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[Senate Report 114-34]
[From the U.S. Government Publishing Office]

114th Congress  }                                              { Report
 1st Session    }                                              { 114-34

                         AMERICAN VETERANS ACT


                 April 23, 2015.--Ordered to be printed


         Mr. Isakson, from the Committee on Veterans' Affairs,
                        submitted the following

                              R E P O R T

                        [To accompany H.R. 203]

    The Committee on Veterans' Affairs (hereinafter, ``the 
Committee''), to which was referred the bill (H.R. 203), to 
amend title 38, United States Code (hereinafter, ``U.S.C.''), 
to provide for the conduct of annual evaluations of mental 
health care and suicide prevention programs of the Department 
of Veterans Affairs (hereinafter, ``VA'' or ``the 
Department''), to require a pilot program on loan repayment for 
psychiatrists who agree to serve in the Veterans Health 
Administration (hereinafter, ``VHA'') of the Department, and 
for other purposes, having considered the same, reports 
favorably thereon without amendment and recommends that the 
bill do pass.


    On January 7, 2015, Representative Timothy Walz introduced 
H.R. 203, to provide for the conduct of annual evaluations of 
mental health care and suicide prevention programs of the 
Department, to require a pilot program on loan repayment for 
psychiatrists who agree to serve in VHA of the Department, and 
for other purposes. Representatives Courtney, Duckworth, Esty, 
Kirkpatrick, Miller (FL), Murphy (PA), O'Rourke, Rush, Scott 
(GA), Slaughter, and Smith (NJ) were original cosponsors. 
Representatives Bonamici, Brown (FL), Bustos, Cicilline, 
Cleaver, Costello, Cramer, Fitzpatrick, Foster, Garamendi, 
Gibson, Israel, Kline, Kuster, Lujan, Lujan Grisham, Murphy 
(FL), Nolan, Paulsen, Peters, Peterson, Pingree, Quigley, 
Sinema, Walters, Welch, Wenstrup, and Young (IN) were later 
added as cosponsors.
    On January 12, 2015, the House of Representatives suspended 
the rules and passed H.R. 203 by a vote of 403-0. On January 
13, 2015, Senator McCain introduced S. 167, the Clay Hunt 
Suicide Prevention for American Veterans Act. Senators 
Blumenthal, Blunt, Boozman, Brown, Burr, Casey, Donnelly, 
Durbin, Flake, Gillibrand, Hirono, Klobuchar, Manchin, 
Menendez, Moran, Murkowski, Murray, Sanders, Sullivan, and 
Tester were original cosponsors. On January 13, 2015, the bill 
was referred to the Committee. Senators Ayotte, Baldwin, 
Bennet, Boxer, Cantwell, Capito, Cardin, Collins, Coons, 
Cornyn, Daines, Feinstein, Franken, Grassley, Heitkamp, Heller, 
Hoeven, Inhofe, Johnson, King, Kirk, Markey, Murphy, Nelson, 
Peters, Reed, Schumer, Sessions, Shaheen, Stabenow, Tillis, and 
Wyden were later added as cosponsors.

                           Committee Meeting

    On January 21, 2015, the Committee met to consider 
H.R. 203. The bill was ordered to be reported favorably without 

