```

[House Hearing, 115 Congress]
[From the U.S. Government Publishing Office]

 LEGISLATIVE HEARING ON H.R. 1506, H.R. 2322, H.R. 3832, H.R. 4334 AND 
H.R. 4635; VA Medicinal Cannabis Research Act of 2018 and a Draft Bill 
      To Make Certain Improvements in The Family Caregiver Program

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS
                     U.S. HOUSE OF REPRESENTATIVES

                     ONE HUNDRED FIFTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        TUESDAY, APRIL 17, 2018

                               __________

                           Serial No. 115-56

                               __________

       Printed for the use of the Committee on Veterans' Affairs
       
[GRAPHIC NOT AVAILABLE IN TIFF FORMAT]       

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

                    U.S. GOVERNMENT PUBLISHING OFFICE                    
35-469                       WASHINGTON : 2019                     
          
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                     COMMITTEE ON VETERANS' AFFAIRS

                   DAVID P. ROE, Tennessee, Chairman

GUS M. BILIRAKIS, Florida, Vice-     TIM WALZ, Minnesota, Ranking 
    Chairman                             Member
MIKE COFFMAN, Colorado               MARK TAKANO, California
BRAD R. WENSTRUP, Ohio               JULIA BROWNLEY, California
AMATA COLEMAN RADEWAGEN, American    ANN M. KUSTER, New Hampshire
    Samoa                            BETO O'ROURKE, Texas
MIKE BOST, Illinois                  KATHLEEN RICE, New York
BRUCE POLIQUIN, Maine                J. LUIS CORREA, California
NEAL DUNN, Florida                   KILILI SABLAN, Northern Mariana 
JODEY ARRINGTON, Texas                   Islands
JOHN RUTHERFORD, Florida             ELIZABETH ESTY, Connecticut
CLAY HIGGINS, Louisiana              SCOTT PETERS, California
JACK BERGMAN, Michigan
JIM BANKS, Indiana
JENNIFFER GONZALEZ-COLON, Puerto 
    Rico
                       Jon Towers, Staff Director
                 Ray Kelley, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

                     BRAD WENSTRUP, Ohio, Chairman

GUS BILIRAKIS, Florida               JULIA BROWNLEY, California, 
AMATA RADEWAGEN, American Samoa          Ranking Member
NEAL DUNN, Florida                   MARK TAKANO, California
JOHN RUTHERFORD, Florida             ANN MCLANE KUSTER, New Hampshire
CLAY HIGGINS, Louisiana              BETO O'ROURKE, Texas
JENNIFER GONZALEZ-COLON, Puerto      LUIS CORREA, California
    Rico

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

                              ----------                              

                        Tuesday, April 17, 2018

                                                                   Page

LEGISLATIVE HEARING ON H.R. 1506, H.R. 2322, H.R. 3832, H.R. 4334 
  AND H.R. 4635; VA Medicinal Cannabis Research Act of 2018 and a 
  Draft Bill To Make Certain Improvements in The Family Caregiver 
  Program........................................................     1

                           OPENING STATEMENTS

Honorable Brad Wenstrup, Chairman................................     1
Honorable Julia Brownley, Ranking Member.........................     2
Honorable Tim Walz, Ranking Member, Full Committee On Veterans 
  Affairs........................................................     3

                               WITNESSES

The Honorable Beto O'Rourke, Member, U.S. House of 
  Representatives, 16th District; Texas..........................     4
    Prepared Statement...........................................    29
The Honorable Tim Walberg, Member, U.S. House of Representatives, 
  7th District; Michigan.........................................     5
    Prepared Statement...........................................    30
The Honorable Phil Roe, Chairman, Full Committee On Veterans 
  Affairs........................................................     6
The Honorable Neal Dunn, Member, U.S. House of Representatives, 
  2nd District; Florida..........................................     8
    Prepared Statement...........................................    31
The Honorable Luis Correa, Member, U.S. House of Representatives, 
  46th District; California......................................     9
    Prepared Statement...........................................    32
The Honorable Mike Coffman, Member, U.S. House of 
  Representatives, 6th District; Colorado........................     9
    Prepared Statement...........................................    32
Louis J. Celli, Director, National Veterans Affairs and 
  Rehabilitation Division, The American Legion...................    11
    Prepared Statement...........................................    33
Adrian M. Atizado, Deputy National Legislative Director, Disabled 
  American Veterans..............................................    13
    Prepared Statement...........................................    39
Sarah S. Dean, Associate Legislative Director, Paralyzed Veterans 
  of America.....................................................    14
    Prepared Statement...........................................    44
Kayda Keleher, Associate Director, National Legislative Service, 
  Veterans of Foreign Wars of the United States..................    16
    Prepared Statement...........................................    47

                        STATEMENT FOR THE RECORD

Steve Schwab, The Elizabeth Dole Foundation......................    50
Tom Porter, Iraq and Afghanistan Veterans of America (IAVA)......    52
Carrie Stead - The Independence Fund.............................    54
Margaret Kabat - The Indepndence Fund............................    55
Bob Carey - The Independence Fund................................    58
Veterans Cannabis Coalition (VCC)................................    61
Veterans Cannabis Project (VCP)..................................    61
Wounded Warrier Project (WWP)....................................    62

 
 LEGISLATIVE HEARING ON H.R. 1506, H.R. 2322, H.R. 3832, H.R. 4334 AND 
H.R. 4635; VA Medicinal Cannabis Research Act of 2018 and a Draft Bill 
      To Make Certain Improvements in The Family Caregiver Program

                              ----------                              

                        Tuesday, April 17, 2018

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                     Subcommittee on Health
                                                   Washington, D.C.
    The Subcommittee met, pursuant to notice, at 3:35 p.m., in 
Room 334, Cannon House Office Building, Hon. Brad Wenstrup 
[Chairman of the Subcommittee] presiding.
    Present: Representatives Bilirakis, Radewagen, Dunn, 
Rutherford, Higgins, Gonzalez-Colon, Roe, Coffman, Brownley, 
Takano, Kuster, O'Rourke, Correa, Walz.

          OPENING STATEMENT OF BRAD WENSTRUP, CHAIRMAN

    Mr. Wenstrup. The Subcommittee will come to order. Before 
we begin, I would like to ask unanimous consent for our 
colleague and fellow Committee Member, Representative Coffman 
from Colorado, to sit on the dais and participate in today's 
proceedings. Without objections, so ordered.
    Good afternoon, thank you all for joining us. Today we will 
be discussing a number of bills that have been referred to the 
Subcommittee on Health, as well as two draft proposals that are 
sponsored by Chairman Roe and Ranking Member Walz, 
respectively. These bills, which are sponsored by Committee 
Members and colleagues from both sides of the aisle, would 
address some of the most important health care issues facing 
our Nation's veterans and the Department of Veterans Affairs. 
H.R. 1506, sponsored by Congressman O'Rourke, would address 
VA's longstanding recruitment and retention challenges by 
increasing the caps for VA's Education Debt Reduction Program.
    H.R. 2322, sponsored by Congressman Walberg, would improve 
care for injured and amputee veterans, and clarify what those 
in need of prosthetic and orthotic care are entitled to from 
VA, including access to timely and quality care, either in VA 
or in the community, that best meets their needs and goals.
    H.R. 3832, sponsored by Dr. Dunn, would help prevent opioid 
abuse among veterans by allowing for the greater sharing of 
information between VA and state-based prescription drug 
monitoring programs.
    H.R. 4334, sponsored by Congressman Correa, and H.R. 4635, 
sponsored by Congressman Coffman, would improve care for women 
veterans by collecting information regarding access to gender-
specific care in the community and environment of care 
standards in VA medical facilities, and requiring a sufficient 
number of peer-to-peer counselors for women veterans 
respectively.
    The draft bill, the VA Medicinal Cannabis Research Act of 
2018, which is sponsored by Ranking Member Walz with Chairman 
Roe and Congressmen Correa as original co-sponsors, would 
authorize VA to conduct and support research on the efficacy 
and safety of medical marijuana for veterans with chronic pain, 
post-traumatic stress disorder, and other conditions.
    Finally, the draft bill to make certain improvements in the 
Family Caregiver Support Program, which is sponsored by 
Chairman Roe, would require the implementation of an 
information technology system to support VA's Family Caregiver 
Support Program, and then reform and expand that program.
    I look forward to learning more about each of these bills 
and draft proposals today. I am grateful to each of the bill 
sponsors for their leadership on these issues and for being 
here to testify on our first panel. I am also grateful to our 
veteran service organization partners for being here to provide 
their views on these bills on our second panel.
    I now yield to Ranking Member Brownley for any opening 
statements she may have.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Mr. Chairman and Ranking Member 
Walz, for being here and thank you to all of today's witnesses 
for participating in our legislative hearing.
    I am excited to discuss the legislation on today's agenda. 
Each piece of legislation is in response to a serious issue or 
concern affecting our veterans' health care. I look forward to 
hearing from our witnesses addressing any concerns ahead of a 
future markup and moving these important reforms forward.
    As a co-sponsor of several of the bills before the 
Subcommittee today, I am proud of the work being done within 
this Committee and throughout this congress to preserve and 
enhance the VA health care so that many veterans utilize, 
value, and recommend.
    During my time on this Committee, I have made it a special 
priority to ensure women veterans have access to high-quality 
gender-specific care in a safe and welcoming environment. I 
believe that two of the bills on today's agenda will advance 
this goal.
    The Improving Oversight of Women's Veterans Care Act 
requires the VA to practice oversight on the community care 
providers that the VA contracts with to provide gender-specific 
health care to women veterans. We need to do a better job 
tracking the quality of care provided to women veterans and 
conduct effective oversight to ensure that they are well served 
no matter where they get their care.
    I am also excited to lend my support for Congressman 
Coffman's legislation to require the VA to ensure that 
veterans' peer counseling programs includes enough peer 
counselors for women veterans. It is clear that peer-to-peer 
counseling is an effective way to reach veterans that may not 
be willing to submit to a formal mental health care treatment 
plan. Peer-to-peer counseling is meant to be sensitive to the 
specific culture of the military and how that culture affects a 
veteran's experience.
    It is integral that veterans seeking peer-to-peer 
counseling are afforded an opportunity to speak with a peer 
that they can relate to, and for many women veterans their most 
relatable peer will be their fellow women. I appreciate 
Congressman Coffman's leadership on this issue and look forward 
to further discussions on the merits of his legislation.
    Finally, I am eager to hear from the Ranking Member of the 
VA Medicinal Cannabis Research Act of 2018. I will leave it to 
the Ranking Memberto discuss its merits, but I will say I am 
proud to co-sponsor the legislation because I believe the VA 
must continue to look at complementary and alternative 
treatments, such as cannabis, that can help veterans cope with 
the invisible wounds of war.
    Thank you also to Congressman O'Rourke and all of our 
colleagues for your legislation and your work supporting 
veterans. I look forward to your input and recommendations of 
our VSO partners. And Mr. Chairman, thank you and I yield back.
    Mr. Wenstrup. Thank you, Ms. Brownley. We are honored today 
to be joined by Ranking Member Walz who will be speaking about 
his respective draft proposal, and I want to thank you for 
being here today, and we will recognize you for five minutes 
for any comments you may have before we begin.

 OPENING STATEMENT OF TIM WALZ, RANKING MEMBER, FULL COMMITTEE 
                      ON VETERANS AFFAIRS

    Mr. Walz. Well, thank you Chairman and Ranking Member. 
Thank you both for your longstanding bipartisanship and your 
ability to bring good solid pieces of legislation forward that 
are able to be passed into law. I am grateful to be here with 
you.
    As a point of personal privilege, I wanted to point out we 
are joined today by a non-profit from Minnesota, Wiggle Your 
Toes, folks we were just talking to, that mission statement is 
pretty clear that they are out here to make sure that folks who 
have lost a limb have the capacity to be able to get back the 
life that they want, working with our veterans as well as some 
of our hero's in the Boston Marathon bombing, appropriate this 
week, so thank you for being here. And I will note that at 
least one of the Members here today is a fellow alumni of 
Minnesota State University Mankato, which the Chairman knows as 
the Harvard of the Midwest in its more common name. So just so 
you know, but thank you for that.
    I appreciate the opportunity to put this forward, and I 
want to thank the Chairman of the Full Committee, Dr. Roe, for 
working with us on this, and my friend and colleague from 
California, Mr. Correa, has been a champion of this. We all 
know that the issues that come with pain, whether they be 
physical or the mental injuries that come with serving this 
Nation, are great. We understand that there are incredibly 
powerful drugs that are able to help at times, but we also know 
the dangers of the abuses of opioids and other therapies that 
we want to try and move folks to.
    The VA has always been, since the early 1920s, this 
Nation's premier research institution, and they have a cohort 
of folks that we owe it to, to get the best possible treatments 
to. And one of the things that we are seeing across the country 
is veterans understanding that the potential for medicinal 
cannabis is great. And what we need to know, and what this Act 
does, is very simple. It simply clarifies that the VA has the 
capacity and the authority to do research into medicinal 
cannabis, and then it asks them to update Congress on where 
they are at.
    It doesn't mandate that they do it. It doesn't tell them to 
do it. It asks us to try and find the data to make sure it is 
there. And what this does is clarify because there have been 
some confusions, and the VA believes that because of being 
labeled a Schedule I drug, that they do not have the capacity 
to do this.
    They have the largest cohort. We have veterans suffering. 
We have the opportunity to do the research, and then find out 
once and for all if we can put this in. We have a patchwork 
system right now. If you are a veteran in one state you have 
access to medicinal cannabis, in another you do not. We don't 
have the hard research to show that the best way that we can do 
this. I want to give a special thanks to some of the partners 
in this, The American Legion, who has come out and asked us to 
find out if this works, find out the research, the VFW, and 
others.
    This is just one of the many things, and I am proud of all 
of you who have worked on here. It wasn't that many years ago 
when we were talking about acupuncture or yoga being 
alternative therapies that couldn't be embraced. Now, we have 
those things in the VA. This is the next step of ensuring that 
the VA has the best possible research, the best possible data. 
And if it is going to provide relief for our veterans, we 
should be looking into what is the next step in medicinal 
cannabis.
    So Mr. Chairman, I thank you for that. I thank you for the 
opportunity for introducing this, and again, I want to give a 
big thank you to Chairman Roe. We have a lot of medical doctors 
on this Committee, and I truly look towards your judgment and 
your ability to understand what we need to do to make sure 
before we start prescribing these. So thank you.
    Mr. Wenstrup. Thank you very much. I now want to introduce 
our first panel. It is a pleasure to be joined today by several 
of our bill sponsors, and I appreciate you all taking the time 
out of your afternoon to be here. With us here today is 
Congressman Beto O'Rourke from Texas, Congressman Tim Walberg 
from Michigan, Congressman Neal Dunn from Florida, Congressman 
Louis Correa from California, and Congressman Mike Coffman from 
Colorado.
    Mr. O'Rourke, if you are ready, you are now recognized for 
five minutes.

              STATEMENT OF HONORABLE BETO O'ROURKE

    Mr. O'Rourke. Thank you, Mr. Chairman. I wanted to speak a 
little bit about H.R. 1506, the VA Healthcare Provider 
Education Debt Relief Act of 2017 which I think will help us to 
address the crisis and provider shortage that we have in the VA 
right now. I think by the last VA Secretary's estimate, we had 
at least 30,000 authorized funded, but unhired, clinical 
positions in the VA. Every day that goes by without those 
positions being hired is another day that we fail to see 
veterans honor the commitment they have made with the care that 
they need, that they deserve, and that they have earned.
    This bill would increase the debt reimbursement available 
to providers for their medical school education from $120,000 
to $150,000. It would also provide the means in certain 
critical shortage areas to waive the cap altogether by working 
between the VA and the Department of Health and Human Services. 
This bill has support from a number of veteran service 
organizations. We have been working with the VA to improve the 
bill and I am grateful to have a chance to get feedback from 
Members of the Committee and veteran service organizations 
today about how we can get this done.
    And with that, I yield back. Thanks.

    [The prepared statement of Beto O'Rourke appears in the 
Appendix]

    Mr. Wenstrup. Thank you. Mr. Walberg, you are now 
recognized for five minutes.

               STATEMENT OF HONORABLE TIM WALBERG

    Mr. Walberg. Thank you, Chairman Wenstrup and Ranking 
Member Brownley. Thank you as well for giving me the 
opportunity to be back in this very special room, dealing with 
a very special constituency, that being our veterans. And thank 
you for allowing me to be here today to testify on H.R. 2322, 
the Injured and Amputee Veterans Bill of Rights.
    I would like to start off by thanking the Subcommittee 
Members and staff for their time and willingness to work with 
me on this very important issue.
    I think we can all agree that our veterans have earned the 
highest quality possible health care. I understand there are 
problems at the Veterans Affairs and that this Committee is 
diligently working to address these concerns to ensure our 
veterans receive the benefits and care they deserve. I also 
know there are great doctors, nurses, and staff that work hard 
to make sure our veterans receive timely care.
    With that being said, I believe a veteran's health care 
decisions are personal choices. We know all too well that the 
VA can be an intimidating and hard-to-navigate bureaucracy. 
There are layers of paperwork and red tape that can make these 
health care decision daunting.
    H.R. 2322 moves to empower veterans when it comes to making 
their own health care choices, and it does so by ensuring that 
injured and amputee veterans know their health care rights. 
Years on the battlefield has taken a toll on our war fighters. 
Our veterans are younger than before, and transitioning from 
active duty can be difficult. We need to ensure that amputee 
veterans have the best access to care and the ability to more 
easily transition into civilian life. The Injured and Amputee 
Veteran Bill of Rights is a bipartisan approach to empowering 
injured and amputee veterans in making their health care 
choices. This bill simply requires the VA to prominently 
display a list of rights in a VA orthotic or prosthetic OMP 
clinics, as well as their Web site.
    These rights include, and aren't limited to, the right to 
access the highest quality and most appropriate OMP care; the 
right to select the practitioner of their choice; the right to 
consistent and portable health care, including obtaining 
comparable services at any VA medical facility; the right to 
timely and efficient OMP care; the right to both a primary 
prosthesis and orthosis, and functional spare.
    Additionally, the VA should be required to educate their 
staff, so VA employees can help veterans navigate this process 
to make sure veterans are receiving the care they deserve and 
need. Our bill also requires the VA to follow up and resolve 
any complaints by veterans who believe the VA is not meeting 
their OMP needs.
    Mr. Chairman, at the end of the day, veterans should 
receive the best available and timely care they can get. I know 
this is something you and I, and your staff, have worked hard 
on and I applaud your unwavering commitment to our veterans. I 
am willing to work with you and your Committee in any way to 
better this legislation so that we can empower injured and 
amputee veterans when they are making their health care 
choices.
    Thank you for your time today and for the work this 
Committee is doing to keep our promises to our Nation's hero's. 
Thank you.

    [The prepared statement of Tim Walberg appears in the 
Appendix]

    Mr. Wenstrup. Thank you, Mr. Walberg. We are honored to 
have Chairman Roe here with us today, and Dr. Roe, if you would 
like to take five minutes to discuss your proposals for the 
Family Caregivers Support Program.

 STATEMENT OF HONORABLE PHIL ROE, CHAIRMAN, FULL COMMITTEE ON 
                        VETERANS AFFAIRS

    Mr. Roe. Thank you, Dr. Wenstrup. It is a pleasure to be 
here with the Subcommittee today, and there are a number of 
worthy pieces of legislation that we are going to discuss this 
afternoon, and I am particularly interested in
    Dr. Dunn's bill, the Veterans Opioid Abuse Prevention Act 
which would give improvement--would improve the Department of 
Veterans Affairs Communication with a state-based prescription 
drug monitoring program to help identify and address opioid 
addiction among veteran patients.
    I am also interested in Representative Walberg's just 
presented an Injured and Amputee Veteran Bill of Rights. That 
bill was discussed at the Committee's field hearing in 
Fayetteville, North Carolina a couple of weeks ago. And when 
clarified that those veterans were in need of prosthetic or 
orthotic services through VA are entitled to the very best care 
at the provider of their choice in light of the unique and 
highly individualized needs.
    And I am grateful that my draft bill to make certain 
improvements in the Department of Veterans Affairs Family 
Caregiver Support Program is included on the agenda for today's 
hearing. My draft bill would require the VA to implement an IT 
system to support the Family Caregiver Program, to use the data 
that the system collects to conduct an assessment of the 
program, and to use that assessment to identify and implement 
needed modifications, and to certify to Congress that the IT 
system and modified program are both working.
    From there, it would expand eligibility for the program to 
pre-9/11 veterans; amend eligibility for the program to 
veterans in need of personal care services due to an inability 
to perform three or more activities of daily living, ADLs, 
rather than the one or more ADL; grant VA the flexibility to 
change how the monthly stipends are calculated by removing 
certain requirements from the current law and requiring VA to 
promulgate regulations regarding stipend determination; require 
a primary caregiver to reside or agree to reside in ``close 
proximity'' with the veteran he or she is caring for, and 
defined close proximity as one that allows regular in-home 
management care, supervision, or treatment; require VA to 
develop and publish in the Federal Register a plan to 
transition those currently approved for the program to the 
amended program.
    This draft has been in development since the Full Committee 
hearing on the program in early February and has been the 
subject of multiple round table discussions with VA and veteran 
service organization since that time. While this bill remains a 
work in progress, I appreciate the thoughtful feedback provided 
in those conversations, and look forward to continuing to work 
with all interested stakeholders on moving this forward.
    I know that there has been much published discussion 
recently about a compromise agreement between Senator Isakson, 
Senator Tester, and me that would expand eligibility to the 
Family Caregiver Program to pre-9/11 veterans without making 
any changes to the eligibility criteria or stipend 
calculations. Inclusion of that provision was one of the chief 
concessions that I made to achieve a compromise agreement. I am 
committed to that compromise agreement and hope to see movement 
on it in the coming weeks.
    That said, negotiations are ongoing. I remain convinced 
that should negotiations prove unfruitful, we must have an 
honest conversation about the findings of right balance between 
clinical appropriateness and the costs within this program, and 
make needed changes to ensure it is working as intended for 
increasing its participants in such a dramatic fashion.
    I also want to mention the draft bill offered by Ranking 
Member Walz and myself to authorize VA to conduct research on 
the efficacy and safety of medical cannabis. As a medical 
doctor, I have written countless prescriptions, but never once 
in my life have I prescribed a drug which has not been proven 
effective by the FDA. Allowing VA to research medical marijuana 
will finally allow us to separate fact from fiction, and 
provide a scientific footing on which sound policy may be 
built.
    As you noted in your testimony, Mr. Celli, 92 percent of 
respondents in veteran households' support researching the 
effort of medical cannabis for mental and physical conditions. 
That is a statistic that should not be ignored. I thank The 
American Legion for leading this effort, so we might, at last, 
find out if medical marijuana is a viable treatment option for 
our Nation's veterans. I look forward to hearing everyone's 
comments on legislation today.
    With that, I thank you again for allowing me to be here 
today, Dr. Wenstrup, and I yield back the balance of my time.
    Mr. Wenstrup. Thank you, Dr. Roe. Dr. Dunn, you are now 
recognized for five minutes to discuss H.R. 3832.

                STATEMENT OF HONORABLE NEAL DUNN

    Mr. Dunn. Thank you very much, Chairman Wenstrup, and thank 
you, Chairman Roe, for your kind words. And I appreciate the 
opportunity today to speak on behalf of H.R. 3832, the Veterans 
Opioid Abuse Prevention Act.
    According to the Centers for Disease Control, 249 million 
prescriptions were written by health care providers in 2013. 
The Department of Veterans Affairs Health Care System is the 
largest health care provider. Because of this, it is in a 
unique position to help curb the opioid epidemic by using every 
tool available when a veteran is prescribed an opioid. The 
Veterans Opioid Abuse Prevention Act gives the VA health care 
providers access to these valuable tools.
    H.R. 3832 comes directly from recommendations from the 
Nation's top policymakers, the White House Commission on 
Combating Drug Addiction, and the Opioid Crisis recommended 
last July that the VA lead efforts to have all state and 
Federal prescribing drug--or prescription drug monitoring 
programs, known as PDMPs, share information.
    The interim report cited multiple published best practices 
for PDMPs, and has identified interstate data sharing as among 
the top priorities to ensure that health care professionals 
have a better understanding for prescribing practices for their 
patients.
    H.R. 3832 directs the VA to have health care providers 
participate in the sharing of prescribing data, across a 
network of interstate prescription drug monitoring programs. 
PDMPs are state-based networks which can access when--which 
providers can access when writing or filling prescriptions. And 
PDMP data includes the type of the medication, the fill dates, 
and the dosage amounts. PDMPs improve a clinician's ability to 
follow good prescribing practices for at-risk patients who may 
have a pattern of prescription opioid abuse.
    In 2011, the National Board of Pharmacy created a national 
platform of prescription monitoring programs, PMPs, called PMP 
Interconnect, which allows the various states to share the PDMP 
data across state lines securely. Today, 44 states and 
Washington, D.C., participate in the PMP Interconnect and more 
states are adding all the time. My own state, Florida, is 
adding now.
    I have veterans in my district who are desperate for 
opioids because well-meaning but underinformed physicians 
repeatedly over-prescribed opioids for them. I can guarantee 
everyone sitting on this dais today has veterans back home 
suffering for the same reason, and let me be clear, this is not 
something that anyone up here on this dais or in this room 
should accept as good treatment for veterans. The tragedy in 
these situations is that so many of them are preventable just 
by giving doctors the right tools and the right information on 
how to prescribe these safely to which patients, and we want to 
make this a high priority.
    H.R. 3832 implements the commission's recommendation by 
granting providers the ability to use an interstate PDMP 
platform for the betterment of our veterans who are at risk of 
opioid abuse. Every doctor has a duty to help the sick, and 
according to one's ability and judgment. So as a Committee, we 
have a duty to ensure the veterans have access to doctors who 
are enabled to make the best clinically informed decision for 
the veterans.
    I encourage my colleagues to support H.R. 3832, and I yield 
my time back, Mr. Chairman.

    [The prepared statement of Neal Dunn appears in the 
Appendix]

    Mr. Wenstrup. Thank you, Dr. Dunn. Mr. Correa, you are now 
recognized for five minutes.

               STATEMENT OF HONORABLE LUIS CORREA

    Mr. Correa. Thank you, Mr. Chairman Wenstrup, Ranking 
Member Brownley, and Members of the Subcommittee for the 
opportunity to speak on my bipartisan bill H.R. 4334, the 
Improving Oversight of Women Veterans Care Act, and I want to 
thank my friend and colleague, Ranking Member Brownley, for her 
support of this legislation.
    Women represent the fastest growing population of veterans 
in our society. In 2015, women represented 9.4 percent of the 
total veteran population. By 2045, this number is expected to 
go above 16 percent. Yet according to the GAO, the Veterans 
Health Administration does not have performance measures to 
determine women's veteran accessibility to gender-specific 
care.
    My bill will enhance the monitoring needed for effective 
oversight of women's veteran's health by requiring the VA to 
submit an annual report on veteran access to gender-specific 
care under community care contracts, and quarterly reports on 
environment of care standards for women veterans. This will 
ensure that we understand women veterans' ability to access 
gender-specific health services.
    I understand my bill may require technical edits, and I am 
open to working with the Committee and others to address those 
needed changes. Again, I thank you for the chance to speak 
before this Subcommittee.
