Text: S.Hrg. 113-203 — HEARING ON PENDING HEALTH CARE LEGISLATION

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[Senate Hearing 113-203]
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                                                        S. Hrg. 113-203

               HEARING ON PENDING HEALTH CARE LEGISLATION

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

                                HEARING

                               BEFORE THE

                     COMMITTEE ON VETERANS' AFFAIRS
                          UNITED STATES SENATE

                    ONE HUNDRED THIRTEENTH CONGRESS

                             FIRST SESSION

                               __________

                              MAY 9, 2013

                               __________

       Printed for the use of the Committee on Veterans' Affairs





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                     COMMITTEE ON VETERANS' AFFAIRS

                 Bernard Sanders, (I) Vermont, Chairman
John D. Rockefeller IV, West         Richard Burr, North Carolina, 
    Virginia                             Ranking Member
Patty Murray, Washington             Johnny Isakson, Georgia
Sherrod Brown, Ohio                  Mike Johanns, Nebraska
Jon Tester, Montana                  Jerry Moran, Kansas
Mark Begich, Alaska                  John Boozman, Arkansas
Richard Blumenthal, Connecticut      Dean Heller, Nevada
Mazie Hirono, Hawaii
                    Steve Robertson, Staff Director
                 Lupe Wissel, Republican Staff Director























                            C O N T E N T S

                              ----------                              

                              May 9, 2013
                                SENATORS

                                                                   Page
Sanders, Hon. Bernard, Chairman, U.S. Senator from Vermont.......     1
Burr, Hon. Richard, Ranking Member, U.S. Senator from North 
  Carolina.......................................................     2
    Letter for the record........................................     4
Begich, Hon. Mark, U.S. Senator from Alaska......................    42
Boozman, Hon. John, U.S. Senator from Arkansas...................    45

                               WITNESSES

Hon. Landrieu, Mary L., U.S. Senator from Louisiana..............     6
    Prepared statement...........................................     7
Jesse, Robert L., M.D., Ph.D., Principal Deputy Under Secretary 
  for Health, U.S. Department of Veterans Affairs; accompanied by 
  Susan Blauert, Deputy Assistant General Counsel................     8
    Prepared statement...........................................    10
    Additional views.............................................    19
    Response to posthearing questions submitted by:
      Hon. Mark Begich...........................................    32
      Hon. Richard Blumenthal....................................    38
    Response to request arising during the hearing by:
      Hon. Bernard Sanders....................................... 39,40
      Hon. Mark Begich...........................................    44
Weidman, Rick, Executive Director for Policy and Government 
  Affairs, Vietnam Veterans of America...........................    47
    Prepared statement...........................................    49
Jonas, Wayne B., M.D., President and Chief Executive Officer, 
  Samueli Institute..............................................    54
    Prepared statement...........................................    56
Ansley, Heather, Esq., MSW, Vice President for Veterans Policy, 
  VetsFirst......................................................    58
    Prepared statement...........................................    59
Gornick, Matt, Policy Director, National Coalition For Homeless 
  Veterans.......................................................    63
    Prepared statement...........................................    65
Bowman, Thomas, Former Chief of Staff, U.S. Department of 
  Veterans Affairs...............................................    67
    Prepared statement...........................................    69

                                APPENDIX

Hon. Boxer, Barbara, U.S. Senator from California; prepared 
  statement......................................................    83
Hon. Donnelly, Joe, U.S. Senator from Indiana; prepared statement    84
American Legion, The; prepared statement.........................    84
Zumatto, Diane M., National Legislative Director, AMVETS; 
  prepared statement.............................................    92
Wallis, Anthony A., Legislative Director/Director of Government 
  Affairs, The Association of the United States Navy; prepared 
  statement......................................................    94
Zampieri, Thomas, Ph.D., Director of Government Relations, 
  Blinded Veterans Association (BVA); prepared statement.........    96
Consortium of Academic Health Centers for Integrative Medicine; 
  prepared statement.............................................   100
Ilem, Joy J., Deputy National Legislative Director, Disabled 
  American Veterans (DAV); prepared statement....................   102
Iraq and Afghanistan Veterans of America (IAVA); prepared 
  statement......................................................   115
Integrative Healthcare Policy Consortium (IHPC); prepared 
  statement......................................................   120
Kahn, Janet R., Ph.D., LMT, President and CEO, Peace Village 
  Projects, Inc.; prepared statement.............................   120
Paralyzed Veterans of America (PVA); prepared statement..........   122
Service Women's Action Network (SWAN); prepared statement........   128
Kelley, Raymond C., Director, National Legislative Service, 
  Veterans of Foreign Wars of the United States; prepared 
  statement......................................................   130
Wounded Warrior Project; prepared statement......................   135

 
               HEARING ON PENDING HEALTH CARE LEGISLATION

                              ----------                              


                         THURSDAY, MAY 9, 2013

                                       U.S. Senate,
                            Committee on Veterans' Affairs,
                                                    Washington, DC.
    The Committee met, pursuant to notice, at 10:03 a.m., in 
room 418, Russell Senate Office Building, Hon. Bernard Sanders, 
Chairman of the Committee, presiding.
    Present: Senators Sanders, Begich, Burr, and Boozman.

          OPENING STATEMENT OF HON. BERNARD SANDERS, 
              CHAIRMAN, U.S. SENATOR FROM VERMONT

    Chairman Sanders. Welcome to today's hearing to examine 
health legislation before this Committee. We have got a lot of 
work to cover. Let us get started.
    This Committee intends to be aggressive in bringing forth 
legislation. We need to have stakeholders, people who are 
familiar with the issues that we are dealing with, comment on 
the concepts that we are bringing forth and then make those 
modifications that make sense.
    Today's agenda reflects important work by Senators on both 
sides of the aisle. We have a number of pieces of legislation 
that Members on this Committee have authored as well as pieces 
authored by Members who are not on this Committee.
    I think people are aware of the fact that veterans 
throughout this country are addressing many serious issues. I 
think both sides of the aisle in this Committee, as well as 
outside of this Committee, you see Members who want to 
introduce legislation to address some of those problems.
    In the 111th Congress, I was pleased to support the 
Caregivers and Veterans Omnibus Health Services Act of 2010, 
which expanded services and benefits for caregivers of post-9/
11 veterans. The Caregiver Program allows these seriously 
wounded veterans to receive care at home, provided by a family 
caregiver. As of the end of February, more than 8,600 veterans 
and their caregivers have benefited from this important 
program.
    For as long as injured veterans have returned from the 
battlefield, family members have worked tirelessly to provide 
the safe environment for these heroes to live comfortably at 
home.
    Historically, these caregivers have done this without any 
support from the Federal Government. This changed with the 2010 
law when, for the first time, veterans' caregivers became 
eligible for supportive services and benefits.
    These benefits included: a tax-free monthly stipend, 
reimbursement for travel expenses, health insurance, mental 
health services and counseling, training, and respite care. 
These benefits and services gave caregivers the support they 
needed to provide the best possible care for their loved ones. 
I am very proud of the success of that piece of legislation.
    However, when the law was passed, these services were only 
made available to post-9/11 veterans and family members. The 
legislation I have introduced, S. 851, expands the Caregiver 
Program and extends these services and benefits to the 
caregivers of veterans of all eras.
    Through this expansion, family members who have been 
providing care to eligible veterans from all other eras will be 
able to access the same supportive services as the caregivers 
of our most recent generation of veterans.
    I hope that my colleagues will join with me in passing this 
important bill so that all of our veterans and the their 
families will be able to get the support that they need. There 
are so many families out there who have done the right thing by 
their loved ones, people who have been injured in war, and I 
think we need to support them.
    The other piece of legislation that I am working on is a 
very consequential piece of legislation. In Vermont and all 
over this country there is an increasing understanding that 
health care is not just treating illness but it is preventing 
disease, supporting wellness and utilizing complementary and 
alternative medicine.
    This broader understanding is growing by leaps and bounds. 
I can remember not so many years ago--Senator Burr, you may 
remember as well--when chiropractic care was thought to be 
somewhat outside of the mainstream. That has certainly come 
into the mainstream now. In fact, it is practiced within VA 
health care today. We have some legislation before us today, 
introduced by Senator Blumenthal, to expand access to 
chiropractic care in VA.
    Acupuncture is also being practiced in VA facilities. 
Meditation and yoga are also being utilized in VA centers. I 
was recently in Brooklyn, NY, and out in Los Angeles. What the 
clinicians there tell me is that many veterans utilize these 
complementary and alternative medicine services with success, 
and the veterans enjoy it.
    So, we are going to be introducing legislation to expand 
those concepts. I will go into that in more length, but Senator 
Burr, please say a few words. Senator Landrieu is also here, 
and I know she has legislation that she wants to talk about. We 
look forward to hearing from her.

        STATEMENT OF HON. RICHARD BURR, RANKING MEMBER, 
                U.S. SENATOR FROM NORTH CAROLINA

    Senator Burr. Thank you, Mr. Chairman. Thank you for 
calling this important hearing. I welcome all of our witnesses 
today and look forward to all of your testimony.
    I also want to especially thank Tom Bowman for being here. 
Boy, he is somebody who has devoted his career to the VA and we 
are grateful for that, and I am grateful that you are here 
today to testify.
    Mr. Chairman, as we consider all the bills on today's 
agenda, I think it is just as important to consider a few 
things, especially before creating or expanding programs. I 
believe we should start by considering how well existing 
programs work and identify any gaps in services and 
inefficiencies that exist.
    By examining current programs, this will help us focus on 
the changes that are truly needed and avoid creating any 
duplication or overlap which is often very frustrating for 
veterans and for their families.
    Last, it is also important to consider the fiscal 
challenges facing our Nation. We need to know the costs of any 
program before that program is moved forward, and we must find 
responsible ways to pay for all of these programs.
    With all that in mind, I look forward to a productive 
discussion about the bills on today's agenda. To start, I would 
like to mention several of those bills which I have sponsored.
    One is S. 543, the VISN Reorganization Act of 2013. This 
legislation would reform VA's Veterans Integrated Service 
Networks, or VISNs. In 1995, the veterans health care system 
was divided into 22 geographic areas. That is now 21 VISNs. 
Each region had its own headquarter with a limited management 
structure to support the medical facilities in that region.
    Since that time, there has been a huge growth in staff at 
the VISN headquarters and increasing duplication in the duties 
they carry out. So, this bill would consolidate the boundaries 
of nine VISNs, move some oversight functions away from VISN 
management, and limit the number of employees at each VISN 
headquarters. All of this should make these networks more 
efficient and, more importantly, should allow resources to be 
reallocated to direct patient care.
    Another bill is S. 529, which would change the start date 
for eligibility of hospital care and medical services in 
connection with exposure to the contaminated water at Camp 
Lejeune, NC.
    This legislation is very simple. It would change the date 
from January 1, 1957, to August 1, 1953, which is based on a 
letter sent to Under Secretary Hickey from Dr. Christopher 
Portier, the Director of the National Center for Environmental 
Health and Agency for Toxic Substance and Disease Registry.
    In this letter, Dr. Portier states, ``according to our 
water modeling, we estimate that the first month any VOC 
exceeded the current EPA MCL in finished water was August 1953, 
and at least one VOC exceeded its current MCL in Hadnot Point 
drinking water from August 1953 through January 1985.'' 
Therefore, I believe there is credible evidence that warrants 
the change in the commencement date.
    I would ask unanimous consent at this time that this letter 
be made a part of the record.
    Chairman Sanders. Without objection.

    [The letter follows:]


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    Senator Burr. Last, I would like to touch on one other 
bill, S. 825, which is a bill Chairman Sanders and I introduced 
together that would improve VA homeless prevention programs and 
VA transitional housing.
    This legislation will reduce barriers many homeless 
veterans face including providing legal services, provide 
services to dependent children of those veterans seeking 
services through the transitional housing program and ensure 
the safety of women by requiring facilities to meet the gender-
specific needs of homeless women veterans.
    Mr. Chairman, all of these bills would provide common-sense 
solutions to real issues affecting our Nation's veterans, their 
families, and their survivors. I look forward to working with 
you and with the rest of our colleagues to see that these and 
other worthwhile bills on today's agenda can soon become law.
    I thank the Chair.
    Chairman Sanders. Senator Burr, thank you very much and 
thank you for your support on the Homeless Veterans' Prevention 
Act of 2013. I look forward to working with you to make sure 
that we pass that important piece of legislation.
    I also want to concur with you. Our job is, as an oversight 
committee, to make sure that we do not see duplication, we do 
not see waste. I happen to believe that, by and large, the VA 
has a very strong health care system. They are doing a good 
job. But it is a huge system and nobody, I think, can tell us 
that everything is perfect. Our job is to see how we can 
improve it, make it cost effective, and add new programs which 
strengthen it.
    With that, I am delighted to welcome our colleague from 
Louisiana who is here to talk about a very important issue.
    Senator Landrieu, thank you very much for being here.

              STATEMENT OF HON. MARY L. LANDRIEU, 
                  U.S. SENATOR FROM LOUISIANA

    Senator Landrieu. Thank you so much, Senator Sanders, and 
thank you, Senator Burr for your focus on the needs of our 
veterans and improving our outreach to them and our health care 
to them. I thank you for the diligence, Mr. Chairman, that you 
bring to this issue particularly.
    I wanted to bring to both of your attention a bill that I 
have filed, S. 412, and I am happy that Senator Blumenthal, 
Senator Isakson, and Senator Hirono have joined me at 
cosponsoring this important legislation that is pending before 
your Committee.
    The bill is called Keep Our Commitment to Veterans Act. It 
would give the go ahead to authorize major medical facilities 
that have been in a holding pattern due to an unexpected and 
recent change in the CBO scoring.
    I am sure your Committee has heard many complaints about 
this. I am sure both of you are very familiar with it, but I 
wanted to bring it to your attention today very briefly.
    Last September, the Veterans' Affairs Committees in the 
House and the Senate were not able to authorize the VA-
requested fiscal year 2013 major medical facility leases in the 
annual construction and extenders package due to a new scoring 
method.
    CBO changed the scoring method for major medical 
facilities, significantly increasing the costs of these 
facilities. Now, we find ourselves here in a situation in 
Louisiana where we have had two clinics, Mr. Chairman, on the 
board now in proposal for several years that are now in 
complete limbo, and we have 20,000 veterans in this area of our 
State, which is in southwest Louisiana--a growing, vibrant area 
of our State--without access to a clinic.
    Under the old scoring method, these 13 clinics would be 
$126 million. Under the new scoring method, it is $1.4 billion. 
We have got to find, I think, an administrative way forward 
here, not just for the clinics in Louisiana, of course, which I 
am here to advocate for and the veterans communities that are 
really in desperate need of these facilities and have been 
promised year after year. But I understand, Mr. Chairman, that 
this affects other States as well. I am sure you are well 
aware.
    So, on behalf on the 20,000 veterans and their families 
that I am here to represent, I look forward to working with you 
to find a solution to help these veterans that have served our 
Nation so proudly and so ably.
    We need to fix this situation. As an appropriator I most 
certainly understand the challenges in our budget, yet perhaps 
with some work between the Appropriations Committee and this 
good oversight and authorizing Committee, we can find a way 
forward.
    It is an opportunity for us to make clear to our veterans 
that the promises we made to them we want to hold to those 
promises.
    Thank you, Mr. Chairman, and I will submit the rest of my 
statement for the record, and thank you, Senator Burr.
    [The prepared statement of Senator Landrieu follows:]
             Prepared Statement of Hon. Mary L. Landrieu, 
                      U.S. Senator from Louisiana
    Thank you Chairman Sanders and Ranking Member Burr for affording me 
the opportunity to speak in support of S. 412, the ``Keep Our 
Commitment to Veterans Act.''
    I would also like to thank Senators Blumenthal, Isakson and Hirono 
for cosponsoring this important legislation.
    The Keep Our Commitment to Veterans Act would give the go ahead to 
authorize major medical facilities that have been in a holding pattern 
due to a change in Congressional Budget Office (CBO) scoring.
    Last September, the Veterans' Affairs Committees in the House and 
the Senate were not able to authorize VA's requested FY 2013 Major 
Medical Facility Leases in the annual construction and extenders 
package due to the way the leases were scored by the CBO.
    The CBO changed the scoring methodology for major medical facility 
leases, significantly increasing the cost of the facilities, by 
requiring 19 years rent up front.
    Now we find ourselves in a situation with no path forward. 
Regardless of whether the CBO scoring method is right or wrong, this 
sort of bureaucratic bottleneck is unacceptable.
    Under the scoring method used in the past, the cost of the FY 2013 
clinics would be a little over $126 million dollars. This amount was 
factored into the budget baseline.
    However, the 15 FY 2013 clinics are now being scored at a cost of 
nearly $1.4 billion dollars. This is a thousand percent increase!! The 
12 FY 2014 clinics would now cost $1.16 billion dollars.
    Given the current budgetary climate, this is no time to implement 
burdensome financial requirements. This scoring system will have 
widespread implications for veterans nationwide, pulling the rug out 
from under our Nation's vets.
    The FY 2013 and FY 2014 clinics would serve over 1.3 million 
veterans in 18 states.
    Nearly 20,000 veterans would be served by the 2 delayed clinics in 
my home state of Louisiana. Those are 20,000 veterans who have served 
our Nation proudly.
    These veterans served in international engagements such as World 
War II, Korea, Vietnam, Iraq, and Afghanistan. They served in the Navy, 
Marines, Army, and the Air Force. They served their country with pride 
and have earned the care they were promised.
    We need to fix this issue as it is only going to get worse. There 
are approximately 50 leases that are due to expire before the end of FY 
2016 and will be impacted if the budgetary treatment of major medical 
facilities is not resolved.
    This is an opportunity to make it clear that this Congress 
recognizes the importance of properly authorizing and appropriating 
funds in order to provide our veterans receive the care that they 
deserve. The ``Keep Our Commitment to Veterans Act'' will do just that.

    Chairman Sanders. Senator Landrieu, thank you very much for 
focusing on an issue which, as you indicated, goes well beyond 
Louisiana.
    One of the great advances made by the VA in recent years 
has been the expansion of the CBOC program which is what you 
are talking about, Community-Based Outreach Clinics.
    I think we all know that when veterans or nonveterans are 
able to access affordable primary health care that keeps them 
healthier, keeps them out of the hospital, in the long run it 
saves our system money. The CBOC program has been very 
successful in Vermont and all over this country. I do not want 
to see an impediment from the way the CBO deals with this issue 
limit our ability to expand CBOCs.
    So, you raise a very important question which is something 
that this Committee has got to address. Senator Burr, did you 
want to add anything to that?
    Senator Burr. As one who participated before the CBO 
determination and exercise, the lease option I understand, the 
benefits that it provided especially at the clinic and 
outpatient level, and I look forward to working with you on 
this.
    Chairman Sanders. We will be dealing with CBO on this issue 
to do our best.
    Thank you, Senator, very much.
    I would now like to bring up our first panel which is Dr. 
Robert Jesse, Principal Deputy Under Secretary for Health at 
the Department of Veterans Affairs. Dr. Jesse is accompanied by 
Susan Blauert, Deputy Assistant General Counsel.
    Thank you both very much for providing the Department's 
perspective on the pending health care legislation. We look 
forward to hearing your testimony. Dr. Jesse, why do you not 
begin please.

STATEMENT OF ROBERT JESSE, M.D., Ph.D., PRINCIPAL DEPUTY UNDER 
  SECRETARY FOR HEALTH, U.S. DEPARTMENT OF VETERANS AFFAIRS; 
 ACCOMPANIED BY SUSAN BLAUERT, DEPUTY ASSISTANT GENERAL COUNSEL

    Dr. Jesse. Good Morning, Chairman Sanders, Ranking Member 
Burr, and Members of the Committee. We thank you for the 
opportunity to address the bills on today's agenda and to 
discuss the impact of these bills on Veterans' Administrating 
health care delivery.
    As you mentioned, joining me today is Susan Blauert, VA's 
Deputy Assistant General Counsel.
    Chairman Sanders, we greatly appreciate your continued 
efforts to support and improve veterans' health care. VA is 
carefully reviewing two of your bills, one concerning 
complementary and alternative medicine and the other expanding 
the Family Caregiver Assistance Act.
    We anticipate providing full views on these bills soon. In 
the meantime, we will work with your staff to provide technical 
assistance. We believe we can provide valuable insight as to 
how VA can better integrate complementary and alternative 
medicine into our mission to provide personalized proactive and 
patient-driven care that support the health and well-being of 
veterans.
    In my oral remarks, I am going to briefly explain VA's 
position on a few of the bills being considered today. A much 
more detailed discussion of all the bills on the agenda can be 
found in my written statement.
    Generally, VA supports bills expanding services to 
veterans. These bills include S. 325, which would increase the 
maximum age for eligibility of children covered under CHAMPVA 
Program and S. 455, which would make permanent our ability to 
use paid drivers to expand access to VA health care for 
individuals traveling for the purposes of medical care.
    The VA also supports S. 529, which would expand the period 
of eligibility for benefits for the Camp Lejeune veterans by 4 
years. I would like to thank Ranking Member Burr for his 
ongoing efforts to support our Camp Lejeune veterans.
    VA has made a number of recommendations on the Camp Lejeune 
program to make it easier to implement and easier for family 
members and veterans alike. These include simplifying the 
administrative eligibility requirements and shifting to DOD the 
determination of whether the veteran and qualified family 
members meet the 30-day requirement on Camp Lejeune. We believe 
these modifications to S. 529 would greatly improve our ability 
to implement the Camp Lejeune law.
    We support much of bill S. 131, which would permit VA to 
provide expanded reproductive services, including in-vitro 
fertilization for certain veterans and their spouses suffering 
from infertility. However, we do not support extending these 
services to engage in surrogates who would bear children for 
veterans primarily because variations and complexities in the 
State laws and policies would make a surrogacy provision 
extremely difficult to implement. We are concerned about our 
authority to support veterans in dealing with the entirety of 
the many complex issues involving surrogates.
    So, a few of the provisions in this bill will require a 
little more time before VA can provide a position. For now, we 
remain hopeful, though, that Congress will enact the much-
needed extension of our authority to operate our existing child 
care pilot so that we can continue to collect and analyze cost 
and utilization data.
    VA supports the intent of S. 422, the Chiropractic Care 
Available to All Veterans Act of 2013, which would expand 
access to chiropractic care to all veterans. However, VA 
believes that the health administration is best situated to 
determine the parameters of such an expansion.
    Decisions regarding the delivery, care through staffing 
versus a fee basis should be predicated both on demand and 
local capability. That would include the availability of 
licensed chiropractic professionals for hire into the VA system 
or through referral to them in the community.
    We acknowledge that there is need for a thorough assessment 
of our current chiropractic services. In fact, such a study is 
now nearing completion, and we would welcome the opportunity to 
work closely with the Committee to ensure that legislation in 
this area supports veterans' preferences.
    And finally, I would like to address S. 543, which would 
consolidate our existing 21 VISNs into 12 and proscribe a 
specific VISN organizational structure and staffing model.
    As we discussed last year, VA shares the goal of increasing 
the efficiency of our operations. However, we do not support 
the imposition of a staffing and organizational structure that 
is not based on a complete assessment of business needs.
    Last month, we provided the Committee staff an update on 
our progress toward implementing our internal reorganization 
and realignment. Standards have been established and we expect 
all VISNs to have completed the first phase of the 
reorganization by the end of this year. This will enhance 
quality and consistency of the management processes and will 
enable VHA to better assess cost effectiveness.
    For phase two, a work group has been charted to undertaken 
an analysis of VISN geographic boundaries and contemporary 
referral patterns. A process we believe is necessary to form 
any decision about redrawing the VISN scope. We look forward to 
keeping the Committee advised on our analysis and the status of 
work in this area.
    I would like to conclude by thanking you all for the 
opportunity to testify before the Committee and I will be 
pleased to respond to questions that you or the other Members 
have about the bills I have touch upon or other bills that were 
addressed in my written statement.
    Thank you.
    [The prepared statement of Dr. Jesse follows:]
 Prepared Statement of Robert L. Jesse, M.D., Ph.D., Principal Deputy 
    Under Secretary for Health, U.S. Department of Veterans Affairs
    Good Morning Chairman Sanders, Ranking Member Burr, and Members of 
the Committee. Thank you for inviting me here today to present our 
views on several bills that would affect Department of Veterans Affairs 
(VA) benefits programs and services. Joining me today is Susan Blauert, 
Deputy Assistant General Counsel.
    We do not yet have cleared views on sections 4, 10, 11, or 12 of 
S. 131, S. 287, section 3 of S. 522, S. 800, S. 832, S. 845, S. 851, 
S. 852, or the draft bill described as ``The Veterans Affairs Research 
Transparency Act of 2013.'' Also, we do not have estimated costs 
associated with implementing S. 131, S. 422, S. 455, or S. 825. We will 
forward the views and estimated costs to you as soon as they are 
available.
                s. 49 veterans health equity act of 2013
    S. 49 would amend Title 38, Part II, Chapter 17, of the United 
States Code (U.S.C.) to include a new section 1706A. Section 1706A 
would require the Secretary to ensure that Veterans in each of the 48 
contiguous States have access to at least one full-service Department 
medical center or to comparable hospital care and medical services 
through contract with other in-State health care providers. Section 
1706A would define a full-service Department medical center as a 
facility that provides medical services including, hospital care, 
emergency medical services, and standard-level-complexity surgical 
care. Additionally, the Secretary would be required to submit a report 
to Congress within one year describing VA's compliance with these 
requirements and how the quality and standards of care provided to 
Veterans has been impacted.
    VA objects to this legislation because it is unnecessary. VA 
engages in an extensive analysis of factors in order to identify 
appropriate locations to site VA health care facilities in order to 
best serve the patient population. These factors include, but are not 
limited to, projected total Veteran population, Veteran enrollee 
population, and utilization trends. VA analyzes this demand projection 
data over a 20-year period and takes into account Veteran access to 
various types of care and services. VA also utilizes its access 
guidelines, which take into account an acceptable amount of time a 
Veteran should reasonably travel to receive care depending upon whether 
the Veteran resides in an urban, rural, or highly rural community.
    VA engages in population-based planning and seeks to provide 
services through a continuum of delivery venues, including outreach 
clinics, community-based outpatient clinics, and medical facilities or 
hospitals. When it is determined that a full-service hospital is not 
required, VA uses a combination of interventions to ensure the delivery 
of high quality health care such as contracting for care in the 
community, use of telehealth technologies and referral to other VA 
facilities. VA improves Veteran access to health care by providing care 
within or as close to the Veteran's community as possible, regardless 
of state boundary lines.
    As an example, we note that VA is providing expanded acute care 
services to New Hampshire Veterans through contracts with local health 
care providers, in order to address the needs and concerns of the New 
Hampshire constituency. This model has been used for more than a decade 
to provide VA-coordinated care in a safe and cost effective manner. 
Providing services in this manner ensures that Veterans who use the 
Manchester VA Medical Center (VAMC) have available locally the same 
level of acute care services as other Veterans within the VA New 
England Healthcare System and elsewhere. Patients who require tertiary 
care, such as cardiac surgery or neurosurgery, and extended inpatient 
psychiatry will continue to be referred to appropriate VA facilities 
for this care.
         s. 62 check the box for homeless veterans act of 2013
    S. 62 would amend the Internal Revenue Code of 1986 to establish in 
the Treasury a trust fund known as the ``Homeless Veterans Assistance 
Fund,'' and would allow taxpayers to designate a specified portion (not 
less than $1) of any overpayment of tax to be paid over to the Homeless 
Veterans Assistance Fund. Amounts in the Fund would be available ``for 
the purpose of providing services to homeless veterans.'' S. 62 would 
require that in the President's annual budget submission for fiscal 
year (FY) 2014 and each year thereafter, VA, Department of Labor, and 
Department of Housing and Urban Development (HUD) include a description 
of the use of the funds from the Homeless Veterans Assistance Fund from 
the previous fiscal year and proposed use of such funds for the next 
fiscal year.
    VA appreciates the sentiment behind this legislation, and we 
believe in emphasizing that Veteran homelessness is a national issue 
where communities and individuals across America can make great 
contributions, in many different ways. We are glad to have a dialog 
with the Committee on what VA is doing now to engage the public and 
communities across the Nation, and discuss innovative ways we can 
increase that engagement. Turning to S. 62, we applaud its intent, but 
cannot offer VA's support for its way of increasing that engagement . 
VA views its services to homeless Veterans as an obligation of the 
Nation, earned by those Veterans by their service. That is also 
reflected in Congress' enactment of laws to allow VA to provide these 
services. The Secretary has made clear that this is in fact one of VA's 
most important obligations. While we appreciate sincerely the motive of 
bringing this issue before the taxpayers, we believe the presence of a 
check-off to fund VA's programs could lead some to see these 
obligations as a discretionary charity. VA does involve charities and 
community organizations in its work, and they provide vital partners 
and complements to the work VA is doing to end Veteran homelessness. 
But VA prefers that all Federal funding come from affirmative 
appropriations provided by the Congress, rather than voluntary 
apportionments through the tax code.
  s. 131 woman veterans and other health care improvement act of 2013
    Section 2 of S. 131 would amend 38 U.S.C. section 1701(6) to 
include fertility counseling and treatment, including treatment using 
assisted reproductive technology, among those things that are 
considered to be ``medical services'' under chapter 17 of title 38, 
U.S.C.
    VA supports section 2 of the bill, but must condition this support 
on assurance of the additional resources that would be required were 
this provision enacted. The provision of Assisted Reproductive 
Technologies (including any existing or future reproductive technology 
that involves the handling of eggs or sperm) 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. 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 3 of the bill would add a new section 1788 to title 38, 
U.S.C., that would require VA to furnish fertility counseling and 
treatment, including through the use of assisted reproductive 
technology, to a spouse or surrogate of a severely wounded, ill, or 
injured enrolled Veteran who has an infertility condition incurred or 
aggravated in the line of duty, if the spouse or surrogate and the 
Veteran apply jointly for such counseling and treatment through a 
process prescribed by VA. This section would authorize VA to 
``coordinate fertility counseling and treatment'' for other spouses and 
surrogates of other Veterans who are seeking fertility counseling and 
treatment. Section 1788 would not be construed to require VA to furnish 
maternity care to a spouse or surrogate of a Veteran, or to require VA 
to find or certify a surrogate for or connect a surrogate with a 
Veteran. Subsection (d) of proposed section 1788 would define the term 
``assisted reproductive technology'' to include ``in vitro 
fertilization and other fertility treatments in which both eggs and 
sperm are handled when clinically appropriate.''
    VA supports section 3 in part, but must condition this support on 
assurance of the additional resources that would be required were this 
provision enacted. VA supports providing infertility services including 
assisted reproductive technology to severely wounded, ill, or injured 
enrolled Veterans described in section 3, and their spouses or 
partners. VA does not, however, support coverage of such services for 
surrogates at this time. The complex legal, medical, and policy 
arrangements of surrogacy vary from state to state due to inconsistent 
regulations between States, and we believe would prove to be very 
difficult to implement in practice. Moreover, the additional coverage 
of surrogates is inconsistent with coverage provided by the Department 
of Defense (DOD), Medicaid, Medicare, and several private insurers and 
health systems. Current DOD policy addressing assisted reproductive 
services for severely injured Servicemembers specifically excludes 
coverage of surrogates. VA acknowledges that surrogacy may offer the 
only opportunity for Veterans and their spouses or partners to have a 
biological child. However, there may be other options to consider when 
exploring how best to compensate these Veterans for their loss and to 
facilitate procreation.
    VA recommends the language of the bill be modified to account for 
different types of family arrangements, so that benefits are not 
limited to only spouses of Veterans described in proposed section 1788; 
VA recommends that section 1788 be revised to refer to a ``spouse or 
partner'' of a specified Veteran. In addition, the meaning and scope of 
the coordination contemplated under proposed section 1788(b) (which 
would authorize VA to ``coordinate fertility counseling and treatment'' 
for the spouses and surrogates of other Veterans not described in 
section 1788(a)) is unclear, and could potentially account for spouses 
and surrogates of all other Veterans. VA recommends that this be 
clarified.
    Section 5 of the bill would require VA to report annually to the 
Committees on Veterans' Affairs of the Senate and House of 
Representatives on the fertility counseling and treatment furnished by 
VA during the preceding year. The first report would be required no 
later than one year after enactment. Each report submitted under 
section 5 would be required to contain specified information, including 
the number of Veterans, spouses, and surrogates who received fertility 
counseling and treatment furnished by VA; the costs of furnishing such 
counseling and treatment; and coordination of such counseling and 
treatment with similar services of DOD. VA does not object to such 
reporting.
    Section 6(a) would require VA, no later than 540 days after 
enactment, to prescribe regulations to carry out proposed sections 1788 
and 1789, and on fertility treatment to Veterans using assisted 
reproductive technology. Section 6(b) would prohibit VA from providing, 
until regulations are prescribed, fertility counseling and treatment 
under 1788, assistance under 1789, and to a Veteran ``any fertility 
treatment that uses an assisted reproductive technology that the 
Secretary has not used in the provision of a fertility treatment to a 
veteran before the date of the enactment.'' The term ``assisted 
reproductive technology'' under section 6 would have the same meaning 
given to the term in proposed section 1788 of section 3.
    VA does not support Section 6(a). While 540 days accorded for the 
drafting of regulations may seem like a long period of time, given the 
complexities of the issues involved, VA estimates that amount of time 
could be insufficient.
    Section 7 of S. 131 would require the Secretary of VA and the 
Secretary of Defense to share best practices and facilitate referrals, 
as they consider appropriate, on the furnishing of fertility counseling 
and treatment. VA does not object to this requirement.
    Section 8 of the bill would add a new section 7330B to title 38, 
U.S.C., entitled ``Facilitation of reproduction and infertility 
research.'' This new section would require the Secretary of VA to 
``facilitate research conducted collaboratively by the Secretary of 
Defense and the Secretary of Health and Human Services'' 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 the 
Veterans' ability to reproduce, such as spinal cord injury. The 
Secretary of VA would be required to ensure that information produced 
by research facilitated under section 7330B that may be useful for 
other activities of the Veterans Health Administration (VHA) is 
disseminated throughout VHA. No later than 3 years after enactment, VA 
would be required to report to Congress on the research activities 
conducted under section 7330B.
    VA supports section 8 of S. 131. 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. We utilize new research into various 
conditions to improve the quality of care we provide. Of note, rather 
than requiring VA to conduct research, this section would require VA to 
facilitate research that is conducted collaboratively by the Secretary 
of Defense and the Secretary of Health and Human Services. It is not 
clear how the term ``facilitate'' would be defined, which could raise 
privacy and security issues with respect to identifiable Veteran 
information. Given the ambiguity over the meaning of this term, VA is 
unable to provide a cost estimate at this time. If facilitation 
requires fairly minor involvement (coordination, distribution, etc.), 
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 9 of S. 131 would require VA to enhance the capabilities of 
the VA Women Veterans Call Center (WVCC) in responding to requests by 
women Veterans for assistance with accessing VA health care and 
benefits, as well as in referring such Veterans to community resources 
to obtain assistance with services not furnished by VA.
    VA supports section 9 and has established an inbound calling system 
specifically for women Veterans. By building on capabilities within 
WVCC, the incoming call center allows women Veterans to call WVCC to 
connect them to resources, assist with specific concerns, and provide 
information on services and benefits. Many of the Veterans are calling 
VA daily requesting more details on how to enroll, how to find their 
DD-214, and what benefits they have earned. WVCC can directly connect 
women Veterans to Health Eligibility Center employees for enrollment 
information and to discuss the benefits that might be available to 
them. The call could also be transferred to the appropriate medical 
center to assist eligible Veterans with obtaining a health care 
appointment. Once the woman Veteran is connected to VA health care 
services, the Women Veterans Program Manager can also assist her in 
finding community resources that may not be provided by VA.
    VA is unable to provide views on sections 4, 10, 11, and 12 at this 
time, but will provide views on those provisions in a later submission 
to the Committee.
            s. 229 corporal michael j. crescenz act of 2013
    S. 229 would designate the Department of VAMC located at 3900 
Woodland Avenue in Philadelphia, Pennsylvania, as the ``Corporal 
Michael J. Crescenz Department of Veterans Affairs Medical Center.'' VA 
defers to Congress in the naming of this facility.
       s. 325 increase of maximum age for children eligible for 
                   medical care under champva program
    Contingent upon Congress providing additional funding to support 
the change in eligibility, VA supports S. 325, which would amend 38 
U.S.C. section 1781(c) to extend eligibility for coverage of children 
under the Civilian Health and Medical Program of the Department of 
Veterans Affairs (CHAMPVA) until they reach age 26 so that eligibility 
for coverage of children under CHAMPVA will be consistent with certain 
private sector coverage under the Affordable Care Act. S. 325 would 
extend eligibility for coverage of children under CHAMPVA regardless of 
age, marital status, and school enrollment status up to the age of 26; 
and the bill would ensure that CHAMPVA eligibility would not be limited 
for individuals described in section 101(4)(A)(ii) (individuals who, 
before attaining age 18, became permanently incapable of self-support). 
The bill would not extend eligibility for children who, before 
January 1, 2014, are eligible to enroll in an eligible employer-
sponsored plan (as defined in Internal Revenue Code section 
5000A(f)(2)). This means that the age, school status, and marital 
status requirements in 38 U.S.C. section 101(4) would, before 2014, 
apply to children who are eligible to enroll in an eligible employer-
sponsored health plan and the bill would not extend eligibility for 
coverage of those individuals. This provision in the bill is in 
accordance with the discretion provided to grandfathered health plans 
that are group health plans in the private sector under the Affordable 
Care Act. The amendments made by S. 325 would apply with respect to 
medical care provided on or after the date of enactment of the bill.
    VHA estimates that this provision would cost $51 million in FY 
2014; $301 million over 5 years; and $750 million over 10 years.
               s. 412 keep our commitment to veterans act
    S. 412 would authorize the Secretary to carry out certain major 
medical facility leases in FY's 2013 and 2014 for VA.
    Section 2 of S. 412 would authorize the Secretary to carry out 
twelve major medical facility leases, all of which were included in 
VA's FY 2013 Budget Submission. Specifically, Section 2 would authorize 
the Secretary to carry out a major medical facility lease for a 
Clinical Research and Pharmacy Coordination Center in Albuquerque, New 
Mexico; a replacement Community Based Outpatient Clinic in Brick, New 
Jersey; a New Primary Care/Dental Clinic Annex in Charleston, South 
Carolina; a Community-Based Outpatient Clinic in Cobb County, Georgia; 
an Outpatient Healthcare Access Center in Honolulu, Hawaii, to include 
a co-located clinic with DOD and the co-location of VBA's Honolulu 
Regional Office and the Kapolei VA Vet Center; a Community-Based 
Outpatient Clinic in Lafayette, Louisiana; a Community-Based Outpatient 
Clinic in Lake Charles, Louisiana; an Outpatient Clinic Consolidation 
in New Port Richey, Florida; an Outpatient Clinic Expansion in Ponce, 
Puerto Rico; a Lease Consolidation in San Antonio, Texas; an Errera 
Community Care Center in West Haven, Connecticut; and a Community-Based 
Outpatient Clinic in Worcester, Massachusetts.
    Section 3 of S. 412 would provide new authorizations for the 
Secretary to carry out a major medical facility lease, previously 
authorized in FY 2010, for a Community-Based Outpatient Clinic in 
Johnson County (Lenexa), Kansas; a major medical facility lease, 
previously authorized in FY 2011, for a Community-Based Outpatient 
Clinic in San Diego, California; and, a major medical facility lease, 
previously authorized in FY 2006, for a Community-Based Outpatient 
Clinic in Tyler, Texas.
    VA supports this section, but requests that the amounts for each 
lease be revised to be consistent with the prospectuses included in 
VA's 2014 Budget Submission. The lease authorizations amounts and 
project scopes changed to reflect more current estimates. VA suggests 
modifying the language as set forth below.

          ``The Secretary of Veterans Affairs may carry out the 
        following major medical facility leases in FY 2014:

          (1) Johnson County, Kansas, Community-Based Outpatient 
        Clinic, in an amount not to exceed $2,263,000.
          (2) San Diego, California, Community-Based Outpatient Clinic, 
        in an amount not to exceed $11,946,100.
          (3) Tyler, Texas, Community-Based Outpatient Clinic, in an 
        amount not to exceed $4,327,000.''

    VA supports S. 412. VA's leasing program is an important component 
of providing health care to Veterans. Leasing has been and continues to 
be an essential part of VA's capital portfolio management, and 
significantly supports VA's mission to meet the service needs of our 
Nation's Veterans.
    In addition, VA has put forth, in its FY 2014 budget, 12 additional 
major medical facility lease projects, for a total of 27 major medical 
facility leases. The 27 leases included in the FY 2014 Budget Request 
are new and replacement leases. The 2014 Budget Request also proposes 
changes to legislation to allow greater collaboration with other 
Federal agencies and proposes changes to legislation to amend VA's 
Enhanced-Use Lease statute. The proposed changes would enhance the 
repurposing of VA's assets and improve the ability to develop joint 
DOD/VA facilities. The details of the leases and proposed legislation 
can be found in the VA budget documents transmitted to Congress on 
April 10, 2013.
     s. 422 chiropractic care available to all veterans act of 2013
    S. 422 would require VA to establish programs for the provision of 
chiropractic care and services at not fewer than 75 medical centers by 
not later than December 31, 2014, and at all VAMCs by not later than 
December 31, 2016. Currently, VA is required (by statute) to have at 
least one site for such program in each VHA geographic services area.
    Section 3(a) would amend the statutory definition of ``medical 
services'' in section 1701 of chapter 17, U.S.C., to include 
chiropractic services. Subsection (b) would amend the statutory 
definition of ``rehabilitative services'' in that same section to 
include chiropractic services. Finally, subsection (c) would amend the 
statutory definition of ``preventive health services'' in that same 
section to include periodic and preventive chiropractic examinations 
and services.
    The bill would also make technical amendments needed to effect 
these substantive amendments.
    In general, VA supports the intent of S. 422, but believes the 
decision to provide on-site or fee care should be determined based on 
existing clinical demands and business needs. Chiropractic care is 
available to all Veterans and is already part of the standard benefits 
package.
    As VA increases the number of VA sites providing on-site 
chiropractic care, we will be able to incrementally assess demand for 
chiropractic services and usage, and to best determine the need to add 
chiropractic care at more sites.
    Currently, VA does not have an assessment that would support 
providing on-site chiropractic care at all VAMCs by the end of 2016. 
Such a mandate could potentially be excessive, given the availability 
of resources for on-site chiropractors and non-VA care to meet the 
current need for services. VA does not object to sections 3(a) and (b) 
as those changes reflect VA's consideration of chiropractic care as 
properly part of what should be considered medical and rehabilitative 
services. VA, however, cannot support section 3(c) for lack of a 
conclusive consensus on the use of chiropractic care as a preventative 
intervention.
 s. 455 transportation in connection with rehabilitation, counseling, 
                    examination, treatment, and care
    S. 455 would make permanent VA's broad authority to transport 
individuals to and from VA facilities in connection with vocational 
rehabilitation, counseling, examination, treatment, or care. That 
authority currently will expire on January 10, 2014. This authority has 
allowed VA to operate the Veterans Transportation Program which uses 
paid drivers to complement the Volunteer Transportation Network, which 
uses volunteer drivers. The Volunteer Transportation Network supported 
by Veterans Service Organizations, especially the Disabled American 
Veterans, is invaluable; however, with increasing numbers of 
transportation-disadvantaged Veterans, there simply are not enough 
volunteers to serve the level of need. Furthermore, volunteer drivers 
are generally precluded from transporting Veterans who are not 
ambulatory, require portable oxygen, have undergone a procedure 
involving sedation, or have other clinical issues. Also, some 
volunteers, for valid reasons, are reluctant to transport non-
ambulatory or very ill Veterans. Paid drivers have resulted in better 
access to VA health care, often for those for whom travel is the most 
difficult.
    VA thus supports enactment of this bill, and proposed a five-year 
extension of this authority in the FY 2014 President's Budget. The 
budget assumes savings of $19.2 million in FY 2014 and $102.7 million 
over five years. As a technical matter, we suggest the bill's insertion 
of a new section 111A be changed to instead reflect the intent to 
replace the existing section 111A with the revised version.
           s. 522, wounded warrior workforce enhancement act
    S. 522, the Wounded Warrior Workforce Enhancement Act, would direct 
VA to establish two grant award programs. Section 2 of the bill would 
require VA to award grants to institutions to: (1) establish a master's 
or doctoral degree program in orthotics and prosthetics, or (2) expand 
upon an existing master's degree program in such area. This section 
would require VA to give a priority in the award of grants to 
institutions that have a partnership with a VAMC or clinic or a DOD 
facility. Grant awards under this provision must be at least $1 million 
and not more than $1.5 million. Grant recipients must either be 
accredited by the National Commission on Orthotic and Prosthetic 
Education or demonstrate an ability to meet such accreditation 
requirements if receiving a grant. VA would be required to issue a 
request for proposals for grants not later than 90 days after the date 
of enactment of this provision.
    In addition to the two purposes noted above, grantees would be 
authorized to use grants under this provision to train doctoral 
candidates and faculty to permit them to instruct in orthotics and 
prosthetics programs, supplement the salary of faculty, provide 
financial aid to students, fund research projects, renovate buildings, 
and purchase equipment. Not more than half of a grant award may be used 
for renovating buildings. Grantees would be required to give a 
preference to Veterans who apply for admission in their programs.
    VA does not support enactment of section 2 of this bill. We believe 
VHA has adequate training capacity to meet the requirements of its 
health care system for recruitment and retention of orthotists and 
prosthetists. VA offers one of the largest orthotic and prosthetic 
residency programs in the Nation. In FY 2013, VA allocated $837,000 to 
support 19 Orthotics/Prosthetics residents at 10 VAMCs. The training 
consists of a year-long 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. Moreover, recruitment and 
retention of orthotists and prosthetists has not been a challenge for 
VA. Nationally, VA has approximately 240 orthotic and prosthetic staff; 
there are currently only 7 positions open and being actively recruited.
    Much of the specialized orthotic and prosthetic capacity of VA is 
met through contract mechanisms. 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.
    We also note the bill would not require these programs to affiliate 
with VA or send their trainees to VA as part of a service obligation. 
We also have technical concerns about the language in section 2, 
subsection (e). Specifically, the language directs the appropriators to 
provide funding ($15 million) in only one fiscal year, FY 2014, which 
would expire after three fiscal years. This subsection contemplates 
that unobligated funds would be returned to the General Fund of the 
Treasury immediately upon expiration. Under 31 U.S.C. section 1553(a), 
expired accounts are generally available for 5 fiscal years following 
expiration for the purpose of paying obligations incurred prior to the 
account's expiration and adjusting obligations that were previously 
unrecorded or under recorded. If the unobligated balance of these funds 
were required to be returned to the Treasury immediately upon 
expiration, then VA would be unable to make obligation adjustments to 
reflect unrecorded or under recorded obligations. A bookkeeping error 
could result in an Antideficiency Act violation. Accordingly, we 
recommend the deletion of paragraph (2) of subsection (e). Further, we 
recommend that the words ``for obligation'' be deleted from paragraph 
(e)(1) of section 2 because they are superfluous. Last, we note that 90 
days after the date of enactment of this provision is not enough time 
for VA to prepare a request for proposals for these grants.
    VA is unable to provide views on section 3 at this time, but will 
provide views for the record at a future time.
            s. 529 modification of camp lejeune eligibility
    Public Law 112-154 provided authority for VA to provide hospital 
services and medical care to Veterans and family members who served on 
active duty or resided at Camp Lejeune for no less than 30 days from 
January 1, 1957, to December 31, 1987, for care related to 15 illnesses 
specified in the public law. S. 529 would modify the commencement date 
of the period of service at Camp Lejeune, North Carolina for 
eligibility under 1710(e)(1)(F) from January 1, 1957, to August 1, 
1953, or to such earlier date as the Secretary, in consultation with 
the Agency for Toxic Substances and Disease Registry (ATSDR), 
specifies.
    VA supports this change due to information provided in the 
scientific studies conducted by ATSDR. We do not believe this change 
would result in substantial additional costs.
    VA also recommends that the Committee consider including language 
to simplify the administrative eligibility determination process and 
thereby relieve some of the burden from the Veteran and family member. 
Other special eligibility authorities included participation by DOD to 
determine exposure while on active duty. The current statute for Camp 
Lejeune Veterans and family members does not include this provision. VA 
recommends including a requirement for DOD to determine if the Veteran 
or family member met the 30-day presence requirement on Camp Lejeune.
                 s. 543 visn reorganization act of 2013
    Section 2 of S. 543 would require VHA to consolidate its 21 
Veterans Integrated Service Networks (VISN) into 12 geographically 
defined VISNs, would require that each of the 12 VISN headquarters be 
co-located with a VAMC, and would limit the number of employees at each 
VISN headquarters to 65 full-time equivalent employees (FTEE). VA 
opposes section 2 for the following reasons.
    By increasing the scope of responsibility for each VISN 
headquarters while reducing the number of employees at each, the 
legislation would impede VA's ability to implement national goals. 
Currently, VISN headquarters are capable of providing assistance to 
supplement resource needs at facilities and are able to support 
transitions in staff within local facilities when there are personnel 
changes; with a responsibility for oversight of more facilities and 
fewer staff, the VISN headquarters would lose the opportunity to 
provide this essential service when needed. VHA has reviewed each VISN 
headquarters and is working with each to streamline operations, create 
efficiencies internal to each VISN, and realign resources. This will 
achieve savings without the negative impact of the restructuring 
proposed in S. 543.
    The requirement in section 2 that VISN budgets be balanced at the 
end of each fiscal year may have unintended consequences. Currently, 
each VISN balances its accounts at the end of each fiscal year. 
Sometimes this is achieved by providing additional resources from VHA. 
These resources may be needed for a number of reasons, including 
greater-than-anticipated demand, a national disaster or emergency, new 
legal requirements enacted during the year, and other factors. Under 
S. 543, VA may lose the flexibility to supplement VISNs with additional 
resources, potentially compromising patient care.
    Section 2 would also require VA to identify and reduce duplication 
of functions in clinical, administrative, and operational processes and 
practices in VHA. We are already doing this by identifying best 
practices and consolidating functions, where appropriate. Further, 
section 2 describes how the VISNs should be consolidated but fails to 
articulate clearly the flow of leadership authority. Consequently, 
S. 543 would blur the lines of authority from VHA Central Office, 
regions, and VISNs to medical centers, which could actually impede 
oversight and create confusion.
    Additionally, the original VISN boundaries were drawn carefully 
based on the health needs of the local population. By contrast, the 
proposed combination of VISNs does not account for the underlying 
referral patterns within each VISN. For example, it is unclear why 
VISNs 19 and 20 should be consolidated. This would produce a single 
Network responsible for overseeing 12 states, 15 VA health care systems 
or medical centers, and a considerable land mass, while VISN 6 would 
continue to oversee three states and eight health care systems or 
medical centers. VA would appreciate the opportunity to review the 
Committee's criteria for determining these boundaries.
    Finally, section 2 seems to assume that locating the management 
function away from a medical center represents an inefficient 
organizational approach. That assumption is not valid in all cases. 
Currently, six VISNs (1, 2, 3, 20, 21, and 23) are co-located with a 
VAMC. The legislation's requirement for co-location with a VAMC would 
require either construction to expand existing medical centers, using 
resources that would otherwise be devoted to patient care to cover 
administrative costs, or would require the removal of certain clinical 
functions to create administrative space for VISN staff in at least 
nine VISNs.
    As a result, Veterans potentially would be forced to travel to 
different locations for services or would be unable to access new 
services that would have been available had construction resources not 
been required to modify existing facilities to accommodate VISN staff. 
While section 4 states that nothing in the bill shall be construed to 
require any change in the location or type of medical care or service 
provided by a VA medical center, the reality is that requiring co-
location would necessitate this result.
    VA also does not support section 3 of S. 543. Section 3 would 
require VA to create up to four regional support centers to ``assess 
the effectiveness and efficiency'' of the VISNs. Section 3 identifies a 
number of functions to be organized within the four regional support 
centers including:

     Financial quality assurance;
     Operation Enduring Freedom/Operation Iraqi Freedom/
Operation New Dawn outreach;
     Women's Veterans programs assessments;
     Homelessness effectiveness assessments;
     Energy assessments; and
     Other functions as the Secretary deems appropriate.

    Certain services are more appropriately organized as national 
functions rather than regional ones. For example, regional functions 
addressing homelessness and women Veterans issues would duplicate 
existing national services. The current structure (VISN accountability 
and national oversight) ensures accountable leadership oversight that 
is proximate to health care services provided to Veterans at VA 
facilities. By contrast, S. 543 would create competing oversight 
entities.
    In addition, the functions listed in section 3 may not be the most 
appropriate ones for consolidation. VHA has created seven Consolidated 
Patient Account Centers to achieve superior levels of sustained revenue 
cycle management, established national call centers to respond to 
questions from Veterans and their families, and is assessing 
consolidation of claims payment functions to achieve greater 
efficiencies and accuracy. We believe these types of functions are more 
appropriate to move off-station. S. 543 appears to contemplate a 
reduction in the FTEE associated with regional management but in 
practice, the proposed regional support centers are likely to increase 
overall staffing needs, resulting in a diversion of resources from 
patient care. If each of the four regional support centers is 110 FTEE, 
a realistic assumption given the scope of responsibilities identified 
in the legislation, the proposed model would result in overall growth 
of regional staff compared with VHA's current plans.
    Currently, it is not possible to identify costs for the proposed 
legislation; however, it is expected that the requirement to collocate 
functions with Medical Centers will result in costlier clinical leases. 
Additionally, the proposed VA Central Office, VISN, and Regional 
Support Center structure will result in increased FTEE requirements.
s. 633 coverage under department of veterans affairs beneficiary travel 
   program of travel in connection with certain special disabilities 
                             rehabilitation
    S. 633 would amend VA's beneficiary travel statute to ensure 
beneficiary travel eligibility for Veterans with vision impairment, 
Veterans with spinal cord injury (SCI) or disorder, and Veterans with 
double or multiple amputations whose travel is in connection with care 
provided through a VA special disabilities rehabilitation program 
(including programs provided by spinal cord injury centers, blind 
rehabilitation centers, and prosthetics rehabilitation centers), but 
only when such care is provided on an in-patient basis or during a 
period in which VA provides the Veteran with temporary lodging at a VA 
facility to make the care more accessible. VA would be required to 
report to the Committees on Veterans' Affairs of the Senate and House 
of Representatives no later than 180 days after enactment on the 
beneficiary travel program as amended by this legislation, including 
the cost of the program, the number of Veterans served by the program, 
and any other matters the Secretary considers appropriate. The 
amendments made by this legislation would take effect on the first day 
of the first fiscal year that begins after enactment.
    VA supports the intent of broadening beneficiary travel eligibility 
for those Veterans who could most benefit from the program, contingent 
on provision of funding, but believes this legislation could be 
improved by changing its scope. As written, the bill could be construed 
to apply for travel only in connection with care provided through VA's 
special rehabilitation program centers and would apply only when such 
care is being provided to Veterans with specified medical conditions on 
an inpatient basis or when the Veteran must be lodged. VA provides 
rehabilitation for many injuries and diseases, including for Veterans 
who are ``Catastrophically Disabled,'' at numerous specialized centers 
other than those noted in S. 633, including programs for Closed and 
Traumatic Brain Injury (CBI+TBI), Post-traumatic Stress Disorder and 
other mental health issues, Parkinson's Disease, Multiple Sclerosis, 
Epilepsy, War Related Injury, Military Sexual Trauma, Woman's Programs, 
Pain Management, and various addiction programs. In addition, many of 
these programs provide outpatient care to Veterans who might not 
require lodging but must travel significant distances on a daily basis 
who would not be eligible under this legislation.
    Therefore, VA feels that the legislation as written would provide 
disparate travel eligibility to a limited group of Veterans. However, 
VA does support the idea of travel for a larger group of 
``Catastrophically Disabled'' Veterans (including Veterans who are 
blind or have SCI and amputees) and those with special needs who may 
not be otherwise eligible for VA travel benefits. VA welcomes the 
opportunity to work with the Committee to craft appropriate language as 
well as ensure that resources are available to support any travel 
eligibility increase that might impact upon provision of VA health 
care.
    VHA estimates costs for this provision as $2.4 million for FY 2014; 
$13.1 million over 5 years; and $29.8 million over 10 years.
            s. 825 homeless veterans prevention act of 2013
    This bill would amend title 38 to improve the provision of services 
for homeless Veterans and their families. VA supports many of the 
sections of this bill, including increasing the amount of per diem 
payments for Veterans that are participating in the Grant and Per Diem 
(GPD) program through a ``transition in place'' grant, providing 
permanent authority for VA's Veteran Justice Outreach program, 
authorizing VA to fund entities to provide legal services to Veterans 
who are homeless or at risk of homelessness, and extending a number of 
VA's existing homeless authorities, provided that any additional 
resources necessary to implement these provisions are enacted. However, 
we do have reservations concerning the following sections.
    Section 4 would amend 38 U.S.C. section 2012(a) to permit a grantee 
receiving per diem payments under VA's Homeless Provider GPD program to 
use part of these payments for the care of a dependent of a homeless 
Veteran who is receiving services covered by the GPD program grant. 
This authority would be limited to the time period during which the 
Veteran is receiving services under the grant.
    VA supports the intent of section 4. We feel that this authority is 
needed to fully reach the entire homeless population. However, we are 
concerned that full implementation of the legislation would require 
additional funding to avoid diminished services for the population of 
homeless Veterans now being served by VA.
    Section 5 would require the Secretary to assess and measure the 
capacity of programs receiving grants under 38 U.S.C. section 2011.
    VA does not support section 5 because it would be an unnecessary 
and duplicative reporting requirement. VA already monitors occupancy 
rates and geographic distribution of GPD grantees through a number of 
resources. Furthermore, section 5 would impose a new reporting 
requirement on GPD grantees, a burden that would be felt by community 
providers not just the Department.
    Section 9 would extend dental benefits under 38 U.S.C. section 2062 
to a Veteran enrolled in VA's health care system who is also receiving 
for a period of 60 consecutive days assistance under section 8(o) of 
the United States Housing Act of 1937 (commonly referred to as section 
8 vouchers).
    VA supports the intent of section 9, but must condition this 
support on assurance of the additional resources that would be required 
were this provision enacted. VA recognizes the need for dental care and 
supports the improvement of oral health and well-being for Veterans 
experiencing homelessness. Studies have shown that after dental care, 
Veterans report significant improvement in perceived oral health, 
general health, and overall self-esteem; thus, supporting the notion 
that dental care is an important aspect of the overall concept of 
homeless rehabilitation. Increasing access to dental care for HUD-VA 
Supportive Housing program participants is, therefore, an important 
step in VA's Plan to End Veteran Homelessness.
    Additionally, to help clarify that subsection (c) of section 8 
describes legal services provided, rather than the organizations that 
provide them, we recommend adding the phrase ``capable of providing the 
legal services'' after the word ``organizations'' in section 8(d)(1).

