Legislative Hearing on Veterans Health and Burial Bills

Good morning. This legislative hearing of the subcommittee on health will now come to order. Without objections, the chair may declare a recess at any point. I'd like to welcome all members and witnesses to today's hearing. Today we'll discuss fifteen bills addressing a wide range of issues facing the nation's veterans. Every every single one of these bills has one goal in mind, putting veterans at the front of every decision we make, I'd also like to encourage all members to keep that common goal in mind as we discuss this legislation before the committee. I'm looking forward to a very productive discussion with my colleagues on these important bills. First, I want to highlight the Wings Act, introduced by Representative Kiggins. This bill would require the VA to examine the long-term neurological and mental ev- health effects associated with military aviation service. Military aviators experience unique exposures during their careers, and significant questions remain about the long-term effects of those exposures on their health and well-being. This bill would help in um help VA ensure that future policy and treatment decisions are informed by evidence. I thank my friend Representative Kiggins for her leadership on this issue, and I'm proud to support this legislation. I would also like to mention the Veteran Burial Timeliness and Death Certificate Accountability Act, introduced by Whip Emmer. This bill would ensure accountability and timeliness at the VA by requiring certification of death within forty-eight hours. This would allow any official coroner to certify the death of a veteran when the VA is unable to meet a forty-eight hour requirement. This common sense legislation addresses an unacceptable reality that our veteran families can face weeks-long delays in receiving their loved one's death certificate. This can delay burials and access to survivor benefits that these families have rightfully earned. The goal of this bill is to ensure that those who served our country are laid to rest without any unnecessary delays. The Veterans Stand Act, introduced by General Bergman, reflects our commitment to improving care for veterans living with spinal cord injuries and disorders by authorizing VA to offer annual preventative health evaluations to eligible veterans. This bill would also expand veterans' access to lifesaving prosthetics and other mobility di- devices that assist with spinal cord injuries. VA has the important responsibility of not only treating our veterans, but also anticipating complications, preserving their independence, and assuring they have access to the highest quality medical care available. This bill would assist VA in this mission and I am proud to support it. I'd also like to highlight the Tours Act introduced by Representative Valadao. In the line of duty, our service members make sacrifices daily to protect our nation. For many, those sacrifices do not end on the battlefield. Instead, they reappear here at home in the form of post-traumatic stress, moral injury, isolation, and hopelessness. This home fought battle is reality for thousands of veterans, and with over seventeen veterans dying by suicide every day, it is a fight we must continue to better understand and better equip or equip ourselves to win. The Tourist Act would do just that. By requiring VA to study its chaplaincy services and faith-based programs through data collection and reporting we can highlight the importance of whole health and spiritual well-being. This data would help VA replicate the areas where its mental health services are making a positive difference in the epidemic of veteran suicide. And I personally heard from veterans in my district that were at the edge, ready to commit suicide, and they have told me that the chaplain was there and saved them from that dire, uh, consequence. I'm grateful to Representative Valadao for his leadership on this important issue. I'm also proud to highlight several pieces of legislation uh that Doctor Murphy, Representative Bresnahan, and I have introduced that would improve coordination between the VA and the Department of Health and Human Services in administering benefits and services throughout the Veterans Community Care Program these three bills would establish memorandum of understanding to enable data sharing between the VA and the centers for Medicare Medicaid services. The goal is to ensure that veterans enrolled in VA care and other federal health programs experience a more coordinated system while helping reduce duplicate or fraudulent payments. When these agencies lack access to the same information, it creates administrative burdens, unnecessary cost for taxpayers, and a more challenging system for veterans to navigate. I thank Representatives Murphy and Bresnahan for introducing these bills and I'm proud to support them. Today, just four days ahead of our nation's two hundred and fiftieth anniversary, let us recommit ourselves to putting veterans first. As Chairwoman, for being here is to ensure that every veteran has the chance to live with the dignity, purpose, and hope they have so justly earned through their service to our nation. This morning we're also joined by several of our colleagues, not on the committee, who will speak in support of their bills. I appreciate their dedication to serving our nation's veterans. I ask unanimous consent that the following members be allowed to wave on to today's hearing. Representative Valadio of California, Representative Bresnahan of Pennsylvania, Representative Harrigan of North Carolina, Representative Min of California, Representative Vindman of Virginia. With that, I now yield to Yankee Member Brownlee for any opening remarks she may have.

Uh, thank you Madam Chair, and I am also looking forward to hearing from our witnesses about the bills on today's agenda. I know that many of our colleagues will be here to speak in support of their bills, so I'll keep my remarks relatively brief. Uh, several of the bills on today's agenda aim to improve transparency in the delivery of veterans' health care. Representatives Dexter and Murphy have introduced the VHA Open Policies Act, which will require public posting of directives, policies, and guidance relating to veterans' health programs. This will help Congress and the public better understand how VHA is directing its facilities to implement its programs. Representative uh Venman and Hamadeh have introduced the VHA Personnel Transparency and Accountability Act, and ranking member Tucano has introduced the VA Health Care Capacity Assessment Act. Among other things, these two bills will help shed light on current staffing levels at VA medical facilities and projected future demand so that we can better equip the VA health care system to meet our veterans' needs. Finally, Representative Min and Fitzpatrick have introduced the Fostering Trust Act which will enable us to better monitor suicides and attempted suicides that occur occur at VA medical facilities and at community care facilities and help us begin to identify trends and potential solutions to these extremely tragic events. I do, however, have some concerns with three bills on the agenda that relate to data sharing between VA and the Centers for Medicare and Medicaid Services, commonly known as CMS. While I appreciate the stated intention of these bills to avoid duplicative payments by federal health care programs, I'm not convinced that these bills will accomplish that goal. Instead, I'm concerned they may be a thinly-veiled effort toward privat privatizing veterans' health care, and helping to boast the profits of private insurance companies that offer Medicare Advantage plans. As VA states in its testimony, it already has in place a data sharing, a agreement with CMS, which enables it to identify providers who have submitted claims for payment to both VA and Medicare. VA also points out that these bills do not address veterans' dual enrollment and TRICARE and how and how a more coordinated effort between the VA, CMS, and DOD would increase its ability to identify and eliminate duplicative, improper, and erroneous billing and payments. I'm concerned that these bills could result in more duly eligible veteran veterans' care being shifted from VA to community providers through traditional Medicare and Medicare Advantage plans. For example, a provision in the discussion draft on coordination in administering the veterans' community care program fails to define duplicative health care and could be interpreted to broadly deny VA provided care to veterans when similar services are available through the veterans' Medicare Advantage plans. This bill promotes a model in which Medicare or Medicare Advantage could become the primary source of care for duly eligible veterans, and VA would increasingly function as a payer or provider of last resort. Under the data sharing requirements of these three bills commercial insurers could argue for even higher capitated payments under Medicare Advantage than they already receive due to CMS having greater insight about veterans' additional health care needs. The capitated payments that go to Medicare Advantage plans are intended to cover all of the vene- beneficiaries' health care. However, most veterans who are currently enrolled in Medicare Advantage plans are getting the majority of their care at VA medical s- facilities. If the goal is to address taxpayers paying twice for veterans' VA care, both in the form of VA spending and in the form of capitated payments to Medicare Advantage plans, there already exists a much simpler solution, the Guard Veterans Health Care Act, which was introduced by Representative Doggett, Ranking Miner- Member Takano, Representative Murth- Murphy, and others. The legislation provides authority for VA to bill

Uh thank you, Ranking Member Brownlee, I guess we got the memo. Uh thank you, Ranking Member Brownlee, I guess we've got the memo. Um, we have a full ag- pink.

Oh, oh.

We have a full agenda today. So I'll be holding everyone to three minutes per bill to ensure we can move in a timely fashion. I now recognize, um, Doctor Murphy to speak, uh, for three minutes on behalf of his legislation.

Thank you, Madam Chairman. Um, thank you for ranking Member Browley and and the comments, um, which you made. I I will address a couple of them. I'm the sponsor of the Veterans Care and Coordination Act of twenty twenty six. Medicare is the largest source of insurance coverage for VHA enrollees with over fifty percent in either traditional Medicare or Medicare Advantage plans. According to Brown, as was cited, the VA paid more than seven, eight billion dollars for health services from twenty eleven to twenty twenty. They also found that while the VHA paid for veterans' health care, taxpayers simultaneously simultaneously made full payments for each duly enrolled veter- veteran to their Medicare Advantage plan. Let me r- let me say that again. Taxpayers simultaneously made full payments for each duly enrolled veteran to the Medicare Advantage plan. Last year the RAND Corporation also highlighted potentially of duplicative payments for duly enrolled veterans both for veterans and taxpayers. This is not an attempt to privatize the VA. It's not attempt to uh push everybody to community care. It's an attempt to stop the duplicative pay duplicative payments. In some instances the veteran may be paying a premium for Medicare Advantage but not using any man-made cover, and the government may be providing a monthly subsidy to the MA plan regardless of whether a veteran uses any care covered by that plan. Plan. Frankly, to me this seems ridiculous. Why are we paying twice for the same thing? As a s- first step, again, as a first step, cuz if the VA were had this in place right now, why aren't they doing it? My bill seeks to promote data sharing coordination to improve veteran health care management, reduce billing errors, and optimize resource use across the VA and Medicare programs. The bill requires VA and HHS to issue a memorandum of understanding to within one year to reciprocal access to veteran health data and enable HHS to identify veterans enrolled in both plans um by sharing data we c- we will create a more efficient delivery system for our veterans and avoid duplicative payments. Um I received uh the VA's testimony, one of their recommendations and concerns is uh that we believe coordination between the VA the Department of War and HHS would be most effective in identifying in eliminating duplicative and improper payments. I welcome the support, and if we do a nature a amendment in the nature of a substitute to include the Department of War, I'm fine with that. Um, again, we don't need to be paying twice for the same health care, and if we're paying Medicare Advantage plans basically for nothing, then we need to stop that. As many know, I'm not a huge fan of the way Medicare Advantage is acting these days. Also, co-lead of Doctor Dexter's bill, the Veterans Health Administration on-line publication and easy Navigation of Policies Act of twenty twenty-six, whoo, mouthful. Bill directs the Under-Secretary of the VA for help to make all national policies of the VHA publicly available online. I think this is common sense and an excellent piece of legislation. Increases transparency by ensuring the public has timely access to VHA policies and our chairs helps our chairs veterans and all that support them, they'll remain up to date. Remain the web site would be up to date updated uh monthly. I think these are both excellent bills and I recommend um passage of them at the appropriate time. Thank you Madam Chairman, I'll yield back.

Uh, thank you, Doctor Murphy, the chair now recognizes Doctor Dexter for three minutes to speak on her.

Thank you very much, Chair Miller-Makes, and and ranking member Brownlee for convening today's hearing, and for the opportunity to speak on my bill, the VHA open policies act. I also very much extend my gratitude to Doctor Murphy for his partnership in this effort. This legislation reflects a genuine collaborative effort, and I'm grateful for your support in advancing the principle that effective congressional oversight requires access to the information that Congress needs, not just the information the executive branch chooses to share. The premise of this bill is simple, VHA's national policies and underlying guidance and procedures govern some of the most consequential um decisions in a veteran's life. What care they receive, how they travel to get it, what benefits they are entitled to. And yet many of those underlying documents live only in the VA's intranet, inaccessible to veterans and those looking to ensure our taxpayer dollars are being used to deliver the ca- care our veterans deserve. The VHA open policy act policies act would require the VA to publish all of that material on a publicly accessible web site. This should not be controversial. It's already done by CMS. It's baseline transparency expectation, and it should not be something that we resist. I thank the VA for engaging with our office on this legislation. We look forward to continuing the dialogue, and we are committed to getting this right. But I will be direct about something. We have heard the argument that VA is already working to improve transparency and that existing processes, FOIA, congressional inquiries, and formal requests are sufficient. With respect, the facts do not support that conclusion. Let me give this example that's very concrete from why a statutory requirement is necessary. Last September I joined my Republican colleague, Representative Luttrell, in sending a bipartisan letter to VA asking for data on average wait times and drive times for VA care in the community. This was not a hostile inquiry, it was not an adversarial demand, it was a request to ensure that veterans have access to tools they need to make informed decisions about their own care, something we all want. For months we heard nothing. Despite consistent follow-up at the staff level, our letter went unanswered. I raised it directly in a hearing with Assistant Secretary Topping. Still nothing. I raised it again with Secretary Collins. Only after that second escalation, five months after the original letter, did we finally receive a response in February of this year. I will be clear. I do not like duplicative requirements. I do not want to legislate things that should be done administratively or in rule. My strong preference is for the VA to choose to do the right thing. But I have to be honest with this committee, with a bipartisan good faith request on an issue where we are naturally aligned, to have that take five months, an escalation to the Assistant Secretary and a second escalation to the Secretary himself to get a response, that tells me something. And what it tells me is this, we cannot get a timely answer to an easy question, then we absolutely will have a hard time from a member of Congress, Our veterans are not going to get the answers that they deserve. I have very little confidence that when Congress asks a harder question, when we are chasing something the VA would rather not answer, that we will get any answer at all to be able to protect our veterans. It is our responsibility, all of us on this dais, to hold the executive branch, whether a Democrat or a Republican, in office accountable. The VHA Open Policies Act is a straightforward action we can take.