    I yield.

    [The prepared statement of Luis Correa appears in the 
Appendix]

    Mr. Wenstrup. Well, thank you. And Mr. Coffman, you are now 
recognized for five minutes.

              STATEMENT OF HONORABLE MIKE COFFMAN

    Mr. Coffman. Thank you. Chairman Wenstrup and Ranking 
Member Brownley, thank you for allowing me to present H.R. 
4635, the Peer-to-Peer Counseling Act that I introduce with 
Congressman Esty to improve VA counseling afforded to female 
veterans. I would also like to thank the Members of the 
Subcommittee who co-sponsored H.R. 4635, Ranking Member 
Congresswoman Brownley, Representative Bilirakis, 
Representative Kuster, Representative Radewagen, Representative 
O'Rourke, Representative Rutherford, and Representative 
Gonzalez-Colon.
    Currently, female veterans make up nearly 10 percent of our 
Nation's veteran population, and this population is expected to 
grow to 15 percent by 2030. Over the past ten years, the VA has 
seen a 45 percent increase in the number of female veterans 
using VA benefits, demonstrating that female veterans are 
relying more and more on VA services. And as the female veteran 
population increases it is critical for VA to meet future 
demand.
    One area of need among female veterans that warrants our 
particular attention is peer-to-peer counseling. Unfortunately, 
many female veterans have experienced sexual trauma and PTSD 
while serving in the military, and are also suffering from 
other mental conditions that put them at risk for homelessness. 
Peer counseling can help female veterans who are facing these 
critical issues.
    The VA's 2016 suicide data report found that the risk of 
suicide for female veterans was 2.4 times higher than non-
female adult females, and the rates of suicide increases more 
among women than men. The data is disturbing. We owe it to our 
female veterans to ensure sufficient resources are available to 
assist with gender-specific needs, and that is why I introduce 
H.R. 4635, the Peer-to-Peer Counseling Act.
    H.R. 4635 enhances the VA's existing peer-to-peer program 
which has been successful in providing peer counseling to all 
veterans by ensuring the current program has a sufficient 
quantity of female peer counselors for female veterans who are 
separating, or newly separated, from military service. Ideal 
counselors will have expertise in gender-specific issues, VA 
services, and benefits focused on women, as well as employment 
mentoring.
    The Act also would emphasize counseling services for female 
veterans who have suffered sexual trauma while serving in the 
military, have PTSD, or any other mental health condition, for 
our female veterans who are at risk of homelessness.
    To ensure these counseling services are not only available 
but also known throughout the veteran community, H.R. 4635 
directs the VA Secretary to conduct outreach to inform female 
veterans about the peer-to-peer program and the services 
available to women.
    H.R. 4635 authorizes the VA Secretary to facilitate 
engagement and coordination with community organizations, state 
and local governments, institutions of higher learning, and 
local business organizations. With the help from our 
communities, we can leverage resources and expertise that exist 
within these communities.
    Peer-to-Peer counseling. The Peer-to-Peer Counseling Act 
ensures VA's peer-to-peer program is better postured to address 
the gender-specific needs of women veterans and updates this 
vitally important program to better represent the growing 
veteran population it serves.
    Mr. Chairman, I encourage my colleagues to support this 
important legislation and I yield back the remainder of my 
time.

    [The prepared statement of Mike Coffman appears in the 
Appendix]

    Mr. Wenstrup. Well, thank you, Mr. Coffman. I thank 
everyone from the first panel for being here today, and you are 
now excused. I will now welcome our second panel to the witness 
table.
    Joining us on our second panel is Louis J. Celli, Director 
of the National Veterans Affairs and Rehabilitation Division of 
The American Legion; Adrian Atizado, the Deputy National 
Legislative Director for the Disabled American Veterans; Sarah 
S. Dean, Associate Legislative Director for the Paralyzed 
Veterans of America, and Kayda Keleher, Associate Director for 
the National Legislative Service of the Veterans of Foreign 
Wars of the United States.
    While VA is unable to be here, I do look forward to 
receiving the Department's views for the record, and appreciate 
our veteran service organizations for their time and attendance 
this afternoon.
    Mr. Celli, we will begin with you. If you are ready, you 
are recognized for five minutes.

                  STATEMENT OF LOUIS J. CELLI

    Mr. Celli. Tree bark, mold spores, poppy, cocoa, 
rhododendrons. There are more than a hundred distinct chemical 
substances that are derived from organic plants being used in 
pharmacology today. From these organic substances, we enjoy the 
benefit of aspirin, a tranquilizer called Rhomitoxin, codeine, 
and morphine, and in 1928, a petri dish contaminated with 
floating mold spores changed the course of human history by 
introducing the first antibiotic, penicillin.
    General Wenstrup, Ranking Member Brownley, distinguished 
Members of the Subcommittee on Health, on behalf of National 
Commander Denise Rohan and The American Legion, I am honored to 
be able to testify on the following and pending draft 
legislation.
    According to The National Institute of Health, cannabis is 
a complex plant with over 400 chemical entities, of which more 
than 60 of them are cannabinoid compounds. Today, 30 states 
have medical cannabis laws that allow patients to use cannabis 
for illnesses ranging from inflammation and pain to epilepsy 
and cancer, and all 50 states have legalized one of the 
chemical derivatives, cannabidiol or CBD, as it is more 
commonly known today.
    And yet there isn't a single physician who has been 
formally trained by an accredited U.S. based medical school on 
what this plant can or can't do. There is no education that 
discusses medicinal use, drug interaction, placebo effect, 
dosage rates, strains, or anything else regarding this plant 
because the United States Drug Enforcement Agency continues to 
insist that cannabis has, and I quote, ``No currently accepted 
medical use, and a high propensity for abuse,'' as opposed to 
Schedule IV drugs, like Xanax, Darvon, Valium, Ativan, Ambien, 
and Tramadol, which according to the DEA have a low propensity 
for abuse and low risk of dependence.
    The National Academy of Medicine recently reviewed 10,000 
scientific abstracts on the therapeutic value of cannabis and 
reached nearly a hundred conclusions in a 2017 report. And yet 
the United States continues to lag behind other developed 
Nations by restricting scientific research into this drug. The 
draft legislation will call on VA to conduct the research 
necessary to determine if the cannabis plant, marijuana, has 
medical value or not. Our veterans are asking for this 
research, and our Nation has an obligation to provide it.
    Next, I will address H.R. 1506, the Health Care Debt 
Reduction Act. The Department of Veteran Affairs went from 
33,000 vacancies in 2016 to 43,000 vacancies today, a 30 
percent increase. The Department has been the subject of 
intense scrutiny over the past several years, and rightfully 
so, but along with that scrutiny comes responsibility, the 
responsibility to be fair and balanced. The VA operates the 
largest health care network in the country, some say in all the 
world, and just like any large organization, VA has a board of 
directors, you.
    We often compare VA to private industry. We hold them up 
against private metrics, quality standards, efficiencies, wait 
times, and cost benefit ratios, but we fall short when it comes 
time to argue that the employees' pay needs to be competitive 
to their non-government peers. H.R. 1506 can help fix that by 
making VA a more attractive employment option for our health 
care community by offering to pay some of their student debt. 
Will this solve the problem? Not entirely, but what it will do 
is prove that we are willing to invest in high quality 
professionals to care for our wounded and ill veterans.
    The Veterans Opioid Abuse Prevention Act will bring VA 
online with state-based prescription monitoring programs. This 
is in the best interest of patients and helps doctors provide 
holistic quality medicine at the Federal level. Patients 
commonly have multiple doctors, and it is especially true for 
veterans who because of their combat related injuries commonly 
suffer more co-morbidities than their civilian counterparts.
    In the absence of a single lifetime medical record that can 
be accessed and shared among all patients--medical 
professionals' participation in a unified database that helps 
guard against drug interaction and duplication of prescriptions 
is an important step in ensuring veterans receive proper and 
accurate care.
    Next, peer-to-peer counseling has always been a preferred 
counseling medium, long supported by The American Legion. VA's 
hundreds of vet centers were built on this very premise, and 
The American Legion continues to support this reliable, 
individual, peer-to-peer counseling where veterans who have had 
similar experiences can share their stories and tactics for 
recovery. That said, we support H.R. 4635.
    At this time, we are unable to support H.R. 2322, the 
Injured Amputee Veterans Bills of Rights Act because it appears 
to be missing some language which appears to be a very simple 
fix. The American Legion is committed to ensuring that all 
veterans, especially those with catastrophic injuries, receive 
expert care. We just have to be careful that we don't create a 
mechanism whereby VA has no control over how that care is 
delivered or how the government will pay for it. We wouldn't 
have an issue if the bill contained the passage that is 
reflected in the VA Handbook stating, ``Or the veteran's 
preferred prosthetist who has agreed to accept the preferred 
provider rate,'' which unfortunately, this bill is missing.
    Thank you and I look forward to your questions.

    [The prepared statement of Luis J. Celli appears in the 
Appendix]

    Mr. Wenstrup. Well, thank you. Mr. Atizado, you are now 
recognized for five minutes.

                 STATEMENT OF ADRIAN M. ATIZADO

    Mr. Atizado. Mr. Chairman, Members of the Subcommittee, I 
want to thank you for inviting DAV to testify at this 
legislative hearing today. As you know, DAV is a non-profit 
service organization. We provide a lifetime of support to all 
generation of veterans, and we have been helping more than a 
million veterans each and every year to better their lives and 
empower them.
    I am pleased to offer DAV's views for your consideration on 
the bills for today's hearing. I would like to start off with 
comments to H.R. 1506. DAV urges the Subcommittee to pass this 
bill, The VA Healthcare Provider Education Debt Relief Act of 
2017, which would improve VA's ability to compete with other 
entities in recruiting and retaining high-quality clinicians to 
take care of our Nation's veterans and provide them 
comprehensive care.
    In our testimony, we make recommendations to improve this 
critical piece of legislation and make it stronger. One, we 
would like to see the deadline for this program be extended 
beyond its current date. Two, we would like to make sure that 
there is increased funding for this program. And three, we 
would like just the Subcommittee to review the staffing for 
this program. According to VA, it requires one staff for any 
additional 1,000 participants in the program, and if we want to 
consider effective use of monies and keep VA accountable, I 
think that is something this Committee should be looking at.
    As you are aware, the average debt that a medical student 
graduates in 2017 is about $190,000, and the student loan, this 
debt, weighs heavily on them when they consider their 
employment. And I think EDRP is one of the most successfully 
utilized programs that VA has. Combined with the caps that this 
Committee had passed and agreed to in 2014, not only has the 
number of participants in this program increased, it has also 
increased the average amount of award, meaning for the same 
amount of money we are having to provide more and more.
    Last year GAO found that local facilities depleted their 
EDRP budgets early in the physical year. They were not able to 
commit to provide debt reduction payments to incoming students 
and clinicians because they simply ran out of money. This bill 
would also amend the condition in which VA could waive these 
authority--these statutory caps. We do ask the Committee review 
that this does not--and we know this is not the intent, but we 
hope that it doesn't impinge on the ability for local 
facilities to use their current statutory authority in light of 
the ones that are being proposed now.
    DAV strongly supports H.R. 4334, The Improving Oversight of 
the Women Veterans Care Act of 2017. This bill would improve 
current efforts to ensure access to quality gender-specific 
health services provided through community care contracts as 
well as highlight VA facilities' performance in meeting 
standard that they have agreed to meet with regard to 
environment of care.
    As this committee knows, women veterans are about 10 
percent of the veteran population in total, and it is growing. 
We have got 20 percent of new recruits are women veterans, 15 
percent of active duty are women veterans, and 18 percent of 
Guard and Reserve are women--or are female servicemembers. The 
provisions in this bill, Mr. Chairman, are consistent with the 
recommendations of DAV's report. We issued that report in 2014. 
It is called Women Veterans: A Long Journey Home.
    This report spans the breadth and depth of all Federal 
assistance that is available to women veterans, and we make 
recommendations in every single one of those. We are in the 
process of updating this report, and we would be so happy to 
brief the Subcommittee as well as the Full Committee on those 
findings.
    DAV also is pleased to offer its support for H.R. 4635, 
which would increase the number of peer-to-peer specialists to 
provide women veteran support and counseling tailored to them 
and their needs. We recommend the Subcommittee consider adding 
funding for this program to ensure peer specialists are given 
priority among other critical clinical professional vacancies 
that VA has to fill.
    Mr. Chairman, VA's existing peer support program has been 
shown to be effective in assisting patients to not only become 
more active and more engaged in their treatment, but to be 
empowered, to be able to advocate for themselves, and it 
improves patient satisfaction as well as their quality of life. 
Facilities such as West Palm Beach, Chillicothe, Cincinnati, 
they have shown that this program is quite effective for their 
patient population.
    Women peer specialists are available to assist and guide 
other women veterans in accessing the services that they need, 
which is the bulk of the legislation for today's hearing.
    This concludes my statement, Mr. Chairman. I would be happy 
and be pleased to answer any questions you or other Members on 
the Subcommittee, may have.

    [The prepared statement of Adrian M. Atizado appears in the 
Appendix]

    Mr. Wenstrup. Thank you, very much. Ms. Dean, you are now 
recognized for five minutes.

                   STATEMENT OF SARAH S. DEAN

    Ms. Dean. Chairman Wenstrup, Ranking Member Brownley, and 
Members of the Subcommittee, Paralyzed Veterans of America 
thanks you for the opportunity to present our views on the 
legislation before you today.
    PVA supports H.R. 3832, the Veterans Opioid Abuse 
Prevention Act. Given the specialized needs of veterans, it is 
not uncommon for some to travel to different states to receive 
their care. And there is no assurance that the prescription 
data of a veteran who receives care at an SCI center in 
Minneapolis, but lives in Wyoming, can be shared. We urge the 
Subcommittee to ensure--to make sure these specialized patient 
populations are benefitting from the opioid safety measures in 
the same way as non-traveling veterans. H.R. 3832 is the means 
to do just that.
    PVA strongly supports H.R. 1506, the VA Healthcare Provider 
Education Debt Reduction Act of 2017. We believe VA must be 
adequately resourced to attract the best and brightest medical 
professionals, and the Education Debt Reduction Program has 
been a markedly successful means to do just that. As there is a 
current and worsening provider shortage in the United States, 
VA must be able to insulate, as best as possible, veterans' 
care from this trend.
    That new residents are hesitant to take a post in an 
underserved community should come as no surprise. The cost 
burden of their education and training is an overwhelming 
prospect, and debt is all but guaranteed. No matter how eager 
to serve any resident may be, a career at an understaffed VA 
may not be a tenable choice, and loan assistance can cultivate 
a culture of commitment from those unburdened by their debt and 
revive areas too long stressed by continuous shortages.
    PVA appreciates deeply the work of this Committee this year 
on behalf of the Caregiver Program. Your staffs have maintained 
a thoughtful and open dialogue on the issues of the draft 
before us and we thank them for that. The draft addresses, in 
part, the greatest malformation of the current program, the 
unequal treatment of veterans with the same service-connected 
needs. And for eight years, VSOs have asked Congress to reckon 
with this unjustice, and we appreciate the Members' commitment 
to that goal.
    This draft does address it, but does so in a way that 
creates a different imbalance. It strikes the date of injury 
requirement, but raises the clinical eligibility from one or 
more activity of daily living to three. And while this would 
make a still imperfect program, it is an imperfection that my 
members, veterans with spinal cord injuries, can endure a 
little easier knowing that they and their caregivers are 
finally receiving the clinical supports and services their 
injuries require.
    Our support for this draft is not any statement on the work 
and sacrifices of those with one or two ADLs. Our position 
remains the full expansion of the current program, but my 
members can't unhear the ticking clock in their lives, not just 
the decades of work their caregivers have done unsupported and 
unacknowledged, but the very real sensitivity of the time they 
have left to them and their wish to spend that time at home.
    We appreciate the cost and quality considerations of the 
draft, and while we support it, we do so as a first step 
because two activities of daily living due to injury or a 
disease are still activities of daily living that a veteran 
need someone else to do because they were injured in their 
service. PVA's organizational mandate is to expand and improve 
the current program to all veterans with catastrophic service-
connected injuries or illnesses, and in this moment in time, 
the means to most closely accomplish that mandate is the 
negotiated package that was to be included in the omnibus last 
month.
    That would see that the equal treatment of injured veterans 
is done by striking the 9/11 date. This issue is an urgent one, 
and aside from any consideration of cost savings, of 
institutional care, or the right way to do eligibility, the 
majority of veterans today are over 65. And those injured 
because they served are having conversations about what the 
rest of their lives will look like, and their caregivers are 
wondering if they can continue to do this alone. These families 
need the financial and clinical supports of this program right 
now. We ask the Subcommittee to see that some relief in some 
form is finally provided to those who need it most as soon as 
possible.
    Mr. Chairman, PVA thanks the Subcommittee and I am happy to 
answer any questions you may have.

    [The prepared statement of Sara S. Dean appears in the 
Appendix]

    Mr. Wenstrup. Thank you very much.
    Ms. Keleher, you are now recognized for 5 minutes.

                   STATEMENT OF KAYDA KELEHER

    Ms. Keleher. Chairman Wenstrup, Ranking Member Brownley, 
Members of the Subcommittee, it is my honor to represent the 
1.7 million members of the Veterans of Foreign Wars of the 
United States and its Auxiliary.
    The VFW is pleased to support bills H.R. 4334 and 4635. As 
you all know, women veterans are the fastest growing 
demographic within the veteran population, and the VFW has 
worked hard alongside Congress and VA to make sure they are 
able to access the best health care possible. While a lot of 
progress has been made, there is still room for improvement.
    H.R. 4635 would be an outstanding asset for VA to be able 
to increase the number of peer-to-peer counselors for women 
veterans who have survived sexual trauma, are diagnosed with 
post-traumatic stress disorder, struggle with other behavioral 
health conditions, or are deemed at risk for homelessness.
    With the hardships faced by these women, including 
increased rates of suicide and homelessness, this legislation 
would be an invaluable benefit.
    H.R. 4334 would be instrumental in providing oversight for 
Congress and VA. This bill would provide oversight for women 
who choose VA, but must still receive care in the community for 
sex-specific appointments. By doing this, we would be assuring 
that patients still receive the highest quality of care 
possible.
    The VFW believes the expansion of VA's Program for 
Comprehensive Assistance for Family Caregivers is long overdue 
and agrees with the intent of this draft legislation, but has 
very serious concerns with it as currently written. The VFW 
would oppose setting arbitrary eligibility requirements, such 
as increasing the criteria to three activities of daily living 
and efforts to lower costs.
    The VFW also has concerns with other aspects of this draft 
legislation, such as the lack of provisions addressing 
caregivers and veterans graduating out of the program. 
Currently, when and if a veteran improves and is slated to be 
removed from the program, there is a lump-sum totaling three 
months of their stipend paid from VA. This abrupt ending has 
resulted in financial, emotional, and medical distress of the 
veteran and their caregiver.
    In addition to this, the VFW believes equity between DoD 
and CMS must be provided by including those who are made ill 
due to their service.
    Moving ahead, the VFW looks forward to continuing to work 
with Congress in assuring the package of the Community Care 
Package from S. 2193 that includes the expansion of caregivers, 
which the VFW supports.
    The VFW is happy to support H.R. 5520 for reiterating VA's 
current authority for research on medical cannabis. With over 
half of the country's states legalizing marijuana, along with 
the current opioid epidemic and ongoing Forever War, the VFW 
believes it is medically irresponsible for VA providers to be 
left in the dark, not knowing about health outcomes and 
pharmaceutical interactions associated with medical marijuana. 
With veteran patients able to easily access medical marijuana 
legally, VA providers must understand the effects associated 
with patient's marijuana use. Many states and academic entities 
have already conducted research and now is the time for the 
next episode of medical cannabis research at the Federal level.
    Previous and current studies have found results showcasing 
how CBD helps patients with chronic pain and decreases opioid 
abuse relapses, an over-represented health struggle for 
veterans. While other studies show THC helps with varying 
symptoms associated with PTSD and cancer recovery -- also 
health concerns either over-represented or of high prevalence 
within the veteran community.
    This is all in addition to high prescription rates from VA, 
though better than those in the private sector, for opioids, 
benzodiazepines, and SSRIs, with little to no data showing how 
marijuana interacts with these FDA-approved drugs. This is 
particularly troubling as the only two drugs FDA approved for 
PTSD are SSRIs. Studies published by AMA show SSRIs are no more 
effective than placebos for most adult patients, and other 
medical research shows that SSRIs are only effective on less 
than half the adult population with depressive symptoms, all 
while medical providers and researchers scramble with 
addressing the highly-addictive negative outcomes that come 
with prescribing opioids, benzodiazepines, and other drugs
    The VFW knows VA is a leader in medical research. VA 
researchers have even won Nobel Peace Prizes in the past. This 
is why we believe that VA should lead the way in allowing our 
country to better understand medical marijuana for the safety 
of our Nation's veterans.
    Chairman Wenstrup, thank you again for the opportunity to 
present to you today, and I look forward to questions you or 
the Subcommittee Members may have.

    [The prepared statement of Kayda Keleher appears in the 
Appendix]

    Mr. Wenstrup. Well, thank you all very much. I appreciate 
your testimony here today. True professionals, you all neatly 
stay right under 5 minutes, I appreciate that. But I yield 
myself 5 minutes for questions.
    I want to start with you, Mr. Celli. You were talking about 
the draft bill to allow VA research on cannabis. You said in 
October 2017 there was a nationwide survey conducted The 
American Legion. Can you describe how the survey was conducted 
and what your findings were?
    Mr. Celli. I can. Thank you, Chairman Wenstrup.
    We hired an independent research firm and gave them some 
really basic questions, Dear Veteran, and they were responsible 
for going out and finding veteran households. They didn't use 
our members, some of them may have been coincidentally our 
members, but it was completely independent, it was hands-off, 
and we just waited for the results. And we asked them a series 
of different questions that gauged their interest in if 
cannabis should be legal medically, if the Federal Government 
should do research, if it should be rescheduled, and we have a 
complete printout of all of those results that we are happy to 
share with this Committee.
    Mr. Wenstrup. What was the response on the research part?
    Mr. Celli. The research was overwhelmingly positive in 
support of legislation that would allow for not only research, 
but also for medical use, overwhelmingly, it was over 90 
percent.
    Mr. Wenstrup. So from that were you able to be guided in 
any way, shape, or form for what type of specific research that 
the American Legion may be interested in the VA doing?
    Mr. Celli. So there is a host of different illnesses that 
the cannabis has been--you know, that our veterans have told us 
that cannabis has been successful for. PTSD is certainly one of 
them, but so is inflammation, so is pain management, epilepsy. 
There is just a variety of different illnesses that this drug, 
which it is a drug, has been successful in patients with.
    Mr. Wenstrup. Why, thank you. And I appreciate if you would 
forward over the results.
    Mr. Celli. I am very much happy to do that.
    Mr. Wenstrup. That would be very helpful. Thank you for 
doing that.
    Mr. Atizado, you talked about the family caregivers and the 
stipend involved. What do you think is a more appropriate 
stipend schedule, what would that look like?
    Mr. Atizado. So, Mr. Chairman, before I answer that 
question, I just want to give a little bit of background about 
the discussion that took place that yielded what we have now.
    At the time that the stipend schedule was being discussed 
from statute to be made into regulation and implemented as a 
program, the idea was the population being served was 
undergoing tremendous stress and strain, and the goal of having 
what is currently the current schedule is to give them a sense 
of stability, that they can count on whatever modest stipend 
that they would be receiving would offer them some financial 
stability and not add to the stress.
    And so the idea that VA decided to use was specifically the 
BLS survey of homemaker/home health aide wages, which is 
referred to in the statute. Now, the statute and the law didn't 
specifically tell them to use that, that is just what the 
agency decided to use. And in its regulation, it had noted 
there was wide variation in the amount of homemaker/health 
wages from any geographic region from one to another and that 
has led to these wild deviations from the norm or for the mean.
    And so we don't believe that the current issue with the 
stipend program being labor-intensive, as well as having such 
wide deviations in pay, is necessarily based on statute and we 
think VA could regulate themselves out of this mess in using 
what this Committee in holding its roundtable, there have been 
talk about maybe using a GS schedule which is both 
geographically reflective, as well as meeting the intent of the 
law of not being any less than what a homemaker/home health 
aide would receive pay for.
    So there are a number of schedules that VA can use that 
meets the intent of the law that doesn't incur this labor-
intensive and this wild deviation of stipends.
    Mr. Wenstrup. Thank you.
    With that, I will now recognize Ms. Brownley for 5 minutes.
    Ms. Brownley. Thank you, Mr. Chairman.
    My first question is really to all four of you. And thank 
you all for being here, and your constant and steadfast counsel 
is very, very helpful. So the question is, how would the lack 
of a grandfather clause--this has to do with the caregiver 
bill--the lack of a grandfather clause allowing currently 
enrolled veterans to continue to participate in the revised 
program impact the veteran caregiver community?
    In other words, we have got, you know, two different sets 
of standards and what do you think the impacts are going to be?
    Ms. Keleher. Thank you. The VFW, moving forward, we would 
not be in support of having two different standards between 
post-9/11 veterans and veterans who did serve beforehand. We do 
believe that including a grandfather clause if eligibility 
requirements are to change is absolutely necessary. It would 
provide clarity to not just the veteran, but to VA as well, for 
what the standard for those currently on it are.
    If by any means that eligibility requirement did change, 
there needs to be something set in stone saying that 
individuals who are currently on the program, even if they are 
not at the same eligibility requirement or standard moving 
forward, saying that they are safe, and they are going to 
remain on the program, and continue getting the support and 
recognition from VA that they have been receiving.
    Ms. Brownley. Any other comments from anyone?
    Mr. Celli. The American Legion could never support a bill 
that reduces benefits for veterans, just as simple as that.
    Ms. Brownley. So PVA has recommended the use of multi-
disciplinary teams in caregiver eligibility assessments in the 
past, Ms. Dean, so what disciplines would you like to see 
represented on the team?
    Ms. Dean. They already are being--that already is the way 
that the program is executed is to use multi-disciplinary teams 
as a way to sort of not allow for the whole decision to rest on 
one doctor at a facility, so that the pressure from the family 
or the veteran doesn't influence that one doctor's decision. So 
it is a team decision already and I think that should continue.
    Ms. Brownley. So, Ms. Keleher, on the medicinal cannabis 
issue you stated I think in your testimony it would be 
medically unethical for Congress to allow VA providers to stay 
in the dark on medicinal cannabis. Could you expand somewhat on 
that statement?
    Ms. Keleher. Yes. As a non-doctor, doctors are required to 
provide ethical treatment that is in the best interest of the 
patient. So particularly in the instance of VA, as a Federal 
entity and they are in states where it is medically legal, the 
VFW views it as being unethical for them not to understand the 
science and medical research behind the interactions, whether 
it be CBD or THC is actually more valuable than a 
pharmaceutical drug, or whether it is that there is an 
interaction between one of the pharmaceuticals that they are 
taking with their recreational or medical use.
    So we view it as being unethical that in a sense VA not 
having this research or the lack thereof with Federal research 
that these providers just they don't know, they are in the 
dark.
    Ms. Brownley. So, and to anyone who would like to answer, 
this particular legislation allows the VA to do research and I 
think that kind of codifies what the VA can already do, it is 
my understanding, but don't you believe that we should have a 
bill that says, you know, the VA should and must do the 
research in this area?
