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S. HRG. 114–186 

HEARING ON PENDING HEALTH CARE AND 

BENEFITS LEGISLATION 

HEARING 

BEFORE THE

COMMITTEE ON VETERANS’ AFFAIRS 

UNITED STATES SENATE 

ONE HUNDRED FOURTEENTH CONGRESS 

FIRST SESSION 

JUNE 24, 2015 

Printed for the use of the Committee on Veterans’ Affairs 

( 

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

(II) 

COMMITTEE ON VETERANS’ AFFAIRS 

JOHNNY ISAKSON, Georgia, Chairman 

JERRY MORAN, Kansas 

JOHN BOOZMAN, Arkansas 

DEAN HELLER, Nevada 

BILL CASSIDY, Louisiana 

MIKE ROUNDS, South Dakota 

THOM TILLIS, North Carolina 

DAN SULLIVAN, Alaska 

RICHARD BLUMENTHAL, Connecticut, Ranking 

Member 

PATTY MURRAY, Washington 

BERNARD SANDERS, (I) Vermont 

SHERROD BROWN, Ohio 

JON TESTER, Montana 

MAZIE K. HIRONO, Hawaii 

JOE MANCHIN III, West Virginia 

TOM BOWMAN, Staff Director 

JOHN KRUSE, Democratic Staff Director 

(III) 

C O N T E N T S 

JUNE 24, 2015 

SENATORS 

Page 

Isakson, Hon. Johnny, Chairman, U.S. Senator from Georgia ............................ 1 

Murray, Hon. Patty, U.S. Senator from Washington ........................................... 7 

Prepared statement .......................................................................................... 8 

Blumenthal, Hon. Richard, Ranking Member, U.S. Senator from Connecticut ... 9 

Moran, Hon. Jerry, U.S. Senator from Kansas ..................................................... 10 

Rounds, Hon. Mike, U.S. Senator from South Dakota ......................................... 42 

Manchin, Hon. Joe, U.S. Senator from West Virginia .......................................... 44 

Cassidy, Hon. Bill, U.S. Senator from Louisiana .................................................. 46 

Sullivan, Hon. Dan, U.S. Senator from Alaska ..................................................... 51 

Letters and articles for the record .................................................................. 52 

WITNESSES 

Baldwin, Hon. Tammy, U.S. Senator from Wisconsin .......................................... 2 

Prepared statement .......................................................................................... 4 

Johnson, Hon. Ron, U.S. Senator from Wisconsin ................................................ 5 

Jain, Rajiv, M.D., Assistant Deputy Under Secretary for Health for Patient 

Care Services, Veterans Health Administration, U.S. Department of Veterans Affairs; accompanied by Catherine Mitrano, Deputy Assistant Secretary, Office of Resolution Management, Office of Human Resources Management; and Jennifer Gray, Staff Attorney, Office of General Counsel ........ 13 

Prepared statement and additional views ...................................................... 14 

Response to request arising during the hearing by: 

Hon. Mike Rounds ........................................................................................ 43,44 

Hon. Bill Cassidy .......................................................................................... 48 

Hon. Patty Murray ........................................................................................ 50 

Response to posthearing questions submitted by: 

Hon. Dean Heller .......................................................................................... 63 

Hon. Sherrod Brown ..................................................................................... 63 

de Planque, Ian, Legislative Director, The American Legion .............................. 64 

Prepared statement .......................................................................................... 65 

Hegseth, Peter B., Chief Executive Officer, Concerned Veterans for America ... 68 

Prepared statement .......................................................................................... 70 

Atizado, Adrian M., Assistant National Legislative Director, Disabled American Veterans ........................................................................................................ 71 

Prepared statement .......................................................................................... 72 

Blake, Carl, Associate Executive Director of Government Relations, Paralyzed 

Veterans of America ............................................................................................. 77 

Prepared statement .......................................................................................... 79 

Stier, Max, President and Chief Executive Officer, Partnership for Public 

Service ................................................................................................................... 83 

Prepared statement .......................................................................................... 84 

Rowan, John, National President, Vietnam Veterans of America ....................... 91 

Prepared statement .......................................................................................... 91 

APPENDIX 

Rubio, Hon. Marco, U.S. Senator from Florida; prepared statement .................. 95 

American Federation of Government Employees, AFL-CIO and its National 

Veterans Affairs Council (AFGE); prepared statement .................................... 95 

Page

IV 

Zumatto, Diane M., National Legislative Director, AMVETS; prepared statement ...................................................................................................................... 100 

American Society for Reproductive Medicine (ASRM); letter .............................. 104 

Military Officers Association of America (MOAA); prepared statement ............. 106 

Grundmann, Susan Tsui, Chairman, U.S. Merit Systems Protection Board; 

prepared statement .............................................................................................. 108 

National Alliance on Mental Illness (NAMI); prepared statement ..................... 121 

Lerner, Carolyn N., Special Counsel, United States Office of Special Counsel 

(OSC); prepared statement .................................................................................. 122 

Collura, Barbara L., President & CEO, RESOLVE: The National Infertility 

Association; letter ................................................................................................. 124 

Fuentes, Carlos, Senior Legislative Associate, National Legislative Service, 

Veterans of Foreign Wars of the United States (VFW); prepared statement .. 126 

Wounded Warrior Project (WWP); prepared statement ....................................... 131 

(1) 

HEARING ON PENDING HEALTH CARE AND 

BENEFITS LEGISLATION 

WEDNESDAY, JUNE 24, 2015 

U.S. SENATE, COMMITTEE ON VETERANS’ AFFAIRS, Washington, DC. 

The Committee met, pursuant to notice, at 2:40 p.m., in room 

418, Russell Senate Office Building, Hon. Johnny Isakson, Chairman of the Committee, presiding. 

Present: Senators Isakson, Moran, Boozman, Heller, Cassidy, 

Rounds, Sullivan, Blumenthal, Murray, Brown, and Manchin. 

OPENING STATEMENT OF HON. JOHNNY ISAKSON, 

CHAIRMAN, U.S. SENATOR FROM GEORGIA 

Chairman ISAKSON. I call this meeting of the Veterans’ Affairs 

Committee of the U.S. Senate to order, and I apologize that we are 

a few minutes late in starting. 

Senator Blumenthal and I have been with 50 of the Wounded 

Warrior star athletes with the Speaker of the House, the Majority 

and Minority Leaders of the Senate, and a number of supporters 

of their games that are going on, and General Dempsey was there, 

so we took a little bit of extra time. We apologize for that—apologize for not being here on time. 

Let me make a few opening remarks. We have some very important proposed pieces of legislation to be discussed today. We are 

looking forward to hearing from our Veterans Service Organizations and we are looking forward to hearing from our two distinguished members from the State of Wisconsin, Senator Baldwin 

and Senator Johnson. Thank you for being here today. 

Let me just say two or three things for the record, which the 

staff can make note of and tell the Members when they get here 

that I said this. You know, during the last markup of NDAA, we 

had an inordinate number of amendments posed that required a 

waiver by the VA Committee to waive jurisdiction so that it could 

be handled by the Armed Services Committee. In most cases, I objected and did not clear those amendments because I am never 

going to cede our responsibility or our jurisdiction as a Member of 

the Veterans’ Committee to another committee of the Senate, and 

that is the reason I objected. 

So, I apologize to any Members that might have felt like I was 

being a little unfair or unfriendly, but I think it is important that 

I protect the integrity of our Committee and its jurisdiction and I 

will continue to do so. So, if you in the future have amendments 

that you are going to put on a bill that is not of a bill before our 

2 

committee, you might talk to the staff ahead of time, so we do not 

run into a last minute conflict on the floor with the Chairman of 

Armed Services or whatever other committee it is. 

I know we are going to discuss issues in terms of over-prescription of opiates and some of the damages that have been done and 

the difficulties in Tomah. I appreciate both the Senators from Wisconsin being here today. 

Patty Murray is not here yet, but Senator Murray has got two 

particular bills, one on IVF benefits for veterans of the services 

that has passed this Committee before. I am working with her to 

help perfect that legislation so it can come before this Committee 

and be passed out. I look forward to her comments on that, as well 

as the VA’s testimony. 

We also have a proposal by Senator Murray regarding caregivers, 

extended benefits to those that served prior to 2001, 9/11/2001. We 

are looking at that, but we have an IG’s report in terms of a number of problems with the existing caregivers’ program regarding eligibility, so we are going to look at making sure we clean up the 

problems that we have got first before we extend further benefits 

and run the risk of having more problems than we intended to 

have. 

I look forward to hearing from the VSOs that provide us with 

such great information always in terms of legislation and their 

opinions on it. I look forward to hearing from the Veterans Administration, as well. 

With that said, I want to introduce our two Senators from the 

State of Wisconsin to make their remarks, which I hope they would 

limit to 5 minutes or less. I will start with Senator Baldwin from 

Wisconsin, then go to Senator Johnson. 

STATEMENT OF HON. TAMMY BALDWIN, 

U.S. SENATOR FROM WISCONSIN 

Senator BALDWIN. Thank you, Mr. Chairman. I want to appreciate you and Senator Blumenthal for convening this hearing to 

discuss a number of important bills, including my bipartisan bill, 

the Jason Simcakoski Memorial Opioid Safety Act. I am tremendously grateful for the opportunity to share my work on this legislation and to share Jason’s story, which inspired this critical proposal. I also want to recognize you, Mr. Chairman, for your willingness to hold a hearing earlier this session that illuminated the 

topic and informed this legislation. 

The issue that I will discuss this afternoon does not run along 

party lines. I believe it is an issue that unites us all; and that is 

the care of those who have served and sacrificed for our Nation, 

America’s veterans. 

I take great pride in the fact that I have worked across the aisle 

to introduce this bipartisan legislation, the Jason Simcakoski Memorial Opioid Safety Act, with Senator Capito of West Virginia, as 

well as Ranking Member Blumenthal. It is also supported by a 

number of other Senators on this Committee, including Senators 

Brown, Hirono, Manchin, Moran, Murray, Sanders, and Tester. 

This bipartisan legislation is aimed at addressing the problem of 

over-prescribing practices at the VA and providing safer and more 

effective pain management services to our Nation’s veterans. 

3 

It is named in honor of Wisconsin veteran, U.S. Marine veteran 

Jason Simcakoski. Jason’s family is here today, and I am so honored to have worked with them in putting together these reforms 

for your consideration. 

On August 30, 2014, Jason tragically died at Wisconsin’s Tomah 

Veterans Affairs Medical Center as a result of what was medically 

deemed mixed drug toxicity. I believe that this exposed a glaring 

failure to serve somebody who had faithfully served our country. At 

the time of his death at the VA, Jason was on 14 different prescription drugs, including opioids. 

Incredibly, this soldier’s heartbreaking story is just one example 

of the over-prescribing problem throughout the VA. After two decade-long wars, a large number of our servicemembers are coming 

home with the damage of combat, and our veterans and their families are facing the very difficult challenge of physical injuries, 

PTSD, and other mental illness. Unfortunately, I believe the VA’s 

over-reliance on opioids has resulted in getting our veterans hooked 

rather than getting them help, and that is not acceptable. 

We have a duty to guarantee that our veterans and their families 

receive the highest quality care that they deserve and that they 

have earned and this bipartisan bill will do just that. The Jason 

Simcakoski Memorial Opioid Safety Act will help improve pain 

management services for veterans and give veterans and their families a stronger voice in patient care to prevent tragedies like Jason’s from occurring to other veterans and their families. It will 

also put in place stronger oversight and accountability for the quality of care that we are providing to our veterans. 

Specifically, my bill will require stronger opioid prescribing 

guidelines and education for VA providers, including stricter standards against prescribing dangerous combinations of opioids with 

other drugs and guidance for prescribing opioids to patients struggling with mental health issues. 

It will increase the coordination and communication throughout 

the VA with medical facilities, providers, patients, and their families surrounding pain management, alternative treatments for 

chronic pain, and appropriate opioid therapy. 

It will hold the VA system accountable for appropriate care and 

quality standards through consistent internal audits, as well as 

GAO reviews and reports to Congress. 

It will strengthen patient advocacy to guarantee that veterans 

truly have their voices heard. 

We all know that pain and pain care is a complex issue, and each 

and every patient’s situation is different and it is unique. The goal 

of my bipartisan bill is to move away from a one-size-fits-all approach of relying only on more opioids to treat patients with pain. 

This legislation will empower doctors with the tools and resources 

they need to take a comprehensive approach to pain management 

care for our veterans, and it will arm both doctors and patients 

with the most up-to-date tools, including education and training, as 

well as the latest scientific guidelines to help provide the best care 

decisions. 

I am going to submit my full statement for the record, as I note 

that my time is up and I want to respect that, but let us work together to fix what has been broken and restore the sacred trust 

4 

with our veterans and their families by passing the Jason Simcakoski Memorial Opioid Safety Act. 

I thank you, Mr. Chairman. 

[The prepared statement of Senator Baldwin follows:] 

PREPARED STATEMENT OF HON. TAMMY BALDWIN, U.S. SENATOR FROM WISCONSIN

The issue that I will discuss this morning does not run along party lines. It is 

an issue that I believe unites us all—and that is the care of those who have served 

and sacrificed for our Nation—America’s veterans. 

I take great pride in the fact I have worked across the aisle to introduce this bipartisan legislation, the Jason Simcakoski Memorial Opioid Safety Act, with Senator Capito of West Virginia, as well as Ranking Member Blumenthal. It is also supported by a number of other Senators on this Committee including Senators Brown, 

Hirono, Manchin, Moran, Murray, Sanders, and Tester. 

This bipartisan legislation is aimed at addressing the problem of overprescribing 

practices at the VA and providing safer and more effective pain management services to our Nation’s veterans. 

It is named in honor of a Wisconsin veteran, U.S. Marine Veteran Jason 

Simcakoski. Jason’s family is here today and I am so honored to have worked with 

them and others in putting these reforms together. 

On August 30, 2014, Jason tragically died in Wisconsin’s Tomah Veterans Affairs’ 

Medical Center as a result of what was medically deemed, mixed drug toxicity. I 

believe that this exposed a glaring failure to serve someone who had faithfully 

served our country. 

At the time of his death at the VA, Jason was on 14 different prescriptions drugs, 

including opioids. Incredibly, this soldier’s heartbreaking story is just one example 

of the overprescribing problem throughout the VA. 

After two, decade long wars, a large number of our servicemembers are coming 

home with the damage of combat and our veterans and their families are facing the 

difficult challenge of physical injuries, PTSD and other mental illnesses. 

Unfortunately, I believe the VA’s overreliance on opioids has resulted in getting 

our veterans hooked instead of getting them help. This is not acceptable. 

We have a duty to guarantee that our veterans and their families receive the 

highest-quality care that they deserve. And my bipartisan bill will do just that. 

The Jason Simcakoski Memorial Opioid Safety Act will help improve pain management services for veterans and give veterans and their families a stronger voice 

in patient care to prevent tragedies, like Jason’s, from occurring to other veterans 

and their families. It will also put in place stronger oversight and accountability for 

the quality of care we are providing our veterans. 

Specifically, my bill will: 

• Require stronger opioid prescribing guidelines and education for VA providers, 

including stricter standards against prescribing dangerous combinations of opioids 

with other drugs and guidance for prescribing opioids to patients struggling with 

mental health issues; • Increase coordination and communication throughout the VA with medical facilities, providers, patients and their families surrounding pain management, alternative treatments for chronic pain, and appropriate opioid therapy; • Hold the VA system accountable for appropriate care and quality standards 

through consistent internal audits as well as GAO reviews and reports to Congress; 

and • Strengthen patient advocacy to guarantee that veterans truly have their voices 

heard. 

We all know that pain and pain care is a complex issue. And each and every patient’s situation is different and unique. The goal of my bipartisan bill is to move 

away from the one-size-fits-all approach of relying only on more opioids to treat patients with pain. 

My legislation will empower doctors with the tools and resources they need to 

take a comprehensive approach to pain management care for our veterans. It will 

arm both doctors and patients with the most up-to-date tools, including education 

and training as well as the latest scientific guidelines to help them make the best 

care decisions. 

It also works to improve coordination and communication throughout the VA and 

puts in place stronger oversight and accountability for the quality of care we are 

providing our veterans. 

Jason’s story is sad example of the devastation caused by addiction and the problem of over-prescription of opioids at the VA. This is a growing problem with an imVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00008 Fmt 6633 Sfmt 6621 Z:\ACTIVE\062415.TXT PAULIN
5 

pact that is being felt beyond the walls of the VA and across America in the communities we work for everyday here in our Nation’s capital. 

It is our job to make sure that the veterans who have bravely served and sacrificed for our country, and their families, do not feel alone and that they feel secure 

in knowing that we are doing everything we can to fix this. 

I want to thank the Simcakoski family and let them know that I have a tremendous amount of respect for the courage they have shown telling their story and 

working to make a difference in the lives of other veterans and their families. 

It is my hope they will inspire my colleagues to join us in taking action. 

Again, I would like thank Senators Blumenthal, Brown, Hirono, Johnson, Kaine, 

Manchin, Markey, Moran, Murray, Sanders, and Tester for signing on as original 

cosponsors to this bipartisan effort. 

I’d also like to thank the many veteran’s service organizations—a number who are 

here today—and medical professionals for their invaluable support and input as we 

crafted this legislation. 

Today, I ask the rest of my colleagues to join us in working to confront the problem of overprescribing practices at the VA and to provide safer and more effective 

pain management services to our Nation’s veterans. 

Let us work together to fix what has been broken and restore that sacred trust 

with our veterans and their families by passing the Jason Simcakoski Memorial 

Opioid Safety Act. Thank you. 

Chairman ISAKSON. Thank you, Senator Baldwin. 

Senator Johnson. 

STATEMENT OF HON. RON JOHNSON, 

U.S. SENATOR FROM WISCONSIN 

Senator JOHNSON. Thank you, Chairman Isakson, Ranking Member Blumenthal, and other distinguished Members of the Committee, for the opportunity to present my legislation, the Ensuring 

Veteran Safety Through Accountability Act of 2015. 

To understand the need for this legislation, it is important to 

know the history of tragedies that have occurred at the Tomah VA 

medical center in Wisconsin. Since January, the Senate Committee 

on Homeland Security and Governmental Affairs has been investigating serious allegations of mismanagement, misconduct, whistleblower retaliation, and, tragically, veteran deaths at Tomah. 

Here is a partial list of what we have learned during our investigation. 

In November 2007, a veteran named Kraig Ferrington died from 

a lethal mixture of seven different drugs shortly after receiving 

treatment at Tomah. 

In April 2009, the Tomah VA Employee Union raised concerns 

about a doctor nicknamed ‘‘Candyman’’ and referred to the facility 

as ‘‘Candyland’’ because veterans were prescribed, quote, ‘‘large 

quantities of narcotics.’’ 

In June 2009, Dr. Noelle Johnson was fired from Tomah for refusing to fill prescriptions she believed to be unsafe. Dr. Johnson 

is in the audience here today. 

In July 2009, Dr. Chris Kirkpatrick was fired from Tomah after 

raising concerns about over-medication. Tragically, the same day 

he was terminated, Dr. Kirkpatrick committed suicide. 

In March 2014, the Office of Inspector General closed its nearly 

3-year health care inspection of the Tomah VA. The report was not 

initially shared with Congress, and it was only made public after 

the media exposed these tragedies. 

On August 30, 2014, Jason Simcakoski died in the Tomah Mental Health Wing as a result of, quote, ‘‘mixed drug toxicity.’’ His auVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00009 Fmt 6633 Sfmt 6601 Z:\ACTIVE\062415.TXT PAULIN
6 

topsy revealed he had over a dozen different medications in his system. Jason’s family is also in the audience here today. 

On January 12, 2015, Candace Delis brought her father, Thomas 

Baer, to the Tomah VA Urgent Care Center with stroke-like symptoms. Mr. Baer waited over 2 hours for attention. His family believes he died of neglect. It is hard not to agree. 

As soon as I became aware of the problems at Tomah, I directed 

committee staff to open an investigation into the problems of the 

facility. Since then, we have received tens of thousands of pages of 

documents, spoken with dozens of whistleblowers, and convened a 

bicameral field hearing at Tomah. There was powerful testimony 

provided there. 

We have faced tremendous resistance in uncovering the facts. 

The VA Inspector General has stonewalled our efforts to obtain 

complete information in its Tomah review. After 3 months of noncooperation, my committee was finally forced to subpoena the VA 

Inspector General on April 29. Even after the subpoena, the VA IG 

has applied inappropriate redactions and outright refused to provide other subpoenaed documents. 

The VA Office of Inspector General conduct made it clear that 

Congress must act. We have already used my authority as Chairman to advance a bill to enhance the transparency and accountability of all Inspectors General that also would prevent the VA Inspector General from writing secret reports in the future. 

The events in Tomah make it abundantly clear that there must 

be more accountability for VA medical professionals. That is why 

I have introduced the Ensuring Veteran Safety Through Accountability Act. Last year’s Phoenix wait time scandal showed us that 

there is a severe lack of accountability for VA officials. Congress attempted to address this accountability shortfall when it gave the 

VA Secretary greater authority to remove high-level VA officials. 

That law was a step in the right direction. 

My committee’s investigation has found that it does not go far 

enough. To date, no one at Tomah has been fired. The medical professionals who prescribed the lethal cocktail of drugs that killed 

Jason Simcakoski are still collecting a paycheck from the American 

taxpayer. 

My bill would give the VA Secretary the authority to expedite 

termination of health care professionals who fail to deliver the 

high-quality care our veterans deserve. Currently, the bill has 16 

cosponsors who share a common goal of holding bad actors 

accountable. 

I would also like to voice my support for Senator Baldwin’s bill 

as an important step in addressing VA’s protocols on prescribing 

highly-addictive opiate drugs to our veterans. 

Our committee’s investigation is ongoing. Tomorrow, our committee will release an interim report that presents some preliminary findings. We will continue to investigate until we gather all 

the facts at Tomah and wrongdoers are held accountable. 

As an initial step, the Ensuring Veteran Safety Through Accountability Act of 2015 is a common sense measure to bring some 

much needed accountability to the VA. 

Again, thank you for giving me this opportunity to speak today. 

7 

Chairman ISAKSON. Well, I want to thank both of you for your 

diligence on this particular issue. 

I want Mr. and Mrs. Simcakoski and their daughter to stand, if 

they would. I want to say with everybody in the Committee present 

what I said to them in my office earlier today, that we share in the 

tragic loss of your son, but we have the greatest respect and admiration for you to advocate on behalf of change so that this does not 

happen again to anyone else. Your courage is appreciated and your 

attendance is appreciated. 

I also told them that the Committee is going to work diligently 

to make sure that the legislation is not redundant in terms of 

things that have already been done in response to the over-prescription of opiates and that it is codified so that it works well for 

the system. We will look forward to the VA’s testimony on this a 

little bit later. 

Thank you all for being here very much. We appreciate your 

service. 

Senator Johnson, as a committee chairman, I respect your authority and your committee’s authority and I look forward to working with you on your Accountability Act. We know that there has 

to be more ability for there to be accountability in the Veterans Administration and there are many barriers to doing that. Your bill 

offers an opportunity for us to begin to tear down some of those 

barriers and see to it that we have a more responsive VA. I commend you on your work. I commend you on your work, Senator 

Baldwin. I appreciate both of you being here today. 

Do any Members of the Committee happen to have a question of 

either member before they are excused? Anybody? [No response.] 

If not, we appreciate your testimony and your time. 

Senator JOHNSON. Thank you. 

Chairman ISAKSON. Before we hear from our panels, we have 

three Members of the Committee that have legislation on the list 

of what is being heard today. Senator Murray has two. Senator 

Moran and Blumenthal have one. I wonder if they wanted to address their bills at this time. 

Senator MURRAY. Mr. Chairman. 

Chairman ISAKSON. Senator Murray. 

STATEMENT OF HON. PATTY MURRAY, 

U.S. SENATOR FROM WASHINGTON 

Senator MURRAY. Mr. Chairman, I appreciate the opportunity to 

speak about the legislation I have before the Committee. We have 

a lot of really important bills on the agenda today. 

But, before I get to those, I do want to address some very disturbing news. According to the VA’s most recent data, wait times 

are again increasing dramatically, and I understand the VA has 

seen an enormous growth in demand, but we are very concerned 

about this, and as the expiration of the Choice Program approaches, we need VA to be ready with a comprehensive plan. So, 

I hope our Committee focuses on that. 

On the agenda today, I do want to address the Women Veterans 

and Families Health Services Act. This is a bill that would finally 

end the VA’s decades-old ban on fertility services and give some 

new hope to our veterans who were injured while fighting for our 

8 

country to realize their dream of starting a family. I really believe 

that offering this service is very important to fulfilling the promise 

to take care of the men and women who served our country. 

It would expand the services that DOD is allowed to offer, taking 

lessons from the best practices of some of our close allies around 

the world, and would also offer assistance for adoption and make 

permanent the Child Care Pilot Program, which has been very successful. So, I really appreciate your having a hearing on that. 

I have heard cost should be a consideration. I absolutely believe 

cost should not be an excuse to deny essential care to our military 

families and our veterans. 

Equally important is my military caregivers legislation which I 

have introduced with Senator Collins. This is a program that recognizes the sacrifices of the friends and family who take care of our 

severely injured servicemembers by offering assistance to ease 

their burden. The bill that we are offering would finally open the 

caregiver program to veterans of all eras through a responsible 

phased-in approach that allows VA to manage the additional 

workload. 

I think this is an absolutely essential service. I understand, Mr. 

Chairman, that you have commented on the GAO report on this 

and want to work with you, because I really believe that this is a 

program that we need to make sure is available for so many men 

and women, their families, and their providers as we move forward. 

So, thank you very much for the hearing today. 

[The prepared statement of Senator Murray follows:] 

PREPARED STATEMENT OF HON. PATTY MURRAY, 

U.S. SENATOR FROM WASHINGTON

Before I get to the bills, I want to address some very disturbing news. According 

to VA’s most recent data, wait times are again increasing dramatically. I understand VA has seen enormous growth in demand for care from veterans. But to see 

wait times climbing again, after we provided $15 billion to address this very problem, is concerning. As the expiration of the Choice Program approaches, VA needs 

to be ready with a comprehensive plan to bring down wait times, and to create a 

comprehensive program for non-VA care that will work for the future. I will continue to keep a close watch on this situation, and I want to see continued progress 

to bring down wait times. 

Now, turning to the agenda—— 

First on the list is my bill, the Women Veterans and Families Health Services 

Act. This bill would finally end VA’s decades-old ban on fertility services and give 

new hope to veterans—who were injured while fighting for our country—to realize 

their dreams of starting a family. I believe offering this service is critically important to fulfilling the promise to take care of the men and women who served our 

country. 

My bill would also expand the services that DOD is allowed to offer, taking lessons from the best practices of some of our close allies around the world. My bill 

would also offer assistance for adoption. And it would make permanent the child 

care pilot program, which has been very successful. 

Caring for our veterans shouldn’t be a partisan issue. I think we all agree that 

our country has a duty to do whatever we can to improve the lives of those who 

have sacrificed so much for our country. Cost cannot be an excuse to deny essential 

care to seriously injured veterans. Not when they have put everything on the line 

to protect our country. 

But since there are concerns about the cost, let’s remember that according to a 

Pentagon report, the military health system can provide a cycle of IVF for $7,000 

which is significantly less than the $12,400 it costs in the private sector. It’s not 

often the right thing to do is also the cost effective option—we should take that opportunity and pass this bill right away. 

9 

Equally important is my military caregivers legislation that I was very pleased 

to introduce with Senator Collins. This program recognizes the sacrifice of the 

friends and family who take care of our injured servicemembers by offering assistance to ease their burden. Our bill would finally open the caregiver program to veterans of all eras, through a responsible, phased-in approach that will allow VA to 

manage the additional workload. This is just common sense, and it’s the right thing 

to do for our veterans and their caregivers. It also expands the services available 

for caregivers, and aligns eligibility for VA and DOD services. Finally, the bill takes 

a major step toward improving caregiver support for the whole country by coordinating the many services offered across the government. 

I am committed to working with my colleagues to make sure VA has the resources 

it needs to effectively administer this program. In fact, an amendment I authored 

to the VA appropriations bill will give VA another $10 million to hire more caregiver 

support coordinators. These additional staff will help address some of the important 

findings from the GAO, strengthen the program, and prepare VA to finally meet the 

needs of veterans of all eras. 

We also know that treating a veteran through the Caregiver Program is far less 

expensive than through a private nursing home or through a VA nursing home. But 

most important, it helps veterans stay out of the hospital, and have shorter stays 

when they do have to go in. It allows veterans to be in their own homes, surrounded 

by their loved ones. Giving veterans a better quality of life is not just the cost effective thing to do, it’s the right thing to do. 

Our veterans shouldn’t have to wait any longer for these important improvements 

to their care. 

Finally, thank you to our witnesses. And a special thank you to the VSOs for appearing today and for your support for these two important bills. 

Thank you, Mr. Chairman, and I look forward to working with you to get these 

bills through markup and then through the Senate floor. 

Chairman ISAKSON. Well, thank you, Senator Murray. And since 

I made reference to both your bills in my opening statement when 

you were not here, you deserve to hear from me what I already told 

everybody else. 

I look forward to working with you on the IVF bill. There are 

some issues I want to work with you on to see to it that we get 

it to the Committee and then, ultimately, get it to the floor of the 

United States Senate. 

The same is true with the caregiver bill. However, I made note, 

as you said, of the GAO report with regard to those who are currently eligible and the way that the program has been handled. I 

want to make sure that we tidy up the caregiver program as it exists before we expand that to those prior to 9/11/2001. 

Senator MURRAY. I have—— 

Chairman ISAKSON. I look forward to working with you on that. 

Senator MURRAY. I appreciate that. I do not mind tidying up; I 

just do not want to delay. 

Chairman ISAKSON. I got the message. 

Senator MURRAY. Thank you. [Laughter.] 

Chairman ISAKSON. Senator Moran. 

Senator MORAN. I defer to the Ranking Member. 

Chairman ISAKSON. Senator Blumenthal. 

STATEMENT OF HON. RICHARD BLUMENTHAL, 

RANKING MEMBER, U.S. SENATOR FROM CONNECTICUT 

Senator BLUMENTHAL. Thanks, Mr. Chairman. Sorry I was delayed at the session that we both attended. I was not here as 

quickly as you, so—— 

Chairman ISAKSON. I had a car. [Laughter.] 

Senator BLUMENTHAL. I, first of all, want to express my appreciation to the Chairman for including so many of our bills on a biparVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00013 Fmt 6633 Sfmt 6601 Z:\ACTIVE\062415.TXT PAULIN
10 

tisan basis, very much in the spirit of this Committee, and I thank 

him. 

I also want to join Senator Murray in expressing my very strong 

alarm about the deeply troubling increase—and it is a dramatic increase—in the wait times for VA care. It is exactly what we have 

been warning might well happen, and I am very hopeful that VA 

and this Committee will have a plan to address it. It is the kind 

of phenomenon that just cannot wait for months to be addressed. 

It has to be addressed right away, and I challenge the VA to come 

forward with a plan to address it, literally within days, not weeks 

or months. 

I want to thank Senator Murray for both of her bills. I strongly 

support them, particularly the caregivers bill, which will expand 

access to caregivers beyond the post-9/11 population and make important changes to this program. 

I express my strong support for Senator Baldwin’s opioid bill, 

named after Jason Simcakoski. I thank his family for being here 

today. Thank you for your courage and strength. You inspire us 

with your presence today. It makes a big difference, so thank you. 

Finally, I want to thank the Veterans Service Organizations represented here today for their strong support of S. 901, the Toxic 

Exposure Research Act of 2015 that Senator Moran and I have 

offered. 

Here is what we know about the modern battlefield. It is filled 

with all kinds of toxic substances, unimaginable just 10 years ago, 

whether it is depleted uranium or pollutants from burn pits or 

nerve gas in unexploded ordinances. It is a fact of life about the 

modern battlefield. The perils of combat, even for the veteran who 

has not been exposed to fire from the enemy, are real and urgent. 

The battlefield is a dangerous place for every man and woman in 

uniform; dangerous not only to them, but to their children and 

their families, and their grandchildren, because those toxic substances can have lasting, enduring effects that are transmitted 

from one generation to another. 

This bill is just one step in the right direction. We need to know 

more about the effects of these toxic substances on veterans and 

their families. We need to support a research center that can do 

the kind of fact finding and fact gathering that other kinds of medical challenges and scientific research will help to solve, and this 

bill helps us to not only conduct the research, but eventually provide the kind of treatment that these veterans need and deserve. 

So, I thank Senator Moran for his partnership in this effort and 

I yield to him, with your permission, Mr. Chairman. 

STATEMENT OF HON. JERRY MORAN, 

U.S. SENATOR FROM KANSAS 

Senator MORAN. Mr. Chairman, thank you very much. Thanks 

for the opportunity to speak briefly about legislation pending before 

the Committee, and I thank you for your active engagement and 

leadership as we try to find solutions to the challenges veterans 

and their family members face. 

I appreciate the opportunity to cosponsor and work with the 

Ranking Member on the Toxic Exposure Act. Let me highlight it 

first and indicate that I think it has significant value and merit. 

11 

When an individual serves their country in the military, I assume that they recognize the challenges and the sacrifices that 

they may make. So, when something happens to them, it is a terrible thing, but I cannot imagine the pain or concern that comes 

to a father or a mother who now sees the consequence of their military service affecting their children and their grandchildren. 

So, while I expect that many veterans do, in a sense, assume a 

risk when they serve, I cannot imagine any circumstance in which 

that veteran, that military man or woman, believes that they are 

causing harm to their children and grandchildren, those born and 

those not yet born. 

So, in listening to many veterans, particularly veterans of the 

Vietnam era, this issue of toxic substances has impacted them and 

greatly impacted their family. And, as usual, missing is the necessary medical research that demonstrates the connection to allow 

the Department of Veterans Affairs to make conclusions about how 

to treat those veterans. But more significantly, there is no ability 

to tie the next generation to any kind of benefit or care and treatment. 

So, the bill that Senator Blumenthal and I have introduced is 

pretty straightforward. It creates two centers within the VA itself 

to study and analyze the connection, intergenerational, between exposure to toxic substances and its effect upon the future generations, and then creates the potential connection between that service and a veteran’s dependent or that dependent’s children. 

And, I would urge this Committee to take this issue very seriously, and when our Veterans Service Organizations testify today, 

I hope that you will listen to them closely. 

If any of you have spent time with these individuals and met 

their family members, you will see exactly what it is that they face, 

no question in their minds but that the connection of their service 

has a consequence—a dramatic consequence—to the health and 

well-being of their children and grandchildren. 

In addition to that, I would say that the NPR story yesterday, 

although only slightly related to this topic—it is related in that it 

is an exposure to a substance, mustard gas, and the circumstances 

that World War II veterans are facing in the lack of attention and 

care, at least described by NPR, is something that is worthy of our 

attention. It is one more instance of fulfilling your military service 

and having a tremendous consequence. 

And, I just—I wanted to quote from the NPR article, Mr. Chairman, just briefly. The point that Harry Bollinger, age 88, is making, a World War II veteran who was used as an individual to test 

the effects of mustard gas, and these individuals were tested in 

various circumstances, according to NPR, including being locked in 

a gas chamber with mustard gas being induced into the room with 

no ability for the veterans to leave, and then they were studied 

consequently to see what the consequence was to them. 

While that in and of itself raises issues, what Mr. Bollinger said, 

he says he still suffers from chronic breathing problems and breaks 

out in eczema in places where he was burned as a young Navy recruit, ‘‘around my privates and under my arms and face and everywhere else.’’ But, here is the point I wanted to make to the Committee. Bollinger gave up appealing VA rejections in 1994, after 4 

12 

years of traveling back and forth 30 miles to a VA office in Pittsburgh. Then in 1996, Bollinger received a military commendation 

in the mail. The document acknowledged his participation in mustard gas experiments. But Bollinger says he would not go back to 

the agency after the way he was treated there. Quote, ‘‘I was disgusted already. What is the use?’’ 

Mr. Chairman, one more example of toxic substance and its consequences to our veterans, but also a reminder that we have to 

have a Department of Veterans Affairs whose focus is clearly on 

the veterans and meeting their needs. 

So, Mr. Chairman, thank you for the opportunity to speak in support of Senator Blumenthal and I’s bill, and I hope that we can 

continue to work to improve the services that all of our veterans 

receive. 

Chairman ISAKSON. Thank you, Senator Moran. 

Would the first panel come forward, please. Dr. Jain, Assistant 

Deputy Under Secretary for Health and Patient Care Services, Veterans Health Administration, U.S. Department of Veterans Affairs; 

Cathy Mitrano, Deputy Assistant Secretary for the Office of Resolution Management of the Office of Human Resources Management; 

and Jennifer Gray, the Staff Attorney of the Office of General 

Counsel. 

Before you start your testimony, Dr. Jain, I want to echo what 

Senator Murray, Senator Blumenthal, and others have said, by acknowledging two things. One and one-half to 2 years ago, VA’s 

problems were being masked in places like Phoenix because employees were doing the wrong thing. They were canceling appointments; they were fudging records. We have done a good job of purging that and we are now getting the right data from the VA. So, 

one statement I want to make, for those that have seen wait times 

protracted or not reduced as fast as we would like, that is bad 

news. But, it is good news that we are getting all the facts, and 

I want the VA to continue to do that. 

But, the VA needs to understand on this issue of running out of 

money, no agency of government has gotten more increases in 

funding than Veterans Affairs over the last 7 or 8 years. The Veterans Choice bill was designed to be a force multiplier for VA, to 

increase our ability to serve our veterans within a timely basis, 

whether they live too far away or whether the Veterans Administration was understocked in performance people. And, we expect as 

a Committee the VA to continue to do everything it can do to make 

Veterans Choice work to be a force multiplier for the agency and 

not just a substitute for money that has already been depleted 

through veterans’ non-VA health care and the like. 

So, as you go back to talk to Sloan and Secretary McDonald and 

the others there, we are watching. We want to be a team with VA, 

to acknowledge the problems that we have and work hard to solve 

those problems, not by blaming each other but by working together 

to see to it we reduce the wait times and eventually get to within 

times we all want. 

So, I appreciate Senator Murray and Senator Blumenthal raising 

that question. I appreciate what Senator Moran said about the VA 

in terms of attention to veterans’ health care problems. 

13 

Now, I will recognize Dr. Jain for your testimony. Please try to 

keep it within 5 minutes, but if you fudge a little bit, I will not hit 

you. 

STATEMENT OF RAJIV JAIN, M.D., ASSISTANT DEPUTY UNDER 

SECRETARY FOR HEALTH FOR PATIENT CARE SERVICES, 

VETERANS HEALTH ADMINISTRATION, U.S. DEPARTMENT OF 

VETERANS AFFAIRS; ACCOMPANIED BY CATHERINE 

MITRANO, DEPUTY ASSISTANT SECRETARY, OFFICE OF RESOLUTION MANAGEMENT, OFFICE OF HUMAN RESOURCES 

MANAGEMENT; AND JENNIFER GRAY, STAFF ATTORNEY, OFFICE OF GENERAL COUNSEL 

Dr. JAIN. Good afternoon, Mr. Chairman, Ranking Member, and 

distinguished Members of the Committee. Thank you for inviting 

us here today to present our views on several bills that would affect the Department of Veterans Affairs benefits, programs, and 

services. 

Joining me today, to my right is Catherine Mitrano, Deputy Assistant Secretary for Resolution Management; and to my left is 

Jennifer Gray, Staff Attorney in the Office of General Counsel. 

I would like to start by thanking you for confirming the nomination of LaVerne Council as Assistant Secretary for Information and 

Technology, and Dr. David Shulkin as Under Secretary for Health, 

and also by stating that many of the bills of the agenda are very 

complex and we do not have completed views for all of them, but 

we do know the Committee is anxious to get our views in anticipation of its legislative markup. We are working to get them to you 

on an expedited schedule. 

I would like to acknowledge the Simcakoski family and thank 

them for being here today. I know they spoke to Dr. Clancy earlier 

today and we both want to express our sorrow at the loss of their 

son, Jason. We hope that this bill will work to help close the gaps 

in prescription drug monitoring. 

We also want to thank Senator Baldwin for drafting the Jason 

Simcakoski Memorial Opiate Safety Act that addresses many details of this important issue. The Department is pleased with the 

collaborative and productive conversations we have had with Senator Baldwin’s staff since April and we look forward to continuing 

this collaboration. 

Our written testimony goes into depth on those efforts. We want 

to work with the Committee to ensure we are not duplicating the 

efforts or perhaps being too prescriptive in some areas. But, again, 

I want to emphasize that many ideas in this bill find much common ground with VA’s multi-pronged approach to opioid safety. 

VA generally supports the concept of S. 469, the Women Veterans and Families Health Services Act, to improve the reproductive treatment provided to certain severely wounded, ill, or injured 

veterans. Although some aspects of the bill present complications, 

VA supports doing all we can to restore to the greatest extent possible a veteran’s quality-of-life, including the ability to have a family. We do have concerns about ensuring that we have the appropriate resources to provide the assisted reproductive services. 

We also support the concept of expanding the child care in VA 

facilities as a way to make access to VA care easier for parents 

14 

with small children. However, we cannot responsibly support creating these programs in every facility without further conversations about the resources required. 

Regarding S. 901, VA understands the importance of research in 

the areas of toxic exposures during military service and in responding when the signs show a connection of that exposure to specific 

ailments. As detailed in our testimony, however, VA believes the 

approaches in the bill may duplicate existing research and relationships with other Federal agencies and organizations that serve the 

same goal. 

S. 1085 would provide expanded support and benefits for caregivers of eligible and covered veterans, most notably an expansion 

beyond the post-9/11 eligibility restriction. In the report required 

by the 2010 caregivers law on the feasibility of this expansion, we 

said that it would provide more equitable access to these programs. 

However, in this report, VA also noted the difficulties in expanding 

the program, again, without addressing the cost issues. Unfortunately, these facts have not changed and, therefore, we are unable 

to offer our support for that reason. 

The discussion draft bill requires the Secretary to work with institutions of higher learning to develop partnerships with the establishment or expansion of programs of advanced degrees in prosthetics and orthotics. While VA supports means to improve and enhance the ability to hire and retain prosthetists and orthotists, it 

cannot support the proposed bill because it would require partnerships with colleges or universities with programs that largely 

would not benefit the VA or the veterans. We would like to work 

with the Committee in making technical adjustments so we could 

directly enhance this bill in benefiting our veterans. 

As for the two bills regarding employee removal actions, we do 

not have views for S. 1117. However, both of these bills are similar 

in that they remove both senior executives and non-senior executive employees from the civil service or demote the employee to a 

reduction in grade or annual rate of pay. While VA understands 

the motivations for this bill, our written statement goes into detail 

on what we believe would be the negative unintended consequences, including real concerns about degrading our ability to recruit 

and retain the best and brightest to serve veterans. 

Thank you, Mr. Chairman, for the opportunity to testify here 

today. My colleagues and I would be pleased to respond to questions that you or the other Members may have at this time. 

[The prepared statement of Dr. Jain follows:] 

PREPARED STATEMENT OF DR. RAJIV JAIN, ASSISTANT DEPUTY UNDER SECRETARY

FOR HEALTH FOR PATIENT CARE SERVICES, VETERANS HEALTH ADMINISTRATION

(VHA), U.S. DEPARTMENT OF VETERANS AFFAIRS (VA) 

Good morning Chairman Isakson, Ranking Member Blumenthal, and Members of 

the Committee. Thank you for inviting us here today to present our views on several 

bills that would affect VA benefits programs and services. Joining us today is Catherine Mitrano, Deputy Assistant Secretary for Resolution Management, and Jennifer Gray, Staff Attorney in VA’s Office of General Counsel. 

