[House Hearing, 119 Congress]
[From the U.S. Government Publishing Office]


                          LEGISLATIVE HEARING

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

                                HEARING

                               BEFORE THE

                         SUBCOMMITTEE ON HEALTH

                                 OF THE

                     COMMITTEE ON VETERANS' AFFAIRS

                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED NINETEENTH CONGRESS

                             FIRST SESSION

                               __________

                        TUESDAY, MARCH 11, 2025

                               __________

                           Serial No. 119-10

                               __________

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


                    Available via http://govinfo.gov
                    
                                __________

                   U.S. GOVERNMENT PUBLISHING OFFICE                    
60-671                  WASHINGTON : 2025                  
          
-----------------------------------------------------------------------------------     
 
                     COMMITTEE ON VETERANS' AFFAIRS

                     MIKE BOST, Illinois, Chairman

AUMUA AMATA COLEMAN RADEWAGEN,       MARK TAKANO, California, Ranking 
    American Samoa, Vice-Chairwoman      Member
JACK BERGMAN, Michigan               JULIA BROWNLEY, California
NANCY MACE, South Carolina           CHRIS PAPPAS, New Hampshire
MARIANNETTE MILLER-MEEKS, Iowa       SHEILA CHERFILUS-MCCORMICK, 
GREGORY F. MURPHY, North Carolina        Florida
DERRICK VAN ORDEN, Wisconsin         MORGAN MCGARVEY, Kentucky
MORGAN LUTTRELL, Texas               DELIA RAMIREZ, Illinois
JUAN CISCOMANI, Arizona              NIKKI BUDZINSKI, Illinois
KEITH SELF, Texas                    TIMOTHY M. KENNEDY, New York
JEN KIGGANS, Virginia                MAXINE DEXTER, Oregon
ABE HAMADEH, Arizona                 HERB CONAWAY, New Jersey
KIMBERLYN KING-HINDS, Northern       KELLY MORRISON, Minnesota
    Mariana Islands
TOM BARRETT, Michigan

                       Jon Clark, Staff Director
                  Matt Reel, Democratic Staff Director

                         SUBCOMMITTEE ON HEALTH

               MARIANNETTE MILLER-MEEKS, Iowa, Chairwoman

JACK BERGMAN, Michigan               JULIA BROWNLEY, California, 
GREGORY F. MURPHY, North Carolina        Ranking Member
DERRICK VAN ORDEN, Wisconsin         SHEILA CHERFILUS-MCCORMICK, 
JEN KIGGANS, Virginia                    Florida
ABE HAMADEH, Arizona                 MAXINE DEXTER, Oregon
KIMBERLYN KING-HINDS, Northern       HERB CONAWAY, New Jersey
    Mariana Islands                  KELLY MORRISON, Minnesota

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

                              ----------                              

                        TUESDAY, MARCH 11, 2025

                                                                   Page

                           OPENING STATEMENTS

The Honorable Mariannette Miller-Meeks, Chairwoman...............     1
The Honorable Julia Brownley, Ranking Member.....................     2

                         SPEAKING FROM THE DAIS

The Honorable Steve Womack, U.S. House of Representatives, (AR-3)     4
The Honorable Sylvia Garcia, U.S. House of Representatives, (TX-
  29)............................................................     5
The Honorable Greg Murphy, U.S. House of Representatives, (NC-3).     6
The Honorable Chris Deluzio, U.S. House of Representatives, (PA-
  17)............................................................     6
The Honorable Lauren Underwood, U.S. House of Representatives, 
  (IL-14)........................................................     7
The Honorable Don Bacon, U.S. House of Representatives, (NE-2)...    11

                               WITNESSES
                                Panel I

Dr. Thomas O'Toole, Deputy Assistant Under Secretary for Health 
  for Clinical Services, Quality and Field Operations, Veterans 
  Health Administration, U.S. Department of Veterans Affairs.....     8

        Accompanied by:

    Dr. Antoinette Shappell, Deputy Assistant Under Secretary for 
        Health for Patient Services, Veterans Health 
        Administration, U.S. Department of Veterans Affairs

    Dr. Thomas Emmendorfer, Executive Director, Pharmacy Benefits 
        Management, Veterans Health Administration, U.S. 
        Department of Veterans Affairs

Dr. Jeffrey Gold, President, University of Nebraska System.......    10

                                Panel II

Ms. Sue Morris, President, Veterans Trust........................    23

Mr. Brian Dempsey, Director of Government Affairs, Wounded 
  Warrior Project................................................    24

Dr. Andrew Kozminski, Medical Director of Hyperbaric Medicine, 
  University of Iowa Health Care.................................    26

Mr. Ed Harries, President, National Association of State Veterans 
  Homes..........................................................    27

Mr. Jon Retzer, Deputy National Legislative Director for Health, 
  Disabled American Veterans.....................................    29

                                APPENDIX
                    Prepared Statements Of Witnesses

Dr. Thomas O'Toole Prepared Statement............................    43
Dr. Jeffrey Gold Prepared Statement..............................    62
Ms. Sue Morris Prepared Statement................................    74

                          APPENDIX--continued

Mr. Brian Dempsey Prepared Statement.............................    75
Dr. Andrew Kozminski Prepared Statement..........................    81
Mr. Ed Harries Prepared Statement................................    89
Mr. Jon Retzer Prepared Statement................................    96

                       Statements For The Record

Veterans Healthcare Policy Institute Prepared Statement..........   103
American Association for Marriage and Family Therapy and 
  California Association of Marriage and Family Therapists 
  Prepared Statement.............................................   105
Paralyzed Veterans of America Prepared Statement.................   107
American Federation of Government Employees, AFL-CIO Prepared 
  Statement......................................................   111
Trajector Medical Prepared Statement.............................   112
Document for the Record Submitted by Greg Murphy.................   123

 
                          LEGISLATIVE HEARING

                              ----------                              


                        TUESDAY, MARCH 11, 2025

                    Subcommittee on Health,
                    Committee on Veterans' Affairs,
                             U.S. House of Representatives,
                                                    Washington, DC.
    The subcommittee met, pursuant to notice, at 2:15 p.m., in 
room 360, Cannon House Office Building, Hon. Mariannette 
Miller-Meek [chairwoman of the subcommittee] presiding.
    Present: Representatives Miller-Meek, Murphy, Hamadah, 
King-Hinds, Brownley, Cherfilus-McCormick, Dexter, Conaway, and 
Morrison.
    Also present: Representatives Deluzio, Womack, Underwood, 
Garcia, and Bacon.

   OPENING STATEMENT OF MARIANNETTE MILLER-MEEKS, CHAIRWOMAN

    Ms. Miller-Meeks. The legislative hearing of the 
Subcommittee on Health will now come to order. I would like to 
welcome all members and witnesses for today's hearing. We look 
forward to a very productive discussion on some impactful 
veterans legislation.
    Today we will discuss 12 bills, including bills which would 
enable the U.S. Department of Veterans Affairs (VA) to enter 
into innovative public-private partnerships, research cutting-
edge hyperbaric oxygen therapy, and provide some long overdue 
oversight of the VA's budget management. Also on today's agenda 
are four bills I have had the pleasure of introducing.
    Before I discuss my bills, I would like to thank our 
witnesses again for being here today. I would like to 
especially thank Dr. Andrew Kozminski, who is the medical 
director of the Hyperbaric Medicine at my beloved University of 
Iowa. I had the pleasure of touring Dr. Kozminski's office a 
few months ago and learned about the incredible healing 
properties that hyperbaric oxygen therapies can provide. Dr. 
Kozminski, welcome to my office and I would like to look 
forward to hearing your thoughts about Dr. Murphy's bill, the 
Veterans National Traumatic Brain Injury Treatment Act.
    Now to my bills. First, the Supporting Prosthetics 
Opportunities an Recreational Therapy (SPORT) Act. The SPORT 
Act would make sure athletic prosthetics are defined as 
medically necessary for amputee veterans. Every year in my 
district, severely disabled veterans gather to play golf. I am 
not a golfer except for miniature golf, but it is amazing to 
see how many sports, even golf can improve veterans' mental and 
physical well-being. I think all veterans should be able to 
enjoy the benefits and camaraderie sports provide, and my 
legislation would achieve just that.
    I am also proud to introduce the No Wrong Door for Veterans 
Act. This bill would reauthorize VA's successful Fox grant 
Program. Fox grants enable community organizations to provide 
services to veterans, screen them for suicidal ideation, and 
connect them with the VA so they can receive the mental health 
support that meets their individual needs. My bill would ensure 
organizations who have been successful in our mission to expand 
mental health can receive additional funds by partnering with 
the VA to reach even more veterans. The Fox Grant Program is a 
great example of public-private partnerships working for the 
better. House Republicans will continue to push the needle and 
protect programs like this one.
    Next, I am proud to lead the Providing Veterans Essential 
Medications Act. This bill would allow the VA to provide very 
high-cost medications to severely disabled veterans receiving 
care at State veterans homes. VA pays for these medications for 
all other veteran patients, but antiquated laws require VA to 
pay State veterans home a fixed per diem, limiting their 
ability to provide for veterans who desperately need these 
medications while residing at a veterans home. Unfortunately, 
these high-cost medications can cost as much as $1,000 per day, 
meaning State veterans homes are not able to house many of our 
most deserving veterans. My bill would fix this clear mistake 
and ensure veterans with complex needs are cared for.
    Ironically, the last bill I would like to mention is the 
Standardizing Treatment and Referral Times (START) Act. Far too 
often our veterans receive community care referrals that are 
only valid for a fixed period of time, but due to provider 
shortages and bureaucratic delays, veterans might not even get 
in until halfway through the authorized time period. My START 
Act addresses this issue by ensuring that the validity of the 
referral begins only once a veteran has attended their initial 
appointment. It is pretty common sense.
    It is a privilege to collaborate on crafting impactful 
legislation for our veterans and to address critical issues in 
the delivery of their healthcare.
    I would now like to turn to Representative Brownley for any 
opening remarks she may have. Representative Brownley, you are 
now recognized.

      OPENING STATEMENT OF JULIA BROWNLEY, RANKING MEMBER

    Ms. Brownley. Thank you, Madam Chair.
    At the outset, I have to say I find it a bit crazy that we 
are having a legislative hearing today rather than an oversight 
hearing. The Trump administration's executive orders, mass 
firings of VA employees, reckless contract terminations, and $1 
spending limit on purchase cards are causing significant 
upheaval within the Veterans Health Administration (VHA). That 
we are here today proceeding to consider new legislation as if 
these changes are not already significantly impacting veterans 
access to care is absurd.
    Our time today would be much better spent examining the 
administration's plan to gut VA's workforce by 80,000 employees 
before September. This would be in addition to the 2,400 or 
more VA employees who have already been terminated. Committee 
Democrats have already heard a multitude of instances of these 
terminations negatively impacting patient care, despite 
Secretary Collins insisting that they are not. The terminations 
that have already occurred include positions like procurement 
professionals who play a critical role in purchasing 
prosthetics and medical devices veterans need. We are aware of 
numerous VA medical facilities where such terminations have 
occurred.
    Supply chain staff who are responsible for equipping 
surgical suites with necessary supplies, the committee has 
heard from several supply chain professionals who were 
terminated from the VA facilities in Florida, Texas, Oklahoma, 
and in California. Human resources professionals who are 
necessary for filling clinical staff vacancies. While clinical 
staff have largely been exempted from the Trump 
administration's hiring freeze, VA cannot efficiently fill 
clinical positions without human resources professionals. 
Psychology technicians at the Cleveland Veterans Affairs 
Medical Center (VAMC), who perform neuropsychological tests for 
individuals with neurological conditions, like strokes, 
Traumatic Brain Injury (TBI), Post-Traumatic Stress Disorder 
(PTSD), and concussions. Staff that perform, manage, and 
analyze mammogram results at the Hampton VAMC. One veteran 
whose mammogram was canceled due to a staffing shortage at the 
Hampton VAMC just found out the earliest she could reschedule 
her appointment elsewhere is June, 4 months from now. These are 
just a few examples that the committee has heard about from 
across the Nation.
    Unfortunately, none of the bills we are considering today 
will address the very real threat to VA healthcare access, 
quality, and safety that veterans are facing. In just the last 
few days, my Democratic colleagues and I have received tens of 
thousands of emails from veterans across the country asking 
that we do all we can to stop the VA workforce cuts and 
eliminations of crucial contracts. I certainly hope that our 
Republican colleagues are receiving the same messages.
    Veterans do not support these cuts. I would encourage the 
witnesses and members here today to keep in mind that if we 
continue to see efforts to dismantle VA by firing hardworking 
employees, canceling vital research, terminating healthcare 
contracts, and eroding veterans' trust in VA, it will not 
matter what excellent legislation we put forth. There will not 
be employees or even an infrastructure left at VA to implement 
these bills, and veterans' care will suffer because of it.
    I would hope the chair shares these same concerns and I 
understand that we must protect the many VA employees that 
provide critical care to our Nation's veterans. However, I 
understand that despite what I have laid out today, we are here 
to consider legislation today on this committee.
    I am pleased today's agenda includes my VA Marriage and 
Family Therapist Equity Act. I am also glad that a bill I am 
coleading with my friend from Texas, Congresswoman Garcia, the 
Women Veterans Cancer Care Coordination Act, is on the agenda. 
I look forward to hearing from our witnesses on all of the 
bills on today's agenda.
    With that, Madam Chair, I will yield back.
    Ms. Miller-Meeks. Thank you very much, Ranking Member 
Brownley.
    We have a full agenda today, so I will be holding everyone 
to 3 minutes per bill to ensure we can move in a timely manner.
    This morning we are joined by several of our colleagues who 
will speak in support of their bills. We appreciate the 
dedication to serving our Nation's veterans. With that, I ask 
unanimous consent that all non-subcommittee members be waived 
on to speak on their bills from the dais. Hearing no objection, 
we will move forward.
    I now recognize Representative Womack for 3 minutes.

                   STATEMENT OF STEVE WOMACK

    Mr. Womack. I thank the chairwoman.
    Chairwoman Miller-Meeks, Ranking Member Brownley, and 
distinguished members of this subcommittee thank you for 
considering my bill, H.R. 1107, Protecting Veteran Access to 
Telemedicine Services Act of 2025. I also want to express my 
sincere gratitude for allowing me to speak in support of this 
legislation.
    This bill aims to guarantee that our Nation's veterans, 
whether in bustling cities or remote rural areas, have 
continuous access to the healthcare services they need and 
deserve. The Ryan Haight Online Pharmacy Consumer Protection 
Act, enacted in 2008, was designed to regulate the prescription 
of controlled substances via telemedicine in response to the 
rise of online pharmacies and the risk of misuse. While this 
law plays a crucial role in protecting public health, it has 
not been updated to reflect the realities of 2025, nor does it 
account for the fundamental differences between the VA and 
civilian online pharmacies.
    During the COVID-19 pandemic, the Ryan Haight Act's in-
person consultation requirement for prescribing controlled 
substances was temporarily waived. The Drug Enforcement (DEA) 
and U.S. Department of Health and Human Services (HHS) later 
extended these flexibilities through the end of this year. My 
bill, the Protecting Veteran Access to Telemedicine Services 
Act of 2025, would make this exemption permanent for the VA, 
allowing VA healthcare professionals to prescribe medically 
necessary controlled substances via telemedicine under specific 
conditions. This exemption has been a lifeline for our 
veterans. Without it, many will face severe restrictions in 
accessing vital healthcare.
    For veterans in urban areas, letting this exemption expire 
would mean longer wait times for in-person appointments, 
further straining an already overburdened VA healthcare system. 
The impact is even greater for veterans in rural communities 
where geographic isolation and limited healthcare providers 
create significant barriers. The exemption has allowed them to 
receive care from VA specialists hundreds of miles away without 
the burden of costly and time-consuming travel.
    Continuing this exemption is not just a matter of 
convenience, it is a necessity. It ensures that every veteran, 
no matter where they live, has equal access to the care they 
have earned and deserve. I am honored to speak in support of 
this legislation today. I urge my colleagues to act swiftly in 
passing the bill. Our veterans have sacrificed so much for all 
of us. It is our duty to ensure they receive the care they need 
in a way that meets the demands of today's world.
    Madam Chairwoman, thank you for the time and a yield back 
my balance.
    Ms. Miller-Meeks. Thank you very much. Representative 
Womack.
    The chair now recognizes Representative Garcia for 3 
minutes.

                   STATEMENT OF SYLVIA GARCIA

    Ms. Garcia. Thank you, Madam Chair. Thank you to the 
ranking member for giving me a few minutes to talk about my 
bill, the Women Veterans Cancer Care Coordinator Act. I am 
pleased to lead this bill with Ranking Member Brownley to 
improve the breast and gynecological cancer care that the VA 
provides to our heroines.
    Every day, more and more American women sign up to serve in 
these U.S. military. As women sign up, the women veteran 
community also grows. In Fiscal Year 2000, women veterans made 
up just about 4 percent of all the veteran population. Today, 
they rank at about 11.3 percent, over 2.1 million women 
veterans nationwide. However, as the women veteran community 
ages, breast and gynecological care rates in this population 
will also increase. The VA responded to this need by 
establishing the Breast and Gynecological Oncology System of 
Excellence in late 2020, a program that ensures women veterans 
are getting the appropriate cancer care they deserve.
    The VA also partners with community care providers to treat 
these veterans when the VA does not have the means to provide 
care. Now, that sounds great, but the system that we set up for 
women is not entirely working as it should. Veterans must 
navigate multiple facilities alone and ensure that providers 
communicate with the VA. The lack of coordination between both 
the VA and these providers lead to treatment delays, 
miscommunication, and unnecessary stress. Without a well-
coordinated care team, a lot can go wrong. No veteran fighting 
cancer should struggle with red tape. They should be focused on 
getting better.
    My bill will effectively address these challenges by 
creating dedicated regional cancer care coordinators at the VA. 
These professionals would guide veterans through their 
treatment journey, improve communication between the VA and 
community care providers, track patient progress, and address 
the existing delays in their care. These coordinators would 
also provide veterans with emergency health information and 
mental health resources to support their well-being.
    I firmly believe that a grateful nation shows its gratitude 
in the care and benefits we provide to our heroines. Supporting 
our veterans is one of the solemn promises we have made, and it 
is a promise we must keep.
    Thank you again, Madam Chairwoman, and, of course, to 
Ranking Member Brownley for support on this issue. I yield 
back.
    Ms. Miller-Meeks. Thank you very much, Representative 
Garcia.
    The chair now recognizes representative Dr. Murphy for 3 
minutes.

                    STATEMENT OF GREG MURPHY

    Mr. Murphy. Thank you, Madam Chair. Thank you, Ranking 
Member Brownley.
    Delighted for the second time to introduce my bipartisan 
bill, H.R. 1336, the Veterans National Traumatic Brain Injury 
Treatment Act, being discussed here today. It is long overdue 
that we do something further for our veterans who suffer from 
PTSD and TBI. Sadly enough, we lose 17, up to 22 veterans a day 
due to suicide, many who are suffering from TBI and PTSD.
    I am a big fan and have been for over 30 years of the 
treatments of hyperbaric oxygen therapy. We have used this in 
surgical wounds for wounds that will not heal. It has enjoyed 
great success amongst many different maladies. It has been my 
own experience now in exploring this issue for TBI and PTSD 
that this is not only a viable but a very, very successful 
intervention.
    I am going to introduce into the record a meta analysis 
study from National Institutes of Health (NIH). This was done 
in January to March 2020, which is an exhaustive list of mostly 
randomized double-blind control studies which shows great 
objective improvement for those veterans who have suffered from 
TBI and PTSD, not only in cognitive function but mood disorder. 
I ask this be submitted for the record.
    This organization now, HBOT4Heroes in North Carolina, has 
successfully treated over 200 veterans who suffer from TBI and 
PTSD. We had a witness here before the executive director, Mr. 
Ed Di Girolamo, who gave very compelling testimony at a 
roundtable concerning alternative therapy specifically for 
Hyperbaric Oxygen Therapy (HBOT). My bipartisan bill sets up a 
pilot program for 5 years at three veterans service networks. 
Costs are borne by donations, not to the taxpayer, but by 
donations. The veterans service organizations are supportive, 
multiple, and listed here. We also have expert witness from Dr. 
Andrew Kozminski, an M.D. from the great University of Iowa, I 
think somebody went there or knows there, who is a Hyperbaric 
Oxygen (HBO) medicine specialist.
    I have thought this through and through. I believe it is 
sad that we get our veterans when they hit the wall, when there 
is literally nothing else that the VA can offer that we are not 
offering this therapy to them. It is a proven alternative and a 
successful alternative. I will say it again, and I have said 
this before, I believe it is medical malpractice that is not 
being offered to our veterans at this point in time.
    I thank you for your support. I would ask that this 
committee at some point review this favorably, bring this to 
the floor so that we can get our veterans the care that they 
need.
    Thank you Madam Chairman. I will yield back.
    Ms. Miller-Meeks. The chair now recognizes Representative 
Deluzio for 3 minutes.

                   STATEMENT OF CHRIS DELUZIO

    Mr. Deluzio. Thank you, Chairman Miller-Meeks, Ranking 
Member Brownley, and members of the Health Subcommittee. It is 
great to be back with all of you and appreciate your 
flexibility working with me and my team on my bill, considering 
this important measure to reduce veteran suicide, Saving Our 
Veterans Lives Act of 2025. It is H.R. 1987.
    I am proud to say this has been a bipartisan effort from 
the start. Although they are not here, I commend 
Representatives Fitzpatrick, James, and Landsman, alongside 
Senators King and Sheehy, and a wide variety of organizations 
who have come together and worked with me and others on such an 
important issue of veteran suicide.
    This bill will create a program at VA to provide and 
distribute gun lockboxes to veterans, including those who are 
not enrolled with the Veterans Health Administration. This 
aspect of the bill is very important. Cited in VA's 2024 
National Veterans Suicide Prevention Annual Report, the rate of 
veteran suicide is about 17-1/2 per day, and the majority of 
those come, those terrible deaths, from veterans outside of 
VHA. We have got to do a better job at reaching these veterans 
and connecting them with resources that could make a difference 
in their lives, and this bill will help bridge that gap.
    That said, I have read the VA's testimony. I know VA 
recommends some changes in the bill text. I welcome amendments 
and working with the subcommittee and its members to make this 
legislation stronger so we can save more of my fellow veterans' 
lives from the scourge of veteran suicide.
    Madam Chairwoman, thank you for your time and engagement. I 
yield back.
    Ms. Miller-Meeks. Thank you very much, Representative 
Deluzio.
    The chair now recognizes Representative Underwood for 3 
minutes.

