Pending Veterans Health Care Legislation

Chairman Wenstrup, Ranking Member Brownley and distinguished members of the Subcommittee on Health; on behalf of National Commander Denise H. Rohan and The American Legion, the country’s largest patriotic wartime veterans service organization, comprising over 2 million members and serving every man and woman who has worn the uniform for this country, we thank you for the opportunity to testify on behalf of The American Legion’s positions on the following pending and draft legislation.

H.R. 1506 - VA Health Care Provider Education Debt Relief Act of 2017

To amend Title 38, United States Code, to increase the maximum amount of education debt reduction available for health care professionals employed by the Veterans Health Administration, and for other purposes

The American Legion is deeply troubled by the Department of Veterans Affairs (VA) leadership, physicians and medical specialist staffing shortages within the Veterans Health Administration (VHA). Since the inception of our System Worth Saving program in 2003, The American Legion has identified, and reported staffing shortages at every VA medical facility and reported these critical deficiencies to Congress, the VA Central Office (VACO), and the President of the United States.

Currently, there are 43,000 vacancies throughout the VA in primary care, mental health care and dental care providers. Moreover, the June 2016 Commission on Care report has concluded that, “in the area of educational debt repayment relief, VHA lags behind other federal and state agencies that use such programs to fill critical physician shortages in medically under-served areas.”

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This bill provides an incentive to attract qualified providers to fill the above noted vacancies by increasing total educational loan repayment amounts from $120,000 to $150,000 and annual debt repayment amounts from $24,000 to $30,000.

During testimony before the joint House and Senate Veterans’ Affairs Committees this February, our National Commander called for raising the ceiling of the VA Debt Relief Reduction program to $200,000 to increase VA probability of attracting high-quality talent in its recruitment efforts.

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In VA’s Office of Inspector General (VAOIG) September 27, 2017 report entitled “Veterans Health Administration’s Occupational Staffing Shortages,” VAOIG determined based on data provided by VHA that the largest critical need occupations were Medical Officers, Nurses, Psychologists, Physician Assistants, and Medical Technologists.

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One medical center interviewed by VAOIG reported encountering recruitment challenges generally related to “extreme competition” for quality healthcare professionals. The facility further stated that it made use of multiple recruitment endeavors such as special salary rates, incentives (for recruitment, relocation, and retention), and an education debt reduction program.

During The American Legion May 2017 System Worth Saving site visit to the Alaska VA Healthcare System, medical center personnel voiced concerns that community hospitals are offering to repay a provider’s debt in exchange for them coming to work at their hospital. While VA has a debt reduction program, VA does not forgive provider’s debt in exchange for acceptance of a position at a particular VAMC.

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A common theme our System Worth Saving team hears from VHA medical center human resource staff and physicians is VA’s debt reduction program is not adequately funded and the amount VA can offer to a VA provider is not in keeping with what local community hospitals can pay.

Under current law, the amount of education debt reduction payments made to or for a participant under VA’s Education Debt Reduction Program may not exceed $120,000 over a total of five years of participation in the Program, of which not more than $24,000 of such payments may be made in each year of participation in the Program.

According to the Association of American Medical Colleges, the average medical school debt balance for graduating physicians in 2015 was $183,000, and is no doubt higher today. Add that burden to their average undergraduate balance of $24,000 and the total average student loan balance for a doctor is $207,000.

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Once interest is factored in, repayment amounts can range from $329,000 to $480,000.

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Through The American Legion Resolution No. 377, Support for Veteran Quality of Life, we support any legislation and programs within the VA that will enhance, promote, restore or preserve benefits for veterans and their dependents, including, but not limited to, the following: timely access to quality VA health care, timely decisions on claims and receipt of earned benefits, and final resting places in national shrines and with lasting tributes that commemorates their service.

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The VA Health Care Provider Education Debt Relief Act will grant this nation’s veterans better access to care by increasing the number of doctors available to be seen and will improve the overall quality of care that the VA is able to provide.

The American Legion supports H.R. 1506.

H.R. 2322 - Injured and Amputee Veterans Bill of Rights

To direct the Secretary of Veterans Affairs to educate certain staff of the Department of Veterans Affairs and to inform veterans about the Injured and Amputee Veterans Bill of Rights, and for other purposes

The American Legion has long opposed the privatization of the Department of Veterans Affairs (VA.) Though we understand the intention of HR 2322, which is to highlight and provide more and better benefits and educations as to the rights of those who have lost a limb in service of this nation, the VA in concert with the veteran patient, must determine when the veteran should seek and obtain care outside the community. In order for the VA to remain an organization that is there to serve the 9 million currently enrolled veterans, and those in the future, the VA must have the final approval on when a veteran is approved for outside care.