    Mr. Chairman, this concludes my statement. Thank you for the 
opportunity to appear before you today. I would be pleased to respond 
to questions you or the other Members may have.
                                 ______
                                 
                  Additional Views Received from the 
                  U.S. Department of Veterans Affairs


  s. 131, woman veterans and other health care improvement act of 2013
    Section 2 of S. 131 would amend 38 U.S.C. Sec. 1701(6) to include 
fertility counseling and treatment, including assisted reproductive 
technology, among those things that are considered ``medical services'' 
under chapter 17 of title 38, U.S.C. As discussed in VA's May 9, 2013, 
testimony, VA supports section 2 of the bill, conditioned on the 
availability of the additional resources needed to implement this 
provision.
    VA estimates that section 2 would cost $81.5 million in fiscal year 
(FY) 2015; $296 million over five years; and $652 million over ten 
years. These estimates reflect the costs of new services that are not 
included currently in the medical benefits package and costs associated 
with maternity services for additional pregnancies that may result from 
the use of assisted reproductive technology. These estimates do not 
reflect potential costs associated with additional enrollment or 
utilization of currently covered services that may result if the bill 
is enacted.
    Among other things, section 3 of S. 131 would add a new section 
1788 to title 38, U.S.C., that would require VA to furnish fertility 
counseling and treatment, including assisted reproductive technology, 
to a spouse or surrogate of a severely wounded, ill or injured enrolled 
Veteran who has an infertility condition that was incurred or 
aggravated in the line of duty, if the spouse or surrogate and Veteran 
apply jointly through a process prescribed by VA. As discussed in VA's 
May 9, 2013 testimony, VA supports section 3 of the bill in part, 
conditioned on the availability of the additional resources that would 
be required to implement this provision.
    VA estimates that section 3 would cost $102 million in FY 2015; 
$319 million over five years; and $717 million over ten years. These 
estimates include coverage of spouses and partners of covered Veterans. 
These estimates do not include costs associated with coverage of 
surrogates; as discussed in VA's May 9, 2013 testimony, VA does not 
support coverage of surrogates at this time.
    Section 4 of S. 131 would authorize the Secretary to provide 
adoption assistance to severely wounded, ill, or injured Veterans who 
suffer from infertility conditions incurred or aggravated in the line 
of duty. VA understands the intent of this provision but has numerous 
concerns that merit further consideration. VA would need to consider 
the possible associated responsibilities that could go along with 
monetary adoption support, including adequate oversight of the agencies 
or entities that would receive the funds and potential issues of State 
law. VA also must carefully consider additional demands on its 
resources that would not be directed at core medical services for 
Veterans.
    VA estimates that section 4 would cost $96.27 million in FY 2015; 
$521.46 million over five years; and $1.16 billion over ten years.
    Section 10 of S. 131 would expand the locations and duration of the 
pilot program required by section 203 of Public Law 111-163. Section 
203 required VA to carry out a pilot program to evaluate the 
feasibility and advisability of providing reintegration and 
readjustment services in group retreat settings to women Veterans 
recently separated from service after a prolonged deployment. Section 
10(a) would increase the number of locations at which VA is required to 
carry out the pilot program from three to fourteen. Section 10(b) would 
extend the duration of the pilot from two to four years. Section 10(c) 
would amend section 203(f) to authorize the appropriation of $400,000 
for each of FY 2013 and FY 2014 to carry out the pilot program.
    VA supports section 10 of S. 131. VA has completed the final year 
of the original two-year pilot program, and the report required by 
section 203 was submitted to Congress on May 9, 2013. Initial reports 
show favorable results, indicating that the retreats, which focus on 
building trust and developing peer support in a therapeutic 
environment, supply participants with tools needed for successful 
reintegration into civilian life. Additional retreats would generate 
more data to inform a comprehensive assessment of the program during 
the new final reporting phase under section 10.
    Although VA supports section 10, there may not be fourteen distinct 
geographic locations that satisfy the retreat requirements, such as the 
need for specialized locations for outdoor team-building exercises. VA 
would continue to look for new locations, but recommends that section 
10(a) be amended to require VA to carry out the pilot program in up to 
fourteen locations, some of which may be repeat locations from the 
original pilot program.
    In addition, VA recommends that section 10(b) be amended to require 
the pilot program be ``carried out through September 30, 2015,'' rather 
than requiring that it be ``carried out during the four-year period 
beginning on the date of the commencement of the pilot program.'' This 
would ensure that VA has a sufficient period of time to carry out 
additional retreats for eligible women Veterans and generate data for 
analysis. For the same reason, we recommend section 10(c) be amended to 
authorize the appropriation of $400,000 ``for each of fiscal years 2013 
through 2015'' to carry out the pilot program.
    VA estimates section 10 would cost $337,320 in FY 2014 and, if the 
pilot extends through FY 2015, $350,520 in FY 2015, for a total cost of 
$687,840.
    Section 11(a) of S. 131 would add a new section 1709B to title 38, 
U.S.C. that would make permanent VA's authority to provide assistance 
to qualified Veterans to obtain child care so that such Veterans can 
receive certain health care services. VA would be required to carry out 
the program in no fewer than three Veterans Integrated Service 
Networks. This section would also identify certain forms of assistance 
that may be provided. VA's pilot program providing such services under 
section 205 of Public Law 111-163 would expire upon enactment of 
section 11(a).
    VA does not support a permanent mandatory authority to provide 
child care assistance. VA has four operational pilot locations where 
child care assistance is provided pursuant to section 205 of Public Law 
111-163. The first pilot began operation in October 2011. The remaining 
pilots were set up in a staggered fashion with the most recent pilot 
not beginning until 2013. Under current law, all pilots are scheduled 
to end on October 2, 2013, therefore, not affording three pilots the 
benefit of two full years of operation.
    Without two full years of operational data from each pilot, VA is 
not able to adequately assess long-term utilization needs and cost 
implications of the program. In light of this longer term analysis that 
includes an evaluation of resources, VA believes permissive authority 
to allow expansion of the program would be preferable to a permanent 
mandatory authority to provide child care assistance. Permissive 
authority would allow facilities at the local level to make a 
determination based on need and utilize resources, space and security 
as necessary.
    VA is unable to provide an accurate cost estimate for a permanent 
mandatory child care program, in part, because of the lack of data on 
the existing pilots that have run for less than two years, but also 
because such an estimate would be dependent on location of the sites, 
the ability to contract in the area of the designated sites, and the 
utilization of services.
    Section 11(b) of S. 131 would add a new section 1709C to title 38, 
U.S.C. that would require VA to carry out a program to provide 
assistance to qualified Veterans to obtain child care so that such 
Veterans can receive readjustment counseling and related mental health 
services. The program would be carried out in at least three 
Readjustment Counseling Service Regions selected by VA. This section 
would identify certain forms of child care assistance that may be 
provided, and it would define ``Vet Center'' as ``a center for 
readjustment counseling and related mental health services for veterans 
under section 1712A of [title 38, U.S.C.].''
    VA supports section 11(b) in principle. 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 impacted 
their ability to use Vet Center services consistently. Although Vet 
Center staff are always searching for new initiatives to increase 
Veteran access to services, VA has concerns about implementing child 
care assistance under section 11(b) without the opportunity to pilot 
this type of benefit. A pilot program is needed because VA currently is 
unable to predict utilization of this type of assistance. Comparisons 
to medical center pilots are not useful because Vet Centers provide 
services during non-traditional hours, including after normal business 
hours and on weekends when requested by the Veteran. This inability to 
predict utilization affects VA's ability to budget the program 
appropriately. VA recommends that section 11(b) be modified to 
authorize a pilot program to determine the feasibility, advisability, 
and costs of providing child care assistance to Veterans who utilize 
Vet Center services.
    VA is not able to provide an accurate cost estimate for section 
11(b) because VA lacks child-care experience for the special Vet Center 
context as described above and comparable models.
    Section 12 of S. 131 would add a new section 323 to title 38, 
U.S.C., entitled ``Contractor user fees.'' Under proposed section 
323(a), VA would be required to impose a fee on each person with whom 
the Secretary engages in a contract for a good or service as a 
condition of the contract. The fee amount would be the lesser of: (1) 
seven percent of the total value of the contract, and (2) the total 
value of the contract multiplied by an applicable percentage calculated 
for the fiscal year. Before each fiscal year, VA would be required to 
establish an annual estimate of the total value of contracts for the 
next fiscal year and an annual estimate of the total cost of furnishing 
fertility counseling and treatment--including the use of assisted 
reproductive technology--and payments under proposed section 1789 
(under section 4 of S. 131) for the next fiscal year, both of which 
would be used in estimating the applicable percentage for the fiscal 
year (the percentage by which the former exceeds the latter). The 
Secretary would have discretion to waive the fee for a person as the 
Secretary considers appropriate if the person is an individual or 
``small business concern'' (as defined in section 3 of the Small 
Business Act). Fees could not be collected under proposed section 
323(a) unless the expenditure of the fee is provided for in advance in 
an appropriations Act.
    Proposed section 323(e) would establish a fund in the Treasury to 
be known as the ``Department of Veterans Affairs Fertility Counseling 
and Treatment Fund,'' and all amounts received under proposed section 
323(a) would be deposited in the fund. Subject to the provisions of 
appropriations Acts, amounts in the fund would be made available, 
without fiscal year limitation, to VA to furnish fertility counseling 
and treatment--including the use of assisted reproductive technology--
to eligible individuals and to make payments under proposed section 
1789 (under section 4 of S. 131). Amounts received by VA under proposed 
section 323(a) would be treated for the purposes of sections 251 and 
252 of the Balanced Budget and Emergency Deficit Control Act of 1985 as 
offsets to discretionary appropriations (rather than as offsets to 
direct spending), to the extent that such amounts are made available 
for expenditure in appropriations Acts for the purposes specified.
    VA does not support section 12, which VA estimates could result in 
up to 7 percent less money available for contract actions. That is 
because contractors could be expected to pass this cost back to VA in 
the form of higher contract prices. Applying the proposed fee to ``a 
contract for a good or service'' without limitation would subject VA 
Administrations' and Offices' (e.g., Veterans Benefits Administration, 
National Cemetery Administration, Office of Human Resources and 
Administration, and Office of General Counsel) budget dollars for 
contracts to funding health care services. This would impact these 
entities' budgets, particularly in smaller offices, for a purpose that 
is wholly unrelated to their primary functions. In this difficult time 
of budget limitations, this is impractical and could negatively impact 
overall VA performance. In addition, determining a percentage and 
implementing it for the beginning of each fiscal year would be 
difficult administratively, as would the process of collecting and 
accounting for these funds. (As a technical matter, the word ``person'' 
should be replaced with ``contractor'' throughout this provision.)
    In many industries and for many contractors, the existing profit 
margins would not tolerate a 7 percent cut.
        s. 287, expansion of the definition of homeless veteran
    VA supports S. 287, which would broaden the definition of 
``homeless Veteran'' in 38 U.S.C. Sec. 2002(1). Section 2002(1) 
currently defines homeless Veteran by reference to the definition of 
homeless person found in subsection (a) of the McKinney-Vento Homeless 
Assistance Act, 42 U.S.C. Sec. 11302. The bill would amend Sec. 2002(1) 
to also refer to subsection (b) of Sec. 11302, which includes in the 
definition of homeless person ``any individual or family who is 
fleeing, or is attempting to flee, domestic violence, dating violence, 
sexual assault, stalking, or other dangerous or life-threatening 
conditions in the individual's or family's current housing situation, 
including where the health and safety of children are jeopardized, and 
who have no other residence and lack the resources or support networks 
to obtain other permanent housing.''
    VA serves Veterans fleeing from domestic violence and intimate 
partner violence (DV/IPV) when they otherwise meet the definition of 
homeless and when it is clinically appropriate to do so. Even when it 
is not clinically appropriate to place a Veteran affected by DV/IPV in 
a VA homeless program, VA works closely with local community 
organizations to identify resources that would most effectively address 
the needs of the Veteran. S. 287 would more closely align the 
definitions of homeless used by VA and the Department of Housing and 
Urban Development. This would facilitate data sharing and promote 
comprehensive interagency program evaluation.
    Although VA supports the bill, we note that it may not always be 
clinically appropriate to merely place a victim of DV/IPV in a VA 
homeless program. VA clinical experience and empirical research has 
shown that effective DV/IPV intervention involves collaboration among 
many programs and agencies. An array of services, from crisis 
intervention to long-term assistance, is needed to serve Veterans 
fleeing violent relationships. Immediate crisis intervention may 
include medical care and assistance with food, shelter, child care and 
general safety. Long-term assistance may include ongoing medical care, 
counseling to cope with the lasting emotional and psychological effects 
of DV/IPV, and services to address economic and housing stability.
    In recognition of the complex needs of Veterans affected by DV/IPV, 
VA recently chartered a Domestic Violence Task Force. The Task Force 
will develop a national plan to address DV/IPV issues in depth. 
However, as noted, effectively addressing the problem of DV/IPV will 
require collaboration between many programs and local, State, and 
Federal agencies.
    Within VA, there is a continuum of care with homeless services 
ranging from rapid stabilization to permanent supportive housing. VA's 
homeless programs may help prevent future DV/IPV by providing Veterans 
with alternative housing options so that they can safely exit abusive 
relationships. VA is committed to Veterans affected by DV/IPV, and VA 
programs addressing DV/IPV specifically will continue to collaborate 
with VA homeless programs to ensure those fleeing DV/IPV get the care 
and support they need.
    VA is not able to provide an accurate cost estimate for S. 287 
because we lack detailed data regarding the size and characteristics of 
this population. We do note that many VA providers have limited 
training related to DV/IPV, and that S. 287 would likely require 
additional training. This would generate additional costs and a 
commensurate requirement for funding.
    The definition of ``homeless veteran'' in 38 U.S.C. Sec. 2002(1) 
also applies to the Homeless Veterans Reintegration Programs (HVRP) 
administered by the U.S. Department of Labor. VA defers to the 
Secretary of Labor on the application of the new definition of 
homelessness to the HVRP program.
    s. 422, chiropractic care available to all veterans act of 2013
    VA provided views on S. 422 in our testimony on May 9, 2013. In 
general, VA supports the intent of S. 422, but believes the decision to 
provide on-site or fee care should be determined based on existing 
clinical demands and business needs. Chiropractic care is available to 
all Veterans and is already part of the standard benefits package. As 
VA increases the number of VA sites providing on-site chiropractic 
care, we will be able to incrementally assess demand for chiropractic 
services and usage, and to best determine the need to add chiropractic 
care at more sites.
    Currently, VA does not have an assessment that would support 
providing on-site chiropractic care at all VAMCs by the end of 2016. 
Such a mandate could potentially be excessive, given the availability 
of resources for on-site chiropractors and non-VA care to meet the 
current need for services. VA does not object to sections 3(a) and (b) 
as those changes reflect VA's consideration of chiropractic care as 
properly part of what should be considered medical and rehabilitative 
services. VA, however, cannot support section 3(c) for lack of a 
conclusive consensus on the use of chiropractic care as a preventative 
intervention. VA estimates the costs associated with S. 422 to be $4.99 
million in FY 2014; $26.8 million over five years; and $59 million over 
ten years.
           s. 522, wounded warrior workforce enhancement act
    Section 3 of S. 522 would require VA to award a $5 million grant to 
an institution to: (1) establish the Center of Excellence in Orthotic 
and Prosthetic Education (the Center) and (2) improve orthotic and 
prosthetic outcomes by conducting orthotic and prosthetic-based 
education research. Under the bill, grant recipients must have a robust 
research program; offer an education program that is accredited by the 
National Commission on Orthotic and Prosthetic Education in cooperation 
with the Commission on Accreditation of Allied Health Education 
Programs; be well recognized in the field of orthotics and prosthetics 
education; and have an established association with a VA medical center 
or clinic and a local rehabilitation hospital. This section would 
require VA to give priority in the grant award to an institution that 
has, or is willing and able to enter into: (1) a memorandum of 
understanding with VA, the Department of Defense (DOD), or other 
Government agency; or (2) a cooperative agreement with a private sector 
entity. The memorandum or agreement would provide resources to the 
Center or assist with the Center's research. VA would be required to 
issue a request for proposals for grants not later than 90 days after 
the date of enactment of this provision.
    VA does not support section 3 because VA would not have oversight 
of the Center and there would be no guarantee of any benefit to VA or 
Veterans. Further, we believe that a new Center is unnecessary. DOD has 
an Extremity Trauma and Amputation Center of Excellence (EACE), and VA 
works closely with EACE to provide care and conduct scientific research 
to minimize the effect of traumatic injuries and improve outcomes of 
wounded Veterans suffering from traumatic injury. VA also has six 
Research Centers of Excellence that conduct research related to 
prosthetic and orthotic interventions, amputation, and restoration of 
function following trauma:

    1. Center of Excellence for Limb Loss Prevention and Prosthetic 
Engineering in Seattle, WA.
    2. Center of Excellence in Wheelchairs and Associated 
Rehabilitation Engineering in Pittsburgh, PA.
    3. Center for Functional Electrical Stimulation in Cleveland, OH.
    4. Center for Advanced Platform Technology (APT) in Cleveland, OH.
    5. Center for Neurorestoration and Neurotechnology in Providence, 
RI.
    6. Maryland Exercise and Robotics Center of Excellence (MERCE) in 
Baltimore, MD.

    These centers provide a rich scientific environment in which 
clinicians work closely with researchers to improve and enhance care. 
They are not positioned to confer terminal degrees for prosthetic and 
orthotic care/research but they are engaged in training and mentoring 
clinicians and engineers to develop lines of inquiry that will have a 
positive impact on amputee care. Finally, the requirement to issue a 
request for proposals within 90 days of enactment would be very 
difficult to meet as VA would first need to promulgate regulations 
prior to being able to issue the RFP.
    VA estimates that sections 2 (views previously provided) and 3 of 
S. 522 would cost $160,000 in FY 2014 and $21.7 million over 5 years.
s. 800, treto garza far south texas veterans inpatient care act of 2013
    VA does not support S. 800. The bill would require VA to ensure 
that the South Texas Health Care Center in Harlingen, Texas, which 
currently operates as an expanded outpatient clinic, include a full 
service inpatient health care facility. More specifically, S. 800 would 
require the facility to provide 50 inpatient beds, an urgent care 
center, and a full range of services for women Veterans that are 
already provided at the outpatient clinic on location.
    The region served by the South Texas VA Health Care Center in 
Harlingen, referred to in S. 800 as Far South Texas, has been the 
subject of three studies by VA since 2007 (two conducted internally and 
one by an outside contractor) to assess the need for an acute care 
inpatient facility. The conclusions of the most recent study affirm 
those of previously conducted studies, indicating no sound basis for 
building an inpatient facility in this area. Completed analysis of 
enrolled Veteran population demographics, demand for services or 
utilization, and geospatial analysis of drive time access measures 
indicate that Veterans in the area have access to acute inpatient care 
through contracts at rates that meet or exceed the current VA standard. 
Based on these studies and for the following reasons, VA believes the 
Harlingen facility should remain an expanded outpatient clinic.
    Currently, VA provides inpatient care in the relevant geographic 
region through contracts with non-VA providers. Nearly all enrollees in 
the relevant counties have access to acute care facilities within a 60-
minute drive from their home. Through these contracts, supplemented by 
referrals of complex cases to San Antonio VA Medical center, VA 
provides complete inpatient care for Veterans in Far South Texas. The 
expenditure to build and operate a new 50 bed inpatient facility would 
not significantly increase the percentage of Veterans gaining access to 
inpatient care within a 60 minute drive from their home. Consolidating 
inpatient care for Veterans at a new VA hospital, when compared to the 
current contract model, would increase operating expenses by 
approximately $14-15 million annually without significantly increasing 
the percentage of enrollees meeting VA's access standard.
    VA estimates that construction to add inpatient care to this 
facility would cost $406.5 million. VA estimates that total salary 
expenditures for the first year full year of operation, FY 2121, would 
be $51.29 million.
            s. 825, homeless veterans prevention act of 2013
    S. 825 would amend title 38 to improve the provision of services 
for homeless Veterans and their families. In our May 9, 2013 testimony, 
VA indicated that it supported many of the sections of S. 825 but did 
not provide detailed views on all sections. Outlined below are VA's 
views and costs on sections 2-3 and 5-10 of S. 825. VA is working to 
develop a cost estimate for section 4.
    Section 2(a) of S. 825 would amend current law to authorize the 
Secretary, when awarding grants under the Grant and Per Diem (GPD) 
Program, to assist eligible entities not only in establishing, but also 
in maintaining programs to furnish services for homeless Veterans 
(i.e., outreach services; rehabilitative services; vocational 
counseling and training; and transitional housing assistance). VA 
supports Section 2(a). As VA works toward ending Veteran homelessness, 
VA does not anticipate a pressing need to create additional 
transitional housing beds. Consequently, rehabilitating and maintaining 
current GPD beds would be a more cost effective way of maintaining GPD 
transitional beds nationwide.
    Section 2(b) would amend current law to prohibit the Secretary from 
making a grant under the GPD Program unless the prospective grantee 
agrees to maintain the physical privacy, safety and security needs of 
homeless Veterans receiving services though the project. VA supports 
Section 2(b). This new requirement would reinforce the GPD Program's 
inspection efforts and ensure that grantees comply with VA's ongoing 
efforts to meet the privacy, safety and security needs of Veterans 
participating in the program. As a practical matter, current GPD 
grantees would absorb the costs of these improvements because VA lacks 
authority to remodel or renovate existing GPD facilities.
    VA does not anticipate that section 2(a) would lead to additional 
costs beyond the current authorization of appropriations (38 U.S.C. 
2013). The provision would allow VA to allocate existing funds to 
support rehabilitating and maintaining existing GPD projects. Section 
2(b) also would not result in any additional costs. If subsequent 
legislation provided more specific definitions of physical, privacy, 
safety and security, however, it is possible that VA could incur costs 
or costs that cannot presently be determined.
    Section 3 would amend current law to increase the per diem payments 
for Veterans who are participating in the GPD Program through a 
``transition in place'' (TIP) grant. The per diem payments under GPD 
TIP would be increased by 150 percent of the VA State Home rate. VA 
supports Section 3. Supporting Veterans' transition from homelessness 
to permanent housing is fundamental to ending homelessness among 
Veterans. By allowing Veterans to ``transition in place'' to permanent 
housing, the Department would provide a valuable alternative for 
Veterans who may not need or be interested in participating in the 
Housing and Urban Development--VA Supportive Housing (HUD-VASH) 
program.
    VA estimates that section 3 would be cost neutral since the funds 
would come from existing appropriations to the GPD program.
    As indicated in our testimony on May 9, 2013, VA supports the 
intent of section 4. VA has not yet completed its cost analysis for 
this provision, however, and will provide the completed cost estimate 
as soon as it is completed.
    Section 5 would require VA to assess and measure the capacity of 
programs receiving grants under 38 U.S.C. 2011 or per diem payments 
under 38 U.S.C. 2012 and 2061 and to use the information to set goals, 
inform funding allocation decisions, and improve the referral of 
homeless Veterans to programs receiving funding. VA supports the intent 
of section 5 but does not believe legislation is needed because VA 
conducts internal assessments of service programs.
    VA estimates that section 5 would cost approximately $21,000 to 
gather and analyze the required information, and to draft the required 
report.
    Section 6 would repeal section 2065 of 38 U.S.C. to remove the 
requirement that VA report to the Senate and House of Representatives 
Veterans' Affairs Committees on VA's activities during the preceding 
calendar year related to VA's programs homeless assistance programs.
    VA supports section 6. Time spent on this reporting function would 
be better used by VA personnel to internally asses the programs and 
implement changes to enhance the benefits and services provided to 
homeless Veterans. VA conducts ongoing data analysis of VA homeless 
programs and remains committed to reporting data to the Committees upon 
request.
    Section 6 would result in a small cost savings for VA. In FY 2013, 
VHA Homeless Programs prepared the FY 2012 VA Specialized Homeless 
Programs Report to Congress. At that time, VHA Homeless Programs 
estimated that it cost approximately $2,800 to produce the report. If 
Section 6 were enacted, VA expects that this would save at least $2,800 
in each subsequent FY.
    Section 7 would strike section 2023(d) of 38 U.S.C. and replace it 
with section 2023(e). This would eliminate the September 30, 2013 end 
date for VA's Veteran Justice Outreach (VJO) Program and VA's 
Healthcare for Reentry Veterans (HCRV) Program, programs that provide 
referral and counseling services for Veterans who are transitioning out 
of penal institutions and are at risk of homelessness. VJO's goal is to 
avoid the unnecessary criminalization of mental illness and extended 
incarceration among Veterans by ensuring that eligible Veterans 
involved with the criminal justice system have timely access to VA's 
mental health and substance use services when clinically indicated, and 
other VA services and benefits as appropriate. Similarly, HCRV's goals 
are to prevent homelessness, reduce the impact of medical, psychiatric, 
and substance abuse problems upon community readjustment, and decrease 
the likelihood of re-incarceration for Veterans leaving prison.
    VA supports section 7. Making these programs permanent would 
recognize the crucial role these programs play in preventing and ending 
Veteran homelessness.
    Section 7 would not result in any new costs. The provision 
permanently authorizes VA's Veterans Justice Programs, including VJO 
and HCRV, but does not require direct spending and would be subject to 
available appropriations.
    Section 7 would also eliminate the September 30, 2013 end date for 
the Department of Labor's Incarcerated Veterans Transition Program. VA 
defers to the Secretary of Labor for his views on the extension of this 
program.
    Section 8 would authorize the Secretary to fund entities to provide 
legal services to Veterans, particularly those who are homeless or at 
risk of homelessness. Section 8 recognizes that the Secretary may 
partner with a wide variety of organizations for the provision of 
services. Additionally, the language authorizes VA to fund only a 
portion of the cost of legal services; VA may not pay for all of these 
services. This would require VA to properly leverage any expenditure 
under this authority by finding viable public or private entities 
capable of providing legal services.
    VA supports section 8. Homeless and at-risk Veteran access to legal 
services remains a crucial but largely unmet need. Lack of access to 
legal representation for outstanding warrants or fines, child support 
arrearages, driver's license revocation, and other legal matters 
continues to contribute to Veterans' risk of becoming and remaining 
homeless. A demonstration project conducted by the Department of 
Veterans Affairs, the Department of Health and Human Services' Office 
of Child Support Enforcement, and the American Bar Association 
indicates that legal services are instrumental in assisting Veterans 
who have child support arrearages.''
    VA estimates that section 8 would cost $750,000 in FY 2014; $3.9 
million over five years; and $8.2 million over ten years.
    Section 9 would extend dental benefits under 38 U.S.C. Sec. 2062 to 
enrolled Veterans who are receiving, for a period of 60 consecutive 
days, assistance under section 8(o) of the United States Housing Act of 
1937 (commonly referred to as section 8 vouchers). Section 9 would also 
amend current law to permit breaks in the continuity of assistance or 
care for which the Veteran is not responsible.
    VA supports the intent of section 9, conditioned on the 
availability of additional resources that would be required if the 
provision is enacted. VA recognizes the need for dental care and 
supports the improvement of oral health and well-being for Veterans 
experiencing homelessness. Studies have shown that after dental care, 
Veterans report significant improvement in perceived oral health, 
general health and overall self-esteem, thus, supporting the notion 
that dental care is an important aspect of the overall concept of 
homeless rehabilitation. Increasing access to dental care for HUD-VASH 
program participants is, therefore, an important step in VA's Plan to 
End Veteran Homelessness.
    VA estimates that section 9 would cost $88.6 million in FY 2014; 
$148.5 million over five years; and $216 million over 10 years.
    Section 10 contains extensions to various existing VA authorities 
in U.S. Code. Section 10(a) would authorize appropriations of 
$250,000,000 for FY 2014 and $150,000,000 each fiscal year thereafter 
for VA's GPD Program.
    VA supports Section 10(a) in part. Under current law, the amount 
authorized to be appropriated for FY 2014 will be reduced from 
$250,000,000 to $150,000,000 and then remain the same for each 
subsequent fiscal year. We support section 10(a) to the extent that it 
would retain the program's current level of authorization for FY 2014. 
We have concerns, however, about decreasing the authorization level to 
$150,000,000 for FY 2015 and each subsequent year. Such a decrease 
would be highly problematic. At the current rate, GPD expenditures 
would far exceed the amount authorized to be appropriated for the 
program for FY 2015 and thereafter. VA would require additional funding 
to support the existing projects at anticipated per diem and occupancy 
rates in FY 2015 and beyond. Otherwise, VA would be forced to cut per 
diem payments to GPD community providers or to summarily terminate GPD 
projects presently serving homeless Veterans.
    Section 10(b) would extend the authorization of annual 
appropriations of $50,000,000 for the U.S. Department of Labor's 
Homeless Veterans Reintegration Programs through fiscal year 2014. We 
defer to the views of the Secretary of Labor on this provision.
    Section 10(c) would extend VA's general treatment and 
rehabilitation authority (codified at 38 U.S.C. 2031(a)) for seriously 
mentally ill and homeless Veterans from December 31, 2013 to 
December 31, 2014. VA supports reauthorizing VA's Health Care for 
Homeless Veterans Program, VA's program offering outreach services and 
contract therapeutic housing, but suggests that section 2031 be amended 
in subsection (b) by striking ``2013'' and inserting ``2016.'' VA does 
not anticipate any additional costs associated with this section.
    Section 10(d) would extend VA's operation of comprehensive service 
centers for homeless Veterans under section 2033 of 38 U.S.C. from 
December 31, 2013 to December 31, 2014. VA supports section 10(d), 
which would re-authorize VA's Community Resource and Referral Centers 
but suggests that section 2033 be amended in subsection (d) by striking 
``2013'' and inserting ``2016.'' VA does not anticipate any additional 
costs associated with this section.
    Section 10(e) would extend through December 31, 2014, the 
Secretary's authority under section 2041 of 38 U.S.C. to sell, lease, 
or donate properties to nonprofit organizations that provide shelter to 
homeless Veterans. Under current law, the authority will expire on 
December 31, 2013. VA supports section 10(e) because it will help VA 
meet the Secretary's goal of ending Veteran homelessness by 2015. While 
any extension of authority under 38 U.S.C. 2041 would result in a 
reduction in property sales proceeds, neither a one-year, nor a five-
year extension would result in any significant loan subsidy costs.
    Section 10(f) would require VA to make available (from amounts 
appropriated for Medical Services) $300,000,000 for FY 2013 for its 
program under section 2044 of 38 U.S.C. offering financial assistance 
for supportive services for very low-income Veteran families in 
permanent housing (Supportive Services for Veterans Families, or SSVF). 
VA has already budgeted $300 million for the SSVF Program in FY 2014. 
VA supports section 10(f), which would re-authorize appropriations for 
the SSVF Program, VA's premier prevention and rapid re-housing program. 
However, VA suggests that 38 U.S.C. 2044(e)(1) be amended by adding 
after subparagraph (E): ``(F) Such sums as may be necessary for fiscal 
year 2014, and thereafter.'' This change would provide VA with the 
flexibility to devote the necessary funding to operations under the 
SSVF Program. SSVF is an essential part of VA's plan to end Veteran 
homelessness, and VA may need to devote more resources to SSVF as VA 
concludes the Veteran homelessness initiative. There are no costs 
associated with this section as it provides authorization for 
appropriations beginning in FY 2014.
    VA also suggests that 38 U.S.C. 2044(e)(3) be amended to read: 
``From amounts appropriated to the Department for Medical Services, 
there shall be authorized $1,500,000 for each fiscal year to carry out 
the provisions of subsection (d).'' These changes would allow VA to 
devote more resources to technical assistance for SSVF grantees. By the 
beginning of FY 2014, VA will have more than tripled the number of SSVF 
grantees from the first grant round. With this influx of grantees, VA 
needs a larger authorization so that VA can provide ongoing training 
and assistance to these grantees.
    Section 10(g) would extend VA's GPD Program for homeless Veterans 
with Special Needs through 2015. VA supports this measure but suggests 
that 38 U.S.C. 2061 be amended in subsection (d) by striking ``for each 
of fiscal years 2007 through 2013.'' VA does not anticipate any 
additional costs associated with this section.
    Section 10(h) would extend VA's authority under 39 U.S.C. 2064 to 
offer technical assistance grants for non-profit community-based 
groups. VA supports this measure. VA does not anticipate any additional 
costs associated with this section.
    Section 10(i) would extend VA's Advisory Committee on Homeless 
Veterans from December 31, 2013, to December 31, 2014. VA supports this 
measure but suggests that 38 U.S.C. 2066 be amended in subsection (d) 
by striking ``2013 and inserting ``2016.'' This technical change would 
authorize the Advisory Committee through the end of the Veteran 
homelessness initiative so that the Committee can assess the successes 
of the initiative and identify actions that could be taken to improve 
other VA Programs as well as other homelessness programs across the 
country. VA does not anticipate any additional costs associated with 
this section.
 s. 832, improving the lives of children with spina bifida act of 2013
    Section 2 of S. 832 would require VA to carry out a three-year 
pilot program to assess the feasibility and advisability of furnishing 
children of Vietnam Veterans and certain Korea service Veterans born 
with spina bifida and children of women Vietnam Veterans born with 
certain birth defects with case management services under a national 
contract with a third party. The Secretary would have the option to 
extend the program for an additional 2 years.
    Under the bill, a covered individual is any person who is entitled 
to health care under chapter 18 of title 38 and who lives in a rural 
area and does not have access to case management services. The 
Secretary would be responsible for determining the appropriate number 
of covered individuals to participate in the pilot. S. 832 would 
require VA to provide these individuals with coordination and 
management of needed health care, monetary, and general care services 
authorized under Chapter 18; transportation services; and such other 
services as the Secretary considers appropriate. The bill would also 
require the Secretary to inform all covered individuals of the services 
available under the pilot program and to submit preliminary and final 
reports to the Senate and House Committees on Veterans Affairs.
    VA supports section 2 of the bill but notes that VA already has 
authority to provide case management services, and currently reimburses 
beneficiaries for case management services by an approved provider. 
Support of section 2 of S. 832 is contingent on appropriation of any 
additional funds for services beyond what are currently provided by VA. 
See 38 U.S.C. Sec. 1803(c)(1)(A). In addition, VA is reviewing the 
viability of providing case management via contract to increase access 
to these services to all covered beneficiaries, including those in 
rural areas. As this beneficiary population ages into adulthood, 
increased case management and care coordination services are needed to 
meet their unique health care challenges, and a systematic approach to 
offering these services may better serve this group of beneficiaries.
    In addition, VA has several technical comments to the bill 
language. As noted above, section 2(e)(2) would require VA to provide 
``transportation services'' to all covered individuals in the program. 
These services could include transportation for both health care 
purposes and personal purposes such as for vacations etc. The services 
could also include transportation for visiting family and friends and 
for those providing health care and other services to the covered 
individuals. It is unclear whether the Committee intends to require VA 
to provide the full extent of transportation services described above 
and not permit VA to limit transportation services provided. If this is 
not the case, we recommend that the Committee clearly authorize VA to 
limit the scope of transportation services by adding ``as the Secretary 
considers appropriate'' after ``transportation services'' in section 
3(e)(2).
    As noted above, section 2(e)(1) would require VA to provide 
``[c]oordination and management of needed health care, monetary, and 
general care services authorized under chapter 18 of title 38, United 
States Code.'' The reference to ``monetary, and general care services'' 
is confusing. The term ``health care'' is already defined in chapter 
18, and that definition does not include monetary and general care 
services. It is unclear whether monetary and general care services are 
intended to be services in addition to what is included in the 
definition of ``health care.'' If so, we recommend revising this 
provision to read: ``[c]oordination and management of needed health 
care authorized under chapter 18 of title 38, United States Code, and 
monetary and general care services.'' We further recommend defining the 
terms ``monetary services'' and ``general care services.'' Finally, we 
note that section 2(a) would require VA to enter into ``a national 
contract with a third party entity'' to carry out the pilot program 
while section 2(f)(2) would require VA to enter into ``contracts'' for 
the same purpose. It may be possible to provide these services through 
a national contract but in case that is not feasible, we would prefer 
the flexibility to enter into contracts regionally as needed. 
Accordingly, we recommend replacing the words ``a national contract 
with a third party entity'' in section 2(a) with the words ``contracts 
with third party entities.''
    VA estimates the total costs for section 2, including case 
management, care coordination and oversight, to be $3.024 million in FY 
2014; $15.98 million over five years; and $36.97 million over ten 
years.
    Section 3 of S. 832 would require VA to carry out a three-year 
pilot program to assess the feasibility and advisability of providing 
assisted living, group home care, and similar services in lieu of 
nursing home care to covered individuals. The Secretary would have the 
option to extend the pilot for an additional two years. Section 3(d) of 
the bill would require VA to provide covered individuals with assisted 
living, group home care, or such other similar services; transportation 
services; and such other services as the Secretary considers 
appropriate. The bill would also direct the Secretary to provide 
covered individuals with notice of the services available under the 
pilot; to consider contracting with appropriate providers of these 
services; and to determine the appropriate number of covered 
individuals to be enrolled in the pilot and criteria for enrollment. 
Section 3 of the bill would also specify preliminary and final 
reporting requirements.
    VA does not support section 3 of the S. 832. The provision would 
extend benefits to spina bifida beneficiaries beyond what VA is 
authorized to provide to Veterans, including service-connected 
veterans. Service-connected Veterans who need assisted living, group 
home care, and similar services are equally deserving of receiving 
these benefits.
    VA is unable to develop an accurate cost estimate at this time; 
however, we have several technical comments to the bill language. 
Section 3(a) would require VA to commence carrying out this program not 
later than 180 days after enactment of this Act. This would not be 
sufficient time because VA would be required to issue regulations, 
including a notice and public comment period, prior to carrying out 
this program. In particular, regulations would be required to define 
assisted living and group home care, to designate what services are 
similar to assisted living and group home care, and to identify any 
other services appropriate for the care of covered individuals under 
the pilot program. Finally, VA would be required by regulation to 
establish the criteria for enrollment of the appropriate number of 
covered individuals.
    By requiring VA to carry out the program of providing assisted 
living, group home care, or similar services to covered individuals 
``in lieu of nursing home care,'' VA could only provide these services 
if the spina bifida beneficiary would otherwise need nursing home care. 
We question whether many spina bifida beneficiaries who need nursing 
home care could be provided care instead in assisted living facilities, 
group homes or similar institutions. The Committee may wish to consider 
deleting the reference to ``in lieu of nursing home care.''
    Section 3(b) defines ``covered individuals'' for purposes of this 
section to be spina bifida beneficiaries who are entitled to health 
care under subchapter I or III of chapter 18 of title 38, United States 
Code. This would include many beneficiaries who do not need assisted 
living, group home care, or similar services. The scope of services 
that VA is required to provide under this program includes services 
that could be useful to these beneficiaries even if they do not need 
assisted living, group home care, or similar services. These services 
include transportation services and such other services as the 
Secretary considers appropriate for the care of covered individuals 
under the program. This section thus could be interpreted to require VA 
to provide these additional services to covered beneficiaries even if 
they are not in need of assisted living, group home care, or similar 
services in lieu of nursing home care. If the Committee intends this 
program to be for only spina bifida beneficiaries who need care in 
assisted living facilities, group homes or similar institutions, we 
recommend amending the definition of covered individual to require that 
they be determined to need assisted living, group home care, or similar 
services.
    As noted above, section 3(d)(2) would require VA to provide 
``transportation services'' to all covered individuals in the program. 
These services could include transportation for both health care 
purposes and personal purposes such as for vacations. The services 
could also include transportation for visiting family and friends and 
for those providing health care and other services to the covered 
individuals. It is unclear whether the Committee intends to require VA 
to provide the full extent of transportation services described above 
and not permit VA to limit transportation services provided. If this is 
not the case, we recommend that the Committee clearly authorize VA to 
limit the scope of transportation services by adding ``as the Secretary 
considers appropriate'' after ``transportation services.''
    Section 3(g) would limit funding for this program to amounts 
appropriated or otherwise made available before the date of enactment 
of this Act. This would severely limit funding for the program. We 
suggest deleting ``before the date of enactment of this Act.''
    Finally, this section does not provide for what happens to covered 
beneficiaries who are in assisted living when the pilot ends, who have 
no place else to go, and who have insufficient personal funds to stay 
in their current location. Although VA does not support section 3 of 
S. 832, if enacted we recommend authorizing VA to continue providing 
assisted living, group home care, or similar services to those who had 
received these services prior to the completion of the program to avoid 
adverse impact on this population.
   s. 845, to improve the professional educational assistance program
    VA supports S. 845, which would amend 38 U.S.C. Sec. 7619 by 
eliminating the December 31, 2014 sunset date for the Health 
Professionals Scholarship Program (HPSP). The HPSP authorizes VA to 
provide tuition assistance, a monthly stipend, and other required 
education fees for students pursing education/training that would lead 
to an appointment in a healthcare profession. This program will help VA 
meet future need for health care professionals by obligating 
scholarship recipients to complete a service obligation at a VA health 
care facility after graduation and licensure/certification.
    Extending this program for an additional five years would allow VA 
to offer additional scholarships to satisfy recruitment and retention 
needs for critical health care providers. The regulation development 
process is lengthy, involving legal review and public comment, and VHA 
anticipates that final HPSP regulations will be published by early 
2014. If HPSP expires in December 2014, the program would be in 
operation for less than one academic year.
    VA estimates that this bill would cost $850,000 in FY 2014 and 
$23.73 million over five years.
        s. 851, caregivers expansion and improvement act of 2013
    The Caregivers and Veterans Omnibus Health Services Act of 2010, 
Public Law (P.L.) 111-163 (the Act), 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 under the 
Act 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.
    S. 851, the Caregivers Expansion and Improvement Act of 2013, 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 such program to 
Veterans of all eras who otherwise meet the applicable eligibility 
criteria.
    Recently, VA sent a report to the Committees on Veterans' Affairs 
of the Senate and House of Representatives (House) (required by Section 
101(d) of the Act) on the feasibility and advisability of such an 
expansion, as would be effected by S. 851. 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. VA also noted that families 
across every generation have been caregivers who have sacrificed much 
for their Veteran and this Nation.
    In the report, VA noted difficulties with making reliable 
projections of the cost impact of opening the Program of Comprehensive 
Assistance for Family Caregivers to eligible Veterans of all eras, but 
estimated a range of $1.8 billion to $3.8 billion in FY 2014.
    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. 
This is especially true as VA presses to buttress mental health 
services and ensure the fullest possible access to care in rural areas. 
VA is also mindful as we look ahead to the allocations for the Veterans 
Benefits and Services functions in the Senate-passed and House-passed 
FY 2014 budget resolutions (S. Con. Res. 8 and H. Con. Res. 25, 
respectively).
    We wish to make it very clear that VA believes an expansion of 
those benefits that are 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 top-line fiscal constraints, 
within the context of all of VA health care programs. VA welcomes 
further discussion of these issues with the Committee.
             s. 852, veterans health promotion act of 2013
    Section 2 of S. 852, the Veterans Health Promotion Act of 2013 
would require VA, acting through the Director of the Office of Patient 
Centered Care for Cultural Transformation (OPCC&CT), to operate at 
least one center of innovation for complementary and alternative 
medicine (CAM) in health research, education and clinical activities in 
each VISN.
    Section 3 of the bill would require VA to establish a 3-year pilot 
program through OPCC&CT to assess the feasibility and advisability of 
establishing CAM centers within VA medical centers to promote the use 
and integration of such services for mental health diagnoses and pain 
management. The pilot would operate in no fewer than 15 separate 
medical centers and would provide voluntary CAM services to Veterans 
with a mental health condition diagnosed by a VA clinician or a pain 
condition for which the Veteran has received a pain management plan 
from a VA clinician. Section 3 would also impose quarterly and final 
reporting requirements.
    VA supports sections 2 and 3 of S. 852. CAM practices already are 
widespread within VA, although with significant variation. According to 
the National Institute of Health (NIH) National Center for 
Complementary and Alternative Medicine (NCCAM), defining CAM is 
difficult. Thus, VA recommends using the term ``Integrative Health'' 
(IH) instead. In addition, because IH impacts the entire spectrum of 
healthcare and involves practitioners across healthcare professions and 
all points of care, VA recommends that the legislation not limit the 
provision of care to clinicians who provide IH services exclusively.
    VA supports an integrated implementation of sections 2 and 3 that 
could build on the existing infrastructure within VHA and OPCC&CT that 
could include: (1) Expanding the capacity of existing VHA OPCC&CT 
Centers of Innovation to serve as National Integrative Health Centers 
of Innovation to develop and implement innovative clinical activities 
and systems of care, serve as regional learning centers, and work 
collaboratively with the identified pilot sites; (2) Creating 
additional sites of innovation (i.e., one in each VISN) that could 
develop specific models for the delivery of Integrative Health, 
including CAM; (3) Expanding the OPCC&CT Field Implementation Teams and 
educational initiatives to include IH and IH coaching to support the 
implementation of these sites/pilot projects; (4) Creating a national 
strategy and to address any barriers to implementation identified 
through the pilot and Centers of Innovation; and (5) Developing an 
evaluation strategy to assess impact.
    These pilots would also operate in conjunction with existing 
initiatives, including the Mental Health Innovations Committee, the VA/
DOD Health Executive Council's Pain Management Work Group, VHA's 
National Pain Office, and IH pilot projects being undertaken at three 
Polytrauma Centers by OPCC&CT and the Physical Medicine and 
Rehabilitation Service National Program Office. Building on these 
pilots, VA recommends the legislation specify a total of ``up to five'' 
pilot projects at Designated Polytrauma Centers rather than five. The 
funding source for this proposed legislation is unclear, and 
implementation of sections 2 and 3 would be problematic without 
additional funding.
    Section 4 of S. 852 would require VA to carry out a 3-year pilot 
program through the award of grants to public or private nonprofit 
entities to assess the feasibility and advisability of using wellness 
programs to complement the provision of mental health care to veterans 
and family members eligible for counseling under 38 U.S.C. 
Sec. 1712A(a)(1)(C). Grantees would be required to periodically report 
to the Secretary, and VA in turn would report to Congress every 180 
days during the pilot period.
    VA supports section 4 but recommends that contracts be used instead 
of grants, because of the limited ability to fund grants within 
existing VA funding authority. In addition, VA uses the term ``well-
being'' instead of wellness because well-being is a broader concept 
that incorporates whole person health, inclusive of mind, body and 
spirit.
    As a component of the pilots identified in section 3 of S. 852, VA 
would pilot at up to five sites the use of wellness programs as a 
complementary approach to mental health care. This would be 
accomplished by training peers, volunteers, and patient advocates as IH 
coaches who will link Veterans to community organizations that can 
provide support focused on the Veterans' health and well-being, 
including self-development and spirituality, concepts that until 
recently were not associated with traditional medical care in the 
United States.
    Section 5 of S. 852 would require VA to carry out a 2-year pilot 
program through the National Center for Preventive Health to assess the 
feasibility and advisability of promoting health in covered Veterans 
through support for fitness center membership. Covered Veterans would 
be defined as any Veteran who is determined by a VA clinician to be 
overweight or obese at the commencement of the pilot and who resides 
more than 15 minutes driving distance from a fitness center at a VA 
facility that would otherwise be open to the public for at least 8 
hours, 5 days a week. The program would be piloted at no less than ten 
VA medical centers. VA would cover the full reasonable cost of a 
fitness center membership at a minimum of five locations; VA would 
cover half of the reasonable membership costs at a minimum of five 
other locations.
    Section 6 of S. 852 would require VA to carry out a 3-year pilot 
program to assess the feasibility and advisability of promoting health 
in covered Veterans through the establishment of VA fitness facilities 
at no fewer than 5 VA medical centers and 5 VA outpatient clinics. 
Covered Veterans would include any Veteran enrolled under 38 U.S.C. 
1705. In selecting locations, VA would consider rural areas and areas 
not in close proximity to an active duty military installation. Section 
6 would set a $60,000 cap on spending for a fitness facility at a VA 
medical center and a $40,000 cap on spending for a facility at an 
outpatient clinic. Under the bill, VA could not assess a fee for use of 
the facilities.
    VA strongly supports the intent of sections 5 and 6 to support 
physical activity interventions for overweight or obese and all 
Veterans because of the substantial evidence that physical activity has 
significant health benefits and is an important component of weight 
management and other chronic disease self-management strategies, but 
does not support the provisions as drafted.
    VA is committed to providing effective physical fitness education, 
training, and support for all Veterans to enhance their health and well 
being. VA has a number of programs available for Veterans, both young 
and old, that encourage regular physical activity. The Gerofit program 
is an example of an effective physical activity intervention for frail 
elderly Veterans. A new program has been developed to reach overweight/
obese Veterans in the MOVE! Weight Management Program who receive care 
in outpatient clinics. This program uses telehealth technology to 
provide group sessions, led by a physical activity specialist at a VA 
medical center, to multiple outpatient clinic sites simultaneously.
    Costs for this bill are still under development, but we believe it 
could be challenging to implement the programs in this Bill on a 
system-wide scale. Constructing space in medical centers and outpatient 
clinics for fitness centers may not be feasible in many locations. As 
noted above, we are committed to encouraging physical activity and VA 
will continue to develop cost effective and innovative ways to support 
active, healthy lifestyles for all Veterans.
    Section 7 of S. 852 would require VA to enter into a contract to 
study the barriers encountered by Veterans in receiving CAM from VA. 
Specifically, VA would study the perceived barriers associated with 
obtaining CAM, the satisfaction of Veterans with CAM in primary care, 
the degree to which Veterans are aware of eligibility for and scope of 
CAM services furnished by VA, and the effectiveness of outreach to 
Veterans about CAM. The head of specified VA departments would be 
required to review the results of the study and to submit findings to 
the Under Secretary for Health.
    VA supports section 7 of the bill. The current healthcare system 
supports conventional approaches to prevention and disease care. 
Barriers exist and need to be addressed in order to optimize and 
incentivize health and well-being. VA would coordinate research 
activities around the design, diffusion, and evaluation of IH. The 
creation and diffusion of the IH initiative will be informed by 
Veterans and VA healthcare team end users. VA recommends studies in two 
areas of focus: (1) Veteran and healthcare team end users; and (2) 
system properties. With respect to the first area, VA could ascertain 
from Veterans VHA healthcare team end users their experiences with IH 
and the real and perceived barriers to IH. With respect to the second 
area of focus, VA could study the current VHA system and other barriers 
(laws, policies, business practices, workload capture, credentialing 
and privileging, etc.) that support or impede the delivery of IH.
    Findings of a comprehensive report would inform recommendations for 
system changes and program design and implementation. VA would 
coordinate and oversee the writing, approval process, and dissemination 
of the report. VA estimates the requirements of this section would cost 
approximately $2,000,000.
    Section 8 would define the term ``complementary and alternative 
medicine'' to have the meaning in 38 U.S.C. 7330B, as added by section 
2 of the bill. As stated in sections 2 and 3 above, VA recommends using 
the term Integrative Health instead of CAM.
    VA is working to develop a complete cost estimate for this bill. As 
noted in the views, fully implementing an enterprise wide system of 
integrative health and complementary alternative medicine is complex 
and would include multiple types of clinicians, clinical practices and 
new products and services. On a smaller scale, the same is true for 
pilot sites. VA is analyzing the multiple components that would go into 
the full cost estimate and will provide to the Committee upon 
completion of this analysis.
     s. 877, the veterans affairs research transparency act of 2013
    S. 877, the ``Veterans Affairs Research Transparency Act of 2013,'' 
would permit public access to research results on VA Web sites. 
Specifically, the bill would require VA to make available data files 
that contain information on research, data dictionaries on data files 
for research, and instructions how to access such files. Under the 
bill, VA would also be required to create a digital archive of peer-
reviewed manuscripts that use such data. Finally, the bill would direct 
VA to submit to the Senate and House Committees on Veterans Affairs 
annual reports that include the number, title, authors, and manuscript 
information for each publication in the digital archive.
    VA supports the objectives of this bill but does not believe that 
legislation is needed to achieve them. Key elements of S. 877 are 
already covered by the February 22, 2013 memorandum from the Office of 
Science and Technology Policy (OSTP) regarding ``Increasing Access to 
the Results of federally Funded Scientific Research.'' Efforts are 
already underway to coordinate governmentwide compliance with the OSTP 
memorandum.
    VA believes that transparency is most effectively accomplished 
using PubMed Central, an archive maintained by the NIH. VHA Office of 
Research and Development is negotiating with NIH with the objective of 
disseminating published findings using this vehicle. Using this common 
platform to disseminate VA funded research would be more cost-effective 
and would better serve the needs of the Federal and non-Federal 
research community.
    VA estimates the costs associated with this bill to be $107,518 in 
FY 2014; $1.46 million over five years, and $8.8 million over ten years 
for the entire research program.
                                 ______
                                 
  Response to Posthearing Questions Submitted by Hon. Mark Begich to 
  Robert L. Jesse, M.D., Ph.D., Principal Deputy Under Secretary for 
              Health, U.S. Department of Veterans Affairs
    Question 1. A question about IHS/VA and Tribal agreements, as you 
may know each year I have been here I have been pushing my Alaska 
Hero's Card, and I want to commend the VA on getting the Tribes to see 
veterans in rural areas where there are no VA facilities.
    My question is, how do you think the agreements are doing and what 
do you need from the Committee to ensure the continuity of the good 
health care for Veterans closer to home?
    Response. VA is implementing a national reimbursement agreement 
with the Indian Health Service (IHS) and individual reimbursement 
agreements with Tribal Health Programs (THP). As is the case now, the 
reimbursement agreements with tribal health care programs preserve the 
ability for eligible American Indian/Alaska Native (AI/AN) Veterans to 
choose where to receive their care, at VA or the tribal health care 
facilities. For IHS, we have one signed VA-IHS National Reimbursement 
Agreement, with over 81 signed local implementation plans covering 106 
IHS health care facilities. As of November 2013, there are 35 signed 
THP reimbursement agreements. Of those, 26 are Alaska-based VA-THP 
agreements. VA continues to work closely with individual THPs to 
finalize more VA-THP reimbursement agreements. Currently, assistance 
from the Committee is not required for VA reimbursement agreements with 
IHS and THP facilities.
    The Alaska-based VA-THP reimbursement agreements specifically allow 
for non-AI/AN and AI/AN eligible Veterans to receive care at tribal 
health care facilities. This helps to achieve the goals set forth in 
the Alaska Hero's Card Act of 2011 (H.R. 2203, 112th Congress (1st 
Session 2011)) as well.
    In FY 2013, 2,000 eligible AI/AN Veterans have been treated under 
the VA reimbursement agreements with IHS and THP accounting for 
approximately $1.8 million in care.
    VA looks forward to the continued growth of these agreements 
enabling Veterans to have greater access to VA benefits.