Uh, thank you, Doctor Dexter. The chair now recognizes representative King Hines for three minutes to speak on her bill.

Thank you, Chairman Miller-Meeks and Ranking Member Rowley, for holding this legislative hearing on several important bills, including my legislation to support veterans in the Northern Mariana Islands and the freely associated states. I'm proud to sponsor H R nine three one six, the travel assistance for veterans in medical deserts act. Under current law, veterans generally must have a service-connected disability rating of thirty percent or higher to qualify for VA's beneficiary travel program. While that standard may work in places with access to VA facilities, it creates an unjust burden for veterans in the Northern Mariana Islands where there is not a single VA medical facility available. For veterans in my district, travel is not a choice, it is a necessity. Regardless of their disability rating, they must leave home to receive most forms of care because there are simply no local alternatives. Today there's only one part-time primary care provider serving veterans across our three populated islands Saipantanian and Rota. Doctor Adda provides exceptional care but there are limits to what primary care alone can accomplish. Specialty services are unavailable and when veterans require more advanced treatment they must travel to Guam Hawaii or the continental United States. A veteran with a ten or twenty percent disability rating should not be denied travel assistance simply because The Department of the Veterans Affairs has not established a medical facility in our islands this inequity is exactly what H R nine three one seek six seeks to address. The Travel Assistance for Veterans in Medical Des- Deserts Act would waive the thirty percent disability rating requirement for veterans residing in the CNMI and the FAS. Vets should not have to shorter the financial burden of traveling hundreds or even thousands of miles to access care that is unavailable where they live. Our veterans answered the call to serve this nation, we should not make them pay extra simply because

Uh thank you Representative King-Hines. The chair now recognizes Representative McGarvey for three minutes to speak on his bill.

Thank you Madam Chair and for ranking member for allowing me to be here as part of this committee today. I want a chance to speak to you about an issue that is deeply personal for so many families. It's caregiving youth. Now, caregiving youth is what we're gonna call them in this committee and in the title of the bill, but what is it really? It's kids who are taking care of their parents. Kids who are taking care of service members and veterans because of chronic disease, illness, or disability. What do those people look like? I'll tell you about one. Eliza, she was nine years old when her father, who was a Staff Sergeant in the Air Force, He's he came home, and from that point on, her childhood focused on his recovery, the emotional ups and downs, the memory losses, uh the everyday tasks that were made harder by his traumatic brain injury. It was his daughter, Eliza, who quietly stepped in to help. And nobody knew why she was showing up to school exhausted. Nobody knew why she didn't have time for friends.

Mm.

No federal program recognize what she was carrying. She was invisible in every system meant to help her family. See, a kid like Eliza is never going to refer to herself as a caregiver. But they bear responsibilities far beyond their years, and they do it without recognition or support. We know what this means for their lives. Some struggle in school. Some miss out on friendships. Some don't have the opportunity to participate in activities or sports. Some face anxiety or depression. And these kids shouldn't have to sacrifice their education, their well-being, or really, their childhood to make sure that their family or loved one gets the care that they need. So right now federal programs don't identify caregiving youth or coordinate support across agencies. They're invisible. That's unacceptable. We have a responsibility to understand who they are, to understand what they need and how we can make sure that they're not left behind. That's why I introduced H R nine four seven five, the National Task Force on Caregiving Youth, a Veterans Act. It brings together the VA, DOD, the Department of Education, and HHS to figure out how many caregiving youth there are and what challenges they face. It requires consultation with families and experts and requests targeted policy recommendations to expand resources, improve mental health support, create department-specific programs, and more. This isn't a partisan issue. This is a human issue. It's about recognizing the full reality of service and sacrifice in military veteran families. I look forward to working with you all to move this bill forward. Thanks again for including it in today's discussion, and I yield back.

Thank you, Representative Garvey, the chair now recognizes Representative Kiggins for three minutes to speak on her bill.

Thank you, Chairwoman Meeks, and thank you to the witnesses for being here today to discuss the importance of these pieces of legislation. One of the bills on the agenda today is my bill, the Warrior Impact from Neurological and G-force Stress Act. or the Wings Act. I'd especially like to thank uh we have a person on this second panel, a woman from my district who is a Gold Star spouse, Chelsea, who will be sharing her story uh of her former or of her husband who was a uh F-eighteen pilot. But we've done significant work in this committee to take care of our veterans, especially in the mental health space, access to mental health, making sure they have timely care, uh comprehensive care. We've looked at things like blast exposures and TBIs. especially the special ops community who has had a significant amount of exposure to these things and has really been leading in so many uh ways to to uh point out what these cognitive changes are that our military members are experiencing we've looked at cancer rates for people like aviators we passed over last congress to study that uh but i i wanted today and to highlight with my bill a very special group of people our aviators from the military who are exposed in different ways and and in the cognitive space and some of their changes. As a former Navy pilot, married to an F-eighteen pilot, now the mother of an F-eighteen pilot, many of my friends, my family, my Navy family, uh, are are these special people who fly through the air, who we sense tip of the spear, mobile air superiority, into harm's way. When they land on an aircraft carrier, they are frequently traveling about two hundred miles an hour and can stop in a mere second. Think about what that does to and and when you talk to them and actually spend some time talking to them they'll say we only black out sometimes for a couple of seconds they will tell you that if you spend some time and we have failed to look at these brain changes in our aviators but the stories i've heard far too often from my my friends uh some of friends of my family people very close to me and the funerals that i have attended too many times for former aviators we have to take a better look at this issue aviators are different they will not complain when they have so much as a sniffle Because if they complain, they will not fly. They cannot complete their mission. It is so important that we treat them differently and we highlight this issue because they suffer in silence and their families suffer in silence. They're exposed to things like G forces, to oxygen pressure changes, radar equipment, electric equipment. In addition to the usual stressors, stressors and uh and just situations that we have in military life, as a nurse practitioner and a healthcare provider, I know that good policy comes from the research, evidence-based research. So what might is to make sure that we are prioritizing them. We are looking at at conducting a long-term study of the cognitive and psychological impact of military aviation. The study will also examine the link between flight exposure and risks of TBI, depression, PTSD, and suicide among aviators. I want to thank the committee for considering this legislat- legislation along with the other important bills before us today. I also want to thank our witnesses, especially Chelsea, for sharing their expertise in helping highlight the importance of these issues. I look forward to continuing the work with the committee to expand and improve veteran health care. With that, I yield back. Thank you.

I thank you, Representative Kiggins, the chair now recognizes Representative Vindman for three minutes to speak on his bill.

Mr. Kennedy.

Oh. Representative Kennedy.

No problem, Vindman's a great-looking guy. Uh, Chair Miller-Meeks. Ranking member Brownlee and members of the subcommittee, thank you for the opportunity to speak in support of my bill, HR nine four three three, the VA Coaching into Care Act. This committee and our panel of witnesses today know all too well the mental and behavioral health challenges our veterans face. Each and every day millions of veterans across the US struggle with depression, anxiety, post-traumatic stress, and suicidal thoughts. Every single day statistically, approximately seventeen US veterans take their own lives. And in fiscal year twenty twenty five, about half of veterans under fifty years old use the VA for support related to mental health challenges. Behind every service member is a family member, spouse or partner who also serves, giving unwavering support day in and day out, no matter the struggle. They are often the first to recognize early warning signs of a mental health crisis, respond and seek the care needed for the loved one before it's too late. In recognizing this burden of care, the VA created the Coaching into Care program in twenty eleven, a successful service within the Office of Mental Health and Suicide Assistance that provided spouses and partners of at-risk veterans with guidance on recognizing early warning signs of a mental health crisis, and how to respond when a veteran may be experiencing thoughts of suicide. Unfortunately, this program was discontinued on March first, twenty twenty four, and today these calls are rerouted to VA caregiver support lines which is often overburdened with high call volume, high demand, and long wait times. Additionally, the hotline responder is oftentimes unaware that they can provide resources to individuals who are not formally recognized as caregivers. Between twenty ten and twenty twenty five, the number of veterans who received mental health care directly from the Veterans Health Administration grew by about eighty percent. An increase in demand for support services made worse by a reduction in critical resources continuation of the coaching and a care program. This leaves a significant gap in support, not just for our nation's veterans but for the spouses, partners and loved ones who are instrumental in ensuring that we quickly act to help our veterans in crisis and prevent tragedies that far too often, families have experienced. To close this gap, my bill, the VA Coaching and a Care Act of twenty twenty six restarts this program at the VA for three years providing phone-based counseling and guidance family members of at-risk veterans. It strengthens the VA mental health support system and put simply, will save lives. This hotline staffed by social workers and psychologists who specialize in crisis intervention will provide family members with access to real-time mental health support resources, ensuring that those beyond formally recognized caregivers can intervene when a veteran's life is at risk. We ask a great deal of those who serve our country In this body, it's our responsibility to care for those who've protected us our livelihoods liberty and democracy. It's also our duty to support the people who care for them. This legislation is about uplifting our veterans and those who stand by their side, on their hardest days, navigating the trials and tribulations that come with supporting someone after service. I'm proud to lead this legislation that will strengthen our support system, improve access to mental health services at the VA, and ultimately save lives of veterans. I yield back.

Thank you, Chairwoman Miller-Meeks, and all members of the subcommittee for your time today. Since two thousand one, more than six thousand veterans have died by suicide each year. Each loss not only impacts the service members' loved ones and their community, but the greater veteran population. The VA's National Veteran Suicide Prevention Annual Report is one of the most valuable tools for understanding this crisis. but one important gap remains. We don't have meaningful data on how the VA's chaplaincy service and other faith-based programs may help reduce veteran suicide. That's exactly what my bill, the TORS Act, seeks to address. This legislation directs the VA to conduct a two-year study on the relationship between participation in the chaplaincy or and other faith-based uh services, on the risk of suicide among veterans. Because conversations with chaplains are private, there hasn't been However, the TORACs takes steps to ensure veteran privacy by preserving the confidentiality of of religious communications and ensuring that participation is entirely voluntary. For many veterans, healing involves more than medical treatment alone. Chaplains provide spiritual care, emotional support, and a trusted presence for veterans of every faith, often reaching those who may not be ready to seek help elsewhere. We believe these services make a difference and this study will help us better understand their impact so we can make informed decisions about the future investments. Our veterans continue to face physical, emotional, and spiritual challenges after their service, and we owe it to them to ensure the care the VA provides reflects the full range of those needs. I want to thank the subcommittee for their time and I urge all met members to support this common sense bill. Thank you and I yield back.

Thank you, Representative Valadao, the chair now recognizes Representative Min.

