Chairman Tester, Ranking Member Moran, and distinguished members of the committee, on behalf of our National Commander, James W. “Bill” Oxford, and our nearly 2 million members, we thank you for inviting The American Legion to comment on the pending legislation before this committee. Whenever The American Legion testifies, those within the military and veteran community have a direct voice in the legislative process. As a resolutions-based organization, The American Legion’s position on legislation is guided by more than 100 years of advocacy that originates at the grassroots level of our organization. We hope you will take into consideration The American Legion’s position as well as recommendations.

S.372 – Ensuring Quality Care for Our Veterans Act

To require the Secretary of Veterans Affairs to enter into a contract or other agreement with a third party to review appointees in the VHA who had a license terminated for cause by a state licensing board for care or services rendered at a non-VHA facility and to provide individuals treated by such an appointee with notice if it is determined that an episode of care or services that they received was below the standard of care.

In 2018, the Government Accountability Office (GAO) released a report based on an investigation of incidents at Department of Veterans Affairs (VA) hospitals with different employment practices and standards.¹ According to the report, VA leadership stated that each facility makes their hiring decisions and ascertains whether their clinicians meet VA's licensing standards. In one specific incident, a doctor was not hired due to an official reprimand that led to a medical license forfeiture. That same doctor was later hired at a different VA medical center in a different regional network. VA was not able to explain why the two different facilities came to different conclusions about hiring the same doctor.

In another case, a VA facility hired a registered nurse who had a reprimand on his license due to substance use. He was hired in 2002 and received the reprimand in 2008 whereupon the VA center learned about prior undisclosed convictions. This nurse also had three DUI convictions between 1984 and 1999, an assault conviction in 1998, and a disorderly conduct conviction in 2006. The GAO report said the nurse is still working at VA. Department policy stated that a reprimand on a license does not disqualify someone from employment if they have at least one full, current, active and unrestricted license. The registered nurse did not tell VA about his license reprimand until September 2008, but officials told GAO they did not discipline him for not disclosing his prior convictions. Currently, there is no standard for all Veterans Health Administration (VHA) medical centers to follow.

The Ensuring Quality Care for Our Veterans Act will fix this problem by requiring VA to contract with an organization outside the federal government to conduct a clinical review for quality management of hospital care or medical services furnished by covered providers within VA. It would mandate the Secretary of Veterans Affairs ensure that each review of a covered provider is performed by an individual who is licensed in the same specialty as the covered provider. With respect to hospital care or medical services furnished by a covered provider, if a clinical review for quality management determines that the standard of care was not met, VA shall notify the individual who received care from the covered provider.

This legislation will mitigate bad actors within VA by ensuring third-party reviewers are assigned to cases and that negligent providers do not continue providing care. By assigning a third-party reviewer, the case receives an extra look from an entity outside of VA, providing an unbiased analysis and recommendation for the case. The American Legion supports legislation designed to mitigate bad actors within VA by conducting a clinical review of VA covered providers who had their license terminated. Through Resolution No. 377: Support for Veteran Quality of Life, The American Legion supports Congress and VA enacting legislation and programs within VA that will enhance and preserve benefits for veterans and their dependents, including, but not limited to, timely access to quality VA health care.²

The American Legion supports S.372 as currently written.

S.539

To direct the Secretary of Veterans Affairs to submit to Congress a report on the use of video cameras for patient safety and law enforcement at medical centers of the VA.

Seven veteran homicides occurred within 11 months at the Louis A. Johnson VA Medical Center, in Clarksburg, West Virginia, at the hands of a nursing assistant via intentional lethal insulin injection to non-diabetic veterans. When law enforcement officials conducted an investigation, the lack of eyewitness or security footage was a complicating factor. Later, it was learned that the hospital ward did have cameras in the common areas and supply room where the insulin was stored; however, they were not working properly. This tragic crime exposed the inadequate maintenance, upkeep, and oversight that exists within the Department of Veterans Affairs (VA) physical surveillance program. Legislation like S.539 will aid in ensuring these tragedies do not happen again.

S.539 requires VA to submit a report to Congress on the placement, maintenance, and authority for supervisors to review video feed when protecting veterans, staff, and visitors. Within the report, it must include an analysis of how cameras are used to monitor staff and patients, the procedures regarding the positioning of cameras, and the specific units within medical facilities in which the use of cameras is prioritized to protect patient safety. Furthermore, it must include recommendations to improve patient safety and consideration of the extent to which cameras monitor locations where drugs are stored to ensure that drugs are accounted for.

This legislation will enhance oversight of VA video camera policy to ensure patient safety. Previously, The American Legion has supported legislation like the VA Policy Improvement and Accountability Act to increase the use of cameras used at Veterans Health Administration (VHA) medical facilities. We have routinely supported oversight and encouraged further Government Accountability Office (GAO) and Office of Inspector General (OIG) reports.

The American Legion supports S.539 as currently written.

S.544

To direct the Secretary of Veterans Affairs to designate one week each year as Buddy Check Week for the purpose of outreach and education concerning peer wellness checks for veterans, and for other purposes.

Suicide continues to be a significant concern within the veteran community. Unfortunately, the COVID-19 pandemic has exacerbated this issue by increasing isolation for veterans already struggling with their mental health.³ This past year, the Centers for Disease Control and Prevention confirmed this when it reported the results of a survey that demonstrated the physiological and emotional impact of the pandemic. These outcomes included a tripling of reported anxiety since 2019 and a quadrupling of reports of depression.⁴

To combat this issue, The American Legion is dedicated to taking care of members of the military, their families, caregivers, and veterans throughout the various stages of life and ensuring these mental health struggles do not go untreated. This is why, in March 2019, we launched “Buddy Check Weeks” where Legionnaires call fellow veterans to connect and if necessary, offer support and assistance such as getting their groceries and medications delivered, driving them to doctors’ appointments, and connecting them to VA resources such as the Veterans Crisis Line.

S.544 would ensure this effort becomes permanent by directing the Department of Veterans Affairs (VA) to designate one week annually as “Buddy Check Week” for the purpose of encouraging outreach and peer wellness checks by veterans. It would require VA to collaborate with Veterans Service Organizations (VSO) and mental health experts to provide educational opportunities for veterans which includes a script on how to conduct a buddy check and training on how to transfer a call directed to the Veterans Crisis Line.

This initiative creates space to have an open and candid dialogue with a veteran peer who has had similar experiences and potentially make them aware of resources at VA or in the community. This week will be VA-led but not VA-coordinated. The success of the Buddy Check Week will be reliant on grassroots efforts by veterans reaching out to veterans they served with and letting them know they are part of a community that cares about them.

A VA-led national “Buddy Check Week” will reach, support, and aid significantly more veterans than The American Legion would otherwise be able to on its own. Through Resolution No. 18: Buddy Check, The American Legion supports the establishment of a formal “Buddy Check Week” and we urge Congress to take expeditious action on S.544 to ensure no veteran is left behind.⁵

The American Legion supports S.544 as currently written.