    Question 2. The recent reports and testimony I have heard on my 
time on this Committee and SASC on the increase of Military Sexual 
Trauma, (MST) is appalling. What steps is the VA taking to provide 
services for those who have been assaulted and are dealing with the 
trauma years later?
    Response. Since 1992, when VA was first authorized to provide 
counseling and care to Veterans who experienced Military Sexual Trauma 
(MST), VA has dedicated significant resources and staff to ensure this 
is, and remains, a robust treatment program, which continues to improve 
and excel. VA surveys have shown that when Veterans are asked about the 
quality of the care they have received from VA, overall ratings are 
high for both men and women, with 78.5 percent of men and 72.3 percent 
of women rating the quality of care received from VA as ``very good'' 
or ``excellent.'' Importantly, ratings of overall quality did not 
significantly differ among Veterans who did and did not report MST, 
after adjusting for patient characteristics.
    The terms of 38 United States Code Sec. 1720D authorize VA to 
provide Veterans with counseling, care, and services needed to overcome 
psychological trauma which, in the judgment of a mental health 
professional employed by VA, resulted from a physical assault of a 
sexual nature, battery of a sexual nature, or sexual harassment which 
occurred during their service on active duty or active duty for 
training. In implementing this authority, the Veterans Health 
Administration (VHA) has developed a number of initiatives to 
facilitate provision of these services, including the following:
Services & Treatment
     Screening. Recognizing that many survivors of MST do not 
disclose their experiences unless asked directly, it is VA policy that 
all Veterans seen for health care be screened for MST. Screening is 
conducted in a private setting by qualified providers trained in how to 
screen sensitively and respond to disclosures. Veterans who report 
experiencing MST are offered a referral to mental health for further 
assessment and/or treatment.
     Free care. Health care services (inpatient, outpatient, 
and pharmaceutical care) for physical and mental health conditions 
authorized to be provided under section 1720D are provided free of 
charge (i.e., no copayments apply). Eligibility for MST-related 
treatment is also separate from and independent of the Veterans 
Benefits Administration (VBA) disability claims process. That is to 
say, eligibility for MST-related care does not require or depend on the 
Veteran filing and/or obtaining adjudication from VBA that the 
condition secondary to MST is service-connected. In addition, some 
Veterans not generally eligible for VA services may still be able to 
receive free care for conditions related to MST.
     Access to care. Facility MST Coordinators serve as contact 
persons for MST-related issues and can help Veterans find and access VA 
services and programs. All Veterans seen in VHA who screen positive for 
MST are offered a referral to mental health services.
     Outpatient services. Every VA health care facility 
provides MST-related mental health outpatient services, including 
formal psychological assessment and evaluation, psychiatry, and 
individual and group psychotherapy. Specialty services are also 
available to target problems such as Post Traumatic Stress Disorder 
(PTSD), substance abuse, depression, and homelessness. Every facility 
has providers knowledgeable about mental health treatment for the 
aftereffects of MST. Because MST is associated with a range of mental 
health problems, VA's general services for PTSD, depression, anxiety, 
substance abuse, and others are important resources for MST survivors. 
In addition, many VA facilities have specialized outpatient mental 
health services focusing specifically on sexual trauma. Many community-
based Vet Centers also have specially trained sexual trauma counselors.
     Residential/inpatient care. For Veterans who need more 
intensive treatment, many VA facilities have Mental Health Residential 
Rehabilitation and Treatment Programs (MHRRTP), a resource that is rare 
in the private sector. VA also has inpatient programs available for 
acute care needs (e.g., psychiatric emergencies and stabilization, 
medication adjustment).
Education of Staff
     All VHA mental health and primary care providers are 
required to complete mandatory training on MST.
     VHA's national MST Support Team hosts monthly continuing 
education calls on MST-related topics that are open to all VA staff and 
available online afterwards.
     Since 2007, the MST Support Team has hosted an annual, 
multi-day, in-person training focused on provisions of clinical care to 
MST Survivors and MST-related program development.
     The MST Resource Homepage is a VA intranet community of 
practice Web site where VA staff can access MST-related resources and 
materials, review data on MST screening and treatment, and participate 
in MST-related discussion forums.
     Staff also has access to an online independent study 
course on MST and other Web-based training materials.
     Information about MST has been integrated into VA's 
rollouts of empirically-supported treatments for PTSD, depression, and 
anxiety. These conditions are strongly associated with MST, meaning 
these national initiatives have been an important means of expanding 
MST Survivors' access to cutting-edge treatments. Furthermore, several 
of these treatments were originally developed in treatment of sexual 
assault survivors and have a particularly strong research base with 
this population.
     Since 2008, the MST Support Team has engaged in national 
activities to support and encourage facilities to host events as part 
of Sexual Assault Awareness Month (SAAM) in April. These activities 
include selection of a national theme, dissemination of support 
materials, publication of information about SAAM in the VAnguard 
magazine and other outlets, and, in April, hosting a special national 
MST training call designed to be of general interest to VA staff.
     At a facility level, MST Coordinators may host Grand 
Rounds and other educational presentations, distribute informational 
newsletters or fact sheets, and engage in other activities.
Outreach to Veterans
     To help ensure information about MST-related services is 
readily available to Veterans, VA's national MST Support Team developed 
outreach posters, handouts, and educational documents for Veterans, 
secured inclusion of information about MST on relevant va.gov Web 
sites, and developed an MST-specific Internet Web site 
(www.mentalhealth.va.gov/msthome.asp).
     The MST Support Team identified Transitioning 
Servicemembers and newly discharged Veterans as high priority groups 
for outreach in fiscal year 2013. The team is collaborating with DOD's 
Sexual Assault Prevention & Response Office and other national VHA 
program offices to ensure that these Veterans are aware of MST-related 
services available through VHA.
     Facility MST Coordinators engage in local outreach efforts 
to raise awareness about the availability of MST-related services. Tips 
sheets from the MST Support Team help facilitate these efforts.
     MST is included in ``Make the Connection'' 
(www.maketheconnection.net) and ``About Face'' (www.ptsd.va.gov/
aboutface) Web sites featuring Veteran's stories of recovery.

    Question 3. I have introduced a bill to expand the definition of 
homeless veterans to include victims fleeing domestic violence.
    Do you have any numbers or sense of the problems for veterans 
fleeing domestic violence and wind up homeless? Is there something else 
we should be doing with homeless and domestic violence to help 
veterans? Concerning the definition of Homeless, what if any problems 
do you see from expanding this definition? Seems like a very small 
change that would benefit many veterans.
    Request: Do you have any numbers or sense of the problems for 
veterans fleeing domestic violence and wind up homeless?
    Response. VA does not specifically track this data, but we do have 
a sense of the problem for Veterans fleeing domestic violence who are 
at risk for homelessness.
    VA recognizes that Veterans who experience past or present Domestic 
Violence/Intimate Partner Violence (DV/IPV) face complex issues, 
including, homelessness. There is evidence that IPV is among the 
leading contributors to housing instability and homelessness among 
women (Baker, Billhardt, Warren, Rollins & Glass, 2010; Hamilton, Poza, 
& Washington, 2011) and likely contributes to risk for homelessness 
through multiple pathways. For example, fleeing an abusive relationship 
can be a contributing factor to homelessness among women (Baker, Cook, 
& Norris, 2003; Baker, et al., 2010).
    In addition, IPV leads to and exacerbates mental health conditions, 
such as PTSD and substance use disorders that significantly increase 
risk for homelessness among women Veterans (Hamilton, et al., 2011; 
Washington, et al., 2010). Similarly, IPV is associated with other risk 
factors for homelessness, such as MST. Among homeless women Veterans, 
the prevalence of MST is 53 percent, compared to 26.8 percent among 
non-homeless women Veterans (Washington, et al., 2010).
    Although male Veterans also experience IPV, male-to-female IPV 
results in greater severity of violence, number of injuries, and mental 
health consequences relative to IPV experienced by men (Archer, 2002; 
Carbone-Lopez, Kruttschnitt & Macmillan, 2006). Moreover, the link 
between IPV and homelessness risk has not been as robustly established 
for men as it has been for women. Thus, the need to address DV/IPV and 
risk for homelessness is arguably most urgent for women. Yet, VA 
programs that address DV/IPV will work hand-in-hand with homelessness 
programs to address this health issue among all Veterans regardless of 
gender.
    An array of services, from crisis intervention to long-term 
assistance, is needed for Veterans fleeing violent relationships. 
Immediate crisis intervention may include attention to physical 
injuries and assistance with food, shelter, child care (when needed), 
and general safety. Long-term assistance may include ongoing medical 
care and programs to help Veterans cope with lasting emotional and 
psychological effects of IPV to regain or achieve economic and housing 
stability.

    Request: Is there something else we should be doing with homeless 
and domestic violence to help veterans?
    Response. Addressing complex DV/IPV issues will require a 
coordinated, interdisciplinary approach. In 2012, a Domestic Violence 
Task Force was chartered to develop a national plan to address issues 
relating to the identification of domestic violence and access to 
services for Veterans who experience DV/IPV. The Task Force's 
recommendations involve collaboration and coordination of care between 
all types of VA services, including, but not limited to, physical 
health care, evidence-based mental health treatments, employment, and 
supportive housing services.
    In addition, available data suggest that many VA providers have had 
limited training related to DV/IPV (Iverson et al., in press). Thus, 
training and education of VA staff will be vital to the successful 
implementation of comprehensive care for Veterans who experience DV/
IPV, and those who use DV/IPV. A Veteran who experiences violence is 
the recipient of violent behavior and is traditionally referred to as 
``victim'' or ``survivor'' of DV/IPV. A Veteran who uses violence 
toward his or her partner is typically referred to as a ``batterer,'' 
``abuser,'' or ``perpetrator.'' VA is in a unique position to provide 
care for both those who experience and those who use violence. Training 
initiatives will include information about DV/IPV being a risk factor 
for homelessness among the Veteran population and will provide specific 
guidance for addressing these often co-occurring issues.
    Effective intervention involves collaboration among many programs 
and agencies working together to provide identification and assessment, 
risk evaluation and provision of safety supports, treatment planning 
and delivery, and coordination with law enforcement and other relevant 
providers. In addition to ending violence and preventing further 
violence, services in response to DV/IPV often address needs related to 
healing from the physical, psychological, and social effects of 
violence. VA has resources in place that can also address the long-term 
health effects of DV/IPV.
    Community partnerships/resources must be further developed and 
maintained to ensure that Veterans and their family members have 
adequate assistance to quickly and safely transition from unsafe 
settings putting them at risk for DV/IPV. These partnerships will 
assist in supplementing what VA can provide and address access to safe 
homes for immediate shelter, transitional homes for newly displaced 
Veterans and their family members, and assistance with permanent 
housing.

    Request: Concerning the definition of Homeless, what if any 
problems do you see from expanding this definition? Seems like a very 
small change that would benefit many veterans.
    Response. Addressing DV/IPV is likely to lead to reductions in 
homelessness since many individuals end up homeless trying to flee DV/
IPV. VA Homeless Programs do not currently track the data for this 
subpopulation; hence, we are unable to estimate the impact of expanding 
the definition of homeless. VA has a homeless continuum of care with 
services ranging from emergency shelter to permanent supportive 
housing. Veterans who are fleeing from DV/IPV and satisfy the current 
definition of homeless are already served in VA's homeless programs 
when it is clinically appropriate. Even when a VA homeless program is 
not a clinically appropriate placement for a Veteran affected by DV/
IPV, VA works closely within the local community to identify resources 
best suited to the clinical needs of the Veteran. To this end, VA's 
programs that address homelessness may help prevent future DV/IPV by 
assisting Veterans in finding alternative housing options so they can 
safely exit abusive relationships. VA does not know the scope or the 
true needs of the DV/IPV Veteran population and currently lacks a VA 
domestic violence safehouse program. A safehouse provides shelter for 
women and children fleeing imminent danger and can provide a spectrum 
of life-saving, supportive, and educational services to help women and 
children leave behind a life of domestic violence and begin a new life 
of stability. Staff training and informational outreach are essential 
components for DV/IPV-related programming. Medical and mental health 
providers and staff will undergo recommended training which will be 
tailored to the specific needs of clinical, non-clinical, and mental 
health staff. Training content for providers and staff will include an 
overview of the prevalence, risk factors, protective factors, and 
specific issues related to Veterans including risk assessment, safety 
planning, and procedures for situations where the Veteran is in 
imminent danger. DV/IPV programming will work hand-in-hand with current 
initiatives aimed at addressing homelessness among Veterans ensuring 
Veterans get the care they need.

    Question 4. I see you did not have time to comment on my research 
bill (S. 877), but I would like the VA to weigh in. This bill would 
allow public access to research of the VA. The VA budget (2013) for 
medical and prosthetic research is about $1.9 Billion, access to the 
results remain limited. For example, nearly $53 million on post-
deployment mental health and $7 million on Gulf War illness. The 
information from this research is frequently inaccessible for 
clinicians outside the VA system, a significant number of veterans 
receive at least some of their health care from non-VA clinicians.
    How could public access to VA research improve the care veterans 
receive from those clinicians?
    Response. VA Research's success in improving Veteran health care is 
predicated on making its results publicly available. Information 
generated by VA researchers needs to be known, translated, and 
implemented in order for it to positively impact Veterans health care. 
The VHA Office of Research and Development (ORD) continues to emphasize 
the importance of publishing results and ensuring timeliness in 
completion of its funded activities. Within VA, ORD disseminates 
research results to groups involved in patient care, including Pharmacy 
Benefits Management and distribution groups for Center for Information 
Dissemination and Education Resources communications. Public access to 
VA research primarily involves two aspects, access to publications and 
access to data. Currently, VA has a group examining ways to improve 
access to research results in conjunction with similar activities by 
other research funding agencies. More specifically, VA is looking at 
ways to partner with the National Institutes of Health's PubMed Central 
repository for making its publications more widely accessible. Clinical 
trials sponsored by ORD are also complying with Section 801 of the Food 
and Drug Administration Amendments Act by submitting results for 
posting on clinicaltrials.gov. Registration and posting results of 
studies on clinicaltrials.gov also provides a mechanism to accessing 
publications through links established by the National Library of 
Medicine between a study profile and any subsequent publication. 
Finally, VA is exploring mechanisms for how data from its multi-site 
clinical trials can be made available after the publication of the 
primary results manuscript. Altogether, these efforts can provide 
state-of-the-art knowledge in those areas for which clinicians in VA 
and throughout the Nation to better inform decisions in providing care. 
Since a core requirement of VA research is to be Veteran centric, 
publications and results have a direct relevance for informing VA care. 
Even further, VA research is part of a more national effort to help 
better inform patients about diseases, treatment, and options in such 
care.

    Question 5. S. 877 will enhance public access to findings from VA-
funded research; I believe that the access to research afforded by this 
bill could serve as a tool to assess the return on investment of 
research funding.
    A. How could implementing a public access policy for VA research, 
like the public access policy that is already in place for the National 
Institutes of Health, help VA to assess return on investment?
    Response. While discussions on biomedical research's return on 
investment are beyond the economic expertise VA maintains, several 
publications including a 2011 report issued by the National Academy of 
Science, National Academy of Engineering and the Institute of Medicine, 
are available on this topic. However, ORD is already considering public 
access policies that are consistent with those used by the National 
Institutes of Health (NIH). Any determinations of return on investment 
would be likely similar. Currently, ORD uses NIH's Electronic Research 
Administration (eRA) tool for handling proposal submissions and 
scientific peer review. Additionally, VA has been among leading groups 
committed to posting information on its clinical trials on the NIH/
National Library of Medicine's clinicaltrials.gov public registry and 
has established relationships with them to enable communication and 
execution of best practices. Further, VA is exploring more systematic 
processes for uploading trial results across the system on 
clinicaltrials.gov. While VA agrees in principle with NIH policies, 
there are some notable differences that have to be taken into account. 
Given that VA is part of an integrated health care system, protections 
for patient data and data security, in general, is of the utmost 
concern. There are considerations in that context that may not have 
been addressed in NIH's policies. Implementing any public access would 
also be contingent upon information technology (IT) systems and 
resources. Since VA IT support comes from a separate appropriation with 
no direct tie to research activities, VA research may face challenges 
that NIH does not.

    B. Do you see any problems, drawbacks in making information 
publicly available that could improve the care of veterans? And will 
you work with the DOD to merge data files to expedite important 
research to help veterans?
    Response. Making publications derived from VA research available 
has many important benefits to clinicians and patients. In fact, VA 
research has been a leader for decades in the area of comparative 
effectiveness research which can enable clinicians and patients to be 
better informed about differences between available treatment, 
prevention, and/or screening options. Providing information about 
active clinical research protocols that Veterans can participate in is 
also of significant value to advancing care for Veterans and the 
Nation. However, having research data publicly available should 
consider safeguards and policies for appropriate use. Making research 
data available allows for analyses or even combinations with other data 
to enable more advances in the field. In this context, making research 
data available allows for a greater return on investment. The major 
drawback is that data that is too widely accessible to individuals who 
may not have requisite knowledge or skills for using them could be 
misinterpreted. For example, statistically, repeated analyses of a 
dataset can generate positive results by chance. Such results, if 
published, may actually misinform clinicians and patients by suggesting 
benefits that may not be true. Further, use of data for which they were 
not originally intended may result in inappropriate analyses or 
conclusions. It potentially bypasses the well-established scientific 
peer review process for vetting results for broader dissemination. 
Finally, prior to publishing data obtained from clinical research 
protocols, VA needs to also consider ethical principles behind informed 
consent and the purposes for which study participants knowingly 
contributed their information. A lack of consideration for these points 
can potentially result in unintended consequences that inhibit moving 
science and medicine forward.
    VA and DOD worked together on a National Research Action Plan 
(NRAP) in response to an Executive Order, ``Improving Access to Mental 
Health Services for Veterans, Servicemembers, and Military Families,'' 
issued on August 31, 2012. The NRAP contains plans for future data 
sharing between VA and DOD to improve research.

    Question 6. Next week is VA Research Week calling attention to the 
achievements of VA researchers and the role they play in advancing 
medical science. I know that the VA's Research and Development division 
does some very innovative work. The Million Veteran Program is 
comprehensive and when finished will have a wealth of information for 
the VA.
    My question, do you see the advantage of sharing this kind of info? 
And do you see the value in sharing this comprehensive data collecting 
with non-VA clinicians?
    Response. The Million Veteran Program (MVP) is a research program 
created to be a resource that combines genetic information, self-
reported survey information, and health record information from over 
one Million consenting Veteran users of the VA health care system. 
Approved researchers will be able to access this information to carry 
out studies to better understand the effects of genetics on health and 
disease. Currently, this information is not returned directly to 
participants or to their clinicians, as it is for research purposes 
only. Initially, MVP data access will be restricted to approved VA 
researchers on a small scale in order to test out the complex 
infrastructure that will securely house Veterans' information. Once the 
process is thoroughly vetted, the collected information could be made 
available to approved researchers in other Federal agencies and 
academic institutions. One advantage of making this information 
available to approved non-VA researchers is the possibility of 
leveraging resources, in the form of public-private partnerships, 
particularly in the bioinformatics and computational fields, to advance 
the analysis of complex genetic data and the pace of scientific 
discovery.
                                 ______
                                 
Response to Posthearing Questions Submitted by Hon. Richard Blumenthal 
  to Robert L. Jesse, MD, Ph.D., Principal Deputy Under Secretary for 
              Health, U.S. Department of Veterans Affairs
    Question 1. Dr. Jesse, I would like to focus on the Chiropractic 
Care Available to All Veterans Act, which I am proud to sponsor with my 
colleague, Senator Moran. The most frequent medical diagnoses reported 
among Iraq and Afghanistan veterans are musculoskeletal and connective 
system issues. In fact, nearly 200,000 recent veterans who have sought 
VA care since 2002 have been diagnosed with these conditions. 
Chiropractic care can be an appropriate and effective means of 
treatment for these individuals.
    However, the VA currently provides chiropractic care at only a 
fraction of its medical centers. As a consequence, many deserving 
veterans who would benefit from chiropractic care are unable to access 
the specialized medical attention they need. The Chiropractic Care 
Available to All Veterans Act would require VA to provide chiropractic 
care services at all of its medical centers by the end of 2016. All 
veterans deserve access to these cost-effective chiropractic treatments 
at VA facilities.
    Your assessment of veterans' access to these services, that the 
care is currently available to ``all veterans,'' does not line up with 
the Veterans' Health Administration's own reporting that fewer than 50 
medical centers currently offer these services. Even veterans taking 
advantage of fee-based chiropractic care outside of the VA system may 
not be able to readily access these services, depending on geographic 
location. I am not convinced that these current options are sufficient 
to meet veterans' increasing demand for chiropractic care.

    How does VA currently accommodate these veterans, if at all, in 
areas far away from a VA facility with chiropractic services and far 
away from fee-based service options?
    Response. The Department of Veterans Affairs (VA) provides 
chiropractic services as part of the medical benefits package and 
administers this service based on clinical need, similar to all other 
medical care. Chiropractic services are provided on-station by VA 
staff, or when not available through VA, services are provided through 
the Non-VA Purchased Care program (Fee Basis). When chiropractic 
services are obtained under the Non-VA Purchased Care program, VA works 
to accommodate (to the extent possible) the Veteran's preference 
regarding choice of community provider. In Fiscal Year 2013, VA spent 
over $10.3 million on chiropractic services, including $5.5 million on 
purchased chiropractic services. Even when VA seeks to procure this 
service, the needed chiropractic services may not be available in the 
Veteran's local community, especially in rural areas. This creates a 
barrier to access that is outside of VA's control. Where VA cannot 
procure the services locally, the only option may be for the Veteran to 
travel to the distant VA Medical Center. Costs of such travel may be 
offset if the Veteran is eligible for beneficiary travel benefits.

    Chairman Sanders. Thank you very much. Dr. Jesse. As you 
know, I have introduced legislation to expand VA's caregiver 
program to veterans of all eras.
    Dr. Jesse. Yes.
    Chairman Sanders.While VA did not provide written testimony 
on this particular bill, I would very much appreciate you 
providing this Committee with information on the progress of 
this program. My understanding is that it is filling a real 
need.
    Can you speak to that? For example, how many veterans and 
their families have accessed the program to date?
    Dr. Jesse. Sir, I do not have those numbers in front of me 
but we will get them to you for the record. I will say that we 
have briefed senior management on the progress of the program. 
As you know, I think a report is due 2 years after the 
implementation of the program which would be at the end of this 
month.
    Chairman Sanders. Can we expect to receive that report at 
the end of this month?
    Dr. Jesse. I can hope so but not promise. How is that?
    Chairman Sanders. Sometimes this Committee has had a 
problem with getting reports in a timely manner. So, please 
ensure your leadership is aware that we expect the report at 
the end of this month.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Dr. Jesse. I shall. I think the program is quite 
successful. In terms of expanding the program, you, I think, 
are well aware that the equity issue to all veterans of all 
generations is important to us; and expanding this program I 
think very much fits within that. Of course, the question is 
the cost and the eligibility issues that would have to be well-
defined.
    But these are important issues to us. We very much 
appreciate the opportunity to have started off in this initial 
view of the post-9/11 veterans and clearly can see the impact 
of having this capability.
    Chairman Sanders. In other words, what you are telling us 
is you think that program is filling a real need.
    Dr. Jesse. I believe so, yes.
    Chairman Sanders. OK. And would you agree that it is hard 
to argue from an equity standpoint why it is only available to 
post-9/11 families?
    Dr. Jesse. Yes.
    Chairman Sanders. Senator Burr raised the point that he and 
I are working together on the homeless issue. Let me applaud VA 
for its work in this area. I know it is easy to beat up on the 
VA but the VA has made some significant improvements under 
General Shinseki and taken important steps in dealing with what 
I consider a national embarrassment, and that is homelessness 
among veterans.
    VA has set an ambitious goal of ending homelessness among 
veterans by 2015.
    The VA's homeless programs serve a number of populations 
with different needs. Senator Burr and I have introduced 
legislation to make common sense improvements to some of VA's 
programs for homeless veterans, including making transitional 
housing programs more accessible to the growing population of 
homeless women veterans.
    Last December, the Interagency Council on Homelessness 
released the report that detailed challenges around stable 
housing for veterans in rural areas and tribal lands. The 
report included several recommendations on how to improve 
services for this population. My question is two-fold.
    First, does VA believe we can continue to make significant 
progress in dealing with the tragedy of homelessness in our 
veterans' population and especially the growing needs of women 
veterans?
    Second, what actions is VA taking to address the needs of 
homeless veterans in rural areas and on tribal lands?
    Dr. Jesse. Senator, the first question is, are we making 
significant progress? And I think the answer to that is simply 
yes. We have in place a multitude of programs across both urban 
and rural venues.
    I will say that I think the homeless program in VA has 
taught us an incredibly important lesson, and that is that the 
success of programs like this are not necessarily predicated on 
what we ourselves do, but our ability to partner with the 
incredibly dedicated local, State, and other Federal agencies 
that are addressing these issues.
    I had the opportunity a couple of years ago to go to some 
of the veteran homeless stand-downs that we were conducting and 
was just thoroughly impressed that the comments from the local 
government, faith-based, and NGO's about the role that the VA 
was playing to supporting the communities.
    Granted, our authority is to take care of the homeless 
veteran but much of the capability to do that requires 
interacting with all the local folks. I think the best comment 
I had gotten was that they were very pleased whenever they 
identified a homeless person as a veteran because they knew 
that one phone call and that person would be engulfed with 
services.
    So, I think we are making great strides in those areas. I 
went to the Point-in-Time count this year out in Los Angeles 
and was equally impressed by the fact they were not necessarily 
counting homeless people because they knew them all. And, that 
is a far more important statement because when you know who the 
homeless people are, you know how to serve them best and get 
them the appropriate services.
    Regarding rural and tribal areas, I confess I cannot speak 
to the tribal areas. I can get that back for you for the 
record. The rural areas, I think we are equally dedicated to 
which is a matter of working in lower volume areas but, again, 
supporting the local communities who are working in these 
areas.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Chairman Sanders. Thank you. As I mentioned, Senator Burr 
and I have introduced sound legislation, and we are going to do 
our best to see that it is passed. We look forward to working 
with you for its implementation.
    Senator Burr.
    Senator Burr. Thank you, Mr. Chairman.
    Dr. Jesse thank you for being here. I have great affection 
for the entire VA workforce----
    Dr. Jesse. Thank you.
    Senator Burr [continuing]. For what they commit to do; and 
I appreciate that the VA supports my Camp Lejeune bill. I am 
concerned, though, that the family members at Camp Lejeune and 
the veterans are waiting to access benefits provided by the 
current law.
    In an explanation of the health care benefits provided by 
Camp Lejeune Act, VA's budget justification indicated the VA 
would start treating family members in fiscal year 2015.
    Let me ask you. Why are these family members who are 
fighting cancer and other devastating diseases being forced to 
wait 18 months for the health care they need right now?
    Dr. Jesse. So, part of that answer was embedded in the 
initial legislation which required the authorization, 
appropriation of the funding to do so. We have been engaging 
with the family members. We have, I think, at this point 
identified approximately 500, but in terms of actually 
beginning to disburse money to pay for their health care----
    Senator Burr. I need to cut you short. The authorization is 
in this year's continuing resolution. It is in this year's. It 
is in next year's. There is no explanation as to why it would 
take to 2015 except that we have thrown a dart on a map and 
that was the date that came up.
    Dr. Jesse. I would like to get back to you for the record.
    Senator Burr. I would ask only this of you; go back and 
read the act.
    Dr. Jesse. OK.
    Senator Burr. It is now law. Go back and look at the CR. 
The authorization is there. The Act, when it was adopted was 
offset. The money was there.
    I am just going to be real candid. There is no excuse. To 
do this is to turn your back on individuals that are reliant on 
the VA partnership to provide them health care.
    And, let me just say to all my colleagues, we did not put 
VA in the primarily spot; they are secondary. These people have 
to turn to their own insurance first. VA is a backup. It is 
there for any cost overage. It is there if they do not have 
insurance. These are folks that, in many cases, are in terminal 
illness. They may not make it to 2015.
    Dr. Jesse, you testified that VA was reviewing the staffing 
structure of the VISN headquarters to streamline and 
standardize their operation and that you were going to go back 
to determine, geographically, what the number was.
    Now, I am not a bureaucrat. I am a business guy. It makes 
sense to me that you would go in and figure out geographically 
how many you needed before you looked at how to streamline it.
    Have I got it backwards or do you?
    Dr. Jesse. So, I am a cardiologist. I think the ability to 
reconfigure the entire administrative organization of the VA is 
complex and probably more than just determining what the right 
number of VISNs is; and the ability go to in and look at the 
efficiency and effectiveness of the existent VISN structure is 
a relatively straightforward process.
    What it really required us to do--and I think, frankly, was 
very important--is to really speak to what is the role of the 
VISN structure. It has changed over time from their original 
conception back in 2008 when they were put together. And if you 
are trying to understand why there was such a great variance 
across the sizes of the VISNs regardless of the scope of size 
of----
    Senator Burr. Do you intend to sort of go back to the 
original intent of the creation of the VISNs to use the 
template to look at the current numbers?
    Dr. Jesse. So, the original VISNs were built on the 
structure geographic including referral patterns. I think 
having done the first part which is: we said what we have done 
and we briefed your staff on it; we have leaned down the size 
of the VISNs. The next thing to do is really go look at the 
referral patterns.
    Frankly, there are a lot of people for care across VISN 
lines which creates at some level of both confusion and 
complication. If we can re-adjust them on what are the 
contemporary VISN patterns, I mean, I think we can make some 
significant changes in how the preferred VISN structures are 
aligned. But I do not know if 12 is the right answer or 15 is 
the right answer.
    Senator Burr. VA's own testimony states that they are 
unclear why VISNs 19 and 20 are consolidated and VISN 6 would 
be untouched and stated VA would appreciate the opportunity to 
review the Committee's criteria for determining these 
boundaries. I am ready. I think we have been very specific.
    Let me just, Mr. Chairman, ask one last question. Your 
written testimony states that if this VISN Reorganization Act 
were to become law, veterans could potentially, ``be forced to 
travel to different locations for care because the space for 
clinical operations would be used to comply with the provision 
calling for VISN offices to be co-located within a medical 
center.''
    Since the bill outlines the process for VA to enter into 
leases, how in the world would this provision change where a 
veteran received their care?
    Dr. Jesse. I think what that statement refers to is--let me 
back that up and say one of the reasons why many of the VISN 
headquarters are not on the grounds of a medical center is 
because the space needs in those medical centers was to deliver 
clinical care and it felt it was more appropriate to move an 
administrative function that was not directly attached to that 
medical center offsite and use the space for delivery of care.
    The notion is if we then had to collapse the space to 
deliver care, we would have to distribute that care somewhere 
else. I think that is what it is referring to.
    Senator Burr. I thank the Chair.
    Chairman Sanders. Senator Begich.

                STATEMENT OF HON. MARK BEGICH, 
                    U.S. SENATOR FROM ALASKA

    Senator Begich. Thank you, Mr. Chairman.
    Thank you both for being here this morning. Let me ask you, 
in reference to two bills that I have. One is S. 287, which is 
a bill to amend Title 38 of the Code to expand the definition 
of homeless veterans for the purpose of benefits under the 
administration.
    For purpose of eligibility or what it would change through 
the VA, the bill includes veterans, families fleeing from 
domestic or dating violence, sexual assaults, stalking and 
other dangerous life-threatening events as well as children who 
may be at risk or jeopardized. There is no other type of 
residency. The idea is to expand the definition of 
homelessness.
    Last year, you all supported it but this year you have no 
comment. Can you tell me where you are on this? Just give me 
your thoughts on it.
    Dr. Jesse. Sure. Ms. Blauert.
    Ms. Blauert. Yes, sir. We did provide views in September of 
last year; and to be honest, we were not really satisfied 
coming back to you with essentially the same view this year. We 
want a little bit more time to dig in and look at the issues 
and exactly what the impact would be on our existing programs 
with expanding who we capture with the term ``homeless 
veteran.'' You can be assured that VA does not turn away a 
veteran who is out on the streets and in need.
    Senator Begich. I understand that. But what I guess I am 
trying to--if that was September of last year, it is now May. I 
battled this issue before with HUD because what they always 
would say is we hear you, the definition of family, and some 
other definitions. But what it would do is statically change 
their numbers. In other words, it would show that you had more 
homeless. Well, of course, because now you have increased the 
definition. I hope that is not one of the reasons. That is now 
one of the reasons, correct?
    Ms. Blauert. No. Absolutely.
    Senator Begich. OK. Then when can I see a response, because 
it seems logical that we would want to make sure veterans and 
families fleeing domestic violence or dating violence or other 
situations of this nature that become homeless would be even at 
higher risk because of the situations they were in, now they 
are on the streets. So, is there philosophical opposition to 
it?
    Ms. Blauert. No, I do not believe there is philosophical 
opposition to it. It is my understanding that there is interest 
in making sure that we have clinicians and services available 
to treat the needs of these persons. Some of them are going to 
be different than the current population that we consider 
homeless.
    Senator Begich. I understand.
    Ms. Blauert. I understand that VHA recently undertook a 
task force to specifically look at the domestic violence issue.
    Dr. Jesse. We could break a bit of the discussion away from 
the definition of homeless and speak to our ability and frankly 
our desperate need to attend to his very vulnerable population.
    You know, we take the issue of domestic violence incredibly 
serious. As you know, the women's health program in VA has been 
doing some magnificent work over the past couple of years. They 
have a task force which has just completed its report on 
domestic violence.
    Senator Begich. Does the task force, did they deal with the 
issue of homelessness?
    Dr. Jesse. I do not know that they specifically addressed 
the issue of homelessness. What they are specifically 
addressing is how we support and care for victims of domestic 
violence, which would generally mean getting them out of the 
living environment that they are in into some other 
environment.
    Senator Begich. I only have limited time here so I want to 
get right to it.
    Dr. Jesse. Yes.
    Senator Begich. So, the task force is done. They have 
prepared a report. When will that be public?
    Dr. Jesse. That I do not know, but I know that the report 
has been done and we would see the recommendations coming out 
shortly. We can get that back to you.
    Senator Begich. OK. That would be great.

    [Responses were not received within the Committee's 
timeframe for publication.]

    Senator Begich. So, if you are subject to domestic violence 
or sexual assault in a home environment, then you leave.
    Dr. Jesse. Right.
    Senator Begich. OK. So, they become couch-hoppers where 
they are going from house to house or they are on the street. 
This is not the population you want on the streets.
    Dr. Jesse. No.
    Senator Begich. So, I am hopeful, if that is a draft report 
and it does not address this it should, and then refer to the 
bill itself because the definition is what helps make sure 
resources follow these individuals.
    Dr. Jesse. Exactly.
    Senator Begich. That is really important.
    Let me quickly go to one last thing, and that is there was 
another piece of legislation, S. 877, the Veterans Fair 
Research Transparency Act. This is very simple.
    The National Institute of Health does this now, and a lot 
of the work that they do they can share; therefore, the data 
helps with other research, et cetera.
    Why can the VA not replicate what the National Institute of 
Health does in the sense of creating a database and ability for 
sharing of information? Of course, not individuals by names and 
so forth. Why can we not do that if another Federal agency does 
that now?
    Dr. Jesse. Well, I do not think it is an issue that we 
cannot. I think the issue is we just have not had the time to 
look at exactly the best way to do this. I fully agree with you 
that the NIH does this now. They require any NIH-funded study 
to make that journal article available free of charge.
    Senator Begich. So, let me ask you this. Again 
philosophically, does the VA oppose this?
    Dr. Jesse. No. No.
    Senator Begich. So, really it is about looking at this 
legislation and seeing how you can implement it?
    Dr. Jesse. The simple answer might be just to tag on to the 
NIH's role.
    Senator Begich. Mr. Chairman, with the time we get, we have 
all these bills; it is hard to get agencies to say, yea, nay, 
or here are the five things we need fixed.
    All I am asking for is--when I was mayor of a city, our 
legislative body asked for something. We would respond by 
saying we do not like it; we do like it; or we have problems 
and here are the six things we need fixed. Can you do that with 
this bill?
    Dr. Jesse. We can.
    Senator Begich. Thank you. That is all I have. My time was 
up. I am sorry I had to rush you. I am respecting the Chairman 
here, and I do not want to get in trouble.
    Chairman Sanders. Senator Boozman.

                STATEMENT OF HON. JOHN BOOZMAN, 
                   U.S. SENATOR FROM ARKANSAS

    Senator Boozman. Thank you, Mr. Chairman, and thank you for 
being with us, Dr. Jesse.
    Dr. Jesse. Yes, sir.
    Senator Boozman. We have gotten behind in the backlog of 
disability claims, and this and that. But I do think that we 
have a really good story to tell in regard to homelessness. You 
all have done a good job with that, which is something we need 
to talk more about.
    In the last 15 years--I have been on the VA Committee in 
the House or the Senate now for a long time and just the 
increase in veterans health care in general has improved 
dramatically. We have still got a long way to go in the sense 
of just fighting the battle but it really is much better.
    We currently have just completed and are going to dedicate 
a expansion in Fayetteville, AK, providing a lot more 
outpatient services. That has become a large VA facility now 
with a tremendous veteran population. It was very much needed, 
and it truly is state-of-the-art.
    I was out visiting our clinics. The advances that we are 
using: telemedicine and things like that; those are good 
things. So, those are things that we can be very proud of.
    I also appreciate your comments about recognizing, in 
regard to homelessness, the value of State, local, faith-based, 
and other NGO's, the partnerships, which have been big factors 
in pushing us forward in that regard.
    I hope that we will do the same thing in regard to suicide 
and some of these other challenges we have and really make a 
concentrated effort.
    I guess what I am interested in is things that work. I 
think in homelessness at some point we kind of threw our hands 
up and said the government has the want-to but they do not have 
the heart to get this done and we allowed others to come in and 
help. I hope that we will do that again with the suicide.
    In a second, I would like you to comment about these 
things. We have been working with Senator Begich on the bill. I 
am an original cosponsor of the one that he mentioned. I guess 
the thing there is, you know, going out to rural States like 
ours you will have communities that do an excellent job helping 
with people that are put in very difficult situations where 
essentially the community provides. Then, you have other places 
where there are no resources at all.
    I am committed to getting this thing done as quickly as we 
can, but until then, you mentioned the fact that you could 
provide resources. Can we do this somewhat administratively in 
the sense that when people are in this situation, does that 
qualify them for homelessness in another way? Do you see what I 
am saying?
    Dr. Jesse. Yes, I see what you are saying. My gut answer is 
I would sure hope so. If there is a technical reason we cannot, 
I am not aware of it but I will try to find that out. I think 
that one of the other brilliant parts of the homeless program 
that is under-recognized is the prevention piece of it.
    Senator Boozman. Right.
    Dr. Jesse. VBA watches the mortgages real carefully. As 
people look like they are defaulting, VBA has interventions. 
They can keep people in their homes. Keeping people employed, 
opening up the GI Bills to get people in school so at least 
they are getting educated if they cannot get a job. All these 
things contribute to the prevention of homelessness which I 
think are part of the bigger story.
    But in terms of that specific, I will have to get a 
technical answer to that. I would sure hope that we do not deny 
somebody there. Again, I think that providing a safe place to 
live for a victim of domestic violence is absolutely key. 
Whether they are called homeless or not is less important than 
making sure that they are safe.
    Senator Boozman. You know, short term until we can reach 
agreement and get this thing sorted out officially, I think 
that would be very helpful in trying to, because that is one of 
the things that we all agree on needs to be done.
    Dr. Jesse. Yes, we do.
    Senator Boozman. The other thing is, you know, in doing 
that these folks are going to be eligible for other things.
    So if you can always head these things off at the pass, 
invariably it costs a lot less money in the future because then 
you do not get into destructive behavior and things like that 
which are so difficult to deal with.
    Dr. Jesse. That is a great statement because that applies 
even to things like the transportation bills which getting 
people to their appointments. While it is difficult to 
quantitate the savings, we know from both the U.S. Health Care 
and other national health care systems that people who do not 
make their appointments that is what costs, because getting to 
those appointments allows you to help patients manage their 
chronic diseases best and is part of our commitment to the use 
of telemedicine and all its derivatives to keep engaged with 
patients rather than relying just on those point-to-point 
visits.
    Senator Boozman. Thank you. I have used all my time. The 
only thing I would say, you do not have time to respond, but I 
would hope that you support the Veterans' Drug Courts. I think 
that is another solution that is a big deal.
    Chairman Sanders. OK, panelists, thank you very much. And, 
Dr. Jesse, remember again the law says we should get that 
report at the end of this month.
    Dr. Jesse. Yes, sir.
    Chairman Sanders. We will be looking at our mailbox.
    Dr. Jesse. OK. Thank you for having us. Thank you for your 
support.
    Chairman Sanders. I would like to welcome our second panel.
    [Pause.]
    Chairman Sanders. Clearly, if this Committee is to do its 
job well, it is important that we hear not just from 
representatives of the VA but from people on the ground who 
will be impacted by legislation that this Committee considers. 
So, we are delighted to have a wonderful panel with us. These 
individuals have devoted years of their lives to the needs of 
American veterans.
    We are going to begin with Rick Weidman, Executive Director 
for Policy and Government Affairs at Vietnam Veterans of 
America.
    We will then hear from Dr. Wayne Jonas, who is the 
president and Chief Executive Officer of the Samueli Institute.
    We will hear from Heather Ansley, Vice President for 
Veterans Policy at VetsFirst; next, Matt Gornick, Policy 
Director for the National Coalition for Homeless Veterans.
    And finally Thomas Bowman, Former Chief of Staff of the 
Department of Veterans Affairs. We thank all of you very much 
for being with us.
    Mr. Weidman, please begin.

 STATEMENT OF RICK WEIDMAN, EXECUTIVE DIRECTOR FOR POLICY AND 
        GOVERNMENT AFFAIRS, VIETNAM VETERANS OF AMERICA

    Mr. Weidman. Mr. Chairman, thank you for inviting Vietnam 
Veterans of America to share some of our views on the issues 
before the Committee today.
    The first issue I want to touch on is the issue of children 
of Vietnam Veterans with spina bifida. With the help of your 
staff and that of Senator Donnelly, we are finally making some 
progress in that regard in terms of taking care of one case, 
Honey Sue Newby, who had come to our attention.
    Our concern, though, is with the other thousand children, 
as nobody knows whether or not they are being taken care of. It 
once again comes back to the same issue that you and your 
colleagues have touched on this morning of accountability for 
things that were clearly defined in the statute some time ago.
    It is that accountability issue that we struggle with with 
the Veterans Administration in all facets of it. In regard to 
the Veterans' Health Equity Act, we think it is important for 
the States that do not have any medical center and access to 
care, whether it be in the State of Vermont or New Hampshire or 
Wyoming or North Dakota, is very important and we thank Senator 
Shaheen for that.
    The Women Veterans and Other Health Care Improvements of 
2013, introduced by Senator Murray, we are for this bill 
strongly. In fact, we recognized one of your staff who worked 
on this bill as Congressional Staffer of The Year for the 112th 
Congress.
    And, it provides many additional steps toward what was 
envisioned by Senator Inouye 30 years ago when we started this 
process of making the VA responsive to the needs of women 
veterans and it is another important milestone.
    We support Senator Begich's broadening the definition of 
homeless veterans and would, for the record, make the point 
that we have always defined, at Vietnam Veterans of America, 
homeless veterans as those without a permanent home.
    VA does not define it that way. They only define it if you 
are on the street. Most people, before they hit the street, 
have stayed on couches or in basements or in attics, friends' 
houses, relatives, et cetera; and it is only when they have 
exhausted all of those other opportunities that they end up on 
the street. We need to catch them before they hit the street 
and that is where VA often falls down.
    I wanted to touch on the Reorganization Act because while 
we applaud the effort, Senator Burr, to get at the 
administrative overhead, we are not necessarily sure that this 
is the way to get at it.
    We were told when they reorganized into VISNs that it would 
reduce administrative overhead and, in fact, it has gone 
exactly the other way. There is more admin overhead at the 
medical centers than there was before; and still, on top of 
that, you have the admin overhead at the VISNs.
    We have never quite figured out what the heck a nurse 
executive is. Is that a person trained as a nurse who does not 
work as a nurse anymore? All of those kinds of euphemisms 
trouble us deeply.
    And their new reorganization plan reminds some of us of a 
certain age of the old Kelvinator washers, and it looks like a 
big wash tub.
    It is so confusing that even though we have tried to 
understand it, we cannot. What they have done is divide 
operations from policy, and anytime you divide that, what you 
do is neuter the policy people--who really know what ought to 
be done--from the operations people; and the operations people 
will always trump the policy people.
    So, we think that far too many people that have been hired 
since 2006 by VHA have not been more clinicians who actually 
directly serve veterans. And, that really is the heart of the 
matter which we would encourage the Committee to look into 
deeply and possibly request a GAO report about how this has 
shaken out; what percentage of those new funds have actually 
gone to care deliverers versus more people in the admin 
overhead.
    Regarding chiropractic, we thank very much Senator 
Blumenthal for stepping forward on that one. This is yet 
another case where Congress has spoken clearly, just like in 
the case of physician assistants, and VA ignores it.
    It was clear 10 years ago that Congress wanted chiropractic 
care to be available to any veteran who needed it within the VA 
and yet VA has dragged its heels.
    So, it is really a question of VA not being responsive and 
not fulfilling the will of the Congress. It is the 
accountability issue that bothers us.
    I see I am out of time but I would just mention that we are 
strongly in favor of the Homeless Veterans' Prevention Act of 
2013, and we have shared in our written statement some specific 
ideas and concepts that we would appreciate your looking at 
before that bill comes to markup.
    Mr. Chairman, distinguished Senators on the Committee, 
thank you very much for hearing our views.
    [The prepared statement of Mr. Weidman follows:]
Prepared Statement of Vietnam Veterans of America, Submitted by Richard 
F. Weidman, Executive Director for Policy and Government Affairs on the 
                             National Staff
    Mr. Chairman, Ranking Member Burr, and other distinguish members of 
the Senate Veterans' Affairs Committee. We appreciate your giving 
Vietnam Veterans of America (VVA) the opportunity to express our 
thoughts on pending legislative proposals vital to veterans and their 
families that are before this Committee today.
    Mr. Chairman and members of the Senate Veterans' Affairs Committee, 
VVA would like to go on the record in support of the Secretary of 
Veterans Affairs, the Honorable Eric K. Shinseki, as well as the 
Undersecretary for Benefits (USB), the Honorable Allison Hickey. We 
know they have faced difficult challenges in their jobs. The easy 
answer to the problems confronting the veterans' community are 
difficult and thorny ones. VVA believes in much greater accountability 
on the part of managers and supervisors within the VA system. However, 
we have been pushing for a plan to ``fix'' the Veterans Benefits 
Administration (VBA) for more than 15 years. We now have a 
modernization plan, so we urge that all lower their voices and let the 
top leaders do their job.
    What VVA does urge is that VBA do a great deal more ``addition by 
subtraction'' of key highly paid staff both at the headquarters and out 
in the Regional Offices who are just doing ``business as usual the way 
they have always done.'' In fact many of these are working almost as 
hard on undermining Undersecretary Hickey as she is in trying to move 
the transformation forward. Those who continue to be part of the 
problem instead of party of the solutions need to be weeded out, and 
afforded a chance to pursue other opportunities outside of the VA.
        care for children of vietnam veterans with spina bifida
    Mr. Chairman, Vietnam Veterans strongly urges you to ensure that 
overall (non-medical) case management services be provided to the 
almost 1,000 now adult children of those veterans who served in Vietnam 
during the war and who now suffer from diabetes. VVA has been working 
particularly with one such young woman, Ms. Honey Sue Newby, and her 
parents for some time.
    With assistance from your staff and that of Senator Donnelly, we 
are finally making some progress. However, VVA is very concerned about 
the other nine hundred plus children as to what quality of medical care 
and services they are receiving (if in fact they are receiving such 
care as needed). This is a problem that is upon us now, and it will 
only intensify as to what happens to these severely disabled progeny of 
veterans when their parents get too old and sick to take care of them 
anymore, or they die before their time as so many Vietnam veterans 
have.
    We ask that you move a legislative fix to address Ms. Newby's 
situation and that of the other most disabled sons and daughters with 
Spina Bifida, as quickly as possible. VVA also urges that you and the 
Committee take additional steps to ensure that there is a detailed 
assessment of each and every disabled person and their family in this 
program as to what care they have received until now, an assessment of 
what they need today, and a means of ensuring that these unfortunate 
victims of their parent's military service are cared for in the future 
in a comprehensive manner. Obviously this assessment should assess both 
quantity and quality of medical services rendered. VVA also urges that 
you include custodial care in addition to the full range of medical, 
remedial, rehabilitative, respite, home based care, and other services 
that VA can should provide today.
    While all of these services were supposed to be provided through 
CHAMP-VA offices located in Denver Colorado, the governing rule book 
was never shared with the parents. It was also not provided to VVA even 
when we submitted a Freedom Of Information Act (FOIA) request for all 
relevant documents. However, We were able to get a copy of this 
handbook from another very competent veterans' advocate, and we are 
submitting it as an Addendum to this statement, with your permission, 
to get it on the record in a public way, so that all of the effective 
families may go to your web site and see what they are supposed to be 
getting for this disabled child.

    S. 49--Veterans Health Equity Act of 2013, introduced by Senator 
Jeanne Shaheen, requires the Secretary of Veterans Affairs, with 
respect to each of the 48 contiguous states, to ensure that veterans 
who are eligible for hospital care and medical services through the 
Department of Veterans Affairs (VA) have access to: (1) at least one 
full-service VA medical center in the state, or (2) hospital care and 
medical services comparable to that provided in full-service VA medical 
centers through contract with other health providers in the state.
    This proposed legislation directs the Secretary to report to 
Congress on compliance with such requirement, including its effect on 
improving the quality and standards of veterans' care.
    Vietnam Veterans of America (VVA) strongly favors this bill. For 
too long veterans who live in low population density states have not 
had proper access to tertiary medical care within a reasonable distance 
from their home. Seven years ago VVA first testified that collectively 
the veterans' community needed to develop a new paradigm or paradigms 
of delivering health care because of the nature of the military today.
    This is the most rural Army that the United States has fielded 
since World War I. Almost 40% come from towns of 25,000 or less, yet 
most of the VA medical centers are all located in or near major 
metropolitan centers. Furthermore, the role of the National Guard and 
the Reserves has changed dramatically. They are no longer regarded as a 
strategic reserve force to be activated only in case of the direst 
national emergency. Rather, they are being used as part of the 
operational force. At this moment more than 52% of those serving on 
active duty in the U.S. Armed Forces are mobilized National Guard and 
Reserve forces. This percentage will only go up as the number of full 
time active duty is drawn down, as is planned in the next few years. 
The National Guard tends to come from rural areas, so as they get 
wounded or hurt they naturally want to return to where their family and 
friends support system is located. Yet that is not where the majority 
of the medical centers are located, whether we are speaking of South 
Dakota, Alaska, New Hampshire, or any other of the less populous 
states.
    VVA thanks Senator Shaheen for introducing S. 49, and urge early 
enactment of this much needed step to ensure proper medical care for 
veterans outside of major metropolitan areas.

    S. 62--Check the Box for Homeless Veterans Act of 2013, introduced 
by Senator Barbara Boxer, amends the Internal Revenue Code to: (1) 
establish in the Treasury the Homeless Veterans Assistance Fund; and 
(2) allow individual taxpayers to designate on their tax returns a 
specified portion (not less than $1) of any overpayment of tax, and to 
make a contribution of an additional amount, to be paid over to such 
Fund to provide services to homeless veterans. This bill when enacted 
into law will establish the Homeless Veterans Assistance Fund which 
would provide additional funding sources for the Departments of 
Veterans Affairs and Labor to enhance their current program to 
assistant homeless veterans. VVA National Homeless Veterans Committee 
fully supports S. 62 and would recommend that additional language in 
the bill provide assistance to homeless veterans and their families.
    VVA thanks Senator Boxer for her efforts in this regard.

    S. 131--Women Veterans and Other Health Care Improvements Act of 
2013, introduced by Senator Patty Murray, includes fertility counseling 
and treatment within authorized Department of Veterans Affairs (VA) 
medical services. Directs the Secretary of Veterans Affairs to furnish 
such counseling and treatment, including the use of assisted 
reproductive technology, to a spouse or surrogate of a severely 
wounded, ill, or injured veteran who has an infertility condition 
incurred or aggravated in the line of duty and who is enrolled in the 
VA health care system, as long as the spouse and veteran apply jointly 
for such counseling and treatment.
    It has been thirty years since Senator Inouye led the effort to 
start the process that is still ongoing of ensuring that the needs of 
the women veterans are properly addressed and met by the Department of 
Veteran Affairs. As always, we are grateful to Senator Murray for her 
continued stalwart and thoughtful leadership as we move toward the goal 
of parity in health care for women who have served their country well 
in military service.
    Furthermore the need to address fertility and procreation problems 
has been apparent for many years, and this proposal in a good and 
comprehensive approach to this problem for both male and female 
veterans. VVA strongly supports this legislation.

    S. 229--Corporal Michael J. Crescenz Act of 2013, introduced by 
Senator Pat Toomey, Designates the Department of Veterans Affairs (VA) 
medical center at 3900 Woodland Avenue in Philadelphia, Pennsylvania, 
as the ``Corporal Michael J. Crescenz Department of Veterans Affairs 
Medical Center.''
    Corporal Michael J. Crescenz of West Virginia served in 4th 
Battalion, 31st Infantry, 196th Infantry Brigade, Americal Division, 
Rifleman Company A Hiep Duc Valley area, Republic of Vietnam, 
20 November 1968. His bravery and extraordinary heroism at the cost of 
his life are in the highest traditions of the military service and 
reflect great credit on himself, his unit, and the U.S. Army and we are 
proud that his legacy will live on and his bravery will not be 
forgotten. The West Virginia State Council of VVA strongly supports 
this legislation. VVA fully supports this bill.

    S. 287--Introduced by Senator Mark Begich; a bill to amend title 
38, United States Code, to expand the definition of homeless veteran 
for purposes of benefits under the laws administered by the Secretary 
of Veterans Affairs, and for other purposes, Includes as a homeless 
veteran, for purposes of eligibility for benefits through the 
Department of Veterans Affairs (VA), a veteran or veteran's family 
fleeing domestic or dating violence, sexual assault, stalking, or other 
dangerous or life-threatening conditions in the current housing 
situation, including where the health and safety of children are 
jeopardized, there is no other residence, and there is a lack of 
resources or support networks to obtain other permanent housing.
    Homelessness is hundreds of thousands of individual disasters 
occurring side by side, unfortunately, the need to flee domestic 
violence is one of those terrible conditions that lead to such 
homelessness. VVA commends Senator Begich for leading on this issue. 
VVA supports the bill as written.

    S. 325--Introduced by Senator Jon Tester; a bill to amend title 38, 
United States Code, to increase the maximum age for children eligible 
for medical care under the CHAMPVA program, and for other purposes. 
Makes a child eligible for medical care under the Civilian Health and 
Medical Program of the Department of Veterans Affairs (CHAMPVA) 
eligible for such care until the child's 26th birthday, regardless of 
the child's marital status. Makes such provision inapplicable before 
January 1, 2014, to a child who is eligible to enroll in an employer-
sponsored health care plan.
    This proposed legislation corrects an ``unintended consequence'' of 
the children of disabled veterans not being included under the 
provisions of the Affordable Care Act when the requirement for 
insurance companies to allow children to be carried on their parents' 
medical insurance policy until the age of 26.
    VVA strongly supports this legislation.

    S. 412--Keep Our Commitment to Veterans Act, introduced by Senator 
Mary Landrieu, authorizes the Secretary of Veterans Affairs (VA) to 
carry out specified major medical facility leases in FY 2013-FY 2014 in 
New Mexico, New Jersey, South Carolina, Georgia, Hawaii, Louisiana, 
Florida, Puerto Rico, Texas, Connecticut, and Massachusetts. Reduces 
lease amounts authorized in previous fiscal years for VA outpatient 
clinics in: (1) Johnson County, Kansas; (2) San Diego, California; and 
(3) Tyler, Texas.
    VVA supports this authorization to move forward with needed leases 
in the above noted locations.

    S. 422--Chiropractic Care Available to All Veterans Act of 2013, 
introduced by Senator Richard Blumenthal, amends the Department of 
Veterans Affairs Health Care Programs Enhancement Act of 2001 to 
require a program under which the Secretary of Veterans Affairs 
provides chiropractic care and services to veterans through Department 
of Veterans Affairs (VA) medical centers and clinics to be carried out 
at: (1) no fewer than 75 medical centers by December 31, 2014, and (2) 
all medical centers by December 31, 2016. Includes chiropractic 
examinations and services within required VA medical, rehabilitative, 
and preventive health care services.
    VVA supports this bill, and thanks Senator Blumenthal for his 
leadership on this issue. This is yet another case where the Veterans 
Health Administration (VHA) has arrogantly ignored the will of the 
Congress for some years, possibly because of a petty professional 
``guild'' mentality. It is shameful that Congress has to enact yet 
another law to try and force the VHA to do the right thing. It is 
similar to the situation where VHA continues to discriminate against 
Physician Assistants, no matter how often or how forcefully the 
Congress revisits that issue or the one at hand regarding chiropractic 
PR actioners.

    S. 455--Introduced by Senator Jon Tester; A bill to amend title 38, 
United States Code, to authorize the Secretary of Veterans Affairs to 
transport individuals to and from facilities of the Department of 
Veterans Affairs in connection with rehabilitation, counseling, 
examination, treatment, and care, and for other purposes. Authorizes 
the Secretary of Veterans Affairs to transport individuals to and from 
facilities of the Department of Veterans Affairs (VA) in connection 
with vocational rehabilitation, counseling, examination, treatment, or 
care.
    As noted elsewhere, Vietnam Veterans of America thanks Senator 
Tester for his continued leadership to ensure that veterans in rural 
and remote locales receive the support needed to ensure they are 
afforded the same level of quantity and quality of medical care and 
rehabilitative services as other veterans who are the city dwellers.