                    Summary of H.R. 203 as Reported

    H.R. 203, as reported (hereinafter, ``the Committee 
bill''), would provide for the conduct of annual evaluations of 
mental health care and suicide prevention programs of VA, 
require a pilot program on loan repayment for psychiatrists who 
agree to serve in VHA, and serve other purposes.
    Section 1 provides a short title of, the ``Clay Hunt 
Suicide Prevention for American Veterans Act'' or the ``Clay 
Hunt SAV Act.''
    Section 2 would require VA to obtain an independent third 
party evaluation of VA's mental health care and suicide 
prevention programs to include: (1) use of metrics that are 
common and useful for mental health and suicide prevention 
practitioners; (2) identifying the most effective programs; (3) 
identifying the cost-effectiveness of each program; and (4) 
proposing best practices. The first report will be due no later 
than December 1, 2018, and subsequent reports will be required 
annually thereafter; two interim reports cataloging and 
reporting data on existing programs will be required.
    Section 3 would require VA to publish an interactive Web 
site designed to serve as a centralized source of information 
regarding all VA mental health services.
    Section 4 would require VA to establish a pilot program to 
repay education loans relating to psychiatric medicine for no 
less than ten individuals on the condition that they agree to 
serve no less than 2 years of obligated service within VA.
    Section 5 would require VA to establish a pilot program in 
no less than five Veterans Integrated Service Networks 
(hereinafter, ``VISNs'') to assist veterans transitioning from 
active duty to veteran status and to improve veteran access to 
mental health services with community cooperation.
    Section 6 would authorize VA to collaborate with non-profit 
mental health organizations to: (1) improve the efficiency and 
effectiveness of suicide prevention efforts; (2) assist non-
profit mental health organizations through VA expertise; and 
(3) jointly carry out suicide prevention efforts.
    Section 7 would extend an additional 1 year of eligibility 
for VA health care services for certain combat veterans who 
have not enrolled and whose 5-year combat eligibility period 
recently expired.
    Section 8 stipulates that no additional funds are 
authorized to be appropriated to carry out this Act.

                       Background and Discussion

    Background. The number of veterans using VA mental health 
care treatment has risen from about 900,000 in 2006 to more 
than 1.4 million in 2013 and is expected to increase as 
servicemembers exit the military and enter the VA health care 
system. VA has attributed this increase to the improved 
screening, awareness, and understanding of post traumatic 
stress disorder (hereinafter, ``PTSD'') and other common mental 
health conditions. In testimony submitted for the Committee's 
November 19, 2014, hearing on Mental Health and Suicide Among 
Veterans, Dr. Harold Kudler, Chief Mental Health Consultant for 
VHA, noted the Department ``anticipate(s) that VA's 
requirements for providing mental health care will continue to 
grow for a decade or more after current operational missions 
have come to an end.''
    Mental health diagnoses of veterans range from mild 
depression to severe PTSD, requiring an equally broad range of 
treatment options. According to statistics from VA, since 2002, 
more than 1.7 million servicemembers have left active duty and 
become eligible for VA care. Fifty-eight percent of those 
individuals have sought care from VA and, of those, 55 percent 
have been either diagnosed provisionally or confirmed with a 
mental health condition.
    Additionally, different veterans with the same diagnosis 
may respond differently to the same treatment. The most severe 
cases of PTSD are frequently treated with intensive therapies 
at VA medical centers. Less severe cases can be treated at Vet 
Centers, which often appeal to veterans because of their 
welcoming, home-like nature. Certain veterans respond better to 
one-on-one therapies, while others respond well to group 
environments. Community Based Outpatient Clinics (hereinafter, 
``CBOC'') play an important role in telehealth delivery by 
connecting rural veterans to psychiatry services from the 
medical center.
    In an effort to meet the needs of veterans, VA began 
offering expanded access to mental health services through 
extended evening and weekend clinic hours at larger VA medical 
centers. Moreover, VA began offering same day appointments at 
some VA medical centers and services are available to veterans 
in an emergency situation. Another important change has been 
the inclusion of mental health professionals into primary care 
delivery through VA's Patient Aligned Care Teams. This improves 
the screening process to recognize and treat those veterans who 
present in their primary care location.
    VA clinicians are now trained in--and utilizing--a variety 
of evidence-based therapies, including Cognitive Behavioral 
Therapy and Prolonged Exposure Therapy. The use of these 
therapies helps ensure veterans throughout the country are 
receiving the high-quality care most likely to assist them in 
the treatment and recovery of a broad spectrum of mental health 
diagnoses. However, VA must do a better job tracking 
utilization of these services to ensure clinicians are using 
them appropriately and to make sure they are being used across 
    Despite these changes to VA's mental health program, 
difficulties still exist. Over the last few years, the 
Committee has heard from stakeholders about several ongoing 
concerns, which will be discussed below in further detail.