                 STATEMENT OF LAUREN UNDERWOOD

    Ms. Underwood. Thank you, Madam Chair. As a nurse, I am 
really proud to be here to testify before you today on one of 
the first bills that I introduced in Congress with my friend 
Senator Duckworth, the Copay Fairness for Veterans Act.
    While I currently sit on the Appropriations Committee, I 
have the honor of serving on the House of Veterans' Affairs 
Committee in the 116th and 117th Congresses. Our veterans are 
heroes who have given so much to our country, and serving 
veterans and their families is one of the greatest privileges 
we have as Members of Congress. At a time where research shows 
us that veterans face worse health outcomes than the general 
public and have higher burden of chronic diseases, no veteran 
should go without the ready access to preventive healthcare 
services that can improve their healthcare and quality of life. 
That is why my legislation would eliminate, once and for all, 
all of the financial barriers that could prevent veterans from 
accessing basic care.
    Under the Affordable Care Act (ACA), almost all private 
health insurance plans are required to provide coverage of 
preventive services without charging copays. However, while 
most civilians have been able to access preventive services 
without copays for nearly 15 years thanks to the ACA, this same 
guarantee does not exist for our veterans, at least who get 
their healthcare through the VA. Despite their sacrifices and 
commitment to our country, veterans are still at risk of being 
charged out-of-pocket costs for services like cancer 
screenings, mammograms, diabetes care, and screenings for 
depression and anxiety. That is just unfair. Luckily, friends, 
we can fix it.
    My Copay Fairness for Veterans Act rights this wrong by 
eliminating out-of-pocket costs for veterans seeking the 
preventive services that they need and deserve at the VA. My 
bill will ensure that veterans are not charged copays for basic 
essential care, such as screenings for cancer, depression, 
anxiety, diabetes, and other diseases; interventions to prevent 
and treat heart disease; maternal healthcare and breastfeeding 
support for new moms; help with alcohol and tobacco abuse; well 
woman visits; and other critical healthcare services for 
veterans and their families.
    I am proud to say that this bill is endorsed by the 
Disabled American Veterans (DAV) and the Minority Veterans of 
America, among others. Our veterans have earned the best, and I 
urge my colleagues on both sides of the aisle to support this 
critically important legislation.
    Thank you, Madam Chair, for including this bill in today's 
legislative hearing. Thank you to our witnesses for being here. 
I yield back.
    Ms. Miller-Meeks. Thank you, Representative Underwood.
    As is our practice, we will forego a round of questioning 
for the members. For those off committee members, you may stay 
around to ask questions of the witnesses if you have time.
    Our first panel is already at the table. Thank you. Joining 
us from the Department of Veterans Affairs is Dr. Thomas 
O'Toole, the VA's deputy assistant under secretary for Health 
and Clinical Services for Quality and Field Operations. He is 
accompanied by Dr. Antoinette Shappell, VA's deputy assistant 
undersecretary for Health and Patient Care Services, and Dr. 
Thomas Emmendorfer, VA's executive director of Pharmacy 
Benefits Managers. Also on our first panel, we have Dr. Jeffrey 
Gold, president of the University of Nebraska System. Welcome, 
Dr. Gold.
    Dr. O'Toole, you are now recognized for 5 minutes to 
present the Department's testimony.

                  STATEMENT OF THOMAS O'TOOLE

    Dr. O'Toole. Great. Thank you and good afternoon, 
Chairwoman Miller-Meeks, Ranking Member Brownley, and members 
of the subcommittee. Thank you for inviting us here today to 
present our views on several bills that will affect Department 
of Veterans Affairs' programs and services. Joining me today 
are Dr. Antoinette Shappell, deputy assistant undersecretary 
for Health for Patient Care Services, and Dr. Thomas 
Emmendorfer, executive director of Pharmacy Benefits 
Management.
    I joined the VA 19 years ago, leaving a senior position at 
a large academic health center to work at the VA Hospital in 
Providence, Rhode Island. The surge in deployments needed for 
the Iraq War was underway. We were seeing more and more 
veterans returning from the war needing our help, and it is a 
decision I have never regretted. I have been incredibly proud 
to work in the VA. Our commitment to mission, the 
professionalism and dedication of my colleagues, and the 
excellence in care and quality that VA provides to our Nation's 
veterans defines us as an agency. Much of this has come from 
the strong partnership, guidance, and oversight we receive from 
Congress, and the thoughtfulness and intent of the legislation 
being discussed today reflects that. While the Department views 
are provided in detail in written testimony, I would like to 
highlight several bills in my opening remarks.
    The No Wrong Door for Veterans Act makes several amendments 
to the Staff Sergeant Parker Gordon Fox Suicide Prevention 
Grant Program. VA strongly supports the intent in some of the 
amendments the bill would make, particularly extending the 
program through Fiscal Year 2028 and requiring grantees to 
inform individuals about emergent suicide care. However, we do 
have concerns about some of the bill's amendments and look 
forward to working with the subcommittee to address those 
further. This bill aligns with the Department's priority of 
reaching veterans at risk for suicide.
    VA also supports the Standardizing Treatment and Referrals 
Act, or START Act. This bill ensures that the referral period 
for care from a non-VA provider begins on the date of the first 
appointment. VA supports this bill. However, we would like the 
opportunity to work with the subcommittee to ensure the text is 
clear and does not result in any unintended consequences.
    VA strongly supports, we all support efforts to reduce 
veteran suicide. However, in its current writing, we do not 
support the Saving Our Veterans Lives Act. As written, the bill 
is overly broad and the resources needed to implement would 
significantly exceed the authorized appropriation of $5 million 
per year.
    VA supports with amendments the Women Veterans Cancer Care 
Coordination Act and the Veterans Supporting Prosthetics 
Opportunities and Recreation Therapy Act. VA supports H.R. 217, 
the Communities Helping Invest through Property and Improvement 
Needs (CHIP IN) for Veteran Acts, which would allow VA to 
modernize infrastructure more efficiently and cost effectively. 
VA supports efforts to ensure veteran State homes are 
adequately supported in covering the costs of care for 
veterans.
    Though we do not support the Providing Veterans Essential 
Medications Act, we would appreciate the opportunity to discuss 
this bill and VA's concerns with the committee. VA supports the 
Copayment Fairness for Veterans Act with amendments and subject 
to appropriations.
    Regarding the Veterans National TBI Treatment Act, this 
bill requires VA to implement a pilot program for hyperbaric 
oxygen therapy, or HBOT, for veterans with TBI or PTSD. VA does 
not support this bill due to the lack of scientific evidence 
supporting HBOT for these conditions and we have concerns about 
the proposed funding mechanism. VA does not support H.R. 658, 
qualifications for marriage and family therapists. We defer to 
the Comptroller General regarding H.R. 1823, directing VA and 
the Comptroller General to report on certain funding shortfalls 
in VA.
    Finally, VA does not have views on H.R. 1107, Protecting 
Veteran Access to Telemedicine Services of 2025, and we will 
provide these views in a letter to the subcommittee after the 
hearing.
    This concludes my statement. We appreciate the continued 
support and oversight of the committee. My colleagues and I are 
prepared to respond to any questions you or other members of 
the subcommittee may have about the legislation before us. 
Thank you.

    [The Prepared Statement Of Thomas O'Toole Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Dr. O'Toole.
    The chair now recognizes Dr. Gold for 5 minutes.

                   STATEMENT OF JEFFREY GOLD

    Dr. Gold. Thank you and good afternoon, Chairwoman Miller-
Meeks, Ranking Member Brownley, and other members of the 
committee and Congressman Bacon. I am Dr. Jeff Gold and I have 
the distinct privilege of serving as the president of the 
University of Nebraska System, which has campuses in Lincoln, 
Omaha, and Kearney, as well as a top-ranked academic medical 
center in Omaha. We educate approximately 50,000 students, do 
approximately $700 million in peer-reviewed medical research. I 
myself am a recovering pediatric heart surgeon by training, but 
for the last 10 years, prior to my current position, I had the 
privilege of serving as the chancellor of the University of 
Nebraska Medical Center.
    For many decades, UNMC, University of Nebraska Medical 
Center, has had a broad and deep relationship with civilian and 
military Federal departments focused on training, research, and 
quality clinical care. However, over the past decade there has 
been intense multi-departmental focus with key partnerships in 
civilian and military Chemical, Biological, Radiological, 
Nuclear, and High-yield Explosives (CBRNE) global health 
security challenges.
    Thank you for the opportunity to testify today to support 
Congressman Bacon's H.R. 217, which seeks to make permanent the 
CHIP IN for Veterans Act. This bill supports our service 
members through innovative and productive approaches to develop 
and finance VA facilities through public-private partnerships.
    In 2016, Congressman Brad Ashford of Nebraska and Senator 
Deb Fischer were instrumental in passing this new legislation 
creating a unique pilot program that allowed public-private 
partnerships with the VA. This opportunity led to remarkable 
improvement in care for local veterans in our community, 
including the construction of a new ambulatory center that 
today serves as a key resource for outpatient diagnostic, 
procedural, and interventional veterans care services in the 
Nebraska Western Iowa region. This project was funded through 
Federal dollars and private philanthropic support, and has been 
recognized nationally as a true pillar of success.
    However, at this time, the University of Nebraska Medical 
Center, one key of the University of Nebraska system, has 
identified a significant need to replace several of our own 
aging academic facilities on the Omaha campus, and among these 
projects is a forthcoming $2.19 billion project known as 
``Project Health''. This will serve as a state-of-the-art 
medical facility with unique training opportunities focused on 
meeting Nebraska's growing need for medical professionals. This 
project will also provide access to high-quality advanced 
medical care, a unique interprofessional multidisciplinary 
learning environment, and access to life-saving clinical trials 
for patients across the State and in the region. Project HEALTH 
is a collaboration of the State of Nebraska, the city of Omaha, 
the University of Nebraska, the Academic Medical Center and, of 
course, extensive participation by Nebraska's philanthropic 
community.
    Therefore, we have proposed that the much needed 
replacement local VA hospital now be repositioned on the UNMC 
campus to better meet the needs of veterans in Nebraska and 
Western Iowa. This would be constructed to replace the aging 
facility currently in use on the VA campus. This new 
freestanding facility would be branded, staffed, and operated 
by the VA with physical connectivity to Project Health for 
potentially shared diagnostic, interventional, laboratory, and 
support services. This would also provide proximity for 
university clinicians and learners from UNMC and also remain 
open to staffing and training for other public and private 
academic medical center professional staff.
    Leveraging private construction and adjacent resources 
significantly creates more cost-effective facilities and 
opportunities for renovating and replacing the existing VA 
hospital that was opened in 1950. Our approach is not only 
cost-effective, but also ensures that veterans will receive the 
highest standard of care by utilizing private sector 
construction efficiencies and philanthropic support. We can 
significantly reduce construction timelines and costs, ensuring 
timely delivery of quality services to those that have served 
our country.
    Our community has demonstrated the potential of highly 
successful public-private partnerships, the Veterans Health 
Care and the CHIP IN Act born in your committee. This is just 
one example of proven success. By effecting the proposed 
partnership in Omaha, we together can set the standard for 
future care for those that have worn the cloth of our Nation 
and protected our freedom.
    I thank you for your time and look forward to your 
question.

    [The Prepared Statement Of Jeffrey Gold Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you, Dr. Gold.
    The chair now recognizes General Bacon for 3 minutes to 
speak on his bill H.R. 217.

