their mental health, often due to military sexual
trauma and issues surrounding gender isolation.
My bill would require the Department of Veterans Affairs to
extend an ongoing pilot program jointly run with the U.S. Air
Force under the Transition Assistant Program that educates
transitioning servicewomen about women's health care at the VA.
Participants of this pilot program have shown higher rates of
confidence with the VA, and reported an increased likelihood to
use the VA health care and resources.
Specifically, the bill would mandate an extension of the
program across all service branches and require a report on the
feasibility of making it permanent. It is time our women
servicemembers and veterans receive the care they need.
I would like again to share my sincere appreciation for my
colleague Representative Houlahan for her work with me on this
effort to expand transitional assistance for women
servicemembers and veterans. Under her leadership, we secured a
complementary provision in the fiscal year 2020 National
Defense Authorization Act as approved by the Committee on Armed
Services last week, requiring DoD to expand and encourage
participation in this program. I look forward to closing the
loop on the VA's responsibility in this pilot program through
this Committee as well.
And the last thing I will say is that it was testified in
front of this Committee, I believe maybe the Health
Subcommittee, but this program is working in the Air Force,
this pilot program, and it is time for us to expand it into the
other services to make sure that our women veterans are getting
the support that they need when they transition into civilian
life.
I thank you all for the consideration of my bill and I
yield back the balance of my time.
The Chairman. Thank you, Mr. Cisneros.
Congressman Bilirakis, I understand you have a bill you
would like to present.
Mr. Bilirakis. Yes.
The Chairman. You are recognized for 5 minutes.
OPENING STATEMENT OF GUS BILIRAKIS
Mr. Bilirakis. Thank you very much, Mr. Chairman. I
appreciate it. Again, thank you for recognizing me and thank
you for putting my draft bill, the Ryan Kules Specially
Adaptive Housing Improvement Act of 2019, on today's agenda.
This bill, which I will be introducing soon with Chairman
Levin--by the way, I commend you for selecting Chairman Levin
as the Chairman of the Economic Opportunity Committee; he is
doing an outstanding job, Mr. Chairman. So this bill would make
needed improvements to the VA's Specially Adaptive Housing
Program.
This benefit provides funding to severely service-connected
disabled and services to adapt their homes and meet the needs
of their disability. This grant can be used on all kinds of
adaptations, to include grab bars, wheelchair ramps, lifts,
lower counter tops, wider doorways, and other necessary home
adaptations.
While this great benefit has helped thousands of veterans
over the years, there is a need to make improvements. Many of
the ideas proposed in this bill came from testimony provided
last Congress to the Subcommittee on Economic Opportunity by
several VSO witnesses.
One of these many witnesses was Mr. Ryan Kules of the
Wounded Warrior Project. Mr. Kules is an Iraq War veteran of
the U.S. Army and is a recipient of this grant. And Mr. Kules
is here.
Mr. Kules, thank you so very much for your input. I am so
excited about this bill and we are going to get it across the
finish line. Can you please wave?
Thank you so very much, sir. Thank you for your service to
our country and your continued service.
And I want to thank the Wounded Warrior Project as well. I
thank you and the other VSOs who testified, especially the
Paralyzed Veterans of America, for their suggestions on how to
improve this program, very important program.
This bill would require prioritization when processing SAH
for those with serious life-threatening illnesses such as ALS,
better known as Lou Gehrig disease. It would also double the
number of times a veteran may use this grant from three to six
times, and increase the base amount of funding available to
participants by 15 percent.
Finally, this bill would authorize VA to provide a second
part of funding for veterans 10 years after they use the SAH
grant to make further improvements if they need more
assistance.
While I know that this bill is not the perfect remedy to
address every issue some veterans have within the SAH program,
I am hopeful that this bill will be viewed as a down payment on
much-needed reforms that will help the most severely disabled
veterans live more independently in their own home. That is the
goal, Mr. Chairman.
So I want to thank you for agenda-ing me this draft and I
look forward to the discussion today. I yield back the balance
of my time.
The Chairman. Thank you.
We have--I think that concludes the presentation of bills
from our first panel. If there are any questions from members
of the members who presented on the first panel? I don't see
any and we will move on to the second panel. All right, so we
will move on to the second panel.
The second panel consists of members of our Veterans
Service Organizations and a clinical expert. I would like to
call up to the table Mr. Adrian Atizado, Deputy National
Legislative Director of Disabled American Veterans; Mr. Travis
Horr, Director of Government Affairs of the Iraq and
Afghanistan Veterans of America; Mr. Carlos Fuentes, Director,
National Legislative Service of the Veterans of Foreign Wars;
Mr. Derek Fronabarger, Director of Government[DF1] Affairs at
the Wounded Warrior Project; and Dr. Igor Grant, Director for
the Center for Medicinal Cannabis Research at the University of
California.
Are we all situated there? We will give people a chance to
get settled. I see Mr. Atizado is settled in.
Mr. Atizado, you are recognized for 5 minutes.
STATEMENT OF ADRIAN ATIZADO
Mr. Atizado. Thank you, Mr. Chairman, members of the
Committee. I would like to thank everybody here for inviting
DAV to testify at this legislative hearing.
DAV is a non-profit Veterans Service Organization. We have
about more than one million wartime service-disabled veterans
and they are all dedicated to making sure veterans lead high-
quality lives with respect and dignity.
We are pleased to support both the Medicinal Cannabis
Research Act and the VA Survey of Cannabis Use Act based on
DAV's Resolution No. 023. This resolution calls for more
comprehensive and scientifically rigorous research into the
therapeutic benefits and risks of cannabis and cannabis-derived
products as a possible treatment for service-connected disabled
veterans.
Medical literature has thus far been rather inconclusive
about the effectiveness of marijuana for improving symptoms of
chronic pain and PTSD in veterans, noting that there are both
risks and in some cases benefits, and many veterans report the
use of medical cannabis for these purposes is in fact
beneficial to them. So we want to ensure the survey and the
research contemplated by these bills will yield scientifically-
valid and reliable data, and we do urge this Committee to work
with the research community on any issues with regards to
research design. Correspondingly, we urge VA to recognize its
current effort in this area is not meeting the needs of
veterans.
These bills should be treated as an opportunity to find the
right balance between the glacial movement of research in this
particular area and the need for expedience, with the health
and well-being of our Nation's veterans being on the line.
DAV also supports H.R. 485, which addresses VA's routine
denial of medical ambulance reimbursement claims, because the
Department does not consistently apply its existing authority
to pay for such transportation to a VA facility for additional
care. In light of VA's inconsistent performance in
administering this authority, we do urge the Committee to
include an evaluation and reporting requirement of VA's actual
performance in executing the intent of this legislation, and it
should be conducted by an entity independent of the Veterans
Health Administration.
DAV is proud to be a strong supporter of H.R. 2942 and
thanks Congressman Cisneros for introducing this bill that
would build from a successful ongoing transition assistance
pilot program between VA and the Air Force.
DAV made this policy recommendation in our report, ``Women
Veterans: The Long Journey Home.''
Our report also recommends the TAP program address
employment, educational opportunities, and gender-specific
information needs in additional workshops 6 to 12 months after
separation. We believe this kind of training may arm women
veterans with information they need to prevent or otherwise
minimize transition challenges, and prevent health and mental
health conditions from getting worse or leading to tragedies
such as homelessness or even suicide, which too many of our
veterans, both male and female, are lost to.
DAV strongly opposes H.R. 3083, the VA Asset and
Infrastructure Review Acceleration Act, which would eliminate
the prohibition for the Asset and Infrastructure Review
Commission to convene before 2022.
By removing the time constraints on the commission, VA will
accelerate the asset and review process and, in doing so,
undercut one of the key elements of the compromise that allowed
the AIR Act to be part of the MISSION Act to begin with, and
that is to have a truly transparent, inclusive, deliberative,
and data-driven process.
VA has already shown its proclivity to move unilaterally or
otherwise not meaningfully consult with veterans and Veterans
Service Organizations in other matters regarding the VA health
care system on which our members depend.
The timing within the AIR Act is another key element to
guard against premature decisions on VA's health care
infrastructure. The new integrated networks under the VA
MISSION Act must first be optimized. Note it was just rolled
out a few weeks ago. The new patient demand and referral
patterns that will result because of this new integrated
network must yield sufficient historical data before accurate
forecasting and market assessments can begin the process to
decide the future alignment of VA's health care infrastructure.
Mr. Chairman, this concludes my testimony. I would be happy
to answer any questions the Committee may have.
[The prepared statement of Adrian Atizado appears in the
Appendix]
The Chairman. Thank you, Mr. Atizado.
Mr. Travis Horr, you are recognized for 5 minutes.
STATEMENT OF TRAVIS HORR
Mr. Horr. Thank you, Chairman Takano, Ranking Member Roe,
and members of the Committee. On behalf of Iraq and Afghanistan
Veterans of America and our more than 425,000 members
worldwide, thank you for the opportunity to share our views,
data and experiences on the pending legislation before the
Committee today.
While I serve as Director of Government Affairs at IAVA, I
am also a Marine Corps veteran. I enlisted in the infantry in
2007 and deployed to Helmand, Afghanistan in 2010. The issues
of the Post-9/11 generation are my issues. I was exposed to
burn pits on a remote patrol base, I utilized the Post-9/11 GI
Bill, and I have seen first-hand the positive impact that
medicinal cannabis can have. Sadly, I have lost too many of my
friends to the veterans' suicide epidemic. These issues are
personal to me and I am proud to represent IAVA's views in
front of the Committee today.
In IAVA's latest member survey, a resounding 90 percent
believe cannabis should be researched for medicinal uses. IAVA
members are vastly in support of cannabis research and it is
time for the VA to catch up.
For these reasons, the VA Medicinal Cannabis Research Act
is the centerpiece of IAVA's Cannabis for Vets campaign.
Without this research, we are unable to make policy decisions
that could improve the lives of veterans.
One such veteran whose life was improved through medicinal
cannabis is Army veteran and former IAVA intern Julie Howell.
Her story, in her own words, follows.
``For years after I returned from Iraq, I struggled to
sleep through the night. As it turns out, I suffer from
something known as maintenance insomnia. I would fall asleep,
but would wake for hours in the middle of the night, and then
fall back asleep right before needing to wake up. Thanks to
California passing legislation regarding medicinal cannabis, I
now have access to a product that I ingest that helps me sleep
through the night. I do not use cannabis recreationally, but
this product has allowed me to thrive. I am currently working
through a master's degree in public policy with the hope of
assisting veterans like me.''
In addition to Julie, over 100 IAVA members have shared
their stories of their cannabis use, with dozens sharing how VA
retaliated against them or mishandled them. In fact, it is
because of these reasons that Julie herself, even after
advocating here on Capitol Hill and back home in California,
still hasn't talked to her VA doctor about her use, and Julie
isn't alone. Twenty percent of IAVA members report using
cannabis for medicinal purposes and of those only 31 percent
have talked to their doctor about it.
If veterans are unable to receive the care that they
deserve, then they will go around it. We must ensure that VA
clinicians can have open and honest discussions with their
patients.
For these reasons, IAVA is proud to support the Veterans
Equal Access Act.
IAVA is also supportive of the VA Survey of Cannabis Use
Act, and H.R. 2677 to increase clinician training for medicinal
cannabis.
Millions of veterans also rely on VA for their health care.
We need a system that leverages the use of these new
technologies and streamlined processes and enable VA to respond
to the needs of today's veterans. Even so, the best technology
will not save a system if it is built upon outdated structures.
Because of these reasons, IAVA supports the AIR Acceleration
Act, which will allow the commission to be nominated,
appointed, and start their important work as soon as possible.
However, we strongly recommend that the Secretary not move
forward with this process until the VA completes local capacity
and commercial market assessments with full stakeholder
consultation, and stabilizes community care efforts.
Additionally, IAVA is supportive of H.R. 2943, to ensure
that all VA fact sheets are produced in both English and
Spanish; H.R. 485, to expand VA's ability to reimburse
emergency ambulance services; and the draft legislation
concerning specially adaptive housing.
Data shows that women veterans on average do not seek
support from VHA until 2.7 years after leaving service. Women
veterans also tend to face more health-related challenges than
their male counterparts. And most importantly, since 2001, the
suicide rate for women veterans has increased by 85 percent
while the suicide rate for males has increased by 30 percent.
It is because of these reasons that the VA Air Force
Women's Health Transition Training pilot was created. It is
aiming to provide servicewomen with a deeper understanding of
women's health services within the VA system and allow a warm
handoff between DoD and VA.
The Helping Expand and Launch Transitional Health for Women
Veterans Act is consistent with IAVA's groundbreaking She Who
Borne the Battle campaign, to recognize the service of and fill
gaps in care for women veterans. Women veterans are the
fastest-growing cohort of veterans and it is critically
important that they receive the same care as their male peers.
IAVA supports H.R. 2942.
Veterans are proven to be more productive and have higher
retention rates once hired into careers, and ensuring that they
have appropriate training and degrees is paramount to their
success. The successful transition to the civilian workforce
often begins on college campuses.
To this end, IAVA is supportive of the draft legislation
that addresses and improves the VA Work Study program. We
believe that by using the Department of Education as a model VA
will be able to make work study payments more reliably.
Ensuring that veterans are supported on campus is of utmost
importance.
Members of the Committee, thank you again for the
opportunity to share IAVA's views on these issues today and I
look forward to answering any questions you may have. Thank
you.
[The prepared statement of Travis Horr appears in the
Appendix]
The Chairman. Well, I am impressed, 5 minutes exactly.
[Laughter.]
The Chairman. I was like, will he do it or not?
Thank you, Mr. Horr, for your very exact timing.
Mr. Fuentes, you are recognized for 5 minutes.
STATEMENT OF CARLOS FUENTES
Mr. Fuentes. Thank you, Mr. Chairman. I first want to say
kudos with the Spanish. I think you may be speaking better
Spanish than I do, but well done.
Chairman Takano, Ranking Member Roe, and members of the
Committee, on behalf of the 1.6 million members of the VFW and
our Auxiliary, I would like to thank you for the opportunity to
present our views before the Committee.
The VFW is proud to support the VA Medicinal Cannabis
Research Act of 2019. VA's over reliance on opioids to treat
chronic pain and other conditions has, unfortunately, led to
addiction and even death. To its credit, VA has made a
concerted effort to reduce the reliance on pharmaceutical
treatments, now VA must expand research on the efficacy of
nontraditional alternatives to opioids, like medical cannabis
and other holistic approaches.
VFW members tell us that medicinal cannabis works, and it
is a better alternative than the cocktail of drugs the VA
provides. The VFW and Student Veterans of America Fellow
Christopher Lamy, an Army veteran and LSU Law School student,
focused his semester-long research on medicinal cannabis. Chris
found that veterans experience chronic pain at 40 percent
higher rates than non-veterans and, if not properly treated,
such chronic pain leads to depression, anxiety, and decreased
quality of life.
Chris also discovered that veterans fear they may be
wrongfully denied care or have their care altered without their
consent if they discuss their use of medicinal cannabis with
their VA doctors.
To ensure participants of this study do not have their VA
health care impacted, the VFW recommends prohibiting VA doctors
from denying or altering treatment to patients without
consultation and concurrence of such veterans.
The VFW also supports the Veterans Reimbursement for
Emergency Ambulance Service Act and has a recommendation to
improve it. The VA emergency transportation reimbursement
process is cumbersome and unreasonably long. Veterans who
believe they are experiencing an emergency should not be
delayed or deterred from contacting 911 for emergency
assistance because VA may refuse to cover the cost of emergency
transportation and leave them in crippling health care debt.
This bill would rightfully streamline VA's authority to
reimburse emergency transportation costs; however, it would
require that veterans be taken to the closest and most
appropriate medical facility as a prerequisite for
reimbursement. Veterans experiencing emergencies typically
don't have the ability to influence where they are taken. For
that reason, we would recommend removing that restriction, so
that veterans aren't forced to pay ambulance fees simply
because the VA and ambulance service can't agree on what
constitutes closest and most appropriate.
The VFW fully supported the Asset and Infrastructure
Review, or AIR, provisions of the VA MISSION Act of 2018. They
are important to fully examine VA's aging infrastructure and
determine what changes are needed to improve the high-quality
care VA provides veterans. However, we would be very concerned
with expediting this process. It is vitally important that the
AIR process be implemented correctly. The VFW warns Congress
not to rush the AIR process, because it may cause irrevocable
harm to the care and benefits America provides veterans.
The VFW supports draft legislation to expand the VA's
Specially Adaptive Housing grants, which help veterans with
service-connected conditions live independently in barrier-free
environments by providing critical housing adaptation. The VFW
is pleased this would increase the number applicants VA is able
to approve annually from 30 to 120; however, we do not think a
cap is needed for this important. Every veteran who needs to
adapt their house because of a service-connected condition
should have the ability to do so.
The VFW also thanks the Committee for its intention on a VA
Work Study program, which student veterans use to supplement
their income. This important program must be improved to ensure
veterans receive their payments on a timely basis. VA's
outdated, paper-based payment process forces veterans to wait
several weeks or months to receive their work study payments,
which they need to make ends meet.
Mr. Chairman, this concludes my statement. I am happy to
answer any questions you or members of the Committee may have.
[The prepared statement of Carlos Fuentes appears in the
Appendix]
The Chairman. Thank you. Thank you, Mr. Fuentes.
I would now like to recognize Mr. Fronabarger for 5
minutes.
STATEMENT OF DEREK FRONABARGER
Mr. Fronabarger. Chairman Takano, Ranking Member Roe,
distinguished members of the Committee, thank you for inviting
Wounded Warrior Project to testify about legislation before
this Committee this afternoon. While there are many significant
bills and issues being considered today, and our written
testimony outlines our stance on each of them, Wounded Warrior
Project would like to use this time to highlight one bill that
is extremely important to us, the Ryan Kules Specially Adapted
Housing Improvement Act of 2019.
As you already know, he is currently sitting directly
behind me and I invite you all to speak with him after the
hearing to better understand his personal story. Retired Army
Captain Kules is 24 years old and newly married when he was
injured in Iraq in 2005. While on patrol, an IED struck his
vehicle. In that attack, Captain Kules lost his right arm and
left leg and fellow servicemembers from his unit. While this
was a tragic loss, this event did not define him or hold him
back from leading a productive life.
After multiple surgeries and rehabilitation, Captain Kules
is ready to transition into civilian life. And in 2019, he was
in the position to purchase a home in the DC area for his
growing family. He used the specially adapted housing grant to
alter this home to meet current needs. The key phrase being his
current needs. Unfortunately, the existing SAH grant does not
account for future needs of the catastrophically injured
veteran population.
Although Captain Kules was provided with $64,000 through
the VA SAH grant, there was a gap of nearly $40,000 that was
needed to cover in order to make necessary home modifications
that would ultimately total more than $100,000.
Captain Kules would then move six years later to a new home
after he and his wife welcomed their second child into their
family. As is the case for some homeowners, the Kules family
did not recoup the cost of their home adaptation improvements
when they sold their first house. As a result, Captain Kules
and his family were required to financially pay for the new
adaptations. These new adaptations would total more than
$90,000 for a second home.
Catastrophically injured veterans should not be obligated
to pay for disability accommodations due to injuries sustained
while service to this country. The SAH grant program honors
that commitment but it does not reflect the fact that many
veterans, like other adults in this country, will have needs
that change. In this case, younger critically injured veterans
will age, many will marry, and some will be fortunate enough to
grow families with children.
Injured veterans can also be expected to have disabilities
that worsen over time. Adaptations for one stage of a
disability may not be suitable for later stages and new
adaptations will cost money. Additionally, we want warriors to
thrive in their workplace and personal lives. For those who
seek new and better opportunities in life and career,
relocation has to be an option. It is, in our estimation,
unreasonable to expect a veteran to buy a home and never leave.
Therefore, we are pleased to see that this draft legislation
before the Committee today addresses the points raised in this
testimony.
The bill would allow previous beneficiaries the opportunity
to refresh their specially adapted housing grant every ten
years. This means that veterans can update or move homes and
not be expected to pay for adaptations. Moreover, this bill
raises the current grant amount of $85,000 to $98,000, which
falls in line with what home adaptations can cost. It will also
eliminate the three time use cap that restricts the full and
intended potential of this program.
If passed, this bill would ensure that when critically
injured veterans need a new home, whether it is because they
have had more children, found a different job, or retire, that
they will not be expected to pay for these home adaptations
themselves. This benefit is reserved for those catastrophically
injured and who deserve our assistance throughout their entire
life, not just one portion of it.
On behalf of Wounded Warrior Project, I thank the Committee
and its distinguished members for the invitation to testify.
Additionally, a special thank you to Congressman Bilirakis and
Congressman Levin for your continued work on this legislation.
We look forward to any questions this Committee may have.
[The prepared statement of Derek Fronabarger appears in the
Appendix]
The Chairman. Thank you, Mr. Fronabarger. Dr. Grant, you
are recognized for 5 minutes.
STATEMENT OF IGOR GRANT
Dr. Grant. Thank you, Chairman Takano, Ranking Member Roe,
and distinguished members. Good afternoon. My name is Igor
Grant. I am a physician, neuro-psychiatrist, and professor at
the University of California, San Diego, where I direct the
center for medicinal cannabis research. During my career, I
also served three decades as a staff physician at the VA San
Diego Medical Center.
Some of the prevalent health problems of our veterans
include chronic pain, post-traumatic stress disorder, traumatic
brain injury, as well as sleep disorders. Our veterans have not
always found the treatments that we offer them to be fully
beneficial and they therefore sought recourse outside the VA
medical framework, including with medicinal cannabis in states
where it has been legalized.
I am here today to provide you with my medical opinion as
to the current state of knowledge on medicinal cannabis.
Clearly, this is a controversial area, but there are important
facts that are emerging. The Center for Medicinal Cannabis
Research at UC San Diego was established following the passage
in 1996 of the Compassionate Use Act, which was California's
initiative to enable medicinal cannabis.
We have since completed eight different shorter term
clinical trials with cannabis provided to us by NIDA through
their drug supply program. As you may know, NIDA is the only
legal source of cannabis for medical research. Our studies
found that THC contained in cannabis, ranging in strength from
two percent to seven percent showed benefit--type of chronic
pain called neuropathic pain, which is sometimes difficult to
control with traditional medicines.
Our results dovetailed with emerging data from other
investigations, as well as the 2017 report from the National
Academies of Sciences, Engineering and Medicine. Now, that
report also noted that there was some evidence for benefits for
certain sleep disorders, particularly where pain was a factor
and possibly for anxiety control, including PTSD.
As you know, most recently cannabidiol, which is a non-
psychoactive constituent of cannabis has been shown to be
effective in control of certain uncommon intractable epilepsies
of children. We have started, or will be beginning studies
soon, to determine whether THC, THC CBD combinations, or CBD
alone may be helpful in the treatment of some symptoms of PTSD,
psychosis, anxiety, autism, essential tremor, and sleep
disorders.
Another area of increasing interest, as has been mentioned
already is the possibilities the cannabinoids may have a so-
called opioid sparing effect. What this means is it may be
possible that the administration of cannabis or cannabinoids
may reduce requirement for opioids or potentially completely
substitute for them.