    S. 522--Wounded Warrior Workforce Enhancement Act, introduced by 
Senator Richard Durbin. VVA fully supports this bill, and thanks 
Senator Durbin for bringing it forth in the Senate. The need for more 
training opportunities for those who would learn and practice orthotics 
is readily apparent for all who have looked at this situation. Our war 
fighters are surviving grievous wounds and multiple amputations that 
would have killed them on the battlefield even as recently as the Gulf 
War in 1991. This only increases the need for more and better trained/
educated orthotics specialists. This legislation, if enacted, will 
assist in that advancement of care.

    S. 529--Introduced by Senator Richard Burr; a bill to amend title 
38, United States Code, to modify the commencement date of the period 
of service at Camp Lejeune, North Carolina, for eligibility for 
hospital care and medical services in connection with exposure to 
contaminated water, and for other purposes. Changes the commencement 
for the period of military service at Camp Lejeune, North Carolina, for 
purposes of eligibility for hospital care and medical services for 
specified illnesses or conditions related to exposure to contaminated 
water at such installation, from January 1, 1957, to either August 1, 
1953, or an earlier date that the Secretary of Veterans Affairs (VA), 
in consultation with the Agency for Toxic Substances and Disease 
Registry, shall specify. Requires the Secretary to publish in the 
Federal Register any earlier date chosen.
    VVA supports the bills as written, and thanks Senator Burr for 
continuing to champion the cause of the servicemembers and their 
families who are still suffering adverse consequences as a result of 
exposure to harmful toxic pollutants many decades ago at Camp Lejeune. 
We do urge that there be continued strong oversight to ensure that the 
intent of the law is being fulfilled, and if necessary that there be 
additional enforcement measures taken to ensure that justice is done 
for these veterans and their families.

    S. 543--Reorganization Act of 2013, introduced by Senator Richard 
Burr, directs the Secretary of Veterans Affairs to organize the 
Veterans Health Administration (VHA) into 12 geographically defined 
Veterans Integrated Service Networks (VISNs).
    VVA supports the motivation behind this well-meaning proposal, in 
that it seeks to greatly reduce the resources devoted to administrative 
overhead, thus freeing additional resources to be invested in more 
clinicians who actually provide hands on care to veterans. The enormous 
increase in the appropriation for the Veterans Health Administration 
(VHA) since 2006 was motivated by the desire of those on both sides of 
the aisle to ensure that there were adequate resources available to 
deliver quality medical care in a timely way to those who had served 
our country well in military service.
    In response to pressure from Capitol Hill the VHA has now decreased 
the number of persons on the staff of the various VISNs to 55 each, 
with any additional staff beyond this standard supposedly subject to a 
rigorous justification process. Many feel that this number is still way 
too high. Particularly in light of the fact that we have not seen the 
great diminishment of administrative overhead at the individual VA 
medical centers that were promised almost twenty years ago.
    What is of even greater concern to VVA is the dividing of all 
policy people into one ``stove-pipe'' and all of the ``operations'' 
managers into another ``stove-pipe.'' Not only does this result in many 
more people who are performing tasks other than direct provision of 
medical services to veterans, to separate policy from actual operations 
is a dangerous effort which in many cases will result in operational 
expediency prevailing over the best medical policy that is supposed to 
be derived from evidence based medicine. Eliminating this dual chain of 
command would free up many more resources than reducing the number of 
VISN from 21 to 12. While we commend Senator Burr for attempting to 
ensure that more resources actually go to having more actual care 
deliverers, we are not sure that this is the best way to accomplish 
that laudable goal.

    S. 633--Introduced by Senator Jon Tester; a bill to amend title 38, 
United States Code, to provide for coverage under the beneficiary 
travel program of the Department of Veterans Affairs of certain 
disabled veterans for travel in connection with certain special 
disabilities rehabilitation, and for other purposes.
    VVA supports this bill, and thanks Senator Tester for continuing to 
be the champion of improved means for veterans in rural and remote 
locations to have adequate access to vitally needed medical and 
rehabilitation care.

    S. 851--To amend title 38, United States Code, to extend to all 
veterans with a serious service-connected injury eligibility to 
participate in the family caregiver services program.
    Many Vietnam veterans are alive today because their wives, or 
sisters, or other relative have been taking care of them for decades. 
Heretofore there was never any recognition of the fact that these 
veterans would either have had to enter into long term care or would 
have been on the street if not for the extraordinary efforts of these 
family caregivers. Either way the additional cost to American society 
would have been extremely large, whether in fiscal cost or the societal 
cost of having many additional veterans among the homeless.
    The Veterans Service Organizations (VSO) were basically asked by 
The White House to support the bill as it was originally set to apply 
only to the post-9/11 generation of veterans and their families. We did 
this, but asked that the clause be inserted to require a report to the 
Congress by May 2013 as a prelude to having this apply to veterans and 
their families of every generation, based on need for such a program 
regardless of when the veteran served.
    Several years ago VVA did support legislation to assist family 
caregivers of catastrophically wounded or injured warriors after 9/11. 
Just as we saved badly desperately, horribly--wounded troops during our 
war, troops who would have died during World War II or Korea, thanks to 
the bravery and the tenacity of our medevac crews and military medical 
personnel at evacuation hospitals, this new generation of medevac crews 
and medical personnel have been saving catastrophically wounded 
warriors who would surely have died in Vietnam. Heart-rending testimony 
before congressional committees by some of these surviving veterans, 
and by their wives and mothers, moved Congress to enact into law the 
Caregivers and Veterans Omnibus Health Services Act of 2010 Public Law 
111-163 to assist family caregivers of catastrophically wounded or 
injured warriors after 9/11.
    As noted above, there was a caveat in Public Law 111-163 that 
requires the Secretary of Veterans Affairs to report to Congress by 
May 2013 on how the caregiver program has been working, and what, in 
his judgment, might be the efficacy of extending the program to embrace 
family caregivers of veterans of Vietnam and Somalia and the first 
fight with Saddam Hussein in the Persian Gulf.
    VVA strongly supports S. 851.

    S. 825--Homeless Veterans Prevention Act of 2013; VVA supports the 
bill as written, however, would like for the Senate Committee on 
Veterans to also consider adding the following homeless language to the 
bill:

        Legislation establishing Supportive Services Assistance Grants 
        for VA Homeless Grant & Per Diem Service Center Grant awardees

    Under the VA HGPD program non-profits receive per diem at rates 
based on an hourly calculation ($5.24 per hour) for the actual time 
that the homeless Veteran is actually on site in the center. This 
amount does not come close to paying for the professional staff that 
must provide the assistance and comprehensive services that continue on 
the Veteran's behalf, long after they leave the facility. As one can 
well imagine the needs of these Veterans are great and demands an 
enormous amount of time, energy, and manpower in order to be effective 
and successful. We believe it is possible to create ``Service Center 
Staffing/Operational'' grants, much like the VA ``Special Needs'' 
grants.
    One of the most effective front line outreach operations funded by 
VA HGPD is the Day Service Center, sometimes referred to as a Drop-In-
Center. These service centers are unique and indispensable as a 
resource for VA contact with homeless Veterans. They reach deep into 
the homeless Veteran population that are still on the streets and in 
the shelters of our cities and towns. They are the portal from the 
streets and shelters to substance abuse treatment, job placement, job 
training, VA benefits, VA medical and mental health care and treatment, 
homeless domiciliary placement, and transitional housing. They are the 
first step to independent living. For many it is the first step out of 
homelessness. In light of the Special Needs grants, passing the 
legislation to establish this funding stream would not be setting a 
precedent. ``Special Needs'' grants have been doing it for years. And 
VVA believes that these service centers can't wait too much longer. 
Agencies have been advocating for years for the VA to recognize a more 
appropriate funding distribution process of HGPD resources for their 
true operational activities. These agencies have been holding on to 
survival by their fingertips for a very long time. Without serious and 
speedy activation of staffing grants the result may well be the demise 
of these critically needed services centers. We cannot lose these 
valuable front line, ``on the streets,'' service center outreach 
programs. They are the heartthrob of VA homeless Veteran programs; the 
first hand up offered too many of the homeless Veterans who are on the 
streets and in the shelter system of our cities.
    VVA feels the cost of implementing these grants would be offset by 
the benefit given to those Homeless Veterans still on the streets and 
provide a vehicle by which the VA five year plan to end Veteran 
Homelessness would be more achievable.
   department of labor homeless veterans reintegration program (hvrp)
    Once a Veteran has signed a lease he or she is no longer homeless 
and cannot enter any HVRP program. Providers have been told that all 
they need to do is enroll the Veteran into the HVRP program before they 
sign the lease and then put them in the HVRP training program after 
they are housed.
    The Department of Labor (DOL) Homeless Veterans Reintegration 
Program directly trains homeless Veterans in an effort to provide 
skills and abilities leading to employment in order to maintain an 
independent life-style. Recently housed Veterans should not be excluded 
from this viable program (HVRP) because of an emphasis on the ``housing 
first'' model. They are being penalized for following the direction of 
their case managers, with housing placement being expedited at an 
exceptionally fast pace. The defined HVRP eligibility criteria are at 
the crux of the matter. The rub comes with the DOL requirement that the 
assessed and enrolled Veteran must enter the training program within 
the quarter they are enrolled. A ``fix'' to this situation may only 
require DOL regulation but in all likelihood it may require legislative 
action. Our position is that we believe it would best be accomplished 
by a direct redefinition of the eligibility requirement and permit 
recently housed Veterans to enroll into the HVRP training programs for 
up to one year after housing placement. If we are to eliminate 
homelessness among Veterans then we also are essentially being charged 
to make sure that once housed they can remain in independent housing. 
Ultimately, we further believe that if documentation can be provided 
that proves that the Veteran is in imminent danger of becoming homeless 
they should also be considered for eligibility in HVRP training 
programs.
    Legislation to amend the eligibility criteria for veterans in 
enrolled in the Department of Labor Homeless Veterans Reintegration 
Program (HVRP) so those veterans entering into ``housing first'' would 
be able to access this training for a period of up to 12 months after 
placement into housing.
special needs funding under the department of veterans affairs homeless 
    grants & per diem program is due to expire on september 30, 2013
    In accordance with Title 38 of the US Code, Part II, Chapter 20, 
Benefits for Homeless Veterans, Subchapter VII, Other Provisions, Sec. 
2061, Grant Programs for Homeless Veterans with Special Needs, the 
statute reads that the Secretary shall carry out a program to make 
grants to health care facilities of the Department and to Grant and Per 
Diem Providers in order to encourage development by those facilities 
and providers of programs for homeless veterans with special needs. 
These special needs veterans include women and women who have care of 
minor dependents; frail, elderly; terminally ill; and chronically 
mentally ill.
    Many of the veterans falling out under special needs categories 
require services above and beyond what the original grant was for. 
Services such as Military Sexual Trauma counseling end of life and 
bereavement counseling, or learning how to function with a severe 
mental health condition. These services, many times, require 
individuals with special training and certifications to act as 
counselors. Many non-profit agencies do not have the funding 
capabilities to sustain licensed practitioners on staff. Special Needs 
grants provide additional funding to allow for those individuals to be 
hired and to provide for additional services necessary for the veterans 
to achieve the greatest level of self-sufficiency.
    Vietnam Veterans of America will continue to aggressively advocate 
for legislation forward that would extend the Homeless Veterans with 
Special Needs due to expire on September 30, 2013.

    I am happy to answer any questions, Mr. Chairman, and again thank 
you and your distinguished colleagues for the opportunity to offer our 
views here today.

    Chairman Sanders. Thank you very much, Mr. Weidman.
    Dr. Jonas.

    STATEMENT OF WAYNE B. JONAS, M.D., PRESIDENT AND CHIEF 
              EXECUTIVE OFFICER, SAMUELI INSTITUTE

    Dr. Jonas. Thank you very much, Mr. Chairman, Senator 
Sanders, Members of the Committee. It dawned on me as I was 
coming here actually last night that I am not only a veteran 
that I am a fourth-generation veteran.
    I had forgotten that my great-grandfather actually was in 
the Philippines in the military and rode in the Rough Riders. 
My grandfather was with Patton going across Germany, and my 
father was a 30-year chaplain in three wars in the Army.
    So, when I became a family physician after medical school, 
there was no question I was going to be an Army doctor. I had 
the great opportunity during those 24 years to also run the 
Office of Alternative Medicine at the NIH, run a WHO 
traditional medicine office that looked at traditional 
practices from around the world; sit on the White House 
Commission for Complementary and Alternative Medicine; and run 
a research program at Walter Reed Army Institute of Research.
    I now run an institute called the Samueli Institute which 
is a non-profit 501(c)(3) research institute that examines the 
inherent healing capacity of individuals with a scientific lens 
in order to determine how they can be implemented into whole 
systems, into large systems in these areas. We do a lot of work 
with active duty, DOD, and with veterans.
    I fully support the integration of evidence-based, whole 
person health promotion, and complementary medicine practices 
into veterans' care.
    After 10 years of wars, we have tremendous suffering of 
which only the tip of the iceberg is seen when people walk into 
the clinic in the veterans' area.
    Right now when someone walks into a clinic anywhere, 
whether it is veteran or non-veteran clinic, military clinic, 
because of the structure of medicine, you get divided up.
    If you have psychological issues, PTSD, you go see the 
behavioral medicine person. If we were told you got hit in the 
head or you claimed you were exposed to trauma, you go see the 
neurologist. If you lost a leg or had surgery, you go see the 
orthopod.
    Yet, people do not experience this suffering that way. 
People experience this suffering as whole persons, from the 
physical pain to the psychological injuries to the cognitive 
difficulties to the energetic problems to the spiritual and 
moral injuries that have occurred in war. That spreads into the 
social and family areas then they experience the suffering 
also.
    We need a whole system, whole person approach to dealing 
with these things the way people experience them, not a 
divided, disintegrated system. Thus, we need practices that can 
help them reset, reheal, tap into their inherent healing 
processes and, more importantly, teach them the skills that 
they need in order to build resilience for the long run.
    Many of the folks from the current wars are young and they 
may have a lifetime of suffering. We do not want that to be a 
lifetime of dependency. We want it to be a lifetime of optimal 
healing and functioning.
    These practices have the potential, if they are properly 
evaluated and integrated, not simply to treat a disease but, in 
fact, to provide that resetting.
    One of our grant recipients just published the first 
randomized controlled trial published in the journal Spine of 
low back pain with chiropractic, demonstrating that 
chiropractic, when added on to standard medical care, 
significantly decreased pain and increased functionality in 
active duty populations who had carried big loads for many 
years.
    We have just completed a study at Walter Reed in 
partnership with Walter Reed looking at the use of acupuncture 
for Post Traumatic Stress Syndrome.
    One month of eight treatments of acupuncture reduced Post 
Traumatic Stress Syndrome by 56 percent and improved all the 
other symptoms of the trauma spectrum including pain, improved 
sleep, reduced medication, and even to my surprise, improved 
cognitive function.
    On a study published about 4 or 5 months ago that we did in 
conjunction with Scripts and Camp Pendleton Marines in Post 
Traumatic Stress Syndrome took a very simple relaxation, self-
care practice taught by nurses to include relaxation skills 
training program an individual's Post Traumatic Stress 
Syndrome, added on to usual behavioral care significantly 
reduced PTSD.
    Then that was followed up, as was the acupuncture study. 
After those were finished, 3 months later they continued to 
maintain improvement. In other words, it was not a one-off 
treatment. It was actually a reset, a rehealing through those 
practices.
    Those types of self-care practices can be taught to 
families and become a normal part of recovery, not requiring 
the system. These practices should be a main part of the 
integration into the system but they have to be done and 
evaluated in a careful way in order to determine how the 
benefits can be properly induced.
    What are the economic drivers? There are no economic 
drivers for these self-care practices. They are not a device. 
They are not a new drug. They do not have a new company behind 
them throwing millions of dollars trying to get them into the 
system.
    Thus, they incrementally and slowly creep into the system 
only to the extent that veterans pay attention to them. That 
requires a coordinated and concerted effort in those areas. I 
think that kind of a coordinated, concerted effort can be done. 
There are several blue prints to do that.
    I want to highlight this book that was just completed by 
the Institute of Medicine on chronic multi-symptom illness with 
veterans. They actually show a blueprint for bringing healing-
oriented processes and systems into the Veterans' 
Administration, and I would urge the Veterans' Administration 
to pay close attention to that.
    Thank you very much for your time and attention.
    [The prepared statement of Dr. Jonas follows:]
    Prepared Statement of Wayne B. Jonas, M.D., President and CEO, 
                           Samueli Institute
    Thank you, Senator Sanders and Members of the Committee for the 
invitation to testify on the pending health care legislation, and in 
particular to voice my support for your efforts to promote greater 
integration of complementary and alternative approaches into the 
provision of veterans' health. My name is Wayne Jonas. I am a veteran 
and retired Army family physician. I see patients weekly at a military 
medical center, and am President and CEO of the Samueli Institute of 
Alexandria, Virginia, and Corona Del Mar, California. I have formerly 
served as Director of the Office of Alternative Medicine at the 
National Institutes of Health, a Director of the World Health 
Organization Collaborating Center of Traditional Medicine, the Medical 
Research Fellowship and Walter Reed and a member of the White House 
Commission on Complementary and Alternative Medicine Policy.
    Samueli Institute, a 501(c)(3) non-profit scientific research 
organization, investigates healing processes and their application in 
promoting health, wellness and human flourishing, preventing illness, 
and treating disease. The Institute is one of few organizations in the 
Nation with a track record in complementary and integrative medicine, 
healing relationships, and military and veteran medical research. The 
Institute has extensively investigated the health conditions routinely 
presented by our servicemembers, veterans and their families.
    I state my strong support for greater integration of complementary 
and alternative approaches into veterans' health care based on the 
clinical and outcomes evidence for their effectiveness for a wide array 
of conditions presented every day by our veterans. These approaches are 
also low cost and have few negative side effects.
    In more than ten years of armed conflicts, a large number of the 
Nation's veterans are exhibiting what I term the trauma spectrum 
response--an array of symptoms, including pain, anxiety, depression, 
sleeplessness, excessive drug use and social isolation resulting from 
multiple deployments or a battlefield insult, like an explosion or 
other trauma. These symptoms often progress to chronic conditions, like 
Post Traumatic Stress Disorder and chronic pain; and most of these 
people and families are young, with a long battle for recovery in front 
of them. More and more, our Nation is faced with the weighty imperative 
not only to attempt cure of our veterans' combat wounds, but to help 
them to heal for the rest of their lives. The pilot programs described 
in the draft Veterans' Health Promotion Act will help veterans to heal, 
because it will provide patient-centered approaches that restore them 
to personal and social wholeness.
    Recent research by Samueli Institute, and other leading national 
and international researchers, has shown the effectiveness of drugless, 
self-care and integrative practices for treatment of these prevalent 
conditions and for healing. Our research on acupuncture, mind-body, 
nutrition and self-care approaches has demonstrated that these 
practices can help heal and reset veterans to optimal well-being and 
function. For example, recent studies on acupuncture and relaxation 
approaches have demonstrated marked improvements (as large or larger 
than the best drug or behavioral treatments) in PTSD with additional 
benefits on pain, cognitive function, energy, sleep and anger. The 
Institute's research has shown the growing use of complementary and 
alternative medicine (CAM) practices by veterans, and favorable 
outcomes for individuals who receive CAM in addition to standard care. 
VA practitioners are attempting to secure these practices for their 
patients, but encounter institutional barriers, limited availability 
and the tyranny of the status quo.
    To appropriately address the policy and operational issues related 
to the transition of complementary and alternative medicine approaches 
into the VA's health care operations and infrastructure, I recommend a 
centralized, coordinated, rapid translational program to inform the 
VA's decisions on benefits, manpower, infrastructure and management. 
The provisions of the draft Veterans' Health Promotion Act and, in 
particular, its support for a Center of Innovation for complementary 
and alternative medicine, a pilot program on the establishment of 
complementary and alternative medicine within VA medical centers, and 
the study of barriers encountered by veterans to receive complementary 
and alternative care, are laudable and considerable first steps in the 
right direction. Without this program we will not know how to make 
these practices more widely available to our veterans who need and 
deserve them.
    While that legislation uses the term ``complementary and 
alternative medicine (or CAM)'' freely, I feel the use of the term 
``integrative health care'' is more appropriate as it more clearly 
describes the process of integrating CAM practices into the 
conventional care provided widely across the Nation and by the VA. The 
ultimate goal is to improve health and health care for veterans through 
the seamless integration of the best of conventional medicine and CAM. 
The pilot program will benefit from the work of early champions in the 
VA system who have introduced such things as acupuncture, guided 
imagery, meditation, mindfulness and other CAM practices through 
research and innovative programs. The proposed pilot program will 
create the necessary infrastructure and process for wide adoption of 
these practices, such that they become mainstream options for treating 
symptoms and promoting well-being, in combination with the best of 
conventional care.
    Such a centralized, coordinated and rapid translational program 
would provide a cornerstone for the VA's top priority of providing P4 
(personalized, predictive, preventive and participatory) medicine for 
all vets.

    I appreciate the opportunity to appear before this Committee and I 
look forward to any questions. Thank you.

    Chairman Sanders. Thank you very much, Dr. Jonas.
    Ms. Ansley.

  STATEMENT OF HEATHER ANSLEY, ESQ., MSW, VICE PRESIDENT FOR 
                  VETERANS' POLICY, VETSFIRST

    Ms. Ansley. Chairman Sanders, Ranking Member Burr and 
distinguished Members of the Committee, thank you for inviting 
VetsFirst to share our views and recommendations regarding the 
legislation that is before the Committee this morning.
    My oral testimony will focus on S. 131, S. 324, S. 455, 
S. 633, and S. 851.
    First, we support the Women Veterans and Other Health Care 
Improvements Act of 2013. After more than a decade of war, many 
severely disabled veterans who have experienced trauma-related 
improvised explosive devices and other conditions of warfare 
may experience infertility.
    For many of these same veterans having the ability to start 
or grow their families represents an important part of moving 
forward with their lives.
    S. 131 takes important holistic steps toward addressing 
infertility. VetsFirst supports the addition of fertility 
counseling and treatment including treatment using assisted 
reproductive technology to the definition of medical services.
    We are also pleased that this legislation not only expands 
the definition of medical services to include these treatments 
but also provides them to veterans' spouses or surrogates. 
Importantly, this legislation also provides the opportunity for 
veterans to grow their families through adoption.
    VetsFirst also supports the efforts of S. 131 to improve 
access to VA services for women veterans. To ensure that women 
veterans have full access to medical services, VA must continue 
to improve efforts to address the unique needs and concerns of 
women veterans.
    Increasing the avenues for women to receive information 
through portals such as VA's new women veterans hotline, which 
is a requirement of S. 131, is an important step forward.
    We also support increasing access to mental health and 
readjustment counseling by providing opportunities for child 
care for all veterans.
    Second, VetsFirst supports S. 325, which would increase the 
maximum age for children eligible for medical care under the 
CHAMPVA program. Children who are CHAMPVA beneficiaries 
typically lose their coverage at age 18 unless they are full 
time students in which case they can maintain their benefits to 
age 23.
    The Affordable Care Act or the ACA allows children to 
remain on a parent's health insurance until age 26. However, 
TRICARE and CHAMPVA beneficiaries were not covered by this 
provision. TRICARE has since been brought into alignment with 
the ACA but CHAMPVA has not. S. 325 would correct this 
injustice by allowing those beneficiaries to receive health 
care benefits until age 26.
    Third, we support S. 455 which would provide VA with the 
authority to provide transportation for veterans who need 
assistance to and from VA facilities. Lack of transportation 
options remains a barrier for some veterans who need to travel 
to VA facilities for health care services. For many veterans 
riding with family members and friends, using public 
transportation, or driving themselves allows them to travel to 
a VA facility when needed.
    For veterans who do not have a network of friends and 
family, they are not able to drive. They do not live near 
public transportation. They have to seek other options.
    In January 2013, the President signed the Dignified Burial 
and Other Veterans' Benefits Improvement Act of 2012, which 
authorized VA to transport individuals to and from VA 
facilities for these purposes. This authority will expire in 
2014. We support S. 455, which would extend it to ensure most 
importantly that no veteran is left without the ability to 
access critical VA services.
    Fourth, VetsFirst supports S. 633, which provides 
beneficiary travel benefits for all veterans who have spinal 
cord injuries, vision impairments, and multiple amputations, 
and need to travel to receive inpatient rehabilitation 
services.
    For those veterans who need these services but are not 
eligible for travel benefits, the ability to pay for travel, 
which may include traveling a great distance, can be very 
burdensome, so every effort must be made to reduce the barriers 
that limit access to these services, primarily because without 
those, that assistance, a veteran can lose their independence 
and may end up in a higher cost care somewhere.
    Last, VetsFirst supports the Caregiver Expansion and 
Promotion Act of 2013. Many families of disabled veterans play 
a crucial role in providing needed services and supports that 
allow veterans to return to and remain in their homes.
    Spouses and family members, however, often must leave the 
work force to assist their husbands, wives, adult children in 
their efforts to rehabilitate and reintegrate into their 
communities. That sacrifice may include lost income and other 
benefits, including health insurance. S. 851 would extend 
enhanced caregiver benefits originally provided to family 
caregivers of post-9/11 veterans with serious injuries to 
caregivers of veterans of all eras who have serious service-
connected disabilities.
    Many of these caregivers have sacrificed for decades in 
order to be able to provide assistance to their veterans and 
gladly have done so.
    But we would hope that this would be an opportunity to 
recognize their significant contributions that they have made 
for, in several cases, many years to keep those veterans 
independent, working, and living in their communities.
    Again, thank you for the opportunity to share VetsFirst's 
views of the legislation today. This concludes my testimony.
    [The prepared statement of Ms. Ansley follows:]
      Prepared Statement of VetsFirst, a Program of United Spinal 
Association, Submitted by Heather L. Ansley, Esq., MSW, Vice President 
                           of Veterans Policy
    Chairman Sanders, Ranking Member Burr, and other distinguished 
Members of the Committee, thank you for the opportunity to testify 
regarding VetsFirst's views on the bills under consideration today.
    VetsFirst, a program of United Spinal Association, represents the 
culmination of over 60 years of service to veterans and their families. 
We provide representation for veterans, their dependents and survivors 
in their pursuit of Department of Veterans Affairs (VA) benefits and 
health care before VA and in the Federal courts. Today, we are not only 
a VA-recognized national veterans service organization, but also a 
leader in advocacy for all people with disabilities.
 women veterans and other health care improvements act of 2013 (s. 131)
    After more than a decade of war, many severely disabled veterans 
who have experienced trauma related to improvised explosive devices and 
other conditions of warfare may experience infertility. For many 
veterans, the ability to start or grow their families represents an 
important part of moving forward with their lives. Unfortunately, the 
current services available from VA in many cases do not reflect the 
needs of these veterans and their families.
    Presently, VA provides male veterans who have spinal cord injuries 
with fertility services for retrieving, storing, and preparing sperm 
for use for assisted reproductive technology. These services are 
available to male veterans who are service-connected and also for those 
who have access to VA health care but whose disabilities are not 
related to their military service. Although VA provides these services 
for male veterans who have spinal cord injuries, there is no provision 
to provide the assisted reproductive technologies needed for 
fertilization.
    The Women Veterans and Other Health Care Improvements Act takes 
important steps toward assisting veterans, their spouses, and 
surrogates in holistically addressing infertility. VetsFirst supports 
the addition of fertility counseling and treatment, including treatment 
using assisted reproductive technology to the definition of medical 
services. We are also pleased that this legislation not only expands 
the definition of medical services to include these treatments, but 
also provides them to veterans' spouses or surrogates. We are 
disappointed, however, that these services are not required for 
veterans who are not service-connected.
    This legislation also provides the opportunity for veterans who are 
severely wounded, ill, or injured to grow their families through 
adoption. VA's assistance would be available for the adoption of up to 
three children or one cycle of in vitro fertilization, whichever is of 
lesser cost. VetsFirst believes that providing the option for disabled 
veterans to adopt is a critical recognition of the many paths to 
parenthood.
    This legislation also requires VA to facilitate collaborative 
research with the Department of Defense and the National Institutes of 
Health which will help VA to address the long-term reproductive health 
needs of veterans. This research will be critical in addressing the 
unique infertility issues of veterans with combat-related injuries. We 
are also pleased that the legislation requires that the research be 
disseminated within the Veterans Health Administration to guide 
treatment practices.
    VetsFirst also supports efforts in this legislation to improve 
access to VA services for women veterans. Women make up an increasing 
percentage of the veteran population. By 2040, VA projects that women 
will make up nearly 18 percent of the veteran population. As of 2012, 
360,000 women veterans were using VA health care. VA must continue to 
improve efforts to address the unique needs and concerns of women 
veterans.
    As part of these efforts, VA recently launched the Women Veterans 
hotline. The purpose of the hotline is to provide a single portal for 
women veterans to receive information about VA benefits and services. 
The call center staff will work collaboratively with other VA hotlines, 
including VA's crisis line. The Women Veterans and Other Health Care 
Improvements Act would complement and build upon these efforts by 
ensuring that the Women Veterans hotline is able to connect women 
veterans with needed services not provided by VA.
    One of the services that many veterans, women and men, need to be 
able to fully access VA health care and readjustment counseling is 
affordable, convenient childcare. This legislation also provides 
veterans who are the primary caretaker of their children the 
opportunity to receive childcare assistance from VA when receiving 
mental health care services, readjustment counseling, or other 
intensive health services. This assistance may include stipends for 
licensed childcare services and VA provision of childcare services.
    VetsFirst supports the Women Veterans and Other Health Care 
Improvements Act. This comprehensive legislation is needed to ensure 
that veterans are able to begin or expand their families and receive 
the health care assistance they need following their military service.
     to increase the maximum age for children eligible for medical 
                   under the champva program (s. 325)
    The Civilian Health and Medical Program of the Department of 
Veterans Affairs (CHAMPVA) is a robust health care program for the 
spouses and dependent children of veterans who are permanently and 
totally disabled, died while on active duty, or died due to a service-
connected disability. For the families of these veterans, CHAMPVA 
provides critical physical and mental health care benefits. Children 
who are CHAMPVA beneficiaries typically lose coverage at age 18 unless 
they are full-time students, in which case they maintain benefits until 
age 23.
    The Affordable Care Act (ACA) allows children to remain on a 
parent's health insurance until age 26. However, TRICARE and CHAMPVA 
child beneficiaries were not covered by this provision. The National 
Defense Authorization Act (NDAA) for FY 2011 brought TRICARE into 
alignment with the ACA provision by extending coverage to age 26 for 
TRICARE beneficiaries. CHAMPVA child beneficiaries, however, were not 
included in the NDAA.
    Consequently, CHAMPVA child beneficiaries are prohibited from 
receiving benefits provided to other adult children in our Nation. 
S. 325 will correct this injustice by allowing child beneficiaries to 
continue to receive health care benefits under the CHAMPVA program 
until age 26. This legislation will ensure parity for the children of 
permanently and totally disabled veterans and those who died in service 
to our Nation.
    VetsFirst supports S. 325 because it will ensure that the children 
of men and women who have sacrificed greatly for our Nation are able to 
finish educational opportunities and begin careers without having to 
forgo access to critical health care benefits. We urge swift passage of 
this critical legislation.
 to authorize va to transport individuals to and from va facilities in 
connection with rehabilitation, counseling, examination, treatment, and 
                             care (s. 455)
    Lack of transportation options can present significant barriers to 
disabled veterans in their efforts to actively participate in their 
communities. VetsFirst has been an active supporter of efforts to make 
public transportation, taxis, and other modes of transportation more 
accessible to wheelchair users and other people with disabilities. We 
also support and promote travel training to help people who have 
acquired disabilities learn how to navigate their community's 
transportation options.
    Despite these efforts, transportation remains a barrier for some 
veterans who need to travel to VA medical services for health care. For 
many veterans, riding with family members and friends, using public 
transportation, or driving themselves allows them to travel to VA 
facilities when needed. For veterans who do not have a network of 
family and friends who can drive them to appointments, or who live in 
areas without public transportation or widespread assistance from 
volunteer organizations, they must seek other options.
    To address unmet needs, VA launched the Veterans Transportation 
Service (VTS) initiative in 2010. The VTS initiative provides funding 
for mobility managers, transportation coordinators, and vehicles at 
local VA facilities. Although volunteer drivers are an integral part of 
transporting many disabled veterans to and from VA facilities, the need 
for drivers is greater than the number of volunteers. In addition, some 
veterans who need transportation have significant medical needs or are 
unable to ambulate, and volunteer drivers may be hesitant to transport 
these veterans.
    In January 2013, the President signed the Dignified Burial and 
Other Veterans' Benefits Improvement Act of 2012 (Public Law 112-260). 
Section 202 of this legislation authorized VA to transport individuals 
to and from VA facilities for vocational rehabilitation, counseling, 
and for the purpose of examination, treatment, or care. This authority 
will expire in 2014.
    S. 455 will extend VA's authority to ensure that no veteran is left 
without the ability to access critical VA services. VetsFirst supports 
this legislation and urges swift passage.
   to provide coverage under va's beneficiary travel program for the 
 travel of certain disabled veterans for certain special disabilities 
                        rehabilitation (s. 633)
    Veterans who have spinal cord injuries or disorders, vision 
impairments, or double or multiple amputations require access to 
rehabilitation services that allow them to live as independently as 
possible with their disabilities. For those veterans who need these 
services but who are not eligible for travel benefits, the ability to 
pay for travel to these rehabilitation programs can be very burdensome. 
In addition, few of these services are available locally, particularly 
to veterans who live in rural areas.
    All disabled veterans who need to travel to receive in-patient care 
at special disabilities rehabilitation programs should be eligible to 
receive travel benefits from VA. Every effort must be made to reduce 
barriers that limit access to these services. The long-term savings of 
ensuring that these veterans are able to maintain their health and 
function significantly outweighs the short-term costs associated with 
this legislation.
    VetsFirst supports S. 633 because it will improve access to 
rehabilitation services for all veterans who have spinal cord injuries 
or disorders, vision impairments, or double or multiple amputations.
           caregiver expansion promotion act of 2013 (s. 851)
    Many families of disabled veterans play a crucial role in providing 
needed services and supports that allow veterans to return to, and 
remain in, their homes. The sacrifice of family caregivers not only 
supports veterans, but also VA's mission. Spouses and family members 
often must leave the workforce to assist their husbands, wives, and 
adult children in their efforts to rehabilitate and reintegrate into 
their communities. The sacrifice of these caregivers, however, may 
result in lost income and other benefits, including health insurance.
    Although the commitment of the caregivers of our Nation's veterans 
has been evident for many decades, a study released in November 2010 by 
the National Alliance for Caregiving provides statistical evidence 
supporting the depth of the commitment that these caregivers have made 
to our veterans. For instance, the study report titled, ``Caregivers of 
Veterans-Serving on the Homefront,'' noted that 70 percent of 
caregivers for our Nation's veterans are spouses. For all populations, 
only 6 percent of caregivers are spouses. Clearly, immediate family 
members have an important role in caregiving for our Nation's veterans.
    An even higher number of caregivers, 80 percent, live with the 
veteran for whom they are providing care. Nationwide, only 23 percent 
of caregivers of all adults live with the care receiver. Consequently, 
68 percent of caregivers of veterans report a high level of emotional 
stress due to caregiving which is more than double the level of stress 
endured by caregivers of all adults.
    The lifelong commitment made by caregivers of our Nation's veterans 
is clearly represented by the 26 percent of parents who are providing 
care for their sons and daughters who are veterans of the wars in Iraq 
and Afghanistan. The long-term caregiving relationship of our Nation's 
veterans with disabilities and their caregivers exceeds that of other 
caregiving relationships. According to the National Alliance for 
Caregiving, 30 percent of caregivers of veterans from all eras give 
care for 10 years or longer, as opposed to only 15 percent of 
caregivers nationwide.
    In May 2010, the President signed the VetsFirst supported 
Caregivers and Veterans Omnibus Health Services Act of 2010 (Public Law 
111-163), to provide critical supports for caregivers of veterans with 
disabilities. Caregivers for all eligible veterans who are enrolled in 
the VA's health care system are to have access to education sessions, 
support services, counseling, mental health services, and respite care. 
The law also provides certain caregivers of veterans who have a serious 
injury, such as a Traumatic Brain Injury, that was incurred or 
aggravated in the line of duty on or after September 11, 2001, with a 
monthly stipend and access to medical care.
    The expansive services provided through Title I of Public Law 111-
163 provided hope for many caregivers who as the National Alliance for 
Caregiving study demonstrates provide care for a longer period of time 
and have a higher stress level than other types of caregivers. In order 
to receive assistance under the program of comprehensive assistance for 
family caregivers, a caregiver must be providing care to an ``eligible 
veteran.'' According to 38 U.S.C. Sec. 1720G(a)(2),

        [A]n eligible veteran is any individual who (A) is a veteran or 
        member of the Armed Forces undergoing medical discharge from 
        the Armed Forces; (B) has a serious injury (including Traumatic 
        Brain Injury, psychological trauma, or other mental disorder) 
        incurred or aggravated in the line of duty in the active 
        military, naval, or air service on or after September 11, 2001; 
        and (C) is in need of personal care services because of (i) an 
        inability to perform one or more activities of daily living; 
        (ii) a need for supervision or protection based on symptoms or 
        residuals of neurological or other impairment or injury; or 
        (iii) such other matters as the Secretary considers 
        appropriate.

    Under the comprehensive program, family caregivers are eligible to 
receive training, technical support, counseling, and lodging and 
subsistence. For the family caregiver who is chosen as the primary 
provider of personal care services additional benefits are available. 
These benefits include mental health services, respite care of not less 
than 30 days annually, medical care, and a monthly personal caregiver 
stipend. As identified by the National Alliance for Caregiving, these 
benefits are desperately needed by the caregivers of disabled veterans.
    Public Law 111-163 requires VA to submit a report to Congress 
regarding the feasibility of expanding comprehensive caregiver benefits 
for veterans who have a serious service-connected injury that was 
incurred or aggravated before September 11, 2001. To date, VA has not 
released this report.
    The Caregiver Expansion and Improvement Act of 2013 (S. 851) would 
build on Public Law 111-163 by extending these enhanced caregiver 
benefits to the caregivers of veterans of all eras who have serious 
service-connected disabilities. Many of these caregivers have 
sacrificed for decades to serve their seriously injured disabled 
veterans. We must recognize the significant contributions made by these 
caregivers by ensuring that they have full access to all VA caregiver 
benefits. The determination for which caregivers receive comprehensive 
caregiver benefits should be based on a veteran's level of need, 
particularly as those with serious injuries, including spinal cord 
injuries, age.
    VetsFirst strongly supports the expansion of comprehensive 
caregiver assistance to family caregivers of all veterans with a 
serious service-connected disability. We urge swift pass of S. 851.
            to provide for certain requirements relating to 
                  the immunization of veterans (draft)
    For veterans who have spinal cord injuries and disorders or other 
significant disabilities, contracting influenza or pneumonia can lead 
to severe, debilitating health problems, or even death. Since focusing 
on the need for veterans with spinal cord injuries and disorders to 
receive influenza vaccinations due to their high-risk of influenza 
related complications, VA has seen an increase in the vaccination rate 
for these veterans from 28 percent in 2000 to 79 percent in 2010. 
Similarly, VA saw an increase in vaccination rates for pneumococcal 
pneumonia from 40 percent in 2000 to 94 percent in 2010.
    Receiving every recommended immunization as suggested is critical 
for all veterans. This draft legislation would ensure that veterans 
have access to immunizations against infectious diseases in accordance 
with the recommended adult immunization schedule. The legislation 
requires VA to include information about immunizations in VA's annual 
report to Congress on preventive health. Importantly, this legislation 
also requires VA to develop and implement quality measures and metrics, 
including targets for compliance, to ensure that recommended 
immunizations are delivered in accordance with the schedule.
    VetsFirst fully supports legislation to establish requirements for 
immunizations and metrics for their delivery. Veterans, particularly 
those who are at high-risk for contracting diseases that vaccines can 
prevent, must receive those immunizations. As efforts to address 
influenza and pneumonia have proven, concerted efforts to increase 
immunizations can increase the number of veterans who are offered and 
accept those vaccines.

    Thank you for the opportunity to testify concerning VetsFirst's 
views on these important pieces of legislation. We remain committed to 
working in partnership to ensure that all veterans are able to 
reintegrate in to their communities and remain valued, contributing 
members of society.

    Chairman Sanders. Thank you very much, Ms. Ansley.
    Mr. Gornick.

STATEMENT OF MATT GORNICK, POLICY DIRECTOR, NATIONAL COALITION 
                     FOR HOMELESS VETERANS

    Mr. Gornick. Chairman Bernard Sanders, Ranking Member 
Richard Burr, and distinguished Members of the Senate Committee 
on Veterans' Affairs, I am honored to appear before this 
Committee as the policy director of the National Coalition for 
Homeless Veterans.
    On behalf of the 2,100 community- and faith-based 
organizations NCHV represents, we thank you for your steadfast 
commitment to serving our Nation's most vulnerable heroes.
    My testimony today will focus on three bills currently 
before this Committee: S. 62, the Check the Box for Homeless 
Veterans Act of 2013; S. 287, a bill to expand the definition 
of homeless veteran for purposes of benefits under the laws 
administered by the Secretary of Veterans Affairs; and S. 825, 
the Homeless Veterans Prevention Act of 2013.
    Since their inception, Federal assistance programs for 
homeless veterans have received overwhelming bipartisan support 
from Congress. While critical, some of these investments have 
been modest in consideration of the full range of problems 
associated with veteran homelessness.
    Sen. Barbara Boxer's Check the Box for Homeless Veterans 
Act would help address some of the shortfalls by establishing a 
national Homeless Veterans Assistance Fund, supported through 
designated tax overpayments and other direct contributions.
    This fund would be used for two purposes: one, to develop 
and implement new and innovative strategies to prevent and end 
veteran homelessness; and two, to provide services through any 
homeless veteran program administered by the VA, HUD, and 
Labor.
    This fund's primary purpose should be to help close gaps in 
service delivery systems for veterans. It would be 
counterproductive to reduce appropriations for homeless veteran 
assistance simply due to this fund's establishment.
    The next bill I would like to discuss is S. 287. Over the 
past few years, VA's homeless programs have evolved to 
accommodate the growing number of homeless women veterans and 
single veterans with dependent children.
    Unfortunately, the Department still defines homeless 
veteran based on an incomplete citation of the McKinney-Vento 
Homeless Assistance Act. The full definition of ``homeless'' 
under this act includes individuals and families who are 
fleeing, or attempting to flee, domestic violence, dating 
violence, sexual assault, stalking, or other dangerous or life-
threatening conditions in their housing situation.
    Senator Mark Begich's S. 287 serves a straightforward 
purpose: to include this provision in VA's definition of a 
homeless veteran.
    Although some veterans who meet this expanded definition 
may already qualify for VA homeless assistance due to the 
nature of their circumstances, we must ensure that they are not 
denied the help that they need.
    The last bill that I would like to discuss is Chairman 
Sanders and Ranking Member Burr's S. 825, the Homeless Veterans 
Prevention Act of 2013.
    The breadth of this bill is a testament to this Committee's 
leadership in the effort to prevent and end veteran 
homelessness. Among its many important provisions, S. 825 would 
reauthorize competitive grant programs for community- and 
faith-based veteran service providers.
    These programs include the Grant and Per Diem Program, 
Homeless Veterans' Reintegration Program, and Supportive 
Services for Veteran Families Program.
    NCHV concurs with VA in its fiscal year 2014 Budget 
Proposal on the following items, which are not reflected in 
this bill. The Grand Per Diem Program should be permanently 
authorized at $250 million. This program has the capacity to 
serve 30,000 homeless veterans each year and is vital to VA's 
mission to end veteran homelessness.
    The Supportive Services for Veteran Families Program should 
be permanently authorized at $300 million. This program will 
serve as the foundation of VA's strategy to prevent veteran 
homelessness well beyond 2015.
    Last, the Grant Program for Homeless Veterans with Special 
Needs should also be permanently authorized. Therefore, NCHV 
recommends that the Homeless Veterans Prevention Act be amended 
to accommodate these proposals. Without these extensions, VA 
cannot adequately plan for these programs' future.
    Additionally, while this bill would provide increased per 
diem payments for service providers implementing a Transition-
in-Place housing model, the need to reform the per diem payment 
method remains.
    This Committee helped pass legislation that became Public 
Law 112-154, which requires VA to study all matters relating to 
the per diem payment method, including anticipated changes in 
the cost of providing services to homeless veterans.
    VA must report to Congress on its findings less than 3 
months from today. Anything short of a proposal to thoroughly 
modernize this outdated reimbursement policy from a flat per 
diem rate to a flexible, cost-of-services payment method should 
be deemed insufficient.
    In closing, thank you for the opportunity to present this 
testimony. It is a privilege to work with this Committee to 
ensure that every veteran in crisis has reasonable access to 
the support services they earned through their service to our 
country.
    Thank you.
    [The prepared statement of Mr. Gornick follows:]
       Prepared Statement of Matt Gornick, NCHV Policy Director, 
                National Coalition for Homeless Veterans
    Chairman Bernie Sanders, Ranking Member Richard Burr, and 
distinguished members of the Senate Committee on Veterans' Affairs: I 
am honored to appear before this Committee as the policy director of 
the National Coalition for Homeless Veterans (NCHV). On behalf of the 
2,100 community- and faith-based organizations NCHV represents, we 
thank you for your steadfast commitment to serving our Nation's most 
vulnerable heroes.
    This testimony will focus on our support for three bills currently 
before this Committee:

     S. 62, the ``Check the Box for Homeless Veterans Act of 
2013;''
     S. 287, a bill ``to expand the definition of homeless 
veteran for purposes of benefits under the laws administered by the 
Secretary of Veterans Affairs;'' and
     S. 825, the ``Homeless Veterans Prevention Act of 2013.''

    Additionally, this testimony will recommend ways to improve 
effective service delivery to homeless veterans.
                               background
    For decades, the veteran service provider community represented by 
NCHV has worked arduously toward the goal of ending veteran 
homelessness. The announcement of Secretary of Veterans Affairs Eric 
Shinseki's Five-Year Plan to End Veteran Homelessness in 
November 2009--fully incorporated into the ``Federal Strategic Plan to 
Prevent and End Homelessness''--demonstrated the Federal Government's 
solidarity in making that goal a reality.
    Congress has seen the promise of this plan and, through fiscal year 
(FY) 2013, has increased funding for successful community-based 
programs to end veteran homelessness. These investments have fueled 
consistent decreases in the number of homeless veterans on a given 
night--down 17.2% since 2009, according to the latest Point-in-Time 
Report from the U.S. Department of Housing and Urban Development (HUD).
    As the maturity date of the Five-Year Plan approaches, NCHV 
maintains that our Nation is on a path to ensure that no veterans, 
regardless of their personal haunts and challenges, are ever left to 
fend for themselves on the streets.
    The legislation currently before this Committee would help keep our 
Nation on this path.
       s. 62, ``check the box for homeless veterans act of 2013''
    Since their inception, Federal assistance programs for homeless 
veterans have received overwhelming bipartisan support from Congress. 
While critical, some of these investments have been modest in 
consideration of the full range of problems associated with veteran 
homelessness.
    Sen. Barbara Boxer's S. 62 would help address some of the 
shortfalls by establishing a national Homeless Veterans Assistance 
Fund, supported through designated tax overpayments and other direct 
contributions. The fund would be used for two purposes:

    1. To develop and implement new and innovative strategies to 
prevent and end veteran homelessness; and
    2. To provide services through any homeless veteran program 
administered by the Department of Veterans Affairs (VA), the Department 
of Labor-Veterans' Employment and Training Service (DOL-VETS), and HUD.

    This fund's primary purpose should be to help close gaps in service 
delivery systems for veterans. It would be counterproductive to reduce 
appropriations for homeless veteran assistance programs simply due to 
this fund's establishment.
    The Homeless Veterans Assistance Fund should help organizations 
that cannot compete for Federal grants under limited programs--such as 
those in highly rural areas--provide support to veterans in crisis. The 
fund should also support nontraditional, high-demand activities such 
as:

     Contracting with veteran service providers to administer 
case management for veterans in permanent supportive housing in 
underserved communities.
     Providing child care assistance for veterans in employment 
assistance programs.
     Helping veterans make security deposits and pay utility 
hook-up fees for housing placements.

    All of the above activities are already authorized in some form. By 
focusing on these areas of service delivery, S. 62 would serve a vital 
role in both eliminating and preventing veteran homelessness.
   s. 287, a bill ``to expand the definition of homeless veteran for 
 purposes of benefits under the laws administered by the secretary of 
                           veterans affairs''
    Over the past few years, VA's homeless programs--such as the 
Supportive Services for Veteran Families (SSVF) and HUD-VA Supportive 
Housing (HUD-VASH) Programs--have evolved to accommodate the growing 
number of homeless women veterans and single veterans with dependent 
children. Unfortunately, the department still defines ``homeless 
veteran'' based on an incomplete citation of the McKinney-Vento 
Homeless Assistance Act (42 U.S.C. 11302(a)). The full definition of 
``homeless'' under this act includes the following provision:

        ``Any individual or family who is fleeing, or is attempting to 
        flee, domestic violence, dating violence, sexual assault, 
        stalking, or other dangerous or life-threatening conditions in 
        the individual's or family's current housing situation, 
        including where the health and safety of children are 
        jeopardized, and who have no other residence and lack the 
        resources or support networks to obtain other permanent 
        housing.''

    Sen. Mark Begich's S. 287 serves a straightforward purpose: to 
include this provision in VA's definition of ``homeless veteran.''
    Although some veterans who meet this expanded definition may 
already qualify for VA homeless assistance due to the nature of their 
circumstances, we must ensure that we do not deny any of these veteran 
families the help that they need.
          s. 825, ``homeless veterans prevention act of 2013''
    The breadth of this bill is a testament to this Committee's 
leadership in the effort to prevent and end veteran homelessness. 
Introduced by Chairman Bernie Sanders and Ranking Member Richard Burr, 
S. 825 would--among many important provisions--reauthorize competitive 
grant programs for community- and faith-based veteran service 
providers. These programs include the Grant and Per Diem (GPD) Program, 
Homeless Veterans' Reintegration Program (HVRP), and SSVF Program. 
Along with the continued buildup of the HUD-VASH Program, expansion of 
these programs has contributed to the steady reduction in veteran 
homelessness over recent years.
    NCHV concurs with VA in its FY 2014 Budget Proposal on the 
following items, which are not reflected in this legislation:

     The GPD Program should be permanently authorized at $250 
million. As currently written, S. 825 would allow the program's 
authorization to drop to $150 million after FY 2014.
     The SSVF Program should be permanently authorized at $300 
million. As currently written, S. 825 would allow the program's 
authority to expire after FY 2014. This program will serve as the 
foundation of VA's strategy to prevent veteran homelessness well beyond 
2015, and its permanent authorization is critical to sustain the 
national priority to end veteran homelessness.
     The grant program for homeless veterans with special needs 
should be permanently authorized. As currently written, S. 825 would 
allow the program's authority to expire after FY 2014.

    Therefore, NCHV recommends that S. 825 be amended to accommodate 
these proposals. Without these extensions, the Department of Veterans 
Affairs cannot adequately plan for these programs' future.
    Additionally, while this bill would provide increased per diem 
payments for service providers implementing a ``Transition in Place'' 
housing model, the need to reform the per diem payment method remains. 
This Committee helped pass legislation that became Public Law 112-154, 
which requires VA to:

        ``Complete a study of all matters relating to the method used 
        by the Secretary to make per diem payments under section 
        2012(a) of title 38, United States Code, including changes 
        anticipated by the Secretary in the cost of furnishing services 
        to homeless veterans and accounting for costs of providing such 
        services in various geographic areas.''

    The law requires VA to report to Congress on its findings no later 
Aug. 6, 2013. Anything less than a proposal to thoroughly modernize 
this outdated reimbursement policy--from a flat per diem rate to a 
flexible, cost-of-services payment method--should be deemed 
insufficient.
                              in summation
    Thank you for the opportunity to present this testimony for today's 
hearing. It is a privilege to work with the Senate Committee on 
Veterans' Affairs to ensure that every veteran in crisis has reasonable 
access to the support services they have earned through their service 
to our country.

    Chairman Sanders. Thank you very much, Mr. Gornick.
    Mr. Bowman.