S.612 – Improving Housing Outcomes for Veterans Act of 2021

To require the Under Secretary for Health of the VA to provide certain information to medical center staff and homelessness service providers of the Department regarding the coordinated entry processes for housing and services operated under the Continuum of Care Program of the Department of Housing and Urban Development.

Homeless veterans comprise 16 percent of the U.S. homeless adult population. Simultaneously, there are challenges related to shortages of Department of Veterans Affairs (VA) case managers, rising housing costs and availability, and transportation limitations that are hindering service providers that cover large geographic regions. Unfortunately, the Department of Labor (DoL) does not have a written policy on its process for validating performance data, which has impacted their ability to obtain reasonable assurance that these are the most accurate and reliable data available.

Exacerbating this issue is local VA staff and service providers who are misunderstanding how program data is used in assessing performance, while others are unaware of VA’s feedback processes on performance measures. The result is less veterans are served. The Improving Housing Outcomes for Veterans Act requires VA to provide staff of VA medical centers and homelessness services providers with information related to best practices with respect to the collaboration between VA medical centers, homelessness services providers, and local partners.

It mandates VA clearly communicate with VA employees whose responsibilities are related to homelessness assistance programs regarding how to obtain and provide feedback about performance measures and the measurement of performance of such programs by the VA Homeless Programs Office. This legislation will assist in creating clearer lines of communication between VA and the Veterans Health Administration (VHA) programs that are in operation to fight veteran homelessness while also ensuring providers are more aware of existing programs there to aid them.

Over time, The American Legion has continued to support efforts of public and private sector agencies and organizations that aid homeless veterans and their families by supporting sustained and coordinated efforts to achieve this. In July 2018, The American Legion testified before Congress on U.S. Department of Housing and Urban Development-VA Supportive Housing (HUD-VASH), Supportive Services for Veteran Families (SSVF), and Homeless Veterans Rehabilitation Program (HVRP) where we reiterated that veteran homelessness remains a special priority for the organization. Through Resolution No. 319: Expanding Veterans Employment and Homeless Services within the VA, The American Legion advocates for efforts to centralize information to provide more cohesiveness between the VHA, VA medical centers, HUD, and DoL.⁶

The American Legion supports S.612 as currently written.

S.613 – PAWS for Veterans Therapy Act

To direct the Secretary of Veterans Affairs to carry out a pilot program on dog training therapy and to amend title 38, the United States Code, to authorize the Secretary to provide service dogs to veterans with mental illnesses who do not have mobility impairments.

The PAWS for Veterans Therapy Act makes service dogs accessible to veterans wanting an alternative post-traumatic stress disorder (PTSD) treatment option. Currently, the Department of Veterans Affairs (VA) does not fund service dogs or recognize the use of therapy service dogs as a possible treatment method for veterans suffering from PTSD. There have been multiple studies proving that service dogs can provide mental healing to veterans suffering from physically invisible wounds of war.

This legislation would create a five-year pilot program that pairs veterans who served on active duty in the Armed Forces on or after September 11, 2001, with eligible therapy service dogs if they have been diagnosed with PTSD severe enough to warrant treatment. Eligible veterans must have also completed an evidence-based treatment program and remain significantly symptomatic by clinical standards.

The American Legion supports this legislation because it allows for an alternative form of treatment to injured veterans returning home from war with traumatic brain injury (TBI) and PTSD. Service dogs can act as an effective complementary therapy treatment component, especially for those veterans who suffer daily from the physical and psychological wounds of war.

PTSD has become an epidemic, and VA has estimated that between 11 and 20 percent of veterans who served in Afghanistan or Iraq have PTSD.⁷

While VA continues to stall with their dog-based therapy studies, veterans are being denied alternative forms of treatment. As VA is continually accused of over-prescribing medications to veterans, and as veterans continue to complain about over-prescription, it is time that VA, and the federal government, look at alternative options.⁸ Through Resolution No. 160: Complementary and Alternative Medicine, The American Legion supports any legislation that provides oversight and funding to the VA for innovative, evidence-based, complementary and alternative medicine in treating various illnesses and disabilities.⁹

The American Legion supports S.613 as currently written.

S.727 – CHAMPVA Children’s Care Protection Act of 2021

To amend title 38, United States Code, to increase the maximum age for children eligible for medical care under the CHAMPVA program, and for other purposes.

The provisions of this bill fall outside the scope of established resolutions of The American Legion. As a large grassroots organization, The American Legion takes positions on legislation based on resolutions passed by the membership or in meetings of the National Executive Committee. With no resolutions addressing the provisions of the legislation, The American Legion is researching the material and working with our membership to determine the course of action which best serves veterans.

The American Legion has no position on S.727.

S.796 – Protecting Moms Who Served Act of 2021

To codify maternity care coordination programs at the VA, and for other purposes.

The American Legion has been a constant supporter of improving women’s healthcare. We have also testified on numerous occasions in support of maternal care. Our members are persistent in the fight to provide women veterans with quality gender-specific care by introducing and passing Resolution No. 37: Improvements to VA Women Veterans Programs10 and Resolution No. 147: Women Veterans.¹¹ Currently, the Department of Veterans Affairs (VA) offers: full exams after the first positive pregnancy test, prenatal education, screenings, ultrasounds, genetic testing, specialty consultations, and necessary medication and supplements, such as prenatal vitamins.

These services are all offered to ensure a safe and successful birth for the veteran mother. VA's additional services include the first seven days of newborn care, breastfeeding support, social services, and mental health services. Studies show that women veterans are at a higher risk for major depression, post-traumatic stress disorder (PTSD), urogenital issues, and hormone imbalance, which may lead to infertility or miscarriage. Subsequently, VA offers services in cases of miscarriage or stillbirth. There is a gap in research about maternal mortality within the women veteran population and even less research on women veterans of color.

As well, there is a shortage of women providers as care coordinators for veterans who choose to obtain maternity care from VA. The American Legion strongly supports the allocation of additional funds to improve maternity care coordination for women veterans. We also recommend further research into women veterans' exposure to potentially harmful substances during service, race and ethnicity statistics, maternal death rates, maternal death causes, and other correlations.

The American Legion supports S.796 as currently written.

S.887 – VA Supply Chain Resiliency Act

To make certain improvements relating to the supply chain of the VA, and for other purposes.

The COVID-19 pandemic presented innumerable challenges to Department of Veterans Affairs (VA) as it struggled to maintain the fidelity of its supply chain. Obtaining critical medical supplies in the early phases of the pandemic became especially difficult for many VA medical facilities as global supply chains constricted and manufacturers shut down. Additionally, dependence on foreign sources for essential medical and safety equipment became problematic as countries limited exports to meet increased domestic demand.¹²

VA became abruptly aware of the vulnerabilities and lack of resiliency built into its supply chain as it struggled to acquire critical medical supplies throughout the pandemic. The lack of a comprehensive strategy for its supply chain management modernization efforts and inefficient acquisition management procedures were primarily responsible for the lack of resiliency. Additionally, the nation’s healthcare systems dependence on foreign sources for critical medical and safety equipment served to further exacerbate the issue.