    Mr. Celli. Well, you know, I think that VA has really 
stepped up to the plate. Former Secretary David Shulkin had 
issued a memo stating that primary care physicians would have 
these conversations with their patients and in good faith, and 
would record that conversation in their medical records. 
Unfortunately, you know, to VFW's point, right now physicians 
don't have the clinical training because there is no research 
that the Federal Government supports that they can learn from. 
You know, it is a vicious cycle.
    We definitely think that the VA should do the research, but 
we also understand, you know, VA's apprehension of wanting to 
be at cross purposes with Federal law and their boss. So, you 
know, legislation is what they need, I think that is what we 
are here for today, and we support that.
    Ms. Brownley. Thank you very much.
    I have no more questions. I yield back.
    Mr. Wenstrup. Mr. Higgins, you are now recognized for 5 
minutes.
    Mr. Higgins. Thank you, Mr. Chairman.
    Mr. Celli, regarding your organization's position on 
medical marijuana, cannabis research, there have been thousands 
of studies around the world on this subject already.
    Mr. Celli. There are and, you know, the nice thing about 
having those studies already at the Federal Government's 
disposal is that, once they make a decision to study cannabis 
and take it off of Schedule I, put it down into, you know, a 
schedule that will allow medical institutions, allow colleges, 
allow the Federal Government to study it, they can then absorb 
those existing research studies. So they wouldn't have to start 
from ground zero, so it is very beneficial.
    Mr. Higgins. So isn't it, specifically regarding the VA, 
let's stay away from society in general for the moment, much to 
the chagrin of my friend at the rear of the room, let's focus 
on veterans, for a Federal program, wouldn't there have to be a 
federally mandated standard of THC within the cannabis?
    And hasn't this always been the difficulty amongst the 
thousands of surveys and studies that have been done around the 
world is not the question of whether or not cannabis has 
medicinal value, certainly I don't question it and I support 
it, by the way, but our challenge, isn't it to actually 
introduce cannabis medicinally into the Federal system, the VHA 
system, doesn't that challenge come down to the THC content and 
how to regulate that? We are talking about growing a plant. Or 
does the Legion support synthetic production of a medicinal 
equivalent?
    And just share with us what your thoughts are on that, 
please.
    Mr. Celli. Congressman Higgins, that is an excellent point, 
and what the Legion supports right now is research specifically 
to answer those very questions that you have. There is no 
standard dosage, there is no standard efficacy, there is no 
standard strength, and just like with an opiate, you wouldn't 
just randomly take a poppy plant, grind it up, and create your 
own opiates and decide that--
    Mr. Higgins. Exactly.
    Mr. Celli [continued]. --you are going to self-medicate.
    So the research absolutely needs to be done; it needs to be 
done professionally by scientists, it needs to be validated by 
the Federal Government, and then they can turn around and take 
this drug and they can distill it into whatever media or 
whatever delivery method that is appropriate for the patient 
based on the illness, and then they can deliver it that way.
    Mr. Higgins. Thank you for your clarification and you have 
just very eloquently explained why I support this draft 
legislation.
    Mr. Atizado, I believe we should support veterans if they 
would like to look outside the VA for their prosthetics. 
Reasonable accommodations should always be made to ensure that 
veterans receive the best care available according to that 
veteran's unique needs.
    Is it your understanding that the VA's policy pertaining to 
prosthetic or orthotics and other rehabilitative services have 
effectively changed, and are veterans now experiencing more 
difficulty or less getting the authorizations they need for the 
life-changing items when they use providers outside of the VA? 
Just share with the Committee, please, your feelings on it.
    Mr. Atizado. Thank you for that question, Congressman 
Higgins.
    So we, a lot of our members use VA's prosthetics and 
sensory-aid service by virtue of who our organization 
representations and are trying to serve. So, over the years the 
program, the service has actually changed, and because 
fundamental aspects of that program has changed over years it 
has impacted service delivery, but there is a catch. The change 
is supposed to have yielded some positive results, which we are 
still trying to engage VA to make sure that has happened, 
because there has been some problems getting the care and 
services and the items in a timely manner.
    We are very appreciative of VA actually creating my 
understanding is a complaint line that patients can actually 
call and get their attention, and get the leadership of the 
program's attention to address those situations in a more 
timely manner that has been occurring lately.
    And so to your question, it has had some growing pains, 
that it has adversely impacted patients who need this service, 
but we are working very closely with VA to improve them, 
because we hear from our members and other patients about these 
programs and we can identify possibly policy issues or 
statutory limitations to just make it work better for veterans.
    Mr. Higgins. Thank you for your answer, sir, very thorough.
    Mr. Chairman, I yield back, my time has expired.
    Mr. Wenstrup. Mr. Takano, you are now recognized for 5 
minutes.
    Mr. Takano. Thank you, Mr. Chairman.
    I want to just echo Ranking Member Brownley's comments 
about the Family Caregivers Program and I would like to back 
the sentiments of The American Legion that I would not support 
anything that would diminish the benefits for any veteran, and 
that I prefer what I see occurring with the Senate bill, which 
is to expand the current program to veterans to all eras is our 
best option. And so I just want to make sure we get that on the 
record now.
    But I want to move on to H.R. 1506, which has been the VA 
Care Provider Education Debt Relief Act of 2017, which has been 
offered by my colleague Mr. O'Rourke. How can Congress ensure 
that the authority granted under this legislation to increase 
the caps for educational debt is properly implemented and 
utilized following enactment?
    Mr. Atizado. Thank you for that question, Mr. Takano. I 
would have to direct you to VA and, unfortunately, they are not 
here to answer this question, but the EDRP program is well 
tracked by VA. They can project with a good amount of certainty 
the number of new applicants that will be coming into the 
program, as well as how many are currently in and how long they 
will be in.
    And so I think if you work with the department, with that 
agency, in identifying what they believe will be the new demand 
because of these new caps, I think you will get a very 
respectful answer as far as funding levels moving forward.
    Mr. Takano. Well, Mr. Atizado, in your written testimony 
you highlight the fact that the Education Debt Reduction 
Program is set to expire at the end of next year. What impact 
would that have on VA's ability to recruit and retain medical 
providers?
    Mr. Atizado. Well, so it would be quite devastating for 
these medical graduates, these clinicians. The award under this 
program is usually a multi-year award, and so what you will get 
is a number of current participants who probably, you know, are 
serving as clinicians in the VA health care system with an 
agreement that VA may not need. And so they will be saddled 
with these student debts that they thought would otherwise be 
taken care of, at least in part or if not in whole by the VA, 
suddenly find themselves having to repay those because of the 
extinguishment of this program, not to mention the number, the 
thousands of vacancies that are out there that facilities won't 
be able to fill simply because they don't have this as a tool 
at their disposal.
    Mr. Takano. So you are saying it is a very important tool 
to be able to bring medical professionals into our health care 
system, that without it these positions will continue to be 
vacant or we could see more vacancies occur as people leave the 
VA through separations or retirements.
    Mr. Atizado. Well, yes, sir. So that is actually a very 
good point. If this were to expire and they have these loans 
that they need to pay, they are likely going to get released 
from the agreement and probably seek employment elsewhere where 
they can have those debts extinguished.
    But to the point, you know, facilities use this program, 
the Education Debt Reduction Program, as well as another 
program called the Relocation, Recruitment, and Retention 
Program, the RRR Program. That program actually suffers from a 
cap as well, much like this. And so those two are actually very 
important tools that local facilities use to recruit new 
medical graduates, as well as retain high quality health 
professionals within the health care system, and because those 
two are under stress now, to us, we understand why VA's 
vacancies remain as high as they are.
    Mr. Takano. Well, I hadn't heard about the caps on this 
other program. What is the program called again, the RRR you 
said?
    Mr. Atizado. So it stands for Recruitment, Relocation and 
Retention. It got swept into the VA Choice bill that was 
enacted back in 2014 and it was swept into the cap for bonuses 
being paid.
    So we actually supported the idea of limiting bonuses being 
paid to clinicians because of poor performance, right? But the 
RRR is not a performance-based, it is actually a recruitment 
and retention instrument, but it somehow got pulled into those 
caps. And we have been working very closely with not only the 
Full Committee, but the Senate VA Committee to address that 
issue as well.
    Mr. Takano. All right. Well, thank you very much.
    My time is up. I'm sorry I went over, Mr. Chairman, and I 
yield back.
    Mr. Wenstrup. Mr. Rutherford, you are now recognized for 5 
minutes.
    Mr. Rutherford. Thank you, Mr. Chairman.
    First, I would like to say that I am a strong supporter of 
improving and expanding the loan-repayment program at VHA and 
that is why I offered my VA Physician Recruitment Act, which 
includes that loan repayment, as an amendment to the Choice 
legislation that the Committee agreed to and moved earlier last 
year.
    Everything Mr. O'Rourke said highlights the fact that we 
have got to get this right and we have got to get it right 
soon, because half of all providers in VA are eligible for 
retirement within the next 10 years. That is a scary thought.
    And what is even scarier is the Senate Choice Act, their 
proposal still extends the Graduate Medical Education Program 
as a way to bring more doctors into the system. However, in 
hearings that we have had with the previous Secretary and Dr. 
Clancy, we have learned that, number one, this is more 
expensive, less effective, and potentially brings in less 
qualified physicians to care for our veterans, where loan 
repayment provides VA with more flexibility to recruit the most 
qualified candidates.
    And so, Mr. Atizado, can you give me your perspective on 
the GME versus the loan repayment? The GME as it still remains 
in the Senate Choice Act.
    Mr. Atizado. So, Congressman Rutherford, I first have to 
let you know that I think we do support the GME proposal. We 
think VA frankly needs every tool in the bucket that they can 
have in there. Certainly, GME has its own purpose and it is 
successful in its own way, but I don't believe the two should 
be seen as a competition. I think they both work in different 
ways to enhance the local facility, fill a critical need.
    I think GME works in areas where there are facilities who 
have very strong affiliate relationships where they have that 
pool of talent that comes in to help care for veterans, both in 
the academic institution as well as in the VA facilities, and I 
think that program works very well, but not all facilities have 
that kind of relationship with an affiliate. And so these other 
tools, these financial-incentive tools, become more important 
for those other facilities.
    So I think those two are good programs and each--
    Mr. Rutherford. Complementary?
    Mr. Atizado. I believe so, yes, sir, for the whole system 
as a whole to address its workforce shortage issues.
    Mr. Rutherford. Okay. Anybody else want to comment on that, 
GME vs. loan repayment? Okay.
    Let me share this experience too. Mr. Chairman, when I was 
sheriff in Florida, I had an opportunity, I was a legislative 
chairman for the Florida Sheriffs Association. When we actually 
as an association of 67 sheriffs advocated for Charlotte's Web, 
which is an extract of cannabis, very high in CBDs, but low in 
THC, and I have seen, I can tell you firsthand the results of 
Charlotte's Web on a little girl who was around eight or nine 
years old suffering a tremendous number of seizures every day. 
Her legs, she couldn't get out of bed, her legs had atrophied. 
With Charlotte's Web, a year later, that girl was up walking 
around.
    That is why I support this idea that we have to look at 
this drug, see what we can do to help individuals with a drug 
that I think for too long we have just mischaracterized--well, 
I don't want to--I am not defending marijuana, but I am saying 
there is a medicinal purpose and efficacy there that I would 
like to see studied.
    And so with that, Mr. Chairman, I will yield back.
    Mr. Wenstrup. Mr. O'Rourke, you are now recognized for 5 
minutes.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    Mr. Chairman, I have got to say I really appreciate the 
conversation today and the fact that on almost every one of 
these bills there seems to be bipartisan agreement on what it 
is we are trying to do here, and very helpful feedback from the 
panel, some constructive criticism that on at least the bill 
that we have authored, H.R. 1506, will incorporate into the 
changes that we will propose.
    And I agree with some of the panelists that perhaps the 
only complaint I have is that some of these bills do not go far 
enough. And I love what the Chairman is doing on the Family 
Caregiver Program, but I want to make sure, as one of the 
panelists said, that this is just a first step, it doesn't get 
us to where we are.
    And I think implied in some of the questions about medical 
cannabis is how much more study do we need to do for something 
that is legal in 29 states, that doctors are already 
prescribing. That veterans in Texas at least come up to me at 
town hall meetings and say this is the only thing that I can 
take that makes life livable for me, but I am treated as a 
criminal under the law in this state. How screwed up is that? 
And if we are going to wait for study upon study upon study for 
veterans to get the care they need, especially if it is an 
alternative to opioids, from which veterans are dying today.
    I had a town hall meeting in El Paso, a veteran came 
forward and he said, listen, the VA cut off my opioid 
prescription and I understand why the VA is doing this, but 
they didn't provide an alternative in its place and I am--and 
he said this in front of 200 people at the town hall--I am 
buying heroin on the street right now because this is how I can 
take care of this issue.
    I think we have got to go, you know, within the bounds of 
reason and medicine and science as quickly as we can to making 
sure that doctors can prescribe what they think is in the best 
interest of their patients, including cannabis or marijuana. I 
think we are there. And just given the number of states who are 
there, the number of countries who are there, the number of 
veterans who need it, I mean, let's get there.
    On the debt repayment issue--and we authored it--I don't 
think it goes far enough. I mean, that is my complaint. We 
should be much more aggressive in raising the caps, and if we 
have got between 30 and 40,000 vacancies, let's be aggressive 
on that. I mean, there are people literally dying right now 
because they cannot get in to see an appointment. We still have 
a crisis in veteran suicide, though the last Secretary made it 
his number one clinical priority.
    And so I think, especially in those under-served, in-demand 
professions I think of psychiatry, and the need for those who 
treat traumatic brain injury and post-traumatic stress 
disorder, let's make it as easy as possible to make the choice 
to practice medicine in the Veterans Health Administration or 
to stay there, if you are already there. And I think everyone 
is on the same page, it is just I want us to be as aggressive 
as possible. And so your comments about making sure that this 
is funded, that we get past the sunset, and that we do 
everything within our power to make this attractive hit home, 
and I will do everything that I can.
    And I just, I think within the context of $1.4 trillion in 
outstanding student loan debt, why do we make it so hard for 
people to better themselves, so that they can do better for 
their fellow Americans, especially in the VA. This is an 
investment this country absolutely should make. And so I hope 
there is bipartisan commitment to actually fund what we are 
proposing to authorize.
    So I don't really have a question. I think you all did such 
a great job in providing your feedback and we are taking notes 
on all this, and just I want to tell you that we are grateful 
for that.
    And I will yield back to the Chairman.
    Mr. Wenstrup. Thank you.
    Dr. Dunn, you are now recognized for 5 minutes.
    Mr. Dunn. Thank you, Chairman Wenstrup.
    My principal interest today has been the Veterans Opioid 
Abuse Prevention Act, one of the bills we are considering here. 
I don't have the sense, as Mr. O'Rourke said, I don't have the 
sense of any pushback from anybody, but I want to poll you 
explicitly. Do you have the sense in any of the VSOs that there 
is opposition to this prescription database sharing plan? Any 
of you or all of you.
    Mr. Celli. So based on the feedback from our veterans, it 
is not that there would be opposition to it, it is that there 
has been such a pendulum swing of, you know, the opioid crisis 
with veterans who are in chronic pain and on systemic lifelong 
opioid prescriptions, they are very concerned that their 
prescriptions will be reduced and that they will not be able to 
perform the daily functions that they are currently able to 
enjoy now.
    So any time there is legislation, legislative efforts, or 
efforts by our Federal Government to try to curtail the abuse, 
the patients who are taking this as prescribed get very 
nervous. So that would be the only thing.
    And the only other thing that I would add to that is, if we 
had the lifetime electronic medical record, we wouldn't need 
additional legislation specifically to track prescriptions. So 
I think that we have work to do in both of those areas.
    Mr. Dunn. So I appreciate that comment as a surgeon myself 
and I don't look forward to having my hands tied on how long I 
can prescribe a medicine for. I don't know that I can say that 
that won't happen, honestly, because as you have hinted at, you 
know, the Government tends to overreact when they react. So, 
you know, buckle up, it could be a bumpy ride, but I do agree 
with that.
    I do also want to make one more comment about the cannabis 
research. You know, we have a form of legal cannabis now that 
really has no abuse history at all, very effective. It is 
actually tetrahydrocannabinol, the stuff that makes you high in 
cannabis. And I just looked it, because I want to be sure I was 
right, it is a Schedule III drug. So it should be very easy to 
do research on, at least that form or that cannabinoid, which 
is just one of dozens to hundreds of cannabinoids in a 
marijuana plant and it is different than the cannabinoid that 
Congressman Sheriff Rutherford mentioned, which I am familiar 
with and is effective against, you know, seizure disorders in 
some children, and certainly want to make that available, it is 
available in Florida to children. I don't see a lot of veterans 
with that particular affliction, because it affects infant 
children.
    But, you know, I think we could study the THC in the 
Marinol, the generic name is Dronabinol and it is just 
tetrahydrocannabinol. So I don't know if you have any comment 
on that, but it is available, and it actually would be pretty 
easy to do research on a Schedule III drug, I think.
    Any thoughts?
    Mr. Celli. Well, the only thing that I would add to that, 
and I am not a scientist, but I do know that there are 
components within that tetra cannabinol that are in the 
Schedule IV--or in Schedule I, rather, that prohibits the 
Federal Government from authorizing--
    Mr. Dunn. Well, so that is a marijuana plant. So I am just 
saying--
    Mr. Celli. Correct, that is right.
    Mr. Dunn [continued]. --if you want to do research on THC, 
tetrahydrocannabinol, you can go at it all day long and it is 
not even a particularly controlled drug. I have prescribed it 
and it is only used currently for anorexia, and for pain 
potentiation in typically terminal patients, but, you know, it 
is a very available drug and I have never seen it abused, I 
have never seen it stolen, I have never heard of it, you know, 
walking out of a pharmacy. I wish Buddy Carter were here. But I 
think it is a pretty, you know, available drug for study right 
now.
    I have no other questions, Mr. Chairman, and I am happy to 
yield back.
    Mr. Wenstrup. Ms. Kuster, you are now recognized for 5 
minutes.
    Ms. Kuster. Thank you very much, Mr. Chairman, and thank 
you to all of you for being with us. I just want to join my 
colleagues that these are predominantly bipartisan bills and it 
is great to make progress here in the Veterans' Affairs 
Committee, and I have joined as a cosponsor on most of the 
bills.
    I want to direct some of my concerns. I appreciate the 
efforts that Dr. Roe has made to come up with a bipartisan 
compromise on the benefits for family caregivers, but I still 
am concerned about the policy proposed and the fact that it 
doesn't really resolve the fundamental lack of fairness between 
our post-9/11 and pre-9/11 veterans.
    This is just directed at any of the VSO witnesses. Besides 
increased cost to the VA, is there any other reason not to 
expand the program to include all veterans of all eras that 
require home caregivers?
    Mr. Celli. We believe it is only a cost issue.
    Ms. Keleher. Yes. The VFW doesn't see any reason to not 
expand to everybody as is. We do understand there is constant 
concern and some criticisms on VA for the way the current 
program has been implemented and road bumps that they have 
undoubtedly had along the way. But, again, VFW doesn't look at 
that as a reason to not expand for all eras of veterans.
    Ms. Kuster. I mean, sometimes, this is just my impression, 
I think we spend a whole lot of money trying to limit care and 
determine who is eligible for what, and I really like the way 
you said it that, you know, being unable to do two activities 
of daily living is a major constrain on someone's life that you 
need help with.
    So could the VSOs explain some of the potential unintended 
consequences of expanding benefits to only those with three or 
more activities of daily living? So, just briefly, examples of 
how that would be a problem.
    Ms. Dean. I think we have seen it the last 8 years of the 
program as is. This inherent unfairness about people who need 
these services, but are not allowed because of an arbitrary 
date. We are picking a new lucky cohort, essentially.
    Ms. Kuster. Well, now we're not only having an arbitrary 
date, but now we're having an arbitrary number of issues that 
you might have, which I can't imagine medically that has any 
basis in reality.
    And then could you give us some examples of veterans that 
would not qualify for expanded benefits, but reasonably might 
need additional help? Does anybody have an example of what this 
might look like?
    Mr. Atizado. So, in the current program now, you would have 
a significant majority who would fall under the one and two ADL 
who would have to be transitioned out and I can't even imagine 
the impact on their lives, not only on the veteran's, but the 
caregiver's and their families as well if that were to happen.
    I do want to make sure we understand, though, you know, the 
intent of the legislation is to operate to expand the program, 
within certain constraints, and so we appreciate that work. We 
very much appreciate the work that Congressman Roe has done, 
his staff has done to talk to us about how to do this within 
these constraints, and we appreciate that. But to echo my 
colleague's comments, we have an opportunity, we have an 
historic opportunity before us, before this Committee and the 
Senate and Congress, to actually not even have to talk about 
the proposed draft bill, because we are talking about actually 
expanding the current program to all eras. And I really have 
been thankful of my colleagues' support and all the Members' 
support to try and make that a reality this year. And so I 
would prefer we actually focus on making that a reality and 
then pick up, if that in case doesn't happen, then perhaps take 
up this conversation after.
    Ms. Kuster. Well, I would love to work with you on that, 
and I certainly think that is the direction we want to go.
    Otherwise, I just want to join my colleagues, anything that 
we can do to improve access to care for women veterans and also 
the veteran opioid abuse prevention, this is something that I 
have dedicated the past five years of my life. We have a 
bipartisan task force with 105 Members, Republicans and 
Democrats, trying to tackle the opioid epidemic all across our 
country. And I think the VA is where a lot of the innovative 
solutions will come from, both to lower the rate of opioid 
prescriptions by using alternative pain management, and also to 
help with this prescription monitoring program, and help with 
more efficient and effective methods for treatment and long-
term recovery.
    And I yield back.
    Mr. Wenstrup. I want to thank everyone once again. Thank 
you all for being here. I appreciate all the input you provided 
with us today and the second panel is now excused.
    And I ask unanimous consent that all Members have 5 
legislative days to revise and extend their remarks and include 
extraneous material.
    Without objection, so ordered.
    I would like to once again thank all of you, our witnesses 
and audience members, for joining us this afternoon. The 
hearing is now adjourned.

    [Whereupon, at 5:04 p.m., the Subcommittee was adjourned.]

                            A P P E N D I X

                              ----------                              

             Prepared Statement of Honorable Beto O'Rourke
    Chairman Wenstrup, Ranking Member Brownley, honorable Members of 
the Committee it is my pleasure today to present to the House Committee 
on Veterans Affairs Subcommittee on Health H.R. 1506 -VA Health Care 
Provider Education Debt Relief Act of 2017. Thank you for this 
opportunity. I introduced H.R. 1506 on March 10, 2017 to address 
serious staffing shortages throughout the Department of Veterans 
Affairs (VA) and to increase the VA's recruitment and retention 
capacity for high need and difficult to fill medical provider 
positions. It is my hope we can work together to ensure talented 
medical professional remain in the VA to deliver quality care to our 
veterans.
    H.R. 1506 increases the maximum amount of education debt reduction 
available for health care professionals employed by the Veterans Health 
Administration (VHA) participating in certain education reimbursement 
programs. The bill also makes clear the definition of a provider 
shortage so that VA facilities can better address their efforts to fill 
the highest need provider positions.
    Colleagues, you are well aware of the enduring provider shortage at 
the VA. When this bill was introduced, the VA reported a shortage of 
43,000 medical providers nationally. This number remains in the tens of 
thousands. Last week, VA spokesman, Mark Cashour, reported, as of early 
March 2018, there are more than 33,000 full-time vacancies at the VA. 
\1\ At the February 15th Full Committee VA budget hearing, we learned 
from then Secretary Shulkin that the VA has approximately 2,800 vacant 
mental health provider positions. These are positions critical for 
ensuring veterans get the care they need - care they have earned 
through their service - in a timely fashion.
---------------------------------------------------------------------------
    \1\ Washington Post, 10 April 2018.
---------------------------------------------------------------------------
    In many cases, timely care can save lives. Currently, veterans are 
waiting approximately four days for primary care and mental health care 
appointment. In some regions, this can be upwards of 7-10 days. \2\ A 
2016 report from the RAND Corporation states ``only about half of 
veterans reported getting care ``as soon as needed.'''' \3\ Today, 
mental health care providers at the VA are doing their best to serve 
veterans, however, their case loads are much too large and they report 
``burn out'' and frustration.
---------------------------------------------------------------------------
    \2\ VA, Report: Pending Appointments as of 1 April 2018.
    \3\ ``Balancing Demand and Supply for Veterans' Health Care,'' RAND 
Corporation, 2016, pg. 9.
---------------------------------------------------------------------------
    Staffing shortages also hurt retention. Medical providers, 
specifically, mental health care providers cite being overworked and 
underpaid as one of the top reasons they seek positions in the private 
sector. In February, I met with a nurse from the Houston VA who shared 
his experience in this kind of work environment; he also impressed upon 
me the importance of recruitment and retention efforts focused on 
specialty providers. This reinforces the importance of H.R. 1506. 
According to the 2016 Commission on Care Report, medical providers at 
the VA make an average $74,631 less than those in the private sector, 
while the long-term earning potential differential at the top of the 
salary range can be as much as $310,000. Furthermore, the report 
explains, ``lower salaries reduce VHA's competitive edge [.] when 
trying to attract top talent.'' \4\
---------------------------------------------------------------------------
    \4\ Commission on Care Report, 2016, VA.
---------------------------------------------------------------------------
    H.R. 1506 bill seeks to make the VA a more attractive employer by 
increasing the benefit available for a VA medical professional who is 
part of the Education Debt Reduction Program (EDRP). The EDRP is a 
student loan reimbursement program for employees with qualifying 
student loans in provider positions that are difficult to recruit and 
retain as determined by each VHA facility. \5\ The VA estimated there 
are about 3,000 medical professionals participating in this program. In 
accordance with 38 U.S. Code Section 7683(d) and under the 
EDRP, an employee with student loans for a degree program that 
qualified the individual for their position at the VA is eligible for a 
maximum benefit of $120,000 over the course of five years as 
reimbursement for their proven student loan payments.
---------------------------------------------------------------------------
    \5\ VA, Education Debt Reduction Program (EDRP).
---------------------------------------------------------------------------
    H.R. 1506 increases the total amount of reimbursement eligible from 
$120,000 to $150,000 keeping in place the five year time frame. 
Accordingly, the bill would increase the total amount of debt reduction 
possible per year from $24,000 to $30,000. Keeping in mind the average 
long-term earning difference between medical professional at the VHA 
and their counterparts in the private sector is estimated at $74,631, 
this bill provides a modest increase in the benefit available for a VA 
professional by $30,000.
    H.R. 1506 is both relevant and important. At a time when the 
collective student debt held by Americans is around $1.3 trillion 
dollars, \6\ making loan repayment possible for those who serve in high 
need and critical public service positions could not be more important. 
For the 2017-2018 academic year, the Association of American Medical 
Colleges (AAMC) reports the average cost of attendance (tuition fees, 
and health insurance) for an in-state student at a public medical 
school was $53,327 per year, while the average cost per year for a 
private medical school (all nonresident) was about $67,000 per year. 
\7\ The cost of attendance estimates show a 3.5% increase from 2016. At 
the least, H.R. 1506 will provide additional support for the rising 
cost of attendance for medical school. And, I hope this bill will help 
further recruitment and retention for critical medical professional and 
specialists at VA.