    STATEMENT OF THOMAS BOWMAN, FORMER CHIEF OF STAFF, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

    Mr. Bowman. Chairman Sanders, Ranking Member Burr, and 
distinguished Members of the Committee, it is a pleasure to be 
here and offer my comments on S. 543, the VISN Reorganization 
Act of 2013.
    I believe the proposed legislation is both timely and 
necessary to ensure that the VA with predictable regularity, 
reviews, reorganizes or right sizes, as appropriate, its VISN 
organizational structure and operation to more efficiently and 
effectively oversee and manage the budgetary and planning 
responsibilities for the respective networks.
    At the outset, I believe it important to state that I 
receive all my health care through the VA at the Bay Pines VA 
Medical Center in St. Petersburg, FL. Although I have many 
other health care options available to me, I choose the VA 
because I believe in its mission and its people.
    My comments have been influenced most particularly by my 
last 3-1/2 years experience as an employee of VA, day to day, 
as the senior advisor to the VISN 8 network director.
    There has been no serious review or right-sizing of the 
VISN geographic boundaries in approximately 18 years until 
prompted by the proposed legislation.
    The legislation reduces the number of VISNs from 21 to 12 
by combining existing geographic boundaries and eliminating 
excess VISN headquarters, and assisting the transfer or 
reassignment of affected personnel to nearby VA medical centers 
or other VA facilities. Many could fill existing vacancies at 
these facilities based upon their exceptional skill sets.
    With the closure of 9 VISN headquarters under the 
reorganization, the funding saved could be provided to other VA 
medical centers to support their clinical needs, other capital 
asset upgrades, and maintenance, as needed.
    I have provided the Committee a map reflecting the proposed 
realigned boundaries. The map also reflects the current 
location of existing VA medical centers, community-based 
outpatient clinics and VISN headquarters.
    The geographic combinations result in a re-balancing across 
VA of the aggregate number of today's veteran beneficiaries 
under one VISN director instead of two or possibly, in one 
case, three separate VISN headquarters.
    Some might argue that despite smaller unique or enrolled 
patient numbers, you need to separate VISNs because of the 
challenge presented by the number of VA medical centers or the 
expansion of geographic areas that the combinations would 
entail.
    VA medical centers are not all the same complexity level or 
size. The same management process and procedures for budgeting 
and planning can be applied by a VISN director whether the 
number of medical centers is 8, 14, or in the largest proposed 
VISN combination--VISNs 1, 2 and 3--would be 20.
    The management tools, reports, information technology 
capability, tele and video communications venues, and site 
visits available to a VISN director and staff are significant 
and effective, if appropriately utilized.
    It should be noted that the realignment of the VISN 
geographic boundaries would not adversely impact individual 
veteran patient referral patterns as they exist today. They 
would continue as before.
    Patients would still be cared for by their VA medical 
center staff or wherever they may be referred for care. The 
VISN headquarters does not currently, nor under the proposed 
restructuring, provide direct patient care.
    What would change is that the VA medical center directors 
in realigned VISNs would have a new VISN director to which they 
will be accountable, and a new boss.
    The proposed legislation states, in essence, that a VISN 
headquarters is to be located on the grounds of a VA medical 
center. At the same time, however, it provides that the 
Secretary can justify keeping the VISN headquarters in a leased 
location off campus by justifying his decision in a report to 
appropriate Congressional oversight committees.
    The Secretary, in providing that report, then is offering 
his justification for keeping a lease that may be in existence 
or to possibly move into an offsite location.
    In the absence of an unanticipated exigent circumstance--
natural disaster or other unforeseen emergencies--there is very 
little justification for not being able to balance the VISN 
books at the end of the fiscal year.
    VISNs begin to plan for the closure of their books, and VA 
Central office is generally well aware of any deficiencies well 
in advance of the end of the fiscal year. VA Central Office has 
the ability to transfer reserve funds held at their level to 
cover the deficiencies in VISN accounts in advance of the end 
of the fiscal year where and when they propose to do so.
    In addition, the Under Secretary for Health has a number of 
means and methods by which to hold VISN directors accountable 
for year-end budget deficiencies.
    Mr. Chairman, this concludes my comments; I offer others in 
my written statement.
    [The prepared statement of Mr. Bowman follows:]
  Prepared Statement of Thomas G. Bowman, J.D., Colonel USMC (Ret.), 
       Former Chief of Staff, U.S. Department of Veterans Affairs
    Chairman Sanders, Ranking Member Burr, Distinguished Members of the 
Senate Committee on Veterans Affairs, Thank you for the opportunity to 
appear before you and offer my comments on S. 543, ``VISN 
Reorganization Act of 2013.'' I believe the proposed legislation is 
both timely and necessary to ensure that the Department of Veterans 
Affairs with predictable regularity, reviews, reorganizes or right 
sizes, as appropriate, its VISN organizational structure and operation 
to more efficiently and effectively oversee and manage the budgetary 
and planning responsibilities for veteran healthcare in the respective 
networks.
    By way of personal background, I retired from the Marine Corps in 
September 1999 after 30 years having served as both an infantry officer 
and Judge Advocate; my last assignment as the Senior Military Assistant 
to the Under Secretary of Defense for Personnel and Readiness. Upon 
retirement, I joined the Committee on Government Reform and Oversight, 
U.S. House of Representatives as a Senior Counsel and served there 
until February 2002 when I joined the Department of Veterans Affairs. I 
served in various positions at VA headquarters which included Acting 
Assistant Secretary for Public and Intergovernmental Affairs, Deputy 
Chief of Staff and Chief of Staff. I departed VA Central Office in 
January 2009 and assumed the position of Senior Advisor to the Director 
of the VA Sunshine Healthcare Network (VISN 8) in St. Petersburg, 
Florida. I retired from the VA in June 2012.
    In 1995, Dr. Kenneth Kizer, then the Under Secretary for Health for 
VA implemented a plan for the reorganization of both the field 
operations and its central office management. It was called Vision for 
Change: A Plan to Restructure the Veterans Health Administration, 
March 17, 1995. Under the plan the basic budgetary and planning unit of 
healthcare delivery in the field was moved from individual medical 
centers into integrated service networks providing care for veteran 
beneficiaries in pre-determined geographic areas. Dr. Kizer stated:

        ``These network service areas and their veteran populations are 
        defined on the basis of VHA's natural referral patterns; 
        aggregate numbers of beneficiaries and facilities needed to 
        support and provide primary, secondary and tertiary care; and 
        to a lesser extent, political jurisdictional boundaries such as 
        states.''
                       visn geographic boundaries
    Although 22 VISN's were part of the original implementation plan, 
two of the smallest VISN's were combined to better justify and 
accommodate staffing, funding and patient population leaving 21 VISN's 
to initiate Dr. Kizer's plan. The VISN staffing level was to be 10 FTE. 
There has been no serious review and right sizing of the VISN 
geographic boundaries in approximately 18 years until prompted by the 
proposed legislation.
    The proposed legislation reduces the number of VISN's from 21 to 12 
by combining existing geographic boundaries and eliminating excess VISN 
headquarters, and assisting the transfer or reassignment of affected 
personnel to nearby VA medical centers, or other VA facilities. Many 
could fill existing vacancies at these facilities based upon their 
exceptional skillsets. With the closure of 9 VISN headquarters under 
the reorganization, the funding saved could be provided to other VA 
medical centers to support clinical needs and other capital asset 
upgrade and maintenance, as needed. Attached is a map reflecting the 
proposed realigned boundaries identifying affected VISN's. The map also 
reflects the current location of existing VA medical centers, community 
based outpatient clinics (CBOC) and VISN headquarters locations.
    The geographic combinations result, across the VA, in a re-
balancing and closer standardization of the aggregate number of today's 
veteran beneficiaries under the budgetary and planning management of 
one VISN director instead of spread across two or, in one case, three 
separate VISN headquarters with its associated staff. In essence, the 
combining of the selected VISN's is analogous to what Dr. Kizer found 
appropriate to do for roughly similar reasons in the very beginning 
when he combined two VISNs.
    By way of an example below, I am using approximate 2011 VA data for 
VHA unique patient/veteran enrollee numbers. Combining VISN 1 (232,490/
353,911), VISN 2 (129,815/140,415) and VISN 3 (167,172/183,382) would 
result in approximately 529,477/677,708 total unique patients/veteran 
enrollees would result in one VISN director and associated staff 
managing them, instead of the VISN headquarters budget and FTE overhead 
of three VISN. Those numbers compare more favorably to what one VISN, 
VISN 8, had as numbers for the same categories at the same time--
505,133/714,755. Another example is combining VISN 17 (261,560/394,110) 
and VISN 18 (240,044/363,209) would result in one VISN director 
managing 501,604/757,319. A further example is combining VISN's 19 and 
20. VISN 19 (170,608/261,736) combined with VISN 20 (243,872/375,968) 
results in 414,480/637,704 total unique patients/veteran enrollees; 
numbers still smaller than those of VISN 8.
    Some might argue that despite smaller unique and enrollee patient 
numbers, you need separate VISN's because of the challenge presented by 
the number of VA medical centers or the expansion of geographic areas 
that the combinations would entail. VA medical centers are not all the 
same complexity level or size. The same management process and 
procedures for budgeting and planning can be applied whether the number 
of medical centers is 8, 14, or in the largest proposed VISN (combining 
VISN's 1, 2 and 3) would be 20. The management tools, reports, IT and 
tele and video communications venues available to a VISN director and 
staff are significant and effective, if utilized appropriately. Much of 
the intended mission of the VISN operation is accomplished through data 
analysis and ``dashboards'' All too often in recent years the immediate 
response to any additional tasking or expansion of responsibility at 
the VISN headquarters level has is a request for more FTE instead of 
working with what staff already exist. Doing so underestimates the fact 
that current VISN staff are individually and collectively more capable 
of assuming more responsibilities if asked, especially in the 
restricted budget environment that VA will be challenged with in future 
years.
    It is important to note that the realignment of the VISN geographic 
boundaries would not adversely impact individual veteran patient 
referral patterns. They would continue as before. Patients would still 
be cared for by their VA Medical Center staff, or wherever they may be 
referred for care. The VISN headquarters does not currently, nor under 
the proposed restructuring, provide direct patient healthcare. What 
would change is that VA Medical Center directors in realigned VISN's 
would have a new VISN director to which they will be accountable * * * 
a new boss.
                             visn staffing
    The current review by VHA into the VISN headquarters FTE staffing 
numbers seems to be consistent in its results (55-65 FTE) with VISN 
staffing levels recommended by the proposed legislation--not more than 
65 FTE. However, the current VHA review was done assuming 21 VISN's. I 
believe the review started with approximately 1720 adjusted VISN FTE 
staff, and VHA is in the process of reducing VISN staffing to a total 
of 1230 FTE, a reduction of approximately 490 FTE. With the proposed 
realignment, VISN staffing could be further reduced by approximately 
520 FTE. The budgetary savings and FTE benefit could be moved to 
support operations at the VA medical centers.
    In conjunction with the reorganization of the number of VISN's, I 
would strongly urge that the position of VISN Deputy Director be 
upgraded to SES level at all VISN headquarters. VA medical centers are 
healthcare systems and each health system has a director that is an 
SES. They are accountable to the VISN director (an SES) in the chain of 
command. As the term Deputy Director is currently applied, it is a 
misnomer. If a VISN director retires; is replaced for cause; or, absent 
for a significant period of time, VA has to identify an SES level 
individual to replace him or her for the duration of the absence or 
vacancy. Usually that replacement is through detailing a current 
sitting medical center director within the VISN, or seeking someone 
from another VISN to assume the director responsibilities until a 
replacement is appointed. At the present time, that recruitment and 
appointment process can be rather time consuming.
    An SES Deputy Director can immediately assume the Acting Director 
role with current understanding of the VISN issues; no ``learning 
curve'' would be necessary. Medical center directors will be more 
inclined to see the SES Deputy Director as more of a ``peer'' and 
interact with that person more completely and confidentially on 
business and other related issues that they usually reserve for 
conversations with the VISN director. Additionally, upgrading the 
position can be an excellent succession planning venue for potential 
medical center director candidates allowing them to gain significant 
experience and insight into executive planning and decisionmaking. SES 
allocations for these positions can possibly come from SES positions 
that become available through the VISN consolidations if retirements 
occur or from those currently available within VA Central Office.
                     location of visn headquarters
    The proposed legislation states, in essence, that a VISN 
headquarters is to be located on the grounds of a VA medical center. At 
the same time, however, it provides that the Secretary can justify 
keeping the VISN headquarters in a leased location off campus by 
justifying his decision in a report to appropriate Congressional 
oversight committees. The preference for colocation upon a VA medical 
center campus is in keeping with what Dr. Kizer recommended. Colocation 
on a VA medical center campus provides for veteran and medical center 
situational awareness for the VISN staff by witnessing their budget 
policy and planning being implemented at the operational level. If the 
Secretary ultimately directs the movement on campus, there would 
possibly be some associated costs, but that would be the decision of 
the Secretary.
                          visn balanced budget
    In the absence of an unanticipated exigent circumstance (natural 
disaster, or other unforeseen emergencies), there is very little 
justification for not being able to balance at the end of the fiscal 
year. VISN's begin to plan for the closure of their books, and VA 
Central office is generally well aware of any deficiencies in advance 
of the end of the fiscal year. VA Central Office has the ability to 
transfer reserved funds held at their level to cover the deficiencies 
in VISN accounts in advance of the end of the fiscal year where and 
when they want to do so. In addition, the Under Secretary for Health 
has a number of manner, means and methods of holding VISN directors 
accountable for year-end budget deficiencies.
                   triennial review of visn structure
    A review and report to Congress every three years will provide 
appropriate ``checks and balances'' for VA leadership as it plans and 
programs for VISN field operations; preclude unnecessary FTE increases; 
and, facilitate and enhance appropriate Congressional oversight of VISN 
operations.

    Mr. Chairman, this concludes my statement. I am pleased to answer 
any questions that you or other Members may have.
    [Included in Mr. Bowman's testimony:]


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



    Chairman Sanders. Mr. Bowman, thank you very much. Each of 
you provided excellent testimony. You all have made an 
important contributions to the discussion on how we should go 
forward.
    Dr. Jonas, let me start with you. As you may know, your 
statement is fairly revolutionary. As I understand it, what you 
are suggesting is that complementary or alternative medicine 
should be integrated into our health care system. What you are 
suggesting is that if we move aggressively in areas like 
meditation, acupuncture, chiropractic care, and other areas, we 
can ease the suffering of veterans and we can save the system 
substantial sums of money.
    Is my characterization correct? If so, what would you 
suggest that we do with VA to increase access to these 
therapies? How aggressive should we be? The VA has already made 
efforts in all of these areas and may even be ahead of the 
curve compared to the private sector.
    Dr. Jonas. I think your characterization could be correct 
provided these practices are integrated in the proper way. They 
are not simply tagged on as if they were another treatment 
system for another condition and a specialty is created.
    So, my first suggestion is that the VA--and they have made 
a lot of progress in these areas--get outside help. And what I 
mean by that is that by definition, these things are not part 
of the mainstream system. That is why they are called 
complementary and alternative medicine. They are outside of the 
way things normally are done.
    That means the skills in terms of the delivery of them are 
not things that are normally part of the educational part of 
practitioners that are in the VA. They are integrated into 
medical records, for example. They are not part of the benefits 
system. They are not tightly linked to the priorities such as 
the personalized person-centered care center.
    So, we will go into a patient-centered medical home. In the 
VA version, it is a pact, and we will look for whether these 
practices are even on the radar screen; and in most cases they 
are not or they are on the side. They are not fully integrated.
    We will go into the distribution system for primary care 
enhancements, for example, called the Scan System. That 
infrastructure is there to do it but you do not see integrative 
practices as part of that.
    There needs to be a retraining program and an evaluation 
and quality assurance program that is coordinated with current 
existing practices so that they are systemically designed and 
evaluated as they are put in to the system.
    Chairman Sanders. Are there any health care systems in this 
country which are doing a better job than the VA that we can 
learn from?
    Dr. Jonas. In this area there are, and I suggest the VA 
really look at some of those care systems that have 
demonstrated improvements in pain, improvements in function, 
and reduction of costs in those areas.
    There are a number of them. The Allina System up in 
Minnesota, for example, has a wonderful inpatient example of 
how to integrate complementary practices into mainstream in a 
systematic way.
    Chairman Sanders. And the results have been positive?
    Dr. Jonas. Very positive, yes, reductions in pain, anxiety, 
cost, length of stay in the hospital, this type of thing.
    There are some examples within the VA also but they tend to 
be champion driven meaning that if you have a passionate person 
who is organized in the VA, it is done. Salt Lake City had a 
wonderful one, for example, that showed, documented, and 
published major improvements in outcomes, reductions in costs, 
including impact on homelessness and that type of thing through 
a whole-person integrated practice.
    But when the medical director of that VA retired and left, 
it largely went away. It was not embedded into the system, into 
the benefits, or into the training and education of the entire 
system.
    So, these are the kinds of things that need to be 
coordinated.
    Chairman Sanders. My impression is that people are 
gravitating more to these type of procedures. My impression 
also, having visited a number of VA centers, is that many 
veterans look forward to and want to access these types of 
alternative treatments. Is that accurate?
    Dr. Jonas. That is absolutely right. Surveys done on the 
DOD side, and also on the VA side, show that the use of these 
practices tends to be even higher in those populations than 
they are out in the civilian population, especially for stress-
related pain and those types of conditions, mental health 
conditions.
    Chairman Sanders. All of us are wrestling the epidemic of 
PTSD.
    Dr. Jonas. Right.
    Chairman Sanders. It is a huge problem. You touched on it 
in your testimony. You think there are treatments, 
complementary and alternative treatments, that can help?
    Dr. Jonas. Well, I mentioned two. One is a relaxation 
treatment that we tested out at Camp Pendleton which was 
delivered by nurses. It induced a deep relaxation. It actually 
involved training skills; in other words, training veterans and 
their families how to do that. We are doing another one of 
those programs down at Fort Hood and at some VAs that show 
improvements in that.
    Those are the kinds of practices. They are skill-based 
training. They are not treatments per se. They are not 
something where you have a pill or you have even a needle or a 
manipulation where you require a professional. It is self-care 
practice.
    Chairman Sanders. You have done that within the DOD. Am I 
correct that there is no reason why that could not be done 
within VA, as well?
    Dr. Jonas. There are mind, body, and relaxation practices 
going on in the DOD. Few of them have been evaluated. There 
have been some that have had impact in those areas.
    They need to be designed with experts from the outside that 
get involved, subject matter experts, and done in coordination 
with the VA practitioners so they learn how to actually deliver 
them because they are the implementation experts.
    So, that is why a team approach is required in those areas.
    Chairman Sanders. Thank you very much. My time has expired.
    Senator Burr.
    Senator Burr. Mr. Chairman, thank you, and to the panel. I 
found it to be fascinating. I will probably need another round 
just to let you know now because I want to cover as much ground 
as I can today.
    Tom, thank you for being here and retirement looks like it 
is treating you well.
    The VISN Reorganization Act would create regional support 
centers, and they were set up to measure the efficiency and the 
effectiveness of the VISNs.
    Now, the VA has testified that these centers would likely 
increase staffing, are not the best functions to be moved to a 
regional level, and could produce conflicting oversight 
programs.
    Let me ask you. Do you believe that this function could be 
carried out without additional staff?
    Mr. Bowman. Senator, I do. And, by way of background, the 
functions that have been identified in the legislation--
finance, compliance, outreach, women veterans, homelessness, 
and could be others. In each VISN, there are individuals that 
are responsible for those tasks and responsibilities of 
analysis and oversight of what is occurring in the medical 
centers within the respective VISN.
    If you were to move forward with the regional support 
centers, what you are doing is taking what would be a number of 
personnel. Now, it could be a one, two, or three personnel 
office that would be looking at a larger number of VA medical 
centers. It would not be an expansion or an explosion of 
additional FTE.
    And in fact, in the legislation, the approach that is taken 
is that you would attempt to move individuals who had those 
responsibilities in VISNs where there were a closure of the 
VISN headquarters and move them into the regional support 
center.
    An important point to remember is that at the VISN level, 
the individuals who are conducting those responsibilities, 
those analysis and assessment responsibilities are accountable 
to the VISN director.
    If their functions are moved to a regional support center 
and they are looking at more VISNs, you gain the ability to 
assess good practices, good implementation across a larger 
number of headquarters.
    I am aware that there has been some comments about a 
confusion in the chain of command. So, if you create a regional 
support center, do you now blur the chain of command, the 
answer is no, because as the legislation is discussed, the 
regional support center would be looking at a predetermined 
number of VISNs as determined by the Under Secretary or the 
Secretary.
    Then, they would take a look at whether or not they are 
performing, those medical centers are performing. If they are 
not performing, the VISN director is going to be made aware of 
it by reports and information that would come down from VA 
central office. The regional support centers would be a field 
entity where accountability by the VISNs can be taken to the 
VISN level of accountability back up to VA central office.
    Senator Burr. So, to some degree, some VISNs or some 
directors might look at this as a threat because there would 
actually be data that they could not influence what it said 
that makes its way to central office.
    Mr. Bowman. Yes, there would be a concern there.
    Senator Burr. You know, Tom, I noticed in your written 
testimony you mentioned the lack of succession planning, and 
specifically you state that VISN deputy directors should be at 
the SES level to match the VA medical center directors.
    I am wondering. Can you expand on that to some degree?
    Mr. Bowman. At the present time, the way VISNs are 
constructed and the way medical centers are constructed, you 
have an SES as a VISN director and you have an SES as a medical 
center director. At the present time and by exception in one 
case, VISN 8, the deputy network director is not an SES.
    Now, from an operational standpoint that I witnessed for 3-
1/2 years is that when a deputy director is not a VISN, if 
there is a gap or an absence on the part of the VISN director, 
either they were relieved for cause or they retire or for some 
other reason are going to be gone for a long period of time, VA 
has to pull in either an existing medical center director to 
act temporarily as the VISN director. This means he or she is 
no longer managing the business of the medical center from 
which they came or they are going to be the VISN director until 
the personnel process of replacing the VISN director occurs. 
And, as we know, that is not a very quick process.
    The other point is that if you have the deputy network 
director as an SES, it becomes a position that career 
employees--as they advance in their rank within the VHA 
structure--it will be a position that they look to compete for 
because of the advantage of experience to be gained.
    It becomes part of a succession planning venue because, if 
you have individuals who have served as deputy network 
directors, they then become good candidates to be looking at or 
to be considered for medical center directors because they have 
gained the advantage of the experience and background of what a 
VISN operation is like as they oversee medical centers.
    It would, at the same time, allow the medical center 
directors to feel more comfortable in bringing to the attention 
of a deputy network director issues sensitive in nature, 
whether they be business or personal as it relates to 
happenings within the VISN much more so than somebody who is 
not at the SES level.
    Senator Burr. Great. Thank you, Mr. Chairman.
    Chairman Sanders. Thank you, Mr. Bowman.
    Senator Boozman.
    Senator Boozman. Thank you, Mr. Chairman.
    Rick, you mentioned and Dr. Jesse alluded to it earlier of 
the sense of having HUD look at in preventing--sometimes we do 
not talk about the prevention of homelessness which again are 
very, you know, are so beneficial.
    I think you make an interesting point if you have the--it 
might be an intervention there. If that does not resolve it, 
then the next step is that you are sleeping on somebody's 
couch. That is another opportunity to intervene before the bad 
things happen where you are physically out on the street.
    So, I think you make a really good point there. Perhaps, 
you know, there is something that we can do to figure out how 
we can do that step. I certainly would like to work with you in 
that regard.
    I just want to thank all of you. We really can be proud of 
a lot of things that have happened in the last several years 
and your advocacy in different ways really has made a huge 
difference, working with the VA. And so, we really do 
appreciate it.
    The other thing is you mentioned spina bifida and that is 
something that I would like to look at.
    The Vietnam era is my era. I can recall somebody that was 
just a wonderful employee whose husband died very, very young 
that was up to his eyebrows in Agent Orange. They had two 
children who had multiple problems, you know, as a result of 
this.
    So, we all know of those kind of stories. But like I said, 
I would like to be involved in that and I will get with you on 
that.
    Mr. Bowman, I think you have got some great ideas. I 
appreciate your service and have enjoyed working with you now 
for the last several years.
    And again, you know, we have got a great story to tell in 
regard to making changes. I guess good ideas were there for 
quite a while. I am sure that you are frustrated in the sense 
of getting some of those ideas done then, as we all are.
    I have been on the Committee for a long time. We have all 
been working in these areas. What is your recommendation? How 
do we actually get those good ideas that you had implemented?
    What is the next step in actually getting some of this 
stuff done in regard to perhaps looking at reorganization, 
looking at, I guess--what I would like to know is how do we get 
that done?
    And then the other question is what is the low hanging 
fruit out there that you think that the Committee, the VSOs, 
the nonprofits, what are some of the low hanging fruit that we 
can get at to help VA? I think a lot of this stuff, probably 
the vast majority VA wants to be helped to implement.
    What are the things we need to address that we could 
actually get done fairly quickly?
    Mr. Bowman. Well, sir, in the area of veterans' health and 
the operation at the field level, I think the one thing that 
needs to occur to be able to kind of pave the way for ideas to 
be immediately identified as beneficial is that the more 
opportunity that senior officials in the VA central office have 
to go into the field and spend time in the field, a 2-day visit 
down to a particular medical center is not going to gain a 
senior official an opportunity to fully understand or grasp 
what may be an issue. They can get that based upon a briefing 
in their office.
    When senior officials come down, they are going to then be 
able to see what is being commented upon as needs. I believe 
that the collaboration and close coordination with veteran 
service organizes and their state-level entities is 
exceptionally important because of lot of the day-to-day 
adjustments and practice of outreach, of information flow is 
accomplished by and through and with the veteran service 
organizations and what I saw in my 3-1/2 years down at the VISN 
8 area was the community- and faith-based organizations were 
more interested in what was happening through the process of 
conveyance of information.
    The low hanging fruit I believe----
    Senator Boozman. So, in regard to the other, some of that 
is just the tyranny of the urgent that you are dealing with 
that prevents you from--it is interesting. I think, you know, 
the advice that you are giving is good advice for us.
    I mean, we are in the same position as senior officials in 
having oversight and getting out in the field, you know, 
spending time. We just simply do not do enough of that, yet I 
am not being critical. We are the people who are actually 
interested in spending a lot of time but I think that is good 
advice for all of us.
    Mr. Bowman. The follow-up comment is that with my time in 
central office and then down in the field in VISN 8 that the 
impact of a visit by a senior official or a Member of Congress 
on the morale of the employees at the operational level in the 
medical center is tremendous--oftentimes it may go overlooked--
because the mere fact you have taken the time to go down there 
sends a very clear signal that you are interested and that you 
are aware.
    And then, what will happen is I think there is doing to be 
an exchange of information through staff because they believe, 
I mean, if you were to come down an say, what do you need here?
    Intuitively and institutionally, it will either find its 
way into the vapor, you know, the higher it goes up through the 
chain of command, now some of it has to go up through the chain 
of command and should because senior officials within the VA 
chain of command should be made aware.
    However, if a Members of Congress comes down and talks to a 
medical center director and says, is there anything that I can 
do for you; and if that medical center director has already, 
you know, expressed that, I believe there should be the 
latitude, the internal belief that he could be candid with the 
Member of Congress.
    That is not the feeling, and I think that the morale out 
there in tough times can be significantly enhanced by very 
small events and that is by ``small'' I mean it could be 1 or 2 
days but the fact that you have oversight individuals, whether 
they be senior officials at the headquarters level but 
especially Members of Congress.
    Senator Boozman. Thank you.
    Chairman Sanders. Thank you, Senator Boozman.
    Senator Boozman, at one of our recent hearings, you raised 
an issue that I want to pick up on now with Dr. Jonas. I think 
you raised a concern that many of us have heard about, which is 
the over medication of many of our veterans. We have heard that 
time and time again. Dr. Jonas, let me ask you about that 
issue. Is it fair to assume that by increasing the availability 
of complementary and alternative medicine we could address, at 
least to some degree, the problem of over medication?
    Dr. Jonas. Overmedication is a large problem. We spend less 
than .01 percent of our research budget on pain treatments, for 
example, that are not some type of intervention or medication 
aspect, the vast majority of that. We wonder why that is the 
tool that the physicians have to use to do that.
    Sir, I know you saw Escape Fire. I would recommend it to 
the rest of you. There was a servicemember there who gets the 
typical kinds of medical treatment for multiple problems. Each 
of these practitioners that I mentioned that you go to has 
their own special medication that they treat for sleep, for 
anxiety, for depression, for pain, et cetera.
    Part of the trauma spectrum is medication addiction used 
for treating pain and these other aspects. So, many of these 
things, in fact, can substitute for that and can lower that. In 
fact, some of the demonstration projects that I mentioned to 
you have all demonstrated that as ways of substituting for 
medications in many of these areas.
    Chairman Sanders. Thank you very much.
    Rick, we have introduced legislation to expand the 
Caregivers Expansion and Improvement Act. I think you heard 
from the VA today that the program has been a success with the 
families of post-9/11 veterans.
    Is there any reason, in your judgment, why we should not 
expand the program to Vietnam-era veterans, their families, as 
well as those veterans from other eras?
    Mr. Weidman. Senator, when the bill was first advanced in 
the Congress, people asked, what is your contribution in 
getting this law enacted? I said, our contribution at Vietnam 
Veterans of America is we are going to be quiet.
    In other words, our folks, a lot of our members who are 
alive today because their spouse has been taking care of them 
for 40 years and without any assistance from the government and 
saving the government over that period of time billions of 
dollars that otherwise would have had to go into custodial care 
or long-term care of one form or another.
    We had always hoped that, and the White House at that point 
assured us, that they would follow on with expanding it to all 
generations based on medical needs or life situation needs. 
Yet, that has not happened from there. We are very pleased that 
it is coming from the Committee and we are strongly in favor of 
expanding it to every generation.
    Chairman Sanders. Thank you.
    Mr. Weidman. May I say one thing, sir?
    Chairman Sanders. Sure.
    Mr. Weidman. Senator Boozman, you asked the question about 
what can VA do that is low hanging fruit? What VA can do is 
implement the executive order that was issued on January 21, 
2009, having to do with open government, transparency, and 
participation of stakeholders.
    It is not followed anywhere in VHA. They give lip service 
to it. They have a quarterly meeting, as an example, at the 
VISN level that is mostly what we used to call a ``dog and pony 
show'' where they fill the air with talk for 2 hours and 45 
minutes of a 3-hour session. Then, you have 15 minutes to ask 
questions and then everybody has got to go.
    That is not participation in our view and it is not either 
the letter or the spirit of that executive order. Might I 
suggest, Mr. Chairman and Ranking Member, that you even 
consider taking that and enacting that into statute so it will 
live beyond this presidency.
    Chairman Sanders. Mr. Bowman, as I understand the essence 
of your testimony, regarding Senator Burr's legislation is that 
we should not support bureaucracy but put our resources into 
providing care to veterans. That is certainly a noble goal, one 
which I support.
    How many years have you worked with the VA?
    Mr. Bowman. Almost 11 before I retired.
    Chairman Sanders. OK. And you worked at the national level 
and the local level.?
    Mr. Bowman. Yes, sir.
    Chairman Sanders. You began your testimony by saying to get 
your health care the VA. Overall, understanding that every 
health care system has its share of problems, including VA, 
does VA do a fairly good job for our veterans, do you think, in 
terms of providing quality health care?
    Mr. Bowman. In the delivery of health care to veterans at 
the medical center level, I would say yes, they do. My concern 
would be, as I look at my experience in VISN 8, is that there 
are more veterans out there who belong in the VA system and 
they are not there because of an outreach deficiency.
    Chairman Sanders. Let me pick up on that point. You know, 
we had a hearing just on that issue.
    Mr. Bowman. Yes, sir.
    Chairman Sanders. So, what you are telling me, and excuse 
me. VISN 8 is where?
    Mr. Bowman. VISN 8 is essentially of all Florida except for 
a little chunk of the panhandle.
    Chairman Sanders. OK. And a lot of veterans live there?
    Mr. Bowman. Yes, sir.
    Chairman Sanders. So, what you are telling this Committee 
is there are veterans who are eligible for and need care who do 
not know how to access the system?
    Mr. Bowman. Yes, sir; and I know it may sound strange with 
all of the publicity that has been----
    Chairman Sanders. No, it does not sound strange to me. All 
of us here, no matter what our political views may be, share 
one understanding.
    You do not get elected unless you figure out how to 
communicate with the people in your State, right? And sometimes 
bureaucracies do not do that. What I am hearing you say just 
confirms why we held that hearing.
    Mr. Bowman. Yes, sir.
    Chairman Sanders. I want to see every veteran in this 
country who is entitled to benefits to get them or at least 
know about them. You agree with that?
    Mr. Bowman. Yes, sir.
    Chairman Sanders. You are telling me that this is a problem 
in Florida?
    Mr. Bowman. I believe it is a problem in the Florida area, 
and from my time in Washington, I believe that it is a problem 
across the country that there needs to be more aggressive 
outreach.
    Chairman Sanders. Good. I very much share that concern.
    Senator Burr.
    Senator Burr. Dr. Jonas, you mentioned that there is recent 
research that has shown the effectiveness of complementary and 
alternative medicines. In standard research studies, they 
include experimental groups and control groups. Did any of that 
research that was done adopt this standard of two different 
groups?
    Dr. Jonas. Yes, sir, all the studies that I mentioned in my 
testimony were done in what is called randomized controlled 
trials which is not only two different groups but they are 
equally distributed into the comparison and the control group 
so that they start at the same level when they are looking for 
comparative benefits, yes.
    Senator Burr. If there is an executive summary to that 
research out there, I hope you will provide it for the 
Committee. If it is in your testimony I apologize, or is it in 
the book?
    Dr. Jonas. So, we just supplied the IOM. I was on the 
Committee for the IOM, and we just supplied them with a 
comprehensive analysis of complementary medicine and guidelines 
and what are called ``meta analysis'' which is where you look 
at these kinds of studies and look for the quality and the 
quantity of them into this book. So, they are available, 
especially Chapter 6, which really talks about that.
    Senator Burr. In your professional opinion, is the 
reluctance to utilize more alternative treatment unique to the 
VA or is it across medicine as a whole?
    Dr. Jonas. This is across medicine as a whole. This is not 
unique at all to the VA. In fact, as Senator Sanders said, the 
VA tends to be ahead of the curve in the use of these compared 
to a civilian population where these things do not get paid 
for.
    Senator Burr. So, is this an ignorance of understanding 
that your research is out there or a disregard for its 
conclusion?
    Dr. Jonas. It is partly ignorance and it is partly the 
squeaky wheel. When you have billions and billions of dollars 
dumped into technologies that are then advertised and pushed on 
the system--and I get them in my medical bag as a primary care 
practitioner and I have .01 percent of the research dollars 
going into my medical bag--going into drugless approaches like 
this, it is no wonder I cannot find them in the bag. They are 
buried underneath other types of things.
    There is actually no economic driver to deliver these low-
cost self-care types of practices. That is a large part of it. 
So, I never learned about them. I did not learn about 
nutrition, for example, in my medical school, and yet I know it 
is a very important part of brain function, of cardiovascular 
disease, hypertension, you know, depression, et cetera.
    Senator Burr. So, when you talked earlier about evidence-
based, you would not be highlighting that VA or the health care 
system in this country should adopt anything that there is not 
clinical reason to implement.
    Dr. Jonas. Absolutely. This has to be evidence-based. If we 
do not do this, then we end up doing things that not only are 
wrong but they may actually harm people. So, it has to be that 
way.
    Senator Burr. Good. Mr. Gornick, in your testimony, you 
talked about shortfalls that exist that would be solved by 
establishing a national assistance fund. Detail for me, if you 
would, what these shortfalls are that exist?
    Mr. Gornick. Thank you for that question.
    Some of the different things that I laid out in my written 
testimony include providing child care assistance for veterans 
in employment assistance programs, and helping veterans make 
security deposits and pay utility hook-up fees for housing 
placements.
    The latter could be addressed by the SSVF program, but 
generally with a limited amount of funds; that is not where the 
dollars go.
    For a veteran that receives a HUD-VASH voucher, for 
instance, that veteran now has a rental subsidy indefinitely so 
long as Congress provides funding for that. But that does not 
pay for the bed. That does not pay for the couch. That does not 
pay for the down payment that he or she needs to make on an 
apartment. Therefore, that veteran could continue being 
homeless without these additional forms of help.
    Senator Burr. So, we have a lot of different pieces out 
here. We are hopeful because we say we have got a homelessness 
program and they all come together to fill the need of an 
individual, whatever that gap is.
    But what you are saying is there is still--if everything 
came together perfectly--there are still some shortfalls out 
there that are relatively inexpensive but that blow up the 
whole model if we do not address them. Is that an accurate 
statement?
    Mr. Gornick. Undoubtedly.
    Senator Burr. Well, you know, Dr. Jonas talked about a 
holistic approach and I think I share this with the Chair. We 
do have a lot of programs, and I think we have got a passionate 
commitment on the part of the Secretary and Members and 
everybody within the VA to end homelessness for veterans.
    What we do not do is a good job of holding accountable and 
verifying that all these pieces come together. I think there is 
a tendency that when the roof goes over somebody's head, we 
walk away and we sleep well that night because we know that 
they are no longer under a bridge.
    I would suggest to you that our goal should not be to end 
there. It is to make sure that the complementary, wraparound, 
holistic services come to that veteran so that the mental 
health treatment is there, substance abuse treatment is there.
    Our goal cannot be temporary relief from veterans' 
homelessness. It has to be constructed for permanent 
transition. So, Mr. Gornick, I hope if there are more gaps than 
what you have listed in your testimony, you will provide those 
to the Committee so that we can begin to work with VA to see if 
there are ways to fill them.
    I thank all of you.
    Chairman Sanders. Thank you very much Senator Burr. And let 
me thank all of our witnesses. I have enjoyed your testimony 
very much and I thank you for being here. We will continue our 
discussion of pending legislation with a new panel next week.
    Again, thank you all very much. This hearing is adjourned.
    [Whereupon, at 11:53 a.m., the Committee was adjourned.]
                            A P P E N D I X

                              ----------                              


 Prepared Statement of Hon. Barbara Boxer, U.S. Senator from California
       s. 62, the check the box for homeless veterans act of 2013
    Chairman Sanders, Ranking Member Burr: Thank you for considering 
S. 62, the Check the Box for Homeless Veterans Act of 2013 at today's 
hearing.
    I am so grateful to you both for your longstanding commitment to 
our Nation's veterans and particularly for your tireless efforts to 
eliminate the epidemic of veteran homelessness.
    Ending veteran homelessness is one of the most critical challenges 
facing our Nation today. It is also an issue that brings Americans 
together because we all agree it is simply unacceptable that more than 
60,000 veterans are homeless on any given night.
    I strongly believe that if we work together as a Nation, we can end 
veteran homelessness once and for all. And I know so many Americans are 
looking for ways to give back to our veterans who have sacrificed so 
much for us.
    That is why I introduced S. 62, the Check the Box for Homeless 
Veterans Act of 2013. This straightforward bill would create a ``check-
off box'' on the annual Federal tax return form and allow taxpayers to 
make a voluntary contribution in the amount of their choice to support 
programs that prevent and combat veteran homelessness.
    Taxpayer contributions would be deposited and safeguarded in a new 
Homeless Veterans Assistance Fund established in the U.S. Treasury. 
These funds would be available to the VA--in consultation with the 
Departments of Labor and Housing and Urban Development--solely to 
provide services to homeless veterans, including developing and 
implementing new and innovative strategies to end veteran homelessness. 
My bill would also authorize the transfer of funds between these three 
agencies to support programs that assist homeless veterans.
    To ensure transparency and accountability in how these taxpayer 
dollars are spent, my bill requires the President's annual budget 
submission to include proposed uses of funds from the Homeless Veterans 
Assistance Fund. Additionally, my bill stipulates that Congress must be 
notified 60 days in advance of any expenditure of such funds.
    The Check the Box for Homeless Veterans Act of 2013 would provide 
additional necessary resources to help end the cycle of homelessness 
for men and women like Air Force veteran Mike Hofler. After completing 
his military service, Mike struggled with Post-Traumatic Stress and hit 
rock bottom when he was hospitalized in a VA mental health unit.
    The VA eventually referred Mike to the non-profit organization 
Swords to Plowshares, where he got the support he needed to get his 
life back on track. Within months, Mike found his own apartment and 
began pursuing his bachelor's degree in social work. Today, Mike is a 
recent graduate of the Columbia University School of Social Work's 
Master of Science program and is working with returning veterans in New 
York.
    I am proud that this bill has strong support from our military and 
veteran communities and has been endorsed by the National Coalition for 
Homeless Veterans, the American Legion, the Veterans of Foreign Wars, 
AMVETS Department of California, the Center for American Homeless 
Veterans, the California Association of Veteran Service Agencies, and 
Swords to Plowshares.
    According to the National Coalition for Homeless Veterans, ``The 
simple act of checking a box would enable taxpayers to prevent and end 
homelessness for those who have served this country in a way 
increasingly few Americans ever will. By supplementing proven Federal 
programs, the `Check the Box for Homeless Veterans Act' will have a 
strong and lasting impact in communities nationwide.''

    I look forward to working with my colleagues to see this important 
legislation enacted into law.
                                 ______
                                 
   Prepared Statement of Hon. Joe Donnelly, U.S. Senator from Indiana
 s. 832, improving the lives of children with spina bifida act of 2013
    Chairman Sanders, Ranking Member Burr, Members of the Committee, 
Thank you for the opportunity to submit a statement on behalf of 
S. 832, the Improving the Lives of Children with Spina Bifida Act of 
2013. This bill requires the Secretary of Veterans Affairs to carry out 
pilot programs on furnishing case management services and assisted 
living for children of Vietnam veterans and certain Korea service 
veterans suffering from spina bifida.
    Currently, the Department of Veterans Affairs (VA) provides 
monetary allowances, vocational training and rehabilitation, and VA-
financed health care benefits to certain Korea and Vietnam veterans' 
birth children who have been diagnosed with spina bifida. As of 2008, 
Public Law 110-387, Section 408, outlined changes to the program, 
providing comprehensive health care for spina bifida beneficiaries.
    I first became aware of this program from a constituent whose step-
daughter suffers from spina bifida, and is a beneficiary of the VA 
program. My constituent has worked for years to get the comprehensive 
care services needed for his step-daughter and family, and has 
struggled every step of the way. For several months, I have been 
working in coordination with the Committee, the Vietnam Veterans of 
America, and the VA to resolve his concerns, and I appreciate the 
Committee's support during this process. We are beginning to make 
progress in the VA's compliance with providing the services required by 
law.
    Earlier this year, the Committee conducted oversight activities on 
implementation of the VA's spina bifida program, its outreach to spina 
bifida beneficiaries, and options for improving the program. My office 
was briefed on the conversations, and two key conclusions emerged: (1) 
spina bifida patients are in need of comprehensive case management to 
coordinate services, provide follow-up and follow-through support, and 
help patients work in their home to resolve problems. Case management 
is allowed for in the existing law, but has not been utilized; and (2) 
as spina bifida beneficiaries and their caretakers age, beneficiaries 
will need lifelong management of their health issues. Assisted living 
facilities may enable these beneficiaries to maintain their 
independence, and may be a better option than nursing home care.
    Based on these conclusions, I worked with the Committee to develop 
S. 832 calling for two pilot programs to address case management and 
assisted living care. A key component of the pilot programs is a 
requirement for the VA to inform all covered individuals of the 
services available under the pilot programs. This can help narrow the 
gap between the number of eligible beneficiaries, and those actually 
utilizing the services provided by the VA. Additionally, this bill 
relies on funding already appropriated or otherwise made available 
within the spina bifida program to furnish case management and nursing 
home care. We are not seeking to increase the benefits provided to 
spina bifida beneficiaries, but rather to improve their access to care 
and VA implementation of the services required under the law.
    I believe this bill can make a meaningful difference in the lives 
of spina bifida children, and encourage VA to live up to its 
obligations under the law. I am grateful for the support of the 
Committee in developing this legislation, as well as for the support of 
Vietnam Veterans of America and Veterans of Foreign Wars.

    Thank you for your consideration of the bill, and for your support.
                                 ______
                                 
               Prepared Statement of The American Legion
               s. 49, veterans health equity act of 2013
    To require the Secretary of Veterans Affairs, with respect to each 
of the 48 contiguous states, to ensure that veterans who are eligible 
for hospital care and medical services through the Department of 
Veterans Affairs (VA) have access to: (1) at least one full-service VA 
medical center in the state, or (2) hospital care and medical services 
comparable to that provided in full-service VA medical centers through 
contract with other health providers in the state; and directs the 
Secretary to report to Congress on compliance with such requirement, 
including its effect on improving the quality and standards of 
veterans' care.

    The American Legion has no position on this bill.
         s. 62, check the box for homeless veterans act of 2013
    To offer taxpayers the opportunity to help keep those who have 
served our country off the streets by making a voluntary contribution 
on their annual Federal income tax return to support programs that 
prevent and combat veteran homelessness.
    On any given night in January 2013 over 60,000 veterans were 
homeless in the United States. As such, The American Legion strongly 
believes, in accordance with Resolution No. 306, Funding for Homeless 
Veterans, passed at National Convention 2012, that homeless veteran 
programs should be granted sufficient funding to provide supportive 
services such as, but not limited to, outreach, healthcare, 
rehabilitation, case management, personal financial planning, 
transportation, vocational counseling, employment and training, and 
education.
    Resolution 306 states that The American Legion ``seek[s] and 
support[s] any legislative or administrative proposal that will provide 
medical, rehabilitative and employment assistance to homeless veterans 
and their families.'' This bill would help do that by establishing a 
Homeless Veterans Assistance Fund in the Treasury Department which 
would supplement proven Federal programs for homeless and at-risk 
veterans and their families. Additionally, this bill would provide 
funding for innovative and relevant programs/services that would 
improve and expand services available to homeless veterans. The 
Department of Veterans Affairs (VA) Five-Year Plan to eliminate veteran 
homelessness by 2015 is past the halfway mark. By helping to provide 
the necessary resources to reach this obtainable, and worthy, goal, 
this Nation can finally end the scourge of veteran homelessness.

    The American Legion supports this bill.
            s. 229, corporal michael j. crescenz act of 2013
    To designate the Department of Veterans Affairs (VA) medical center 
at 3900 Woodland Avenue in Philadelphia, Pennsylvania, as the 
``Corporal Michael J. Crescenz Department of Veterans Affairs Medical 
Center.''

    The American Legion has no position on this bill.
  s. 287, a bill to amend title 38 united states code, to expand the 
definition of homeless veteran for purposes of benefits under the laws 
   administered by the secretary of veterans affairs, and for other 
                                purposes
    To include as a homeless veteran, for purposes of eligibility for 
benefits through the Department of Veterans Affairs (VA), a veteran or 
veteran's family fleeing domestic or dating violence, sexual assault, 
stalking, or other dangerous or life-threatening conditions in the 
current housing situation, including where the health and safety of 
children are jeopardized, there is no other residence, and there is a 
lack of resources or support networks to obtain other permanent 
housing.
    The Department of Veterans Affairs (VA) currently defines 
``homeless veteran'' based on an incomplete citation of the McKinney-
Vento Homeless Assistance Act (42 U.S.C. 11302 (a)). The full 
definition of ``homeless'' under this act includes the following:

        ``Any individual or family who is fleeing, or is attempting to 
        flee, domestic violence, dating violence, sexual assault, 
        stalking, or other dangerous or life-threatening conditions in 
        the individual's or family's current housing situation, 
        including where the health and safety of children are 
        jeopardized, and who have no other residence and lack the 
        resources or support networks to obtain other permanent 
        housing.''

    The expansion of the ``homeless veteran'' definition proposed by 
S. 287 would align VA and HUD, making their partnership at the state 
level more efficient. The bill would include as homeless veterans those 
getting emergency shelter or other services as a result of their being 
victims of domestic violence.
    According to Resolution No. 306 Funding for Homeless Veterans, 
passed at the 2012 National Convention, The American Legion is 
committed to assisting homeless veterans and their families, continues 
to support the efforts of public and private sector agencies and 
organizations with the resources necessary to aid homeless veterans and 
their families; and, supports any legislative or administrative 
proposal that will provide medical, rehabilitative, and employment 
assistance to homeless veterans and their families.

    The American Legion supports this bill.
 s. 325, a bill to amend title 38, united states code, to increase the 
 maximum age for children eligible for medical care under the champva 
                    program, and for other purposes
    To make a child eligible for medical care under the Civilian Health 
and Medical Program of the Department of Veterans Affairs (CHAMPVA) 
eligible for such care until the child's 26th birthday, regardless of 
the child's marital status, and to make such provision inapplicable 
before January 1, 2014, to a child who is eligible to enroll in an 
employer-sponsored health care plan.

    The American Legion has no position on this bill.
              s. 412, keep our commitment to veterans act
    To authorize the Secretary of Veterans Affairs (VA) to carry out 
specified major medical facility leases in FY 2013-2014 in New Mexico, 
New Jersey, South Carolina, Georgia, Hawaii, Louisiana, Florida, Puerto 
Rico, Texas, Connecticut, and Massachusetts, and to reduce lease 
amounts authorized in previous fiscal years for VA outpatient clinics 
in: (1) Johnson County, Kansas; (2) San Diego, California; and (3) 
Tyler, Texas.

    The American Legion has no position on this bill.
    s. 422, chiropractic care available to all veterans act of 2013
    To amend the Department of Veterans Affairs Health Care Programs 
Enhancement Act of 2001 to require a program under which the Secretary 
of Veterans Affairs provides chiropractic care and services to veterans 
through Department of Veterans Affairs (VA) medical centers and clinics 
to be carried out at: (1) no fewer than 75 medical centers by 
December 31, 2014, and (2) all medical centers by December 31, 2016, 
and to include chiropractic examinations and services within required 
VA medical, rehabilitative, and preventive health care services.

    The American Legion has no position on this bill.
s. 455, a bill to amend title 38, united states code, to authorize the 
  secretary of veterans affairs to transport individuals to and from 
  facilities of the department of veterans affairs in connection with 
 rehabilitation counseling, examination, treatment, and care, and for 
                             other purposes
    To authorize the Secretary of Veterans Affairs to transport 
individuals to and from facilities of the Department of Veterans 
Affairs (VA) in connection with vocational rehabilitation, counseling, 
examination, treatment, or care.
    The American Legion's Resolution No. 294, Department of Veterans 
Affairs Rural Healthcare Program, passed at the 2012 National 
Convention, states that one out of every three veterans that receive 
their health care at VA facilities live in rural communities and that 
veterans residing in these areas have been underserved due to a lack of 
access to health care, which can be attributed to greater travel 
barriers and a lack of public transportation in these areas.
    During The American Legion's 2012 System Worth Saving site visits, 
which focused on Rural Veterans Health Care, it was recommended to the 
Undersecretary of VHA for the Department of Veterans Affairs and the 
Office of Rural Health that VA medical centers fully implement a 
Veterans Transportation Service (VTS) Department to coordinate all 
veteran transportation programs for the hospital, i.e. staff to conduct 
transportation catchment area analysis, VTS program initiatives, 
volunteer transportation drivers/scheduling and beneficiary travel 
programs.
    The American Legion believes that the provisions in this bill would 
be extremely beneficial to veterans who reside in rural and/or highly 
rural areas of the country where public transportation is less frequent 
and/or unavailable. This bill would also assist veterans who cannot 
utilize public transportation as a result of their existing medical 
condition and/or disability.
    The American Legion believes that no veteran should be penalized 
based on where they chose to live and that the VA has an obligation to 
provide veterans across the country access to the medical center and/or 
community based outpatient clinic closest to them in order to receive 
care.

    The American Legion supports this bill.
           s. 522, wounded warrior workforce enhancement act
    To direct the Secretary of Veterans Affairs (VA) to award grants to 
eligible institutions to: (1) establish a master's or doctoral degree 
program in orthotics and prosthetics, or (2) expand upon an existing 
master's degree program in such area; to require a grant priority for 
institutions in partnership with a medical center administered by the 
VA or a facility administered by the Department of Defense (DOD); to 
provide grant amounts of at least $1 million and up to $1.5 million. 
Defines as eligible institutions those either accredited by the 
National Commission on Orthotic and Prosthetic Education or 
demonstrating an ability to meet such accreditation requirements if 
receiving a grant; and to require the Secretary to award a grant to an 
institution with orthotic and prosthetic research and education 
experience to: (1) establish the Center of Excellence in Orthotic and 
Prosthetic Education; and (2) improve orthotic and prosthetic outcomes 
for veterans, members of the Armed Forces, and civilians by conducting 
orthotic- and prosthetic-based research.
    Due to an aging population, increased rates of diabetes and 
cardiovascular disease, and advances in military medicine, more 
Americans will continue to need the skills of prosthetists and 
orthotists in the coming years. Newer models of orthotics and 
prosthetics improve the lives of many Americans but are hard to fit and 
require highly skilled professionals at the same time that many 
orthotists and prosthetists are retiring.
    Currently, only five universities offer O&P master's programs 
accredited by the Commission on Accreditation of Allied Health 
Education Programs; the University of Hartford is among those five 
programs.\1\ Only ten educational institutions offer any kind of 
currently accredited O&P program, but five will have to adapt their 
programs in order to meet the new master's degree requirement.
---------------------------------------------------------------------------
    \1\ http://www.caahep.org/Find-An-Accredited-Program/
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    The proposed bill would devote $5 million per year for three years 
to award competitive grants to institutions that prove their ability to 
create or expand an accredited master's or doctoral program in O&P. The 
grants would be between $1 million and $1.5 million and could be used 
to build new programs, expand existing programs, further faculty 
development, supplement salaries, fund faculty research projects, or 
construct O&P facilities.
    The second part of this bill appropriates $5 million for the VA to 
establish a second Center of Excellence in Prosthetic and Orthotic 
Education to provide evidence-based research in the knowledge, skills 
and training most needed by clinical professionals in the field. The 
first Center of Excellence is in Long Beach, CA. The legislation 
directs the VA Secretary to consider joint applications from a VA 
medical center and an academic institution with an established 
orthotics and prosthetics program.
    The bill also establishes DOD grants to research best practices for 
the use of O&P, including for wounded warriors. The legislation calls 
on the Defense Department to work in coordination with the VA, use data 
from peer-reviewed sources, and draw on the expertise of individuals 
and institutions outside of the Federal Government. $30 million is 
appropriated for the grants.
    Resolution No. 108: Request Congress Provide the Department of 
Veterans Affairs Adequate Funding for Medical and Prosthetic Research, 
passed at the 2012 National Convention states that The American Legion 
``supports adequate funding for VA biomedical research activities,'' 
and requests that ``Congress and the Administration encourage 
acceleration in the development and initiation of needed research on 
conditions that significantly affect veterans--such as prostate cancer, 
addictive disorders, trauma and wound healing, Post-Traumatic Stress 
Disorder (PTSD), Traumatic Brain Injury (TBI), rehabilitation, and 
others--jointly with the Department of Defense, the National Institutes 
of Health, other Federal agencies, academic institutions and the 
Department of Veterans Affairs.''

    The American Legion supports the bill.
  s. 529, a bill to amend title 38, united states code, to modify the 
   commencement date of the period of service at camp lejeune, north 
  carolina, for eligibility for hospital care and medical services in 
 connection with exposure to contaminated water, and for other purposes
    To amend title 38, United States Code, to modify the commencement 
date of the period of service at Camp Lejeune, North Carolina, for 
eligibility for hospital care and services in connection with exposure 
to contaminated water, and for other purposes.
    For a period of over thirty years, servicemembers in the Marine 
Corps and other branches of service, as well as their families, were 
exposed to contaminated ground water at the Marine Corps Base at Camp 
Lejeune, North Carolina. In response to this, the government has acted 
to provide medical care to those affected by this terrible 
contamination.
    This bill, S. 529, would extend the affected period under the law, 
expanding the period from its current onset of January 1, 1957 back to 
an onset date of August 1, 1953. Should the Secretary of Veterans 
Affairs, in consultation with the Agency for Toxic Substances and 
Disease Registry determine the need for an earlier effective onset 
date, the earlier date should be set after a proper publication of such 
a date in the Federal Register.
    Since at least the early 1980s, The American Legion has been at the 
forefront of advocacy for veterans exposed to toxic, environmental 
hazards such as Agent Orange, Gulf War related hazards, ionizing 
radiation, and others, by pushing for epidemiological studies based on 
DOD records, in order to address environmental exposure issues. The 
American Legion's Resolution 95\2\ thoroughly supports vigorous 
research into the effects of environmental exposures on servicemembers, 
and the expansion of benefits and treatment to ameliorate such 
exposures when research determines those benefits are merited. The 
American Legion supports this expansion of effective dates, to reflect 
the most accurate knowledge of the periods of exposure at Camp Lejeune. 
Furthermore, continued monitoring of the period to determine the full 
extent of damage done to those who served and their families is 
essential to ensure this country fulfills its obligations to those who 
have served.
---------------------------------------------------------------------------
    \2\ Resolution 95: Environmental Exposure, Indianapolis, IN 
August 2012.

    The American Legion supports this bill.
                s. 543, visn reorganization act of 2013
    To direct the Secretary of Veterans Affairs to organize the 
Veterans Health Administration (VHA) into 12 geographically defined 
Veterans Integrated Service Networks (VISNs), and for other purposes.
    According to The American Legion's Resolution No. 162, Department 
of Veterans Affairs Veterans Integrated Service Networks (VISN's), 
passed at the 2012 National Convention, ``The American Legion urges 
Congress to direct the Government Accountability Office (GAO) and 
Department of Veterans Affairs (VA) Office of the Inspector General 
conduct a comprehensive study to include purpose, goals, objectives and 
budget and evaluation of the effectiveness of the 21 Veteran Integrated 
Service Networks (VISNs),'' and ``urges the Veterans Health 
Administration (VHA) leadership conduct an internal review and develop 
an action plan to address VISN management, staffing and its current 
geographic boundaries/catchment areas concerns, in order to better 
provide timely access and quality health care for veterans.''
    Department of Veterans Affairs (VA) Veterans Health Administration 
is organized into a national central office and 21 VISN's (or regions) 
which oversee several VA medical facilities and Community Based 
Outpatient Clinics (CBOC's). The concept of VISN's was established by 
Dr. Kenneth Kizer, former Undersecretary for Health for VHA, in order 
to decentralize the medical centers and associated CBOC's from the 
central office. VISN's were established to promote best practices, 
innovation, and be responsible for all financial and operational 
activities for the medical facilities within their jurisdiction.
    Since the model was developed, however, there has been no official 
documentation from VHA leadership on the overall effectiveness of the 
current structure. Therefore, before any comprehensive restructuring of 
the VISNs, of the type required by this legislation, is implemented, 
The American Legion believes that Congress should direct the GAO and VA 
Office of Inspector General conduct a comprehensive study to include 
purpose, goals, objectives and budget evaluation of the effectiveness 
of having 21 VISNs, and that the VHA leadership conduct an internal 
review and develop an action plan to address VISN management, staffing 
and its current geographic boundaries/catchment areas concerns, in 
order to better provide timely access and quality healthcare for 
veterans.

    The American Legion does not support this bill.
 s. 633, a bill to amend title 38, united states code, to provide for 
  coverage under the beneficiary travel program of the department of 
veterans affairs of certain disabled veterans for travel in connection 
    with certain special disabilities rehabilitation, and for other 
                                purposes
    To authorize payment under the Department of Veterans Affairs (VA) 
beneficiary travel program of travel expenses in connection with 
medical examination, treatment, or care of a veteran with vision 
impairment, a spinal cord injury or disorder, or double or multiple 
amputations whose travel is in connection with care provided through a 
VA special disabilities rehabilitation program, if such care is 
provided: (1) on an inpatient basis, or (2) while a veteran is provided 
temporary lodging at a VA facility in order to make such care more 
accessible and to require a report from the Secretary to the 
congressional veterans committees on the travel program.

    The American Legion has no position on this bill
s. 800, treto garza far south texas veterans inpatient care act of 2013
    To require the Secretary of Veterans Affairs to ensure that the 
South Texas Department of Veterans Affairs Health Care Center at 
Harlingen, located in Harlingen, Texas, includes a full-service 
inpatient health care facility of the Department of Veterans Affairs, 
to redesignate such center, and for other purposes.

    The American Legion has no position on this bill.
            s. 825, homeless veterans prevention act of 2013
    To amend title 38, United States Code, to improve the provision of 
services for homeless veterans, and for other purposes.
    In order to fully implement VA's pledge to end homelessness among 
veterans by 2015, Congress must continue making responsible investments 
in affordable housing and supportive services programs that move 
veterans and their families off the streets and into stable housing. 
These homeless assistance programs should be intended to serve all 
groups of low-income veterans--veterans at risk of becoming homeless, 
veterans who are homeless for a short time, and veterans and their 
families who have spent years without a place to call home. To make 
this seamless system of care work, funding must be provided for a broad 
range of appropriate and effective interventions. Funding that prevents 
veterans from becoming homeless or quickly re-house veterans who need 
nothing more than short-term rental assistance and limited case 
management in order to get back on their feet could be used effectively 
by community organizations and other stakeholders. These funds could 
also be used to pay for employment services, utility assistance, child 
care costs, legal services, and other housing-related expenses. 
Additionally, there is still a need for funding that can provide short-
term housing to help homeless veterans get stabilized, along with 
allowing them to get connecting with jobs, supportive services, more 
permanent housing, and ultimately to become self-sufficient.
    With the affects of the wars in Iraq and Afghanistan, it is widely 
known that psychological stress, such as PTSD, TBI and other mental 
illnesses play a significant role in pushing a certain population of 
veterans into homelessness. Funding, along with grants that go to 
homeless veterans programs and organizations that assist this 
vulnerable demographic, are needed more than ever. Due to our work with 
homeless veterans and their families, The American Legion understands 
that homeless veterans need a sustained coordinated effort that 
provides secure housing and nutritious meals; essential physical 
healthcare, substance abuse aftercare and mental health counseling; as 
well as personal development and empowerment. Veterans also need job 
assessment, training and placement assistance. The American Legion 
believes all programs to assist homeless veterans must focus on helping 
veterans reach their highest level of self-management.
    Furthermore, The American Legion has provided housing for homeless 
veterans and their families as well (i.e., Departments of Pennsylvania, 
North Carolina and Connecticut). One of the goals of The American 
Legion is to help bring Federal agencies, non-profit organizations, 
faith-based communities and other stakeholders to the table to discuss 
best practices, along with funding opportunities, so homeless veterans 
and their families can obtain the necessary care and help in order for 
them to properly transition from the streets/shelters into gainful 
employment and/or independent living.
    Last, The American Legion strongly believes that with more 
collaboration and civic engagement, access to stable and affordable 
housing, and economic security to prevent and end homelessness, the 
goal of eliminating veteran homelessness is well within reach.
    According to Resolution No. 306, Funding for Homeless Veterans, 
passed at the 2012 National Convention, The American Legion is 
committed to assisting homeless veterans and their families, continue 
to support the efforts of public and private sector agencies and 
organizations with the resources necessary to aid homeless veterans and 
their families, and, support any legislative or administrative proposal 
that will provide medical, rehabilitative, and employment assistance to 
homeless veterans and their families.