An effective medical supply chain that can deliver the correct item, at the right time, to the right place, in a time of crisis requires a comprehensive approach. VA has multiple interrelated supply chain modernization initiatives underway that are intended to improve its acquisition management. However, without a comprehensive strategy communicating how each interrelated initiative will move VA forward, VA risks wasting resources and missing opportunities to build resilience into its supply chain. To ensure VA is able to deliver critical items in the face of future national emergencies will require a comprehensive and multifaceted approach.

The VA Supply Chain Resiliency Act requires VA to identify critical supply items and anticipate the needs of VA medical system in the event of future public health or national emergencies. Additionally, it requires VA to participate in the Department of Defense (DoD) Warstopper Program and thereby “ensure the maintenance and stability of items are identified as critical.” Furthermore, this legislation mandates VA partner with manufacturers and distributors to secure a supply of critical items rather than holding physical inventories.

This comprehensive, multi-faceted, and forward-looking strategy ensures VA is better prepared to provide essential life-saving care to veterans in the face of the next national emergency. The American Legion supports efforts to expand contracts and agreements with producers to ensure the availability of critical items and encourages VA to partner with domestic business to ensure increased supply chain resiliency. Through Resolution No. 13: Support “Buy American” Policy within the Federal Government to Create Opportunities for Veterans,¹³ The American Legion “supports legislation and policy that incentivizes the return of manufacturing from overseas and the creation of more domestic manufacturers. The government, through its collective purchasing power, can programmatically incentivize the return of domestic manufacturing of emergency supplies to prevent supply chain breakdowns in future national emergencies.”

The American Legion supports S.887 as currently written.

S.951 – Puppies Assisting Wounded (PAWS) Servicemembers Act of 2021

To direct the Secretary of Veterans Affairs to make grants to eligible organizations to provide service dogs to veterans with severe post-traumatic stress disorder, and for other purposes.

In November 2020, the Department of Veterans Affairs (VA) published an annual report on the veteran suicide prevention using data collected from 2005-2018.¹⁴ According to the report, mental health disorders were associated with an increased risk for suicide and as of 2018 17.6 veterans were dying by suicide daily. A mental health survey conducted by The American Legion in 2019 corroborated these unfortunate statistics when it found 76 percent of participants never sought mental health care from a VA medical center, 80 percent never sought mental healthcare outside of a VA facility, and 84 percent never sought mental healthcare at a Vet Center facility.

However, a recently published VA study found a 3.7 point drop in post-traumatic stress disorder (PTSD) symptom scores as measured by the PCL-5 over an 18-month period for veterans who used service dogs.¹⁵ These results indicated veterans paired with service dogs had less suicidal ideation and an improvement in overall mental health than those paired with emotional support dogs. Offering a wider variety of mental health treatment options encourages help seeking behavior because it allows the veteran to choose their preferred method of treatment.

Research suggests when individuals desire control, choice over treatment alternatives improves treatment effectiveness by enhancing personal control.¹⁶ The PAWS Act makes this a reality by establishing a three-year program where the Secretary of Veterans Affairs would provide grants of up to $25,000 per veteran to organizations to pair veterans suffering from severe PTSD with service dogs. Grants would cover a veterinary health insurance policy for the life of the dog, service dog hardware, and payment for travel expenses for the veteran to obtain the dog.

Through Resolution No. 134: Service Dogs for Injured Service Personnel and Veterans with Mental Health Conditions, The American Legion believes legislative action to ensure veterans have access to VA provided service and guide dogs to aid in treating mental health illnesses is critical.¹⁷ The PAWS Act will no doubt aid in decreasing the stigma surrounding veterans seeking treatment for their mental health issues and a ensure proven form of alternate treatment is accessible for those in need.

The American Legion supports S.951 as currently written.

S.1040

To amend title 38, United States Code, to expand eligibility for hospital care, medical services, and nursing home care from the VA to include veterans of World War II.

Approximately 325,000 of the 16 million Americans who served in World War II are still alive and as many as 296 pass away every day.¹⁸ Under VA regulations, there are guidelines in place that determine a veteran’s eligibility for healthcare benefits based on factors related to income level, disability rating, and military service history. Because of this, not all veterans are eligible for VA healthcare services. By way of the Veterans Health Care Eligibility Act of 1996, all veterans of the Spanish-American War and World War I are exempt from the means test required to enter the VA healthcare system.

Yet, World War II veterans are not and as a result some veterans previously enrolled in VHA healthcare prior to 1996 VA eligibility reforms were dropped or are now subjected to a means test. It is unacceptable some veterans of the Greatest Generation do not have access to benefits they earned due to loopholes in federal law. S.1040 would fix this problem by expanding automatic eligibility to all World War II veterans so veterans who currently do not qualify for VHA healthcare will have access to VA hospital care, medical services, and nursing home care.

Previously, The American Legion has submitted letters directly to the Secretary of Veterans Affairs concerning the lifting of current means test standards for the aging World War II veteran cohort in order to get all remaining WWII veterans’ full access to VA healthcare. Through Resolution No. 3: WWII Veterans Hospital and Medical Eligibility, The American Legion supports extending the exemption from a means test to World War II veterans and urges VA to place all World War II veterans in Priority Group Category 5.¹⁹ Members of the Greatest Generation deserve equitable access to care and rescinding this loophole will honor their bravery and courage.

The American Legion supports S.1040 as currently written.

S.1198 – Solid Start Act of 2021

To amend title 38, United States Code, to improve and expand the Solid Start program of the VA, and for other purposes.

Based upon Department of Veterans Affairs (VA) publicly available data, roughly 17.6 veterans die by suicide daily.²⁰ On average, 60 percent of them have had no consistent contact with VA services.²¹ A 2019 American Legion mental health survey revealed 40 percent of veterans were not sure whether they were eligible or not for VA mental health services.²² These concerning statistics are supported by a Journal of the American Medical Association study conducted on almost two million servicemembers who were separated from service. The study found those who identified as male, younger, and with shorter lengths of service, or were separated from the Marine Corps or Army, had a significantly higher risk of suicide after separation.²³

In 2018, the Trump Administration issued Executive Order 13822 to stem veteran suicide by improving access to mental healthcare and suicide prevention resources to recently transitioned servicemembers the year following their discharge, separation, or retirement.²⁴ After the Executive Order was published, VA devised a Joint Action Plan for better screenings, identification, and warm hand-offs to peer support programs.²⁵ By December 2019, the VA Solid Start Program was launched to proactively engage all newly separated servicemembers at least three times during their first year of transition from the military to establish a strong relationship and promote awareness of VA benefits and services.

Succeeding the success of this new VA pilot program, the Solid Start Act of 2021 was introduced. The Solid Start Act of 2021 would permanently fund the Solid Start Program, codify it into law, and require the Government Accountability Office (GAO) to assess the program’s efficiency and effectiveness in meeting its goals. Specifically, it requires the GAO to review VA’s ability to prioritize outreach to veterans who access mental health resources prior to separation and collect up-to-date contact information during the transition process. Additionally, the GAO would need to review whether VA was calling each veteran at least twice annually in the first year after separation and was including programmatic information in VA booklets, on their website, and through other resources.