Now, in summary, I would recommend to you that the area of
medicinal applications of cannabis and cannabinoids have
matured to the level that it is now clear these drugs can be
helpful for some conditions, including conditions that are
found in moderately high prevalence among our veteran
population.
As such, it is my opinion that the VA would be benefitting
veterans by making sure providers are informed of the state of
medical science concerning the cannabinoids and that ultimately
providers are authorized to recommend these products, where
that is legal and medically and scientifically justified.
This leads me to my final comment. It is essential, as
everyone has said previously that high quality medical studies
continue to be done in this area. I recommend that the VA work
closely with academic universities that have expertise in the
area to pave the way to a better understanding of efficacy and
limitations of these products. It is important, also, to focus
on specific cannabinoids, their combinations, their
pharmacology, which we don't know a lot about, particularly as
it is influenced by root of administration and interaction with
other medicines, as well as understand the optimum duration of
treatment.
May years ago, when I was in training as a psychiatrist, I
learned about the VA's landmark role in determining the value
and limitations of anti-psychotic medicines in the treatment of
schizophrenia. I believe the VA, with its academic partners,
can be at the forefront again of creating a better
understanding of the place of cannabis and cannabinoids in
addressing the health needs of our patients.
Thank you, Mr. Chairman.
[The prepared statement of Igor Grant appears in the
Appendix]
The Chairman. Thank you, Doctor. And you hit the zero, just
five minutes exactly. All right. Thank you. I am going to begin
the questioning. I recognize myself for 5 minutes.
I will start my question with Mr. Fuentes, so the VFW. Your
testimony states that the VFW members have no indicated that
lack of Spanish language materials present a barrier to
accessing benefits. Has the VFW recently spoken to its members
in Puerto Rico about the Mission Act and whether veterans
understand the new law?
Mr. Fuentes. Thank you, Mr. Chairman. We reached out. We
haven't heard back yet exactly on the barriers to access. Just
to be clear, the VFW supports eliminating all access--all
barriers to access to care and benefits for veterans. This is
just not one that we have been hearing about often.
The Chairman. Okay. So let us know what you hear from your
members from Puerto Rico. Has the VFW called the Spanish
language veteran's crisis line in Puerto Rico?
Mr. Fuentes. I have not, but I will do so when we get out
of here.
The Chairman. Okay. All right. They are probably going to
turn it on now. That will be--we put them on blast right now. I
haven't used that word since I was a teacher, ``Put them on
blast.'' I don't even know if they still use that, the
students. Do you have any other recommendations to improve the
bill?
Mr. Fuentes. We do. So the VFW has posts in Puerto Rico,
also in Panama, but throughout southeast Asia, in Europe, and
even in Australia, where their English is a little bit
different too. But we recommend just do an analysis to
determine if it is more than just Spanish. I mean, VA does have
a post--I am sorry, a CBOC in the Philippines and some of its
literature in Tagalog as well. So maybe there is a need
elsewhere. It would be good to do an analysis to determine if
there are other languages that could be barriers as well.
The Chairman. Okay. Well, thank you. Thank you for that.
I would like to go to the--is this on the third panel? This
one? This question here? Okay, great.
We all want to update and right size VA's medical
infrastructure, but in an abundance of caution, without
understanding the impact of the access standards, without
knowing if they are assessments will accurately depict
veterans' medical needs today and into the future, and both
VA's and the community's capability to supply some or all of
the care, I feel that this is the wrong road to go down.
What are your chief concerns with accelerating the timeline
of the Air Act Commission? And I want to just have all of the
VSOs, starting with Mr. Atizado to give kind of a brief answer
to that.
Mr. Atizado. A brief answer?
The Chairman. Well, what you can. I have two and a half
minutes.
Mr. Atizado. Mr. Takano, listen, I thank you for that
question and I appreciate the comments that Ranking Member Roe
has made about the bill. You raised the issue about whether
their role is going to help or hurt the infrastructure
realignment of the VA and I think--our impression is if you
allow commission to meet without the preliminary work ready for
them then there is additional pressure to create the
preliminary work. And the kind of work that needs to be done is
quite complex. It is a heavy lift for VA. And the information
from which they are trying to gather that data for the
commission still has not been--it is still not there. There is
no reality for that.
This Committee is very well aware of VA' ability to
forecast community care. It has come to VA a couple of times
over the last several years for emergency supplemental funding
for care in the community through the Choice Act. There is just
not enough data in VA's health care system to forecast what the
demand is going to be like in the Choice program. And now we
have a new program with, as you had mentioned, different
eligibility criteria.
This new network has not been integrated. It hasn't been
optimized. The behavior patterns and the demand on VA for
health care because we are allowing a fivefold increase in a
number of veterans who would otherwise be eligible for
community care, that kind of data is not going to be had by VA
for at least two or three years. That is what they need to do
proper forecasting, accurate forecasting.
And if we are to look at and realign VA's health care
infrastructure into the future by using historical data, I
would think that we would want to make sure we use valid and
reliable data. And that is what we are most concerned about.
There will be pressure to accelerate and we have seen what VA
has done in times of pressure to perform and it has not yielded
very good results for our members.
The Chairman. Well, thank you. I want to be consistent with
myself. I am out of time, so I want to just go ahead and
recognize Dr. Roe, even though I really want to hear from the
other VSOs, their response to this question. Go ahead, Dr. Roe,
5 minutes.
Mr. Roe. Thank you. I am going to go quickly and put my
doctor hat on first. And Dr. Grant, thank you for the work you
have done with our veterans over the years, the decades of
years you have been spent doing that. I have--look, every
single person up there I think wants medical marijuana,
cannabinoids studied. The question is how you do it. And I am
just going to ask--and let me just introduce this with the NIH.
U.S. Food and Drug Administration hasn't approved
marijuana, the plant, for treating any health problems.
However, some states and the District of Columbia allowed its
use for certain health purposes. While the marijuana has
therapeutic benefits and outweighs the health risks is
uncertain.
And as a physician, let me just go over how complicated
this is. Here is a Yale study that I have right here. And
individual, personal testimonials are good. They can head you
in a direction, but they are not science. And here is--
basically this Yale study says that stopping marijuana during
the treatment and contrast was associated with the greatest
improvement in PTSD. Our findings do now suggest, however, that
marijuana is associated with improvement in PTSD. Previous
evidence suggests that marijuana improves PTSD symptoms come
from--reports. Another possible interpretation of this data is
that marijuana use in patients with PTSD provides transient
relief, but the subsequent periods of withdrawal contribute to
a worsening of baseline symptoms.
Now, this is what--I have read 15 articles this morning in
a couple of hours. It is very confusing. What I would like to
do is to take the shackles off Dr. Grant and the other
scientists that are out there, and don't prescribe to them how
we do these studies, but do have a study on whether you can
reduce opioids. And I do have--multiple studies, actually,
would be better as you well know in different populations to
refute or to--look, it may work very well. I don't know from
reading all of this. And literally, I spent two hours this
morning doing that, reading, and I have got the articles right
here in my binder.
Dr. Grant, would you like to be constrained or would you
like to be allowed just to open up and study this, an expert
like you for 30 years, would you like me telling you how to do
it or would you like to allow the scientists to figure out how
to do it?
Dr. Grant. Am I allowed--I don't like to be told what to
do, but that is just my personality.
You know, I think it is right that first of all, one should
get down to the concepts that need to be clarified. And these
include things that have been mentioned already, for example,
are there particular conditions that particularly are
benefitted. If so, for how long? Are there restrictions on age,
for example, or co-morbidities, like if you have diabetes and
so on and so forth.
Another set of questions relates to the compounds
themselves. It is important to have a certain strength of THC,
CBD, some mix of those things? We really don't know that.
Another has to do with root of administration. Not everybody is
smoking marijuana anymore. In fact, okay, there is vaping, but
a lot of it is being taken by mouth.
We know much less about the whole pharmacology of these
drugs taken by mouth. And we also don't know much about what
happens to the endo-cannabinoid system, our own internal
signaling system and physiology in response to these things.
My own thought would be that what one needs to do is really
set up some kind of centers of excellence or something of that
nature, as the VA has done with some other topic areas where
you could look at this from many perspectives and at different
parts of the country and look at different populations.
That might be an approach that would bring together a lot
more things than trying to do everything in one study. Having
said that, if it is kind of do this study or zero, I guess I
would prefer to see this go forward than nothing happen. So I
don't know if that answers your question.
Mr. Roe. I would rather do it right and I think what you
mentioned is right.
I am just going to make a couple because I have very little
time left, but just on the Air Act, changing the dates or
expanding the time available for the commission would not in
any way impact the status of market assessments, which will be
done next year.
And I spoke to the secretary about this at length. His
concern is you get the market assessments that are done next
summer and by the time this gets going, those market
assessments are out of date. That is his major concern. And
actually, this will give us a time to push even further.
Look, this is a big undertaking. I totally get that. And
you all know me well, and everybody at that dais I think does.
I have said a thousand times, I would rather go slow and get it
right than go quick and get it wrong, just like the Mission Act
and everything else. So there is no rush, but I think waiting
is not going to change.
And I appreciate your comments. I yield back.
The Chairman. Thank you, Dr. Roe. I now would like to
recognize Mr. Lamb for 5 minutes.
Mr. Lamb. Thank you, Mr. Chairman. Dr. Grant, have you
actually looked at the requirements of the Cannabis Research
Act we have today? There are some objections from the VA about
the way the bill is written and the types of studies it would
mandate. I think that is what Dr. Roe was asking about. Are you
familiar with what the bill actually calls for?
Dr. Grant. Yes. I have it here and I have read it. I don't
say--I can't tell you I have memorized it, but I have it and I
have read it. Yes.
Mr. Lamb. This isn't a pop quiz. I was just trying to get a
feel for whether you, just as a physician doing research and
practicing in this area, do you share the same concerns that
the VA is telling us, which is that it sort of forces them to
do too many things at once as opposed to earlier, smaller, more
controlled trials?
Dr. Grant. Well, as I said earlier, I think what is in this
bill is very ambitious. It has a lot of elements to it. And as
you know, in science, you never know exactly where things are
going to go. You have to be positioned to move in different
directions. It would be my personal preference that there be
outlined, ``Here are the things we want to have answers to,''
and then develop an approach to that.
But having said that, I will repeat what I said before, it
is critically important to do this kind of work. And if this is
the path forward and everything else will, you know, devolve
into five years of discussion, then it is better to do this
than to do nothing. But it would be preferred to have a more
multi-pronged approach, slightly less prescriptive approach as
a scientist.
Mr. Lamb. Thank you. That is very helpful. Now, in your
testimony when you talked about the possibility that
cannabinoids could have an opioid sparing effect and the need
for further research in that area, could you explain maybe in a
little bit more detail what is the state of knowledge or
certainty as it exists now with respect to the potential for
cannabinoids to have that effect? Have there been early initial
studies? Is that what your comment is based on or is there
still sort of an unknown?
Dr. Grant. Well, first of all, there are pre-clinical
studies, animal studies, that make it clear that there is a
reduction in an animal's intake of opioid in pain models of
various kinds when cannabinoids are administered
simultaneously. So there is pre-clinical data.
I think the clinical data are still very preliminary and
really relate a lot to these indirect surveys that you have
read about where opioid use may or may not decrease in certain
states where medical marijuana exists, and also the testimony
of physicians in pain clinics that say that, ``Gosh, I have a
number of patients that I have not been able to wean off of
these opioids because they are using medicinal cannabis.'' And
that is certainly true at our center. But I don't consider that
a definitive study.
Mr. Lamb. Right. Has that been true in your own experience
or is that mainly reported to you by colleagues?
Dr. Grant. Well, I am not a pain physician myself but one
of the pain physicians who runs our pain clinic is part of our
center and he has reported this, that he has been able to
reduce opioid prescription and in some case discontinued
totally, in people who have taken medicinal cannabis. Again,
this is not a formal study, though.
Mr. Lamb. Right. Do you know if that is typically combined
with other non-opioid methods of treatment or has that been--
from what you know, has that been sort of solely attributable
to the use of the cannabinoid?
Dr. Grant. Well, again, I don't know about other clinics.
In ours, it is a comprehensive program. It does also involve
behavioral approaches and such things. But even adjusting for
that, it seems like the cannabinoids may be helpful. Certainly,
I think the pre-clinical data is very suggestive.
Mr. Lamb. Great. Thank you very much, Mr. Chairman. I yield
back.
The Chairman. Thank you, Mr. Lamb. I now recognize Mr.
Bilirakis for 5 minutes.
Mr. Bilirakis. Thank you, Mr. Chairman. I appreciate it.
Mr. Fuentes, can you please tell us why you believe it is
important to prioritize SAH grants for veterans with serious
illnesses such as ALS?
Mr. Fuentes. ALS is one of those conditions that
deteriorate very quickly. And unfortunately, VA is limited to
30 grants per year today and the process takes a good long time
as well. So not only does it progress really quickly, so we
want to make sure those adjustments are done very quickly, it
could also take years because they didn't get in before the 30
grants were approved.
Mr. Bilirakis. Okay, thank you. And I understand that, you
know, we are raising the amount of grants anyhow overall under
this legislation. But I am not sure whether the caps apply for
ALS. But in any case, we actually covered this, Mr.
Fronabarger, you actually covered this in your testimony, but
it is definitely worth mentioning again. There is no question.
Why do you believe the reinstatement of SAH benefit ten
years after the veteran's initial grant would be helpful to
veterans?
Mr. Fronabarger. Absolutely. And I appreciate that
question, Congressman.
As many of you know, veterans normally do not just stay in
one location. Specifically, our population, we deal a lot with
the injured, ill, and wounded of today's generation. So we
don't find it, I guess, normal for someone to adapt their first
home and then stay there until they pass away, hopefully at a
very, very old age.
So with every 10 years, that lines up with about the
average house an American homeowner will own, anywhere between
five and six. So if you get injured at 30, but by the time you
are 90, you still have that benefit going on and you fall in
line with the average American. So every 10 years is kind of
how we came up with that and we feel that it is an equitable
way to honor those veterans.
Mr. Bilirakis. Thank you very much. And another question
for you, sir. How does the current three time usage limit or
cap on the SAH grant impact a veteran's ability to adapt his or
her home?
Mr. Fronabarger. Thank you for that, Congressman. Currently
the SAH grant has a three time usage cap, as you said. The
benefit is up to $85,000. So right--as now, the veteran can
use--if they need $20,000 to adapt their home, they can use
that $20,000 and they have two more usages up to that cap.
So for those that are injured but don't require the entire
amount, changing that from three to six can help them because
$20,000 times three is $60,000. They are not reaching the full
potential of what they might need if they move. So we look at
that as a beneficial way for veterans to utilize the full
benefit-
Mr. Bilirakis. More flexibility?
Mr. Fronabarger. Absolutely. Yes, Congressman.
Mr. Bilirakis. That is--yeah, very important. Thank you
very much. And again, we have a lot of non-profits that do a
wonderful job of building homes for vets, but raising the
amount by 15 percent and giving the veteran the flexibility, as
well. And then again, the 10 year rule under this bill is
wonderful to have the full amount again after 10 years. It is
just something that the veteran deserves. It is a quality of
life issue. So I appreciate it and I would like to see the
whole Committee co-sponsor the bill. I appreciate--for that
matter, the whole House.
Thank you very much and I don't know if anybody wants the
rest of my time, but if not, I yield back.
The Chairman. I will take it back. Thank you.
Mr. Bilirakis. All right. Take it back. You got it. You got
it, Mr. Chairman.
The Chairman. Thank you. Mr. Levin, you are recognized for
5 minutes.
Mr. Levin. Thank you, Mr. Chairman. And I would like to
thank my friend, Mr. Bilirakis, the Ranking member. I am
honored to have the opportunity to help introduce this
legislation.
And I wanted to begin by asking about it and then move to
cannabis with the time I have remaining. I appreciated the
testimony, as always, from all the VSOs today in sort of the
discussion draft. Mr. Fuentes, in your written testimony, you
talked about two difficulties. One was long wait times and the
other was--we were talking about months, which is amazing, and
the other is the requirements for contractors to meet.
Can you talk about the--kind of our understanding what is
causing the roadblocks? Again, it can be up to many months.
Mr. Fuentes. The application process, you know,
specifically when it comes to ALS and severe illnesses, these
are illnesses that require immediate attention and it takes a
lot--too long for VA to process the applications. The
contractors, because of the requirements of exactly what needs
to be met sometimes aren't familiar with those requirements, so
then it takes time to find one that is not only familiar with
it, but also willing to undertake the task.
Mr. Levin. Thanks for that. And the second difficulty again
is finding contractors. Can you speak more to that, to the
requirements for finding contractors, why that is such a
difficult issue?
Mr. Fuentes. It comes, in terms of the requirements that VA
has on how it must be completed and also the quantity of
contractors that are out there as well, even though we do have
a good amount who are willing to work and assist veterans.
Because of the long process that it takes to get everything
approved, some of them may not want veterans to go through the
SAH process.
Mr. Levin. Thank you. I appreciate that and your continued
support, working together with Mr. Bilirakis and my colleagues
as we get this over the finish line.
I wanted to turn to cannabis, and Dr. Grant, I wanted to
thank you for being here today. I represent UC San Diego. SO I
am really honored that you are doing some of the leading
research on this. It is a great honor. If you watch the
Congressional baseball game next week, I will be proudly
wearing the UC San Diego uniform.
In your testimony, you explain that research has confirmed
the benefit of medicinal cannabis in cannabinoids for some
chronic conditions, but further studies are needed to fully
understand the effects of these drugs. And of course, we know
about the supply constraints. And I wanted to ask you about
that.
You are basically limited to the University of Mississippi
and I wanted to understand from you, how did those supply
constraints impact the work that you are doing?
Dr. Grant. Yes, well, it is in several ways. First of all,
the University of Mississippi program is doing its best. So
this is not about dissing them. But they are one provider and
they have a lot of difficulty, I think, keeping up with what is
going on in the real world. So for example, up until a year or
so ago, there were upper limits on how much THC was in a
product, whereas on the street now, it is 15 percent and we
have been studying 4 percent and 2 percent and such.
Now, it may be that those percentages are all you need
medicinally. You need a lot more to get super looped, but maybe
for the treatment benefit, you may need a much lower dose.
The other has to do with the types of formulations. As you
know, a lot of people are taking edibles of various sorts. You
know, if we had to study, say marijuana in brownies, we would
have to bake them ourselves, literally. We would have to get
the product from Mississippi and set up and we are not really
equipped to do those kinds of things.
The other has to do with different mixes. So it may be the
case that having a say 20 to 1 mix of CBD, the cannabidiol to
THC, may be optimal for some things because it may be the CBD
is cutting the effects of the THC and so forth. These are all
theories, but we don't have those kinds of products.
So, you know, one option is to pursue importation because
in Canada, they have a number of GMP facilities, manufacturing
practice facilities. Maybe that could be expedited in some way
while, you know, kind of we catch up in this country. The other
is the DEA a long time ago, a couple of years ago said they may
license more manufacturers in the U.S., but as far as I
understand it, nothing has happened with that process. So the
supply is a real problem.
Mr. Levin. Thank you, Dr. Grant. I am out of time, but I
want to thank you for your decades of good work at the medical
school and the Department of Psychiatry at UCSD.
Dr. Grant. Go Tritons.
Mr. Levin. Go Tritons.
The Chairman. Say, ``Go Highlanders.'' Okay. Dr. Dunn, you
are recognized for 5 minutes.
Mr. Dunn. Thank you very much, Mr. Chairman. I will be
brief.
I noted at our VA Health Subcommittee hearing on April 30th
that Federal laws and state laws often do not exempt VA
physicians from criminal punishment were they to prescribe
cannabis or any illegal substance to a veteran. It is our job
as policymakers to protect both the physicians and the veterans
before we go off and encourage them to prescribe or recommend
any illegal substance as a treatment for any of the myriad of
conditions that have been indicated for cannabis.
One way I personally support this is by looking into
rescheduling cannabis into a Schedule 2 substance. The benefit
of this is just that it facilitates serious scientific
research. It makes it much easier to get the substrate that the
good doctor mentioned.
And I think we have many divergent opinions regarding the
utility and value of cannabis as a medicine, but I think we can
all agree that we need more research, serious scientific
research into this topic. And as a final comment, I would like
to note that the research should be designed and directed by
scientists and not policy makers.
And with that, Mr. Chairman, I yield back.
The Chairman. Thank you, Dr. Dunn. Ms. Luria, you are
recognized for 5 minutes.
Ms. Luria. Thank you. And I would like to start by talking
about the proposed H.R. 1647, Veterans' Equal Access Act
proposed by Representative Blumenauer. And just to recap the
summary of that is to authorize the Department of Veterans
Affairs Health Care Providers to provide recommendations and
opinions to veterans regarding participation and state medical
marijuana programs. So in states where it is legal and
accessible.
And I just wanted to address this question specifically to
the VFW because your testimony states that your opposition to
this, and I am just trying to quantify if this is the only
reason for opposition, that it is unacceptable for VA providers
to recommend a treatment that they are unable to provide for
veterans. Thus, a treatment that the veteran would have to pay
for at their own expense. Is that your sole reason for
objecting to this particular item?
Mr. Fuentes. Yes, ma'am.
Ms. Luria. So you otherwise support in states where
cannabis is legal, VA providers being able to make those
recommendations to patients?
Mr. Fuentes. We certainly fully support VA having that
discussion with veterans. We would not like for VA providers
and doctors to prescribe a medicine or any type of drugs that
VA is unable to provide to veterans. I don't know the cost of
medicinal cannabis in those states, but it could pose a barrier
for veterans and many of them are already struggling to meet
VA's copays, certainly don't want to put the full cost of any
of the medications that their doctor says they need on them.
Ms. Luria. So in a scenario where potentially there could
be a reimbursement, if it was anything other than the cost, you
would not object to it?
Mr. Fuentes. Correct.
Ms. Luria. Okay. And then I wanted to shift to the Iraq and
Afghanistan Veterans of America and I have fortunately had the
opportunity to speak to some of your colleagues and some of
your members over the course of the last few months in looking
across this legislation relative to cannabis, we have a very
friendly chart here that shows red, yellow, or green based off
of the level of support of the people who are going to be
testifying so we can kind of understand the trend.
But the trend I see for you is that IAVA has support on
every single one of these. Can you discuss kind of the
demographics of your membership age-wise, and then the
statistics you have amongst your members as a younger group of
veterans, their perception of marijuana as a potential
treatment for some of the things that they suffer from?
Mr. Horr. Yeah. We have a younger generation of veterans,
as you mentioned, who are all post-9/11 veterans. In order to
take our member survey, the stats I have been quoting, you have
to be confirmed as deployed to Iraq or Afghanistan. And so to
talk to some of those statistics that you mentioned, 90 percent
support cannabis research. I think it is right around 80
percent that support full legalization of cannabis. 91 percent
also state that they would take cannabis if it was available to
them. And currently, as I mentioned, only 20 percent reporting
are taking it, so that is a huge difference of people that
could be affected and could benefit from this.