---------------------------------------------------------------------------
    \6\ ``Student Loan Debt In 2017, A$1.3 Trillion Crisis,'' Forbes, 
21 February 2017.
    \7\ Association of American Medical Colleges, ``Tuition and Student 
Fees for First-Year Students,'' 2017-2018.
---------------------------------------------------------------------------
    Finally, this bill more clearly defines what it means to have a 
provider shortage, thus allowing for the waiver of reimbursement caps 
for certain positions at VA facilities in Health Professional Shortage 
Areas (HPSA) set annually by the Department of Health and Human 
Services (HHS). This bill would encourage the Secretary of Veterans 
Affairs to exercise the authority to waive provider education debt 
reimbursement limits to fill provider vacancies with a focus on 
geographic locations as having shortage areas in primary care.
    I remain dedicated to ensuring the brave men and women who have 
served this country receive excellent care. To do this, we must provide 
the VA resources necessary to recruit and retain the best and the 
brightest in the field of medicine. I look forward to working with my 
colleagues to ensure the VA is equipped with the resources needed to 
take care of our nation's heroes. Again, it is my pleasure to lead on 
this legislation and look forward to working with everyone here to 
close the provider gap, retain talented and motivated VA professions, 
and, most importantly, care for our veterans. Thank you to all Members 
of the Committee, Ranking Member Brownley, and Chairman Wenstrup for 
your time and attention.

                                 
                Prepared Statement of Honorable Walberg
VA Committee Hearing on H.R. 2322 Testimony

    Chairman Wenstrup and Ranking Member Brownley, thank you for 
allowing me to be here today to testify on H.R. 2322, The Injured and 
Amputee Veterans Bill of Rights. I would like to start off by thanking 
the Subcommittee members and staff for their time and willingness to 
work with me on this important topic.
    I think we can all agree that our veterans have earned the highest 
quality possible health care. I understand there are problems at the 
Veterans Affairs and that this committee is diligently working to 
address these concerns to ensure our veterans receive the benefits and 
care they deserve. I also know there are great doctors, nurses and 
staff that work hard to make sure our veterans receive timely care.
    With that being said, I believe a veteran's healthcare decisions 
are personal choices. We know all too well that the VA can be an 
intimidating and hard to navigate bureaucracy. There are layers of 
paperwork and red tape that can make these healthcare decisions 
daunting. H.R. 2322 moves to empower veterans when it comes to making 
their own healthcare choices and it does so by ensuring injured and 
amputee veterans know their healthcare rights.
    Years on the battlefield has taken a toll on our war fighters. Our 
veterans are younger than before and transitioning from active duty can 
be difficult. We need to ensure that amputee veterans have the best 
access to care and ability to more easily transition into civilian 
life.
    The Injured and Amputee Veterans Bill of Rights is a bipartisan 
approach to empower injured and amputee veterans in making their 
healthcare choices. This bill simply requires the VA to prominently 
display a list of ``rights'' in VA Orthotic and Prosthetic (O&P) 
clinics as well as on their website.
    These rights include:

    1. The right to access the highest quality and most appropriate O&P 
care

    2. The right to continuity of care during their transition

    3. The right to select the practitioner of their choice

    4. The right to consistent and portable healthcare, including 
obtaining comparable services at any VA medical facility

    5. The right to timely and efficient O&P care

    6. The right to play a meaningful role in their rehabilitation 
process and a second medical opinion

    7. The right to both a primary prosthesis and orthosis and a 
functional spare

    8. The right to be treated with respect and dignity during and 
after their rehabilitation

    9. The right to transition and readjust to civilian life in an 
honorable manner

    Additionally, the VA would be required to educate their staff so VA 
employees can help veterans navigate this process.
    To make sure veterans are receiving the care they deserve and need, 
our bill also requires the VA to follow up and resolve any complaints 
by veterans who believe the VA is not meeting their O&P needs.
    Mr. Chairman, at the end of the day, veterans should receive the 
best available and timely care they can get. I know this is something 
you and your staff have worked hard on and I applaud your unwavering 
commitment to our veterans.
    I am willing to work with you and your committee in any way to 
better this legislation so that we can empower injured and amputee 
veterans when they are making their healthcare choices.
    Thank you for your time today and for the work this committee is 
doing to keep our promise to our nation's heroes.

                                 
         Prepared Statement of Honorable Rep. Neal P Dunn, M.D.
Statement for the Record - H.R. 3832, ``Veteran's Opioid Abuse 
    Prevention Act''

    Mr. Chairman, thank you for the opportunity to speak today on 
behalf of H.R. 3832, the ``Veterans Opioid Abuse Prevention Act.''
    According to the Centers for Disease Control, 249 million 
prescriptions were written by healthcare providers in 2013. The 
Department of Veterans' Affairs healthcare system is the nation's 
largest healthcare provider, and because of this, is in a unique 
position to help curb the opioid epidemic by using every tool available 
when a veteran is prescribed an opioid. The ``Veterans Opioid Abuse 
Prevention Act'' gives VA health care providers access to these 
valuable tools.
    H.R. 3832 comes directly from recommendations from the nation's top 
policy makers. The White House's Commission on Combatting Drug 
Addiction and the Opioid Crisis recommended last July that the VA lead 
efforts to have all state and Federal Prescription Drug Monitoring 
Programs - known as PDMPs - share information. The interim report cited 
multiple published best practices for PDMPs, and has identified 
interstate data sharing among PDMPs as a ``top priority'' to ensure 
that healthcare professionals have a better understanding for 
prescribing practices for their patients.
    H.R. 3832 directs the VA to have healthcare providers participate 
in sharing prescribing data across a network of interstate prescription 
drug monitoring programs. PDMPs are state-based networks which 
healthcare providers and pharmacists can access when writing or filling 
a prescription. PDMP data includes types of medications dispensed, fill 
dates, and dosage amounts. PDMPs improve a clinician's ability to 
follow good prescribing practices for at-risk patients who may have a 
pattern of prescription opioid abuse. In 2011, the National Board of 
Pharmacy created a national platform of Prescription Monitoring 
Programs - or PMPs - called ``PMP Interconnect'' - which allows states 
to share PDMP data across state lines securely. Today, 44 states and 
Washington D.C. participate in PMP Interconnect, with more soon to 
follow suit.
    I have veterans in my district who are desperate for opioids 
because well-meaning but underinformed doctors have time and time again 
have overprescribed opioids for them. I can guarantee everyone sitting 
on this dais today has veterans back home suffering for the same 
reason. And let me be clear - this is not something anyone up here on 
this dais or in this room should accept as good treatment for our 
veterans. The tragedy in these situations is that so many of them are 
preventable by just giving doctors the right tools to decide on how to 
prescribe an opioid safely. We must make sure this is a priority.
    H.R. 3832 implements the Commission's recommendation by granting 
providers the ability to use an interstate PDMP platform for the 
betterment of our veterans who are at risk of opioid abuse. Every 
doctor has a duty to help the sick according to one's own ability and 
judgment, and we as a Committee have a duty to ensure veterans have 
access to doctors who are enabled to make the best clinically-informed 
judgments for veterans.
    I encourage my colleagues to support H.R. 3832, and I yield my time 
back to the Chairman. Thank you.

                                
       Prepared Statement of Honorable Congressman J. Luis Correa
H.R. 4334 - Improving Oversight of Women Veterans' Care Act

    Thank you, Chairman Wenstrup, Ranking Member Brownley, and Members 
of the Subcommittee. I appreciate the opportunity to speak on my 
bipartisan legislation today: H.R. 4334, the Improving Oversight of 
Women Veterans' Care Act. I am particularly grateful to my friend and 
colleague Ranking Member Brownley for her support of the bill.
    Women represent the fastest growing population in the veteran 
community. According to the Department of Veterans Affairs, there are 
about two million women veterans today. That number is expected to 
increase at an average rate of about 18,000 women per year for the next 
ten years. It is important that we ensure that women veterans receive 
quality care in a safe and dignified environment, as well as in a 
timely manner.
    According to the Government Accountability Office, the Veterans 
Health Administration does not have performance measures to determine 
women veterans' accessibility to gender-specific care delivered through 
certain community care programs despite having such metrics for 
Patient-Centered Community Care (PC3). Additionally, GAO reports that 
the Veterans Health Administration does not have accurate or complete 
data regarding VA medical centers' compliance with environment of care 
standards for women veterans. Currently, medical centers must conduct 
regular inspections and report instances of noncompliance, but 
sometimes these cases are not reported to VHA.
    My legislation will enhance the monitoring needed for effective 
oversight of women veterans' by requiring VA to submit an annual report 
on veteran access to gender-specific care under community care 
contracts and quarterly reports on environment of care standards for 
women veterans. This will ensure we understand women veterans' ability 
to access gender-specific health services.
    I understand the legislation may require technical edits and I am 
open to working together with my colleagues to address those needed 
changes. Again, thank you for the chance to speak before the 
Subcommittee.

                                 
              Prepared Statement of Honorable Mike Coffman
    Chairman Wenstrup and Ranking Member Brownley, thank you for 
allowing me to present H.R. 4635, The Peer-2-Peer Counseling Act that I 
introduced with Congresswoman Esty to improve VA counseling afforded to 
female veterans. I would also like to thank the members of the 
Subcommittee who co-sponsored H.R. 4635 - Rep Bilirakis, Rep Radewagen, 
Rep O'Rourke, Rep Rutherford, and Rep Gonzalez-Colon.
    Currently, female Veterans make up 10% of our nation's veteran 
population and this population is expected to grow to 15% by 2030. Over 
the past 10 years, the VA has seen a 45% increase in the number of 
female veterans using VA benefits, demonstrating that female veterans 
are relying more and more on VA services. As the female veteran 
population increases, it is critical for VA to meet future demand.
    One area of need among female veterans that warrants our particular 
attention is peer-to-peer counseling. Unfortunately, many female 
veterans have experienced sexual trauma and PTSD while serving in the 
military and are also suffering from other mental conditions that put 
them at risk for homelessness. Peer counseling can help female veterans 
who are facing these critical issues.
    The VA's 2016 suicide data report found that the risk of suicide 
for female veterans was 2.4 times higher than non-veteran adult females 
and the rates of suicide increase more among women than men. This data 
is disturbing. We owe it to our female veterans to ensure sufficient 
resources are available to assist with gender-specific needs and that 
is why I introduced H.R. 4635, The Peer-2-Peer Counseling Act.
    H.R. 4635 enhances the VA's existing Peer-to-Peer program, which 
has been successful in providing peer counseling to all veterans, by 
ensuring the current program has a sufficient quantity of female peer 
counselors for female veterans who are separating or newly separated 
from military service. Ideal counselors will have expertise in gender-
specific issues, VA services and benefits focused on women, as well as 
employment mentoring.
    The act would also emphasize counseling services for female 
veterans who have suffered sexual trauma while serving in the military, 
have PTSD or any other mental health condition, or female veterans who 
are at risk for homelessness.
    To ensure these counseling services are not only available but also 
known throughout the veteran community, H.R. 4635 directs the VA 
Secretary to conduct outreach to inform female veterans about the peer-
to-peer program and the services available to women.
    Finally, H.R. 4635 authorizes the VA Secretary to facilitate 
engagement and coordination with community organizations, state and 
local governments, institutions of higher learning, and local business 
organizations. With the help from our communities, we can leverage 
resources and expertise that exists within our communities.
    The Peer-2-Peer Counseling Act ensures VA's peer-to-peer program is 
better postured to address the gender-specific needs of women veterans 
and updates this vitally important program to better represent the 
growing veteran population it serves.
    Mr. Chairman, I encourage my colleagues to support this important 
legislation and I yield back the remainder of my time.

                                 
                Prepared Statement of Louis J. Celli Jr.
    Chairman Wenstrup, Ranking Member Brownley and distinguished 
members of the Subcommittee on Health; on behalf of National Commander 
Denise H. Rohan and The American Legion, the country's largest 
patriotic wartime veterans service organization, comprising over 2 
million members and serving every man and woman who has worn the 
uniform for this country, we thank you for the opportunity to testify 
on behalf of The American Legion's positions on the following pending 
and draft legislation.

H.R. 1506 - VA Health Care Provider Education Debt Relief Act of 2017

    To amend Title 38, United States Code, to increase the maximum 
amount of education debt reduction available for health care 
professionals employed by the Veterans Health Administration, and for 
other purposes
    The American Legion is deeply troubled by the Department of 
Veterans Affairs (VA) leadership, physicians and medical specialist 
staffing shortages within the Veterans Health Administration (VHA). 
Since the inception of our System Worth Saving program in 2003, The 
American Legion has identified, and reported staffing shortages at 
every VA medical facility and reported these critical deficiencies to 
Congress, the VA Central Office (VACO), and the President of the United 
States.
    Currently, there are 43,000 vacancies throughout the VA in primary 
care, mental health care and dental care providers. Moreover, the June 
2016 Commission on Care report has concluded that, ``in the area of 
educational debt repayment relief, VHA lags behind other federal and 
state agencies that use such programs to fill critical physician 
shortages in medically under-served areas.'' \1\
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    \1\ Commission on Care Final Report, June 30, 2016, page 145
---------------------------------------------------------------------------
    This bill provides an incentive to attract qualified providers to 
fill the above noted vacancies by increasing total educational loan 
repayment amounts from $120,000 to $150,000 and annual debt repayment 
amounts from $24,000 to $30,000.
    During testimony before the joint House and Senate Veterans' 
Affairs Committees this February, our National Commander called for 
raising the ceiling of the VA Debt Relief Reduction program to $200,000 
to increase VA probability of attracting high-quality talent in its 
recruitment efforts. \2\
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    \2\ https://www.veterans.senate.gov/hearings/legislative-
presentation-of-the-american-legion--02282018
---------------------------------------------------------------------------
    In VA's Office of Inspector General (VAOIG) September 27, 2017 
report entitled ``Veterans Health Administration's Occupational 
Staffing Shortages,'' VAOIG determined based on data provided by VHA 
that the largest critical need occupations were Medical Officers, 
Nurses, Psychologists, Physician Assistants, and Medical Technologists. 
\3\
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    \3\ VAOIG Report 17-00936-835
---------------------------------------------------------------------------
    One medical center interviewed by VAOIG reported encountering 
recruitment challenges generally related to ``extreme competition'' for 
quality healthcare professionals. The facility further stated that it 
made use of multiple recruitment endeavors such as special salary 
rates, incentives (for recruitment, relocation, and retention), and an 
education debt reduction program.
    During The American Legion May 2017 System Worth Saving site visit 
to the Alaska VA Healthcare System, medical center personnel voiced 
concerns that community hospitals are offering to repay a provider's 
debt in exchange for them coming to work at their hospital. While VA 
has a debt reduction program, VA does not forgive provider's debt in 
exchange for acceptance of a position at a particular VAMC. \4\
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    \4\ 2017 Alaska VA Healthcare System Worth Saving Site visit
---------------------------------------------------------------------------
    A common theme our System Worth Saving team hears from VHA medical 
center human resource staff and physicians is VA's debt reduction 
program is not adequately funded and the amount VA can offer to a VA 
provider is not in keeping with what local community hospitals can pay.
    Under current law, the amount of education debt reduction payments 
made to or for a participant under VA's Education Debt Reduction 
Program may not exceed $120,000 over a total of five years of 
participation in the Program, of which not more than $24,000 of such 
payments may be made in each year of participation in the Program.
    According to the Association of American Medical Colleges, the 
average medical school debt balance for graduating physicians in 2015 
was $183,000, and is no doubt higher today. Add that burden to their 
average undergraduate balance of $24,000 and the total average student 
loan balance for a doctor is $207,000. \5\ Once interest is factored 
in, repayment amounts can range from $329,000 to $480,000. \6\
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    \5\ Gitlen, Jeff. Average Medical School Debt, LendEDU, Feb. 15, 
2017, lendedu.com/blog/average-medical-school-debt/
    \6\ Marquit, Miranda. Is Medical School Worth It? 4 Questions to 
Ask Before Deciding, Student Loan Hero, Feb. 9, 2018, 
studentloanhero.com/featured/cost-of-medical-school-worth-it/
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    Through The American Legion Resolution No. 377, Support for Veteran 
Quality of Life, we support any legislation and programs within the VA 
that will enhance, promote, restore or preserve benefits for veterans 
and their dependents, including, but not limited to, the following: 
timely access to quality VA health care, timely decisions on claims and 
receipt of earned benefits, and final resting places in national 
shrines and with lasting tributes that commemorates their service. \7\
---------------------------------------------------------------------------
    \7\ The American Legion Resolution No. 377 (2016): Support for 
Veteran Quality of Life
---------------------------------------------------------------------------
    The VA Health Care Provider Education Debt Relief Act will grant 
this nation's veterans better access to care by increasing the number 
of doctors available to be seen and will improve the overall quality of 
care that the VA is able to provide.

    The American Legion supports H.R. 1506.

H.R. 2322 - Injured and Amputee Veterans Bill of Rights

    To direct the Secretary of Veterans Affairs to educate certain 
staff of the Department of Veterans Affairs and to inform veterans 
about the Injured and Amputee Veterans Bill of Rights, and for other 
purposes
    The American Legion has long opposed the privatization of the 
Department of Veterans Affairs (VA.) Though we understand the intention 
of HR 2322, which is to highlight and provide more and better benefits 
and educations as to the rights of those who have lost a limb in 
service of this nation, the VA in concert with the veteran patient, 
must determine when the veteran should seek and obtain care outside the 
community. In order for the VA to remain an organization that is there 
to serve the 9 million currently enrolled veterans, and those in the 
future, the VA must have the final approval on when a veteran is 
approved for outside care.
    Allowing veterans to elect when the VA pays more for outside care, 
especially when they may have the internal ability, will destroy the 
VA, leaving a dilapidated system.
    H.R. 2322, calls for a veteran to have the right to select a 
practitioner that best meets their orthotic and prosthetic needs, 
whether or not that practitioner is an employee of the VA, a private 
practitioner who has entered into a contact with the VA, or even a 
private practitioner with specialized expertise. Allowing veterans to 
simply dictate when they government spends money is a dangerous slope 
that will turn the robust VA system into nothing more than an over-
paying insurance system.
    Through American Legion Resolution No. 372: Oppose Closing or 
Privatization of Department of Veterans Affairs Health Care System, 
passed in 2016, The American Legion opposes any legislation or effort 
to close or privatize the Department of Veterans Affairs healthcare 
system.

    The American Legion Opposes H.R. 2322.

H.R 3832 - Veterans Opioid Abuse Prevention Act

    To direct the Secretary of Veterans Affairs to enter into a 
memorandum of understanding with the executive director of a national 
network of State-based prescription monitoring programs under which 
Department of Veterans Affairs health care providers shall query such 
network, and for other purposes
    America continues to be in the throes of an opioid addiction 
crisis, including an epidemic of overdose deaths, affecting veterans 
and non-veterans alike. \8\ H.R. 3832 directs the Department of 
Veterans Affairs (VA) to connect VA health care providers to a national 
network of state-based prescription drug monitoring programs (PDMPs), 
databases which track controlled substance prescriptions. PDMPs ensure 
health care providers do not accidently prescribe dangerous and 
potentially lethal combinations of drugs to patients who also see other 
healthcare providers. These state programs also have been proven to 
curb ``doctor shopping'' whereby people visit multiple health care 
providers to solicit more prescription medications than their original 
doctor has agreed to prescribe.
---------------------------------------------------------------------------
    \8\ http://thehill.com/blogs/congress-blog/healthcare/241243-a-
national-prescription-drug-database-to-combat-opioid
---------------------------------------------------------------------------
    Currently, VA doctors are required to consult state-based PDMPs 
before prescribing potentially dangerous pain medications to veterans. 
VA doctors, however, lack the ability to consult a national network of 
state-based PDMPs that can identify someone from another state who is 
at high risk for abuse, overdose, and death.
    H.R. 3832 would help overcome this lack by directing VA to enter 
into a memorandum of understanding with the executive director of a 
national network of state-based prescription drug monitoring programs 
under which VA health care providers shall query such a network to 
support the safe and effective prescribing of controlled substances to 
covered patients. Under such memorandum of understanding:

    (1) Department health care providers practicing in a state that 
participates in such network shall query such network in accordance 
with the agreement between that state's prescription drug monitoring 
program and such network in accordance with applicable Veterans Health 
Administration policies; and

    (2) Department health care providers practicing in states that do 
not participate in such network shall query such network through the 
drug monitoring program of the participating State that is in closest 
proximity to the State where the provider is practicing.

    Because prescription abuse, misuse, and diversion is a nationwide 
issue, it is vital that VA and states work together to share PDMP data 
and provide a national solution to prescription abuse issues. \9\ The 
President's Commission on Combating Drug Addiction and the Opioid 
Crisis issued a preliminary report in July 2017 that cited the lack of 
cross-state interoperability as one significant shortcoming of state 
PDMPs. The Commission recommended ``enhancing interstate data sharing 
among state-based prescription drug monitoring programs.'' \10\
---------------------------------------------------------------------------
    \9\ https://www.pharmacist.com/sites/default/files/files/
Prescription%20Drug%20Monitoring%20Programs.pdf
    \10\ https://www.whitehouse.gov/ondcp/presidents-commission/
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    Through The American Legion Resolution No. 83: Virtual Lifetime 
Electronic Record, we support the use of Electronic Health Records as a 
method of coordinating care provided to veterans inside and outside VA 
medical facilities and the controlled but widespread sharing of 
electronic medical records so that veterans can receive the highest 
possible quality healthcare available. \11\
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    \11\ American Legion Resolution No. 83 (Sept. 2106): Virtual 
Lifetime Electronic Record

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    The American Legion supports H.R. 3832.

H.R. 4334 - Improving Oversight of Women Veterans' Care Act of 2017

    To provide for certain reporting requirements relating to medical 
care for women veterans provided by the Department of Veterans Affairs 
and through contracts entered into by the Secretary of Veterans Affairs 
with non-Department medical providers, and for other purposes
    H.R. 4334 would enhance the monitoring needed for effective 
oversight of women veterans' healthcare in the Department of Veterans' 
Affairs (VA) and community care programs.
    According to a December 2016 Government Accountability Office (GAO) 
report, the Veterans Health Administration (VHA) does not have data and 
performance measures to determine women veterans' accessibility to 
gender-specific care delivered through the Veterans Choice Program, a 
community care program. VHA does, however, already collect data to 
evaluate women veterans' access to gender-specific care received 
through PC3 - a different community care program. \12\
---------------------------------------------------------------------------
    \12\ Improved Monitoring Needed for Effective Oversight of Care for 
Women Veterans. GAO-17-52: Published: Dec 2, 2016
---------------------------------------------------------------------------
    The GAO report also found that VHA does not have accurate or 
complete data regarding medical centers' compliance with environment of 
care standards for women veterans. Medical centers must conduct regular 
inspections and report instances of noncompliance, however sometimes 
instances of noncompliance are not reported to VHA.
    This legislation would require VA to report to Congress women 
veterans' accessibility to gender-specific healthcare in any community 
of care program. The report must include the average waiting period 
between the veteran's preferred appointment date and the date on which 
the appointment is completed, and driving time required for veterans to 
attend their appointments. The bill would also require VA medical 
facilities to report to the Secretary the compliance and noncompliance 
of the facility to ensure they meet quality care standards for women 
veterans. Evidence gathered from the reports could potentially help the 
VA enhance and preserve the benefits and the medical care for women 
veterans while providing timely access to care.
    Through The American Legion Resolution No. 377, Support for Veteran 
Quality of Life, we support any legislation and programs within the VA 
that will enhance, promote, restore or preserve benefits for veterans 
and their dependents, including, but not limited to, the following: 
timely access to quality VA health care, timely decisions on claims and 
receipt of earned benefits, and final resting places in national 
shrines and with lasting tributes that commemorates their service. \13\
---------------------------------------------------------------------------
    \13\ The American Legion Resolution No. 377 (2016): Support for 
Veteran Quality of Life

---------------------------------------------------------------------------
    The American Legion supports H.R. 4334.

H.R. 4635

    To direct the Secretary of Veterans Affairs to increase the number 
of peer-to-peer counselors providing counseling for women veterans, and 
for other purposes.
    H.R. 4635 would help ensure that the Department of Veterans' 
Affairs (VA) existing peer-to-peer counseling program has sufficient 
female peer counselors for female veterans who are separating or newly 
separated from military service.
    This bill, as written, would also emphasize counseling for women 
who suffered sexual trauma while serving, have PTSD or another mental 
health condition, or are at risk of becoming homeless. The American 
Legion supports the goal of this legislation recognizing the risk of 
suicide is 2.4 times higher among female veterans when compared to 
their civilian counterparts. The American Legions also recognizes 
existing peer-to-peer counseling programs have been successful and this 
bill creates a more representative program for the veteran population. 
Peer counselors are veterans themselves and can relate in profound ways 
to the mental health challenges facing fellow veterans. By connecting 
female veterans with one another, peer-to-peer assistance can empower 
female veterans to connect with each other and their communities.
    Through The American Legion Resolution No. 364, Department of 
Veterans Affairs to Develop Outreach and Peer to Peer Programs for 
Rehabilitation, we continues to exert maximum effort to ensure that the 
Secretary of Veterans Affairs utilizes returning servicemembers for 
positions as peer support specialists in the effort to provide 
treatment, support services and readjustment counseling for those 
veterans requiring these services \14\.
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    \14\ The American Legion Resolution No. 364 (2016) Department of 
Veterans Affairs to Develop Outreach and Peer to Peer Programs for 
Rehabilitation

---------------------------------------------------------------------------
    The American Legion supports H.R. 4635.

Draft Bill

    To authorize the Secretary of Veterans Affairs to use the authority 
of the Secretary to conduct and support research on the efficacy and 
safety of medicinal cannabis
    The federal government continues to list cannabis as a Schedule I 
drug - the most addictive and dangerous - although its addiction rates 
are lower than alcohol, and the less-restrictive Schedule II 
classification that applies to opioids, which kill 91 Americans every 
day.
    Medical schools offer limited formal education in the human 
endocannabinoid system, or the impact of cannabinoids on the human 
body. Every day, thousands of citizens ingest cannabis but have no 
federally certified doctor to turn to for accredited consultation. In 
response to this dire need, medical education must be updated, as well. 
By continuing to consider accumulating evidence of the efficacy of 
cannabis-based medicines, the federal schedule fails patients fighting 
debilitating conditions, including PTSD and potentially lethal opioid 
addiction. The American Legion fully supports research for potential 
medicinal use of cannabis and responsible action in the interest of 
advancing medicine, particularly for veterans who report relief from 
service-connected conditions, thanks to this important drug.
    For over two years now, The American Legion has called on the 
federal government to support and enable scientific research to 
clinically confirm the medicinal value of cannabis. The National 
Academies of Science, Engineering, and Medicine recently reviewed 
10,000 scientific abstracts on the therapeutic value of cannabis and 
reached nearly 100 conclusions in a 2017 report. As a two million 
member strong veteran service organization, our primary interest and 
advocacy is grounded in the wellbeing and improved health of our 
veterans, and specifically our service disabled veterans.
    The American Legion is a strong, vocal proponent of the Department 
of Veterans Affairs (VA) and has published several books, pamphlets, 
and magazines that help showcase VA's value to The United States of 
America. Our members have long been ferocious advocate's for evidence-
based, complementary and alternative medicines and therapies. For 
decades, we have supported increased funding and research in such 
therapies as hyperbaric oxygen therapy, Quantitative 
Electroencephalography (QEEG), animal therapy, recreational therapy, 
meditation, and mindfulness therapies, just to name a few, to improve 
outcomes for veterans confronted with PTSD and other combat related 
illnesses and injuries.