The American Legion has staunchly advocated for mental health services for veterans recovering from the invisible wounds of war through legislation like the Debra Sampson Act and the Cmdr. John Scott Hannon Veterans Mental Health Care Improvement Act. Through Resolution No. 12: Accountability and Enhancements of Transition Assistance Program, Outcomes and Delivery for Today’s Digital Transitioning Servicemembers, The American Legion believes Congress must require VA to conduct assessments on the efficiency of delivering “for life” support to veterans and transitioning servicemembers.²⁶ Transitioning from military to civilian life can be extremely stressful for new members of the veteran community. Any period of uncertainty elevates the risk of suicide. Passing legislation such as the Solid Start Act of 2021 will help ensure that risk is as low as possible.

The American Legion supports S.1198 as currently written.

S.1220 – United States Cadet Nurse Corps Service Recognition Act of 2021

To amend title 38, United States Code, to recognize and honor the service of individuals who served in the United States Cadet Nurse Corps during World War II, and for other purposes.

The U.S. Cadet Nurse Corps (CNC) was created in July 1943 to help alleviate the nursing shortage that existed during World War II. The program was open to all women between the ages of 17 and 35 who were in good health and had graduated from an accredited high school. At the time, CNC was the largest of the federal nurse-training programs, allowing young women to serve their country in uniform while being protected by law against discrimination. It operated from 1943 to 1948 and during this period, more than 124,000 student nurses graduated from participating nursing schools. Now, it serves as the only uniformed service from World War II whose members are not recognized as veterans for Department of Veterans Affairs (VA) purposes.

The American Hospital Association credited the cadet student nurses with helping to prevent the collapse of civilian nursing in the U.S. during the war. However, it is their ongoing status as “civilians” that has prevented them from receiving VA benefits. Legislation like the United States Cadet Nurse Corps Service Recognition Act will rectify this issue by recognizing service in the CNC with an honorable discharge “active duty” for the purposes of eligibility and entitlement to VA benefits.

It also directs the Secretary of Defense to issue honorable discharge certificates to former CNC members if their service record meets the appropriate criteria necessary for an honorable discharge. This legislation will ensure the large population of women veterans who are not enrolled in VA healthcare, who feel they lack gender specific services, will have their needs met. To fix this problem, The American Legion supports VA’s obligation to develop and expand healthcare services for women, the fastest growing demographic in the veteran community.

Through Resolution No. 147: Women Veterans, The American Legion supports legislation ensuring the current women veteran population needs are met by VA services and programs.²⁷ We also support legislation directing VA to provide full comprehensive health services for women veterans’ department-wide of all ages. Passing the United States Cadet Nurse Corps Service Recognition Act will achieve this outcome and better serve the tens of thousands of older women veterans who need adequate healthcare services.

The American Legion supports S.1220 as currently written.

S.1280 – Veteran Families Health Services Act of 2021

To improve the reproductive assistance provided by the DoD and the VA to certain members of the Armed Forces, veterans, and their spouses or partners, and for other purposes.

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As of 2021, the Centers for Disease Control and Prevention has reported six percent of women aged 15-44 showed signs of infertility compared to nine percent of men aged 25-44 who reported they or their partner sought advice, testing, or treatment for infertility.²⁸ This statistic is more alarming in the veteran population. A 2014 infertility study showed the frequency of lifetime history of infertility was 15.8% for women and 13.8% for men serving in Operation Enduring Freedom (OEF) and Operation Iraqi Freedom (OIF).²⁹ Yet, less than 2% of OEF and OIF women veterans received infertility diagnoses from the Department of Veterans Affairs (VA) and of those 22% received an infertility assessment or treatment.³⁰

While VA does offer infertility services, such as in vitro fertilization (IVF), to eligible veterans they are limited and do not include surrogacy and the use of donated genetic material. Currently, IVF services are only offered to veterans enrolled in VA care, legally married with service- connected conditions causing infertility, and the couple must be able to use their own genetic material.³¹ The Veteran Families Health Services Act of 2021 would provide access to these reproductive, surrogacy, and adoption assistance services. This legislation would require coordination between the Department of Defense (DoD) and VA on information sharing, referrals, and genetic material when a servicemember transfers into VA care.

It mandates fertility treatment and counseling be covered for veterans, spouses, partners, or gestational surrogates of covered veterans without regard to the sex, gender identity, sexual orientation, or marital status. Additionally, it would provide adoption assistance and direct a report to be completed on fertility treatment and counseling with a required demographic breakdown of collected data. .³² The Veteran Families Health Services Act of 2021 will allow for greater access to comprehensive fertility treatments for veterans looking to expand their families.

As well, the research requirement will provide necessary information on infertility assistance so further VA infertility policy can be informed by evidence-based knowledge. Through Resolution No. 16: Reproductive Assistance and Pregnancy Counseling, The American Legion supports legislative efforts to ensure VA provides adequate and appropriate reproductive assistance services to include IVF for all veterans with a service-connected loss of reproductive dysfunction.³³ It is a morale imperative that veterans who have had their ability to reproduce impacted by their service be provided with the same options as their civilian counterparts.

The American Legion supports S.1280 as currently written.

S.1319 – VA Quality Health Care Accountability and Transparency Act

To direct the Secretary of Veterans Affairs to make certain information publicly available on one internet website of the VA.

The Department of Veterans Affairs (VA) has a long history of major issues with the complexity of their numerous websites which makes it difficult for many veterans to navigate their VA records and manage their care. These sites include My HealtheVet, eBenefits, and now Cerner’s new database for the electronic health record modernization. This complexity is only exacerbated by VA’s history of patient wait times, quality of care, and frequent staffing shortages. A Government Accountability Office (GAO) report found VA failed to disclose wait time, patient safety, and quality of care information in an easily accessible and usable manner.³⁴

The American Legion has a long-standing tradition of holding VA accountable for providing the quality of care this nation’s veterans deserve. This includes ensuring information regarding key aspects of VA care is easily accessible to guarantee the high standards we expect from VA are maintained as well as enabling the identification of best practices and areas VA can improve. Each year, The American Legion conducts a series of site visits to VA medical facilities and Regional Offices. While on site, they meet with veterans, their families, and VA administrators and employees to discuss successes, challenges, and limitations at each site. These observations are compiled annually in a report titled System Worth Saving that is distributed to VA officials, members of Congress, and the President of the United States.

This draft legislation would improve the overall quality of VA care through enhanced accountability and transparency of services by streamlining how information is disclosed. This will be achieved by ensuring certain information, such as staffing and patient wait time information, is publicly available on a single, easily accessible website. The bill would also require the information be updated regularly and there are regular audits and reports of the information to ensure accuracy. Through Resolution No. 194: Department of Veterans Affairs Veteran Integrated Service Networks, The American Legion supports legislation which would mandate studies and reviews of Veterans Health Administration (VHA) “in order to better provide timely access and quality healthcare for veterans.”³⁵

The American Legion supports S.1319 as currently written.