Ms. Luria. SO if I interpret that data, this is a younger
group of veterans who think that this is beneficial to them.
And I would take that as they are asking us as Congress and
lawmakers to find a way to make that happen: all the elements
of that, be that research, be that all of the elements outside
of the purview of this Committee, but you know, making it
accessible, making it standardized, making production
standardized, essentially. Just regulating the industry so it
can become a product and a commodity that we can research and
use safely. Is that what I would take away from this group of
younger veterans? They want us to do something to make it
available to them.
Mr. Horr. Yes, I believe that is fair. And I think we need
to start with the research, which is why we are supportive of
the Medicinal Cannabis Research Act. That is why it has been
our centerpiece for our cannabis campaign, that we have been
out and talking with offices like yourself about. So that is
where we need to start. And I think once we have that data,
once we have more good data from the VA, then we can go from
there as far as what we need to do.
Ms. Luria. Thank you. I yield back my time.
The Chairman. Thank you, Ms. Luria. Ms. Radewagen, you are
recognized for 5 minutes.
Ms. Radewagen. Thank you, Mr. Chairman. My question is for
Mr. Fuentes. In your written statement, you commented that you
oppose the change to the work study program because you believe
VA just needs to do a better job processing claims. Given VA's
poor track record of delivering education benefits in a timely
manner, don't you think it may be time for a new approach?
Mr. Fuentes. Thank you, ma'am, we completely agree that VA
needs to fix the work study program. It is preventing veterans
from essentially meeting ends meet. They rely on this benefit
to pay for housing for food. Right now, the difference is that
VA pays the veteran directly, so the school simply just
certifies that the veteran worked the number of hours that are
required and then the--a similar program under the Department
of Education pays the school or gives the school a certain
amount of money and then the school pays the veteran.
The VA knows how to pay veterans. It does so for millions
for disability compensation. It does so for the GI bill. We
have confidence that VA can get it right and fix it, instead of
changing a new process. We think that VA would probably better
be able to fix the current process as a paper-based process
than they would be at adopting a new business process.
That, again, we certainly refer to VA if they think that a
better business--a new business process is easier for them to
manage. At the end of the day, we will hold them accountable to
it because these veterans need their payments now and as soon
as possible.
Ms. Radewagen. Thank you. Mr. Horr, can you please tell us
why you believe using the way the Department of Education pays
work study could be a better model than the way that VA
currently pays benefits.
Mr. Horr. Yeah, the Department of Education model has been
proven to where it can get work study payments on time. We
understand that there have been issues with the VA's IT
infrastructure, especially with the G.I. Bill payments and
things like that. But using the Department of Education's
model, which already exists, the VA can easily more restraining
order that, in order to get these work study payments out on
time. So, we believe that is how it can been easily integrated.
Ms. Radewagen. Thank you, Mr. Chairman.
I yield back.
The Chairman. Thank you, Ms. Radewagen.
Mr. Sablan, you are recognized for 5 minutes.
Mr. Sablan. Thank you, Mr. Chairman. I have no questions at
this time for this panel, but I thank everyone for being here.
The Chairman. Thank you, Mr. Sablan.
Mr. Barr, you are recognized for 5 minutes.
Mr. Barr. Thank you, Mr. Chairman.
Thanks for our witnesses for your service and for your
testimony here today. As you all can see, this Committee is
very interested in the possible benefits of medical cannabis.
I have had an opportunity to listen to veterans of
different eras--Post-9/11 veterans, Iraq-Afghanistan veterans--
about their interests in the therapeutic benefits for post-
traumatic stress, and anxiety, sleep deficiency, and also
Vietnam-era veterans in my veterans coalition, who have
expressed an interest in us proceeding with this.
So, I am a co-sponsor of Dr. Roe's bill, H.R. 747, which
does direct the VA to conduct medical cannabis research.
And I also want to thank Mr. Correa for the VA Medicinal
Cannabis Research Act.
I share Dr. Roe's concern that Mr. Correa's bill may be a
little bit too prescriptive, but I appreciate Dr. Grant's point
that if that is our only opportunity to proceed with research,
I would prefer that than nothing. So, I have a preference here
and it is Dr. Roe's bill, but I do want to see us move
expeditiously on the research because of the intense interest
that the veteran's community has expressed to me.
Let me just ask any of you about that difference between
the Roe version and the Correa version. Do we need to have an
approach that lets the researchers, as Dr. Grant has expressed
a preference for, direct this, as opposed to folks up here--and
admittedly, I am not a physician and I don't have an expertise
in this area--what is the best approach here, because maybe we
can get a larger consensus to pursue this, and I invite anyone
to offer an opinion on that.
Mr. Atizado. Mr. Barr, thank you for posing that question,
and I do appreciate your comments and Ranking Member Roe's
comments on the matter, as well.
I think in my testimony I mentioned that we have to
recognize a couple of things and that is, in fact, VA is not
doing much in this space when there is a definite need that
they need to be a leader in this area. I think the veterans
have spoken. I think Congress is speaking to them.
I think it would be helpful if we can have members in
Congress, some of the Veterans Service Organizations, and the
scientific research community come together and find--and I
don't want to use this as a way to slow the legislative process
down. I want to help inform the two bills that are out there
now and maybe Mr. Roe and Mr. Correa can craft the bill
together, but with VA's definitive opposition, we need to get
over that, because they are the ones that are going to have to
execute on this, and that might be a way forward.
Mr. Barr. Well, thank you. Any other thoughts on that
point?
Mr. Horr. Yeah, I think just to echo what DAV was saying, I
think there is a concern that if VA is not explicitly told how
to do it, that they will drag their feet and withhold this
research or--
Mr. Barr. Well, maybe there is a middle road.
Mr. Horr. Yeah.
Mr. Barr. A mandate that they do it, but give the
professionals and the scientists and the researchers a little
bit of control in terms of setting the parameters for the
research and providing some deference to the expertise of
people like Dr. Grant. So, I am willing to step in and try to
work on that compromise to help move this forward and not
having the delay. And I look forward to working with the VSOs
on that if I can be helpful.
In Kentucky, we have kind of led the way in de-scheduling
industrial hemp, which is low THC/CBD and so, for Dr. Grant--
and we de-scheduled in the Farm Bill. I am interested in your
research and what your research tells us about low THC/CBD and
any therapeutic benefits that can provide separate and apart
from the psychoactive THC substance in marijuana.
Dr. Grant. Thank you. Let me see if I can address that.
First of all, as you know, and as we have discussed,
cannabidiol, which is a common ingredient in cannabis, in
marijuana, is not thought to be psychoactive, but it may have
antianxiety, anti-inflammatory, antiepileptic, and other
qualities. So, clearly, this is a substance, first of all, that
needs further study, but already in the area of epilepsy, we
have seen that its benefits children. That drug, in my opinion,
should not be on a schedule. There is no evidence that it is an
addictive substance.
As for THC-containing things, it seems to be a more
sensible approach would be something along the lines that we
have used with codeine. So, low-codeine preparations are in
Schedule 3, for example, and higher-codeine preparations are in
Schedule 2, and that makes a lot of sense. If you give more or
the higher potency, it may be more dangerous. And I think the
THC products belong somewhere in that zone, personally.
Mr. Barr. My time, obviously, has expired and I have gone
over and I am sorry. I appreciate the Chairman's indulgence.
I would just say that as we move forward with research on
both the high-THC and the low-THC, that the researchers look at
what CBD cannabidiol could do separate and apart from the
higher psychoactive, higher-THC psychoactive parts.
And I yield back, and I appreciate the Chairman's
indulgence.
The Chairman. Thank you, Mr. Barr.
Mr. Bergman--General Bergman, you are recognized for 5
minutes.
Mr. Bergman. Thank you, Mr. Chairman.
And I see a lot of familiar faces out there--good to see
you all again. And I know I have at least two Marines. Anymore?
Okay. Well, you guys have already taken over the panel just by
having two out of five, right? All right. Well, we are not
going to talk about service cultures here.
You know, it is always very instructive to sit here and
listen to people who have, both on the panel and my colleagues,
who have got a lot of time and effort in researching and trying
to figure out what the best way is to go forward to help our
veterans, whether it be in pain management, addiction, or shall
we say the kind of facilities that they get their care in that
the VA has.
And let's talk about the asset review, first of all. You
know, time is finite; once time is gone, it is gone. And I
would suggest to you very strongly that the more we wait to
kick off the asset review and to not speed up the timelines in
a mission-oriented manner like we would do in the military, of
prioritization and responding quickly, we have to move forward
with the asset review and not waste any more time on that.
Twenty-five-year-old brain development, full brain
development for the average male, is that--am I in the ballpark
there?
Dr. Grant. Some of us take longer.
Mr. Bergman. Well, some of us are still works in progress,
as my wife would probably say.
Dr. Grant, we have a lot of our veterans who will serve
honorably and complete a four-year enlistment by the age of 22.
Any comments on what risks we might be accidentally assuming if
we move forward with cannabis research with the target
population, what parameters you might put on that so that we
don't further potentially hinder a young veteran who has, you
know, put their life on the line?
Dr. Grant. You know, thanks for the question. And it is
very complicated, as you very well know.
I think what I can say with some reasonable confidence is
that marijuana in the strengths that it has been traditionally
used--and I am going back now 4 decades--among adults is
probably not harmful to the brain. There have been a number of
kinds of retrospective studies that have looked at IQ and
cognitive function and brain-imaging and so forth. But that is
marijuana that was not very potent and that, typically, people
are not using day-in and day-out and many times a day.
In terms of the developing brain, teenagers and young
adults, we really don't have the answers. And I have to say I
see practically every month some report saying, Oh, marijuana
causes this and that terrible thing to happen to the brain,
but, actually, when you look at the research, it is not that
clear. That doesn't mean it isn't bad, but I don't think it is
very definitive. And, certainly, we don't want to give
chronically, in high doses, any drug that affects the brain
because we don't know what is going to happen there.
Mr. Bergman. I just wanted to make sure that we, you know,
didn't accidentally put a certain age group at risk moving
forward with a good idea.
And I guess you mentioned something that kind of caught my
attention, Doctor, on some of the things that Canada has to
offer. Are there any other countries around the world who have
already walked down this road with the research side that we
can either partner with, model after, you know, have a list of
dos and don'ts? Any other countries that stand out?
Dr. Grant. Well, I think not to the kind of comprehensive
extent of Canada, but, certainly, the Netherlands has had a
fairly long history of some permissiveness, at least, in the
marijuana area, and they have also done a lot of work on
driving and those kinds of impairments.
Mr. Bergman. Has there been any outreach made to the
Netherlands at all?
Dr. Grant. Well, we certainly have consultations with those
people, but no, I don't know the answer to that.
Mr. Bergman. Well, thank you very much.
Mr. Chairman, I yield back.
The Chairman. Thank you, General.
Mr. Meuser, you are recognized for 5 minutes.
Mr. Meuser. Thank you, Chairman, and thank you Dr. Roe very
much. Thank you very much all to you for being here with us and
to the veterans on the panel, and all the veterans, thank you
very much for your service.
I'd like to focus my questions on the draft legislation on
the Specialty Adaptive Housing grant program. I do commend
Chairmen Levin and Bilirakis for this draft legislation that I
do plan to be supportive of.
Mr. Fronabarger, do you hear from disabled veterans
regularly on the housing issues and the need for adaptive
specialty access?
Mr. Fronabarger. Thank you for that question, Congressman.
We do. We have a program with--called the Independence
Program. That project that we have going on actually assists
critically injured, ill, and wounded servicemembers in home
adaptation, caregiver services, and any other issues they might
like. So, we do have about 500 individuals in that program
right now.
Mr. Meuser. Five hundred.
Describe briefly, if you would, the type of disability that
someone would have in order to be eligible for this type of
housing grant.
Mr. Fronabarger. Absolutely. I would say you would see two
primary kinds of individuals with bilateral amputees and also
those with ALS. Those are relatively common, unfortunately.
Mr. Meuser. So, those with loss of limb, normally, it was
lost in the field in combat?
Mr. Fronabarger. I couldn't break down specifically if it
was combat or training, but most likely with this most current
war, yes, I would--
Mr. Meuser. Yes, great sacrifices.
And work is pretty difficult for those with these high
level of disability?
Mr. Fronabarger. It is. I mean, it is difficult to move
from an injury like that into a normal civilian life.
Mr. Meuser. Maybe part-time, just difficult to get there,
even.
Mr. Fronabarger. Correct.
Mr. Meuser. In a normal home environment, how would they
mobilize?
Mr. Fronabarger. Well, that is a difficult question. A lot
of it depends on the home itself. If there are stairs, that can
be incredibly difficult for somebody who is lost both the lower
limbs, obviously. If it is, you know, a long walk from the
driveway up to the house, if there is not a garage on the front
that leads straight into the house, all of those--
Mr. Meuser. Typically very, very difficult.
Mr. Fronabarger. Correct.
Mr. Meuser. Very difficult.
Can you describe a project that was--comes to your mind and
a veteran that has benefited by the current initiative for this
type of specialty housing?
Mr. Fronabarger. Absolutely. I [DF2]Captain Kules
[DF3]right behind me used the program. He was able to purchase
a house in D.C. And as you all know, D.C. homes are probably
some of the least adapted homes possible; they were all built
in the 1930s and older. So, he was able to take a house and add
the things that he needed, including a ramp, to make that home
fit his needs.
Mr. Meuser. Okay. Great. Well, these projects are not only
life-sustaining, I think they are life-changing. They are quite
essential.
And Captain Kohls, thank you very much for your service.
And I don't have any further questions, so, Chairman, I
yield back.
The Chairman. Thank you, Mr. Meuser.
That concludes, I think, our work with our second panel.
So, you are all now excused. Thank you all very much for your
testimony and for your answering our questions.
I would like to now invite Mr. Larry Mole, Chief
Consultant, Population Health Services Patient Care Services of
the Veterans Health Administration to come to the table.
And I will just take a note that we statements for the
record from Ms. Thelma Roach-Serry of the Nurses Organization
of Veterans Affairs; we have Mr. Eric Goepel also submitting a
statement, Founder and CEO of Veterans Cannabis Coalition, VCC;
Mr. Morgan D. Brown, National Legislative Director of Paralyzed
Veterans of America; Mr. J. David Cox of AFGE; Mr. Randy Erwin,
National President of the National Federation of Federal
Employees; Mr. William Attig, the Union Veterans Council, AFL-
CIO; Mr. Brett Copeland, Executive Director of the Veterans
Healthcare Policy Institute; Mr. David Holway, National
Association of Government Employees; and Mr. Justin Strekal,
Political Director of the National Organization for the Reform
of Marijuana Laws, otherwise known as NORML.
The Chairman. So, Mr. Mole, welcome. Thank you for
testifying today. I will begin--oh, no, you need to do your 5
minutes of--go ahead. Five minutes--you have 5 minutes, Mr.
Mole.
Dr. Mole. And go Highlanders.
STATEMENT OF LARRY MOLE
Dr. Mole. Good afternoon, Chairman Takano, Ranking Member
Roe, and members of the Committee. Thank you for inviting us
here today to present VA's views on a number of important bills
covering cannabis policy, transitional care for women veterans,
and ensuring that language is not a barrier to access to VA
services.
We are unable to provide views on today's written testimony
on four proposals that were added recently to the agenda, but
we will follow-up with the Committee as soon as possible.
Regarding the bill to require continuation of Women's
Health Transition Training Pilot Program, I am pleased to share
that last week, the VA committed to a permanent women's health
component to the Transition Assistance Program by 2021. In the
interim, VA will provide the pilot activities currently in
place for active-duty servicemembers. Although we have no
objections to its enactment, we do not believe this bill is now
necessary.
Concerning the bill, Making Fact Sheets Available in
English and Spanish, VA agrees that it is important that we
help ensure that language is not a barrier seeking care or
other services from VA. VA publishes many critical materials in
English and Spanish, including VHA enrollment forms and our
annual guide to benefits.
More systematically, VA is implementing a language access
plan covering all organizations to ensure as much as possible
there are not language barriers for veterans and their
advocates. Given the breadth and complexity of VA program, VA
favors this more systematic and flexible approach, as opposed
to a statutory mandate for one category of document. As a
result, VA does not support this legislation. We are glad to
discuss our current efforts with the Committee.
Next, I begin my discussion on the medical cannabis bills
by setting out the current landscape. According to the National
Conference on State Legislatures, 47 states, the District of
Columbia, and 3 of 5 territories have some form of state or
territory regulation on medical cannabis use. These laws
permits various types of cannabis-derived products to cover
various symptoms and conditions. These laws greatly vary from
each other and conflict with Federal law which classifies
cannabis as a Schedule 1 controlled substance. That complex
legal landscape makes it important that legislation in this
area receives a thorough airing and we appreciate the
Committee's attention to these issues today.
It is critical for the Committee, veterans, and the public,
to know that the veterans will not be denied VHA services
solely because they participate in state-approved programs and
that clinical staff may discuss marijuana use with their
patients. But we should also be clear that VA cannot pay for
state-approved marijuana products and VA providers cannot
recommend, make referrals to, or complete forms or register
veterans for participation in state-approved marijuana
programs.
The Veteran Medical Cannabis Research Act of 2019 would
require VA to conduct a large-scale clinical trial to examine
multiple health outcomes among veterans with various diagnoses
using multiple strains and formulations of cannabis. Typically,
smaller early-phase trial designs would be used to advance our
knowledge of benefits and risks associated with cannabis before
moving to a more expansive trial. VA currently supports a VA
clinical trial of cannabis for treatment of PTSD. Because we
believe research on such a scale would be premature ahead of
other related research, VA does not support this bill.
The VA Equal Access Act would require VA to authorize its
physicians and other health care providers to provide
recommendations and opinions to veterans who are residents of
states with state-approved marijuana programs. While VA
encourages its providers to discuss marijuana use with
veterans, we cannot support this bill for the detailed reasons
provided in my written statement; namely, that there are legal
issues presented by the legislation that would require
significant involvement of other agencies to resolve.
This VA Survey of Cannabis Use Act would require VA to
enter into an agreement with a federally funded research and
development center to conduct nationwide surveys to measure
cannabis use by veterans. We have significant concerns detailed
in our testimony, one of which is that we believe veterans and
providers will not want to participate, despite the survey
being anonymous; moreover, the survey results would likely only
be meaningful if we knew where veterans lived and where
providers practiced, information that could compromise the
identity of the veterans and the providers. That is why VA
cannot support this bill.
The bill, Training in the Use of Medical Cannabis for All
VA Primary Care Providers would require VA to train these
specific providers in the use of medicinal cannabis. We already
make available to all providers, information sessions on
cannabis, including the latest on marijuana use and side
effects, treatment implications for veterans with PTSD, and on
caring for patients who use marijuana at the end of life.
In addition, VA's academic detailing program provides
resources for providers to have meaningful conversations on
cannabis with their patients; as a result, we do not believe
that this legislation is necessary.
This concludes my statement. I would be happy to answer any
questions you or other members of the Committee may have.
[The prepared statement of Larry Mole appears in the
Appendix]
The Chairman. Thank you, Mr. Mole.
I am going to call upon, as a courtesy to Dr. Roe, call on
him first for 5 minutes.
Mr. Roe. Thank you, Mr. Chairman. I have a phone call here
in just a couple of minutes about some veterans' issues at
home.
And just for clarification, Dr. Mole, the secretary's
testified multiple times before this Committee and before the
Senate Committee on Veterans Affairs, expressing his desire for
the AIR Commission to begin their important work as soon as
possible and asking Congress for our helping in accomplishing
that. Given that, is it fair to say that VA is supportive of
H.R. 3083?
Dr. Mole. I can answer that I don't think VA has put out
its official position. I agree with you that the secretary has
made statements in support of that and that is as far as I can
comment, sir.
Mr. Roe. And the AIR act requires the VA--and I know
because we wrote it on this Committee--to consult with VSOs as
it conducts its market assessments. Explain VA's efforts,
because we heard some objection to that--probably rightfully
so--our plans to consult with VSOs as it conducts market
assessments. Have you all decided how you will do that? I think
that is a fair ask of the VSOs.
Dr. Mole. Yeah, and I agree with you. I will need to take
that back for additional information, because I don't know what
that particular office is doing, but I can get that and bring
that information back to you, sir.
Mr. Roe. We appreciate you doing that. And can you clarify
for the record that the market assessments that are required
for the AIR Commission are the same market assessments as
Secretary Wilkie has testified will be completed by June, one
year from now?
Dr. Mole. Yes, they are.
Mr. Roe. Okay. So, in other words, what we will have a year
from now are the market assessments across the country, and I
think what I heard the secretary say multiple times--as a
matter of fact I know what I heard him say multiple times is
that if you wait a subsequent year, then you have got data that
may not be accurate that you are making decisions on.
The other side of that is--and I have said it from the very
beginning when I started the discussion in my office with the
VSOs--that I would rather make sure that we get it right than
fast. And I don't think this is a fast--and as a matter of
fact, I don't think we have any choice but to do this. And
whether it is the AIR Commission or some other commission, it
is just not the way that VA provides health care anymore.
And if you look at what the VA is doing around the country,
which I wholeheartedly applaud them for, is pushing more and
more of the care out into the community where the veterans
actually live. That was the idea of the MISSION Act. So, if you
are in Los Angeles where the traffic--I mean, it is horrific. I
could drive to several states in the time I could get 30 or 40
minutes in downtown LA, to put that care closer to the
veterans. That is the purpose of all of this.
And to repurpose those bills--and I have challenged every
medical center that I have gone to in the last 3 years since--
because we have done it at our own medical center at home in
Mountain Home VA in Johnson City--start thinking about how you
would like your medical center to look in 3, 5, or 10 years
from now and what demands are being made. We know that the
veteran population, the actual numbers are going down.
Hopefully, the number of veterans will go up. I hope the
number of veterans that use the VA goes up and not down, and I
think it will. So, with that in mind, I would think that we
could get started with this with our partners in the VSOs. And
it doesn't mean you are going to end any quicker--you aren't by
law; you are just going to get started a little sooner is all.
Am I correct in that?
Dr. Mole. I think I am not--
Mr. Roe. --AIR Act.
Dr. Mole. Yeah. I mean, I am not well enough connected to
know the pieces to know how it starts once you get through the
market assessments. I don't know all the other milestones, so
that is hard for me to comment on, but, again, I can take that
back, sir.
Mr. Roe. Thank you.
I yield back. Thank you, Mr. Chairman.
The Chairman. Thank you, Dr. Roe.
I will now recognize myself for 5 minutes. Mr. Mole, have
VA leaders recently spoken to the employees and veterans at the
VA Medical Center in San Juan, Puerto Rico?
Dr. Mole. I don't have an answer to that.
The Chairman. You don't know?
Dr. Mole. Yeah.
The Chairman. What I wanted to know was whether the San
Juan Medical Center has Spanish language materials they need to
communicate with veterans and conduct training at the hospital.
I don't imagine you would know that, either.
Dr. Mole. I only know to some extent because of Spanish
articles I have worked on historically, but what was mentioned
earlier today about the MISSION Act and materials developed for
Spanish, that is the first that I have heard of that.