    The American Legion supports this bill.
 s. 832, improving the lives of children with spina bifida act of 2013
    To require the Secretary of Veterans Affairs to carry out pilot 
programs on furnishing case management services and assisted living to 
children of Vietnam veterans and certain Korea service veterans born 
with spina bifida and children of women Vietnam veterans born with 
certain birth defects, and for other purposes.
    The effects of Agent Orange and other herbicides on veterans of the 
Vietnam conflict appear to be ongoing. Recent changes regarding the 
expansion of presumptive conditions reveal that the medical community 
has yet to realize the full effects of herbicide exposure. Considering 
the manifestation of some conditions by children of Vietnam veterans, 
it would stand to reason that the medical community has yet to 
determine the long term effects of Agent Orange upon the children of 
Vietnam veterans.
    Through the awarding of benefits associated with herbicide exposure 
to children of Vietnam veterans, VA has conceded a chronic condition 
was caused by herbicide exposure and passed from parent to child. We 
encourage VA to provide the necessary resources to ensure the highest 
quality of life possible for these children of Vietnam veterans. 
Additionally, we ``seek legislation to amend title 38, United States 
Code, Chapter 18, to provide entitlement to spina bifida benefits for 
the child or children of any veteran who was exposed to Agent Orange as 
the result of service in the Republic of Vietnam or in other locations 
where Agent Orange was tested, sprayed, or stored.''\3\ The American 
Legion, as one of the longest standing advocates for veterans exposed 
to environmental hazards, will continue the push to ensure that all 
those who have been affected and continue to suffer as a result of this 
exposure are cared for.
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    \3\ Resolution No. 199: Agent Orange

    The American Legion supports this bill.
 s. 845, a bill to amend title 38, united states code, to improve the 
    department of veterans affairs health professionals educational 
              assistance program, and for other purposes.
    To extend Department of Veterans Affairs Health Professional 
Scholarship Program until December 31, 2019; To repeal the cap on the 
amount of Education Debt Reduction Payments Under Department of 
Veterans Affairs Education Debt Reduction Program, and to stipulate 
that the maximum amount--the total amount payable to a participant in 
the Education Debt Reduction Program for any year may not exceed the 
amount of the principal and interest on certain loans paid by the 
individual during such year.
    The nation is facing an unprecedented health care shortage that 
could potentially have a profound impact on the care given to this 
Nation's veterans. Shortages in health care staff threaten the Veterans 
Health Administration's (VHA's) ability to provide quality care and 
treatment to veterans. These shortages also influence VHA's ability to 
provide timely access to quality care and, in some instances, its 
ability to provide certain types of care.
    The American Legion supports comprehensive efforts to establish VA 
as a competitive force in attracting and retaining health care 
personnel, especially nurses, essential to the mission of VA health 
care. The Federal Government estimates that, by 2020, nurse and 
physician retirements will create a shortage of about 24,000 physicians 
and almost 1 million nurses nationwide. The American Legion strongly 
believes that what happens at the Department of Veterans Affairs 
Medical Centers (VAMCs) often reflects the general state of affairs 
within the health care community as a whole.
    The Health Professionals Educational Assistance Program (HPEAP) and 
the VA Learning Opportunities Residency are the major education related 
programs currently in use to promote nurse recruitment and retention. 
HPEAP is comprised of the Employee Incentive Scholarship Program (EISP) 
and the Education Debt Reduction Program (EDRP). The EISP authorizes VA 
to award scholarships to employees pursuing degrees or training in 
health care disciplines for which recruitment and retention of 
qualified personnel is difficult. EISP awards cover tuition and related 
expenses such as registration, fees, and books. The academic curricula 
covered under this initiative include education and training programs 
in fields leading to appointments or retention in Title 38 or Hybrid 
Title 38 positions. The specific health care professions include: 
physician, dentist, podiatrist, pharmacist, licensed practical/
vocational nurse, expanded-function dental auxiliary, registered nurse, 
certified registered nurse anesthetist, physician assistant, 
optometrist, physical therapist, occupational therapist, certified 
respiratory therapy technician, and registered respiratory therapist.
    The Education Debt Reduction Program (EDRP) authorizes VA to 
provide education debt reduction payments to employees with qualifying 
loans who are recently appointed to positions providing direct-patient 
care services or services incident to direct-patient care services for 
which recruitment and retention of qualified personnel is difficult. 
The EDRP has been a powerful recruitment incentive for registered 
nurses.
    The American Legion is appreciative of the many contributions of 
VHA nursing personnel and recognizes their dedication to veterans who 
rely on VHA health care. Every effort must be made to recognize, reward 
and maximize their contributions to the VHA health care system because 
veterans deserve nothing less.

    The American Legion supports this bill.
        s. 851, caregivers expansion and improvement act of 2013
    To amend title 38, United States Code, to extend to all veterans 
with a serious service-connected injury eligibility to participate in 
the family caregiver services program
    Currently under title 38, only veterans who receive a serious 
injury (including Traumatic Brain Injury, psychological trauma, or 
other mental disorder) incurred or aggravated in the line of duty in 
the active military, naval, or air service on or after September 11, 
2001 are eligible for the family caregiver benefits. This bill would 
amend the law and afford all veterans with a serious injury, as 
defined, to be eligible to participate in the family caregivers service 
program.
    According to The American Legion's Resolution No. 126, Veterans 
Receive Same Level of Benefits, passed at National Convention 2012, 
``The American Legion urge[s] Congress to direct the Department of 
Veterans Affairs to provide the same level of benefits for any veteran, 
regardless of the dates or theater of operations during their military 
service.'' This legislation would ensure that veterans of every era 
receive the benefits they earned through their service. This would 
recognize that, for the purpose of receiving care for serious injuries 
incurred or aggravated in the line of duty, all service is equal. The 
American Legion, as the voice of America's wartime veterans, believes 
this is the right thing to do.

    The American Legion supports this bill.
             s. 852, veterans' health promotion act of 2013
    To improve health care furnished by the Department of Veterans 
Affairs by increasing access to complementary and alternative medicine 
and other approaches to wellness and preventive care, and for other 
purposes.
    While modern medicine has proven immensely powerful in finding 
treatments and cures for a host of health issues, there remain some 
areas in which so-called ``alternative'' medicine has proven just as, 
and at times perhaps more, effective. The Department of Veterans 
Affairs has been exploring Complementary and Alternative Medicine (CAM) 
since 2002. While a number of VA medical centers offer some sort of 
CAM, it is not currently offered in any uniform manner.
    The American Legion developed a Traumatic Brain Injury (TBI) and 
Post Traumatic Stress Disorder (PTSD) Ad Hoc Committee in 2010 to look 
to ``investigate the existing science and procedures, as well as 
alternative methods for treating TBI and PTSD currently being employed 
by the DOD and VA.'' The primary treatment of both agencies for TBI and 
PTSD were treatment of the symptoms, and in many cases, overuse or 
misuse of medications such as Risperidone, an anti-psychotic medication 
that had no therapeutic benefit to veterans. The evidence based 
treatments defined by DOD/VA's joint clinical practice guidelines are 
cognitive processing therapy, prolonged exposure therapy and 
antidepressants.
    The American Legion's TBI and PTSD Ad Hoc Committee's was concerned 
with the lack of research studies on new and innovative treatments such 
as Virtual Reality Therapy, Hyperbaric Oxygen Therapy and other 
complementary and alternative therapies. To this end, the Committee 
worked with the Veterans Affairs and Rehabilitation Commission to adopt 
American Legion Resolution No. 108, passed at the 2012 National 
Convention that stated that The American Legion recommends ``Congress 
and the Administration encourage acceleration in the development and 
initiation of needed research on conditions that significantly affect 
veterans--such as prostate cancer, addictive disorders, trauma and 
wound healing, PTSD, TBI, rehabilitation, and others--jointly with the 
Department of Defense, the National Institutes of Health, other Federal 
agencies, academic institutions and the Department of Veterans 
Affairs.''
    Unfortunately, most of the existing research for the last several 
years has validated the current evidence-based treatments being used. 
In addition, there seems to be no fast-track mechanism to employing 
innovative or novel therapies in a standardized way. This legislation 
would make important strides toward the implementation of alternative 
medicine by requiring VA to establish a minimum of one center of 
innovation for complementary and alternative medicine in health 
research, education, and clinical activities in each Veterans 
Integrated Service Networks (VISN). This legislation would also require 
the initiation of a pilot program to assess the feasibility and 
advisability of establishing complementary and alternative medicine 
centers within VA medical centers in order to promote the use and 
integration of complementary and alternative medicine services for 
mental health diagnoses and pain management. Finally, this legislation 
would require the VA to conduct a comprehensive study of the barriers 
encountered by veterans in receiving complementary and alternative 
medicine from the Department of Veterans Affairs.
    The American Legion believes that all possibilities should be 
considered in the attempt to find treatments and cures for these 
conditions which affect significant numbers of veterans, including 
alternative medicine, if it be shown to be effective, and that these 
treatments and cures should be available to all veterans, once they are 
verified.

    The American Legion supports this bill.
         s. xxx, the veterans affairs research transparency act
    To require the Secretary of Veterans Affairs to allow public access 
to research of the Department, and for other purposes.
    The mental health issues facing veterans, particularly with regard 
to Traumatic Brain Injury and Post Traumatic Stress Disorder, require 
collaboration between the Department of Veterans Affairs (VA), the 
Department of Defense (DOD), medical health professionals, The American 
Legion and Veteran Service Organizations (VSOs) in order to find cures 
and best-practice solutions. Therefore, it makes sense that the 
research efforts of VA and DOD should be available to VSOs and others 
in order to facilitate the necessary collaboration.
    The American Legion believes that the provisions in this bill would 
be beneficial by allowing for communication of what the VA and DOD have 
accomplished in their research efforts. This would allow The American 
Legion, along with other VSOs, and any other interested parties, to 
track and analyze the activities associated with the research in order 
to understand how the VA and DOD are working to solve issues related to 
veterans and servicemembers.
    The American Legion's Resolution No. 285 Traumatic Brain Injury and 
Post Traumatic Stress Disorder Programs, passed at National Convention 
2012, calls for direct collaboration between VA& DOD and the 
compilation of research of the two agencies in one location (including 
an office). Resolution No. 44 Decentralization of Department of 
Veterans Affairs Programs, passed in the Fall of 2012 by the National 
Executive Committee of The American Legion, calls for the 
decentralization of programs, especially IT, which will allow the VA 
Office of Research & Development to improve their IT technology in 
order to create the warehouse of research studies. The American Legion 
believes that this bill makes strides toward these ends.

    The American Legion supports this bill.
                                 ______
                                 
                Prepared Statement of Diane M. Zumatto, 
                 National Legislative Director, AMVETS
                              introduction
    Chairman Sanders, Ranking Member Burr and distinguished members of 
the Senate Veterans' Affairs Committee, it is my pleasure, on behalf of 
AMVETS, to offer this testimony on pending health care legislation.
    I would like to begin today by commending the Committee for all of 
its work on behalf of American veterans everywhere, especially its 
dedication to improving efficiencies by eliminating redundant and/or 
counterproductive programs and its unwavering commitment to all of the 
men and women whose job it is to protect and defend this country.
    As the United States absorbs the aftereffects of more than a decade 
of continuous war and in the face of the planned draw-down of military 
personnel, the VA health care system will be severely stressed to 
adequately meet the physical and mental health care needs of this 
Nation's veterans. Thanks to improvements in battlefield medicine, 
swift triage, aeromedical evacuations and trauma surgery, more combat-
wounded than ever before are surviving horrific wounds and will be 
needing long-term rehabilitation, life-long specialized medical care, 
sophisticated prosthetics, etc. Your committee has a responsibility to 
ensure that the VA and our Nation live up to the health care 
obligations imposed by the sacrifices of our veterans.
    It is encouraging to acknowledge at this time that, despite the 
extraordinary sacrifices being asked of our men and women in uniform, 
the best and the brightest continue to step forward to answer the call 
of our Nation in its time of need. I know that each of you is aware of 
and appreciates the numerous issues of importance facing our military 
members, veterans, retirees, families, and survivors, therefore this 
testimony will be, following these introductory remarks limited to 
specific health care legislation.
    I would also like to delineate several general issues that AMVETS 
would like the Committee to monitor and enforce as it goes about its 
work:

     ensure that the VA provides a continuity of health care 
across all the service branches and for all individuals who were 
wounded or injured in the line of duty including those who are ill due 
to their service;
     ensure that member of our Reserve Components not only have 
adequate access, but timely and appropriate treatment, for all of their 
physical and mental healthcare needs;
     continue to press the VA to work collaboratively with the 
DOD in creating and implementing a completely operational and fully 
integrated electronic medical records system;
     continue the strictest oversight to ensure the safety, 
physical and mental health and confidentiality of victims of military 
sexual trauma;
     ensure that the VA continues to provide competent, 
compassionate, high quality health care to all eligible veterans; and
     ensure that the VA continues to receive sufficient, timely 
and predictable funding for VA health care.
                    specific health care legislation
    S. 131: AMVETS fully supports this legislation which seeks to 
improve VA health care options for women veterans to include fertility 
counseling and treatment. Thanks to the proliferation of improvised 
explosive devices (IEDs) in Iraq and Afghanistan, the issues of 
urotrauma and infertility have become a growing concern among active 
military personnel and veterans.
    IEDs, which are generally detonated on the ground, can 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, 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 
or had their reproductive capabilities severely compromised.
    This legislation also requires the VA to provide reproductive 
counseling and treatment, including the use of assisted reproductive 
technology, to a spouse or surrogate of a severely wounded, Ill, or 
injured veteran who has an infertility condition incurred or aggravated 
in the line of duty. AMVETS believes that this aspect is of critical 
importance to the intent of this legislation.
    Another important aspect of this bill the requirement to facilitate 
research conducted by DOD and HHS with the intent of improving VA's 
ability to meet the long-term reproductive health care needs of 
veterans who have incurred service-connected uro-trauma or other line 
of duty injuries that affect a veterans' ability to reproduce.
    AMVETS fully supports all of the provisions of this legislation and 
feels strongly that these disabilities are not merely health issues; 
they are quality of life issue as well.

    S. 325: AMVETS supports this legislation which seeks to amend title 
38, United States Code, to increase the maximum age for children 
eligible for medical care under the CHAMPVA program. AMVETS sees this 
as an equity issue since the expansion of eligibility for CHAMPVA for 
eligible children up to age 26 is in line with provisions in both the 
Patient Protection and Affordable Care Act (ACA) and the TRICARE Young 
Adult benefit.
    According to a new GAO Report on the relationship of TRICARE and VA 
care to the ACA, ``[the] ACA requires that if a health insurance plan 
provides for dependent coverage of children, the plan must continue to 
make such coverage available for an adult child until age 26. This 
requirement relating to coverage of adult children took effect for the 
plan years beginning on or after September 23, 2010. Under ACA, both 
married and unmarried children qualify for this coverage. The 
authorizing statute for CHAMPVA currently does not conform to this 
requirement.''
    AMVETS appreciates the concern expressed in this legislation for 
the sacrifices of children who have had their lives negatively impacted 
by:

     the loss of a veteran-parent's mobility;
     the battlefield death of a veteran-parent; and/or
     the loss of a veteran-parent due to a chronic, service-
connected condition.

    S. 852: AMVETS supports this legislation which seeks to improve 
health care provided by the VA by increasing access to complementary/
alternative medicine and innovative approaches to wellness/preventative 
care. This is a multi-part piece of legislation with several important 
and specific requirements including:

     the designation and operation of centers of innovation for 
complementary/alternative medicine;
     a pilot program on the establishment of complementary/
alternative medicine centers within VA medical centers;
     a pilot program on the use of wellness programs;
     a pilot program on health promotion for overweight/obese 
veterans;
     a pilot program on health promotion for veterans through 
the establishment of VA fitness facilities; and
     a study on the barriers veterans face in receiving 
complementary/alternative medicine

    Considering the stress being put on the VA's traditional clinical 
services, AMVETS believes that this legislation, by promoting wellness 
and preventative medicine, will both improve timely access to services 
and provide cost-effective treatment options for all participants of 
the VA's health care system.
    AMVETS believes that veterans should be afforded the opportunity to 
utilize alternative medical therapies to help ameliorate the effects of 
any chronic or residual mental and/or physical distress they may be 
experiencing. The term ``alternative therapy'' covers a wide variety of 
treatments, which would vastly expand the health care options available 
to veterans including:

     exercise therapy;
     acupuncture;
     group experiential activities;
     chiropractic therapy; and
     other forms of unorthodox medical treatment.

    These alternative health care options might provide stand alone or 
coordinated treatment options which could not only provide better 
results but would be more cost effective too.
                                 ______
                                 
Prepared Statement of Anthony A. Wallis, Legislative Director/Director 
    of Government Affairs, The Association of the United States Navy
Regarding Consideration of S. 629, The Honor America's Guard and 
        Reserve Retirees Act
                              introduction
    Chairmen, Ranking Member and Members of the Senate Veterans' 
Affairs Committee, the Association of the United States Navy (AUSN) 
would like to thank you and the Committee for the work that you do in 
support of our Navy, retirees and Veterans, as well as their families. 
Your hard work has allowed significant progress in creating legislation 
that has left a positive impact on our military community. AUSN 
supports legislation seeking the classification of certain affected 
groups of our Navy Reservists as Veterans of the Armed Forces.
                              the problem
    Currently, a problem exists whereby a Reserve Component member can 
successfully complete a military career, 20 plus years, but not earn 
the title of ``Veteran of the Armed Forces of the United States,'' 
unless he or she served on Title 10, U.S. Code, Active Duty for other 
than training purposes for a period consisting of over 180 consecutive 
days of Active Duty service. Drill training, annual training, Active 
Duty for training and Title 32 duty are not deemed qualifying service 
to qualify for ``Veteran'' status under the current definition. For 
instance, the service of our Guard and Reserve members in Operation 
Noble Eagle (ONE) would not qualify to earn the status of ``Veterans of 
the Armed Forces,'' because it is technically a ``training'' status. 
The same goes for those Guard and Reserve members who served in 
Southern Border Security missions, as well as those who served in 
Hurricane Sandy, Hurricane Katrina and other disaster relief missions. 
Reserve Component members in the aforementioned operations have 
performed countless tasks that contribute to the overall well-being of 
the populace. In addition, the U.S. Navy has orders often written for 
``training'' due to funding reasons. However, the fact may be that the 
mission could be considered Active Duty, further excluding Navy 
Reservists from qualifying under the current definition of ``Veteran.''
    Section 101(2) of Title 38, U.S. Code provides the basic definition 
of the term ``Veteran'' for purposes of benefits under laws 
administered by the Department of Veterans Affairs (VA). The term 
``Veteran'' is used repeatedly in Title 38, U.S. Code, to identify an 
individual, ``who is eligible for benefits by virtue of his or her 
service.'' The Section 101(2) definition establishes a standard 
regarding the quality of active service which dictates eligibility for 
Veterans' benefits. (www.va.gov/ogc/docs/1991/PREC_61-91.doc)
    Many of these affected Reserve Component members, despite never 
being called to Title 10, U.S. Code, Active Duty, already receive many 
of the same benefits as their full-time counterparts, placing them 
within the thinking behind the current definition of ``Veteran.'' 
However, these affected Reserve Component members, classified as 
retirees but not Veterans due to the consecutive service day 
parameters, are already eligible for benefits such as TRICARE, GI Bill 
benefits and Reserve Retirement Pay. Current Veterans that fulfill the 
180 consecutive days are eligible for these same benefits, leaving 
these Retirees in `limbo', not knowing if they are classified to be a 
Veteran.
    According to the Defense Manpower Data Center (DMDC), currently 
over 280,000 Reservist Component members and, in particular, nearly 
46,000 Navy Reservists across the country could be affected by this 
problem.
                                solution
    AUSN applauds the Senate for the introduction of S. 629, the Honor 
America's Guard and Reserve Retirees Act, which would rightfully grant 
full Veteran status to members of the Reserve Component who have served 
at least 20 years but have not been called for the Active Duty 
parameters required under the current definition. AUSN was pleased to 
see that the bill was introduced earlier this year by Senator Mark 
Pryor (D-AR) and is continuing to garner support from a bipartisan list 
of cosponsors including Senators John Boozman (R-AR), Mark Begich (D-
AK), Al Franken (D-MN), Chuck Grassley (R-IA), Tom Harkin (D-IA) Tim 
Johnson (D-SD), Patrick Leahy (D-VT), Jon Tester (D-MT), and Ron Wyden 
(D-OR), Kirsten Gillibrand (D-NY), Jeff Sessions (R-AL), Amy Klobuchar 
(D-MN), Mazie Hirono (D-HI) and Mike Crapo (R-ID). S. 629 would 
authorize Veteran status under Title 38 for Guard and Reserve members 
of the Armed Forces who are entitled to a non-regular retirement under 
Chapter 1223 of 10 U.S.C. but were never called to active Federal 
service during their careers through no fault of their own. In the 
112th Congress, the bill passed through the House in the form of H.R. 
1025 by Unanimous Consent. Now, having passed through the House 
Veterans' Affairs Committee (HVAC), Subcommittee on Disability 
Assistance and Memorial Affairs (DAMA) last month and on its way to 
Full Committee consideration, currently in the form of H.R. 679, AUSN 
hopes the Senate will approve S. 629 as well.
                          unwarranted concerns
    Critics have suggested that this bill is not needed since these 
Reserve Component members already receive many of the same benefits. 
Reserve military service opens eligibility to certain benefits provided 
the member meets the specific criteria established in law. As 
previously noted, Reservists already can qualify for certain Veterans' 
benefits, such as educational benefits under Chapter 1606, 10 U.S.C. 
for an initial enlistment of 6 years in the Selected Reserve; VA-backed 
home mortgage loans upon completion of 6 years' Reserve service; 
Servicemembers Group Life Insurance (SGLI) managed by the VA while 
serving in the National Guard or Reserve Burial in a national cemetery 
if qualified for a Reserve retirement at age 60. Ironically, however, 
20+ year career Reservists who have earned specified Veterans' benefits 
but never served on Active Duty orders are not ``Veterans of the Armed 
Forces.''
    Critics have also suggested that expanding the definition of 
``Veteran'' to include these Reserve Component members could lead to 
bestowing additional benefits they currently do not receive. This 
argument is not sound, as Section 2(b) of the bill states stronger 
language than similar legislation in previous years with a provision of 
``Clarification Regarding Benefits,'' which states ``No person may 
receive any benefit under the laws administered by the Secretary of 
Veterans Affairs solely by reason [of passage of this act].'' As a 
result, the Congressional Budget Office (CBO) has scored this bill at 
zero cost. Concerns about Congress passing legislation to bestow 
additional benefits as a result of this change in the future would be 
even more difficult if S. 629, and H.R. 679, passes as the anti-
benefits language would be codified. Thus, it is in the best interest 
of critics to have this bill passed so as to not confer additional 
benefits in the future.
    All said, there are three main reasons for this legislation. First, 
honor. Honor is important to those who have volunteered to serve the 
Nation in uniform. Second, for decades Guard and Reserve Component men 
and women have performed military missions at home and overseas but 
because of accounting technicalities, including funding sources and 
duty codes, their military missions were not considered valid active 
duty work; i.e., they performed the mission, but the orders did not 
credit the work as Active Duty. Thus, their very real contributions to 
the national security appear underappreciated, leaving them in a no-
man's land of ``non-Veteran'' status. Third, the bill simply provides 
statutory and public recognition that a full career of service in 
uniform qualifies a person with recognition as a Veteran. Career 
reservists have earned specific military retirement and Veterans' 
benefits but technically are excluded from being recognized as Veterans 
under the law.
    However, if the arguments stated above are not evidence enough, 
there is another positive impact that passage would have.
                       potential economic impact
    This zero-cost bill has the potential to help combat high levels of 
unemployment among the Reserve Component community, including the 
approximately 101,000 Gulf War era Reservist and National Guard 
personnel who are currently unemployed in this country. The Reserve 
Component currently suffers from rather high unemployment, as stated in 
data from a recent House Veterans' Affairs, Subcommittee on Economic 
Opportunity hearing on 14 March 2013.
    During the hearing, according to Ronald D. Young, Director of 
Family and Employer Program and Policy for the Department of Defense, 
overall Guard and Reserve unemployment stood at 13.1% for 
February 2013. For E-1s and E-4s, according to Young, the unemployment 
rate soared to 23%. However, the overall Guard and Reserve figures 
following the latest status of force survey, now stand at 11%, with 
junior enlisted at 18% compared to the original 23%. Also testifying 
was Major General Terry M. Haston, Adjutant General for the Tennessee 
National Guard and Major Ty Shepard, Director of the California 
National Guard Employment Initiative, who provided state-level 
perspectives on Guard and Reserve unemployment. Major General Haston 
described returning deployed units as suffering from a 25-30% 
unemployment rate, while, Major Shepard noted that units returning from 
deployment had even suffered in the past from ``unemployment rates well 
over 50%.''
    With such high unemployment rates among the Reserve Component one 
may conclude that by providing ``Veteran'' status to affected 
Reservists, employment opportunities may be available for them to be 
hired by employers that actively seek Veterans in the workplace.
                                summary
    In conclusion, S. 629 would not bestow any benefits other than the 
honor of claiming Veteran status for those who honorably served and 
sacrificed as career Reserve Component members. AUSN believes that our 
Reserve Component deserve nothing less. We look forward to hearing of 
the progress of this legislation and welcome any questions or concerns 
you or your staff may have.
    AUSN continues to stand ready to be the Voice for America's 
Sailors, abroad and upon their return home, and looks forward to 
working with Congress and the VA on serving our Veterans. Thank you.
                                 ______
                                 
 Prepared Statement of Thomas Zampieri, Ph.D., Director of Government 
                Relations, Blinded Veterans Association
                              introduction
    The Blinded Veterans Association (BVA) is the only congressionally 
chartered Veterans Service Organization exclusively dedicated to 
serving the needs of our Nation's blinded veterans and their families. 
The organization has served blinded veterans for 68 years. On behalf of 
BVA, thank you for this opportunity to submit for the record on the 
current legislation before the Committee on VA Health Care Programs. 
Chairman Sanders, Ranking Member Burr, and members of the Senate VA 
Committee, thank you for the changes you already have made to 
Beneficiary Travel in recent years, and today we appreciate the 
introduction of S. 633 and S 455 both to improve the access for 
disabled blind and spinal cord injured veterans who require services at 
the VA specialized Blind Rehabilitation Centers (BRCs) and Spinal Cord 
Injury Centers (SCIs) and authorize local VA personnel to transport 
veterans who are unable to use volunteer vans for transportation.
Beneficiary Travel for Blinded Veterans: S. 633
    BVA thanks Senator Tester for introducing S. 633 and S. 455. We 
also express appreciation to Congresswoman Brownley for H.R. 1284 the 
companion House legislation for disabled SCI and blinded veterans who 
are currently ineligible for travel benefits. This bill would assist 
mostly low-income and catastrophically disabled veterans by removing 
the travel financial burdens to access vital care that improve 
independence and quality of life. Veterans who must currently shoulder 
this hardship, which often involves airfare, can be discouraged by 
these costs to travel to a BRC or SCI site. The average age of veterans 
attending a BRC is 67 because of the high prevalence of degenerative 
eye diseases in this age group.
    It makes little sense to have developed, over the past decade, 
outstanding blind rehabilitation programs with 13 Blind Centers and 
with high quality inpatient specialized services, only to tell low 
income, non-service-connected disabled blinded veterans that they must 
pay their own travel expenses to access the training they need. To put 
this dilemma in perspective, a large number of our constituents are 
living at or below the poverty line while the VA Means threshold for 
travel assistance sets $14,340 as the income mark for eligibility to 
receive the benefit. VA utilization data revealed that one in three 
veterans enrolled in VA health care was defined as either a rural 
resident or a highly rural resident. The data also indicate that 
blinded veterans in rural regions have significant financial barriers 
to traveling without utilization of public transportation.
    To elaborate on the challenges of travel without this financial 
assistance analysis confirmed that rural veterans are a slightly older 
and a more economically disadvantaged population than their urban 
counterparts. Twenty-seven percent of rural and highly rural veterans 
were between 55 and 64. Similarly, approximately 25 percent of all 
enrolled veterans fell into this age group.\1\ In FY 2007, rural 
veterans had a median household income of $19,632, 4 percent lower than 
the household income of urban veterans ($20,400)\2\. The median income 
of highly rural veterans showed a larger gap at $18,528, adding 
significant barriers to paying for air travel or other public 
transportation to enter a BRC or SCI rehabilitation program. More than 
70 percent of highly rural veterans must drive more than four hours to 
receive tertiary care from VA. Additionally, states and private 
agencies do not operate blind services in very rural regions. In fact, 
almost all private blind outpatient agency services such as Lighthouse 
for Blind are all located in large urban cities and majority are 
established as all outpatient visits again barrier for rural veterans 
traveling long distances every day to get training verses VA 
rehabilitation centers. With the current economic problems with state 
budgets clearly in view, we expect further cuts to these types of state 
social services that will bring even more challenges to the disabled in 
rural regions.
---------------------------------------------------------------------------
    \1\ Department of Veterans Affairs, Office of Rural Health, 
Demographic Characteristics of Rural Veterans Issue Brief (Summer 
2009).
    \2\ VSO IB 2013 Beneficiary Travel pg 119-120, 124-125.
---------------------------------------------------------------------------
    Consider the following facts:

     In a study of new applications for recent vision loss 
rehabilitation services, 7 percent had current major depression and 
26.9 percent met the criteria for subthreshold depression.\3\
---------------------------------------------------------------------------
    \3\ Horowitz et al. 2005, Major and Subthreshold Depression Among 
Older Adults Seeking Vision Rehabilitation Services The Silver Book 
2012, Volume II pg 9 [email protected]
---------------------------------------------------------------------------
     Vision loss is a leading cause of falls in the elderly. 
One study found that visual field loss was associated with a six-fold 
risk of falls.\4\
---------------------------------------------------------------------------
    \4\ Ramratten, et al. 2001 Arch Ophthalmology 119(12) 1788-94. 
Prevalence and Causes of Visual Field Loss in the Elderly, 
www.Silverbook.org/visionloss Silver Book, Volume II 2012 pg 9.
---------------------------------------------------------------------------
     While only 4.3 percent of the 65 and older population 
lives in nursing homes, that number rises to 6 percent of those who are 
visually impaired, and 40 percent of those who are blind and Medicaid 
direct costs of $11 Billion per year.\5\
---------------------------------------------------------------------------
    \5\ Rein, David B., et al. 2006 The Economic Burden of Major Adult 
Visual Disorders in the U.S. www.Silverbook.org/visionloss Silver Book, 
Volume II 2012 pg 9.
---------------------------------------------------------------------------
     Individuals who are visually impaired are less likely to 
be employed-44 percent are employed compared to 85 percent of adults 
with normal vision in working population age 19-64.\6\
---------------------------------------------------------------------------
    \6\ Rein, et al. The Economic Burden of Major Adult Vision 
Disorders in the U.S. 2006 www.Silverbook.org/visionloss Volume II 
pg 10.

    If blinded veterans are not able to obtain the blind center 
training to learn to function at home independently because of travel 
cost barriers, the alternative--institutional care in nursing homes--
may be far more expensive. The average private room charge for nursing 
home care was $212 daily ($77,380 annually), and for a semi-private 
room it was $191 ($69,715 annually), according to a MetLife 2008 
Survey. Even assisted living center charges of $3,031 per month 
($36,372) rose another 2 percent in 2008. BVA would point to these more 
costly alternatives in describing the advantages of VA Beneficiary Care 
so that veterans can remain in their homes, functioning safely and 
independently, and with the rehabilitation training needed to re-enter 
the workforce.
    We caution that private agencies for the blind are almost always 
outpatient centers and located in large urban cities. Many rural states 
have no vision rehabilitation centers and they do not have the full 
specialized nursing, physical therapy, audiology, pharmacy, radiology 
or laboratory support services that are necessary for the clinical care 
that VA BRCs and SCIs provide. BVA requests that private agencies 
demonstrate peer reviewed quality outcome measurements that are a 
standard part of VHA Blind Rehabilitative Service and they must be 
accredited by either the National Accreditation Council for Agencies 
Serving the Blind and Visually Handicapped (NAC) or the Commission on 
Accreditation of Rehabilitation Facilities (CARF). Blind Instructors 
should be certified by the Academy for Certification of Vision 
Rehabilitation and Education Professionals (ACVREP).
S. 455, Proposed Program Change in Law:
    Current Law or Practice: Under 38 U.S.C. 111A, the Secretary has 
the authority to transport any Veteran to or from a VA facility or 
other place in connection with vocational rehabilitation, counseling, 
or for the purpose of examination, treatment, or medical care. Last 
session 112th Congress this Committee passed Public Law 112-260, 
section 202 that revised VA's transportation authority's providing VA 
the authority to supplement volunteer drivers with VA staff to drive 
VTS vehicles which BVA supports. The clarifying authority established 
under Public Law 112-260 expires on January 10, 2014 unless Congress 
acts though and must be changed.
    BVA supports proposed legislation to extend this recently enacted 
provision, change Title 38 U.S.C. Sec. 111A that authorized VA to 
transport any person to or from a VA facility or other place in 
connection with vocational rehabilitation or counseling required by the 
Secretary pursuant to chapter 34 or 35 of Title 38, or for the purpose 
of examination, treatment, or care. This authority was enacted in 
January 2013 under Public Law 112-260, Section 202, of the Dignified 
Burial and Other Veterans' Benefits Improvement Act of 2012 and expires 
one year after the data of enactment. This proposal would extend the 
authority for an additional five years.
    VA launched a Veterans Transportation Service (VTS) initiative in 
2010 to enhance, support, and organize transportation efforts for 
Veterans by VA health care facilities to improve access. Through the 
VTS program, VA provided funding to local VA facilities for mobility 
managers, transportation coordinators and vehicles to complement the 
existing access to care that volunteers already provide. The service 
provides Veterans with the ability to be transported to and from their 
VA health care appointments. Between October 2011 and May 2012, VTS 
transported more than 43,000 Veterans door to door, making more than 
50,000 trips that totaled more than 2.1 million miles.
    The average length of a trip is almost 60 miles--a considerable 
distance in some rural communities, and a prohibitive distance for 
those with poor health if transportation was not available. However, 
with increasing numbers of transportation-disadvantaged Veterans, there 
simply are not enough volunteers in all regions of the country to 
sustain the current level of service. Furthermore, volunteer drivers 
generally do not transport Veterans who are not ambulatory, require 
portable oxygen, have undergone a procedure involving sedation, or have 
other clinical issues.
    Additionally, some volunteers, for valid reasons, are reluctant to 
transport nonambulatory or very ill Veterans. We have had reports of 
volunteer drivers not assisting blinded veterans in walking out to find 
the vans when parked in various locations, whereas VA employees will 
assist the veteran. Section 111A allows VA to supplement volunteer 
drivers with VA staff to drive the VTS vehicles for one year and VHA 
has stated its full support for this law. Without the proposed 
extension, it is possible that VTS will need to be significantly 
reduced or curtailed in January 2014, particularly in rural areas of 
the country.
    S. 325: BVA supports this bill to amend title 38 U.S.C., to 
increase the maximum age for children eligible for medical care under 
the CHAMPVA program that would allow same coverage mandated in other 
current Federal programs. Dependent children who currently turn age 21 
have loss of coverage under CHAMPVA and have difficulty finding and 
being able to afford health insurance.
    S. 522: BVA supports Senator Durbin's bill to require the Secretary 
of Veterans Affairs to award grants to establish, or expand upon, 
master's degree or doctoral degree programs in orthotics and 
prosthetics, and for other purposes. The VA population of disabled 
veterans requires more advanced degree specialists in the area of 
prosthetics as technological advances are made in these devices. VA 
must have the ability to provide support for these orthotics and 
prosthetic specialists.
    S. 845: BVA supports extension of the Department Veterans Affairs 
Health Professional Educational Assistance Program. This program is 
valuable as recruiting and retention tool for allied health care 
professionals and allows VA to be competitive in assisting employees in 
advancing in their college degrees.
    S. 851: Chairman of the Senate Veterans' Affairs Committee Bernie 
Sanders introduced S. 851, the Caregivers Expansion and Improvement Act 
of 2013.
    BVA strongly supports this bill as it would expand eligibility for 
comprehensive benefits and services to family caregivers of all 
veterans who were severely injured in the line of duty while serving in 
the Armed Forces. Currently, only family caregivers of veterans 
severely injured on or after September 11, 2001, are eligible for these 
benefits and services such as: caregiver training; support groups, 
counseling and other support services; a monthly stipend; health 
coverage through CHAMPVA; respite care; mental health services and 
counseling related to the caregiver role and burden. Our 
catastrophically disabled service-connected veterans from previous wars 
caregivers have sacrificed for decades trying to keep their family 
member at home. They should have the same Caregiver support as in the 
current law for Post-9/11 veterans.
                               conclusion
    Chairman Sanders and Ranking member Burr, BVA again expresses its 
support for these proposed changes to VHA programs listed above and 
will limit our submission to those because we have no resolutions on 
some of the other bills being considered here today. BVA requests 
support for these bills which will ensure that VHA can improve care and 
access for disabled veterans. BVA appreciates the opportunity to 
provide this statement for the record today.
                                 ______
                                 
    Prepared Statement of Consortium of Academic Health Centers for 
                          Integrative Medicine