S.1467 – VA Medicinal Cannabis Research Act of 2021

To direct the Secretary of Veterans Affairs to carry out a series of clinical trials on the effects of cannabis on certain health outcomes of veterans with chronic pain and post-traumatic stress disorder, and for other purposes.

In 1970, the Controlled Substances Act was signed into law combining all previously existing federal drug laws into a single statute.³⁶ The statute regulated the manufacturing and distribution of controlled substances including stimulants, narcotics, depressants, and hallucinogens.³⁷ These substances were further categorized into five classifications based upon the potential for abuse. According to the Drug Enforcement Administration (DEA), Schedule I drugs have the highest potential for abuse and severe psychological and/or physical dependence.³⁸ By definition, the DEA looks at these types of Schedule I substances as having no accepted medical use and a high potential for abuse. This is why other Schedule I drugs include heroin, ecstasy, and lysergic acid diethylamide (LSD).

Marijuana (cannabis) is currently listed as one of these Schedule I substances. Designating cannabis as a Schedule I substance makes it extraordinarily challenging to conduct necessary research on the use of medical marijuana as a treatment option for veterans suffering from chronic pain and mental health conditions. Legislation like the VA Medicinal Cannabis Research Act of 2021 will help alleviate these stringent guidelines by directing the Secretary of Veterans Affairs to carry out a series of clinical trials on the effects of medical grade marijuana on certain health outcomes of veterans with chronic pain and post-traumatic stress disorder (PTSD)

Clinical trials would include an evaluation of the effects of the use of cannabis on osteopathic pain, the reduction/increase in opioid use/dosage, sleep quality, agitation, and quality of life to name a few. With respect to covered veterans diagnosed with PTSD, an evaluation would be directed on the effects of the use of cannabis on the symptoms of PTSD as established by or derived from the clinician administered PTSD scale, the PTSD checklist, and other applicable methods of evaluating PTSD symptoms. This legislation ensures there is adequate and appropriate research done on the impacts of medicinal cannabis.

Through Resolution No. 11: Medical Marijuana Research, The American Legion supports efforts to enhance medical cannabis research, urges Congress to remove cannabis from the Schedule I controlled substance list, and believes the DEA should license privately funded medical marijuana production operations in the U.S.³⁹ Any medical cannabis research legislation should take into consideration clinical trials that track the developing of symptoms related to Cannabis Use Disorder. Enabling safe and efficient cannabis drug development research is vital to providing innovative evidence-based, complementary, and alternative medicine to veterans in the treatment of chronic pain and mental health disorders. It is imperative that VA continue to explore alternative treatments to ensure those suffering from PTSD and chronic pain are provided the best possible care.

The American Legion supports S.1467 as currently written.

S.1863 – Guaranteeing Healthcare Access to Personnel Who Served Act

A bill to amend title 38, United States Code, to improve access to healthcare for veterans, and for other purposes

The future of VA healthcare is a hybrid and agile system that can fully leverage all the tools at its disposal to address the needs of an increasingly diverse veteran population. Passage of the American Legion-supported VA MISSION Act of 2018 has given the Department of Veterans Affairs (VA) important tools to improve access to high-quality care either in person at VA facilities, virtually through tele-health, or with increased community care options. The means by which VA delivers care may change, but one thing won’t: VA should continue to deliver the best care anywhere to our nation’s veterans.

Access standards are crucial to the MISSION Act’s success and must be applied uniformly to VA and to community providers in the Third-Party Administrator (TPA) networks. In recent years, VA has developed online tools and mobile applications to help veterans self-schedule internal Veterans Health Administration (VHA) care. In the case of community care, veterans are only able to self-schedule community care appointments online in limited instances and must be assigned to a Veterans Integrated Services Networks (VISN) that has proactively enabled the function. VA has expanded self-scheduling for community care but has not made the technological advances necessary to streamline and efficiently roll out self-scheduling online.

In most instances, VA provides an authorization letter the veteran presents to the community provider to schedule an appointment if the veteran is interested in self scheduling. These have led to inefficiencies within the system and created roadblocks for veterans in rural areas. The American Legion encourages a well-defined and consistent community care coordination program, policy and procedure that includes a patient-centered care strategy which takes veterans’ unique medical injuries and illnesses as well as their travel and distance into account. Every veteran does not live within 30 minutes of a VHA facility and not every VHA facility has the staff and resources to schedule an appointment for the veteran within 20 days.

Veterans in rural areas face more severe problems with access and The American Legion has supported more service programs benefiting rural people to fulfill The American Legion’s commitment of service to all veterans. This legislation codifies existing access standards for the Veterans Community Care Program (VCCP) eligibility and creates uniformed patient-centered standards for community care across the different regions and TPAs. With codification, future generations of veterans will be more assured of access to community care when it makes sense for them. This ensures access for the veteran, regardless of if they live in a rural or urban community, in cases where VHA facilities are scarce, or drive-times are too great for reasonable access.

Through Resolution No. 46: VA Non-VA Care Programs, The American Legion supports legislation to require VA to develop a well-defined and consistent non-VA care coordination program, policy and procedure that includes a patient-centered care strategy which takes veterans’ unique medical injuries and illnesses as well as their travel and distance into account.⁴⁰

The American Legion supports S.1863 as currently written.

S.1875 – Veterans’ Emergency Care Claims Parity Act

A bill to amend title 38, United States Code, to provide a deadline of 180 days for the filing of claims for payment for emergency treatment furnished to veterans, and for other purposes.

Claims for non-Department of Veterans Affairs (VA) care are processed through the Claims Adjudication and Reimbursement (CAR) Directorate under VA’s Office of Community Care (OCC). According to a 2019 Office of Inspector General (OIG) report, VA audit team’s nationwide accuracy review found an estimated 31% of denied or rejected non-VA emergency care claims were inappropriately processed by CAR staff.⁴¹ It also found approximately 17,400 veterans, with bills totaling at least $53.3 million, were negatively affected during the audit period.⁴²

If corrective action is not taken, the OIG report noted these errors could result in $533 million in improper underpayments to claimants over five years. Now, because of inappropriately processed claims, veterans are forced to carry the financial burden of covering expensive services rendered like emergency care bills. The Veterans’ Emergency Care Claims Parity Act would help fix this problem by extending the timeline to submit claims for veterans from 90 to 180 days and relinquish veterans from any liability to pay for emergency treatment if the claim for direct payment was submitted after the deadline due to administrative error.

It calls for the Secretary of Veterans Affairs to publish, on at least one publicly available internet website, a list of all authorities to authorize emergency care from non-VA providers and their corresponding deadline for submission of claims, a summary of steps so non-VA providers can assure compliance with the claims-filing process, and their associate contact information. This legislation will address the financial burden faced by many veterans who visit an emergency department by ensuring they do not have to pay for more than they are required.