    Tragically, over the past year, it is estimated this nation 
has lost, on average, twenty-two veterans a day to suicide. 
While much of the attention has been focused on the youngest 
cohort of veterans returning from the wars in Iraq and 
Afghanistan, it is reported to be the older cohort of veterans 
who are committing suicide at higher rates. VA's Suicide Data 
Report 2012 found more than 69 percent of veteran suicides are 
among those age 50 years or older.
    Among the youngest cohort of VHA users, the largest 
increase in suicide rates has been among males under 30, 
especially those between 18-25 years of age, according to VA's 
2014 Suicide Data Report Update. This report also highlighted 
an increase in the suicide rate in female VHA users since the 
start of the wars in Iraq and Afghanistan. It is important to 
note, however, that the increase seen in this population is 
comparable to the increases among non-veteran women in the 
United States.

                        ACCESS AND SCOPE OF CARE

    The events at the Phoenix VA Health Care System in 2014 
underscored VA's inability to provide timely access to medical 
services, including mental health appointments. Concerns about 
the Department's scheduling practices had been raised by the 
VA's Office of Inspector General (hereinafter, ``VAOIG'') and 
the Government Accountability Office as early as the 1990s. In 
fact, in April 2012, the VAOIG released a report entitled 
Review of Veterans' Access to Mental Health Care, which showed 
VA was not meeting benchmarks for timely access to mental 
health care services. Some veterans were waiting as long as 60 
days for an evaluation.
    In her written testimony for the Committee hearing entitled 
VA Mental Health Care: Ensuring Timely Access to High-Quality 
Care on March 20, 2013, Kim Ruocco, National Director of 
Suicide Postvention Programs, Tragedy Assistance Program for 
Survivors, provided several examples of veterans who struggled 
to get timely access to treatment. She also discussed the 
challenges of navigating the system:

          At some point, the veteran may decide to go to the VA 
        because he or she is struggling and needs help. Often 
        this happens after a long battle and the 
        servicemember's life is already falling apart and he or 
        she is very sick. The servicemember then contacts the 
        VA looking for help with his or her symptoms, whether 
        it is addiction, anxiety, depression, uncontrollable 
        outbursts of rage, etc. This is a critical time for the 
        veteran . . . . Very often the veteran's suffering is 
        complicated with combinations of physical and emotional 
        pain including issues like traumatic brain injury, 
        post-traumatic stress, depression, moral injury, and 
        survivor guilt. These issues become the veteran's own 
        personal barriers to care. In this population we see 
        avoidance, anxiety and trouble concentrating. Symptoms 
        like panic attacks, flashbacks and hyper-vigilance 
        among this population of veterans are often described 
        to us by our surviving families.
          These symptoms run counterintutitive to navigating a 
        complex system of paperwork, crowded waiting rooms, 
        extended wait times for appointments, referrals and 
        disability ratings. The veteran enters the system 
        tentatively with trepidation and some fear. The veteran 
        is barely holding on. The veteran may feel like people 
        do not understand him and that the public does not 
        appreciate what he or she has sacrificed for this 
        country . . . . When the veteran asks for help, he or 
        she is desperate, and may be thinking of killing 
        himself or herself because he or she is losing hope 
        that things will get better. This is the composite 
        profile of the veteran who dies by suicide, who 
        initially approaches the VA for help.

    During the Committee's November 19, 2014, hearing, Susan 
Selke, Clay Hunt's mother, testified that her son exclusively 
used VA for his medical care after leaving the Marine Corps. 
She went on to note:

          Clay constantly voiced concerns about the care he was 
        receiving, both in terms of the challenges he faced 
        with scheduling appointments as well as the treatment 
        he was receiving for PTS, which consisted primarily of 
        medication . . . . Clay used to say, ``I am a guinea 
        pig for drugs.''

    Mrs. Selke also recalled a conversation she had with her 
son 2 weeks before his death:

          Clay had only two appointments in January and 
        February 2011, and neither was with a psychiatrist. It 
        was not until March 15 that Clay was finally able to 
        see a psychiatrist at the Houston VA medical center. 
        But after the appointment, Clay called me on his way 
        home and said, ``Mom, I can't go back there. The VA is 
        way too stressful and not a place I can go. I will have 
        to find a Vet Center or something.''