We do not yet have cleared views on the Draft Biological Implant Tracking and 

Veteran Safety Act of 2015 or on S. 1117, the Ensuring Veteran Safety Through Accountability Act of 2015. Additionally, we do not have cleared views on sections 203, 

205, 208, and 209(b) of S. 469, sections 3 through 8 of S. 1085, section 2 of the draft 

bill referred to on the agenda as ‘‘Discussion Draft’’ or sections 101–106, 204, 205, 

403 and 501 of The Jason Simcakoski Memorial Opioid Safety Act. We will be glad 

15 

to work with the Committee on prioritization of those views and cost estimates not 

included in our statement. 

S. 469, WOMEN VETERANS AND FAMILIES HEALTH SERVICES ACT OF 2015

VA is providing views on Title II—Reproductive, Adoption, and Child Care Assistance for Veterans except for sections 203, 205, 208, and 209(b). 

Section 201 would amend the definition of ‘‘medical services’’ in 38 U.S.C. 1701 

to include ‘‘Fertility treatment and counseling, including treatment using assisted 

reproductive technology.’’ This amendment would in effect require VA to provide 

these services and override VA’s regulation prohibiting the provision of in vitro fertilization at 38 CFR 17.38(c)(2). VA supports section 201 conditioned on the availability of the additional resources needed to implement this provision. The provision 

of fertility treatment and counseling, including assisted reproductive technologies 

(ART) is consistent with VA’s goal to restore to the greatest extent possible the 

physical and mental capabilities of Veterans and improve the quality of their lives 

and that of their families. For many, having children is an important and essential 

aspect of life. Those who desire but are unable to have children of their own commonly experience feelings of depression, grief, inadequacy, poor adjustment, and 

poor quality of life. 

Section 202 would require VA to furnish fertility treatment and counseling, including the use of ART, to a spouse, partner, or gestational surrogate of a severely 

wounded, ill or injured Veteran who has an infertility condition which was incurred 

or aggravated while on active duty. This treatment would be furnished regardless 

of the sex or marital status of the Veteran. In vitro fertilization would be limited 

to 3 completed cycles or 6 attempted cycles to a spouse, partner or gestational surrogate. Section 202 would not require VA to find a gestational surrogate for a Veteran 

or furnish additional maternity care. For a spouse, partner, or gestational surrogate 

of a Veteran who is not severely wounded, ill or injured, VA could only coordinate 

fertility treatment and counseling. 

VA supports section 202 in part, conditioned on the availability of the additional 

resources needed to implement this provision. VA supports providing fertility services and counseling to an enrolled severely wounded, ill, or injured Veteran and his 

or her spouse or partner. However, VA does not support coverage of gestational surrogates. The complex legal, medical and policy arrangements of surrogacy vary from 

state to state due to inconsistent local regulations. If implementing this provision, 

VA would need to consider potential conflicts with state and local laws governing 

surrogacy arrangements. VA acknowledges that surrogacy may offer the only opportunity for Veterans and their spouses/partners to have a biological child. There may 

be other options to consider when exploring how best to compensate these Veterans 

for their loss and to facilitate procreation. 

VA estimates costs associated with enactment of the draft bill to be as follows: 

$177 million (consisting of approximately $64 million for Veterans and $113 million 

for eligible spouses). Expenditures are expected to decline to approximately $80 million in FY 2017, gradually increasing to $154 million by FY 2025. Total expenditures from FY 2016 to FY 2025 are expected to be approximately $1,207 million (approximately $437 million for disabled Veterans and $769 million for eligible 

spouses). Expenditures for pregnancies resulting from fertility services are estimated to be $28.9 million from FY 2016 through FY 2025. 

Section 204 would require VA to submit an annual report to Congress on the fertility treatment and counseling furnished by VA. VA has no objection to this 

provision. 

Section 206 would require VA to facilitate research conducted collaboratively by 

the Secretary of Defense and the Secretary of Health and Human Services to help 

VA meet the long-term reproductive health care needs of Veterans with service-connected disabilities affecting Veterans’ ability to reproduce. 

Generally, VA supports implementing research findings that are scientifically 

sound and that would benefit Veterans and improve health care delivery to Veterans. VA’s goal is to restore the capabilities of Veterans with disabilities to the 

greatest extent possible, and we utilize new research into various conditions to improve the quality of care we provide. VA expects the costs of this provision would 

be nominal; however, if facilitation is intended to mean direct funding, proposal reviews, and additional staff, costs would be greater. 

Section 207 would require VA to enhance the capabilities of the Women Veterans 

Call Center (WVCC). VA supports section 207 to improve the WVCC by extending 

its current capability to host an interactive, secure chat capability. In addition to 

the efficient handling of both incoming and outgoing calls, the system would provide 

real-time messaging collaboration (‘‘Live Chat’’ or ‘‘Text’’) with WVCC Contact RepVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00019 Fmt 6633 Sfmt 6621 Z:\ACTIVE\062415.TXT PAULIN
16 

resentatives (CR) upon user (Veteran) request. This would provide women Veterans 

who have questions and/or concerns about VA health care and benefits with an online, one-to-one ‘‘Live Chat’’ service, in addition to the already provided WVCC telephone-based service. 

Section 209(a) would require VA to carry out a program to provide assistance to 

qualified Veterans to obtain childcare so that the Veterans can receive health care 

services. Such assistance may include stipends for payment of child care by licensed 

centers, direct provision of child care at VA facilities, payment to private child care 

agencies, and collaboration with other Federal facilities or programs. VA would be 

required to carry out the program at each VA medical center not later than five 

years after the date of enactment of this bill. 

VA is aware of the challenges faced by Veterans with children in regard to access 

to medical appointments and other medical care, counseling, and care giving services. With the growing numbers of younger Veterans and the increasing demands 

placed on grandparents to care for grandchildren, lack of child care can create a barrier to access to health care services at VA facilities. With the projected doubling 

of the number of women receiving health care through VA in the next several years 

and the projected number of those women who are of child bearing age, in addition 

to the reality of single-parent households with men as well as women serving as the 

parent, facilitating child care as a means of enhancing access to services is an important consideration. VA recognizes that the lack of competent, accessible child 

care negatively impacts the ability of Veterans who are primary caretakers of a 

child or children to attend scheduled appointments. 

VA cannot responsibly provide a position in support of creating a new child care 

assistance program for veterans without a realistic consideration of the resources 

necessary, including an analysis of the future resources that must be available to 

fund other core direct-to-Veteran health care services. That consideration includes 

the budget levels included in the fiscal year 2016 budget resolution adopted by Congress, S. Con. Res. 11, as well as the fiscal year 2016 Military Construction/VA appropriations measures passed in the House and awaiting action in the Senate (H.R. 

2029). 

S. 901, TOXIC EXPOSURE RESEARCH ACT OF 2015

In general, S. 901 would require the Secretary to establish a National Center 

(Center) charged with researching the diagnosis and treatment of health conditions 

of descendants of individuals who were exposed to toxic substances while serving 

in the Armed Forces. It would also establish an Advisory Board (the ‘‘Board’’) that 

would oversee and assess the work of the National Center, meet with the National 

Center, review the annual report of the National Center, and advise the Secretary 

on various matters. 

VA is committed to working with other Federal departments and agencies to ensure that Veterans exposed to toxic substances receive the best possible care we can 

provide and the benefits for which they are eligible. With respect to military exposures, VA is working closely with DOD to ensure that those who have transitioned 

to Veteran status are identified and provided information about their exposures. VA 

will also ensure their records document their exposures and they are provided access to the health care and benefits for which they are eligible. 

Section 2 would define several terms for purposes of the bill, including the term 

‘‘toxic substance,’’ which would mean any substance determined by the Administrator of the Environmental Protection Agency to be harmful to the environment or 

hazardous to the health of an individual if inhaled or ingested by or absorbed 

through the skin of that individual. 

Section 3 would require VA, in consultation with the Board established by section 

4 of the bill, to select, not later than one year after the date of enactment, a VA 

medical center to serve as the Center for research on the diagnosis and treatment 

of health conditions of descendants of individuals exposed to toxic substances while 

serving in the Armed Forces that are related to such exposure. It would also establish selection criteria for the site and require the Center to conduct research on the 

diagnosis and treatment of health conditions of such descendants. In conducting 

such research, the Center would be required, at the election of the individual, to 

study individuals whom the Secretary has determined to be descendants of individuals who served as members of the Armed Forces who were exposed to a toxic substance while serving as a member of the Armed Forces; and who are afflicted with 

a health condition that is related to such exposure. 

Section 3 would require the Secretary of Defense or the head of another Federal 

agency to make available to VA, for review, records held by DOD, an Armed Force, 

or that Federal agency, as appropriate, that might assist the Secretary in making 

17 

the determinations required above. To this end, VA and DOD or the head of the 

appropriate Federal agency would be compelled to jointly establish a mechanism for 

the availability and review of records by VA. This measure would also require the 

Center to reimburse the reasonable cost of travel and lodging of any individual participating in a study at the Center, plus those of any parent, guardian, spouse, or 

sibling who accompanies the individual. In addition to other reporting requirements, 

the Center would further be required to submit a report to the Congress, at least 

annually, that summarizes, for the preceding year, the functions of the Center, its 

completed research efforts, and the research that is still on-going. Finally, section 

3 would require the Center to employ not less than one licensed clinical social worker to coordinate access of individuals to appropriate Federal, State, and local social 

and health care programs and to handle case management. 

Section 4 would, in general, require the Secretary to establish, not later than 180 

days after the Act’s enactment, the Board, which would, among other things, be 

charged with advising the Center and overseeing and assessing its work, plus advising the Secretary of Veterans Affairs with respect to the work of the Center. The 

measure would also establish specific requirements related to composition of the 

Board, selection of members, terms of service, and duties. The Board would be required to review the annual reports submitted by the Center and advise the Secretary of Veterans Affairs on issues related to the Center’s research; health conditions of descendants of individuals who were exposed to toxic substances during 

service in the Armed Forces that are related to such exposure; health care services 

that are needed by these descendants; and, any determinations or recommendations 

that the Board may have with respect to the feasibility and advisability of VA providing health care services to these descendants. This section would also establish 

separate Congressional reporting requirements for the Board. 

Section 5 would require the Secretary of Defense to declassify documents related 

to any known incident in which no fewer than 100 members of the Armed Forces 

were exposed to a toxic substance that resulted in a least one case of a disability 

that a member of the medical profession has determined to be associated with that 

toxic substance. It would limit such declassification to information necessary for an 

individual who was potentially exposed to a toxic substance to determine: whether 

that individual was exposed to that toxic substance; the potential severity of the exposure; and any potential health conditions that may have resulted from the exposure. Declassification would not be required, however, if the Secretary of Defense 

‘‘determines that declassification of those documents would materially and immediately threaten the security of the United States.’’ 

Section 6 would require the Secretary of Veterans Affairs, in consultation with the 

Secretaries of Health and Human Services and Defense, to conduct a national outreach and education campaign directed toward members of the Armed Forces, Veterans, and their family members. Specific details about the type of information to 

be included in this program and the manner of its dissemination are also set forth 

in this section. 

Section 7 would prohibit additional funds from being authorized (to be appropriated) to carry out this Act; VA would be required to carry it out using amounts 

otherwise made available for this purpose. 

VA does not support this bill. Unlike VA, other Federal Departments and agencies 

are chartered and funded to support research on the multi-generational health effects of toxic exposures. VA would be better designated as a collaborator with these 

organizations. To determine health effects of exposure for what are expected to be 

relatively rare health outcomes, large populations need to be studied over many 

years, perhaps decades. A proposed Center focusing solely on military toxic exposures would likely not have the statistical basis to support conclusive findings. 

VA’s approach to date has been to monitor Veterans’ health, conduct surveillance 

studies, and remain abreast of findings from well-conducted studies in other populations. Based on that evidence, new Veteran-centric studies are then conducted as 

appropriate, that is, when indicated by findings from clinical care, surveillance, or 

recommendations from the clinical/scientific community for such studies—and particularly when they are likely to yield new insights. 

Examples of current VA activities include collaborations with CDC to improve national surveys and databases to better understand Veterans’ health, and communications research investigators from the Agency for Toxic Substances and Disease 

Registry regarding studies of Veteran populations. If enacted, this Act would effectively force VA to redirect already scarce funds—necessary for Veterans’ care—to 

this Center. Any effort to study health conditions of descendants of individuals exposed to toxic substances should focus on rigorous scientific studies. The legislation’s 

direction for the Center to conduct research on the diagnosis and treatment of deVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00021 Fmt 6633 Sfmt 6621 Z:\ACTIVE\062415.TXT PAULIN
18 

scendants of Veterans would not contribute to the scientific understanding we believe are at the center of the bill’s purpose. 

This new Center, as proposed, would clearly duplicate work already being done 

by the National Institute of Environmental Health Sciences, the Agency for Toxic 

Substances and Disease Registry, other non-governmental agencies, as well as work 

already within VHA programs, such as the War Related Illness and Injury Study 

Center, the Office of Research and Development, and the Office of Public Health). 

These existing organizations have for many years conducted research on the impact 

of environmental exposures on human health. In addition, the Department of Justice advises us that it opposes the inclusion of section 5 in the Toxic Exposure Research Act on the ground that it interferes with the President’s exclusive authority 

to ‘‘classify and control access to information bearing on national security.’’ Dep’t of 

Navy v. Egan, 484 U.S. 518, 527 (1988). 

Without authorization for additional appropriations to carry out the program established by the bill, resources would have to be diverted from existing Veterans’ 

health care programs. VA estimates the costs associated with enactment of the draft 

bill to be $7.2 million for FY 2016; $96 million over a 5-year period; and $222 million over a 10-year period. 

S. 1082, DEPARTMENT OF VETERANS AFFAIRS ACCOUNTABILITY ACT OF 2015

Section 2 of S. 1082 would give the Secretary of Veterans Affairs the same authority for VA non-Senior Executive employees granted to him for VA Senior Executives 

under 38 U.S.C. § 713. Under section 2, the Secretary could remove a VA non-Senior 

Executive employee from the civil service or demote the employee, either through 

a reduction in grade or annual rate of pay. If the individual being removed or demoted is seeking corrective action from the Office of Special Counsel (OSC) the Secretary could not take an action under this section without approval from OSC. Individuals removed or demoted under section 2 could appeal that action to a Merit Systems Protection Board administrative judge (AJ), who would be required to issue a 

decision on the appeal within 45 days. Decisions issued by an AJ would be final and 

not subject to further appeal. 

Section 3 of this bill would require all new VA employees who are competitively 

appointed or appointed to the Senior Executive Service at VA to serve a probationary period of at least 18 months. The probationary period could be extended past 

18 months by the Secretary. 

S. 1082 is the latest in a series of legislative proposals targeting VA employees 

by providing extraordinary authority to sanction them, not available in other Federal agencies. Last summer, section 707 of the Veterans Access, Choice, and Accountability Act of 2014 added 38 U.S.C. § 713, establishing an expedited removal 

authority that strictly limits VA Senior Executives’ post-termination appeal rights. 

While that provision gave the Secretary additional flexibility in terms of holding VA 

Senior Executives accountable for misconduct or poor performance, it constrained 

the Secretary’s ability to retain gifted senior leaders by singling out VA Senior Executives for disparate treatment from their peers at other agencies. 

It is likely that S. 1082 would result in unintended consequences for VA, such as 

a loss of qualified and capable staff to other government agencies or the private sector. Section 2 of this bill, which is based on 38 U.S.C. § 713, would apply to all VA 

employees regardless of their grade or position. VA’s workforce consists of a diverse 

array of employees, including employees with advanced degrees in business, law, 

and medicine. Many of these employees accept lower pay to serve at VA, and a large 

number of these employees are Veterans. While VA’s employees are motivated first 

and foremost by a desire to serve Veterans, another motivation to accept lower pay 

shared by many Federal employees is the job security afforded by protections such 

as appeal rights that attach at the end of a probationary period. Diminishing those 

appeal rights or expanding the probationary period will reduce the motivation to 

pursue public service at VA. 

Section 2 of the bill poses due process concerns, due to its failure to provide the 

employee with a chance to be heard prior to losing the benefits of employment and 

its failure to guarantee that an employee’s case will be fairly judged before the sanction becomes final. 

Section 3 of this bill would also adversely impact recruitment at VA by extending 

the probationary period for employees from what is usually 12 months to 18 months 

and authorizing the Secretary of Veterans Affairs to extend the probationary period 

beyond that time at his discretion. In general, the probationary period serves as a 

way of examining whether an employee is suitable for his or her position. The 12- 

month cap of probationary periods serves a dual role: it gives management a finite 

amount of time within which to gauge an employee’s performance, and it gives the 

19 

employee a reasonable period of time within which he or she would be made a permanent Federal employee. By expanding that time to 18 months and allowing the 

Secretary to extend the probationary period past 18 months, section 3 of this bill 

may impact VA’s ability to recruit employees. Like the diminishment of due process 

and appeal rights, the longer probationary period simply makes VA less competitive 

for the candidates seeking job security. In effect, S. 1082 would create a new class 

of employees in the government, a ‘‘VA class.’’ These ‘‘VA class’’ employees could be 

removed or demoted at the discretion of the Secretary, would receive fewer due process rights and abbreviated MSPB appeal rights in actions taken under section 2 of 

the bill and would serve longer probationary periods than their peers at other government agencies. This will hinder VA efforts to make the ‘‘VA class’’ of employee 

the very finest employees to serve our Veterans and ensure that they timely receive 

the benefits and care to which they are entitled. 

By singling out VA employees, the legislation would dishearten a workforce dedicated to serving Veterans and hurt VA’s efforts to recruit and retain high performing employees. VA will continue to work with the Committee and VSO’s on how 

the Secretary can best hold employees accountable while preserving the ability to 

recruit and retain the highly skilled workforce VA needs to best serve Veterans. 

S. 1085, MILITARY AND VETERAN CAREGIVER SERVICES IMPROVEMENT ACT OF 2015

The Caregivers and Veterans Omnibus Health Services Act of 2010, Public Law 

111–163, signed into law on May 5, 2010, provided expanded support and benefits 

for caregivers of eligible and covered Veterans. While the law authorized certain 

support services for caregivers of covered Veterans of all eras, other benefits were 

authorized only for qualified family caregivers of eligible Veterans who incurred or 

aggravated a serious injury in the line of duty on or after September 11, 2001. These 

new benefits for approved family caregivers, provided under the Program of Comprehensive Assistance for Family Caregivers, include a monthly stipend paid directly to designated primary family caregivers and medical care under CHAMPVA 

for designated primary family caregivers who are not eligible for TRICARE and not 

entitled to care or services under a health-plan contract. 

Section 2 of S. 1085, the Military and Veteran Caregiver Services Improvement 

Act of 2015, would remove ‘‘on or after September 11, 2001’’ from the statutory eligibility criteria for the Program of Comprehensive Assistance for Family Caregivers, 

and thereby expand eligibility under the program to Veterans of all eras who otherwise meet the applicable eligibility criteria. Family caregivers could not receive assistance under this expanded eligibility until Fiscal Years 2016, 2018, or 2020 depending on the monthly stipend tier for which their eligible Veteran qualifies. Section 2 would also add ‘‘or illness’’ to the statutory eligibility criteria, and thereby 

expand eligibility to include those Veterans who require a caregiver because of an 

illness incurred or aggravated in the line of duty. In addition, the bill would expand 

the bases upon which a Veteran could be deemed to be in need of personal care services, to include ‘‘a need for regular or extensive instruction or supervision without 

which the ability of the Veteran to function in daily life would be seriously 

impaired.’’ 

The bill would also expand the assistance available to primary family caregivers 

under the Program of Comprehensive Assistance for Family Caregivers to include 

child care services, financial planning and legal services ‘‘relating to the needs of 

injured and ill veterans and their caregivers,’’ and respite care that includes peeroriented group activities. The bill would ensure that in certain circumstances VA 

accounts for the family caregiver’s assessment and other specified factors in determining the primary family caregiver’s monthly stipend amount. In addition, the bill 

would require VA to periodically evaluate the needs of the eligible Veteran and the 

skills of the family caregiver to determine if additional instruction, preparation, 

training, or technical support is needed, and it would require certain evaluation be 

done in collaboration with the Veteran’s primary care team to the maximum extent 

practicable. 

Section 2 of S. 1085 would also authorize VA, in providing assistance under the 

Program of Comprehensive Assistance for Family Caregivers, to ‘‘enter into contracts, provider agreements, and memoranda of understanding with Federal agencies, States, and private, nonprofit, and other entities’’ in certain circumstances. It 

would expand the definition of family member to include a non-family member who 

does not provide care to the Veteran on a professional basis, and it would amend 

the definition of ‘‘personal care services.’’ The bill would also end the Program of 

General Caregiver Support Services on October 1, 2020, but would ensure that all 

of its activities are carried out under the Program of Comprehensive Assistance for 

20 

Family Caregivers. Finally, the bill would amend the annual reporting requirements 

for the Program of Comprehensive Assistance for Family Caregivers. 

In September 2013, VA sent a report to the Committees on Veterans’ Affairs of 

the Senate and House of Representatives (as required by Section 101(d) of the Public Law 111–163) on the feasibility and advisability of expanding the Program of 

Comprehensive Assistance for Family Caregivers to family caregivers of Veterans 

who incurred or aggravated a serious injury in the line of duty before September 11, 

2001. In that report, VA noted that expanding the Program of Comprehensive Assistance for Family Caregivers would allow equitable access to seriously injured Veterans from all eras (who otherwise meet the program’s eligibility criteria) and their 

approved family caregivers. 

In the report, however, VA noted difficulties with making reliable projections of 

the cost effect of opening the Program of Comprehensive Assistance for Family 

Caregivers to eligible Veterans of all eras, but estimated a population range of 

32,000 to 88,000 additional Veterans in the first year (estimated for FY 2014), at 

a cost of $1.8 billion to $3.8 billion in the first year (estimated for FY 2014). After 

VA provided this report to Congress, the RAND Corporation published a report titled, ‘‘Hidden Heroes: America’s Military Caregivers,’’ which estimates a significantly larger eligible population (1.5 million) that may be eligible if the program 

were expanded to caregivers of pre-9/11 Veterans. VA’s estimates in the 2013 report 

did not account for expansion to eligible Veterans with an illness incurred or aggravated in the line of duty, other Veterans who would become eligible for the program 

based on the amendments in section 2 of S. 1085, or the additional assistance that 

would become available to primary family caregivers under the bill. 

VA cannot responsibly provide a position in support of expanding the Program of 

Comprehensive Assistance for Family Caregivers without a realistic consideration of 

the resources necessary to carry out such an expansion, including an analysis of the 

future resources that must be available to fund other core direct-to-Veteran health 

care services. That consideration includes the budget levels included in the fiscal 

year 2016 budget resolution adopted by Congress, S. Con. Res 11, as well as the 

fiscal year 2016 Military Construction/VA appropriations measures passed in the 

House and awaiting action in the Senate (H.R. 2029). This is especially true as VA 

presses to strengthen mental health services and ensure the fullest possible access 

to care across the system. 

While VA has not provided views on section 7 of S. 1085, the Department of Justice advises that it has constitutional concerns with that provision, which it will provide to the Committee under separate cover. 

We wish to make it very clear that VA believes an expansion of those benefits 

that are currently limited by era of service would result in equitable access to the 

Program of Comprehensive Assistance for Family Caregivers for long-deserving 

caregivers of those who have sacrificed greatly for our Nation. However, VA cannot 

endorse this measure before further engaging with Congress on these fiscal constraints, within the context of all of VA health care programs. VA welcomes further 

discussion of these issues with the Committee. 

H.R. 91, VETERAN’S I.D. CARD ACT

H.R. 91, the ‘‘Veteran’s I.D. Card Act,’’ would establish a program under which 

VA would issue a Veteran identification card, produced by VA, upon request by a 

Veteran who was discharged from the Armed Forces under honorable conditions. 

The Veteran would have to present to VA a copy of his or her DD–214 form or other 

official document from his or her official military personnel file describing his or her 

service, as well as pay a fee set by VA to recoup the cost of implementing the 

program. 

The bill makes clear that issuance of a card would not serve as proof of entitlement to any VA benefits, nor would it establish eligibility for benefits in its own 

right. The purpose of the card, made clear in section 2(a)(3) and (4) of the bill, would 

be for Veterans to use the card to secure goods, services, and the benefit of promotional activities offered by public and private institutions to Veterans without 

having to carry official discharge papers to establish proof of service. Furthermore, 

the bill would clarify that the new Veteran’s I.D. Card would not affect identification cards provided by the Secretary to Veterans enrolled in the health care system 

established under 38 U.S.C. 1705. 

Veterans in 45 States and the District of Columbia may apply for a driver’s license or State-issued ID card that designates veteran status. The remaining states 

(California, Hawaii, Illinois, Minnesota, New Jersey, and Washington) are either 

pending legislation or have legislation that has been signed into law but is not yet 

effective. We believe the availability already of this Veteran designation can meet 

21 

the intent of the legislation without creating within VA a new program that may 

not be cost-efficient. It is not known whether enough Veterans would request the 

card to make necessary initial investments in information technology and training 

worthwhile. 

Also, another VA-issued card could create confusion about eligibility. Although the 

bill states that a card would not by itself establish eligibility and would not affect 

other identification cards provided by VA to Veterans enrolled in the VA health care 

system, there could nonetheless be misunderstandings by Veterans that a Government benefit is conferred by the card. As the Committee knows, entitlement to some 

VA benefits depends on criteria other than Veteran status, such as service connection or level of income. Confusion may also occur because the Veterans Health Administration issues identification cards for Veterans who are eligible for VA health 

care, and recently issued every enrolled Veteran a Veterans Choice Card. Having 

several VA-issued cards creates the potential for confusion on several levels. 

Because it is difficult to predict how many Veterans would apply for such a card, 

VA cannot provide a reliable cost estimate for H.R. 91. Although the bill is intended 

to allow VA to recoup its costs by charging Veterans for the cards, in reality VA 

could be assured of recouping its costs only if it knew in advance what those costs 

would be, and those costs cannot be reliably estimated without knowing how many 

Veterans would request the card. 

DISCUSSION DRAFT

Section 1 of the Discussion Draft would require the Secretary of Veterans Affairs 

to work with institutions of higher learning to develop partnerships for the establishment or expansion of programs of advanced degrees in prosthetics and orthotics 

with a goal of improving and enhancing the availability of prosthetic and orthotic 

care for Veterans. 

VA provides rehabilitation services to Veterans with a mix of providers, including 

physical medicine and rehabilitation physicians, physical therapists, occupational 

therapists, prosthetists and orthotists all of whom work with the Veteran to enable 

the best possible rehabilitation given the individual’s needs. VA offers in-house 

orthotic and prosthetic services at 79 locations across VA. In addition, VA contracts 

with more than 600 vendors for specialized orthotic and prosthetic services. Through 

both in-house staffing and contractual arrangements, VA is able to provide stateof the art commercially available items ranging from advanced myoelectric prosthetic arms to specific custom fitted orthoses. Nationally, VA has approximately 312 

orthotic and prosthetic staff. 

With regard to training and development, VA offers one of the largest orthotic and 

prosthetic residency programs in the Nation. In fiscal year 2015, VA’s Office of Academic Affiliations allocated $877,621 to support 20 orthotics and prosthetics residents at 10 Veterans Affairs Medical Centers. The training consists of a yearlong 

post-masters residency, with an average salary of $44,000 per trainee. In recent 

years, VA has expanded the number of training sites and the number of trainees, 

but expansion has been limited due to a lack of certified supervisors for the training 

programs. 

While VA supports means to improve and enhance the ability to hire and retain 

prosthetists and orthotists, it cannot support the proposed bill. Under the proposed 

bill, VA would be required to partner with colleges and universities for the establishment or expansion of programs of advanced degrees in prosthetics and orthotics. 

These programs, however, would not directly benefit VA or Veterans as the legislation does not require that the programs affiliate with VA or send their trainees to 

VA as part of a service obligation. 

Tying the granting of funds to the establishment or expansion of programs of advanced degrees that would directly benefit VA and Veterans is one of the changes 

that VA recommends for this legislation. VA looks forward to working with the 

Committee to craft a bill that more directly enhances advanced degrees in prosthetics and orthotics while benefiting VA and Veterans. 

DRAFT LEGISLATION: JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

Section 201 would establish within the Office of the Under Secretary for Health 

an office to be known as the ‘‘Office of Patient Advocacy.’’ The Office would carry 

out the Patient Advocacy Program of VA. This section would also establish the responsibilities of patient advocates at VA medical facilities. 

VHA currently has a Patient Advocacy program established to ensure that all Veterans and their families served in VHA facilities and clinics have their complaints 

addressed in a convenient and timely manner. The program operates under a philosVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00025 Fmt 6633 Sfmt 6621 Z:\ACTIVE\062415.TXT PAULIN
22 

1Merlino, J (2015). Service fanatics: how to build a superior patient experience the Cleveland 

Clinic way. New York, NY: McGraw-Hill Education. 

ophy of Service Recovery, whereby patient complaints are identified, resolved, classified, and utilized to improve overall services to Veterans. 

As health care continues to evolve, so does the role of the Patient Advocate. The 

role of the advocate in VHA has traditionally been more reactive, i.e. responding to 

issues as they arise, hearing and reacting to patient complaints as they bring them 

forward. With a heightened awareness of the importance of a positive, patient experience, VHA is on the pathway to transform the program including the role of the 

Patient Advocate to focus on a more proactive approach by all staff that would result in a more positive patient experience. 

Earlier this month, to maintain the highest standard for responding to patient 

issues while continually improving the advocacy program, VHA established the Client Services Response Team (CSRT), reporting directly to the Office of the Under 

Secretary for Health. The CSRT is charged to centralize and streamline internal 

processes to improve VHA’s overall responsiveness to the concerns of Veterans, employees and other key stakeholders. 

The proposed bill reflects the existing Patient Advocacy program but does not account for the strategy to transform the Patient Advocate role to keep pace with private sector advances in patient experience. The model has been successfully demonstrated in VHA pilots and private sector health care systems1 and is consistent 

with VA’s vision of providing world-class customer service. This vision will engage 

staff from across the organization as well as Veterans to be actively involved in the 

transformation process. VA is thus very supportive of the concept in section 201, but 

has concerns that detailed statutory directives could restrict the evolution and 

breadth of the Patient Advocacy program. 

VA supports section 202 which would require VA medical centers and Community 

Based Outpatient Clinics to host community meetings, open to the public, on improving health care from the Department. This section is consistent with current 

practices of hosting Town Hall meetings to hear from Veterans, families, and other 

stakeholders. 

Section 203 would require VA display at each VA medical facility the purposes 

of the Patient Advocacy Program, contact information for the patient advocate, and 

the rights and responsibilities of patients and family members. VA supports increasing the awareness of the Patient Advocacy Program and the Rights and Responsibilities of Veterans and family members. This section is consistent with current practices of posting this information in medical facilities and would only require the addition of posting the Patient Advocacy Program’s purpose. 

VA supports the intent of title III which seeks to expand research, education and 

delivery of complementary and integrative health (CIH) to Veterans. VA is committed to expanding the research, education and delivery of complementary and integrative health services to Veterans. Aligning with VA’s Blueprint for Excellence 

VHA leadership identified as its number one strategic goal ‘‘to provide Veterans personalized, proactive, patient-driven health care.’’ This approach to health care 

prioritizes the Veteran and their values, and partners with them to create a personalized strategy to optimize their health, healing, and well-being. Many of the strategies that may be of benefit extend beyond what is conventionally addressed or provided by the health system and includes CIH. To this end, VA is establishing the 

Integrative Health Coordinating Center within the Office of Patient Centered Care 

and Cultural Transformation (OPCC&CT). 

OPCC&CT, along with Patient Care Services, deployed a national survey on CIH 

to better understand the evolution of how these services are being provided across 

the system and to advance further implementation. The survey was deployed to all 

VA parent medical facilities with a 100% completion rate. This report is being finalized this month for review by VHA and VA leadership. 

VA is preparing the current workforce through a focus on education of the clinical 

staff. OPCC&CT developed the Whole Health Clinical Education Program which is 

designed to educate clinicians in providing a proactive, whole person approach. This 

includes learning how to effectively integrate CIH approaches. This inter-professional training includes VA physicians, nurses, dietitians, chaplains and other clinical staff. The core curriculum was designed and launched in 2014 and targets traditional healthcare providers across VHA. 

The evaluation demonstrated that clinicians had improved attitudes toward Integrative Health, as well as changes in intentions to integrate mindful awareness in 

interactions with Veterans, encourage the use of self-care strategies, encourage the 

use of integrative health strategies during clinical encounters, and to co-manage patients with practitioners outside their own medical paradigm. 

23 

To implement safe and effective management of pain, VHA’s National Pain Program office oversees several work groups and a National Pain Management Strategy 

Coordinating Committee representing the VHA offices of nursing, pharmacy, mental 

health, primary care, anesthesia, education, integrative health, and physical medicine and rehabilitation. Working with the field, these groups develop, review and 

communicate strong pain management practices to VHA clinicians and clinical 

teams. 

VHA has multiple projects, coordinated under the National Pain Program office, 

to support and educate clinicians and Veterans about safe and effective stepped pain 

management, including use of opioids. Programs such as the Opioid Safety Initiative 

(OSI), the Joint Pain Education and Training Project (JPEP) with Department of 

Defense (DOD), the Tiered Acupuncture Training Across Clinical Settings (ATACS) 

with DOD, the Pain Mini-residency, Pain Specialty Care Access Network (SCAN 

ECHO), asynchronous Web-based training, and Community of Practice calls all 

reach across the VHA to train primary care providers in all settings in the assessment and treatment of pain and in the use of patient education in self-management, 

the use of multiple modalities such as behavioral, integrative medicine (Complementary and Alternative Medicine, or CAM), and physical therapies and the use of consultant specialists in pain, mental health, and CAM. 

For example, on the topic of opioids safety, all the education programs listed 

above, except ATACS which is focused on acupuncture skill training, have presentations on universal precautions and risk management in opioid therapy for pain, 

including clinical evaluation, written informed consent, screening such as urine drug 

monitoring, use of state monitoring programs, and safe tapering. Related specifically 

to safe opioid prescribing, the VHA has implemented the Opioid Safety Initiative, 

a mandatory academic detailing program that identifies targets of risky practices 

(e.g., high opioid doses, co-prescribed benzodiazepines, use of urine drug screens) 

and universally monitors these practices in VHA at the provider and facility/VISN 

level through appointed VISN and facility OSI and Pain Management Point of Contact, or POCs. A POC is a clinician appointed and supported at the VISN level who 

is an appropriately trained, experienced and credentialed in pain medicine, pain 

management, or another credential appropriate to the clinical discipline. These individuals identify targets of risky practices through regular monthly and ‘on-demand’ 

progress reports, and provide education and counseling for facilities and prescribers 

whose patterns of prescribing and pain management practices require remediation. 

To provide clinical education and resource support to providers and facilities for 

successful OSI implementation, the National Pain Program office established the 

interdisciplinary OSI Toolkit Task Force to systematically peer-review and standardize clinical education and patient education materials for distribution throughout 

VHA. The OSI Toolkit Task force has completed peer-review, revision and approval 

of the below trainings and materials and meets regularly to peer-review, revise, and 

publish new ‘‘strong practices’’ that are identified in VHA. 

Most recently, in March 2015, the National Pain Management launched the new 

Opioid Therapy Risk Report tool which provides detailed information on the risk 

status of Veterans taking opioids to assist VA primary care clinicians with pain 

management treatment plans. This tool is a core component of a reinvigorated focus 

on patient safety and effectiveness. 

In 2014, VA’s Office of Academic Affiliations in conjunction with Physical Medicine and Rehabilitation Services launched a national VA Chiropractic residency program. The VA Chiropractic program has been engaged in chiropractic education and 

training for a decade. Since 2004 over 1,500 chiropractic students have completed 

clinical rotations at 24 VA facilities. The VA chiropractic residency program focuses 

on Integrated Clinical Practice, with training emphasizing the provision of chiropractic care in an integrated healthcare system, collaborating with primary care Patient Aligned Care Teams (PACTs), specialty care, and other medical and associated 

health providers and trainees. Individual residencies are administered by the respective local VA facilities. Each VA facility partners with its affiliated Council on 

Chiropractic Education accredited chiropractic school in conducting the program. 

VA Research is actively engaged with the community of scientists in establishing 

the evidence base for complementary and integrative health treatments for physical 

and mental conditions, the latter including examining the benefit of CIH therapy 

for PTSD, suicide prevention, and mood disorders. As these studies are completed, 

results will be evaluated to determine potential impact on Clinical Practice Guidelines. The VA Evidence-based Synthesis Program in conjunction with OPCC&CT 

and Patient Care Services has examined the scientific literature on various CAM 

services and have presented the findings in the form of ‘‘evidence maps.’’ An evidence review and map in acupuncture, yoga, Tai Chi and mindfulness has been comVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00027 Fmt 6633 Sfmt 6621 Z:\ACTIVE\062415.TXT PAULIN
24 

pleted. The findings from these reviews are helping to inform decisions on how to 

best use CAM within VA and identify areas for further research. 

Section 401 would require that as part of the hiring process VA reach out to state 

medical boards to ascertain whether a prospective employee has any violations over 

the past twenty years, or has entered into a settlement agreement related to the 

employee’s practice of medicine. VA does not feel that additional legislation is needed to accomplish this. VHA policy, already in place, requires the verification of all 

current and previously held licenses for all licensed health care providers. At the 

time of initial appointment all current and previously held licenses are verified with 

the state licensing board issuing the license. Verification requires querying the state 

licensing board for not only the issue date and expiration date, but also any pending 

or previous adverse actions. If an adverse action is identified, the verification requires obtaining all documentation available associated with such action, including 

but not limited to copies of any agreements. At the time of expiration of a license 

as well as at the time of reappraisal, VHA policy requires querying the state licensing board to confirm renewal of the license as all as whether or not there have been 

any new pending or previous adverse actions. If the license is not renewed, VHA 

policy requires confirmation that the license expired in good standing and if not, 

what was not in good standing. 

At the time of initial appointment, all health care providers are queried through 

the National Practitioner Data Bank (NPDB). The NPDB is a national flagging system that serves as a resource for hospitals and other healthcare entities during the 

provider credentialing process. The NPDB provides information about past adverse 

actions of health care providers. VHA also enrolls all independent, privileged providers in the NPDB’s Continuous Query program for ongoing monitoring of not only 

adverse actions taken against a credential, but also paid malpractice. VHA receives 

notification of a new report within 24 hours of the report being filed with the NPDB. 

Additionally, at the time of initial appointment, all physicians are queried 

through the Federation of State Medical Boards (FSMB) Federation Physician Data 

Center, a nationally recognized system for collecting, recording and distributing to 

state medical boards and other appropriate agencies data on disciplinary actions 

taken against licensees by the boards and other governmental authorities. The report returned from the FSMB Physician Data Center not only identifies if there are 

any adverse actions recorded against a physician’s license but also lists all of the 

physician’s known licenses, current or previously held, serving as double-check that 

the physician reported all licenses during the credentialing process. In addition, the 

licenses of all physicians are monitored through a contract with the FSMB’s Disciplinary Alert Service (DAS). Through this contract, all physicians are enrolled in 

the DAS which offers ongoing monitoring of physician licensure. If a new action 

against a physician’s license is reported to the FSMB DAS, VHA receives a notification of the report within 24 hours. The staff at the physician’s facility then contacts 

the reporting state licensing board to obtain the details of the action. 

If the facility learns of an adverse action taken against a provider license, the 

staff at the facility must obtain information from the provider against whom the action was taken and consider it as well as the information obtained from the state 

licensing board. This review is documented to include the reasons for the review, 

the rationale for the conclusions reached, and the recommended action for consideration and appropriate action by the facility. 

Section 402 would require VA to provide the relevant state medical board detailed 

information about any health care provider of VA that has violated a requirement 

of their medical license. We also believe in this case additional legislation is not required. VA has broad authority to report to state licensing boards those employed 

or separated health care professionals whose behavior or clinical practice so substantially failed to meet generally-accepted standards of clinical practice as to raise 

reasonable concern for the safety of patients. The authority to report those professionals is derived from VA’s long-standing statutory authority, contained in 38 

U.S.C. 7401–7405, which authorizes the Under Secretary for Health, as head of 

VHA, to set the terms and conditions of initial appointment and continued employment of health care personnel, as may be necessary, for VHA to operate medical facilities. This authority includes requiring health care professionals to obtain and 

maintain a current license, registration, or certification in their health care field. 

The Veterans Administration Health-Care Amendments of 1985, Public Law 99– 

166, and Part B of Title IV of Public Law 99–660, the Health Care Quality Improvement Act of 1986, are Acts require VHA to strengthen quality assurance and reporting systems to promote better health care. Pursuant to section 204 of Public Law 

99–166, VA established a comprehensive quality assurance program for reporting 

any licensed health care professional to state licensing boards who: 

25 

(1) Was fired or who resigned following the completion of a disciplinary action relating to such professional’s clinical competence; 

(2) Resigned after having had such professional’s clinical privileges restricted or 

revoked; or 

(3) Resigned after serious concerns about such professional’s clinical competence 

had been raised, but not resolved. 

The statutory provisions of 38 U.S.C. 7401–7405, augmented by Public Laws 99– 

166 and 99–660, provide VHA ample authority to make reports to state licensing 

boards when exercised consistent with Privacy Act requirements for release of information. VHA policy requires the VA medical facility Director to ensure that within 

seven calendar days of the date a licensed health care professional leaves VA employment, or, information is received suggesting that a current employee’s clinical 

practice has met the reporting standard, an initial review of the individual’s clinical 

practice is conducted to determine if there may be substantial evidence that the individual so substantially failed to meet generally-accepted standards of clinical practice as to raise reasonable concern for the safety of patients. 

Usually this review is conducted and documented by first and second level supervisory officials. When the initial review suggests that there may be substantial evidence that the licensed health care professional so failed to meet generally-accepted 

standards of clinical practice as to raise reasonable concern for the safety of patients, the medical facility Director is responsible for immediately initiating a comprehensive review to determine whether there is, in fact, substantial evidence that 

this reporting standard has been met. This review involves the preparation of a 

state licensing board Reporting File. VHA policy defines the process for collecting 

evidence; notifying the provider of the intent to report which affords the provider 

the opportunity to respond in writing to the allegations; and then the review process 

to assure that VHA has complied with the Privacy Act prior to reporting. 

It is VA’s policy to cooperate whenever possible with an inquiry by a state licensing board. VA medical facilities must provide reasonably complete, accurate, timely, 

and relevant information to a state licensing board in response to appropriate 

inquiries. 

Mr. Chairman, thank you for the opportunity to present our views on the legislation today and we will be glad to answer any questions you or other Members of 

the Committee may have. 

DEPARTMENT OF VETERANS AFFAIRS, 

Washington, DC, July 15, 2015. 

Hon. JOHNNY ISAKSON, 

Chairman, 

Senate Committee on Veterans’ Affairs 

U.S. Senate, Washington, DC. 

DEAR MR. CHAIRMAN: The agenda for the Senate Committee on Veterans’ Affairs’ 

June 3, 2015, and June 24, 2015, legislative hearings included a number of bills 

that the Department of Veterans Affairs (VA) was unable to address in our testimony. We are aware of the Committee’s interest in receiving our views and cost estimates for those bills. 

By this letter, we are providing the following remaining views and cost estimates 

for the following bills from the June 3, 2015, legislative hearing: S. 471, the Women 

Veterans Access to Quality Care Act of 2015; and sections 4(b)-(c) and 5 of the draft 

Veterans Health Act of 2015. 