In the past, The American Legion has worked to fix this issue by joining other Veterans Service Organizations (VSO) in sending a letter to the Secretary of Veterans Affairs urging him to compel VA to reimburse veterans for emergency medical expenses incurred at non-VA facilities.⁴³ Through Resolution No. 2: Uniform Payment Policy for Emergency Care at Non-Department of Veteran Affairs (VA) Medical Center, The American Legion believes VA must promptly pay non- VA providers for emergency care furnished to veterans. Veterans will no doubt benefit from the implementation of the Veterans’ Emergency Care Claims Parity Act.⁴⁴

The American Legion supports S.1875 as currently written.

S.1965 – Planning for Aging Veterans Act

A bill to direct the Secretary of Veterans Affairs to improve long-term care provided to veterans by the VA, and for other purposes.

During a House Committee on Oversight and Reform hearing, the Department of Veterans Affairs (VA) testified that 50 percent of all veterans currently enrolled in the Veterans Health Administration (VHA) healthcare system are 65 years old or older, with enrolled veterans aged 75 and older, projected to increase by 46 percent between 2018 and 2028.⁴⁵ Under the 85 years-of- age and older demographic, VHA enrolled veterans increased almost 300 percent between 2003 and 2018 with projections showing the expectation of a 500 percent surge by 2038. One of the results of this is an increase in demand for long-term services and support. Previously, this support has been provided by family members with women providing most of the care.

Unfortunately, the consequence is VA continues to face challenges meeting the demands for future long-term care for aging veterans because they have not yet fully addressed its inconsistencies in management of its long-term programs. Moreover, they have struggled with the standardization process across all VA medical centers to enter into sharing agreements with State Veteran Homes (SVH), geriatric psychiatry assistance, SVH inspection reports, and working with public housing authorities and local organizations to assist aging homeless veterans. The Planning for Aging Veterans Act fixes these issues by paving the way for future investments in long-term care, improving VA’s relationship with SVH’s, and expanding the care veterans receive in SVH’s.

This legislation requires VA to develop a strategy addressing current and future long-term care needs of aging veterans to identify areas for future investment and standardizes the process VA- wide for medical centers entering into sharing agreements with SVH’s. It requires any deficiencies during SVH inspections be reported to VA and inspection reports be publicly published on VA website. As well, it would create a pilot program to provide geriatric psychiatry assistance to eligible veterans in SVH’s and instruct VA to work with public housing authorities and local organizations to assist aging homeless veterans in accessing existing housing and supportive services.

Additional bill provisions include directing each VA medical center to use a standardized process when entering sharing agreements with SVH’s and instructing the waiver of prescription copayments for catastrophically disabled veterans residing within SVHs. Furthermore, it would codify a GAO recommendation by requiring, no less than quarterly, the Secretary of Veterans Affairs to review SVH inspection results. This legislation will improve long-term care provided to veterans by ensuring better VA quality assurance initiatives at SVH’s.

In 2008, The American Legion testified before Congress and advocated VA discontinue the collection of copayments from veterans deemed catastrophically disabled because this practice is unconscionable and warrantless when measured against the sacrifices veterans made in serving this nation. Today, The American Legion has an active Homeless Veterans Task Force to coordinate and direct assistance and advocacy. Through Resolution No. 140: Policy on SVH Inspections, The American Legion supports effective and judicious SVH inspections through a consolidated process.⁴⁶

The American Legion supports S.1965 as currently written.

S. 2102 - Supporting Expanded Review for Veterans in Combat Environments (SERVICE) Act

A bill to direct the Under Secretary for Health of the VA to provide mammography screening for veterans who served in locations associated with toxic exposure.

Breast cancer is the single greatest cause of cancer deaths among women under 40 and a significant cause of mortality for women in the U.S. Armed Forces. In the U.S. alone, it is estimated there will be over 280,000 new cases of breast cancer by the end of 2021. Those within the veteran and military population are estimated to be at a 20 to 40 percent higher risk than the general population. Those female servicemembers exposed to toxic substances during service are also found to have higher rates of breast cancer. A 2021 study published through Department of Veterans Affairs (VA) showed breast cancer rates have tripled from 1995 to 2012.

Under current law, VA’s policy on breast cancer mammogram screening for veterans advises screening based on age, symptoms, or family history – Not based on toxic exposures. Further worsening the issue is a high percentage of female veterans are not enrolled in VA due to the lack of those gender-specific services. Legislation such as the SERVICE Act helps to bridge this gap. It would revise the current guidance to include female veterans who served in areas associated with burn pits and other toxic exposures and direct VA to conduct a mammogram screening for female veterans who served in areas associated with burn pits.

Mammograms can detect breast cancer up to two years before the tumor can be felt by an individual or doctor.⁴⁷ Authorizing mammogram screenings for female veterans in relation to geographic locations of toxic exposure can increase the chances of identifying the presence of cancer early. An early diagnosis of breast cancer can both increase treatment options and the chances of survival. Every female veteran deserves the chance to prevent premature death because of an illness obtained while serving their country.

In 2010, The American Legion testified in support of the Armed Forces Breast Cancer Research Act which would have required the Department of Defense (DoD) and VA to collaboratively study the incidence rate of breast cancer in servicemembers and veterans. Through Resolution No. 239: Support Research About Breast Cancer, The American Legion supports efforts to urge VA to develop a comprehensive study to determine if breast cancer is increasing at a faster rate for military personnel exposed to toxins compared to the civilian population.⁴⁸

The American Legion supports the discussion draft as currently written.

Discussion Draft – the Building Solutions for Veterans Experiencing Homelessness Act

To improve grants, payments, and technical assistance provided by the Secretary of Veterans Affairs to serve homeless veterans, and for other purposes.

Veteran homelessness has been a persistent issue which has only been further aggravated by the COVID-19 pandemic. A lack of affordable housing in many communities has contributed as well. In some cases, the Grant and Per Diem Program (GPD) has been grossly understaffed and unable to properly accommodate the needs of the increased homeless veteran population. Even those who do receive GPD assistance have been found to not fully understand the service and lack the technical skills to utilize it. At the same time as these homeless veterans are facing housing insecurity, they are often struggling with other substance use disorders because of PTSD.

This has created a need for the modernization of the GPD program and additional substance abuse treatment resources for homeless veterans. This discussion draft bridges those gaps by directing the Department of Veterans Affairs (VA) to allot no less than 2% of program VA GPD funding to provide help in the form of training and technical assistance to grant awardees. It would increase Homeless Veteran Reintegration Programs funding to $75 million and extend it to 2025. Furthermore, it would establish a pilot program using grants for substance use disorder treatment and authorize an evaluation of the shallow subsidy program for veteran families.

Other provisions include requiring an evaluation to outline the availability of affordable housing for veteran through the VA Homeless Programs and creating a program composed of navigators who assist homeless veterans navigating housing and health related resources. This legislation benefits those most at risk of experiencing homeless by providing additional assistance they would not otherwise have. Increasing access to resources for the most at-risk veterans, including those who are homeless, is vital to the overall health of the individual veteran.