Allowing veterans to elect when the VA pays more for outside care, especially when they may have the internal ability, will destroy the VA, leaving a dilapidated system.

H.R. 2322, calls for a veteran to have the right to select a practitioner that best meets their orthotic and prosthetic needs, whether or not that practitioner is an employee of the VA, a private practitioner who has entered into a contact with the VA, or even a private practitioner with specialized expertise. Allowing veterans to simply dictate when they government spends money is a dangerous slope that will turn the robust VA system into nothing more than an over-paying insurance system.

Through American Legion Resolution No. 372: Oppose Closing or Privatization of Department of Veterans Affairs   Health Care System, passed in 2016, The American Legion opposes any legislation or effort to close or privatize the Department of Veterans Affairs healthcare system.

The American Legion Opposes H.R. 2322. 

H.R 3832 - Veterans Opioid Abuse Prevention Act

To direct the Secretary of Veterans Affairs to enter into a memorandum of understanding with the executive director of a national network of State-based prescription monitoring programs under which Department of Veterans Affairs health care providers shall query such network, and for other purposes

America continues to be in the throes of an opioid addiction crisis, including an epidemic of overdose deaths, affecting veterans and non-veterans alike.

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H.R. 3832 directs the Department of Veterans Affairs (VA) to connect VA health care providers to a national network of state-based prescription drug monitoring programs (PDMPs), databases which track controlled substance prescriptions. PDMPs ensure health care providers do not accidently prescribe dangerous and potentially lethal combinations of drugs to patients who also see other healthcare providers. These state programs also have been proven to curb “doctor shopping” whereby people visit multiple health care providers to solicit more prescription medications than their original doctor has agreed to prescribe.   

Currently, VA doctors are required to consult state-based PDMPs before prescribing potentially dangerous pain medications to veterans. VA doctors, however, lack the ability to consult a national network of state-based PDMPs that can identify someone from another state who is at high risk for abuse, overdose, and death.

H.R. 3832 would help overcome this lack by directing VA to enter into a memorandum of understanding with the executive director of a national network of state-based prescription drug monitoring programs under which VA health care providers shall query such a network to support the safe and effective prescribing of controlled substances to covered patients. Under such memorandum of understanding:

(1) Department health care providers practicing in a state that participates in such network shall query such network in accordance with the agreement between that state’s prescription drug monitoring program and such network in accordance with applicable Veterans Health Administration policies; and

(2) Department health care providers practicing in states that do not participate in such network shall query such network through the drug monitoring program of the participating State that is in closest proximity to the State where the provider is practicing.

Because prescription abuse, misuse, and diversion is a nationwide issue, it is vital that VA and states work together to share PDMP data and provide a national solution to prescription abuse issues.

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The President's Commission on Combating Drug Addiction and the Opioid Crisis issued a preliminary report in July 2017 that cited the lack of cross-state interoperability as one significant shortcoming of state PDMPs. The Commission recommended “enhancing interstate data sharing among state-based prescription drug monitoring programs.”

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Through The American Legion Resolution No. 83: Virtual Lifetime Electronic Record, we support the use of Electronic Health Records as a method of coordinating care provided to veterans inside and outside VA medical facilities and the controlled but widespread sharing of electronic medical records so that veterans can receive the highest possible quality healthcare available.

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The American Legion supports H.R. 3832.

H.R. 4334 - Improving Oversight of Women Veterans’ Care Act of 2017

To provide for certain reporting requirements relating to medical care for women veterans provided by the Department of Veterans Affairs and through contracts entered into by the Secretary of Veterans Affairs with non-Department medical providers, and for other purposes

H.R. 4334 would enhance the monitoring needed for effective oversight of women veterans’ healthcare in the Department of Veterans’ Affairs (VA) and community care programs.

According to a December 2016 Government Accountability Office (GAO) report, the Veterans Health Administration (VHA) does not have data and performance measures to determine women veterans’ accessibility to gender-specific care delivered through the Veterans Choice Program, a community care program. VHA does, however, already collect data to evaluate women veterans’ access to gender-specific care received through PC3 – a different community care program.

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The GAO report also found that VHA does not have accurate or complete data regarding medical centers’ compliance with environment of care standards for women veterans. Medical centers must conduct regular inspections and report instances of noncompliance, however sometimes instances of noncompliance are not reported to VHA.