    The American Legion supports VA's statutory medical research 
mission and has donated millions of dollars toward expanding their 
scientific research. VA innovation is widely championed for their 
breakthrough discoveries in medicine and has been recognized over the 
years with several Nobel Prizes for scientific work that has benefited 
the world over.
    The opioid crisis in America is having a disproportionate impact on 
our veterans, according to a 2011 study of the VA system, as they 
contend with the facts that poorly-treated chronic pain increases 
suicide risk, and veterans are twice as likely to succumb to accidental 
opioid overdoses. Traumatic brain injury and PTSD remain leading causes 
of death and disability within the veteran community.
    VA officials report that about 60 percent of veterans returning 
from combat deployments and 50 percent of older veterans suffer from 
chronic pain compared to 30 percent of Americans nationwide. Many 
veterans suffering from post-traumatic stress disorder and chronic pain 
- especially those of the Iraq and Afghanistan generation - have told 
The American Legion that they have achieved improved health care 
outcomes by foregoing VA-prescribed opioids in favor of medical 
cannabis.
    While the stories of these wartime veterans are compelling, more 
research must be done in order to enable lawmakers to have a fact-based 
debate on future drug policy. As a scientific research leader in this 
country with a statutory obligation to care for and improve the lives 
of our nation's veterans, The American Legion supports the draft bill 
``VA Medicinal Cannabis Research Act of 2018'' co-sponsored by Chairman 
Roe and Ranking Member Walz, that will continue to put VA at the 
forefront of national cutting edge research.
    The American Legion calls for immediate reclassification of 
cannabis from Schedule I to Schedule III on the DEA Controlled 
Substance Act Schedule to allow research into its potential for medical 
application. We call on Congress to conduct oversight hearings and 
support legislation that enables research on cannabis, and the medical 
impact it could have for Americans suffering from; opioid over-
prescription, pain, depression and a host of other known ailments, and 
direct departments and agencies within the administration to fully 
cooperate in all federally authorized scientific research and offer 
assistance as needed to authorize extensive research.
    In October 2017, The American Legion conducted a nationwide survey 
of veterans. \15\ The results are significant and reinforce The 
American Legion's continued efforts, under Resolution 11, to urge 
Congress to amend legislation to remove marijuana from Schedule I of 
the Controlled Substances Act and reclassify it, at a minimum, as a 
drug with potential medical value.
---------------------------------------------------------------------------
    \15\ https://www.legion.org/documents/legion/pdf/medical--
cannabis--study.pdf
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    According to the survey - which included more than 1,300 
respondents and achieved a +/- 3.5 percent margin of error at a 95 
percent confidence level - 92 percent of veteran households support 
research into the efficacy of medical cannabis for mental and physical 
conditions.
    Eighty-three percent of veteran households surveyed indicated that 
they believe the federal government should legalize medical cannabis 
nationwide; \16\
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    \16\ https://www.legion.org/sites/legion.org/files/legion/
documents/Veterans%20and%20Medical%20Cannabis.pdf

      82 percent said they wanted cannabis as a federally legal 
treatment option.
      Only 40 percent lived in states with medical marijuana 
laws.
      Over 60 percent were 60 and older, the largest cohort of 
veterans committing suicide.
      22 percent of veterans are currently using cannabis to 
treat a medical condition.

    And as former Speaker of the House John Boehner revealed in his 
official statement when he joined the Board of Advisors for one of the 
nation's largest, multi-state actively-managed cannabis corporations 
last week, ``We need to look no further than our nation's 20 million 
veterans, 20 percent of whom, according to a 2017 American Legion 
survey, reportedly use cannabis to self-treat PTSD, chronic pain and 
other ailments.'' \17\
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    \17\ https://www.acreageholdings.com/news-release-board-of-
advisors-appointment
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    Based on The American Legions extensive advocacy, The Department of 
Veterans Affairs' recently issued updated guidance on medical marijuana 
that urges government doctors to discuss medical marijuana use with 
veterans, due to its clinical relevance to patient care, and discuss 
marijuana use with any veterans requesting information about marijuana. 
Because marijuana is a Schedule I controlled substance, VA doctors 
cannot prescribe, recommend, or assist patients with getting it.
    Following the VA's announcement, American Legion National Commander 
Rohan issued the following statement, ``I applaud the VA in taking this 
bold move toward treating veterans and also fulfilling resolutions 
passed by The American Legion. We do not support recreational use of 
drugs, but we do think the medicinal possibilities of cannabis should 
not be ignored by the VA. We are all about putting the health of 
veterans first.''
    Over the course of the past two years, The American Legion has 
passed two resolutions, testified on the necessity for additional 
research into the effectiveness of medical cannabis, and has held a 
press conference right here in this very room. We have received 
thousands of comments and interactions on this issue through our 
website, social media, as well as letters, phone calls, and personal 
interactions around the country, and the support we receive is 
overwhelmingly positive.

    For more information on this research, please visit www.Legion.org/
mmjresearch

    American Legion Resolution No. 11, passed in 2016, titled, Medical 
Marijuana Research, The American Legion calls on the Drug Enforcement 
Agency to license privately funded medical marijuana production 
operations in the United States to enable safe and efficient cannabis 
drug development research; and urging Congress to remove marijuana from 
Schedule I and reclassify it in a category that, at a minimum, will 
recognize cannabis as a drug with potential medical value. \18\
---------------------------------------------------------------------------
    \18\ https://archive.legion.org/bitstream/handle/20.500.12203/5763/
2016N011.pdf?sequence=4&isAllowed=y

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The American Legion supports the Draft Bill.

Draft Bill

To make certain improvements in the family caregiver support program of 
    the Department of Veterans Affairs

    The American Legion advocates for equal benefits for all veterans 
regardless of period of service, and will never support a reduction in 
benefits. This bill reduces benefits to the existing caregiver program. 
The American Legion opposes this bill.

    The American Legion Opposes this Draft Bill.

Conclusion

    As always, The American Legion thanks this Subcommittee for the 
opportunity to elucidate the position of the over 2 million veteran 
members of this organization. For additional information regarding this 
testimony, please contact Assistant Director of the Legislative 
Division, Jeff Steele, at (202) 861-2700 or [email protected].

                                 
                Prepared Statement of Adrian M. Atizado
    Mr. Chairman and Members of the Subcommittee:

    Thank you for inviting DAV (Disabled American Veterans) to testify 
at this legislative hearing of the Subcommittee on Health of the House 
Veterans' Affairs Committee. As you know, DAV is a non-profit veterans 
service organization comprised of more than one million wartime 
service-disabled veterans that is dedicated to a single purpose: 
empowering veterans to lead high-quality lives with respect and 
dignity. DAV is pleased to offer our views on the bills under 
consideration by the Committee.

H.R. 1506, the VA Health Care Provider Education Debt Relief Act of 
    2017

    DAV supports passage of this important legislation based on DAV 
Resolution 128, calling for enabling the Department of Veterans Affairs 
(VA) to compete for, recruit and retain the types and quality of VA 
employees needed to provide comprehensive health care services to sick 
and disabled veterans.
    We recommend the Education Debt Reduction Program be extended 
beyond the current December 31, 2019 deadline, the baseline funding be 
increased to achieve the intent of this measure, and that additional 
program staff may be needed for successful implementation.
    To recruit and retain health professionals to work at VA to meet 
the health care needs of over 6 million ill and injured veterans, VA 
provides financial incentives under four broad categories to improve on 
the rigid government pay scales that has less room for growth than in 
private practice: market-based salaries, recruitment, retention, and 
relocation incentives (3Rs), Continuing Medical Education funds (CME), 
and Health Professionals Educational Assistance Program (HPEAP).
    This bill seeks to improve HPEAP, which includes other critical 
recruitment and retention programs such as the Education Debt Reduction 
Program (EDRP). EDRP is one of the most utilized programs and allows 
the Veterans Health Administration (VHA) to reimburse qualifying 
education loan debt for employees, including physicians, in hard-to 
recruit positions. Physicians apply directly to the VA medical center, 
and applications are approved by VHA to repay student loans for up to 
five years.
    Section 302 of Public Law 113-146, the Veterans' Access to Care 
through Choice, Accountability, and Transparency Act of 2014 (VACAA) 
made improvements to EDRP by increasing the monthly and annual caps on 
debt reduction payments to an individual participant from $12,000 to 
$24,000 and from $60,000 to $120,000, respectively. As a result, both 
the number of new EDRP awards are increasing, the current active 
participants increased by 45 percent and the current average award has 
increased by more than 40 percent.
    This measure seeks to build on the success of EDRP due to the VACAA 
cap increases by increasing the current annual cap of $24,000 and five-
year cap of $120,000 to $30,000 and $150,000 respectively.
    As this Subcommittee is aware, the Government Accountability Office 
(GAO) October 19, 2017 reported, based on conversations with VA medical 
center officials, that their EDRP program funding was insufficient, 
given that both the number of applicants and the amount awarded to 
individual physicians increased significantly, and that they depleted 
their EDRP budgets early in the fiscal year. As a result, some 
facilities GAO reviewed would not commit to providing EDRP during the 
recruitment process. Instead, officials routinely told candidates that 
they would consider EDRP eligibility if funding was available.
    The bill would also amend the conditions under which VA could waive 
such caps. Currently, the caps could be waived if the health 
professional is serving in a position for which there is a shortage of 
qualified employees, by reason of either location or requirements of 
the position. If enacted, the bill would change the waiver criteria to 
apply to health professionals working in a geographical area designated 
by the Department of Health and Human Services as a health professional 
shortage area with respect to such participant's specialty or 
assignment. Because of the difference between these two definitions, we 
urge the Subcommittee to ensure this change does not adversely impact 
the ability for local VA medical centers to use EDRP in meeting their 
staffing needs.

H.R. 2322, the Injured and Amputee Veterans Bill of Rights

    This bill would require the Secretary of Veterans Affairs to ensure 
that the ``Injured and Amputee Veterans Bill of Rights'' (hereafter 
referred to as the Amputee Bill of Rights) is posted on signage and 
displayed prominently in each prosthetics and orthotic clinic of the 
VA. The measure includes provisions for targeted outreach to notify 
veterans and veterans service organizations of the Amputee Bill of 
Rights, including placement on the Department's website. H.R. 2322 also 
requires VA employees working in prosthetic and orthotic clinics, 
federal recovery coordinators, case managers, and those working as 
patient advocates to receive training on the Amputee Bill of Rights.
    The bill includes provisions mandating that each fiscal quarter 
patient advocates and veterans' liaisons collect information related to 
complaints and alleged mistreatment from veteran patients and report it 
to the VA's Chief Consultant of Prosthetics and Sensory Aids. The Chief 
Consultant would then be required to address and investigate 
allegations and complaints in accordance with the Amputee Bill of 
Rights.
    Based on the bill, injured and amputee veterans would have the 
right to:

      access prosthetic and orthotic devices of the highest 
quality, and appropriate technology, while receiving care from the best 
qualified practitioners;
      continuity of care between VA and DoD by including 
comparable benefits relating to prosthetic and orthotic services;
      select the practitioner that best meets a veteran's needs 
regardless of the practitioner's Department affiliation (VA/DoD), to 
include private practitioners that have entered into contracts with the 
VA Secretary;
      comparable services and technology at any VA medical 
facility;
      timely and efficient orthotic care, including a speedy 
authorization process with expedited authorization for veterans 
visiting from another area of the country;
      be included in rehabilitation decisions and have the 
ability to get a second opinion regarding their prosthetic and orthotic 
treatment and needs;
      receive a primary and functional spare prosthetic or 
orthotic device;
      access to VA vocational rehabilitation, employment 
programs, and housing assistance; and
      be treated with respect and dignity.

    DAV does not have a resolution that specifically calls for an 
Amputee Bill of Rights; however, DAV Resolution No. 178 calls for 
sufficient funding for the Prosthetic and Sensory Aid Service and 
timely delivery of prosthetic items. It also urges VA to rededicate 
itself to becoming a leader in prosthetic care by providing cutting-
edge services and items to help injured, ill and wounded veterans fully 
regain mobility and achieve maximum independence in their activities of 
daily living, and in sports activities such as running, cycling, 
skiing, rock climbing and other physical exercises if they so choose. 
For the reasons mentioned above, we have no opposition to the enactment 
of this legislation.

H.R. 3832, the Veterans Opioid Abuse Prevention Act

    The Veterans Opioid Abuse Prevention Act requires the Secretary of 
Veterans Affairs to enter into a memorandum of understanding with the 
executive director of the national network of state prescription drug 
monitoring programs. The purpose of this agreement would be to allow VA 
to submit queries on veterans who are longer-term users of controlled 
substances to such programs in the states in which the clinicians 
practice, or for non-participating states, the nearest state with a 
monitoring program. Submitting these veterans to these monitoring 
programs would enhance the safety and effectiveness of prescribing 
controlled substances to certain veterans who are prescribed such 
substances for more than 90 days by ensuring they are not receiving the 
same prescribed drugs from different clinicians.
    DAV does not have a resolution calling for support of VA's 
participation in state prescription drug monitoring programs. However, 
we believe this enhances patient safety in prescribing controlled 
substances with many known adverse effects, including addiction and 
overdose, to veteran patients therefore; we have no objection to its 
enactment.
    DAV also urges Congress to ensure that VA redoubles its efforts to 
conduct a uniform national pain management program to ensure that 
veterans with chronic pain who have been prescribed pain medications 
over long periods of time are managed in a patient-centered 
environment, with balanced regard for both patient safety and provided 
humane alternatives to the use of controlled substances. Additionally, 
while under VA care veterans should be confident they will receive 
their prescribed medications in a timely fashion to relieve unnecessary 
pain or anxiety. We urge VA to monitor pain management efforts and 
resolve any conflicts between the effects of the Controlled Substances 
Act of 1970 and its prescribing policies and procedures to ensure the 
Department is compliant with its own national pain management policy 
and guidelines and comport with its stated goals of patient-centered, 
safe care that offers appropriate alternatives and carefully monitors 
withdrawal from controlled substances for veterans who have been long-
term users of such medications.

H.R. 4334, the Improving Oversight of Women Veterans' Care Act of 2017

    DAV strongly supports H.R. 4334, in accordance with DAV Resolution 
No. 225, which calls for support for enhanced medical services and 
benefits for women veterans. This resolution seeks to ensure that 
health care services and specialized programs provided by VA to 
eligible women veterans are provided to the same degree and extent that 
services are provided to eligible male veterans, inclusive of 
counseling and/or psychological services incident to combat exposure or 
sexual trauma.
    DAV urges VA to strictly adhere to stated policies regarding 
privacy and safety issues relating to the treatment of women veterans 
and to proactively conduct research and health studies as appropriate, 
periodically review, adjust and improve its women's health programs, 
and seek innovative methods to address barriers to care, thereby better 
ensuring women veterans receive the quality treatment and specialized 
services they so rightly deserve.
    H.R. 4334, the Improving Oversight of Women Veterans' Care Act of 
2017, would require the VA Secretary to submit an annual report to 
Congress on women veterans' access to covered sex-specific services 
under community care contracts including the average wait time for 
appointments, the veteran's driving time to the appointment and reasons 
why appointments could not be scheduled with non-Departmental medical 
providers.
    The bill would also require each VA medical facility to submit 
quarterly reports on compliance with environment of care standards to 
the VA Secretary and to develop a plan within 180 days of enactment for 
strengthening the process to verify non-compliance data is accurate and 
complete; that all patient care areas are inspected; and to include the 
list of inspected items to align with those outlined in the Women 
Veterans Program Manager's Handbook.
    The provisions in this bill are also consistent with 
recommendations in DAV's 2014 report, Women Veterans: The Long Journey 
Home. I am pleased to report that DAV will be releasing an update to 
that report in the near future and we look forward to sharing our 
findings and recommendations with the Subcommittee.

H.R. 4635, to increase the number of peer-to-peer counselors providing 
    counseling for women veterans

    DAV is pleased to offer its support for H.R. 4635, legislation 
calling for an increase in the number of peer-to-peer specialists to 
provide support and counseling specific to women veterans. This bill is 
consistent with DAV Resolution No. 225, calling for enhanced health 
care services and benefits to meet the unique needs of women veterans.
    If enacted, this bill would require the Secretary of Veterans 
Affairs to ensure the Department has a sufficient number of peer 
counselors for women veterans. These counselors may be employees of VA 
and have expertise in gender-specific issues and services, employment 
mentoring, service and benefits provided by the Secretary. The bill 
would also require the Secretary to emphasize facilitation of peer-to-
peer counseling for women veterans who have experienced military sexual 
trauma (MST), have post-traumatic stress disorder (PTSD), or other 
mental health conditions, or are at risk of becoming homeless.
    The Secretary would be required to conduct outreach to inform women 
about the peer-to-peer program, and facilitate engagement and 
coordination with community organizations, state and local governments, 
institutions of higher education, chambers of commerce, local business 
organizations, and organizations that provide legal assistance to 
facilitate the transition of women veterans. The bill would require the 
Secretary to use existing funds to carry out the mandates and 
provisions in H.R. 4635.
    Women comprise a small, but growing portion of the veteran 
population using VA services. Many service-disabled women veterans face 
challenges reintegrating into their communities following military 
service. Researchers have found that women veterans often lack a 
supportive social network during the transition period and that they 
face a number of barriers to accessing the care and benefits they need. 
Women veterans often do not self-identify as veterans and seek benefits 
at lower rates than their male peers. Lack of child care services is 
frequently noted as a barrier to accessing post-deployment mental 
health readjustment counseling. Exposure to military sexual trauma and 
abuse of alcohol are complicating factors among this population that 
also make them more prone to homelessness and suicide.
    Peer specialists have been shown to be especially effective in 
engaging VA users in accessing needed mental health services. Ensuring 
that women peer specialists are available to assist and guide other 
women veterans with accessing the services they need, such as mental 
health care, child care, legal assistance and assistance with job 
placement or training and in identifying appropriate resources within 
and outside of VA, will lead to a more successful transition and better 
health outcomes for this population.
    DAV supports using peer specialists as a means of expanding VA's 
workforce and providing additional support to veterans with complex and 
comorbid conditions such as PTSD, substance-use disorders and traumatic 
brain injury. However, we are concerned that other priorities such as 
filling critical health occupation vacancies within the Veterans Health 
Administration (VHA) such as physicians, nurses, psychologists, and 
other credentialed professionals may hamper VHA's ability to hire more 
women peer specialists. For these reasons, we recommend the 
Subcommittee consider adding funding for this important program.
    It is critical that these peer specialists are available to provide 
culturally competent and gender-sensitive assistance in navigating the 
many federal government programs available to meet women veterans' 
needs. VA's existing peer support program has been shown to enhance 
patient engagement, increase veterans self-advocacy skills, increase 
quality of life and patient satisfaction and ensure more appropriate 
use of services.

Draft Bill, the VA Medicinal Cannabis Research Act of 2018

    The VA Medicinal Cannabis Research Act of 2018 would allow the 
Secretary of VA to engage in research on the safety and efficacy of 
medicinal cannabis use on health outcomes for veterans with chronic 
pain, post-traumatic stress disorder (PTSD) and other conditions the 
Secretary deems appropriate. The bill would require that VA include 
certain forms of cannabis in addition to different delivery methods for 
using cannabis products in its research and develop a means of 
preserving data for future studies. It further requires that VA develop 
a five-year implementation plan for conducting such research, including 
issuance of requests for proposal, within 180 days of enactment. 
Finally, the bill would require VA to submit progress reports to 
Congress not less frequently than annually.
    DAV understands that use of cannabis for medicinal purposes is now 
legal in 29 States and the District of Columbia. However, we note there 
have been no changes made to federal law regarding use of these 
products for any purpose. We further understand that, while the medical 
literature has been inconclusive about the effectiveness of marijuana 
for improving symptoms of chronic pain and PTSD, noting both risks and, 
in some cases, benefits, many veterans report the use of cannabis for 
these purposes is beneficial.
    While DAV has no specific resolution calling for VA to conduct 
research on the safety and efficacy of medicinal cannabis for veterans 
with chronic pain or PTSD, DAV Resolution No. 129 notes strong support 
for VA research on common conditions related to military service and 
effective treatments to help veterans recover, rehabilitate and improve 
the overall quality of their lives. We must ensure that any 
intervention for treatment of chronic pain and PTSD is both safe and 
effective for veteran patients especially veterans with clinically 
complex comorbid conditions such as traumatic brain injury, PTSD and 
chronic pain from amputations and other war-related injuries. For these 
reasons we have no objection to passage of this bill.

Discussion Draft, to make certain improvements in the family caregiver 
    support program of the Department of Veterans Affairs

    Public Law 111-163, the ``Caregivers and Veterans Omnibus Health 
Services Act of 2010,'' established the Program of General Caregiver 
Support Services and the Program of Comprehensive Assistance for Family 
Caregivers. The Program of Comprehensive Assistance for Family 
Caregivers (the Comprehensive Program) provides additional support 
services to caregivers beyond what is provided through the Program of 
General Caregiver Support Services, including a modest monthly 
financial stipend, health care coverage through CHAMPVA, counseling and 
mental health services, respite care, and technical assistance. 
However, the Program is only available to veterans who have serious 
injuries (including traumatic brain injury, psychological trauma, or 
other mental disorder) incurred or aggravated in the line of duty in 
the active military, naval, or air service on or after September 11, 
2001 (post-9/11).
    We are encouraged the program is working as intended based on 
comments from a qualitative online survey conducted by DAV, which 
received 1,833 validated responses from veterans and caregivers. This 
is described in greater detail in our testimony before the full 
Committee during its oversight hearing on February 6, 2018. But our 
members recognize there is always room for improvement.
    Since the program's enactment, DAV has fought for legislation that 
improves the program and provides family caregivers and veterans 
severely ill and injured before September 11, 2001 (pre-9/11) equitable 
access to comprehensive caregiver support services.
    During the February 6, 2018 oversight hearing, DAV, along with 
virtually all of our VSO colleagues, called on the full Committee to 
take bold and decisive actions, similar to what the Senate Veterans' 
Affairs Committee did last fall, and pass legislation extending 
eligibility for the full array of caregiver support services to 
veterans from all eras.
    As such, we continue to advocate that the most equitable solution 
is for Congress to amend existing statute by removing ``on or after 
September 11, 2001'' so that all veterans and caregivers have equal 
access to the Program. Furthermore, Congress should amend the statute 
by including provisions allowing severely ill veterans and their family 
caregivers to be eligible for the Program.
    DAV, along with our VSO colleagues, has been working with both the 
House and Senate Veterans' Affairs Committees to come to an agreement 
and pass a legislative package, which includes extending the current 
eligibility criteria for the Comprehensive Program to family caregivers 
of veterans severely injured pre-9/11; requires the implementation and 
certification of an information technology system to assess, support, 
and improve the family caregiver support program, and modifies the 
annual evaluation report of the program.
    In light of current circumstances, DAV has grave concerns regarding 
Section 3 of this draft measure, which proposes to address the 
unfairness of excluding pre-9/11 veterans from the Comprehensive 
Program by raising the bar for eligibility on both pre- and post-9/11 
veterans. We could not support limiting or restricting eligibility to 
the Comprehensive Program for family caregivers and veterans when a 
more supportive and equitable caregiver policy has already tentatively 
been agreed to and is under active consideration by Congress.
    We urge the Subcommittee to amend and reconsider the provision in 
this draft bill that would amend paragraph (3)(C) of section 1720G(a). 
The original intent of this paragraph remains sound and is an important 
one, which is to mitigate the financial impact of caregiving, by 
providing caregivers a modest stipend that would not be less than the 
amount a commercial home health entity would pay an individual in the 
geographic area of the veteran to provide equivalent personal care 
services. We believe the source of the issues surrounding both the 
labor intensive process in calculating local stipend rates and the 
resulting outlier stipend rates are more the result of the Department's 
regulatory decision to calculate such rates by using the Bureau of 
Labor Statistics hourly wage for home health aides in a geographic 
area. \1\
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    \1\ 38 C.F.R. 71.40(c)(4)(v)
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    This draft measure could better address the disadvantages of this 
particular regulation by assisting VA in establishing a more 
appropriate stipend schedule that does not erode current benefits while 
addressing program inefficiencies. We urge the Subcommittee to work 
with VA in crafting more suitable language to accomplish the desired 
intent and for VA to make improvements through regulatory action.
    There is also a conditional effective date for the sections in 
draft bill amending title 38, United States Code, section 1720G. Rather 
than leaving the effective date open ended, we recommend a date certain 
be included in Section 3 of this bill to ensure program improvements 
contemplated in such section is realized and not left to uncertainty.
    Finally, we urge the Subcommittee to consider additional provisions 
such as integrating a research component to VA's caregiver support 
program, which could help find answers such as how to most effectively 
support family caregivers of severely ill and injured veterans in a 
cost-effective manner and could better inform program managers, policy 
makers and the public. In addition, because the success of the Program 
and the quality of life of severely ill and injured veterans relies 
heavily on the ability for VA to provide in-home assistance, and based 
on DAV's report ``American's Unsung Heroes: Challenges and Inequities 
Facing Veteran Caregivers,'' which found that family caregivers of 
severely ill and injured veterans often do not get the support they 
need, such as financial assistance, respite care, medical training or 
home health aide services, we urge the Subcommittee to include a 
provision that would instruct the Government Accountability Office to 
update its 2003 report on veterans' access to non-institutional/home- 
and community-based care.
    In reviewing Section 2 of this draft bill, we believe it is 
intended to address the recommendations in GAO's September 2014 report 
on VA's caregiver support program that VA ``expedite the process for 
identifying and implementing an [IT] system that fully supports the 
program and will enable [VHA] program officials to comprehensively 
monitor the program's workload, including data on the status of 
applications, appeals, home visits, and the use of other support 
services, such as respite care,'' and that VA ``use data from the IT 
system, once implemented, as well as other relevant data to formally 
reassess how key aspects of the program are structured and to identify 
and implement modifications as needed to ensure that the program is 
functioning as envisioned so that caregivers can receive the services 
they need in a timely manner.''
    DAV continues to press VA to ensure it meets the GAO's 
recommendations to implement an IT system that fully supports the 
program. We are encouraged that VA's long-term IT solution for the 
caregiver program is due to be delivered by the end of September. We 
urge this Subcommittee to use its oversight powers to ensure progress 
in its development is maintained to meet the delivery date.
    This concludes my testimony, Mr. Chairman. DAV would be pleased to 
respond for the record to any questions from you or the Subcommittee 
Members concerning our views on these bills.

                                
                  Prepared Statement of Sarah S. Dean
    Chairman Wenstrup, Ranking Member Brownley, and members of the 
Subcommittee, Paralyzed Veterans of America (PVA) would like to thank 
you for the opportunity to present our views on the broad array of 
pending legislation impacting the Department of Veterans Affairs (VA) 
that is before the Subcommittee. No group of veterans understand the 
full scope of care provided by the VA better than PVA's members-
veterans who have incurred a spinal cord injury or disease. Most PVA 
members depend on VA for 100 percent of their care and are the most 
vulnerable when access and quality of care is threatened. Several of 
these bills will help to ensure veterans receive timely, quality care 
and services.