The Chairman. Okay. Do you have any effort on VA's part to
staff the Veterans Crisis Line so it can assist Spanish
language speakers nationwide?
Dr. Mole. Yeah, I don't know that. I can get that for you,
sir.
The Chairman. Okay. Were you aware that Puerto Rico had
created its own Spanish language Veterans Crisis Line and that
it is not being answered?
Dr. Mole. That, I did not know.
The Chairman. Okay. I just want to make sure that through
you, the Department is aware of this--
Dr. Mole. Yes.
The Chairman [continued]. --and can maybe address these
questions.
Has VA conducted any studies or collected data to determine
whether Spanish-speaking or non-English speaking veterans are
accessing benefits at the same rate as English-speaking
veterans?
Dr. Mole. Not to my knowledge, but I am not in that program
office that would do that, but that is another one to be
answered, yes.
The Chairman. I appreciate your getting back to my staff on
that.
Dr. Mole. Yes, sir.
The Chairman. Now, I want to turn to the medicinal
cannabis.
Dr. Mole. Uh-huh.
The Chairman. If the VA has concerns with the VA Medicinal
Cannabis Act and how it could limit the design and research or
clinical trials, would VA be willing to work with the Committee
to address those concerns that VA can conduct objective
research?
Dr. Mole. Absolutely.
The Chairman. And you said that, really, that there were
other research priorities that you didn't support this Act
because there are other research priorities.
Dr. Mole. The way that the bill is written--
The Chairman. Uh-huh.
Dr. Mole [continued]. --it implies that a big, large
clinical trial would be designed that would have many, many
arms that would be studied all at once.
The Chairman. I understand.
Dr. Mole. And we are kind of ahead of ourselves in doing it
that way, because to some extent, we may not know some of the
products that are being tested, whether they actually do any
good or what the risks are of using those.
The Chairman. I see where you guys are coming from.
Dr. Mole. Yeah.
The Chairman. So, I mentioned may be working with the VA in
an approach that the VA would support. So, I see how you guys
are thinking that this is too prescriptive for you.
In your previous testimony, you stated that VA has gone so
far as to, ``Encourage other research on possible medical uses
for marijuana.'' Specifically, what steps has VA taken to
encourage this type of research?
Dr. Mole. So, I can give you a partial answer. Our research
department would be the best to give you a full listing of
everything they have done. But they hold seminars. They have
done series on educating what you can and cannot do, with
regards to research with cannabis, and actively participate
with our regional experts in research to determine what they
can do as a national program office to assist them and help
them develop good, strong, scientific protocols to then submit
for funding for research.
The Chairman. All right. Well, thank you, Mr. Mole. I am
not going to use all my time, but I would like to now call on
and recognize Mr. Barr if he has any questions.
Mr. Barr. Thank you, Mr. Chairman, again.
And Dr. Mole, thank you for your testimony here today. Just
to further explore where the VA is, specifically, with its
research on medical marijuana and cannabis, I understand your
concerns with the proposed legislation in this hearing that it
is too prescriptive, and I note in your testimony that you
would advocate or the VA would advocate for smaller early-
phase, controlled clinical trials with a focused set of
specific aims that are warranted to determine initial proof of
concept for medical marijuana for a specific condition. And I
appreciate the Chairman's overture to work with the VA on what
the right framework should be going forward on this.
My question is, you heard the testimony from the earlier
testimony, some of the VSOs, and the frustration with the
delays or the concern that this might slow down the process.
What could you reassure--how could you reassure the Committee
that if it was structured in a way that made the criteria that
it wouldn't slow things down?
Dr. Mole. Well, I think the first thing would be that the
VSOs have to be at the table when we are having conversations
about a research plan and what a full research portfolio would
look like. So, I would start there. There needs to be
engagement. We need to educate each other on what each other's
expectations are and then set what those expectations would be
for that research plan.
I think some of the times we kind of cross-talk each other
in terms of trying to explain what is involved in a research-
type program and I think we just miscommunicate, and we need
everybody at the table from the beginning on this.
Mr. Barr. Well, again, can you provide an update on the
specific research that is ongoing now. If there is not a broad-
ranging clinical trial that is going on, what, specifically, is
happening?
Dr. Mole. So, what I can comment on is the one study that
is actually looking at cannabidiol in combination--and it is a
double-blind, placebo-controlled study; it is actually out at
UC San Diego--and they just enrolled their first patient last
week. And they have a number of veterans lined up who wish to
be involved in the clinical trial.
And so, that is really our first one that is being done
specifically for PTSD, taking the standard of care and then
determining whether or not there is an impact by having
cannabidiol in that standard of care treatment plan.
Mr. Barr. That interests me, because as you say, it is
cannabidiol--
Dr. Mole. Right.
Mr. Barr [continued]. --so what is being tested is
basically hemp; it is low-THC--
Dr. Mole. Yeah. It is the refined available product that
was previously mentioned by Dr. Grant.
Mr. Barr. Or I suppose CBD could also be derived from
marijuana--
Dr. Mole. Yes.
Mr. Barr [continued]. --but there is no THC in it or low
THC in the substance that is being tested?
Dr. Mole. That is correct, sir.
Mr. Barr. So, that is the baby-steps approach, I guess, on
this.
Dr. Mole. Right. And I want to point out that this is the
one that is funded by VA. There are other VA researchers that
are getting funding from other sources, as well as other
university researchers and so forth that are looking at this.
So, I think when we are trying to assess what sort of work is
going on out there, I think we need some sort of catalog or
something to understand all of these different studies so when
VA comes up with, here's the portfolio that we are going to do,
it actually complements what else is going on.
Mr. Barr. Doctor, are there any preliminary findings so far
with the CBD and PTSD?
Dr. Mole. No, they just started enrolling patients.
Mr. Barr. Okay. Very good.
Finally question, could you describe some of the risks of
requiring the training of VA providers in the use of medical
cannabis in light of the fact that it remains a federally
scheduled substance?
Dr. Mole. I would have to defer to our colleagues over at
the Department of Justice and what they decide they want to
prosecute or not.
Mr. Barr. Yeah. I guess the reason--what motivates that
question is some of the other legislation that is being
considered here today on training, it appears to put the cart
before the horse. I think we do need to come to a consensus on
an expedited, good, thoughtful, research-driven, evidence-based
approach to research. But training VA providers before we have
all the evidence in seems to be a little bit premature.
So, with that, Mr. Chairman, thank you, and I yield back.
The Chairman. Thank you, Mr. Barr.
I now recognize Mr. Levin for 5 minutes.
Mr. Levin. Thank you, Mr. Chairman.
And thank you, Doctor, for being here today. I am trying to
understand the timeline and where VA really is on this issue.
In 2017, there was a poll conducted for The American Legion,
showed that support for medical cannabis and research on
medical cannabis was high across veterans and caregivers, all
age ranges, genders, political leanings, and geography showed
92 percent of all respondents supporting medical marijuana
research, 82 percent of all respondents supporting legalizing
medical cannabis.
Are you familiar with that poll?
Dr. Mole. Yes.
Mr. Levin. And then in 2017, VA's Evidence-based Synthesis
Program found, ``Methodologically strong research in almost any
area of inquiry is likely to add to the strength of evidence''
regarding the benefits and/or harms associated with medicinal
cannabis.
Also in 2017, VA sent this Committee a letter that stated
that VA was unable to perform research into medical cannabis.
Are you familiar with that letter?
Dr. Mole. Yes.
Mr. Levin. And then after some back-and-forth in the media,
your spokesman or VA's spokesman, a gentleman named Curt
Cashour admitted that VA could, in fact, perform the research,
but found pursuit of the research to be overly burdensome.
Are you familiar with that 2018 statement?
Dr. Mole. Yes, I am.
Mr. Levin. So, then in 2019, VA met with staff where they
expressed support for the need for research, but seemed to
further muddy the waters and confuse things. Can you clarify
what the VA's position is on cannabis research?
Dr. Mole. So, VA can do research. The research is initiated
by our investigators across the field. They are to do research
on cannabis. Given its schedule on controlled substance has
some extra steps in the process. None of those steps are
onerous, as evidenced by the fact that you see--as our San
Diego site was able to set this up fairly quickly.
Once they get through their funding and once they started
moving, actually getting product and bringing it in and working
with it was relatively straightforward. And that investigator
has made a nice training video for anyone else who needs to go
through the process.
So, we can do clinical trials and the process it takes to
bring the product in and then study it is doable.
Mr. Levin. So, when I go back to my district, which I do
every weekend, which has UCSD in it, and I speak to veterans,
which I do virtually every weekend, what am I to tell them when
they ask, When is this actually going to happen? When is this
research going to occur? When is the VA going to listen to the
92 percent of veterans across all political stripes and
ideologies that want to see this done?
Dr. Mole. I think you can start by hopefully proudly saying
that your local VA actually has a study. They have begun
enrollment. If any of those veterans are interested in actually
participating in the study, they can go to clinicaltrials.gov
and they can look up that study. They can just type in
``veterans'' and ``cannabis'' and they will get that study. And
you may find that some of your voter's back home are really
interested in participating or not.
But I think you can tell them that we have begun this
process. We have gotten over these initial hurdles and we are
going to continue to encourage VA investigators to investigate
cannabis.
Mr. Levin. Thanks, Doctor. I appreciate that.
I wanted to shift for a minute, with the time I have left,
to the Veterans Equal Access Act. In the 2009 guidance issued
by the DOJ that you cited in your testimony, the agency accepts
that in the Ninth Circuit, which includes my state of
California, a physician's ability to recommend cannabis use to
their patients is a right protected by the First Amendment.
What efforts has VA taken to allow physicians within these
states to enjoy their First Amendment right to make these
recommendations?
Dr. Mole. The opinion that we requested back then from DOJ
came to us as quoted in the testimony that what is the
precedent as Federal employees, is the Controlled Substance
Act. And to my knowledge, since 2008, I do not believe there
has been another request to DOJ to visit that opinion.
Mr. Levin. Okay. I appreciate your being here. I look
forward to working together on this issue and others, and I
will yield back the balance of my time.
The Chairman. Thank you, Mr. Levin.
This legislative hearing has been well-attended and very
informative. Again, I would like to thank the witnesses.
I thank you, Dr. Mole, for appearing before us today. You
are excused.
I would like to thank all the witnesses from our three
panels for their testimony.
All members will have 5 legislative days to revise and
extend their remarks and include extraneous material.
Again, thank you for appearing before us today, and this
hearing is now adjourned.
[Whereupon, at 4:16 p.m., the Committee was adjourned.]
A P P E N D I X
----------
Prepared Statement of Congressman J. Luis Correa
Chairman Takano and Ranking Member Roe, thank you for the
invitation to speak on my bipartisan bill: H.R. 712, the VA Medicinal
Cannabis Research Act.
I appreciate the chance to return to the House Veterans Affairs
Committee, where I served in the last Congress, to speak on our urgent
need for research on medical cannabis as a possible treatment option
for our nation's veterans.
The U.S. Department of Veterans Affairs is uniquely positioned to
pursue the necessary research on what cannabis can and cannot do for
our veterans.
Our brave men and women return from military service in Iraq and
Afghanistan, at times with psychological wounds as well as physical
injuries.
Unfortunately, for many veterans with PTSD and chronic pain, the
use of prescription opioids has been ineffective in providing relief.
Worse, the use of prescription opioids has led to addiction or even
death.
Tragically, VA patients are almost twice as likely to die from
accidental opioid overdoses than non-veterans.
In California, I have met with multiple veterans who use medical
cannabis as an alternative to prescription opioids and other treatment
methods.
The men and women that I meet back home vouch for the therapeutic
benefits of medical cannabis and support further research into the
issue.
In fact, according to the Iraq and Afghanistan Veterans of America,
over 90 percent of their membership support medical cannabis research.
As more veterans use cannabis for medical purposes, it is important
that doctors be able to fully advise on the potential benefits and
effectiveness of medical cannabis.
Currently, VA doctors can discuss cannabis usage with patients, but
they have limited federally approved research on which to base
recommendations or clinical opinions.
For that reason, with my colleague and friend Congressman Clay
Higgins of Louisiana, I introduced the VA Medicinal Cannabis Research
Act.
The bill requires the U.S. Department of Veterans Affairs to
conduct a double-blind clinical study on the safety and effectiveness
of medical cannabis.
The legislation provides a framework for that research to ensure a
scientifically-sound study on the issue.
Research on the safety and effectiveness of medical cannabis is
timely, necessary, and supported by the veteran community.
I want to thank the Iraq and Afghanistan Veterans of America,
Veterans of Foreign Wars, Disabled American Veterans, and many others
for their support of the bill.
H.R. 712 is a pragmatic and sensible approach to the need for
research on medical cannabis and could result in potentially lifesaving
information.
I look forward to working with you all to move this bill forward.
Prepared Statement of Adrian M. Atizado
Mr. Chairman and Members of the Committee:
Thank you for inviting DAV (Disabled American Veterans) to testify
at this legislative hearing of the House Committee on Veterans'
Affairs. 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. We are pleased to offer our views on
the bills under consideration by the Committee.
H.R. 2676, the VA Survey of Cannabis Use Act
H.R. 712, the VA Medicinal Cannabis Research Act of 2019
DAV supports both the VA Medicinal Cannabis Research Act of 2019
and VA Survey of Cannabis Use Act based on DAV Resolution No. 023,
calling for more comprehensive and scientifically rigorous research by
the Department of Veterans Affairs (VA) into the therapeutic benefits
and risks of cannabis and cannabis-derived products as a possible
treatment for service-connected disabled veterans.
H.R. 2676 would require VA to partner with a federally-funded
research and development center that will study how veterans use
cannabis, their experiences and any side effects of use. It also
requires VA to report to Congress on the results of the survey. H.R.
712 would allow the VA to engage in research on the safety and efficacy
of medicinal cannabis use on health outcomes for veterans with chronic
pain and post-traumatic stress disorder (PTSD). In addition, the bill
would allow a long-term observational study of clinical trial
participants and require VA develop a means of preserving data for
future studies. The bill would also require VA to submit periodic
progress reports to Congress not less frequently than annually.
DAV understands that use of cannabis for medicinal purposes is now
legal in 33 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 medicinal
cannabis for these purposes is beneficial.
DAV is a strong supporter of 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.
H.R 3083 - AIR Acceleration Act
DAV strongly opposes H.R. 3083, the AIR Acceleration Act, which
would eliminate the requirement that the Asset and Infrastructure
Review Commission, a key element of the Asset and Infrastructure Review
(AIR) Act, not be allowed to convene any earlier than 2022. This
requirement was drafted to ensure sufficient time and opportunities for
stakeholder engagement in the multi-step review and approval process
that could result in substantial changes to VA's health care
infrastructure. By removing the time constraints on the Commission, VA
would be free to accelerate the AIR process, as the title of this bill
reflects, which would undercut one of the key elements of the
compromise that led to inclusion of the AIR ACT as part of the VA
MISSION Act.
Mr. Chairman, when the original draft version of the AIR Act was
presented to DAV and other VSOs in 2017, one of the major concerns we
expressed was that its timeline was far too short for a truly
deliberative process on something as critical as the future of VA's
health care infrastructure. Further, we were concerned about the lack
of mandated stakeholder engagement throughout the proposed AIR process.
Finally, we argued that VA should wait until after new VA capacity
enhancements were completed, and after new integrated networks created
by the VA MISSION Act had been established and stabilized before
beginning the process to decide which VA facilities would be necessary
to most effectively deliver medical care to veterans.
In building a compromise on the proposed AIR Act last Congress,
then-Chairman Roe, the bill's sponsor, worked closely with DAV and
other VSO stakeholders to address numerous concerns raised about his
bill. We greatly appreciated Dr. Roe's open and collaborative approach
to developing the final language of the AIR Act, which reflected
significant changes from the bill's original text. On October 30, 2017,
in a letter to DAV, The American Legion, Paralyzed Veterans of America
(PVA) and Veterans of Foreign Wars (VFW), he wrote that:
``Based on the feedback you provided during those Committee
meetings as well as in numerous meetings and conversations with me and
my staff since, I have made a number of changes to the AIR Act to make
it stronger, more transparent, and more veteran-centric. For example,
at your request, the revised AIR Act would:
Greatly expand the entire AIR Act timeline to allow VA sufficient
time to gather needed data, complete local capacity and commercial
market assessments, and stabilize community care efforts.''
It was with these and many other substantive changes made that DAV
and other VSOs were able to support the inclusion of the AIR Act within
what became the VA MISSION Act. However, if H.R. 3083 were enacted, and
Secretary Wilkie were to accelerate the AIR process as he has
repeatedly indicated his desire to do, it would fundamentally undermine
the dynamic structure of the VA MISSION Act by forcing premature
decisions on infrastructure before decisions on health care delivery
have been finalized.
Although VA has already contracted for market assessments, and we
understand that the first tranche have essentially been completed, it
is important to understand that the MISSION Act had two separate
sections requiring market assessments. Section 106(a) requires VA to
undertake a Quadrennial Veterans Health Administration review, which
would encompass comprehensive market assessments as the predicate for
Section 106(b), which requires VA to deliver a Strategic Plan to Meet
Health Care Demand not less than every four years. These market
assessments and the strategic plan based upon them were due no later
than June 6, 2019, the effective date for the new Veterans Community
Care Program. These market assessments were not intended to inform the
future Asset and Infrastructure Review. In fact, this market assessment
process was already begun by VA prior to enactment of the MISSION Act,
when inclusion of the AIR Act was far from certain.
Section 203(b)(3) of the MISSION Act, in the AIR Act section,
requires capacity and commercial market assessments to be performed to
guide the Secretary's recommendations for infrastructure realignment,
which are due no later than January 31, 2022. These market assessments
were intended to reflect the capacity and demand after the new Veterans
Community Care Program had been implemented and reached a point of
optimization and stabilization. Because the MISSION Act includes
provisions to increase VA's capacity to deliver care through VA
facilities, it would be premature to assess VA's capacity before the
MISSION Act changes were fully implemented. The creation of new
integrated networks, the expansion of telehealth and the creation of a
new urgent care benefit will all impact how, when and where veterans
will seek care in the future; however, these changes will not be known
for at least a couple of years.
This was one of the key reasons then-Chairman Roe agreed with our
request to ``.expand the entire AIR Act timeline to allow VA sufficient
time to gather needed data, complete local capacity and commercial
market assessments, and stabilize community care efforts.''
In addition, the market assessments required under Section
203(b)(3) have mandatory requirements for VA to ``consult with veterans
service organizations and veterans.'' different than Section 106.
However, we are unaware of VA engaging with DAV or any other VSOs in
any meaningful way regarding either the process or methodology for
conducting the current market assessments or in the field as they
performed individual market assessments. It is our understanding that
VA's contractor has effectively completed the first group of market
assessments and we remain unaware of any efforts to contact VSOs
locally or nationally to solicit input regarding veterans' needs or
preferences for future medical care delivery.
Mr. Chairman, the AIR Act was included in the VA MISSION Act with
the very clear understanding among all stakeholders that VA would not
begin a process that could result in closures of VA health care
facilities until after the new community care program had been fully
established and stabilized. Decisions on how VA will ensure the
delivery of health care to millions of veterans must be made first, and
only after new demand patterns have stabilized should decisions be made
about the future alignment of VA infrastructure to deliver that care.
Furthermore, because of the importance of ensuring that VSO
stakeholders were fully engaged throughout the process, the MISSION Act
included numerous specific consultation requirements. Such
collaboration with VSOs is not only important to help ensure that VA's
plans for creating integrated networks reflect veterans' needs and
preferences, but robust engagement is essential to achieve the level of
support from veterans that will be necessary to implement real reform
and realignment of VA's health care infrastructure.
Mr. Chairman, throughout the development of the AIR Act
specifically, and the MISSION Act in general, DAV and other key
stakeholder VSOs were regularly engaged with this Committee, working
closely with both sides of the aisle in the House and the Senate.
Unfortunately, the implementation by VA has too often been done with
little or limited engagement with VSO stakeholders, even when the law
specifically requires such consultation.
For these reasons, while we recognize the good faith intentions of
the bill's sponsor, Dr. Roe, throughout the development and passage of
the MISSION Act, and particularly the AIR Act section, we strongly
oppose this legislation. Accelerating the AIR process - which Secretary
Wilkie has indicated is his desire - would run contrary to clearly
bipartisan and bicameral intentions of the MISSION Act compromise and
could lead to a fundamentally flawed infrastructure review process.
H.R. 485, the Veterans Reimbursement for Emergency Ambulance Services
Act
With our recommendation, DAV is pleased to support H.R. 485, based
on DAV Resolution No. 075, calling on Congress to improve
administration of the emergency care benefit for service-connected
veterans. DAV believes access to emergency care is a necessary
component of a robust and complete medical care benefits package.
This bipartisan bill would clarify the circumstances under which VA
would be required to reimburse emergency transportation of veterans.
Veterans seeking reimbursement for both emergency transportation and
care have routinely been denied because VA does not consistently apply
a standard definition of ``prudent layperson understanding'' in
providing reimbursement for claims.
VA, like many other federal providers and payors, uses the prudent
layperson standard created under the Emergency Medical Treatment and
Labor Act (EMTALA) to define what constitutes a medical emergency.
However, medical literature has shown that there are significant
differences in perceptions of need for emergency care between laypeople
and medical professionals-lay people are actually more conservative in
applying the ``emergency'' label to some specific conditions than
health care workers; however, they are also more likely to label
conditions that affect ability to work, conditions that happen after
business hours and any other conditions the patient believes is an
emergency as ``emergent'' than health care workers.
H.R. 485 aims to clarify the language defining a medical emergency
that qualifies for VA reimbursement for emergency transportation by
requiring that a condition have a sudden onset; that the layperson
believes that the emergency is an immediate risk to life or health; or
that a delay in treatment will result in serious consequences to life
or health. This reimbursement for emergency transportation would apply
to veterans who were transported to the closest medical facility that
can respond to the veteran's needs.
We understand these more detailed requirements for approval of
emergency ambulance reimbursement claims may provide better guidance
for claims administrators and help standardize administration to the
veteran's favor; however, in light of VA's inconsistent and lackluster
performance in administering Section 1725, we urge the Committee
include an evaluation and reporting requirement of VA's performance in
executing the intent of this legislation to be conducted by an entity
independent of the Veterans Health Administration.
H.R. 2942
DAV strongly supports this measure introduced by Congressman
Cisneros based on DAV Resolution No. 304, which urges the Department of
Defense (DoD) and other transition partners including VA and the
Department of Labor (DOL) to include VSOs in the program and ensure
that service members are obtaining meaningful employment and making
adequate progress toward their life goals in the period of time shortly
following military service.
This bill would build from a successful ongoing pilot between VA
and the Air Force, by establishing a pilot program to assist women who
are transitioning from military to civilian life with obtaining
appropriate health care.
