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[Senate Hearing 114-186]
[From the U.S. Government Publishing Office]

                                                        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

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                     COMMITTEE ON VETERANS' AFFAIRS

                   Johnny Isakson, Georgia, Chairman
Jerry Moran, Kansas                  Richard Blumenthal, Connecticut, 
John Boozman, Arkansas                   Ranking Member
Dean Heller, Nevada                  Patty Murray, Washington
Bill Cassidy, Louisiana              Bernard Sanders, (I) Vermont
Mike Rounds, South Dakota            Sherrod Brown, Ohio
Thom Tillis, North Carolina          Jon Tester, Montana
Dan Sullivan, Alaska                 Mazie K. Hirono, Hawaii
                                     Joe Manchin III, West Virginia
                       Tom Bowman, Staff Director
                 John Kruse, Democratic Staff Director
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                 
                            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
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

 
        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 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.
    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 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 impact 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 autopsy 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 non-cooperation, 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.
    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 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.
    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 bipartisan 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.
    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 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.
    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 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 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 
Representatives (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 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 descendants 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. Sec. 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. Sec. 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. Sec. 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 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 peer-oriented 
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 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 
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 state-of 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 philosophy 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 systems\1\ 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.
---------------------------------------------------------------------------
    \1\ Merlino, J (2015). Service fanatics: how to build a superior 
patient experience the Cleveland Clinic way. New York, NY: McGraw-Hill 
Education.
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    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.
    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 completed. 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:

    (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 Safety Act. The remaining views 
can be forwarded in a separate and final follow-up 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,'' 
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 biological 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 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 benefits 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.
    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 
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 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 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.
    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. 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 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 
deployment-related 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 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?
    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 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.
    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.
    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 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 disciplinary 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 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.
    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 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----
    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.

    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 well-being.
    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 2\1/2\ days. 
How important is it to veterans' 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.
    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:]
  Letter from Hon. Lisa Murkowski, U.S. Senator from Alaska, to Hon. 
    Robert McDonald, Secretary, U.S. Department of Veterans Affairs

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
Letter from Gov. Bill Walker, State of Alaska, to Hon. Robert McDonald, 
             Secretary, U.S. Department of Veterans Affairs

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 
Letter from Rep. Don Young, Congressman for All Alaska, to Hon. Robert 
        McDonald, Secretary, U.S. Department of Veterans Affairs

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                                 ______
                                 

        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-va-health-care-program-jeopardizes-alaska-system/29029189/

       Copyright 2015 The Associated Press. All rights reserved. 
      This material may not be published, broadcast, rewritten or 
                             redistributed.

                                 ______
                                 

              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.
    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.
    [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-VA-WOMEN 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; 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:]
 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.
---------------------------------------------------------------------------
    \1\ Resolution No. 182: Support Military Quality of Life 
Standards--AUG 2014
---------------------------------------------------------------------------
    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\ 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.
---------------------------------------------------------------------------
    \2\ Resolution No. 125: Environmental Exposures--AUG 2014.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \3\ Resolution No. 30: Department of Veterans Affairs 
Accountability--MAY 2015
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \4\ Resolution No. 160: Veterans Receive the Same Level of 
Benefits--AUG 2014
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \5\ Resolution No. 30: Department of Veterans Affairs 
Accountability--MAY 2015
---------------------------------------------------------------------------
    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 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 licenses\6\ 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.
---------------------------------------------------------------------------
    \6\ Resolution No. 43: Veteran Coding on Driver's Licenses--OCT 
2012
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \7\ Resolution No. 311: The American Legion Policy on VA Physicians 
and Medical Specialists Staffing Guidelines--SEP 1998
---------------------------------------------------------------------------
    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\
---------------------------------------------------------------------------
    \8\ Resolution No. 72: Benefits and Burial Rights for Select 
Surrogate Forces--AUG 2014
---------------------------------------------------------------------------
    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 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\
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    \9\ Resolution No. 190: Support for Pain Management Research, 
Treatments and Therapies at DOD, VA and NIH--AUG 2015
    \10\ Resolution No. 292: Traumatic Brain Injury and Post Traumatic 
Stress Disorder Programs--AUG 2014
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \11\ Resolution No. 26: Veterans Benefits Centers--MAY 2015
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    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.
    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 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.
---------------------------------------------------------------------------
    \1\ http://www.stripes.com/news/veterans/it-s-worse-than-ever-
employees-of-beleaguered-philadelphia-va-office-vent-to-visiting-
lawmakers-1.352536
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    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 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\
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    \2\ http://www.govexec.com/management/2015/05/va-officials-say-
theyre-trying-fire-people-its-still-really-hard/112717/
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    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.
    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.
    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 
organic 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.
    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.
      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 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.
    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 
removal 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. 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 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 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.
   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.
    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).
    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 ``at-will'' employment system for the Department of 
Veterans Affairs is not one of them.
---------------------------------------------------------------------------
    \1\ Partnership 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.
---------------------------------------------------------------------------
    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.
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    \2\ Title 5 U.S. Code Sec. 2301 ``Merit System Principles,'' 
https://www.law.cornell.edu/uscode/text/5/2301.
---------------------------------------------------------------------------
    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.
---------------------------------------------------------------------------
    \3\ Partnership 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.
---------------------------------------------------------------------------
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 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 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 high-performing 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.
            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.
---------------------------------------------------------------------------
    \4\ Public Law 113-146.
---------------------------------------------------------------------------
    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.
    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 Sec. 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 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.
---------------------------------------------------------------------------
    \5\ Partnership 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.
    \6\ Merit Systems Protection Board, What is Due Process in Federal 
Civil Service Employment, May 2015.
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            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.
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    \7\ FedScope (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.
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                               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.

    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.
              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-of-Agent-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,
  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.
 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.]

                            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.
                                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. 
Sec. 7513(b) and 5 U.S.C. Sec. 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;
     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. Sec. 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 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.
            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.
                                 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;
     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.

    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 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 non-clinical, 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.
                                 ______
                                 
         Letter from American Society for Reproductive Medicine

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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 bi-partisan 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 legislation 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.

                                 ______
                                 
         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 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.
              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.
    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.
    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 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.
                                 ______
                                 
             Prepared Statement of Wounded Warrior Project

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