We are also providing views and costs on the following bills from the June 24, 

2015, legislative hearing: the Draft Biological Implant Tracking and Veteran Safety 

Act of 2015; on S. 1117, the Ensuring Veteran Safety Through Accountability Act 

of 2015; sections 203, 205, 208, and 209(b) of S. 469, the Women Veterans and Families Health Services Act of 2015; sections 3 through 8 of S. 1085, the Military and 

Veteran Caregiver Services Improvement Act of 2015; section 2 of the draft bill referred to on the agenda as ‘‘Discussion Draft;’’ and sections 101–106, 204, 205, 403 

and 501 of the draft Jason Simcakoski Memorial Opioid Safety Act. 

In the time requested for transmittal of follow up views, VA was not able to include in this letter the following views: sections 2 and 4 of S. 297, the Frontlines 

to Lifelines Act of 2015; the draft bill on establishing a joint VA-Department of Defense (DOD) formulary for systemic pain and psychiatric medications; sections 2, 3, 

and 5 of the draft Veterans Health Act of 2015, sections 203, 208, and 209(b) of 

S. 469, the Women Veterans and Families Health Services Act of 2015; sections 4(b) 

and 8 of S. 1085, the Military and Veteran Caregiver Services Improvement Act of 

2015; and sections 105, 205, 403, and 501 of the Jason Simcakoski Memorial Opioid 

26 

Safety Act. The remaining views can be forwarded in a separate and final followup views letter. 

We appreciate this opportunity to comment on this legislation and look forward 

to working with you and the other Committee Members on these important legislative issues. 

Sincerely, 

ROBERT A. MCDONALD, 

Secretary. 

Enclosure. 

* * * * * * * 

JUNE 24, 2015, AGENDA

DRAFT BILL, BIOLOGICAL IMPLANT TRACKING AND

VETERAN SAFETY ACT OF 2015

Section 2 of the draft bill would add a new section 7330B to title 38 to require 

the Secretary to adopt or implement the unique device identification system developed by the Food and Drug Administration (FDA) for medical devices (or a comparable standard identification system) for use in identifying biological implants intended for utilization in VA medical procedures. VA would be required to permit a 

vendor to use any accredited agency identified by the FDA as an issuing agency pursuant to 21 CFR 830.100. Section 2 would also require the Secretary to implement 

a system for tracking biological implants from donor to implantation and implement 

a system of inventory controls compatible with such system. The inventory controls 

would need to enable the Secretary to notify, as appropriate (based on an evaluation 

of the risks and benefits provided by appropriate VA medical personnel), VA patients who are in receipt of biological implants that are subject to recall by the FDA. 

In addition, section 2 of the bill would provide that in cases of conflict between the 

proposed revision to title 38 and a provision of 21 U.S.C. 301 et seq. or 42 U.S.C. 

262, (including any regulations issued pursuant to such Acts), the provisions of 

these other laws or regulations would apply. 

VA agrees with the general purpose of these requirements, and VA intends to institute new recommendations from the Department of Health and Human Services 

(HHS) for tissue tracking. On April 7–8, 2015, the HHS Advisory Committee on 

Blood and Tissue Safety and Availability voted unanimously to recommend that the 

HHS Secretary adopt a step-wise, risk-based approach to standardizing the identification, tracking, and tracing of medical products of human origin. In particular, 

the Committee recommended establishing ISBT 128 labeling as ‘‘a universal standard for mandatory implementation of unique donation identifiers for all human tissue products.’’ It suggested that the HHS Secretary promote the integration of 

transplantation records into searchable, electronic patient records. It further recommended taking steps to ensure that patients are informed when they receive a 

tissue product and provided a means of tracing it. The Committee asked that the 

HHS Secretary promote education for health care providers regarding the risks of 

human tissue transplants, the need for meaningful informed consent and the necessity of engaging in activities to ensure tracking and tracing of tissue products. Lastly, it noted the importance of promoting international collaboration and data sharing on outcomes of tissue transplantation. 

The draft bill recognizes the need for a higher standard for human biologics as 

indicated by the requirement for the use of a production identifier at all stages in 

production; however, as currently written, the bill would force human tissues to be 

grouped with other biologics in terms of identification. 

Additionally, the bill states that VA shall permit vendors to use any of the FDA 

accredited entities identified as an issuing agency for adopting or implementing a 

standard identification system for biological implants. This effectively limits VA to 

the use of the FDA’s Unique Device Identifier (UDI) and its minimum standards. 

VA already tracks blood and cellular products successfully using ISBT 128 identifiers in its facilities, and as a result, we should be able to extend this system to 

ISBT 128-labeled human tissue products providing both electronic health record documentation and inventory control. VA is working with HHS and other Federal partners to identify the optimal tracking and tracing systems to ensure the highest safety standards for human tissues 

The term ‘‘biological implant’’ would be defined as any human cell, tissue, or cellular or tissue-based product: (1) under the meaning given the term ‘‘human cells’’ 

in 21 C.F.R. 1271.3 (or any successor regulation); or (2) that is regulated as a device 

under section 21 U.S.C. 321(h). With respect to biological implants of ‘‘human cells,’’ 

27 

the standard identification system would have to be implemented not later than 180 

days after the Act’s enactment. With respect to products that are regulated as a device), the Secretary would be required to adopt or implement such standard identification system in compliance with the compliance dates established by the FDA 

pursuant to 21 U.S.C. 360i(f). 

Should the tracking system for biological implants not be operational by the 180- 

day deadline described above, the Secretary would be required to submit a written 

explanation to the Committees on Veterans’ Affairs explaining why the system is 

not operational for each month until the system is operational. 

Section 3 would add a new section 8129 to title 38 to govern the procurement of 

biological implants. VA would be limited to procuring human biological implants 

from vendors that meet several conditions. First, the vendors would have to use the 

standard identification system adopted or implemented by VA with safeguards to 

ensure that a distinct identifier has been in place at each step of distribution from 

its donor. Additionally, each vendor would have to be registered with the FDA, ensure that donor eligibility determinations and other records accompany each biological implant at all times, and agree to cooperate with all biological implant recalls 

initiated by the vendor, the manufacturer, or by the FDA. Moreover, the vendors 

would have to agree to notify VA of any adverse event or reaction it provides to 

FDA, or any warning letter from FDA. The vendors would have to agree to retain 

all records associated with procuring a biological implant for at least 10 years, and 

would have to provide assurances that the biological implants provided are acquired 

only from tissue processors that maintain accreditation with the American Association of Tissue Banks or a similar national accreditation. 

Vendors supplying biological implants of non-human origin would have to use the 

standard identification system adopted or implemented by VA, be registered with 

the FDA and agree to cooperate with all biological implant recalls initiated by the 

vendor, the manufacturer, or by the FDA. For a vendor that is not the original product manufacturer, the vendor would have to provide assurances that the original 

product manufacturer is registered with FDA or is not required to register. Vendors 

would also have to agree to notify VA of any adverse event or reaction it provides 

to FDA, or any warning letter from FDA. Finally, vendors would have to agree to 

retain all records associated with procuring a biological implant for at least 10 

years. 

VA would be required to procure biological implants under the Federal Supply 

Schedules (FSS) of the General Services Administration (GSA) unless such implants 

are not available under these schedules. VA would be required to accommodate reasonable vendor requests to undertake outreach efforts to educate VA medical professionals about the use and efficacy of biological implants if the implants are listed 

on the FSSs. If FSSs were unavailable, VA would be required to procure such implants using competitive procedures in accordance with applicable law and the Federal Acquisition Regulations (FAR). The bill would also clarify that 38 U.S.C. 8123, 

which addresses procurement of prosthetic appliances, does not apply to the procurement of biological implants. 

Paragraph (b) of the new section 8129 would establish penalties, in addition to 

any penalty under another provision of law, for procurement employees who are 

found responsible for a biological implant procurement transaction with intent to 

avoid or reckless disregard of the requirements of this section. Such an official 

would be ineligible to hold a certificate of appointment as a contracting officer or 

to serve as the representative of an ordering officer, contracting officer, or purchase 

card holder. 

Paragraph (c) of the new section 8129 would define several terms. The new section 8129 would take effect on the date that is 180 days after the date on which 

the tracking system is required. The bill also contains a special rule for cryopreserved products, allowing VA for 3 years to procure biological implants produced 

and labeled before the effective date of section 8129 without relabeling the product 

as would be required under the new section 7330B. 

VA has several concerns with section 3 of the bill. First, vendors would be required to retain records for up to 10 years under the draft bill. VA notes that some 

institutions permanently retain these records. In particular some types of biologic 

may be stored for extended periods prior to use and it may take several years for 

an adverse outcome to manifest. Disposal of records, in particular, the actual production identifier and donor documentation, will prevent the ability to track human 

derived biologics to their donor and ensure the presence of biologics in VHA that 

cannot be reliably tracked back to the original donor. 

VA also has concerns with the requirement that biological implants be procured 

from FSS sources (unless the products are not available from these sources). This 

would unduly restrict VA’s authority to determine the hierarchy of sources. All bioVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00031 Fmt 6633 Sfmt 6621 Z:\ACTIVE\062415.TXT PAULIN
28 

logical implants are not currently available on the FSS, and clinicians are not involved in the decision to place these products on contract. Additionally, VHA has 

determined that these should be available through national contracts that would 

take precedence over FSS. VA is developing an appropriate initial contract vehicle 

to acquire such products. 

We are also concerned that the penalties imposed under proposed section 8129(b) 

could produce unfair results if a procurement employee needed to purchase a product off-contract to meet the immediate needs of a patient and provider. This could 

be exacerbated by vendors choosing not to contract with VA given the new requirements imposed upon them, thereby eliminating or limiting the availability of products for our patients. Shortages of biologic products could also affect VA’s ability to 

obtain products under contract or through competitive processes. As a result, Veterans’ medical care could be delayed. 

VA is unable to estimate the costs for the draft bill at this time. 

S. 1117, ENSURING VETERAN SAFETY THROUGH ACCOUNTABILITY ACT OF 2015

S. 1117 would amend 38 U.S.C. 713 to allow the Secretary to remove individuals 

appointed under 38 U.S.C. 7401, which include health care and scientific professionals (e.g., physicians, dentists, nurses), if the Secretary determines the performance or misconduct of the individual warrants removal. Under S. 1117, actions 

taken under 38 U.S.C. 713 would not be subject to the provisions of 38 U.S.C. 

7461(b) and 7462, or 5 U.S.C. 7503, 7513, and 7543(b). The bill would also make 

conforming amendments to 38 U.S.C. 7461(b) and 7462. 

38 U.S.C. 713 was established last summer under section 707 of the Veterans Access, Choice, and Accountability Act of 2014 (Public Law 113–146). Under 38 U.S.C. 

713, the Secretary may remove or, under certain circumstances, transfer an employee to a General Schedule position, if the Secretary determines that the performance or misconduct of the individual warrants such a removal or transfer. Individuals who are removed or transferred under 38 U.S.C. 713 have limited post-termination or transfer appeal rights. 

At present, 38 U.S.C. 713 only applies to VA Senior Executives: career appointees 

in the Senior Executive Service or individuals appointed under 38 U.S.C. 7306(a) 

or 7401(1) to an administrative or executive position. S. 1117 would expand the application of 38 U.S.C. 713 to allow the Secretary to remove other Title 38 employees, 

including practicing physicians, dentists, nurses, and other individuals, regardless 

of their grade or rank, while limiting the post-termination appeal rights for these 

employees. 

While 38 U.S.C. 713 gave the Secretary additional flexibility in terms of holding 

VA Senior Executives accountable for misconduct or poor performance, it constrained the Secretary’s ability to retain gifted senior leaders by singling out VA 

Senior Executives for disparate treatment from their peers at other agencies. It is 

likely that S. 1117 would result in unintended consequences for VA, such as a loss 

of qualified and capable health care and scientific professionals to other government 

agencies or the private sector. Many of these employees accept lower pay to serve 

at VA, and a large number of these employees are Veterans. While VA’s employees 

are motivated first and foremost by a desire to serve Veterans, another motivation 

to accept lower pay shared by many Federal employees is the job security afforded 

by protections such as appeal rights that attach at the end of a probationary period. 

Diminishing those appeal rights will reduce the motivation to pursue public service 

at VA. 

The bill also poses due process concerns, due to its failure to provide the employee 

with a chance to be heard prior to losing the benefits of employment and its failure 

to guarantee that an employee’s case will be fairly judged before the sanction becomes final. 

By singling out VA employees, the legislation would dishearten a workforce dedicated to serving Veterans and hurt VA’s efforts to recruit and retain high performing employees. VA will continue to work with the Committee and VSO’s on how 

the Secretary can best hold employees accountable while preserving the ability to 

recruit and retain the highly skilled workforce VA needs to best serve Veterans. 

S. 469, WOMEN VETERANS AND FAMILIES HEALTH SERVICES ACT OF 2015

Section 203 would add a new section 1789 to title 38 authorizing the Secretary 

to pay to assist a covered veteran in the adoption of one or more children. Covered 

veterans would include any severely wounded, ill, or injured veteran who has an infertility condition incurred or aggravated in the line of duty and who is enrolled in 

VA’s health care system. VA would be limited to paying an amount equal to the cost 

29 

to the Department of paying the expenses of three adoptions by covered Veterans, 

as determined by the Secretary. 

VA’s goal is to restore to the greatest extent possible the physical and mental capabilities of Veterans and improve the quality of their lives and that of their families, and adoption would be a means to that end. However, we note that payment 

for adoption services raises a host of issues regarding differing State laws, as well 

as complications from administering what would be a non-medical benefit. We would 

also note that additional funds would be necessary to support adoption services. VA 

is still analyzing this section and would be glad to provide further views at a later 

time. 

Section 205 would require VA to promulgate regulations within 540 days of the 

enactment of the Act on the furnishing of fertility treatment to veterans using reproductive technology; fertility treatment and counseling for spouses, partners, and 

gestational surrogates of Veterans under the new section 1788; and adoption assistance for covered Veterans under the new section 1789. Prior to publishing these regulations, VA would be prohibited from furnishing any fertility treatment that uses 

an assisted reproductive technology that the Secretary has not used before the enactment of this Act, to furnish any fertility treatment or counseling under the new 

section 1788, or to offer any adoption assistance under the new section 1789. 

While VA has no objection to section 205, we note that our previous testimony 

cited only partial support for some of the programs in question 

Section 208 would modify the pilot program on counseling in retreat settings for 

women Veterans newly separated from service in the Armed Forces by increasing 

the number of locations from 3 to 14 and by extending the duration of the program 

another 3 years through calendar year 2018. It would also authorize such sums as 

may be necessary to be appropriated to support the program for fiscal years 2016, 

2017, and 2018. 

VA is still analyzing this section and would be glad to provide views at a later 

time. We note that additional funds would be necessary to support the extension of 

this program. 

Section 209(b) would require VA to carry out a program to provide child care assistance for certain Veterans receiving readjustment counseling and related mental 

health services at Vet Centers. VA would be required to carry out this program in 

not fewer than three Readjustment Counseling Service Regions selected by the 

Secretary. 

The child care program requirements would generally be the same as the requirements for the current child care pilot program, with several notable exceptions. 

First, VA would be limited to assisting qualified Veterans with child care only during the period that the qualified Veteran is receiving readjustment counseling and 

related health care services at a Vet Center, but not the time to travel to and from 

the Vet Center. VA is unsure if this is an accidental omission, but believes this limitation could significantly limit the effect of this authority. Second, under this provision, VA would not be authorized to directly provide child care services as an acceptable form of child care assistance. This omission is potentially troublesome in light 

of the first concern we raised, because if VA cannot directly provide child care assistance but also cannot provide child care during the travel time to and from the 

appointment, there would be at least some amount of time when either the Veteran 

would be liable for the cost of child care services or the Veteran’s child could not 

receive such services. We would also note that additional funds would be necessary 

to support program. VA is still analyzing this section and would be glad to provide 

views at a later time. 

S. 1085, MILITARY AND VETERAN CAREGIVER SERVICES IMPROVEMENT ACT OF 2015

Section 3 of this bill proposes to add a new section 3319A to title 38 to authorize 

individuals who are eligible for and participating in a program of comprehensive assistance for family caregivers under 38 U.S.C. 1720G(a) the opportunity to transfer 

their unused Post-9/11 GI Bill education benefits to their dependents. Veterans may 

complete the transfer of entitlement any time during the 15-year period beginning 

on the date of their last discharge or release from active duty. Transferees would 

be subject to the same rules in place for individuals who receive transferred benefits 

under 38 U.S.C. 3319. However, there is no length of service requirement, and the 

monthly rate of educational assistance would be the same rate payable to the individual making the transfer. The Secretary would be authorized to prescribe regulations to carry out this section. 

Currently, DOD determines eligibility for transfer of entitlement. If enacted, the 

proposed legislation would require VA to develop procedures to receive requests to 

transfer entitlement for certain individuals, determine eligibility, and award beneVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00033 Fmt 6633 Sfmt 6621 Z:\ACTIVE\062415.TXT PAULIN
30 

fits for the transfer of entitlement program. Because the transfer of entitlement provisions of the Post-9/11 GI Bill were established as a recruitment and retention tool 

for the uniformed services, VA defers to DOD on this section of the bill. However, 

VA notes that Congress would need to identify appropriate offsets for the cost of 

this legislation, which we are unable to estimate at this time. 

Section 4(a) would amend 37 U.S.C. 439, providing for special compensation for 

members of the uniformed services with catastrophic injuries or illnesses requiring 

assistance in everyday living, by amending the definition of covered members to include those Servicemembers who have a serious injury or illness that was incurred 

or aggravated in the line of duty, are in need of personal care services as a result 

of the injury, and who would require hospitalization, nursing home care, or other 

residential care in the absence of such personal care services. Section 4(b) would further amend section 439 by requiring VA to provide family caregivers of a Servicemember in receipt of monthly special compensation assistance available to family 

caregivers of eligible veterans under 38 U.S.C. 1720G(a)(3)(A), other than the 

monthly caregiver stipend. VA would provide assistance under this subsection in accordance with a memorandum of understanding (MOU) between VA and DOD, and 

an MOU between VA and the Secretary of Homeland Security. Section 4(c) would 

define the term ‘‘serious injury or illness,’’ which would replace the term ‘‘catastrophic injury or illness,’’ to mean an injury, disorder, or illness that (1) renders 

the afflicted person unable to carry out one or more activities of daily living; (2) renders the afflicted person in need of supervision or protection due to the manifestation by such person of symptoms or residuals of neurological or other impairment 

or injury; (3) renders the afflicted person in need of regular or extensive instruction 

or supervision in completing two or more instrumental activities of daily living; or 

(4) otherwise impairs the afflicted person in such manner as the Secretary of Defense or Homeland Security prescribes. 

VA defers to DOD and the Department of Homeland Security regarding amendments sections 4(a) and 4(c). 

VA is still analyzing section 4(b) and would be glad to provide views at a later 

time. 

Section 5 would authorize the Office of Personnel Management (OPM) to promulgate regulations under which a covered employee, which would include a caregiver 

defined in 38 U.S.C. 1720G or a caregiver of an individual receiving compensation 

under 37 U.S.C. 439, to use a flexible schedule or compressed schedule or to 

telework. 

VA defers to OPM on this section. 

Section 6 would amend the Public Health Service Act (42 U.S.C. 300ii), which governs lifespan respite care, to amend the definition of ‘‘adult with special need’’ to 

include a veteran participating in the family caregiver program under 38 U.S.C. 

1720G. It would also amend the definition of ‘‘family caregiver’’ to include family 

caregivers under 38 U.S.C. 1720G. Furthermore, in awarding grants or cooperative 

agreements to eligible State agencies to furnish lifespan respite care, the HHS 

would be required to work in cooperation with the interagency working group on 

policies relating to caregivers of Veterans established under section 7 of this bill. 

Section 6 would also authorize appropriations of $15 million for fiscal years 2016 

through 2020 for these grants. 

VA defers to HHS on this section. 

Section 7 would establish an interagency working group on policies relating to 

caregivers of Veterans and Servicemembers. The working group would be composed 

of a chair selected by the President, and representatives from VA, DOD, HHS (including the Centers for Medicare & Medicaid Service), and the Department of 

Labor. The working group would be authorized to consult with other advisors as 

well. The working group’s duties would include regularly reviewing policies relating 

to caregivers of Veterans and Servicemembers, coordinating and overseeing the implementation of policies relating to these caregivers, evaluating the effectiveness of 

such policies, developing standards of care for caregiver and respite services, and 

others. Not later than December 31, 2015, and annually thereafter, the working 

group would be required to submit to Congress a report on policies and services relating to caregivers of Veterans and Servicemembers. 

VA generally supports a working group that would provide a forum for analyzing 

and evaluating different issues that family caregivers of Veterans and Servicemembers face. Such a working group would be ideally suited to considering in depth the 

types of issues other provisions of this bill are intended to address, and would also 

be able to evaluate emerging issues. 

The Department of Justice advises, however, that it believes the method for selecting members of the working group raises Appointment Clause concerns, which 

DOJ will convey in greater detail under separate cover. 

31 

Section 8(a) would require VA to conduct a longitudinal study on Servicemembers 

who began their service after September 11, 2001. VA would be required to award 

a grant to or enter into a contract with an appropriate entity unaffiliated with VA 

to conduct the study. Within 1 year of the date of the enactment of the Act, VA 

would be required to submit to the Committees on Veterans’ Affairs a plan for the 

conduct of the study. Not later than October 1, 2019, and not less frequently than 

once every 4 years thereafter, VA would be required to submit to the Committees 

on Veterans’ Affairs a report on the results of the study. Section 8(b) would require 

VA to provide for the conduct of a comprehensive study on Veterans who have incurred a serious injury or illness and individuals who are acting as caregivers for 

Veterans. VA would be required to award a grant to or enter into a contract with 

an appropriate entity unaffiliated with VA to conduct the study. The study would 

be required to include the health of the Veteran and the impact of the caregiver on 

the health of the Veteran, the employment status of the Veteran and the impact 

of the caregiver on that status, the financial status and needs of the Veteran, the 

use by the Veteran of VA benefits, and any other information VA considers appropriate. Not later than 2 years after the date of the enactment of this Act, VA would 

be required to submit to the Committees on Veterans’ Affairs a report on the results 

of this study. 

VA is still analyzing this section and would be glad to provide views at a later 

time. 

DRAFT BILL, DISCUSSION DRAFT

Section 2 of the discussion draft would require, within 2 years of enactment, the 

Secretary, in consultation with the Secretary of Defense and such agencies and individuals the Secretary considers appropriate, to submit a report to Congress. The report would include the extent to which Laotian military forces provided combat support to the Armed Forces of the United States between February 28, 1961, and May 

15, 1975; whether the current classification of the service by individual of the 

Hmong ethnicity by the Civilian/Military Service Review Board of the Department 

of Defense is appropriate; and any recommendations for legislative action. 

VA does not support this section because DOD is in better position than VA to 

research this issue. In determining whether a claimant is eligible for a VA benefit, 

VA is legally bound by service department determinations as to what service a 

claimant performed. 

DRAFT BILL, THE JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

Section 101 would require, within 1 year of the date of the enactment of the Act, 

VA and DOD to jointly update the VA/DOD Clinical Practice Guideline for Management of Opioid Therapy for Chronic Pain. The guidelines would have to include 

guidelines for safely prescribing opioids for the treatment of chronic, non-cancer 

pain in outpatient settings; enhanced guidance with respect to absolute contraindications for opioid therapy; enhanced guidance with respect to the treatment of 

patients with behaviors or comorbidities, or a history of substance abuse or addiction, that require consultation or co-management of opioid therapy with one or more 

specialists; enhanced guidance with respect to the conduct by health care providers 

of an effectiveness assessment for patients receiving opioid therapy; requirements 

that each VA and DOD provider, before initiating opioid therapy, use VA’s Opioid 

Therapy Risk Report tool to assess the risk for adverse outcomes; guidelines to govern the methodologies used by VA and DOD providers to taper opioid therapy when 

adjusting or discontinuing opioid therapy; guidelines with respect to appropriate 

case management for patients receiving opioid therapy who transition between inpatient and outpatient settings; enhanced recommendations on the use of routine and 

random urine drug tests for all patients before and during opioid therapy; and guidance that health care providers discuss with patients before initiating opioid therapy 

other options for pain management therapies. Before updating these guidelines, VA 

and DOD would be required to jointly consult with the working group on pain management and opioid therapy established under section 3 of this bill. Within 1 year 

of the date of enactment of this Act, GAO would be required to submit to the Committees on Veterans’ Affairs a report on the implementation of the updated guidelines by each VA medical facility and the compliance of each medical facility with 

these guidelines. 

VA appreciates the intent of this thoughtful and comprehensive bill, and agrees 

that more needs to be done to support clinicians with clearer guidance and training 

on prescribing medications for pain management. VA, because of its central role in 

training physicians across the country, can provide leadership by training clinicians 

in pain management and supporting a team approach to care. There are cases 

32 

where the use of opioids is clinically indicated, albeit closely controlled and monitored, to control pain when nothing else does. We have a number of recommendations to improve the bill, and would be glad to meet with the Committee to discuss 

these further. For example, the requirement in section 101(b) that VA and DOD 

jointly consult the working group on pain management and opioid therapy established in section 103 of the bill would be redundant, as the VA/DOD Health Executive Council (HEC) already has a Pain Management Work Group whose focus is on 

improving pain management practices in the two Departments. 

Section 102(a) would require VA, within 180 days of enactment, to expand the 

Opioid Safety Initiative to include all VA medical facilities. 

Section 102(b) would require VA to ensure all providers responsible for prescribing opioids to receive education and training on pain management and safe 

opioid prescribing practices. The education and training would have to cover a number of identified areas, and in providing the training, VA would be required to use 

the Interdisciplinary Chronic Pain Management Training Team Program. 

Section 102(c) would require each VA medical facility to identify and designate 

a pain management team of health care professionals responsible for coordinating 

and overseeing therapy at the facility for patients experiencing acute and chronic 

pain that is not related to cancer. Each VISN Director would be responsible for establishing protocols for the designation of a pain management team at each VA 

medical facility in the VISN, and the protocols would need to ensure that any health 

care provider without expertise in prescribing analgesics or who has not completed 

required training not prescribe opioids, with limited exceptions. Within 1 year of enactment of this Act, each VA medical facility would be required to submit to the 

VISN Director a report identifying the health care professionals that have been designated as members of the pain management team at the facility. 

Section 102(d) would require, within 18 months of the date of the enactment of 

the Act, that VA provide for real time tracking and access to data on the use of 

opioids and prescribing practices. VA also would be required to ensure access by VA 

health care providers to information on controlled substances prescribed by community providers through State prescription drug monitoring programs. Within 180 

days of the enactment of this Act, VA would be required to submit to Congress a 

report on the implementation of these improvements. 

Section 102(e) would require VA to increase the availability of opioid receptor antagonists, such as naloxone, to veterans and for use by VA health care providers 

treating Veterans. Within 90 days of enactment of this Act, VA would be required 

to equip each VA medical facility with opioid receptor antagonists approved by FDA. 

VA notes that other opioid receptor antagonists approved by FDA exist, but only one 

type (naloxone) is approved for overdose reversal. This section also directs VA to enhance training of providers on distributing such antagonists, and to expand the 

Overdose Education and Naloxone Distribution program to ensure all Veterans in 

receipt of health care who are at risk of opioid overdose (as defined by the bill) have 

access to opioid receptor antagonists and training on their proper administration. 

Within 120 days of the date of the enactment of this Act, VA would be required to 

submit to the Committees on Veterans’ Affairs a report on compliance with this 

requirement. 

Section 102(f) would require that VA include in the Opioid Therapy Risk Report 

tool information on the most recent time the tool was accessed by a VA health care 

provider with respect to each Veteran and information on the results of the most 

recent urine drug test for each Veteran. VA would also be required to determine 

if a provider prescribed opioids without checking the information in this tool first. 

Section 102(g) would require VA to modify VA’s Computerized Patient Record System (CPRS) to ensure that any health care provider that accesses the record of a 

Veteran will be immediately notified whether the Veteran is receiving opioid therapy and has a history of substance use disorder or prior instances of overdose, has 

a history of opioid abuse, or is at risk of becoming an opioid abuser. 

VA agrees that additional training for providers is necessary. Clinicians want to 

help Veterans and Servicemembers, but often do not have the skills and resources 

to do so. A well-trained physician and clinical team will know how to evaluate comprehensively a patient with pain, including making clinical diagnoses and how to 

develop a goal oriented management plan for pain, as well as how to engage the 

particular resource needs of each patient. Regarding other parts of section 102, VA 

is currently taking steps to fulfill the intent of many of these provisions. For example, section 102(e) would require VA to increase the availability of opioid receptor 

antagonists approved by the FDA, and VA is currently exploring ways to increase 

the availability of these life-saving medications. Similarly, section 102(g) would require VA to modify the Computerized Patient Record System to ensure providers 

will be immediately notified about opioid risks for each patient. VA’s electronic 

33 

health record already has real-time mechanisms in place to alert VA health care 

providers of existing opioid prescriptions to prevent prescribing of additional opioids 

to Veterans who receive all their healthcare and prescriptions through the VA system. These mechanisms include real-time order checks that alert providers of prescriptions with potential problems with duplication, drug interactions, and doses in 

excess of the maximum recommended amount. In some facilities, VA health care 

providers also can check the State Prescription Drug Monitoring program databases 

to determine if a Veteran has an opioid prescription outside of VA. 

Section 103 would establish within the VA-DOD Joint Executive Committee (JEC) 

a working group on pain management and opioid therapy for individuals receiving 

health care from either VA or DOD. The working group would cover the prescribing 

practices of health care providers in both Departments, the ability of each Department to manage acute and chronic pain, the use of complementary and integrative 

health in treating such individuals, the concurrent use of opioids and prescription 

drugs to treat mental health disorders, the practice of prescribing opioids, the coordination in coverage and consistent access to medications for patients receiving 

care from VA and DOD, and the ability of each Department to identify and treat 

substance use disorders. The working group would be required to coordinate with 

other working groups established under 38 U.S.C. 320, consult with other Federal 

agencies, and review and comment on the VA/DOD Clinical Practice Guideline for 

Management of Opioid Therapy for Chronic Pain. The Secretaries of VA and DOD 

would be required to jointly ensure that the working group is able to consult meaningfully with respect to the updated guideline required by section 101 of this bill 

within 1 year of the date of the enactment of this Act. 

As noted previously, the VA-DOD HEC already has a pain management work 

group, so to that extent, we think VA and DOD are already meeting the intent of 

section 103. 

Section 104 would add a new section 7309A to title 38, which would require VA 

to establish in each VISN a Pain Management Board. These Boards would have a 

series of defined duties, including consulting with health care professionals and 

other VA employees in the VISN about resources and best practices for pain management, overseeing compliance and providing oversight of professionals using pain 

management practices, and carrying out educational forums and public hearings on 

best practices on pain management. The Boards would be able to provide treatment 

recommendations for patients in some situations. Each Board would be required to 

submit an annual report to the Under Secretary for Health on pain management 

practices within the VISN and recommended best practices. VA would be required 

to submit an annual report to Congress that contains comprehensive information 

from the reports submitted by the Boards. 

VA appreciates the intent of this provision, but is concerned that the time it 

would take to participate in this admittedly very important activity would be time 

these professionals are not able to furnish direct clinical care and treat patients. In 

particular, the clinicians who would be best qualified to serve on such boards are 

also those likely to be treating the most complex patients. If additional resources 

were available to ensure that patient care would not suffer as a result of implementing these Boards, this concern would be alleviated. We note that the bill is unclear in terms of the appointment of non-Federal employees to the Pain Management Boards and the implications of such appointments under other laws. 

Section 105 would require VA to conduct a study on the feasibility and advisability of carrying out a pharmacy lock-in program under which veterans at risk for 

abuse of prescription drugs would be permitted to receive prescription drugs only 

from certain specified VA pharmacies. VA would be required to report to the Committees on Veterans’ Affairs within 1 year on this study. 

VA is still analyzing this section and would be glad to provide views at a later 

time. 

Section 106 would require the Comptroller General, within 2 years of the date of 

the enactment of this Act, to submit to the Committees on Veterans’ Affairs, a report on the Opioid Safety Initiative and the opioid prescribing practices of VA health 

care professionals. The report would include recommendations for improvement, and 

VA would be required to report to the Committees on Veterans’ Affairs on a quarterly basis on the actions taken by VA to address any outstanding findings and recommendations from the Comptroller General. 

We defer to GAO on this provision. 

Section 106 would also require VA to conduct an annual report and investigation 

on opioid therapy, and to submit this report to the Committees on Veterans’ Affairs. 

This report would include information on patient populations and prescribing patterns for opioids. Facilities that are among the top 10 percent in prescription rates 

would be subject to a full investigation by the Office of the Medical Inspector, and 

34 

VA would be required to notify the Committees on Veterans’ Affairs and the senators and representatives from the area in which the facility is located. 

Section 204 would require the Comptroller General to submit to the Committees 

on Veterans’ Affairs a report on VA’s Patient Advocacy Program, including recommendations and proposals for modifying the program and other information the 

Comptroller General considers appropriate. 

We defer to GAO on this provision. 

Section 205 would require VA, within 180 days of the date of the enactment of 

this Act, to submit to the Committees on Veterans’ Affairs a report on the transitions undergone by Veterans in receiving health care in different health care settings. The report would have to include an evaluation of VA’s standards for facilitating and managing the transitions undergone by veterans in receiving health care 

in different settings, an assessment of the case management services that are available, an assessments of the coordination in coverage of and consistent access to 

medications, and such recommendations to improve transitions, including coordination of drug formularies between VA and DOD. 

VA is still analyzing this section and would be glad to provide views at a later 

time. 

Section 403 would require, within 2 years of the date of the enactment of this Act, 

VA to submit a report on its compliance with VA’s policy to conduct a review of each 

health care provider who transfers to another VA medical facility or leaves VA to 

determine whether there are any concerns, complaints, or allegations of violations 

relating to the medical practice of the health care provider, and to take appropriate 

action with respect to any such concern, complaint, or allegation. 

VA is still analyzing this section and would be glad to provide views at a later 

time. 

Section 501 would add a new section 527A to title 38 requiring VA to carry out 

a program of internal audits and self-analysis to improve the furnishing of benefits 

and health care to veterans and their families. The Secretary would be required to 

establish an office within the Office of the Secretary to carry out these audits. The 

office would conduct periodic risk assessments, develop plans in response to these 

assessments, and conduct internal audits. At least five covered administrations, 

staff organizations, or staff offices would have to be audited each year. Within 90 

days of completing an audit, the Secretary would be required to submit to Committees on Veterans’ Affairs, the House Committee on Oversight and Government Reform, and the Senate Committee on Homeland Security and Government Affairs a 

report on the audit. The first audit would have to be completed within 180 days of 

the date of the enactment of this Act. 

VA is still analyzing this section and would be glad to provide views at a later 

time. 

Overall, VA understands the bill is a well-intentioned effort to combat a national 

public health problem, as outlined in a 2011 study by the Institute of Medicine 

(IOM). 

DEPARTMENT OF VETERANS AFFAIRS, 

Washington, DC, September 4, 2015. 

Hon. JOHNNY ISAKSON, 

Chairman, 

Committee on Veterans’ Affairs, 

U.S. Senate, Washington, DC. 

DEAR MR. CHAIRMAN: The agenda for the Senate Committee on Veterans’ Affairs’ 

June 3, 2015, and June 24, 2015, legislative hearings included a number of bills 

that the Department of Veterans Affairs (VA) was unable to address in our testimony or in our prior correspondence with you on July 15, 2015. By this letter, we 

are providing the final remaining views and cost estimates on the following bills 

from the June 3, 2015, legislative hearing: sections 2 and 4 of S. 297, the Frontlines 

to Lifelines Act of 2015; the draft bill on establishing a joint VA-Department of Defense (DOD) formulary for systemic pain and psychiatric medications; and sections 

2, 3, and 5 of the draft bill, Veterans Health Act of 2015. 

We are also providing the final remaining views and cost estimates on the following bills from the June 24, 2015, legislative hearing: sections 203, 208, and 

209(b) of S. 469, Women Veterans and Families Health Services Act of 2015; sections 4(b) and 8 of S. 1085, Military and Veteran Caregiver Services Improvement 

Act of 2015; and sections 105, 205, 403, and 501 of the Jason Simcakoski Memorial 

Opioid Safety Act. 

35 

We appreciate this opportunity to comment on this legislation and look forward 

to working with you and the other Committee Members on these important legislative issues. 

Sincerely, 

ROBERT A. MCDONALD, 

Secretary. 

Enclosure. 

* * * * * * * 

JUNE 24, 2015, AGENDA

S. 469, WOMEN VETERANS AND FAMILIES HEALTH SERVICES ACT OF 2015

Section 203 would add a new section 1789 to title 38 authorizing the Secretary 

to pay to assist a covered Veteran in the adoption of one or more children. Covered 

Veterans would include any severely wounded, ill, or injured Veteran who has an 

infertility condition incurred or aggravated in the line of duty and who is enrolled 

in VA’s health care system. VA would be limited to paying an amount equal to the 

cost to the Department of paying the expenses of three adoptions by covered Veterans, as determined by the Secretary. 

VA understands the intent of this provision, and VA’s goal is to restore to the 

greatest extent possible the physical and mental capabilities of Veterans and improve the quality of their lives and that of their families, and adoption would be 

a means to that end. However, we note that payment for adoption services raises 

a host of issues regarding differing state laws, as well as complications from administering what would be a non-medical benefit. As a result, VA cannot offer support 

for this provision. We would also note that additional funds would be necessary to 

support adoption services. 

Section 208 of S. 469 would modify the pilot program on counseling in retreat settings for women Veterans newly separated from service in the Armed Forces by increasing the number of locations from 3 to 14 and by extending the duration of the 

program another 3 years through calendar year 2018. It would also authorize such 

sums as may be necessary to be appropriated to support the program for fiscal years 

2016–2018. 

VA supports the intent of section 208, conditioned on the availability of additional 

resources to implement this provision. VA is currently in the final year of a pilot 

program consisting of three retreats per year to determine the feasibility and advisability of such retreats. Since June 2011, a total of eight retreats were conducted 

for women Veterans. One more is planned for November 2015. These retreats focus 

on building trust and developing peer support for the participants in a therapeutic 

environment. Data have shown that those who participated in these retreats were 

able to increase their coping abilities and decrease their symptoms associated with 

Post Traumatic Stress Disorder (PTSD). VA is expecting similar results for those 

who participated in the retreats in 2015. 

While VA agrees that providing these retreats is beneficial to women Veterans, 

other Veteran and Servicemember cohorts could also benefit from this treatment 

modality, conditioned on the availability of the additional resources needed to implement these additional services. VA recommends that legislative language be amended to provide permanent authority and allow VA the ability to conduct these retreats for all Veteran or Servicemember cohorts eligible for Vet Center services. Examples include those who have experienced military sexual trauma, Veterans and 

their families, and families who experience the death of a loved one while on active 

duty. VA estimates the total cost of the bill for fiscal years 2016–2018 would be $1.1 

million. We note that additional funds would be necessary to support the extension 

of this program. 

Section 209(b) would require VA to carry out a program to provide child care assistance for certain Veterans receiving readjustment counseling and related mental 

health services at Vet Centers. VA would be required to carry out this program in 

not fewer than three Readjustment Counseling Service Regions selected by the Secretary. 

VA appreciates the goal of section 209(b) and notes that additional resources 

would be required to carry out this program. Some Veterans who use Vet Center 

services, especially those who have served in Iraq or Afghanistan, have voiced concern that a lack of child care has affected their ability to use Vet Center services 

consistently. Although Vet Center staff continue to search for new initiatives to increase Veteran access to services, VA has concerns about implementing child care 

assistance under section 209(b) without the opportunity to pilot this type of benefit. 

36 

A pilot program is needed because VA is currently unable to predict utilization of 

this type of assistance within the Vet Center program. Comparisons to medical center pilots are not useful because Vet Centers provide services during non-traditional 

hours, including before and after normal business hours and on weekends. This inability to predict utilization affects VA’s ability to budget for the program appropriately. VA recommends that if Congress desires to provide this authority, it consider authorizing a pilot program in five Readjustment Counseling Service Regions 

to determine the feasibility, advisability, and costs of providing child care assistance 

to Veterans who utilize Vet Center services. 

The child care program requirements would generally be the same as the requirements for the current child care pilot program, with several notable exceptions. 

First, VA would be limited to assisting qualified Veterans with child care only during the period that the qualified Veteran is receiving readjustment counseling and 

related health care services at a Vet Center but not the time to travel to and from 

the Vet Center. VA is unsure if this is an accidental omission but believes this limitation could significantly limit the effect of this authority. Second, under this provision, VA would not be authorized to directly provide child care services as an acceptable form of child care assistance. This omission is potentially troublesome in light 

of the first concern we raised, because if VA cannot directly provide child care assistance but also cannot provide child care during the travel time to and from the 

appointment, there would be at least some amount of time when either the Veteran 

would be liable for the cost of child care services or the Veteran’s child could not 

receive such services. We would also note that additional funds would be necessary 

to support program. 

VA is unable to determine the cost of this provision at this time because it is unknown which locations would be selected or how many Veterans would participate 

in the program. 

S. 1085, MILITARY AND VETERAN CAREGIVER SERVICES IMPROVEMENT ACT OF 2015

Section 4(b) of S. 1085 would amend 37 U.S.C. 439 by requiring VA to provide 

family caregivers of a Servicemember in receipt of monthly special compensation assistance under 37 U.S.C. 439(a) the assistance that is currently provided to family 

caregivers of eligible Veterans under 38 U.S.C. 1720G(a)(3)(A), other than the 

monthly caregiver stipend. VA would provide assistance under this subsection in accordance with a memorandum of understanding (MOU) between VA and DOD and 

an MOU between VA and the Secretary of Homeland Security. 

VA does not support section 4(b). DOD already provides many of the services and 

supports available under VA’s Program of Comprehensive Assistance for Family 

Caregivers including health care coverage, mental health services, and respite care. 

Requiring VA to furnish these services as well would result in a duplication of 

benefits. 

Section 8(a) would require VA to conduct a longitudinal study on Servicemembers 

who began their service after September 11, 2001. VA would be required to award 

a grant to or enter into a contract with an appropriate entity unaffiliated with VA 

to conduct the study. Within 1 year of the date of the enactment of the Act, VA 

would be required to submit to the Committees on Veterans’ Affairs a plan for the 

conduct of the study. Not later than October 1, 2019, and not less frequently than 

once every 4 years thereafter, VA would be required to submit to the Committees 

on Veterans’ Affairs a report on the results of the study. Section 8(b) would require 

VA to provide for the conduct of a comprehensive study on Veterans who have incurred a serious injury or illness and individuals who are acting as caregivers for 

Veterans. VA would be required to award a grant to or enter into a contract with 

an appropriate entity unaffiliated with VA to conduct the study. The study would 

be required to include the health of the Veteran and the impact of the caregiver on 

the health of the Veteran; the employment status of the Veteran and the impact 

of the caregiver on that status; the financial status and needs of the Veteran; the 

use by the Veteran of VA benefits; and any other information VA considers appropriate. Not later than 2 years after the date of the enactment of this Act, VA would 

be required to submit to the Committees on Veterans’ Affairs a report on the results 

of this study. 

We do not believe this section is necessary. Currently, VA researchers are seeking 

new ways to address the mental health issues of Iraq and Afghanistan Veterans, 

including PTSD. They are also researching Traumatic Brain Injury (TBI) and its 

treatment and are developing and testing prostheses that will allow Veterans with 

amputations or other issues to live as independently as possible. One major effort 

is the Marine Resiliency Study (MRS), involving some 2,600 Marines who deployed 

to Iraq and Afghanistan. Beginning in 2008, the research team conducted clinical 

37 

interviews on Marine bases and collected psychological, social, and biological data 

before deployment and then multiple times after deployment. Researchers are analyzing the data to identify risk and resilience factors for combat-related PTSD. The 

team recently published two articles in JAMA Psychiatry. One shows deploymentrelated brain injury to be a significant risk factor for PTSD. Another implicates high 

levels of inflammation in the body as a PTSD risk factor. VA is also conducting a 

longitudinal study of the neuropsychological and mental outcomes of Veterans of the 

Iraq war (CSP #566). VA will soon have large datasets to characterize health status 

and changes over time for Vietnam, Iraq, and Afghanistan Veterans, which will be 

a rich resource for researchers. 