H.R. 1506, the ``VA Health Care Provider Education Debt Relief Act of 
    2017"

    PVA supports H.R. 1506, the ``VA Health Care Provider Education 
Debt Reduction Act of 2017.'' This legislation would increase the 
maximum amount of education debt reduction available for health care 
professionals employed by the Veterans Health Administration (VHA). 
Currently, the total amount VA may provide for debt reduction of a 
provider is $120,000 over a five year period, provided the amount does 
not exceed more than $24,000 per year. This legislation would increase 
the maximum amount to $150,000 and $30,000, respectively, in order to 
match education debt average.
    If the Secretary determines there is a particular shortage in an 
area or specialty, VA currently has the authority to waive the maximum 
amount of debt, and pay the principal plus interest of a provider's 
loans. This proposal would specify shortages and adopt the Department 
of Health and Human Services' definition of Health Professional 
Shortage Areas.
    PVA believes VA must be adequately resourced to attract the best 
and brightest medical professionals. The Education Debt Reduction 
program has been a markedly successful means to do just that. There is 
a current and worsening provider shortage in the United States. VA must 
be able to see that veterans are insulated from this trend. That new 
residents are hesitant to take a post in an underserved community, 
should come as no surprise. The cost burden of their education and 
training is an overwhelming prospect and debt is all but guaranteed. No 
matter how eager to serve, or desirous of giving back to veterans a new 
resident may be, a career at an understaffed VA may not be a tenable 
choice. Loan assistance can cultivate a culture of commitment from 
those unburdened by their debt and revive areas too long stressed by 
continuous shortages.

H.R. 2322, the ``Injured and Amputee Veterans Bill of Rights''

    PVA supports H.R. 2322, the ``Injured and Amputee Veterans Bill of 
Rights'' to better educate injured and amputee veterans on their rights 
and the requirement that VA staff who work at prosthetics and orthotics 
clinics or who work as patient advocates for veterans understand these 
rights as well. This bill would ensure that VA prosthetics clinics 
around the country prominently display the ``Injured and Amputee 
Veterans Bill of Rights'' and, ideally, that VA employees understand 
it. This reaffirms the idea that a veteran in need of an assistive 
device or prosthetic gets the highest quality item available and in a 
timely manner. PVA is concerned, however, that the language ignores 
veterans who are in need of special equipment because of a specific 
disease and not a physical injury. Further, we remain concerned VA is 
not sufficiently resourced to procure prosthetics for veterans in a 
manner that is timely and clinically precise.

H.R. 3832, the ``Veterans Opioid Abuse Prevention Act''

    PVA supports H.R. 3832, the ``Veterans Opioid Abuse Prevention 
Act.'' This legislation would direct the Secretary to enter into a 
memorandum of understanding with the executive director of a national 
network of state-based prescription drug monitoring programs (PDMP) in 
order to assess if opioids have been accessed in other states. 
Currently, VA doctors cannot consult a national network of state-based 
PDMPs in order to identify those at high risk for abuse. A July report 
from the President's Commission on Combating Drug Addiction and the 
Opioid Crisis said the lack of cross-state interoperability is a 
shortcoming of state PDMPs and recommended ``enhancing interstate data 
sharing among state-based prescription drug monitoring programs.''
    In 2016, Public Law 114-198, the ``Comprehensive Addiction and 
Recovery Act'' (CARA), required providers at the VHA to participate in 
their respective state's PDMP. Prescribers must check patient records 
in the state databases before prescribing pain killers. The pharmacists 
are responsible for recording when they fill those prescriptions.
    The United States is in the midst of an opioid epidemic and PDMPs 
are a critical tool for safe prescribing practices by providers. VA has 
been authorized to share prescription data with PDMPs since 2011 and 
last year, CARA required VHA to participate. The effectiveness of 
Opioid Safety Initiatives is dependent on the availability of all 
prescription data and the ability to see it across state lines. This 
loophole allows for veterans to `doctor shop' across states with 
neither entity the wiser. These veterans suffering from chemical 
dependency must have the safety protections we can reasonably provide. 
This bill ensures VA can better mitigate the potential consequences of 
opioid use.
    Given the specialized needs of veterans, it is not uncommon for 
veterans to travel to different states to receive their care. Each VA 
Medical Center (VAMC) only shares prescription data to the state PDMP 
in which the VAMC is located. Some have established regional Memoranda 
of Understanding, communicating information only with neighboring 
states. But there are veterans, particularly veterans with a spinal 
cord injury or disease (SCI/D) who regularly travel across multiple 
state lines to one of the 24 SCI Centers across the country. There is 
no assurance that the prescription data of an SCI/D veteran who 
receives care at an SCI/D center in Minneapolis, but lives in Wyoming, 
can be shared. We urge the Committee to make sure these specialized 
patient populations are benefiting from the opioid safety measures in 
the same way as non-traveling veterans. H.R. 3832 is the means to do 
just that.

H.R. 4334, the ``Improving Oversight of Women Veterans' Care Act of 
    2017"

    PVA supports H.R. 4334, the ``Improving Oversight of Women 
Veterans' Care Act of 2017.'' This legislation would require the 
Undersecretary of VHA to submit to Congress an annual report on the 
ability of women veterans to access gender specific care in the 
community. It would also require each medical facility to report to the 
Secretary, on a quarterly basis, the compliance and noncompliance of 
the facility with the environment care standards for women veterans, as 
defined in VHA Directive 1330.01(1). Each report is to name the person 
at each facility who is responsible for compliance and the facility 
plan to strengthen environment of care standards.
    According to GAO report 17-52 from December 2016, VHA does not have 
data and performance measures for women veterans' accessibility to 
gender-specific care delivered through the Veterans Choice Program. 
However, VHA does collect data to evaluate women veterans' access to 
gender-specific care received through PC3 - a different community care 
program. The report also found VHA does not have accurate or complete 
data regarding medical centers' compliance with environment of care 
standards for women veterans, allowing for instances of noncompliance 
not reported to VHA.
    H.R. 4334 would require VA to report to Congress accessibility to 
gender-specific health care in any community of care program; and 
include the average waiting period between the veteran's preferred 
appointment date and the date on which the appointment is completed, 
reasons VA could not fulfill the appointment, and driving time required 
for appointments.
    If VA cannot meet the needs of women veterans and refers them to 
providers in the community, then VA must still ensure that care is the 
quality, appropriate care that best meets the veterans' needs. Holding 
VA and community care providers to different standards while the 
taxpayer pays for both is unacceptable. VA must be able to ensure the 
care a veteran receives in and outside its walls is the best clinical 
option available. As such, Congress must have the data to conduct the 
appropriate oversight on that care.
    H.R. 4635, to direct the secretary of Veterans Affairs to increase 
the number of peer-to-peer counselors providing counseling for women 
veterans, and for other purposes.
    PVA supports H.R. 4635, to ``direct the secretary of Veterans 
Affairs to increase the number of peer-to-peer counselors providing 
counseling for women veterans, and for other purposes.'' This 
legislation would require VA to employ sufficient numbers of peer 
counselors to meet the needs of women veterans, particularly to address 
military sexual trauma, post-traumatic stress, and those at risk of 
homelessness.
    For those veterans who have been able to access peer-to-peer 
counseling or retreats for women provided through VA, participants 
report a better understanding of how to develop support systems and to 
access resources at VA and in their communities. Peer counseling 
programs have been a marked success for most veterans who show 
consistent reductions in stress symptoms and increased coping skills. 
It is essential for the life and wellbeing of women veterans that 
Congress make their needs a priority. By hiring peer counselors 
familiar with issues specific to women veterans' experiences we can 
move a step closer to meeting those needs.

A draft bill to authorize VA to conduct and support research on the 
    efficacy and safety on medicinal cannabis

    PVA has no position on the drafted legislation at this time.

A draft bill to make certain improvements in the Family Caregiver 
    Program

    Established by Public Law 111-163, the ``Caregivers and Veterans 
Omnibus Health Services Act of 2010,'' the Program of Comprehensive 
Assistance for Family Caregivers provides caregivers of post-9/11 
service-connected, injured veterans with support services. These 
include a modest monthly financial stipend, health care through 
CHAMPVA, mental health services, and respite care.
    For those PVA members able to access the program, it has made all 
the difference in their lives. For eight years, PVA, along with nearly 
all VSOs, has ardently advocated the program be made accessible to 
those injured before 9/11 and to those made ill as a result of service 
in any era.
    During the February 6, 2018, full committee hearing, PVA, DAV, and 
the Elizabeth Dole Foundation asked the House Committee to be as bold 
as the Senate Committee was last November and pass an expansion effort 
that treats all veterans the same, regardless of date of injury. This 
remains our chief legislative priority for the 115th Congress.
    PVA's organizational mandate is to expand and improve the Caregiver 
Program. In this moment in time, the means to most closely accomplish 
that mandate is the negotiated package that was to be included in the 
omnibus last month. This legislative package would eliminate the date 
of injury requirement for the Comprehensive Program; require the 
implementation and certification of an information technology system to 
assess, support, and improve the program; and modify the annual 
evaluation report. While this effort was not actualized in the omnibus, 
it is our intention to see such a deal, both bipartisan and bicameral, 
passed as soon as may be accomplished. It is with this in mind that we 
provide our views on the draft legislation.
    As this proposal would make eligible veterans with catastrophic 
injuries of all eras, PVA would support it as a first step to full 
expansion. This proposal would achieve what former Secretary Shulkin 
desired; serve those with a particular high need, while at the same 
time, simplify the program structure to be more efficiently 
implemented. A clearly understood eligibility, and efficient 
assessment, implemented nationwide, would greatly enhance this vital 
program. In order to accomplish both aims, this draft adopts a 
restrictive criteria for all future participants to require assistance 
with three Activities of Daily Living (ADLs).
    If the committee moves forward with this restricted eligibility, we 
strongly encourage VA be enabled to develop or adopt a validated 
instrument to measure needs and caregiver burden. The current clinical 
assessment tool of ADLs and tiers can be unnecessarily confusing and 
does not clearly capture need. Tightening eligibility under the same 
structure ensures the same concerns of inconsistency, espoused over the 
years by this Committee, continue. Because the participation is 
dependent on ADLs and their ongoing clinical assessment, variability is 
innate to each clinical team's opinion. Using a standardized assessment 
tool, such as the United Kingdom's Functional Assessment Measurement 
and Functional Independence Measurement (FAM & FIM), may help to 
clearly delineate the level of care required to accomplish ADLs and 
Instrumental Activities of Daily Living (IADL). Such an approach could 
help to make clear to families the means by which their loved ones 
needs, both physical and psychological, are measured.
    As expressed in the February hearing on caregivers, we encourage 
the Subcommittee to advance provisions that support research into how 
to best support family caregivers of veterans with catastrophic 
disabilities and how to delay the costs of institutional long term 
care. We also encourage the draft include a GAO report on VA's Home and 
Community Based Services. It has been nearly a decade since such a 
study was conducted and would illustrate the needs of pre-9/11 
caregivers today.
    PVA would once again like to thank the Subcommittee for the 
opportunity to submit our views on the programs affecting veterans and 
their caregivers. We look forward to working with you to ensure our 
catastrophically disabled veterans and their families receive the 
medical services and supports they need.

                                 
                  Prepared Statement of Kayda Keleher
    Chairman Wenstrup, Ranking Member Brownley and members of the 
Subcommittee, on behalf of the women and men of the Veterans of Foreign 
Wars of the United States (VFW) and its Auxiliary, thank you for the 
opportunity to provide our remarks on legislation pending before this 
Subcommittee.

H.R. 1506, VA Health Care Provider Education Debt Relief Act of 2017

    The VFW supports this legislation which would increase the maximum 
amount of education debt reduction available for health care 
professionals who work at the Department of Veterans Affairs (VA) 
Veterans Health Administration (VHA).
    With over 35,000 current job vacancies, VA must be provided all 
tools necessary to address personnel shortages. This is particularly 
worrisome for VHA, where provider shortages result in access issues and 
insufficient wait times for veterans needing to receive treatments they 
have earned.
    To address these personnel shortages, this legislation would 
authorize VA to work alongside the Department of Health and Human 
Services to identify areas with increased health professional 
shortages. Where these shortages are found to exist, VA would then be 
able to aggressively use their authority to provide new hires with 
educational debt reduction at increased cap rates.
    Congress and VA must assure that funding appropriated for 
educational debt reduction is properly disbursed. The VFW has received 
feedback from multiple locations that VA facilities are only receiving 
the capped rate equivalent to what the maximum would be for one 
employee. For this authority to be effective in recruiting and 
retaining employees at VA, it must be properly implemented and 
utilized.

H.R. 2322, Injured and Amputee Veterans Bill of Rights

    The VFW believes this legislation would unintentionally establish 
an unattainable expectation for VA. Therefore, the VFW cannot support 
this bill.
    This legislation would require VA to display what would become the 
``Veterans Bill of Rights'' throughout all VA prosthetics and orthotics 
clinics as a means of outreach for education. The VFW fully supports VA 
outreach campaigns to educate and connect with veterans, and believes 
that this legislation would be better routed as an outreach campaign to 
veterans who were injured and/or are amputees.
    With this said, the VFW has concerns with some of the verbiage used 
in what would be the Bill of Rights. In the third subparagraph of these 
rights, it would be publicly shared and expressed that a veteran would 
have the right to see a private practitioner entered into a community 
care contract with VA, or the veteran would be able to access a 
practitioner with specialized expertise. This language may stand to be 
interpreted that if a veteran opts to see a specialized practitioner 
who has not entered into contract with VA, that the veteran would still 
have the right to see the practitioner. The VFW opposes veterans having 
the ability to see any provider outside VA of their choosing and VA 
then paying for the appointment without coordinating the care. Keeping 
VA as the coordinator of care not only provides assurance that patients 
are seeing quality doctors for appointments they need, but it also 
provides quality assurance and oversight for the patient as well as VA 
appropriations. It is also worth noting that this legislation would 
build expectations going beyond current law, without amending what is 
currently in statute. For example, the Bill of Rights would establish 
that all amputees are eligible for a backup prosthetic, but that would 
not align with current eligibility requirements.
    The VFW also believes the quarterly reporting requirement would be 
over legislating. This report would require every medical center within 
VA to submit a report for each fiscal quarter containing all 
information related to alleged mistreatment of injured and amputee 
veterans. Each of these allegations would then receive a full 
investigation. The VFW believes this is something VA already does and 
should be doing, making these provisions unnecessary.

H.R. 3832, Veterans Opioid Abuse Prevention Act

    The VFW supports this legislation which would direct VA to enter 
into a memorandum of understanding (MOU) with the executive director of 
a national network of state-based prescription monitoring programs. By 
entering into this MOU, providers within VA will be able to access data 
regarding controlled substance prescriptions for patients regardless of 
which state they are in, so long as that state has entered into an MOU 
as well.
    There are currently 43 states and the District of Columbia that 
have entered into an MOU with the National Association of Boards of 
Pharmacy for the association's prescription monitoring program (PMP) 
InterConnect. This allows participating states' PMPs across the entire 
country to be linked regardless of state lines, and provides an 
effective means of combating drug diversion and/or abuse. Data is 
shared and collected through a secure communications platform that 
transmits PMP data to authorized requestors, while the state's 
individual data access rules and laws are enforced. PMP InterConnect 
also does not house any data itself.
    Having access to this data and being able to share with the states 
already entered into an MOU would benefit VA. VA would be more easily 
able to access prescription data for patients across state lines, such 
as winter snowbirds, while also making sure patients' information is 
shared with the private sector--providing great potential to identify 
and prevent prescription drug abuse and fraud.

H.R. 4334, Improving Oversight of Women Veterans' Care Act of 2017

    The VFW supports this legislation which would require reporting 
associated with medical care for women veterans provided by VA and 
through non-VA providers entered into contract agreements with VA. 
Assuring veterans who receive care from non-VA providers receive the 
same high-quality standard of care, or above, that they would receive 
at VA is critical.
    Not all appointments can be fulfilled by VA, and this is especially 
true for certain specialized services such as sex-specific treatments. 
Whether there is a shortage of gynecologists, or not enough women 
veteran patients to meet annual certification requirements for 
mammogram technicians, there is the need at times for women veterans to 
receive sex-specific health care in the community. For this reason, the 
VFW is pleased to see the reporting requirements this legislation would 
put into law.
    To improve women veterans' health care within VA, it is also 
important for VA to keep up to date on where facilities need to 
improve, as well as for Congress to be aware of these needs. This is 
why the VFW is pleased to see the reporting requirements for the 
environment of care standards within VA facilities.

H.R 4635, to direct the Secretary of Veterans Affairs to increase the 
    number of peer-to-peer counselors providing counseling for women 
    veterans

    The VFW supports this legislation which would increase the number 
of peer-to-peer counselors for women veterans within VA. This 
legislation would also emphasize the demand for peer-to-peer support 
specialists for women veterans who have survived sexual trauma during 
their time in service, have post-traumatic stress disorder (PTSD), any 
other mental health condition, or are in other ways at risk of becoming 
homeless. This would be particularly useful as ***40 percent of women 
veterans who participated in the VFW's women veterans' survey either 
currently use or have previously used VA for mental health services.
    This legislation would also coordinate assistance for women 
veterans under the Department of Defense's employment, job training and 
transitional assistance programs with the Department of Labor to help 
women veterans identify employment and training opportunities, as well 
as how to obtain these necessities and other related information and 
services. The VFW is pleased to see this in the legislation, as 
addressing mental health care needs and avoiding homelessness must be 
addressed with a holistic approach. To do this, veterans must have 
assurance and a sense of self-worth and meaningfulness through their 
work, as well as a means to provide food and shelter for themselves and 
their families.

Draft legislation, VA Medicinal Cannabis Research Act of 2018

    The VFW supports this draft legislation which would direct VA to 
use its authority to conduct and support medical research on the 
effects and safety of medicinal cannabis.
    The VFW supports expanding research of non-traditional medical 
treatments for alternative therapies and less harmful ways of 
addressing health care issues for veterans within VA. With the ongoing 
opioid epidemic, an increase in veterans who suffer from chronic pain, 
the constant co-morbidity of chronic pain with PTSD and a continuing 
list of other health ailments--all while VA is under constant scrutiny 
for over-prescribing pharmaceuticals, while still managing to prescribe 
opioids at nearly half the rate of the private sector, VA must be 
proactive in finding solutions to responsibly treat veterans.
    There are currently 30 states and the District of Columbia that 
have passed legislation legalizing medical or recreational marijuana. 
This means veterans are able to legally obtain marijuana for medical 
purposes in over half the country. Some may see a private sector 
provider about using medical marijuana, while others may self-prescribe 
without a health care provider's guidance. Regardless of how veterans 
in the majority of the country choose to obtain medical marijuana, they 
are doing this without the medical understanding or proper guidance 
from their coordinators of care at VA. This is not to say VA providers 
are opting to ignore this medical treatment, but that there is 
currently a lack of federal research and understanding of how medical 
marijuana may or may not treat certain illnesses, injuries, and the way 
it interacts with other drugs. Due to this, the VFW believes it is 
medically unethical for Congress to allow VA providers to stay in the 
dark. VA must conduct research on medical marijuana to determine what 
is in the best interest of veteran patients.
    This draft legislation would reiterate VA's current authority to 
conduct schedule one research for ailments ranging from physical injury 
to behavioral health. Three different strain variants consisting of 
differing ranges of phenotypical traits as well as ratios of 
tetrahydrocannabinol (THC) and cannabidiol (CBD) compositions must be 
researched in the study. The VFW believes it is important to test at 
minimum three strains, which can vary in strength such as when 
pharmaceuticals study dosing variations of both major chemical 
components found in marijuana. It is also important to test varying 
ratios of THC and CBD, as scientists know these chemicals affect 
different receptors in the human body. For example, in some studies, 
patients with PTSD or who are recovering from cancer have been found to 
benefit from THC. Meanwhile, other studies have found that patients 
struggling with chronic pain have been found to benefit from CBD. 
Participants in the study would use the marijuana in varying ways, 
subject to VA's decision on how to break up participant groups.
    To assure the research study would be implemented as intended, VA 
would report to Congress 180 days from the date of enactment with a 
plan moving forward. At this time VA would then also make requests for 
anything needed to carry on with the study. After this initial report, 
VA would then be required over a five-year period to submit a report at 
a minimum of once per year to Congress.
    The VFW is pleased to see bipartisan support for this very 
important issue for our nation's veterans, and looks forward to 
continuing to work on medical cannabis research with Congress and VA.

Draft legislation, to make certain improvements in the Family Caregiver 
    Program

    The VFW agrees with the intent of this draft legislation but has 
serious concerns with it as written. Since the Program for 
Comprehensive Assistance for Family Caregivers was first discussed, the 
VFW has urged Congress to expand eligibility to those caring for 
veterans who served before Sept. 11, 2001. The VFW strongly believes 
the contributions of family caregivers cannot be overstated, and our 
nation owes them the support they need and deserve. Regrettably, the 
program is unjustly limited to caregivers of severely wounded post-9/11 
veterans. Severely wounded and ill veterans of all conflicts have made 
incredible sacrifices, and all family members who care for them are 
equally deserving of our recognition and support. The fact that 
caregivers of previous era veterans are currently barred from the 
program implies that their service and sacrifices are not as 
significant, and we believe this is wrong.
    The VFW currently supports H.R. 1472 and S. 591, as well as S. 
2193, which includes the expansion of VA's caregiver program. The VFW 
has been pleased to see the committee's willingness to evaluate and 
advance a bill to expand this important program.
    As currently written, this draft would increase the eligibility 
requirements from the current requisite of assistance for one or more 
activities of daily living (ADL) to a minimum of three ADLs. The VFW 
opposes setting arbitrary eligibility requirements and urges the 
committee to evaluate other means of accurately determining who should 
and should not be in the program. The VFW believes that eligibility 
determination must be clinically made by VA, and not restricted by 
arbitrary thresholds. There must also be an inclusion of instrumental 
activities of daily living (IADL), so the program does not disregard 
those in need for cognitive purposes. Moving forward, discussions of 
eligibility for the program should focus around accountability and 
rehabilitation, rather than limiting the program in efforts to save 
money as well as prevent fraud and abuse. This is particularly 
pertinent as VA has consistently provided feedback that less than one 
percent of those who have been removed from the program were removed 
for reasons at cause, which includes fraud. The VFW would also oppose 
any restrictive changes in program eligibility that does not provide a 
grandfather clause for current program recipients. This current draft 
would not only restrict eligibility, but would not offer a grandfather 
clause for those currently in the program. To draft a grandfather 
clause, technical assistance must be given by VA.
    The VFW also believes that moving forward with new legislation, 
there must be an inclusion of veterans who were made ill. This would 
provide equity between caregivers to align more with caregiver programs 
in Titles 10 and 42, as well as assure equity between service members 
and veterans. For a veteran who is ill and unable to take care of 
herself or himself without the assistance of a caregiver, the VFW finds 
no just reason to continue not defining them as eligible for VA's 
caregiver program. This is particularly true for veterans who are ill 
from diseases undoubtingly linked to their service, such as non-
Hodgkin's lymphoma.
    Caregivers must be capable of providing care that is in the best 
interest of the veteran, and in a clinically timely manner determined 
by the veteran's VA provider in accordance with their treatment plan. 
The VFW believes the language within the draft for caregiver criteria 
living proximity requirements is moving in the right direction, but 
must be better defined to avoid inconsistent implementation.
    Finally, the VFW believes any legislation amending the caregiver 
program must include provisions for caregivers and veterans who are 
graduating out of the program. Currently, when a veteran improves and 
is slated to be removed from the program, a lump sum of three months 
stipend is paid out for financial assistance. This has resulted in 
financial, emotional, and health distress of the veterans and their 
caregivers. The VFW urges this Subcommittee to amend this legislation 
to establish new off-ramp requirements which would remove the lump sum 
payment, continue a monthly stipend and insurance coverage for a 
reasonable amount of time, and provide employment training and 
assistance to the caregiver from the caregiver program coordinator they 
have worked with through their time in the program. This is imperative 
to the veteran and caregiver's success out of the program, as well as 
the well-being both physically and mentally of these highly regarded 
patriots.
    In conclusion, the VFW supports expanding the caregiver program to 
veterans who served before 9/11, but opposes reducing eligibility 
requirements simply to lower cost.
    Mr. Chairman, this concludes my testimony. I am prepared to take 
any questions you or the Subcommittee members may have.

                                 
                       Statements For The Record

                              STEVE SCHWAB
UNITED STATES HOUSE OF REPRESENTATIVES ON ``A DRAFT BILL TO MAKE 
    CERTAIN IMPROVEMENTS IN THE FAMILY CAREGIVER PROGRAM''

    Chairman Roe, Ranking Member Walz, and Members of the Committee, 
the Elizabeth Dole Foundation is pleased to present its views on the 
House Committee on Veteran Affairs' draft legislation, which makes 
modifications to the Program of Comprehensive Assistance for Family 
Caregivers (PCAFC).
    We thank the Committee for its continued leadership to support more 
than 5.5 million military and veteran caregivers serving across the 
nation. The PCAFC is a critical program that provides comprehensive 
caregiver support, helps offset the cost of income lost from caregiving 
responsibilities, and recognizes the service they provide to our 
nation's wounded warriors. As the preeminent organization empowering, 
supporting, and honoring our nation's military caregivers, the 
Elizabeth Dole Foundation seeks to strengthen and empower American 
military and veteran caregivers and their families by raising public 
awareness, driving research, championing policy, and leading 
collaborations that make a significant impact on their lives. We 
appreciate that the Committee has made this legislation a priority and 
has conducted an open process by convening focused discussions on this 
draft legislation with VSOs and caregiver support organizations and 
incorporating feedback into modifications to the draft legislation.

Expanding the Program to Pre-9/11 Veterans

    We are pleased that the Committee has put forward legislation that 
addresses what the Foundation has felt is the most significant deficit 
in the PCAFC; that only a limited scope of veterans and their 
caregivers are eligible under the current law. It is unfair that since 
the Program's enactment, pre-9/11 caregivers - who make up 80 percent 
of our nation's 5.5 million veteran and military caregivers - are 
arbitrarily barred from accessing the PCAFC because of their veterans' 
era of service or diagnosis with a service-connected illness. We 
appreciate that the Committee has demonstrated its intent to correct 
this injustice, and we are wholly supportive of expansion.
    While the expansion of the program in the draft legislation 
represents a momentous victory for the caregiver community, it comes 
with some significant trade-offs. The Committee's bill proposes more 
restrictive thresholds for eligibility to the program, including that a 
caregiver provide support with an increased number of activities of 
daily living. This provision will drastically reduce the number of 
eligible veterans and demonstrate a considerable tightening of the 
Program's criteria. We understand that the Committee has proposed this 
provision to reduce the overall cost of the program and ensure that the 
program is in place to serve those who need it most. However, the 
Foundation strongly recommends that the Committee eliminate, make 
modifications to, or adjust this eligibility-reducing provision - as it 
may be detrimental to current and future generations of veteran 
caregivers.

Activities of Daily Living

    The Foundation is a strong proponent of expansion with unaltered 
eligibility requirements, as proposed in the Senate's Caring for Our 
Veterans Act, which passed the Senate Veterans Affairs Committee with 
overwhelming bipartisan support in November 2017. However, we recognize 
that the Committee would like to explore different options related to 
eligibility and standardization of the program.