DAV made this recommendation in our 2014 Report, Women Veterans:
The Long Journey Home. This report found that the effectiveness of the
Transition Assistance Program (TAP) has yet to be evaluated. Often upon
returning home from deployment, service members are eager to return to
their homes and loved ones. Focusing on problems they may encounter
later on is not something they are prepared to address. DoD often
conducts TAP immediately prior to separation, but our report recommends
that DoD consider addressing employment, educational opportunities and
gender-specific information through additional workshops 6-12 months
after separation to ensure that veterans are adequately primed to
receive and make use of the information they receive.
The report further recommends that DoD share contact information
with VA and the DOL to ensure that outreach can be conducted and assess
service members' satisfaction with participation, the effectiveness of
TAP for all separated service members and the outcomes of participation
in the program by gender and race in terms of addressing service
members' need for education and employment opportunities.
DAV's 2014 report also found that while there were many federal
programs for women veterans, women were often unaware of the programs
available to assist them and that there were many ``gaps'' between
programs that transitioning service members could fall between in
ensuring their successful transition home. DAV often lauds VA for the
``wraparound'' services it provides to veterans with significant
challenges such as homelessness or severe mental illness, yet veterans'
access to programs that may assist them are often dependent upon one
discharge planner or case manager's knowledge of them and often the
crosswalks between VA and other federal agencies' programs are not
widely understood. We believe that VSOs are part of the answer to this
challenge if they are included in transition planning activities.
As we have learned from both our 2014 report and 2018 Report, Women
Veterans: The Journey Ahead, women transitioning from service often
have difficult and different challenges to successful reintegration
with families and communities than their male counterparts. Women are
less inclined to have awareness of their veteran status, even after
deployment. They are more prone to divorce and being single parents
than male veterans. These factors often affect their economic stability
and create or exacerbate the stress they have experienced during
deployment. Likewise, more than half of the women veterans using VA
services have a service-connected condition, use more VA mental health
services than their male peers, have higher rates of suicide and
homelessness compared to civilian women peers and a significant number
report military sexual trauma all complicating their journeys to
reintegration.
In a recent hearing of the House Veterans' Affairs Subcommittee on
Health, Representative Cisneros cited outcomes of the pilot to include:
99 percent of participants would recommend the program to other women
veterans and 80 percent agreed to allow follow up. Dr. Patricia Hayes,
the VA Women's Health Program Director indicated that the program began
because rates of suicide are high and growing among women veterans. She
stated that the program allows women veterans to visit a VA medical
center to dispel any stereotypes they believe may affect women's
understanding of the program. She also stated that the Navy had agreed
to have Navy and Marine sites began participating in the program.
We believe this training may arm women veterans with information
they need to prevent or minimize their challenges with transition by
allowing them to acknowledge and obtain resources for addressing the
residual health issues with which they are struggling in order to
prevent health and mental health conditions from becoming more severe
and chronic or leading to tragedies such as homelessness or even
suicide, which too many of our veterans-both male and female-are lost
to.
Discussion Draft, Specially Adaptive Housing
DAV does not have a resolution on VA's grant program for Specially
Adapted Housing and Special Housing Adaptation; however, DAV Resolution
No. 055 speaks to another benefit under VA's Special Housing Adaptation
Program, the Home Improvement and Structural Alterations (HISA) grant
program.
A HISA grant is available to veterans with service-connected
disabilities or veterans with nonservice-connected disabilities and who
have received a medical determination indicating that improvements and
structural alterations are necessary or appropriate for the effective
and economical treatment of the veteran for disability access to the
home and essential lavatory and sanitary facilities.
Notably, a veteran may receive both a HISA grant and either a
Special Home Adaptation grant or a Specially Adapted Housing grant.
While this bill seeks to increase the grant amounts for Special Home
Adaptation and Specially Adapted Housing, DAV's resolution calls for a
reasonable increase in the HISA benefit for veterans. Correspondingly,
this bill seeks to increase the amount for Special Home Adaptation from
$12,756 to $20,271, and Specially Adapted Housing from $63,780 to
$101,350, which would be help ensure the continued effectiveness of
these grant programs.
We note this bill does not cure inherent weaknesses in VA's Special
Home Adaptation program. For example, the Specially Adapted Housing
grant program differentiates between veterans who need this benefit
based on when they were injured. A veteran suffering a loss, or loss of
use of one or more lower extremities due to service on or after
September 11, 2001, which so affects the functions of balance or
propulsion as to preclude ambulating without the aid of braces,
crutches, canes, or a wheelchair would be eligible. Yet a veteran who
sustained a loss of or loss of use of both arms, or a loss of or loss
of use of one leg and is blind in both eyes, or suffers from certain
severe burns due to military service on or after September 11, 2001
would not be eligible. Moreover, a veteran who sustained these injuries
due to military service before September 11, 2001 would be eligible.
These different eligibility criteria appear as a fundamental problem of
arbitrary versus responsible government but does little to encourage,
if not belie, the recognition of military service regardless of when
such sacrifice was rendered.
Mr. Chairman, this concludes DAV's testimony. Thank you for
inviting DAV to testify at today's hearing. I would be pleased to
address any questions related to the bills being discussed in my
testimony.
Prepared Statement of Travis Horr
Chairman Takano, Ranking Member Roe, and Members of the Committee,
on behalf of Iraq and Afghanistan Veterans of America (IAVA) and our
more than 425,000 members worldwide, thank you for the opportunity to
share our views, data, and experiences on the pending legislation
before the Committee today.
While I serve as the Director of Government Affairs at IAVA, I'm
also a Marine Corps veteran. I enlisted in the infantry in 2007 and
deployed to Southern Helmand, Afghanistan in 2010. The issues of the
post-9/11 generation are my issues. I was exposed to burn pits on my
small patrol base in Afghanistan, I utilized the Post-9/11 GI Bill to
become the first person in my family to graduate college. I've seen
first hand the positive impact that medicinal cannabis can have on my
fellow veterans' lives once they transition out of the service. And
I've lost too many of my friends to the suicide epidemic in the veteran
community. These issues are personal to me and I'm proud to represent
IAVA's views in front of the Committee today.
We thank the Committee for bringing forward important legislation
that touches on a number of our Big Six priorities for 2019, which are:
the Campaign to Combat Suicide, Defend Veterans Education Benefits,
Support and Recognition of Women Veterans, Advocate for Government
Reform, Support for Injuries from Burn Pits and Toxic Exposures, and
Support for Veterans who Want to Utilize Medicinal Cannabis.
Support for Veterans Who Want to Utilize Medicinal Cannabis
For years, IAVA members have been supportive of medical cannabis.
In IAVA's latest Member Survey, 83% of IAVA members agree that cannabis
should be legal for medical purposes. And a resounding 90% believe
cannabis should be researched for medicinal uses, an increase from 63%
just last year. IAVA members are vastly in support of cannabis
research, and support will continue to grow in the months and years
ahead. It's time for the Department of Veterans Affairs (VA) to catch
up.
IAVA members have set out to change the national conversation
around cannabis and underscore the need for bipartisan, data-based,
common-sense solutions that can bring relief to millions, save
taxpayers money and create thousands of jobs for veterans nationwide.
The veteran community has made it very clear that it supports research
done on the use of cannabis as a treatment option.
However, this demand has not resulted in a change in policy. For
these reasons, the VA Medicinal Cannabis Research Act (H.R. 712) is the
centerpiece of IAVA's Campaign to Support Veterans who Want to Utilize
Medicinal Cannabis. This legislation will advance research and
understanding of the safety and effectiveness of cannabis to treat the
signature injuries of war. At this time, we have limited evidence on
cannabis' effectiveness to treat the injuries that impact huge swaths
of the post-9/11 generation.
Without research done by VA surrounding cannabis, veterans will not
have conclusive answers to ways cannabis might aide their health needs.
This is unacceptable. VA houses some of the most innovative and best-
in-class research this country has to offer. It should not be shutting
its doors on a potentially effective treatment option because of
politics and stigma. Our nation's veterans deserve better.
In IAVA's most recent Member Survey, a staggering 72% of veteran
and military members reported suffering from chronic pain. Sixty-six
percent report joint injuries, and over 50% report either PTSD,
anxiety, or depression. Cannabis may be an effective treatment option
for all of these service-connected injuries, but we must invest in the
research to ensure it is. The VA Medicinal Cannabis Research Act will
build on this evidence and provide further data to explore the
effectiveness of cannabis as a treatment option. Without comprehensive
cannabis research, we are unable to make policy decisions that could
improve the lives of veterans.
One such veteran whose life was improved through medicinal cannabis
was Army veteran and former IAVA intern, Julie Howell. Her story, in
her own words, follows:
For years after I returned from Iraq I struggled to sleep through
the night. As it turns out, I suffered from something known as
maintenance insomnia, I would fall asleep but would wake for hours in
the middle of the night and then fall back asleep right before needing
to wake up. Thanks to California passing legislation regarding
medicinal and recreational cannabis I now have access to a product that
I ingest which contains a small amount of cannabis that helps me sleep
through the night. I do not use cannabis recreationally, I do not even
smoke, but this product has allowed me to thrive. Without access to
cannabis, I would never have been as successful in the pursuit of
higher education. I am currently working through a masters degree in
public policy with the hope of assisting veterans like me, to live
their best lives.
In addition to Julie, over 100 IAVA members have shared the stories
of their cannabis use, with dozens sharing how VA retaliated against or
mishandled them and dozens more sharing that they flat out refuse to
tell VA about their use. Left unchecked, this practice is harmful and
dangerous. In fact, Julie herself, even after advocating on Capitol
Hill and back home in California, still hasn't talked to her VA doctor
about her cannabis use.
Julie isn't alone. Twenty percent of IAVA members report using
cannabis for medicinal use and of those, only 31% have talked to their
doctor about their cannabis use. Twenty-four percent either do not feel
comfortable or only feel slightly comfortable talking about their
cannabis use with their doctors. For the vast majority of those that
use cannabis, they are not talking to their doctors about their
cannabis use.
VA care is an earned benefit for our nation's veterans, they
shouldn't feel that they have to hide and circumvent VA to access a
standard of care their civilian counterparts access easily. Yet VA's
policies inhibit realistic discussion and open conversations around
cannabis. If veterans are unable to receive the care that they deserve,
then they will go around it.
We must ensure that VA clinicians can have open and honest
discussions with their patients, allowing VA clinicians to recommend
cannabis to their patients when appropriate, and ensure VA clinicians
can submit forms for state medical cannabis programs for their veteran
patients.
For these reasons, IAVA is proud to support the Veterans Equal
Access Act (H.R. 1647) that will allow VA clinicians to provide
recommendations and fill out forms for state cannabis programs. IAVA is
also proud to support the VA Survey of Cannabis Use Act (H.R. 2677), in
order for VA to understand the scope and scale of veterans currently
using cannabis. IAVA also supports H.R. 2677, which will allow VA
physicians to undergo training to understand how to best use medicinal
cannabis, where it is already available in state programs.
Reform VA for Today's Veterans
Millions of veterans rely on VA for both health care and benefits.
Ensuring that the system is able and agile enough to accommodate the
millions of veterans who use its services is paramount to ensuring the
lasting success and health of the veteran population. About 48% of all
veterans and about 55% of post-9/11 era veterans are enrolled in VA
care. Among IAVA member survey respondents, 81% are enrolled in VA
health care, and the vast majority have sought care from VA in the last
year, 81% of these VA users rated their experience at VA as average or
above average. IAVA members have been clear that access to VA care can
be challenging, but once in the system, they prefer that care. Further,
independent reviews of VA health care support that the care is as good,
if not better than the private sector.
A bold approach to ensuring today's veterans have a system willing
to bend and adapt to them will take the full coordination of the
executive branch and Congress, along with stakeholder partners in state
and local governments, and the private and nonprofit sectors. We need a
system that leverages the use of new technologies to streamline
processes and enables VA to take a more dynamic approach to respond to
the needs of today's veterans. Even so, the best technology will not
save a system if it is built upon outdated structures.
Because of these reasons, IAVA is proud to support the AIR
Acceleration Act (H.R. 3083) which will remove a restriction of the AIR
Act to allow the commission to be nominated, appointed, and start their
important work as soon as possible. Modernizing VA needs to be a top
priority, the longer we wait, the bigger the problem it will become.
The Veterans Reimbursement for Emergency Ambulance Services Act
(VREASA) (H.R. 485) will expand VA's ability to reimburse emergency
ambulance services. Typically, VA can reimburse ambulance services,
however, there are still times when veterans are stuck with the bill.
For instance, if a veteran experiences a medical emergency and a
bystander calls for emergency services and it was later determined to
not be life-threatening, then the veteran must pay for ambulance
services, through no fault of their own. VREASA seeks to fix this
loophole and aligns reimbursement to current law under Medicare and
Medicaid. It is for these reasons that IAVA is supportive of the
legislation.
H.R. 2943 would direct VA to ensure that all fact-sheets are
produced in both English and Spanish. The US Military is a diverse
organization and a cross-section of the United States as a whole. I
personally served with a large number of Marines who spoke English as a
second language. All veterans should have equal access to information
provided by VA in a language they are proficient in and it is for these
reasons that IAVA is supportive of the legislation.
IAVA is also supportive of the draft legislation to address
specially adaptive housing. We are pleased to see the expansion of this
program, to include the increase in the amount of assistance given, the
increased amount of applicants that can be approved, and the
elimination of the cap on grants given out.
Recognize and Improve Services for Women Veterans
Data shows that women veterans, on average, do not seek support
from the Veteran Health Administration (VHA) until 2.7 years after
leaving the service, or until mental or physical health issues have
manifested. On top of that, VA states that women veterans tend to face
more health-related challenges than their male counterparts. And most
importantly, since 2001, the suicide rate for women veterans has
increased by 85.2%, while the suicide rate for males has increased by
30.5%.
It is because of those reasons that the VA Air Force Women's Health
Transition Training pilot was created. It is aiming to provide
servicewomen with a deeper understanding of womens' health services
within the VA health care system. The courses are all led by women
veterans, and everyone has the opportunity to personalize their
training.
The Helping Expand and Launch Transitional Health (HEALTH) for
Women Veterans Act (H.R. 2942) is consistent with IAVA's groundbreaking
She Who Borne The Battle campaign to recognize the service of, and fill
gaps in care for women veterans. This legislation not only ensures the
pilot program remains in place until 2020 but expands it across all
services, and creates a feasibility study to make the program
permanent. Women veterans are the fastest growing cohort of veterans
and it is critically important that they receive the same care as their
male peers. IAVA supports H.R. 2942.
Defend Military and Veteran Education Benefits
The Post-9/11 GI Bill can only go so far in ensuring the future
success of today's fighting force. While an earned benefit, the Post-9/
11 GI Bill is also an investment in America's next ``Greatest
Generation.'' Veterans are proven to be more productive and have higher
retention rates once hired into a career, and ensuring they have the
appropriate training and degrees is paramount to this success. This
successful transition to the civilian workforce often begins on a
college campus. In fact, according to Student Veterans of America and
the Institute for Veterans and Military Families, 2.9 million post-9/11
veterans have entered higher education since transitioning out of the
military and I'm proud to be one of them. This means that ensuring
veterans are supported and successful on campus is of utmost importance
to the long-term success of each veteran.
To this end, IAVA is supportive of the draft legislation that
addresses and improves VA Work Study program. This bill will update the
work-study program to mirror the already successful program used by the
Department of Education (ED). By using previous years' data, VA will be
able to give more timely work-study payments to students and ensure
that they paid on time and in full. While we are all intimately aware
that IT issues continue to be a problem at VA, we feel confident that
by using ED as a model, VA will be able to make their work-study
payments more reliably.
Members of the Committee, thank you again for the opportunity to
share IAVA's views on these issues today. I look forward to answering
any questions you may have and working with the Committee in the
future.
Prepared Statement of Carlos Fuentes
Chairman Takano, Ranking Member Roe, and members of this committee,
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 committee.
H.R. 485, Veterans Reimbursement for Emergency Ambulance Services Act
This legislation would decouple ambulance reimbursement from
reimbursement for emergency room health care services. The VFW supports
this bill and has a recommendation to improve it.
The Department of Veterans Affairs (VA) emergency transportation
reimbursement process is cumbersome and tends to take unreasonably
long. VA must first adjudicate a claim for emergency room care before
VA pays for the emergency transportation. In order to have a claim for
emergency room services approved, VA must confirm the veteran
experienced an emergency, whether the veteran has received VA health
care within the past 24 months, if there is an acceptable reason a VA
medical facility was not used, and whether the veteran notified VA of
the emergency within 72 hours. When the emergency is for a non-service-
connected condition, the veteran is required to exhaust all other
health care insurance options before VA can cover the cost of
transportation.
Veterans who believe they are experiencing an emergency must not be
delayed or deterred from contacting 9/11 for emergency assistance
because they are concerned VA will refuse to cover the cost of
emergency transportation and leave them with crippling health care
debt. This bill would rightfully authorize VA to pay claims for
emergency room transportation without having to first process a claim
for emergency health care.
This legislation would require that a veteran be taken to the
closest and most appropriate medical facility as a prerequisite for
reimbursement of emergency transportation costs. Ambulance services
typically take patients to the nearest emergency room. VA must make
certain emergency transportation services are doing their best to take
veterans to VA hospitals when possible. Since veterans who are facing
an emergency typically do not have the opportunity to influence where
they are taken, the VFW would recommend this committee strike the
requirement that they be taken to the ``closest and most appropriate''
medical facility. Doing so would ensure veterans are not forced to pay
emergency room reimbursement bills out-of-pocket because VA and the
ambulance service disagree on what constitutes closest and most
appropriate.
H.R. 712, VA Medicinal Cannabis Research Act of 2019
This legislation would require VA to conduct a double-blind
scientific study on the efficacy of medicinal cannabis. The VFW is
proud to support this important bill and thanks this committee for its
consideration.
Prescribed use of opioids for chronic pain management has
unfortunately led to addiction for many veterans, as well as for many
other Americans. VA uses evidence-based clinical guidelines to manage
pharmacological treatment of post-traumatic stress disorder, chronic
pain, and substance use disorder because medical trials have found them
to be effective. To reduce the use of high-dose opioids, VA must expand
research on the efficacy of non-traditional medical therapies, such as
medicinal cannabis and other holistic approaches.
Medicinal cannabis is currently legal in 33 states and the District
of Columbia. This means veterans are able to legally obtain cannabis
for medical purposes in more than half the country. For veterans who
use medical cannabis and are also VA patients, they are doing this
without the medical understanding or proper guidance from their
coordinators of care at VA. Many states have conducted research for
mental health, chronic pain, and oncology at the state level. States
that have legalized medicinal cannabis have also seen a 15-35 percent
decrease in opioid overdose and abuse. A comprehensive study by the
National Academy of Sciences and the National Academic Press also
concluded that cannabinoids are effective for treating chronic pain,
chemotherapy-induced nausea and vomiting, sleep disturbances related to
obstructive sleep apnea, multiple sclerosis spasticity symptoms, and
fibromyalgia--all of which are prevalent in the veteran population.
While VA has testified that it has the authority to study Schedule 1
drugs, it has failed to do so and veterans are tired of waiting for VA.
This bill would prevent VA from further delaying needed research.
VFW-Student Veterans of America Fellow Christopher Lamy, an Army
veteran and Louisiana State University law school student, focused his
semester-long research project and advocacy effort on this important
bill. Chris' research discovered that veterans experience chronic pain
at 40 percent higher rates than non-veterans and if not properly
treated, such chronic pain often leads to depression, anxiety, and
decreased quality of life. Chris also found that states with medicinal
cannabis programs have, on average, a 25 percent lower rate of death
from opioid overdose than states without such programs.
Veterans Health Administration (VHA) Directive 1315, Access to VHA
Clinical Programs for Veterans Participating in State-Approved
Marijuana Programs, provides protections for veterans who use medicinal
cannabis. However, Chris found that veterans who discuss their use of
medicinal cannabis with their doctors are ostracized and have their
medications changed or discontinued. The fear of reprisal for medicinal
cannabis prevents veterans from disclosing information to their VA
health care providers, which can lead to problems caused by drug
interactions. This legislation would prohibit VA from making
eligibility determinations for benefits based on participation in the
study. To ensure veterans who participate in the study do not have
their VA health care negatively impacted, the VFW recommends this
committee amend the bill to prohibit VA from denying or altering
treatment for veterans who participate in the study. Doing so would
provide veterans peace of mind.
H.R. 1647, Veterans Equal Access Act
This legislation would authorize VA doctors to provide
recommendations for participation in state-approved medicinal marijuana
programs. The VFW agrees with the intent of this legislation, but
cannot offer its support at this time.
The VFW agrees that veterans who rely on the VA health care system
must have access to medicinal cannabis, if such therapies are proven to
assist in treating certain health conditions. Without such evidence, VA
would not have the authority to prescribe or provide medicinal cannabis
to veterans. The VFW believes it is unacceptable for VA providers to
recommend a treatment that they are unable to provide veterans and
force patients to pay for the full cost of such care. If VA recommends
a treatment plan, it must be able to provide required therapies or
prescriptions. That is why the VFW supports H.R. 712, which would
enable veterans to participate in medical cannabis research without
having to bear the full cost of treatment.
H.R. 2676, VA Survey of Cannabis Use Act
The VFW supports this legislation, which would require VA to
commission surveys of veterans and health care providers to measure
cannabis use by veterans.
VFW members tell us that medicinal cannabis has helped them cope
with chronic pain and other service-connected health conditions.
Conducting a scientific survey of veterans and health care providers
would assist in identifying the current landscape of medicinal cannabis
use and measure its effectiveness. The VFW is pleased the survey would
require anonymity, but it does not preclude VA from affecting the
employment status of health care providers who participate in the
surveys or prevent VA from denying or altering treatment or benefits
for veterans who participate in the surveys. The VFW urges this
committee to prohibit VA from doing so, which would ensure the fear of
reprisal does not affect participation in the surveys.
H.R. 2677, to provide training in the use of medical cannabis for all
VA primary care providers
The VFW supports this legislation, which would require VA to train
its primary care providers on the use of medical cannabis. While VA
health care providers are precluded from prescribing medical cannabis,
it is important for them to understand its use and how it affects their
patients.
H.R. 2942, to direct the Secretary of Veterans Affairs to carry out the
Women's Health Transition Training pilot program through at least
fiscal year 2020
The VFW supports this legislation, which would track participation
in VA health care and Transition Assistance Program (TAP) courses
developed specifically for transitioning women service members. The VFW
believes more information about what programs within VA are being used
and where there needs more attention is vital to improving the
transition process for women veterans. The United States (U.S.) Air
Force currently operates a pilot program which adds a voluntary program
to the end of the TAP classes for women veterans. This bill would
require VA to participate in the additional workshop for women veterans
to help guide them toward VA health care and benefits.
H.R. 2943, to make all fact sheets of the VA in English and Spanish
This legislation would require all VA fact sheets to be published
in English and Spanish. The VFW agrees that VA must address all
barriers to access, including language barriers, but VA must first
evaluate the need before it can devote time and resources to
translating and publishing its outreach material in different
languages.
The VFW represents veterans who live throughout the world and use
VA health care and benefits. The VFW has posts in Cambodia, Saipan,
France, Germany, Guam, Italy, Japan, Korea, Panama, Philippines, Puerto
Rico, Taiwan, Thailand, and Australia. The primary language used by VFW
members who reside in those U.S. territories or countries may not be
English. The VFW also has many members who reside in the United States,
but prefer to use their native language, such as veterans who were born
in foreign countries, Native Americans, or Pacific Islanders.