Thank you, Chair Mel Monix and Ranking Member Brownlee, for holding today's legislative hearing. I also want to thank Representative Fitzpatrick for agreeing to co-lead this important bipartisan legislation to try to strengthen transparency and accountability in the care of our nation's veterans. This bill, H. R. ninety-eighteen, builds on previous legislation introduced by Representative Max Rose in the one hundred sixteenth Congress the Fight Veteran Suicide Act. Uh, but what's clear several Congresses later is that there is still significant work to do in this regard of properly addressing suicide, that this is unfortunately one of the most persistent and urgent challenges facing service members, veterans, and their families today. According to the VA, in twenty twenty-three there were sixty, almost sixty-four hundred veteran suicides deaths, thirty-nine percent of which were receiving VHA care either in twenty-twenty-two or twenty-twenty-three. In twenty twenty three, suicide was the twelfth leading cause of death for veterans and was the second leading cause of death for veterans under the age of forty five. This is an important district across the nation, but including in my district, which has about f- twenty four thousand veterans and their families. Uh, across Orange County, of course, that number is much higher. We need better accountability, transparency, and data to try to deliver the right resources and care for those struggling. My bill, the Fostering Trust Act of twenty twenty six, would try to do this by requiring the VA to notify the House and Senate Veterans Affairs committees, as well as the members of Congress representing the district where a facility is located and the district where the veterans reside when a suicide or attempted suicide happens. Standardizing this notification process and the important uh information that each notification would include uh would help strengthen this body's ability to try to focus its efforts legislative and otherwise, and employee resources more effectively to address the crisis. This bill specifically would expand existing reporting requirements to cover veterans receiving care through VA community care providers, require the VA to notify Congress within seven days of a suicide or attempted suicide occurring at a VA facility or a community care provider facility, would require the VA to provide Congress with follow-up information regarding a veteran's interaction with VA or community care providers, and ensure that fa- immediate family members

Uh, thank you, Representative Min. The chair now recognizes Representative or General Bergman for three minutes to speak on his bill.

Thanks, Madam Chair. Uh, I appreciate the opportunity to speak on my bill, H R six eight three five, the Veterans Stand Act. I want to start by welcoming Miss Brittany Elliott back to the subcommittee along with her father, Morgan. And it's great to see you all again. Miss Elliott's willingness to come back and tell her story again says more about why this bill matters than anything I could say here today. Miss Elliott served as United States Marine, She earned the right to expect that when she came home, the VA would fight for her the way she fought for our country. Instead, Miss Elliott spent four years fighting her own VA just to keep a device that helped her reclaim her life after her injury. That should never have taken four years, and it shouldn't take four years for anyone else. The VA cares for more than twenty-seven thousand veterans with spinal cord injuries and disorders every year. through twenty-five regional centers and over one hundred and thirty clinics nationwide. That's a real commitment to our veterans, and I don't take it for granted. None of us should. But a network like this is only as good as the care it actually delivers to the veteran. The Veterans Stand Act is simple. It requires the VA to actually perform annual evaluations it claims to ha- to already be doing. It requires those evaluations to include a real look at assistive technologies, exoskeletons, neural modulation, powered mobility devices, not just whatever happens to be on hand locally. It requires the VA to bring in a spinal cord specialist, clinicians, veteran service organizations, and the manufacturers who actually understand these devices instead of making decisions in a vacuum, especially a bureaucratic vacuum. And it holds the VA accountable by requiring regular reporting to Congress. Nearly half of all spinal cord injuries happen between the ages of seventeen and thirty. That means a lot of our veterans are looking at decades of life, productive life in front of them. The least we owe them is a system that keeps pace with what modern medicine can offer and the advancements in technology that make that life that they're gonna be leading full, positive if somewhat modified in a lot of cases electronically. With that, I yield back.

Thank you, General Bergman. The chair now recognizes representative uh Vindman, a. k. a. Representative Kennedy to speak for three minutes on his bill.

Thank you, Chair. Uh, Rep. Kennedy is also not a bad-looking guy, so I appreciate that. Um,

So you heard.

thank you, Chair Miller-Meeks, and ranking member Brownlee. After serving twenty-five years in uniform, I know firsthand the sarc- sacrifices our service members, veterans, and military families make every single day. Veterans have earned every benefit this nation provides, and that is why it's critical we ensure they have timely access to high-quality care at VA health facilities. My district, Virginia's seventh, is home to one of the newest, largest, and most state of the art VA facilities in the country, the Fredericksburg VA Health Care Center. I attended the ribbon-cutting for the facility in March of last year and was encouraged that veterans in my district would be able to receive excellent health care in their community rather than commute to large city centers like DC or Richmond unfortunately the top complaint I hear from veterans in my district to this day is that the facility remains understaffed and my constituents still need to travel long distances or experience extended wait times in order to receive care it's particularly disconcerting driving by this beautiful facility new facility on I-ninety-five, you can't miss it, and seeing the parking lot nearly empty. That's why I'm here today to discuss my bipartisan bill, the Health the Veterans Health Administration Personnel Transparency and Accountability Act. This measure requires the VA to report facility staffing monthly instead of quarterly and to do so with greater specificity regarding which roles are vacant at each facility. Veterans, Congress, and advocacy organizations cannot hold the VA accountable if they rely on stale, outdated, and unclear data. My bill ensures that veterans and their allies gain a clear picture of staffing levels at the agency enabling us to hold the VA to the highest standards that our veterans deserve. I hope that you all support this common sense measure and I yield back.

Uh, thank you, Representative Vindman, the chair now recognizes Representative Harrigan for three minutes to speak on his bill.

Well, thank you, Madam Chairwoman, and uh good morning to all of my colleagues. Thank you for allowing me to come here before the committee today and talk about the Foreign Medical Program Integrity and Improvement Act. What are we doing here? The FMP exists for one reason and one reason alone, to make sure that veterans that have service-connected disabilities that either live or travel abroad are actually able to access the medical care that they have earned. When there's no VA nearby, the FMP steps in. There's an issue though. The program has tripled in size since twenty eighteen. Claims are up a hundred and fifty percent. Reimbursements are up two hundred and sixty-three percent. And that would be fine, but there has been essentially zero additional oversight to match that growth. This has led to some problems. In February of this year, the GAO confirmed that I think many uh on this committee already suspect that the FMP had no fraud controls, no assigned lead, no risk framework, no debarment list, nothing. It was a program without control, meaningful control. And that had some negative outcomes. We had one in Panama. Uh, just to list out what this cost, uh, a group of criminal doctors and pharmacies working together billed the VA for services that were never rendered. This cost taxpayers an estimated loss of sixty-seven million dollars. After the VA finally suspended thirty-six different providers, the projec- they uh the VA projected that the savings from fiscal year twenty-twenty-five alone were in excess of twenty-five million dollars. That's what action looks like, but imagine if we had prevented it in the first place. On top of that, the program still runs on legacy IT and males' paper checks. in violation of federal law. Veterans are waiting eight to ten months to get reimbursed by this program. So, what does this bill do? It's got four fixes. Number one, payment caps. We've gotta reimburse at the lesser amount of billed or at Medicare rates. This is something that will absolutely close the loophole that Panama exploited. We've gotta do Death Master file checks. No payments to or by anyone who's listed as deceased. The IRS does this, Medicare already does it. The FMP does not, but it needs to. Third, we've gotta have a dedicated fraud coordinator and a debarment list. There's gotta be one person accountable, mandatory IG referrals, and a do not pay list that is distributed directly to veterans. And fourth, it creates a third party administrator and a hard IT deadline. We've gotta modernize claims processing and we've gotta get this done within one year of enactment. There's gotta be no more stalled migrations. Veterans who retire overseas, I think we all agree, don't stop being veterans. They've got to stop navigating a fraud riddled system to get the care that they have earned. The VA agrees with these recommendations. It's time to actually implement these recommendations to hold the VA accountable, not just ask them politely. Panama, in my opinion, was the canary. If we don't act, we're choosing to let it happen again, and that'll happen on the backs of our veterans and the American taxpayer. Thank you and I yield back.

Thank you, Representative Harrigan, the chair now recognizes Representative Bresnahan for three minutes to speak on his bill.

Thank you, mister, mrs. Chairwoman, and to the ranking member for inviting me here today to discuss my legislation, to protect seniors and veterans from healthcare fraud act. Many of our nation's veterans who receive healthcare through the VA are also enrolled in Medicare, and some are eligible for Medicaid. While the VA and the CMS currently operate under a computer matching agreement to help reduce improper double double billing under traditional Medicare, the information sharing is limited and does not extend to Medicare Advantage or Medicaid. As a result, the agencies face unnecessary challenges identifying and preventing improper payments leaving tax dollar taxpayer dollars vulnerable to waste and abuse. My legislation builds on existing agreements by expanding information sharing to include both Medicare Advantage and Medicaid. Specifically, it directs the VA and the Department of Health and Human Services to enter a memorandum of understanding, establishing reciprocal access to enrollment and billing information, giving both agencies the tools they need to better detect improper billing, prevent fraud, and protect the integrity of both these critical health care programs. The MOU would remain in effect for two years and would support improved oversight and coordination between federal health care systems, for the purposes of preventing double billing. The bill would also require a report to summarize the results of the agreement and assess whether the data sharing partnerships successfully reduce duplicative and improper payments. This is a common sense solution that should have been implemented years ago. Veterans enrolled in both VA health care and CMS programs deserve a more efficient and accountable system that protects their benefits, safeguarding taxpayer dollars, and ensures federal health care resources are used as intended. Thank you again for having me here today. I hope I can continue to work with the members of this committee to advance this legislation and I yield back.

Thank you, Representative Bresnahan, seeing that n- uh no other members wish to uh speak, um we will forgo a round of questioning for the members until after the witness presentation. For those off-committee members, you may remain uh here to ask your questions, your, the witnesses' questions if uh time is feasible. I n- uh our first panel is already at the table. Joining us from the Department of Veterans Affairs is Doctor Lisa um Arfons, Acting Assistant Under Secretary for Health. for the VA's Office of Integrated Veteran Care. She is accompanied by Doctor Mark Koeniger, uh, VA's Assistant - Acting Assistant Under Secretary for Health for Patient Care Services and Doctor Mark, uh, Koelbelja, VA's Executive Director of National Programs for Veterans Health Administration. I'll ask the witnesses to please stand and raise your right hand. Do you sw- solemnly swear that the testimony you're about to provide is the truth, the whole truth, and nothing but the truth? Uh, thank you, and let the record reflect that all witnesses have answered any affirmatives. Doctor Afrens, you're now recognized for five minutes to present the department's testimony.

Thank you. Chairwoman Miller-Meeks, Ranking Member Brownlee, and distinguished members of the subcommittee, thank you for the opportunity to testify today on a number of bills affecting VA health care programs and services. I am joined by Doctor Mark Koeniger, Acting Assistant Under Secretary for Health for Patient Care Services, and Doctor Mokh Krabelya, Executive Director of National Programs for VHA. I will briefly summarize VA's positions on the bills we will be discussing today. Additional details are provided in my written statement. VA supports the intent of the Veteran Burial Timeliness Timeliness and Death Certificate Accountability Act, and looks forward to working with the committee to address two issues. VA supports the intent of the WINGS Act to study long-term physiological and psychological effects of military aviation. And we also look forward to working with the committee to address some concerns we have with the specific language. VA supports the underlying objective of the draft bill to expand eligibility of veterans with service-connected disabilities who reside in certain territories, or the freely associated states, for beneficiary travel. However, the bill is unclear on several critical aspects regarding eligibility and scope of benefits. We welcome working with the committee to resolve these issues. Regarding the VHA's Personnel Transparency Act, VA supports greater transparency but has concerns about shifting from quarterly to m- monthly reporting. Monthly data are susceptible to human resources processing variation and short-term volatility. On the Foreign Medical Program Integrity Act, VA strongly agrees with the need to modernize and strengthen VFMP oversight, and we agree with GAO's recent findings on fraud risks. However, we recommend amending the bill to address the issues VA's is experiencing with the FMP and to avoid creating additional issues. We would welcome working with the committee to address these concerns. VA does not support the Veterans Stand Act because VA already provides annual comprehensive preventive evaluations to all veterans with spinal cord injuries and disorders. We are also concerned about the requirement to consult with device manufacturers in broad reporting mandates. VA does not support the fostering trust act as written. While VA shares the goal of congressional oversight on veteran suicides, the bill also raises significant privacy con concerns and could create barriers to community providers' participation in VA care. VA does not support the VHA open policies act, but is dedicated to transparency for veterans. VA already maintains a public web site with directives, handbooks, and notices. Publishing internal operational guidebooks would not improve public understanding but would impede VA's ability to update guidance quickly. VA does not support the biennial staffing report bill as its requirements are substantially duplicative of existing statutory reporting obligations including the VA Mission Act and Inspector General mandates. VA does not support the Tours Act as written. VA already has authority to study chaplaincy in spiritual care in relation to suicide prevention, and we plan to begin that work this year. Finally, VA does not support the three draft bills regarding data coordination between VA and HHS. VA agrees with the premise, we should not pay twice for the same services. And VA already has a data matching agreement with CMS towards that goal. However, these bills do not grant new authority and, more importantly, they do not address the core obstacle. Current law limits how VA and HHS can share billing and payment data. VA would welcome working with the committee on legislation that directly addresses these data sharing limitations. VA remains committed to working collaboratively with this subcommittee to improve care and services for veterans beneficiaries and their families. We appreciate the opportunity to share our views and are happy to answer your questions. Thank you.