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


                                 ______
                                 
                  Prepared Statement of Joy J. Ilem, 
    Deputy National Legislative Director, Disabled American Veterans
    Chairman Sanders, Ranking Member Burr and Members of the Committee: 
On behalf of the DAV (Disabled American Veterans) and our 1.2 million 
members, all of whom are wounded and injured veterans, I am pleased to 
present our views on several of the legislative measures that are of 
particular interest to the Committee or to DAV and our members.
               s. 49, veterans health equity act of 2011
    This measure would require availability of at least one full-
service Department of Veterans Affairs (VA) hospital or comparable 
services be provided through contract, in each of the 48 contiguous 
states.
    Arguments have been made that New Hampshire is the only lower 48 
state without a VA full-service medical center and that most ill 
veterans in that state routinely must drive or be transported to Boston 
for more comprehensive health care services. Members of Congress have 
stated they are particularly concerned that the sickest and generally 
very elderly veterans with complex and chronic health problems were 
subjected to having to first report to the VA's Manchester facility--
which could be up to a three-hour drive--and then continue on for 
another hour to the Boston VA Medical Center (VAMC) or other VA 
provider sites, in order to receive their care. It was also noted 
(during her first term) by Representative Shea-Porter of New Hampshire, 
that it may not be fiscally responsible, given the veteran population 
of New Hampshire, to force VA to directly provide a full continuum of 
hospital services, and that contracting for such services may be a 
better option.
    Convenient access to comprehensive VA health care services remains 
a problem for many of our Nation's sick and disabled veterans. While VA 
must contract or use fee-basis arrangements to provide care to some 
veterans, it maintains high quality care and cost effectiveness by 
providing health services directly within the system. According to VA, 
the Manchester VAMC in New Hampshire provides urgent care, mental 
health and primary care services, ambulatory surgery, a variety of 
specialized clinical services, hospital based home care and inpatient 
long-term care. In addition, community-based outpatient clinics (CBOCs) 
are located in Somersworth, Tilton, Portsmouth, Littleton and Conway.
    In light of the escalating costs of health care in the private 
sector, and to its credit, VA has done a remarkable job of providing 
high quality care and holding down costs by effectively managing in-
house health programs and services for veterans. However, outside care 
coordination is poorly managed by VA. When it must send veterans 
outside the system for care, those veterans lose the many safeguards 
built into the VA system through its patient safety program, evidence-
based medicine, electronic health records, and bar code medication 
administration program (BCMA). The proposal in S. 49 to use broad-based 
contracting for necessary hospital services in the New Hampshire area 
concerns us because these unique internal VA features noted above 
culminate in the highest quality care available, public or private. 
Loss of these safeguards, which are generally not available in private 
sector health systems, equate to diminished oversight and coordination 
of care, and, ultimately, may result in lower quality of care for those 
who deserve it most. However, we agree that VA must ensure that the 
distance veterans travel, as well as other hardships they face in 
gaining access, be considered in VA's policies in determining the 
appropriate locations and settings for providing VA health care 
services.
    In general, current law places limits on VA's ability to contract 
for private health care services in instances in which VA facilities 
are incapable of providing necessary care to a veteran; when VA 
facilities are geographically inaccessible to a veteran for necessary 
care; when medical emergency prevents a veteran from receiving care in 
a VA facility; to complete an episode of VA care; and for certain 
specialty examinations to assist VA in adjudicating disability claims. 
VA also has authority to contract for scarce medical specialists in VA 
facilities, and to share health resources with community providers. 
Beyond these limits and outside certain ongoing rural health 
initiatives by VHA, there is no general authority in the law to support 
broad-based contracting for the care of populations of veterans, 
whether rural or urban.
    DAV believes that VA contract care for eligible veterans should be 
used judiciously and only in these authorized circumstances so as not 
to endanger VA facilities' ability to maintain a full range of 
specialized inpatient and outpatient services for all enrolled 
veterans. VA must maintain a ``critical mass'' of capital, human, and 
technical resources to promote effective, high-quality care for 
veterans, especially those with complex health problems such as 
blindness, amputations, spinal cord injury, Traumatic Brain Injury or 
chronic mental health problems. Putting additional budget pressures on 
this specialized system of services without making specific 
appropriations available for new VA health care programs would only 
exacerbate the problems currently encountered.
    Nevertheless, after considerable deliberation, and in good faith to 
be responsive to those who have come forward with legislative proposals 
such as S. 49, to offer alternatives to VA health care and VA's flawed 
fee-basis program, VA has developed and is implementing a new, 
nationwide program entitled ``Patient Centered Community Care (PCCC).'' 
As we understand the concept, VA will be awarding contracts to 
intermediary managed-care firms that will, in turn, establish networks 
of providers and facilities for referred veterans when VA's internal 
resources are not available or are insufficient to meet known needs, 
when academic affiliates cannot meet them, and when no preexisting VA-
contracted provider can provide for that need. We are optimistic that 
the principles of our recommendations from the ``Contract Care 
Coordination'' section of the FY 2014 Independent Budget will be used 
to guide VA's approaches in this new effort. We support the requirement 
that firms that are awarded these PCCC contracts must agree to meet a 
number of VA's standards for quality, safety, data security, records 
management, etc.
    VA must work to improve access for veterans that are challenged by 
long commutes and other obstacles in getting reasonable access to a 
full continuum of health care services at VA facilities and explore 
practical solutions when developing policies in determining the 
appropriate location and setting for providing VA health care services. 
We believe that the PCCC initiative may offer a practical resolution to 
this longstanding dilemma.
         s. 62, check the box for homeless veterans act of 2013
    S. 62 would amend the Internal Revenue Code of 1986 to allow 
taxpayers at the time of filing the tax return to designate any 
overpayment of taxes not less than $1.00, as well as make additional 
contributions to the Homeless Veterans Assistance Fund. It also notes 
that the Secretary could designate another time other than at the 
filing of a tax return to make a contribution to the fund. This 
addition to the Internal Revenue Code would also be coupled with the 
creation of a trust fund to become known as the Homeless Veterans 
Assistance fund which would use contributions to develop and implement 
new and innovative strategies to prevent and end veteran homelessness 
as well as toward implementation of current homeless programs in the 
Department of Veterans Affairs, the Department of Labor Veterans' 
Employment and Training Service, and the Department of Housing and 
Urban Development. These Departments will also include a description of 
the use of the funds from the previous fiscal year, beginning with FY 
2014, in the President's annual budget submission.
    DAV Resolution 234 urges Congress to sustain sufficient funding to 
support VA's initiative to eliminate homelessness among veterans and 
strengthen the capacity of the VA Homeless Veterans Program, to 
include: increasing its mental health and substance-use disorder 
programs capacity, provide vision and dental care services to homeless 
veterans as required by law, and improve its outreach efforts to help 
ensure homeless veterans gain access to VA's specialized health and 
benefits programs. Additionally, we urge Congress to continue to 
authorize and appropriate funds for competitive grants to community-
based and public organizations including the Department of Housing and 
Urban Development to provide health and supportive services to homeless 
veterans placed in permanent housing.
    Although this bill would provide additional funding to support VA's 
Homeless Program and initiatives to prevent and end veterans' 
homelessness DAV has no specific resolution from our membership related 
to this funding being provided on a voluntary basis from the American 
public. Therefore, we take no position on this bill.
 s. 131, women veterans and other health care improvements act of 2013
    Sections 2 through 8 of the bill would require VA to provide 
fertility counseling and treatment for spouses or surrogates of 
severely wounded, ill, or injured veterans (enrolled in the VA health 
care system) who have infertility conditions incurred or intensified in 
the line of duty. In addition to fertility counseling and treatment, 
adoption assistance may be provided for covered veterans. The Secretary 
of Veterans Affairs would be required to prescribe regulations on the 
furnishing of fertility treatment to veterans and annually report to 
the Committee on Veterans' Affairs of the Senate and House of 
Representatives on such treatment provided to veterans.
    The bill instructs the Secretary of Veterans Affairs to facilitate 
reproductive and infertility research conducted collaboratively by the 
Secretary of Defense and the Director of the National Institutes of 
Health to find ways to meet the long-term reproductive health care 
needs of veterans who have a service-connected genitourinary disability 
or a condition that was incurred or aggravated while serving on active 
duty, such as spinal cord injury, that affects their ability to 
conceive. The Secretary would ensure that any information produced by 
the research deemed useful for other activities of the VHA be 
disseminated throughout the VHA and report to Congress on the research 
activities conducted within three years after the date of enactment.
    While DAV has no specific resolution from our membership related to 
reproductive and infertility research and fertility counseling and 
treatment, this section of the bill is focused on improving the 
Departments' ability to meet the long-term reproductive health care 
needs of veterans who have a service-connected injury or condition that 
affects the veteran's ability to conceive. For these reasons, DAV has 
no objection to the passage of these sections of the bill.
    Section 9 of this bill requires that the Secretary of Veterans 
Affairs enhance the capabilities of the VA Women Veterans Call Center 
by responding to requests by women veterans for assistance with 
accessing health care and benefits and by referring such veterans to 
community resources to obtain assistance with services not furnished by 
VA. Since introduction of this measure, VA has launched a new hotline, 
1-855-VA-WOMEN, to receive and respond to questions from veterans, 
their families and caregivers about VA resources available to women 
veterans. We are pleased that VA has added this service, similar to the 
provisions proposed in this section of the bill, and is making progress 
to better communicate and inform women veterans of their benefits, 
specialized services and health care options. We recommend VA provide 
periodic updates to the Committee and veterans service organizations 
related to the number of women veterans calling the hotline and the 
types of requests for information received to assess its effectiveness.
    Sections 10 and 11 of the bill seek to modify the pilot program of 
counseling women veterans newly separated from active duty in retreat 
settings by increasing the number of locations from three to fourteen 
and by extending the time of the pilot program from two years to four 
years. The bill also directs the Secretary to carry out a pilot program 
of providing child care assistance to veterans receiving or in need of 
VA readjustment counseling and related mental health services or other 
intensive health care services in at least three Veterans Integrated 
Service Networks and in no fewer than three Readjustment Counseling 
Service Regions.
    Child care assistance under this subsection may include: stipends 
for the payment of child care offered by licensed child care centers 
either directly or through a voucher program; payments to private child 
care agencies; collaboration with facilities or programs of other 
Federal departments or agencies; or other forms of assistance as the 
Secretary considers appropriate. When the child care assistance under 
this subsection is provided as a stipend, it must cover the full cost 
of such child care.
    Section 12 of the bill directs the Secretary to impose a contractor 
user fee for each contract entered into by the VA for goods or services 
as a term of the contract. The fee amount is to equal 7 percent of the 
total value of the contract and authorizes the Secretary to waive the 
fee if the contractor is an individual or a small business. This bill 
would also establish a VA Fertility Counseling and Treatment Fund in 
the Department of the Treasury and all funds received as a result of 
the contractor user fee imposed by this section would be deposited into 
the Fund.
    We support the Committee's continued efforts on improving VA's 
women veterans health programs and services and are pleased to support 
this bill in keeping with DAV Resolution 213. DAV has heard positive 
feedback related to the pilot program of counseling women veterans 
newly separated from active duty in retreat settings and the child care 
pilots established by Public Law 111-163 and look forward to a full and 
comprehensive report from VA on these initiatives. We supported the 
original provisions for these pilot programs and are pleased to support 
the proposal to expand them.
            s. 229, corporal michael j. crescenz act of 2013
    S. 229 would designate the Department of Veterans Affairs medical 
center located at 3900 Woodland Avenue in Philadelphia, Pennsylvania, 
as the ``Corporal Michael J. Crescenz Department of Veterans Affairs 
Medical Center.'' DAV has no national resolution on this issue and has 
no national position on this bill; however, we leave the decision up to 
the local DAV leadership in Pennsylvania.
s. 287, to amend title 38, united states code, to expand the definition 
      of homeless veteran for purposes of benefits under the laws 
           administered by the secretary of veterans affairs
    This bill seeks to amend Section 2002(1) of title 38, United States 
Code, by striking `in section 103(a) of the McKinney-Vento Homeless 
Assistance Act (42 U.S.C. 11302(a))' and inserting `in subsection (a) 
or (b) of section 103 of the McKinney-Vento Homeless Assistance Act (42 
U.S.C. 11302)'. This change would expand the definition of a homeless 
veteran by including veterans who are fleeing, or attempting to flee, 
domestic violence, dating violence, sexual assault, stalking, or other 
dangerous or life-threatening conditions in the individual's or 
family's current housing situation, including where the health and 
safety of children are jeopardized, and who have no other residence and 
lack the resources or support networks to obtain other permanent 
housing.
    Currently, in order to qualify for assistance under the homeless 
veteran programs governed by title 38 of the U.S. Code, veterans must 
meet the definition of ``homeless veteran.'' This term may appear 
straightforward but it has two layers, the first of which is the 
definition of ``veteran'' which for purposes of title 38 benefits is a 
person who ``served in the active military, naval or air service who 
was not dishonorably discharged.'' The second layer is that veterans 
are considered homeless if they meet the definition of a ``homeless 
individual'' codified as part of the McKinney-Vento Homeless Act (P.L. 
100-77) which was signed into law in 1987. Until recently a ``homeless 
individual'' was: 1) a person who lacks a fixed, regular and adequate 
nighttime residence; 2) who has a nighttime residence that is a 
supervised publicly or privately operated shelter designed to provide 
temporary housing; an institution that provides a temporary residents 
for individuals intended to be institutionalized; and 3) who utilizes a 
public or private place not designed for regular sleeping accommodation 
for human beings.
    In December 2011, as a result of the HEARTH Act passed in the 111th 
Congress that expanded the definition of ``homeless individual,'' HUD 
issued regulations regarding the new definition that took effect on 
January 4, 2012. This definition moves away from the requirement for 
literal homelessness and added three new categories: 1) imminent loss 
of housing; 2) the addition of unaccompanied youth and homeless 
families with children who have experienced a long-term period without 
living independently in permanent housing, and 3) a person who has had 
frequent moves and can be expected to continue in unstable housing due 
to a number of chronic health factors. Another Federal change to the 
definition of a homeless individual is, ``a person fleeing a situation 
of domestic violence or other life-threatening condition,'' but until 
title 38 is changed to include the subsection of the McKinney-Vento 
Act, this definition is not part of the definition of a homeless 
veteran, and while DAV does not have a national resolution specific to 
defining a homeless veteran, defining a homeless veteran to match the 
national standard is fair and we do not oppose passage of this bill.
 s. 325, a bill to amend title 38, united states code, to increase the 
 maximum age for children eligible for medical care under the champva 
                                program
    This measure would address a needed adjustment to current 
eligibility requirements for adult children who receive health care 
through age 18 (or age 23 if in school) under the Civilian Health and 
Medical Program of the Department of Veterans Affairs (CHAMPVA).
    Established in 1973, CHAMPVA provides cost reimbursement for 
private health care services provided to dependents, survivors, and 
some primary caregivers, of certain disabled veterans. CHAMPVA 
enrollment has grown steadily over the years and, and as of fiscal year 
2011, CHAMPVA covers approximately 355,000 beneficiaries.
    Under current law, a dependent child loses eligibility for CHAMPVA 
upon turning 18 years of age, unless the person is enrolled in school 
on a continuing and full time basis. Under current law, a dependent 
child loses eligibility for CHAMPVA upon turning 18 years of age, 
unless that individual is enrolled in school on a continuing and full 
time basis, up to age 23. If full-time school attendance is 
discontinued, or upon attaining the age of 23 years, the individual 
loses eligibility.
    With the passage of the Patient Protection and Affordable Care Act 
(PPACA), Public Law 111-148 (as amended by the Health Care and 
Education Reconciliation Act of 2010, Public Law 111-152), DAV on 
behalf of numerous service-connected veterans and their families has 
expressed concern regarding these individuals' health care coverage. We 
rest our position on the precedent that PPACA extends health insurance 
coverage to dependent children until age 26, except for those in the 
CHAMPVA program, and we believe the omission of these CHAMPVA 
beneficiaries was inadvertent but inequitable.
    In accordance with DAV Resolution No. 222, we fully support 
enactment of this bill that would ensure CHAMPVA recipients, without 
regard to their student status, remain eligible for health care 
coverage under their parents' plans in the same manner as for adult 
children of the vast majority covered under PPACA.
     s. 412, a bill to authorize major medical facility leases for 
                   the department of veterans affairs
    If enacted, this bill would authorize (and in three cases, 
reauthorize) VA to carry out leases for community-based outpatient 
clinics in 15 locations in 12 states, and one in Puerto Rico.
    DAV has not received a national resolution from our membership on 
the specific topic of VA facility leases, but we would not object to 
passage of this bill.
    It is important to note for the record that the authorizing statute 
requires VA to obtain Congressional approval for a commercial lease of 
a future VA medical facility if the estimated first-year lease cost 
exceeds $1 million. This policy has been in place for decades. Hundreds 
of leases for VA-operated community-based outpatient clinics have been 
approved by Congress and executed by VA under this procedure. Using a 
leasing authority rather than constructing VA-owned facilities allows 
VA to quickly establish convenient primary care facilities for veterans 
in communities where they live. Veterans who use these community 
clinics report high satisfaction with their care and the convenience 
they offer. Employing leased facilities is a cost-effective method of 
providing high quality VA primary care.
    In 2012, in evaluating a similar bill for these 15 proposed VA 
leases that each exceed the $1 million threshold, the Congressional 
Budget Office (CBO) concluded that Congressional rules require that 
funds to offset the entire 20-year prospective lease cost would need to 
be included either in the VA budget, or would be taken from funding of 
ongoing veterans programs--all in the first year of each lease. CBO 
indicated this policy also would apply in the future to renewals of 
existing VA leases that exceed the threshold cost. This CBO decision 
multiplied VA's costs for these proposed 15 leases 20-fold, for a total 
need of $1.2-$1.5 billion in fiscal year (FY) 2013 funds. Since funds 
of this magnitude could not be diverted from other VA accounts for this 
surprising new requirement and were not covered in the budget request 
that had been submitted to Congress, these 15 leases were dropped from 
further Congressional consideration last year only to return once 
again.
    In VA's current planning, including these 15 clinics for 
California, Connecticut, Florida, Georgia, Hawaii, Kansas, Louisiana (2 
sites), Massachusetts, New Jersey, New Mexico, Puerto Rico, Texas (2 
sites), and South Carolina, VA projects a need to lease or renew 
existing leases for 38 community-based health care facilities through 
FY 2017 to provide care for more than 340,000 veterans across 22 states 
and US territories.
    Unless CBO changes its policy or Congress acts to overturn this CBO 
decision with legislation or makes a change in House Rules in current 
funding policy, most if not all these leases remain in jeopardy. 
Veterans consequently will be denied convenient VA health care.
    Absent a change VA may be forced to buy land and construct 
government-owned clinics, or more likely will require veterans who need 
VA care to travel longer distances to receive it. VA-built clinics 
would be more expensive, would take much longer to activate, and would 
reduce VA's flexibility to place and move facilities based on the 
changing needs of the veteran population. Forcing veterans to travel 
for care would increase inconvenience and add additional costs.
    We ask the Committee to take action in consideration of this 
dilemma to ensure the leases that would be authorized in this bill, and 
future leases, can be accommodated in the budget process without VA's 
having to reserve or offset billions of dollars from other VA programs 
in order for them to be authorized.
    s. 422, chiropractic care available to all veterans act of 2013
    S. 422 would accelerate the expansion of chiropractic care by 
requiring VA to provide chiropractic care and services at no fewer than 
75 medical centers by December 31, 2014, and at all VA medical centers 
by December 31, 2016.
    The National Institute of Health's National Center for 
Complementary and Alternative Medicine (NCCAM) cites spinal 
manipulation as one of several options--including exercise, massage, 
and physical therapy--that can provide mild-to-moderate relief from 
low-back pain.
    VA was authorized to offer chiropractic care and services under the 
provisions of section 204 of Public Law 107-135, the Department of 
Veterans Affairs Health Care Programs Enhancement Act of 2001. By 
January 2011, 43 VA facilities directly provided chiropractic care and 
by January 2012, 45 VA facilities were providing on-site chiropractic 
care. The Department of Defense also offers chiropractic care at 60 
military treatment facilities including the Walter Reed National 
Military Medical Center.
    Progress toward providing chiropractic care at each VA medical 
center is contingent on discretionary decisions made locally. Many 
facilities have decided that eligible veterans can receive chiropractic 
care through VA's outpatient fee-basis program (based only on referrals 
by primary care providers, with advance authorization). Directly 
providing chiropractic care would provide more practical access 
compared to the eligibility criteria for fee-basis care, which 
generally restricts access to a limited number of veterans. Our 
interpretation of the law is that chiropractic care through fee-basis 
may only be provided to a smaller subset of enrolled veterans,\1\ and 
this result conflicts with Section 204(b) of Public Law 107-135, which 
states, ``veterans eligible to receive chiropractic care and services 
under the program are veterans who are enrolled in the system of 
patient enrollment under Section 1705 of title 38, United States 
Code.''
---------------------------------------------------------------------------
    \1\ 38 U.S.C. 1703, and 38 C.F.R.   17.52-17.56.
---------------------------------------------------------------------------
    Therefore, in conjunction with DAV Resolution No. 217, adopted by 
the delegates to DAV's most recent national convention, calling for 
more complementary and alternative medicine (CAM) programs in VA 
facilities for the care of veterans, DAV supports enactment of this 
bill that will bring additional and non-traditional care options to 
veterans enrolled in VA health care.
s. 455, a bill to amend title 38, united states code, to authorize the 
  secretary of veterans affairs to transport individuals to and from 
  facilities of the department of veterans affairs in connection with 
      rehabilitation, counseling, examination, treatment, and care
    This bill would provide VA a renewed authority to transport 
individuals in connection with their vocational rehabilitation, 
counseling, examination, treatment, or care, and would specifically 
vitiate a prior act of Congress that eliminated an important 
transportation program after only one year of life.
    Notably, VA has implemented the provisions of Section 202 of Public 
Law 112-260, the Dignified Burial and Other Veterans' Benefits 
Improvement Act of 2012, except for eliminating the authority granted 
under Section 111A of title 38, United States Code, to create a VA-
operated transportation program one year after enactment. That act had 
prompted VA to initiate the Veterans Transportation Service (VTS), 
supported by the Veterans Health Administration (VHA) Chief Business 
Office (CBO). The VTS was established to provide veterans with 
convenient and timely access to transportation services and to overcome 
access barriers certain veterans may have experienced, and in 
particular to increase transportation options for veterans who need 
specialized forms of transportation to VA facilities. The VTS 
transportation services to VA medical centers include the use of 
technology and mobility management training for medical center staff 
that in turn enable VTS services to better interface with other 
community transportation resources.
    VA medical centers and sites where VTS is operating can be ideal 
partners with the DAV National Transportation Network and for the 
Veterans Transportation and Community Living Initiative grant projects 
establishing One-Call/One-Click Transportation Resource Centers. Based 
on our review of this situation, were it not for the expiration of 
statutory authority from Public Law 112-260, VTS would have grown from 
its current 45 sites to all remaining VA locations by 2015.
    The DAV National Transportation Network continues to show 
tremendous growth as an indispensable resource for veterans. Across the 
Nation, DAV Hospital Service Coordinators operate 200 active programs. 
They have recruited 9,249 volunteer drivers who logged over 27 million 
miles last year, providing almost 721,000 rides for veterans to and 
from VA health care facilities. These veterans rode in vans DAV 
purchased and donated to VA health care facilities for use in the DAV 
National Transportation Network. DAV Departments and Chapters, together 
with our national organization, have now donated 2,586 vans to VA 
health care centers nationwide at a cost to DAV of $56.7 million.
    DAV believes VTS serves the transportation needs of a special 
subset of the veteran patient population that the DAV National 
Transportation Network is unable to serve--veterans in need of special 
modes of transportation due to certain severe disabilities. We believe 
that with a truly collaborative relationship, the DAV National 
Transportation Network and VTS will meet the growing transportation 
needs of ill and injured veterans in a cost-effective manner.
    Currently, DAV supports enactment of this bill; however, our 
support is based on the progress gained through our collaborative 
working relationship with VHA and CBO to resolve weaknesses we have 
observed in the VTS program. As you may be aware, VTS operates with 
resources that would otherwise go to direct medical care and services 
for veterans. These resources should be used carefully for all 
extraneous programs to ensure veterans are not denied care when they 
most need it.
    We thank VHA and CBO for their commitment and efforts in working 
with DAV to ensure VTS will indeed work in concert with all existing 
and emerging transportation resources for veterans who need VA care, 
and to guard against fraud, waste and abuse of these limited resources.
    We look forward to continuing our work with the Committee on this 
measure, and to work for its passage.
         s. 522, the wounded warrior workforce enhancement act
    This bill would establish two VA grant programs, one to be made to 
educational institutions to establish or enhance orthotic and 
prosthetic masters and doctoral education programs, with an 
appropriations limitation of $15 million; and the other to establish a 
private ``center of excellence in orthotic and prosthetic education,'' 
with an appropriations limitation of $5 million.
    DAV has no resolution from our membership that would support the 
establishment of these specific activities. Nevertheless, prosthetic 
and orthotic aids and services are important to injured and wounded 
veterans, and constitute a specialized medical program within the VA. 
Nevertheless, absent a defined shortage of individuals who possess 
related skills and knowledge in these fields, justification for 
enactment of this bill seems questionable. Also, assuming the grant 
programs take form, graduating students who benefited from them would 
not be required to provide obligated employment within VA to repay the 
government's investment in their education such as is required in VA's 
existing health professional scholarship programs under Chapters 75 and 
76 of title 38, United States Code. We believe consideration of that 
existing and highly successful mandate be considered in adopting the 
concept embedded in this bill, to ensure that VA regains at least some 
of the value of the work of these students following their VA-
subsidized education and training. Finally, assuming the establishment 
of a center of excellence in this particular field is warranted, DAV 
questions whether the center should be outside VA, rather than become a 
new VA in-house center of excellence along the lines of those centers 
already established in law in Chapter 73 of title 38. We ask that the 
sponsor of this bill reconsider the proposal in light of our testimony.
     s. 529, to amend title 38, united states code, to modify the 
   commencement date of the period of service at camp lejeune, north 
  carolina, for eligibility for hospital care and medical services in 
            connection with exposure to contaminated water.
    This bill would expand the number of eligible persons to the 
benefits extended to certain persons by Public Law 112-154, the 
Honoring America's Veterans and Caring for Camp Lejeune Families Act of 
2012. This proposed expansion will add tens of thousands of new 
individuals to the estimated 750,000 currently eligible.
    DAV has no resolution specific to this issue, but we remain 
concerned that the burden of care for this population rests with VA 
through its CHAMPVA program rather than with the military TRICARE 
program. Adding more eligible persons as proposed will only make VA's 
burden of care more challenging.
              s. 543, the visn reorganization act of 2013
    This bill would consolidate VA's current 21 Veterans Integrated 
Service Networks (VISNs) into 12 prescribed new units with similar 
responsibilities but significantly smaller staffs than at present. 
Excess staffs would be integrated into subordinate VA medical 
facilities or be provided other reemployment assistance. Also, in 
making this consolidated restructuring, the bill would require VA to 
collaborate with other Federal offices, state and local offices, with 
VA affiliates and certain private and voluntary organizations within 
each of the 12 new geographical areas. The bill would establish no more 
than four regional support centers that would provide certain 
administrative and analytic functions dealing with effectiveness and 
efficiency of the VISNs. Finally, the bill would require several 
reports associated with the proposed consolidations.
    DAV has not received a national resolution from our membership on 
this specific issue, but we wish to bring a number of concerns to the 
attention of the sponsor, and of the Committee as it considers this 
bill.
    VA's adoption of VISNs as a regional health care organization was 
derived from the geographic service area concept of the 1991 VA 
Commission on the Future Structure of Veterans Health Care, a Federal 
advisory commission chartered by then-VA Secretary Edward J. Derwinski 
to make recommendations for organizational, structural, quality, safety 
and cultural improvement in VA health care, among other aims. VA 
considered the Commission's recommendations for three years before 
implementing this one as a part of VHA's 1995 administrative 
reorganization. Initially, 22 VISNs were established but two of them--
the smallest in terms of patient workload, staff and funding--were not 
independently viable and were soon consolidated, so that today 21 
networks remain, covering the continental US, Hawaii, Puerto Rico and 
US possessions.
    DAV supported the VA's decision to restructure the VA health care 
system, the principle benefit of it being a regionalization of health 
care delivery, coordination of leadership and decentralization of 
decisionmaking with a corresponding reduction of VA Central Office's 
involvement in local health care management matters. Like Congress at 
the time, we believed that health care decisions were best left to 
local VA facility managers and clinicians, while VA Central Office 
should focus on national strategy and policies, program development, 
practices and standards-setting. The idea was simple: policy is set at 
the top; implementation occurs at the local level.
    Testimony before this Committee in the last year suggested VA 
facility managers are ``gaming the system'' to meet goal numbers 
established by the VISNs, rather than providing needed care to veterans 
as provided for by law. Potential gaming is also one of our concerns. 
We receive much anecdotal information from our members and VA employees 
that is consistent with such allegations--although these troubling 
reports are difficult to prove in any systematic way. The House 
Veterans' Affairs Committee's 2012 oversight hearing on chronic 
problems at the Miami VA Medical Center was illustrative of how such 
challenges can fester undetected because of lack of adequate public 
reporting and the general unavailability of documentary data.
    A second concern is the number of staff assigned to the VISNs. When 
the networks were formed, VA asserted that they would be staffed by 
network directors with small cadres of staff. Management functions that 
exceeded this staff's ability to perform them were to be accomplished 
by working groups composed of VAMC staffs on temporary assignments. 
Over the past 15 years, however, the network offices grew dramatically, 
and morphed into 21 permanent mini-central offices, staffed with full-
time professional staffs focused on operations, clinical care, human 
resources, quality, safety, internal and external review, media, press, 
public affairs, budget, academic affairs, and numerous other functions.
    Perhaps the most worrisome concern with the VISN organization has 
been the enormous administrative overhead that is being incurred by 
these seemingly bloated numbers of staff. We believe thousands of VA 
permanent, full-time staff may now be assigned to VISN offices (but 
until recently exact numbers were elusive due to lack of publicly 
available information). Within VA these network positions are popular 
because they represent opportunity for career mobility, professional 
advancement, and promotion of local VA employees. We believe a large 
number are clinicians who in their network assignments no longer 
provide clinical care to veterans. While we believe that clinical 
leadership is a strength of VA health care, we believe that the size 
and complexity of the current VISNs depart from the recommendations of 
the Commission's report, and from the original vision of those who 
implemented the geographic service area recommendation. Not only are 
clinical staff members being taken away from frontline positions but 
also valuable technical and administrative staff have been drained from 
medical centers to VISN offices.
    Many of the additional positions were VACO-mandated to respond to 
the ``crisis of the day'' phenomena. Instead of developing thoughtful 
solutions for recognized problems, previous Administrations simply 
added new mandatory positions, functions or new offices.
    Our third concern with the networks deals with the geographical 
boundaries of VISNs. With the exception of the one major consolidation 
change mentioned above, no adjustment of VISN boundaries has occurred 
in the 15-plus years of the life of this organizational model. The 
original VISN geographic boundaries were drawn based on VA patient-
referral patterns and delivery systems from well over twenty years ago; 
these may well have changed. Also, some historical anomalies of the 
VISN map seem to cry out for review, for example, the small state of 
West Virginia remains subdivided into parts of four VISNs; the western 
Panhandle of Florida is part of the eight-state VISN 16, while the 
remainder of the large state of Florida is in VISN 8. We see other 
examples in the current VISN map that raise questions as well.
    Another concern is the allocation of appropriated medical care 
funds below the level of the network offices. VA's Veterans Equitable 
Resource Allocation system is a risk-adjusted capitation model that 
allocates Congressional appropriations to the networks rather than the 
facilities. Theoretically, this model enables regional coordination and 
funding of highly specialized, scarce medical resources, while the 
facilities remain the major delivery systems and serve as VHA's basic 
building blocks to formulate VHA's annual budget request. VHA's 
appropriations have grown dramatically over the past several years--yet 
VA facilities often indicate to us that they are significantly 
underfunded and must ration spending for numerous categorical needs 
across the operating year. We believe the resource allocation model or 
the systems being employed by the VISN offices to allocate resources to 
the VAMCs might need scrutiny and possibly re-balancing for their 
effects on local operations.
    Less than one month ago, the VA announced its intention to 
dramatically reduce VISN offices' core staffing, limiting it to between 
55-65 persons on average for each of the 21 offices, depending on size 
and complexity. VA has not provided DAV information about disposition 
of the staff affected by the new organizational model. We reserve 
judgment on whether the new staffing pattern changes any of our 
expressed concerns.
    With these thoughts in mind, rather than advancing this bill now, 
we would recommend the Committee commission an independent, outside 
review of the VA network concept, subsequent implementation and current 
status of VA's new plan, with recommended changes that may be warranted 
by review findings. We believe the time has come for a critical review 
of the organization, functions, operations, and budgeting process at 
the VISN and VAMC levels. We recommend the review be conducted by the 
Institute of Medicine (IOM) rather than by VA or a private contractor. 
Involving the IOM would ensure a thoroughgoing, apolitical and unbiased 
review. In addition to examining the current referral patterns, the 
analysis should account for future demand, changes in veteran and 
family expectations, and the changing trends in health care delivery.
    Also, we would recommend that the IOM's review and analysis be 
comprehensive to include a review of the VHA Central Office 
organization. This evaluation should address a value-based analysis of 
those programs that are optimally managed and funded at a national, 
VISN or VAMC service level.
    While the IOM's report should be made to the Committee, VA should 
be permitted to comment on the report. We would also recommend the 
Committee hold hearings on the results of this review to include 
testimony from IOM, VA, this community and other interested parties. 
The IOM reviewers should be carefully instructed as to the goals of the 
study, which we believe should focus on ways to improve health care 
quality, safety, satisfaction, consistency and access. The study should 
focus on delivery of comprehensive, patient-centered care to today's 
veterans that builds on the obvious progress VA has made over the past 
17 years. The IOM's work on this project should be closely monitored by 
the Committee as the process occurs to ensure your goals, and those of 
this bill's sponsor, are met.
s. 633, to amend title 38, united states code, to provide for coverage 
  under the beneficiary travel program of the department of veterans 
  affairs of certain disabled veterans for travel in connection with 
              certain special disabilities rehabilitation
    This bill would amend the VA beneficiary travel statute to ensure 
beneficiary travel eligibility for travel expenses in connection with 
medical examination, treatment, or care on an inpatient basis, and 
while a veteran is being provided temporary lodging at VA medical 
centers. Veterans eligible for this benefit would be restricted to 
those with vision impairments, spinal cord injury or disorder, and 
those with double or multiple amputations whose travel is in connection 
with care provided through a VA special disabilities rehabilitation 
program.
    Currently, VA is authorized to pay the actual necessary expenses of 
travel (including lodging and subsistence), or in lieu thereof to pay 
an allowance based upon mileage, to eligible veterans traveling to and 
from a VA medical facility for examination, treatment, or care. 
According to title 38, United States Code, Section 111(b)(1), eligible 
veterans include those with service-connected ratings of 30 percent or 
more; those receiving treatment for service-connected conditions; 
veterans in receipt of VA pensions; those whose incomes do not exceed 
the maximum annual VA pension rate, or; veterans traveling for 
scheduled compensation or pension examinations.
    DAV has no resolution on this specific issue and thus takes no 
position on this bill. However, we would note that while the intended 
recipients of this expanded eligibility criteria would certainly 
benefit from it, we would urge the Committee to consider a more 
equitable approach rather than one based on the specific impairments of 
disabled veterans. Further, we ask that if the Committee does favorably 
consider this measure, it also take appropriate action to ensure that 
sufficient additional funding be provided to VA to cover the cost of 
the expanded program.
s. 800, the treto garza far south texas veterans inpatient care act of 
                                  2013
    This bill would require VA to establish an inpatient bed service 
for veterans at its Harlingen, Texas facility. DAV has no national 
resolution on this issue and has no national position on this bill; 
however, we leave the decision up to the local DAV leadership in Texas.
          s. 825, the homeless veterans prevention act of 2013
    S. 825, the Homeless Veterans Prevention Act of 2013, is a 
comprehensive bill that focuses on improving services for homeless 
veterans.
    Section 2 of the bill requires that recipients of VA grants for 
comprehensive service programs for homeless veterans meet physical 
privacy, safety, and security needs of such veterans.
    Sections 3 and 4 authorize increased per diem payments for 
transitional housing assistance that becomes permanent housing for 
homeless veterans. Also, the section would authorize per diem payments 
for furnishing care for a dependent of a homeless veteran while the 
veteran receives services from a grant recipient.
    Section 5 requires the VA to assess and measure the capacity of 
service programs for homeless veterans for which entities receive 
grants under section 2011 of title 38, United States Code, or per diem 
payments under sections 2012 or 2061 of the same title. The Secretary 
would be required to develop and use tools to examine whether 
sufficient capacity exists to meet the needs of the population of 
homeless veterans in each geographic area, and to determine the 
capacity of services that grant and per diem recipients provide. The 
information that the Secretary collects would be used to set goals to 
ensure that the grant and per diem homeless programs are effectively 
serving the needs of homeless veterans, to improve the homeless veteran 
referral process, to assess if the programs are meeting goals, and to 
inform future funding allocations. The Secretary would be required to 
submit a report to the Committee on Veterans' Affairs of the Senate and 
House of Representatives no later than 180 days after the completion of 
the assessment.
    Section 6 would repeal the requirement for annual reports on 
assistance to homeless veterans. Section 7 would make permanent the 
authority in section 2033, title 38, United States Code, for VA to 
carry out a program of referral and counseling services for veterans at 
risk for homelessness who are tramsuitionMing from certain 
institutions.
    Section 8 authorizes the Secretary to partner with public and 
private entities to provide legal services in an equitably distributed 
geographic area to include rural areas and tribal lands, to homeless 
veterans and veterans at risk of homelessness subject to availability 
of funding. The legal services provided would be related to housing, 
including eviction defense and landlord-tenant cases; family law, 
including assistance with court proceedings for child support, divorce 
and estate planning; income support, including assistance in obtaining 
public benefits; criminal defense, including outstanding warrants, 
fines and driver's license revocation, and to reduce the recidivism 
rate while overcoming reentry obstacles in employment or housing. The 
Secretary may require entities that have partnered with VA and provided 
legal services to homeless veterans to submit periodic reports.
    Section 9 expands the authority of VA to provide dental care to 
eligible homeless veterans who are enrolled for care, and who are 
receiving assistance under section 8(o) of the United States Housing 
Act of 1937 (42 U.S.C. 17 1437f(o)) for a period of 60 consecutive 
days; or receiving care (directly or by contract) in a domiciliary; 
therapeutic residence; community residential care coordinated by the 
Secretary; or a setting for which the Secretary provides funds for a 
grant and per diem provider.
    Section 10 of this measure extends the sunset dates affecting 
homeless veterans for the following programs in title 38, United States 
Code:

     Comprehensive Service programs
     Homeless veterans reintegration programs
     Treatment and rehabilitation for seriously mentally ill 
and homeless veterans
     Centers for the provision of comprehensive services to 
homeless veterans
     Housing assistance for homeless veterans
     Financial assistance for supportive services for very low-
income veteran families in permanent housing
     Grant program for homeless veterans with special needs
     Technical assistance grants for non-profit community-based 
groups; and
     The Advisory Committee on Homeless Veterans

    DAV is pleased to support S. 825, the Homeless Veterans Prevention 
Act of 2013, in conjunction with DAV Resolution No. 234, which calls 
for us to support sustained and sufficient funding for the VA's 
initiative to eliminate homelessness among veterans and improve its 
existing supportive programs. This resolution also urges Congress to 
strengthen the capacity of VA's programs to end homelessness among 
veterans by increasing capacity for health care, specialized services 
for mental health, substance-use disorders as well as vision and dental 
care.
 s. 832, improving the lives of children with spina bifida act of 2013
    This bill would require VA to carry out pilot programs to furnish 
case management and assisted living services to children of Vietnam 
veterans and certain Korea service veterans who were born with spina 
bifida, and children of women Vietnam veterans who have certain birth 
defects, and for other purposes.
    There are approximately 1,200 enrollees in VA's Spina Bifida Health 
Care Program (SBHCP). The SBHCP is administered for those biological 
children diagnosed with spina bifida of veterans who served in Vietnam, 
and of veterans who served in Korea during the period September 1, 
1967, through August 31, 1971.\2\ The program provides reimbursement 
for comprehensive medical care for those beneficiaries diagnosed with 
spina bifida, except for conditions associated with spina bifida 
occulta.
---------------------------------------------------------------------------
    \2\ 38 U.S.C.   1803; 1821.
---------------------------------------------------------------------------
    Approximately 15 individuals are enrolled in the Children of Women 
Vietnam Veterans Health Care Program (CWVV). Under this program, VA 
reimburses for care related to conditions associated with certain birth 
defects except spina bifida, which is covered under the VA's Spina 
Bifida Program identified by the VA as resulting in permanent physical 
or mental disability of the biological child of a woman veteran who 
served in Vietnam between February 28, 1961, and May 7, 1975.\3\
---------------------------------------------------------------------------
    \3\ 38 U.S.C.   1811; 1812; 1813.
---------------------------------------------------------------------------
    We note that children suffering from associated with certain birth 
defects are now dependent adults. Furthermore, Vietnam veterans who 
care for dependent adult children are also aging and in all likelihood 
are contending with their own health care needs.
    Although DAV has no specific resolution regarding this proposal, 
DAV would not oppose passage of this legislation since SBHCP and CWVV 
are currently provided to children of veterans exposed to Agent Orange 
during service in the Republic of Vietnam and would greatly assist 
Vietnam veterans.
     s. 845, to amend title 38, united states code, to improve the 
    department of veterans affairs health professionals educational 
              assistance program, and for other purposes.
    This bill would extend for five years VA's existing health 
professionals scholarship program, and would place a limitation on the 
annual amount of VA-paid educational debt reduction not to exceed 
actual amounts paid by eligible employees.
    DAV has no resolution from our membership on these specific issues, 
but we would not object to enactment of this bill.
        s. 851, caregivers expansion and improvement act of 2013
    S. 851 would to extend eligibility to all veterans with a serious 
service-connected injury for the comprehensive caregiver support and 
services program under Section 1720G of title 38, United States Code.
    For generations, wives, husbands, parents and other family members 
have taken the role of caregivers of veterans who were seriously ill or 
injured while serving. Family caregiving is a complex role that bridges 
both quality of care and quality of life of disabled veterans. 
Caregivers play a critical role in facilitating recovery and 
maintaining veterans' independence and quality of life while residing 
in the community, and are an important component in the delivery of 
health care by the VA. The critical care they provide amounts to 
significant personal sacrifice resulting in lost professional 
opportunities and reduction in income. Caregiving exacts a tremendous 
toll on that caregiver's health and well-being.
    Implementation of caregiver benefits and services authorized by the 
Caregivers and Veterans Omnibus Health Services Act of 2010, has 
improved the lives of caregivers by giving them the support they need. 
These services and benefits include a tax-free monthly stipend, travel 
expenses, health coverage through CHAMPVA, mental health services and 
counseling, caregiver training and respite care for caregivers of 
veterans seriously injured on or after September 11, 2001. However, 
these services were not made available to caregivers in need of support 
caring for veterans with equally serious injuries incurred in military 
service before September 11, 2001.
    Many caregivers of veterans have been caring for injured veterans 
for years with little or no support and DAV believes it is appropriate 
to provide equal benefits to veterans and their family caregivers from 
all eras.
    DAV believes caregivers of severely disabled veterans should be 
seen as a resource and supported in their role. Accordingly, the 
delegates to our most recent National Convention, held in Las Vegas, 
Nevada, August 4-7, 2012, approved resolution number 221 calling 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. Accordingly, DAV supports this legislation and urges 
its enactment.
    DAV urges Congress to provide sufficient program funding to expand 
and sustain this program's success. We also urge the Committee to 
consider other needed changes to Section 1720G of title 38, United 
States Code.
    These changes include adding the term ``seriously ill'' as we 
believe was intended by Congress under title 38 United States Code, 
section 1720G(a)(2)(B). Clarification is also needed of the term 
``independent activity of daily living'' contained in 1720G(d)(4)(A) to 
define ``personal care services.'' VA indicated the statutory term 
``independent activity of daily living,'' [d]oes not have a commonly 
understood usage or meaning,'' and interprets the phrase to mean, 
``[p]ersonal functions required in everyday living to sustain health 
and well-being and keep oneself safe from hazards or dangers incident 
to one's daily environment.\4\ DAV agrees that ``independent activity 
of daily living'' is not a commonly used phrase; however, based on the 
context of the statute, the goal of this program, and VA health care 
programs and services that allow disabled veterans to remain in the 
community, we believe it is reasonable for VA to include in its 
proposed definition, services that provide the veteran assistance with 
Activities of Daily Living and Instrumental Activities of Daily Living.
---------------------------------------------------------------------------
    \4\ 76 Fed. Reg. at 26149.
---------------------------------------------------------------------------
    The Committee's strong oversight is critical to ensure the 
effectiveness and viability of this key program. Notably, the two 
reports on caregiving required by law have yet to be submitted to the 
House and Senate Veterans' Affairs Committees not later than two years 
after the effective date (January 30, 2013) on a comprehensive annual 
evaluation on implementation and on the feasibility and advisability of 
expanding caregiver assistance under Section 1720G of title 38, United 
States Code, to caregivers of veterans seriously injured in the line of 
duty prior to September 11, 2001.
    DAV and others have submitted comments on VA's Interim Final Rule 
(IFR) to implement title I of the Caregivers and Veterans Omnibus 
Health Services Act of 2010, Public Law 111-163. The natural tendency 
for Federal agencies in rulemaking is to be intolerant and at times 
defensive once it makes a formal rule determination. However, VA has 
testified before this Committee that it considers the IFR to be a good 
start and that VA is open to suggestions. We urge this Committee to 
ensure that VA carries out the required good faith and serious 
consideration of post-promulgation comments from the public on the 
proposed IFR. Congressional oversight is critical in this instance to 
ensure the IFR is not perceived as, and is not allowed to become, a 
monocratic decision.
             s. 852, veterans health promotion act of 2013
    This bill would establish a new complementary and alternative 
medicine (CAM) program in the Department of Veterans Affairs, including 
basic legislative authority; 21 new centers of innovation for CAM in 
research, education and clinical activities, to include conducting 
research, education and outreach on CAM. The bill would authorize a 
series of pilot programs in CAM and wellness, including the award of 
grants to non-profit entities focused on CAM for veterans with mental 
health conditions, and for their families who are eligible for 
counseling from VA's Vet Centers; in health promotion for overweight 
and obese veterans through direct support of fitness center 
memberships, and through establishment of fitness facilities within VA 
medical centers and community-based outpatient clinics. The bill would 
also authorize a study by an outside entity of barriers to veterans' 
receiving CAM within VA facilities. The bill would require a series of 
reports to Congress specific to these authorities, if enacted.
    In accordance with DAV Resolution No. 217, adopted by our 
membership, DAV supports the purposes of the bill to advance CAM 
initiatives within the VA health care system, in addition to those 
already in place. Whether the various pilot programs the bill would 
authorize help cement CAM within VA is difficult to assess, but if VHA 
establishes the innovation centers as envisioned in the bill, they 
could serve to spark VHA's existing CAM programs into new areas that 
could be very helpful to veterans seeking alternatives to traditional 
health care.
    DAV is concerned with one aspect of the bill. It would not only 
enable CAM practitioners to compete for VA's Medical and Prosthetic 
Research funding, but in cases of rural CAM practitioners it would 
promote a ``priority'' for funding of their research proposals. DAV 
strongly supports the scientific merit review practices endemic to VA 
research management of awards; DAV does not recommend specific research 
be funded by VA; and, we see no justification for granting one type of 
research proposal a special priority in law, especially if it had the 
potential to introduce bias in the research award process. Therefore, 
we ask that this provision be dropped from the bill.
   draft bill, the veterans affairs research transparency act of 2013
    This bill would require VA to make available in a publicly 
accessible form research data from VA-funded projects, and post-
publication manuscripts of research funded by VA. The bill would 
require VA to observe copyright law and to provide reports of 
activities occurring under this authority subsequent to enactment.
    DAV has no resolution from our membership on these specific issues, 
but we would not object to enactment of this bill.
    DAV would again like to thank the Committee for the opportunity to 
submit our views on the numerous legislative measures under 
consideration at this hearing. Much of the proposed legislation would 
significantly improve VA benefits and services for our Nation's 
servicemembers, veterans and their families.

    This concludes my testimony. I am happy to answer any questions 
Committee Members may have related to my statement.
                                 ______
                                 
     Prepared Statement of Iraq and Afghanistan Veterans of America


------------------------------------------------------------------------
Bill #            Bill Name                Sponsor          Position
------------------------------------------------------------------------
 S. 49 Veterans Health Equity Act   Shaheen           Support
        of 2013
------------------------------------------------------------------------
 S. 62 Check the Box for Homeless   Boxer             Support
        Veterans Act of 2013
------------------------------------------------------------------------
S. 131 Women Veterans & Other       Murray            Support
        Health Care Improvements
        Act of 2013
------------------------------------------------------------------------
S. 229 Corporal Michael J.          Toomey            Support
        Crescenz Act of 2013
------------------------------------------------------------------------
S. 287 Bill to amend title 38 to    Begich            Support
        expand the definition of
        homeless veteran for
        purposes of benefits under
        the law
------------------------------------------------------------------------
S. 325 Bill to amend title 38 to    Tester            Support
        increase the maximum age
        for children eligible for
        medical care under CHAMPVA
------------------------------------------------------------------------
S. 412 Keep Our Commitment to       Landrieu          Support
        Veterans Act
------------------------------------------------------------------------
S. 422 Chiropractic Care Available  Blumenthal        Support
        to All Veterans Act of
        2013
------------------------------------------------------------------------
S. 455 Bill to amend title 38 to    Tester            Support
        authorize the Secretary of
        Veterans Affairs to
        transport individuals to
        and from VA facilities
------------------------------------------------------------------------
S. 522 Wounded Warrior Workforce    Durbin            Support
        Enhancement Act
------------------------------------------------------------------------
S. 529 Bill to amend title 38 to    Burr              Support
        modify the commencement
        date of the period of
        service at Camp Lejeune
------------------------------------------------------------------------
S. 543 VISN Reorganization Act of   Burr              Support
        2013
------------------------------------------------------------------------
S. 633 Bill to amend title 38 to    Tester            Support
        provide for coverage under
        the beneficiary travel
        program
------------------------------------------------------------------------
S. 800 Tetro Garza Far South Texas  Cornyn            Support
        Veterans Inpatient Act of
        2013
------------------------------------------------------------------------
S. 825 Homeless Veteran Prevention  Sanders           Support
        Act of 2013
------------------------------------------------------------------------
S. 832 Bill to require the          Donelly           Support
        Secretary of Veterans
        Affairs to carry out
        certain pilot programs
------------------------------------------------------------------------
S. 845 Bill to amend title 38 to    Tester            Support
        improve the Department of
        Veterans Affairs Health
        Professionals Educational
        Assistance Program
------------------------------------------------------------------------
S. 851 Caregiver Expansion and      Sanders           Support
        Improvement Act of 2013
------------------------------------------------------------------------
S. 852 Veterans Health Promotion    Sanders           Support
        Act of 2013
------------------------------------------------------------------------
S. 877 The Veterans Affairs         Begich            Support
        Research Transparency Act
        of 2013
------------------------------------------------------------------------


    Chairman Sanders, Ranking Member Burr, and Distinguished Members of 
the Committee: On behalf of Iraq and Afghanistan Veterans of America 
(IAVA), I would like to extend our gratitude for this opportunity to 
share with you our views and recommendations regarding these important 
pieces of legislation.
    IAVA is the Nation's first and largest nonprofit, nonpartisan 
organization for veterans of the wars in Iraq and Afghanistan and their 
supporters. Founded in 2004, our mission is important but simple--to 
improve the lives of Iraq and Afghanistan veterans and their families. 
With a steadily growing base of over 200,000 members and supporters, we 
strive to help create a society that honors and supports veterans of 
all generations.
    IAVA believes that all veterans must have access to quality health 
care and related services. The men and women who volunteer to serve in 
our Nation's military do so with the understanding that they and their 
families will be cared for during their period of service, and also 
after their period of service should they sustain injuries or 
disabilities while serving.
                                 s. 49
    IAVA supports S. 49, the Veterans Health Equity Act of 2013. 
Ensuring equal access to quality care and services is critical to 
helping veterans maintain their quality of life. This bill ensures that 
eligible veterans in the 48 contiguous states can receive services in 
at least one in-state, full-service Department of Veterans Affairs 
medical center, or receive comparable services provided by contract 
care.
                                 s. 62
    IAVA supports S. 62, the Check the Box for Homeless Veterans Act of 
2013, which will allow taxpayers to check a box on their tax forms to 
indicate that a portion of their tax refund can be donated to the 
Homeless Veterans Assistance Fund. Homelessness within the veteran 
community is an alarming trend that deserves national attention and 
resources, and IAVA stands behind any effort to support ending veterans 
homelessness and to engage the public in this effort.
                                 s. 131
    IAVA supports S. 131, the Woman Veterans and Other Health Care 
Improvements Act of 2013. IAVA believes that all servicemembers and 
veterans should be able to pursue one of the most fundamental of 
American dreams--starting a family. Unfortunately, many of our Nation's 
severely wounded veterans are not able to pursue this goal as a direct 
result of their service-connected injuries. This bill will help give 
these injured veterans an alternative pathway to starting a family if 
they so choose.
    IAVA also believes this bill is a step in the right direction 
toward eliminating yet another hurdle to mental health care that many 
veterans with children may experience. By establishing a pilot program 
to provide child care assistance to veterans receiving or in need of VA 
readjustment counseling or other mental health services, this 
legislation helps veterans who need counseling and treatment to also be 
able to pursue that care.
                                 s. 229
    IAVA supports S. 229, the Corporal Michael J. Crescenz Act of 2013. 
This bill will designate the Department of Veterans Affairs medical 
center at 3900 Woodland Avenue in Philadelphia, Pennsylvania, as the 
``Corporal Michael J. Crescenz Department of Veterans Affairs Medical 
Center.''
                                 s. 287
    IAVA supports S. 287. This bill would expand the definition of 
``homeless veteran'' to include veterans fleeing domestic violence, 
sexual assault, or stalking so that they are able to qualify for 
assistance from the VA under the McKinney-Vento Homeless Assistance 
Act. The definition of homelessness was updated in the 2009 Homeless 
Emergency Assistance and Rapid Transition to Housing (HEARTH) Act to 
cover individuals escaping domestic violence. We strongly believe that 
title 38 must be updated as well to reflect this definition of 
homelessness and to provide services to those veterans who are fleeing 
domestic violence.
                                 s. 325
    IAVA supports S. 325. With the enactment of the Affordable Care 
Act, children up to age 26 can now be covered by their parents' health 
insurance plans. However, these provisions did not extend to recipients 
of TRICARE and the Civilian Health and Medical Program of the 
Department of Veterans Affairs (CHAMPVA). While legislation was 
subsequently enacted to extend this coverage option to eligible 
children of TRICARE recipients, no action has been taken on behalf of 
the same population under CHAMPVA. IAVA believes that we must enact 
this bill so that CHAMPVA benefits continue to be provided to the 
children of our Nation's wounded warriors and those who paid the 
ultimate price in service to our country.
                                 s. 412
    IAVA supports S. 412, the Keep Our Commitment to Veterans Act. This 
bill will authorize the VA to carry out specified major medical 
facility leases in FY 2013-FY 2014 in New Mexico, New Jersey, South 
Carolina, Georgia, Hawaii, Louisiana, Florida, Puerto Rico, Texas, 
Connecticut, and Massachusetts. This bill also reduces lease amounts 
authorized in previous fiscal years for VA outpatient clinics in 
Johnson County, Kansas, San Diego, California, and Tyler, Texas.
                                 s. 422
    IAVA supports S. 422, the Chiropractic Care Available to All 
Veterans Act of 2013. This bill will require VA to provide chiropractic 
care and services to veterans at all Department of Veterans Affairs 
medical centers. It will also expand access to chiropractic care to 
veterans as an option for physical rehabilitation and preventative 
wellness care. IAVA believes this bill will benefit all veterans who 
are seeking new options as a part of their overall health care plan. 
Furthermore, IAVA has always advocated that all veterans should have 
equal access to VA care and services regardless of where they reside in 
the Nation. This bill is a step in the right direction toward achieving 
that goal.
                                 s. 455
    IAVA supports S. 455. This bill offers a long-term solution to the 
VA's Veterans Transportation Service (VTS) program. In 2010 the VA 
launched its VTS initiative to enhance transportation services for 
disabled veterans accessing VA health care and resources. However, in 
the summer of 2012 the VA Office of the Inspector General decided that 
the VA never had the authority to run such an initiative and thus 
halted the program. This quickly became a problem in communities 
throughout the Nation because VTS, which had been in operation for 
approximately seven months, had been tremendously successful in 
connecting tens of thousands of veterans to the care they needed. It 
became clear that while volunteers were providing an amazing service, 
they, in many instances, were unable to transport veterans who were not 
ambulatory, required portable oxygen, or had other medical needs 
associated with their disability. While Congress did answer this need 
with a one-year extension of the VTS program, IAVA believes that it is 
time to address the transportation needs of disabled veterans with a 
more long-term approach. IAVA believes S. 455 will start this process.
                                 s. 522
    IAVA is pleased to offer our support for S. 522, the Wounded 
Warrior Workforce Enhancement Act of 2013. This bill will authorize 
funding to help schools train more professionals in the fields of 
orthotics and prosthetics (O&P), and it establishes a second VA 
Training Center of Excellence for O&P. Today's wounded warriors are 
returning from combat with injuries that are more complex than those we 
have seen during past conflicts. These complex wounds require highly 
trained professionals in specialized fields like O&P. However, while 
the need for these highly trained professionals is at an all time high, 
the number of schools designed to train individuals in this complicated 
field remains incredibly low. The Wounded Warrior Workforce Enhancement 
Act of 2013 addresses this critical shortage of providers and helps 
further advancements in the field of O&P so that our wounded warriors 
can receive the highest quality of care and services available.
                                 s. 529
    IAVA supports S. 529, which would modify the date set out in 
Section 1710(e)(1)(F) of title 38 from January 1, 1957 to August 1, 
1953. Public Law 112-84, or the Honoring America's Veterans and Caring 
for Camp Lejeune Families Act of 2012, provides hospital and related 
medical services to veterans and their families who were exposed to a 
contaminated water supply while they were stationed at Camp Lejeune, 
North Carolina. Since the enactment of this law, further research has 
shown that the water contamination at Camp Lejeune started in 1953, as 
opposed to the originally designated year of 1957. IAVA believes it is 
necessary to care for any servicemember, veteran, or military family 
member who has suffered an illness or disability as a result of 
exposure to toxins while serving this Nation.
                                 s. 543
    IAVA supports S. 543, the VISN Reorganization Act of 2013. 
According to numerous reports released by the VA Office of the 
Inspector General in 2011 and 2012, the Veterans Health Administration 
has failed to manage and monitor the growth of Veterans Integrated 
Service Network (VISN) offices. These reports also noted that the VA 
lacked adequate management controls and needed to improve the quality 
of VISN office data to oversee and evaluate the effectiveness of VISN 
staff and organizational structures. IAVA believes that given our 
Nation's current economic situation and the projected increase of 
veterans seeking VA care over the next few years, the VA must 
demonstrate more fiscal responsibility and purpose driven resource 
allocation. IAVA believes that the VISN structure has grown far beyond 
its original intent and no longer necessarily functions in the best 
interest of the veteran or the VA's overall budget. IAVA believes 
S. 543 will help eliminate duplication of efforts, bring VISN staffing 
levels back to where they should be, and ultimately offer veterans more 
options in health care.
                                 s. 633
    IAVA supports S. 633, which will authorize the VA to reimburse the 
travel costs associated with seeking approved in-patient care at a VA 
Special Disabilities Rehabilitation Program for additional categories 
of catastrophically disabled veterans. Under current law, the VA 
reimburses certain veterans for costs associated with travel to and 
from approved VA medical facilities. However, there are certain 
categories of catastrophically disabled veterans who are not entitled 
to this reimbursement. We believe this legislation would provide 
critical assistance for more disabled veterans to allow them to receive 
the specialized in-patient treatment they need.
                                 s. 800
    IAVA supports S. 800, the Tetro Garza Far South Texas Veterans 
Inpatient Act of 2013. This bill will require the South Texas VA Health 
Care Center at Harlingen, Texas to include a full-service inpatient 
health care facility, an urgent care center, and to provide gender-
specific care to women veterans. IAVA supports these requirements given 
the large veterans population currently residing in this area.
                                 s. 825
    IAVA strongly supports S. 825, the Homeless Veterans Prevention Act 
of 2013. This comprehensive piece of legislation provides a 
multifaceted approach to assisting the VA in its goal of eradicating 
veteran homelessness by 2015 and ensuring the safety of veterans while 
working toward that goal. This piece of legislation also addresses 
other often-overlooked needs that homeless veterans may have, including 
free legal services and dental care.
                                 s. 832
    IAVA supports S. 832, the Improving the Lives of Children with 
Spina Bifida Act of 2013. This bill requires the VA to conduct pilot 
programs for certain services for the children of Vietnam and Korea-era 
veterans with Spina Bifida and other birth defects. IAVA believes these 
pilot programs will be helpful in measuring the potential impact of 
such services on the children of these veterans. They can also provide 
useful data and metrics for the VA to use should future presumptive 
conditions arise from the wars in Iraq and Afghanistan. We must ensure 
that our newest generation of veterans and their families do not have 
to endure the unnecessary hardships that many Vietnam and Korean War 
veterans had to endure.
                                 s. 845
    IAVA supports S. 845. This bill improves the VA's Health 
Professional Education Assistance Program by extending the Health 
Professional Scholarship Program through 2019 and increasing the 
maximum amount of funding that program participants can receive. These 
adjustments will be critical in recruiting and retaining high quality 
health professionals within the VA's health care system. IAVA, also 
believes this bill will assist the VA in filling certain health care 
provider vacancies that it has struggled to fill.
                                 s. 851
    IAVA supports S. 851, the Caregiver Expansion and Improvement Act 
of 2013. IAVA believes that every veteran who has sustained severe 
injuries and illnesses as a result of their service must be cared for, 
regardless of which war or conflict they served in and when those 
injuries or illnesses present. Part of caring for our wounded warriors 
entails caring for the family members who devote their time and their 
lives to rendering necessary care for those veterans. All of our 
Nation's veteran caregivers deserve support, and this bill would help 
provide that support to more veteran caregivers.
                                 s. 852
    IAVA supports the understood intent of S. 852, the Veterans Health 
Promotion Act of 2013. IAVA has been a proponent of various types of 
alternative medicine programs and practices, which many veterans of all 
generations have found to be very helpful and therapeutic. However, we 
are still unclear as to the specific complementary and alternative 
medicine programs referred to in this bill and look forward to finding 
out more about what these specific programs referred to here would 
entail.
                                 s. 877
    IAVA supports S. 877, the Veterans Affairs Research Transparency 
Act of 2013. This bill requires the VA to allow public access to 
research executed by its Department of Research and Development. IAVA 
believes that transparency as well as the sharing of important findings 
with the public is an important goal and practice, and this bill will 
allow and encourage those types of practices with respect to VA 
research.

    We again appreciate the opportunity to offer our views on these 
important pieces of legislation, and we look forward to continuing to 
work with each of you, your staff, and the Committee to improve the 
lives of veterans and their families. Thank you for your time and 
attention.
                                 ______
                                 
     Prepared Statement of Integrative Healthcare Policy Consortium


[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]



                                 ______
                                 
      Prepared Statement submitted by Janet R. Kahn, Ph.D., LMT, 
            President and CEO, Peace Village Projects, Inc.
    I thank Senator Sanders and Members of the Committee for the 
opportunity to offer a statement for the record regarding pending 
legislation to increase access to complementary and alternative 
medicine and other preventive and wellness oriented care, for those 
receiving health care through the Department of Veterans' Affairs. This 
is important legislation with real promise to address the physical, 
mental and spiritual injuries incurred in war, and I am honored to 
address to it.
    My name is Janet Kahn. I am a medical sociologist, a massage 
therapist, and a social scientist actively engaged in research with 
veterans of Iraq and Afghanistan. I am Research Assistant Professor in 
the Department of Psychiatry at the University of Vermont, where we 
have a MindBody Medicine Clinic. I currently serve the Federal 
Government as a member of the Advisory Group on Prevention, Health 
Promotion and Integrative and Public Health, for which I chair the 
Working Group on Integrative Healthcare. Previous service includes 
terms as a member the National Advisory Council for NIH's National 
Center for Complementary and Alternative Medicine, and reviewer for the 
Institute of Medicine on their Report of the Committee on the Use of 
Complementary and Alternative Medicine by the American.
    I am also President of Peace Village Projects (PVP), a 501(c)(3) 
non-profit organization of Burlington, Vermont and Acton. PVP engages 
in both educational and research efforts, and is currently involved in 
a Phase II SBIR grant from NIMH entitled ``Mission Reconnect: Promoting 
Resilience and Reintegration of Post-Deployment Veterans and their 
Families,'' for which I am I am Co-Principal Investigator with William 
Collinge, Ph.D. As a Vermonter I am particularly interested in 
provision of care to veterans in rural areas and those too far from 
care to access it easily. I am also aware that many veterans perceive, 
somewhat accurately, that there may be a career price paid for 
accessing mental health services. For that reason, Mission Reconnect is 
designed as a self-education program in which veterans and their 
partners are provided with media materials through which they teach 
themselves mind-body techniques known to beneficially alter 
neurochemistry (e.g. increase of serotonin production, decrease of 
cortisol), which in turn may render a veteran more able to benefit from 
contemplative techniques to quiet the mind, control anger, etc.
    While Phase I data (see below) indicate positive results from 
Mission Reconnect, and demonstrate veterans' openness to these 
therapies, I have no doubt that the best care for the mental health 
spectrum we address--which is worried well through high PTSD--would be 
a combination of in-person treatment by professionals supplemented by a 
Mission Reconnect-like program that the veteran can use at home, on 
their own schedule, as often as they like. The pending ``Veterans 
Health Promotion Act of 2013'' will make this possible, at the same 
time that it makes possible complementary and alternative medicine care 
for veterans with acute and chronic pain conditions.
    In addition to mind-body and contemplative techniques, Mission 
Reconnect provides veterans and their partners instruction in 
relaxation massage techniques which Phase I participants found very 
helpful in reducing pain and anxiety and in promoting better sleep. 
Sleeplessness is a serious issue for veterans and exacerbates other 
problems including irritability, pain levels and more. A growing body 
of literature indicates that therapeutic massage enhances sleep and we 
were delighted to find that this was true even of non-professional 
partner-provided massage. Given the findings of Mission Reconnect, I 
encourage you to be sure that the legislation is written such that 
educational programs may be included along with complementary and 
alternative health care clinical treatments.
    While I am aware that the VA generally treats only the veteran, not 
family members, I have become acutely aware of the extent of secondary 
trauma suffered by spouses of veterans with PTSD. In addition, the 
design of Mission Reconnect draws on lessons learned in 1995 when PVP 
was unexpectedly drawn into teaching Israeli and Palestinian parents 
touch-based and mind-body techniques to ease children who were 
suffering from war trauma. In fact, we were asked to treat children who 
had gone mute from war trauma. Despite having been a massage therapist 
since 1969, I was stunned to see the power of touch with these 
children, a number of whom cried and then spoke for the first time in a 
few years.
    While the children of U.S. veterans have not experienced the 
immediate danger and trauma faced by Palestinian and Israeli children 
in the 1990's, our children are suffering and it is possible that 
complementary and alternative medicine care and education would be 
helpful to the entire family. Perhaps there can be at least one Center 
of Innovation allowed to conduct research on this.
    The VA and the Department of Defense have each served at times as 
leaders for this country in advancing health care, as well as other 
areas of science and technology. A solid body of literature indicates 
the potential of individual complementary and alternative medicine 
therapies and of integrated healthcare for servicemembers and civilians 
alike. The potential of integrated care can only be explored when lack 
of reimbursement and other obstacles to complementary and alternative 
care are removed. I believe that S. 852 will give us the opportunity to 
pilot these methods responsibly within the VA in ways that target the 
mental health and pain issues with which so many of our soldiers are 
returning home. I expect this will be another instance in which the 
country learns from the VA.
    The attention given in the bill to staff training, and the decision 
to coordinate this through Dr. Gaudet's Office of Patient Centered Care 
and Cultural Transformation are important. My experience at the 
Community Health Center of Burlington included critical lessons about 
the challenges of integration in a clinic whose staff had not chosen 
specifically to work in an integrated environment. Many integrated 
clinics in the US are private clinics attracting a workforce seeking an 
integrated care environment. That will not be true of the whole VA. The 
training, beginning with listening to the staff of the VA Centers for 
Innovation, will be a critical element in the success of this program.