Yet, VFW members have not indicated that fact sheets or outreach
material written in English present a barrier for accessing the care
and benefits they have earned. That is why the VFW cannot support this
bill. To validate the need, this committee should commission a review
of language barriers to accessing VA care and benefits before requiring
VA to devote time and resources to translate and publish its fact
sheets in Spanish.
H.R. 3083, AIR Acceleration Act
The VFW fully supported the Asset Infrastructure Review (AIR)
portion of the VA MISSION Act of 2018. The intent of the review is to
fully examine the physical infrastructure of VA's health care system
and determine what changes are needed to continuously deliver high-
quality care. We would, however, be very concerned with expediting the
timeline for the AIR commission without further knowledge of the
ongoing market area assessments and allowing for proper implementation
of the new Veterans Community Care Program.
Secretary Robert L. Wilkie has stated VA would like to move up the
timeline of the review because of the market assessments, but he has
not provided veterans service organizations information regarding the
outcomes of these assessments. Additionally, a significant change to
community care was recently implemented, which is estimated to impact
the landscape and demand on the VA health care system. It is vitally
important VA implements AIR correctly. The VFW warns Congress not to
rush the AIR process, because it may cause irrevocable harm to the care
and benefits America provides its veterans.
Discussion Draft to improve the work-study allowance program
administered by the Secretary of Veterans Affairs
The VFW supports the intent of this legislation, which is to
improve and streamline the VA work-study program. This is a vital tool
student veterans use to supplement their income. The VFW agrees that
improvements are urgently needed to ensure veterans who use this
program receive timely work-study payments.
VA's outdated paper-based payment process is negatively affecting
students who have to wait several weeks or months to receive payments
they need to make ends meet. This legislation would change how VA
processes claims by authorizing the school to directly pay program
beneficiaries. This would align the VA work-study program with a
similar program administered by the Department of Education. The VFW
recommends that VA analyzes the similarities and differences of the two
work-study programs to glean best practices to improve the delivery of
benefits, including alternative ways of delivering payments to student
veterans.
However, we cannot support changing the current business practice.
Instead, the VFW urges this committee to require VA to evaluate and
address barriers that delay work-study payments to ensure bureaucratic
processes do not impact the financial well-being of student veterans.
Specially Adapted Housing Discussion Draft
The VFW supports this draft legislation to expand the VA Specially
Adaptive Housing Grant Programs (SAH), which help veterans with
service-connected disabilities to live independently in a barrier-free
environment by providing critical housing adaptations. The
accessibility provided through this program greatly increases the
quality of life for such veterans, but to qualify, the individual must
endure a lengthy and cumbersome process.
This draft bill would allow for more eligible veterans to utilize
this life-enhancing benefit and would also increase the maximum amount
of each grant. The VFW is pleased this bill would quadruple the number
of applicants VA is able to approve annually from 30 to 120. However,
we do not think there is a need for a cap on the number of veterans who
can use this important program. Every veteran who needs to adapt their
home because of service-connected disabilities must have the
opportunity to receive an SAH grant.
Common issues veterans face when seeking SAH grants are the
timeliness of approvals and the difficulty in finding contractors who
are familiar with the SAH grant process. In some cases, the approval
may take months, which makes completing activities of daily living
difficult. We are encouraged to see this bill would prioritize the
application of those veterans who are seriously ill. Veterans with
illnesses that progress quickly, such as amyotrophic lateral sclerosis,
must be granted an opportunity to adapt their homes as soon as
possible.
Mr. Chairman, this concludes my statement. I am happy to answer any
questions you or the members of the committee may have.
Prepared Statement of Derek Fronbarger
Chairman Takano, Ranking Member Roe, and distinguished members of
the House Committee on Veterans' Affairs, thank you for inviting
Wounded Warrior Project (WWP) to testify on these important legislative
priorities.
Wounded Warrior Project's mission is to honor and empower wounded
warriors. Through community partnerships and free direct programming,
WWP is filling gaps in government services that reflect the risks and
sacrifices that our most recent generation of veterans faced while in
service. Over the course of our 15-year history, we have grown to an
organization of nearly 700 employees in more than 25 locations around
the world, delivering over a dozen direct-service programs to warriors
and families in need.
Through our direct-service programs, we connect these individuals
with one another and their communities; we serve them by providing
mental health support and clinical treatment, physical health and
wellness programs, job placement services, and benefits claims help;
and we empower them to succeed and thrive in their communities.
We communicate with our warriors on a weekly basis and are
constantly striving to be as effective and efficient as possible by
matching our programs - and our advocacy before Congress - to meet
warriors' needs. We use these weekly engagements, our yearly WWP Alumni
Survey, and direct programming to inform us of our positions outlined
in this testimony.
Draft Bill: Ryan Kules Specially Adaptive Housing Improvement Act of
2019
One of WWP legislative priorities is the passage of legislation
that expands VA's Specially Adaptive Housing Grant program (SAH). These
expansions are outlined in the draft bill titled the Ryan Kules
Specially Adaptive Housing Improvement Act of 2019. Ryan Kules is a
bilateral wartime amputee who works at Wounded Warrior Project and
helped highlight many of the program's deficiencies.
One aspect of this legislation that WWP is supportive of is the
full reinstatement of the SAH benefit every ten years. As younger
veterans age, get married, and have families, their needs in an
adaptive home may change drastically. This is also true for those whose
disabilities get worse over time. A veteran with a prosthetic leg might
be fine to walk around their home when they are in their thirties, but
they might require a wheelchair when they become senior citizens. We
want warriors to thrive in their work and personal lives. Often, they
must move to take advantage of opportunities to improve their
socioeconomic conditions. It is not reasonable to expect a veteran to
buy a home and never leave. This benefit is reserved for those
catastrophically injured and who deserve our assistance throughout
their entire life, not just one portion of it.
This bill also increases the total grant amount from $81,080 to
$98,492, increases the total amount of applicants into the ``expanded''
SAH grant program from 30 to 120 a year, and increases the times a
veteran may use the grant from three to six. These were all identified
as deficiencies in the program that needed updating.
The VA Specially Adaptive Housing Grant assists the most critically
ill, injured, and recognizes that Wounded Warriors find solitude in
their homes as they transition from service into the civilian world.
Wounded Warrior Project supports this Draft Bill as written and
considers this piece of legislation a major priority for WWP during the
116th Congress.
H.R. 2942: To Direct the Secretary of Veterans Affairs to Carry Out the
Women's Health Transition Training Pilot Program through at Least
Fiscal Year 2020, and for other purposes
There are currently around 2,000,000 women veterans in the United
States, which comprise 10% of the entire veteran population. Women
veterans are the fasted growing cohort which is expected to double by
2045\1\. Transition from military to civilian life is a critical touch
point for VA and DoD. While women veterans are more likely to attend
college, they are also more likely to be homeless over their male
counterparts with a homelessness rate of 7.1 percent versus 5.3
percent\2\. Understanding the unique challenges that women veterans
face during transition is critical in ensuring success among this
population. The Women's Health Transition Training Pilot Program helps
transitioning women servicemembers by informing them of women's health
and mental health care services available through the Veterans Health
Administration, along with other tools that may be of use during their
transition from military service.
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\1\ https://www.pewresearch.org/fact-tank/2017/11/10/the-changing-
face-of-americas-veteran-population/
\2\ https://www.woundedwarriorproject.org/media/183005/2018-wwp-
annual-warrior-survey.pdf
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We support H.R. 2942, which would expand the Women's Health
Transition Training Pilot Program through fiscal year 2020.
H.R. 2676, H.R. 2677, H.R. 712, H.R. 1647: VA Survey of Cannabis Use
Act, To Require the Secretary of Veterans Affairs to Provide Training
in the Use of Medical Cannabis for all Department of Veterans Affairs
Primary Care Providers, VA Medical Cannabis Research Act of 2019,
Veterans Equal Access Act
Several emerging and alternative therapies have reported some
initial results that are promising for the management and treatment of
the invisible wounds of war, including post-traumatic stress disorder
(PTSD) and traumatic brain injury (TBI). A debate surrounding veterans'
rights to access medical cannabis has emerged as a popular topic of
discussion in the context of alternative therapies.
Choosing an alternative treatment method is a personal decision
that should be made between each warrior, his or her family, and his or
her medical team. Wounded Warrior Project encourages warriors to make
informed decisions in pursuing the treatment options that are most
relevant to their circumstances under guidance from their health care
providers. Wounded Warrior Project supports evidence-based and
evidence-informed therapies, as well as complementary and alternative
therapies that have proven to be successful in rehabilitation and
recovery.
While our position is limited in scope, we are using our annual
survey to try to better understand how warriors are using cannabis. The
2018 WWP Alumni Survey reveals that around 18 percent of our alumni
indicate they have used marijuana; 4.7 percent of those used marijuana
less than once a month and 8.4 percent of them used marijuana more than
twice a week, with the remainder falling in between\3\. To better
inform our position on the use of medical cannabis, we added additional
questions to our 2019 WWP Alumni Survey. While 2019 data is not
published yet, we did find that 17 percent of our warriors indicated
they use cannabis to treat a mental or physical condition and 49
percent of warriors know a veteran who is using cannabis to treat a
condition.
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\3\ https://www.woundedwarriorproject.org/media/183005/2018-wwp-
annual-warrior-survey.pdf
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H.R. 2676
Wounded Warrior Project supports legislation to expand research,
evidence-based, and evidence-informed therapies. One avenue to help
understand the ``whole picture'' of an issue is survey-based data
gathering. We routinely do this with our WWP Alumni Survey and, to this
end, support H.R. 2676 as it will require the Secretary of Veterans
Affairs to partner with a federally funded research center to conduct
surveys to measure cannabis use by veterans. We would recommend a
change on page 6, line 5, to strike ``not later than one year after the
date,'' and replace this with ``not later than two years after the
date'' as we have found that surveys take a considerable amount of time
to develop, disseminate, and analyze. We do not think one year is long
enough for VA to conduct a suitable survey on this topic.
H.R. 2677
H.R. 2677 requires VA to establish a training program to inform
primary care providers on the use of medical cannabis. While we do not
have a position on H.R. 2677, we are concerned with the lack of clarity
on what training VA primary care providers would receive under this
proposal and whether the fact that they are federal employees limits
their ability in any way. We think that before VA can start training
health care providers on the usages of medical cannabis, there must be
additional studies on the effects of this drug on this population and
the risks regarding the usage of a schedule I drug for veterans while
it remains categorized as such.
H.R. 712
Much like H.R. 2676, WWP supports legislation to expand research,
evidence-based, and evidence-informed therapies. H.R. 712 would require
the Secretary of Veterans Affairs to carry out a clinical trial of the
effects of cannabis on certain health outcomes of adults with chronic
pain and PTSD. While we support the intent of the bill, we do have some
concerns regarding the ability of VA to implement this research study.
Specifically, page 5, line 4 through 13, requires the VA to use varying
forms of cannabis to include, full plants and extracts, at least three
different strains of cannabis, and varying methods of cannabis
delivery. Currently, the University of Mississippi is the only
institution with DEA approval to grow cannabis for research purposes.
This is also the only institution that the federal government may
purchase cannabis from for a federal study. Reports from former
federally funded researchers have indicated that the University of
Mississippi is limited in what they grow, which would hamper this
proposed research study. If this bill were to pass, VA could possibly
be put in a position to perform a study on cannabis strains that may
not currently available to the federal government.
While we support the intent of H.R. 712, we recommend reviewing
page 5, line 4 through 13, to avoid a failure in the study due to lack
of appropriate cannabis availability.
H.R. 1647
While WWP supports legislation on medical cannabis that is
researched-based, we are concerned regarding legislation that could be
detrimental to veterans and VA employees due to complications regarding
federal and state cannabis laws. Currently, cannabis is a schedule I
drug, but many States have laws legalizing medical or recreational
cannabis. H.R. 1647 is concerning as it will authorize VA federal
employees to recommend and give their opinion on a possible State-level
approved medical cannabis treatment alternatives. While medical
cannabis is legal in some States, it is still deemed illegal by the
federal government. Given that veterans receive medical advice and
treatment across different states, it is plausible that a federal
employee would recommend medical cannabis to a veteran who resides in a
state where it is not legal. This could lead to unnecessary legal
action against the veteran due to confusion regarding Federal versus
State medical cannabis laws. Additionally, there are insufficient
protections in place for veterans regarding employment when using
medical cannabis. Lastly, there is no protection for federal employees
who recommend the usage of a federally scheduled I drug. This could
lead to legal troubles for medical providers who recommend medical
cannabis to a veteran as an alternative treatment. These fears lead us
to oppose H.R. 1647 until such a time where these concerns can be
addressed.
H.R. 3083: AIR Acceleration Act
Wounded Warrior Project acknowledges that VA needs the ability to
alter its footprint to become more focused and better aligned with
today's ever-changing veteran population. The Asset & Infrastructure
Review (AIR) Act was passed in order to assess current resources and
allow for a more focused and better-aligned infrastructure that will be
designed to support the care to veterans where they might need it.
Additionally, this legislation includes stakeholder involvement and
other safeguards in the review process to ensure that the final result
of the AIR Act is what the community would approve of. With this in
mind, we support H.R. 3083 as it would accelerate the implementation of
the AIR Act but recommend adding language that clearly states that this
bill will be implemented after the market assessments have been
completed.
H.R. 2943: To Direct the Secretary of Veterans Affairs to Make all Fact
Sheet of the Department of Veterans Affairs in English and Spanish
Wounded Warrior Project does not have a position on this piece of
legislation at this time.
H.R. 485: Veterans Reimbursement for Emergency Ambulance Services Act
Wounded Warrior Project does not have a position on this piece of
legislation at this time.
Draft Bill: To Improve the Work-Study Allowance Program Administered by
the Secretary of Veterans Affairs
Wounded Warrior Project does not have a position on this piece of
legislation at this time.
Closing Remarks
In closing, we would like to acknowledge the bipartisan and
inclusive spirit that guides the work of these committees. We share a
sacred obligation to ensure that our veterans and their families get
the support and care they have earned, and the success they deserve. At
Wounded Warrior Project, we are committed to that mission, and we are
constantly striving to be as effective and efficient as possible in the
life changing programs we provide, as well as our advocacy efforts. We
appreciate the committee inviting WWP to comment on these pieces of
legislation and the work each member has done on behalf of veterans
across the country.
Prepared Statement of Igor Grant, M.D.
Good afternoon,
My name is Igor Grant. I am a physician, neuropsychiatrist and
Professor at the University of California San Diego where I direct the
Center for Medicinal Cannabis Research (CMCR). During my career I also
served for 3 decades as a Staff Physician at the VA San Diego Medical
Center where I oversaw the opening the hospital's first mental health
outpatient clinic in 1972. Therefore, I have some familiarity with the
mental health needs of our veterans.
Some of the prevalent health problems of our veterans include
chronic pain, posttraumatic stress disorder (PTSD), certain
inflammatory disorders, as well as sleep disorders. Our veterans have
not always found the treatments that we offer them to be fully
beneficial and they therefore sought recourse outside the VA medical
framework including with medicinal cannabis in states where it has been
legalized.
I am here today to provide you with my medical opinion based on our
experience with the Center for Medicinal Cannabis Research as to the
state of current knowledge on medicinal cannabis. Clearly, this is a
controversial area, but there are important facts that are emerging.
The Center for Medicinal Cannabis Research at University of California
San Diego was established in 2000 by legislation of the State of
California. The establishment of the Center followed the passage in
1996 of an initiative called the Compassionate Use Act which made
California the first state to authorize use of medicinal cannabis. The
legislators wished to be provided with more scientific evidence in
regard to that initiative.
Since our establishment we completed 8 different short-term
clinical trials with cannabis provided to us by the NIDA Drug Supply
Program. As you may know, the only legal source of cannabis for medical
research is through NIDA which has a contract with the University of
Mississippi to grow cannabis.
Our studies found that tetrahydrocannabinol (THC) containing
cannabis ranging in strength from 2% to 7% in the several studies
showed benefit in a type of chronic pain called neuropathic pain, which
can be a complication of HIV/AIDS, diabetes, and certain kinds of
injuries; a pain that is sometimes difficult to control through
traditional pain medicines. We also found that patients with severe
muscle spasticity due to multiple sclerosis derived benefit. Our
results dovetailed with emerging data from other investigations, and
also were consistent with the report of the National Academies of
Sciences, Engineering and Medicine in 2017. That report noted that
there was ``conclusive evidence'' for cannabis and/or cannabinoid
benefit in terms of management of certain types of pain, muscle
spasticity, as well as nausea control. That report also noted modest
evidence for benefit in improvement of certain sleep conditions,
particularly when pain was a component, as well as possible evidence
for anxiety control, including PTSD. More recently the non-psychoactive
cannabinoid cannabidiol (CBD) has been shown to be effective in control
of certain uncommon forms of severe intractable epilepsies of children.
There are studies that have been initiated to determine whether either
THC or THC/CBD mixtures or CBD alone may be helpful in the treatment of
some symptoms of PTSD, psychosis, anxiety, autism, essential tremor and
sleep disorders.
Another area of increasing interest is the possibility that
cannabinoids may have an ``opioid sparing'' effect. What this means is
that it may be possible that the administration of cannabis or
cannabinoids may reduce the requirement for opioids for patients with
severe chronic pain problems, and it might in theory be possible to
entirely eliminate the opioids. If research shows that these benefits
are there, then this would be a step forward in combating the morbidity
and mortality associated with chronic opioid use in our patients.
In summary, what I would recommend to you is that the area of
medicinal applications of cannabis and cannabinoids has matured to a
level that it is now clear that these drugs can be helpful for some
chronic medical conditions, including conditions that are found in
moderately high prevalence among our veteran population. As such, it is
my opinion that the VA would be benefitting our veterans by:
1)Assuring that VA physicians and other medical staff receive
education on both the potential value of medicinal cannabinoids as well
as their side effects and possible harms, as well as what remains
unknown;
2)Encouraging VA health providers to provide unbiased,
authoritative information to veteran patients on medicinal cannabis and
cannabinoids if the veteran's medical condition might be benefitted
from these based on emerging scientific consensus, such as articulated
in the National Academies 2017 report and subsequent analyses;
3)That in medical marijuana legal states, VA physicians be allowed
to recommend use of medicinal cannabis if the emerging scientific
evidence indicates there may be benefit;
4)That in States that permit medicinal cannabis use, veterans who
receive medicinal cannabis in a manner compliant with State law not be
subjected to any adverse action in regard to their VA treatment or
other benefits as a consequence;
5)That the VA collaborate with Medical Boards in Medicinal Cannabis
states to develop protocols and decision trees to guide medicinal
cannabis and cannabinoid administration based on the emerging science.
This leads me to my final comment and that is it is essential that
high quality medical studies continue to be done in this area. I
recommend that the VA work closely with academic universities that have
expertise in this area, to pave the way to a better understanding of
indications, cautions, factors that might affect benefit and risk in
special populations, such as the elderly or persons with substance use
disorders, values of specific cannabinoids and their combinations,
pharmacology related to routes of administration, interactions with
other medicines, and optimal duration of treatment.. Many years ago,
when I was training as a psychiatrist, I learned about the VA's
landmark role in determining the value and limitations of antipsychotic
medicines in the treatment of schizophrenia. I believe the VA, with its
academic partners, can be at the forefront again of creating a better
understanding of the place of cannabis and cannabinoids in addressing
the health needs of our patients.
Thank you for your attention.
Prepared Statement of Larry Mole, PHARM.D.
Good morning, Chairman Takano, Ranking Member Roe, and Members of
the Committee. Thank you for inviting us here today to present our
views on several bills that would affect VA health programs and
services, including H.R. 712, H.R. 1647, H.R. 2676. H.R. 2677, H.R.
2942, and H.R. 2943. Due to the delay in notification regarding H.R.
485, H.R. 3083, the draft Specially Adapted Housing Improvement bill,
and the draft Work-Study Allowance Program Improvements bill, we are
unable to provide views on those bills at this time, but will follow up
with the Committee as soon as possible. With me today are [TBD].
H.R. 712 - VA Medical Cannabis Research Act 2019
H.R. 712 would require VA conduct a clinical trial of a size and
scope to include multiple strains of cannabis compositions and multiple
administration methods on covered Veterans with multiple medical
diagnoses and a multitude of clinical outcome measures.
VA has a rich history of scientifically driven contributions that
have advanced health care through planning and implementing high
quality clinical trials so that we can all better understand the
results and potential for changing clinical practice when trials are
complete. VA's Office of Research and Development has a program in
place to fund clinical trials that are submitted to our expert peer
review system for evaluation of scientific merit based upon the
rationale, design, and feasibility of a proposal. Such trials could
include the topic of medical uses of cannabis for conditions that
impact Veterans. Clinical trial applications must detail the underlying
rationale for the use of an experimental intervention such as cannabis
for use in humans.
The proposed legislation with the mandated requirements is not
consistent with the practice of scientific design for randomized
clinical trials nor is it possible to conduct a single trial to obtain
the information desired. The specification in the legislation of the
multiple requirements such as type and content, administration route,
diagnostic specifications representing potential inclusion and
exclusion criteria, and outcome measures are not consistent with the
current state of scientific evidence, which suggests that smaller,
early phase controlled clinical trials with a focused set of specific
aims are warranted to determine initial proof of concept for medical
marijuana for a specific condition. Any trial with human subjects must
include evaluation of risks and benefits/safety and include the
smallest number of participants needed to avoid putting subjects at
risk unnecessarily. In any study, the size of the experimental
population is determined statistically so that the power or ability to
detect group differences (between control and experimental groups) is
based on known effects that can be shown using a specific outcome
measure. For a cannabis trial, some of these effects are not known,
thus a circumscribed approach to determine dose, administration
modality, and best outcome measure(s) must still be studied or shown in
a proof of concept approach to ensure the research would have the
ability to detect the impact of the intervention in a controlled way.
Typically, smaller early phase trial designs, instead of the extremely
large study suggested in legislation, would be used to advance our
knowledge of benefits and risks regarding cannabis before moving to the
type of more expansive approach described in this proposed legislation,
which is more akin to a program of research than a single clinical
trial. The requirements to simultaneously address different modes of
administration, different compositions, and different medical diagnoses
without consideration of underlying rationale and mechanisms would not
be a good use of taxpayer money, and in fact would not engender a
favorable scientific peer review evaluation or regulatory approval. A
plan forward to determine the legislative mandate should start with a
scientific query or review of what is known for diagnostic categories
of interest and what is logically called for in exploring next level
clinical investigation.
VA is actively exploring pathways to contribute to the overall
understanding of the possible contribution of medical cannabis to
Veterans' health care. VA is reviewing the clinical state of the
evidence regarding medical marijuana, which concluded more research is
needed, especially related to clinical trials. VA is currently
supporting a clinical trial of cannabidiol for posttraumatic stress
disorder (PTSD) based upon a strong design and rationalized mechanism
in a trial that will assess risks and benefits. VA has also encouraged
other medical marijuana research. For all these reasons, VA is not
supportive of this proposed legislation.