Thank you very much, uh, Doctor Afrens. The chair will now recognize ranking member Brownlee, uh, for five minutes for any questions she may have.

Uh, uh, thank you to the VA for being here, and thank you for your testimony. Excuse me. I wanted to talk briefly about the, um, TOURS Act, the suicide prevention and chaplaincy engagement. So can you briefly expand on the ways that VA is currently incorporating chaplain services and religious organizations in its suicide prevention work?

Yes, uh Mark Cabalia, uh National Programs, and I'm happy to take that question. Thank you for asking it. Um so the chaplains are a critical part of VA care, spiritual care to veterans, um and has long been recognized as something that uh veterans uh uniquely deserve.

I wanna know how you're coordinating them into suicide prevention, specifically.

Sure, I'm happy to. The several several initiatives are all already underway one is uh the chaplains are participating in a guided therapy training for suicide prevention they have several ongoing projects with our office of suicide prevention to further enhance that cooperation chaplains are also uh participating in several projects with our readjustment counseling service to integrate chaplain services in suicide prevention at our vet centers

Thank you for that. I have heard from outside groups like the um American Humanists Association and Center for Freethought Equality that the process for becoming a VA recognize um uh ecclesiastical endorsing organization can be cumbersome. How many pending applications does VA currently have And how long have these applications been pending?

Uh, thank you for that question. I'll I'll take that for the record and we'll get you accurate information on that.

Well, I would like to get that information from you. Uh, recently DOD reduced its list of Excuse me. reduced its uh list of recognized religious faiths and belief systems from two hundred and eleven faiths down to just thirty-one. Given this drastic shift, it's likely that DOD may no longer recognize the religious faith or belief of some active duty service members. Does VA currently collect any data about veterans' religious beliefs and are are there any plans to limit the number of recognized religious beliefs at VA um as DOD has done?

Uh, we have no such plans.

Very good. So you will get back to me on the the other question on applications. Great. Um, so on the coaching and the care act, um, are you currently tracking how many non-caregivers call into caregiver support line and the kinds of services that they are requesting?

I believe w- uh, to answer that question, thank you for the question, I believe we have some of that information, um, and we can certainly get back to you with that, uh, but I don't have it handy with me today.

Okay. Um and can you tell me how you communicate to caregiver support line responders that non-caregivers can call the line and what resources do you provide to non-caregivers? How do you communicate that?

Uh our Uh yeah, thank you for that question. Our caregiver support program uh provides a broad range of outreach and education and they always talk about the services, the clinical and um behavioral services are available to caregivers through the caregiver support program so it is widely um provided as education and outreach.

So on the um Veterans Stand Act as drafted, does VA interpret the Veterans Stand Act mean that it would be required to evaluate veterans for any investigational investigational or non-V uh non-VDA approved vices?

Ma'am, we would um we would again, any veteran who has a uh spinal cord injury or disease is evaluated thoroughly by um a VA physicians. And we evaluate them in terms of what devices may be able to help uh with mobility and uh improved outcomes.

OK. So uh in the bill it specifies implantable spinal cord st- uh stimulators must be FDA a- approved but it does not include similar language for other a assistive technologies like spinal cord neuromodulation powered exoskeletons and speech generating devices uh what implications would that have for VA's existing clinical protocols and the development of future clinical protocols for veterans with spinal cord injuries or disorders.

Ma'am, any uh FDA-approved devices uh we would absolutely uh look at and evaluate um if those devices could be used to improve mobility improve um the outcomes of veterans then uh those are all potential options.

So you would only evaluate or current practices only to evaluate uh non or excuse me, FDA approved devices.

The FDA approved devices um we would consider for evaluation.

Thank you, I yield back.

Thank you, Ranking Member Brownlee. The chair now recognizes Representative King-Hines for any questions that she may have.

Chairman, so I wanna uh first of all thank you for going over the bill and and making recommendations as to how we can make it better. Obviously we wouldn't have a need for this legislation if we actually had a CBOC right, and so you know the thought behind this was how do we address an ongoing problem where there are just no services, and how do we ensure that the vets who have served w- wherever they live, especially in remote communities, can have access. And so Uh one of the things, one of the concerns that that you raised in your assessment of the bill is um the eligibility for travel. Uh and I guess I uh under current law uh you know beneficiary travel is tried is tied into specific purposes. And so I kinda wanted to kinda hear from you uh wha- how you think that that should be drafted. I'm certainly not trying to create any special uh privileges, you know, creating further financial burden, right? I I'm just trying to bring people up to up to par regardless of, you know, their the the geography that they live in and so what what what do you recommend that scope should look like?

Yes, thank you so much, uh appreciate that. Uh, really it's it's looking at for compensation and pension exams, vocational rehab opportunities, and really better defining what are unique needs for those veterans in in those areas to make sure that we are covering their beneficiary travel that is helpful for them.

Okay. So let's work together on that then, because I think you would have access to better data than than we do in terms of those types of services that should be covered, right?

Yes ma'am.

I think the other concern that you r- that you raise is that um you know, whether this legislation creates a whole new program or does it rely on existing authority and so I wanted to get further clarification from you um so if the bill explicitly states that the expanded eligibility operates consistently with existing authorities would that address your concern and and can you just you know further flesh out the concerns with regards to covered jurisdictions freely associated states so that you know folks who are tuning in understand where the underlying concerns are.

Yes, that thank you so much, um and and better alignment and understanding with uh thirty-eight USC one eleven would be helpful along with then section seventeen twenty-four in coordination with COFA um looking at those collectively would give us a better understanding of making sure that we have consistent language um and that we are covering territories with the freely associated states and then other uh very small islands in the Pacific that we also want to understand if those should be covered as well, again providing veterans with the most opportunity for for coverage.

Yes, I think, you know, you you mentioned that we l- had left out Wake Island, I think it was intentional, right, because I don't think there's any vets living there anyhow and I and I'm very you know as a Macro- as a woman from Micronesia I'm very well with the COFA States Agreement and so I'm certainly not trying to you know, overstep authorities here. What I'm looking for basically is just technical assistance to how to ensure that whatever are c- you know uh are allowable under existing agreements and to ensure that we're not overstepping lanes, right? Uh, we're not getting into international agreements, we're just literally sticking with what's provided pro- currently provided for under existing statutes. Um, the other thing is You you made further recommendation for reforms like prepayment instead of reimbursement clearer you know and and improved payment rates. Can you flesh that out just a little bit for me in the last minute that I have?

Sure. That affects all beneficiary travel and we do recognize opportunities again to streamline our beneficiary travel process for veterans. Um and as you point out with the thirty percent service connected are there opportunities for us to expand on that? Uh so with this bill do we then naturally question what we're doing uh for beneficiary travel within the States as well. And so that is worth a conversation. But we look forward to working with you.

Yeah, I wou- I wou- really uh love to have a conversation to just go over perhaps some like uh technical amendments, right, as to the language of the bill, but also to kind of just look at the travel program in and of itself, and how do we make it better for everybody.

Yes, ma'am. Thank you.

Thank you, Madam Chair. I go back.

Uh, thank you, Representative King-Hines. The chair now recognizes Doctor Dexter for five minutes for any questions she may have.

Thank you, Madam Chair. As we've discussed, veterans disser deserve timely, transparent information about how the VHA delivers their health care. This is basic. It's a standard that we should all agree on. As a physician, I know very well that policies affect the delivery of care. And patients need all the relevant information to make a decision and to be able to access care promptly. The VHA Open Policies Act, which I lead with Doctor Murphy, addresses exactly that. The Veterans Health Administration must be an entity veterans can trust. Transparency is fundamental to that trust, and Congress has a role in part- and as a partner in supporting the VHA in upholding your accountability. Your testimony highlighted perceived implementation challenges with making more VHA policies publicly available. I am committed to ensuring we resolve those, um, challenges to make sure that timely access to information is delivered to our veterans. So, Doctor Afran's, our fr- our funds, I'm sorry, what is necessary to achieve this outcome? Making VHA policies as accessible as they are for CMS. Um, I just accessed it very easily on online travel policies and others. It's updated regularly. Please help me understand what do we need to do for the VA to uphold the same standards that CMS is.

Yes, and thank you. F first of all, we support transparency, and with that transparency does make an understanding that veterans then, when they receive that information, have a full awareness and can interpret it. If we are providing policies and guidebooks and documents that veteran and the public cannot understand, I don't think that that uh advances the intent of full transparency in this in this situation. Um, what we are worried about, however, um, are the delays that would be associated with making public documents five O eight compliance. Um, and that would then keep us from actually, um, putting out and delivering very technical, detailed, um, uh, standard operating procedures that we sometimes have to turn around very quickly uh to get out to the field. Um, so we are concerned that, again, transparency that we are committed to, there would be a misunderstanding if we are not providing the right documentation that that veterans can easily assess.

So help me understand how it's more complicated to get that information available to veterans than it is to other civilians. Um, CMS is able to do it. Why why is the VHA not able to do it?

So, public period, we wanna make sure that it's five O eight accessible and compliant, so anyone has access and an understanding of that data. So we don't think that it's different. We're welcome to work with CMS and understand how they're doing it, um, so we can understand how to get that guidance out.

Yeah, and I I think our veterans, um, already are frustrated with access to information, and so there should be a h higher level of commitment, I think, at this point, trying to make sure that they are able to access that. Um, for now I I understood that your stance is that FOIA requests, um, are one way, um, that veterans can access information. And I'm just gonna note for the record you are nodding, so, um,

Yes, ma'am.

i- i- i- How long does it take for a FOIA request to be fulfilled right now?

We'll take that for the record.

Okay. And, um, I would also submit as a member of Congress who asked us a bipartisan question, It took us five months with escalation to the secretary themselves to get the information. I suspect FOIA requests are not gonna be within ninety days of a bill being passed or thirty days of an update. I just will p- stand on that that is unacceptable for our veterans, especially those needing to access care. We have had um committee staff trying to help find out travel um policies and other things and even here we can't access that so not only do members of congress and our teams need access to this, but veterans and their caregivers and care providers need access. I've been in a VA on the internet. I cannot be the one as a doctor who has to find that information for our veterans. We are already um impeding the ability to deliver care for our physicians,

Yes, you are.

so and our other VA employees it should be publicly accessible as urgently as possible. Thank you, Madam Chair, I yield back.

Uh, thank you, Doctor Dexter. The chair now recognizes uh Representative Kiggins for five minutes for any questions she may have.

Doctor Arfons, military aviators have been exposed to repeated G forces, hypoxia, vibration, and other occupational hazards for decades. What measures, if any, has the VA taken to test and treat our aviators due to long-term neuro neurological effects of these exposures and do any studies even exist?

So I

Sorry, that'll be fine.

Congresswoman, um, uh, thanks for the question, and and your question uh actually resonates personally with me. I uh am I spent thirty-six years in the Air Force as a uh former aviator and flight surgeon. I have over twenty-two hundred uh hours in military in a variety of military aircraft to include fighters and helicopters. So uh so yes. uh this is very important. The uh VA uh again looks at has an has an office that looks at a variety of um pot- potential issues or exposures that uh service members had uh during their time that they were uh again in the service uh to include uh aviation type exposures. I mean you're probably familiar with uh uh fuels exposures and things like that, so there are ongoing studies in a number of areas that look at that. Um I also had while on active duty had the opportunity to serve as a commander of the human performance wing i at Wright-Patterson Air Force Base, um and again uh in that capacity we did uh a lot of research in those areas, also worked with the Naval Aeromedical Research Lab that was co-located there. So I am very familiar with uh the aviation type issues that uh could potentially exist longer term.

So do we make that connection then with former aviators when they when they do show up for mental health especially diagnosis and treatment do we uh is there a s- are they looked at differently using that background that you kinda described. Since seems like there's an awareness, but I know that uh, you know, and I feel like we we haven't identified really even what some of the long-term impacts are of aviation, especially carrier landings. I feel like that's a little bit of a different sub-note slide to the Air Force, but uh, but we do land rather quickly on carriers, and so that that impa- that jarring impact, which you and I have both as a helicopter and an Air Force pilot probably never experienced but just listening to those people in my district that's that's an just an added factor when we think of things like tbis and even you look at sports injuries repetitive concussions, these types of of things so uh so I wanna make sure we're looking especially at a at our carrier pilots a little bit uh differently, but all aviators and so I'm just wondering if if we are uh making that Mm.

