U.S. GOVERNMENT PUBLISHING OFFICE

35–469 WASHINGTON : 2019

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 

( 

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

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COMMITTEE ON VETERANS’ AFFAIRS 

DAVID P. ROE, Tennessee, Chairman 

GUS M. BILIRAKIS, Florida, Vice-Chairman 

MIKE COFFMAN, Colorado 

BRAD R. WENSTRUP, Ohio 

AMATA COLEMAN RADEWAGEN, American 

Samoa 

MIKE BOST, Illinois 

BRUCE POLIQUIN, Maine 

NEAL DUNN, Florida 

JODEY ARRINGTON, Texas 

JOHN RUTHERFORD, Florida 

CLAY HIGGINS, Louisiana 

JACK BERGMAN, Michigan 

JIM BANKS, Indiana 

JENNIFFER GONZALEZ-COLON, Puerto 

Rico 

TIM WALZ, Minnesota, Ranking Member 

MARK TAKANO, California 

JULIA BROWNLEY, California 

ANN M. KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

KATHLEEN RICE, New York 

J. LUIS CORREA, California 

KILILI SABLAN, Northern Mariana Islands 

ELIZABETH ESTY, Connecticut 

SCOTT PETERS, California 

JON TOWERS, Staff Director 

RAY KELLEY, Democratic Staff Director 

SUBCOMMITTEE ON HEALTH 

BRAD WENSTRUP, Ohio, Chairman 

GUS BILIRAKIS, Florida 

AMATA RADEWAGEN, American Samoa 

NEAL DUNN, Florida 

JOHN RUTHERFORD, Florida 

CLAY HIGGINS, Louisiana 

JENNIFER GONZALEZ-COLON, Puerto Rico 

JULIA BROWNLEY, California, Ranking 

Member 

MARK TAKANO, California 

ANN MCLANE KUSTER, New Hampshire 

BETO O’ROURKE, Texas 

LUIS CORREA, California 

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. 

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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 

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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. 

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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 genderspecific 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 vetleonard.horne on VACREP0180 with DISTILLER

3 

erans. 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. 

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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 

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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 

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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 sysleonard.horne on VACREP0180 with DISTILLER

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tem 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 pre9/11 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. 

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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 statebased 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 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 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. 

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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 

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10 

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]

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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 

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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 nongovernment 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]

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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 grad- uates 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 

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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 

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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 

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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 sexspecific 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. 

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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 overrepresented 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 

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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. 

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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 post9/11 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 

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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. 

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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 sensoryaid 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. 

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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 

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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 

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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. 

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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. 

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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 

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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. 

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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.] 

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1Washington Post, 10 April 2018. 

2 VA, Report: Pending Appointments as of 1 April 2018. 

3 ‘‘Balancing Demand and Supply for Veterans’ Health Care,’’ RAND Corporation, 2016, pg. 

9. 4 Commission on Care Report, 2016, VA. 

5 VA, Education Debt Reduction Program (EDRP). 

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. 

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. 

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

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 

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30 

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. 

are about 3,000 medical professionals participating in this program. In accordance 

with 38 U.S. Code Section a7683(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. 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. 

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. 

f 

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. 

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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. 

f 

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. 

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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. 

f 

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. 

f 

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 GonzalezColon. 

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. 

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1 Commission on Care Final Report, June 30, 2016, page 145 

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 genderspecific 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. 

f 

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

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. 

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2https://www.veterans.senate.gov/hearings/legislative-presentation-of-the-american-legion— 

02282018 3 VAOIG Report 17–00936–835 

4 2017 Alaska VA Healthcare System Worth Saving Site visit 

5Gitlen, Jeff. Average Medical School Debt, LendEDU, Feb. 15, 2017, lendedu.com/blog/average-medical-school-debt/ 6Marquit, 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/ 7The American Legion Resolution No. 377 (2016): Support for Veteran Quality of Life 

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 highquality talent in its recruitment efforts. 2

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

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

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

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

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. 

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8http://thehill.com/blogs/congress-blog/healthcare/241243-a-national-prescription-drug-database-to-combat-opioid 9https://www.pharmacist.com/sites/default/files/files/ 

Prescription%20Drug%20Monitoring%20Programs.pdf 10https://www.whitehouse.gov/ondcp/presidents-commission/ 

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. 

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 statebased 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

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 

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11 American Legion Resolution No. 83 (Sept. 2106): Virtual Lifetime Electronic Record 12 Improved Monitoring Needed for Effective Oversight of Care for Women Veterans. GAO– 

17–52: Published: Dec 2, 2016 13The American Legion Resolution No. 377 (2016): Support for Veteran Quality of Life 

but widespread sharing of electronic medical records so that veterans can receive 

the highest possible quality healthcare available. 11

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

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

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 

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14The American Legion Resolution No. 364 (2016) Department of Veterans Affairs to Develop 

Outreach and Peer to Peer Programs for Rehabilitation 

to provide treatment, support services and readjustment counseling for those veterans requiring these services 14. 

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 cannabisbased 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 releonard.horne on VACREP0180 with DISTILLER

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15https://www.legion.org/documents/legion/pdf/medical—cannabis—study.pdf 16https://www.legion.org/sites/legion.org/files/legion/documents/ 

Veterans%20and%20Medical%20Cannabis.pdf 17https://www.acreageholdings.com/news-release-board-of-advisors-appointment 18https://archive.legion.org/bitstream/handle/20.500.12203/5763/ 

2016N011.pdf?sequence=4&isAllowed=y 

search 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. 

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

• 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, multistate 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

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

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 

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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 jsteele@legion.org. 

f 

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 

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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 cuttingedge 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. 

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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 

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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 

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1 38 C.F.R. a71.40(c)(4)(v) 

able 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 (post9/11). 

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

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 

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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. 

f 

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 

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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 peleonard.horne on VACREP0180 with DISTILLER

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riod 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 

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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. 

f 

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 

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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-topeer 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 

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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 selfprescribe 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 

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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. 

f 

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 

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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 

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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. 

f 

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, commonsense 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. 

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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 

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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. 

f 

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 recleonard.horne on VACREP0180 with DISTILLER

55 

ommend 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. 

f 

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? 

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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. 

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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. 

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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 

B.Carey@IndependenceFund.org or 202–779–1598. 

Very Respectfully, 

Bob Carey 

Director, Policy & Advocacy 

f 

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 

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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 

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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. 

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61 

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, antipsychotics, 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 eric@veteranscannacoalition.org. 

f 

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 

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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 nick@vetscp.org. 

f 

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 apleonard.horne on VACREP0180 with DISTILLER

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1Quil 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-droppedfrom-va-plan). 

preciate 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. 

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 post9/11 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 

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2https://www.va.gov/oig/pubs/VAOIG–17–00936–385.pdf 

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. 

ployment 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. 

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. 

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 patientcentered 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 

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5Source: National Center for Veterans Analysis and Statistics: Profile of Veterans: 2016: Data 

from the American Community Survey. 2016. 6Source: Office of Suicide Prevention, Department of Veterans Affairs, Suicide Among Veterans and Other Americans 2001–2014, 4 (August 2016). 

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. 

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. 

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 

Æ 

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