    Ensuring VA is providing veterans with the types of mental 
health care they want is paramount. In testimony before the 
House Committee on Veterans' Affairs on July 10, 2014, Warren 
Goldstein, Assistant Director for Traumatic Brain Injury and 
PTSD programs in the National Veterans Affairs and 
Rehabilitation Commission of The American Legion, discussed the 
findings of a survey conducted by the organization, which found 
more than half of the 3,100 veterans surveyed did not believe 
their symptoms improved as a result of psychotherapy or 
medication prescribed at VA. Furthermore, nearly a third of 
veterans actually terminated their treatment before it 
concluded. They cited reasons like stigma, travel burden, side 
effects, and frustration with the lack of progress that drove 
veterans to discontinue treatment before the end of the 
treatment cycle.

                           STAFFING SHORTAGES

    Presenting testimony on behalf of the American Federation 
of Government Employees (hereinafter, ``AFGE''), AFL-CIO, and 
the AFGE National VA Council, Michelle Williams, Ph.D., a 
coordinator of PTSD Services and Evidence Based Psychotherapy 
at the Wilmington VA Medical Center, recounted numerous stories 
about staffing issues related to mental health providers during 
the November 30, 2011, hearing on VA Mental Health Care: 
Addressing Wait Times and Access to Care. In one instance, a 
psychiatrist in a general mental health clinic stated he felt 
like ``staffing levels [would] `never catch up' with the 
growing demand for services and that at his medical center, 
trying to keep up with patients' needs [is] like `a finger in 
the dike'.'' Another psychologist at a CBOC noted she was 
overbooked every day, as she was the only mental health 
provider at that facility. She found herself handling 
individual and group appointments, walk-ins, and call-ins, as 
well as some compensation and pension examinations. This 
provider had a caseload of more than 200 patients, many of whom 
were considered high-risk patients.
    In an effort to address staffing shortages, on August 31, 
2012, President Obama signed an Executive Order directing VA to 
hire 1,600 more mental health professionals. Despite these 
additions, the Committee continued to hear concerns about 
shortages of mental health professionals across the country. As 
a result, recruitment and retention of medical professionals at 
VA became a focus during the 113th Congress as events at 
Phoenix and other VA facilities came to light during the summer 
of 2014. The Veterans Access, Choice, and Accountability Act of 
2014 (hereinafter, ``VACAA'') sought to increase the number of 
graduate medical education residency slots by up to 1,500 over 
a 5-year period, with an emphasis on those pursuing primary 
care, mental health, and other specialties the Secretary deems 
appropriate; gave priority to the five medical occupations the 
VAOIG has identified as having the largest staffing shortages; 
and increased the maximum amount of money available to eligible 
VA health care professionals in their Education Debt Reduction 
    However, given the extent of the national shortage of 
mental health care professionals across the United States, VA 
must continue to enhance its ability to recruit and retain 
staff. Rural and highly rural parts of the country face the 
largest burden.
    In the months following VACAA's implementation, the 
Committee heard from Dr. Elspeth Cameron Ritchie, Chief 
Clinical Officer, District of Columbia Department of Mental 
Health and Member of the Committee on the Assessment of Ongoing 
Efforts in the Treatment of Posttraumatic Stress Disorder, 
Institute Of Medicine, The National Academies, during the 
Committee's November 19, 2014, hearing on Mental Health and 
Suicide Among Veterans. She stated:

          [The Department of Defense] and VA have substantially 
        increased their mental health staffing--both direct 
        care and purchased care. However, staffing increases do 
        not appear to have kept pace with the demand for PTSD 
        services. Staffing shortages can result in clinicians 
        not having sufficient time to provide evidence-based 
        psychotherapies readily and with fidelity. The lack of 
        time to deliver psychotherapy with fidelity is 
        reflected in the fact that in 2013 only 53 percent of 
        [Operation Enduring Freedom (hereinafter, ``OEF'')] and 
        [Operation Iraqi Freedom (hereinafter, ``OIF'')] 
        veterans who had a primary diagnosis of PTSD and sought 
        care in the VA received the recommended eight sessions 
        within 14 weeks.