Yes.

connection if they it takes so much for them to show up for to even ask for help, so when they do show up for ti- some type of mental health treatment are we are we looking at them in a different light?

So, um, I would have to, uh, get back to you to find out if those specific type of questions are asked, you know, say during a mental health visit. I know that when, uh, military exposures are talked about and there are certainly, uh, instances when veteran come when veterans come to the VA that those are focused on. I again, I don't know that that those are brought up at something like a mental health visit or other visits per se.

And that's what this bill hopes to accomplish, the fact that we can make that connection, that that either uh, you know, is it is it uh as a repetitive concussing, is it some type of exposure, is it what is it that we have sub you know, subject our aviators to, that we can make that connection so that we can better help to to test and treat for whatever their their mental health diagnosis is. I mean uh depression, anxiety, there's there's some you know big ones, but then there's also maybe a little less noticeable that are uh that y- you know maybe personally they see or their family members see or caregivers. So so I just wanna make sure we're we're kind of s- at least studying, looking at it because ev- again evidence-based research is always where we start in healthcare. And then uh just real quick, does the VA work with or employ in flight surgeons? You know y- you know you'd you mentioned flight surgeons and those are who are assigned to us in squadrons who are our health care providers. Those are the people you're gonna come to first line of defense. So so are we are we making that connection? They are probably have the most expertise. They are, you know, sources of wealth of experience. Does the VA make any type of connections with flight surgeons?

Um, so that specific question I'm I'm unsure of. Um, but what I can tell you is clearly there are people uh or there are physicians who are employed with VA who were flight surgeons, like myself. Um we also have the uh Health Outcomes and Military Exposures Office, and they actually focus on uh any type of military exposures to include uh specifically aviators and all of the different uh environments uh that aviators So that office can specifically uh start to look at um the medical literature to see what kind of studies have already been done in terms of exposures um and uh to your point uh if they can't find anything then uh look and decide do we need to set up a study in this particular area because there is no health related data on it yet.

Mm, good, and that's what our bill helps to accomplish. Thank you very much, Ilden.

Thank you. Thank you for yielding. The chair now recognizes Dr. Conaway for five minutes for any questions he may have.

Uh, thank you, uh, Madam, uh, Chair, and uh thank you and uh ranking member for bringing us here today. Thank you, uh, Doctor Arfrans and your um fellow physicians on the VA for presenting yourself to us today for questions. Um, we can all agree, uh, that more needs to be done to eliminate the instances uh in which both the centers of medicare and medicaid services and the va are billed or billed for the same episode of care by a veteran uh this sort of double billing question currently medicare advantage plans receive capitated payments which are meant to cover the entire cost of an enrollee's healthcare and but as it turns out the vha often uh provides the uh the payments for those episodes of care Um, and so, uh, it would appear, uh, uh, that veterans are paying for, uh, Medicare Advantage plans and then because they have a VA, a benefit, uh, the VA is sort of carrying the bulk of - of the payments, uh, for episodes of care, um, and, uh, episodes of health care needed by the veteran. Um, we are all supportive, I presume, to eliminate, reduce, uh, improper, uh, billing, um, improper payment, duplicative uh bills being proposed and sent forward. Um the proposed draft uh that we heard about today would direct the Secretary of Veterans Affairs to seek uh to enter into a memorandum of understanding with the Secretary of Secretary of Health and Human Services to avoid uh these duplications uh and erroneous billings I just mentioned. Um again in situations where the VA um administration is providing care for someone with a Medicare advantage plan. Uh my concern is that that draft that we've heard today is not uh doing enough and that um uh to deal with this uh these concerns and that the the Medicare Advantage plans are improperly uh gaining revenue um that should otherwise um not be paid to them so um Ms. Horfans can you tell us what the um what the VA is doing uh to correct this problem of duplicative payments or bills and payment for services uh that are being paid for by the VA when someone has a second plan, that is Medicare Advantage, uh that is uh designed to pay for their care.

Yes, thank you. Uh, so as we announced last year, we are already in an agreement with uh HHS looking at duplicate payments. Um, up to this point CMS has uh has uh recouped uh most of the funds with that. VA has it's on its way to recouping about five million in expected funds with that data sharing. point one million right now. Um, this is of course not the bulk of our healthcare delivery, um, and our community care network under our TPAs as, um, the the contracts already capture duplicate payments that to assure that VA is not paying. Um, so with the structure of CMS and then the varied structure with with VA, those recruitment efforts are a little bit different. Um, but within v a and our community care network we already have reduced improper payments down to around two percent. So we are doing a lot with with our t p a's in this work. Thank you.

Oh very that's good to hear. Uh we did have uh introduced in uh a previously a bill h r forty f seventy seven the garbage veterans health care act um this bill came through the full uh committee here and uh would give the authority uh for uh the veterans uh for your um uh administration to bill medicare advantage plans is that w- that's what you're doing actually to get this recoup this money are you billing them um and i don't you might not be using this act i guess it's not in law but um is this uh i don't know if you're aware of it but that was bipartisan billing and we think that might also help you do the job that we all want to see you do

yes thank you so we bill separately through uh our t p a s our t p a s bill their providers and then we pay our t p a s In terms of the um agreement that we have, we'll get those details to you to to explaining what we're what we're paying and who we're we're getting funds from.

Thank you for that.

Thank you.

I just wanted to move on, I think I have a little bit of time uh to deal with um uh to ask questions about a bill we heard from today by Representative Min uh regarding uh suicidality among our veterans and um uh does the VA a track um episodes of suicide that occur outside of of the uh Veterans Administration out of uh outside of Veterans VA facilities that is.

We're so the VA is made aware of some of those completed suicides um and the typically it's n- we're notified either through the third party administrator or through local physicians um or other health care providers that might be associated and and sometimes the family will um alert us that um a veteran that we may have had shared care with a community provider. Um.

There's no process to search death certificates that identify this you're you're it's you're gonna have to receive this information. You don't have any,

You have

I guess, proactive way to get at this question.

That's correct. We don't we don't have a system in place that allows us to systematically do that.

Uh, thank you, uh, Doctor Conaway for yielding. The chair now recognizes Doctor Bergman for five minutes, or General Bergman for five minutes for any questions you may have.

Is there a Hollywood line in there, Doctor General? Whatever general w- okay, never mind.

Surely.

Not general hospital anyway. Not a soap opera. Uh, let's start with the rhetorical question first. Not to be answered, just to be thought about. Is the VA the very best place, entity, to evaluate and monitor spinal cord injuries and advance new technologies? Cuz when we think about places like the Mayo Clinic or Johns Hopkins or whatever, not every entity is a specialist in everything, but I think that's something that we need to consider here, as in this particular case we look at what is the VA spectacular at and what are the things that maybe you could get it done better outside and the VA becomes a recipient of good good advance uh you know technology. So uh Doctor Arfons, your written testimony suggests that tracking how many veterans with spinal cord injuries and disorders that are evaluated who's offered devices, who's qualifies and who declines, you know, all of those bureaucratic steps would impose too great a burden to report to Congress. Um, you know, does that make sense? Is there any burden that's too hard?

General General Bergman, um, the first of all, I think that the VA uh through its uh spinal cord injury

oh let me let me i don't wanna cut you short but eh compare it to the advancement of the electronic health record since we're bringing that that's been a long road a road paved with more than potholes but when you have advancements like the electronic health record how do we equate the two so we can get results

um sir if i understand your question correctly i I think that by bringing that uh health record online, the ability to track uh veterans, particularly veterans with spinal cord injuries and uh disorders through the system will become a lot easier um and a lot a lot more uh effective and efficient as veterans move around the country.

So we're gonna get better, but right now we're opposing some things Because we're not there yet?

Well, I didn't say that we were opposing anything.

I heard I thought a couple of the doctor said something about you you oppose

Uh.

some things. How do you how's this where does the VA sit on this?

Yeah, um, sir, I'm not sure I understand the question. Sit on what, the electronic health record?

Exo exo exoskeleton.

Oh, the exoskeletons. Okay.

It's very visible actually.

I understand, sir. The exoskeletons uh the VA is certainly supportive of the use of exoskeletons um in veterans that have spinal cord injuries and uh disorders um but what we also do is we recognize that those exoskeletons also come with potential risks. And so uh what we do is

You know, you know, anybody who served in uniform, and you served in uniform, and I thank you for your commitment.

Yes, sir.

we naturally are risk-takers to an extent, and for any bureaucracy to not be willing to take appropriate risk for mission accomplishment, which basically means better technologies. And I, we could, we could talk for a very long time about advancements in medical technologies. Uh, I was involved in that, uh, market for thirty-plus years, so not without I was I was around when da Vinci became reality. And that was not Leonardo.

Okay. Yes, sir.

So, give me a quick answer, not a bureaucratic answer.

Ab- absolutely, sir. Um, we absolutely, uh, understand that sometimes you do take risk. But again, in the medical profession, you know, we start off with first do no harm. And so we wanna make sure that the devices are evaluated appropriately both in terms of will they be beneficial to

ok but but the point is there are other entities think of dean kamen when he when he invented what he invented is this va um psychologically do you wanna be part of the solutions going forward

Sir, absolutely.

Or just evaluating what somebody else has brought to you, and then having a process that takes too long, cuz these veterans live every day with limited mobility.

Y- sir, the VA is not just, uh, reactive.

Okay, uh, my time is my my t- my time is up, but do you get the point? The VA can do so much better, but sense of urgency within any bureaucracy is essential for better outcomes. Madam Chair, I yield back.

Thank you very much, General Bergman. I now recognize myself for five minutes. Doctor um Arfons, in your testimony you state that uh the VA strongly agrees with the need to enhance and improve the foreign medical program and supports the bill subject to amendments. What specific amendments does VA need from Congress to strengthen program integrity, reduce fraud, waste and abuse, and protect veterans receiving care overseas?

Yes ma'am, thank you. Uh we do appreciate this bill. Uh we do, as I mentioned previously, uh is understand the scope of authority with FAS and COFA um to make sure that we are aligning and providing those veterans in foreign countries um equal and equitable opportunities. Um the bill also suggests that we use Medicare rates and Medicare rates only, uh when discussing the uh lesser of the two billed charges or federal rates. Uh we would like to explore TriCare. TriCare does have international rates that may be uh, more appropriate for this this set of veterans and for this type of healthcare delivery. So we would like to see that language expanded. Um, there is the the language around the reimbursement of claims after a provider passes away. Um, this is not necessarily a a sign of fraud. Um, we do want to make sure that claims that have been received after either a veteran passes away or in in cases when a provider of that care may pass away, that they are still paid for their services when either of them uh were still alive. So we would like clarity in that. Uh, there is no appeals process right now for veterans and the providers. We do think that that is an important piece of of legislation. Um, and then finally we have some concerns that notifying all FMP enrollees of someone who may be on a uh disbarred list may be confusing, especially for those veterans who have no intention of traveling to Panama or other places.

Thank you. Uh, Doctor Erfrins, the VA sites data showing nearly one third of veterans who use an exoskeleton during the trial period decide against using it beyond that trial period. But the frame ignores the other side of the VA's own statistic, roughly two thirds of those veterans do not decline continued uh use. Now, I started out my career in the military as a nurse actually on a neurosurgical unit at Walter Reed. uh, taking care of spinal cord injuries, halos, striker frames, and then taking care of patients once they've left their military military facility at home providing care. So, in something that can help a veteran to be independent and functional, especially our young veterans, why is the VA relying on one-third of those who do not continue as a reason to oppose the bill rather than focusing on how Congress can improve access for the majority of veterans who do use and benefit from this technology.

Ma'am, we we do not oppose the bill because of the one-third of veterans who don't use the device who don't end up using the device. Um, we would be happy to work with the committee on the verbiage cuz there are aspects of the bill as it is written uh that would be problematic for the VA and so we'd be more than happy to work with the committee

Thank you. We'd be happy to work with you so that our veterans that have spinal cord injuries get access to this technology and can lead productive functional and uh lives uh, that are um important to them as well. Um, Doctor, uh, our funds, roughly seventeen veterans continue to die to die by suicide every day. Congress has a responsibility to better understand every intervention that may help reduce this number. and we've not seen uh those outcomes uh uh reduce at this time. Your testimony states that no additional authority is needed to accomplish the intent of the Tours Act. However, if the VA already has the authority to study the relationship between chaplaincy services, faith-based programs, and veteran suicidality, why has it not done so?