In addition, VA researchers are already studying the impact of caregivers on the 

health of Veterans. For example, one recently initiated randomized study is examining the effectiveness of an innovative caregiver skills training program and whether it can help Veterans to have increased days at home, reduced total health care 

costs, and higher satisfaction with VHA health care compared to Veterans in usual 

care; it will also examine if caregivers in the program have lower depressive symptoms than caregivers who do not receive the training. Another ongoing project is 

studying an intervention aimed at dementia patients with pain, assessing whether 

it decreases incidence of aggression, pain, caregiver burden, injuries, use of 

antipsychotic medication, and nursing home use. Another study is seeking to understand better how war-related psychiatric symptoms of Operation Enduring Freedom/ 

Operation Iraqi Freedom Veterans may interfere with family reintegration and negatively affect family functioning; this study is testing whether difficulties with family reintegration account for the impact of psychiatric symptoms on overall family 

functioning over time. Another current study is examining whether a brief, inexpensive intervention to foster end-of-life preparation and completion improves quality 

of life and health utilization for Veterans with serious illness and improves outcomes for caregivers of these Veterans at the end of life. 

Additionally, VA works closely with other Federal research agencies to ensure effective use of scarce taxpayer resources in executing its research mission. We carry 

out joint programmatic reviews with DOD and NIH to ensure that our research efforts are complementary and not duplicative. Under the auspices of the President’s 

National Research Action Plan, VA has worked with DOD to create two research 

consortia for TBI and PTSD, at a combined investment of $107 million over 5 years. 

This tight coordination has become routine for all three agencies, with benefits that 

accrue to Veterans and the American public at large. 

DRAFT BILL, THE JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

Section 105 would require VA to conduct a study on the feasibility and advisability of carrying out a pharmacy lock-in program under which Veterans at risk 

for abuse of prescription drugs would be permitted to receive prescription drugs only 

from certain specified VA pharmacies. VA would be required to report to the Committees on Veterans’ Affairs within 1 year on this study. 

VA has numerous concerns with section 105. We believe a pharmacy lock-in program, under which Veterans at risk for abuse of prescription drugs are permitted 

to receive prescription drugs only from certain specified VA pharmacies, will lead 

to negative patient outcomes. For example, Veterans who are traveling or require 

emergent/urgent medical care from a VA facility may need to receive a prescription 

from another VA facility’s pharmacy to treat the Veteran’s emergent/urgent condition. The pharmacy lock-in program would prevent medically-necessary drugs from 

being dispensed to Veterans. VA health care providers receive duplicate order 

checks from other VA facilities at the point of prescribing. These duplicate order 

checks would notify the provider and pharmacist in real-time that the Veteran is 

receiving similar medications at another VA facility. Therefore we do not believe a 

study on a pharmacy lock-in program would yield useful information. 

Section 205 would require VA, within 180 days of the date of the enactment of 

this Act, to submit to the Committees on Veterans’ Affairs a report on the transitions undergone by Veterans in receiving health care in different health care settings. The report would have to include an evaluation of VA’s standards for facilitating and managing the transitions undergone by Veterans in receiving health care 

in different settings, an assessment of the case management services that are available, an assessments of the coordination in coverage of and consistent access to 

medications, and such recommendations to improve transitions, including coordination of drug formularies between VA and DOD. 

VA does not support Section 205 because its requirements would duplicate multiple GAO investigations regarding the health care transition of Servicemembers 

and Veterans, most notably a November 2012 report, Recovering Servicemembers 

38 

and Veterans: Sustained Leadership Attention and Systematic Oversight Needed to 

Resolve Persistent Problems Affecting Care and Benefits. In response, DOD and VA 

are enhancing care coordination and case management to improve transitions across 

health care settings, including the development of an Interagency Comprehensive 

Plan for Servicemembers and Veterans requiring complex care coordination as well 

as a Lead Coordinator to align and standardize care coordination processes, roles, 

and responsibilities and to reduce confusion, duplication, and frustration. 

In addition, GAO is currently conducting a study, Engagement on Care Transitions and Medication Management for Post-Traumatic Stress Disorder and Traumatic Brain Injury (GAO code 291282). GAO is interviewing DOD and VA officials, 

as well as staff in the field. Thus far, GAO has conducted interviews at the Washington, DC VA Medical Center, at Fort Hood, Texas, and at Fort Carson, Colorado. 

VA looks forward to their objective, third-party assessment. 

Section 403 would require VA, within 2 years of the date of the enactment of this 

Act, to submit a report on its compliance with VA’s policy to conduct a review of 

each health care provider who transfers to another VA medical facility or leaves VA 

to determine whether there are any concerns, complaints, or allegations of violations 

relating to the medical practice of the health care provider and to take appropriate 

action with respect to any such concern, complaint, or allegation. 

VA does not support section 403 because reporting systems are already in place. 

VA has broad authority to report employed or separated health care professionals 

to state licensing boards when their behavior or clinical practice so substantially 

failed to meet generally accepted standards of clinical practice as to raise reasonable 

concern for the safety of patients. VA medical facility Directors are required to ensure that a review is conducted of the clinical practice of a licensed health care professional who leaves VA employment or when information is received suggesting 

that a current employee’s clinical practice has met the reporting standard. VA has 

established a comprehensive quality assurance program for reporting any licensed 

health care professional to state licensing boards who was fired or resigned following the completion of a disciplinary action relating to such professional’s clinical 

competence, resigned after having had such professional’s clinical privileges restricted or revoked, or resigned after serious concerns about such professional’s clinical competence had been raised but not resolved. When a report is made to a state 

licensing board, a copy of that letter is also forwarded to VA Central Office. VA 

would be happy to provide this information upon request, but we do not believe a 

statutory requirement to submit this information is warranted. 

Section 501 would add a new section 527A to title 38 requiring VA to carry out 

a program of internal audits and self-analysis to improve the furnishing of benefits 

and health care to Veterans and their families. The Secretary would be required to 

establish an office within the Office of the Secretary to carry out these audits. The 

office would conduct periodic risk assessments, develop plans in response to these 

assessments, and conduct internal audits. At least five covered administrations, 

staff organizations, or staff offices would have to be audited each year. Within 90 

days of completing an audit, the Secretary would be required to submit to the Committees on Veterans’ Affairs, the House Committee on Oversight and Government 

Reform, and the Senate Committee on Homeland Security and Governmental Affairs a report on the audit. The first audit would have to be completed within 180 

days of the date of the enactment of this Act. 

VA understands the intent of this section, but is concerned about creating an entirely new structure that would in essence duplicate efforts of other organizations, 

such as the Inspector General or the Office of the Medical Inspector. We are also 

concerned that legislation directing VA to create certain offices or functions could 

produce conflict with the Department-wide restructuring effort underway through 

the MyVA initiative. VA recommends against further consideration of this section 

until VA’s MyVA restructuring plans are more advanced so we can ensure that any 

new offices and functions are properly aligned and do not overlap with the missions 

of other organizations. 

Chairman ISAKSON. Thank you, Dr. Jain. 

I will start the questioning. Would you please explain to me—I 

scanned the testimony quickly, so if I missed it, I apologize—but 

would you please explain to me—and Senator Johnson, you might 

wait 1 second, if you do not mind—would you explain to me what 

your reluctance is in terms of the unintended consequence of 

S. 1117? 

39 

Dr. JAIN. Sir, let me start, and then I will turn to Cathy in a second here. I think the big concern we have—we certainly understand that we need to do a better job in accountability, so no question about that. But, part of our concern is that the bills as they 

are structured would make it harder for us to recruit the type of 

quality people that we need as senior managers in the VA. And, 

I can tell you from being in the VA for a number of years, it is already having a—I hate to say this—a chilling effect on many of our 

senior administrative-type people who would want to become an 

SES, a director, an associate director, or a chief of staff tomorrow. 

They see all of what is going on. It really gives them cause for concern so they really do not want to step up to those roles. 

So, I think we want to find a way where we could retain the best, 

hold people accountable, no question about that, but find a way to 

go forward. 

Chairman ISAKSON. Well, let me pose this question as succinctly 

as I can. Your legal counsel may want to be the person to respond 

to this. But, I cannot for the life of me comprehend a recruiting 

problem if the reasons for dismissal or removal are for a cause that 

is clearly defined. I can recognize if it is a vague term, where somebody might say, well, I do not want to take the risk of losing my 

job because somebody on a whim is going to fire me. 

But, I ran a company, and I know Senator Johnson ran a company, and others have, as well, and accountability is the essence 

of making an organization work in a timely fashion, whether it is 

a rifle platoon in the U.S. Army, a cup manufacturer in Wisconsin, 

or whether it is a real estate brokerage in Georgia. 

And, I cannot understand—what I want to ask Senator Johnson 

to maybe comment on this after the answer from Dr. Jain—if we 

define what ‘‘cause’’ is in terms of the discipline, and it was clearly 

things like insubordination, over-prescription of opioids, not following through on mental health appointments for somebody who 

commits—things that are definitively, obviously breaches of the 

duty and responsibility, would you still have a fear of having accountability provisions in the VA code? 

Dr. JAIN. No, sir, I will not, but let me turn to Cathy. 

Ms. MITRANO. Thank you, sir. I think what you have pointed out 

there is exactly one of our concerns, is that the bill as currently 

structured does not require any type of written notice at all for employees as to the cause for their removal. They can be removed, basically, without any type of notice or an opportunity to respond. 

Sometimes that is very critical to all of our employees, that opportunity to respond. Many times, that is when we identify for the 

first time that maybe there are mitigating factors in the misconduct or maybe even the facts surrounding the misconduct or 

lack of performance were not fully developed. 

So, I do think what you are proposing right now, if worked into 

the requirements of the legislation, would be a very positive factor 

that would, as you put it, make us less reluctant to endorse such 

a procedure. But right now, as currently written, we do not see 

that in there. 

Chairman ISAKSON. Well, and I am not trying to meddle in Senator Johnson’s legislation in the least, and I am going to get you 

to respond in just a second, but it would seem to me like, given the 

40 

problems that we have had at Tomah and a lot of other places, and 

the fact that we have moved 700 people laterally with pay and only 

fired one who was upheld in court, which was a lady who had broken the illegal gratuity law. It was not the reason we fired them. 

And, it is time we had a situation of accountability in the VA 

that worked, and I would hope the VA—you can talk to Secretary 

McDonald and Sloan Gibson—but there ought to be a list of things 

that are clear cause, that could be delineated clearly in an accountability act, that would not be a deterrent to any morally sound person wanting to come to work for the VA, but would be a deterrent 

to somebody who did not want to be held accountable. 

Senator Johnson. 

Senator JOHNSON. Well, thanks, Senator Isakson. 

Let us first acknowledge, I think the vast majority of people 

working in the VA are incredibly dedicated, professional, doing everything they can to honor the promises to the finest among them. 

I think that is just true. 

What my bill is addressing is we have made it a little bit easier 

to terminate bad apples at the SES-level category, but we are seeing in terms of the caregivers themselves, the doctors and nurses, 

we have to hold them accountable also. 

Now, I have been involved in business management for 31 years. 

I do not think there is anything more corrosive to the morale of an 

organization than if bad actors just continue to be able to conduct 

themselves in an inappropriate manner. So, what I have found in 

business is the good employees wanted the bad employees terminated. They wanted people held accountable, so long-term, there is 

nothing more corrosive to an organization than allowing bad actors 

to continue to be employed. That destroys an organization. 

So, all my bill is trying to do is provide accountability, give the 

VA the tools to remove truly those people that are not honoring the 

promises, that are the bad actors that need to be held accountable. 

Thank you, Mr. Chairman. 

Chairman ISAKSON. To that end, my message to the VA is this. 

If I were the VA—so you clearly understand the attitude of this 

Committee—I would be working with the authors of accountability 

bills to try and come up with language that does not cause concern. 

The better the specificity in terms of the discipline, the better the 

concern can be enforced. I think Senator Johnson is on the right 

track there. 

I understand that too vague, undisciplined, amd broad brush approaches could cause a problem. But, we have had too many instances of situations that really should not be tolerated, where if 

there was an ability to have an accountability system with the VA, 

I think it would help the VA, it would help the veterans, and it 

would help all of you. 

Senator JOHNSON. Mr. Chairman, let me say, I am happy to work 

with the VA to structure the bill that maintains high morale and 

high quality health care for our veterans. 

Chairman ISAKSON. Thank you. 

Senator Blumenthal. 

Senator BLUMENTHAL. Thanks, Mr. Chairman. 

41 

Dr. Jain, I take it from your non-response that you would be willing to work with the Committee in devising some language that 

might meet the concerns that you have expressed. 

Dr. JAIN. Yes, Senator. 

Senator BLUMENTHAL. And you are in favor of that goal of 

accountability? 

Dr. JAIN. I think I am in favor of the goal of accountability. I 

think that—— 

Senator BLUMENTHAL. Well, you think you are in favor of it? 

Dr. JAIN. No, no, I am. There is no question about that. I guess 

my only hesitation is we need to just work together to work out the 

language—— 

Senator BLUMENTHAL. Well, we are all in favor of working together—— 

Dr. JAIN. Right. 

Senator BLUMENTHAL [continuing]. But I strongly support 

heightening and intensifying accountability within the VA. This 

need was plainly apparent as a need in the wake of crises just a 

year ago, the revelations about wait times and cooking the books 

and culpability, which in my view still have not been adequately 

addressed in terms of discipline. So, I would recommend that you 

do work with the Committee. 

Doctor, I am actually surprised by your testimony opposing the 

bill that Senator Moran and I have offered relating to toxic exposures. I am surprised, because you say that this work is already 

being done by other agencies, and your written testimony talks 

about duplicate work already being done by the National Institute 

of Environmental Health Sciences, the Agency for Toxic Substances 

and Disease Registry, and other non-government agencies. 

Is that sufficient reason, in your view, to oppose establishing a 

center that would focus on the effects of toxic exposures on veterans and their families and the children and grandchildren who 

come after them? 

Dr. JAIN. Thank you, Senator, for that question. Let me state 

that we are committed to working with the other departments and 

agencies to ensure that the veterans exposed to toxic substances receive the best possible care and benefits. So, to the extent that the 

bill supports the research and those aspects, I think that those are 

certainly consistent with what we are—— 

Senator BLUMENTHAL. I understand your willingness to work 

with other agencies, but why are you abrogating and refusing responsibility to protect veterans? That is your job. 

Dr. JAIN. We are not, Senator. I think what we are saying—— 

Senator BLUMENTHAL. Well, the legislation gives you that responsibility and obligation to take ownership, in effect, for addressing this problem. It is veterans who are affected. There is no agency, none, whose exclusive or even primary responsibility is to address this problem, would you not agree? 

Dr. JAIN. I would agree with that, Senator. I think the difference 

is that the legislation asks that there be a center created. We are 

already—we already have a center. We have the War-Related Injury and Illness Centers that do a lot of research in this area. So, 

part of our position is that creating another center would not necessarily add anything to that. That is, I think, part of the concern. 

42 

The other part of the concern is that in the legislation, as proposed, there is discussion about clinical care to be provided, and we 

do not have the evidence at the present time. If you look at the literature, the evidence—— 

Senator BLUMENTHAL. Well, it is really a catch–22. If you do not 

do the research—— 

Dr. JAIN. I understand. 

Senator BLUMENTHAL [continuing]. You will not have the evidence. If you do not have an agency responsible for doing the research, it will not be done, because the National Institute of Environmental Health Science and the Agency for Toxic Substance and 

Disease Registry, with all due respect to them—they may be doing 

great work—have a lot of other issues they want to address. This 

one has been ignored and neglected and disregarded which is the 

reason that we do not have the evidence to support the clinical 

treatment. Do you disagree? 

Dr. JAIN. No, I do not disagree with that, sir. I think the only 

issue is, you know, do we let—I think if there is a way to get there 

where we can collaborate with these agencies, we have a process 

either through legislation or through other processes that we can 

be more focused on doing that kind of work, I think is the key. 

Now, whether creating a center and a board gets us there, or perhaps there is another mechanism, I think that may make some 

difference. 

Senator BLUMENTHAL. My time has expired, but the word ‘‘collaboration’’ bothers me when it comes to a problem this urgent that 

has been neglected and I think there ought to be a center that can 

be held accountable. 

Thank you, Mr. Chairman. 

Chairman ISAKSON. Senator Rounds. 

HON. MIKE ROUNDS, U.S. SENATOR FROM SOUTH DAKOTA 

Senator ROUNDS. Thank you, Mr. Chairman. 

Dr. Jain, I am just curious. You mentioned your multi-pronged 

approach to opiate safety. We have not really gone into that, so I 

would like to have you explain a little bit about where that is. It 

would appear that we have got folks that have come here in support of changing what is going on because, clearly, there is a need. 

I would love to have you just take a few minutes to explain to us 

just what you mean by your existing multi-pronged approach. 

Dr. JAIN. Thank you, Senator, for that question. So, for example, 

we in the VA now have published VA/DOD guidelines for management of pain. We also have a system where there is a facility pain 

management team, and there is also a network or a VISN lead for 

pain management. 

A lot of Senator Baldwin’s bill about the board, about having a 

joint work group with the Department of Defense, those are activities that are presently going on. What we like about Senator Baldwin’s bill is that it further enhances what is currently ongoing in 

the VA and makes it more focused, more concentrated. So, I think 

there are lots of parts of the bill that we already have in place. 

Senator ROUNDS. What went wrong with the existing program 

that requires and has clearly caused the loss of life and clearly has 

43 

become an item which this Committee finds itself very concerned 

about? What went wrong with your existing program? 

Dr. JAIN. So, as we look at the existing programs, we do believe 

there needs to be a stronger monitoring of the prescriptions by our 

providers. We also feel that the participation with the State Prescription Monitoring Program can be strengthened. We have some 

of that now. But, I think in the bill, there is a stronger provision 

for doing that, including getting the information back to the VA on 

an ongoing basis, which is a positive part of the bill. 

So, I think we see pieces of what we have, but clearly, the unfortunate incident in Tomah and other experiences are really showing 

us that we need to do a lot more. We are willing to do more and 

we need to do more. We recognize that and we are going to move 

forward. Certainly, the legislation could help us in that direction, 

but we are certainly taking the steps to go forward with that. 

Senator ROUNDS. Even if you discover using the new tools available within the bill, even if you discover the individuals responsible 

for the over-prescribing, systems in which they are failing now to 

catch it, what do you do about it? What is your tool? How do you 

fix it once you have found it? And, you will find it. What do you 

do then? 

Dr. JAIN. Well, we normally have at least two different processes. 

One would be our standard process of peer review in which we 

would then have the peer review done, and if the provider is discovered to be over-prescribing the narcotics, then you have the 

tools available. 

When I was chief of staff in Pittsburgh or when I was in Salem, 

I would work with the clinicians then—I mean, there are a lot of 

options. You can start with education. You can take disciplinary actions. You can do other types of—if you have evidence that is, indeed, based on the peer review, that the practice is not consistent 

with the community standard, then we do have tools available to 

work with them. 

Senator ROUNDS. Let me ask, about how many peer reviews for 

this type of activity do you believe have been accomplished over the 

last, whatever number you want to use, 1 year, 2 years, 3 years? 

How many peer reviews have actually been done? 

Dr. JAIN. I do not have access to that, Senator—— 

Senator ROUNDS. Could you get that for me? Is it available? 

Dr. JAIN. We can certainly try to see if we can get that data. 

[The information requested during the hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. MIKE ROUNDS TO

DR. RAJIV JAIN, U.S. DEPARTMENT OF VETERANS AFFAIRS

Response. Twenty-five peer reviews for quality management were conducted in 

April 2015 for a single VHA facility related to opioid prescribing. The peer review 

for the quality management process is a quality assurance activity. As such, there 

would not have been any disciplinary actions issued in conjunction with the peer 

review. 

Senator ROUNDS. I would like to see that, because what we are 

hearing here is that if you are doing peer reviews, the next question is if you find the problems, what do you do to fix them, and 

you have suggested that you have the disciplinary capabilities 

today. Could you also get me or get the Committee the actual disVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00047 Fmt 6633 Sfmt 6601 Z:\ACTIVE\062415.TXT PAULIN
44 

ciplinary actions that have occurred so far, whether it be in a 1- 

year period, 2-year period, or 3-year period of time? 

Dr. JAIN. Senator, yes, sir, we will. 

Senator ROUNDS. OK. You do not have that available today, by 

any chance? 

Dr. JAIN. No, sir, I do not. 

[The information requested during the hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. MIKE ROUNDS TO

DR. RAJIV JAIN, U.S. DEPARTMENT OF VETERANS AFFAIRS

Response. No disciplinary actions were initiated as a result of these reviews. Peer 

Review for Quality Management is a 5705 protected (quality assurance) process, and 

as such, administrative actions are not applicable. For additional information please 

see VHA Directive 2010–025—Peer Review for Quality Management. Administrative 

actions, such as, summary suspension of privileges, could be initiated based on clinical findings from the Ongoing Professional Practice Evaluation and Focused Professional Practice Evaluation process, or if there were executive concerns that warranted initiation of management reviews. The findings from a management review 

would determine if formal disciplinary action was warranted. 

Senator ROUNDS. OK. It would appear to me that what Senator 

Johnson has proposed here has been designed to be able to make 

it more—it would provide the Department with more capabilities to 

actually take care of the problems that clearly exist. And I would 

most certainly second what the Chairman has suggested, which is 

that you find a way to come forward with a plan that clearly will 

take care of those individuals who have not been following the existing guidelines already in place with regard to opiate distributions that are clearly occurring right now. 

Dr. JAIN. Yes, sir. 

Senator ROUNDS. Thank you. Thank you, Mr. Chairman. 

Chairman ISAKSON. Thank you, Senator Rounds. 

We will go in the following order: Senators Manchin, Cassidy, 

Sullivan, and Boozman. 

Senator Manchin. 

HON. JOE MANCHIN, U.S. SENATOR FROM WEST VIRGINIA 

Senator MANCHIN. Thank you, Mr. Chairman. I was just talking 

to the sponsor here and seeing if she had anything that she wanted 

me to follow up on. 

Chairman ISAKSON. You will be a good surrogate, I am sure. 

[Laughter.] 

Senator MANCHIN. First of all, Doctor, I have been very much 

concerned about this. While I think in every part of the country we 

are concerned, West Virginia has been hit very hard by opiates, as 

you know—— 

Dr. JAIN. Yes, sir. 

Senator MANCHIN [continuing]. Number 1 killer in my State, prescription drugs. So, I started getting very interested in finding out 

why we have such a high unemployment rate with our veterans. 

Once I looked into it further, I discovered they could not pass drug 

tests. That was the biggest problem that we had. So, where are 

they getting it, why were they getting it, and how come so much 

has been prescribed? Why were alternatives not being used? 

I talked to Secretary McDonald and I believe that if VA, Medicaid, and Medicare, the three providers where we have some input 

45 

as Congress and we pay for as taxpayers, basically did not go to 

prescribing opiates first, but as a last resort versus prescribing opiates on the front end, it would make such a difference. And, the 

Secretary has told me that he is committed to trying, basically, the 

alternatives. 

In my State, I do not have alternatives. They do not even offer 

an alternative to opiates. Are you trying it, where you have said, 

absolutely—or could you, or do you need us to have legislation to 

move you in that direction? So, I am understanding it could be anywhere from acupuncture to equine to all these different things. Secretary McDonald seemed to be very receptive, but no one is practicing them. They are still going to the easiest front line defense, 

which is prescribing opiates. 

Dr. JAIN. Thank you, Senator, for that question. So, let me try 

to respond to that. I think your point is very well taken. There are 

some alternatives to opiates in management of chronic pain, and 

you mentioned some of them—acupuncture, chiropractors, massage 

therapy, and other types of relaxation therapies. 

I think part of the challenge as a large system that we are trying 

to balance is that you have to balance the regulatory meaning, licensing, and other types of authorities to hire the chiropractors— 

chiropractors are not an issue. You can hire them now. The issue 

with acupuncturists, for example, we just recently passed some regulation to be able to look at the qualification standards, so we will 

very soon be able to hire acupuncturists. 

So, I think we are just going one step at a time to offer these 

options—— 

Senator MANCHIN. Well, I am not saying that the VA has to. 

Dr. JAIN. Right. 

Senator MANCHIN. If the person, basically, is prescribed this type 

of service—— 

Dr. JAIN. Right. 

Senator MANCHIN [continuing]. Which is what the VA is going to 

pay for, you are paying for the pills. Why not pay for the service 

that would be needed that would not get them addicted? 

Dr. JAIN. I think as a general rule, Senator, I mean, that is a 

good question and I can ask our legal folks to comment on that. 

You have to look at the standard of care, and if there is evidence 

for it and it is within the standard of care, then the VA, as a general rule, can pay for it, but do you want to comment on that, 

Jennifer? 

Ms. GRAY. I think the—— 

Senator MANCHIN. Let me ask you, from a legal standpoint, do 

you all have guidelines for alternative services right now? Is there 

anything that you have developed within the VA? 

Ms. GRAY. We have—do we not have the new committee that is 

working on—— 

Senator MANCHIN. But you have no—I do not think there is 

any—— 

Dr. JAIN. I do not think there is anything specific, Senator. 

Senator MANCHIN. You do not have alternative guideline 

treatments? 

Ms. GRAY. Not—— 

Dr. JAIN. No, sir. 

46 

Ms. GRAY. No, not specific—— 

Dr. JAIN. Not at the present time. 

Senator MANCHIN. Are you developing them? 

Dr. JAIN. Yes, sir, we are. 

Senator MANCHIN. So, you are looking at different options. 

Dr. JAIN. We are looking at the evidence maps for these alternate 

services. I think, as you indicated, the Secretary is very concerned 

about this issue. I know that a lot of the leadership is very concerned about this issue. So, I think we are now in the process of 

developing the evidence maps. That is just the first step, and then 

once the evidence map is together—— 

Senator MANCHIN. Let me ask one follow-up question, if I may, 

because my time is so—sorry, time is precious here. If this was 

1960 or 1970, what would you have—the opioids were not there. 

What would you be doing then? 

Dr. JAIN. I think you—well, the—you had—I do not know. I was 

not practicing back then—— 

Senator MANCHIN. I know, but I am just saying, we did not have 

all these concoctions. 

Dr. JAIN. Right. 

Senator MANCHIN. So, I am saying, all of a sudden now, because 

the pharmaceuticals are making—— 

Dr. JAIN. Yes. 

Senator MANCHIN [continuing]. So many products on the market, 

and FDA seems to be approving everything they bring to the market. We have got to look at how did we become the most addicted 

nation on earth. 

Dr. JAIN. I could not agree with you more, Senator. It is a very 

important issue to us and we are working on it. 

Senator MANCHIN. But, from what we are saying as Senators 

here, elected officials—— 

Dr. JAIN. Yes. 

Senator MANCHIN [continuing]. We have the ability through the 

VA, Medicaid, and Medicare to do something, and if we can set the 

culture going in a different direction—— 

Dr. JAIN. Yes, sir. 

Senator MANCHIN [continuing]. Maybe we can set the country 

going in a different direction. 

Dr. JAIN. Yes, sir. 

Senator MANCHIN. But, if—you are not pushing back on that. If 

we continue to push you on alternative treatments and do different 

things that allow you to offer alternatives and help us develop 

some plans and regulations—— 

Dr. JAIN. Yes, sir. I think we can work together on that. We can 

also work with DOD on it, and we do. We already have a lot of 

joint work with them. 

Senator MANCHIN. I am so sorry, my time is up, but thank you. 

Chairman ISAKSON. Thank you, Senator Manchin. 

Well, next, in order, will be Senators Cassidy, Murray, and 

Sullivan. 

HON. BILL CASSIDY, U.S. SENATOR FROM LOUISIANNA 

Senator CASSIDY. I will just make a point, Senator Manchin. I 

read an article, if I can find it, that oral opioids are not indicated 

47 

for chronic nonmalignant pain. So, if we are speaking of a standard 

of care, the standard of care is not to give oral opioids for non-cancer chronic pain. I say that as a physician. 

Let me also weigh in on the Johnson bill. As a doctor, I agree 

totally. If I have a bad actor as a colleague physician, I would like 

that bad actor to be relieved of responsibility because it reflects 

poorly upon the care that is delivered at the institution. So, I would 

agree with Senator Isakson’s point that we could have an accountability, a fair, due process—— 

Dr. JAIN. Yes. 

Senator CASSIDY [continuing]. But people who are abusing their 

medical license should be released from the practice of which I am 

entertaining. 

OK. Now to my real point. Dr. Jain, I assume that VA uses medical devices. 

Dr. JAIN. Yes, sir. 

Senator CASSIDY. And, I assume they use things like porcine or 

pig heart valves, correct? 

Dr. JAIN. Yes, sir. 

Senator CASSIDY. Non-human-based tissue, correct? The tracking 

system, and I assume that you will be compliant with the FDA’s 

directive to have the tracking systems in place, the unique device 

identification rule, correct? You will be in compliance? 

Dr. JAIN. Uh—— 

Senator CASSIDY. You plan to be in compliance with that. 

Dr. JAIN. There is some new guidance that has just come out, 

Senator, that talking with our SMEs, we are now trying to put 

some systems in place to make sure that we are in compliance. So, 

this is an evolving field, the standards are evolving and changing 

and we are certainly trying to stay on top of that. 

Senator CASSIDY. Now, according to the piece of literature I have 

from the American Association of Tissue Banks, after September 

24, 2015, all labels and packages of devices produced (i.e. biological 

devices), must bear a unique device identifier. 

Dr. JAIN. That is correct. 

Senator CASSIDY. Now, I am told, and I have a letter confirming 

this, that of the three systems approved by the FDA, the VA plans 

to use the one—all these initials, but let me just suffice it to say, 

use the one that is only appropriate to use on human tissue products. And, I have a letter here from Dr. Clancy confirming it. But, 

you have already said that you use pig valves. Specifically, pig 

valves are not humans. It seems kind of self-evident, but I will 

make that point. [Laughter.] 

So, if you are going to use a system which only tracks human tissue, how do you plan to comply with the FDA rule to have a unique 

device identification if you are using non-human tissue? That is my 

question, I suppose. 

Dr. JAIN. Senator, I do not have that answer, but I will certainly 

look into that and will provide that answer for you. 

Senator CASSIDY. Now, there is no answer. You are either going 

to get a waiver—— 

Dr. JAIN. Yes. 

Senator CASSIDY [continuing]. Or you are going to be out of compliance. I mean—— 

48 

Dr. JAIN. Right. Right. 

Senator CASSIDY [continuing]. We do not need you to research—— 

Dr. JAIN. Right. 

Senator CASSIDY [continuing]. With a porcine valve, and you cannot track a porcine valve. Do you see what I am saying? 

Dr. JAIN. Right. 

Senator CASSIDY. I am not saying this to fuss at you. 

Dr. JAIN. Right. 

Senator CASSIDY. I am just saying this is logical. 

Now, our legislation—I see that you do not have a cleared response on it—our legislation would allow the VA to use a tracking 

system that could track non-human tissue. And since you have 

used, I have learned, non-human tissue devices, why would the VA 

not want to track that and be in compliance with the FDA rule? 

And, this does not have to be cleared testimony. It is just kind of 

an obvious—it begs to be asked. Why would you not want to be in 

compliance, and, therefore, why would you not use another system 

that allowed you to track such tissue? 

Dr. JAIN. I think the way you are asking the question, we would 

want to be in compliance, but I cannot answer that today, but I 

will certainly look into that and get the answer for you. 

[The information requested during the hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. BILL CASSIDY TO DR. 

RAJIV JAIN, U.S. DEPARTMENT OF VETERANS AFFAIRS

Response. VA’s tracking system will use all forms of approved Unique Device 

Identifications (UDI) as appropriate to track both human and non-human derived 

biologics. The International Society of Blood Transfusion (ISBT–128) is preferred for 

human derived tissues as they require a higher standard for tracking as discussed 

in IUSH response to the Senator’s letter from April 9th 2015 requesting the VA rationale for ‘‘* * * why VA is contemplating the use of ISBT–128 for some biological 

implants and not allowing the use of all the three issuing agencies for the labeling 

of biological products.’’ 

Non-human products will be required to use the other forms of UDI from the approved issuing agencies, GS1 (global barcoding and numbering organization) and 

Health Industry Business Communications Council (HIBBC) as ISBT–128 is only 

for human tissues. 

This approach is entirely consistent with current FDA regulations and publically 

agreed at the recent 46th Meeting of the Advisory Committee on Blood & Tissue 

Safety & Availability (April 7 & 8, 2015). Moreover, this Committee, a workgroup 

of clinical, industry, public health professionals and patient advocates (including 

FDA, CDC, DHHS) unanimously voted to recommend that the DHHS Secretary take 

action in a stepwise risk-based approach to: ‘‘Establish use of ISBT 128 code in electronically readable format as a universal standard for mandatory implementation 

of unique donation identifiers for all human tissue products.’’ 

While it is was expressed that the intent of H.R. 1016 is to allow the VA to use 

a system to track both human and non-human biologics, Section 2 requires VA to 

permit a vendor to use any of accredited entities identified by FDA in adopting or 

implementing a standard identification. As written, this would require VA to use 

identifiers which while adequate for tracking animal tissues, are inadequate for 

tracking human tissues at our facility level. Section 2 would compel VA to be out 

of compliance with FDA and international guidelines and treat human tissue in the 

same fashion as animal tissue. This is the very system of vendor controlled tracking 

and reporting databases, which, has been shown to be both slow and inadequate for 

tracking human biologics. Section two should permit VA to require the use of any 

of the accredited entities identified by FDA to promote the optimal care and business practices for US veterans, not compel the VA to accommodate products which 

hinder it efforts. 

49 

Senator CASSIDY. OK. Well, my point, Mr. Chairman, is that we 

have a letter from Dr. Clancy, and as I gather, they are not going 

to use the system which will allow—to be in compliance with an 

FDA rule to track non-human tissue. Anyone in this room with an 

artificial heart valve, there is a good chance it is from a pig. So, 

we are not going to be tracking that which is commonly used. So, 

our legislation would allow the VA—in fact, direct the VA—to use 

that system which would allow them to track these devices that 

currently (under the system they indicate they are going to use), 

they will be unable to track. 

With that said, I yield back. 

Chairman ISAKSON. That is why we have hearings, to get input 

and differences and then try and find a way to work them out. 

And, I appreciate your attention and respect the fact that you are 

the only physician on the Veterans’ Committee, so you know from 

whence you come. Thank you. 

For the benefit of everyone here, we are going to have five votes 

at four o’clock. Senator Murray is next, followed by Senator Sullivan for questions. I am going to recognize both of them and hope 

they will be succinct. Then we will take the VSOs’ testimony as far 

as we can take it, until about 10 minutes after 4 o’clock, when I 

am going to go vote. That may change if votes get put off, but I 

just want to give you all that fair warning. 

So, Senator Murray. 

Senator MURRAY. Mr. Chairman, thank you very much. I will try 

to be succinct. 

Dr. Jain, I want to thank the VA for its support of my bill to improve fertility services at the VA. In your testimony to us, you described some of the serious consequences for veterans when, as a 

result of their injuries from their service, they cannot have children. And, I have certainly heard from veterans how difficult it can 

be to deal with this new reality. It can destroy relationships. It can 

be very stressful. And, it can create an incredible financial burden 

for our veterans. 

Can you describe some of the other health effects veterans face 

when they cannot realize their dream of starting a family? 

Dr. JAIN. Well, Senator, thank you for that question. In talking 

with our program lead in women’s health, they have talked about 

depression clearly is one of those that they see. It is also about the 

overall quality-of-life, and I think it goes to, you know, how one 

feels as a human being, and having a biological family is clearly 

a part of the equation that makes a person feel whole. So, I do 

think that there are lots of other types of softer mental health type 

of issues, but there is clearly an issue in the overall sense of wellbeing. 

Senator MURRAY. Well, thank you for that answer; and Mr. 

Chairman, again, thank you for your commitment to working with 

me to get that done. 

I also want to ask about my caregivers bill. In an earlier study 

by VA, the Department found that for veterans in the caregiver 

program, their inpatient hospital admissions decreased by 30 percent, and VA found that when a veteran was hospitalized, their 

length of stay decreased by 21⁄2 days. How important is it to vetVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00053 Fmt 6633 Sfmt 6601 Z:\ACTIVE\062415.TXT PAULIN
50 

erans’ health and quality-of-life to spend less time in the hospital 

and more time at home? 

Dr. JAIN. I think it is hugely important, Senator. Thank you for 

that question. We are encouraged by that preliminary report. So, 

based on that, what we have done a few months ago, 4 or 5 months 

ago, we began a more formal evaluation of the caregivers program, 

which would be ready by about this time next year. It looks at multiple aspects, not only the aspect on the veterans themselves, some 

of the issues relating to length of stay, but also looks at the caregivers. What impact is it having on their health and well-being as 

they are serving as the caregivers for our veterans. So, it will be 

a very comprehensive evaluation, and when it is ready, I will be 

very happy to share that with the Committee. 

Senator MURRAY. OK, very good. GAO has raised some important 

concerns about the caregivers program. I really believe that the VA 

can address those concerns and strengthen the program while also 

finally opening up the program to veterans of all eras. 

Mr. Chairman, to help the VA meet that goal, I did include in 

the veterans appropriations bill an additional $10 million for VA to 

hire more caregiver support coordinators. So, I do look forward to 

working with you on that. 

Dr. Jain, I did want to ask you, as you may be aware, DAV, citing a VA report, found the caregivers program to be one of the 

most cost-effective ways to provide care for this group of veterans. 

For example, the average cost per veteran to participate in the 

caregiver program was $36,800, significantly less than the average 

$332,800 per veteran in a VA nursing home. Overall, can you tell 

us how much VA estimates it saves when it can provide care 

through a caregivers program rather than through other types of 

care? 

Dr. JAIN. Thank you, Senator, for that question. I do not have 

those numbers for you today, but we could certainly try to find that 

and respond back. I think it is a very important issue you are raising and we certainly agree with DAV’s evaluation. I think when 

you talk to our clinicians, they are very impressed by the results 

of the caregivers program, which is why in our report a few months 

ago we talked about, conceptually, being all for expanding the program. The challenge always has been how do you find the resources to match that. 

[The information requested during the hearing follows:] 

RESPONSE TO REQUEST ARISING DURING THE HEARING BY HON. PATTY MURRAY TO

DR. RAJIV JAIN, U.S. DEPARTMENT OF VETERANS AFFAIRS

Response. VA does believe over the long term, health care savings can result from 

participation in the caregiver program. Those savings would only be realized over 

the long term and cannot be projected with any specificity. There can be in some 

instances sooner and more quantifiable savings from individuals who otherwise 

would likely be placed in nursing home care. However, only a small fraction of Veterans in the caregiver program are in that circumstance, given the variety of types 

and severity of injuries and conditions for Veterans in that program. 

Senator MURRAY. From my position, whether it is IVF care or 

whether it is caregivers program, when someone serves us in this 

country overseas and is injured as a result, our country should step 

up. So, I hope we can move forward with both of these bills. 

Thank you, Mr. Chairman. 

51 

Chairman ISAKSON. Thank you, Senator Murray. 

Senator Sullivan. 

HON. DAN SULLIVAN, U.S. SENATOR FROM ALASKA 

Senator SULLIVAN. Thank you, Mr. Chairman, and thank you, 

Ranking Member Blumenthal. 

I know we are looking at several bills here, but I have a developing crisis in my State, Dr. Jain, that I would like to talk about. 

I think all the Members of this Committee care deeply about our 

veterans. I certainly do, as a veteran myself, coming from a State 

with the largest per capita number of veterans in the country, and 

I have certainly viewed my role on this Committee as wanting to 

work with the VA, wanting to work with you, the leadership, the 

Secretary. That has been the constructive approach to trying to 

solve our numerous problems. But, I must admit, after what has 

been going on in my State the last few months, I am starting to 

lose patience. 

As you know, Dr. Jain, the Choice Act in many ways removed 

some of the positive aspects of what we were actually doing in 

Alaska with regard to VA health care. Many of the challenges that 

we have, many are unique, given our distances, given the number 

of veterans we have, the partnerships that we have developed. We 

had a system that was not perfect by any means, but in many ways 

it was working. Now, we have, I think, without exaggeration, a 

five-alarm fire going on in my State with our veterans because of 

the way the Choice Act is being implemented. 

Mr. Chairman, for the record, I have a couple of things. An AP 

story, ‘‘Federal VA Health Care Program Jeopardizes Alaska’s System.’’ I would like to submit all of these for the record, with your 

permission. 

Chairman ISAKSON. Without objection. 

Senator SULLIVAN. A local TV report in Alaska last week, ‘‘Veterans’ Federal Health Program Under Fire Due to Health Care 

Delays.’’ Senator Murkowski, the senior Senator from Alaska, several pages to Secretary McDonald, Congressman Young, Governor 

Bill Walker, the Governor of Alaska, all within the last 2 weeks: 

urgent, urgent problems in Alaska. 

[The submissions by Senator Sullivan follow:] 

52 

LETTER FROM HON. LISA MURKOWSKI, U.S. SENATOR FROM ALASKA, TO HON. ROBERT

MCDONALD, SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS


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LETTER FROM GOV. BILL WALKER, STATE OF ALASKA, TO HON. ROBERT MCDONALD, 

SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS


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LETTER FROM REP. DON YOUNG, CONGRESSMAN FOR ALL ALASKA, TO HON. ROBERT

MCDONALD, SECRETARY, U.S. DEPARTMENT OF VETERANS AFFAIRS


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Federal VA health care program jeopardizes Alaska system 

By Becky Bohrer, The Associated Press 9:46 a.m. EDT June 20, 2015 

[The URL to the article follows, in respect of the AP Copyright request.] 

http://www.armytimes.com/story/military/benefits/veterans/2015/06/20/federal-vahealth-care-program-jeopardizes-alaska-system/29029189/ 

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Veterans’ Federal health program under fire 

due to health care delays 

ADAM PINSKER, Reporter, apinsker@ktuu.com / POSTED: 08:18 PM AKDT Jun 22, 2015 

ANCHORAGE, Alaska—A new program designed to streamline access to health 

care for military veterans is coming under fire as veterans say they’ve been stymied 

by Federal health care program. 

Senator Dan Sullivan, of Alaska says Congress will hold hearings on the ‘‘Choice’’ 

program Wednesday, after complaints about delays in delivering health care to Alaska veterans. 

‘‘It’s making sure that veterans have access to care when they need it and where 

they need it,‘‘said the freshman senator. ‘‘The Choice Act, which is supposed to do 

that in Alaska is actually undermining it.’’ 

Congress passed the Choice Act in 2014, in the wake of a scandal that rocked the 

Veterans Administration when 40 veterans died at a Phoenix hospital mainly because of delay in care. 

The Choice Act was intended to make wait times shorter by allowing veterans to 

seek care outside the VA system but since its implementation, some veterans say 

it has done just the opposite. 

‘‘I had the appointment on a Tuesday and I got a call on the Monday before and 

said we’re not canceling your appointment, we’re canceling your authorization for 

payment,’’ said Jeff Foener of Anchorage. 

A 9-year army veteran, Foener had been waiting 6 weeks to have his hand 

checked after complications from surgery. 

‘‘I think the choice program should live up to its name.’’ 

The rest of Alaska’s congressional delegations has also called for reforms to the 

Choice Care Act. 

Senator Sullivan says hearings over the Choice act will also be held in Alaska this 

summer, with VA officials present. 