    I applaud the intention and design of this bill and commend you for 
taking the initiative in this vital area.
                                 ______
                                 
          Prepared Statement of Paralyzed Veterans of America
    Chairman Sanders, Ranking Member Burr, and Members of the 
Committee, Paralyzed Veterans of America (PVA) would like to thank you 
for the opportunity to present our views on the broad array of pending 
legislation impacting the Department of Veterans Affairs (VA) that is 
before the Committee. These important bills will help ensure that 
veterans receive the best health care services available to them.
           s. 49, the ``veterans health equity act of 2013''
    PVA does not support S. 49, the ``Veterans Health Equity Act of 
2011,'' which proposes to amend title 38, U.S.C. to require veterans to 
have access to at least one full-service Department of Veterans Affairs 
(VA) medical center in each of the 48 contiguous states, or have access 
to hospital care and medical services comparable to the services 
typically provided by full-service VA medical centers through contract 
with health care providers in the state. Under this legislation, if a 
VA medical center is not a full-service facility, ``does not provide 
hospital care, emergency medical services, and surgical care that is 
rated by the Secretary as having a surgical complexity level of 
`standard,''' veterans may utilize contracted services from private 
health care providers in their state. While this legislation is an 
attempt to address issues involving access to health care, PVA believes 
that if enacted, S. 49 will lead to diminution of VA health care 
services, and increased health care costs in the Federal budget. This 
legislation would turn VA's current fee-basis policy, which allows VA 
to purchase care from a private provider when VA medical care is not 
``feasibly available to veterans,'' into a permanent treatment plan.
    While access is indeed a critical concern for PVA, we believe VA is 
the best health care provider for veterans. Providing primary care and 
specialized health services is an integral component of VA's core 
mission and responsibility to veterans. Unfortunately, funding for VA 
health care in the past has had difficulty keeping pace with the 
growing demand. Even with the passage of Advance Appropriations and 
record budgets in recent years, funding is not guaranteed to be 
sustained at those levels and PVA is concerned that contracting health 
care services to private facilities is not an appropriate enforcement 
mechanism for ensuring access to care. In fact, it may actually serve 
as a disincentive to achieve timely access for veterans seeking care.
    PVA is also concerned about the continuity of care. The VA's unique 
system of care is one of the Nation's only health care systems that 
provides developed expertise in a broad continuum of care. The VA 
provides specialized health care services that include program specific 
centers for care in the areas of spinal cord injury/disease, blind 
rehabilitation, Traumatic Brain Injury, prosthetic services, mental 
health, and war-related polytraumatic injuries. Coordination of such 
care is critical to providing veterans quality care, and contracting 
out to private providers will leave the VA with the difficult task of 
not only ensuring that veterans seeking treatment at non-VA facilities 
are receiving quality health care, but also coordinating the various 
types of care that may be provided by a contractor. The quality of VA's 
health care and ``veteran-specific'' expertise cannot be adequately 
duplicated in the private sector.
    For these reasons, PVA does not support S. 49, and strongly 
believes that VA remains the best option available for veterans seeking 
health care services.
     s. 62, the ``check the box for homeless veterans act of 2013''
    PVA does not have a position on the, ``Check the Box for Homeless 
Veterans Act of 2013,'' a bill to amend the Internal Revenue Code of 
1986 to allow tax payers to designate overpayments of tax as 
contributions and to make additional contributions to the Homeless 
Veterans Assistance Fund. PVA, however, fully supports the VA and the 
Secretary's goal to eradicate homelessness among veterans.
s. 131, the ``women veterans and other health care improvements act of 
                                 2013''
    PVA strongly supports S. 131, the ``Women Veterans and Other Health 
Care Improvements Act of 2013.'' If enacted, this bill would improve 
health care services for women veterans within the VA.
    PVA is particularly pleased to see the provisions related to 
reproductive services for catastrophically disabled service-connected 
veterans. One of the most devastating results of spinal cord injury or 
dysfunction for many individuals is the loss of the ability to have 
children and raise a family. PVA has long sought inclusion of 
reproductive services in the spectrum of health care benefits provided 
by the VA. Sections 2, 3 and 4, of the proposed legislation are 
significant steps in securing these much needed and long overdue 
treatment modalities that are critical components of catastrophically 
disabled veterans' maximization of independence and quality of life.
    Advancements in medical treatments have for some time made it 
possible to overcome infertility and reproductive disabilities. For 
some paralyzed veterans procreative services have been secured in the 
private sector at great cost to the veteran and family. In April 2010, 
a Memorandum promulgated by the Office of the Assistant Secretary of 
Defense (Health Affairs) extended reproductive services, including in-
vitro fertilization, to servicemembers and retired servicemembers who 
had a loss of reproductive ability due to serious injury while on 
Active Duty. The Memorandum notes ``Although many medical and other 
benefits are available to these members and their families, members 
with spinal and other injuries that make it impossible to conceive a 
child naturally are not provided TRICARE coverage, which can assist 
them in becoming a parent.''
    An implementing guidance memorandum described available 
reproductive services as sperm retrieval, oocyte retrieval, in-vitro 
fertilization, artificial insemination, and blastocyst implantation. 
Similar to the Department of Defense's recognition that reproductive 
services are crucial elements in affording catastrophically disabled 
individuals and their spouses with life-affirming ability to have 
children and raise a family, so too will passage of the provisions of 
this bill that authorize the VA to offer similar services to veterans 
disabled in service to the Nation.
    This bill also proposes to improve the VA's Women Veterans Contact 
Center by making information involving health care services and 
benefits, provided in the community or by the VA, readily available to 
women veterans when it is requested. PVA believes that the VA must 
continue working toward developing a comprehensive model of care that 
provides woman veterans with a variety of quality services. As the 
number of woman veterans seeking health care services and benefits 
through the VA continues to increase, we must not only work to improve 
the variety of services available to meet women's health care needs, 
but also work to ensure that there is adequate care coordination and 
referral services with the non-VA providers as well. Care coordination 
is the only way to monitor the quality of care provided to women 
veterans outside the VA health care system. Women veterans are one of 
the fastest growing populations within the VA health care system and we 
must make certain that they have access to, and receive, quality health 
care services.
    PVA also supports the proposed modifications of the pilot program 
for counseling in retreat settings for women veterans newly separated 
from service, and the assistance programs for child care for certain 
veterans. Providing veterans with child care assistance eliminates a 
barrier to care that prevents many veterans from receiving appropriate 
health services.
                                 s. 229
    PVA's National office has no position on naming the VA medical 
center in Philadelphia, Pennsylvania as the ``Corporal Michael J. 
Crescenz Department of Veterans Affairs Medical Center. PVA believes 
naming issues should be considered by the local community with input 
from veterans organizations within that community. With that in mind, 
we would defer to the views of PVA's Keystone Chapter or to our 
Colonial Chapter.
                                 s. 287
    PVA supports S. 287, a bill that expands the legal definition of 
``homeless veterans'' to align with the commonly accepted legal 
standard for homelessness that exists in this country. Due to an 
oversight in the law, the legal definition of ``homeless veterans'' 
differs significantly from the existing definition of homelessness. 
Specifically title 38 U.S.C. does not recognize as being homeless an 
``individual or family who is fleeing, or is attempting to flee, 
domestic violence, dating violence, sexual assault, stalking, or other 
dangerous or life-threatening conditions in the individual's or 
family's current housing situation'' (42 U.S.C. Sec. 11302b). The 
wording change proposed by S. 287 would allow veterans who experience a 
domestic violence situation, and choose to leave that situation, to 
access the same benefits available to all other homeless veterans. 
Currently, in order to qualify for benefits offered to homeless 
veterans through the VA, an individual must only meet the definition of 
homeless in outlined by 42 U.S.C. Sec. 11302a. It only makes sense that 
the VA's definition for homelessness align with the larger Federal 
standard.
                                 s. 325
    PVA supports S. 325, legislation to amend title 38, United States 
Code, to increase the maximum age for children eligible for medical 
care under the Civilian Health and Medical Program of the Department of 
Veterans Affairs (CHAMPVA) program. CHAMPVA is a comprehensive health 
care program in which the VA shares the cost of covered health care 
services for eligible beneficiaries, including children up to age 21. 
As a part of health reform, all commercial health insurance coverage, 
as well as health care coverage provided to servicemembers and their 
families through TRICARE, the age for covered dependents to receive 
health insurance on their parents plan was increased from 21 years of 
age to 26 years, in accordance with the provisions of Public Law 111-
148, the ``Patient Protection and Affordable Care Act.''
    At this time the only qualified dependents that are not covered 
under a parent's health insurance policy up to age 26 are those of 100 
percent service-connected disabled veterans covered under CHAMPVA. This 
unfortunate oversight has placed a financial burden on these disabled 
veterans whose children are still dependent upon the parents for 
medical coverage, particularly if the child has a preexisting medical 
condition. This legislation makes the necessary adjustment in this VA 
benefit.
          s. 412, the ``keep our commitment to veterans act''
    PVA supports S. 412, a bill which would authorize major medical 
leases by the Veterans Health Administration (VHA). However, we remain 
concerned with the ongoing problem VHA has to complete a number of 
capital leases as a result of new rules that the Congressional Budget 
Office (CBO) is now using to score the costs of those leases. Last 
year, CBO changed its methodology for estimating costs of capital 
leases. While previously, CBO recognized that capital lease costs were 
spread out over a 15 or 20-year period, now the CBO scores all of the 
cost of a major capital lease up front. This leads to lease 
authorization legislation having very large cost estimates. As a 
result, without having a method to pay this high cost, legislation is 
essentially blocked from consideration. This has left a number of major 
medical facility leases in limbo with many more still pending. We 
encourage the Committee and Congress to take whatever action is 
necessary to correct this action by CBO. Otherwise, veterans face the 
real possibility of not receiving critical care as a result of 
political nonsense.
                                 s. 422
    PVA supports the provisions of S. 422, the ``Chiropractic Care 
Available to All Veterans Act.'' Chiropractic care has become a widely 
accepted and used medical treatment. It is a treatment covered by 
TRICARE and it is only appropriate that it should be provided at VA 
facilities. But it is also important for the Subcommittee to recognize 
that by providing this treatment benefit to veterans, it will entail a 
new type of care which is currently not considered in funding. When new 
treatments are authorized at VA facilities, they must be considered 
when determining VA appropriations to prevent those becoming unfunded 
mandates.
                                 s. 455
    PVA supports S. 455, a bill to amend title 38 U.S.C. to authorize 
the Secretary of Veterans Affairs to transport individuals to and from 
facilities of the VA in connection with rehabilitation, and counseling 
required by the Secretary; or for the purpose of examination, 
treatment, or care. Often disabled veterans do not have adequate access 
to health care services because they do not have transportation that is 
cost efficient or accessible. While PVA believes that S. 455 is a step 
toward the elimination of transportation as a barrier to health care 
access, we strongly suggest that language be included in the bill that 
requires the VA to provide accessible transportation for disabled 
veterans, specifically veterans who have incurred a spinal cord injury 
or disorder, or veterans who use a wheelchair. For disabled veterans 
who do not have personal means of transportation, arranging for 
accessible transportation can be very arduous and time consuming. 
Unfortunately, it is not uncommon for disabled veterans who are not 
able to drive themselves to delay medical visits until transportation 
can be arranged or forgo medical attention completely. PVA believes 
that authorizing the VA to provide veterans with accessible 
transportation to and from VA facilities will increase veterans' access 
to care.
                                 s. 522
    PVA does not have a position on S. 522, the ``Wounded Warrior 
Workforce Enhancement Act,'' legislation that would provide funds for 
the VA to award grants to eligible institutions to assist in 
establishing post- graduate degree programs in orthotics and 
prosthetics, or to expand on existing masters or doctoral programs. PVA 
members utilize VA prosthetic services on a regular basis and rely on 
prosthetics devices daily, and therefore, we fully support and 
understand the importance of enhancing the quality of VA prosthetic 
services, and developing a professional staff that is able to meet the 
complex prosthetic needs of veterans. While PVA supports increased 
promotion and development of professionals in the field of prosthetics, 
we believe that any partnership that VA enters into with an educational 
institution must include specific agreements that help VA recruit and 
retain quality professionals in the field of prosthetics.
    S. 522 would also provide funds to an institution with experience 
in these areas to establish a Center of Excellence in orthotic and 
prosthetic education. While PVA agrees that such a center is much 
needed to conduct research, and coordinate and disseminate information 
involving veterans and prosthetics, it must first be determined if it 
is best for both veterans and the VA to have such a center established 
within the VA or with an outside entity. PVA believes that the primary 
focus of a Center of Excellence in Orthotic and Prosthetic Education 
should be the prosthetic needs of veterans.
                                 s. 529
    PVA has no objection to the provisions of S. 529. However, we 
believe that the emphasis should be placed on providing the VA 
Secretary all the discretion necessary to make a determination as to 
the commencement date for the period of military service to establish 
the eligibility for hospital care and medical services provided to 
servicemembers and their families who experienced toxic exposure at 
Camp Lejeune, North Carolina. In fact, we believe that a specific 
delimiting date should be removed all together.
            s. 543, the ``visn reorganization act of 2013''
    PVA opposes S. 543, a bill that would establish a new 
organizational structure for the alignment of the Veterans Integrated 
Service Networks (VISN) around the country. PVA has serious concerns 
about the precedent that this legislation would set. The VA currently 
uses the VISN structure as a management tool for the entire VA health 
care system. It makes no sense for Congress to legislate how the VA 
should manage its system. Furthermore, this sets a dangerous precedent 
whereby any member could decide that the VA's VISN alignment is not 
satisfactory (in their opinion), and that it should be redrawn in such 
a way to support his or her own state or district.
    However, we believe that the current network alignment could be 
reassessed and possibly realigned. There is certainly nothing that 
suggests that 21 service networks is the optimal structure. But where 
does the VA draw the line when establishing its health care system 
structure? With the current 21 VISN's, the VA seems to do a good job of 
managing a massive health care system. This is not to suggest that the 
administration of these networks is not bloated, but the alignment 
itself seems satisfactory.
    Meanwhile, it is our understanding that the Veterans Health 
Administration is already considering a realignment of its VISN 
structure. With this thought in mind, we believe it would be prudent to 
withhold this proposed legislation until all of the details of the VA's 
plan can be assessed.
                                 s. 633
    PVA strongly supports S. 633, a bill to amend title 38, United 
States Code, to provide for coverage under the beneficiary travel 
program of the VA of certain disabled veterans for travel in connection 
with certain special disabilities rehabilitation. If enacted, this 
legislation would provide reimbursement for travel that is in 
connection with care provided through a VA special disabilities 
rehabilitation program to veterans with a spinal cord injury or 
disorder, double or multiple amputations, or vision impairment. Such 
care must also be provided on an inpatient basis or during temporary 
lodging at a VA facility. For this particular population of veterans, 
their routine annual examinations often require inpatient stays, and as 
a result, significant travel costs are incurred by these veterans. Too 
often, catastrophically disabled veterans choose not to travel to VA 
medical centers for care due to significant costs associated with their 
travel. When these veterans do not receive the necessary care, the 
result is often the development of far worse health conditions and 
higher medical costs for the VA. For veterans who have sustained a 
catastrophic injury like a spinal cord injury or disorder, timely and 
appropriate medical care is vital to their overall health and well-
being.
    PVA believes that expanding VA's beneficiary travel benefit to this 
population of severely disabled veterans will lead to an increasing 
number of catastrophically disabled veterans receiving quality 
comprehensive care, and result in long-term cost savings for the VA. 
Eliminating the burden of transportation costs as a barrier to 
receiving health care, will improve veterans' overall health and well 
being, as well as decrease, if not prevent, future costs associated 
with both primary and long-term chronic, acute care.
 s. 800, the ``treto garza far south texas veterans inpatient care act 
                               of 2013''
    PVA generally supports the provisions of S. 800, the ``Treto Garza 
Far South Texas Veterans Inpatient Care Act.'' This bill would ensure 
that the Department of Veterans Affairs (VA) has the resources and 
capacity to meet the health care needs of veterans living in the Far 
South Texas area. Specifically, this bill will require the VA medical 
center in Harlingen, Texas, to provide ``full-service'' inpatient 
health care for veterans in Far South Texas. This legislation improves 
access to VA health care for approximately 108,000 veterans.
    We do have questions about the provisions of the legislation that 
specifically require adding inpatient beds, an urgent care center, and 
women veterans' services. It is our understanding that this facility 
and its network have established a women veterans' health care program. 
Additionally, we are uncertain as to what analysis has been done to 
justify the increased number of inpatient beds. We certainly see no 
problem with providing urgent care services, if those services do not 
already exist at this facility.
    However, PVA's National office has no position on naming the VA 
medical center in Harlingen, Texas as the ``Treto Garza South Texas 
Department of Veterans Affairs Health Care Center. PVA believes naming 
issues should be considered by the local community with input from 
veterans organizations within that community. With that in mind, we 
would defer to the views of PVA's Lonestar Chapter or Texas Chapter.
        s. 825, the ``homeless veterans prevention act of 2013''
    PVA supports S. 825, the ``Homeless Veterans Prevention Act of 
2013,'' a bill that will help insure the safety of facilities that 
offer services to homeless veterans and extend VA's authority to 
provide and fund support programs and services for veterans. Many of 
the grant programs outlined in the legislation will help veterans who 
are homeless, or facing the prospect of homelessness, overcome the 
hurdles that prevent them from becoming socially and financially 
established. PVA believes that S. 825 is in direct alignment with 
Secretary Shinseki's goal of eradicating homelessness among America's 
veterans. Ultimately, in order to ensure that the myriad of homeless 
programs are successful, fully sufficient resources must be provided to 
these programs. Otherwise, overcoming homelessness becomes a policy 
without the possibility of true success.
                                 s. 832
    PVA supports, S. 832, the ``Improving the Lives of Children with 
Spinal Bifida Act of 2013.'' This legislation would require the VA to 
carry out two pilot programs that furnish case management services and 
assisted living to children of Vietnam veterans, and certain Korea 
service veterans born with Spina Bifida and children of women Vietnam 
veterans born with certain birth defects. When living with physical 
disabilities and disorders such as Spina Bifida, the impact of 
associated illnesses and complications requires frequent medical visits 
and various types of routine medical treatments and therapies. Managing 
such care can be extremely difficult and overwhelming. Providing case 
management services will help ensure that proper care is received by 
the children of veterans who are living with Spina Bifida. PVA believes 
that both pilot programs promote independence and allow people with 
disabilities a degree of personal freedom, and give them the 
opportunity to become a part of and engaged in their local communities.
                                 s. 845
    PVA strongly supports, S. 845, a bill to amend title 38 U.S.C., to 
improve the VA Health Professionals Educational Assistance Program. 
Maintaining a skilled and competent professional staff is critical to 
the successful delivery of high-quality VA medical services. Extending 
the Health Professionals Educational Assistance Program will not only 
serve as a recruitment incentive for potential VA employees, but also 
prove to be an effective retention tool within VHA. This legislation 
also proposes to repeal the cap on the amount of the Education Debt 
Reduction Program (EDRP). PVA supports this change and believes that as 
educational costs continue to rise and new professional graduates enter 
the workforce with educational debt, this is a benefit that the VA must 
improve in order to attract the highest caliber of new graduates and 
students from degree programs to provide quality care to veterans, and 
remain competitive with private sector employers in the health care 
industry.
    s. 851, the ``caregiver expansion and improvement act of 2013''
    PVA fully supports S. 851, the ``Caregiver Expansion and 
Improvement Act of 2013.'' This legislation addresses the greatest 
concern that we had with the original legislation when this program was 
established. PVA was extremely disappointed that veterans who became 
injured or ill prior to September 11, 2001, were excluded from the 
comprehensive caregiver support programs. The fact is, PVA's members--
veterans with spinal cord injury or disorder--would benefit from this 
program more than any other population of veterans. And yet, the 
majority of those veterans were excluded by the arbitrary date of 
September 11, 2001, from the comprehensive caregiver program. No 
reasonable justification (other than cost considerations) can be 
provided for why pre-9/11 veterans with a service-connected injury or 
illness should be excluded from the comprehensive caregiver program. 
Catastrophically disabled veterans needs are not different simply 
because they may have been injured prior to the selected date.
    PVA also encourages the Committee to consider amending the 
legislation to ensure that veterans who have incurred a catastrophic 
illness or disease will benefit from the caregiver program. Currently, 
veterans who have incurred a severe illness or disease as a result of 
their service are excluded from consideration as eligible for this 
program. This proposed legislation excludes these veterans as well. 
Aside from the fact that nearly all PVA members are unfairly excluded 
from this program, the second biggest complaint that we have received 
from our members who are eligible under the Post-9/11 criteria for this 
program is the exclusion for serious illnesses or diseases. A spinal 
cord disease is no less catastrophic than a spinal cord injury. It is a 
fact that veterans who have been diagnosed with Amyotrophic Lateral 
Sclerosis (ALS) and Multiple Sclerosis (MS) will eventually experience 
a catastrophic impact on their activities of daily living. And yet, 
these individuals who may be in greater need of caregiver services than 
any other population of injured veterans have no avenue for support 
through the new caregiver program. We strongly urge the Committee to 
consider these issues when marking up this legislation.
    Additionally, we urge the Committee to follow through on oversight 
regarding the reporting requirements that the VA has as a result of 
Public Law 111-163, the ``Caregivers and Veterans Omnibus Health 
Services Act.'' In accordance with the provisions of the law, the VA is 
required to report on the feasibility of expanding the caregiver 
program. Specifically, the law states:

        ``Not later than 2 years after the date described in subsection 
        (a)(3)(A), the Secretary shall submit to the Committee on 
        Veterans' Affairs of the Senate and the Committee on Veterans' 
        Affairs of the House of Representatives a report on the 
        feasibility and advisability of expanding the provision of 
        assistance under section 1720G(a) of title 38, United States 
        Code, as added by subsection (a)(1), to family caregivers of 
        veterans who have a serious injury incurred or aggravated in 
        the line of duty in the active military, naval, or air service 
        before September 11, 2001.''

    As of this time, the VA has already missed its deadline for 
submitting this important report. We understand that VA is currently in 
the process of developing this report. However, the Committee must not 
allow the VA to simply choose to ignore this requirement so as not to 
draw attention to an obvious deficiency in the caregiver program that 
it cannot or will not be able to implement. The VA must ensure that it 
fulfills this reporting requirement as it is an integral part of the 
implementation of the caregiver program. This critical report will pave 
the way to access to much-needed caregiver assistance for many more 
catastrophically disabled veterans who are currently being denied 
eligibility simply because of the arbitrary date assigned to this 
benefit by Congress.
          s. 852, the ``veterans health promotion act of 2013
    PVA does not have a position on S. 852, the ``Veterans' Health 
Promotion Act of 2013,'' a bill to improve health care furnished by the 
VA by increasing access to complementary and alternative medicine and 
other approaches to wellness and preventive care. Nonetheless, 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. However, PVA cautions VA to make certain that 
clinicians utilize evidence-based therapies when selecting 
complementary and alternative forms of medicine. Veterans' safety and 
overall health and well-being must not be compromised. PVA also 
believes that the implementation of preventive health programs within 
VA will potentially lead to positive health outcomes for veterans, as 
well as create long-term cost savings for the VA if veterans are 
informed of the prevention health services and incentivized to use 
them.
       the ``veterans affairs research transparency act of 2013''
    PVA supports the ``Veterans Affairs Research Transparency Act.'' 
PVA is intimately involved in research activities, funding a great deal 
of research in the areas of spinal cord injury and disorder with the 
long-term goal of finding a cure for spinal cord injury. We certainly 
recognize the benefits of having information about research activities 
being conducted through VA available to the larger public. Much of the 
American public is not even aware of the great advancements and 
discoveries that have been made through the efforts of VA research. 
This legislation should help disseminate that work.
    However, we would offer a couple of cautions as this legislation is 
considered. First, we must emphasize the importance of confidentiality 
of any human subjects involved in the research that is made available. 
Additionally, we believe some clarification is necessary to address 
copyright and intellectual property issues that may arise from outside 
entities accessing research that VA essentially owns.

    PVA would once again like to thank the Committee for the 
opportunity to submit our views on the legislation considered today. 
Enactment of much of the proposed legislation will significantly 
enhance the health care services available to veterans, servicemembers, 
and their families. We would be happy to answer any questions that you 
may have for the record.
                                 ______
                                 
          Prepared Statement of Service Women's Action Network
    Chairman Sanders, Ranking Member Burr and distinguished Members of 
the Committee: Thank you for the opportunity to submit written 
testimony for the record and thank you for your continued leadership on 
veteran's issues and for convening this hearing today.
    The Service Women's Action Network (SWAN) is a non-profit, non-
partisan veterans led civil rights organization. SWAN's mission is to 
transform military culture by securing equal opportunity and freedom to 
serve without discrimination, harassment or assault; and to reform 
veterans' services to ensure high quality health care and benefits for 
women veterans and their families.
    We challenge institutions and cultural norms that deny equal 
opportunities, equal protections, and equal benefits to servicemembers 
and veterans. SWAN is not a membership organization, instead we utilize 
direct services to provide outreach and assistance to servicemembers 
and veterans and our policy agenda is directly informed by those 
relationships and that interaction.
    SWAN extends opportunities to and promotes the voices and agency of 
service women and women veterans without regard to sex, gender, sexual 
orientation or gender identity or the context, era, or type of their 
service.
    SWAN welcomes the opportunity to share our views on three of the 
bills before the Committee today, S. 131, the Woman Veterans and Other 
Healthcare Improvement Act of 2013, S. 287, a bill to amend title 38, 
United States Code, to expand the definition of homeless veteran for 
purposes under the laws administered by the Secretary of Veterans 
Affairs and S. 325, the proposed bill to amend title 38, United States 
Code and increase the maximum age for children eligible for medical 
care under CHAMPVA.
                                 s. 131
    SWAN supports S. 131. This bill will provide access to much needed 
fertility treatments for seriously injured veterans and their spouses, 
research into infertility treatments adoption assistance, permanent 
authority for VA to provide child care, and in addition improve the 
responsiveness of the VA to women's health issues and significantly 
expand a critical pilot program for women's VA heath retreat centers.
    After a decade at war, many women servicemembers are still at risk 
for reproductive and urinary tract issues due to deployment conditions 
and a lack of predeployment women's health information, compounded by 
privacy and safety concerns. Moreover, the nature of the current 
conflict and increasing use of improvised explosive devices leaves both 
men and women servicemembers far more susceptible to blast injuries 
including spinal cord injury and trauma to the reproductive and urinary 
tracts. Pentagon data shows that between 2003 and 2008 nearly 2,000 
women and men suffered these life-altering battle injuries while 
serving in Iraq or Afghanistan.\1\
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    \1\ http://blogs.seattletimes.com/today/2012/12/senate-lifts-ban-
on-va-funding-for-in-vitro-fertilization/
---------------------------------------------------------------------------
    Infertility is a devastating diagnosis to receive and it is further 
complicated by a lack of access to readily available infertility 
treatments. S. 131 would provide research, treatment and adoption 
assistance to veterans grievously wounded in the line of duty and allow 
them to have the family that many of them right now can only dream of 
having.
    Additionally, S. 131 would assist VA in making greater strides in 
improving the area of women's health services. The bill would enhance 
the Department of Veterans Affairs women veterans contact center to 
respond to requests for assistance with accessing health care and 
providing referrals. It would also improve the VA's women's health 
retreat pilot program by more than quadrupling the number of facilities 
(from 3 to 14) and doubling the length of the program.
    It is important for the Committee to note that more than 250,000 
women have served in Iraq and Afghanistan, and as the population of 
women veterans continues to grow, VA must continue to adapt to meet the 
unique health care needs of women veterans and their families. VA has 
taken steps in this direction, yet studies have indicated that women 
veterans who use VA services reported a lower quality of care and 
higher dissatisfaction compared to women using outside care.\2\ Clearly 
more work remains to make VA a friendly environment for women veterans.
---------------------------------------------------------------------------
    \2\ Kelly et al. 2008. ``Effects of Military Trauma Exposure on 
Women Veterans' Use and Perceptions of Veterans Health Administration 
Care.'' Journal of General Internal Medicine 23 (6):741-747.
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                                 s. 287
    SWAN supports S. 287. This is an extremely important bill that 
ensures veterans fleeing domestic violence or another life threatening 
condition are eligible for VA homeless assistance. The 2009 Homeless 
Emergency Assistance and Rapid Transition to Housing (HEARTH) Act 
updated the definition of homelessness to cover individuals fleeing 
domestic violence. However, the definition of ``homeless veteran'' was 
not updated to reflect this change. The Department of Veterans Affairs 
has developed a number of programs to assist homeless veterans, however 
the outdated definition of ``homelessness'' could cause problems for 
victims of domestic violence. S. 287 addresses this issue by updating 
the legal definition of ``homeless veteran'' to bring it to the same 
standard as the rest of the law, and it will allow veterans who are in 
a domestic violence situation to access the same benefits available to 
other homeless veterans. It corrects a grievous oversight and will 
allow those who have served our country and find themselves in 
difficult and dangerous domestic violence situations to receive the 
support and benefits they have earned.
                                 s. 325
    SWAN supports S. 325. This common-sense bill would allow CHAMPVA 
beneficiaries to keep coverage until age 26. Currently, beneficiaries 
lose coverage at age 18 unless they are enrolled as full-time students. 
Then, they become ineligible at age 23. The bill would create program 
parity with age requirements of the Affordable Care Act, which now 
allows adult children to remain on their parents' health insurance 
until age 26. This bill is similar to a law passed in January 2011 that 
increased coverage for adult children of TRICARE beneficiaries, 
bringing it on par with the Affordable Care Act.

    Again, we appreciate the opportunity to offer our views on these 
key bills and we look forward to continuing our work together to 
improve the lives of veterans and their families. Any questions can be 
directed to Greg Jacob, Policy Director at 646-569-5216 or 
[email protected]
                                 ______
                                 
Prepared Statement of Raymond C. Kelley, Director, National Legislative 
         Service, Veterans of Foreign Wars of the United States
     With Respect to S. 49, S. 62, S. 131, S. 229, S. 287, S. 325, 
    S. 412, S. 422, S. 455, S, 522, S. 529, S. 543, S. 633, S. 800, 
     S. 825, S. 832, S. 845, S. 851, S. 852, and Draft Legislation
               s. 49, veterans health equity act of 2013
    VA routinely assesses veterans' health care access needs through 
its Strategic Capital Investment Plan (SCIP). SCIP prioritizes all 
levels of construction projects based on a scoring system, placing 
those with the highest score at the top of the list. This model of 
evaluation and resource allocation allows for equitable and consistent 
distribution of capital funding. However, for SCIP to fully be 
realized, sufficient funding must accompany the plan.
    The requirement in S. 49 mandating VA to maintain a full-service 
medical center in each of the 48 contiguous states could cause funding 
for a higher priority construction project to be redirected. The VFW 
does encourage VA to reevaluate New Hampshire, to ensure at any gaps in 
service are identified and prioritized by SCIP.
         s. 62, check the box for homeless veterans act of 2013
    The VFW appreciates the spirit of this legislation, but has some 
reservations about the possible negative unintended consequences of 
creating non-traditional funding sources for important VA programs. 
This bill would give taxpayers the option of donating to a new Homeless 
Veterans Assistance Fund, which would be established through the U.S. 
Treasury, by checking a box on their annual tax returns. That money 
would then be made available to VA, the Department of Labor, and the 
Department of Housing and Urban Development, for the purposes of 
supporting programs that serve homeless veterans. It also provides for 
oversight of the Homeless Veterans Assistance Fund by requiring that 
the secretaries of the aforementioned departments submit detailed 
expenditure plans prior to using the funds, and that the use of the 
funds for the prior and upcoming years must be described in the 
President's annual budget submission.
    Although the VFW commends the intent of this legislation which is 
designed to support the administration's goal of ending homelessness by 
2015, we are concerned that the establishment of the Homeless Veterans 
Assistance Fund may create the rationale for future reductions in 
traditional funding for homeless veterans' programs. VA has made marked 
and consistent progress toward that goal over the past several years 
through adequate funding for effective initiatives such as Supportive 
Services for Veterans Families, the Grant Per Diem Program, the 
Homeless Veterans Reintegration Program, and HUD-VASH vouchers. The VFW 
feels that now is not the time to experiment with alternative funding 
sources for these critical services. We must continue to pay for these 
programs with congressionally appropriated dollars in order to ensure 
that they receive consistent and reliable funding levels.
 s. 131, women veterans and other health care improvements act of 2013
    A decade of war has put servicemembers at risk for experiencing 
reproductive and urinary tract issues due to the lack of pre-deployment 
health information, and the use of improvised explosive devices (IED) 
leaving many more susceptible to blast injuries including trauma to the 
reproductive areas. DOD has reported that from 2003 to 2011at least 
2,000 servicemembers have suffered from reproductive and/or urinary 
tract trauma.
    Providing reproductive services that meet the complex needs of our 
severely wounded veterans is critical in helping many move forward with 
their lives and aspirations. Dreams of having a family often are at the 
top of the list. Currently, VA offers some fertility services, but they 
often do not meet the needs of those severely injured with more complex 
reproductive needs (In-vitro fertilization or IVF is excluded from VA 
medical benefits package under 38CFR 17.38 (c) (2)).
    The VFW thanks Senator Murray for taking the lead on this issue and 
supports Sections 2 and 3 which will provide fertility counseling and 
treatment to include assisted reproductive technology, like IVF, to a 
spouse or surrogate of a severely wounded, ill or injured veteran who 
has an infertility condition which was incurred in the line of duty or 
while on active duty. The patient must be enrolled in VHA and, in the 
case of a spouse or surrogate of a veteran not enrolled, VA would 
coordinate fertility and counseling for them. VA is not required to 
find or certify a surrogate, or connect the veteran with a surrogate, 
or provide maternity care for the spouse or surrogate, which will 
negate any legal issue that may arise during the process.
    The legislation also calls on VA to conduct collaborative research 
with DOD and Health and Human Services (National Institutes of Health) 
to address the long-term reproductive health care needs of veterans 
with service-connected reproductive injuries. We believe that this 
research is critical in addressing and treating the unique infertility 
issues of veterans with combat injuries now and in to the future.
    The VFW also supports section 9 which improves access to services 
for women veterans through VA's Women Veterans Call Center. With an 
increasing number of female veterans entering the health care arena, VA 
must take every opportunity to reach out and provide assistance and 
guidance, as well as referrals to community resources for services not 
offered within VA.
    We are also pleased to see provisions in sections 10 and 11 of the 
bill that would expand the child care pilot program for veterans 
seeking readjustment counseling at Vet Centers, and also increase the 
number of counseling retreat locations which help to ease newly 
separated female veterans back into civilian life. The VFW supported 
the original language established in Public Law 111-163, and is happy 
to see these programs continue.
            s. 229, corporal michael j. crescenz act of 2013
    The National VFW does not take positions on the designation of 
Federal property. We do encourage our state and local VFW members to be 
involved in these designations to ensure community buy-in.
  s. 287, a bill to amend title 38, united states code, to expand the 
definition of homeless veteran for purposes of benefits under the laws 
   administered by the secretary of veterans affairs, and for other 
                               purposes.
    The VFW is pleased to support S. 287, legislation that would 
clarify the definition of ``homeless,'' thereby aligning it with the 
McKinney-Vento Act to include those displaced by domestic violence.
    No veteran should ever be homeless, and expanding the definition to 
include those veterans who are fleeing situations of domestic abuse is 
the right thing to do. By making this change, we support this 
population of veterans and help them to have the courage and means to 
leave their abusive and sometimes life-threatening situation. This bill 
will also ensure they receive access to the benefits VA already 
provides thousands of homeless veterans.
    We believe this legislation will significantly improve the lives of 
those who become homeless as a result of difficult circumstances 
outside of their control, and help them on their way to beginning a new 
chapter in their lives. We urge the Committee to pass this bill 
quickly.
 s. 325, a bill to amend title 38, united states code, to increase the 
 maximum age for children eligible for medical care under the champva 
                    program, and for other purposes.
    The VFW strongly supports this legislation to extend the age limit 
for coverage of veterans' dependents through the Civilian Health and 
Medical Program of the Department of Veterans Affairs (CHAMPVA) to the 
level set by the Patient Protection and Affordable Care Act.
    The health care reform legislation, passed in early 2010, allowed 
families with private health insurance coverage to keep their children 
on their plans until age 26. Left out of that change was TRICARE and 
CHAMPVA recipients. Thanks to responsible leaders in Congress, TRICARE 
coverage has been guaranteed to this age group. Unfortunately, CHAMPVA 
beneficiaries have not been afforded the same privileges. This program, 
which was established in 1973 and has more than 330,000 unique 
beneficiaries comprised of dependents and survivors of certain 
veterans, should in no instance ever receive less than the national 
standard. This legislation would provide equity to CHAMPVA 
beneficiaries and rectify this outstanding issue.
              s. 412, keep our commitment to veterans act
    The VFW supports S. 412. Congress must authorize the funding of the 
FY 2013-FY 2014 major medical leases. Without this funding, twelve VA 
facilities across the United States may not be able to properly serve 
their communities. For example, the Errera Community Care Center 
(ECCC), a leading center of innovation providing psychological 
rehabilitation, homeless reintegration, substance abuse counseling, and 
employment services to over 4,700 veterans in the greater West Haven, 
Connecticut area must relocate to a larger facility in order to remain 
effective. The facility that currently houses the ECCC is so 
insufficient to meet the demand for services that veterans' group 
therapy sessions are conducted in hallways, and two to three staff 
members share a single desk. In order to ensure that the momentum that 
has recently been achieved in solving the complex problems many 
veterans face is maintained, community centers like the ECCC must be 
provided with adequate facilities.
    However, the passage of this Act does not solve the long-term 
problem of funding VA major medical leases under the Congressional 
Budget Office's new lease evaluation. While S. 412 is a good first 
step, Congress must take action to ensure that these annually 
appropriated leases are not continually delayed.
    s. 422, chiropractic care available to all veterans act of 2013
    The VFW supports this legislation which would establish 
chiropractic care services at all VA medical centers by the end of 
2016. In accordance with Public Law 107-35, chiropractic care is 
currently offered at 47 of the 152 VA medical centers nationwide, with 
at least one facility being in each VISN. This bill would initiate a 
gradual expansion of chiropractic care services, requiring that they be 
made available at no fewer than 75 medical centers by December 31, 
2014, and all medical centers by December 31, 2016.
    It is well known that servicemembers who deploy to combat and 
participate in military training are subject to extraordinary physical 
demands, often resulting in the premature onset of painful spine and 
joint conditions. The 2010 VA analysis of health care utilization among 
OIF and OEF veterans listed ``diseases of musculoskeletal system/
connective system'' as the number one condition for which Iraq and 
Afghanistan veterans sought VA care. Chiropractic care can often be a 
successful alternative to drugs or invasive procedures for treating 
musculoskeletal disorders, while also offering suggestions for 
lifestyle modifications which promote overall wellness. The VFW 
believes that chiropractic care is a valuable option and should be made 
available to veterans at all VA medical centers.
s. 455, a bill to amend title 38, united states code, to authorize the 
  secretary of veterans affairs to transport individuals to and from 
  facilities of the department of veterans affairs in connection with 
 rehabilitation, counseling, examination, treatment, and care, and for 
                            other purposes.
    The VFW supports this legislation to permanently authorize the 
Veterans Transportation Service (VTS). This program, commissioned by 
the VHA Office of Rural Health in 2010, has greatly improved access to 
care for rural and seriously disabled veterans by allowing VA 
facilities to establish and coordinate networks of local transportation 
providers including VSOs, community and commercial transportation 
providers, and government transportation services. The VTS serves an 
innovative supplement to the existing beneficiary travel programs of 
mileage reimbursement, which does nothing to assist in the coordination 
of transportation for those who need it, and special mode travel, for 
which few veterans medically qualify.
    The VTS program suffered a major setback in 2012 when it was 
temporarily suspended following a determination by the VA Office of 
General counsel that VA lacked the statutory authority to provide the 
new benefits. Congress wisely passed a one-year authorization of the 
program in January 2013, but a long-term fix is still needed.
    The VFW believes that unnecessary hardships associated with 
accessing VA health care should be eliminated at every opportunity. 
This legislation would guarantee the continuation and future expansion 
of VTS, which plays a critical role in minimizing the challenges many 
veterans face in traveling to their appointments due to physical 
disabilities or great distances.
           s. 522, wounded warrior workforce enhancement act
    The VFW does not support this legislation which would require the 
VA to award grants to eligible educational institutions that establish 
or expand existing master's degree programs in orthotics and 
prosthetics. The bill would also create a grant to be awarded to an 
institution that establishes a private Center of Excellence in Orthotic 
and Prosthetic Education. Although the VFW recognizes the importance of 
promoting the development of high quality prosthetic staff and 
services, we feel that this bill takes the wrong approach. Since it 
mandates no service requirement for the students who would benefit from 
the funding provided by the grants, VA does not stand to reap any 
direct benefit from their enhanced training. Additionally, the VFW 
questions whether veterans would be better served by a Center of 
Excellence in this field within the VA, as opposed to one that is 
privately operated.
  s. 529, a bill to amend title 38, united states code, to modify the 
   commencement date of the period of service at camp lejeune, north 
 carolina, for eligibility for hospital care and medical services with 
        exposure to contaminated water, and for other purposes.
    The VFW supports this legislation which would adjust the date for 
VA health care eligibility associated with exposure to contaminated 
water at Camp Lejeune, North Carolina from January 1, 1957 to August 1, 
1953 or an earlier date specified by the Secretary in consultation with 
the Agency for Toxic Substances and Disease Registry, due to recent 
findings by the ATSDR that the drinking water at that installation was 
contaminated as early as 1953.
                s. 543, visn reorganization act of 2013
    The VFW does not support the enactment of S. 543. The intent of 
this bill has merit. VA should assess the VISN structure for improved 
efficiency and possible VISN realignment. VA has taken steps to improve 
efficiency and is studying the impacts of VISN realignment. Congress 
should continue oversight of this process to ensure veterans are 
receiving the highest level of care in the most effective and efficient 
manner.
 s. 633, a bill to amend title 38, united states code, to provide for 
  coverage under the beneficiary travel program of the department of 
veterans affairs of certain disabled veterans for travel in connection 
    with certain special disabilities rehabilitation, and for other 
                               purposes.
    The VFW supports this legislation which would extend beneficiary 
travel benefits to veterans with certain severe non-service-connected 
disabilities who travel to receive care provided through a VA special 
disabilities rehabilitation program. Veterans who are catastrophically 
disabled due to spinal cord injuries, visual impairments, and multiple 
amputations often require in-patient care in order to achieve full 
rehabilitation. Not all VA facilities, however, offer the specialized 
programs of care needed to properly treat these severe disabilities, 
and many veterans are forced to travel great distances to receive the 
care they need. Those not eligible for travel reimbursement must do so 
at great personal cost and, as a result, may be forced to forego 
essential primary or preventative care for financial reasons. This 
legislation would alleviate that hardship for this small but vulnerable 
population of veterans.
s. 800, treto garza far south texas veterans inpatient care act of 2013
    The VFW does not hold an opinion regarding this legislation. The 
bill calls for the expansion of the Harlingen VA Outpatient Clinic to a 
full-service, inpatient care facility. The VFW would suggest that VA 
assess South Texas' access and utilization gaps to ensure that veterans 
in that region are receiving a full continuum of care without the 
burden of excessive travel, and if there are gaps, prioritize the need 
and have it added to Strategic Capital Investment Plan.
            s. 825, homeless veterans prevention act of 2013
    The VFW supports most provisions of this legislation which expands 
and reauthorizes a number of programs aimed at addressing the 
unacceptable problem of homelessness among veterans. It also keeps 
families together by allowing VA to house the children of veterans in 
transitional housing, while also improving the security of those 
facilities. The VFW firmly believes that no veteran who has honorably 
served this Nation should have to suffer the indignity of living on the 
streets. We praise the great progress that has been made in reducing 
veterans' homelessness in recent years as a direct result of 
coordinated efforts across multiple government agencies to provide 
transitional housing, rapid re-housing, and employment programs for 
veterans in need. The extension and adequate funding provided by this 
bill for these and other programs are vital to achieving the 
Secretary's goal of eradicating homelessness among veterans by 2015.
    The VFW generally supports Section 8 of the bill which would allow 
the Secretary to ``enter into partnerships with public or private 
entities'' to fund a portion of certain legal services for homeless 
veterans. While we recognize that legal problems are often a 
significant barrier to homeless reintegration and must be addressed, we 
are concerned that there may be some for-profit legal entities that 
would view this program as an opportunity to exploit the availability 
of government resources in exchange for poor or inadequate services. 
For this reason, we suggest that the language in this section be 
changed to allow VA to only enter into partnerships with public or non-
profit private legal entities that provide services to homeless 
veterans.
 s. 832, improving the lives of children with spina bifida act of 2013
    Current law (Chapter 18, title 38, United States Code) defines the 
services provided to children of Vietnam veterans and certain Korea 
service veterans born with spina bifida to include comprehensive health 
care, but some veterans have reported that they have had difficulty 
accessing these benefits for their severely handicapped children.
    This bill will help remedy some of these issues by requiring VA to 
carry out a pilot program in rural areas, and report to Congress on 
services they are providing to children under the law. The legislation 
is of little or no cost to VA and will allow Congress an inside view of 
specifics within the program to include statistics on what types of 
services and how many are being provided.
    The VFW believes that this is an appropriate use of Congressional 
oversight and the findings will provide insights into the program, 
specifically answering questions as to whether VA is doing everything 
within the law to provide care and services to this most vulnerable 
population. The VFW encourages Congress to enact this legislation so 
those in need of care and services can access what is rightfully and 
legally theirs--we owe them nothing less.
 s. 845, a bill to amend title 38, united states code, to improve the 
department of veterans affairs health professionals assistance program, 
                        and for other purposes.
    The VFW supports this legislation which removes the $60,000 cap on 
the total amount payable under the Education Debt Reduction Program 
(EDRP) and extends the expiration date of the Health Professionals 
Education Assistance Program from December 31, 2014 to December 31, 
2019. VA must be given the tools to recruit and retain high quality 
medical professionals in order to guarantee the continued delivery of 
the highest level of care. By providing targeted education debt 
repayment incentives to physicians in specific fields based on VA need 
in exchange for service obligations, these programs play a vital role 
in properly meeting VA staffing needs.
        s. 851, caregivers expansion and improvement act of 2013
    The VFW strongly supports this legislation which would extend 
current caregiver benefits to those who care for veterans who were 
severely injured prior to September 11, 2001. We believe that severely 
wounded veterans of all conflicts have made incredible sacrifices, and 
that all family members who care for them are equally deserving of 
recognition and support.
    The VFW applauded the passage of the Caregivers and Veterans 
Omnibus Health Services Act of 2010 which provided a monthly stipend, 
respite care, mental and medical health care, and the necessary 
training and certifications required for caregivers of severely 
disabled Post-9/11 veterans, but have consistently maintained that 
eligibility should be expanded to include veterans of all eras. By 
striking ``on or after September 11, 2001'' from 38 U.S.C. Section 
1720G(a)(2)(B), this bill would accomplish that objective.
             s. 852, veterans' health promotion act of 2013
    This legislation would create a new complementary and alternative 
medicine (CAM) program within VA in order to promote the overall health 
and well-being of veterans. Although the VFW feels that CAM and 
wellness programs have the potential to play a significant role in VA 
health care, we would like to offer several suggestions which we feel 
would strengthen this bill.
    S. 852 would establish at least one Center of Innovation for CAM in 
each of the 21 VISNs for health research, education, and clinical 
activities in each VISN, while simultaneously establishing a three year 
pilot program to assess the feasibility of CAM centers in VA medical 
facilities. The VFW feels that it would be more appropriate to conduct 
the pilot program and analyze its results before mandating the 
establishment of CAM Centers of Innovation across VA. Additionally, we 
are concerned that some VISNs may not currently have a medical center 
suitable to be designated a center of excellence.
    The bill also establishes two pilot programs intended to address 
the issue of obesity. The first would subsidize fitness center 
memberships for veterans who are determined to be overweight or obese 
by VA physicians. The VFW suggests that veterans who participate in 
such programs should be required to report for regular examinations to 
ensure that fitness programs are being executed effectively and 
benefits are being achieved. The second pilot program would establish 
fitness centers at VA facilities which would be made available to any 
veteran enrolled in the VA health care system. Recognizing that space 
and resources are scarce, the VFW recommends that the use of such 
fitness centers be reserved for those veterans deemed overweight or 
obese by a VA physician. With these changes, we believe that these 
programs would enhance the overall wellness of the veterans' community, 
while allowing VA to most effectively experience the associated long-
term cost savings.
     draft bill, veterans affairs research transparency act of 2013
    The VFW has no position on this legislation which would establish a 
new Web site to make VA research data available to the public, and 
require the Veterans Affairs-Department of Defense Joint Executive 
Committee to submit recommendations on the establishment of a data--
sharing program between VA and DOD in order to better facilitate 
research. Although we see the value of the public dissemination of 
information and greater cooperation between VA and DOD with regards to 
data-sharing, we are unable to comment on whether the mandates of this 
bill would achieve those objectives most effectively.
                                 ______
                                 
             Prepared Statement of Wounded Warrior Project
    Chairman Sanders, Ranking Member Burr, and Members of the 
Committee: Thank you for inviting Wounded Warrior Project (WWP) to 
provide views on pending health-related legislation. Several of the 
measures under consideration address issues of keen importance to 
wounded warriors and their family members.
                            health promotion
    Among these bills, Mr. Chairman, we welcome the focus on health-
promotion in S. 852, and believe VA health care facilities can be 
important settings to advance the goal of wellness. As an organization 
deeply engaged in developing and operating programs to empower wounded 
warriors, we work very actively to promote health and wellness. 
Complementing WWP's programmatic work, we see merit in advancing 
health-promotion and wellness in the VA, and in expanding through 
rigorous scientific study our understanding of the potential benefits 
of complementary and alternative medicine (CAM) for certain chronic 
health conditions. Given its size and reach, the VA health care system 
could certainly serve as a national laboratory to participate in 
studying the potential of certain avenues of complementary and 
alternative medicine to treat, or complement the conventional treatment 
of, particular conditions. Working in concert with NIH's National 
Center for Complementary and Alternative Medicine, VA could, for 
example, help mount large-scale, rigorous studies to assess the 
effectiveness and safety of particular practices in the treatment of 
certain chronic conditions.
    S. 852 would direct VA to operate in each network at least one 
center to conduct CAM research, education and training, and clinical 
care. The bill would also direct VA to establish several pilot 
programs, including establishing an additional 15 centers to provide 
services involving CAM for veterans who have mental health conditions 
and suffer with pain; a grant program to assess the use of wellness 
programs for combat veterans and their family members; and pilot 
programs involving fitness activities. While we are supportive of an 
increased emphasis in VA on health promotion and wellness for wounded 
warriors, we would encourage further refinement of S. 852.
    We see particular value in fostering the study and evaluation of 
promising therapies to complement the treatment of certain behavioral 
health conditions and the management of chronic pain and to help 
improve overall wellness of wounded warriors and their family members. 
These are areas where we--and many warriors--see a need for more 
therapeutic options than conventional health care offers. But there 
exist a wide range of therapies, products and practices under the 
umbrella of ``complementary and alternative medicine.'' These include 
alternative health care systems (such as homeopathic medicine, 
naturopathic medicine, ayurvedic medicine, traditional Chinese 
medicine, and Native American medicine); mind-body interventions 
(including hypnosis, meditation, and guided imagery); biological-based 
therapies (including herbal therapies, special diets, and megavitamin 
therapy); therapeutic massage and somatic movement therapies; energy 
therapies (quigong, reiki, and therapeutic touch); and 
bioelectromagnetics.\1\ Some of these systems of care have evolved over 
generations (such as in traditional Chinese medicine), and others from 
the clinical experiences of a single practitioner or small groups of 
practitioners who have developed a particular intervention.\2\ Some 
seem much more promising than others. To illustrate, the National 
Center for PTSD recently reported on the current state of research for 
complementary and alternative treatments for PTSD. They concluded that 
while CAM treatments like acupuncture, relaxation, and meditation hold 
some promise as an adjunct to traditional therapies, there is limited 
evidence of their effectiveness as alternative or stand-alone 
approaches. They report there is better support for using complementary 
methods in addition to other treatments or as a gateway to evidence-
based services to engage those veterans who might otherwise not take 
part in other approaches.\3\ Not only should distinctions be drawn 
among interventions in terms of their likely efficacy, but establishing 
the safety of interventions can be no less important with respect to 
complementary and alternative medicine than to conventional 
medicine.\4\
---------------------------------------------------------------------------
    \1\ Final Report, White House Commission on Complementary and 
Alternative Medicine Policy (March 2002), accessed at http://
www.whccamp.hhs.gov/pdfs/fr2002_document.pdf
    \2\ Id.
    \3\ Strauss, J. & Lang, A. Complementary and Alternative Treatments 
for PTSD. PTSD Research Quarterly (2012). Accessed at: http://
www.ptsd.va.gov/professional/newsletters/research-quarterly/v23n2.pdf
    \4\ Recent study found that ginko biloba, a widely-used herbal 
supplement, caused carcinogenic activity in mice. ``New Doubts about 
Ginko Biloba,'' New York Times (April 30, 2013) accessed at http://
well.blogs.nytimes.com/2013/04/29/new-doubts-about-ginkgo-biloba/
---------------------------------------------------------------------------
    We recommend that S. 852 provide for a specific framework to assure 
that any CAM programs carried out under VA's auspices adhere rigorously 
to such fundamental imperatives as safety and effectiveness. Equally 
important, we urge that any legislation involving CAM be built on the 
bedrock of the scientific method, to assure that any VA provision of 
CAM interventions, through pilot programs or otherwise, contributes to 
scientific and medical understanding, and better care in the future. 
Finally, we would suggest consideration of further revisions to the 
bill to take account of the following:

     that priority for research funding for CAM or any other 
health-related research should be determined through a merit-based 
peer-review process;
     that the designation of any specific number of new centers 
or programs involving the study or evaluation of CAM should be based on 
a methodology that includes such elements as (1) an independent 
assessment of what are the most promising CAM interventions that have 
particular relevance to health care issues prevalent among veterans, 
and (2) rigorous evaluation of the capabilities (including the 
potential size of a study cohort) of one or more VA medical centers to 
study each such issue (independently, collaboratively with other VA 
medical centers, or in partnership with an affiliated academic 
center(s); and
     whether a particular proposed pilot program can produce 
statistically significant results or is susceptible of meaningful 
evaluation.
                          caregiver-assistance
    S. 851 would expand VA's comprehensive caregiver-assistance program 
to cover caregivers of veterans who were injured prior to 9/11. The 
Caregivers Act of 2010 was historic legislation that directed VA to 
provide important services and supports. However VA has yet to meet in 
full its obligations under that law. More than two years after initial 
implementation, VA still has not answered--let alone remedied--the 
problems and concerns that WWP and other advocates raised regarding the 
Department's implementing regulations. For example, those regulations 
leave ``appeal rights'' unaddressed (including appeals from adverse 
determinations of law); set unduly strict criteria for determining a 
need for caregiving for veterans with severe behavioral health 
conditions; and invite arbitrary, inconsistent decisionmaking. Simply 
extending the scope of current law at this point to caregivers of other 
veterans would inadvertently signal to VA acquiescence in its flawed 
implementation of that law. We recommend that the Committee insist on 
VA's resolving these long-outstanding concerns as a pre-condition to 
extending the promise of this law to caregivers of pre-9/11 veterans.
                       prosthetics and orthotics
    S. 522, the Wounded Warrior Workforce Enhancement Act, would direct 
VA both to establish a program to provide grants to institutions that 
provide or intend to provide graduate education in prosthetics and 
orthotics, and to award a grant to support the establishment of a 
center of excellence in orthotic and prosthetic education, and research 
into the skills and optimal training needed by clinical professionals 
in such fields.
    WWP has had concerns regarding the VA's prosthetics and orthotics 
program. With its generally older patient population whose prosthetic 
needs are most often linked to diabetes and post-vascular disease, VA 
has faced a steep adaptation-curve as it relates to serving young 
warriors who have lost limbs in war.\5\ War zone injuries that result 
in amputations are often complex and can prove difficult for later 
prosthetic fitting because of length, scarring, and additional related 
injuries such as burns.\6\ VA has instituted an amputation system of 
care and initiated the development of amputee centers of excellence 
which can become important components of needed changes, but much more 
progress is needed to realize the underlying vision. Indeed the 
Department of Defense (DOD) has surpassed VA in providing state-of-the-
art rehabilitation for this generation of combat-injured amputee 
servicemembers and veterans. Some have suggested that VA's leadership 
role in prosthetics has declined and that prosthetics no longer holds 
the priority for VA it did in the past.\7\ VA prosthetics research, 
particularly--an area of real strength in the past and so important to 
serving wounded warriors tomorrow--has lagged, even as the numbers of 
new veteran-amputees climb steadily.
---------------------------------------------------------------------------
    \5\ Sigford BJ, ``Paradigm Shift for VA Amputation Care,'' J 
Rehabil Res Dev; 47(4): (2010) xv-xx.
    \6\ Ibid.
    \7\ See Hearing, ``Optimizing Care for Veterans with Prosthetics,'' 
Subcommittee on Health, Committee on Veterans Affairs, House of 
Representatives (May 16, 2012) accessed at http://veterans.house.gov/
hearing/optimizing-care-for-veterans-with-prosthetics
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    We do see a need for Congress to press VA to make these concerns a 
higher priority, and have urged such steps as the following:

     Ensure through ongoing oversight that the vision of a VA 
Amputee System of Care is realized; that VA meets its commitment to 
provide timely, needed prosthetics; and that it works to regain 
leadership in prosthetics research and service.
     Ensure that VA's amputee-registry is deployed and used to 
track amputee-care and outcomes, conduct longitudinal studies and other 
research, and--working in concert with DOD--expand understanding of 
best practices;
     Establish a steering committee of experts composed of 
academicians, clinicians, and researchers to oversee and provide 
guidance to VA on the direction and operation of its prosthetics and 
orthotics program; and
     Develop guidance to assist clinicians in more 
appropriately prescribing durable medical equipment (in particular, 
expanding clinical practice recommendations through the use of 
guidelines such as are commonly employed in other fields of medical 
practice).

    With regard to S. 522, we would acknowledge that VA may well face 
challenges in filling future vacancies in prosthetics and orthotics. 
But it is not clear that S. 522, while authorizing grants to 
institutions for a wide range of uses relating to prosthetics and 
orthotics education, is sufficiently focused to meet VA's potential 
workforce needs.
                        reproductive assistance
    S. 131, the Women Veterans and Other Health Care Improvements Act 
of 2013, raises important issues in proposing that VA would provide 
reproductive services and adoption assistance to assist in helping 
severely wounded, ill or injured veterans who have service-incurred 
infertility conditions to have children.
    The experience of our operations in Iraq and Afghanistan has 
heightened the importance of grappling with the issue of reproductive 
services. Blasts from widespread use of improvised explosive devices 
(IED's) in Iraq and Afghanistan, particularly in the case of warriors 
on foot patrols, have increasingly resulted not only in traumatic 
amputations of at least one leg, but also in pelvic, abdominal or 
urogenital wounds.\8\ While not widely recognized, the number and 
severity of genitourinary injuries has increased over the course of the 
war, with more than 12% of all admissions in 2010 involving associated 
genitourinary injuries.\9\ With that increase has come not only DOD 
acknowledgement of the impact of genitourinary injuries on warriors' 
psychological and reproductive health,\10\ but recent adoption of a 
policy authorizing and providing implementation guidance on assisted 
reproductive services for severely or seriously injured active duty 
servicemembers.\11\ DOD's policy, set forth in recent revisions to its 
TRICARE Operations Manual, applies to servicemembers of either gender 
who have lost the natural ability to procreate as a result of 
neurological, anatomical or physiological injury. The policy covers 
assistive reproductive technologies (including sperm and egg retrieval, 
artificial insemination and in vitro fertilization) to help reduce the 
disabling effects of the servicemember's condition to permit 
procreation with the servicemember's spouse.\12\
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    \8\ Dismounted Complex Injury Task Force, ``Dismounted Complex 
Blast Injury: Report of the Army Dismounted Complex Injury Task 
Force,'' I (June 18, 2011) available at: http://
www.armymedicine.army.mil/reports/DCBI%20Task%20Force%20Report%20% 
28Redacted%20Final%29.pdf.
    \9\ Id. at 16.
    \10\ Id.
    \11\ Asst. Secretary of Defense (Health Affairs) & Director of 
TRICARE Management Activity, Memorandum on Policy for Assisted 
Reproductive Services for the Benefit of Seriously or Seriously Ill/
Injured (Category II or III) Active Duty Servicemembers (April 3, 2012) 
available at: http://www.veterans.senate.gov/upload/
DOD_reproductive_letter.pdf.
    \12\ Dept. of Defense, TRICARE Operations Manual 6010.56-M, Chapter 
17, Section 3, para. 2.6 (Sept. 19, 2012).
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    For veterans, however, VA coverage is very limited in scope. The 
regulation describing the scope of VA's ``medical benefits package'' 
states explicitly that in vitro fertilization is excluded \13\ and that 
``[c]are will be provided only * * * [as] needed to promote, preserve, 
or restore the health of the individual * * * .'' \14\ Consistent with 
that limiting language, the VA's benefits handbook advises women 
veterans with regard to health coverage that `` * * * infertility 
evaluations and limited treatments are also available.'' \15\
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    \13\ 38 CFR Sec. 17(c)(2).
    \14\ 38 CFR Sec. 17(b) (Emphasis added).
    \15\ Dept.of Veterans Affairs, ``Federal Benefits for Veterans, 
Dependents and Survivors'' available at http://www.va.gov/opa/
publications/benefits--book/benefits--chap01.asp.
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    In a departure from longstanding policy, the VA stated last year 
that ``[t]he provision of Assisted Reproductive Services (including any 
existing or future reproductive technology that involves the handling 
of eggs or sperm) is in keeping with VA's goal to restore the 
capabilities of Veterans with disabilities to the greatest extent 
possible and to improve the quality of Veterans' lives.'' \16\ In its 
statement, the Department also expressed support in principle for 
legislation authorizing VA to provide assistive reproductive services 
to help a severely wounded veteran with an infertility condition 
incurred in service and that veteran's spouse or partner have children. 
It conditioned that support, however, on ``assurance of the additional 
resources that would be required.'' \17\
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    \16\ Health and Benefits Legislation Hearing Before the S. Comm. on 
Veterans Affairs, 112th Cong. (2012).
    \17\ Id.
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    Certainly the administration of a VA program that would assist 
wounded warriors and their spouses to conceive children would require 
careful attention to ethical \18\ and regulatory \19\ issues associated 
with providing advanced reproductive services. Economic considerations 
certainly can arise in that regard.\20\ But while these advanced 
interventions can be quite costly, cost should not be a barrier as it 
relates to this country's obligation to young warriors who sustained 
horrific battlefield injuries that impair their ability to father or 
bear children.
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    \18\ See Meena Lal, ``The Role of the Federal Government in 
Assisted Reproductive Technologies, 13 Santa Clara Computer and High 
Tech. L.J. 517 (1997).
    \19\ See Michelle Goodwin ``A Few Thoughts on Assisted Reproductive 
Technology,'' 27 L. & Ineq. 465 (2009). Among these regulatory issues, 
VA would have to address the need for physicians providing advanced 
reproductive technologies to fully inform couples as to their risks, 
including greater health risks in children born through these 
technologies. See N.Y. State Dept. of Health Task Force on Life and the 
Law, Assisted Reproductive Technologies: Analysis and Recommendations 
for Public Policy, available at: http://www.health.ny.gov/regulations/
task--force/reports--publications/execsum.htm
    \20\ Id.
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    WWP urges Congress to enact legislation that would enable couples 
who are unable to conceive because of the warrior's severe service-
incurred injury or illness to receive fertility counseling and 
treatment, including assisted reproductive services, subject to the 
development of reasonable regulations.
                           beneficiary travel
    S. 633 would amend current law governing VA's ``beneficiary 
travel'' program to cover certain severely disabled veterans' travel in 
connection with care provided on an inpatient (or lodger-basis) through 
a special VA disability-rehabilitation program.
    WWP works extensively across the country with wounded warriors, 
specifically veterans and servicemembers who were injured, wounded or 
developed an illness or disorder of any kind in line of duty during 
military service on or after September 11, 2001. Our warriors certainly 
encounter barriers to receiving needed VA services--barriers that 
include sometimes-rigid VA appointment-scheduling, long-distance 
travel, and instances of inflexible program requirements. We are not 
aware, however, of problems that warriors have encountered regarding 
receipt of beneficiary travel generally or with respect to travel to 
special disability-rehabilitation programs. As such, we have no 
position on S. 633.

    Thank you for your consideration of WWP's views on these issues.