H.R. 1647 - Veteran Equal Access Act
This bill would require VA to authorize its physicians and other
health care providers to provide recommendations and opinions to
Veterans who are residents of states with state-approved marijuana
programs regarding participation in such programs and to complete forms
reflecting such recommendations and opinions.
The Veterans Health Administration's (VHA) policy prohibiting VA
providers from recommending or making referrals to or completing
paperwork for Veteran participation in state marijuana programs is
based on guidance provided to VA by the United States Drug Enforcement
Administration (DEA), the agency with authority to interpret the
Controlled Substances Act (CSA).
Under CSA, marijuana is presently a schedule I controlled
substance. VA defers to the Department of Justice (DOJ) to determine
the legal effect of the phrase ``notwithstanding any other provision of
law'' on the enforcement of CSA against VA providers who might assist
Veterans in participating in state-approved marijuana programs.
VA encourages its providers to discuss marijuana use with Veterans
who are participating in state-approved marijuana programs, but we do
not support this bill. Though research studies are in progress, the
scientific benefit of most products derived from the marijuana plant is
still not proven, and VA must provide consistent, safe, science-based
care for all Veterans. Further, the marijuana industry is largely
unregulated, and products are often not accurately labeled, so
providers cannot ascertain the strength and levels of active
ingredients in the product being used by a particular patient,
complicating medication management and treatment.
H.R. 2676 - VA Survey of Cannabis Use Act
H.R. 2676 would require VA to enter into an agreement with a
federally-funded research and development center to conduct nationwide
surveys to measure cannabis use by Veterans. The center selected by VA
would have to have: (1) an in-depth knowledge of all state medicinal
marijuana programs and the ability to tailor the required surveys
accordingly; and (2) expertise and a record of independent, peer-
reviewed publications with respect to behavioral health research and
conducting independent evaluations of mental health programs using
multidisciplinary methods. In conducting the surveys, the center would
have to survey Veterans who are enrolled for VA health care and those
who are not, collect information from VA health care providers and be
conducted in a manner that ensures the anonymity of the individual
being surveyed. The surveys of Veterans would have to cover 12
different topics, and the surveys of providers would have to cover 7
different topics. Not later than 1 year from the date of the enactment
of this bill, VA would have to submit a report to Congress on the
results of these surveys.
We do not support this bill. The legislation would prescriptively
define how the surveys would be conducted, but it does not provide the
purpose, goals, or objectives for the surveys. We have significant
concerns that Veterans will not want to participate, despite the survey
being anonymous. The survey of providers would be difficult to complete
because it is asking for both overall impressions of cannabis use among
Veterans and specific documentation for patients using cannabis. This
would produce a significant burden on providers, requiring a review of
charts for their patient panels. It is very likely that the response
rate would be low, both because of this burden and because of the
anonymity of responses (which would make it impossible to identify and
follow up with non-responding providers). Moreover, the survey results
would likely only be meaningful if we knew where Veterans live and
where providers practice, given the variability of state laws, but
submitting information on the state could reduce the anonymity of the
survey as well (particularly in small states). Finally, we note that
the survey of Veterans might be subject to the Paperwork Reduction Act
(44 U.S.C. 3501 et seq.), and compliance with the requirements of this
Act could delay VA's implementation of this survey beyond the 1-year
period the bill would permit.
H.R. 2677 - Training in the Use of Medical Cannabis for All VA Primary
Care Providers
H.R. 2677 would require VA, within 1 year of the enactment of the
bill, to provide an initial training for all VA primary care providers
in the use of medical cannabis. VA would be required to provide
supplemental training, as necessary. In developing this training, VA
would be required to enter into partnerships with medical schools that
have incorporated education on medical cannabis into their curricula.
VA does not support this bill. We do not believe there is
sufficient scientific study and research findings to support a
comprehensive training program. Marijuana potency is highly variable,
and state laws governing medical marijuana are inconsistent, which
would further complicate our ability to develop training for all
providers, ultimately making it difficult to construct a curriculum
that provides recommendations for a standard of care without a
sufficient evidence base. Additionally, we are concerned that the bill
requires partnering with medical schools who have incorporated medical
cannabis into their curricula. A medical school's curriculum in this
area likely reflects the applicable state laws, but any national
training VA provided should not be state specific. This would, again,
make it difficult to adapt any single school's curriculum to the
Federal level. We further note that VA already makes available to all
providers information sessions on cannabis, including a course on
caring for patients who use marijuana at the end of life, a review of
current findings and clinical considerations regarding cannabis use and
PTSD, and the latest on marijuana use, effects, and treatment
implications for Veterans. VA's Academic Detailing Program also
provides resources for providers to have meaningful conversations with
their patients. Finally, VA has tried to limit the amount of mandatory
training directed at clinical providers. Instead, we have used other
mechanisms to spread awareness and information about key clinical
issues. Each hour of mandatory training takes over 20,000 doctors,
80,000 nurses, and thousands of other practitioners away from direct
patient care duties. This is not only expensive but reduces access to
vital services for Veterans.
H.R. 2942 - Women's Health Transition Training Pilot Program
H.R. 2942 would require VA to carry out the Women's Health
Transition Training pilot program until at least September 30, 2020. VA
and the Department of Defense would be required, by September 30, 2020,
to jointly submit a report to Congress on the pilot program including a
number of specified elements.
Carrying out this pilot program until at least September 30, 2020,
is favored by VA for the reasons stated below, and while we do not
believe this bill is necessary in order to do so, we do not oppose the
bill. Our authority to operate the pilot program is not limited; VA is
conducting the pilot under the direction of the VA/Department of
Defense Health Executive Committee. The pilot program is currently
funded through December 2019 for an additional 24 face-to-face training
sessions and initial virtual training sessions. VA will plan to
continue the pilot through 2020 to ensure additional face-to-face
sessions are conducted for statistically-meaningful results on the
efficacy of the pilot program. Currently, the vast majority of the
pilot program participants have been from the Air Force. Extension of
the pilot program through Fiscal Year (FY) 2020 will allow for greater
inclusion of transitioning Servicewomen from the Navy, Marine Corps,
and Army. We anticipate that robust participation from these services
could help achieve sample size requirements and greatly inform the
full-scale implementation of this program. We also will need until
September 2020 to be able to account for at least half of our current
cohort's outcomes. We expect that continuing this program through 2020
will allow us to answer questions about the program's efficacy,
participant satisfaction, and the impact on participant awareness; it
will also provide an opportunity to collect a wealth of qualitative
information for women across various Service branches. Understanding
the needs of Servicewomen across military branches can help inform
future VA health education and training programs, including and beyond
women's health. We believe that completing the pilot program at the end
of FY 2020 would allow VA to submit a report to Congress by the end of
that calendar year.
H.R. 2943 - Making Fact Sheets Available in English and in Spanish
H.R. 2943 would require VA to make versions of all VA fact sheets
in English and Spanish.
We agree with the intent of this legislation, but we do not support
the bill because it is unnecessary as VA currently has the authority to
produce materials in English and in Spanish, and our efforts already
meet the goals of the legislation. Initially, we note that VA is
committed to ensuring no individual is subject to discrimination
because of national origin. In March 2016, VA adopted a Language Access
Plan to ensure equal access to services provided by VA to individuals
with Limited English Proficiency (LEP). The Plan aims to eliminate or
reduce, to the maximum extent practicable, LEP as a barrier to
accessing VA benefits and services. The Plan establishes detailed
policies and processes, including the use of bilingual employees in
telephone and face-to-face encounters. For written materials, the Plan
leaves VA discretion concerning what steps it should take regarding
translation of documents into Spanish or other languages. We believe
this discretion is necessary given the huge variety and volume of
written materials produced by VA. We note that the legislation only
refers to ``fact sheets,'' but does not define that term, which could
make implementation of this bill difficult if it were enacted. We would
be glad to discuss with the Committee VA's efforts toward ensuring all
Veterans and beneficiaries are able to access the benefits and services
for which they are eligible.
Conclusion
This concludes my statement. I would be happy to answer any
questions you or other Members of the Committee may have.
Prepared Statement of Representative Scott R. Tipton (CO-03)
Chairman Takano, Ranking Member Roe, and distinguished Committee
Members, thank you for considering H.R. 485, the Veterans Reimbursement
for Emergency Ambulance Services Act or VREASA, during today's
legislative hearing.
Costs associated with emergency ambulance services to non-VA
facilities are a huge financial burden for our nation's veterans, and
one that those who have earned healthcare benefits through their
service to this nation should not be required to pay.
VREASA is bipartisan legislation intended to address Department of
Veterans Affairs' (VA) regulations that could unfairly burden veterans
with the costs of emergency ambulance services to non-VA facilities.
Historically, some veterans have been denied their reimbursement
claims for emergency ambulance services to non-VA facilities primarily
because of how the VA was interpreting its regulations. Unfortunately,
the VA's interpretation would leave these veterans to pay for these
ambulance bills out of pocket. VREASA would clarify that veterans'
expenses for emergency ambulance services to non-VA facilities are
authorized to be reimbursed by the VA. In addition, VREASA ensures that
the prudent layperson standard will be applied to emergency ambulance
services to non-VA facilities.
I was pleased that the VA promulgated a regulation as an attempt to
remedy this problem. However, to better ensure that our nation's
veterans will be reimbursed by the VA for their emergency ambulance
services at non-VA facilities, Congress should codify this requirement
since administrations are free to change regulations. VREASA achieves
codification giving our nation's veterans certainty, stability, and
peace of mind to know that should the unforeseen occur where they need
emergency ambulance services to a non-VA facility those expenses will
be reimbursed.
Again, I thank the Committee for its consideration of VREASA today
and look forward continuing to work in a bipartisan manner with the
Committee to advance VREASA through the legislative process and toward
final passage in the House.
Prepared Statement of David Cox, Sr.
The Honorable Mark Takano Chairman
House Committee on Veterans' Affairs
B234 Longworth House Office Building
Washington, D.C. 20515
The Honorable Dr. Phil Roe
Ranking Member
House Committee on Veterans' Affairs
3460 O'Neill House Office Building
Washington, D.C. 20024
June 18, 2019
Dear Chairman Takano, Ranking Member Roe, Members of the Committee,
On behalf of the more than 700,000 federal and D.C. government
employees represented by the American Federation of Government
Employees, AFL-CIO (AFGE), including the 260,000 frontline Department
of Veterans Affairs (VA) employees represented by our National VA
Council (NVAC), I write to register strong opposition to
H.R. 3083, the ``AIR Acceleration Act,'' a bill that would
authorize the Asset and Infrastructure Review Commission to begin its
operations on an earlier schedule than that which was included in the
VA Mission Act.
This Mission Act's provision for this Commission was modeled on the
Defense Department's Base Realignment and Closure (BRAC) process, and
there has never been any doubt that its purpose is to reduce the number
of VA medical centers and clinics. AFGE strongly opposed this section
of the Mission Act and opposes accelerating the dismantlement of VA
through H.R. 3083.
From the beginning of the debate surrounding the MISSION Act, AFGE
has warned against the negative consequences that closing VA facilities
will have on patient care and the capacity of VA to meet veterans'
demand for services. Make no mistake: the Asset and Infrastructure
Review Commission will not result in improved infrastructure, it will
serve to facilitate the closure of VA facilities.
Once the closures begin, veterans will no longer have the
``choice'' of VA's world-class integrated healthcare system. Their only
choice will be private care. Privatized care will be the only care.
A closure commission for VA takes away Congressional responsibility
- and authority - for VA's infrastructure decisions. The default
position is that the Commission's recommendations will advance unless
Congress explicitly overrides a Commission decision. It is
unconscionable to leave the future of VA hospitals and clinics -whether
they will be built, renovated, or closed and sold - to an unelected
group of political appointees. To allow H.R. 3083 to become law would
be a terrible abdication of responsibility on the part of the Congress.
Please also be aware that BRAC-style closures do not result in cost
savings. In particular, when healthcare provided in VA facilities is
replaced by care purchased from providers in the private sector, costs
will rise substantially. Costly and unaccountable private care does not
meet the promises our nation has made to veterans.
In the strongest possible terms, AFGE urges you to oppose H.R.
3083. We ask instead that the Committee focus its attention toward
requiring the VA to fully staff its hospitals and clinics and fill its
more than 50,000 open positions so that veterans can obtain the world-
class, veteran-centric care at the VA that they have earned. If you
have questions regarding AFGE's position on H.R. 3083, please contact
Matt Sowards at [email protected].
Sincerely,
J. David Cox, Sr.National President
Prepared Statement of Eric Goepel
Chairman Takano, Ranking Member Roe, and Members of the House
Committee on Veterans' Affairs,
The Veterans Cannabis Coalition would like to thank you for the
opportunity submit a statement for the record to the Committee
concerning veterans and cannabis issues currently under consideration.
We would especially like to thank the Committee for its continuing work
to address the needs of veterans for effective, low-risk treatments.
The staggering rate of veteran deaths by suicide and overdose (an
outcome that is too often ignored) is indicative of the ongoing crisis
in our community. We know what veterans need to be successful, because
they are the same basic components every citizen needs for success:
patient-centered healthcare, housing, and gainful employment.
Overview:
The House Committee on Veterans' Affairs has several bills related
to cannabis and veteran issues currently before the body. Collectively,
these bills seek to address the friction that exists between federal
and state law and better understand cannabis and how veterans use it
medicinally. The underlying issue of prohibition is beyond the scope of
the Committee, but there are still many ways to serve veterans by
addressing specific concerns that have arisen.
Current Legislation
H.R. 2676 - VA Survey of Cannabis Use Act (Moulton)
Position: Support. We appreciate the intent to establish the shape
and extent of cannabis use among veterans but would add that a survey
of this kind would create the opportunity to collect important
information about veterans current and past pharmaceutical and drug
use. There is an immediate need to establish a clear picture of how
substances are impacting veterans and we should be looking at the full
range of substance use: alcohol, tobacco, pharmaceuticals (of
particularly interest is non-steroidal anti-inflammatory drug (NSAID)
opioid, benzodiazepine, and antidepressant use), and illicit drugs.
H.R. 2677 - To require VA to provide training in the use of medical
cannabis in conjunction with medical schools that have incorporated
education on medical cannabis into their curricula. (Moulton)
Position: Support. VA physicians are not unique in lacking
substantive knowledge about cannabis, cannabinoids, or the endo-
cannabinoid system (ECS)-this lack of knowledge is reflected in the
larger medical community. This particular point was highlighted
recently in an op-ed in the Journal of the American Medical
Association. While the need for primary education is apparent, we would
suggest that conditioning VA participation on the actions of an
independent party (a medical school, in this case) leaves too much room
for delay.
Past statements have made it clear that if cannabis remains a
Schedule I substance, VA will not support changes to how they interact
with cannabis beyond some narrow adjustments. Simultaneously, the
Department has boasted that some 70% of the country's doctors receive
professional training at VA facilities-this would suggest that VA is
uniquely equipped in leading the development of cannabis education for
providers, has the resources necessary, and therefore should do so with
all haste.
H.R. 712 - VA Medicinal Cannabis Research Act (Correa)
Position: Strongly support. The VA Medicinal Cannabis Research Act
is a much needed, directed effort to jump start VA cannabis research.
The Department has publicly disclosed two cannabis research studies and
identified one specifically at the University of California San Diego.
Our concern is that the UCSD study uses a limited form of cannabis
(synthetic cannabidiol (CBD) isolate), is still recruiting for a target
sample of 136, and is scheduled to be completed in 2023. It costs $1.6
million, which is a rounding error in a Department with a $200 billion
budget.
VA has demonstrated that, as mentioned before, they do not intend
to support changes to the status quo without a change in cannabis'
schedule. This is, frankly, a shirking of responsibility to veterans,
of which 1-in-5 surveyed by the American Legion and Iraq and
Afghanistan Veterans of America (IAVA) self-report using cannabis for
their service-connected injuries. It is especially striking in light of
rampant veteran suicide and overdose, a noted lack of urgency or
results from the VA in stemming or reversing these outcomes, and the
link many veterans have reported between attempted suicide and legal
pharmaceutical use. One of the answers to this inertia and a status quo
that sees at least 6,000 veteran dead by suicide and overdose a year is
a robust, funded, and coordinated research initiative lead by VA that
explores the potential of cannabis.
H.R. 1647 - Veterans Equal Access Act (Blumenauer)
Position: Strongly support. The language in this bill has been
introduced for the third Congress in a row and represents a basic
concession to the needs of veterans who use the VA as well as closing
an obvious gap in continuity of care. The fact that this effort is
still not in law, that it is still opposed by VA, and is still being
asked for by veterans is another demonstration of the disconnect
between those charged with providing the best care possible and those
they serve.
Conclusion:
The sheer number of bills introduced in the 116th Congress dealing
with veterans and cannabis demonstrates both an immediate need for
reform and a critical lack of progress at the VA's current self-
directed pace. Congress and the VA both have a historic responsibility
to veterans that has devolved into endless rounds of delays, denials,
and unfulfilled promises while veterans die at a staggering pace, day
after day, year after year. As advocates, we see how this grind is
damaging our community on a regular basis and see few solutions being
offered and fewer still being acted on. It is far past time for members
of Congress to listen to veterans themselves and do everything in their
power to deliver on the promise the nation makes to every man and woman
who serves in uniform.
Respectfully,
Eric Goepel
Founder & CEO
Veterans Cannabis Coalition
Bill FergusonvCo-founder
Veterans Cannabis Coalition
Prepared Statement of Randy Erwin
The Honorable Mark Takano
Chairman
House Committee on Veteran Affairs
B234 Longworth House Office Building
Washington, D.C. 20515
The Honorable Phil Roe
Ranking Member
House Committee on Veteran Affairs
3460 O'Neil House Office Building
Washington, D.C. 20024
June 18, 2019
Chairman Takano, Ranking Member Roe, Members of the Committee,
On behalf of the more than 100,000 federal workers and the
employees of the Veterans Affairs Department (VA) represented by the
National Federation of Federal Employees (NFFE), I write to you today
to urge you to oppose H.R. 3083, the ``AIR Acceleration Act.'' This
legislation. Should it become law, would authorize the Asset and
Infrastructure Review Commission to meet earlier than the agreed upon
timelines established in the VA MISSION Act. While the commission is
called ``asset and infrastructure review'' it is nothing more than a
Base Realignment and Closure (BRAC) style panel for VA facilities. NFFE
unequivocally opposes this section of the law and, without question,
opposes this legislation.
From the beginning of the debate surrounding the MISSION Act, NFFE
has sounded the alarm on this proposal and the negative affect it will
have on patient care generally and the world-class VA system broadly.
The commission will result in the closure of VA facilities. That,
coupled with the MISSION Act's extremely broad access standards, will
mean the VA's increased reliance on private providers for veterans'
healthcare needs - privatization of the VA.
What is especially troubling about this commission is that it will
take away Congressional authority involving the building, renovating,
and closing of VA facilities. The way this commission is designed,
Congress would have to pass a resolution of disapproval in order to
override a decision made by the commission. Congress should be
responsible for overseeing the funding and the maintenance of the VA's
physical plant, not unelected political appointees in Washington, D.C.
Once VA facilities are closed, every veteran in that area will then
be issued a voucher and forced to the private sector. Given the
continuing problems of VA private sector care and standards, under no
circumstances should we speed up this process by allowing the
Commission to meet earlier than the agreed upon timelines as H.R. 3083
would do if enacted.
NFFE strongly urges you to oppose H.R. 3083; rather, and support
the world-class, veteran-centric institution that is the VA, employing
and caring well for America's veterans.
Sincerely,
/s/ Randy Erwin
Randy Erwin, National President
Prepared Statement of Thelma Roach
June 19, 2019
The Honorable Mark Takano
Chairman
House Committee on Veterans' Affairs
420 Cannon House Office Building
Washington, D.C. 20515
Dear Chairman Takano:
On behalf of the nearly 3,000 members of the Nurses Organization of
Veterans Affairs (NOVA), we would like to provide comments to the
Committee in opposition to H.R. 3083, The AIR Acceleration Act,
legislation that would accelerate the timeline on the Asset and
Infrastructure Review Commission. If anything, we believe the timeline
of the AIR Commission should be slowed down or eliminated entirely.
P.L 115-182, Sec 202(d) of The MISSION Act, established an external
Asset and Infrastructure Review (AIR) Commission to evaluate all
Veterans Health Administration facilities with respect to utilization.
On final recommendations, the AIR Commission will recommend closure,
expansion or replacement of VA facilities. Unlike the Department of
Defense BRAC Commission on which it is modeled, Veterans receiving care
at a closed facility would not transfer to another VA. Instead,
Veterans would automatically be moved into the Veterans Community Care
Program (VCCP).
As NOVA has asserted in the past, Veterans are served better at a
VHA facility than in outside communities. Data collected by RAND and
Dartmouth researchers have confirmed that the quality of VA's
healthcare in regional markets is as good as, and in many instances
superior to that of non-VA facilities. Veterans receive care in an
environment where healthcare professionals are better trained to
provide the right kind of care for service-connected injuries and
illness like TBI, PTSD, spinal cord injuries, toxic exposures, military
sexual trauma and suicide.
VA remains the expert in treating these health concerns.
NOVA also would like to remind the Committee that closing a
facility and sending Veterans into the fee-for-service private sector
is likely to add, not reduce, overall spending. And timely access to
care is less likely since VA's Access Standards ensure that VA
facilities' wait times are monitored and enforced, but there are no set
expectations of timeliness for care of Veterans in the community.
Finally, we would like to point out that Members of Congress will
have limited authority to alter the final proposed recommendations. H.R
.3083, and in fact any plan to close VHA facilities, must be met with a
thorough assessment of the many ramifications - cost, quality and
timeliness of care, research, employment opportunities - and an
understanding of the vital services that VA Medical Centers provide to
our Nation's Veterans.
Sincerely,
Thelma Roach-Serry, BSN, RN, NE-BC
President
Nurses Organization of Veterans Affairs (NOVA)
CC: Ranking Member, Dr. Phil Roe
Statements For The Record
PARALYZED VETERANS OF AMERICA (PVA)
Morgan Brown
Chairman Takano, Ranking Member Roe, and members of the Committee,
Paralyzed Veterans of America (PVA) would like to thank you for the
opportunity to submit our views on the broad array of pending
legislation impacting the Department of Veterans Affairs (VA) that is
before the Committee. No group of veterans understand the full scope of
care provided by VA better than PVA's members-veterans who have
incurred a spinal cord injury or disorder. Several of these bills will
help to ensure veterans receive timely, quality care and benefits. PVA
provides comment on the following bills included in today's hearing.
H.R. 485, the ``Veterans Reimbursement for Emergency Ambulance Services
Act''
VA is authorized to reimburse the cost of emergency transport for
veterans but often denies emergency ambulance claims due to improper
interpretation of its own regulations, leaving tens of thousands of
veterans to pay these bills out of pocket. No eligible veteran should
ever have to worry if VA is going to reimburse a transportation company
for transporting them to the closest and most appropriate medical
facility capable of treating their emergency. Therefore, PVA supports
H.R. 485 which seeks to make reimbursement for emergency ambulance
services consistent with how VA reimburses for other emergency medical
services.