Uh, thank you for the question. Uh, yes, we recognize that we have the authority and we're actually planning to do exactly such a study.

Uh, thank you. I'm gonna yield back, uh, the balance of my time. On behalf of this subcommittee, I wanna thank all of you for your testimony and for joining us here today. You're now excused, and we'll wait a moment as the second panel comes to the witness table. Welcome everyone and thank you for your participation today. On our second panel we have uh Brandon Lee Wilson, Chief Operating Officer, Asheville Bund Comm Community Christian Ministry, Brittany Melissa Elliott, Marine Corps Veteran and Advocate, Chelsea Morea, Gold Star Spouse, and Alex Rich, Director of Data and Anal- Analytics, Common Defense Education Fund. Thank you all for attending today. I'll ask witnesses on the panel to please stand and raise your, where you can. stand and raise your right hand. Uh, Miss Elliott, if you prefer to sit, that's fine. Do you solemnly swear that the testimony you're about to, uh, provide is the truth, the whole truth, and nothing but the truth? Uh, thank you. You may, uh, sit. Let the record reflect that all the witnesses have answered in the affirmative. Mister Wilson, you're now recognized for five minutes.

Chairman, uh, Miller-Makes, uh, Ranking Member Brownlee, and distinguished members of the committee, Thank you for the opportunity to testify today in support of the Trauma Outreach, Understanding and Resiliency through Spirituality Act, commonly known as the TORS Act. My name is Brandon Wilson. I am a United States Marine Corps veteran and currently serve as the Chief Operating Officer of the Ashford Buncombe Community Christian Ministry, one of North Carolina's largest faith-based nonprofit human service organizations. For more than four decades, our organization has served veterans through housing, employment, behavioral health, health care and supportive services programs. Throughout my career, I've had the privilege of serving veterans on a local and a state level. Today I oversee a wide array of programs serving veterans experiencing homelessness, behavioral health challenges, and economic hardships. We are work we work to maximize every available investment and create sustainable solutions for the communities that we serve. Like many veterans, my own personal transition from military service was not a single event, but a process. While my uniform came off, the search for purpose continued. My faith played an important role in helping me navigate this very transition. One passage that become particul- particularly meaningful during that season was Hebrews ten twenty-four through twenty-five. And let us consider how we may spur one another on toward love and good deeds, not giving up meeting together, as some are in the habit of doing, but are encouraging one another, and all more as you see the day that is approaching. This passage encourages not to journey through life's challenges alone, but to remain connected to one another and encourage one another toward purpose and service. My support for the Tours Act is also shaped by loss. On August third, two thousand sixteen, I lost a fellow Marine and friend, Corey Hafner, to suicide. Like so many families and communities, we were left asking what connections, relationships, or protective factors might have made a difference. It was during this time that VA chaplains and the strength of my faith helped me carry me and my fellow Marines through their our journey of grief, reminding us that healing is not physical and mental, it is awfully, oftentimes deeply spiritual as well. Throughout my career I've worked with thousands of veterans facing an array of hardships. One lesson has remained consistent. Veterans heal, recover, and successfully transition through connection, not isolation. The veterans who thrive are often the ones who we are reconnected with something larger than themselves. family, community, service, work, and too many times, faith. These connections provide belonging, accountability, and hope. The Department of Veterans Affairs twenty twenty-five National Veteran Suicide Prevention Report identifies social isolation as one of the most significant risk factors associated with suicide and a common and co- and as a meaningful protection against it. However, there is then no mention or reference to chaplains in this report, as previously stated today. Chaplains have a long-standing and important role in the lives of veterans, and the impact is known and testified to by thousands of veterans who owe their lives to chaplains and spiritual counsel. Yet we have no record or data of the measurable impact on veteran outcomes. Chaplains routinely walk alongside service members and veterans through combat, grief, moral injury, transition, and recovery. They often help individuals navigate questions of meaning, purpose, guilt, forgiveness, and hope through this connection. The question before us is not whether chaplains are valuable. The question is whether we are willing to study their impact with the same rigor as we apply to other interventions within the VA system. If engagement with chaplains contributes to stronger social connectedness increased treatment engagement improved mental health outcomes or reduced suicide risk we should understand this relationship. The TORS Act does not replace clinical care. It strengthens our understanding of one potential component within the broader continuum of care. Chaplains meet veterans where medicine and paperwork cannot, at the intersection of the heart and soul of the human struggle. In my experience, chaplains are often the first person veterans trust with their battles, and the last person who would ever give up on them. We have spent decades studying what places veterans at risk. The TORS Act gives us an opportunity to better understand what helps them to heal. I respectfully urge the committee to support the TORS Act, and continue exploring evi- every evidence-informed pathway that make strength and resilience, improved well-being, and reduce suicide among the men and women who have served our nation. Thank you for this opportunity to testify, and I look forward to any of your questions. And I remain semper fidelis.

Uh, thank you very much, Mister Wilson. Uh, Miss Elliott, you're now recognized for five minutes.

Madam Chairwoman Miller-Meeks, Ranking Member Brownlee, and distinguished members of the subcommittee. My name is Brittany Elliott and I'm a medically retired US Marine Corps veteran. I'm honored to join you today now my second appearance before this subcommittee to discuss the critical importance of HR six eight three five the spinal trauma access to new devices act, or the stand act. While I gratify for me that I could not display the technology due to my recent hand surgery it's not medically safe to do so I am so grateful to General Bergman again for his reauthoring and I want to personally thank Chairman Bost and Congressman Neis and Gottenheimer for their willingness to co-lead this effort. My thanks as well to those who have agreed in a bipartisan fashion to co-sponsor the stand act I would also strongly encourage those on the committee the who have supported stand in the last Congress to do so again. It's no less important now. By way of background, I'm a medically VA medically eligible veteran and I'm fully paralyzed from my chest down as a result of a head-on collision with a drunk driver July three, two thousand fifteen, after which I was simply placed in a VA wheelchair and told I would never walk again. In twenty seventeen, I was introduced through social media, not the VA, to a device that I that I thought may have some utility for me if I were to ever regain the ability to stand and walk, the personal powered exoskeleton. I've approached my providers at the V Memphis VA and started pushing to gain access to the technology. After significant hesitation by my local providers, I was finally able to get them to agree to enroll me in VA's landmark study on these devices. The study was being undertaken at several VA facilities across the country, but not in Memphis. So I traveled at my own expense to the St. Louis VA Medical Center at Jefferson Barracks. I spent three weeks undergoing intensive training on the device and sex successfully completed the trial well in advance of the normal pace. I am a Marine after all. at which point I was able to take the device home and start using it. I took it everywhere. Unfortunately, the story does not end there. When I returned to the St. Louis VA in two thousand eighteen, my provider, the very same provider who entered me into the trial informed me she would not support my continued use of the device, and to this day has failed to provide sufficient rationale for that decision. The device was returned to the VA and I was left in a chair and told, you should get used to it because that's all you can expect. As a trained warfighter, that was simply not, and is not, good enough. For the next four years, yes, that's right, four years, I was engaged in a local and regional battle to regain access to the device that had already changed my life. Thanks to a forward-thinking physician at the Sunny Montgomery VA Medical Center in Jackson, Mississippi, I was seen, re-evaluated over the course of weeks, again on my own dime, and ultimately provided a new device, which I still have and use nearly every day of my life. I am eternally grateful to this provider as his disposition was not of one of an agency bureaucrat, but one that consider the entirety of the medical evidence and the utility of this device for me, a young, vibrant, and motivated marine. I'm also extremely pleased to the revised language in Stan specifically calls out the use of neurostimulation technologies that are now increasingly being used in the community and VA to help restore vital bodily function in areas often traumatized by paralysis. I have been very fortunate enough to to have experienced this technology as well. Again, in the community, and fin- And again, not finding about it through the VA, but on my own, since my VA will not provide it. And I do believe this has enormous potential for me and other veterans like me. While my exoskeleton affords me the opportunity to ambulate, these technologies return to me some of what was lost in terms of my ability to better manipulate my hands, reduce spasticity which can create pain and s- and can make daily activities a challenge, ultimately easing what would normally be simple everyday tasks. These fights should not need to happen. But the system in many cases, it seems to me, is built to protect itself instead of the veterans it serves. In my view, stand is critical for a few reasons. As you all know, the bill seeks to codify what VA is already supposed to be doing in the way of performing annual e- examinations I can tell you with absolute certainty they are not. I've only had seven exams over the last ten years, and I had to push for several of those myself. Additionally, I think it is imperative that VA assess the viability of assistive technologies for all veterans with SCI as simply forcing them to stay in chairs if they are clinically eligible for other devices is just simply not good enough. The Stand Act mandates this type of assessment. One thing I've learned over my years of fighting the VA is that clinical behavior is often very difficult to change. One way to accomplish change, however, is to demand accountability for those responsible for making clinical decisions. This bill seeks to accomplish this by two means, make the VA reportable to Congress on their success against the metrics I mentioned, and hold VISA and leadership accountable through their annual performance evaluations for those same metrics. In conclusion, Madam Chairwoman, Ranking Member Brownlee, and members of this subcommittee, I am confident Stan can truly be tr- life-changing for those like me, who have faithfully served our nation and dramatically reduced the burden on the veteran to have to engage in year-on-year year-on-year battles to receive the technologies they have earned through their service. Now yield back.

And thank you, Miss Elliott. Miss Murray, you're now recognized for five minutes.

Chairwoman Miller-Meeks, Ranking Member Brownlee, and distinguished members of the committee. Thank you for the opportunity to speak with you today. My name is Chelsea Morea, and I am honored to represent the critical importance of the Wings Act. I want to personally extend gratitude to Congresswoman Kiggins for introducing this act. Before today ends, as you've heard, an estimated seventeen veterans will die by suicide. In a span of eighteen months, three experienced Super Hornet pilots died by suicide. I am here today because one of them was my husband, Commander Doug Morea. Doug spent nearly twenty years as an F-eighteen fighter pilot in the US Navy. He completed six hundred and seventy-five carrier landings, eighty combat missions, and served as a top gun instructor. To many, he represented the very best of naval aviation. Imagine going from zero to two hundred miles per hour in just one second. Your brain slamming into the back of your skull. Now imagine doing that six hundred and seventy-five times. That is part of the reality we are urging Congress to study. But flight hours and credentials are documented and known. I came here to share what you could not see, what was happening inside our home as the suffering deepened. There is one sentence I will hear over and over in my head for a lifetime. Often said in pain in the middle of the night facing insomnia, Doug would say, " Something is off in my brain. There is something wrong with me." He searched for answers in every way he knew how. He looked into his family medical history. He spent the night hours researching symptoms and possibilities. But the one thing he could not do was get h- the help he needed. Why? Aviators carry a deep reality that being honest could cost them their entire career. Suffering in silence and the safety of their homes is often the answer they're left to. When his flight suit was on, he flew every fi- flight with precision. He led his squadron to win awards, exhibit top-tier readiness, and the highest of qualifications. When his flight suit came off, I saw the insomnia, the isolation, decision-making anxiety, and the slow loss of normal daily life. Sometimes getting out of the bed was harder than getting into the jet. If there's one thing I need you to remember today, it is this. Excellence can hide suffering, and official records miss what families see every single day. Research conducted by the Army Staff College on aviators shows the same gap. Nearly half screened positive for mental health conditions, such as depression. The official records captured only a small portion. Culture does not change without clear research and data. And one of the most powerful warning signs comes from inside the Navy community itself. In twenty twenty four, a former FAA-eighteen pilot and current Navy flight Navy physician submitted a memorandum for record warning about preventable loss of life in the strike fighter community. As part of that effort, an anonymous forum was conducted with active duty and veteran aviators. Of the twenty aviators who expressed concern, three reported having contemplated or attempted suicide. This is not a distant statistic. This is a room full of people trained to perform at the highest level, quietly carrying risk our systems are not fully seeing. In the days after Doug died, a junior pilot from his command reached out to me. He told me that when he had become med down and was struggling with depression and substance use, Doug saved his life. Doug was the reason he stayed in service and the reason he did not lose his life or his own family. That was less than six months before Doug chose to die by suicide. Since Doug's passing, I have heard from current aviators with twelve to twenty-two years of service who have been suffering in silence but told no one in fear of being grounded. Just last night, another pilot's wife texted me these words. He hung his flight suit up and he got the help he so desperately needed. That is the choice too many pilots and families are facing, hang up the flight suit or suffer in silence. This is why the Wings Act matters and is critical. A suicide should not be what's saving another person's life. We need to study what aviators endure while they are still here with us, and a culture that allows them to be honest before crisis. Thank you, and I'm happy to answer any questions you may have.