    Under current law, participants must be in need of personal care 
services due to - among other criteria - the inability to perform one 
or more activities of daily living (ADLs). The Committee's draft 
increases the threshold to three or more ADLs. In 2012, the Foundation 
commissioned the RAND Corporation to conduct a study on military and 
veteran caregiving; the findings of which are detailed in a 2014 report 
``Hidden Heroes: America's Military Caregivers.'' The report found 
that, on average, post-9/11 caregivers help with 1.0 ADL, while pre-9/
11 caregivers help with 1.3 ADLs (and instead help with an increased 
level of safety and supervisory assistance). The research did not 
provide analysis as to how many caregivers help with three or more 
ADLs. We believe that the proposed increased threshold may be too high 
and would severely limit the effectiveness of the PCAFC in supporting 
those who need the program most.
    There is a lack of available information on the number of veterans 
potentially affected by the proposed increase to the activities of 
daily living. Therefore, the Foundation recommends that the Committee 
either consider eliminating this provision entirely or allow the 
Secretary of Veterans Affairs to make any eligibility-restricting 
determination only after conducting a comprehensive impact analysis and 
following the appropriate rule-making process.

Addition of Service-Connected Illnesses

    The Foundation urges the Committee to consider expansion of the 
program to service-connected illnesses, not just injuries from all eras 
of service. The way the bill is written today, it still does not 
include service-connected illnesses, such as ALS or the hundreds of 
other illnesses included in the VA's Presumptive Disease List. That is 
unjust. We believe for this program to be genuinely inclusive of our 
nation's veterans and their caregivers, it must not exclude those with 
service-connected illnesses.

The Inclusion of the Financial Planning Services

    The 2014 RAND report examined characteristics of military and 
veteran caregivers and services available to them. The report indicated 
that, of the military caregiver-specific programs, few provide long-
term planning assistance, including financial planning, for military 
caregivers.
    The Senate's Caring for Our Veterans Act includes a provision which 
would require the VA to include financial planning and legal services 
related to the needs of injured veterans and their caregivers as a 
service provided to caregivers. The bill language makes clear that VA 
should provide these services through the use of contracts with or the 
provision of grants to public or private entities. The Senate Committee 
intends that VA and VA employees not provide these services, but 
instead partner with public or private entities.
    We believe the financial planning services would be a critical 
improvement to the PCAFC program. We are also supportive of offering 
legal services to caregivers, but sympathetic to the VA's concerns that 
this might pose a conflict of interest. We urge the Committee to 
consider the inclusion of financial planning services to caregivers in 
the PCAFC.

Grandfathering Current Program Participants

    The Foundation appreciates that Committee has added additional 
language to its current draft legislation to address what happens to 
current program participants who will be no longer eligible under the 
new criteria. However, we are concerned that the language allowing the 
Secretary of Veterans Affairs to develop a transition plan is too 
broad, creates further program uncertainty, and places the thousands of 
current program participants at potential risk of losing their 
caregiver benefits. The Foundation believes the legislation should 
explicitly protect current program participants from losing support as 
a result of these legislative changes.
    Thank you again for this opportunity to submit our comments on the 
Committee's draft legislation. We look forward to continuing to work 
with the Committee to ensure support for our nation's military and 
veteran caregivers.

                                 
                               TOM PORTER
    Chairman Wenstrup, Ranking Member Brownley, and Members of the 
Subcommittee:

    On behalf of Iraq and Afghanistan Veterans of America (IAVA) and 
our more than 425,000 members and supporters, thank you for the 
opportunity to share our views on the legislation being discussed 
today.

VA Medicinal Cannabis Research Act of 2018

    IAVA is proud to express our support for the VA Medicinal Cannabis 
Research Act of 2018 and I would like to commend Chairman Roe and 
Ranking Member Walz for working in a bipartisan manner to develop the 
measure and hold this hearing to underscore the importance of getting 
this research right for our veterans at the VA.
    IAVA veterans have made it clear that 2018 is the year we will be 
heard on the important and emerging health issue of utilizing cannabis 
to treat injuries of war. Veterans consistently and passionately have 
communicated that cannabis offers effective help in tackling some of 
the most pressing injuries we face when returning from war.
    In our latest Member Survey, 63% supported and only 15% opposed 
legalization for the medical use of cannabis. The youngest of the Post-
9/11 generation are most supportive; with about three-fourths of IAVA 
members under 35 supporting the allowance of medical cannabis.
    Medical cannabis is rapidly gaining support across party lines in 
Congress and across the country. Yet our national policies are 
outdated, research is lacking, and stigma persists. In 2018, IAVA 
members will set out to change that and launch a national conversation 
underscoring the need for bipartisan, data-based, common-sense 
solutions that can bring relief to millions, save taxpayers billions, 
and create thousands of jobs for veterans nationwide. Those solutions 
must include the approval of medical cannabis for every veteran in 
America who needs it.
    Our nation is rapidly moving toward legalizing cannabis, and twenty 
nine states plus the District of Columbia now permit medical cannabis. 
Yet, as with many innovative solutions to veteran needs, progress on 
this issue within the VA has been slow and incremental--and lags behind 
the needs of veterans and the changing reality of state-level laws.
    There has been marginal progress, as in late 2017, when the 
Veterans Health Administration issued a policy change which urged 
patients to discuss medical cannabis use with their doctors. This 
policy change alleviates previous concern that admitting to cannabis 
use could jeopardize VA benefits, a policy recommendation noted in 
IAVA's Policy Agenda. But VA physicians still cannot refer patients to 
legally sanctioned state medical cannabis programs because of the 
federal prohibition. Moreover, patients are not allowed to have any 
cannabis on VA property, even if it is medically recommended to them 
and the state they are living in allows it. And VA employees are still 
barred from using any form of cannabis, including medical cannabis, 
while roughly one-third of VA employees are veterans and may want 
access to cannabis as a treatment option.
    Further, in opposition to strong and rising popular opinion across 
the veterans community, the VA Secretary announced in early 2018 that 
the VA will not conduct research into whether medical cannabis could 
help veterans suffering from PTSD and chronic pain. This is despite 
protest from many in the VSO community who posit medical cannabis could 
serve as an alternative to opioids and antidepressants. A January 2017 
National Academy of Sciences study that stated: there was ``conclusive 
or substantial'' evidence that cannabis is effective in treating 
chronic pain, moderate evidence that cannabis helps with sleep (which 
may impact other mental and physical health conditions), limited 
evidence in improving anxiety symptoms, and limited evidence in 
improving PTSD symptoms.
    It is important to note that in our most recent member survey, 46% 
report suffering from PTSD, 38% report suffering from chronic pain, and 
almost 40% report depression and anxiety. These service-connected 
injuries are hard to treat, and if there is any possibility that 
cannabis can be used as an effective treatment, we should be willing to 
do the research to explore that opportunity.
    Again, thank you for allowing IAVA to share our views. We thank 
Chairman Roe and Ranking Member Walz for taking this valuable step in 
moving forward with such a significant piece of legislation. We need 
the definitive research to be conducted on the efficacy and safety of 
medical cannabis use by veterans - and it is long past the time for the 
VA to have taken this up.
    Congress must prioritize passage of this legislation this year.

Discussion Draft, to make certain improvements in the family caregiver 
    support program of the Department of Veterans Affairs

    IAVA opposes this draft bill as it raises the bar of eligibility 
for the post-9/11 veterans currently eligible for the Caregiver 
Program, as well as for pre-9/11 veterans that would gain eligibility 
under this draft.
    IAVA has consistently supported expanding the Caregiver Program to 
all generations of veterans, but we cannot support legislation that 
reduces benefits by raising the eligibility bar for program 
beneficiaries.
    The Improving Oversight of Women Veterans' Care Act of 2017 (H.R. 
4334) and Legislation (H.R. 4635) to ``direct the secretary of Veterans 
Affairs to increase the number of peer-to-peer counselors providing 
counseling for women veterans, and for other purposes.''
    IAVA thanks the sponsors for putting forth H.R. 4334 and H.R. 4635, 
as they are consistent with our She Who Borne The Battle campaign in 
the 115th Congress to close gaps in care for women veterans.
    H.R. 4334 would require the Undersecretary of the Veterans Health 
Administration to submit to Congress an annual report on the ability of 
women veterans to access gender specific non-VA medical care in the 
community, including the average wait time between the veteran's 
preferred appointment date and the date on which the appointment is 
completed, driving time required for veterans to attend appointments, 
and reasons why appointments could not be scheduled. The bill would 
also require each VA medical facility to submit a quarterly report to 
the VA Secretary on the compliance and noncompliance of the facility 
with the environment of care standards for women veterans.
    H.R. 4635 would increase number of peer-to-peer counselors 
providing counseling for women veterans, with an emphasis on treating 
women veterans who suffered military sexual trauma, suffer from PTSD or 
other mental health conditions, or are at risk of becoming homeless.
    IAVA remains focused on the centerpiece of our She Who Borne The 
Battle campaign, the bipartisan Deborah Sampson Act (H.R. 2452), the 
most comprehensive legislation this Congress that addresses shortages 
in care for female veterans. H.R. 2452 establishes peer-to-peer 
assistance, makes permanent programs to provide counseling in retreat 
settings, provides legal and support services, doubles the newborn care 
at the VA, funds retrofits at VA facilities to improve privacy, 
requires the VA to collect gender-specific data on all veterans 
programs, and expresses a sense of Congress that the VA motto should be 
more inclusive, among other initiatives.
    On this last provision, our campaign has had an impact, as we know 
that VA leadership had taken recent, concrete steps to make motto 
changes more welcoming to our transitioning women warriors, but 
partisan infighting at the VA derailed those steps from moving forward.
    IAVA encourages this committee to support a greater level of 
progress on making VA care more reflective of the growing numbers of 
women serving in uniform and move to enact the Deborah Sampson Act and 
other legislation that shares this spirit.
    Thank you for allowing IAVA to share our views.

                                 
                              CARRIE STEAD
    Chairwoman Dole, Members of the Committee, thank you for the 
opportunity to comment on the future of the Program of Comprehensive 
Assistance for Family Caregivers (PCAFC). I am Carrie Stead, Director 
of Programs for The Independence Fund, and am a caregiver myself.
    The Independence Fund, founded 10 years ago, has provided more than 
$50 million in adaptive equipment and support services for 
catastrophically wounded and seriously disabled Veterans, as well as 
Caregiver support services for the Caregivers of those wounded and 
disabled veterans.
    Overall, The Independence Fund's greatest concern with the PCAFC 
program is the apparent lack of standardization throughout the program. 
We see wide variation not only across Veterans Intergrated Service 
Networks (VISNs), but even across VA facilities within a VISN, or even 
a single VA facility itself.
    This lack of standardization leads to wide variation in tier 
classification for similar cases; for what services and support 
individual Veterans and Caregivers are eligible; and even whether the 
Caregiver will be allowed to stay in the program or be ``graduated.''
    Because of that lack of standardization, we see VA officials 
improperly apply the Caregiver eligibility standards, such as they 
exist, especially in cases of spouse or other family caregivers. VA 
officials apply improper ``rules'' in ways like telling Caregivers they 
cannot have outside employment. We also see it where individual 
veterans are forced by reviewing VA officials, without warning, to 
prove they cannot do certain activities, even where an occupational 
therapy order has not been issued.
    The result is a pervasive and underlying presumption on the part of 
the medical administrators that Veterans or Caregivers are frauds, and 
need to be ``tricked'' into displaying their actual, greater, 
capabilities. Shame on the VA for such tactics.
    While not the topic of today's hearing, this Committee is charged 
with making recommendations on other VA benefits and services that 
impact families and caregivers. Given that, the single biggest issue 
raised by the severely disabled Veterans and Caregivers we serve is the 
lack of access to timely and quality medical care. While we are 
uniformly told the clinicians that serve our clients, especially the 
doctors, are first rate, the medical administration staff that is 
supposed to support the Veteran in gaining access to that medical care, 
instead seem to consistently and uniformly act to block timely access.
    We've received hundreds of complaints from our clients detailing 
the bureaucratic roadblocks; local ``policies'' and ``guidance'' not 
based on law, regulation, or printed VA directive; or simply what 
appears to be simple indifference on the part of the medical 
administration staff; which hinder, if not stop, Veteran access to the 
care they need. We've received numerous reports of medical providers 
repeatedly directing care outside the VA, or not in accordance with 
current standards of care or formularies, only to be repeatedly denied 
by the medical administration staff, often without justification or 
explanation.
    Ultimately, this comes down to who is in charge of a Veteran's 
medical care decisions: the Veteran and his family, or the VA 
bureaucracy? Our experience is that the individual Veteran and his or 
her family are consistently denied the opportunity to make that choice 
themselves. In fact, we often experience an underlying, if unspoken, 
attitude the Veteran is incompetent to make such medical care 
decisions. This condescension towards the Veteran is unfortunately 
shared by many of the largest, and oldest, Veteran service 
organizations.
    We believe the vast majority of Veterans are competent to make 
medical care decisions, just as they would if they were being served by 
Medicare or Tricare instead of the VA. We are heartened by the 
commitment President Trump made to that Veteran empowerment in the 
campaign. Therefore, we implore this Committee to recommend to the 
Secretary that he fully support a Veteran's ability to choose his or 
her health care provider, whether within the VA or in the community. Of 
note, in the current debate underway in Congress, neither the House or 
the Senate Veterans Affairs Committee passed bills come close to 
providing the real healthcare choice the President promised.
    Finally, the VA issued a Request for Comments on the Caregiver 
program, with those comments due last month. The Independence Fund 
responded to that Request with its own recommendations for further 
refining the Caregiver program. In the interest of time, I request the 
attached copy of that Response be included in the record today.
    Thank you for the opportunity to discuss this with you today.

                                 
                             MARGARET KABAT
    Margaret Kabat
    National Director
    Caregiver Support Program (10P4C)
    Veterans Health Administration
    Department of Veterans Affairs
    810 Vermont Ave., NW
    Washington, DC 20420

    Dear Ms. Kabat:

    Thank you for the opportunity to comment on the future of the 
Program of Comprehensive Assistance for Family Caregivers (PCAFC). The 
Independence Fund, founded 10 years ago, has provided more than $40 
million in adaptive equipment and support services for catastrophically 
wounded and seriously disabled veterans, as well as caregiver support 
services for the caregivers of those wounded and disabled veterans. Our 
Executive Director and our Director of Programs are both caregivers to 
catastrophically wounded veterans. As well, most of our employees are 
either disabled Veterans or Caregivers themselves.
    Overall, The Independence Fund's greatest concern with the PCAFC 
program is the apparent lack of standardization for large segments of 
the program, from initial eligibility to program execution and 
classification standards, not only across Veterans Intergrated Service 
Networks (VISNs), but even across VA facilities within a VISN, and even 
a single VA facility itself. While we understand the need for a 
clinical determination to establish individualized eligibility based on 
the need for assistance with activities of daily living, such clinical 
determination appears to justify not pursuing any type of national 
standardization for assessment or continuing eligibility standards for 
the program, essentially leaving those decisions to be implemented 
arbitrarily by the personal fiat of individual clinicians and VA 
medical administrators throughout the country.
    Because of that, The Independence Fund regularly sees wide 
variation in the Caregiver tier classification determined for 
individually similar cases, for what services and support individual 
Veterans and Caregivers are eligible, and even whether the Caregiver 
will be allowed to stay in the program or be ``graduated.'' Given the 
close similarities we see in these underlying cases with vastly 
different results, this broad variation across regions and even 
facilities appears to be an arbitrary execution of the law within the 
Department.
    Further The Independence Fund receives numerous anecdotal 
complaints of VA officials improperly applying the Caregiver 
eligibility standards, such as they exist, especially with spouse or 
other family caregivers. One of the most commonly heard improper 
``rules'' is that Caregiver scannot have outside employment besides 
serving as a Caregiver. Considering the Caregiver stipend is based upon 
40 hours per week of Caregiver assistance (even for the most 
catastrophically wounded, or the barely conscious Veterans), those 
Administrators who do try to tell Caregivers that they cannot work 
outside their Caregiver assistance must believe these Caregivers do not 
provide any additional Caregiver assistance outside normal working 
hours. That's outrageous, as is VA officials wrongly telling Caregivers 
they cannot work outside the caregiving assistance they provide. The 
regulations regarding PCAFC should specifically state Caregivers can 
have outside employment beyond the Caregiver assistance they provide.
    Within that framework, below are our answers to the specific 
Request for Comments.

1. Should VA change how ``serious injury' is defined for the purpose of 
    eligibility?

    Yes.

    Per the authorizing legislation, the Secretary is authorized to 
expand eligibility for PCAFC to an individual's need for personal care 
services of, ``.such matters as the Secretary considers appropriate (38 
USC 1720G(a)(2)(A)-(B)). While there are obviously 100% disabled 
veterans who do not need and should not qualify for Caregiver support 
(which would seem to call into question why such a Veteran would be 
awarded a 100% disability rating), we do believe certain disability 
ratings, such as Special Medical Compensation rating R1 or R2, should 
carry with it a presumption of eligilibity for the PCAFC program. We 
believe the Secretary should use that special authority referenced 
above to establish such a presumption.

A: Should the severity of injury be considered in determining 
    eligibility to ensure VA is supporting family caregivers of 
    Veterans most in need? If so, how should the level of severity be 
    determined?

    This question is confusing in its sentence structure. The program 
was, in our estimation, established on a clear standard of the Veteran 
not being able to complete activities of daily living. Congressional 
intent would appear clear that those Veterans are already considered 
most in need of Caregiver support?
    If the Department is asking whether it should further limit access 
to the Caregiver program beyond the standard already established by 
Congress, then the answer is categorically no.No.
    The question appears to imply the Department wishes to prioritize 
eligibility in order to ration access, something which The Independence 
Fund categorically rejects. The PCAFC program should be administered in 
a way that any Veteran qualified for the program gains immediate access 
to it.
    However, establishing national eligibility standards would, in our 
estimation, reduce much of the variability across Caregiver eligibility 
described above, and would, in our opinion, reduce the need to even 
conduct such prioritization by providing bright line standards for 
clinicians and administrators to follow.

C. Should eligibility be limited to only those Veterans who without a 
    family caregiver providing personal care services would otherwise 
    require institutionalization?

    Absolutely not.

    The paltry stipend paid to current caregivers, and the presumption 
apparently applied by many of the VA eligibility gatekeepers that 
family caregivers should automatically be assisting Veterans with 
activities of daily living (including eating, mobility, hygiene and 
toileting) without compensation is insulting and atrocious. 
Essentially, considering to limit the Caregiver program to only those 
Veterans without a family caregiver available is to leverage the love 
families have for their disabled Veterans to provide the care the 
Department would otherwise provide, but at a far cheaper rate. 
Essentially, the US Government is leveraging that familial love for the 
Veteran against the family in order to save the US Government money. 
Considering to further limit eligibility to only those without a family 
caregiver available is, in our opinion, unconscionable.

2.To be eligible for the program, participation must be determined to 
    be `in the best interest' of the Veteran. How should `best 
    interest' be defined.

    The way ``best interest'' is currently implemented perpetuates a 
paternalistic and condescending approach of how the Department should 
provide care to Veterans, assuming a Veteran is incapable of 
understanding what health care is and is not in their best interest. 
Such a ``Big Brother'' approach to health care decisions implies that 
the Veteran is incapable of making his or her own health care 
decisions.
    Instead, The Independence Fund believes if a Veteran applies for 
Caregiver assistance, it should automatically be presumed that such 
assistance is in the best interest of the Veteran. Given the law 
requires a ``Best Interest'' determination by the Secretary, The 
Independence Fund recommends the ``Best Interest'' determination be 
changed to a negative only determination: Unless the Department 
specifically determines it is not in the best interest of the Veteran 
to participate in the program, the ``Best Interest'' test should be 
presumed to be met by the Veteran's application.

A. How can VA improve consistency in `best interest' determinations for 
    participation in the program?

    By changing the ``Best Interest'' determination into a negative 
determination: Unless the Department specifically determines it is not 
in the best interest of the Veteran to participate in the program, the 
``Best Interest'' test should be presumed to be met by the Veteran's 
application.

B. Are there any conditions under which participation would not be in a 
    Veterans best interest?

    The Independence Fund cannot think of any except where the 
Caregiver is abusing or taking financial advantage the Veteran, and 
where ending eligibility is the only way the Department would have to 
end the abuse.

4. Once approved for the PCAFC should the Veterans eligibility be 
    reassessed at specific time intervals or based on clinical 
    indicators?

    Many Veterans assisted by PCAFC are catastrophically, permanently 
and totally disabled, and as such, their disability ratings are set at 
that minimum level with no future downgrading allowed. Similarly, The 
Independence Fund points out the Caregivers for these permanently and 
totally disabled veterans are, absent a miracle, going to be Caregivers 
for the rest of that Veteran's life. Requiring periodic reevaluations, 
especially at the current 90 day interval, is insulting to the Veteran, 
introduces uneccessary stress and disruption for both the Veteran and 
the Caregiver, and completely unnecessary. The Independence Fund 
recommends reassessment be eliminated for the Caregivers of permanently 
and totally disabled Veterans enrolled in the program, who are also 
rated R1 or R2 under the Special Medical Compensation program.

b.1. Should reassessments be standard for every participant?

    No.
    The Independence Fund recommends reassessment be eliminated for the 
Caregivers of permanently and totally disabled Veterans enrolled in the 
program, who are also rated R1 or R2 under the Special Medical 
Compensation program.

b.2. Are there conditions under which continued eligibility should be 
    presumed and a reassessment not needed?

    Yes.

b.3. If so, what would these conditions be?

    For the Permanently and Totally Disabled, who are also rated R1 or 
R2 under the Special Medical Compensation program.

6.b. Under what circumstances should the family caregiver benefits be 
    continued after revocation?...How long should the benefits be 
    continued under such circumstances?

    Many caregivers give up careers and all outside employment to care 
for wounded and disabled veterans. The Caregiver stipend, completely 
insufficient though it is, is often the only income that Caregiver 
family has outside the Veteran's VA compensation. When the Veteran 
dies, that family loses a huge portion of their income, compounded by 
the fact the Veteran's Caregiver could very well have been out of the 
workforce for years. Further, the Caregiver loses health insurance 
coverage they receive under CHAMPVA.
    Therefore, The Independence Fund recommends Caregiver stipends and 
CHAMPVA coverage be continued for at least a year after the death of 
the enrolled Veteran.

7. How should VA calculate stipends?

    The Caregiver stipend rate is an embarrassment for our country. 
With a maximum weekly stipend of 40 times the rate for personal care 
assistance in that geographical region, for the most catastrophically 
wounded veteran who nevertheless provide round the clock care, such a 
paltry sum is an insult to the care Veterans' Caregivers provide. If 
that family caregiver were not available, the institutionalization of 
the Veteran would cost the Department far more, likely somewhere in the 
$7,500 to $10,000 per month range, under the best of circumstances. 
Further, basing the stipend on the presumption the family Caregiver 
will only provide 40 hours per week for the Veteran is fanciful, and 
seems to be chosen to save the government money, not properly 
compensate the Caregiver for his or her services.
    Therefore, The Independence Fund recommends the stipend by 
calculated by what home care licensed vocational nurse care of that 
Veteran would cost the US Government, times 80 hours per week.

    a.Should VA use one BLS rate per state?

    No. Costs of living can vary greatly within a State, and varying 
stipends based on those costs of living.is reasonable.

8.b. A Veteran is assigned a stipend tier based on the amount and 
    degree of personal care services provided. How should VA assess and 
    determine the amount and degree of personal care services provided 
    to the Veteran by the family caregiver?

    While much of the PCAFC program eligibility is related to needs 
regarding activities of daily living, given the well established 
disability rating program the Department already executes, both with 
the standard disability rating system and the Special Medical 
Compensation ratings, it should rely upon those standards to the extent 
that it can, regardless of the underlying activities of daily living 
standard, as there is likely a strong correlation between the two, and 
using such ratings would bring much greater transparency and uniformity 
to the Caregiver tier and compensation systems.
    Thank you for the opportunity to submit these comments. If you need 
further clarification or if you wish to discuss further, I can be 
reached at [email protected] or 202-779-1598.

    Very Respectfully,

    Bob Carey
    Director, Policy & Advocacy

                                 
                               BOB CAREY
    Dear Chairman Wenstrup, Representative Brownley, and Members of the 
Subcommittee, thank you very much for inviting The Independence Fund to 
testify before your Subcommittee today. I am Bob Carey, Director of 
Policy & Advocacy of The Independence Fund, headquartered in Charlotte, 
North Carolina, with additional offices in Washington, DC and San 
Antonio, TX.
    Only 10 years old, we were founded in 2007 with the very specific 
purpose of assisting the most catastrophically wounded veterans from 
the Iraq and Afghanistan with adaptive mobility devices, and returning 
to them, at least in part, their independence. Since those humble 
beginnings, The Independence Fund's grown to also provide assistance 
for the caregivers of the catastrophically wounded and disabled, 
assistance to adaptive athletes and teams, wellness programs to combat 
the scourge of veteran suicide and post-traumatic stress disorder, 
veteran service programs to navigate the overly complex VA health care 
and benefit systems, advocacy programs to change the laws and 
regulations that unnecessarily limit veterans access to their earned 
benefits, and our newest program, Heroes at Home, which will assist the 
children of the catastrophically wounded and disabled.
    To date, The Independence Fund's provided more than $50 million in 
assistance to the catastrophically wounded and disabled and their 
Caregivers. This includes more than 2,200 motorized cross-country 
wheelchairs, 1,500 adaptive bicycles, and more than 150 Caregiver 
support retreats.

Overall Issues and Compromise Legislation

    Mr. Chairman, we would be remiss if we did not discuss the failed 
opportunity to bring widespread reform to the VA system with the 
recently considered compromise VA Choice, Caregiver expansion, and 
capital asset review legislation that was proposed to include on the 
Comprehensive Appropriations Act for FY 2018, recently passed by 
Congress. The Independence Fund supported this compromise legislation, 
as we believe most every other major veteran service organization did. 
We do not believe a single veteran service organization opposed the 
compromise legislation. That is why we joined our VSO colleagues in our 
disappointment it was not included in the final omnibus legislative 
package.
    That said, it is not too late to enact this groundbreaking 
legislation. With the VA Choice program projected to run out of money 
by late May or early June, some type of legislative action will be 
needed very soon. The Independence Fund believes that original 
compromise legislation, without amendment, is our best chance to break 
ourselves from this endless cycle of budgetary brinksmanship with the 
VA Choice program, to bring meaningful and real choice to the VA health 
care system, to expand the caregiver program, and to analyze 
deliberatively and rigorously the real capital asset requirements of 
the VA.
    While we share the Chairman's and the prior Secretary's concerns 
expanding the VA Caregiver program without revising the eligibility 
criteria may swamp the program so completely that current caregivers 
are denied the support they need, the need for expanding choice in the 
VA health care system is so severe, we are willing to take that risk 
with the Caregiver program as part of a broad legislative compromise 
proposal.
    Therefore, Mr. Chairman and members of the Subcommittee, The 
Independence Fund strongly recommends the proposed omnibus legislative 
compromise language, with all three pieces major reform - VA health 
care choice expansion and community care consolidation; VA Caregiver 
expansion, and the capital asset review - be pursued in their entirety, 
and without further amendment, before alternative texts are considered. 