                     STATEMENT OF DON BACON

    Mr. Bacon. Thank you, Madam Chair. I appreciate the 
opportunity to advocate on this bill in the subcommittee and 
the bill is H.R. 217, Communities Helping Invest through 
Property and Improvements Needed for Veterans Act, otherwise 
known as the CHIP IN for Veterans Act.
    This bill will make the current pilot program a permanent 
site. Chairman Bost has been out to our district and seen the 
new facility. I appreciate that Chairwoman Miller-Meeks has 
been out there. I invite the ranking member and, frankly, 
anybody that wants to go to Omaha to see literally one of the 
most beautiful VA facilities in the country, and it was done 
through this bill that was temporary that we would like to make 
permanent.
    I also want to thank President Gold for being here and Ms. 
Sue Morris, who helps manage the philanthropic operation here 
to make this possible.
    The CHIP IN for Veterans Act enables communities to take 
the lead, contribute resources, and complete VA construction 
projects on time and in a cost-efficient manner, benefiting 
taxpayers, the communities, and, most importantly, our 
veterans. The Ambulatory Care Center in Omaha, Nebraska, was 
the first public-private partnership project for the VA. Now, I 
would like to get your attention on this because this is what 
makes this so important. The VA had budgeted this for $135 
million. That was going to be the cost. The community doing 
with State and local financing and philanthropic, plus Federal, 
was able to do this for $85 million. Right away we saved $50 
million for the taxpayer.
    It gets even better. Out of that $85 million, $35 million 
came from not Federal sources; philanthropic, State, and local. 
In other words, this cost went from $135 million for the VA 
down to approximately $50 million. This is why this bill is so 
important. We can do this all over the country where folks want 
to donate and contribute and where states, local governments 
want to help.
    Since the doors opened in August 2020, the Ambulatory Care 
Center has provided--cares for 31,744 patients and over 261,000 
visits. Now, we want to replace the inpatient facility now. We 
already have approximately $100 million outside of the VA ready 
to invest in this facility. It will be a great deal for the VA.
    Look forward to working with the committee to enact this 
legislation and with the Department of VA and the philanthropic 
community to bring this to fruition. Another innovative 
facility for the benefit of veterans across the country.
    I yield back.
    Ms. Miller-Meeks. Thank you, Representative Bacon.
    As is my typical practice, I will reserve my time until all 
other members have had a chance to ask their questions.
    I now recognize Ranking Member Brownley for 5 minutes for 
any questions she may have.
    Ms. Brownley. Thank you, Madam Chair.
    Dr. O'Toole, I am disappointed that the VA is opposing my 
bill, the VA Marriage and Family Therapist Equity Act. You 
know, VA is an outlier among its peers, including TRICARE, in 
terms of requiring licensed marriage and family therapists to 
have graduated from a Commission on Accreditation for Marriage 
and Family Therapy (MFT) Education program in order to be 
promoted within the VA. MFTs are among the occupations for 
which VA has been developing national standards of practice for 
the last several years. Perhaps you can reconsider this 
standard as part of that effort if it is still underway under 
the new administration. Can you share any updates on the 
National Standards of Practice Initiative?
    Dr. O'Toole. Thank you, Chair--thank you, Congresswoman. 
The national standards work is ongoing. The intent behind that 
effort is to ensure that there is minimized variance across 
states in terms of accreditation and licensure.
    The VA is very supportive of position of marriage and 
family therapists. We see it as an integral part of the VA. Our 
primary concern with this is that there are currently no 
statutory requirements for supervisorial roles in any of our 
Title 38 positions and our concerns with State variances that 
currently exist and how those supervisorial roles are 
supported. We are very open and would be happy to work with the 
subcommittee further to, you know, further advance this 
legislation in a way that would work or that our rules would 
work.
    Ms. Brownley. Thank you for that. I mean, I just believe 
that this kind of clinician is so critically important to the 
veteran community. You know, for a while, we did not even 
accept marriage and family therapists. Now we do. In order to 
keep them, they have to have a road of opportunity to be 
promoted. I just think it is so many other states, TRICARE, so 
forth, does not require this. It requires another accreditation 
and it works pretty well. Anyway, I hope that you will continue 
to consider it because I think it is really, really important.
    Next question I had is I wanted to talk a little bit about 
the VA and its undertaking to expand access to lockboxes and 
other suicide prevention tools for veterans. You know, I think 
Mr. Deluzio's bill is a good one, and I think we need to 
strengthen those efforts. Can you sort of expand on the lockbox 
distribution program that you are already providing?
    Dr. O'Toole. Thank you, Congresswoman. To begin, we very 
much share the concerns about the need and the essential 
capacity of we have to be there to reduce veteran suicides. I 
can speak personally to having had patients who have died by 
suicide. I think all of us know, sadly, individuals who have 
family members who have friends who have died by suicide. This 
is an emergency.
    Currently, the VA does have a lockbox program that began 
last year. It is run jointly between our Office of Suicide 
Prevention and the Prosthetics Department to provide lockboxes 
for veterans identified as part of a clinical encounter and 
clinical screening who are determined to have risk for suicide, 
moderate to high risk; who have access to firearms or 
peripheral access to firearms, meaning a member of the family 
or household has access to firearms. In which case they are 
provided a lockbox, which is a proven method of trying to 
create space between the impulsivity of wanting to commit 
suicide and having access to a lethal means.
    Our concern with this bill is that----
    Ms. Brownley. I am not asking about the bill. I am asking 
about the program and what you are doing.
    I want to know, it is my understanding that under the 
current program, lockboxes have to be requested by their 
provider. How would a veteran or their provider know this 
program is available?
    Dr. O'Toole. Thank you, ma'am. We have an extensive 
education experience both to the veteran as well as to the 
provider to promote this program to both groups to try to, you 
know, encourage its application and use.
    Ms. Brownley. Okay. We know it is a good program. You have 
already said that it is a good program. I just, you know, it 
seems to me that making sure that any veteran who wanted a 
lockbox should receive a lockbox because there are many 
veterans out there where we might not know their situation or 
their vulnerabilities. I think it is important to do that.
    I guess what kind of--oh, I have run out of time. I yield 
back, Madam Chair.
    Ms. Miller-Meeks. Thank you, Representative Brownley.
    The chair now recognizes Representative Hamadeh for 5 
minutes.
    Mr. Hamadeh. Thank you, Chairwoman.
    As an Army intelligence officer who served overseas, I 
understand firsthand the obligation we have to the those who 
wore our uniform. Our veterans deserve more than gratitude. 
They deserve action. That is why I am proud to support several 
of the bills before us today that will directly improve 
healthcare access and quality of life for veterans all across 
Arizona and our country.
    My first question is for Dr. O'Toole. The alleged budget 
shortfall within the VA raises serious concerns about your 
organization's financial planning and resource allocation. Do 
you believe the VA should undergo an annual forensic audit?
    Dr. Emmendorfer. Thank you, Congressman. First, I just 
wanted to say thank you for your service in the military as 
well as here with us today.
    On this particular bill, we do defer to the Comptroller 
General.
    Mr. Hamadeh. What is their recommendation?
    Dr. Emmendorfer. By deferring, we are deferring to the 
Comptroller General on the forensic audit.
    Mr. Hamadeh. Do you believe that having a forensic audit 
would give confidence to veterans and the taxpayers that their 
money is being spent wisely?
    Dr. Emmendorfer. I do appreciate the question, Congressman, 
but we would defer to the Comptroller General.
    Mr. Hamadeh. Dr. O'Toole, the Parker Gordon Fox Suicide 
Prevention Grant Program has helped expand access to mental 
healthcare for veterans. In what ways has the program been most 
effective and how can it be further improved to ensure veterans 
and crisis receive timely mental healthcare?
    Dr. O'Toole. Thank you, Congressman. This act has been 
serving our veterans very well, and we support many of the 
amendments, several of the amendments that are in the bill. The 
grant program in particular, we have found very helpful and has 
been very supportive. Four of the amendments in particular we 
are supportive of, including the extending the duration of the 
pilot program because of its successes; requiring grantees to 
inform individuals about their ability to receive emergency 
suicide care, which we currently do, but I think codifying it 
is going to be a strength; ensuring that eligible entities have 
provided mental healthcare and support for veterans over the--
excuse me, support services in the U.S. for the previous 2 
years, we feel strengthens it. There is some technical 
corrections as well we support.
    The concern we have with this bill is the $500,000 cap and 
the $10,000 per grantee additional payment, which we think 
would be difficult logistically to manage in the context of how 
Federal grants are currently managed with providers in that 
form.
    Mr. Hamadeh. Thank you. Going off of Congressman Bacon's 
comments earlier, it is a very impressive facility from what I 
see and I would like to visit that, Congressman.
    My first question--or third question is to Dr. Gold. What 
were the biggest advantages of using the public-private 
partnership for the Omaha center project and how can this model 
be replicated across the country?
    Dr. Gold. Thank you for asking, sir. Of course, thank you 
for your service.
    There are so many different advantages. One was to, of 
course, save a lot of money. What would have cost the VA $136 
million ended up costing $56 million out of the VA budget.
    Second was this project was finished not only exactly on 
budget, but ahead of schedule, which does not always happen in 
large Federal construction projects. At least that has been my 
multidecade experience. It also was able to bring to bear the 
experience that our university had with being part of this 
small, but very effective 501(c)(3) corporation, in that we 
have built lots of different healthcare facilities, ambulatory 
care centers, ambulatory surgery centers, and many other 
inpatient and out patient health care facilities, women's 
health centers, imaging centers, et cetera. Being able to bring 
all that to bear with the architects, the engineers, and with 
the construction contractors allowed us to accelerate the 
planning for the process in partnership with the local VA and 
deliver it on time and on budget.
    Mr. Hamadeh. A truly, truly impressive project.
    Dr. Gold. It is a beautiful facility, an award-winning 
facility.
    Mr. Hamadeh. Right. On time and under budget. That is 
pretty rare for the Federal Government.
    I yield back.
    Mr. Bacon. Like $85 million under budget.
    Ms. Miller-Meeks. Thank you very much, Representative 
Hamadeh.
    The chair now recognizes Representative Cherfilus-McCormick 
for 5 minutes.
    Ms. Cherfilus-McCormick. Thank you so much. I would first 
like to say thank you to our panelists for testifying today. 
Thank you for your dedication and service.
    Dr. O'Toole, Representative Garcia's Women Veterans Cancer 
Care Coordination Act identifies the difficulties veterans face 
in navigating transitions to and from community care. For 
instance, I have heard of cases where medical records from 
community providers took weeks to return, delaying crucial 
treatment and causing unnecessary stress for the veterans and 
their families. No veteran should navigate their battle with 
cancer alone.
    Dr. O'Toole, do you have--Dr. O'Toole, do VA hospitals need 
dedicated community care coordinators, teams, to help veterans 
navigate and keep contractors accountable?
    Dr. O'Toole. Thank you, Congresswoman. First, we agree with 
you absolutely that no veteran, no person, should have to 
navigate the management of cancer by themselves. We strongly 
support the role of care coordinators in helping them both 
navigate the care within the VA and navigating the care in the 
community.
    Ms. Cherfilus-McCormick. What is the impact to the 
veteran's care when there is not a seamless through line 
between community care and the VA?
    Dr. O'Toole. The biggest challenge, Congresswoman. I think, 
as we would all acknowledge, is the concern about care falling 
through the cracks, not being communicated well to different 
providers who were involved in that care for the veteran, not 
knowing what was going on with their care. These are things 
that nobody should have to experience in their care journey.
    Ms. Cherfilus-McCormick. Dr. O'Toole, my second question, 
having a regional breast and gynecological care cancer care 
coordinator for each Veterans Integrated Service Network (VISN) 
has the potential to save many lives if Representative Garcia's 
bill were to become law. However, I have deep concerns that 
Department of Government Efficiency (DOGE) may work to stop 
this position from being in existence. Over the weekend, the 
New York Times uncovered a horrifying consequence of DOGE's 
indiscriminate workforce cuts. The VA hospital employees 
responsible for enrolling veterans with throat cancer in an NIH 
clinical trial was fired. As a result, the clinical trial was 
put on hold and veterans with cancer were left without access 
to potential life-saving medication.
    Dr. Gold, should we exempt clinical trial coordinators and 
the coordinator position established by the Women Veterans 
Cancer Care Coordination Act from DOGE's indiscriminate firing?
    Dr. Gold. There is no question that access to clinical 
trials is life-saving, particularly in cancer, but also in end 
stage congestive heart failure, in neurodegenerative diseases, 
and so many others. Our veterans should be afforded the very 
best quality care that our Nation can provide, which means they 
need to have access to all of those trials. In order to do 
that, we must have qualified personnel to enroll and to perform 
those trials and to monitor them.
    Ms. Cherfilus-McCormick. You would recommend expanding the 
exemption to other areas and other positions, also?
    Dr. Gold. Access to clinical trials is absolutely state-of-
the-art care and needs to be available to all patients in our 
Nation.
    Ms. Cherfilus-McCormick. Do you believe VA's plan to lay 
off 83,000 workers will help facilitate veterans access to 
cancer care?
    Dr. Gold. I know that the staffing of any medical center, 
large or small, is what makes it work. Buildings are beautiful, 
the coffee shops are important, but at the end of the day, it 
is the doctors, the nurses, the pharmacists, and the therapists 
that make it all work. I also know that you need a critical 
mass of that workforce to make it successful.
    Ms. Cherfilus-McCormick. Is that a yes or a no?
    Dr. Gold. Do you mind repeating your question?
    Ms. Cherfilus-McCormick. Do you believe that VA's plan to 
lay off 83,000 workers will help facilitate the VA's access to 
cancer care?
    Dr. Gold. Without understanding the details of which 83,000 
workers will be laid off, it is difficult to give you a 
specific answer. Anything that materially reduces the workforce 
will materially reduce access to care and quality of care.
    Ms. Cherfilus-McCormick. I will take that as a yes. Well, 
thank you.
    I would like to know that the VA research has led to the 
best treatment in the world when it comes to prosthetics, 
spinal cord injuries, and TBI. In addition, VA researchers also 
brought use of the pacemaker, nicotine patches, and aspirin as 
a method to preventing heart attacks. Attacks on these 
healthcare researchers and the VA affects every veteran in 
America, not just the veterans who are presently receiving 
care.
    Thank you so much for your time. I yield back.
    Ms. Miller-Meeks. Thank you very much, Representative 
Cherfilus-McCormick.
    The chair now recognizes Representative King-Hinds for 5 
minutes.
    Ms. King-Hinds. Thank you, Madam Chair.
    My question is to Dr. O'Toole. I come from the territories 
and I just wanted to get your thoughts. Given that the Parker 
Gordon Fox Suicide Prevention Grant Program is designed to 
reach veterans who may not necessarily be engaged with the VA, 
how is the program ensuring that the resources are effectively 
reaching veterans in remote or underserved areas, such as U.S. 
territories, like the Commonwealth of the Northern Mariana 
Islands (CNMI)?
    Dr. O'Toole. Thank you, Congresswoman. That is obviously of 
great importance. I think the intent and design of the grantee 
process is critical to that, to ensuring and both also our 
monitoring of grantees to ensure that that is appropriately 
managed and distributed to every veteran no matter where they 
live.
    Ms. King-Hinds. Okay. Then, in addition to that question, 
what strategies are in place to support community-based 
organizations in these areas that may lack the infrastructure 
or capacity to apply for and manage these grants effectively so 
that we do meet the mission of certain serving our veterans, 
especially in underserved, remote areas?
    Dr. O'Toole. Thank you, ma'am. I would have to take the 
specifics of that response on the record and defer to our 
subject matter experts in that program. It is something, 
though, we fully agree with in terms of its importance.
    Ms. King-Hinds. Thank you, I appreciate that. I yield my 
time, Madam Chair.
    Ms. Miller-Meeks. Thank you very much, Representative King-
Hinds.
    The chair now recognizes Dr. Dexter for 5 minutes.
    Ms. Dexter. Thank you, Chairwoman Miller-Meeks, and thank 
you to our witnesses for being here today and for your service 
to our veterans.
    Although I am very grateful for the opportunity to consider 
this legislation before us today, I have to state the obvious. 
We are proceeding with business as usual when nothing about 
what is happening in the world is business as usual. In a 
matter of hours, everyone on this dais will leave this room to 
vote on legislation put forth by my Republican colleagues to 
cut nearly $23 billion in advance funding to ensure we can care 
for our veterans exposed to toxic chemicals in the line of 
duty. If that were not bad enough, that vote comes just days 
after we found out that Trump's team will fire an additional 
83,000 VA workers on top of the 2,400 they have already 
stripped of their jobs, and return us to the staffing levels we 
saw before implementation of the Sergeant First Class Heath 
Robinson Honoring our Promise to Address Comprehensive Toxics 
(PACT) Act, the biggest expansion of veterans' benefits in 
generations.
    Make no mistake, these firings are as good as a cut for 
veterans. Without those dedicated workers, our veterans will 
absolutely have trouble accessing the care and benefits they 
have earned, waiting longer for their claims to be processed, 
or, worse, not being able to access new benefits at all. Look, 
I built a track record at the State level for being able to 
reach across the aisle. I absolutely want to get things done. 
Several of the bills before us--and several of the bills before 
us are good policy, whether it is ensuring veterans have access 
to essential medicines regardless of where they are cared for, 
improving care coordination for women veterans, or advancing 
cost-effective gun safety measures. I have serious doubts about 
our ability to implement any of these policies if the VA does 
not have the staffing or the funding that it needs.
    I spent much of my professional career practicing as a 
physician at Kaiser Permanente in Oregon and served first as a 
board member and then as chair of the board. I understand 
intimately the challenges of running a large medical system.
    I simply have a--I have a simple question for you, I hope, 
Dr. O'Toole. First, would it make it easier or harder to 
implement a new initiative at the VA if it were uncertain that 
the VA would be provided with the funding required to do so?
    Dr. O'Toole. Thank you, Congresswoman. I am, you know, 
trying to fully, I guess, understand the question. Obviously, 
any bill that comes through, it helps to have the 
authorizations associated with that bill to be able to 
implement it.
    Ms. Dexter. Okay, thank you. Would it make it easier or 
harder to implement a new initiative at the VA if there were no 
staff to do so?
    Dr. O'Toole. Thank you, Congresswoman. Again, you know, I 
think in--I am not--I would have to take for the record 
specifics related to, you know, current issues related to 
staffing and the staffing proposals underway. I think, in 
general, though, I think your question is rather self obvious.
    Ms. Dexter. Thank you. Following up on my colleague's 
questions regarding care coordination, do you have objective 
reasons to believe that care coordination within the VAMC, 
especially around cancer care, is superior to care outside 
coordination with our community care systems?
    Dr. O'Toole. I would need to defer to our subject matter 
experts who have spent, you know, many of them have spent their 
careers studying differences in quality between the VA and care 
outside the VA. I have been very proud to be a clinician in the 
VA system and very proud of the care that we provide and the 
outcomes we provide. You know, it is not to say we could never 
do better. We always can. I think the role of care 
coordination, particularly in complex care that involves 
multiple providers, it has been well proven to be an important 
element of that care.
    Ms. Dexter. I absolutely agree with you having had access 
to care coordinators throughout my practice as well on lung 
cancer treatment.
    I am going to ask, Madam Chair, if we can submit some 
studies for the record looking at the comparison of outside 
versus inside care, one of which is titled, ``VA Delivered or 
VA Purchased Care: Important Factors for Veterans Navigating 
Care Decisions.''
    Ms. Miller-Meeks. No objection.
    Ms. Dexter. Thank you.
    I just urge my colleagues to keep in mind the importance of 
this legislation. I certainly appreciate the work that folks 
are doing, but that we cannot expect better care when we gut 
the system that has to deliver it.
    With that, I yield back, Madam Chair.
    Ms. Miller-Meeks. Thank you very much, Dr. Dexter.
    The chair now recognizes Dr. Conaway for 5 minutes.
    Mr. Conaway. Thank you, Madam Chair, and thank you, thanks 
to our witnesses for presenting themselves to us today and 
offering information on the bills at hand.
    Mr. O'Toole, this question is, I think, directed at you. 
You are taking most of the incoming now, it seems. In the last 
Congress, the No Wrong Door Act was introduced to demonstrate 
improvements in veterans' mental health, a very critical issue. 
We are seeing, sadly, the number of suicides among that cohort 
going up. The updated version has changed that requirement that 
now grantees must show that funds are being used to assist a 
significant number of veterans. My concern is it went from 
showing that you have good outcomes to showing that you have, 
quote, unquote, ``significant numbers of veterans'' who are 
receiving assistance.
    The question is, what does ``significant'' mean in that 
context? How do we measure it? When do people meet the bar?
    Dr. O'Toole. Thank you, sir. That reflects similar concerns 
that we have to the construct of this bill. Absolutely, these 
pilot programs have made a difference and we are strong 
supporters of them. The bill as drafted and changing from the 
$750,000 grant amount to $500,000 with an additional $10,000 
per individual served, we feel would create challenges and 
logistics to both how the grant would be administered, but also 
challenges to how we would be assessing performance of those 
grants.
    We stand very much in support of this legislation and the 
intent of it. You know, I think we share the subcommittee's 
concerns and try to make sure we have the best bill going 
forward.
    Mr. Conaway. I agree that the effort is more than 
worthwhile, the concerns that we are seeing among the veterans 
community and indeed mental health more broadly, and certainly 
would have a particular need and duty to provide that care to 
those who have given so much to our country.
    Next, I want to address H.R. 1336, the Veterans National 
Traumatic Brain Injury Treatment Act. This bill aims to direct 
the Secretary of Veterans Affairs to establish a pilot program 
to provide hyperbaric oxygen therapy to veterans suffering from 
traumatic brain injuries or post-traumatic stress disorder. 
Indeed, we have seen studies in the traumatic brain injury 
space which suggests that the use of hyperbaric oxygen therapy 
would be really quite beneficial.
    The VA conducted its own study and which showed, you know, 
great promise. Does the VA have any reservations regarding this 
pilot program and the potential impact of this therapy on 
veterans?
    Dr. Shappell. Thank you. Thank you for your question. VA 
shares your concerns. Mental health and suicide preventions are 
huge priorities for VA. We do not support this bill.
    Our VA subject matter experts are continuously reviewing 
scientific literature and updating and publishing our clinical 
practice guidelines. Published results of the scientific 
rigorous research that has been done by VA and U.S. Department 
of Defense (DOD) repeatedly they have shown hyperbaric oxygen 
therapy has the same impact as a placebo.
    Mr. Conaway. What is that? If you would speak into the mic, 
it would be very helpful.
    Dr. Shappell. Published studies----
    Mr. Conaway. There you go.
    Dr. Shappell. Published results of the scientifically 
rigorous research that has been done by both VA and DOD has 
shown repeatedly that hyperbaric oxygen therapy has the same 
impact as placebo. There is no scientific basis to support the 
use of hyperbaric oxygen therapy for PTSD. There is strong 
scientific basis that hyperbaric oxygen therapy is not 
recommended for traumatic brain injury.
    Mr. Conaway. We are looking at a study here on our desk 
that would suggest otherwise. It is an NIH study and certainly 
we do want to look at the preponderance of evidence across 
multiple studies. They are done, hopefully, according to the 
most rigorous standards. Therefore, if you do not like the 
hyperbaric oxygen as a treatment, could you suggest alternate 
therapies that--alternative therapies that we are perhaps not 
using now that ought to be deployed deal with these important 
conditions?
    Dr. Shappell. Thank you. As I mentioned, our subject matter 
experts are continuously reviewing scientific literature. I 
would be happy to provide you a review of other alternate 
therapies that we are currently considering.
    Mr. Conaway. Great. Thank you, Madam Chair.
    Ms. Miller-Meeks. Thank you, Dr. Conaway.
    I now recognize General Bacon for 5 minutes for any 
questions you may have.
    Mr. Bacon. Thank you, Madam Chair, for the opportunity to 
be part of your subcommittee today. I would like to follow up 
with President Gold and some of his comments on the numbers 
because I think they are worthy of repeating.
    What he said is that the VA--we saved the VA, or the 
Federal Government, approximately $80 million. What was going 
to cost the VA $135 million ended up costing the Federal 
Government $56 million. I think I got the numbers that you said 
right there.
    President Gold, could you lay out what can we expect for 
the inpatient hospital, rough numbers? Like, what does the 
Federal Government or the VA think it is going to cost versus 
what we can probably build it at versus how much State and 
local philanthropic money we may get? We just want to show the 
benefit of this for our future facility.
    Dr. Gold. A great deal would depend upon how much shared 
services we are talking about. Certainly replacing inpatient 
med surg, critical care, and other bed space would be 
essentially at the standard construction rates for large, high-
quality academic medical centers. However, a lot of the cost of 
construction in healthcare now really is not on the inpatient 
bed space, but it is in the extremely expensive equipment 
including diagnostics, procedural, and interventional space. 
Biplane fluoroscopy, for instance, some of the modern 
laparoscopic and endoscopic operating rooms, et cetera. Even in 
the ophthalmology world, the equipment has gotten incredibly 
expensive with the operating microscopes interventional 
technology.
    To the extent that some of that diagnostic and procedural 
space could be shared, some of the clinical and anatomic 
pathologies space, some of the imaging space, some of the--even 
some of the central sterile supply space that would need to be 
connected, shared parking, shared logistics, and 
infrastructure. Right now, the project is on the VA 
construction priority list, as, I believe, the number two 
priority for 2029 and, if I am correct, at $1.56 billion. I 
would estimate based on discussions with the local VA and VISN 
leadership, that we could probably save the Federal Government 
if we did this in a shared fashion and shared these types of 
resources, we estimate you could save a half a billion dollars 
to the taxpayers.
    Mr. Bacon. That is what I was waiting to hear.
    Dr. Gold. Well, it all depends on how much you saved due to 
shared very expensive space and equipment.
    Mr. Bacon. That is the savings right there. If I may ask 
our VA representatives, and I will defer to which one, could 
you talk about what this CHIP IN bill has done, what it means 
to you? I would love to get your perspective on this.
    Dr. O'Toole. Thank you, Congressman. I think we are adding 
to the chorus, VA supports this bill. As you know, we were 
authorized as part of the pilot for up to five projects. Two 
have been undertaken, one completed in Omaha, as you have 
heard, and the hospital in Oklahoma is currently under 
construction. We do support this legislation.
    Mr. Bacon. With that, Madam Chair, I yield back.
    Ms. Miller-Meeks. Thank you very much, General Bacon.
    I now yield myself 5 minutes.
    I am going to follow up on something Dr. Gold said, which 
is carrying the public-private partnership even beyond, i.e., 
sharing facilities, especially those expensive facilities, and 
sharing parking, and some people may be aghast at that. Dr. 
O'Toole, do not many VA hospitals, are not they staffed by 
people that have dual appointment between a medical center and 
a VA center?
    Dr. O'Toole. Thank you, Congressman. Yes, actually we have 
a very deep academic partnership and footprint and particularly 
in our level 1A, 1B, and C facilities. I would note that 70 
percent of doctors practicing in the United States all went 
through a veteran hospital as part of their training.
    Ms. Miller-Meeks. As did I. Dr. Gold, the Omaha VA 
Ambulatory Care Center was completed a year ahead of schedule 
and over $40 million under budget thanks to the CHIP IN for 
Veterans pilot program. How did the VA's CHIP IN authorities 
foster such a successful public-private partnership?
    Dr. Gold. Thank you for the question. One of the biggest 
advantages that we shared was that we were able to plan this 
the way we would plan a commercial, large academic medical 
center clinic and then deliver it on a schedule that we would 
normally do it. Over my decade of leadership at the University 
of Nebraska Medical Center, we have done over a billion dollars 
of healthcare and academic construction and have never exceeded 
the budget and really never significantly exceeded the 
timeline, except minimally during the early months of the 
COVID-19 pandemic.
    The construction standards are absolutely critical because 
of the penalties associated with going over budget and going 
over timeline. Anybody that has been involved with large 
academic medical centers understands that, that time is money 
for all of these types of projects. That type of precision was 
used through the 501(c)(3) and you will hear from Sue Morris in 
a little bit of how that actually worked. That type of 
precision was used in a very, very careful way to ensure we 
delivered this project.
    Ms. Miller-Meeks. Thank you. It is one of the reasons we 
are hoping to make this permanent. For those who are 
interested, there is a pamphlet here that shows that clinic. It 
is quite outstanding.
    Dr. O'Toole, the Parker Gordon Fox Suicide Prevention Grant 
has made tremendous progress in connecting veterans with timely 
mental healthcare in their communities. Why is it vital that we 
quit quickly reauthorize the program?
    Dr. O'Toole. Excuse me while I catch up to my notes here on 
this. Thank you. Yes, we fully endorse the importance of this.
    My understanding is that the concern is obviously being 
able to reauthorize it before the pilot project expires, which 
my understanding is September 30, 2028. We strongly endorse 
this legislation as an important armament in our effort to 
reduce veteran suicide. Thank Congress definitely for all of 
your work and support on this effort.
    Ms. Miller-Meeks. Then again, Dr. O'Toole, the START Act 
would ensure community care referrals remain valid through the 
veterans standard episode of care. Would this help veterans 
receive all the care that the VA has determined necessary?
    Dr. O'Toole. We think so, ma'am. I think this is an 
important element where this legislation will help the VA 
practice to its policy. Obviously, our intent is obviously 
ensuring that it is not just the episode of care or the first 
appointment, but rather the episode of care, which can be up to 
1 year and renewable beyond that. More importantly, it is about 
helping the VA, I think, you know, shore up its practices to 
ensure that we are doing a better job of ensuring that that is 
actually what we are practicing, too.
    Ms. Miller-Meeks. I think, Dr. Gold, you were asked a 
question that may be difficult for you to answer, was in 
letting people go and managing a very large healthcare 
facility. Let me just say that if you were given an increase in 
your budget by 126 million over a 4-year period, and over that 
same past 4 years, you had an increase in full-time employees 
of 60,000 and part-time employees for 23,000 and you were 
looking at 80,000 employees, exempting hiring of nurses and 
doctors, would you consider that gutting a program?
    Dr. Gold. It would depend on the role of those individuals 
employees. You know, having been a pediatric heart surgeon for 
over two decades of my life, it is not just the person that 
stands at the operating room or over the ether screen, but it 
is the person that mops the floors and stocks the supply 
cabinets and does so much else in our system.
    Ms. Miller-Meeks. You would need to know----
    Dr. Gold. I would need to know.
    Ms. Miller-Meeks [continuing]. what those positions are. 
Thank you so much. With that, I yield back.
    I am going to ask if we would have our--on behalf of the 
subcommittee, I want to thank all of our witnesses for their 
testimony and joining us. You are now excused. We are going to 
wait a moment while the second panel comes to the witness 
table.
    Welcome, everyone, and I thank you for your participation 
today.
    On our second panel we have Ms. Sue Morris, president and 
CEO of Veterans Trust; Mr. Brian Dempsey, director of 
Government Affairs for Wounded Warrior Project; Dr. Andrew 
Kozminski, medical director of hyperbaric medicine for the 
University of Iowa Healthcare; Mr. Ed Harries, president of the 
National Association of State Veterans Homes; and Jon Retzer, 
deputy national legislative director for Health, Disabled 
American Veterans.
    Ms. Morris, you are now recognized for 5 minutes.

                    STATEMENT OF SUE MORRIS

    Ms. Morris. Good afternoon, Chairman Miller-Meeks, Ranking 
Member Brownley, and members of the Health Subcommittee. My 
name is Sue Morris. I am the president of Veterans Trust, the 
nonprofit philanthropic entity that partnered with the 
Department of Veterans Affairs under the CHIP IN Act to 
construct VA's Ambulatory Care center in Omaha, Nebraska, 
serving Western Nebraska and Western Iowa.
    Our nationally award-winning ambulatory care center project 
was completed and donated to Veterans Affairs in July 2020 as 
the first public-private partnership to be completed under the 
CHIP IN Act. The project received several national awards for 
healthcare design and construction. I am here today to speak in 
favor of taking the pilot program authorized under the CHIP IN 
Act and making it permanent, as H.R. 217 would do. Our project 
showed how VA, in partnership with the private sector, 
delivered a truly superb facility in a cost-effective and 
efficient manner.
    What allowed the Omaha project to be successful? First, the 
project was owned by Veterans Trust during the development and 
construction phases and then donated to Veterans Affairs upon 
completion. While there was very close coordination and 
cooperation between Veterans Trust and VA officials at both the 
national and local levels, it was not a government construction 
project. This structure allowed Veterans Trust, whose 
leadership had a history of facilitating or over a billion 
dollars on local projects, to use local vendors and suppliers 
in its procurement of services and materials, leveraging 
demonstrated relationships for best pricing. We were able to 
tell our partners in design and construction that they will 
make money on the project, but not a lot of money, as this is a 
community project to serve our veterans.
    Second was a strong commitment from Veterans Affairs' 
senior leadership. We met regularly at VA headquarters, 
including three meetings directly with the Secretary, to ensure 
project milestones were achieved. There was zero scope creep, 
which helped the project to be delivered on time and on budget.
    One key factor in this regard was Veterans Affairs' 
willingness to review VA's normally applicable construction and 
physical security standards. We were able to come to agreement 
on which of those standards made sense, resulting in value 
engineered savings of $23 million. In the end we delivered the 
facility for a total of $86 million when it was originally 
budgeted at $135 million, saving the taxpayers $50 million. In 
addition, the private philanthropic contribution to the project 
was $30 million.
    Based upon our experience and success with this effort, we 
recommend that H.R. 217 go further than simply making CHIP IN 
permanent to also consider other changes. In particular, we 
suggest the following. Add the option to construct facilities 
on land leased to VA, not just owned or donated real property. 
Add the ability to use the program for minor construction, not 
just major projects, and make clear that the act applies to 
more than just healthcare, but also to construction projects 
providing other types of facilities to veterans, such as 
housing and community centers.
    In amending the act itself, we suggest the subcommittee and 
staff engage a small group of VA leadership and private sector 
representatives to recommend forward-looking best practices and 
new models for public-private partnerships. My team and board 
would be pleased to have been included in this effort.
    In summary, we wholeheartedly support the effort to make 
CHIP IN a permanent tool to deliver state-of-the-art 
facilities. The act allows Veterans Affairs the ability to 
leverage advantages of private sector construction processes to 
deliver significant cost savings. We are tremendously proud of 
our role in helping lead in this effort to deliver a world 
class facility to our veterans and cost savings to our 
taxpayers.
    I want to add one final point. As Dr. Gold mentioned, there 
is no doubt that a new inpatient facility to replace Omaha's 
aging VA hospital is sorely needed. Veterans Trust stands ready 
to partner with Veterans Affairs and the University of Nebraska 
Medical Center to assist in developing a new, state-of-the-art, 
inpatient facility that will better serve the veteran 
community.
    I am happy to answer any questions that you might have. 
Thank you for including me today.

    [The Prepared Statement Of Sue Morris Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you.
    Mr. Dempsey, you are now recognized for 5 minutes.