Copyright c 2015, KTUU-TV 

Senator SULLIVAN. It is a very big crisis, and part of the problem 

that we have seen with this crisis is this issue of the lack of accountability that has been an ongoing matter we have discussed 

today, and we have been talking about for months. We worked— 

my staff, Senator Murkowski’s staff—worked with the local VA in 

Alaska. They helped us identify these problems with regard to the 

implementation of the Choice Act. They knew it was a problem. 

And then when we raised it to senior staff in Washington, you 

know what they said? This is not our fault, it is Congress’ fault because they implemented the Choice Act. As recently as last week, 

we were hearing from officials here that there is no problem in 

Alaska. Well, let me guarantee you, there is a problem in Alaska, 

a big problem. 

I talked to Dr. Shulkin last night. I was going to put a hold on 

his nomination because of this. He was confirmed, as you know, 

last night. He is going to be your new boss. So, I got a commitment 

from him to come to Alaska as part of field hearings, because this 

is an issue that is way bigger than this hearing. 

62 

So, Mr. Chairman, Senator Blumenthal, I appreciate the opportunity to have field hearings in the State from the Committee. I 

certainly would want to invite any Members of the Committee to 

come to Alaska to learn about our unique challenges and this 

problem. 

But, Dr. Jain, I know that in many ways, you are not responsible 

for this, but here is what I need from you: a commitment. Dr. 

Shulkin committed to me he would come to Alaska as part of these 

hearings to help address these issues. These hearings will be in 

August. I want a commitment from you, as someone who understands the bureaucracy—he is brand new—to help make sure when 

you get to Alaska, it is not just to hear what the issues are. We 

know what the issues are. To have solutions ready, solutions to 

what is clearly a crisis in a State that in many ways was the model 

for the Choice Act. Now, implementing the Choice Act, we are undermining the whole system in Alaska. 

It is Phoenix all over again. People are having their appointments canceled at the last minute, showing up for surgery. The VA 

in Washington has to take responsibility. You cannot blame this on 

the Congress. 

So, can I get your commitment to help Dr. Shulkin come to my 

State with answers, with solutions when he comes up in August? 

Dr. JAIN. Yes, sir, Senator. Thank you for that question, and I 

completely agree with you. I know that Dr. Tuchschmidt and Dr. 

Lynch recently visited your State and saw firsthand how the health 

care is structured, working with Department of Defense, joint ventures, and also with the Alaska Native Health Care model, and—— 

Senator SULLIVAN. And these models are very innovative. 

Dr. JAIN. They are very innovative—— 

Senator SULLIVAN. And now they are not working. 

Dr. JAIN. Well, no, I understand, and I think that is what they 

have come back with—what I understand from them is that they 

are now committed to supporting those models, because they are 

what is working. We cannot have veterans going 500 miles or 400 

miles. So, what I heard from them is that they are committed to 

supporting that, and I would certainly take the word back in terms 

of Dr. Shulkin’s support at the field hearing that you bring up. 

Senator SULLIVAN. Great. Thank you; and Mr. Chairman, I am 

sorry I took so long on this, but it is a huge issue for my State and 

we need to fix it. 

Chairman ISAKSON. Let the record reflect that the Senator from 

Alaska came to me over a month ago about having a field hearing 

in Alaska, which I have approved; and I think it is an important 

field hearing to have. 

I want to also acknowledge the fact that he could have last night, 

had he exercised his authority as a Senator, held up Dr. Shulkin’s 

final approval, but he did not in the spirit of cooperation. I hope 

that VA will, in the same spirit of cooperation, ensure that Dr. 

Shulkin and the appropriate people are in Alaska with solutions 

and not questions when you have the field hearing. 

Dr. JAIN. Yes, sir. 

Chairman ISAKSON. Thank you all for your testimony. 

63 

[Responses to posthearing questions to VA follow:] 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. DEAN HELLER TO DR. 

RAJIV JAIN, ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH FOR PATIENT

CARE SERVICES, VETERANS HEALTH ADMINISTRATION (VHA), U.S. DEPARTMENT OF

VETERANS AFFAIRS (VA) 

Question 1. During the last hearing on June 3rd, my Women Veterans Access to 

Quality Care Act, which I introduced with Senator Murray, was on the agenda. I 

was disappointed that the VA failed to provide views on this important bill. The VA 

not providing these views delays this bill from moving forward through the regular 

process in Committee. Why was the VA unable to provide the views on the Women 

Veterans Access to Quality Care Act in time? 

Response. The Department of Veterans Affairs (VA) understands the importance 

of providing its views on legislation to the Committee. In some cases the number, 

complexity, and subject matters of the combined agenda make it necessary for VA 

to provide its official views for some bills or parts of bills in a follow-up letter. This 

was the case with the Women Veterans Access to Quality Care Act. VA will do everything possible to work with the Committee to ensure views on bills are timely 

to the fullest extent possible. 

Question 2. On what date will the views for S. 471 be provided to the Committee 

and to my office? 

Response. VA provided those views to the Committee by letter dated July 15, 

2015, a copy of which is appended to these responses. 

RESPONSE TO POSTHEARING QUESTIONS SUBMITTED BY HON. SHERROD BROWN TO

DR. RAJIV JAIN, ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH FOR PATIENT

CARE SERVICES, VETERANS HEALTH ADMINISTRATION (VHA), U.S. DEPARTMENT OF

VETERANS AFFAIRS (VA) 

RE: S. 469, WOMEN VETERANS AND FAMILIES HEALTH SERVICES ACT OF 2015

Question 3. Dr. Jain, you mentioned the VA’s support for Section 207 of the proposed Women Veterans and Families Health Services Act which would require VA 

to enhance the capabilities of the Women Veterans Call Center. In July 2012, I 

wrote to the VA about the women’s hot line number, which was then a 202 area 

code number and not toll free. In May 2013, the VA launched the 1–855-VAWOMEN toll free line, which I applaud. 

Do you know if the capabilities of the Women Veterans Call Center were enhanced as proposed with real time text messaging, would that service be provided 

at the expense of the veteran or the VA? 

Response. VA supports section 207 to improve the Women Veterans Call Center 

(WVCC). This legislation does not require real time messaging capabilities. While 

VA believes such capabilities would be beneficial, they would require additional IT 

capabilities and resources. Decisions on whether to move forward will depend on 

available resources and other IT priorities. 

Section 207 can be fulfilled through additional training and other improvements 

that would not require additional real time text messaging or other IT investment. 

We also note that as part of the MyVA initiative the Department is planning to 

consolidate its numerous toll-free numbers to improve customer service to Veterans. 

Chairman ISAKSON. We will change panels real quick. Our VSOs, 

if they will come forward. [Pause.] 

So that you are all prepared, what I am going to ask you to do— 

we have votes starting at four o’clock. I think that is still the case. 

We do not have time to hear everybody’s testimony if everybody 

took 5 minutes. So, I want you to make your best shot at 3 minutes 

or less so you can say what you need to say as quickly as possible. 

If you cannot do it within 3 minutes, there might not be any of us 

here to listen, so I want to encourage you to do that. 

We have Ian de Planque from The American Legion; Peter 

Hegseth from the Concerned Veterans of America and Fox News, 

which I see him on Fox News all the time; Adrian Atizado, Assistant National Legislative Director, Disabled American Veterans; 

64 

Carl Blake, Associate Executive Director, Paralyzed Veterans of 

America; Max Stier, President and CEO of the Partnership for 

Public Service; and John Rowan, the National President, Vietnam 

Veterans of America. 

We will start with Ian. Ian. 

STATEMENT OF IAN DE PLANQUE, LEGISLATIVE DIRECTOR, 

THE AMERICAN LEGION 

Mr. DE PLANQUE. Thank you, Mr. Chairman, Ranking Member 

Blumenthal—— 

Chairman ISAKSON. Three minutes, Ian. [Laughter.] 

Mr. DE PLANQUE. I will go through as quickly as I can. 

First of all, I want to thank Senator Baldwin for her press conference this afternoon and for pushing forth this legislation. I was 

happy to be there, and I am happy to see the family is here, as 

well, and can see that this is moving forward. I think that is a 

strong bill and The American Legion is behind it. We would really, 

really like to see some improvement in that area. 

I am going to cut short to one other thing that we wanted to address and that is proper accountability within the VA. Let us be 

clear here; this is also about protecting VA employees. VA employs 

well over 300,000 employees, and more than one-third of those are 

veterans. The vast majority of them are good people who go to 

work every day to help America’s veterans. They do not need to see 

the good name of VA employees dragged through the mud every 

time there is a bad employee who gives the system a bad name. 

This would not happen if VA could and would swiftly take action 

when employees cross the line and hurt veterans with their 

actions. 

Senator Rubio’s bill, like the Veterans Access to Care and Accountability Act of last year, seeks to extend the same level of accountability we sought for executives at all levels. We need a system of accountability that is enforceable and is the same for employees at all levels. VA employees can and should take charge of 

VA and make it the veteran-centric agency that it needs to be. 

To do so, VA needs to be able to clear out employees who would 

manipulate the system and put veterans at disadvantage or for 

their own gain. We should be championing the brave whistleblowers who come forward because they believe VA should serve 

veterans, and they observe practices and operations that are contrary to that mission. It is those brave men and women that we 

should direct our focus to when it comes to VA employees, not the 

men and women who lie, and cheat, and then sit on paid leave for 

months and even years because a toothless system cannot remove 

them from VA payrolls. Those bad employees only stay in the public focus because VA cannot or will not deal with them swiftly. 

When we can turn the tide to quickly remove these few problem 

employees, we can turn our attention more easily to the hundreds 

of thousands of VA employees who work very hard every single day 

in the service of veterans. 

I know we are keeping it short. As always, I thank you for the 

opportunity to present the views of The American Legion and I am 

happy to answer any questions you might have. 

[The prepared statement of Mr. de Planque follows:] 

65 

1 Resolution No. 182: Support Military Quality of Life Standards—AUG 2014 2 Resolution No. 125: Environmental Exposures—AUG 2014. 

PREPARED STATEMENT OF IAN DE PLANQUE, DIRECTOR, NATIONAL LEGISLATIVE

DIVISION, THE AMERICAN LEGION

Chairman Isakson, Ranking Member Blumenthal and distinguished Members of 

the Committee, on behalf of National Commander Michael D. Helm and the over 

2 million members of The American Legion, we thank you and your colleagues for 

the work you do in support of servicemembers, veterans, and their families. 

S. 469: WOMEN VETERANS AND FAMILIES HEALTH SERVICES ACT OF 2015

As a result of more than a decade of war, thousands of male and female servicemembers are returning home with physical and/or psychological wounds of the war 

resulting in a variety of fertility and reproductive health issues. Many young servicemembers have been documented with low testosterone levels that can be attributed to the medications that they are taking for their physical injuries, and conditions such as Traumatic Brain Injury (TBI) or Post Traumatic Stress Disorder 

(PTSD), as well as the poisonous effects of environmental exposures they have faced 

while serving on active duty. 

Currently, the Department of Defense (DOD) and Department of Veterans Affairs 

(VA) offer servicemembers and veterans some form of fertility and reproductive 

treatment and counseling. However, the servicemembers and veterans who choose 

to start a family but struggle with fertility issues as a result of their injuries will, 

in many cases, face paying tens of thousands of dollars out of pocket for treatments 

and services that are not paid for by the DOD or VA. Some fertility treatments can 

be extremely costly. In addition, veterans currently cannot receive many of these 

services from VA. 

The DOD and VA need to create solutions for those who have lost anatomical 

parts required to participate in the physical act, but there seems to be little support 

either through counseling or medical intervention to offer young veterans who have 

lost their ability to procreate due to lack of testosterone. Unfortunately, many veterans with TBI are also on hypertension medications, and adding sexual performance medications may represent a serious health risk. This can also create a loss 

of intimacy in relationships, exacerbating psychological disorders such as PTSD and 

depression. Ultimately, it affects the self-esteem of both veteran and spouse. 

Through Resolution, The American Legion urges Congress to support and fund 

quality of life features including, but not limited to, adequate medical, mental 

health, and morale services.1 Congress should also extend and improve additional 

quality of life benefits to those servicemembers and dependents that have been injured while serving on active duty. 

The American Legion supports this legislation. 

S. 901: TOXIC EXPOSURE RESEARCH ACT OF 2015

The effects of the often dangerous environments in which servicemembers operate 

is a top concern of The American Legion, as thousands of servicemembers and veterans who are and/or have been exposed to various toxins are often ‘‘left behind’’ 

when it comes to vital medical treatments and benefits. The American Legion remains committed to ensuring that all veterans who served in areas of toxic exposure 

receive recognition and treatment for conditions linked to environmental exposures. 

This legislation requires VA to establish a national center for research on the diagnosis and treatment of health conditions of the descendants of veterans that were 

exposed to toxic substances during their military service, as well as an advisory 

board on exposure to toxic substances. 

The American Legion has long been at the forefront of advocacy for veterans who 

have been exposed to environmental hazards such as Agent Orange, Gulf War-related hazards, ionizing radiation, the various chemicals and agents used during 

Project Shipboard Hazard and Defense (SHAD), and contaminated groundwater at 

Camp Lejeune, North Carolina. Through Resolution, The American Legion continues 

to urge the study of all environmental hazards and the long-term effects they have 

on our servicemembers, veterans, and their families. 

The American Legion has also called on the DOD to immediately cease burning 

dangerous chemicals in open burn pits, exposing servicemembers to deadly and debilitating toxins. 

The American Legion believes in treating the veteran first, funding the necessary 

research, and ensuring servicemembers are not exposed to chemical hazards again.2

66 

3 Resolution No. 30: Department of Veterans Affairs Accountability—MAY 2015 4 Resolution No. 160: Veterans Receive the Same Level of Benefits—AUG 2014 5 Resolution No. 30: Department of Veterans Affairs Accountability—MAY 2015 

This legislation addresses the need to better understand the toxins that many veterans have been exposed to, and enhance the understanding of the effect toxic exposures may have on veterans’ descendants. 

The American Legion supports this legislation. 

S. 1082: DEPARTMENT OF VETERANS AFFAIRS ACCOUNTABILITY ACT OF 2015

This bill would provide for the removal or demotion of Department of VA employees based on performance or misconduct. Last year Congress passed and President 

Obama signed into law H.R. 3230; Public Law (PL) 113–146, The Veterans’ Access 

to Care through Choice, Accountability, and Transparency Act of 2014, which provided the Secretary of Veterans Affairs the authority to remove any individual from 

the Senior Executive Service (SES) if the Secretary determines the performance of 

the individual warrants such removal, or transfer the offending individual to a General Schedule position without any increased monetary benefit. 

The American Legion supported H.R. 3230, The Veterans’ Access to Care through 

the Choice, Accountability, and Transparency Act of 2014 due in part to the systematic failures in the VA which included: preventable deaths, delays in providing timely and quality health care, and VA’s failure to adjudicate claims in a timely manner.3 While H.R. 3230 provided the Secretary of Veterans Affairs with authority to 

hold SES officials accountable, The American Legion remains concerned about the 

lack of accountability within VA for non SES employees. S. 1082 would provide the 

Secretary of Veterans Affairs the legal authority to better manage all VA employees, 

and hold them accountable when they fail to perform their duties in a manner that 

is befitting of a Federal employee who veterans have entrust their care to, and it 

establishes consistent standards across all grades of employees within VA. 

The American Legion supports this legislation. 

S. 1085: MILITARY AND VETERANS CAREGIVER SERVICES IMPROVEMENT ACT OF 2015

The struggle to care for veterans who have been wounded in the defense of this 

Nation takes a terrible toll on their families. In recognition of this, Congress passed, 

and President Obama signed into law, the Caregivers and Veterans Omnibus 

Health Services Act of 2010 in May of that year. However, the toll of war does not 

discriminate between periods of service. Veterans of all wars and conflicts suffer no 

less than veterans of the Post-9/11 era. 

The American Legion does not distinguish between periods of service. Simply put, 

a veteran is a veteran is a veteran, and all veterans are entitled to receive the same 

level of benefits.4 This legislation would remove a restriction limiting the benefits 

to veterans and their caregiver ‘‘on or after September 11, 2001’’ as well as adding 

additional enhancements to the Caregiver program. The American Legion urges 

Congress to restore consistency and equitability to veterans’ programs and treat the 

caregivers of all critically wounded veterans the same regardless of when the veteran served. 

The American Legion supports. 

S. 1117: ENSURING VETERAN SAFETY THROUGH ACCOUNTABILITY ACT OF 2015

This bill seeks to improve the ability of the VA to discipline and dismiss physicians for poor performance or bad behaviors. This bill will also expand the expedited 

disciplinary authority that was given to the Secretary of Veterans Affairs under the 

Veterans Choice, Access and Accountability Act of 2014. 

The American Legion supports the intentions of this bill, but rather than an individual, piecemeal approach targeting each class of VA employees, instead favors a 

more complete and streamlined authority affecting ALL employees of the Department of Veterans Affairs such as is proposed in Senator Rubio’s bill S. 1082.5 Accountability is one of the most vital components needed in reforming and improving 

VA’s relationship with the veterans’ community and must be consistently enforced 

across all levels. 

The American Legion does not support this legislation. 

H.R. 91: VETERANS I.D. CARD ACT

This bill would require VA to issue veterans an identification card (ID) for purposes other than obtaining VA benefits, and would require veterans to pay a minimal fee for the ID card. The American Legion does not see how this program would 

67 

6 Resolution No. 43: Veteran Coding on Driver’s Licenses—OCT 2012 7 Resolution No. 311: The American Legion Policy on VA Physicians and Medical Specialists 

Staffing Guidelines—SEP 1998 8 Resolution No. 72: Benefits and Burial Rights for Select Surrogate Forces—AUG 2014 9 Resolution No. 190: Support for Pain Management Research, Treatments and Therapies at 

DOD, VA and NIH—AUG 2015 

support VA’s core missions which includes providing VA benefits to eligible veterans 

and their eligible dependents, medical; education, research, national emergency preparedness, and DOD contingency support. 

The American Legion does support ensuring veteran status is listed on state identification cards and driver’s licenses6 however adding this as an additional mission 

to VA at this time rather than integrating it into the existing mission of state departments of motor vehicles raises additional challenges to an already heavily burdened VA. 

The American Legion does not have a position on this legislation. 

DISCUSSION DRAFT: S. 1021: WOUNDED WARRIOR WORKFORCE ENHANCEMENT ACT

This bill would require the Secretary of the Department of Veterans Affairs to 

award grants to establish, or expand upon, master’s degree programs in orthotics 

and prosthetics, and for other purposes. 

The American Legion believes due to the shortage of physicians in certain specialized areas, such as orthotics and prosthetics, Congress must ensure resources and 

funding are available to support continuing education and training of such physicians.7 Through this continuing education program, VA would benefit from providers of these professions being available to treat VA patients through their continuing education program, and upon completion of the program becoming gainfully 

employed by the VA. 

The American Legion supports this legislation. 

S. 1358: HMONG VETERANS’ SERVICE RECOGNITION ACT

The American Legion is deeply committed to the indigenous people of Vietnam, 

and by resolution has called upon Congress and the administration to work to affect 

real change to assist those peoples in their native homeland. The American Legion 

believes in basic human rights for the Hmong, the Montagnards and all others within that country. 

The issue of burial in national cemeteries is complex, and must balance consideration of American servicemembers, veterans and their families with the needs of 

those who have served maintaining primacy. The American Legion recognizes the 

heroic sacrifices and service of the indigenous people of Vietnam. Through resolution, The American Legion urges Congress to investigate, evaluate, and prescribe 

legislation to provide these special groups who have lawfully obtained United States 

citizenship, burial rites in national cemeteries.8

The American Legion supports this legislation. 

DISCUSSION DRAFT: JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

In the wake of serious concerns about over prescription of medications at the 

Tomah Veterans Affairs Medical Center, the Nation has become more focused on ensuring veterans and servicemembers are treated properly with opioid medications 

and do not unduly suffer due to mixed drug toxicity. The American Legion has been 

concerned about increasing reports of overmedication with pain management even 

before the stories began to circulate out of Tomah. 

This legislation would work to improve pain management policies between the Departments of Defense and Veterans Affairs through establishing better clinical 

guidelines, countering overdoses, encouraging more collaboration between VA and 

DOD, and establishing pain management boards across VA to ensure better compliance. The legislation would also strengthen communication between VA and the veterans’ community, enhance patient advocacy, and improve research and education 

on complementary and alternative care. 

The American Legion firmly believes in increasing Federal funding throughout 

the Department of Defense, Department of Veterans Affairs and the National Institutes of Health for pain management research, treatment and therapies. Furthermore, The American Legion urges these institutions to increase investment in pain 

management clinical research by accelerating clinical trials at military and VA 

treatment facilities, as well as at affiliated university medical centers and research 

programs.9 The increased use of complementary and alternative medicine is directly 

68 

10 Resolution No. 292: Traumatic Brain Injury and Post Traumatic Stress Disorder Programs—AUG 2014 11 Resolution No. 26: Veterans Benefits Centers—MAY 2015 

in line with policies of The American Legion regarding treatment for veterans with 

mental health and brain injuries, and represents a welcome expansion of care in 

these areas.10

The American Legion supports this legislation. 

DISCUSSION DRAFT: BIOLOGICAL IMPLANT TRACKING AND VETERAN SAFETY ACT

At a March 25, 2014, House Committee on Veterans’ Affairs Legislative hearing, 

The American Legion raised concerns about the lack of a robust tracking system in 

the Veterans Health Administration (VHA). The VA Office of the Inspector General 

(OIG) conducted an audit in 2012 and made recommendations regarding VA’s management of their prosthetics supply inventory. In VHA’s response, they indicated 

that they would work to develop a plan to replace the Prosthetic Inventory Package 

(PIP) and the Generic Inventory Package (GIP) with a more comprehensive system. 

The target completion date was March 30, 2015. In the interim, VHA indicated they 

were working on a VA Office of Information and Technology (OI&T) patch (VistA 

Prosthetics patch 101), which was 95 percent completed. 

While reaching this goal by 2015 is indeed laudable, 2015 is rapidly becoming a 

critical year for VA to meet strategic goals including the elimination of veteran 

homelessness and the disability claims backlog. The American Legion would like to 

see a more detailed timeline implementing these changes and improvements for veterans. Reports through System Worth Saving Task Force visits and contact with 

VHA employees indicate responsibility for entering serial numbers of implant devices is manual, not automated, and are inconsistently implemented. 

Although VHA claims to work to a standard of ‘‘removing recalled products from 

inventory within 24 hours of a recall,’’ there is still no clear policy on how veterans 

who have already received implants are being tracked. It is not enough to cutoff the 

problem at the source, attention must be paid to veterans who are already downstream in the process. Without consistent tracking of implants, including positive 

identification by serial number and other identifying factors, uncertainty remains as 

to how veterans are served in the case of recalls. The American Legion noted that 

we would like to see a more comprehensive procedure and policy clearly delineated 

by VA Central Office to ensure consistency in all Veterans Integrated Service Networks (VISNs). 

The analysis of the current inadequacy of the tracking system for bio-implants derives directly from The American Legion’s System Worth Saving Task Force reports.11 The System Worth Saving Task Force was established to examine the state 

of VA Medical Facilities by resolution in 2004. This annual report that is provided 

to the Administration, Congress, VA leadership, and the veterans’ community is a 

vital resource as the primary third party analysis of the quality of VA healthcare 

throughout the country. The work of the System Worth Saving Task Force has now 

combined with the Regional Office Action Review visits to create Veterans Benefits 

Centers to continue this work, and in more detail that addresses concerns not solely 

with the healthcare system, but also with the disability claims system and indeed 

any manner in which veterans interact with VA. 

The American Legion supports this legislation. 

CONCLUSION

As always, The American Legion thanks this Committee for the opportunity to explain our position on these bills. Questions concerning this testimony may be directed to Warren Goldstein in The American Legion Legislative Division (202) 861– 

2700, or wgoldstein@legion.org. 

Chairman ISAKSON. Thank you, Ian. 

Peter. 

STATEMENT OF PETER B. HEGSETH, CHIEF EXECUTIVE 

OFFICER, CONCERNED VETERANS FOR AMERICA 

Mr. HEGSETH. Mr. Chairman, Ranking Member Blumenthal, 

thank you very much for the time. I will do my best micro-machine 

impression here. 

69 

I will focus the balance of my time on one bill, the VA Accountability Act, S. 1082, Sen. Marco Rubio’s bill, that would simply empower the VA Secretary to efficiently and fairly remove underperforming VA employees. I would also note that there is a bipartisan 

companion bill in the House. 

We believe S. 1082 is critical to overhauling a dysfunctional and 

bureaucratic culture that has infected VA at all levels. We certainly 

recognize that VA has a lot of great employees, many of which are 

veterans themselves. But, the fact of the matter is, for a long time, 

mediocrity and failure has been rewarded at VA, and it, in many 

ways goes back to Congress, as well. 

What happens when VA fails to properly manage its massive and 

growing budget? It just gets rewarded with more money, another 

$3 billion here, another $3 billion there into the same bureaucracy 

and nothing changes, which is despite the best of intentions. I 

think more money gets thrown at VA in the hopes that it would 

fix itself. The VA’s budget has doubled in the last 7 years, as you 

noted, Mr. Chairman, yet according to the New York Times, wait 

times have increased in the last year, significantly. More money 

should not equal longer wait times, and this is a clear image of 

what rewarding failure looks like. Ultimately, veterans pay the 

price for a lack of accountability. 

There was a field hearing in Philadelphia with whistleblowers 

where it was acknowledged that morale is worse than it has ever 

been, and this should be a surprise to nobody. Who would want to 

work at a place where mediocrity is continually rewarded, a place 

where if you speak up about dysfunction and waste, instead of getting rewarded, you get a target on your back? That is a real morale 

crusher. And, because there is no accountability, there is lowering 

morale which results in losing good employees; and you are never 

going to attract the best employees, the quality employees that veterans deserve. 

Now, we realize that some, almost exclusively public employee 

unions, have voiced concern about protections for rank and file employees. We strongly believe their concerns to be unfounded. Not 

only would existing whistleblower protections remain in place, but 

S. 1082 actually increases protections for whistleblowers. As far as 

willy-nilly firings, all VA workers retain the same Federal protections afforded other government workers. They simply would not be 

on paid administrative leave for as long. This bill is not about 

unions. This bill is about veterans. 

Now, I know there is another bill that has been largely discussed 

today, Senator Johnson’s bill, S. 1117. It makes a laudable move 

toward expanding removal authority. However, we do not think it 

goes far enough, because the problem is, unfortunately, not just 

health care workers. The Phoenix problem was largely an administrative problem, not a health care problem, which Senator Johnson’s bill would not address. We think S. 1082 is full and fair in 

its accountability, medical and administrative, and is necessary to 

achieve the kind of cultural change that VA badly needs. That is 

what S. 1082 would deliver. 

Ultimately, CVA believes that the VA will never provide efficient 

service and real choice until it is reformed, which is why CVA continues to fight for a complete overhaul of VA care. If you want to 

70 

1http://www.stripes.com/news/veterans/it-s-worse-than-ever-employees-of-beleaguered-philadelphia-va-office-vent-to-visiting-lawmakers–1.352536 

address wait times, you need to introduce Choice, and VA is never 

going to do it on their own. That is why we believe veterans deserve the VA Accountability Act. 

Thank you, Mr. Chairman. 

[The prepared statement of Mr. Hegseth follows:] 

PREPARED STATEMENT OF PETER B. HEGSETH, CEO, CONCERNED VETERANS FOR

AMERICA

Chairman Isakson, Ranking Member Blumenthal and Members of the Committee, 

thank you for affording me the opportunity to testify on pending legislation today 

on behalf of Concerned Veterans for America. 

While several of these bills do worthwhile things, I want to focus the balance of 

my time on one bill that we believe represents a crucial step toward fixing ongoing 

culture problems at the Department of Veterans Affairs. The bill is S. 1082, the Department of Veterans Affairs Accountability Act of 2015, introduced by Senator 

Marco Rubio. The legislation builds on the work already begun by last year’s Veterans Access, Choice and Accountability Act of 2014, which made it easier to remove 

incompetent and negligent VA Senior Executive Service officials. This common sense 

bill—S. 1082—simply expands the Secretary’s authority to swiftly remove poor employees, regardless of their rank in the organization. 

We believe this bill is badly needed—and critical to VA’s recovery—because so 

much of what ills VA stems from a dysfunctional and bureaucratic culture that has 

infected the organization at all levels. Of course we recognize that the vast majority 

of VA employees care deeply for veterans and have a strong desire to serve them. 

As is often noted, many of these employees are veterans themselves. However, in 

a system that punishes whistleblowers and all too often rewards complacency and 

incompetence, even the best employee can become jaded, and just ‘‘go along to get 

along.’’ When this becomes the case throughout an organization, mediocrity—and 

even failure—can become the norm. 

As a matter of fact, VA has a history of rewarding mediocrity and failure. Employees that failed at their job—and ought be fired swiftly—are instead put on paid administrative leave, or even paid a bonus. Remember, it was not long ago that we 

were discussing improper bonus practices at the VA. This reward-for-failure practice 

goes all the way back to Congress itself. What happens when VA fails to properly 

manage its massive and growing budget resources and finds itself in a budget shortfall? It always gets rewarded with more resources. If we keep rewarding failure— 

if we keep just spending another $3 billion here and $3 billion there—we can only 

expect more failure. 

For years, that has been Congress and the veterans community’s default response: 

throw money at a failing VA bureaucracy and it will fix itself. That is the reason 

why the VA’s budget has more than doubled in the last seven years, while the number of veteran patients (as reported by VA) grew by less than one million. In fact 

just this week the New York Times reported yet again that wait times have actually 

increased since the VA scandal broke last year. This is a clear image of what rewarding mediocrity and failure looks like at the Departmental level—failure that 

cascades down from the leadership to the frontline employee, and ultimately, to the 

underserved veteran. Remember, it is veterans who pay the price for no accountability at VA. 

A whistleblower even noted at a field hearing this month at the VA regional office 

in Philadelphia that conditions there are now ‘‘worse than ever,’’ 1 and employee morale is at an all-time low. This should surprise nobody. Who would want to work 

at a place where mediocrity and failure gets rewarded? A place where, if you speak 

up about dysfunction and waste, instead of getting rewarded you get a target on 

your back? Because there is no accountability at VA, VA is losing good employees— 

and will continue to be unable to attract the best employees. 

This common-sense bill—S. 1082—would simply increase the accountability for 

VA employees, but more importantly it would make the removal of bad employees 

more efficient, thereby enhancing the morale and dedication of the good employees 

which constitute the majority. 

We realize that some—especially public employee unions—have voiced concerns 

about protections for rank-and-file employees, fearing that the VA Accountability 

Act would result in an increase in retaliations of whistleblowers and/or politicized 

personnel decisions. We strongly believe these concerns are unfounded. Not only 

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2http://www.govexec.com/management/2015/05/va-officials-say-theyre-trying-fire-people-itsstill-really-hard/112717/ 

would existing whistleblower protections remain in place, but S. 1082 actually increases protections for whistleblowers. As far as willy-nilly firings, all VA workers 

will retain the same Federal protections afforded other government workers. S. 1082 

simply condenses the appeal and adjudication period for fired workers—placing 

them on unpaid administrative leave in the process. VA workers retain full protections and full appeal rights; they just won’t be sitting on paid administrative leave 

for months and years. Again, common sense stuff. 

Another bill being considered today—Senator Ron Johnson’s S. 1117, Ensuring 

Veteran Safety Through Accountability Act of 2015—makes a laudable move toward 

expanded removal authority. However, this bill simply does not go far enough. By 

applying the increased firing authority only to VA health care workers (Title 38 employees), many potentially problematic VA employees will continue to fly beneath 

the radar with little accountability. The bill also strikes us as unfair—with some 

employees held accountable, others not. Full and fair accountability for all VA employees is necessary to achieve the kind of culture change that VA badly needs. That 

is what S. 1082 delivers. 

As we all know, the stories associated with the actions of bad VA employees are 

numerous and infuriating. For example, it took over year to fire a VA employee in 

Alabama who took a drug-addicted veteran to a crack house and left him overnight. 

Worse, a year after the scandal broke, still not a single VA employee have been fired 

specifically for manipulating patient wait times. In fact, overall firings have actually 

decreased at the VA since the wait list scandal broke despite the fact that the manipulation of waitlists was found to be a wide and systemic problem. The status quo 

is unacceptable. 

It’s blindingly obvious that more accountability is needed to help fix what ills the 

VA bureaucracy. In fact, Deputy Secretary Sloan Gibson recently testified before the 

House Veterans’ Affairs Committee, saying ‘‘it’s hard to hire and it’s hard to fire’’ 

employees across the Federal Government, including at VA. He added that, ‘‘We will 

not change the culture of the VA unless we hold people accountable.’’ 2

We adamantly agree with Secretary Gibson—as do all the VSOs who also support 

S. 1082. 

It is to give VA the tools they need to live up to their own words. 

Chairman ISAKSON. Thank you very much. 

Adrian Atizado. 

STATEMENT OF ADRIAN M. ATIZADO, ASSISTANT NATIONAL 

LEGISLATIVE DIRECTOR, DISABLED AMERICAN VETERANS 

Mr. ATIZADO. Chairman Isakson, Ranking Member Blumenthal, 

Senator Baldwin, Senator Rounds, I would like to thank all of you 

for inviting DAV to testify at this legislative hearing. 

As you know, DAV is a nonprofit Veterans Service Organization. 

Through our 1.3 million members, who are wartime service-disabled veterans, our nearly 4,000 service officers, and nearly 13,000 

volunteers, we are dedicated to one purpose, one goal: to empower 

veterans to lead high-quality lives with dignity and respect. 

Three minutes is an awful short time. I will get to it. 

S. 469, the Women Veterans and Families Health Services Act of 

2015, is a comprehensive bill, as Senator Murray has said. We support this bill. We support it with a resolution that our delegates 

passed last year in our National Convention. 

S. 1085, the Military and Veteran Caregiver Services Improvement Act, this would expand eligibility to VA’s comprehensive 

Caregivers Support Program from veterans severely injured before 

September 11, 2001. This will be done by phasing in veterans 

based on need to allow VA to manage the workload while keeping 

quality services high. DAV supports parts of this bill in accordance 

with our resolution, again, passed by our delegates from our last 

convention. 

72 

Now, for all the effort over the past 3 years, the greatest obstacle 

to expanding this program to the greatest generation and after 

them is cost. I heard Chairman Isakson talk about a GAO report 

which primarily hinges on IT. The IT solution that VA has been 

going for is in their budget request, $6 million, I think, $6.8. I 

think that in and of itself will address GAO’s concerns about this 

program, its ability to meet the new workload if the program is expanded. We have worked with VA to address its current IT solution, to stabilize it, to make sure people in the program are being 

served properly as well as into the future. 

Perhaps it is because caregivers lie outside a market economy 

that it is socially and politically invisible and its economic value is 

not generally acknowledged. What we do acknowledge is the cost 

of deploying servicemembers to war. Caregivers of veterans severely disabled before September 11, 2001, bear the cost every day 

with little recognition of services and sacrifices. A recent Met Life 

study put that cost at over $320,000 in terms of lost wages and 

benefits. This is not including the quality-of-life that they suffer. 

The business case for expanding this program has been made by 

RAND, by AARP, a number of other formidable institutions. We 

ask this Congress to pass this in 2015. 

Thank you. 

[The prepared statement of Mr. Atizado follows:] 

PREPARED STATEMENT OF ADRIAN M. ATIZADO, ASSISTANT NATIONAL LEGISLATIVE

DIRECTOR, DISABLED AMERICAN VETERANS

Chairman Isakson, Ranking Member Blumenthal, and Members of the Committee: Thank you for inviting DAV (Disabled American Veterans) to testify at this 

legislative hearing, and to present our views on the bills under consideration. As 

you know, DAV is a non-profit veterans service organization comprised of 1.2 million 

wartime service-disabled veterans that is dedicated to a single purpose: empowering 

veterans to lead high-quality lives with respect and dignity. 

S. 469, THE WOMEN VETERANS AND FAMILIES HEALTH SERVICES ACT OF 2015

This is a comprehensive bill that would expand child care and women veteran retreat pilot programs in the Department of Veterans Affairs (VA), and would direct 

the Department of Defense (DOD) and VA to furnish voluntary fertility treatment 

and counseling programs. 

Section 101 would direct the Secretary of Defense to furnish fertility treatment 

and counseling, including through the use of assisted reproductive technology, to a 

spouse, partner, or gestational surrogate of a severely injured, ill or wounded member of the Armed Forces who has an infertility condition incurred or aggravated 

while serving on active duty. This service would be provided regardless of the servicemember’s sex or marital status. This section would further require that if the 

servicemember were unable to provide gametes for fertility treatment purposes, 

DOD would pay or reimburse the reasonable cost of the member’s procuring donor 

gametes. In addition, a maximum of three completed cycles or six attempted cycles 

of in vitro fertilization (IVF) could be provided to a spouse, partner, or gestational 

surrogate of the member. 

Section 102 would direct DOD to establish procedures for gamete retrieval from 

a severely injured, ill or wounded servicemember when the fertility of the member 

is potentially jeopardized as a result of military service. 

Section 103 would mandate DOD to give active duty members the opportunity to 

cryopreserve and store gametes prior to deployment to a combat zone, at no cost. 

The gametes would be stored until one year after the retirement, separation, or release of the member from the Armed Forces, and the member would retain the option of extending the preservation of gametes by paying out-of-pocket to continue 

such storage or transfer the material to a private cryopreservation and storage facility, or to a VA facility if cryopreservation and storage were available. 

Section 104 would require DOD and VA to share best practices and facilitate fertility treatment and counseling referrals for eligible individuals. 

73 

Section 201 would amend section 1701(6) of title 38 to include fertility counseling 

and treatment under the definition of authorized VA medical services. 

Section 202 would direct the VA Secretary to furnish fertility treatment and counseling, including through the use of assisted reproductive technology, to a spouse, 

partner, or gestational surrogate of a severely injured, ill or wounded veteran who 

is enrolled in VA and has an infertility condition incurred or aggravated while serving on active duty. In the case of IVF treatment furnished, a maximum of three 

completed cycles or six attempted cycles of IVF would be authorized, whichever occurs first, to a spouse, partner, or gestational surrogate of the veteran. 

Section 203 would authorize VA to pay adoption expenses for up to three adoptions for a severely wounded, ill, or injured veteran with an infertility condition incurred or aggravated in the line of duty, and who is enrolled in the VA health care 

system. 

Sections 204 and 205 would direct VA to report annually to Congress on the counseling and treatment provided under this act; and would require prescribed regulations on the furnishing of such counseling, treatment, and adoption assistance. 

Section 206 would direct VA to facilitate research conducted collaboratively by 

DOD and the Department of Health and Human Services in order to improve VA’s 

ability to meet the long-term reproductive health care needs of veterans with service-connected genitourinary disabilities or conditions incurred or aggravated in the 

line of duty that affect reproductive ability. 

Section 207 would require VA to enhance the capabilities of the women veterans 

contact center to respond to requests for assistance with accessing VA health care 

and benefits, and would require referral of such veterans to Federal or community 

resources to obtain assistance not furnished by VA. 

Section 208 would modify the Caregivers and Veterans Omnibus Health Services 

Act of 2010 that authorized a pilot program of group retreat reintegration and readjustment counseling for women veterans recently separated from service. Section 

208 would increase the number of counseling locations from three to 14, and extend 

the program through December 31, 2018. 

Section 209 would establish VA programs to provide child care assistance to qualified veterans so that such veterans could receive regular mental health care services; intensive mental health care services; other intensive health care services; and, 

readjustment counseling and related mental health services. 

DAV is pleased to support this bill, parts of which are in accord with DAV’s Resolution No. 040, which supports enhanced medical services and benefits for women 

veterans. DAV also supports this bill on the strength of Resolution 220, calling for 

VA to provide comprehensive services to enrolled veterans. While DAV has no specific resolution from our membership related to reproductive and infertility treatments per se, this bill is focused on improving VA’s authority to meet the long-term 

reproductive health care needs of veterans with service-connected conditions that 

negatively affect their reproductive health. For these reasons, DAV looks forward 

to favorable consideration and enactment of this bill. 

S. 901, THE TOXIC EXPOSURE RESEARCH ACT OF 2015

The 2008, 2010 and 2012 Institute of Medicine (IOM) Committees to Review the 

Health Effects in Vietnam Veterans of Exposure to Herbicides concluded there is a 

plausible basis that male veterans exposed to the herbicides the US military deployed in Vietnam could result in adverse effects being manifested in the adult children and grandchildren as a result of epigenetic changes, and such potential would 

most likely be attributable to the 2,3,7,8-tetrachlorodibenzo-p-dioxin (TCDD) contaminant, the most toxic form of dioxin in Agent Orange. 

The 2012 Agent Orange Study Committee reported it favors renewed efforts to 

conduct epidemiologic studies on all the developmental effects in offspring that may 

be associated with paternal exposure. In addition, new studies should evaluate offspring for defined clinical health conditions that develop later in life, focusing on 

organ systems that have shown the greatest effects after maternal exposure, including neurologic, immune, and endocrine eaeffects. Finally, although the IOM committee recognized that there is evidence that environmental exposures can affect 

later generations, epidemiologic investigations designed to associate toxic exposures 

with health effects manifested in later generations will be even more challenging 

to conduct than research on adverse effects on the first generation. 

While TCDD mostly associated with herbicide-exposed Vietnam veterans, it is also 

one of 56 pollutants, including several types of dioxins, of interest to the 2011 IOM 

Committee on the Long-Term Health Consequences of Exposure to Burn Pits in Iraq 

and Afghanistan. Moreover, the Agency for Toxic Substances and Disease Registry 

has been working on possible adverse health outcomes from exposure to volatile orVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00077 Fmt 6633 Sfmt 6621 Z:\ACTIVE\062415.TXT PAULIN
74 

ganic compounds (VOCs) perchloroethylene (PCE), trichloroethylene (TCE), and benzene, in the water supply at the Camp Lejeune Marine Corps Base, North Carolina. 

This bill would establish a national VA center to conduct research on the diagnosis and treatment of health conditions of the descendants of veterans exposed to 

any toxic substance, as defined by the Environmental Protection Agency, during 

military service provided those health conditions are related to the veterans’ exposures. The bill would also establish an advisory board to oversee and assess the national center, to advise the VA Secretary on issues related to the national center, 

and to assess the health care needs of the descendants of exposed veterans. Finally, 

the bill would authorize no additional funds for the purposes of this program. 

DAV does not have a resolution from our membership to enable DAV to support 

this legislation. We encourage the Committee and VA to work together to ensure 

the legislation is in consonance with the IOM committees’ recommendations. 

S. 1117, THE ENSURING VETERAN SAFETY THROUGH ACCOUNTABILITY ACT OF 2015, 

AND

S. 1082, THE DEPARTMENT OF VETERANS AFFAIRS ACCOUNTABILITY ACT OF 2015

S. 1117 would amend section 713, title 38, United States Code, which authorizes 

the VA Secretary to remove senior VA executives for performance or misconduct. 

This bill would expand the Secretary’s authority, to enable the Secretary to remove 

anyone employed on a full-time basis under a permanent appointment in a position 

listed in section 7401, title 38, United States Code. Positions identified in section 

7401 are all of VA’s direct health care providers. 

S. 1082 would provide the VA Secretary the authority to remove from the civil 

service or demote a VA employee through a reduction in grade or annual pay rate 

based on performance or misconduct. 

Under S. 1082 employees affected by removal or demotion would be given seven 

days to appeal to the Merit Systems Protection Board. An administrative law judge 

would be required to make a final decision within 45 days of such appeal, or the 

original decision would become final. 