    In an effort to better meet the needs of veterans with 
mental health conditions, as a part of the President's 2012 
Executive Order to hire additional mental health staff, VA 
announced some of those slots would be used to hire peer 
support specialists. Within the last 2 years, VA has been able 
to hire 900 peer support specialists and apprentices to be 
incorporated into VA's mental health programs. These peer 
support specialists are uniquely positioned to relate to 
veterans and can serve on the front line of support for those 
veterans who are hesitant to seek care. VA has announced that 
it will start piloting the expansion of peer support to 
veterans in primary care settings. The pilot is expected to 
place one to two peer specialists in 25 primary care sites 
across the country.
    The Committee has heard from multiple witnesses over the 
years about the value of peer support. For example, in his 
written testimony to the Committee on November 30, 2011, John 
Roberts, the Executive Vice President of Mental Health and 
Family Services for the Wounded Warrior Project (hereinafter, 
``WWP'') drew attention to this when he discussed the findings 
of a survey of WWP alumni. He stated that ``nearly 30 percent 
identified talking with another OEF/OIF veteran as the most 
effective resource in coping with stress--the highest response 
rate of all the resources cited, including VA care (24 
percent), medication (15 percent) and talking with non-military 
family or friend (8 percent).''


    The effect of combat does not end when veterans return from 
the battlefield. For many servicemembers returning home from 
war, chronic pain is part of daily life. VA's latest health 
care utilization report notes musculoskeletal ailments--like 
joint, neck, and back disorders--are the most frequent 
conditions diagnosed among post-9/11 veterans. A common symptom 
of these ailments is chronic pain. In fact, VA's own statistics 
from the Office of Health Service Research & Development show 
50 percent of male veterans treated by VHA suffer from chronic 
pain and among female veterans the prevalence may be higher. As 
noted earlier in this report, 55 percent of the 58 percent of 
post-9/11 veterans seeking care at VA have a mental health 
diagnosis. Treating the invisible wounds of war can be 
challenging and often requires veterans to take multiple 
medications in order to help these individuals live fuller 
lives. However, these drugs come with significant risk if not 
properly monitored. In response to numerous stories in the 
media highlighting the problem of overmedication as it relates 
to servicemembers and veterans, especially in regards to 
opioids, the Committee held a hearing on the subject on April 
30, 2014.
    Recognizing both the need for these medications in order to 
properly treat veterans as well as the risks associated with 
their misuse, VA has taken steps to address this issue. One of 
the Department's most recent efforts is the Opioid Safety 
Initiative (hereinafter, ``OSI''). Started in October 2013 in 
Minneapolis, Minnesota, with a goal of reducing dependency on 
opioid use, this initiative includes a team approach that 
educates veterans and provides patient monitoring with 
feedback. This program also helps ensure access to, and 
encourages the use of, Complementary and Alternative Medicine 
therapies for its participants. In written testimony to the 
Committee on April 30, 2014, Dr. Robert Petzel, Under Secretary 
for Health at VHA, noted that, as a result of implementing the 
OSI, ``Minneapolis has seen a nearly 70 percent decrease in 
high-dose opioid prescribing for chronic non-cancer pain 
patients.'' Given the positive results seen in Minnesota, VA 
decided to implement this initiative nationwide.
    VA has also begun a program known as the Academic Detailing 
Service to identify and disseminate best practices for 
evidence-based mental health treatments. It also seeks to 
improve treatment outcomes while reducing reliance on high-dose 
medications to treat chronic mental health conditions. This 
initiative was initially piloted in VISNs 21 and 22. Following 
its success, VISNs 3, 12, 17, 19, and 23 are preparing to 
implement the program as well.
    While these efforts to reduce the use of opioids at VA are 
commendable, more remains to be done. A recent Administrative 
Closure by the VAOIG for alleged inappropriate prescribing 
practices of opioids at the VA Medical Center in Tomah, 
Wisconsin, has raised new concerns about the overuse of opioids 
at VA.