                   STATEMENT OF BRIAN DEMPSEY

    Mr. Dempsey. Chairwoman Miller-Meeks, Ranking Member 
Brownley, and distinguished Health Subcommittee members, thank 
you for inviting Wounded Warrior Project to testify on 
legislation intended to improve VA's ability to provide better 
access to care and ensure better health outcomes for our 
Nation's veterans.
    Over 20 years ago, when the first wounded servicemembers 
returned from the battlefields of Iraq and Afghanistan, the 
founders of our organization made a promise: to be there for 
these warriors no matter what. In the years since, our 
organization has grown to provide more than a dozen programs 
and services to more than 227,000 veterans and servicemembers, 
and our reach continues to grow by the day. These programs and 
the relationships we have built with warriors along the way are 
what inform our advocacy before Congress. Today, I am pleased 
to speak on three bills from the agenda that we believe will 
have the biggest impact on those who serve.
    First, we strongly support the Veterans Support Act. This 
bill would amend VA's legal definition of medical services to 
clarify that the agency's existing ability to provide 
artificial limbs includes the authority to provide adaptive 
prosthesis and terminal devices for sports and other 
recreational activities. If you are unfamiliar with what an 
adaptive prosthesis or terminal device is, think of the curved-
shaped blades you might see on someone who has lost a lower 
limb or a waterproof fin that allows someone with an upper body 
prosthetic to swim in a pool. Now think about stress relief you 
may know from running, the community you found playing in a 
local softball league, or the body transformation you may have 
seen from lifting heavy weights. Participating in activities 
like these should be simple, but for veterans who use VA for 
prosthesis, it can be a challenge.
    Under current law and stated as simply as possible, 
veterans often struggle to get this kind of prosthetic support 
if they are not actively pursuing a rehabilitation plan, even 
if they have completed one in the past and are very familiar 
with what they need to do what they want. These regulations 
focus on the clinical need for adaptive prosthetics, but 
disregard their potential to improve a veteran's quality of 
life. If a clinical need cannot be found, providers cannot 
offer the equipment.
    The Veterans Support Act would help these veterans by 
effectively removing the requirement that they be enrolled in a 
VA rehabilitative program in order to receive the adaptive 
prosthetics for sports and recreation. The current population 
of post 9-11 veterans as young, young, mobile and energetic. We 
believe that VA should be building an ecosystem of care that 
encourages an active lifestyle and makes it easier to 
experience the profound health benefits, both mental and 
physical provided by sports and other recreational activities.
    Second, we support efforts to renew the Staff Sergeant 
Parker Gordon Fox Suicide Prevention Grant pilot program, 
including the No Wrong Door for Veterans Act. Our 
organization's approach to mental healthcare appreciates that 
no one organization and no single agency can fully meet all 
veterans' needs. Evidence-based mental health treatment 
absolutely works when available and when pursued, but the best 
results will be found by incorporating a public health approach 
focused on increasing resilience and psychological well-being. 
This kind of suicide prevention strategy embraces upstream 
prevention efforts, like helping with case management, peer 
support, work outreach, and establishing financial wellness, 
all of which are recognized as suicide prevention services 
through the Fox Grant Pilot program. Each year since the Fox 
Grant Pilot was launched, VA has discussed it as a key 
initiative for helping prevent suicide in its National Suicide 
Data Report.
    Previous congressional oversight and legislative hearings 
have revealed that the pilot program is not perfect, but we 
appreciate efforts like the No Wrong Door Act that would 
continue to refine the pilot's operation and foster community 
collaboration in ways tailored to local needs. We hope that 
this legislation can be prioritized as a vehicle for 
bipartisan, bicameral action to renew this program in time and 
disperse grants in Fiscal Year 2025.
    Third and finally, we support the Protecting Veteran Access 
to Telemedicine Services Act. This legislation would extend a 
COVID-19 era waiver from a law that requires patients to 
complete at least one in-person visit with a healthcare 
provider before that provider can prescribe them a controlled 
substance. If the waiver expires as planned in December 2025, 
rural veterans who do not live near VA or community healthcare 
facilities, who rely primarily on telehealth services, likely 
will be negatively impacted. Appointment coordination 
challenges and travel logistics may lead to interruptions in 
their care or lapses in prescriptions. The list of controlled 
substances contains not only pain medications, but also 
multiple mental health drugs that are important parts of 
treatment plans for many veterans dealing with mental health 
issues and for whom an in-person appointment may present 
additional challenges.
    Members of the committee, it is my distinct honor to be 
here on behalf of Wounded Warrior Project to speak to the needs 
of our Nation's wounded warriors and their families. Thank you 
for letting us do our part to keep the promise. This concludes 
my testimony and I look forward to your questions.

    [The Prepared Statement Of Brian Dempsey Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you.
    Dr. Kozminski, you are now recognized for 5 minutes.

                 STATEMENT OF ANDREW KOZMINSKI

    Dr. Kozminski. Good afternoon, Chairwoman Dr. Miller-Meeks, 
Ranking Member Brownley, and members of the subcommittee. Thank 
you for inviting me to participate in this hearing to discuss 
H.R. 1336, the Veterans National Traumatic Brain Injury 
Treatment Act.
    I am Dr. Andrew Kozminski, an emergency medicine physician 
with a specialization in undersea and hyperbaric medicine. I am 
the current medical director for Hyperbaric Medicine at 
University of Iowa Healthcare and medical director for the 
United Hospital Center (UHC) Wound Center.
    This legislation aims to improve the health of our 
veterans, establishing a pilot program for the implementation 
of hyperbaric oxygen therapy for veterans with traumatic brain 
injury or post-traumatic stress disorder. As an emergency 
medicine physician, I have cared for numerous veterans 
suffering from TBIs and PTSD. With my experience in hyperbaric 
medicine, I think the implementation of hyperbaric oxygen for 
these ailments would be uncomplicated. Veterans already use 
this therapy through their VA insurance for currently approved 
HBO indications. Consequently, HBO, hyperbaric oxygen, has 
proven its safety after many decades of use by the medical 
community. For these reasons, this legislation has been 
potential to help improve the lives of our friends, families, 
and neighbors.
    I want to comment on the potential for an increased 
likelihood of oxygen toxicity seizures in this patient 
population as 1 in 50 TBI patients develop post-traumatic 
epilepsy. However, an oxygen toxicity seizure is a complication 
that trained hyperbaric medicine professionals are well versed 
in how to manage and should be able to ensure continued patient 
safety throughout a treatment course. Clinical trials, I will 
mention, even utilize a protective pressure of 1.5 Atmospheres 
Absolute (ATA), which should reduce the likelihood of this 
complication. However, this is an important reason to create a 
pilot program through the VA Health System, as this would 
provide a safe option for patients seeking treatment for what 
is currently an off-label indication. Without this program, 
desperate patients may find themselves at the mercy of popular 
health spas. Businesses that might not have adequately trained 
staff may use incorrect treatment profiles and at times pose 
serious risk to their patients or their clients.
    The research that investigators in my field have completed 
on the utility of HBO for TBI and PTSD shows promise for 
improving health outcomes in these patient populations. For 
chronic TBI cases, HBO has been found to improve cellular 
metabolism, reduce cell death and oxidative stress, and enhance 
mitochondrial function. These mechanisms aim to promote 
neuronal repair and regeneration. The Brain Injury and 
Mechanism of Action, BIMA, trial published in 2016 demonstrated 
improved post-concussive symptoms, PTSD, cognitive processing 
speed, sleep quality, and balance function by 13 weeks after 40 
60-minute HBO sessions at 1.5 ATA.
    Unfortunately, these improvements did not persist beyond 
that 6-month follow up. In February 2025, however, just last 
month Dr. Lindell Weaver, a leader in my field, and his team 
published their most recent study a double-blind randomized 
trial of hyperbaric oxygen for persistent symptoms after brain 
injury. This study showed similar results to what was observed 
in the BIMA trial for both sham and HBO groups at 13 weeks, 
with the HBO treatment group maintaining the neuropsychiatric 
benefits at 6 months.
    A second phase within the trial offered another 40 HBO 
sessions to all participants. Final follow up 3 months after 
the last of the second round of HBO treatments were given, 
patients who received 80 HBO treatments had greater 
neuropsychiatric improvement compared to their results after 40 
sessions. Patients who received a maximum of 40 treatments also 
showed neuropsychiatric improvements compared to their baseline 
scores, but less improvement than their counterparts received 
80 treatments.
    In conclusion, I find the outcomes of these clinical trials 
seem promising. Establishing a pilot program for the VA to 
offer HBO therapy for veterans with TBIs and PTSD could help 
improve these patients' quality of life, provide access to safe 
healthcare environments in which to receive these treatments, 
and continue to build insight on how best to construct and 
administer treatment courses in the future. Thank you.

    [The Prepared Statement Of Andrew Kozminiski Appears In The 
Appendix]

    Ms. King-Hinds. [Presiding.] Mr. Harries, you are 
recognized for 5 minutes.

                    STATEMENT OF ED HARRIES

    Mr. Harries. Members of the subcommittee, as president of 
the National Association of State Veterans Homes, thank you for 
the opportunity to testify today and offer our strong support 
for the Providing Veterans Essential Medications Act. This 
legislation would remove an inequity in the law concerning 
high-cost medication for veterans that are preventing many of 
them from living in State veterans homes.
    As you know, State veterans homes are not able to receive 
reimbursement from the VA for high-cost medications provided to 
seriously disabled veterans, even though private nursing homes 
that contract with the VA can. As a result, many State homes 
are losing hundreds of thousands of dollars every year that 
could be used to improve the lives of aging and disabled 
veterans.
    For example, at the Iowa State Veterans Home they are 
caring for a 55-year-old service-connected Air Force veteran 
who suffers from Crohn's disease. Fortunately, a drug called 
Stelara can help control his symptoms. However, this medication 
costs about $20,000 a month, which is more than the full cost 
of care prevailing rate the VA pays the home. Despite the 
financial burden, the Iowa State Home decided to care for this 
veteran at a significant operating loss. However, that likely 
means that they will have to cut costs elsewhere, perhaps 
admitting fewer veterans, spouses, or Gold Star parents, or 
maybe cutting back on social, recreational, or other nonmedical 
services.
    The same situation is occurring at State veterans homes 
across the country. At an Idaho State Veterans Home, a 63-year-
old service-connected Army veteran is receiving a medication 
called Duopa for Parkinson's disease, which costs the home 
about $16,000 a month. The prevailing rate that Idaho receives 
for this veteran does not fully cover the cost of this one 
medication, let alone the cost of all the other care provided. 
Unfortunately, due to the financial strain from high-cost 
medications, some State homes can only afford to care for a 
limited number of such veterans who need these medications.
    For example, a 76-year-old 100 percent service-connected 
Air Force veteran living in a VA contracted community nursing 
home in Idaho was taking a special medication called Promacta. 
The cost of that drug was $18,000 a month. The VA was providing 
this medication to the veteran's spouse, who took it to the 
private nursing home where they would administer it to him. 
Although the private nursing home was receiving a prevailing 
rate for the full cost of care, just like the State homes do, 
their contract included a provision for them to receive or be 
reimbursed for these high-cost medications. The veteran wanted 
to move into the State veterans home and his spouse asked if 
she could continue to pick up the medication and bring it to 
the home. The VA told her that by law they could not allow it, 
effectively denying this veteran the ability to live in State 
veterans home, which was his choice.
    There are also cases where this inequity in the law is 
literally throwing away money that could be used to improve the 
care of veterans. In Wisconsin, a 76-year-old veteran who 100 
percent service-connected veteran, a Marine sharpshooter, was 
admitted to the State veterans home while receiving 
chemotherapy medication free of charge through an Astellas 
Patient Assistance Program. After the veteran moved to the 
State veterans home, his wife brought the medication so that it 
could be administered to him. However, according to the VA's 
rules, they could not use the free medication. Instead, the 
facility itself incurred a cost of $12,000.
    Wisconsin also had a service-connected army veteran living 
in one of their homes who was prescribed a chemotherapy drug by 
his VA oncologist, which was shipped directly from the VA 
pharmacy to the State home. When the medication arrived, the 
home contacted the VA, aware knew that it could not utilize the 
drug because they had not purchased it themselves under the 
program. When inquiring how to avoid wasting the $20,000 
medication, the VA told them it could not be returned even 
though it was in its original sealed packaging and to dispose 
of it.
    Madam Chairwoman, the Providing Veterans Essential 
Medication Act would require VA to furnish or reimburse State 
veterans homes for these high-cost medications, just like they 
are doing for the private homes. This would ensure that 
veterans could choose where they want to spend their twilight 
years without illogical statutes and regulations limiting their 
choices.
    That concludes my statement and I will be pleased to answer 
any questions that you or the members of the subcommittee may 
have.

    [The Prepared Statement Of Ed Harries Appears In The 
Appendix]

    Ms. Miller-Meeks. Mr. Retzer, you are now recognized. Thank 
you.
    Mr. Retzer, you are now recognized for 5 minutes.

                    STATEMENT OF JON RETZER

    Mr. Retzer. Chairwoman Miller-Meeks, Ranking Member 
Brownley, and members of the subcommittee, thank you for 
inviting DAV to testify at today's legislative hearing. DAV is 
pleased to support the following bills.
    The SPORT Act seeks to include adaptive prosthesis terminal 
devices for sports and other recreational activities and the 
medical services provided to eligible veterans of the VA. DAV 
has long recognized and continues to support the importance of 
adaptive sports through our involvement with the National 
Disabled Veterans Winter Sports and Golf Clinics, which helps 
veterans improve their physical and mental health by overcoming 
limitations and challenge their perceived disabilities.
    The Saving Our Veterans Lives Act aims to tackle the 
devastating issue of veteran suicide by providing secure 
firearm storage. Firearms are involved in nearly 72 percent of 
veteran suicides and offering lockboxes creates time and space, 
reducing access to lethal means during moments of crisis, 
allowing veterans to reconsider their actions and seek help.
    The Marriage and Family Therapist Qualification of Veterans 
Health Administration Act aims to ensure that veterans receive 
care for high qualified marriage and family therapists through 
effective supervision and improved therapeutic practices. 
Incorporating family and relationships into mental health 
treatment can result in more effective outcomes, reinforcing 
coping strategies and provide a sense of belonging and 
stability.
    The Protecting Veterans Access to Telemedicine Service Act 
would ensure veterans can access controlled medications and 
consultations remotely, enabling convenience scheduling and 
thus improving treatment adherence and health outcomes. It 
breaks down barriers, such as distance, mobility challenges, 
and transportation limitations, particularly for those in 
underserved areas.
    The Women Veterans Cancer Care Coordination Act aims to 
ensure that women veterans diagnosed with breast and 
gynecological cancers receive seamless and tailored support 
through regional care coordinators. This would ensure veterans 
receive timely and appropriate care.
    The START Act aims to streamline the referral process for 
veterans receiving community care, ensuring smoother 
transitions and reducing administrative barriers. By 
establishing a clear referral period, it would ensure better 
care coordination.
    The Providing Veterans Essential Medication Act aims to 
address the financial burdens faced by safe veterans homes, 
ensuring veterans have access to high cost medications without 
added strain to the facilities. The bill guarantees continued 
high-quality care for veterans in long-term care, reflecting 
our commitment to their well-being.
    The Copay Fairness for Veterans Act aims to eliminate 
copayments for medications and preventive health services 
provided by the VA. Removing financial barriers will encourage 
routine checkups and screenings, leading to better overall 
health management and fewer emergency medical situations. We 
commend the thoughtful intent beyond the next two bills and 
encourage incorporating our recommendations to enhance their 
effectiveness.
    The No Wrong Door for Veterans Act reauthorizing and 
extending the Staff Sergeant Gordon Fox Grant Program, 
providing ongoing support for community-based mental health 
services. To enhance its impact, DAV recommends reiterating the 
importance of the original requirements of baseline mental 
health screening, using validating tools, and measuring the 
effectiveness of suicide prevention services with pre and post 
evaluations.
    Furthermore, funding criteria should focus on improvements 
in veterans' well-being rather than the number of participants 
served. Payment structure should be clearly defined to avoid 
overcompensation for minimal services. An annual renewal 
process is recommended until comprehensive data confirms the 
program's efficacy and identifies the most effective services 
in reducing suicide risk among veterans.
    The Veterans National Traumatic Brain Injury Treatment Act 
aims to establish a pilot program to provide hyperbaric oxygen 
therapy for veterans whose PTSD and TBI symptoms have not 
responded to traditional therapies. While initial research 
shows promise, researchers suggest further rigorous studies are 
necessary to validate its efficacy and safety. DVA recommends 
amending the bill to prioritize research along treatment axis 
to ensure veterans receive care that is both effective and 
evidence based.
    In conclusion, these legislative bills represent a 
comprehensive approach to addressing the urgent needs of our 
veterans to receive the services and healthcare that they have 
earned. This concludes my testimony on behalf of DAV and I am 
pleased to answer questions you subcommittee may have.

    [The Prepared Statement Of Jon Retzer Appears In The 
Appendix]