The bill would prohibit removal or demotion of an employee without the approval 

of the Special Counsel if the individual sought corrective action from the Office of 

Special Counsel based on an alleged prohibited personnel practice. 

The bill also would prescribe a minimum 540-day probationary period for appointment of an individual to a permanent position within the competitive service or as 

a career appointee within the Senior Executive Service, and would give the Secretary discretion to extend this probationary time. Final appointment to a permanent position would be the exclusive decision of the employee’s supervisor, but based 

on regulations established for this purpose by the Secretary. 

Last, under S. 1082, the Government Accountability Office would be required to 

study and report to Congress the amount of time spent by VA employees carrying 

out labor organization activities, the amount of VA space used for such activities, 

and provide a cost-benefit analysis of the use of such time and space for the conduct 

of these activities. 

In order to ensure that veterans receive the benefits and services they have 

earned, every VA employee, manager and leader must faithfully fulfill their duties 

and responsibilities. When they fail to do so, whether due to poor performance or 

misconduct, systems must be put in place to support decisive and timely actions to 

hold them accountable, including appropriate training, demotion, suspension, and 

termination when appropriate. 

Mr. Chairman, we, too, become frustrated and angry when veterans are harmed 

due to poor performance or misconduct by a VA employee, manager or leader, and 

more so when no action is taken to hold them accountable. 

However, it is also vitally important to VA’s long-term future to create an environment in which the best and brightest professionals choose VA over other Federal 

or private employers. While poor performance and misconduct cannot be tolerated, 

VA employees must be confident that fairness and due process govern how they are 

selected, promoted, demoted, sanctioned or terminated. 

Without such assurances of fairness and due process in the workplace, talented 

doctors, nurses and other professionals may not even entertain working in the VA, 

especially since they must already be willing to accept below-market salaries, pay 

and hiring freezes, government shutdowns, and other challenges of working in the 

Federal Government. 

We must not forget that civil service protections enacted decades ago came about 

as a result of politicization and ill treatment of government employees, including 

terminations for almost any reason, or no reason. 

75 

Ensuring that the civil service remains free of political influence is a principle 

that we must protect to guarantee that employees are neither appointed, demoted 

nor terminated for political reasons, and that benefits and services are delivered to 

veterans without any partisan bias. 

While DAV has no resolution from our membership on this topic or these specific 

proposals to enable us to take a position on these bills, we do want to stress to the 

Committee and these bills’ sponsors that any legislation changing the existing employment protections in VA must strike an appropriate balance between holding 

civil servants accountable for their work, while maintaining VA as an employer of 

choice for the best and brightest individuals. 

S. 1085, THE MILITARY AND VETERAN CAREGIVER SERVICES IMPROVEMENT ACT

This measure would expand eligibility for VA’s Comprehensive Caregiver Support 

Program to veterans of all eras, by phasing in veterans based on need, allowing VA 

to manage the new workload, while keeping service quality high. It would also include a wider range of injuries and illnesses that require caregiving, place a greater 

emphasis on mental health injuries and Traumatic Brain Injury (TBI), and remove 

certain restrictions in current law on those eligible to become caregivers. 

The bill would also make improvements to the VA caregiver program by making 

caregivers eligible for VA child care programs, or by providing a stipend to offset 

the cost of child care. Also, the bill would authorize VA to provide caregivers financial advice and legal counseling. 

This bill would affect the Department of Defense caregiver program as well. Improvements in DOD’s Special Compensation for Assistance with Activities of Daily 

Living (SCAADL) would include expanding eligibility for the program by making the 

criteria similar to those for the VA caregivers program and make caregivers of servicemembers receiving SCAADL eligible for a range of critical supportive services 

provided by VA. 

DAV supports this bill based on Resolution No. 042, which calls for legislation 

that would expand eligibility for comprehensive caregiver support services, including 

but not limited to financial support, health and homemaker services, respite, education and training, and other necessary relief to caregivers of veterans from all 

eras of military service. 

VA’s comprehensive caregiver program had been operating for over three years 

when Congress held a hearing late last year on how best to expand eligibility for 

the services and benefits of this program to severely ill and injured veterans of all 

eras. During the hearing, concerns were expressed about the program, and arguments were made that improvements should be made to the existing program prior 

to its further expansion. 

We believe that program improvements can be achieved while expanding eligibility without further delay. DAV continues to address concerns about the program 

with VA, and we are engaging Congress to ensure caregivers of all severely disabled 

veterans receive comprehensive support. 

Members of Congress pointed out that additional VA caregiver support coordinators (CSC) were needed in order to be responsive and meet the needs of caregivers 

currently participating in the program. DAV worked with VA to ensure funding was 

allocated for an additional 42 CSCs at the beginning of the current fiscal year (FY), 

and we are working with Congress to ensure a minimum of $10 million is directed 

to hire additional CSCs for FY 2016. Also, as was noted in the hearing, the information technology (IT) system that supports caregivers needs improvement. We have 

worked with VA to ensure that funds were released in FY 2015 to make necessary 

IT corrections and we have urged the Department to request additional funding for 

FY 2016 to deliver a comprehensive IT solution for the program that would serve 

caregivers of severely ill and injured veterans of all eras. 

The greatest obstacle to expanding this program is the cost for enacting legislation that would provide comprehensive caregiver support to all severely disabled 

veterans; nevertheless, we must also acknowledge the cost of deploying servicemembers to war. Caregivers of veterans severely ill and injured before September 11, 2001, bear that cost already, with little recognition or services for their 

sacrifices. 

The business case to expand the comprehensive caregiver program has already 

been made in the report Hidden Heroes: America’s Military Caregivers, by the 

RAND Corporation. The loving assistance provided by family caregivers saves taxpayers billions of dollars each year in health care costs, and enables severely wounded, injured and ill veterans to live at home rather than in institutions. DAV believes 

it is time for Congress to act to expand these benefits to veterans of all eras. 

76 

DRAFT BILL—THE JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

This draft bill, the ‘‘Jason Simcakoski Memorial Opioid Safety Act,’’ named in 

honor of a Wisconsin veteran who died from prescribed opioid drugs while in the 

care of the Department of Veterans Affairs (VA), would strengthen and better regulate VA’s policies on the use of opioids and drugs containing benzodiazepine, particularly patients with mental health challenges and those suffering from chronic 

pain. 

We strongly support the sponsor’s intention to control and reduce the use of addictive substances in VA health care. The VA has previously acknowledged it is 

challenged by the prescribing practices of some of its providers. 

Title I of the bill would establish a far-reaching and ambitious new program to 

deal with, protect against, control, and report any over-prescribing of benzodiazepines and opioid substances in the care of veterans enrolled in health programs of 

VA. While VA has made recent efforts to address overprescribing, its existing pain 

management program is not well organized, and is insufficiently staffed in our view, 

so enactment of this bill would call attention to the need for VA to better manage 

and staff this function at both the national and local levels. 

DAV strongly supports Title II of the bill, which would establish a formalized national patient advocacy program in VA. As a co-author of the Independent Budget, DAV has called for improvements in patient advocacy and ombudsman programs in 

VA for several years. We believe the bill would give this program the weight and 

importance it deserves to help veterans to better navigate the VA health care 

system. 

Title III of this bill would enhance complementary and alternative health care 

programs in VA. We support the advent of complementary and alternative care, 

both in substitute to VA’s use of pharmacological agents, and to better respond to 

the needs and demands of a younger generation of veterans, who often do not want 

traditional medical management—especially if it involves the prescribing of pain 

and psychotropic medications. 

Title IV of the bill would require VA to strengthen its scrutiny in hiring practices 

for physicians and other providers by validating that such candidates for employment in VA carry no blemishes on their state licenses. If a VA provider were to violate a requirement of medical licensure, VA would be required by the bill to report 

any such violation to the state medical board(s) of the state(s) that had granted licensure. Also, if the VA provider were to resign from VA, or transfer from one VA 

facility to another, this bill would require VA to determine whether there were any 

‘‘concerns, complaints, or allegations related to the medical practice’’ of the individual during VA employment, and to take appropriate action in response. In respect to these requirements, the Committee may wish to consider amending the bill 

to clearly define the term ‘‘provider,’’ and whether the intention is to include all or 

only some of the individuals identified as direct care providers in section 7401 of 

title 38, United States Code. 

Title V of the bill would require the establishment and reporting to Congress of 

a series of internal audits of VA administrations and key offices. 

In summary, based on several resolutions adopted by our membership in our most 

recent National Convention (Resolution Nos. 039, 201 , 218 , and 220, DAV supports 

this bill, we appreciate the sponsor’s leadership in developing this proposal, and we 

urge Congress to proceed with its enactment this year. 

DRAFT BILL—THE BIOLOGICAL IMPLANT TRACKING AND VETERAN SAFETY ACT OF 2015

This draft bill would require VA to establish a biological implant inventory identification and management system with the same features and requirements of an existing system in use by the Food and Drug Administration to regulate origin, movement, surgical implantation, and recall (if necessary) of any such biological material. 

The bill would define the term biological implant as any ‘‘animal or human cell, 

tissue, or cellular or tissue-based product,’’ and would tie that definition to the existing regulatory definition under the Federal Food, Drug, and Cosmetic Act. 

The bill would set a number of milestone and deadline dates for implementation, 

and would require VA to submit a series of reports to document its progress in implementation of this system. 

The bill would restrict the procurement of biological implants to vendors who 

meet certain conditions laid out in the bill, and would sanction any VA procurement 

employee involved in the procurement of biological implants who acted with intent 

to avoid, or with reckless disregard of the requirements of the bill. 

DAV has received no resolution from our membership that deals with the specific 

topic of biological implants. However, DAV’s Resolution No. 220 calls for VA to provide a comprehensive health care service for all enrolled veterans. Better control of 

77 

the origins, movement, surgical implantation and recall, if necessary, of implantable 

biological material would be in keeping with the intent of our resolution. Therefore, 

DAV supports the purposes of this bill and endorses its enactment. 

DISCUSSION DRAFT

Section one would require a report to the House and Senate Veterans’ Affairs 

Committees from VA about its plan to establish or expand advance degree programs 

in orthotics and prosthetics for the purposes of improving such care to veterans. 

Under the ill, a plan would be developed in consultation with veterans service organizations, institutions of higher education with accredited degree programs in prosthetics and orthotics, and with representatives of the prosthetics and orthotics field. 

As part of the Independent Budget (IB), DAV supports the intent of this section 

of the bill that would develop future VA prosthetists and orthotists. The VA Prosthetic and Sensory Aids Service (PSAS) is a special-emphasis program that serves 

approximately half of the veterans that receive health care services in VA, and continues to have major positive impact on meeting the specialized needs of severely 

disabled veterans. 

This measure is consistent with the IB’s recommendation for VA to revise qualification standards for prosthetics representatives and orthotics/prosthetics personnel 

to most efficiently meet the complexities of programs throughout the VA health care 

system and to attract and retain qualified individuals. Additionally, VA must ensure 

that PSAS departments are staffed by certified professional personnel or contracted 

staff that are capable of maintaining and repairing the latest and most advanced 

prosthetic devices. 

To this end, we urge the Committee to include a provision in this bill that would 

specify that the plan to be reported to Congress would directly improve and enhance 

orthotic and prosthetic care for veterans. For example, VA contracts with academic 

affiliates encompass the Department’s education and training program for health 

professional trainees to enhance the quality of care provided to veteran patients 

through coordinated programs and activities in partnership with academic affiliates. 

Additionally, we ask the Committee to consider defining the term ‘‘veterans service organizations’’ the same as this term is defined in section 5902, title 38, United 

States Code. 

Section two of this measure would require VA to consult with the Department of 

Defense (DOD) and other agencies as appropriate, and afterward to submit a report 

to Congress on the extent to which Laotian military forces provided combat support 

to the Armed Forces of the United States in Southeast Asia between February 28, 

1961, and May 15, 1975; whether the current classification by the DOD Civilian/ 

Military Service Review Board is appropriate; and to make any recommendations 

for legislative action. 

DAV has no resolution on this specific issue, and takes no position on this section 

of the bill. 

H.R. 91, THE VETERAN’S I.D. CARD ACT

This legislation would authorize the Secretary of Veterans Affairs to issue cards 

to certain former military servicemembers that identify them as veterans. While 

DAV has no resolution or position on this matter we recommend this be a collaborative effort between the two principal agencies; DOD, in issuing this type of identification card to those eligible at time of discharge, and VA, in issuing this type of 

identification card to those already separated from military service. 

Mr. Chairman, this concludes my testimony. DAV appreciates your request for our 

views on this legislation. I would be pleased to answer any questions from you or 

members of the Subcommittee dealing with this testimony. 

Senator BLUMENTHAL [presiding]. Thank you very much. 

Mr. Blake. 

STATEMENT OF CARL BLAKE, ASSOCIATE EXECUTIVE DIRECTOR OF GOVERNMENT RELATIONS, PARALYZED VETERANS 

OF AMERICA 

Mr. BLAKE. Thank you, Senator Blumenthal. On behalf of Paralyzed Veterans of America, I would like to thank you for the opportunity to testify today. 

78 

PVA strongly supports S. 1085, the Military and Veteran Caregiver Services Improvement Act. This bill is the number 1 legislative priority of PVA, as our members will benefit more from this 

than any other cohort in the veterans’ population. 

The needs of catastrophically disabled veterans are not different 

simply because they were injured prior to September 11, 2001. No 

reasonable justification can be provided for why veterans with catastrophic service-connected injuries or illnesses should be excluded 

from the Family Caregiver Program. Unfortunately, some have decided that cost is a reasonable justification. Cost is not a justification. Cost is an excuse. It is time to end this unacceptable inequity 

once and for all. 

PVA also strongly supports S. 469, the Women Veterans and 

Families Health Services Act. This bill is also a high priority for 

our members. It would allow the VA to finally provide reproductive 

assistance to severely injured veterans. As a result of the recent 

conflicts in Afghanistan and Iraq, many young men and women 

have incurred injuries from explosive devices that have made them 

unable to conceive a child naturally. While the Department of Defense does provide assistive reproductive technologies, such as in 

vitro fertilization, to servicemembers, the VA does not. But, let us 

be clear. It is not because the VA chooses not to. It is because Congress decided it would not a long time ago. 

For too long, moral arguments have stood in the way of eliminating the prohibition of the VA to provide reproductive services, 

particularly in vitro fertilization. If we accept that this country has 

a moral obligation to make whole those men and women who have 

been sent into harm’s way and returned broken, then it is time for 

this legislation to be enacted. If a Member of Congress wants to debate the moral issues that they believe supercede the need to do 

the right thing by these men and women, we invite that discussion. 

I would suggest that Member of Congress meet face to face with 

the men and women who are impacted by this policy every day. 

The bottom line is the fact that this prohibition even exists is 

shameful. 

Finally, PVA supports S. 1082, the Department of Veterans Affairs Accountability Act of 2015. We believe that Secretary McDonald and Deputy Secretary Gibson want to hold bad employees at 

the VA accountable in the most appropriate fashion. Unfortunately, 

at this point, accountability seems to be only defined by transfers, 

admonishment, reprimands, and retraining, but not termination. 

We realize that termination of Federal employees is a complicated 

proposition, but it should not be impossible. 

The notion that the fear of termination as a part of accountability is bad for morale is nonsense. I believe the VA uses the 

term ‘‘disheartened’’ in their testimony today for how VA employees 

would respond to this legislation. In my experience as an infantry 

platoon leader, unit morale did not suffer from soldiers being fired 

or chaptered out of the military entirely. Morale suffered when soldiers knew there was a substandard soldier dragging down the unit 

and jeopardizing the mission. In fact, morale significantly improved 

when poor performing soldiers were taken out of the unit or taken 

out of the Army. We believe the VA employees who are doing an 

outstanding job understand this concept and will appreciate reVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00082 Fmt 6633 Sfmt 6601 Z:\ACTIVE\062415.TXT PAULIN
79 

moval of those individuals around them who are not performing up 

to the standard. 

However, we must emphasize that we are not wholly convinced 

that this legislation is the solution. In fact, it remains to be seen 

if this legislation will enable the VA to actually hold individuals accountable, and we only have to look at what has happened as a result of the provisions of VACA to know what might actually 

happen. 

Thank you again, Mr. Chairman. 

[The prepared statement of Mr. Blake follows:] 

PREPARED STATEMENT OF CARL BLAKE, ASSOCIATE EXECUTIVE DIRECTOR OF

GOVERNMENT RELATIONS, PARALYZED VETERANS OF AMERICA

Chairman Isakson, Ranking Member Blumenthal, and Members of the Committee, Paralyzed Veterans of America (PVA) would like to thank you for the opportunity to testify today on the pending health care legislation. Several of these proposed bills address very high priorities for PVA and our members, veterans with 

spinal cord injury or disease (SCI/D). We encourage the Committee to give swift consideration to these measures and move them to the floor of the Senate for passage 

as soon as possible. 

S. 469, THE ‘‘WOMEN VETERANS AND FAMILIES HEALTH SERVICES ACT OF 2015’’ 

PVA strongly supports S. 469, the ‘‘Women Veterans and Families Health Services Act of 2015.’’ This bill will allow the Department of Veterans Affairs (VA) to 

provide reproductive assistance to severely wounded veterans. For many disabled 

veterans, one of the most devastating results of spinal cord injury or disease is the 

loss of, or compromised ability, to have a child. As a result of the recent conflicts 

in Afghanistan and Iraq, many servicemembers have incurred injuries from explosive devices that have made them unable to conceive a child naturally. While the 

Department of Defense does provide assisted reproductive technologies (ART), such 

as in vitro fertilization (IVF), to servicemembers and retired servicemembers, VA 

does not. When a veteran has a loss of reproductive ability due to a service-connected injury, they must bear the total cost for any medical services should they 

attempt to have children. It is often the case that veterans cannot afford these services and are unable to receive the medical treatment necessary for them to conceive. 

For many paralyzed veterans procreative services have been secured in the private 

sector at great financial and personal cost to the veteran and family. 

Procreative services, provided through VA, would ensure that certain catastrophically disabled veterans are able to have a full quality of life that would otherwise 

be denied to them as a result of their service. For decades, improvements in medical 

treatments have made it possible to overcome infertility and reproductive disabilities. Veterans who have a loss of reproductive ability as a result of a service-connected injury should have access to these advancements. 

Additionally, this bill addresses specific procreative options for women veterans. 

Some women veterans with a catastrophic injury may be able to conceive through 

IVF but be unable to carry a pregnancy to term due to their disability. In such an 

instance the implantation of a surrogate may be their only option. This legislation 

would allow VA to provide services to a veteran, their partner, or gestational surrogate. 

Further, this legislation would allow for genetic material donation. For veterans 

whose injuries result in the loss or damage of genitalia, a third-party donation may 

be their only option. If the role of VA is to restore to veterans and their families 

what has been sacrificed in service to this country, then passage of this legislation 

is essential. 

As of 2013, the Congressional Budget Office estimated that more than 3,000 veterans injured since September 11, 2001, would benefit from these services. Overturning the existing policy would save catastrophically disabled veterans and their 

families between $25,000 and $36,000 and allow the Federal Government to fulfill 

the moral obligation it has to these men and women. 

Additionally, the bill would also cover expenses involved in the adoption of children, further providing veterans with an option they couldn’t otherwise afford. 

Other elements in the legislation include infertility research, expansion of counseling retreats for women and expansion of the highly successful child care program. 

80 

These are invaluable services that will improve the well-being of our servicemembers and veterans. 

S. 901, THE ‘‘TOXIC EXPOSURE RESEARCH ACT OF 2015’’ 

PVA understands the intent of and generally supports this legislation. This bill 

would require the VA Secretary to select one VA medical center to serve as the national center for research on the diagnosis and treatment of health conditions of descendents of individuals exposed to toxic substances while serving in the Armed 

Forces. It would also require the establishment of an advisory board for the national 

center to determine links between exposure and health conditions. However, the bill 

does not discuss the processes should the advisory board conflict with the findings 

of the IOM. We encourage the Subcommittee and VA to work together to ensure the 

legislation fulfills the IOM Committee recommendations. 

S. 1082, THE ‘‘DEPARTMENT OF VETERANS AFFAIRS ACCOUNTABILITY ACT OF 2015’’ 

PVA supports S. 1082, the ‘‘Department of Veterans Affairs Accountability Act of 

2015.’’ The events over the past year have clearly demonstrated the need for greater 

flexibility for VA leadership to effectively discipline and manage the failures of their 

staff. 

The incompetence, negligence and seemingly willful misconduct at the Phoenix 

VA medical center and other VA facilities around the country have provided a clear 

signal that VA has to change its personnel processes. We continue to see growing 

problems with claims processing, even while VA lauds their successes in reducing 

the backlog, and despite the ever-growing wave of appeals. Recent hearings conducted by the House Committee on Veterans’ Affairs highlighted the failed operations and personnel policies of the Philadelphia and Oakland VA Regional Offices, 

and these are likely not anomalies. Even more troubling is the billion dollar cost 

overrun for the Denver VA medical center, a facility critical to PVA members in that 

region who will rely on the new spinal cord injury center that is included in that 

project. 

Yet in all these events, we have been left wanting when it comes to holding these 

bad actors accountable in a manner that goes beyond the preemptive resignations 

of several senior VA executives whose professional negligence or misconduct was rewarded with ‘‘golden parachute’’ retirement packages and benefits. Moreover, accountability for many of these failures should go well beyond just the senior executives of VA. 

PVA believes that Secretary McDonald and Deputy Secretary Gibson want to hold 

any bad employees at the VA accountable in the most appropriate fashion. Unfortunately, at this point accountability seems to only be defined by transfers, admonishment and retraining, not termination. We realize that termination of Federal employees is a complicated proposition, but it should not be impossible. If this legislation eases the ability of VA to truly hold bad employees accountable, then we encourage the Committee to move this bill quickly. However, we must emphasize that 

we do not believe this legislation really represents the solution. In fact, it remains 

to be seen if this legislation can move VA to actually hold individuals accountable. 

S. 1085, the ‘‘Military and Veteran Caregiver Services Improvement Act of 2015’’ 

PVA strongly supports S. 1085, the ‘‘Military and Veteran Caregiver Services Improvement Act of 2015.’’ PVA’s members would benefit from the passage of this bill 

more than any cohort of the veterans population. And yet, because of an arbitrary 

date, most of them are denied a critically needed service. The needs of catastrophically disabled veterans are not different because they became injured or ill prior 

to September 11, 2001. No reasonable justification can be provided for why veterans 

with a catastrophic service-connected injury or illness should be excluded from the 

Comprehensive Family Caregiver Program. 

Moreover, the need for a caregiver is not lessened simply because a veteran’s service left him or her with a catastrophic illness, rather than an injury. PVA is pleased 

to see that S. 1085 includes catastrophic illness as a program qualifier. For PVA’s 

members, a spinal cord disease is no less devastating than a spinal cord injury. Veterans that have been diagnosed with Amyotrophic Lateral Sclerosis (ALS) and Multiple Sclerosis (MS) will eventually experience significant decline in their ability to 

perform activities of daily living and unquestionably become dependent on a caregiver. 

Caregivers are the most critical component of rehabilitation and eventual recovery 

for veterans with a spinal cord injury or disease. Their well-being directly impacts 

the quality of care provided to veterans. For this reason, PVA includes caregivers 

in our advocacy for veterans. In fact, PVA has partnered with the Elizabeth Dole 

81 

Foundation to work to raise awareness of the role of caregivers in this country and 

to address alarming gaps in caregiver support services. 

Pre–9/11 caregivers have provided decades of uncompensated work to our disabled 

veterans, often with no support services of any kind and at the expense of their own 

health and livelihood. A study by the Rand Corp. in 2014 estimated that veterans’ 

caregivers save taxpayers $3 billion a year. 

The cost of the services the VA Caregiver Program currently denies to veterans 

who became catastrophically injured or severely ill prior to September 11, 2001 will 

ultimately be paid for by society as a whole. The well-being of a family inevitably 

declines without essential supports. Ensuring that a veteran is able to reside in 

their home in their community has been shown time and again to reduce medical 

complications, hospital stays, and costs. At the same time, the veteran and their 

family maintain a psychosocial wellness that is impossible to achieve in an institution. 

No group of veterans understands the importance of caregivers more than PVA 

members and their families. As many as 70,000 veterans (with estimates as high 

as 88,000) would be eligible for the Comprehensive Family Caregiver Program if the 

September 11, 2001 date was eliminated as a barrier. Similarly, nearly half of all 

PVA members (approximately 10,000) and nearly 20,000 veterans with spinal cord 

injury would benefit from this change. 

PVA understands the costs concerns with expanding the program. The Congressional Budget Office estimated that full expansion would be $9.5 billion over the 

next five years. While cost is offered as a barrier to expanding access to this program, these concerns ignore the possible net cost savings that the VA could reap 

by providing services to thousands of veterans through the Comprehensive Family 

Caregiver program rather than through institutional care. Unfortunately, Congress 

generally ignores these principles of ‘‘dynamic scoring’’ except when it is politically 

expedient. When considering the cost of providing caregiver services versus the cost 

of institutional services, expansion could save the Federal Government between approximately $2.5 billion and $7.0 billion in a given year. Moreover, the health outcomes for veterans served at home by caregivers would likely improve. 

Chairman Isakson, we appreciate the positive comments you made concerning the 

need to expand the Comprehensive Family Caregiver Program during the joint hearing of the House and Senate Committees on Veterans’ Affairs when our National 

President testified in May. We hope that the interest you expressed will translate 

to real action on this measure. 

S. 1117, THE ‘‘ENSURING VETERAN SAFETY THROUGH ACCOUNTABILITY ACT OF 2015’’ 

Much like our position with regards to S. 1082, PVA supports S. 1117, the ‘‘Ensuring Veteran Safety Through Accountability Act of 2015.’’ Accountability for misconduct of VA employees should go beyond the senior executives of VA. S. 1117 

would apply the provisions outlined in Public Law 113–146, the ‘‘Veterans Access, 

Choice and Accountability Act,’’ for holding Senior Executive Service employees accountable to health care providers who exhibited poor performance or misconduct. 

This legislation would expand on the expedited disciplinary authority given to the 

VA secretary. 

H.R. 91, THE ‘‘VETERAN’S I.D. CARD ACT’’ 

PVA has not official position on H.R. 91, the ‘‘Veteran’s I.D. Card Act.’’ This bill 

directs the Secretary of Veterans Affairs to issue, upon request, veteran identification cards to certain veterans. We do question why veterans should have to pay a 

fee for a card that identifies them as a veteran. 

THE ‘‘JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT’’ 

PVA supports the ‘‘Jason Simcakoski Memorial Opioid Safety Act.’’ This bill targets problems recently identified in the VA’s use of opioids in treating veterans. Additionally, it seeks to improve patient advocacy by the Department and expand 

availability of complementary and integrative health Services. 

This bill would require the Department of Defense (DOD) and the VA to jointly 

update the VA/DOD Clinical Practice Guideline for Management of Opioid Therapy 

for Chronic Pain that has not been updated since 2010. VA would also be required 

to adopt safe opioid prescribing guidelines for chronic, non-cancer pain in outpatient 

settings. It would require each health care provider of VA and DOD to use VA’s 

Opioid Therapy Risk Report tool before starting opioid therapy, emphasizing discussions with patients about alternative pain management therapies. The education 

and training of health care professionals would be improved for identifying patients 

82 

at-risk for addiction and effective tapering programs for patients on an opioid 

regimen. 

Additionally, the VA would be given the authority to increase the availability of 

naloxone, or ‘‘Narcan,’’ a highly effective opioid antagonist. This drug is on the 

World Health Organization’s list of essential medicines in a basic health system. 

Naloxone reverses the effects of an opioid overdose (typically depression of the central nervous system). When one is prescribed opioids there is always a possibility 

of an overdose. The ability to respond to a worst case scenario of overdose, accidental or otherwise, must be available at every medical facility. According to a 2011 

VA study based on 2005 data, veterans ages 30–64 who received care at VA died 

of accidental overdoses at two times the rate of their civilian peers. Naloxone has 

no risk of dependency and can be administered by a layman in the nasal spray form. 

It is a critical tool that can save lives while the department works to address the 

widespread use of opioids. 

VA would also be required to develop mechanisms for real-time patient information on existing opioid prescriptions from VHA as well as patient prescription information from the state drug monitoring program. This mechanism would alert pharmacists of potential ‘‘double-prescribing.’’ A pain management board would be established in each Veterans Integrated Service Network (VISN). It would serve as a resource of best practices recommendations for veterans, families, and providers alike. 

Finally, this bill would require VA to incorporate alternative pain management 

therapies like yoga and acupuncture. PVA fully supports the use of complementary 

and alternative medicine and believes such care options will give veterans with catastrophic injuries and disabilities additional options for pain management and rehabilitative therapies. 

THE ‘‘BIOLOGICAL IMPLANT TRACKING AND VETERAN SAFETY ACT’’ 

This proposed bill intends to have the VA adopt and implement a standard identification protocol for use in the tracking and procurement of biological implants by 

the Department of Veterans Affairs. While we understand and generally support 

some of the provisions of this legislation, PVA objects to the provisions of the draft 

legislation that would exclude the purchase of biological implants from the authority 

of title 38 U.S.C., Section 8123. The use of this authority has been under fire in 

recent hearings, but the concerns raised ignore the critical importance of this 

authority. 

Section 8123 states, ‘‘the Secretary may procure prosthetic appliances (which includes surgical biological implants) and necessary services required in the fitting, 

supplying, and training and use of prosthetic appliances by purchase, manufacture, 

contract, or in such other manner as the Secretary may determine to be proper, 

without regard to any other provision of law.’’ 

The Federal Acquisition Regulations (FAR) were issued pursuant to the Office of 

Federal Procurement Policy Act of 1974. Statutory authority to issue and maintain 

the FAR resides with the Secretary of Defense, the Administrator of General Services, and the Administrator, National Aeronautics and Space Administration—agencies that do not bear the responsibility of providing lifelong care for disabled veterans. However, the VA does bear the heavy weight of that responsibility. 

With this in mind, it is important to note the distinction between VA’s responsibility to meet specialized needs versus a Federal agency’s responsibility to respond 

to emergency needs. The FAR provides for procuring prosthetics in cases where, for 

example, a natural disaster damaged a veteran’s equipment. However, the writers 

who formulated the FAR in 1974 recognized there was a need for special provisions 

under which VA could purchase prosthetics for disabled veterans with specialized 

needs in a timelier manner than the FAR allowed, irrespective of whether a bona 

fide emergency existed. The authors of the FAR recognized this fact and the need 

for Section 8123 as evidenced by the fact that it is referenced in the FAR. This was 

reconfirmed in subsequent updates and amendments to the FAR. 

Unfortunately, this draft legislation seems to imply that the Federal Supply 

Schedule and the FAR is all that is needed to procure Prosthetic appliances (biological implants) and services based on a misunderstanding of the difference between 

‘‘specialized needs’’ and ‘‘emergency needs.’’ Rather than erode a clinician’s ability 

to acquire these prosthetics in a timely manner or manipulate how these prosthetics 

are defined in order to exclude them from the authority of Section 8123, we believe 

that the legislation should focus on accountability and oversight. It should not be 

making efforts to overturn a system that has served veterans well for over half a 

century. We encourage the removal of the provision of the draft legislation that 

eliminates the authority of Section 8213. 

83 

DRAFT BILL, INCLUDING PROVISIONS DERIVED FROM S. 1021 AND S. 1358

PVA generally supports the draft bill that includes provisions from S. 1021 and S. 1358. We have particularly interest in the provisions that would authorize $10 

million to help to establish or expand advanced degree programs in prosthetics and 

orthotics to improve the availability of such resources to veterans. PVA supports the 

intent of this provision and fully understands the need that this legislation seeks 

to address. No group of veterans understands the importance of prosthetics and 

orthotics more than veterans with spinal cord injury or disease. However, in order 

to ensure that VA receives a proper return on its investment for these advance degree programs, we recommend that students whose education is provided through 

these VA-financed programs be required to provide a term of service back to VA immediately following their completion of the program. This would allow the VA to cultivate future prosthetics and orthotics specialists who may be called to serve 

veterans. 

PVA would like to thank you once again for considering these important bills. Our 

members understand the importance of the provisions of these key measures. We 

encourage you to consider their point-of-view as you give these bills final 

consideration. 

This concludes my statement. I would be happy to answer any questions you may 

have. 

Chairman ISAKSON [presiding]. Thank you, Mr. Blake. 

Mr. Stier, we have—the votes have been called, so if the last two 

will be as quick as you can with the testimony, I would appreciate 

it. 

STATEMENT OF MAX STIER, PRESIDENT AND CHIEF 

EXECUTIVE OFFICER, PARTNERSHIP FOR PUBLIC SERVICE 

Mr. STIER. Thank you very much, Mr. Chairman and other Members of this Committee. I appreciate it. My name is Max Stier. I 

am the President of the Partnership for Public Service. We are a 

nonpartisan, nonprofit organization working to make our government more effective. 

Jumping into the accountability issues, the legislation you have 

before you is not the answer. If anything, it is going to make things 

much worse. The cure will be much worse than the problem you 

are trying to solve. In effect, as written—and I think there are 

things you can definitely do to change it—it will return us to the 

spoils system, the system we have not had for 100 years. 

It is a wonderful idea. We want to make sure that the VA is accountable; but firing federal employees faster is not the right focus. 

The focus should be how to we serve veterans better. 

So, very quickly, here are some things that you could do that 

would make a difference, and then, very quickly, some things you 

could do to change the bills to make them better. 

The number one thing you could do to make a difference would 

be to start at the top. Choose political leaders for VA that have the 

right management experience to run complicated and huge organizations. Typically, the government leaders at the top are selected 

for political reasons and policy expertise and are not held accountable for poor management. The Senate’s confirmation and oversight 

authority can change this. If you want to change things, that is 

where it all begins. 

Number 2, require those very same political leaders to have clear 

performance plans and a transparent assessment of whether they 

are meeting their goals. The career workforce has to do this. Those 

rules do not apply to political leaders, and as a result, you do not 

actually have good accountability. 

84 

Number 3, invest in training and development of the managers 

at VA. Only 60 percent of VA employees think their supervisors are 

doing a good job. Only one-third think senior leaders highly motivate them. We need to select better managers and train them 

more. This is not happening. It happens for the military, but not 

for the civilian side of government. that is why you have many of 

your problems. 

Number 4, you need new tools to hire Federal employees. You 

are not getting the best in, and, therefore, you are going to have 

a big problem. The better choice is to work on getting better talent 

in, so there are fewer people you have to remove down the line. 

Number 5, make the probationary period real. It is not about 

making it longer. Today, by default, Federal employees automatically pass through their probationary period. Supervisors are not 

making an affirmative decision to keep them. The presumption 

should be reversed. A choice should be made that they are actually 

doing the jobs well. This should be true for new employees and new 

supervisors. That would change things. You would have to fire 

fewer people. 

Number 6, use your oversight to make sure the administrative 

remedies are fully utilized. Many agencies are creating their own 

problems. They have the right rules and tools, they are just not 

using them effectively. The DEA example was a perfect one. The 

DEA administrator testified before Congress and said, ‘‘Help me 

fire my employees faster.’’ In fact, there were self-imposed administrative barriers that stood in the way. It is important to look at 

what can be done administratively to change things. 

And, number seven, consolidate the appeals process. 

Mr. Chairman, you mentioned that there is not a clear standard 

for removing employees in the legislation before you.Right now you 

have an open-ended blank check that allows whistleblowers to be 

fired and allows the Secretary to fire people for partisan reasons. 

You are going to create a real problem unless you tighten this language substantially. 

In addition to the whistleblower protections, you need to make 

sure the due process concerns are better addressed. We also recommend that GAO do research to understand what resources 

MSPB and the Special Counsel’s Office will need to actually do this 

work right. 

I am happy to talk about other things you can do to change the 

bills. The bottom line is you need to change them if you want to 

achieve the outcomes that you want. Thank you. 

[The prepared statement of Mr. Stier follows:] 

PREPARED STATEMENT OF MAX STIER, PRESIDENT AND CEO, 

PARTNERSHIP FOR PUBLIC SERVICE

Chairman Isakson, Ranking Member Blumenthal, and Members of the Committee, Thank you for the opportunity to appear before you today. I am Max Stier, 

President and CEO of the Partnership for Public Service, a nonpartisan, nonprofit 

organization dedicated to revitalizing the Federal civil service and transforming the 

way government works. I appreciate your invitation to testify on legislation pending 

before this Committee, specifically, the Department of Veterans Affairs Accountability Act of 2015 (S. 1082) and the Ensuring Veteran Safety through Accountability 

Act of 2015 (S. 1117). 

85 

1Partnership for Public Service and Booz Allen Hamilton, Building the Enterprise: A New 

Civil Service Framework, April 2014, http://ourpublicservice.org/publications/viewcontentdetails 

.php?id=18. 2Title 5 U.S. Code § 2301 ‘‘Merit System Principles,’’ https://www.law.cornell.edu/uscode/text/ 

5/2301. 3Partnership for Public Service and Booz Allen Hamilton, Building the Enterprise: Nine Strategies for a More Integrated, Effective Government, August 2013, http://ourpublicservice.org/ 

publications/viewcontentdetails.php?id=28. 

The Partnership is one of the most vocal and passionate proponents of reforming 

our civil service system, and we issued a report 1 last year outlining a framework 

to improve the management and performance of the Federal workforce across government. However, the reforms being promoted in some of the bills before the Senate Veterans’ Affairs Committee will do more harm than good. Rather than simply 

finding ways to fire Federal employees faster, the focus of legislative reform must 

be on how we can serve our veterans better. There are a number of ways to reform 

our system and improve service to the veteran community, but moving to an ‘‘atwill’’ employment system for the Department of Veterans Affairs is not one of them. 

There are important differences between the Federal Government and the private 

sector. To start, the top leaders in government are selected for political reasons and 

typically valued for policy expertise, rather than management capability. Those 

leaders are not usually held accountable for poor management, and they should be. 

But neither should they be permitted to fire employees at will. Our nation experienced a long and unfortunate period of ‘‘at-will’’ employment at the Federal level 

which amounted to a corrupt spoils system. It took the assassination of a president 

and an angry public to move us to a merit-based system.2 Changes to current law 

must be made carefully, thoughtfully and with high regard for merit and competence. That is why today’s hearing is so important, and so needed. 

The Partnership strongly agrees that poor performance is a real problem, and we 

agree that Federal employees should be held accountable for their performance and 

conduct. Employees themselves cite poor performers as a serious issue: Partnership 

analysis of the 2014 Federal Employee Viewpoint Survey found that just 26.3 percent of employees at VA believe that steps are taken to deal with poor performers 

who cannot or will not improve. But ultimately, we believe that perhaps the biggest 

contributor to the performance problems at the VA is the quality of the management, rather than the quality of the system. While the government’s management 

systems can and must be improved, changing the system alone will not produce the 

desired results. 

You asked me to provide feedback today on pending legislation; however, first I 

would like to share the Partnership’s suggestions for actions that this Committee, 

and the Congress as a whole, can take to address the underlying problems with our 

civil service system and the barriers to attracting, hiring, developing, managing and 

retaining the very best talent. We believe these recommendations for reform will ultimately enable the Department of Veterans Affairs and the Federal Government to 

provide better service and to operate more efficiently and effectively. 

RECOMMENDATIONS

Treat Government as an Enterprise 

Government agencies operate as separate, largely independent organizations; only 

in times of crisis are resources from multiple agencies leveraged to address a single 

problem. But today’s challenges—such as providing timely and high-quality care for 

veterans—are complex, and can rarely be resolved effectively by one agency acting 

alone. The Partnership and Booz Allen Hamilton issued a report in 2013 titled, 

Building the Enterprise: Nine Strategies for a More Integrated, Effective Government.3 In the report, we advocate for a collaborative, multi-agency approach that integrates and leverages the enterprise—that is, the whole of government—to solve 

today’s complex challenges. Encouraging an enterprise approach is one way that 

Congress can respond to the fragmentation and overlap that continue to exist across 

agencies and programs. Common-sense solutions like leveraging Federal buying 

power or sharing mission-support services are possible when we build government’s 

capacity to plan, manage and measure cross-agency goals and missions. There are 

real opportunities, for example, to better integrate health systems at the Departments of Defense and Veterans Affairs, and ultimately achieve better outcomes. 

Civil Service Reform 

In no area is this need for a unified, whole-of-government approach more critical 

than in the way government manages talent. Our civil service system was established over 120 years ago. It governs more than two million workers and is a relic 

86 

of a bygone era, reflecting a time when most Federal jobs were clerical and required 

few specialized skills, and when the Federal Government’s role in society was smaller and far less complicated. The world has changed dramatically, but the civil service system has remained stuck in the past, serving as a barrier rather than an aid 

to attracting, hiring and retaining highly skilled and educated employees needed to 

respond to today’s domestic and global challenges. As previously mentioned, the 

Partnership and Booz Allen Hamilton released a report last year which creates an 

overarching strategy for reforming our civil service system, and includes recommendations for Congress and the administration on reforming pay and classification, 

hiring, performance management and strengthening senior leadership in government. 

We know that civil service reform is ambitious and it will require significant time 

and sustained attention, but we believe it is critical and deserves such deliberation. 

In the absence of comprehensive reform, we believe there are a number of actions 

that can be taken in the near term that will ultimately improve performance and 

management at VA and across government. Some of these actions fall into the category of good human resources or workforce management policies and practices. 

1) Select Agency Leaders with Management Experience, Create Term Appointments and Improve the Presidential Transition Process 

Agency leaders must be more than policy or technical experts. They must be 

equipped to manage and lead their agency. The administration should nominate 

leaders with management experience, and this Committee, as it participates in 

the confirmation process, is in a position to ensure that future leaders at VA 

demonstrate these capabilities. We also urge the Committee to exercise its oversight role and ensure continued focus on departmental management. 

In addition, Congress could consider making the Secretary of VA a five-year 

term appointment, similar to the position of IRS Commissioner, with a performance contract to ensure continuity between administrations and a continued 

focus on solving long-term management problems. Similarly, Congress could 

convert certain management-oriented political appointments to career positions, 

for example C-Suite positions such as chief financial officers, chief human capital officers, chief information officers and the chief acquisition officers, with 

fixed terms and performance contracts. In addition to promoting greater continuity and attention to management challenges, such a change would also help 

retain institutional knowledge and relieve some of the burden on the complex 

and time-consuming political appointments process. The Committee should also 

examine the compensation provided to individuals in these key positions; while 

pay is not the primary motivator for the vast majority of individuals considering 

public service positions, given the level and scope of responsibilities, current pay 

levels seem significantly inadequate compared to those offered in the private 

sector. 

Finally, Congress should pass S. 1172, The Edward ‘‘Ted’’ Kaufman and Michael Leavitt Presidential Transitions Improvements Act of 2015, which is intended to improve knowledge sharing between the outgoing administration and 

the incoming president’s team, ensure agencies are adequately prepared for 

leadership vacancies, and provide accountability for transition activities across 

the Federal Government—all critically important for an agency like the Department of Veterans Affairs. This legislation was introduced by Senators Tom Carper and Ron Johnson, and ordered reported by voice vote in the Senate Homeland Security and Governmental Affairs Committee last month. 

2) Hold Leaders Accountable in Performance Plans for Managing their Agency 

Accountability for management in government starts at the very top. Senior 

agency leaders, as well as career and political executives, should be held accountable for recruiting and selecting the right talent for their agency, engaging 

and motivating those employees, training and developing their people and preparing them for future leadership roles, and holding managers accountable for 

making tough decisions, especially with respect to performance. We recommend 

Congress require all political appointees at VA, and across government, to have 

annual performance plans, similar to those required for career employees, and 

have a transparent assessment of whether they are meeting their goals. 