This legislation would require VA to report to Congress women veterans’ accessibility to gender-specific healthcare in any community of care program. The report must include the average waiting period between the veteran’s preferred appointment date and the date on which the appointment is completed, and driving time required for veterans to attend their appointments. The bill would also require VA medical facilities to report to the Secretary the compliance and noncompliance of the facility to ensure they meet quality care standards for women veterans. Evidence gathered from the reports could potentially help the VA enhance and preserve the benefits and the medical care for women veterans while providing timely access to care.

Through The American Legion Resolution No. 377, Support for Veteran Quality of Life, we support any legislation and programs within the VA that will enhance, promote, restore or preserve benefits for veterans and their dependents, including, but not limited to, the following: timely access to quality VA health care, timely decisions on claims and receipt of earned benefits, and final resting places in national shrines and with lasting tributes that commemorates their service.

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The American Legion supports H.R. 4334.

H.R. 4635

To direct the Secretary of Veterans Affairs to increase the number of peer-to-peer counselors providing counseling for women veterans, and for other purposes.

H.R. 4635 would help ensure that the Department of Veterans’ Affairs (VA) existing peer-to-peer counseling program has sufficient female peer counselors for female veterans who are separating or newly separated from military service.

This bill, as written, would also emphasize counseling for women who suffered sexual trauma while serving, have PTSD or another mental health condition, or are at risk of becoming homeless. The American Legion supports the goal of this legislation recognizing the risk of suicide is 2.4 times higher among female veterans when compared to their civilian counterparts. The American Legions also recognizes existing peer-to-peer counseling programs have been successful and this bill creates a more representative program for the veteran population. Peer counselors are veterans themselves and can relate in profound ways to the mental health challenges facing fellow veterans. By connecting female veterans with one another, peer-to-peer assistance can empower female veterans to connect with each other and their communities.

Through The American Legion Resolution No. 364, Department of Veterans Affairs to Develop Outreach and Peer to Peer Programs for Rehabilitation, we continues to exert maximum effort to ensure that the Secretary of Veterans Affairs utilizes returning servicemembers for positions as peer support specialists in the effort to provide treatment, support services and readjustment counseling for those veterans requiring these services

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The American Legion supports H.R. 4635.

Draft Bill

To authorize the Secretary of Veterans Affairs to use the authority of the Secretary to conduct and support research on the efficacy and safety of medicinal cannabis

The federal government continues to list cannabis as a Schedule I drug – the most addictive and dangerous – although its addiction rates are lower than alcohol, and the less-restrictive Schedule II classification that applies to opioids, which kill 91 Americans every day.

Medical schools offer limited formal education in the human endocannabinoid system, or the impact of cannabinoids on the human body. Every day, thousands of citizens ingest cannabis but have no federally certified doctor to turn to for accredited consultation. In response to this dire need, medical education must be updated, as well. By continuing to consider accumulating evidence of the efficacy of cannabis-based medicines, the federal schedule fails patients fighting debilitating conditions, including PTSD and potentially lethal opioid addiction. The American Legion fully supports research for potential medicinal use of cannabis and responsible action in the interest of advancing medicine, particularly for veterans who report relief from service-connected conditions, thanks to this important drug.

For over two years now, The American Legion has called on the federal government to support and enable scientific research to clinically confirm the medicinal value of cannabis. The National Academies of Science, Engineering, and Medicine recently reviewed 10,000 scientific abstracts on the therapeutic value of cannabis and reached nearly 100 conclusions in a 2017 report. As a two million member strong veteran service organization, our primary interest and advocacy is grounded in the wellbeing and improved health of our veterans, and specifically our service disabled veterans.

The American Legion is a strong, vocal proponent of the Department of Veterans Affairs (VA) and has published several books, pamphlets, and magazines that help showcase VA’s value to The United States of America. Our members have long been  ferocious advocate’s for evidence-based, complementary and alternative medicines and therapies. For decades, we have supported increased funding and research in such therapies as hyperbaric oxygen therapy, Quantitative Electroencephalography (QEEG), animal therapy, recreational therapy, meditation, and mindfulness therapies, just to name a few, to improve outcomes for veterans confronted with PTSD and other combat related illnesses and injuries.

The American Legion supports VA’s statutory medical research mission and has donated millions of dollars toward expanding their scientific research. VA innovation is widely championed for their breakthrough discoveries in medicine and has been recognized over the years with several Nobel Prizes for scientific work that has benefited the world over.

The opioid crisis in America is having a disproportionate impact on our veterans, according to a 2011 study of the VA system, as they contend with the facts that poorly-treated chronic pain increases suicide risk, and veterans are twice as likely to succumb to accidental opioid overdoses. Traumatic brain injury and PTSD remain leading causes of death and disability within the veteran community.