The American Legion has long advocated in support of legislative efforts to reduce veteran homelessness. We continue to support increasing access to technical assistance for GPD providers and expanding programs and resources to meet a demonstrated need for services to end veteran homelessness. As well, we support assisting veterans struggling with substance abuse disorders via programs like the Veterans Treatment Courts and veteran mentor programs. Through Resolution No, 24: Support Funding and Changes to the VA Grant and Per Diem Program, The American Legion supports efforts to enhance funding for VA grant and per diem programs.⁴⁹

The American Legion supports the discussion draft as currently written.

Discussion Draft – Department of Veteran Affairs Provider Accountability Act

To amend title 38, United States Code, to direct the Secretary of Veterans Affairs to enforce licensure and related requirements for healthcare professionals of the VAs, and for other purposes.

A troubling 2018 Government Accountability Office (GAO) report revealed a startingly trend of Department of Veterans Affairs (VA) facilities failing to report providers who made major medical errors to the National Practitioner Data Bank and the relevant state licensing boards responsible for tracking dangerous practitioners.⁵⁰ In many cases, these practitioners can go into private practice or move across state lines without disclosing prior mistakes to patients or state regulators while continuing to provide substandard care.⁵¹ To ensure veterans receive consistent care, VA must hold its healthcare professionals to a dependable standard. Corrective action must be taken after identifying healthcare professionals that meet generally accepted standards of clinical practice.

The Department of Veteran Affairs Provider Accountability Act achieves this outcome by directing the Secretary of Veterans Affairs to monitor VA medical centers to confirm they are complying, verifying, and reviewing documentation for every healthcare professional employed. Documentation includes licensure, certification, and registration. As well, this documentation would cover whether they are registered with the Drug Enforcement Administration and their education, training, experience, malpractice history, and clinical competence. Additionally, it would mandate training take place no less than twice a year on duties including compiling, validating, and reviewing the credentials of healthcare professionals, the quality of clinical care, and determinations relating to disciplinary actions.

When generally accepted medical standards are upheld, quality-of-care increases. This legislation will ensure a consistent continuity of high-quality care conducted by healthcare professionals with adequate and appropriate training and credentials. More importantly, it will ensure no person will receive care from a healthcare professional who is negligently concealing a negative professional background. Veterans deserve better and it is the responsibility of Congress to fix this issue as soon as possible.

To this day, we remain concerned about the lack of accountability within VA and have supported similar legislation to S.1307 that provides the Secretary of Veterans Affairs the legal authority to better manage all VA employees and hold them accountable when they fail to perform their duties in a manner befitting of a federal employee who veterans have entrusted their care too. Through Resolution No. 377: Support for Veteran Quality of Life, The American Legion supports this legislation.

The American Legion supports S.1307 as currently written.

Conclusion

As always, The American Legion thanks this committee for the opportunity to explain the position of the nearly 2 million veteran members of this organization. For additional information regarding this testimony, please contact Ms. Olivia Babine at (202) 861-2700 or OBabine@legion.org

 

 

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¹ Office, U.S. Government Accountability. Department of Veterans Affairs: Actions Needed to Address Employee Misconduct Process and Ensure Accountability, Jul 19, 2018. https://www.gao.gov/products/gao-18-137.

² The American Legion Resolution No.377 (2016): Support for Veteran Quality of Life.

³ Panchal, N., Kamal, R., Orgera, K., Cox, C., Garfield, R., Hamel, L., & Chidambaram, P. The implications of COVID-19 for mental health and substance use. Kaiser family foundation. (2020). Retrieved from: https://www.kff.org/coronavirus-covid-19/issue-brief/the-implications-of-covid-19-for-mental-health-and- substance-use/

⁴ Czeisler, Mark É., Rashon I. Lane, Emiko Petrosky, Joshua F. Wiley, Aleta Christensen, Rashid Njai, Matthew D. Weaver et al. "Mental health, substance use, and suicidal ideation during the COVID-19 pandemic—United States, June 24–30, 2020." Morbidity and Mortality Weekly Report 69, no. 32 (2020): 1049.

⁵ The American Legion Resolution No.147 (2016): Buddy Check.

⁶ The American Legion Resolution No.319 (2016): Expanding Veterans Employment and Homeless Services within the VA.

⁷ “VA.gov: Veterans Affairs.” How Common is PTSD in Veterans?, July 24, 2018. https://www.ptsd.va.gov/understand/common/common_veterans.asp.

⁸ Lawrence, Quil. “Veterans Kick The Prescription Pill Habit, Against Doctors' Orders.” NPR. NPR, July 11, 2014. http://www.npr.org/sections/health-shots/2014/07/11/330178170/veterans-kick-the-prescription-pill-habit-against- doctors-orders.

⁹ The American Legion Resolution No. 160 (2016): Complementary and Alternative Medicine

¹⁰ The American Legion Resolution No.37 (2016):  Improvements to VA Women Veterans Programs

¹¹ The American Legion Resolution No.147 (2016): Women Veterans.

¹² During a hearing before the U.S.-China Economic and Security Review Commission July 31, 2019, in testimony provided by the Hastings Center, it was pointed out that “If China Shut the Door on Exports of Medicines and Their Key Ingredients and Raw Materials, U.S. Hospitals and Military Hospital and Clinics Would Cease to Function Within Months, If Not Days. A natural disaster, global health crisis, or adverse foreign government action could disrupt the supply of medicinal ingredients and finished drugs. Surgeries could not be performed at Walter Reed National Military Medical Center” and other hospital systems, which would include VA.

¹³ The American Legion Resolution No.37 (2020): Support “Buy American” Policy within the Federal Government to Create Opportunities for Veterans

¹⁴ U.S. Department of Veteran Affairs. (2020). National Veteran Suicide Prevention Annual Report. Office of Mental Health and Suicide Prevention. Retrieved from: 2020 National Veteran Suicide Prevention Annual Report (va.gov)

¹⁵ National Academies of Sciences, Engineering, and Medicine. 2021. Letter Report on Review of Department of Veterans Affairs Monograph on Potential Therapeutic Effects of Service and Emotional Support Dogs on Veterans with Post Traumatic Stress Disorder. Washington, DC: The National Academies Press. https://doi.org/10.17226/26039.

¹⁶ Geers, A. L., Rose, J. P., Fowler, S. L., Rasinski, H. M., Brown, J. A., & Helfer, S. G. (2013). Why does choice enhance treatment effectiveness? Using placebo treatments to demonstrate the role of personal control. Journal of Personality and Social Psychology, 105(4), 549–566. https://doi.org/10.1037/a0034005

¹⁷ The American Legion Resolution No.134 (2016): Service Dogs for Injured Service Personnel and Veterans with Mental Health Conditions

¹⁸ McCarthy, Niall, and Felix Richter. “Infographic: When Will the U.S. Lose Its Last WWII Veterans?” Statista Infographics, May 25, 2020. https://www.statista.com/chart/13989/when-the-us-will-lose-its-wwii-veterans/.