3) Create new Tools to Hire the Right People 

If agencies are able to select and hire the right people with the right skills 

this will hopefully minimize performance issues down the line. In our civil service reform report we outline a series of hiring reforms that we believe would 

make it easier for agencies to attract the very best talent. For example, we recommend expanding to all agencies the use of flexibilities now available only to 

87 

certain ‘‘excepted’’ agencies, which can be achieved without compromising core 

principals such as veterans’ preference, merit-based selection, diversity and 

equal opportunity. 

In addition, agencies should be allowed to share their lists of best-qualified 

talent with one another. For example, if VA needs to hire a medical professional 

in a particular area and is having difficulty finding the best talent, the agency 

could get access to the best-qualified list for a similar position at another department. Senators Jon Tester, Rob Portman, Ben Cardin, Jerry Moran and 

Heidi Heitkamp recently introduced the Competitive Service Act, which would 

give agencies this authority. We urge Congress to pass this legislation. 

We also urge Congress to consider legislation that would permit former highperforming Federal employees to be non-competitively reinstated into government service at levels that match their skills and experience. Currently, a 

former Federal employee would only be able to return to government non-competitively at the grade level last held in government, not the higher level for 

which he/she would likely qualify given the additional years of professional experience. This small change would make it easier for VA and other agencies to 

bring experienced talent back into government. 

Creating these new hiring tools would be incredibly valuable, but even more 

importantly, H.R. staff and hiring managers must be knowledgeable about the 

hiring tools available and must be trained in how to use them. 

4) Invest in Training Managers and Hold them Accountable for Addressing 

Performance; Create a Promotion Track for Technical Experts 

VA must focus on providing better training for new managers and supervisors 

so they are prepared to succeed, and must hold their managers accountable for 

managing employee performance. The process for removing or disciplining a 

Federal employee is daunting in terms of the time and effort required, and this 

discourages some managers from taking appropriate action. Often managers are 

not trained in handling these situations and lack the will or the administrative 

and/or top-level support to act. They may have a legitimate concern about the 

personal toll and disruptive impact a removal may have on the work unit. Managers should be required to receive necessary training in how to effectively motivate, manage and reward employees, and how to deal effectively with poor 

performers; they also need access to effective assistance from their H.R. or General Counsel offices. They should also be held accountable in their performance 

plans for taking action to address poor performance or misconduct. 

In addition, VA should create a separate promotion track so that technical experts can advance in their careers without having to go into management positions for which they may be ill-suited. Too often we hear that supervisors promote their employees to management positions because they want to be able to 

pay them more, even when the employees are technical experts and often uninterested or unskilled in managing people. There should be opportunities for advancement without having to become a manager. 

5) Better Utilize the Probationary Period 

In addition to providing more and better training, VA should better utilize the 

probationary period for employees new to government and employees who are 

new supervisors in the agency. The probationary period serves as a continuation 

of the assessment process and gives the manager a chance to determine further 

an individual’s fitness for the position; individuals who have not demonstrated 

the competencies needed to perform well can be removed more easily during 

this period. As an employee’s probationary period is coming to a close, we believe managers should be required to make an affirmative decision as to whether the individual has demonstrated successful performance and should continue 

on past the probationary period. 

For new supervisors, who also serve in a probationary status, successful performance should include demonstrating management competencies in addition 

to technical skills. If an employee’s supervisor decides not to pass them through 

probation, the employee would return to a nonsupervisory position, as is currently the case according to statute. Employees who are new to government 

should be required to demonstrate fitness for the position in order to continue 

in Federal service. In the case that a manager decides the person is not fit for 

the position, he or she would be removed from Federal service. Managers should 

be held accountable in their performance plans for providing regular feedback 

to employees before making a decision on their probationary status. 

88 

4Public Law 113–146. 

6) Review and Expedite Internal Processes for Dealing with Performance 

Issues 

In talking with Federal leaders across government, we hear that many of the 

delays in dealing with performance and accountability happen at the agency 

level before an action is even taken. We believe much can be done administratively to streamline the process within the existing statutes. We recommend creating an interagency ‘‘swat team’’ that could review agency policies across government to determine how to speed up the internal process for addressing performance and misconduct issues. For example, the team could examine how 

managers are able to demonstrate that they have provided opportunities for 

their employee(s) to improve without putting them on a formal Performance Improvement Plan (PIP), which lengthens the time it takes to fire someone who 

may have already demonstrated they are not the right fit for the job. Once the 

team has determined best practices they could share those practices among all 

agencies. 

7) Consolidate and Expedite the Appeals Process 

The current Federal process for dealing with employee complaints and appeals is fundamentally flawed and does not adequately serve the needs of either 

managers or employees. Federal employees have access to multiple and sometimes overlapping dispute resolution forums on a wide range of issues and it 

can routinely take over a year or more to receive a final answer, confusing both 

managers and employees and delaying resolution. 

Greater accountability and workplace justice can be achieved by creating a 

one-stop shop that would simplify the employee complaint and appeal processes 

and expedite a final resolution of these cases to the benefit of both agency managers and employees. We recommend creating a single adjudicated body, a reconstituted MSPB that would handle all administrative appeals of agency decisions to remove or discipline employees that are currently filed with the MSPB 

and/or the EEOC. Such a body, if properly resourced, should be able to issue 

a decision within 90 days, on average. 

COMMENTS ON PENDING LEGISLATION

It is our belief that the legislation pending before the Senate Veterans’ Affairs 

Committee will not fundamentally improve performance and accountability at the 

Department of Veterans Affairs. Indeed, we believe that the legislation has the potential for harmful effects, including diminished protection for whistleblowers and 

little incentive for talented and experienced people to seek employment in the Department. We know through first-hand information that legislation passed by Congress last year 4 is having just such effect—i.e., the Department is finding it harder 

to attract the top-notch talent it needs to Senior Executive Service positions. 

If the Committee chooses to move forward on the legislation discussed below, we 

believe several amendments are necessary to minimize potentially damaging effects. 

Our recommendations are described below. 

Department of Veterans Affairs Accountability Act of 2015 (S. 1082) 

Removal or Demotion of Employee Based on Performance or Misconduct 

Section 2 of this bill would give the Secretary of Veterans Affairs total discretion 

to fire or demote employees. While we understand the intent is to expedite the process for demoting or removing someone from Federal service who is failing to serve 

veterans effectively, we believe this will have several damaging, unintended consequences, including silencing whistleblowers and hindering VA from attracting and 

retaining talent. 

We recommend providing some language to clarify the standard by which the Secretary can take an action to remove someone. A blanket removal for ‘‘performance,’’ 

left undefined, is too vague and could lead to removal for the wrong reasons. 

Our understanding of the language in Section 2(f) ‘‘Limitation on Removal or Demotion’’ is that it was drafted with the intention of protecting employees who have 

already gone to the Office of Special Counsel (OSC) alleging the action was a prohibited personnel practice. While this is important, we are concerned that there is no 

recourse in this bill for individuals who have not already gone to OSC but who believe the action taken against them is a prohibited personnel practice. In other 

words, as written, there are no protections for whistleblowers or employees who believe they have been fired for partisan or other discriminatory reasons. 

89 

5Partnership for Public Service and Booz Allen Hamilton, Building the Enterprise: A New 

Civil Service Framework, April 2014, http://ourpublicservice.org/publications/viewcontentdetails 

.php?id=18. 6Merit Systems Protection Board, What is Due Process in Federal Civil Service Employment, 

May 2015. 

The lack of whistleblower protections is particularly important. According to Partnership analysis of the 2014 Federal Employee Viewpoint Survey, 46.2 percent of 

employees at VA do not currently believe they can disclose a suspected violation of 

any law, rule or regulation without fear of reprisal. Should this legislation pass 

without a provision protecting whistleblowers, we anticipate this number will increase significantly. The very people VA needs to help disclose mismanagement, 

fraud and abuse could refrain from speaking out. One could argue that access to 

an expedited MSPB appeal protects whistleblowers or individuals who believe the 

action taken against them was a prohibited personnel practice; however, the prospect of being fired before having any chance to respond to the charges would inhibit 

many employees from disclosing wrongdoing in the first place because once the action is taken, the person is removed from Federal service and is no longer on the 

payroll. In the case that a whistleblower alleges retaliation as a result of an action 

taken by the Secretary, they would not have a venue to bring a claim if they do 

not do it within seven days from when the action is taken. 

We would support retaining the provision to protect employees who have already 

gone to the Office of Special Counsel (OSC) on an alleged personnel practice, with 

some modifications. We urge the Committee to add a new provision providing 15 calendar days for all employees to respond to the Secretary, should they believe an action taken against them as a result of this legislation is a prohibited personnel action. Current statute requires ‘‘at least 30 days’ advance written notice, unless there 

is reasonable cause to believe the employee has committed a crime for which a sentence of imprisonment may be imposed’’ (5 U.S. Code § 7513). We propose cutting 

this time in half to expedite the process but to still allow a short period of time for 

an employee to respond to the action. If the agency believes the person is a threat 

to other employees or there are other reasons to order removal from the workplace, 

the Secretary can place the individual on paid administrative leave during this 

time—with strict limits on how many days of paid leave are possible. During those 

15 days, the employee should also be allowed to take their complaint to OSC. 

Since a proposed removal or demotion of an employee in Section 2(f) would need 

to be approved by the Office of Special Counsel before it could be taken, we also 

suggest that the language be amended to place a time limit on how long OSC has 

to approve or disapprove a proposed removal or demotion. The bill should also provide a standard to use to determine whether or not to approve the proposed action. 

Such a standard, for example, might include a finding by OSC that there are reasonable grounds to believe that the proposed action is a prohibited personnel action 

(including reprisal for whistleblowing). Of course, it will also be important to ensure 

that OSC has the resources it needs to handle any new responsibilities. This Committee could ask GAO to do a quick study of the resources OSC would need to meet 

specific timeframes. 

Expedited MSPB Review 

Section 2 also includes an expedited appeals process to MSPB. While we are 

pleased to see some due process protections in the bill from the outset, we do have 

concerns about the ability of MSPB to review cases within 45 days without additional resources, particularly since they could see an increase in appeals under the 

proposed changes. In the Partnership’s Building the Enterprise: A New Civil Service 

Framework,5 we call on Congress to expedite the appeals process and argue that 

MSPB should issue decisions in 90 days. While there should be a mechanism in 

place to ensure a timely appeal process, as noted in a recent MSPB report, What 

is Due Process in Federal Civil Service Employment,6 Federal employees no longer 

receive pay and benefits once a removal action is taken and an appeal is pending. 

We believe some of the pressure to shorten the time MSPB has to issue a decision 

is based on an erroneous belief that a terminated employee continues to receive 

their Federal salary while the appeal is pending. The fact that a Federal employee 

is not receiving compensation during the appeals process, therefore, should be taken 

into account. We are also concerned that the bill strips further appeal rights to the 

courts. We believe this provision is unduly punitive since the employee will have 

been removed and the government would be at risk only if the courts determine that 

it acted wrongly. While we agree the process should be streamlined, it is important 

to choose a timeframe that also allows for a thorough review before a decision is 

90 

7FedScope (fedscope.opm.gov), from the Office of Personnel Management, for Federal civilian 

employees at most executive branch agencies who were terminated or removed due to discipline 

or performance during fiscal 2009–2014. 

issued. In the case of alleged whistleblower retaliation, for example, we believe it 

would be difficult for MSPB to resolve issues that typically arise in this type of allegation in 45 days. Congress could ask GAO to assess the resources necessary for 

MSPB to do such an expedited review. 

Probationary Period 

Section 3 makes some changes to the probationary period for employees at VA. 

The language requires employees to serve a probationary period of at least 18 

months, which may be extended at the discretion of the Secretary. The Partnership 

recognizes that there may be value in some cases to having a longer probationary 

period (e.g., in the case of lengthy training) but we think the emphasis should be 

on making good use of the probationary period not just on the length. 

The probationary period provides an opportunity for managers to help develop 

high-potential employees. It also gives them a chance to remove poor performers 

more easily. During this period, all employees should have access to training and 

should receive regular feedback from their supervisor to give them the best opportunity to succeed. However, employees who have not demonstrated the management 

and technical competencies needed to perform well in his or her role in the organization should be removed. 

We were very pleased that S. 1082 and the House companion legislation, H.R. 

1994, include language which would require an employee’s supervisor to make a 

clear decision at the end of the probationary period as to whether or not the employee would continue past the probationary period or be removed from Federal 

service. While this is a great first step, this provision applies only to employees who 

are new to government. We urge the Committee to expand this language to make 

sure it applies to new supervisors in government who also serve a probationary period. We also recommend clarifying what happens if a supervisor does not take an 

action at the end of the probationary period. One option is to have the employee 

continue in a probationary status for a finite amount of time while a higher level 

of review is triggered. 

Ensuring Veteran Safety through Accountability Act of 2015 (S. 1117) 

This bill would expand recently enacted legislation making it easier to fire senior 

executives at the Department to include individuals appointed to the Veterans 

Health Administration. In addition, it would strike procedures under Sections 

7461(b) (adverse actions) and 7462 (major adverse actions involving professional 

conduct or competence) of Title 38 and Sections 7503 (cause and procedure) and 

7543(b) (cause and procedure) of Title 5 in addition to the current law which says 

that procedures under Section 7543(b) (cause and procedure) of Title 5 do not apply. 

Similar to the legislation previously discussed, we are concerned that this language does not provide employees with sufficient due process protections other than 

expedited appeal rights to MSPB after a removal has taken place. In short, it does 

not protect the public interest in a civil service free of prohibited personnel practices, including reprisals against whistleblowers. We recommend the Committee include language that gives employees an expedited opportunity to respond to the action. At the same time, the individual should have the ability to get a quick decision 

from the Office of Special Counsel as to whether there is reasonable cause to believe 

that the termination or demotion proposed constitutes a prohibited personnel practice and, therefore, the action should be stayed until a further review is made. 

While MSPB to date appears to have been able to handle its new responsibilities 

within its current resources, we remain concerned that a truncated appeals process—a 21-day expedited review in this case—could easily exceed MSPB’s capabilities 

if these provisions are expanded to all VHA employees, and especially if it is adopted on a governmentwide basis. Between FY 2009 and FY 2014, a total of 62,965 

employees were terminated (fired) for conduct or performance across government. 

The Department of Veterans Affairs accounted for 13,969 of those 62,965 terminations.7 If this is expanded governmentwide, it would have significant implications 

for MSPB. 

CONCLUSION

Mr. Chairman and Members of the Committee, thank you for the opportunity to 

appear before you today. This is a very important issue that deserves the time, attention and understanding that you are devoting to it. The Partnership stands ready 

to help. 

91 

Chairman ISAKSON. Thank you. 

Mr. Rowan, 3 minutes. Quickly. 

STATEMENT OF JOHN ROWAN, NATIONAL PRESIDENT, 

VIETNAM VETERANS OF AMERICA 

Mr. ROWAN. Thank you, Mr. Chairman. We basically support all 

the bills with certain caveats that are in our written testimony, 

and I think you can get the details on that. 

I really just want to focus on S. 901, which is the main piece of 

legislation that we have been supporting. We thank Mr. 

Blumenthal and Mr. Moran and all the other cosponsors of that 

piece of legislation. 

We are celebrating 50 years—we are going to come here in a couple of weeks to celebrate 50 years since the Vietnam War, and the 

Congress, the Speaker is going to pat me on the back, I guess. But, 

the truth is, in 50 years, the VA has done no studies on the Vietnam War and its effect on us, and certainly not much on anybody 

that came after us. 

And, with all due respect to all of these other agencies that may 

study the effects of toxic exposures or particular items or particular 

issues or particular things, they are not going—covering the comprehensive effects of exposure on the battlefield in Vietnam, the 

Persian Gulf, or the present day, that needs to be done by the VA, 

who is mandated to take care of veterans and not anybody else. 

This particular piece of legislation goes to the effects on our children. It has taken us years, literally years, to come up with a lists 

of all of the illnesses related to Agent Orange and now we are 

going to have to start over again with our children (many of whom 

are in their 40s), our grandchildren (who are now in their 20s), 

some of them? That is not fair. 

And, forget about the folks after Vietnam. Are they going to wait 

40 years? Meaning, my colleagues who came out of Iraq sitting at 

this table are going to wait 40 years to find out what happened to 

them? I hope not. 

So, that is as simply and as succinctly as I can get. Thank you. 

[The prepared statement of Mr. Rowan follows:] 

PREPARED STATEMENT OF JOHN ROWAN, NATIONAL PRESIDENT, 

VIETNAM VETERANS OF AMERICA

Good afternoon, Chairman Isakson, Ranking Member Blumenthal, and other 

Members of this distinguished and important Committee. Vietnam Veterans of 

America very much appreciates the opportunity to offer our comments concerning 

several bills affecting veterans that are up for your consideration. Please know that 

VVA appreciates the efforts of this Committee for the fine work you are doing on 

behalf of our Nation’s veterans and our families. 

I ask that you enter our full statement in the record, and I will briefly summarize 

the most important points of our statement. 

S. 469, WOMEN VETERANS AND FAMILIES HEALTH SERVICES ACT OF 2015

Introduced by Senator Patty Murray (WA), would direct the Secretary of Defense 

(DOD) to furnish fertility treatment and counseling, including through the use of 

assisted reproductive technology, to a spouse, partner, or gestational surrogate of a 

severely wounded, ill, or injured member of the Armed Forces who has an infertility 

condition incurred or aggravated while serving on active duty. 

Vietnam Veterans of America supports this bill as written. VVA has supported 

medically assisted procreation procedures for service-disabled veterans for more 

than three decades, and we will continue to do so. 

92 

S. 901, TOXIC EXPOSURE RESEARCH ACT OF 2015

Introduced by Senator Jerry Moran (KS), would establish in the Department of 

Veterans Affairs a national center for research on the diagnosis and treatment of 

health conditions of the descendants of veterans exposed to toxic substances during 

service in the Armed Forces that are related to that exposure, to establish an advisory board on such health conditions, and for other purposes. 

Among the invisible wounds of war are those brought home by troops, some of 

which may not manifest for a decade or more. Most tragically, they may also pass 

on genetically the effects of these wounds to their progeny. No one can argue that 

our children and grandchildren should have these burdens visited on them. This is 

a multi-generational bill. It provides a common vehicle for evaluating potential 

transgenerational effects of toxic exposures, from Camp Lejeune and Fort McClellan, to Agent Orange in multiple locations, to the toxic plume that sickened thousands of Gulf War veterans. 

Toxins, such as TCDD dioxin, are believed to cause birth defects in children of 

military personnel who came into contact with them—in-country troops during the 

Vietnam War, as well as the several thousand Reservists who rode in and maintained aircraft that had been used to transport the toxins. By means of the desalination units having the perverse effect of concentrating the dioxin up to 30 times, 

Navy personnel who served off of the coast of Vietnam also were exposed. For Gulf 

War veterans, the exposure was to chemical weapons in Iraqi ammo dumps containing chemical and biological agents that were blown up by U.S. Forces during 

the Gulf War; and burn pit smoke and possibly tainted vaccines and medicines ingested by troops in Afghanistan and Iraq. 

This is a simple and straightforward proposal that will begin to address the needs 

of the progeny of every generation of veterans, because the health conditions seen 

in some are so heartbreaking to so many families who wonder, ‘‘Did my service 

cause my children to suffer? ‘‘ 

(Please see ‘‘Faces of Agent Orange’’ at: https://www.facebook.com/pages/Faces-ofAgent-Orange/187669911280144) 

VVA unequivocally supports S. 901. 

Vietnam Veterans of America applauds the leadership of Senator Moran (KS), 

working with his colleague Senator Dick Blumenthal (CT), to construct and introduce this bipartisan bill to begin to properly address the situations outlined above. 

Let me address a few important issues within this legislation: 

First, the National Center envisioned in this bill belongs in the Department of 

Veterans Affairs. Doctrine, law, and precedent all dictate that, since the time of 

Abraham Lincoln, the concerns of veterans and their progeny are vested in this department. This Center for Excellence is a small entity that will functionally manage 

the activities to assist the Advisory Board in overseeing research. 

Second, we agree with VA testimony that the VA lacks the internal capability, capacity, and experience in the intergenerational research that will be required. The 

Advisory Board provides the VA Secretary with knowledge and scientific expertise 

to obtain research required by the legislation. 

Third, we believe that the VA does have the capability, capacity, and experience 

to contract with any number of governmental, quasi-governmental, academic, scientific, or non-profit research organizations skilled in the research and administration outlined in the legislation; and further, such organizations would be able to 

achieve the intent of the legislation in a much more timely and cost-efficient means 

than the VA could ever achieve. 

Fourth, the legislation gives the VA Secretary a strong, independent Advisory 

Board—of unpaid professionals—to provide diverse perspectives and technical expertise, assuring that the VA is provided with research-based outcomes that are respected and acknowledged by the military, our veterans and their descendants, and 

the scientific communities. 

Finally, we agree with VA testimony before the House Veterans’ Affairs Subcommittee on Health on April 23, 2015, that this bill will be funded from existing 

R&D appropriated funding, that it will be deficit neutral, and that VA cost estimates are correct, if maybe even high. 

S. 1082, DEPARTMENT OF VETERANS AFFAIRS ACCOUNTABILITY ACT OF 2015

Introduced by Senator Marco Rubio (FL), would authorize the VA to remove or 

demote a VA employee based on performance or misconduct. 

And, 

93 

S. 1117, ENSURING VETERAN SAFETY THROUGH ACCOUNTABILITY ACT OF 2015

Introduced by Senator Ron Johnson (WI), would expand the authority of the VA 

Secretary to remove senior VA executives for performance or misconduct, to include 

removal of VA health care professionals. 

VVA Supports S. 1082 and S. 1117 with significant reservations, given that there 

is no excuse for the dissembling and lack of accountability in regard to much of 

what happens at the VA. 

Accountability is certainly better at the VA today than it was a year ago, but 

there is a long way to go in regard to cleaning up that corporate culture to make 

it the kind of system it should become. The VA must change so that it can be trusted to get the ‘‘biggest bang for the taxpayer’s buck’’ and, most importantly, get the 

individual veteran the best care or service in a timely way. It can be cleaned up 

if there is the political will to hold people accountable for doing their job properly. 

VVA strongly believes that more due process and other safeguards should be built 

in for workers as opposed to managers. The split would be roughly at Grade 14 and 

above and include anyone who has supervisory or management duties. That does 

not mean that a non-supervisory VA employee or a lower pay grade worker can escape accountability for quality and/or quantity of their work, but it does recognize 

that the problems primarily rest with management. 

Furthermore, it is clear to VVA that those VA employees who voice unwelcome 

truths and who have the courage to stand up for what is right on behalf of our Nation’s veterans are still being harassed, punished, and their livelihoods threatened. 

The President and the Secretary simply must take immediate and effective action 

to address this ongoing problem. 

S. 1085, MILITARY AND VETERAN CAREGIVER SERVICES IMPROVEMENT ACT OF 2015

Introduced by Senator Patty Murray (WA), would expand eligibility for the family 

caregiver program of the Department of Veterans Affairs to include members of the 

Armed Forces or veterans who are seriously injured or who became ill on active 

duty prior to September 11, 2001 (currently limited to service after September 11, 

2001). 

VVA strongly supports S. 1085, which will primarily assist family caregivers of 

catastrophically wounded or injured warriors who served prior to September 2001. 

Thanks to the bravery and the tenacity of our medevac crews and military medical personnel at evacuation hospitals, catastrophically wounded warriors who would 

surely have perished in Vietnam are now being saved. Heart-rending testimony before congressional committees by surviving veterans, by their wives, and by their 

mothers, moved Congress to pass the Caregivers and Veterans Omnibus Health 

Services Act of 2010 to assist family caregivers of catastrophically wounded or injured warriors after 9/11. 

There was a caveat in this legislation: The VA Secretary was to report to Congress on how the caregiver program has been working, and what, in his judgment, 

might be the efficacy of extending the program to family caregivers of veterans of 

Vietnam, Africa, and the Persian Gulf War. That report was two years late. Needless to say, these caregivers did not receive some of the benefits of this legislation. 

Why not? It was not pursued by the Administration because it was deemed to be 

‘‘too expensive.’’ How many caregivers of Vietnam veterans will potentially be eligible for the VA’s caregivers program? We don’t know. What we do know is that we 

will work with Senator Murray to achieve enactment of this bill that will encompass 

qualified caregivers of veterans who served before 9/11, and we will work with leadership to make enactment of this legislation a priority, despite any budgetary misgivings they may have. 

H.R. 91, VETERAN’S I.D. CARD ACT

Introduced by Congressman Buchanan (FL–16), would direct the VA Secretary to 

issue a veteran’s identification card to any veteran who requests such card and is 

neither entitled to military retired pay nor enrolled in the VA system. 

For lack of quick or easy access to their DD–214, many veterans who have received an other-than-dishonorable discharge for their military service lose out on opportunities ranging from obtaining a job, to getting through security to take a flight, 

to a variety of private as well as public services. H.R. 91, when enacted into law, 

will provide these men and women with a simple card that they can carry in a wallet. It is our hope that your colleagues from both sides of the aisle will understand 

its benefits, and we support H.R. 91 as written. 

94 

DISCUSSION DRAFT, INCLUDING PROVISIONS DERIVED FROM S. 1021 (DURBIN), 

S. 1358 (MURKOWSKI/SULLIVAN). 

S. XXX JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

To be introduced by Senator Tammy Baldwin (WI). 

VVA strongly supports this draft bill with two suggested additions: 

1) The Food and Drug Administration should decline to approve or revoke approval for easily abused opioid drugs if an abuse-deterrent version exists. For example, in November 2014, the FDA approved an extended-release formulation of 

hydrocodone bitartrate with abuse-deterrent properties (Hysingla ER) for the treatment of pain severe enough to require daily, around-the-clock, long-term opioid 

treatment, and for which alternative treatment options are inadequate. The tablet 

is designed to be hard to crush, break, dissolve, or prepare for injection. It is available in strengths of 20, 30, 40, 60, 80, 100, and 120 mg and is taken every 24 hours. 

2) VA facilities where such opiate pain medications are authorized should be mandated to become signees to a state’s prescription drug-monitoring program (PDMP) 

where available. According to the National Alliance for Model State Drug Laws 

(NAMSDL), a PDMP is a statewide electronic database which collects designated 

data on substances dispensed in the state. The PDMP is housed by a specified statewide regulatory, administrative or law enforcement agency, which distributes data 

from the database to individuals who are authorized under state law to receive the 

information for purposes of their profession. 

VVA thanks you for the opportunity to share our views on the vitally needed legislation that you are considering today. I will be pleased to answer any questions 

you might have. 

Chairman ISAKSON. I want the record to reflect that Vietnam 

Veterans gets the award for the most succinct and concise 

testimony. [Laughter.] 

Senator BLUMENTHAL. I want to thank all of our witnesses and 

apologize that we have these votes. Obviously, it was not the 

Chairman and I scheduling them. Thanks to the Chairman, also, 

for making sure that we conclude. Your testimony will be in the 

record. We hope to pursue these issues. Thank you. 

Chairman ISAKSON. We stand adjourned. Thank you. 

[Whereupon, at 4:13 p.m., the Committee was adjourned.] 

(95) 

A P P E N D I X 

PREPARED STATEMENT OF HON. MARCO RUBIO, U.S. SENATOR FROM FLORIDA

Chairman Isakson, Ranking Member Blumenthal, and Members of the Committee, thank you for holding this hearing today. I would like to submit for the 

record my views on pending legislation before the Committee, namely S. 1082, the 

Department of Veterans Affairs Accountability Act of 2015. 

In the wake of reports detailing how very few people have been held accountable 

for last year’s scandal at the Department of Veterans Affairs, on April 23, 2015, I 

introduced the ‘‘Department of Veterans Affairs Accountability Act of 2015,’’ which 

would give the VA secretary new, expanded authorities to remove or demote any 

VA employee based on poor performance or misconduct. 

This legislation would expand on last year’s VA reform law by giving the VA secretary the authority to terminate any employees for performance-related issues, not 

just managers. It mirrors legislation (H.R. 1994) filed in the U.S. House of Representatives by House Veterans’ Affairs Committee Chairman Jeff Miller. 

Last year, I was proud to lead the effort to give the VA secretary the authority 

to fire senior executives based on performance. A year later, it’s clear additional authorities are needed to deal with the full scope of the problems at the VA. Once enacted into law, this new legislation will leave the VA secretary with no excuse but 

to hold people accountable for the dysfunction and incompetence plaguing our VA 

system, while protecting whistleblowers from retaliation. We must show our veterans the respect they have earned by removing any employees with terrible performance from the system our veterans rely on. 

I also want to recognize that later this week the Subcommittee of the House Committee on Oversight and Government Reform will hold its own hearing on reforming 

the VA. It will hear testimony from Florida constituent and St. Johns County Assistant Administrator Jerry Cameron about problems stemming from the VA’s selection and leasing process for new facilities. It represents part of a larger national 

problem regarding our VA facilities, which are experiencing significant delays and 

cost overruns that ultimately hurt both veterans and taxpayers. 

I strongly support S. 1082 and recommend the Committee favorably report the bill 

out as soon as possible so that it receives a vote by the full U.S. Senate. I also hope 

today’s hearing will help shed light on VA accountability reform and provide the 

Committee with a better understanding of how we can best serve our veterans. 

PREPARED STATEMENT OF AMERICAN FEDERATION OF GOVERNMENT EMPLOYEES, 

AFL–CIO AND ITS NATIONAL VETERANS AFFAIRS COUNCIL (AFGE) 

Chairman Isakson, Ranking Member Blumenthal, Members of the Committee, 

thank you for the opportunity to present the views of the American Federation of 

Government Employees, AFL–CIO and its National Veterans Affairs Council 

(AFGE) regarding pending legislation. AFGE represents over 670,000 Federal employees, including more than 220,000 employees of the Department of Veterans Affairs. AFGE’s representation of non-management, front line employees working in 

virtually every non-management position in the Veterans Health Administration 

(VHA), Veterans Benefits Administration (VBA), National Cemetery Administration 

and other VA functions allows us to share a unique perspective with the Committee. 

AFGE also greatly appreciates the efforts by Members of this Committee to solicit 

the views of our AFGE locals in settings where they feel free to share their concerns 

and recommendations without reprisal. 

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S. 1082

Overview of S. 1082 

AFGE and the National VA Council strongly oppose S. 1082. We urge lawmakers 

to reject this counterproductive and dangerous anti-accountability bill in favor of 

legislation that will truly improve accountability by reducing mismanagement from 

the outset, expanding protections against prohibited personnel practices for every 

VA employee and strengthening the VA investigative process. 

S. 1082 is dangerous because it destroys the civil service protections of the very 

non-management employees who can hold management accountable to uphold the 

interests of veterans. This bill is dangerous because longer probationary periods will 

subject more veterans in the VA workforce to unfounded or discriminatory terminations. This bill is also dangerous because it diverts the resources of the Office of 

Special Counsel (OSC) and Merit Systems Protection Board (MSPB) away from appropriate claims of retaliation and discrimination. Finally, this bill is dangerous because it will cause significant numbers of physicians and other employees skilled in 

critical shortage occupations to leave the VA or reject a future VA career, undermining veterans’ access to the high quality services they rely on from the VA. 

S. 1082 is poised to set the clock of workers’ rights back more than 100 years. It 

makes the employment of VA employees subject to the whims of the VA Secretary, 

a political appointee. We learned in the Progressive Era that it is a great public 

good to have a civil service insulated from politics. Anyone who doubts that this bill 

creates a full-fledged patronage system should take a look at the history of government employment prior to the passage of the Pendleton Act of 1883. 

By tearing down the due process protections granted to the covered employees, 

this bill would have the overall effect of chilling disclosures, destroying employee 

morale, and undermining the retention of many of VA’s most experienced and valuable employees. 

Analysis of Section 2: Removal or Demotion of Employees Based on Performance or 

Misconduct 

Section 2 of S. 1082 takes away fundamental due process rights from front line, 

non-management VA employees in the VHA, VBA, NCA and other VA units, including thousands of service-connected disabled veterans. This section extends the SES 

due process cuts enacted in the Choice Act to non-SES managers as well as to every 

non-management front line employee. Despite the fact that the bill is presented as 

a tool to enhance accountability for SES and upper management, its greatest target 

is the 350,000 plus non-management employees who work on the front lines, including service-connected disabled veterans who clean operating rooms, police emergency rooms, maintain VA cemeteries and rate disability claims, and their coworkers who are primary care providers, PTSD therapists, surgeons, bedside nurses, 

electronic health record technicians, among so many other essential positions. Stripping job protections from non-management employees will result in more mismanagement in the form of retaliation, discrimination, patronage and anti-veteran 

animus. And veterans care will suffer, along with the employees who have pledged 

their careers to care for veterans. 

This bill proceeds from the false premise that it is ‘‘too hard’’ to remove Federal 

employees under the current system. It is not. The VA already has—and uses—existing tools to fire poor performers and front line employees engaged in misconduct. 

If more terminations need to go forward, lawmakers should focus on poorly trained 

supervisors and inadequate use of the existing probationary period. Employees 

should only be removed for legitimate causes. Yes, this is harder than ‘‘at will’’ employment, but maintaining an apolitical, merit-based civil service requires that termination be for demonstrable causes. This is not ‘‘too hard’’ for a competent and responsible manager. 

According to the Merit Systems Protection Board’s 2015 Report, What is Due Process in Federal Civil Service Employment?, over 77,000 full-time, permanent, Federal 

employees were discharged as a result of performance and/or conduct issues from 

FY 2000 to FY 2014. In FY 2014, 2,572 VA employees were terminated or removed 

for disciplinary or performance reasons, according to the Office of Personnel Management. Also, contrary to some of the rhetoric behind calls to eliminate Federal 

employee job rights, Federal employees do not continue to receive their salaries 

after they are terminated. 

S. 1082 entirely eliminates the procedural protections of 5 U.S.C. § 7513(b) and 5 

U.S.C. § 4303. Section 7513(b) is the adverse action section of the Civil Service Reform Act (CSRA). If S. 1082 were enacted, every non-management VA employee 

would lose the following rights: 

• Right to 30 days’ advance notice before an adverse action may be imposed; 

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• Right to 7 days for the employee to respond; • Right to a representative; and • Right to a written decision. 

Section 4303 serves much the same function for unacceptable performance actions, although the specifics are different. 

By eliminating these two sections, S. 1082 eliminates the ‘‘notice and opportunity 

to be heard’’ that have been a hallmark of Federal sector due process since before 

the CSRA was adopted in 1978. These provisions form the very foundation for due 

process in the civil service system. To be clear, nothing in section 7513 or in section 

4303 currently prevents agencies from removing employees or requires the MSPB 

or any other reviewing body to reach a particular result. 

S. 1082 eliminates 7513(b), the core notice and opportunity to be heard section of 

the CSRA’s adverse action protections. This sets up a fundamental denial of due 

process, which might never be heard because the bill also provides that notwithstanding any other provision of law, including 5 U.S.C. § 7703 (the CSRA’s judicial 

review section for adverse actions), the decision of the MSPB’s administrative judge 

shall be final and shall not be subject to any further appeal. 

Put another way, while the bill provides a nominal right to appeal a removal or 

demotion action by the Secretary to the MSPB, if it is appealed before a harsh 7- 

day deadline that itself has no textual support, the bill substantively precludes both 

full MSPB review and judicial review. 

This creates a situation that is arguably worse than traditional notions of at-will 

employment. In the private sector, for example, at-will employees may have access 

to the courts under a contract or tort theory even if they do not have due process 

rights. Because of the comprehensive nature of the CSRA, and numerous cases interpreting the CSRA, Federal employees are prohibited from bringing these same 

types of contract and tort claims to court. VA employees covered by this bill would 

thus become ‘‘at-will plus’’ or, perhaps more accurately, ‘‘at-will minus.’’ 

Blocking access to the objective review provided by the courts, or even blocking 

full review by the MSPB, would invite VA managers (who have already shown 

themselves willing to abuse the rights of whistleblowers) to engage in arbitrary or 

capricious conduct vis-a`-vis the front line VA workers. This is compounded by the 

fact that bill contains a provision mandating that if the MSPB’s Administrative 

Judge cannot issue a decision within 45 days, then ‘‘the removal or demotion is 

final.’’ Given that the MSPB already has an active and heavy caseload, this provision is an additional and intentional elimination of fundamental employee rights. 

With respect to whistleblower provisions in Section 2, the bill ignores the practical 

reality that not all individuals will file for corrective action and that OSC is not 

well-suited to essentially pre-approving the removal of every putative whistleblower. 

The bill would nonetheless force employees facing discrimination and other forms 

of prohibited personnel practices into OSC complaints in order to shield themselves 

from their new at-will employment status. This helps neither veterans nor whistleblowers. It only precipitates a flood of OSC complaints that are likely to paralyze 

OSC and obscure the most valid cases of whistleblower retaliation at the same time. 

AFGE has worked with more than 40 rank-and-file whistleblowers in the VA who 

have been threatened or retaliated against by VA managers precisely because they 

blew the whistle on waste, fraud and abuse that was, like the wait list scandal, 

caused by VA managers. If S. 1082 is enacted, there will be no recourse for these 

employees, and the derelictions of VA managers will likely be swept under the rug. 

VA employees will be left with the choice of keeping quiet about mistreatment of 

veterans or losing their jobs. 

Analysis of Section 3: Required Probationary Period for New VA Employees 

Section 3 of the bill would extend the current one-year probationary period to 18 

months, and the employee’s ability to secure permanent status after that would be 

subject to the complete discretion of the Secretary to extend that probation to two 

years, three years or even longer. Contrary to the assertions of bill proponents, Section 3 would also extend the probationary periods of over 70,000 health care employees under the Hybrid Title 38 personnel system, including every psychologist, pharmacist, blind rehabilitation specialist, social worker, licensed practical nurse, 

orthotist-prosthetist, respiratory therapist, physical therapist and other positions 

under 38 U.S.C. 7401(3). (Under current law, health care personnel appointed under 

38 U.S.C. 7401(1), including physicians and registered nurses have two year probationary periods.) 

The large numbers of veterans recently hired into the VA workforce know firsthand how powerless they are when a manager who has failed to train them properly 

or resents having to hire a veteran decides to fire them. Congress has heard testimony about claims processors and health care professionals, among others, who 

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were summarily fired during probation without recourse, even though their terminations were motivated by retaliation, or what would otherwise be prohibited personnel practices. 

It is already extremely difficult for agencies such as the OSC and MSPB to protect 

probationary employees from unjustified adverse actions, because the burden of 

proof on employers is extremely low. Subjecting more employees to longer probations and the whim of managers who wish to harass then with even longer periods 

of at-will employment will further devastate the VA’s efforts to hire veterans and 

Hybrid Title 38 mental health professionals in VA ‘‘mission critical’’ occupations in 

short supply such as psychologists, pharmacists and physical therapists. (See the 

Veterans Health Administration’s 2014 report, Interim Workforce and Succession 

Strategic Plan, Table 3.) 

Analysis of Section 4: Comptroller General Study of Department Time and Space 

Used for Labor Organization Activity 

Section 4 of S. 1082 mandates a study of Department time and space for labor 

organization activity. We are concerned that this provision may be used to weaken 

the rights of non-management employees and limit the ability of taxpayers to hold 

VA management accountable. 

Under current law, union official time allows Federal employees who are volunteer union representatives to represent all their coworkers (those who pay dues and 

those who don’t) while in an official duty status. Union representatives are prohibited from using official time to conduct union-specific business, solicit members, hold 

internal union meetings, elect union officers, or engage in partisan political activities. 

The use of official time in the VA benefits taxpayers, veterans, and Federal employees because it reduces costly employee turnover, improves service, creates a 

safer workplace, and leads to quicker implementation of agency initiatives. Official 

time gives workers a voice to resolve disputes efficiently so they can get back to 

work, protect whistleblowers from retaliation, and implement new technology and 

other innovations to solve workplace problems in collaboration with management. 

In its 2014 report, Labor Relations Activities: Actions Needed to Improve Tracking 

and Reporting of the Use and Cost of Official Time (GAO–15–9), GAO studied union 

official time and recommended that the Office of Personnel Management consider 

alternative approaches to developing cost estimate and new opportunities to increase efficiency of data collection and reporting. 

A study that assesses the use of official time in VA according to objective criteria, 

such as those identified and used in the GAO study, is never problematic. But we 

are concerned that the study of official time mandated in S. 1082 may be used as 

a means to legitimize the elimination of this important function, given the overall 

animus toward front line VA employees that infuses the remainder of the bill. We 

urge the Committee to amend the language in the bill to require that the study use 

a template resembling the GAO study referenced above, or OPM’s annual studies 

of official time. The study must not be yet another highly politicized means of eliminating frontline workers’ ability to hold VA management accountable. 

Finally, AFGE urges Committee members to consider the unintended consequences of S. 1082’s extreme assault on civil service protections, as articulated by 

the MSPB in its 2015 report: 

Due process is available for the whistleblower, the employee who belongs 

to the ‘‘wrong’’ political party, the reservist whose periods of military service are inconvenient to the boss, the scapegoat, and the person who has 

been misjudged based on faulty information. Due process is a constitutional 

requirement and a small price to pay to ensure the American people receive 

a merit based civil service rather than a corrupt spoils system. 

S. 1117

Overview of S. 1117 

AFGE and the National VA Council strongly oppose S. 1117. We urge lawmakers 

to reject this equally counterproductive and dangerous anti-accountability bill in 

favor of legislation that will truly improve accountability. Although S. 1117 is described as an SES bill (a bill ‘‘to expand the authority of the Secretary of Veterans 

Affairs to remove senior executives’’), in fact, this bill strips fundamental due process rights from every non-management VA employee. Whereas S. 1082 also targets 

VA employees in Title 5 positions (including VBA, NCA, and information technology), S. 1117 focuses its due process cuts on the vast majority of VHA employees, 

i.e. the Full Title 38 and Hybrid Title 38 employees. 

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Who are the health care employees who will lose all their civil service protections and become at-will employees under S. 1117? 

• Every front-line non-management Full Title 38 employee, i.e. every physician, dentist, registered nurse, physician assistant, podiatrist, optometrist, chiropractor and expanded-function dental auxiliary (38 U.S.C. 

7401(a); and 

• Every front-line non-management Hybrid Title 38 employee including 

every psychologist, audiologist, biomedical engineer, respiratory therapists, physical therapist, licensed practical nurse, nursing assistant, 

orthotist-prosthetist, pharmacist, social worker, family therapist, blind rehabilitation specialist and every other position covered by 38 U.S.C. 

7401(3). 

All these employees will lose the following fundamental due process rights to challenge unfair terminations, demotions, and other adverse actions: 

• Right to 30 days’ advance notice before an adverse action may be imposed; 

• Right to 7 days for the employee to respond; 

• Right to a representative; and 

• Right to a written decision. 

Like S. 1082, S. 1117 is dangerous because it destroys the civil service protections 

of the very non-management employees who can hold management accountable to 

uphold the interests of veterans. This bill is also very harmful to the VA health care 

system because it will cause significant numbers of physicians and other healthcare 

professionals skilled in critical shortage occupations to leave the VA or reject a future VA career, undermining veterans’ access to the high quality of medical services 

they rely on from the VA. 

Like S. 1082, S. 1117 makes the employment of every VA Title 38 employee subject to the whims of the VA Secretary. By tearing down the due process protections 

granted to the covered employees, this bill would have the overall effect of chilling 

disclosures, destroying employee morale, and undermining the retention of many of 

VA’s most experienced and valuable employees. Every brave Title 38 employee from 

Phoenix, Tomah, Pittsburgh, Hines, Wilmington, Delaware and other medical centers who made lifesaving disclosures to Congress, investigators and their own managers in order to protect veterans will become at-will employees with no civil service 

protections if S. 1117 is enacted. 

Analysis of Section 2: Expansion of Authority of Secretary of Veterans Affairs to Removed Senior Executives of Department of Veterans Affairs for Performance or 

Misconduct to Include Certain Other Employees of the Department 

Contrary to the title, Section 2 of S. 1117 does not make any further changes to 

SES rights. Instead, Section 2 applies all the SES due process cuts from the Choice 

Act to every non-management Title 38 employee. 