VA officials report that about 60 percent of veterans returning from combat deployments and 50 percent of older veterans suffer from chronic pain compared to 30 percent of Americans nationwide.  Many veterans suffering from post-traumatic stress disorder and chronic pain – especially those of the Iraq and Afghanistan generation – have told The American Legion that they have achieved improved health care outcomes by foregoing VA-prescribed opioids in favor of medical cannabis.

While the stories of these wartime veterans are compelling, more research must be done in order to enable lawmakers to have a fact-based debate on future drug policy.  As a scientific research leader in this country with a statutory obligation to care for and improve the lives of our nation’s veterans, The American Legion supports the draft bill “VA Medicinal Cannabis Research Act of 2018” co-sponsored by Chairman Roe and Ranking Member Walz, that will continue to put VA at the forefront of national cutting edge research.

The American Legion calls for immediate reclassification of cannabis from Schedule I to Schedule III on the DEA Controlled Substance Act Schedule to allow research into its potential for medical application. We call on Congress to conduct oversight hearings and support legislation that enables research on cannabis, and the medical impact it could have for Americans suffering from; opioid over-prescription, pain, depression and a host of other known ailments, and direct departments and agencies within the administration to fully cooperate in all federally authorized scientific research and offer assistance as needed to authorize extensive research.

In October 2017, The American Legion conducted a nationwide survey of veterans.

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  The results are significant and reinforce The American Legion’s continued efforts, under Resolution 11, to urge Congress to amend legislation to remove marijuana from Schedule I of the Controlled Substances Act and reclassify it, at a minimum, as a drug with potential medical value.

According to the survey – which included more than 1,300 respondents and achieved a +/- 3.5 percent margin of error at a 95 percent confidence level – 92 percent of veteran households support research into the efficacy of medical cannabis for mental and physical conditions.

Eighty-three percent of veteran households surveyed indicated that they believe the federal government should legalize medical cannabis nationwide;

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82 percent said they wanted cannabis as a federally legal treatment option.

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Only 40 percent lived in states with medical marijuana laws.

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Over 60 percent were 60 and older, the largest cohort of veterans committing suicide.

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22 percent of veterans are currently using cannabis to treat a medical condition.

And as former Speaker of the House John Boehner revealed in his official statement when he joined the Board of Advisors for one of the nation’s largest, multi-state actively-managed cannabis corporations last week, “We need to look no further than our nation's 20 million veterans, 20 percent of whom, according to a 2017 American Legion survey, reportedly use cannabis to self-treat PTSD, chronic pain and other ailments.”

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Based on The American Legions extensive advocacy, The Department of Veterans Affairs' recently issued updated guidance on medical marijuana that urges government doctors to discuss medical marijuana use with veterans, due to its clinical relevance to patient care, and discuss marijuana use with any veterans requesting information about marijuana.  Because marijuana is a Schedule I controlled substance, VA doctors cannot prescribe, recommend, or assist patients with getting it.

Following the VA’s announcement, American Legion National Commander Rohan issued the following statement, “I applaud the VA in taking this bold move toward treating veterans and also fulfilling resolutions passed by The American Legion.  We do not support recreational use of drugs, but we do think the medicinal possibilities of cannabis should not be ignored by the VA. We are all about putting the health of veterans first.”

Over the course of the past two years, The American Legion has passed two resolutions, testified on the necessity for additional research into the effectiveness of medical cannabis, and has held a press conference right here in this very room.  We have received thousands of comments and interactions on this issue through our website, social media, as well as letters, phone calls, and personal interactions around the country, and the support we receive is overwhelmingly positive. 

For more information on this research, please visit www.Legion.org/mmjresearch

American Legion Resolution No. 11, passed in 2016, titled, Medical Marijuana Research, The American Legion calls on the Drug Enforcement Agency to license privately funded medical marijuana production operations in the United States to enable safe and efficient cannabis drug development research; and urging Congress to remove marijuana from Schedule I and reclassify it in a category that, at a minimum, will recognize cannabis as a drug with potential medical value.

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Draft Bill

To make certain improvements in the family caregiver support program of the Department of Veterans Affairs

The American Legion advocates for equal benefits for all veterans regardless of period of service, and will never support a reduction in benefits.  This bill reduces benefits to the existing caregiver program.  The American Legion opposes this bill.

The American Legion Opposes this Draft Bill.

Conclusion

As always, The American Legion thanks this subcommittee for the opportunity to elucidate the position of the over 2 million veteran members of this organization.  For additional information regarding this testimony, please contact Assistant Director of the Legislative Division, Jeff Steele, at (202) 861-2700 or jsteele@legion.org.