¹⁹ The American Legion Resolution No.3 (2017): WWII Veterans Hospital and Medical Eligibility

²⁰ U.S. Department of Veteran Affairs. (2020). National Veteran Suicide Prevention Annual Report. Office of Mental Health and Suicide Prevention. Retrieved from: 2020 National Veteran Suicide Prevention Annual Report (va.gov)

²¹ Shane III, Leo. “VA Success Story - New Veterans Answering Calls Checking In.” Military Times, March 4, 2020. https://www.militarytimes.com/news/pentagon-congress/2020/03/03/va-success-story-new-veterans- answering-calls-checking-in/.

²² The American Legion. 2019 Mental Health Survey Executive Report (2019). Retrieved from: https://www.legion.org/publications/248320/2019-mental-health-survey-executive-report

²³ Ravindran, Chandru, Sybil W. Morley, Brady M. Stephens, Ian H. Stanley, and Mark A. Reger. "Association of suicide risk with transition to civilian life among US military service members." Journal of the American Medical Association network open 3, no. 9 (2020): e2016261-e2016261.

²⁴ “Executive Order 13822-Supporting Our Veterans During Their Transition From Uniformed Service to Civilian Life.” Executive Order 13822-Supporting Our Veterans During Their Transition From Uniformed Service to Civilian Life | The American Presidency Project, January 9, 2018. https://www.presidency.ucsb.edu/documents/executive-order-13822-supporting-our-veterans-during-their-transition- from-uniformed.

²⁵ “Joint Action Plan for Supporting Veterans During Their Transition from Uniformed Service to Civilian Life.” va.gov, May 3, 2018. https://www.va.gov/opa/docs/joint-action-plan-05-03-18.pdf.

²⁶ The American Legion Resolution No.12 (2018): Accountability and Enhancements of Transition Assistance Program, Outcomes and Delivery for Today’s Digital Transitioning Servicemembers

²⁷ The American Legion Resolution No.147 (2016): Women Veterans.

²⁸ U.S. Department of Health & Human Services. (2021). Reproductive Health: Infertility Frequently Asked Questions. Centers for Disease Control and Prevention. Retrieved from: https://www.cdc.gov/reproductivehealth/infertility/index.htm#:~:text=About%206%25%20of%20married%20wome n,to%20term%20(impaired%20fecundity).

²⁹ Katon JG, Cyple Y, Raza M, et al. (2014) Self-reported infertility among male and female Veterans serving during OEF/OIF. J Womens Health; 23(2):175-183.

³⁰ Mattocks K, Kross-Desrosiers A, Zephyrin L, et al. (2015). Infertility care among OEF/OIF/OND women Veterans in the Department of Veterans Affairs. Med Care; 53(4 Suppl 1):S68-S75.

³¹ Department of Veteran Affairs. (2017). Infertility brochure: VA infertility services. Retrieved from: https://www.womenshealth.va.gov/WOMENSHEALTH/docs/InfertilityBrochure_FINAL2_508.pdf#

³² Department of Veteran Affairs. (2017). Infertility brochure: VA infertility services. Retrieved from: https://www.womenshealth.va.gov/WOMENSHEALTH/docs/InfertilityBrochure_FINAL2_508.pdf#

³³ The American Legion Resolution No.16 (2021): Reproductive Assistance and Pregnancy Counseling

³⁴ Government Accountability Office. VA Should Improve the Information It Publicly Reports on the Quality of Care at Its Medical Facilities. (2017). [online] Available at: https://www.gao.gov/assets/gao-17-741.pdf. [Accessed April 8, 2021]

³⁵ The American Legion Resolution No.194 (2016): VA Veteran Integrated Service Networks

³⁶ Hudak, J. (2016). RICHARD NIXON FIRES THE OPENING SHOTS IN THE WAR ON DRUGS. In Marijuana: A Short History (pp. 49-58). Washington, D.C.: Brookings Institution Press. Retrieved from http://www.jstor.org/stable/10.7864/j.ctt1hfr1qj.8

³⁷ Reuters, T. (2019). The Controlled Substances Act: Overview. Retrieved from https://criminal.findlaw.com/criminal-charges/controlled-substances-act-csa-overview.html

³⁸ United States Drug Enforcement Administration. (n.d.). Drug Scheduling. Retrieved from https://www.dea.gov/drug-scheduling

³⁹ The American Legion Resolution No.11 (2016): Medical Marijuana Research

⁴⁰ The American Legion Resolution No.46 (2012): VA non-VA care programs

⁴¹ Department of Veterans Affairs Office of Inspector General. (2019). Non-VA Emergency Care Claims Inappropriately Denied and Rejected. Retrieved from https://www.va.gov/oig/pubs/VAOIG-18-00469-150.pdf

⁴² Department of Veterans Affairs Office of Inspector General. (2019). Non-VA Emergency Care Claims Inappropriately Denied and Rejected. Retrieved from https://www.va.gov/oig/pubs/VAOIG-18-00469-150.pdf

⁴³ The American Legion. (2021). American Legion, VSOs urge VA Secretary to reimburse veterans. Retrieved from https://www.legion.org/veteransbenefits/251841/american-legion-vsos-urge-va-secretary-reimburse-veterans

⁴⁴ The American Legion Resolution No.2 (2009): Uniform payment policy for emergency care at non-VA medical center facilities

⁴⁵ “Statement Of Dr. Teresa Boyd Assistant Under Secretary for Health for Clinical Services VHA Department of Veterans Affairs Before The House Committee on Veterans Affairs Subcommittee on Health.” Veteran Health Administration (VHA), July 29, 2020. https://www.congress.gov/116/meeting/house/110943/witnesses/HMTG-116- VR03-Bio-BoydT-20200729.pdf.

⁴⁶ The American Legion Resolution No.140 (2008): Policy on SVH Inspections

⁴⁷ Cancercare. (2021). Breast Cancer: Understanding Risk Factors and Screening. Cancercare.org. Retrieved from: https://www.cancercare.org/publications/82-breast_cancer_understanding_risk_factors_and_screening

⁴⁸ The American Legion Resolution No.239 (2004): Support research about breast cancer

⁴⁹ The American Legion Resolution No.24 (2018): Support Funding and Changes to the VA GPD Program

⁵⁰ Silas, Sharon M., Randall B. Williamson, Marcia A. Mann, Kaitlin M. McConnell, Summar C. Corley, Krister Friday, Jacquelyn Hamilton, Vikki Porter, and Brienne Tierney. VA HEALTH CARE: Improved Policies and Oversight Needed for Reviewing and Reporting Providers for Quality and Safety Concerns. Report no. GAO-18-63. Government Accountability Office. 1-32.

⁵¹ Cassidy B. (2021). Cassidy, Colleagues Introduce Bipartisan Legislation to Hold VA Providers Accountable. Retrieved from https://www.cassidy.senate.gov/newsroom/press-releases/cassidy-colleagues-introduce-bipartisan- legislation-to-hold-va-providers-accountable-