The only difference in due process rights between S. 1117 and S. 1082 relates to 

the length of time the MSPB has to complete its one-level review before the termination is finalized. Under S. 1117, MSPB has 21 days, whereas under S. 1082, 

MSPB has 45 days. Under both bills, if MSPB is unable to review this case within 

the fixed timeframe, the Secretary’s unilateral decision to terminate or demote the 

employee becomes final. Under this bill, Title 38 whistleblowers will have the identical, diminished rights as every other Title 38 employees. 

In summary, AFGE strongly urges the Committee to oppose S. 1117 which will 

have enormous unintended consequences including: (1) a vast reduction in disclosures from non-management employees regarding patient safety issues and other 

mismanagement; (2) additional obstacles to the VA health care system’s ability to 

compete for physicians and other health care professionals and retain valuable clinicians already on board; and (3) increased harm to VA clinicians through retaliation 

and other prohibited personnel practices. 

S. 469

AFGE supports S. 469, the Women Veterans and Families Health Services Act of 

2015. AFGE represents dedicated medical and behavioral health care personnel in 

facilities across the Nation who provide specialized care to women veterans and 

their families. We commend Senator Murray for her continued leadership in ensuring that comprehensive health care services are available to women veterans and 

their families. 

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S. 901

AFGE supports S. 901, the Toxic Exposure Research Act of 2015. We commend 

Ranking Member Blumenthal and Senator Moran for their leadership on this important legislation. 

S. 1085

AFGE support S. 1085, the Military and Veteran Caregiver Services Improvement 

Act. We commend Senator Murray for her leadership in providing adequate support 

to veterans’ caregivers. 

DRAFT BILL—JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

AFGE supports this important legislation and commends Senator Baldwin for her 

continued leadership on behalf of veterans by ensuring safe prescribing practices. 

Front-line health care professionals represented by AFGE played a vital role in disclosing improper prescribing practices at the Tomah, Wisconsin medical center. 

Every day, the dedicated front-line employees we represent at VA medical centers 

strive for maximum patient safety, including proper prescribing practices. We urge 

lawmakers and VA officials to include front line employees and their employee representatives on working groups, pain management boards and other groups and research efforts established under this legislation. 

Thank you for the opportunity to testify on these important legislative issues. 

PREPARED STATEMENT OF DIANE M. ZUMATTO, NATIONAL LEGISLATIVE DIRECTOR, 

AMVETS 

S. 469, THE WOMEN VETERANS AND FAMILIES HEALTH SERVICES ACT OF 2015

As we’re all aware, IEDs, which are generally detonated on the ground, often 

cause severe trauma to the sexual organs and genitourinary system. These debilitating injuries can have devastating impacts—not only to urinary and sexual function, but also on fertility. If the issue of infertility is not adequately addressed for 

the young men and women in uniform, it will be adding insult to injury. Thanks 

to the horrific wounds received in battle on behalf of our country, many servicemembers have entirely lost their reproductive capabilities or their ability to reproduce has been severely compromised. 

While genitourinary organ injuries (urotrauma) do not comprise the highest percentage of battlefield injuries, they have become increasingly more common and are 

no less physically and psychologically devastating. Unfortunately, neither the more 

clinical, care-delivery aspects of research, treatment and rehabilitation of 

urotrauma-type injuries, nor the policy aspect of these injuries, have kept pace with 

the more common battlefield wounds such as amputations, or the neuropsychological 

wounds of war including Post Traumatic Stress Disorder (PTSD) and Traumatic 

Brain Injury. 

AMVETS suggests that the VA take a comprehensive view of the urotrauma issue 

by seeking ways of: 

• improving the prevention of these injuries; 

• improving battlefield medical procedures; 

• improving the reconstruction process; and 

• improving the overall management of both the functional and fertility issues resulting from urotrauma 

AMVETS fully supports legislation that seeks to improve VA health care options 

for both male and female military/veterans to include fertility counseling and treatment. 

AMVETS supports increased research, to be conducted jointly by DOD and VA, 

with the intent of improving VA’s ability to meet the long-term reproductive health 

care needs of veterans who have incurred service-connected urotrauma or other line 

of duty injuries that affect a veterans’ ability to reproduce. AMVETS feels strongly 

that these types of injuries are not merely health issues; they are quality of life 

issue as well. 

AMVETS supports much of this comprehensive legislation which would specifically: 

• furnish fertility treatment and counseling, including through the use of assisted 

reproductive technology, to a spouse, partner, or gestational surrogate of a severely 

wounded, ill, or injured member of the Armed Forces who has an infertility condition incurred or aggravated while serving on active duty in the Armed Forces; 

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• allow the member to be treated with donated gametes and pay or reimburse the 

reasonable costs of procuring donor gametes, if the member is unable to provide 

their own gametes; 

• establish procedures for gamete retrieval from a member of the Armed Forces; 

• give members of the Armed Forces on active duty the opportunity to 

cryopreserve and store their gametes prior to deployment to a combat zone at no 

cost to the member. AMVETS has concerns with this provision due to the myriad 

of ethical issues and fiscal concerns; 

• direct DOD and VA to share best practices and facilitate fertility treatment and 

counseling referrals to eligible individuals; 

• include fertility counseling and treatment within authorized VA medical services; 

• authorize VA to pay the adoption expenses (for up to three adoptions); 

• direct VA to report annually to Congress on the counseling and treatment provided under this Act; and (2) prescribe regulations on the furnishing of such counseling, treatment, and adoption assistance; 

• direct VA to facilitate research conducted collaboratively by DOD and HHS in 

order to improve VA’s ability to meet the long-term reproductive health care needs 

of veterans; 

• require VA to enhance the capabilities of the VA women veterans contact center 

to: (1) respond to requests for assistance with accessing VA health care and benefits, 

and (2) refer such veterans to Federal or community resources to obtain assistance 

not furnished by VA; 

• amend the Caregivers and Veterans Omnibus Health Services Act of 2010 regarding a pilot program of group retreat reintegration and readjustment counseling 

for women veterans recently separated from service to: (1) increase the number of 

counseling locations, and (2) extend the program; and 

• establish VA programs to provide assistance to qualified veterans to obtain 

child care so that such veterans can receive: (1) regular mental health care services, 

intensive mental health care services, or other intensive health care services; and 

(2) readjustment counseling and related mental health services. 

S. 901, THE TOXIC EXPOSURE RESEARCH ACT OF 2015

This issue is at the top of the AMVETS priorities list once again this year. Recognition of the negative health effects caused by exposure to toxic substances, while 

serving in the military, has made extremely slow progress over the years, yet it may 

potentially impact millions of American veterans and their families. 

The newly formed Toxic Wounds Task Force, led by AMVETS, is a coalition of 

veteran and health advocacy organizations united in seeking effective preventions, 

diagnoses, treatments and policy solutions related to any exposure, suffered by current or former military personnel, to toxic chemicals during their military service. 

Our agreed upon definition of a Toxic Wound is any adverse health condition, 

chronic or terminal, suffered by military personnel resulting from, or associated 

with, exposure to toxic substances or environmental hazards during their military 

service, the effects of which may not emerge until months or years after initial exposure. 

Many of us have waited a life time for recognition of, and treatment for, our exposures, especially those of us stationed at Ft. McClellan and those who fought in the 

Persian Gulf War. Historically this issue has been dealt with on a piecemeal basis, 

rather than a comprehensive one, therefore AMVETS applauds your efforts to tackle 

this tough, yet sensitive issue with a more holistic approach. 

With this in mind, AMVETS whole heartedly support this legislation which 

would, among other things: 

• establish a National Center for the Research on the Diagnosis and Treatment 

of Health Conditions of the Descendants of Individuals Exposed to Toxic Substances 

During Service in the Armed Forces; 

• establish an Advisory Board for the National Center responsible for advising 

the National Center, determining health conditions that result from toxic exposure 

and to study and evaluate cases of exposure; 

• authorize the Secretary of Defense to declassify documents related to incidents 

in which at least 100 members of the Armed Forces were exposed to a toxic substance that resulted in at least one case of a disability caused by exposure, except 

when declassification would threaten national security; and 

• create a National Outreach Campaign on Potential Long-Term Health Effects 

of Exposure to Toxic Substances by Members of the Armed Forces and their Descendants. 

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Last year, at the AMVETS 69th annual convention, our members approved two 

separate resolutions in support of legislation which addresses the critical issue of 

military toxic exposure. 

S. 1082, THE DEPARTMENT OF VETERANS AFFAIRS ACCOUNTABILITY ACT OF 2015

This issue continues to be among our highest priorities and AMVETS fully supports this legislation which would in part: 

• authorize the VA to remove or demote a VA employee based on performance or 

misconduct; • also authorize the removal of such individuals from the civil service and/or the 

ability to demote such individuals through a reduction in grade or annual pay rate; • give an employee the right to an appeal before the Merit Systems Protection 

Board within seven days of removal or demotion. An administrative judge shall have 

to make a final decision within 45 days of such appeal or the original decision becomes final; 

• protect a VA employee from removal or demotion without the approval of the 

Special Counsel if the individual seeks corrective action from the Office of Special 

Counsel based on an alleged prohibited personnel practice; 

• provide for the appointment of an individual to a permanent position within the 

competitive service or as a career appointee within the Senior Executive Service 

shall become final after an 18-month probationary period, which the Secretary may 

extend. Final appointment to a permanent hire shall be made by the employee’s supervisor; and 

• require the Government Accountability Office to study the amount of time spent 

by VA employees carrying out labor organizing activities and the amount of Department space used for such activities. 

S. 1085, THE MILITARY AND VETERAN CAREGIVERS SERVICES IMPROVEMENT ACT OF 2015

AMVETS has been actively advocating for this legislation which would in part: 

• expand eligibility for the VA’s family caregiver program to include members of 

the Armed Forces or veterans who are seriously injured or who became ill on active 

duty prior to September 11, 2001 (currently, limited to service after September 11, 

2001); 

• expand much needed services to caregivers of veterans under such program to 

include child care services, financial planning services, and legal services; 

• terminate the support program for caregivers of covered veterans on October 1, 

2020, except that any caregiver activities carried out on September 30, 2020, shall 

be continued on and after October 1, 2020; 

• authorize the transfer of post-9/11 education assistance benefits to family members by veterans who are retired for a physical disability or who are seriously injured veterans in need of family caregiver services, without regard to length-of-service requirements; 

• authorize the VA Secretary to pay special compensation on a monthly basis to 

seriously injured or ill veterans in need of personal care services and to their caregivers; 

• authorize flexible work schedules or telework for Federal employees who are 

caregivers of veterans. 

• amend the Public Health Service Act to designate a veteran participating in the 

program of comprehensive assistance for family caregivers as an adult with a special need for purposes of the lifespan respite care program; and 

• establish, in the executive branch, an interagency working group to review and 

report on policies relating to the caregivers of veterans and members of the Armed 

Forces. 

S. 1117, THE ENSURING VETERAN SAFETY THROUGH ACCOUNTABILITY ACT OF 2015

AMVETS fully supports this short and sweet legislation which provides a mechanism for the removal of any VA Senior Executive Service employee or medical professional for unacceptable performance or misconduct. 

Under the current, antiquated and morbidly dysfunctional civil service system, it’s 

nearly impossible to dismiss or do more than slap the wrists of incompetent, ineffective and wasteful Senior Executive employees and medical professionals. This situation is no doubt largely responsible for the on-going backlog, as well as the problems 

of delayed benefits and inconsistent care experienced by many veterans. 

AMVETS believes that no matter what ideas and policies the Secretary of the VA 

wants to implement, without the ability to remove deadweight executives, their 

hands are tied. Veterans are tired of platitudes and broken promises; the only way 

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to break this cycle of ineptitude and restore our veterans’ faith in the ‘system’ is 

to eradicate the problem at the root—the Senior Executive level. 

AMVETS fully supports any legislation which eliminates redundancy and inefficiencies within the VA or improves the care and services our veterans have earned 

through their service to this Nation. 

H.R. 91, THE VETERAN’S I.D. CARD ACT

AMVETS supports this legislation which calls for a your efforts to provide a Veterans I.D. Card in order to: 

• Provide proof of honorable military service; 

• Minimize the potential of identity theft through the potential loss or theft of a 

form DD–214; 

• Provide employers looking to hire veterans a standard way to verify any employee’s military service; and 

• Provide military veterans the ability to take part in the goods, services or promotional opportunities that are offered to those who are able to provide proof of 

military service. 

AMVETS is especially supportive of this cost-neutral legislation because it will 

not only provide a much needed improvement over the current proof of military 

service document, the DD–214, but it will be carried out in a fiscally responsible 

way which will have minimal impact on the Veterans Administration which finds 

itself mired in the midst of massive claims backlogs and other issues. 

DRAFT LEGISLATION, THE JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

AMVETS supports this important legislation which would: 

• provide VA with some much needed tools to address the problem of overprescribing/over medicating practices; 

• expand the availability of complementary and integrative, both clinical and nonclinical, in an effort to provide safer and more effective pain management services 

to our Nation’s veterans; 

• require stronger opioid prescribing guidelines and education for VA providers 

including stricter standards against prescribing dangerous combinations of opioids 

with other drugs and for prescribing opioids to patients struggling with mental 

health issues; 

• increase coordination and communication throughout the VA with medical facilities, providers, patients and their families surrounding pain management, alternative treatments for chronic pain, and appropriate opioid therapy; and 

• Holding the VA system accountable for appropriate care and quality standards 

through consistent internal audits as well as GAO reviews and reports to Congress. 

DRAFT LEGISLATION, 

THE BIOLOGICAL IMPLANT TRACKING & VETERAN SAFETY ACT OF 2015

AMVETS fully supports this legislation which would require the VA to adopt and 

implement a standard identification protocol for use in the tracking and management of biological implants. This legislation would help to ensure that biological implants such as, tendons, bones, ligaments, skin, eyes, or whole organs, used within 

the VA could be more easily and appropriately tracked from all the way from the 

donor to the recipient. 

This critical capability to ‘‘track and trace’’ implants should help increase patient 

safety in case of product recalls (if necessary), assist with inventory management 

and accountability, and improve efficiencies through the implementation of a standard identification protocol. 

Just as importantly, this legislation puts safeguards in place stipulating the requirements that vendors must meet in order to provide VA with both human and 

non-human biological implants. 

This completes my statement at this time and I thank you again for the opportunity to offer our comments on pending legislation. I will be happy to answer any 

questions the Committee may have. 

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LETTER FROM AMERICAN SOCIETY FOR REPRODUCTIVE MEDICINE


96261ASR1.eps
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96261ASR2.eps
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PREPARED STATEMENT OF MILITARY OFFICERS ASSOCIATION OF AMERICA

On behalf of our more than 390,000 members, MOAA thanks the Committee for 

its long-standing commitment to the health and well-being of our servicemembers, 

veterans and their families and for considering the important health care bills before you. 

The following provides MOAA’s position and recommendations on the following 

provisions: 

• S. 469, Women Veterans and Families Health Services Act of 2015 

• S. 901, Toxic Exposure Research Act of 2015 

• S. 1085, Military and Veteran Caregiver Services Improvement Act of 2015 

• S. _____, Jason Simcakoski Memorial Opioid Safety Act 

S. 469, WOMEN VETERANS AND FAMILIES HEALTH SERVICES ACT OF 2015

MOAA is grateful to Senator Patty Murray (D-WA) for sponsoring S. 469 to improve the reproductive assistance provided by the Departments of Defense (DOD) 

and Veterans Affairs (VA) to severely wounded, ill or injured members of the Armed 

Forces, veterans, and their spouses or partners. 

MOAA generally supports the bill. Our organization has advocated in recent years 

for reproductive services, including fertility treatment and counseling for severely 

wounded, ill and injured members in the DOD and VA for all Uniformed Services, 

including the U.S. Public Health Service (PHS) and NOAA Corps. 

Senator Murray’s bill would end a decade long ban in the VA of providing wounded veterans who want to have children an opportunity to fulfill that dream and ultimately lead to improving their overall quality of life and well-being. While the bill 

extends the services already available in the DOD under its Assisted Reproductive 

Services policy, MOAA is most concerned about fairness and equitability between 

the two heath care systems—that veterans be afforded the same level of medical 

care and services regardless whether the member is seeking assistive reproductive 

services through the VA or DOD. 

Additionally, MOAA fully supports the expansion of the current pilot retreat/readjustment counseling programs for women veterans and the program to expand child 

care to veterans accessing medical care and adoption assistance provisions included 

in the bill. 

MOAA generally supports S. 469, Women Veterans and Families Health Services 

Act of 2015 but recommends that VA and DOD assistive reproductive service programs mirror each other, providing the same level of medical care and services and 

that these benefits be extended to all members of the Uniformed Services, including 

the USPHS and NOAA Corps. Additionally, MOAA fully supports the bill provisions 

to extend women veterans’ retreats and child care pilots and adoption assistance. 

S. 901, TOXIC EXPOSURE RESEARCH ACT OF 2015

Senators Jerry Moran’s (R-KS) and Richard Blumenthal’s (D-CT) S. 901 is a bipartisan bill that would establish in the Department of Veterans Affairs a national 

center for research on the diagnosis and treatment of health conditions of the descendants of veterans exposed to toxic substances during service in the Armed 

Forces. 

The legislation would establish the center of excellence in a VA medical center 

to pursue appropriate and unbiased research on the question of the potential impact 

on the health of first and second generation descendants of military service men and 

women. 

MOAA respectfully recommends substituting the term ‘‘Uniformed Services’’ for 

‘‘Armed Forces’’ in the bill as defined in Section 101(a)(5), 10 U.S.C. to ensure that 

research conducted at a designated VA Medical Center is applicable to members of 

the U.S. Public Health Service and the NOAA Corps of commissioned officers. 

MOAA strongly supports S. 901, the Toxic Exposure Research Act of 2015. 

S. 1085, MILITARY AND VETERAN CAREGIVER SERVICES IMPROVEMENT ACT OF 2015

MOAA applauds Senators Patty Murray (D-WA) and Susan Collins (R-ME) for 

long-term persistence in advancing this a bi-partisan bill that would extend special 

Caregiver Act (P.L. 111–163) services and support to the caregivers of certain disabled veterans of conflict periods prior to Sept. 11, 2001. For primary caregivers, 

services can include training, technical support, counseling, lodging and subsistence, 

mental health care, annual respite care, medical care under CHAMPVA and a 

monthly stipend. At present, those services are available only to caregivers providing support and assistance to veterans who served after 10 Sept. 2001. The legisVerDate Mar 15 2010 16:42 Mar 04, 2016 Jkt 000000 PO 00000 Frm 00110 Fmt 6601 Sfmt 6621 Z:\ACTIVE\062415.TXT PAULIN
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lation would phase in veterans of earlier conflict periods based on a VA needs assessment. 

S. 1085 also would provide a wider array of services for needs which may require 

caregiving; place greater emphasis on mental health injuries; and, remove restrictions on who is eligible to become a caregiver. 

The legislation would make veterans in the VA caregiver program eligible to 

transfer unused Post-911 GI Bill benefits to their dependents in recognition of the 

fact that a spouse might now be required to shoulder primary responsibility for the 

family’s income. 

The underlying Caregivers Act enables spouses, siblings, parents and others to 

provide in kind the services and support once provided by the VA itself at substantially greater cost. That’s because veterans with severe disabilities were placed in 

institutional care. 

MOAA strongly supports S. 1085, the Military and Veteran Caregiver Services 

Improvement Act of 2015. 

S. _____, JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

The Jason Simcakoski Memorial Opioid Safety Act is an extremely important and 

timely piece of legislation. MOAA fully supports the draft bill and commends Senator Tammy Baldwin (D-WI) for championing a measure that will keep veterans 

safe and provide VA with the necessary tools to more effectively management pain 

services. 

Generally the bill would improve the prescribing and distribution management of 

opioids, patient advocacy, and expand availability of complementary and integrative 

health in the VA medical system. 

The bill is named after U.S. Marine Veteran Jason Simcakoski who died on August 30, 2014 at the Tomah Veterans Affairs Medical Center in Wisconsin from ingestion of a deadly toxic mix of drugs. The bill is offered to help prevent such tragic 

occurrences from happening in the future. 

More specifically, this comprehensive bill focuses on: 

• Implementing stricter guidelines and standards for management and training 

of opioid therapy by VA and DOD; 

• Improving VA opioid safety measures; 

• Establishing a working group on pain management and opioid therapy within 

VA and DOD; 

• Conducting a study on carrying out a VA pharmacy lockdown program; 

• Reporting and investigating the use of opioid treatment by VA; 

• Establishing an Office of Patient Advocacy in VA to enhance care and improve 

awareness of advocacy efforts in the Department; and, 

• Expanding complementary and integrative health research, education and delivery at VA medical centers. 

MOAA strongly supports the Jason Simcakoski Memorial Opioid Safety Act. 

MOAA thanks the Committee and the members who sponsored or co-sponsored 

the above measures. These provisions will go a long way toward improving the quality of health care and patient outcomes in the VA medical system. We look forward 

to working with the Committee to make these important provisions a matter of law. 

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PREPARED STATEMENT OF SUSAN TSUI GRUNDMANN, CHAIRMAN, 

U.S. MERIT SYSTEMS PROTECTION BOARD


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PREPARED STATEMENT OF THE NATIONAL ALLIANCE ON MENTAL ILLNESS

NAMI, the National Alliance on Mental Illness, is the Nation’s largest grassroots 

mental health organization dedicated to building better lives for the millions of 

Americans affected by mental illness. Part of our mission is to support our military, 

past and present, who are dealing with mental health issues. In support of that mission, we will often support policy that can improve the lives of our military servicemembers, veterans and their families. 

As an organization, we have become aware of the increasing number of veterans, 

like U.S. Marine veteran Jason Simcakoski, who have been prescribed both Benzodiazepines and opioids; and about the serious complications that can arise from their 

use. Jason Simcakoski died at the age of 35 on August 30, 2014 from the mixed drug 

toxicity of Benzodiazepines and opioids. Unfortunately, we also know that he is not 

the only veteran to die as a result of mixed drug toxicity under the care of doctors 

at the Department of Veterans Affairs. 

Although these types of medications are deemed safe and effective when taken as 

directed, when opioid pain relievers like oxycodone, hydrocodone, hydromorphone, or 

morphine are combined with other drugs that depress Central Nervous System activity, such as benzodiazepine’s—it can present serious or even life-threatening 

problems for those who are taking them. NAMI’s concern goes to the issue of veteran’s morbidity and mortality with the combined prescription of opioid painkillers 

and drugs in the benzodiazepine (BZD) class: best known examples are Librium, 

Valium, Xanax, and Ativan. Like opioid-based pain medications, BZDs are addictive. 

They are prescribed by mental health providers treating Post-Traumatic Stress Disorder (PTSD), Military Sexual Trauma (MST), depression, anxiety, and panic disorder. They are also used in the treatment of seizure disorders, insomnia, and alcohol withdrawal. 

In a National Institute of Health study in 2011 by Macey et al., it was found that 

approximately two-thirds of OEF/OIF veterans with pain issues were prescribed 

opioids over a one-year timeframe, and that over one-third were prescribed opioids 

on a long-term basis. This study extends prior literature documenting high rates of 

opioid use among OEF/OIF veterans suffering from war-related injuries (Clark et 

al., 2009; Wu et al., 2010). The researchers found that despite prescribers adhering 

to guidelines for the treatment of chronic pain there were a high number of opioid 

prescribed veterans with concurrent benzodiazepine prescriptions. Macey et al. 

found that 33% of long-term opioid users in their study were concurrently prescribed 

benzodiazepines. 

An additional December 2014 report was put out by the Drug Abuse Warning Network (DAWN). Their report found that combining benzodiazepines with opioid pain 

relievers significantly increased the risk of a more serious emergency department 

visit outcome. These facts suggest that individuals are at risk and that the baseline 

risks are high enough to suggest a public health concern. We are aware that concurrent use of opioids and benzodiazepines pose a formidable challenge for clinicians 

who manage chronic pain and mental health issues. However, what makes this 

issue serious is that veterans with chronic pain who use opioid analgesics along 

with benzodiazepines have been found to be at higher risk for fatal and nonfatal 

overdose and to have more aberrant behaviors (Gudin et al., 2013). 

According to a May 2014 VA Office of Inspector General (OIG) report (No. 14– 

00895–163) on opioid therapy practices, it was found that approximately 64% of veterans prescribed take-home opioids had been diagnosed with mental health issues. 

A subset of these veterans received prescriptions for Benzodiazepines. According to 

the report ‘‘the concurrent use of Benzodiazepines and opioids can be dangerous because both depress the central nervous system. Benzodiazepines have been strongly 

associated with death from opioid overdose.’’ 

Given the findings, coming up with a solution and a better way to monitor the 

prescribing practices of physicians is critical. Co-administration of these agents produces an increase in rates of adverse events, overdose, and deaths, warranting close 

monitoring. NAMI believes that the veterans in this country deserve safe and responsible health care to recover from the physical and emotions wounds of combat. 

Based on this information and the gravity of the issues discussed in the studies 

we’ve discussed, NAMI supports Senator Tammy Baldwin’s announcement of the 

Jason Simcakoski Memorial Opioid Act, calling for better coordination of care 

throughout the VA, increased scrutiny of prescriptions of opioids and benzodiazepines for our military veterans receiving care through the Department of Veteran’s 

Affairs, and increased accountability for quality standards through appropriate audits and reporting. NAMI also deeply appreciates the Committee’s proven commitment to ensuring that the physical and mental healthcare needs of our Nation’s veterans are met quickly, effectively, and completely and that future deaths from 

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mixed drug toxicity are prevented. We look forward to working with Senator Baldwin and the Senate Committee on Veteran’s Affairs to help achieve those outcomes. 

PREPARED STATEMENT OF CAROLYN N. LERNER, SPECIAL COUNSEL, 

UNITED STATES OFFICE OF SPECIAL COUNSEL


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LETTER FROM BARBARA L. COLLURA, PRESIDENT & CEO, RESOLVE: THE NATIONAL

INFERTILITY ASSOCIATION


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PREPARED STATEMENT OF CARLOS FUENTES, SENIOR LEGISLATIVE ASSOCIATE, NATIONAL LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED

STATES

Chairman Isakson, Ranking Member Blumenthal and Members of the Committee, 

on behalf of the men and women of the Veterans of Foreign Wars of the United 

States (VFW) and our Auxiliaries, thank you for the opportunity to offer the VFW’s 

views on legislation being considered by the Committee. 

S. 469, WOMEN VETERANS AND FAMILIES HEALTH SERVICES ACT OF 2015

This legislation would expand the Department of Veterans Affairs’ (VA) and the 

Department of Defense’s (DOD) authority to furnish fertility treatments to servicemembers and veterans who have lost their ability to have children as a direct result 

of their service-connected injuries. The VFW strongly supports this legislation and 

would like to offer recommendations to strengthen it, which we hope the Committee 

will consider. 

Due to the widespread use of improvised explosive devices during the wars in Iraq 

and Afghanistan, both female and male servicemembers have suffered from spinal 

cord, reproductive, and urinary tract injuries. Many of these veterans hope to one 

day start families, but their injuries prevent them from conceiving. When these veterans seek fertility treatment from VA, they are told VA services are very limited. 

In fact, VA is prohibited from providing certain fertility treatments like In Vitro 

Fertilization. Active duty servicemembers have more fertility options, but DOD’s authorities are also limited by who can be treated and what type of treatments they 

can receive. This legislation would correct this inequity between veterans and servicemembers and expand the options currently available. 

Service-connected infertility is not limited to those who have suffered reproductive 

organ and spinal cord injuries. Other injuries and illnesses, such as Traumatic 

Brain Injuries and mental health conditions, are known to cause infertility. Veterans with such conditions deserve the same opportunity to start a family as their 

fellow veterans who have suffered injuries to their reproductive organs. The VFW 

is glad this legislation would include all ‘‘severely wounded, ill, or injured’’ veterans 

and servicemembers who have infertility conditions incurred or aggregated by their 

military service. 

Additionally, veterans may have personal objections to assisted reproductive technologies such as In Vitro Fertilization and would like to pursue other options. The 

VFW believes that VA and DOD must have the authority to provide veterans the 

fertility treatment options that are best suited for their particular circumstances. 

For that reason, we support this legislation’s inclusion of non-assisted reproductive 

technology modalities, such as adoption. 

This legislation would also require DOD to cryopreserve a veteran’s genetic material for up to a year following a veteran’s retirement, separation or release from active duty. Starting a family is a life changing decision that takes time and should 

not be hastily made. The VFW strongly supports giving veterans the opportunity to 

delay such a decision. However, we urge the Committee to expand the one year window. When totaled, a veteran’s recovery, education and career advancement may 

cause them to wait years before they are physically and financially prepared to start 

a family. The VFW recommends that veterans be allowed to cryopreserve their genetic material for a minimum of 10 years. This will prevent veterans from feeling 

rushed into making family planning decisions before they are ready. 

This legislation would also extend VA’s successful counseling in retreat setting 

program for transitioning women veterans. The VFW supported the original program established by the Caregivers and Veterans Omnibus Health Services Act of 

2010 and believes it is an invaluable tool to help newly discharged women veterans 

seamlessly transition back into civilian life. For this reason, we recommend that the 

Committee amend this legislation to make the program permanent. 

Another successful program created by the Caregivers and Omnibus Health Services Act of 2010 is the VA childcare pilot program. This program has been well received by veterans at all four pilot sites and has also contributed to the success of 

other VA health care programs. The VFW has heard from veterans who say they 

could not have completed their treatment programs if not for the services offered 

through VA’s childcare pilot program. The VFW is glad this legislation would expand this important program to every VA medical center. 

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S. 901, TOXIC EXPOSURE RESEARCH ACT OF 2015

The VFW supports this legislation, which would establish an advisory board and 

national center to research the health effects of toxic exposures on the descendants 

of individuals who were exposed to toxic substances during their military service. 

In its report ‘‘Veterans and Agent Orange: 2012 Update,’’ the Institute of Medicine 

(IOM) stated that ‘‘the amount of research providing reliable information on the consequences of paternal exposure is extremely sparse not only for [Agent Orange] but 

also for the full array of environmental agents that may pose threats to the health 

of future generations.’’ With the existing body of research on this topic, VA has established the Spina Bifida Program to provide health care and benefits to the children of certain Vietnam veterans who were born with spina bifida—an extremely 

debilitating neural tube birth defect. VA also provides health care and benefits to 

children of women Vietnam veterans born with certain birth defects. 

However, exposure to toxic substances is not limited to Vietnam veterans. We believe VA has the responsibility to research whether the descendants of other veterans who have been exposed to toxic substances, such as those who were exposed 

to open air burn pits, chemicals during the Gulf War, and the approximately 

650,000 veterans and family members who now qualify for VA health care benefits 

as a result of their exposure to contaminated water in Camp Lejeune, are at risk 

of developing adverse health conditions. 

For far too long, veterans have struggled to obtain VA benefits for chronic health 

conditions that are associated with their military exposures. The VFW strongly believes the descendants of those veterans should not be forced to wait years for the 

care they need. This legislation would prevent this by ensuring VA devotes the proper time and resources to make objective and evidence-based determinations regarding the health conditions of a veteran’s descendants who are associated with toxic 

exposures. 

S. 1082, DEPARTMENT OF VETERANS AFFAIRS ACCOUNTABILITY ACT OF 2015

The VFW supports this legislation, which would authorize VA to hold employees 

at all levels accountable for malfeasants or poor performance. The VFW believes VA 

and Congress must collaborate to identify and fix what is broken within VA, hold 

employees appropriately accountable to the maximum extent of the law, and do everything possible to restore veterans’ faith in their VA. 

While this Committee focuses on giving VA the authority to fire bad employees, 

it must also look for ways to improve VA’s ability to hire good employees. VA will 

not have the staff needed to care for veterans if it disposes of bad employees without 

the ability to quickly fill vacancies. Unfortunately, the Federal Government’s long 

hiring process puts VA at a disadvantage when recruiting and retaining the best 

and brightest medical professionals. 

In our report, ‘‘Hurry Up and Wait,’’ we highlight deficiencies in VA human resources practices, outlining several recommendations to improve the hiring process 

and customer service training. Section 203 of the Veterans Access, Choice and Accountability Act of 2014 called for a Technology Task Force to perform a review of 

the Department of Veterans Affairs’ scheduling system and software development. 

In their review, the Northern Virginia Technology Council (NVTC) reinforced our 

concerns that VA’s hiring process moves too slowly. NVTC suggested that VA aggressively redesign its human resources processes by prioritizing efforts to recruit, 

train, and retain clerical and support staff. 

The VFW looks forward to working with Congress to expedite passage of this legislation and find workable solutions to VA human resources’ issues to ensure VA 

can move quickly to fire employees who put veterans at risk, while quickly hiring 

the best applicants to set VA on a path to restore veterans’ trust in the system. 

S. 1085, MILITARY AND VETERAN CAREGIVER SERVICES IMPROVEMENT ACT OF 2015

The VFW strongly supports this legislation, which would greatly enhance the 

services provided to caregivers of servicemembers and veterans who were severely 

disabled in the line of duty. Family caregivers choose to put their lives and careers 

on hold, often accepting great emotional and financial burdens, and the VFW believes that our Nation owes them the support they need and deserve. This bill would 

accomplish this in a number of ways, including extending benefits to caregivers of 

veterans with service-connected illnesses, offsetting the costs of their child care, providing them with financial advice and legal counseling, expanding their respite care 

options, and allowing veterans who participate in the VA caregiver program to 

transfer their Post-9/11 G.I. Bill benefits to their family members. 

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Perhaps most significantly, this legislation would extend caregiver eligibility to severely injured and ill veterans of all eras. This is a desperately needed change that 

the VFW has long supported. 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 excluded from the full complement of program benefits implies that their service and sacrifices are not as significant, and we believe this is 

wrong. We support the five year phase-in plan, which would incrementally grant 

program eligibility based on the severity of the veteran’s conditions, as we believe 

this would give VA the opportunity to responsibly expand and improve the program 

without compromising services to current beneficiaries. 

The VFW believes that extending caregiver benefits to veterans of all ages is not 

only a matter of fairness, but one of fiscal responsibility as well. It seems logical 

that the ability of veterans to remain in their homes receiving care from family 

members would allow them to avoid nursing home care which is far more expensive. 

According to VA’s Fiscal Year 2015 Budget Request, VA spent more than $5 billion 

providing institutional care in fiscal year 2014. The average per diem cost for a VA 

Community Living Center was $971.97, totaling over $350,000 per veteran, per 

year. At contracted community nursing homes, VA spends over $90,000 per veteran, 

per year. The VA contribution for a veteran at state-run nursing homes averages 

over $45,000 per veteran, per year. On the other hand, the Congressional Budget 

Office estimates that the average cost of benefits to a primary caregiver would total 

only $33,000 per year. While we recognize that CBO is not able to consider potential 

savings when calculating cost, we contend that expansion of the Family Caregiver 

program could produce real savings to VA in the long run. 

The VFW hears from our members often about Family Caregiver Program eligibility, and their message is clear: they strongly support expanding full caregiver 

benefits to veterans of all eras. As an intergenerational veterans’ service organization that traces its roots to the Spanish American War, this is not surprising. Our 

members are combat veterans from World War II, the wars in Korea and Vietnam, 

the Gulf War, and various other short conflicts, in addition to current era veterans. 

They rightly see no justifiable reason to exclude otherwise deserving veterans from 

program eligibility simply based on the era in which they served. For this reason, 

the VFW urges Congress to swiftly pass the Military and Veteran Caregiver Services Improvement Act of 2015. 

S. 1117, ENSURING VETERAN SAFETY THROUGH ACCOUNTABILITY ACT OF 2015

The VFW appreciates the intent of this legislation, which would improve accountability by holding title 38 employees accountable for poor performance or wrongdoing. 

In order to restore veterans’ faith in their VA, there is no doubt that VA must 

undergo a culture change. Like most places, VA employees work in an environment 

the rewards specific outcomes based on specific performance standards. Last year 

we learned that these outcomes had become unattainable for VA employees throughout the country. But instead of evaluating why standards could no longer be met, 

local VA leaders put pressure on employees to achieve the unattainable. Thus employees were left with two options—be a poor performer or find a way to do the impossible. Now VA is left with an employee-base that has been trained to believe that 

doing the wrong thing is right. This is why VA should not hastily dismiss low-level 

and medical support employees who have been coerced into misrepresenting data or 

hiding the truth. 

However, VA staff at all levels who have been entrusted with the lives and 

wellbeing of veterans should be held to higher standards than other Federal employees. Unlike, their counterparts at other Federal agencies, when medical support assistants and other title 5 employees at VA medical facilities commit malfeasants, 

veterans’ lives are at risk. Thus, VA’s authority to hold employee’s accountable 

should not be limited to SES and title 38 employees. For this reason, the VFW prefers S. 1082, which would authorize VA to hold all VA employees accountable for 

their poor performance or wrongdoing. 

S. 1641, THE JASON SIMCAKOSKI MEMORIAL OPIOID SAFETY ACT

The VFW supports this legislation, which would reduce VA’s reliance of 

pharmacotherapy to treat mental health and complex pain conditions; strengthen 

VA’s patient advocate program; expand VA research, education, and delivery of complementary and alternative medicine (CAM) treatments, and improve VA hiring and 

internal audits. 

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Too often, the VFW hears stories of veterans who have been prescribed high doses 

of ineffective medications to treat their mental health conditions. Countless veterans 

have experienced first-hand the dangerous side of pharmacotherapy. Many of these 

medications, if incorrectly prescribed, have been proven to render veterans incapable 

of interacting with their loved ones and even contemplate suicide. With the expanding evidence of the efficacy of non-pharmacotherapy modalities, such as psychotherapy and CAM, VA must ensure it affords veterans the opportunity to access effective treatments that minimize adverse outcomes. 

Timely and accessible mental health care is crucial to ensuring veterans have the 

opportunity to successfully integrate back into civilian life. With more than 1.4 million veterans receiving specialized VA mental health treatment each year, VA must 

ensure such services are safe and effective. VA has made a concerted effort to 

change its health care providers’ dependence on pharmacotherapy to treat mental 

health conditions and manage pain. In 2011, the Minneapolis VA Medical Center 

launched its Opioid Safety Initiative. Aimed at changing the prescribing habits of 

providers, the Opioid Safety Initiative educates providers on the use of opioids, 

serves as a tool to taper veterans off high-dose opioids, and offers them alternative—non-pharmacotherapy—modalities for pain management. Unfortunately, the 

VA has failed to produce a notable change since implementing the Opioid Safety Initiative system-wide. This legislation includes much needed reforms to ensure VA’s 

clinical practice guidelines for pain management are appropriate and includes the 

proper compliance mechanisms, such as the pain management boards, to ensure 

such guidelines a carried out. 

The VFW has consistently heard from veterans that their patient advocates are 

ineffective or seek to protect the medical facility’s leadership instead of addressing 

their concerns. For this reason, we strongly support title II, which would to create 

the Office of Patient Advocacy and make other improvement to VA’s patient advocacy program. The VFW believes that patient advocates cannot effectively meet 

their obligations to veterans if their chain of command includes VA medical facility 

staff that is responsible for the actions and policies they are required to address. 

In its markup of this bill, the VFW recommends that the Committee explicitly state 

that the Department’s patient advocates would be reassigned to report directly to 

the Office of Patient Advocacy and no longer fall under the chain of command of 

local medical center leadership. 

With the growing body of research on the efficacy of CAM therapies, such as biofeedback, mindfulness meditation, and other non-pharmacologic approaches to treating mental health conditions and manage pain, the VFW believes that more work 

must be done to ensure veterans are afforded the opportunity to receive these safe 

and effective alternatives to pharmacotherapy. This legislation would make significant strides toward ensuring veterans who are tapered off high-dose medications 

have effective alternatives. 

H.R. 91, VETERAN’S I.D. CARD ACT

The VFW appreciates the intent of H.R. 91, which would require VA to issue identification (ID) cards to veterans for use as validation of veteran status. However, the 

VFW believes that states are better suited to provide ID cards verifying veteran status. The infrastructure already exists within each state’s Department of Motor Vehicles to provide picture ID cards to its citizens, whereas the VA would have to expand its capability to accommodate the increase in veteran requests for such cards. 

Forty-eight states and the District of Columbia already provide ID cards with a 

veteran indicator. The remaining two states are in the process of implementing laws 

that require them to issue such cards. The VFW is glad to see all fifty states and 

the District of Columbia have made this a priority and believes it is no longer necessary or beneficial for VA to duplicate such efforts. Additionally, requiring VA to 

issue ID cards to millions of veterans would impede its ability to provide veteran 

health identification (VHID) cards to veterans who are eligible for VA health care 

benefits. Veterans who have waited months, if not years, for their veterans’ benefits 

should not be forced to wait in a backlog for VHID cards. 

Furthermore, duplicating state efforts may result in veterans being eligible for a 

state ID but not a VA ID, or vice versa. As referred to this Committee, H.R. 91 

would require VA to issue an ID to any honorably discharged veteran. However, 

honorable service is not a precondition for veteran identifiers on ID in most states. 

This would be a source of contention for veterans who would be recognized as a veteran by one entity but not the other. Amending the legislation to include all veteran 

who received an other than dishonorable discharge would exacerbate this issue, because VA would be required to make eligibility determinations for veterans who receive administrative, other than honorable and bad conduct discharges. VA already 

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makes such determinations when veterans apply for VA benefits. The VFW is concerned that VA takes too long to make these determination now, and we fear veterans who are waiting to access their VA benefits will have to wait longer because 

VA would be inundated with eligibility determinations for ID card applicants. 

Draft Legislation to Expand the Availability of Prosthetic and Orthotic Care for 

Veterans and to Submit a Report on Laotian Military Support of the Armed Forces 

During the Vietnam War 

The VFW supports section 1 of this legislation, which would authorize VA to establish partnerships to expand the availability of prosthetic and orthotic care for 

veterans. 

Orthotists and prosthetists are vital to ensuring VA provides the prosthetics care 

and services veterans need and deserve. In 2014, VA provided 17.5 million prosthetic items and services to more than three million veterans and estimates a growing demand in future years. The VFW strongly supports expanding the availability 

of orthotic and prosthetic care for veterans. For this reason, we believe the Committee should amend this legislation by adding a service-requirement for health care 

professionals who benefit from this program, similar to service requirements under 

other health professional educational assistance programs. 

The VFW has no official position on section 2, which would require VA to determine whether Laotian military forces supported the United States during the war 

in Vietnam. 

DRAFT LEGISLATION, BIOLOGICAL IMPLANT TRACKING AND VETERAN SAFETY ACT

The VFW support this legislation, which would require VA to purchase biological 

implants that meet Food and Drug Administration (FDA) standards and develop a 

tracking system for such implants. 

VA has an obligation to ensure veterans receive the highest quality care possible. 

This includes ensuring that the care veterans receive from VA meets industry 

standards and does not place veterans at risk. That is why the VFW was concerned 

when GAO reports found that VA may not be able to locate recalled or defective 

biological implants that it has furnished. The VFW supports efforts to prevent veterans from receiving defective or contaminated biological implants and ensure VA 

is able to identify veterans who have received implants that may need to be replaced. 

While, the VFW believes it is important to ensure veterans receive high quality 

care, we firmly believe that they should not be required to wait unreasonably long 

periods of time for their care because of slow bureaucratic processes. That it is why 

we recommend the Committee amend this legislation to ensure VA is authorized to 

use all of its purchasing authorities when furnishing biological implants. 

Chairman Isakson, Ranking Member Blumenthal and Members of the Committee, 

this concludes my testimony. 

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PREPARED STATEMENT OF WOUNDED WARRIOR PROJECT


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