H.R. 712, the ``VA Medicinal Cannabis Research Act of 2019"
There is a growing body of evidence that cannabinoids are effective
for treating conditions like chronic pain, chemotherapy induced nausea
and vomiting, sleep disturbances related to obstructive sleep apnea,
multiple sclerosis spasticity symptoms, and fibromyalgia. H.R. 712
directs the VA Secretary to carry out a clinical trial of the effects
of cannabis on health conditions like these as well as post-traumatic
stress disorder. PVA supports evidence-based alternative treatments,
including research into the efficacy of medical cannabis. A series of
clinical trials on the use of medicinal cannabis would help to
determine if it could provide any medical benefits for veterans.
H.R. 2942, the ``Women's Health Transition Training Pilot Program''
PVA supports this legislation, which would extend and expand an
ongoing pilot program jointly run by VA and the US Air Force to educate
transitioning servicewomen about women's health care at VA. Despite
being the fastest growing cohort in our military community, many
servicewomen are still unaware of the benefits and services available
to them. Early indicators suggest this approach may be effective.
Continuing the pilot program and expanding it to women veterans of
other services should provide the Department of Defense and VA the data
it needs to assess the feasibility of making this program permanent
along with the prospects of offering it in an online version or using
it to auto-enroll participants in VA health care.
H.R. 3083, the ``AIR Acceleration Act''
PVA opposes any legislation that seeks to accelerate the
comprehensive review of VA capital assets directed by the VA MISSION
Act of 2018 (P.L. 115-182). The timeline established in P.L. 115-182
was carefully formulated to ensure proper assessment of VA's facilities
and infrastructure, nomination of commission members, and consultation
with veterans service organizations were completed prior to any
official meetings by the commission. Accelerating this timeline for
commission meetings as allowed under H.R. 3083 would effectively allow
VA to short-circuit this process. We are concerned that such a decision
would undermine the protections put in place to ensure VA's Asset and
Infrastructure Review (AIR) process is conducted in a fair and
impartial manner, and that the commission has accurate data to work
with.
Discussion Draft, the ``Ryan Kules Specially Adaptive Housing
Improvement Act of 2019"
PVA gives its strongest endorsement to this proposed legislation
which raises the number of times veterans can request specially
adaptive housing grants and directs VA to prioritize Specially Adapted
Housing (SAH) claims for veterans with a terminal illness. It also
raises the overall amount for SAH grants to $98,492 and Special Housing
Adaption (SHA) grants to $19,733, and provides a supplementary grant in
case the veteran moves.
VA's specially adaptive housing grant programs help veterans with
certain service- connected disabilities to live independently in a
barrier-free environment by providing critical housing adaptations.
Many PVA members have benefited from the SAH grant program and the
accessibility they gain through it greatly increases the quality of
life for these veterans.
Annual increases for VA's specially adaptive housing grant programs
are tied to the Turner Building Cost Index but these small rises do not
take into account for geographical costs associated with construction.
For example, the cost of an accessibility ramp for a house in western
New York is far less than it would cost here in the National Capitol
Region. The one-time increases for SAH and SHA benefits that this bill
provides will help to accommodate some of these differences.
The bill will also increase the number of times that the grant can
be accessed. Currently, veterans can access their specially adaptive
housing benefit a maximum of three times up to the maximum amount of
the grant. Unfortunately, there are occasions where severely disabled
veterans who previously used specially adaptive housing grants to
modify a home were left without assistance after their disability
became worse. For example, a patient with Multiple Sclerosis who was
able to ambulate with an assistance device used the specially adaptive
housing grants three times to adapt two homes at different periods of
his life now requires a wheelchair to move as the disease has
progressed. The veteran needs to make additional modifications to his
residence to accommodate the use of a wheelchair, but the current cap
on use forces him to pay for these adaptations out of his own pockets.
Increasing the number of times a veteran can access the benefit will
help ensure veterans are able to utilize their maximum specially
adaptive housing benefits.
Additionally, in cases where a veteran has exhausted all of his or
her benefit, this bill would authorize VA to provide a supplementary
grant to eligible veterans. This would be particularly beneficial for
veterans who are in a position to relocate. If a veteran is offered a
job and has to move, historically the veteran would be forced to pay
for any modifications to her new residence if she has exhausted her
benefit. By having a supplementary grant, these veterans would now have
the ability to move to a new residence and receive monetary assistance
for modifications.
Finally, since VA first established Amyotrophic Lateral Sclerosis
(ALS) as a presumptive condition in 2008, PVA has represented the
majority of veterans who have claimed service-connection for this
disease. ALS manifests itself very quickly and it is imperative that
benefits needed to enhance quality of life are approved once a veteran
is diagnosed with it. Prioritizing SAH benefits for terminally ill
veterans, such as those with ALS, is simply the right thing to do and
we appreciate its inclusion in this legislation.
We urge Congress to pass this important legislation as quickly as
possible.
Discussion Draft, ``Improvement to Work-Study Allowance Program''
This draft legislation would grant VA the authority to provide to
educational institutions an annual amount for the school to use in
paying work-study allowances to veterans enrolled at the institution.
PVA supports this proposal which would increase educational
opportunities for veterans pursuing non-traditional means of education
to start a new career and facilitate an easier transition from the
military to civilian life.
PVA would once again like to thank the Committee for the
opportunity to submit our views on the legislation considered today. We
look forward to working with the Committee on this legislation, and
would be happy to take any questions you have for the record.
VETERANS HEALTHCARE POLICY INSTITUTE
Chairman Takano, Ranking Member Roe, and Members of the Committee:
The Veterans Healthcare Policy Institute (VHPI) would like to thank
you for the opportunity to submit a statement on the record regarding
H.R. 3083, The AIR Acceleration Act. We appreciate your bipartisan
recognition that all Americans deserve to know their tax dollars are
being used efficiently to ensure the highest quality and availability
of veterans' health care.
We strongly urge caution when reviewing The AIR Acceleration Act
(H.R. 3083), which would accelerate the timeline for the Asset and
Infrastructure Review Commission. As we document in this analysis,
there are harmful secondary consequences of a Veterans Health
Administration (VA) facility closure that must be very thoroughly
studied. Closure will likely increase overall costs and divert critical
funds away from the national VA healthcare system. Beyond costs,
shuttering any VA facility will erode the care of veterans, reduce the
availability of clinicians with veteran-specific expertise, decimate
healthcare education/research, harm local economies and diminish
emergency preparedness.
Overview
Pub.L. 115-182, The VA MISSION Act of 2018, Sec. 202 established an
Asset and Infrastructure Review (AIR) Commission to evaluate all VA
facilities' utilization patterns and infrastructure needs, and
recommend whether to close, replace, expand or repurpose them. Congress
will have no authority to alter the final set of the Commission's
recommendations. Instead, Congress may only approve or disapprove of
the recommendations in their entirety, within a tight time frame.
Because there will be no ability to walk back the Commission's
proposals, it is critical that Commissioners and Members of Congress be
thoroughly aware of the far-reaching repercussions of any recommended
closures.
This document analyzes the severe economic, healthcare, training,
and research consequences of a VA facility closure. As the nation
debates the future of its largest and only publicly-funded, fully
integrated healthcare system, it is critical to understand the vital
role these medical centers play in their communities and the breadth
and depth of the services they deliver to veterans.
Following is a summary of the major adverse consequences that
closing a VA facility will:
1. Increase overall costs and drain funds from remaining VA
facilities, ultimately eroding the availability of care throughout the
system,
2. Diminish veterans' access to veteran-specific, high quality,
comprehensive and integrated care in their community,
3. Increase wait times for veterans and non-veterans at non-VA
facilities,
4. Eliminate veterans' choice if they prefer to receive their care
in the VA,
5. Decimate residency and fellowship training programs at the
affiliated medical and health professional schools,
6. Diminish the number of graduates who enter the local network of
healthcare providers to treat veterans and the non-veteran public,
7. Impede efforts to recruit providers at other VA facilities,
8. Reduce VA research projects that benefits veteran rehabilitation
and health care for all Americans,
9. Hamper local governments' ability to respond to national
emergencies and natural disasters.
10. Layoff employees, which would significantly impact the local
economy. (Veterans make up a third of VA employees and many will find
it difficult to secure employment).
SPECIFIC ADVERSE IMPACTS OF A VA FACILITY CLOSURE
1. Impact on the VA Budget
Costs associated with closing a VA facility will be higher than
keeping it open because:
The number of veterans whose care is financed by the VA
will increase. Of the approximately 19.6 million veterans, 32% were
enrolled in the system and had some VA or Community Care paid by the VA
last year; 14% were enrolled but did not have any care paid by the VA,
and remaining 54% were not enrolled for VA-paid care\1\.
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\1\ ``Avery Dennison Template - VA.gov.'' https://www.va.gov/
vetdata/docs/pocketcards/ fy2019q1.PDF.
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]
For as long as a VA facility remains open, the VA pays for VA
facility or community healthcare only for veterans in column A. But if
a facility is closed, VA will automatically issue vouchers for the
Veterans Community Care Program (VCCP) to all local veterans in columns
A and B, plus to those veterans in column C who decide to enroll
(because it is advantageous for these veterans to do so). According to
a 2016 report\2\, the total systemic cost of a proposal to allow
community care for veterans could increase usage and outlays nationally
by $96 to $179 billion a year.
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\2\ ``Commission on Care - Amazon S3.'' https://s3.amazonaws.com/
sitesusa/wp-content /uploads/sites/912/2016/07/Commission-on-C are--
Final-Report--063016--FOR-WEB.pdf.
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Health care procedures are more costly in the fee-for-
service private sector, which has a built-in incentive to over treat.
One example is end of life care for veterans whose illnesses are
terminal. VA's utilize more palliative and hospice care, while the
private sector is more likely to use aggressive, expensive treatments,
even if they are unlikely to significantly increase time and quality of
life remaining.
Additional VA administrative staff will be needed for
oversight and reimbursement of veterans' private sector care in the
entire affected region.
2. Impact on the Quality of Clinical Care Provided to Veterans
If a VA facility were to close, the overall quality,
comprehensiveness and integration of care provided to veterans would
decline.
Independent RAND\3\ and Dartmouth\4\ analyses - among many others -
continually affirm that the quality of VA's healthcare in regional
markets is as good as, and in many instances superior to that of non-VA
facilities.
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\3\ ``Comparing Quality of Care in Veterans Affairs and Non ... -
NCBI.'' 25 Apr. 2018, https://www.ncbi.nlm.nih.gov/pubmed/296965 61.
\4\ ``Veterans Health Administration Hospitals Outperform Non-
Veterans'' 19 Mar. 2019, https://annals.org/aim/fullarticle/2718687/
vete rans-health-administration-hospitals-outperfor m-non-veterans-
health-administration-hospitals.
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VA healthcare settings provide the best (and arguably only)
environment for providers and trainees to attain proficiency in
treating veteran-specific issues. Veterans are at higher risk for
particular conditions, including combat- related injuries (e.g.,
gunshot, blast, and shrapnel injuries), traumatic brain injury,
heterotopic ossification, musculoskeletal injuries, spinal cord injury,
toxic exposures, PTSD, military sexual trauma and suicide. Not only do
VA trained personnel know how to treat these conditions, they recognize
which potential sources to investigate. A non-VA practitioner is less
likely to explore PTSD as the cause of chronic insomnia or the impact
of traumatic brain injury on mood and decision-making. Non-VA
practitioners would be less likely to know that conditions such as
asthma, prostate cancer or Type 2 diabetes may be the result of toxic
exposures, including Agent Orange, contaminated water or burn-pits.
RAND's Ready or Not?\5\ study reported that a majority of private
sector providers do not screen for specific health concerns that are
common among veterans.
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\5\ ``Assessing the Capacity of New York State Health ... - RAND
Corporation.'' 1 Mar. 2018, https://www.rand.org/pubs/research--
reports/R R2298.html.
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Private sector providers may, therefore, misdiagnose or
ineffectively treat these critical conditions, order inappropriate
diagnostic tests, and fail to collect information that registries need
for veterans to quality to receive compensation.
RAND's Ready to Serve\6\ study of therapists who treat PTSD and
major depression found that compared to providers affiliated with the
VA or DoD, ``a psychotherapist selected from the community is unlikely
to have the skills necessary to deliver high-quality mental health care
to service members or veterans with these conditions.''
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\6\ ``Community-Based Provider Capacity to Deliver ... - RAND
Corporation.'' 12 Nov. 2014, https://www.rand.org/pubs/research--
reports/R R806.html.
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VA social workers connect patients to veteran-specific follow up
resources, including VA and other community resources that provide home
health services, legal services, transportation, community living and
housing. Such wrap-around services help mitigate homelessness and other
social determinants of disease progression and prevalence of suicide.
Veterans being discharged from the VCCP inpatient facilities to VCCP
outpatient care would not receive the kind of VA expertise and
systematic planning that links them to the array of veterans' resources
they need.
As the Commission on Care Final Report\7\ acknowledged: ``Veterans
who receive health care exclusively through VHA generally receive well-
coordinated care, yet care is often highly fragmented among those
combining VHA care with care secured through private health plans,
Medicare, and TRICARE. This fragmentation often results in lower
quality, threatens patient safety, and shifts cost among payers.''
Compared to VA's best practice integrated model, healthcare delivered
in the community lacks integration or coordination of veterans' care.
The VA, as a unified system, has superior ability to implement and
monitor adherence to assessment and treatment standards.
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\7\ ``Commission on Care - Amazon S3.'' https://s3.amazonaws.com/
sitesusa/wp-content /uploads/sites/912/2016/07/Commission-on-C are--
Final-Report--063016--FOR-WEB.pdf.
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3. Impact on the Timeliness of Clinical Care Provided to Veterans
VA's Access Standards ensure that VA facility's wait times are
monitored and enforced. There are no set expectations of timeliness for
care of veterans in the Community Care Network.
If a VA facility is closed, veterans will struggle to get care in
an overburdened private sector healthcare system. Delays for
outpatient, inpatient and emergency room care for veterans and non-
veterans in the local area would increase.
At present, private sector average outpatient wait times for
primary care, cardiology, and dermatology (though not orthopedics) are
68% longer\8\ than wait times at the VA.
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\8\ ``Comparison of wait times for new patients between ... - JAMA
Network.'' 18 Jan. 2019, https://jamanetwork.com/journals/jamanetwor
kopen/fullarticle/2720917.
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Our nation faces an intractable physician shortage, especially in
primary care. A report\9\ by the American Association of Medical
Colleges warns that by 2030 the U.S. will be short 14,800 to 49,300 of
needed primary care doctors. Non-primary care medical specialties
predict additional shortages of 33,800 to 72,700 physicians. In
geriatric care, an area in which the VA specializes and the private
sector is drastically undersupplied, less than half of geriatric
fellowship positions\10\ even filled last year.
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\9\ ``New research shows increasing physician shortages in both
primary'' 11 Apr. 2018, https://news.aamc.org/press-releases/article/w
orkforce--report--shortage--04112018/.
\10\ ``SAP Crystal Reports - 2017 SMS - NRMP.'' http://
www.nrmp.org/wp-content/uploads/201 8/02/Results-and-Data-SMS-2018.pdf.
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The delivery of health care to rural populations is a particular
challenge. While 20% of the U.S. population is rural, only 12 % of PCPs
are working in rural areas (and only 8% of other specialties)\11\, and
these provider numbers are actually declining. Sixty percent of
counties\12\ - all rural--lack a single psychiatrist. Between 2010 and
2019, 95 rural hospitals closed\13\ and an additional 21% (=430) are at
high risk of closing.
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\11\ ``Rural America Faces Shortage of Physicians to Care for
Rapidly Aging" https://www.asaging.org/blog/rural-america-fa ces-
shortage-physicians-care-rapidly-aging-po pulation.
\12\ ``The Silent Shortage - New American Economy.'' http://
research.newamericaneconomy.org/wp- content/uploads/2017/10/NAE--
PsychiatristSh ortage--V6-1.pdf.
\13\ "2019 healthcare outlook - Navigant.'' https://
www.navigant.com/-/media/www/site/i nsights/healthcare/2019/
navigant2019healthca reoutlook.pdf.
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4. Impact on Veterans Having ``Choice'' for Where to Receive Healthcare
Explicitly, the MISSION Act was developed to offer greater
healthcare choices to veterans. When a facility is closed, veterans who
prefer to receive their care in the VA will no longer have that option.
Forty-six percent of all veterans are enrolled in VA healthcare,
and 17% utilize it as their primary source.\14\ VA utilizers are more
likely to be black, younger, female, unmarried, less educated and have
a lower income.
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\14\ ``US Veterans Who Do and Do Not Utilize Veterans Affairs ... -
NCBI.'' 17 Jan. 2019, https://www.ncbi.nlm.nih.gov/pubmed/306772 66.
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Further, many veterans prefer to receive care in a VA facility
because of the opportunity for peer contact. A third of VA employees
are veterans. The VA has 1,100 Peer Specialists who are veterans in
successful recovery from mental health challenges, integrated in mental
health care programs and uniquely suited to engage veterans and instill
hope. Closure takes that away.
5. Impact on Training of Medical/Healthcare Professionals
If a VA facility were closed, required residency/fellowship
rotations would not be available, core funding would be eliminated,
leading to shrinkage and in some cases collapse of the local university
residency training programs.
There are 135 allopathic medical schools and 30 osteopathic medical
schools that are formally affiliated with VA's. The residency/
fellowship programs housed at local VA's include, but are not limited
to: epilepsy, gastroenterology, geriatric medicine, hematology/
oncology, infectious disease, hospice/palliative medicine, internal
medicine, interventional cardiology, nephrology, neuromuscular
medicine, nuclear medicine, ophthalmology, orthopedic surgery, pain
otolaryngology, medicine, anatomic pathology, plastic surgery,
psychiatry, psychosomatic medicine, pulmonary disease, radiology,
rheumatology, sleep medicine, general surgery, thoracic surgery and
urology.
In addition education would be curtailed for other trainees who
rotate part or full time at VAMCs, such as medical and nursing
students, psychologists, and trainees in more than 40 other health
professions.
6. Impact on the Number of Doctors and Other Healthcare Professionals
Providing Healthcare in the Local Area
Medical schools are a seedbed for training the next generations of
doctors. Graduating residents tend to remain in their local area to
live and work. A loss of hundreds of physician and other health care
profession residency positions means that year by year there will be
incrementally fewer healthcare providers settling in the community to
treat patients, including the very veterans being automatically placed
in the VCCP.
7. Impact on Recruiting a Workforce Committed to Veterans
Training programs are the single best mechanism for the recruitment
of VA health professionals, including those that relocate from other
geographic areas. Positive experiences of treating veterans as well as
being mentored by renowned experts in veterans' healthcare issues are,
for a substantial number of trainees, the biggest determinant in their
decision to seek VA employment. Roughly 60% of current VA physicians
(and even higher percentages of some other professions) participated in
VA training programs.
Closure of a facility means fewer residents, fellows, medical
students and other health profession trainees would train at VA's. That
will diminish this recruitment tool, and VA's in other regions will be
less able to attract physicians and other healthcare professionals
committed to veterans.
8. Impact on Research on Veterans
Over the past 70 years, VA researchers and clinicians have worked
together, along with scientists at academic institutions and the DoD,
to develop innovative treatments that have benefited not only the
nation's veterans, but also patients throughout the country and the
world.
Take, for example, the San Francisco VA Medical Center, which has
over 800 current research projects that would cease if the facility
were closed. These include the study of basic neuroscience and
neuroimaging of combat-related brain and spinal cord injuries,
posttraumatic stress disorder (PTSD), fracture/ polytrauma,
neurological combat-related injuries, rehabilitation after stroke and
traumatic brain injury, Parkinson's disease, fracture repair,
heterotopic ossification after polytrauma, prostate cancer, tinnitus,
oncology, hypertension, stroke, cardiovascular disease, breast cancer,
musculoskeletal disorders, hepatitis C, HIV, renal dialysis, epilepsy,
cardiac surgery, mental health and substance use disorders. Closure of
a VA would shut its lines of research that are unfeasible to transfer
elsewhere.
The VA has a stable population that can be followed over the long-
term, enabling researchers to make big data breakthroughs on emerging
veteran-specific healthcare problems. That will be impossible if
veterans' care becomes scattered across the private sector in which
communication is fragmented. Closure of any VA facility weakens the
VA's ability to identify, diagnose and develop innovative treatments
for the next PTSD or Agent Orange.
9. Impact on Readiness for Emergencies
The Fourth Mission of the VA is to support national, state, and
local emergency management, public health, safety and homeland security
efforts for veterans and non-veterans in the event of war, terrorism,
national emergencies, and natural disasters. VAMCs are federal
emergency response sites.
In the event of an emergency, there will be fewer ER and inpatient
beds. It will also be more difficult to set up the kind of command
center that the VA's routinely organize to track and assist veterans
who are affected by such emergencies.
10. Impact on the Local Economy
Each VA medical center has thousands, and smaller CBOCS have
hundreds, of employees who generate revenue for the local economy. When
a VAMC or CBOC is closed, those employees are laid off. For many of
them, especially those in support roles, finding gainful employment
will be difficult. Veterans on compensated work therapy will likely
face insurmountable challenges. Any decision about closing a VA
facility must also consider how job losses impact the local economy.
The Veterans Healthcare Policy Institute thanks the Committee for
the opportunity to provide this statement for the record.
Authors:
Russell B. Lemle, PhD, Senior Policy Analyst
Suzanne Gordon, Senior Policy Analyst
Contact:
Brett W. Copeland, Executive Director
[email protected]
BILLS FOR THE RECORD (Upon Request)
1. H.R. 2943 - To direct the Secretary of Veterans Affairs to make
all fact sheets of the Department of Veterans Affairs in English and
Spanish. (Cisneros)
2. H.R. 2942 - To direct the Secretary of Veterans Affairs to carry
out the Women's Health Transition Training pilot program through at
least fiscal year 2020, and for other purposes. (Cisneros)
3. H.R. 2676 - VA Survey of Cannabis Use Act- This bill requires VA
to enter into an agreement with a federally funded research and
development center to conduct surveys nationwide to measure cannabis
use by veterans. (Moulton)
4. H.R. 2677 - To require VA to provide training in the use of
medical cannabis in conjunction with medical schools that have
incorporated education on medical cannabis into their curricula.
(Moulton)
5. H.R. 712 - VA Medicinal Cannabis Research Act (Correa)
6. H.R. 1647 - Veterans Equal Access Act (Blumenhauer)
7. H.R. 3083 - To authorize the Asset and Infrastructure Review
Commission of the Department of Veterans Affairs to meet in years other
than 2022 and 2023. (Roe)
8. H.R. 485 - To amend title 38, United States Code, to provide for
the circumstances under which the Secretary of Veterans Affairs shall
provide reimbursement for emergency ambulance services. (Tipton)
9. Discussion Draft - Specially Adaptive Housing
10. Discussion Draft - Work Study