    Ms. Miller-Meeks. Thank you very much.
    Ranking Member Brownley, you are now recognized for 5 
minutes.
    Ms. Brownley. Thank you, Madam Chair.
    Mr. Retzer, thank you for your testimony and I certainly 
appreciate DAV's support of the VA Marriage and Family 
Therapists Equity Act as well as your support for the Women 
Veterans Cancer Care Coordination Act, which I am coleading 
with Representative Garcia. On the Cancer Care Coordination 
bill, can you sort of elaborate a little bit more? I know you 
did somewhat in your testimony, but can you elaborate a little 
bit more on why this legislation would be beneficial, 
especially in the light of previously enacted legislation, like 
the Making Advances in Mammography and Medical Options for 
Veterans (MAMMO) Act, which expanded veterans' access to high-
quality breast imaging services, and the Service Act and the 
PACT Act, which expanded access to screening and made breast 
cancer a presumptive condition for veterans who were exposed to 
toxins during their military service?
    Mr. Retzer. This bill is very important to us on a couple 
different facets. As in our written testimony, we outline the 
importance for our women veterans to get specialized care. The 
coordination of care is so important and the challenges that VA 
has with addressing women veterans' special needs, especially 
when we look at, for example, breast cancer prevention. We need 
to ensure that VA, being that their infrastructure is not built 
to sustain all women veterans care at every VA facility, we 
rely on partnerships and affiliates to be able to supply the 
technical and lab work requirements plus the clinical 
specialists that are out there to provide that care.
    Another thing that we saw that was really meaningful in 
this bill with regards to the care coordinators is the impact 
it has with honoring our PACT Act. Now that we have found that 
male veterans who have been exposed to toxic exposures can also 
be, unfortunately, suffering from the same illness of breast 
cancer, we feel that this piece of legislation will open up the 
door to developing good care coordination not only for women 
veterans who suffer with breast cancer, but also for our male 
veterans who have been exposed to toxic exposures. We feel it 
is very important with the research and the clinical findings 
that they work with.
    Ms. Brownley. Thank you for that. Speaking of the PACT Act, 
I mean, I have to ask you with 83,000 folks being laid off or 
fired in the VA and significant cuts to the PACT Act, what 
impacts--I think it is 23 billion cuts to the PACT Act. What 
are the implications?
    Mr. Retzer. What we are hoping for that the administration 
and VA and Congress itself work together in a bipartisan manner 
to ensure that these bills, and they are very thoughtful bills, 
continue to strengthen the VA system and that is the 
infrastructure, staffing, and technology.
    Ms. Brownley. Thank you. Dr. Kozminski, in your testimony 
you briefly discussed the importance of sufficient training and 
strict safety standards and the potential risks faced by 
patients who are seeking hyperbaric oxygen treatment for off-
label indications, like TBI and PTSD, at health spas. You also 
mentioned the recent tragic explosion of a hyperbaric chamber 
at a facility in Michigan, which killed a 5-year-old child. Dr. 
Murphy's legislation, H.R. 1336, does not seem to include any 
limitations or guardrails on which types of providers veterans 
with TBI or PTSD could receive treatment from under this 
proposed pilot program.
    Do you think we should consider amending it to include 
safeguards such as ensuring that veterans would go to 
institutions that have been accredited by the Undersea and 
Hyperbaric Medical Society or another body? Would you recommend 
other safeguards? The bill literally is like two pages, maybe 
two and a half pages. It is just about funding and having the 
program and starting the program, but no safeguards whatsoever.
    Dr. Kozminski. Frankly, I mean, I do agree that it would be 
best to make sure that whatever treatment they receive, what 
our veterans receive, is done at an accredited facility. 
Amending the bill for that would be probably best for patient 
safety.
    Ms. Brownley. That is it?
    Dr. Kozminski. I am good.
    Ms. Brownley. Thank you. I will yield back.
    Ms. Miller-Meeks. Thank you very much.
    The chair now recognizes Representative King-Hinds for 5 
minutes.
    Ms. King-Hinds. More along the lines of this traumatic 
brain injury treatment option. I guess this is a question for 
Dr. Retzer because it is a policy conversation. Right?
    What additional research or oversight do you suggest or 
recommend is needed basically, that one we could actually 
explore this type of treatment, right, that a lot of folks 
support? How do we ensure balancing the safety of our veterans?
    Mr. Retzer. I think as we see all the research that we see 
and what VA is doing and what NIH is doing, and also the 
Journal of Medicine, we are seeing all these factors that have 
progressed throughout the year, showing from a point of where 
there was an imbalance, where it was not positive, that age 
HBOT was reducing outcomes for traumatic brain injury and PTSD. 
As we started to move through the years, we started to see some 
progress and that is the promise that we are hearing, that we 
are wanting to see that more research. As a resolution-based 
organization, we support research, strongly support 
continuation of VA's research, and also the research partners 
and affiliates out there to ensure that they are looking at 
safe clinical practices, evidence-based methods to ensuring 
that we are providing alternative options of care for our 
veterans.
    Ms. King-Hinds. Okay. Thank you for that. This question is 
also for you. Given the importance of telemedicine in providing 
timely care to veterans, especially those who live in remote 
and underserved communities, like mine, the CNMI, what specific 
safeguards are being considered to ensure that prescriptions 
for controlled substances via telehealth are both safe and 
effective?
    Mr. Retzer. Thank you for that question. With 
pharmaceutical care and trying to address the issues of mental 
health and suicide prevention along with substance use abuse, 
there is a responsibility on VA to ensure when they are 
providing patient care in direct environment or in the 
community care, that there are direct communication, clear 
communications on the treatment processes and what medications 
are given so that the veterans themselves understand being 
informed what those interactions are and what the risk factors 
are and, at the same time, that VA and community are speaking 
directly with themselves.
    For example, my time when I was stationed up in Alaska, 
very remote area, it is very difficult to find clinicians in 
every part of it. When you are dealing with the VA and 
community care and you look at their infrastructure up there, 
it is not built to communicate very directly or well. We hope 
that as we continue with the modernization of electronic health 
record modernization, that is something that will be worked 
very robustly into the system of the pharmaceutical safety 
measures and making sure that patient safety is paramount 
throughout the whole development.
    Ms. King-Hinds. All right, thank you. I yield my time
    Ms. Miller-Meeks. Thank you. The chair now recognizes Dr. 
Morrison for 5 minutes.
    Ms. Morrison. Thank you, Madam Chair. It has been my 
distinct privilege to join in the work that this committee 
leads, ensuring that VA is meeting veterans diverse and 
evolving needs. As a physician myself, I have been part of 
teams that work together to help patients receive the highest 
quality of care and have witnessed firsthand the impact, 
positive impact of building comprehensive care coordination 
that enables effective communication and supports patients 
through their care. With the number of women veterans expected 
to continue growing, obviously we should be proactive in our 
efforts to coordinate care for one of the most pressing health 
issues women veterans face.
    Mr. Retzer, you answered ranking member Brownley's 
question. I am going to direct it to you now, Mr. Dempsey, if I 
may, and thank you for being here today. We have highlighted 
that breast cancer is the most diagnosed cancer for women 
within VA and that we will likely see a rise in the volume of 
cancer care that veterans need. Can you expand a little bit on 
the importance of care coordination for improving health 
outcomes and women veterans overall VA experience?
    Mr. Dempsey. Of course and thank you for the question. 
Thank you additionally for pointing out that breast cancer 
ranks as the second most common cancer among women in the U.S. 
and within VA, it is the most diagnosed cancer. I think for any 
veteran coming through the VA health system, in this case the 
increased volume of female patients that VA sees, it is 
important that patients feel supported with cancer care. In 
particular, where a lot of that care is received in the 
community, it is critically important to make sure that there 
is good coordination between the VA direct care system and 
those community providers. There is no gap in service, whether 
it be transfer of records back and forth, communication between 
the providers to make sure there is gaps in care. I think 
overall just creating a culture where veteran patients feel 
supported by their care providers.
    Ms. Morrison. Thank you. Appreciate that answer. I would 
also like to highlight another health issue that we have 
discussed that affects veterans at 1.5 times greater than 
nonveterans. Suicide rates among servicemembers have risen 
gradually over the decade, with veterans experiencing an 
alarmingly disproportionate rate of suicide by firearm. As the 
wife of a veteran, I find this absolutely heartbreaking.
    While we understand that mental health issues facing our 
veterans do not stem from a single cause, of course, it is 
important that we take any and every path to prevent these 
tragedies and empower veterans to address their mental health 
conditions. Safe firearm storage, education, and resources are 
integral to addressing the elevated risk veterans face for 
firearm suicide.
    With firearms reported to be involved in up to 72 percent 
of veteran suicides, as you noted, Mr. Retzer, the evidence for 
continued support of intervention programs that promote 
potentially life-saving time delays is clear.
    Mr. Retzer, in your testimony you do discuss time and space 
as critical components in preventing suicides. Why is 
approaching suicide prevention through safe firearm storage 
particularly impactful for veterans and their families?
    Mr. Retzer. I can speak as a veteran who owns firearms and 
who suffers with mental health. It is very meaningful to have 
this conversation because it is a responsibility not just of 
the veterans, but to the clinicians and the families integrated 
to understand how to save the veteran and themselves. In our 
testimony we wrote about the community being safe, and that is 
the end goal is to make that community safe, but where it 
starts is that veteran is safe.
    I have gone through the VA process of the clinical side, 
and I wish I was offered a lockbox. I was not. I met all the 
criteria that were actually testified, and I was not given an 
option for the lockbox. The good thing is that VA, throughout 
the process, has been doing and taking steps to ensuring that 
they offer these security measures to our veterans.
    Ms. Morrison. Thank you. The Saving Our Veterans Lives Act 
considered by the committee today includes an education 
element. How do you anticipate the educational component of the 
initiative will work with the resource component of the bill?
    Mr. Retzer. That is a great question and education is 
always very important. That is something we, the veterans, have 
to also own for ourselves, for our responsibilities, something 
that we come from. We come from an environment of being 
educated on how to handle firearms in the military. Hopefully 
that VA will build upon that knowledge that we have and the way 
that we are taught those, so that it relates to us in a manner 
that is meaningful and it also has highlights the importance. 
Education, I think, is going to be very important because it is 
going to open up the dialog for us to talk about something that 
is not always easy to talk about.
    Ms. Morrison. Thank you, Mr. Retzer. The legislative 
efforts considered in today's hearing demonstrate critical 
steps toward delivering the quality care that VHA should 
continuously pursue. I sincerely believe that finding common 
ground on ways to improve VA is a goal that is shared by all of 
my colleagues that sit on this committee.
    In recent weeks, there is been a lot of conversation about 
ramping up efficiency in our government. Every single one of 
the bills we have discussed today would require implementation 
actions that are the responsibility of VA employees. We cannot 
hope to continue to deliver care to our veterans if we throw 
the folks responsible for its delivery into instability and 
uncertainty. We cannot wish for improved access to care if we 
allow the disruption of essential food functions in our VA 
hospitals and facilities. We cannot tell our servicemembers we 
value their well being if we permit critical contracts and 
research initiatives to be slashed.
    I urge my colleagues, particularly those that have 
presented their bills before the committee today, to recognize 
the importance----
    Ms. Miller-Meeks. Your time has expired. I am sorry. We 
have votes that are coming up----
    Ms. Morrison [continuing]. of supporting the workforce.
    Thank you, Madam Chair. I yield back.
    Ms. Miller-Meeks [continuing]. so please wrap-up your time.
    The chair now recognizes Dr. Dexter for 5 minutes.
    Ms. Dexter. Thank you, Madam Chair. Again, thank you to our 
panelists for being here and for the work that you do with our 
veterans.
    As I alluded to earlier, I spent my career in a 
comprehensive coordinated care system very similar to the VA, 
and so I appreciate the ability to really embrace our veterans 
within the system and deliver care. I know that these systems 
work for patients, as you have spoken to, and we have clear 
data that we will submit for the record showing that care 
outcomes and satisfaction for care received inside of the VA is 
superior to outside. We also want to make clear that our 
veterans have access to care and mitigate the need for our 
veterans to be able to access care and have that intervention 
at the moment of impulsivity and despair for our veterans at 
high risk for suicide is critical. Thank you for your support 
for the lockbox display policy. I think that is proven very 
high yield and critical.
    It also is critical that our veterans have time to talk 
with a provider, be able to reach out when they are feeling 
most impulsive and desperate. I believe that is the intention 
with the No Wrong Door Act is to be able to help people at that 
moment. However, I am concerned about our requirement for in-
person care delivery for mental healthcare and the fact that we 
are not going to allow telemedicine mental health any longer, 
that everyone is going to have to be in person because an 
established care provider is trusted and certainly preferable 
having worked in an emergency room to walking into an emergency 
room and expecting high-quality personalized care.
    Despite the good intentions of the Wrong Door Act, it seems 
to run counter to the principles of a capitated inclusive body. 
I also have concerns about the reauthorization of a program for 
which we have collected good outcome data for only 4 percent of 
the participants.
    I wonder, Mr. Retzer, if you would be willing to share your 
thoughts on when VA led interventions are looking to be most 
impactful for our high-risk suicide patients, do you feel like 
we have sufficient data to be confident that the No Wrong Door 
Act is actually saving lives more than further investing in VA 
comprehensive care and even telehealth mental healthcare?
    Mr. Retzer. Thank you for that question. That is such an 
important issue that we have No Wrong Door Act really addresses 
alternative options where VA cannot do it by themselves. That 
is something that we are very realistic to. With having over 9 
million veterans enrolled in the VA healthcare system and you 
have 2.7 million in the rural, we have to be able to provide 
that type of a resource. When the Compact Act came out and that 
was a great win for Congress and for American veterans to be 
able to get healthcare when they were in acute crisis, that is 
another tool. The No Wrong Door has the potential to do what we 
need to do to provide alternative resources and clinical 
support out in the community where veterans may not be enrolled 
in the healthcare system. I think that is the most Important 
thing is that we do not shut the door on this.
    We continue to see what we can do with this. That is why we 
recommended our recommendations and testimony to be fiscally 
responsible, to make sure that it is not participants that are 
being gauged, and we are not a production of veterans going 
through the shop. We want quality care, the same kind of care 
that we get within the VA system and the wraparound services 
that were actually noted in the bill with regards to ensuring 
that they are going back to VA and being informed about how to 
utilize VA.
    We see promise in there, but we are waiting for the report 
and we hope to see the final report and become public for us to 
be able to make a determination.
    Ms. Dexter. I absolutely share the intentions and the 
suppositions of the bill. I just am concerned about only 4 
percent of output being really looked at for the outcomes. It 
is not a question, it is just I think that compelling data 
before we invest when we have so modest resources available to 
us is important.
    What do you think Congress can be doing better to bolster 
interventions to help prevent suicide, which is at a critical 
crisis point for our veterans right now?
    Mr. Retzer. Thank you for that question. I think like I 
said earlier, it is multifaceted. We have to look at every 
avenue directly within the VA healthcare system, making sure we 
have proper staffing. We have clinical psychologists, 
psychiatry shortages in staffing, but also to support them, we 
have to ensure that the VA staffing itself in general is on 
par.
    For example, if we go to the phone call for the crisis 
line, someone has to be manning that line. If we go to the 
phone to call the public contact office, someone has to be 
there. If we go into a VA medical center, the facility has to 
be cleaned where we have our people who are custodians that 
they are working. All the employees that support their VA, it 
is very important that we look at it.
    The other thing is we need more peer-to-peer. Our veterans 
who work within the VA system, they themselves know what the 
life is like and they have the experience to become peer-to-
peer counselors or peer-to-peer to be able to mentor through 
us.
    Ms. Dexter. I recognize that I am over time, so thank you 
for your tolerance, Madam Chair. I thank you for your 
testimony.
    Ms. Miller-Meeks. Thank you. The gentlewoman yields.
    The chair now recognizes herself. I was going to recognize 
Dr. Conaway, but he slipped out. Thank you very much.
    Ms. Morris, were there difficulties executing the 
construction of the VA clinic in Omaha, Nebraska, in 
coordination with the VA? If you could improve the CHIP IN 
authorities, what would you suggest if there, in fact, were 
difficulties?
    Ms. Morris. Really did not experience a lot of difficulties 
in construction. If you remember, probably the biggest 
challenge was the last 4 months. COVID hit March 2020, and we 
needed to finish up the project by the end of July in order to 
do the transfer in August. Our construction team and our design 
team worked diligently to be able to get that done on time, 
which is really kind of amazing that that was able to happen at 
that period.
    Ms. Miller-Meeks. Were there certain waivers or exemptions 
that you sought from the VA in order to get construction done 
under budget and under time?
    Ms. Morris. Well, certainly I referenced the construction 
manuals and the security manuals. Those were critical. We 
actually spent a 2-day time period in Omaha, Nebraska, where 
about 15, 20 VA employees came out. We went through those 
manuals with great precision and, at that point in time, we 
were able to have value engineering of about $23 million.
    Ms. Miller-Meeks. Thank you. Dr. Kozminski, many aging 
veterans and those suffering from diabetes-related 
complications sadly receive amputations due to chronic limb 
ischemia. Could HBOT therapies be potential preventive 
treatment for our veterans suffering from those conditions?
    Dr. Kozminski. Just to clarify, so preventative in the 
sense of preventing those infections or preventing----
    Ms. Miller-Meeks. Amputations.
    Dr. Kozminski. Yes. I do think that hyperbaric oxygen 
therapy has been a fairly well proven implementation for 
salvage therapy in those cases for sure.
    Ms. Miller-Meeks. Thank you so much for coming in. Go Hogs.
    Mr. Harries, I understand the difficulties your members are 
experiencing as a result of the VA's inability to reimburse for 
high-cost medications that the patient may have been on prior 
to coming to a facility. VA testified the status quo is okay. 
Do you agree?
    Mr. Harries. No, we do not. The costs of these drugs that 
are coming in are climbing rapidly. The other thing that is 
happening, with the exposure to toxic chemicals that our 
veterans are having, we are having more and more cancer 
diagnoses. Some of these high-cost drugs, or a good portion of 
them, are related to chemotherapy.
    Ms. Miller-Meeks. They, in fact, cover these drugs if the 
patient was at a different facility or at their home.
    Mr. Harries. Correct. You know, looking at it from a cost 
perspective, the average institutional per diem is $262 for 
State veterans home, whereas with the community homes, it is 
$424. If you looked at balancing that out, it may be a net 
neutral event.
    Ms. Miller-Meeks. Thank you. Mr. Dempsey, how could the 
SPORT Act assist post 9-11 veterans?
    Mr. Dempsey. Thank you for the question. The SPORT Act 
would, I think, do a tremendous job of reforming the way that 
amputee veterans engage with the VA prosthetic department. 
Currently, with the limitation that adaptive and support-
related prosthetics only be provided as part of a clinical 
program, expediting that process and getting these into a 
veteran's life is a great way to re-engage in the community, 
whether it just be participating in athletics, whether it be 
involved in community outings, golf, running, any number of 
activities I think a lot of people take for granted, but which 
could be greatly danced by better access to these prosthetics.
    Ms. Miller-Meeks. Does it seem to you that the VA's current 
status and parameters are geared toward elderly veterans who 
perhaps have amputations from medical conditions, such as 
diabetes, rather than to our younger, much more active post 9-
11 veterans?
    Mr. Dempsey. Well, thank you for the question. To be 
honest, I do not know that I could speak to that. I would say 
that most of the voices that come to our post 9-11 serving 
generation are those who were injured in the early 2000's for 
whom, you know, getting adaptive prosthetics became part of 
their post-injury life very early. They have become familiar 
with how to use them, how they want them, and so ensuring that 
the process works a bit more smoothly for them is the priority 
here.
    Ms. Miller-Meeks. Thank you. I yield my time.
    Thank you to all of you. Thank you to our witnesses and for 
all your thoughtful input.
    Ranking Member Brownley, I am going to ask if you have any 
closing remarks.
    Ms. Brownley. Thank you, Madam Chair. I just wanted to 
associate myself with Representatives Dexter and Morrison and 
their comments that they have made today. I will just repeat 
what I said in my opening remarks and that I find it a bit 
crazy that we are having a legislative hearing today rather 
than an oversight hearing while the Trump administration's 
careless executive orders, mass firings of VA employees, and 
reckless contract terminations are causing significant upheaval 
within the Veterans Health Administration. As I said earlier, 
none of these bills we are considering today will address the 
very real threat to VA healthcare, to VA access to healthcare, 
quality, and safety that our Nation's veterans are facing 
today.
    Veterans do not support these proposed cuts, nor do they 
support cutting 83,000 employees within the VA. If we continue 
to see efforts to dismantle the VA by firing hardworking 
employees, canceling vital research, terminating healthcare 
contracts, and eroding veterans' trust in VA, it will not 
matter what excellent legislation we put forth. There will not 
be employees or even an infrastructure left at VA to implement 
these bills and veterans care will suffer because of it. We can 
do better than that.
    I yield back.
    Ms. Miller-Meeks. Thank you very much.
    Perhaps it is because I am a physician and a 24-year 
military veteran, married to a 30-year military veteran, that I 
find it completely plausible that we as Members of Congress can 
actually make legislation, go through legislation, in addition 
to respond to things that are happening through other parts of 
the Federal Government as well.
    Let me also say that I just need to address some 
misinformation I have heard here today. Whether it is 
intentional or unintentional, there is a $6 billion increase to 
the Toxic Exposure Fund, not a decrease. Let me repeat that. 
The Toxic Exposure Fund in the Continuing Resolution that we 
may be voting on has a $6 billion increase.
    Let me also say that over the past 4 years the VA's budget 
has increased $240 billion--or has increased from $243 billion 
to $369 billion, an over $126 billion increase, while 
nationally the level of veterans seeking care is level. Is 
level. Of that, in the past 4 years an increase of 60,000 full-
time employees and 23,000 part-time employees.
    Given my time in the military, I remember as an Operating 
Room (OR) nurse, I will not say what facility I was in, it was 
1:30 in the afternoon. All of the staff, with the exception of 
three of us, and I can see Dr. Kozminski smiling because he 
knows what I am going to say, three of us were back putting 
together the instruments and putting up our instrument sets. 
Everybody else was in the break room. I would say to look at 
how we spend money in the Federal Government, so precisely what 
Ranking Member Brownley has said, so that we can continue to 
have the funds to deliver high-quality care to our veterans in 
a timely fashion, be it at the VA or in community care, is a 
priority for all of us. None of this dismantles or guts or 
defunds the VA or the Toxic Exposure Fund.
    I want to thank our witnesses who have been here today. I 
appreciate your coming and testifying. I want to thank our 
veterans, most importantly who give us the opportunity to be 
here and to vote this afternoon. On behalf of the subcommittee, 
I want to thank you all again, the witnesses, members who are 
here today. I am looking forward to working with you to address 
the issues facing our veterans.
    The complete written statement of today's witnesses will be 
entered into the hearing record. I ask unanimous consent that 
all members have 5 legislative days to revise and extend their 
remarks and include extraneous material. Hearing no objection, 
so ordered.
    This hearing is now adjourned.
    [Whereupon, at 4:20 p.m., the subcommittee was adjourned.]

    
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                         A  P  P  E  N  D  I  X

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                    Prepared Statements of Witnesses

                              ----------                              


                  Prepared Statement of Thomas O'Toole
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                   Prepared Statement of Jeffrey Gold
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                    Prepared Statement of Sue Morris

    Good afternoon, Chairwoman Miller-Meeks, Ranking Member Brownley, 
Members of the Health Subcommittee.
    My name is Sue Morris. I am the President of Veterans Trust, 
formerly known as Veterans Ambulatory Center Development Corporation, 
the nonprofit philanthropic entity that partnered with the Department 
of Veterans Affairs under the CHIP-IN Act to construct VA's ambulatory 
care center in Omaha, Nebraska, serving Western Iowa and Nebraska. I 
want to note first that our non-profit entity is led by Veterans. Our 
Chairman, John Henderson, is a retired Army Colonel and our Secretary, 
Mike Pallesen who is with me today, is a retired Navy Commander.
    Our nationally award-winning Ambulatory Care Center project was 
completed and donated to Veterans Affairs in July 2020 as the first 
public-private partnership to be completed under the CHIP-In Act. The 
project received several national awards for health care design and 
construction.
    I am here today to speak in favor of taking the pilot program 
authorized under the CHIP-In Act and making it permanent, as H.R. 217 
would do. Our project showed how VA, in partnership with the private 
sector, can deliver a truly superb facility, in a cost-effective and 
efficient manner.
    What allowed the Omaha project to be successful? First, the project 
was ``owned'' by Veterans Trust during the development and construction 
phases and donated to Veterans Affairs upon completion. While there was 
very close coordination and cooperation between Veterans Trust and VA 
officials at both the national and local levels, it was not a 
``government construction project''. This structure allowed Veterans 
Trust, whose leadership had a history of facilitating $1 billion on 
local projects, to use local vendors and suppliers in its procurement 
of services and materials, leveraging demonstrated relationships for 
best pricing. We were able to tell our partners in design and 
construction that they will make money on the project, but not a lot of 
money, as this is a community project for the Veterans.
    Second, was a strong commitment from Veterans Affairs senior 
leadership. We met regularly at VA's headquarters, including three 
meetings directly with the Secretary, to ensure project milestones were 
achieved. There was zero scope creep which helped the project to be 
delivered on-time and on-budget. One key factor in this regard was 
Veterans Affairs' willingness to review VA's normally applicable 
construction and physical security standards. We were able to come to 
agreement on which of those standards made sense, resulting in value 
engineered savings of over $23 million.
    In the end, we delivered a facility for a total of $86 million when 
it was originally budgeted at $135 million, saving the taxpayers $50 
million. The private philanthropic contribution to the project was $30 
million.
    Based upon our experience and success with this effort, we 
recommend that H.R. 217 go further than simply making CHIP-In permanent 
but to also consider other changes that will allow the public-private 
partnership structure to provide even greater opportunities to deliver 
best in class facilities to our Veterans while doing so in a way that 
saves taxpayer dollars. In particular, we suggest the following:

      Add the option to construct facilities on land leased to 
VA, not just owned or donated real property.

      Add the ability to use the program for minor 
construction, not just major projects.

      Make clear that the Act applies to more than just 
healthcare but also to construction projects providing other types of 
facilities to Veterans such as housing and community centers.

    In addition to amending the Act itself, we suggest that the 
Subcommittee and staff engage a small group of VA leadership and 
private sector representatives to recommend forward-looking best 
practices and new models for public--private partnerships. My team and 
Board would be pleased to be included in this effort.
    In summary, we wholeheartedly support the effort to make CHIP-In a 
permanent tool to deliver state-of-the-art facilities. The Act allows 
Veterans Affairs the ability to leverage the advantages of private 
sector construction processes to deliver significant cost-savings.
    Thank you again for the opportunity to express our support for H.R. 
217 and further expansion of the CHIP-In Act. We are tremendously proud 
of our role in helping lead in this nationally groundbreaking effort to 
deliver a world-class facility to our Veterans and cost-savings to 
taxpayers.
    I want to add one final point. As Dr. Gold mentioned, there is no 
doubt that a new in-patient facility to replace Omaha's ageing VA 
hospital is sorely needed. Veterans Trust stands ready to partner with 
Veterans Affairs and the University of Nebraska Medical Center to 
assist in designing and constructing a new state-of-the-art facility 
that will better serve the Veteran community in Nebraska and Western 
Iowa while taking advantage of the public-private partnership model 
offered by the CHIP-In Act.
    I am happy to answer any questions that you might have.

                                 

                  Prepared Statement of Brian Dempsey

    Chairwoman Miller-Meeks, Ranking Member Brownley, and distinguished 
members of the House Committee on Veterans' Affairs, Subcommittee on 
Health - thank you for the opportunity to submit Wounded Warrior 
Project's views on pending legislation.
    Wounded Warrior Project (WWP) was founded to connect, serve, and 
empower our Nation's wounded, ill, and injured veterans, Service 
members, and their families and caregivers. We are fulfilling this 
mission by providing life-changing programs and services to more than 
227,000 registered post-9/11 warriors and 56,000 of their family 
support members, continually engaging with those we serve, and 
capturing an informed assessment of the challenges this community 
faces. We are pleased to share that perspective for this hearing on 
pending legislation that would likely have a direct impact on many we 
serve.