It is in this compromise language that our community finds its best 
hope for passage. With the universal VSO support, if any part of the 
original omnibus language were reopened, we would demand, as we believe 
many other VSOs would demand, for additional reforms of other parts of 
that omnibus package. In our case, it would be further expansion of 
access to non-VA care and refinement and national standardization of 
the Caregiver program. But such renegotiation of the language would 
likely delay consideration to after the deadline for funding VA Choice, 
and with that, the best legislative vehicle for enacting such laws.

HR 2322

    Mr. Chairman, with The Independence Fund's focus on reforming VA 
health care, especially for the catastrophically disabled, and for 
supporting the caregivers and families of those catastrophically 
disabled, we will only comment on HR 2322, HR 4334, and the Revised 
Draft to Make Certain Improvements in the Family Caregiver Support 
Program.
    Which brings us to the specific issue of wheelchairs and 
prosthetics. Our Executive Director, Sarah Verardo, is Caregiver to her 
husband SGT Michael Verardo, USA (Ret), catastrophically wounded in 
Southern Afghanistan in 2010. Mike regularly talks about how his 
biggest battle was not on the battlefield, nor in the immediate 
recovery before his medical retirement from the military in 2013. Mike 
and Sarah's biggest battle is with a VA health care system unresponsive 
to their unique health care needs, and apparently either unwilling or 
unable to make the changes necessary to optimize the care for the 
catastrophically disabled. Their personal experience, and the 
experience of hundreds of our clients served through the years, is that 
the VA cannot deliver wheelchair and prosthetic repairs and 
replacements in a timely manner.
    For example, when Mike was retired from the military and we moved 
back to Rhode Island, his prosthetic leg was damaged, but we had to 
wait 57 days for a VA medical administrator to sign a form authorizing 
the repair of the prosthetic. Eventually, the prosthetic vendor grew 
disgusted with the VA and provided a new prosthetic without 
authorization, risking non-payment. In the meantime, Sarah was forced 
to duct tape Mike's leg to keep it even somewhat operational. More 
recently when Sarah requested a wheelchair repair or replacement from 
VA, sheI was told that the VA needed to evaluate if Mike still had 
injuries that required wheelchair use. Apparently the VA did not 
realized limb loss is permanent.
    The Independence Fund's made eliminating the requirement to see a 
Primary Care Physician first when seeking prosthetics or wheelchair 
repairs one of its type priorities, meeting with the White House, the 
prior Secretary, Congress (including this Subcommittee), and the 
leadership of the Rehabilitation, Wheelchair, and Prosthetics 
departments at the VA. And that is why we are so encouraged by VA's 
announcement week before last eliminating that requirement, allowing 
the Veteran to go directly to the wheelchair and prosthetics offices to 
seek assistance.
    But that, Mr. Chairman, is not enough. The VA Inspector General 
released a report last month detailing the myriad problems with 
wheelchair and prosthetic repairs in VISN 7, which we believe apply 
nationwide. The first remarkable item in this report is that the VA 
apparently has no standard for how long it should take to repair 
wheelchairs and scooters. Second, the VA IG found the average wait time 
was 99 days. Some of the Veterans researched in this study were 
bedridden for more than 100 days while their wheelchairs were being 
repaired. We believe such wait times are similar for prosthetics as 
well.
    Lastly, the VA IG detailed the repair administrative process. That 
process seems incredibly complex and unnecessarily duplicative. A 
simple process review would likely be able to trim substantial time and 
steps from this process. The Independence Fund recently met with the 
Central Office Prosthetics and Wheelchairs Department, and we are 
hoping to enter some Memorandum of Understanding with the VA to help 
them improve those processes. We request your support with the VA to 
enter into such an agreement with us.
    But again, Mr. Chairman, we do not believe there are any 
circumstances where the VA will be able to adequately respond to 
Veterans' prosthetic and wheelchair repair and replacement needs. 
Having to wait until the point of failure for the VA to even initiate 
repair or replacement action and having no spares available for the 
Veteran to use in the interim, highlights a system unresponsive to the 
basic needs of disabled Veterans. Even the 30-day repair standard the 
VA IG arbitrarily applied in their report (since the VA does not have 
its own repair/replacement standard), is unacceptably long. Therefore, 
we recommend Veterans be allowed immediate access to non-VA care for 
the repair or replacement of prosthetics, wheelchairs, and scooters.
    With regards to HR 2322, we believe additions and revisions to the 
bill will help address these problems, and we look forward to working 
with the sponsors of the legislation and the Subcommittee to revise it. 
But spefically, we believe the following recommendations will help 
improve the legislation:
    -Specifically add language for wheelchairs. While many amputees are 
able to use their prosthetics for many hours throughout the day, many 
others are more limited in that use, relying on wheelchairs for the 
other times. Further, administratively, the wheelchair programs and 
prosthetic programs are run by the same offices in the VA, and the 
procedures are developed by the same personnel.
    -Required the VA to develop realistic repair and replacement 
timelines. As the VA IG report highlighted, the VA currently has not 
standards for how long it can take to repair or replace a wheelchair or 
prosthetic device. The VA IG used 30 days as an arbitrary standard, but 
even then, we believe that is unreasonably long. Further, the VA has no 
preventive maintenance programs, or backup/loaner programs, even for 
manual wheelchairs. We believe the Bill of Rights must include timely 
access to repairs and replacements, loaners and backups provided by the 
VA within days of the Veteran contacting VA, and immediate direct 
access to the vendor by the Veteran, rather than having to go through 
the Byzantine VA bureaucracy.

HR 4334

    Mr. Chairman, The Independence Fund salutes the Subcommittee's 
commitment to serving our female Veterans and specifically addressing 
their unique needs. We also believe the bill's focus on exploring non-
VA care options is wise. While female veterans make up an increasing 
portion of the VA health care population, they are still a significant 
minority. We are concerned, at least in some regions, there will never 
be enough of a female patient density to justify unique female programs 
at local VA facilities, and that the unique needs of female Veterans 
are such that the VA will never be able to recruit enough specialists 
to provide adequate VA care to that population at the local level.
    Further, we do not believe regional or national specialist clinics, 
to which female Veterans would travel, are a reasonable way to provide 
the care. It forces sick Veterans to travel long distances, forces them 
inappropriately into inpatient care settings, and takes them away from 
their primary family and local support systems. Therefore, Mr. 
Chairman, The Independence Fund recommends the language regarding 
female Veteran access to non-VA care by strengthened and expanded. We 
look forward to working with the bill sponsors and the Subcommittee on 
those recommendations.

Caregiver Support Programs

    Mr. Chairman, as The Independence Fund's noted many times in the 
past, we share your concern expanding the Caregiver program without 
also refining it may so swamp the VA Caregiver infrastructure that 
current Caregivers are denied the support they need. And in another 
time and another place, we would be excited to help the Subcommittee 
with such refinements. However, our fellow VSOs have made it clear, in 
no uncertain terms, that only absolute expansion of the program, under 
current eligibility rules, to pre-9/11 Veterans, is acceptable to them 
as part of the broader omnibus appropriations compromise legislation. 
Any change to that current language will trigger their opposition to 
the entire package. Therefore, we are concerned consideration of this 
legislation at today's hearing may endanger Congress' ability to get 
not only VA Caregiver expansion enacted, but VA Choice expansion as 
well.
    The Independence Fund's attached it's response to the February 2018 
Federal Register request for comments on the current Caregiver program, 
as well as our testimony before the VA's Caregiver and Military Family 
Advisory Committee, in order to provide the Subcommittee with the 
background on our overall concerns with the program.
    If Congress is unable to pass the omnibus appropriations compromise 
VA reform legislation, and the entire gamut of issues is reopened for 
legislative consideration, The Independence Fund looks forward to 
working with the Subcommittee then on the new Caregiver expansion and 
reform legislation.
    Thank you again, Mr. Chairman, for the opportunity to appear before 
this Subcommittee today. I look forward to answering any questions you 
may have.

                                 
                    THE VETERANS CANNABIS COALITION
    Chairman Wenstrup, Ranking Member Brownley, Members of the 
Subcommittee, on behalf of the Veterans Cannabis Coalition (VCC), we 
thank you for the invitation to submit our remarks to authorize the 
U.S. Department of Veterans Affairs (VA) to conduct and support 
research of medicinal cannabis. We believe that the VA Medicinal 
Cannabis Act of 2018 is a positive first step toward putting the 
incredible research capacity of the Department of Veteran Affairs to 
work investigating the medical value of cannabis.
    The Veterans Cannabis Coalition appreciates the Committee for 
having listened to the concerns of millions of veterans and identified 
the immediate need for more high-quality research into the efficacy of 
cannabis through the Department of Veteran Affairs. The untold number 
of veterans, whom are suffering from a lack of effective treatments for 
their service-connected injuries, need options. Based on current and 
existing research and anecdotal testimonies, we recognize the immense 
potential of cannabis to treat some of the most persistent health 
issues facing veterans today, particularly traumatic brain injury 
(TBI), post-traumatic stress disorder (PTSD), and the pernicious effect 
of chronic pain.
    The comorbidity of these conditions in many veterans returning home 
from Iraq and Afghanistan over the last 17 years has led to a modality 
within the Veterans Health Administration to focus on pharmacology. 
Doctors throughout the VA health system have consistently prescribed 
risky combinations of incredibly powerful drugs in order to manage the 
symptoms of the veterans under their care. These drugs include opioids, 
benzodiazepines, stimulants, sedatives, anti-depressants, anti-
psychotics, and more, and are often taken in conjunction.
    Veterans report that this commonly prescribed drug regimen, 
nicknamed the `combat cocktail', negatively impacts their interpersonal 
relationships and employment, destroys their quality of life, and has 
led many to unsuccessfully attempting to take their own life while 
under the influence of the very same medications prescribed by the VA. 
There are thousands of others, driven by desperation and unable to find 
relief through the only treatments offered, who were successful. The 
veteran suicide and overdose rates reflect this reality.
    As Congress and the public have begun to grapple with the fact that 
millions of Americans-from valedictorians to professional athletes to 
service members-struggle with opioid use disorders, the reaction from 
health systems has been to taper or cut opioid prescriptions for 
patients. The VA has touted their reduction and shift toward other 
therapies and holistic treatments like acupuncture and yoga. Scaling 
such therapies, however, presents massive challenges, while using non-
narcotic medications like non-steroidal anti-inflammatory drugs 
(NSAIDs) carries other long-term risks such as kidney damage. Cannabis 
has no known toxicity, low rates of misuse and abuse, and its use as a 
medication is associated with marked improvements in dozens of 
different conditions, ranging from insomnia to anxiety, PTSD to pain 
management.
    The Veterans Cannabis Coalition recognizes the VA Medicinal 
Cannabis Research Act of 2018 as an opportunity for Congress to 
decidedly address this crisis. Establishing the medical merit of 
cannabis through Department of Veterans Affairs guided and funded 
research will provide immeasurable public good, one that we hope both 
parties will fully support. We look forward to working with your 
offices and Committee staff as we aim to educate and build support for 
this effort in the weeks and months ahead.
    For additional information, please contact Eric Goepel, Founder & 
CEO of the Veterans Cannabis Coalition at (213) 986-8139 or 
[email protected].

                                 
                     THE VETERANS CANNABIS PROJECT
``TO AUTHORIZE THE DEPARTMENT OF VETERANS AFFAIRS TO CONDUCT AND 
    SUPPORT RESEARCH ON THE EFFICACY AND SAFETY OF MEDICINAL CANNABIS''

    APRIL 17, 2018

    Chairman Wenstrup, Ranking Member Brownley, Members of the 
Subcommittee, on behalf of the Veterans Cannabis Project (VCP), we 
thank you for the invitation to submit our remarks to authorize the 
U.S. Department of Veterans Affairs (VA) to conduct and support 
research of medicinal cannabis. It is imperative that Congress pass the 
VA Medicinal Cannabis Research Act of 2018 to provide the VA the 
resources to effectively and comprehensively treat the complexity of 
every veteran's mental and physical wounds.
    The internal wounds of military veterans have become a costly 
nationwide epidemic. Upwards of 20 percent of the 2.7 million Iraq and 
Afghanistan veterans will experience post-traumatic stress or 
depression, according to the VA.
    Veterans are often placated with ``cocktails'' of prescription 
drugs, including powerful and addictive opiates. The current 
arrangement is not meeting veterans' healthcare needs. Recent research 
at the VA indicates a link between increased opioid dosages and suicide 
among veterans. Federal data shows veterans are twice as likely as non-
veterans to die from an accidental overdose of highly addictive 
prescription drugs.
    Medical cannabis is a proven, safe and common-sense personal health 
management option, free of the devastating side effects of opiate-based 
drugs. It is now legal in 30 states and is recognized by experts such 
as the American College of Physicians, the American Public Health 
Association and the American Nurses Association as a safer alternative 
to many legal treatments. Medicinal cannabis is an incredibly effective 
tool for veterans challenged with managing the symptoms of their 
wounds.
    Furthermore, in states where medical cannabis is now legal, 
veterans are stuck in a ``catch-22'' situation if they elect to obtain 
a medical cannabis recommendation: the VA is a federal healthcare 
system, which ignores state cannabis laws, leaving veterans unable to 
openly discuss the issue with their primary care providers and at risk 
of losing hard-earned benefits. Regardless of the legal status of 
cannabis in a state, Veterans Health Administration physicians are 
prohibited from recommending cannabis as a treatment option for their 
Veteran patients.
    The VA Medicinal Cannabis Research Act of 2018 will elevate 
cannabis as a health policy issue and lay the foundation for veterans 
to legally access an effective healthcare treatment. While data already 
exists proving medical cannabis' positive effects, federal research is 
needed to afford the VA the ability to treat cannabis as medicine. We 
owe those who served, currently serve, and will serve our nation access 
to every medically proven healthcare treatment, including medical 
cannabis.
    The Veterans Cannabis Project was founded by veterans, for 
veterans, to create an improved quality of life through the opportunity 
of cannabis. The Veterans Cannabis Project team is comprised of veteran 
leaders and their families through meaningful career progression after 
the military. We thank the Subcommittee for holding this important 
hearing and for the opportunity to explain the views of the Veterans 
Cannabis Project.
    For additional information, please contact Nick Etten, Founder & 
CEO of the Veterans Cannabis Project at (512) 992-7567 or 
[email protected].

                                 
                        WOUNDED WARRIOR PROJECT
    Chairman Wenstrup, Ranking Member Brownley, and distinguished 
members of the Subcommittee on Health - thank you for inviting Wounded 
Warrior Project (WWP) to provide this statement for the record for 
today's legislative hearing on pending health legislation. More than 
113,000 wounded warriors are registered to receive WWP's free direct 
programs and services, and thus far in Fiscal Year 2018, WWP is 
registering an average of more than 1,200 new warriors per month.
    Based on these figures and our own observations and experiences 
working with wounded warriors and their families around the country, we 
believe that the need for strong, sensible, and sustainable veteran-
centric health care laws is great and growing. We are pleased to 
provide the following positions on legislation before the Subcommittee.

H.R.--: A draft bill to make certain improvements in the Family 
    Caregiver Program

    As a crucial component of delivering on our mission to honor and 
empower wounded warriors, WWP has been proud to advocate for benefits 
for seriously injured post-9/11 veterans' caregivers. In addition to 
organizing in support of enacting the Caregivers and Veterans Omnibus 
Health Services Act of 2010, WWP has worked closely with the Department 
of Veterans Affairs (VA) to ensure that the Program of Comprehensive 
Assistance for Family Caregivers (the Program) is carried out as 
effectively as possible.
    Wounded Warrior Project believes the Program should be available to 
all generations with appropriate funding and without a reduction in 
benefits for post-9/11 warriors. While WWP's mission focuses on family 
caregivers of veterans and service members who have been wounded, ill, 
or injured since September 11, 2001, we appreciate that the 
Subcommittee has acknowledged that all generations should receive the 
benefits that have been such a crucial resource for post-9/11 
caregivers over the last seven years.
    In this context, WWP does not support the current draft legislation 
because its proposed improvements do not outweigh the associated 
detriments to the current program. WWP supports the information 
technology provisions in Section 1; however Section 2 creates concerns 
that overshadow the desired goal of expanding the Program to all 
generations. Specifically, raising the threshold for eligibility based 
on activities of daily living would result in the ability to serve 
fewer veterans whose best clinical interest can and should be served by 
participating in the Program.
    Section 2 also proposes to ``transition'' current program 
participants - whose current eligibility may not be sufficient for 
participation under new criteria - to the new program. While WWP has 
concerns about the VA's ability to administer a bifurcated Program with 
different eligibility standards, WWP is strongly opposed to 
implementing a new, single program that holds potential to remove 
current, deserving beneficiaries to accommodate new participants.
    Moreover, it has been approximately one year since VA froze Program 
revocations due, in part, to complaints from veterans who lost access 
to the Program even though their conditions had not improved \1\. 
Anecdotally, WWP has seen such revocations from veterans utilizing our 
Benefits Services program, and in our experience, successful appeals 
are extremely rare. By ordaining a transition process that could 
potentially remove thousands of veterans from the Program, this draft 
bill would amplify these issues even further. Removing current 
participants who have been clinically approved to participate and who 
maintain a severe level of disability is an unacceptable approach to 
realizing the greater community's dream of bringing the Program within 
the reach of other veteran caregivers who are no more or less deserving 
of its critical resources.
---------------------------------------------------------------------------
    \1\ Quil Lawrence, Some VAs are Dropping Veteran Caregivers from 
their Rolls, NPR (April 5, 2017) (available at https://www.npr.org/
2017/04/05/522690583/caregivers-for-veterans-dropped-from-va-plan).
---------------------------------------------------------------------------
    In sum, WWP believes that those who cannot participate in the 
Program now (and all who could potentially participate in the future) 
should have access to the same benefits offered to those currently in 
the Program. Such an expansion can and should be achieved with careful 
management and appropriate funding, and without diminishing the quality 
of the Program for those currently-eligible or those who may become 
eligible in the future. As the current draft proposal does not meet 
these criteria, WWP respectfully opposes the current draft proposal. 
WWP also fully supports S. 2193 Caring for our Veterans Act of 2017, 
which offers full expansion of the Caregiver Program to all generations 
without diminishing the quality of the Program, and WWP will 
aggressively pursue its passage through the House and Senate.

H.R.--: A draft bill to authorize VA to conduct and support research on 
    the efficacy and safety of medicinal cannabis

    Wounded Warrior Project's mission to honor and empower wounded 
warriors drives us to foster the most successful, well-adjusted 
generation of injured veterans in our nation's history. The warriors, 
caregivers, and family members we serve are at the center of every 
decision we make. Several emerging and alternative therapies have 
demonstrated some initial promising results for the management and 
treatment of the invisible wounds of war, including post-traumatic 
stress disorder (PTSD) and traumatic brain injury (TBI). Lately, there 
has been much debate surrounding veterans' rights to access medical 
cannabis as an alternative therapy.
    At WWP, we believe that choosing a treatment method, whether 
alternative or empirically supported, is a personal decision that 
should be made between each warrior, his or her family, and his or her 
medical team. WWP encourages warriors to make informed decisions in 
pursuing the treatment options that are most relevant to their 
circumstances with the guidance of their health care providers. While 
WWP does not have an official stance on the use of medical cannabis, 
WWP is supportive of evidence-based and evidence-informed therapies, as 
well as complementary and alternative therapies that have been 
empirically demonstrated and validated through research to be 
successful in rehabilitation and recovery.
    For these reasons, Wounded Warrior Project supports research and 
investments with potential to expand the number of evidence-based and 
evidence-informed therapies available to treat both the visible and 
invisible wounds of war affecting post-9/11 veterans. As any research 
plan developed by VA to investigate potential uses of medical cannabis 
under this proposal would be subject to additional review by Congress, 
this proposal permits future oversight of potential concerns regarding 
employment constraints and other ramifications of those selected to 
participate. In this context, WWP is pleased to support this draft 
proposal.

H.R. 1506: VA Health Care Provider Education Debt Relief Act of 2017

    Recent work to improve and consolidate VA's community care programs 
has provided an opportunity for WWP and others in the veterans policy 
community to highlight a corresponding need to ensure that VA is given 
the tools and resources necessary to grow and strengthen as it 
struggles to meet the increased demand for services for our nation's 
heroes. Of particular note, VA must be able to recruit, hire, and 
retain high-quality medical professionals.
    WWP views the Health Care Provider Education Debt Relief Act of 
2017 as a way to attract quality personnel to the VA, and with the rise 
of education debt, an opportunity to give VA a competitive advantage to 
hire and retain those best qualified to deliver care to veterans. In 
its Determination of VHA Occupational Staffing Shortages FY 2017 
report, VA's Office of Inspector General found that the largest 
critical need occupations were Medical Officers, Nurses, Psychologist, 
Physician Assistants, and Medical Technologists \2\. In the past four 
years, Medical Officers and Nurses have been the top two critical need 
occupations. Given the amount of cost it requires to obtain a degree in 
one of these two fields, H.R. 1506 would constitute an effective tool 
to attract these critically needed specialists to VHA. For these 
reasons, WWP is pleased to support the Health Care Provider Education 
Debt Relief Act of 2017.
---------------------------------------------------------------------------
    \2\ https://www.va.gov/oig/pubs/VAOIG-17-00936-385.pdf

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H.R. 2322: Injured and Amputee Veterans Bill of Rights

    While the past several years have seen increased focus on the 
mental health needs of post-9/11 veterans, WWP remains vigilant in 
addressing the needs of those with severe physical injuries. From 
January 1, 2001, through December 31, 2016, 1,710 service members 
sustained at least one conflict-related amputation (excluding fingers, 
thumbs, or toes) \3\. This group is just a small segment of a larger 
population. The total number of Veterans with amputations being seen at 
VA facilities increased 325 percent, from 25,000 in FY 2000 to almost 
90,000 in FY 2016 \4\. These figures reflect the need to help ensure 
veterans with injuries and amputations have access to high quality 
prosthetic limb and orthotic care.
---------------------------------------------------------------------------
    \3\ VA/DoD Clinical Practice Guidelines for Rehabilitation of 
Individuals with Lower Limb Amputation. The Rehabilitation of 
Individuals with Lower Amputation Working group; Version 2.0 - 2017; 
pg. 10.
    \4\ Id. at 10.
---------------------------------------------------------------------------
    Although not all amputees elect to wear a prosthesis, the vast 
majority do. The ultimate goal for a prosthesis is to achieve the most 
function and mobility possible, leading to an active and fulfilling 
lifestyle. To achieve that goal, an amputee must work closely with a 
prosthetist who understands their unique needs, such as residual limb 
size, type of amputation, gender- and age-related issues, and activity 
levels.
    The proposed Injured and Amputee Veterans Bill of Rights would 
affirm a commitment to ensuring these veterans have access to timely, 
high quality, and patient-centered care. WWP believes the nine-line 
Bill of Rights in Section 2(d) are all reasonable and non-controversial 
policy statements, including the right to have access to high-quality 
care, the most appropriate prosthesis and orthosis, the most 
appropriate technology, and the best-qualified practitioners, whether 
or not that practitioner is an employee of the VA. A requirement to 
prominently post these rights at each VA prosthetics and orthotics 
clinic, as well as on the VA website, would help ensure they are known 
and understood by both veterans and health practitioners.
    Additionally, with the increasing number of amputees relying on the 
VA for prostheses, WWP supports the reporting requirements for the VA 
to establish transparency of allegations of mistreatment of injured and 
amputee veterans. The educational component of this legislation would 
ensure that VA employees who work at prosthetics and orthotics clinics 
or as a patient advocate for amputees, receive training on such Bill of 
Rights.
    For these reasons, WWP is pleased to support the Injured and 
Amputee Veterans Bill of Rights.

H.R. 4334: Improving Oversight of Women Veterans' Care Act of 2017

H.R. 4635: To direct the Secretary of Veterans Affairs to increase the 
    number of peer-to-peer counselors providing counseling for women 
    veterans, and for other purposes

    Women comprise 8.7 percent of the veteran population and are the 
fastest-growing demographic in the military \5\. At WWP, nearly 16 
percent of our registered alumni are women and as an organization 
dedicated to honoring and empowering wounded veterans and service 
members who have been injured in both mind and body since 9/11, we 
particularly aware of the growing contributions of women in our armed 
services - and the need for programs and services tailored to their 
needs.
---------------------------------------------------------------------------
    \5\ Source: National Center for Veterans Analysis and Statistics: 
Profile of Veterans: 2016: Data from the American Community Survey. 
2016.
---------------------------------------------------------------------------
    The Department of Veterans Affairs has expanded its care options 
and outreach to women veterans, but there is still room for 
improvement. VA offers primary and specialty care to support women at 
every stage of their life - including women's services such as family 
planning, infertility services, menstrual and menopausal management - 
but accessibility in a community-based settings is not fully captured 
and compliance with environment of care standards for women in VA-based 
settings is not fully monitored. The Improving Oversight of Women 
Veterans' Care Act of 2017 aims to correct these deficiencies, and 
women veterans stand to benefit.
    One particular area where women veterans are finding satisfaction 
is peer support. In our experience, peer-to-peer support is critical to 
recovery for many warriors. According to the 2017 Wounded Warrior 
Project Survey, more than half of those surveyed, or 51.6 percent, used 
talking with another Operation Enduring Freedom, Operation Iraqi 
Freedom, or Operation New Dawn veteran as a resource to address mental 
health issues. The only more frequently utilized resource was VA 
Medical Centers.
    Within the context of female veterans, peer-to-peer support is a 
particularly important tool to break through seclusion and isolation. 
As the Subcommittee is aware, shifts in perception of military 
demographics are slow-moving, and many on either side of the civilian-
military divide still think of members of the Armed Forces as male. 
Particularly when combined with injuries to mental health sustained in 
service, these preconceived notions can be harmful to reintegration and 
recovery. VA's 2016 suicide data report found that the risk of suicide 
was 2.5 times higher among female veterans when compared with civilian 
adult females \6\. By connecting female veterans with one another, 
peer-to-peer assistance can empower female veterans to connect with 
each other and their communities. At WWP, we've increased our 
commitment to offering more all-female peer support groups and all-
female alumni workshops based on demand and overall satisfaction.
---------------------------------------------------------------------------
    \6\ Source: Office of Suicide Prevention, Department of Veterans 
Affairs, Suicide Among Veterans and Other Americans 2001-2014, 4 
(August 2016).
---------------------------------------------------------------------------
    Wounded Warrior Project is committed to improving health options 
and outcomes for women veterans as both a program provider and an 
advocate for those receiving care and services through VA. Both H.R. 
4334 and H.R. 4635 are consistent with our commitment to achieving 
these goals, and WWP is pleased to provide its support for both 
proposals.

H.R. 3832: Veterans Opioid Abuse Prevention Act

    Wounded Warrior Project does not take a position on this bill at 
this time.

CONCLUSION:

    Wounded Warrior Project thanks the Subcommittee on Health, its 
distinguished members, and all who have contributed to the policy 
discussions surrounding the bills under consideration at today's 
hearing. We share a sacred obligation to serve our nation's veterans, 
and WWP appreciates the Subcommittee's effort to identify and address 
the issues that challenge our ability to carry out that obligation as 
effectively as possible. We are thankful for the invitation to submit 
this statement for record and stand ready to assist when needed on 
these issues and any others that may arise.

    Sincerely,

    Rene C. Bardorf
    Senior Vice President of Government and Community Relations

                                 [all]
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