Thank you, Miss Maria. Mister Rich, you're now recognized for five minutes.

Chairman Miller-Meeks, ranking member of Brownlee, and distinguished members of the subcommittee on behalf of Common Defense. I thank you for this opportunity to testify regarding our positions on pending legislation. These are tough topics. I wanna start by telling you about a conversation I had on Friday. I went to a baseball game with a friend and at one point in the conversation, my friend pulled out these three coins that he carries with him everywhere he goes. Each of these coins represents a friend of his who served in uniform and went on to take their own life. My friend has had these coins with him every time that I've met him, for the whole time that I've known him. and I had no idea. This is entirely too common in the veteran community. This is why mental health staffing levels are so critically important. This is why I am so profoundly disturbed by the more than two thousand three hundred cuts to mental health staffing that Secretary Collins made at the beginning of this fiscal year. I'm here today to voice Common Defense's emphatic support for the VHA Personnel Transparency and Accountability Act, which is a discussion draft that was inspired by our work in analyzing VHA job cuts. Congress cannot hold VA leadership accountable without persistent transparency on facility-level staffing. This bill would close that gap. I'm Alex Rich, and I'm the Data Director at Common Defense, we're a veteran-led progressive grassroots organization. I'm also a former Air Force Special Operations Pilot and Crash Investigator. I carried that crash investigation experience forward with me after ten years in uniform into public health research and earned a PHD in health informatics. The state of veteran mental health care today is the most heartbreaking investigation of my career. According to the most recent available data, we lose seventeen veterans per day to suicide. The VA projects a thirty-eight percent growth in mental health uh demand between twenty-twenty-three and twenty-thirty-three. The VA consistently reports real struggles in staffing up to meet that demand. Despite all these facts, VA leadership recently engaged in an unprecedented wave of mental health staffing cuts. This spring, after months of delays, the VA finally sent Congress a one-time extract of the more than twenty-six thousand job cuts that they made around VHA at the beginning of this fiscal year. At Kalman Defense we were able to compare these cuts to the VA OIG's August report of severe staffing shortages. We found more than ten thousand instances where a facility reported a severe staffing shortage in a particular occupation in August, and received a cut in that occupation at the end of the year. We built VHAdata.org to help policymakers understand these cuts and recognize the strain that they put on VA facilities. You can see that strain in the wait times that VA posts every day on its access to care website. In January, at a Senate Veteran Affairs Committee hearing, Senator Blumenthal cited access to care data showing that new patients were waiting fifty, sixty, and seventy days for mental health individual appointments. Secretary Collins, instead of addressing Senator Blumenthal's legitimate concerns, said, and I quote, " As of January twenty-first, the national average for mental health care for new patients is eighteen point eight days of wait time." Well, detailed access to care data from the VA's own web site tells a very different story. Common Defense downloads all of that wait time data every day for every facility. And so we can tell you that on January twenty-first, the date cited by Secretary Collins, more than two-thirds of the facilities that reported new patient individual mental health wait times showed wait times that were in excess of the VA's twenty days or less target. In fact, thirty-one of those facilities reported wait times that were longer than ninety days. Facility-level data lets Congress see the details that define veterans' lives. The national average wait time doesn't mean anything to a veteran forced to wait more than three months for a mental health care appointment at the facility nearest them. The VHA Personnel Transparency and Accountability Act was written to address the lack of transparency facility-level staffing at facilities around the country. The bill would require the VA to publish staffing data in the form of monthly reports of encumbered positions at each facility by occupation code. These are the problems driving these wait times. And this is the only path toward holding VA leadership accountable for adequately staffing VA facilities particularly in the critical area of veteran mental health care. I appreciate your time and I look forward to your questions.

You know, as a pilot, if you had more than one button, your chances of pushing the wrong one was fifty percent. So, um, I'll try to reduce that. This is Brownlee, you're recognized for five minutes.

Thank you, General. Um, your humor is always welcomed in this committee. So, um. So, first I just want to say to Mr. Wilson, Miss Elliott, and Mrs. Morea, thank you for your service, and Mrs. Morea, thank you for your husband's service and your service for to our country. Thank you to all of you for your service. Um, Mr. Rich, I I just, you know, I wanted to go back, um, and sort of take a a a deeper dive and what you're saying about data transparency, wait times, et cetera. So, um, why is it so important that Congress and the public also have access to facility level data on the number of positions that are filled within each occupation? And how could this help us better understand VHA's capacity to meet veterans' needs for health care services?

Thank you, Congresswoman, for a for a while. I was a teaching fellow in healthcare operations at the Yale School of Management, and when I was there I founded a practicum program where we put students into the Yale New Haven health system to deal with these kind of queuing theory and wait time problems. What I would teach my students is that they could not start their first process improvement meeting until they had access to three buckets of data. They had to have staffing, demand, and wait times. And that staffing data doesn't mean how many you budgeted for, it doesn't mean how many vacancies you have. It means how many people are actually there doing the work to serve the patients. So what we saw at the beginning of this fiscal year was an unprecedented uh reduction in staffing that we didn't find out about for months. So if we had that facility-level staffing data and a on a monthly basis to be able to watch what's going on, we could understand what's going on with these wait times that continue to be problematic at facilities around the country.

Thank you. And um with regards to wait times, This has been an issue for me since I've been on the on the committee, really in terms of how VA calculates wait times. And for me, wait times is from the day you pick up the phone and ask for an appointment to the day you walk into the facility to be treated. That's that's wait times. But the VA doesn't count it that way. It's um, you know, it's picking up the phone and it's asking for the appointment and then it's about callback to confirm, you know, when you can come. I mean, there's a lot of different things that could happen in there, and they only count from when the appointment is confirmed to the point that um they walk into the office. And I've been trying to get them to change that forever. And so, you know, when Secretary Collins comes in and says, oh no, wait times are, you know, much shorter than you say they are, I mean, it it's probably he's he's looking at the VA's calculations, you tell me if I'm correct or not. Um, but I believe that he's just looking at the calculations in the incorrect way in which they in which they calculate, and that those wait times are are far worse. Um, so if you could talk a little bit about that.

Yes, ma'am. So there are there are two sides to my brain on this front. On the one front, I used to be a pilot, and pilot math means we don't want to do math. It's difficult to do math while you're doing a couple hundred miles an hour, so You want things to be as simple as possible. That's one end of the spectrum. The other end of the spectrum is I'm a health informaticist and I love net data and math and geekery. So in health informatics there are always challenges like this. How much detail do we need? How how fine grained do we need to get things? Uh, I think an issue with Secretary Collins's numbers is that he does not release the methodology and the data on which he bases his conclusions. And if he did, it becomes a math problem. It becomes something that we can all address and understand. And until he does, there are marked differences between what they publish on VHA uh access to care, and what he quotes in testimony. I think that's a significant issue. I think to your point that uh the lived experience of veterans uh waiting for care is different from what's reported is important, and we can continue to get better detail on that. But for right now, the way they do report it, we have significant problems around the nation.

Thank you. Um and um I just have a little bit more time, but I wanted to um With regards to uh Congresswoman Higgins's bill, the Wings Act, um in your testimony uh you elaborate on why it's important for VA to study the neurological effects of military aviation on you two pilots, and maintenance personnel. Can you talk a little bit about that?

Yes ma'am, as a as a health informaticist and a public health researcher, I am a strong supporter of all surveillance programs, particularly those that uh focus on military populations. I think it's incredibly important to track the kind of carrier landings and high G issues that this bill addresses. Uh, as a former military aviator, I also am acutely aware that air crew comprise a relatively small proportion of the team that puts us up in the air. And so all the maintainers who kept all my jets in good condition and kept me coming home safely went through the kind of harsh chemical solvent exposures, jet fuel exposures, noise vibration exposures that I did uh without any of the protections of the kind of anti-fatigue rules that I experienced as a pilot. So I think it's important to track what goes on with them as well. We're seeing high suicide rates among the maintainer population. Also, specific to you two pilots, they would qualify under this bill via their use of T-thirty-eights, but also an exposure that they experience as hypobaric high altitude exposure, which causes uh brain damage that you can see in imaging and neurocognitive effects that you can see.

Excuse me, excuse me, sir. I know the time has expired.

Yes, sir.

You just when you went entered hyperbaric and we could have a whole another hearing on that but it's not good.

I just wanted to say to Doctor Rich, thank you too for your service.

Alright. Congresswoman Kegans, you're recognized.

Thank you, thank you so much again to all of our panelists today, especially uh to Chelsea from my district for sharing your very impactful t- story with us, but uh so Miss Mrs. Maria I'd like you to talk a little bit about just why you started the Doug Moran Memorial Foundation and what you've heard are some of the biggest concerns among aviator families when seeking help through the VA and the barriers they're facing from from what you've heard you feel like the VA and and actually active duty uh as well that's a whole another discussion but have not done a great job in taking care of our aviators so what are those things and some of the stories you've heard

yes ma'am um In my experience, the common barrier that seems to show up both personally and in some studies that have been conducted in forums is a barrier around fear of disclosure to medical records um announcing or sharing a meta a mental health issue causes loss of um career trajectory and being downed. As a pilot, this is a particular barrier that pilots experience. And to the other port of your question, Congresswoman Kiggins, I would say I commonly hear um personal testaments from the pilots who are struggling with everyday activities such as memory loss. As spouses, we see and witness it in our homes where we're um continuing to repeat ourselves. Even making a choice, such as taking the trash out, is debilitating. to some of these pilots and individuals in the safety of their home. The increased anxiety and mood swings, um, continued fear even of being in social settings with families, all of these are indicative of brain trauma. The unfortunate part is that from my understanding, we have not studied brain trauma on pilots specifically. I believe that that's what this Wings Act is giving us the opportunity to do. to look at data and understand what's happening in the brains of these warriors as they search for answers.

Thank you. And pilots just, they don't complain. We were kind of taught that early on. You know, we uh we we certainly don't complain about things that could impact our ability to to fly such as mental health. So I think there's there's a lot of work to to still do to overcome those stigmas, those barriers to even asking for help, uh especially while we're still on the active duty side. But even as we as we transition out of the military into the veteran space I mean that's what this committee does is take care of of the the then the rest of our lives in that that longer time uh so really understanding what those psychological impacts are so can you elaborate a little bit more on why the the cognizant the the cognitive and psychological impacts on aviators brain health might be different from other military professions have you heard from other families who have received any treatment for issues like this from the VA uh or do you still feel like we are we're kind of looping all veterans together i want avators to and that's what this bill does just take a put them in kind of a special bucket cause i feel like we have never done that where we've looked at some of the special challenges so so do you do you feel like that that's true and then also have you heard of any success stories of people who have received va care in this special bucket

ma'am i'd like to address the second question first um I unfortunately have not heard of success stories where the VA has intervened, uh, specifically with the pilot community. It comes back to the barrier of fear in disclosing. I will say that aviators' exposure profile is very different, namely the common factor of g-force and blast pressure impact. As we all know, the professional sports community has studied this in football, and then a study was conducted by the Army staff um, specific to aviators. However, blast pressure, impact, g-force, and some of the conditions that the aviators are experiencing, to my knowledge, have not been studied or are still being privately held confidentially within their family. I hope that further answers your question.

Yeah, the, there's obviously much more work to do and, um, you talk about even the launching, the arresting of the of the aircraft uh just the in addition to all the other g forces pressurization electronic equipment all the things I just think that this is an important opportunity that we definitely cannot miss and so it's certainly been a privilege to to shed some light uh as one of the one of the few uh military pilots that we have here in congress but I just wanna give you an opportunity in the last few seconds is there anything else you'd like to share with the committee I thank you again for being here and sharing your impactful story.

The final thing I'd like to share with the committee is for this not to be the end of the discussion on this. I am curious if the committee would be willing to sit down with senior leaders in the Department of War and medical personnel to talk about this issue.

Great. Thank you again so much. I yield back.

Thank you, Doctor Conaway, you're recognized.