Draft legislation: No Wrong Door for Veterans Act

    Launched in 2022, the Department of Veterans' Affairs (VA) Staff 
Sergeant Parker Gordon Fox Suicide Prevention Grant (``Fox Grant'') 
Program is a groundbreaking initiative that empowers community-based 
organizations to provide targeted mental health and crisis intervention 
services to veterans. The program was established through the Commander 
John Scott Hannon Veterans Mental Health Care Improvement Act (P.L. 
116-171 Sec.  201) and facilitated VA's financial support to more than 
80 organizations in Fiscal Year 2024 to provide or coordinate a range 
of suicide prevention programs for veterans and their families.\1\ In 
each year since its implementation, the program has been discussed as a 
key initiative for helping prevent suicide in VA's national suicide 
data report.
---------------------------------------------------------------------------
    \1\ Press Release, U.S. Dep't of Vet. Aff., VA Awards $52.5 Million 
in Veteran Suicide Prevention Grants, Announces Key Updates in the 
Fight to End Veteran Suicide (Sep. 2023), https://news.va.gov/press-
room/va-awards-veteran-suicide-prevention-grants/.
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    The No Wrong Door Act is one of several legislative initiatives to 
renew the Fox Grant pilot program (see S. 2793; S. 5210 (118th Cong.)). 
This specific effort reflects the most comprehensive legislative effort 
to extend the current Fox Grant pilot and includes provisions to make 
clear that prior grant recipients shall not receive preference from VA 
for future grants; to require prior grantees to include evidence of 
services delivered to a ``significant number'' of veterans in 
applications for future Fox grants; to require that VA brief 
``appropriate personnel'' of each VA medical center within 100 miles of 
a Fox grantee about the Fox grant program in an effort to improve 
coordination; to require Fox grantees to inform veterans receiving Fox 
grant services that they may receive emergent suicide care through VA; 
and to require Fox grantees to use a VA-selected screening protocol 
when using Fox grant funding to provide baseline mental health 
screening.
    The changes outlined above would be welcomed; however, WWP 
encourages the Subcommittee to consider amendments that would lead to 
bipartisan, bicameral support to extend the Fox Grant program with 
enough time to allow for grants to continue to be dispersed to 
community-based grantees at the start of the next fiscal year. We would 
also encourage adoption of language from S. 793 focused on measures and 
metrics.

Draft legislation: Providing Veterans Essential Medications Act

    State Veterans Homes (SVHs) - state-owned and--operated facilities 
that work in tandem with VA - play an important role in meeting the 
nursing home, domiciliary, and adult day health care needs of veterans 
across the country. While SVHs primarily serve an elderly population, 
the future long-term care needs of post-9/11 veterans can be mitigated 
by addressing critical priorities today. Part of that effort includes 
ensuring that veterans residing in SVHs receive the medical care they 
deserve, particularly access to life-saving and high-cost medications.
    Under current law, VA provides per diem payments to SVHs for each 
eligible veteran receiving nursing home, domiciliary, or adult day 
health care.\2\ For veterans with service-connected disabilities rated 
50 percent or greater, the law requires VA to cover the cost of all 
medications administered by SVHs. However, if the veteran has service-
connected disabilities rated 70 percent or greater, VA pays a higher 
``prevailing rate'' to the SVH, but does not pay for any medications, 
even high-cost drugs that can cost upwards of $20,000 a month. These 
medications would otherwise be covered by VA when a veteran is not 
being cared for at an SVH. For example, existing law permits private 
nursing homes to receive VA reimbursement for high-cost medications.
---------------------------------------------------------------------------
    \2\ JARED SUSSMAN, CONG. RSCH. SERV., IF11656, STATE VETERANS HOMES 
(2020).
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    The Providing Veterans Essential Medications Act seeks to amend 38 
U.S.C.Sec.  1745(a)(3) to direct VA to either reimburse SVHs for the 
cost of expensive medications or directly provide these medications to 
the facilities. As defined in this bill, medications would be 
considered ``costly'' if their average wholesale price for a 1-month 
supply, plus a 3 percent transaction fee, exceeds 8.5 percent of VA's 
monthly payment to the SVH for the care of the veteran receiving the 
medication.
    Wounded Warrior Project supports the Providing Veterans Essential 
Medications Act. By requiring VA to either reimburse or directly 
provide these essential medications, this legislation would help 
alleviate the financial strain on SVHs, ensuring they can continue to 
offer quality care without risk of budget constraints that limit 
veterans' access to necessary treatments.

Draft legislation: Veterans Supporting Prosthetics Opportunities and 
Recreational Therapy Act, or Veterans SPORT Act

    The highest priority for amputees requiring prosthetics should be 
improved quality of life. In addition to enabling veterans to live more 
independently and complete activities of daily living, adaptive 
prosthetic devices and equipment can have positive and life-changing 
impacts on a warrior's life through exercise and recreation. WWP has 
witnessed this when assisting warriors through our Adaptive Sports and 
Soldier Ride programs. Adaptive sports equipment empowers warriors to 
engage in modified athletic opportunities designed for their individual 
abilities, resulting in profound improvements to physical and mental 
health.
    VA's current definition of ``medical services'' includes 
``wheelchairs, artificial limbs, trusses, and similar appliances,'' \3\ 
but does not include adaptive prostheses or terminal devices. Although 
VA clinicians work with veterans to identify recreation activities and 
needed adaptive recreation equipment to support a veteran's 
rehabilitation goals, VA will not provide adaptive recreation equipment 
if the purpose of the equipment is to support the veteran's 
participation in an activity for personal enjoyment. Specifically, VA 
regulations only provide adaptive prosthetics and terminal devices for 
sports and other recreational activities for veterans if the device (1) 
is needed to promote, preserve or restore the health of the veteran; 
(2) serves as a direct and active component of the veteran's medical 
treatment and rehabilitation; and (3) does not solely support the 
comfort or convenience of the veteran.\4\ These regulations focus on 
the clinical need for adaptive prosthetics but disregard their 
potential to improve veterans' quality of life.
---------------------------------------------------------------------------
    \3\ 38 U.S.C. Sec.  1701(6)(F)(i).
    \4\ 38 C.F.R. Sec.  17.3230(a)(1).
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    If a veteran is interested in adaptive recreation equipment, VA 
regulations require that he or she must use it to support 
rehabilitation goals and, accordingly, must be enrolled in a VA 
rehabilitation program. The necessity to participate in such 
rehabilitation programs can be a deterrent for some veterans who may 
not be able to travel or devote the time required. These programs are 
also repetitive as they require that veterans be retrained to use 
replacement adaptive equipment for which veterans completed 
rehabilitation training in the past. For these reasons, some veterans 
may choose not to obtain or replace adaptive recreation equipment, 
hindering a veteran's ability to maintain an active and healthy 
lifestyle.
    Wounded Warrior Project supports the Veterans SPORT Act, which 
would amend 38 U.S.C. Sec.  1701 to add adaptive prostheses and 
terminal devices for sports and other recreational activities to VA's 
definition of ``medical services.'' The current population of post-9/11 
veterans is young, mobile, and energetic. WWP believes that VA should 
be building an ecosystem of care that is encouraging of such an active 
lifestyle. We recommend that VA authorize adaptive equipment for 
amputees without requiring that they be enrolled in a VA rehabilitative 
program for the profound benefits provided by sports and other 
recreational activities.

Draft legislation: To direct the Secretary of Veterans Affairs and the 
Comptroller General of the United States to report on certain funding 
shortfalls in the Department of Veterans Affairs

    In July 2024, VA notified Congress about a forecasted $2.8 billion 
shortfall that would prevent the agency from delivering VA benefits to 
veterans at the start of Fiscal Year 2025 (October 1, 2024). VA also 
reported a potential 2025 shortfall of approximately $12 billion for 
its health care system. Those estimates have since been adjusted, as 
the Veterans Benefits Administration (VBA) reported a $5.1 billion 
surplus from Fiscal Year 2024, and the Veterans Health Administration 
(VHA) more recently estimated its 2025 shortfall to be $6.6 billion.
    Wounded Warrior Project is grateful for Congress's action to take 
precautionary steps when it passed the Veterans Benefits Continuity and 
Accountability Supplemental Appropriations Act (P.L. 118-82) to avoid 
any potential harm to veterans through VBA funding challenges. As a new 
budget cycle begins, we appreciate congressional commitment to ensure 
that VHA can meet its solemn obligation to deliver high-quality, timey 
care to veterans throughout 2025 and beyond.

H.R. 217: CHIP IN for Veterans Act

    In 2016, the Communities Helping Invest through Property and 
Improvements Needed (CHIP IN) for Veterans Act of 2016 (P.L. 114-294) 
became law. It authorized VA to carry out a 5-year pilot program to 
improve and expand its medical facilities by allowing private donors, 
local governments, and other organizations to contribute funding or 
property for VA construction projects. The bill was designed to address 
VA's backlog of construction needs - without solely relying on Federal 
funding - by leveraging community involvement to improve veterans' 
healthcare facilities more efficiently.
    The VA Omaha Ambulatory Care Center was the first project completed 
under the CHIP IN Act for Veterans Act of 2016. The facility, which 
opened in 2020, was successfully built using $56 million in Federal 
funding and $30 million in private donations.\5\ In 2021, the CHIP IN 
pilot program was extended for an additional 5 years through the 
Department of Veterans Affairs Expiring Authorities Act of 2021 (P.L. 
117-42). As of today, many VA construction projects continue to face 
delays and budget challenges. VA's Fiscal Year 2024 Budget in Brief 
estimates that between $106 billion and $129 billion will be needed 
over the next 10 years to maintain and enhance VA infrastructure.
---------------------------------------------------------------------------
    \5\ Marc Thomas, U.S. Dep't of Vet. Aff., Redefining Healthcare 
Spaces: The ACC Wins the AIA National Design Award (Nov. 29, 2023), 
https://www.va.gov/nebraska-western-iowa-health-care/stories/
redefining-healthcare-spaces-the-acc-wins-the-aia-national-design-
award/.
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    The CHIP IN for Veterans Act would permanently authorize the 
program, allowing VA to accept private donations to help fund new 
construction and facility improvements. It would also remove the limit 
on the number of donations that VA may accept under the program. The 
CHIP IN for Veterans Act would expand the ability of local communities 
and organizations to invest in and directly support VA medical center 
projects to accelerate the development of VA infrastructure, make these 
projects more affordable, and increase transparency.
    Wounded Warrior Project supports the CHIP IN for Veterans Act.

H.R. 1107: Protecting Veteran Access to Telemedicine Services Act of 
2025

    In 2008, the Ryan Haight Online Pharmacy Consumer Protection Act 
(P.L. 110-425) became law and required patients to complete at least 
one in-person visit with a health care provider before that provider 
could prescribe them a controlled substance. In consideration of the 
COVID-19 public health emergency, this requirement was temporarily 
suspended in March 2020. In November 2024, both the Drug Enforcement 
Agency (DEA) as well as the Department of Health and Human Services 
(HHS) agreed to continue this temporary suspension until December 31, 
2025.\6\ The Protecting Veteran Access to Telemedicine Services Act of 
2025 would make this exemption permanent for veterans and VA providers 
by authorizing the delivery, distribution, and dispensing of controlled 
substances to veterans from VA providers without requiring an in-person 
appointment.
---------------------------------------------------------------------------
    \6\ Third Temporary Extension of COVID-19 Telemedicine 
Flexibilities for Prescription of Controlled Medications, 89 Fed. Reg. 
91,253 (Nov. 19, 2024) (codified at 21 C.F.R. pt. 1307).
---------------------------------------------------------------------------
    If the current COVID-era extension expires, rural veterans who do 
not live near VA or community health care facilities - and who rely 
primarily on telehealth services - would likely be negatively impacted. 
Appointment coordination challenges and travel logistics may lead to 
interruptions in their care or lapses in prescriptions. The list of 
controlled substances contains not only pain medications, but also 
multiple mental health drugs that are important parts of treatment 
plans for many veterans dealing with mental health issues and for whom 
an in-person appointment may present additional challenges.
    Many veterans who began treatment plans that included controlled 
substance prescriptions during the period of this exemption may not be 
aware of, or prepared for, the potential interruptions of their care 
plan. For instance, the PACT Act (P.L. 117-168), the most comprehensive 
authorization of VA benefits in recent history, became law in August 
2022 while this exemption was in place. More than 1.5 million PACT Act-
related claims have since been granted by VA,\7\ meaning that none of 
those veterans have been subject to pre-exemption requirements. This 
dramatically increases the number of veterans who could have their 
current treatment plan impacted by the expiration of this exemption.
---------------------------------------------------------------------------
    \7\ U.S. DEP'T OF VET. AFF., PACT ACT PERFORMANCE DASHBOARD (Feb. 
21, 2025), https://department.va.gov/pactdata/interactive-dashboard/.
---------------------------------------------------------------------------
    Wounded Warrior Project supports this bill in its current form; 
however, we recognize that laws surrounding in-person visits may be 
brought back to scale as we move further away from the COVID-19 public 
health emergency. In such a case, we would also support a modified 
version of this legislation that would authorize the renewal of 
controlled substance prescriptions written for veterans when the 
exemption was in place - and who are still seeing the same provider who 
issued the prescription - to help prevent unexpected disruptions of 
veteran treatment plans.

H.R. 1336: Veterans National Traumatic Brain Injury Treatment Act

    The prevalence of PTSD and TBI among post-9/11 veterans remains 
alarmingly high. WWP's 2025 Warrior Survey \8\ revealed that more than 
3 in 4 responding warriors (76.5 percent) self-reported having PTSD and 
approximately half (52.3 percent) of those respondents screened 
positive for PTSD symptoms using the PCL-5 test.\9\ Another 35.2 
percent self-reported a TBI incurred during military service. As we 
continue to learn more about these invisible wounds and their 
prognosis, investments in research and treatment now and into the 
future must embrace innovation - and VA has an important role in 
leading those efforts.
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    \8\ To review WWP's Warrior Survey in more detail, please visit 
https://www.woundedwarriorproject.org/mission/warrior-survey.
    \9\ The PCL-5 is a validated tool used by VA that assesses symptoms 
over the past month.
---------------------------------------------------------------------------
    Hyperbaric oxygen therapy treatments involve a patient entering a 
special chamber where they breathe pure oxygen in air pressure levels 
1.5 to 3 times higher than average. This helps fill the blood with 
enough oxygen to repair brain tissue and restore normal body function. 
Currently this treatment is approved by the Food and Drug 
Administration (FDA) for treatment of inflammation in the body, and 
some doctors believe that both TBI and PTSD are the result of brain 
inflammation due to trauma. While some research recommends caution when 
administering HBOT treatment to individuals with PTSD, results are 
generally encouraging. \10\
---------------------------------------------------------------------------
    \10\ Keren Doenyas-Barak et al., The Use of Hyperbaric Oxygen for 
Veterans with PTSD: Basic Physiology and Current Available Clinical 
Data, FRONT NEUROSCI.(Oct. 2023), available at https://
www.frontiersin.org/journals/neuroscience/articles/10.3389/
fnins.2023.1259473/full.
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    The Veterans National Traumatic Brain Injury Treatment Act would 
establish a 5-year pilot program at VA to supply hyperbaric oxygen 
therapy (HBOT) to veterans with traumatic brain injuries (TBI) or post-
traumatic stress disorder (PTSD). The pilot program would be funded 
through a general fund of the Treasury, known as the ``VA HBOT Fund'' 
that is supplied solely by donations received for express purposes of 
the Fund. The effort would be implemented in three Veteran Integrated 
Service Networks (VISNs).
    Given these early signs of promise and frequent requests heard from 
warriors for access to HBOT, WWP supports the Veterans National 
Traumatic Brain Injury Treatment Act. If expanded to include reporting 
requirements on clinical outcomes and impact on health care access, we 
believe that this pilot has potential to contribute to the growing body 
of research and longitudinal studies on innovative treatments for TBI 
and PTSD.

Draft legislation: Saving Our Veterans Lives Act

    Gun lockers, also known as firearm storage safes or cabinets, can 
play a significant role in reducing the risk of suicide by limiting 
access to firearms, particularly in moments of crisis. Increasing space 
and time between an individual and lethal means can create 
opportunities for interventions by another or through personally driven 
changes in thought. Many empirical studies have demonstrated that 
creating time and space between an individual and lethal means is 
effective in preventing suicide, and although some individuals might 
seek other methods, many do not.\11\ In such cases, the means chosen 
are often less lethal and are associated with fewer deaths than when 
more dangerous ones are available. In a veterans context, research like 
this helped drive the PREVENTS Task Force to recommend ``increase[d] 
implementation of programs focused on lethal means safety (e.g., 
voluntary reduction of access to lethal means by individuals in crisis, 
free/inexpensive and easy/safe storage options).'' \12\
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    \11\ See, e.g., Paul Yip et al., Means Restriction for Suicide 
Prevention, 379(9834) THE LANCET 2,393-99 (June 2012), available at 
https://www.thelancet.com/journals/lancet/article/PIIS0140-
6736(12)60521-2/abstract.
    \12\ PREVENTS TASK FORCE, PREVENTS: THE PRESIDENT'S ROADMAP TO 
EMPOWER VETERANS AND END A NATIONAL TRAGEDY OF VETERAN SUICIDE (June 
2020), available at https://www.va.gov/PREVENTS/docs/PRE-007-The-
PREVENTS-Roadmap-1-2_508.pdf.
---------------------------------------------------------------------------
    The Saving Our Veterans Lives Act would create a new program to 
provide veterans with lock boxes intended for the secure storage of a 
firearm. It would authorize $5 million per year over a 10-year period 
for VA to carry out this program while also requiring an annual report 
that addresses topics including compliance with the new statute, 
outreach to veterans, obstacles with implementation, and how many lock 
boxes were distributed. The bill makes clear that VA would not be 
permitted to collect personally identifiable information on veterans 
who request a lockbox under the program, require mandatory storage, 
require firearm registration, or prohibit participating veterans from 
purchasing, owning, or possessing a firearm.
    This effort would build upon existing efforts at VA to distribute 
free firearm cable locks to any veteran who requests one, as well as 
more limited availability of gun lockers. As our Nation continues to 
explore new investments and opportunities to end veteran suicide, WWP 
supports the Saving Our Veterans Lives Act.

Draft legislation: Women Veterans Cancer Care Coordination Act

    Breast cancer ranks as the second most common cancer among women in 
the U.S., and within VA, it is the most diagnosed cancer for women.\13\ 
The trend may continue as the recently passed Dr. Kate Hendricks Thomas 
SERVICE Act (P.L. 117-133) allows veterans who served in certain combat 
locations and periods to receive services to check their risk of breast 
cancer and get a screening mammogram if needed. And as the number of 
women veterans continues to increase \14\, VA will likely see a rise in 
the number of female veterans needing cancer care in the coming years.
---------------------------------------------------------------------------
    \13\  How Common is Breast Cancer?, AM. CANCER SOC'Y, https://
www.cancer.org/cancer/types/breast-cancer/about/how-common-is-breast-
cancer.html (last visited Mar. 7, 2025).
    \14\ Katherine Schaeffer, The Changing Face of America's Veteran 
Population, PEW RESEARCH CTR. (Nov. 8, 2023), https://
www.pewresearch.org/short-reads/2023/11/08/the-changing-face-of-
americas-veteran-population/.
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    In its most recent annual budget submission to Congress \15\, VA 
stated that its ``policy requires that facilities have personnel 
assigned to breast and cervical cancer care coordination. To ensure 
accuracy, timeliness and reliability, VA tracks the provision of breast 
and cervical cancer screening and the availability of breast and 
cervical cancer care coordinators across the system.'' The submission 
further elaborated that ``[t]he Breast and Gynecologic Cancer System of 
Excellence is providing state-of-the-art breast and gynecologic cancer 
care and care coordination across the system through VA's tele-oncology 
program.''
---------------------------------------------------------------------------
    \15\ U.S. DEP'T OF VET. AFF., Fiscal Year 2025 BUDGET SUBMISSION - 
MEDICAL PROGRAMS, VOL. 2 OF 5 at VHA-23.
---------------------------------------------------------------------------
    The Women Veterans Cancer Care Coordination Act would build upon 
this foundation by requiring VA to appoint a Regional Breast Cancer and 
Gynecologic Cancer Care Coordinator in each Veterans Integrated 
Services Network (VISN). These coordinators will report directly to the 
Director of the Breast and Gynecologic Oncology System of Excellence. 
The bill sets eligibility standards for patients to receive care 
coordination through a Regional Coordinator and sets several 
responsibilities for those coordinators including ensuring seamless 
care coordination between VA clinicians and community care providers 
specializing in breast and gynecologic cancers and maintaining regular 
contact with veterans based on individual medical needs during 
community care treatments. Notably, the bill would also require VA to 
submit a report to Congress comparing health outcomes between veterans 
receiving cancer care at VA facilities and those treated by non-VA 
providers, evaluating necessary changes or resources to improve cancer 
care coordination, and addressing any other relevant matters.
    Wounded Warrior Project is pleased to support the Women Veterans 
Cancer Care Coordination Act; however, we look forward to increased 
dialog among stakeholders to ensure that existing efforts at VA are 
enhanced and not duplicated.

Agenda items not addressed in this Statement for the Record

      Draft legislation: Standardizing Treatment and Referral 
Times Act

      Draft legislation: Copay Fairness for Veterans Act

      H.R. 658: To amend title 38, United States Code, to 
establish qualifications for the appointment of a person as a marriage 
and family therapist, qualified to provide clinical supervision, in the 
Veterans Health Administration

Concluding Remarks

    Wounded Warrior Project once again extends our thanks to the 
Subcommittee on Health for its continued dedication to our Nation's 
veterans. Our commitment to keeping the promise by rebuilding the lives 
of warriors impacted by war and military service remains as strong as 
ever, and we are honored to contribute our voice to your discussion 
about pending legislation. As your partner in advocating for these and 
other critical issues, we stand ready to assist and look forward to our 
continued collaboration.

                 Prepared Statement of Andrew Kozminski
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                    Prepared Statement of Ed Harries
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                    Prepared Statement of Jon Retzer

    Chairwoman Miller-Meeks, Ranking Member Brownley and Members of the 
Subcommittee:

    Thank you for inviting DAV (Disabled American Veterans) to testify 
at today's legislative hearing of the Subcommittee on Health. DAV is a 
congressionally chartered non-profit veterans service organization 
composed of nearly one million wartime service-disabled veterans. Our 
single purpose is to empower veterans to lead high-quality lives with 
respect and dignity.
    It is crucial to provide timely, coordinated, and comprehensive 
health care tailored to meet the diverse needs of veterans. DAV is 
pleased to offer our views on the bills under consideration today by 
the Subcommittee. These bills address the necessity for timely access 
to medical services, infrastructure improvements, the removal of 
financial barriers, better understanding of health outcomes, the 
incorporation of adaptive sports prosthetics, hyperbaric oxygen 
therapy, secure firearm storage programs and effective care 
coordination.

     H.R. 217, the Communities Helping Invest through Property and 
            Improvements Needed or CHIP IN for Veterans Act

    The CHIP IN for Veterans Act includes provisions that would make 
permanent a pilot program that authorized the Department of Veterans 
Affairs (VA) to accept donated facilities or donations to make facility 
infrastructure improvements. This legislation would eliminate the cap 
on the number of projects allowed in the pilot program and enhance the 
quality and availability of veteran services without additional Federal 
costs. For example, in Omaha, Nebraska, there was a project/donation 
for construction of an ambulatory care center and in Tulsa, Oklahoma a 
project/donation to construct an inpatient facility and parking garage 
to support the Muskogee Veterans Affairs Medical Center (VAMC). In 
2021, VA received $120 million for a capital contribution to execute 
the Muskogee plan. These collaborations lead to improved access to care 
and services for veterans, while fostering community support and 
involvement.
    We support the CHIP IN for Veterans Act in accordance with DAV 
Resolution No. 193, urging necessary infrastructure funding and 
exploring new funding models.