    The Committee has heard regularly from witnesses and 
constituents that VA's outreach efforts are inadequate. Many 
have discussed the difficulties of not only navigating the 
system but also knowing what services are available. In an 
effort to address some of these concerns, the Committee held a 
hearing entitled Call to Action: VA Outreach and Community 
Partnerships on April 23, 2013. During the hearing, it was 
highlighted that from fiscal year (hereinafter, ``FY'') 2009 
through 2013, VA spent a total of $83.7 million on its outreach 
efforts, yet a 2010 survey found 60 percent of veterans knew 
``very little'' or ``nothing at all'' about their VA benefits, 
including access to health care.
    One of the main reasons a veteran may be reluctant to seek 
mental health treatment is the stigma surrounding such 
treatment. In his written testimony for the Committee on April 
23, 2013, Eric Weingarter, the Managing Director of the 
Survival and Veterans program at the Robin Hood Foundation 

          Many individuals fear that seeking mental health 
        services will jeopardize their career, community 
        standing or both. Others are reluctant to expose their 
        vulnerabilities to providers who may also be Armed 
        Forces personnel themselves, given the military's 
        emphasis on strength, confidence, and bravery. And some 
        veterans have found the settings or providers they used 
        especially bureaucratic or unsatisfactory in other 
        ways, and would pursue a different option if available.

    A similar sentiment was expressed by Lieutenant Colonel 
(hereinafter, ``LTC'') Kenny Allred, U.S. Army (Ret.), Chair of 
the Veterans and Military Council of the National Alliance on 
Mental Illness (hereinafter, ``NAMI''), in written testimony 
provided to the Committee on March 20, 2013, for its hearing 
about mental health wait times. LTC Allred stated:

        ``NAMI believes that the key to reducing stigma and 
        strengthening suicide prevention is a change in the way 
        we approach these problems. It is absolutely 
        unacceptable to be applying the resources we have over 
        the last 10 years and to see suicides grow at a rate of 
        twenty-percent among veterans from eighteen to twenty-
        two a day. Many of these suicides are occurring among 
        those who have never been in combat. In 2012, suicide 
        deaths among soldiers were higher than combat deaths.''

He also stressed the need for ``addressing the health and 
mental health care needs of National Guard and Reservists who 
are not considered `veterans' despite their service. These 
individuals have frequently experienced the same challenges and 
trauma as those in the more traditional branches of the 

                            EXPANDED ACCESS

    Under current law, section 1710(e) of title 38, U.S.C., 
combat veterans are eligible to enroll in the VA health care 
system up to 5 years post discharge. During such time, veterans 
are eligible for enrollment in Priority Group 6. Those who 
receive a service-connected disability rating are reassigned to 
the highest applicable health care priority group. At the end 
of the 5-year period, all others are moved to Priority Group 7 
or 8, depending on income level. Veterans in health care 
Priority Groups 7 and 8 generally pay copayments for treatments 
and medications.
    VA reports nearly 1 million of the 1.6 million veterans, 
discharged from active duty since 2002, have received VA health 
care services. Furthermore, OEF/OIF/Operation New Dawn veterans 
constitute 9 percent of the 6.3 million individuals who 
received VA health care during FY 2012.\1\
    \1\Epidemiology Program, Veterans Health Administration, Dep't of 
Veterans Affairs, Analysis of VA Health Care Utilization among 
Operation Enduring Freedom (OEF), Operation Iraqi Freedom (OIF), and 
Operation New Dawn (OND) Veterans 5 (2013).
    Based on anecdotes and research, it has been suggested the 
5-year period under current law may be inadequate. A 2012 study 
found the median time for initiation of mental health 
outpatient care was 4.1 years for veterans. The time between 
first mental health outpatient clinic care and initiation of 
minimally adequate care was 2 years longer for male veterans 
than for female veterans (8.02 and 5.98 years, respectively,