Uh, thank you, uh, General. Um, uh, Mister Rich, um, I wonder if you can share with us, um, as you look to compile very important data on staffing, we know in New Jersey we've passed uh laws on this um uh to try to make sure that in, particularly in um ICU units and labor and delivery and other uh parts of the hospital, uh that we knew what was going on there. And um it's it's not an easy it's not as easy as you might think to actually get those numbers and have Do you have some suggestions on how or what kind of technology or other um methodologies we need to bring uh uh to bear to this question so that we get uh the kind of accurate data that would allow us to take action uh to to improve um the situation with these uh this uh deplorable policy in my view of cutting uh all of these mental health uh providers when they're so desperately needed now at this time.

Thank you, Congressman. I think one of the challenges here is that there is never a a silver bullet technological solution to problems like this. These are often uh policy issues and issues around the way that transparency is or is not enforced on a system. Uh, one of the amazing things about the VA is the VA access to care web site that on a daily basis publishes these wait times, and lets the public see what's going on. We don't yet have that for staffing levels, but At Common Defense, we've built VHAdata.org that lets you see the trending in your district on any given day. That's updated every day.

I I pull I pulled it up on my phone here. I have to get access to it, so we'll take a look at that. Yeah.

Good to hear, sir.

Um, and um, I would just say that um, again, dealing with hospital staff to to get I mean, people are out, um, people uh, you know, call out sick, there's there are issues, this comes up all the time. Getting accurate data is just a difficult uh process and I do wonder um if there's a way to make uh that uh better um ms uh maria um can you give us some insight it sounds like it doesn't happen very often but are you aware of of mechanisms besides uh i guess ad-hoc ones where someone happens to socially involve with someone or some some relationship that allows a family member to get to a decision making in a in a chain of command uh um to address a concern about a a pilot or someone who's who's otherwise struggling.

Thank you for the question, sir. I am not currently aware,

Mm-hmm.

um nor did I experience a way to reach for help.

Mm. Mm. Uh, thank you, and and just um mindful of time, Ms. uh Elliott, uh and I might have missed it as I was um uh following your testimony, but could you um If you already said and I apologize to ask you to go over it again, what were you told when the device that you were using uh to uh help uh with your quality of life was taken from you or you were no longer had access to it, what was what explanation was proffered again?

I was simply told she did not have to give me a reason, she was the provider, and that her decisions did. There was no explanation, absolutely none.

Uh. No question about cost, availability, nothing like that. It was just that uh a decision was made cl- I guess I'm assuming a clinical decision, although you better be careful about assuming, a clinical decision was made that it was not something that uh that you needed? Uh I presume you disagree.

She didn't give any explanation a- at all, With with better assessments. she just said that she decided that I didn't need the de- tech technology and she was gonna deny me access to it, and she did not have to give me a reason why.

Uh did you at the time of hearing this, were you was there some so could you see someone else to get a second opinion, as of often happens uh on the economy as we say, I mean Uh, what was your sp- what avenue did you have to deal with that and try to get the equipment that you needed in the wake of hearing that, uh, distressing news?

I went to several other providers and asked them to please override her.

Within the VA system?

Within the VA system. I get all my care through VA.

I see.

And they all told me that because she was the clinician who gave me permission to do the study, um, because she said no without an explanation, they also would say no. I had one, only one clinician after four years prove me to me that you can use it, travel, and I and I'll see you, and then we can go from there. And I proved not only that I could use the device successfully and safely, and and only then did he write the prescription for me to have my own device. But thanks to him is the reason I have my device today.

And just and so it's a a an advice uh that has been approved by the FDA for um a particular clinical use that we're This was not an experimental device, it was one that was already approved by FDA or

It was already approved by FDA.

I see. All right, thank you, I yield back.

Thank you, Doctor Conaway, the chair now recognizes General Bergman for five minutes for any questions you may have.

Yeah, thank you, Madam Chair. Uh, Miss Elliott, I'm gonna kind of dig right into the middle here quickly because um more and more people are beginning to know your story because you've persevered through this for a long time. You've been that that beacon of hope for others, so You still shine brightly, thank you. Um, the VA has stated that the reporting requirements in the Veterans Stand Act would pull staff away from doing their daily work with veterans with spinal cord injuries and disorders. Is the VA even currently meeting the mark in terms of delivering this care?

Uh, veterans like myself, the annual examinations that are so frequently referred to in the spinal cord injury community. Uh, sometimes, you know, they don't happen or they're virtual. Uh, with a spinal cord injury, you know, how can you possibly provide a comprehensive annual examination virtually? Uh, we have required hands-on care. Our needs are different. Uh, but also, uh, if it was just a checkbox, they ask us about our meds, they ask us about mental health, they ask us about other things, why would this technology not easily be included into Yes, I'm interested, no, I'm not, and follow up an appointment. Um, it's not a difficult to s- to introduce it, but they just won't do it.

Um, if capacity, work capacity, number of people you have to do the number of tasks required is truly an issue, are there community-based resources that could train veterans on these vices instead? Example, you can learn to fly a couple of different ways. You can go through military flight training, or you could go through civilian flight training. In the end, you have a qualified pilot or maintainer. So are there other, you know, community-based entities who are could do this?

Yes, actually, um, the manufacturer would is more than willing to teach any community-based provider, uh, that's willing to take on the challenge to teach a veteran to use a device safely and effectively, uh,

So it's almost like in some ways, I mean, those of us who who for whatever reason uh maybe have gone through a little physical therapy there are different physical therapy pla- you know, therapists that we can go to, maybe, you know, slightly different, but the end result is is the same. So there's a variety of options

Correct.

for you. OK. Um uh do you think there are others or do you personally know of others who may be clinically eligible for the devices you have gained access to? but are simply just being told, " No, sorry."

I do. Because I travel with my device and I do frequent other VA events, I have veterans all across this country who al- only introduce the technology when they see it firsthand and ask me tons of questions. While I'm not a clinician and I can't determine if they're clinically eligible, they do have a spinal cord injury and but their providers will simply not ask. And if they do ask, they're being told no. I actually had a veteran uh out of Palo Alto, California. He was the very first veteran to ever get access to technology, and he could not wait to tell me how much it changed his life. I met him at Winter Sports Clinic and uh he got access to technology after a battle, but uh it took a while. And uh there's other veterans just like him that are begging for access to the technology and simply being told no. There's no capacity is the is the most common thing that they're hearing or they just aren't interested.

You know, I'd like to um I'm gonna yield back the rest of my time here in a second, but I think it's a very positive way to end the fact that that the Veterans Administration can be if it chooses a shining example of how things should be done let's see if we can figure out a way to make that happen and that

Yes, sir.

Yield, yield the rest of your time.

Oh, in that case I would like to yield the rest of my time to the chair.

Uh, thank you very much, Miss Elliott, in your testimony you described uh

Yes, they already have the authority, but they're not doing it. Veterans are begging for access to technology that they're just not getting.

Mm.

through the VA or through anyone else because the VA restricts spinal cord injuries to only get care through them. While there are providers in the community, we do get all of our care through them, and that is the unfortunate reality that we face every day.

And this is gonna, you know, you have to forgive me, I was a nurse taking care of spinal cord injury, uh, traumatic brain injury patients in the army when I was active duty. Then I took care of them post-active duty, uh, in their homes. And so I'm gonna apologize for this, it's kind of a technical thing. In the four years where you did not have your exoskeleton, so I think you'd be able to to give us an anecdotal experience. Uh, the exostelet exoskeleton permitting upright posture, did it reduce some of the muscle weakness and atrophy that one experiences by being remaining in a chair or in a bed? And the bowel and bladder function especially constipation that you get movement as we know, ambulatory movement helps in that regard. So do you think that there was these other health benefits that you obtained by having access to the exoskeleton that you could tell from the time you used it, the four years you didn't, and then having it again?

Absolutely. So a lot of people just think that exoskeletons are for walking. But veterans like myself have found that it uh helps with urinary tract infection, bowel function, in bone density, spasticity, mental health. Um, there's other there's several other factors with circulation getting actually to the feet, um, and moving those that that that it's not just walking. And I and I I think that's important for people to understand there are multiple health benefits that veterans like myself are reporting that we're seeing with access to this technology.

Yeah, I I know it was rather technical and, uh, given that it's lunch time it might not be the most uh polite thing to bring up in a hearing. But I think what's important about that is that we know that these are costly devices. Whether or not that comes into the decision making of the VA or not, I don't know. But my point in saying this is that you're preventing other further medical conditions whether it's muscle muscle wasting bowel bowel and bladder, urinary tract infections, certainly, me- uh, mental health and brain health, but venous stasis, uh, venous stasis ulcers, I all of that is preventing other medical conditions as a result of, uh, being non-ambulatory. So So thank you for your uh your truthfulness in answering that question, even though it's anecdotal. Um, Miss Maria, uh your testimony was very compelling. And I remember as a freshman uh Congresswoman coming uh here uh in the one hundred and seventeenth Congress and we passed uh in the FY twenty-two NDAA the Brandon Act, which said that a member of the military could address their superiors or could seek mental health care without that affecting their promotion, their job, um, or their ability to, to stay in the military. It seems to me that that would apply to aviators as well, and that aviators, uh, as long as they're not under, um, uh, you know, brain health impairing medication, should be able to do their job, but also receive the assistance of the help they need. They sh- as to you, as you very eloquently said, they shouldn't have to hang up their flight suit in order to ask for help. So do you think the Brandon Act is something that we could uh try to enforce upon I you know the military uh for uh you know aviators in order to get them the assistance they need and or PET scans and other things that we're passing in this committee to look at traumatic brain injury or trauma um or concussive injury blast injury which you're correctly describing in the back and forth on landing an air uh aircraft carrier.

Thank you for the question, and while I will say I'm not an expert on that particular bill, I will say that the aviation community is very unique in itself, in that um the direct effect of disclosing any sort of information related to mental health, be it therapy, needing therapy, or having symptoms, or experiencing symptoms like anxiety, immediately refer to um loss of flight status, not in all instances, but there is a very common factor um between aviators and disclosing of that information that impacts their career.

So, based on your testimony, you've made it clear that aviators can appear fully mission capable. Being a doctor, I I understand that completely while privately suffering from serious neurological and mental health symptoms. Based on what you've seen with your husband and his colleagues, why is it important for Congress to require proactive longitudinal study through the WINGS Act and it may even require imaging studies as well?

Thank you again for that question. Brain injury seems obvious from the outside, but we've never given aviators the chance to know. To date, we do not have data and research that studies their brains while they are alive. Referencing one study that I would like to share with you. Current technology cannot definitively assess microscopic damage, though it can detect changes in structural and functional connectivity, and injury, increases in inflammation, and other potentially relevant factors impacting the brain. This means it's critical to study aviators' brain activity and the impact of repeated trauma and G force while they are here with us. not wait until someone passes away to be able to study the impacts on the brain.

Uh, thank you very much, Miss Maria. Um, I uh yield back. I wanna thank all of our witnesses for being here today. Ranking member Brownlee, would you like to make any closing remarks?

I will just say that this has been a good hearing. I think there are, you know, some excellent bills here. I think there are some bills that with a few modifications that we can work on together, we could move all of these bills forward in a bipartisan way.

Uh, thank you very much, Ranking Member Brownlee. I could not agree more. As a matter of fact, uh, although uh, Ranking or Ranking Member of the full committee, uh, Takano is not here, uh, I would wonder if uh, he would wanted to be um, uh, receptive to having an amendment to his bill or modification to his bill, uh, in looking at uh, VA assessment of staffing, how long it takes the VA to actually hire somebody, IE from the application process to uh to the uh time they're brought on board. I know in my own personal experience over nine months I had had numerous job offers, still waited to hear from the VA, finally got a job from the VA uh or notified I was going to get the job, but by that point in time I'd already taken a job uh elsewhere. So I I do think there are some very good bills here especially uh as they care for our uh veteran community. Again, I want to thank all of our witnesses both from the VA uh and uh from Civilian Life for being here today. Um, sorry I ran out of time. I had a question for you also, Mr. Rich. Uh, but, um, on behalf of the subcommittee, I want to thank you again, uh, for the witnesses and the members for being here today. I look forward to working, uh, with you to address the issues facing our veterans as well as, uh, uh, the full committee. Uh, the complete written, uh, statements of today's witnesses will be entered into the hearing record. I ask unanimous consent that all remo- all members have five legislative days to revise and extend their remarks. and include extraneous material. Hearing no objections, so order of this hearing is now uh adjourned.