 H.R. 658, to establish qualifications for the appointment of a person 
   as a marriage and family therapist, qualified to provide clinical 
           supervision, in the Veterans Health Administration

    H.R. 658 seeks to establish qualifications for marriage and family 
therapists (MFTs) providing clinical supervision within the Veterans 
Health Administration (VHA). The bill aims to enhance mental health 
services for veterans and maintain consistent care across VHA 
facilities by ensuring that MFTs are highly qualified and recognized by 
reputable organizations like the American Association for Marriage and 
Family Therapy.
    Veterans face numerous mental health challenges, including post-
traumatic stress disorder (PTSD), depression, anxiety, substance use 
disorders, and traumatic brain injuries (TBI). Qualified MFTs can 
significantly improve mental health outcomes by providing effective 
supervision and promoting better therapeutic practices, potentially 
reducing the incidence of suicide among veterans. Including family and 
relationships in mental health treatment is crucial for the holistic 
well-being of veterans. Many veterans have found that involving their 
loved ones in therapy sessions helps create a better support system, 
and fosters improved understanding and communication. This approach can 
lead to more effective treatment, as the support from family members 
can reinforce coping strategies and provide a sense of belonging and 
stability.
    We support this bill in accordance with DAV Resolution No. 224, 
which calls for program improvements, sufficient staffing, and enhanced 
resources for VA mental health services.

 H.R. 1107, the Protecting Veteran Access to Telemedicine Services Act 
                                of 2025

    The Protecting Veteran Access to Telemedicine Services Act is a 
crucial step toward ensuring that veterans receive the high-quality, 
accessible health care they earned. Many veterans face challenges in 
accessing timely and consistent medical care, particularly in rural and 
underserved areas. This legislation addresses these challenges by 
leveraging the power of telemedicine to provide controlled medications 
to veterans without the need for in-person medical visits.
    Telemedicine bridges the gap for veterans living in remote 
locations, allowing them to receive necessary medications and 
consultations from home. This convenience is particularly beneficial 
for those with mobility issues or limited transportation options. 
Additionally, the flexibility of telemedicine allows veterans to 
schedule appointments that fit their busy lives, leading to better 
adherence to treatment plans and improved health outcomes. The bill 
would ensure that health care providers can maintain regular contact 
with patients, providing continuous care and preventing interruptions 
in treatment, which is vital for managing chronic conditions. 
Telemedicine is also a game-changer for mental health services, helping 
to reduce the stigma and barriers often associated with seeking help by 
providing therapy and support remotely. Finally, the bill includes 
robust guidelines and processes to ensure that the delivery and 
dispensing of controlled substances via telemedicine is safe and legal, 
maintains integrity of the health care system and patient safety while 
expanding access to care for veteran patients.
    We support this bill in accordance with DAV Resolution No. 342, 
which urges the VA to enhance its national pain management program 
using patient-centered, interdisciplinary, and holistic approaches, 
ensuring timely medication delivery and humane alternatives to 
controlled substances. It also encourages the VA to regularly update 
its clinical guidance and policies to comply with Federal law and best 
practices for prescribing and dispensing controlled substances. By 
harnessing the power of telemedicine, we can provide veterans with the 
accessible, efficient, and high-quality care they deserve.

 H.R. 1336, the Veterans National Traumatic Brain Injury Treatment Act

    The Veterans National Traumatic Brain Injury Treatment Act would 
require the VA to establish a pilot program to provide hyperbaric 
oxygen therapy (HBOT) to veterans suffering from TBI or PTSD.
    Veterans with TBI and PTSD face significant challenges, and 
traditional treatments have proven ineffective for some. Studies have 
shown that HBOT, which involves breathing pure oxygen in a pressurized 
chamber, can enhance the body's natural healing processes. This 
therapy, traditionally used for treating severe wounds that won't heal, 
has been found to promote the growth of new blood vessels, reduce 
inflammation, and improve oxygen delivery to injured tissues. One small 
clinical trial, published in the Journal of Clinical Psychiatry (JCP) 
in 2024, has also demonstrated improvements in PTSD symptoms and brain 
function among veterans undergoing HBOT.
    However, despite these promising findings, more comprehensive 
research is necessary to fully understand the efficacy and safety of 
HBOT for patients with TBI and PTSD. According to the VA, the 
scientific evidence is currently mixed, and rigorous, larger-scale 
studies are recommended to validate the initial positive outcomes noted 
in the 2024 JCP study and to address any potential risks. A 2018 report 
by the VA's Evidence Synthesis Program found that large treatment 
benefits demonstrated in uncontrolled case series have not been easily 
replicated in well-controlled randomized controlled trials (RCTs). The 
report suggests that the potential benefits of HBOT may be subtle and 
require larger RCTs to demonstrate significant effects.
    Currently, the VA offers HBOT as a treatment option for a small 
number of veterans with persistent PTSD symptoms that are resistant to 
standard treatments. This treatment is provided through partnerships 
with HBOT providers at select VA health care systems and medical 
centers. The VA is also conducting a multisite research study to 
examine the use of HBOT for patients diagnosed with PTSD.
    While HBOT shows promise, we must remain committed to a 
comprehensive and evidence-based approach. By supporting further 
research and careful evaluation, we can better ensure that our veterans 
receive the best possible and most effective care for TBI and PTSD. We 
therefore recommend the Subcommittee include provisions in this bill to 
prioritize rigorous research alongside providing veterans access to 
HBOT. It is important to thoroughly validate and understand the 
efficacy and risks of this therapy as an alternative treatment option 
for PTSD and TBI before it is more broadly implemented.

             H.R. 1644, the Copay Fairness for Veterans Act

    The Copay Fairness for Veterans Act aims to eliminate copayments 
for medications and preventive health services provided by the VA. It 
would enhance access to these services by removing financial barriers 
that can discourage veterans from seeking essential care. Preventive 
services are critical for early detection and management of certain 
health issues, leading to improved health outcomes. The bill also 
includes provisions for women veterans to ensure they receive 
preventative care services, screenings and contraceptives as outlined 
in the Health Resources and Services Administration Preventative 
Services Guidelines.
    By removing financial barriers, the bill encourages routine check-
ups, vaccinations and critical screenings, leading to better overall 
health management and fewer emergency medical situations. Many 
veterans, especially those on fixed incomes, struggle with copayments 
for health services and medication. By removing required copayments, 
the bill provides much-needed financial relief, ensuring that veterans 
can access the care they need without worrying about additional costs. 
Moreover, promoting preventive care can lead to long-term cost savings 
for both veterans and the health care system by reducing the need for 
more expensive treatments and hospitalizations. Preventive services 
with an ``A'' or ``B'' rating from the United States Preventive 
Services Task Force and immunizations recommended by the Advisory 
Committee on Immunization Practices are essential components of this 
approach.
    We support this bill in accordance with DAV Resolution No. 246, 
which calls for legislation to eliminate or reduce VA and DOD health 
care out-of-pocket costs for service-connected disabled veterans to 
improve health care access, provide financial relief, enhance health 
equity and encourage routine care. This bill reflects our Nation's 
commitment to supporting our veterans and ensuring they receive the 
care they earned.

 H.R. 1823, to direct the VA Secretary and the Comptroller General of 
  the United States to report on certain funding shortfalls in the VA

    This bill seeks to address funding shortfalls in the VA by 
directing the VA Secretary and the Comptroller General of the United 
States to conduct thorough reviews and report on funding shortfalls.
    The bill specifically mandates a review by the Comptroller General 
to investigate the circumstances and causes of funding shortfalls in 
the Veterans Benefits Administration (VBA) for Fiscal Year 2024 and the 
VHA for Fiscal Year 2025. The review must include a comparison of 
monthly obligations and expenditures against the spending plan, an 
analysis of any transfers between accounts, an evaluation of reasons 
for significant diversions from the spending plan, an assessment of the 
accuracy of projections and estimates, and recommendations for remedial 
actions to improve accuracy and prevent future shortfalls. The 
Comptroller General would be required to submit a report to the VA 
Secretary, who will then submit the report to the specified 
congressional committees.
    By identifying and addressing funding shortfalls, the bill aims to 
improve the financial management of the VBA and VHA and establish more 
efficient use of resources and better allocation of funds to critical 
services. The goal of the bill is to improve financial management, 
enhance accountability, establish preventive measures, and ensure more 
timely reporting of projected budget shortfalls. The bill also requires 
thorough reviews and reports aimed at increasing accountability within 
the VA and promoting more transparent and responsible budget management 
practices. The identification of remedial actions may help prevent 
future funding shortfalls, ensuring uninterrupted services for 
veterans.
    We support this bill in accordance with DAV Resolutions Nos. 23 and 
403, advocating for consistent VA funding, full implementation of 
existing laws, and protection of veterans' services and health care 
from budget caps.

       H.R. 1860, the Women Veterans Cancer Care Coordination Act

    The Women Veterans Cancer Care Coordination Act seeks to 
revolutionize cancer care for women veterans by establishing a 
comprehensive support system. The bill mandates the designation of 
Regional Breast and Gynecologic Cancer Care Coordinators within each 
Veteran Integrated Services Network (VISN). These coordinators would be 
tasked with ensuring seamless communication and coordination between VA 
clinicians and community cancer care providers.
    Eligibility for care coordination would be extended to veterans 
diagnosed with breast or gynecologic cancer or those identified with 
precancerous conditions, provided they qualify for health care through 
the Veterans Community Care Program (VCCP). Additionally, the bill 
would require the establishment of regions for care coordination, to 
determine the specific needs of veterans in different areas, including 
rural communities. This regional approach aims to provide tailored 
support, ensuring that veterans receive timely and appropriate care 
regardless of their location.
    The prescribed duties of the Regional Breast and Gynecologic Cancer 
Care Coordinators are multifaceted. They would facilitate the 
coordination of care between VA clinicians and community care 
providers, ensuring that veterans receive consistent and comprehensive 
treatment. They would be responsible for monitoring the services 
provided, tracking health outcomes, and maintaining data on cancer 
care. This data--driven approach will help identify trends, measure 
effectiveness, and guide future improvements in care delivery.
    A significant component of the bill is the requirement for the VA 
Secretary to submit a detailed report to Congress within 3 years of 
enactment. This report would compare health outcomes between veterans 
treated at VA facilities and those treated by community providers. It 
would assess the timeliness, safety, and quality of care, and identify 
any necessary changes or additional resources needed to enhance cancer 
care for women veterans. By establishing dedicated coordinators, 
focusing on data-driven care, and providing essential information and 
support, the bill strives to improve health outcomes and quality of 
life for these veterans and to ensure they receive coordinated, 
comprehensive, and compassionate care.
    The bill would also help to ensure that male veterans who suffer 
from breast cancer due to toxic exposures receive the same specialized 
care as their female counterparts. The Honoring our PACT Act, signed 
into law in August 2022 (P.L. 117-168), expands and extends eligibility 
for VA health care for veterans with toxic exposures. This includes 
male veterans who have been diagnosed with breast cancer.
    The VA has recognized the need to address the health effects of 
toxic exposures and has included male breast cancer in the list of 
conditions presumed to be caused by military service. Male veterans who 
have been exposed to toxic substances during their service and have 
developed breast cancer are eligible for the same benefits and 
specialized care as female veterans.
    We support this bill in accordance with DAV Resolution 39, which 
calls for ensuring that the VA provides health care services and 
specialized programs, including gender-specific services, to eligible 
women veterans at the same degree and extent as services provided to 
male veterans. It also emphasizes improving women's health programs and 
finding innovative methods to address care barriers, ensuring women 
veterans receive quality treatment and specialized services.

         Draft Bill, the Saving Our Veterans Lives Act of 2025

    The Saving Our Veterans Lives Act of 2025 aims to prevent veteran 
suicide by providing eligible veterans with secure firearm storage 
items upon request. The alarming rate of veteran suicide is a stark 
reminder of the urgent need for comprehensive measures to protect those 
who have sacrificed so much for our country. According to the VA 2024 
National Veteran Suicide Prevention Annual Report, there were 6,407 
suicides among veterans in 2022, with firearms being involved in 72 
percent of these cases. Firearms are the primary method of suicide 
among veterans, and by providing secure storage options for firearms--
such as a lockbox or safe, this Act aims to reduce access to lethal 
means during moments of crisis, potentially saving countless lives.
    Creating time and space is a critical component of this Act's 
strategy to reduce veteran suicides. Providing veterans with secure 
firearm storage can create a critical time delay, allowing them to 
reconsider their actions and seek help during moments of crisis. This 
additional time can be a lifesaving interval, as it provides a window 
of opportunity for the veteran to reach out for support, contact the 
crisis hotline, or have a moment of reflection. The VA's 2024 suicide 
prevention report highlighted a reduction in suicide rates among 
veterans with VHA mental health diagnoses, underscoring the 
effectiveness of targeted suicide prevention efforts. By delaying 
access to firearms during a crisis period, the Act empowers veterans to 
make safer choices and access the help they need.
    The Act includes an educational component that would help inform 
veterans about the benefits of secure firearm lock box storage with a 
goal of more responsible firearm handling and storage practices. The 
development of informational videos would help ensure that veterans 
receive the necessary guidance on secure storage as a suicide 
prevention strategy. Proper firearm storage not only protects veterans 
but also their families, reducing the risk of accidental discharges and 
unauthorized access by children or other household members. This 
program aims to promote a culture of safety within the veteran's 
community, fostering a secure environment for all.
    We support this bill in accordance with DAV Resolution No. 224, 
which calls for mental health and suicide prevention program 
improvements to include suicide rate data collection and reporting, 
improved outreach for stigma reduction, sufficient mental health 
staffing, and enhanced resources for VA mental health programs.

             Draft Bill, the No Wrong Door for Veterans Act

    The No Wrong Door for Veterans Act would reauthorize and extend the 
Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program 
through September 30, 2028, ensuring that community-based suicide 
prevention initiatives and mental health services will continue to be 
available to veterans.
    By adjusting the grant amount and clarifying the criteria for 
eligible entities, the bill promotes equitable distribution of funds 
and aims to ensure that qualified organizations can provide high-
quality mental health services to veterans. Moreover, the bill's 
emphasis on improved coordination and communication between grantees 
and VA medical centers is a significant enhancement. Quarterly 
briefings for local VA medical center personnel will help facilitate 
better collaboration and information sharing, hopefully leading to more 
efficient and effective delivery of mental health services. This 
improved coordination is crucial for creating a seamless support 
network for veterans in crisis.
    Another critical provision in the legislation is the bill's 
requirement that grantees notify eligible individuals about emergent 
suicide care options and report requests for such care to the VA. 
Increased awareness and utilization of suicide prevention resources can 
lead to more timely intervention and potentially save lives. By 
requiring the use of screening protocols selected by the Secretary, the 
bill also ensures that veterans receive consistent and standardized 
care, further enhancing the quality of mental health services.
    While the intent of extending the Fox Suicide Prevention Grant 
Program is commendable, DAV recommends strengthening the proposed 
legislation to ensure it meets its primary objective--reducing risk of 
suicide in this population. We recommend the bill reiterate the 
standard of baseline mental health screening that all grantees must 
provide or coordinate the provision of a baseline mental health 
screening to all eligible individuals they serve at the time those 
services begin. This mental health screening must be provided using a 
validated screening tool that assesses suicide risk and mental and 
behavioral health conditions. Applicants or partner organizations must 
measure the effectiveness of suicide prevention services provided to 
eligible individuals and their families using pre-and post-evaluations 
that employ validated measures of suicide risk and mood-related 
symptoms.
    Additionally, funding criteria in the bill is associated with the 
number of participants served rather than prioritizing demonstrated 
improvements in veterans' well-being (i.e., reduction in suicide risk 
factors). We want to ensure that resources are directed to programs 
that achieve measurable outcomes. Finally, we suggest the payment 
structure be more clearly defined to prevent overcompensation for 
minimal services.
    Given that the funding renewal for this initiative was supposed to 
be based on demonstrated improvements in veterans evaluation measures, 
we recommend a cautious, annual renewal process until comprehensive 
data confirms the program's overall efficacy and specifically, which 
services are most effective in reducing suicide risk in the veteran 
population. These changes are essential to maximize the program's 
potential and truly support at-risk veterans.

      Draft Bill, the Providing Veterans Essential Medications Act

    The Providing Veterans Essential Medications Act would amend title 
38, United States Code, to ensure that veterans receiving nursing home 
care in State homes have access to necessary, yet costly, medications.
    Under this bill, the VA Secretary is directed to either reimburse 
State homes for these high-cost medications or furnish them directly, 
at the election of the State home. The bill defines ``costly 
medication'' as any drug or medicine whose average wholesale price for 
a 1-month supply, plus a transaction fee, exceeds 8.5 percent of the 
payment made by the Secretary for the veteran's care. This amendment 
seeks to alleviate the financial burden on State homes and ensure that 
veterans continue to receive appropriate and comprehensive care without 
the added stress of high medication costs.
    The cost of high-cost medications, such as revolutionary cancer 
drugs, can often exceed $1,000 a day. This bill will ensure that State 
homes are not financially strained by these costs. VA providing these 
types of medications also incentivizes more State homes to provide care 
for severely disabled veterans and increases the availability of high-
quality long-term care services across the country. The PACT Act has 
led to an increase in veterans adjudicated as severely disabled due to 
toxic exposure. This rise will more likely than not necessitate State 
Veterans Homes to provide high-cost medications to more veterans. As 
the number of veterans requiring specialized and expensive medications 
grows, State Veterans Homes will face increased financial strain. It is 
essential to ensure that these homes receive adequate funding and 
support to meet the rising demand for care. This bill will help address 
the growing demand for high-cost medications in State homes and ensure 
that all veterans receive the health care they earned.
    We support this bill in accordance with DAV Resolution No. 227, 
which calls on Congress and the VA to provide sufficient funding to 
support State Veterans Homes, including adequate per diem payments for 
skilled nursing care, domiciliary care and adult day health care, which 
properly support different levels of care within each program.

  Draft Bill, to establish the period during which the referral of a 
 veteran, made by a health care provider of the Department of Veterans 
Affairs, to a non-Department provider, for care under the VA Community 
                      Care Program, remains valid.

    This bill seeks to streamline the referral process for community 
services, reduce administrative barriers, and improve access to care. 
The bill's primary objective is to establish the period during which a 
referral of a veteran, made by a health care provider of the VA, to a 
non-Department provider remains valid under the VCCP. The bill 
specifies that this period begins on the day the covered veteran has 
their first appointment with the non-Department provider. This 
provision would ensure veterans referred to non-Department providers 
have a clear referral validity period, facilitating smoother 
transitions.
    We support this bill in accordance to DAV Resolution No. 18, which 
supports legislation that establishes clearly defined VA health care 
services for enrolled veterans.

   Draft Bill, the Veterans Supporting Prosthetics Opportunities and 
                   Recreational Therapy or SPORT Act

    The DAV has long recognized the importance of adaptive sports in 
the rehabilitation and well-being of veterans through our involvement 
with events like the National Disabled Veterans Winter Sports Clinic, 
and the National Disabled Veterans Golf Clinic. These recreational 
therapy programs help veterans improve their physical and mental health 
through sports and activities tailored to their abilities, while 
connecting them with other veterans and a community to help overcome 
limitations and challenge their perceived disabilities.
    The Veterans SPORT Act seeks to include adaptive prostheses and 
terminal devices, for participation in sports and other recreational 
activities, in the medical services provided by VA to eligible 
veterans. Including adaptive sports devices is congruent with VA's 
holistic approach to veteran care, which includes the physical, 
psychological and social aspects of rehabilitation. This legislation 
aims to enhance the quality of life for our Nation's ill and injured 
veterans by providing them with the necessary adaptive devices to 
participate in various sports and recreational activities, which plays 
a vital role in their overall physical and mental well-being. These 
devices enable service-disabled veterans to engage in a wide range of 
activities, including Paralympic sports like track and field, swimming, 
and wheelchair basketball; archery with adaptive equipment; cycling 
with hand cycles and adaptive bicycles; skiing with adaptive equipment; 
hunting with specialized devices; rock climbing with modified safety 
equipment; skydiving with adaptive gear; golf with adaptive golf 
equipment; and various water sports like paddle boarding, kayaking, 
pedal boating, and canoeing.
    We support this bill in accordance with DAV Resolution No. 429, 
which urges the VA to keep centralized funding for Prosthetics and 
Sensory Aids Service to provide high-quality prosthetic items and train 
veterans on their use and care. By supporting this bill, we honor the 
sacrifices of our most severely disabled veterans and promote their 
overall well-being by providing them with the necessary adaptive 
devices to once again engage in sports and recreational activities.
    In closing, the proposed bills under consideration by the 
Subcommittee today represent a comprehensive and multifaceted approach 
to addressing the urgent needs of our veterans. By prioritizing timely 
access to care, effective care coordination, and comprehensive, 
individualized health care options, these bills aim to enhance the 
quality of life for our veterans, who have bravely served our Nation.
    This concludes my testimony on behalf of DAV. I am pleased to 
answer questions you or members of the Subcommittee may have.

                       Statements for the Record

                              ----------                              


                  Veterans Healthcare Policy Institute

    Chairwoman Miller-Meeks, Ranking Member Brownley, and distinguished 
members of the subcommittee:

    On behalf of the Veterans Healthcare Policy Institute, we thank you 
for inviting us to submit a statement for the record for today's 
hearing on improving the health care and services for veterans. Many 
members of our organization are veterans or have family members who are 
veterans. Many of us have had long careers serving veterans, published 
papers on veterans' healthcare in peer-reviewed journals, or presented 
congressional testimony. In today's statement, we wish to convey our 
appreciation for your leadership and commitment to ensuring that 
veterans receive the highest level of health care within the Veterans 
Health Administration (VHA) and supplementary care in the private 
sector when it's both needed and authorized by the VHA.
    While today's hearing considers 12 bills, we limit our comments to 
only one of them--The No Wrong Door for Veterans Act.

Background

    The No Wrong Door for Veterans Act proposes to renew and modify the 
Staff Sergeant Parker Gordon Fox Suicide Prevention Grant Program. This 
pilot initiative allocated $174 million over 3 years to a diverse array 
of private and government community entities to supplement VA efforts, 
including veterans' associations, social service agencies, and tribal 
nations that partnered with the VHA at the local level.
    Under the Fox Grant Program, 80 grantees receive up to $750,000 
annually. Their primary role is to identify and engage veterans 
exhibiting one or more of 14 defined suicide risk factors. Once 
identified, these at-risk veterans and their families are provided with 
peer support, case management, benefits navigation assistance and/or 
other targeted services aimed at reducing suicide risk factors before 
they escalate into crises.

The Importance of the Fox Grant Program's Use of Outcome Measurement

    The original Fox Grant law vastly improved the use of comprehensive 
outcome data to be able to discern which community programs effectively 
enhanced veterans' lives and reduced long-term suicide risk. As 
Congressman Jack Bergman, the bill's co-author, emphasized: ``This bill 
would develop measurement tools to track the effectiveness of these 
community-level programs in order to address the suicide crisis and its 
impact on Veterans.''
    The law authorized the VA to establish and apply a comprehensive 
baseline mental health screening for outcome metrics. Five well-
validated measures were identified for grantees to administer at the 
beginning and end of participants' involvement. These additional 
measures are crucial, given that the programs are not clinical and are 
expected to impact suicidality downstream. The VA was expected to 
analyze changes in these scores to direct renewal funding to the 
interventions that demonstrated improvement in these instrument scores.
    Senator John Boozman (R-AR) hailed the Fox Grant Program for 
establishing ``a common tool to measure the effectiveness of our 
programs and promote better information sharing, data collection, and 
continual feedback in order to identify what services are having the 
most impact.''

Concerns with the No Wrong Door for Veterans Act

    As the 3-year pilot comes up for reauthorization, the proposed ``No 
Wrong Door for Veterans Act'' contains several concerning elements that 
significantly undermine the Fox Grant program. Amendments are needed to 
remedy these shortcomings.

1. Eliminating Demonstrated Effectiveness as a Criterion for Continued 
Funding

    The bill explicitly states that previously funded entities need 
only demonstrate ``serving a significant number of veterans'' to 
qualify for continued funding. That eliminates the core feature of the 
Fox Grant program to utilize participants' pre-post changes for 
decisions about continued funding. Grant recipients would only need to 
demonstrate throughput, not a track record of any successful 
improvements, leaving open the strong possibility that taxpayer funds 
would be misdirected into programs without proven effectiveness.

2. Ambiguous Language About Screening Requirements

    As noted above, the original Fox program required grantees to 
screen for acute suicide risk and collect pre/post measurements of five 
psychosocial suicide risk factors.
    The language in the No Wrong Door legislation is unclear whether 
both types of screening remain mandatory. At a HVAC hearing last 
December, testimony suggested the new bill might eliminate pre/post 
screening requirements. Without these crucial evaluation metrics, it 
will be challenging to accurately assess any program's success in 
addressing the issues surrounding veteran suicide prevention.
    The bill also explicitly permits grantees to use their own 
protocols to screen for risk, undermining the ability to make apples-
to-apples comparisons or aggregate data reporting, which require 
uniform protocols.

3. Insufficient Safeguards on Overpayment to Grantees

    The bill provides $500,000 per grantee ``plus $10,000 per eligible 
individual who receives suicide prevention services provided or 
coordinated by such grantee.'' This ambiguous wording could allow a 
grantee to be reimbursed $10,000 for nominal activities. For example, a 
grantee could be reimbursed for:

      Providing services to an individual that another funder 
is already fully covering

      Conducting a screening with no follow-up services

      Giving a pamphlet to an individual at an outreach event

    There needs to be far more explicit definitions for what 
constitutes reimbursable ``suicide prevention services provided or 
coordinated by such grantee.''

4. Premature Extension of an Unproven Program

    The bill calls for a 3-year extension through 2028 despite the lack 
of a proven track record. Yet, the Interim Report on the Fox Suicide 
Prevention Grant Program revealed extremely significant gaps:

      Of the 80 grantees, 55 failed to report any post-service 
outcome measurements

      The remaining 25 grantees had only 196 participants total 
who completed services and underwent some degree of pre/post 
measurement

      27 percent of eligible participants did not complete even 
one instrument upon entering their program

      23 percent of grantees served fewer than ten veterans/
family members in their first year

      80 percent of grantees had less than fifty participants

    Thus, as of today, grantee effectiveness has been impossible to 
ascertain--either at the disaggregated grantee level or even at the Fox 
Grant program level--as required by law. The purpose of requiring both 
internal VA and external MITRE program evaluations of the pilot is to 
determine whether the Fox Grant program is effective for its intended 
purpose of reducing suicide risk factors. The program should not be 
extended carte blanche for three more years until its effectiveness is, 
as Bergman and Boozman intended, identified by data.

Recommendations:

        1. Tie funding to demonstrated effectiveness: Add language 
        specifying that reauthorizing an entity's funds is based on it 
        serving a significant number of veterans and demonstrated 
        improvements in participant outcomes on the mandated well-being 
        measures.

        2. Strengthen outcome measurement requirements: The Act must 
        explicitly reinforce the requirement that Fox Grant recipients 
        conduct pre-and post-intervention assessments across all 
        relevant metrics. This ensures robust data collection that 
        shows how veterans' scores on the five key measures improve 
        after participating in each grantee's services. All grantees 
        should use the identical measures.

        3. Clarify payment structure: Tighten language to ensure that 
        entities are paid $10,000 per enrollee only for a defined and 
        substantial amount of provided services, not nominal 
        interventions.

        4. Implement a 1-year renewal before blindly funding a long-
        term commitment: Until there is concrete proof of the Fox Grant 
        program's effectiveness, and until the congressionally mandated 
        MITRE Corporation 18-month and 3-year evaluations show 
        systematic success, renewal should proceed on a year-to-year 
        basis rather than a multi-year extension.

    While leveraging non-clinical community organizations is a crucial 
component of an effective upstream public health approach to suicide 
prevention, rigorous evaluation must be maintained to ensure these 
programs truly benefit veterans and represent good stewardship of 
taxpayer dollars.
    We respectfully thank you for the opportunity to provide our 
perspectives on these essential matters. We look forward to working 
with the committee to ensure that veterans can receive timely, high-
quality compassionate care in the VHA and the community now and in the 
future.

                                 

  Prepared Statement of American Association for Marriage and Family 
  Therapy and California Association of Marriage and Family Therapists

    Dear Chairwoman Miller-Meeks and Ranking Member Brownley:

    We are writing on behalf of the American Association for Marriage 
and Family Therapy (``AAMFT'') and the California Association of 
Marriage and Family Therapists (``CAMFT''), organizations that 
represent the professional interests of more than 81,000 licensed 
marriage and family therapists (``MFTs'') who provide individual, 
family, and group psychotherapy services throughout the United States. 
Thank you for providing AAMFT and CAMFT with an opportunity to comment 
in response to legislation considered on March 11, 2025 by the 
Committee on Veterans' Affairs Subcommittee on Health.
    We are commenting in support of H.R. 658, legislation introduced by 
Ranking Member Julia Brownley to correct a problem that impacts care 
and treatment for Veterans. AAMFT and CAMFT would like to thank Ranking 
Member Brownley for sponsoring this legislation. H.R. 658 seeks to 
expand access to licensed MFTs for Veterans and their families by 
removing unnecessary guidelines and policies that currently restrict 
the promotion of many VA MFT employees to supervisory positions, 
resulting in barriers to a qualified mental health workforce and 
barriers to timely access to care. H.R 658 would allow MFTs in the VA 
who are authorized to provide clinical supervision under State law to 
be eligible to provide clinical supervision in the VA.

Background

    In 2006, the Veterans Benefits, Health Care, and Information 
Technology Act of 2006 (P.L. 109-461) was signed into law. This 
legislation established MFTs as recognized professionals within the VA. 
The VA started hiring MFTs in 2010 after the adoption of the first 
qualification standard for MFTs.\1\ In 2018, the VA issued its second 
and current qualification standard for MFTs.\2\ This 2018 standard 
added a new requirement that all MFTs in the VA who are supervising or 
who want to serve at a supervisory or managerial level and above 
designation must first have obtained the AAMFT Approved Supervisor 
designation in order to supervise.\3\ This requirement prevents well-
trained and highly qualified MFTs who are serving in the VA at the GS-
11 full performance level from advancing within the VA into a 
supervisory role. In addition, no such requirement exists in almost all 
other employment settings, and a similar requirement in the VA does not 
exist for psychologists, clinical social workers, or professional 
mental health counselors.
---------------------------------------------------------------------------
    \1\ VA Handbook 5005/41, Part II, Appendix G42
    \2\ VA Handbook 5005/101, Part II, Appendix G44
    \3\ The VA does allow MFTs to are working to obtain the AAMFT 
Approved Supervisor designation to serve as supervisors in the VA. 
These providers have 2 years from the date of placement to obtain the 
AAMFT Approved Supervisor designation.
---------------------------------------------------------------------------
    Currently, the VA requires that MFTs must hold the AAMFT Approved 
Supervisor designation to be promoted to supervisory positions. While 
AAMFT is proud of its high caliber supervisory designation, the AAMFT 
Approved Supervisor designation is not intended to be the only pathway 
for an MFT to become a clinical supervisor in the VA or in other 
settings. The VA does not require that licensed professional mental 
health counselors (``LPMHCs''), licensed clinical social workers 
(``LCSWs'') or other clinicians obtain a designation from a private 
organization in order to serve as a clinical supervisor in the VA.

The Current MFT Supervisor Requirement is an Unnecessary Barrier

    The current MFT supervisor requirement is not necessary, and serves 
as a barrier for providers and Veterans. This requirement places MFTs 
at a disadvantage when it comes to the retention and promotion of MFTs 
within the VA. There are thousands of MFTs who are recognized as state-
approved supervisors, yet they are not able to supervise within the VA 
because they do not have the AAMFT Approved Supervisor designation. We 
are aware of MFTs who have left VA employment because of this 
restriction, including MFTs that are Veterans themselves. We have heard 
that some hiring authorities within the VA are reluctant to hire MFTs 
for entry level positions due to the shortage of MFTs eligible to 
supervise in the VA, thus unnecessarily increasing workforce shortages 
and hampering Veteran's timely access to care.

The Current MFT Supervisor Requirement Does Not Align with State 
    Requirements

    The VA's current MFT supervisor requirement is not in alignment 
with State law. All 50 states and the District of Columbia license 
MFTs. States require that in order to become a licensed MFT, an 
applicant must hold a master's degree or doctoral degree in marriage 
and family therapy or a related field, have 2 years of clinical 
supervised experience, and pass a clinical exam. All states have 
requirements for MFTs who want to provide clinical supervision.
    Based upon a review of the licensure laws governing MFTs in all 50 
states and the District of Columbia, only two states--North Carolina 
and Tennessee--require that clinical supervisors providing supervision 
for MFT licensure must be AAMFT Approved Supervisors. In all 48 other 
states, a clinical supervisor of a candidate for licensure as an MFT 
does not need to be an AAMFT Approved Supervisor. Instead, these 48 
states allow MFTs who have experience and/or training in supervision to 
obtain a State MFT supervisor designation or otherwise legally provide 
supervision to supervisees in those states. For example, under Texas 
law, a person can become a Texas MFT supervisor if have either 
successfully completed a 3-semester hour course in MFT supervision, 
completed a 40-hour continuing education course in clinical 
supervision, or completed a supervision course approved by AAMFT.\4\
---------------------------------------------------------------------------
    \4\ 22 TX Admin Code Sec. 801.143. In addition, all candidates for 
the MFT supervisor status in Texas must document the completion of 
3,000 hours of MFT practice over a minimum of 3 years.
---------------------------------------------------------------------------
    In many states, the supervisor requirements for MFTs are identical 
to, or closely similar to, the State supervisor requirements for other 
mental health professionals. For example, in Iowa, the requirements to 
be an eligible supervisor for MFTs and LPMHCs are identical: hold an 
active license, have a minimum of 3 years of independent practice 
experience, complete at least a 6-hour continuing education course in 
supervisor or one graduate-level course in supervision, and knowledge 
of the law and ethics rules governing supervisees in Iowa.\5\
---------------------------------------------------------------------------
    \5\ Iowa Admin Code r. 481.891.7
---------------------------------------------------------------------------
    The VA's current additional MFT supervisor requirement does not 
align with the VA's own clinical supervisor requirements for other 
healthcare professionals. The VA generally recognizes clinical 
providers in the VA as eligible to supervise if State law allows them 
to supervise. For example, within the mental health professions, LPMHCs 
and LCSWs can provide clinical supervision if they are licensed to 
provide clinical supervision under State law or otherwise can legally 
provide supervision for licensure under State law.\6\ Instead of 
following clinical supervisor requirements under State law, the VA MFT 
supervisor requirement is unique in requiring those applying for a 
supervisory position or having the ability to supervise trainees to 
obtain a supervision designation from a nongovernmental organization. 
Since the VA generally defers to State law pertaining to the minimum 
standards necessary to work in the VA, such as meeting a state's 
requirements for licensure in a recognized healthcare profession, the 
VA should allow MFTs who are authorized to provide clinical supervision 
under State law to be eligible to provide clinical supervision in the 
VA.
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    \6\ VA Handbook 5005/106, Part II, Appendix G43 (LPMHCs) & VA 
Handbook 5005/120, Part II, Appendix G39 (LCSWs)

HR 658 Would Increase the Number of MFT Supervisors While Providing the 
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Best Quality of Care to Veterans

    HR 658 would expand access to licensed MFTs for Veterans and their 
families by removing unnecessary regulations that currently prohibit 
many MFTs employed by the VA from being promoted to supervisory 
positions. This legislation would significantly increase the number of 
current MFTs in the VA who would be eligible to provide clinical 
supervision. By increasing the pool of MFTs eligible to become clinical 
supervisors and be promoted within the VA, this bill would increase the 
retention of MFTs within the VA. Increasing the number of supervisors 
and improving retention of MFTs within the VA will also improve access 
to care in a timely manner for Veterans. H.R 658 protects Veterans by 
requiring that all MFT supervisors must be an AAMFT Approved Supervisor 
or authorized by a State to provide clinical supervisor. As with all 
clinical supervisors of any profession within the VA, under this bill, 
the VA would still retain the ability to manage VA employees, 
investigate supervisors, and take any action against employees who are 
not providing the best care for Veterans.
    We would like to thank the Committee for the opportunity to submit 
comments in support of H.R. 658. AAMFT and CAMFT look forward to 
working with the Committee on this legislation.

                                 

          Prepared Statement of Paralyzed Veterans of America

    Chairman Bost, Ranking Member Takano, and members of the committee, 
Paralyzed Veterans of America (PVA) would like to thank you for the 
opportunity to submit our views on some of the pending legislation 
impacting the Department of Veterans Affairs (VA) that is before the 
committee. No group of veterans understand the full scope of benefits 
and care provided by the VA better than PVA members--veterans who have 
incurred a spinal cord injury or disorder (SCI/D). We appreciate the 
opportunity to offer our observations on some of the bills being 
discussed during today's hearing.

H.R. 217, the Communities Helping Invest through Property and 
Improvements Needed or CHIP IN for Veterans Act

    The Communities Helping Invest through Property and Improvements 
Needed for Veterans Act of 2016 (P.L. 114-294), often referred to as 
the ``CHIP IN'' Act, authorized the VA to carry out a pilot program 
under which it may accept up to five donations from nonfederal entities 
of existing facilities, land, or a facility to be constructed by the 
donor on real property of the VA. Increasing investment in VA's 
infrastructure, particularly facilities that support specialized health 
care services, is a crucial priority for veterans with SCI/D. PVA 
supports this bill, which would make the CHIP IN pilot program 
permanent, thus, increasing the availability of health care services to 
veterans.

H.R. 658, to establish qualifications for the appointment of a person 
as a marriage and family therapist, qualified to provide clinical 
supervision, in the Veterans Health Administration

    PVA supports this legislation, which would establish qualifications 
for the appointment of a person as a marriage and family therapist, 
qualified to provide clinical supervision in the Veterans Health 
Administration (VHA). Veterans who have developed mental health issues 
often find it difficult to resume daily activities, which creates 
stress and anxiety. Well trained marriage and family therapists have 
helped thousands of veterans become productive citizens and improve 
their family relationships. Removing current restrictions that limit 
the growth potential for marriage and family therapists within the VA 
will increase retention of these professionals and improve access to 
the care they provide.

H.R. 1107, the Protecting Veteran Access to Telemedicine Services Act 
of 2025

    PVA supports this legislation, which would permanently extend a 
pandemic-related exemption that allows VA health care providers to 
prescribe certain medications via telemedicine to their veteran 
patients. Specifically, it would authorize a covered health care 
professional to use telemedicine to deliver, distribute, or dispense to 
veterans certain controlled medications via telemedicine under specific 
conditions as determined under the Federal Food, Drug, and Cosmetic Act 
(21 U.S.C. 301 et seq.). Veterans who live in rural communities often 
do not have easy access to a VA health care facility, and telemedicine 
is often the most convenient way to provide essential care. Using 
technology to increase access to care within VA is an important way to 
provide care to better meet veterans' needs, ensuring they receive 
their medications without interruption.

H.R. 1336, the Veterans National Traumatic Brain Injury Treatment Act

    Hyperbaric Oxygen Therapy (HBOT) is a well-established treatment 
for a variety of conditions, including decompression illness, carbon 
monoxide poisoning, or compromised skin grafts and flaps. However, its 
safety and efficacy to treat Traumatic Brain Injury or Post Traumatic 
Stress Disorder is unclear. PVA has no objections to this legislation, 
which seeks to establish a pilot program at the VA to furnish HBOT to 
veterans with these conditions.

H.R. 1644, the Copay Fairness for Veterans Act

    PVA supports this legislation, which would eliminate copayments for 
medications and preventive health services provided by the VA. While 
the VA charges copays to certain veterans for hospital and medical 
care, veterans should not be subject to copays for preventive services. 
These services are essential for management and early detection of 
health issues, that if left untreated, could lead to more serious 
illnesses or conditions. Ending copays for preventative care will also 
ensure parity for veterans with most other Americans who have no copays 
when accessing this type of care.

H.R. 1823, to direct the VA Secretary and the Comptroller General of 
the United States to report on certain funding shortfalls in the VA.

    In July 2024, the Veterans Benefits Administration (VBA) projected 
a $2.88 billion budget shortfall for the remainder of Fiscal Year (FY) 
2024 and VHA projected a $12 billion shortfall for Fiscal Year 2025. 
Toward the end of September 2024, Congress approved H.R. 9468, the 
Veterans Benefits Continuity and Accountability Supplemental 
Appropriations Act of 2024 (P.L. 118-82), which gave VBA an additional 
$2.9 billion to pay veterans' pension and disability benefits for 
Fiscal Year 2024.
    On November 1, 2024, VBA revealed that it carried over 
approximately $5.1 billion from Fiscal Year 2024 to Fiscal Year 2025, 
meaning it did not need the additional funding approved by Congress. 
Also, at the end of November, the VA announced that it only needed $6.6 
billion, not $12 billion, to cover existing shortfalls in the VHA 
budget for Fiscal Year 2025. The lack of clarity on what VA's true 
financial needs are has been a concern for all interested parties, and 
to date, sparse details have been provided about VA's inability to 
track and project its funding. PVA strongly supports this legislation, 
which requires the Comptroller General to investigate the circumstances 
surrounding the reported funding shortfalls for the VHA and VBA in 
Fiscal Year 2024 and Fiscal Year 2025.

Discussion Draft, to establish the period during which the referral of 
a veteran, made by a health care provider of the Department of Veterans 
Affairs, to a non-Department provider, for care or services under the 
Community Care Program of such Department, remains valid.

    PVA supports this draft legislation, which would establish the 
valid time frame for a referral from a VA health care provider to a 
non-VA Community provider under the Community Care Program. As written, 
``valid time'' begins the day a covered veteran has their first 
appointment with the community care provider. This would ensure 
veterans referred to community care providers meet all of VA's 
authorization requirements, allowing the provider to focus on 
delivering appropriate care to a veteran without delay.

Discussion Draft, the Providing Veterans Essential Medications Act

    PVA supports this draft bill, which would ensure that veterans 
receiving nursing home care in State Veterans Homes have access to 
high-cost medications, as needed. Currently, the VA does not pay State 
homes for high-cost medications for veterans. This bill would require 
the VA Secretary to either reimburse State homes for costly medications 
or furnish them directly, which would eliminate financial burdens on 
these long-term care facilities and increase veterans' access to care.

Discussion Draft, The Veterans Supporting Prosthetics Opportunities and 
Recreational Therapy (``SPORT'') Act.

    PVA strongly supports this draft bill, which would provide VA 
coverage of prosthetic limbs that veterans with limb loss use to 
participate in sports and other recreational activities. Specifically, 
this bill would add ``adaptive prostheses and terminal devices for 
sports and other recreational activities'' to the statute governing 
which equipment and aids that the VA is allowed to grant veterans. 
Adaptive equipment is intended to promote and support holistic healthy 
lifestyles for amputees. But occasionally, VA's own internal policies 
create unnecessary barriers for veterans with disabilities. For this 
reason, we highly recommend that VA provide these kinds of adaptive 
equipment for amputees without requiring that the veteran be enrolled 
in a VA rehabilitative program.

Discussion Draft, the Saving Our Veterans Lives Act

    Firearms are the most common method of suicide in the US, with 
veterans representing slightly more than 69 percent of cases.\1\ More 
than 70 percent of male veteran suicide deaths and 50 percent of female 
veteran suicide deaths are the result of firearms, and these rates 
greatly exceed those of non-veterans. Fifty-one percent of veterans 
report owning one or more personal firearms, and of those, over half 
report storing firearms that are loaded and/or unsecured. Many of the 
veterans who store their firearms loaded and unlocked don't even own a 
lockbox or safe. PVA supports this effort to make it easier for 
veterans to access secure firearm storage devices and raise awareness 
about the importance of lethal means safety to help prevent firearm 
suicide among veterans and their families.
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    \1\ Firearm suicide risk and prevention in service members--
ScienceDirect

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Discussion Draft, the Women Veterans Cancer Care Coordination Act

    The Women Veterans Cancer Care Coordination Act would require the 
VA to hire or designate a Regional Breast Cancer and Gynecologic Cancer 
Care Coordinator at each Veterans Integrated Services Network (VISN). 
While PVA supports the intent of this draft bill, some changes are 
needed to make it stronger. The National Women Veterans Oncology System 
of Excellence was established in 2020 to offer increased attention and 
collaborative treatment plans for women experiencing breast or 
gynecological cancers. Their work has led to improved early detection, 
coordinated treatment of cancers, and provided increased trust in VA 
among women veterans. However, the National Women Veterans Oncology 
System of Excellence is not protected in statute. PVA recommends adding 
a provision within the legislation that secures the National Women 
Veterans Oncology System of Excellence to ensure the great work VA is 
doing on behalf of women veterans living with cancer. Additionally, 
cancer care coordination is disparate across the system, and while PVA 
supports additional focus and attention on the needs of women veterans, 
we believe having someone within each VISN to focus on all cancers, 
regardless of gender, should be prioritized.
    PVA would once again like to thank the committee for the 
opportunity to submit our views on some of the bills being considered 
today. We look forward to working with you on this legislation and 
would be happy to take any questions for the record.

  Information Required by Rule XI 2(g) of the House of Representatives

Pursuant to Rule XI 2(g) of the House of Representatives, the following 
information is provided regarding Federal grants and contracts.

                            Fiscal Year 2025

Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events----Grant to support rehabilitation sports 
activities--$502,000.

                            Fiscal Year 2023

Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events----Grant to support rehabilitation sports 
activities--$479,000.

                            Fiscal Year 2022

    Department of Veterans Affairs, Office of National Veterans Sports 
Programs & Special Events----Grant to support rehabilitation sports 
activities--$ 437,745.

                     Disclosure of Foreign Payments

Paralyzed Veterans of America is largely supported by donations from 
the general public. However, in some very rare cases we receive direct 
donations from foreign nationals. In addition, we receive funding from 
corporations and foundations which in some cases are U.S. subsidiaries 
of non-U.S. companies.

Prepared Statement of American Federation of Government Employees, AFL-
                                  CIO
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

                Prepared Statement of Trajector Medical
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]

            Document for the Record Submitted by Greg Murphy
[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


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