Ensuring Veterans' Smooth Transition Act
Floor Speech
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Mr. TAKANO. Mr. Speaker, pursuant to House Resolution 860, I call up the bill (H.R. 4673) to amend title 38, United States Code, to provide for the automatic enrollment of eligible veterans in patient enrollment system of Department of Veterans Affairs, and for other purposes, and ask for its immediate consideration in the House.
The Clerk read the title of the bill.
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Mr. TAKANO. 4673, as amended.
Mr. Speaker, I rise today in support of H.R. 4673, as amended, my bill, the Ensuring Veterans' Smooth Transition, or EVEST Act.
I have made suicide prevention a top priority for the House Veterans' Affairs Committee. Last Congress, we passed bipartisan, bicameral mental health legislative packages, including the Commander John Scott Hannon Veterans Mental Health Improvement Act and the Veterans COMPACT Act. This Congress, we continued this work by passing the Sergeant Ketchum Rural Veterans Mental Health Act into law, but there is always more to do.
EVEST builds on our work and finally closes one of the most glaring gaps for veterans being able to successfully access high-quality VA health services, the enrollment process. We shouldn't be trying to hide VA care from those who earned it.
We know that the months following transition out of the military can be very stressful and particularly risky for new veterans in terms of mental health. With the EVEST Act, servicemembers will be automatically enrolled in VA care during their transition out of the military, with the choice to opt out. This helps simplify the process and prevents veterans from potentially missing out on lifesaving care. It also keeps veterans from having to opt into VA care later and attempt to navigate a new bureaucracy all on their own.
The symptoms of PTSD can be significantly improved in veterans who receive prompt mental healthcare. A 2014 study led by researchers at the San Francisco VA Medical Center looked at nearly 40,000 Iraq and Afghanistan veterans who received VA mental healthcare between 2001 and 2011 and had a post-deployment diagnosis of PTSD. They found that veterans who sought and received care soon after the end of their service had lower levels of PTSD upon follow-up a year after they initiated care. Each year that a veteran waited to initiate treatment, there was about a 5 percent increase in the odds of their PTSD either not improving or getting worse.
Mr. Speaker, I include in the Record the study from the San Francisco VA Medical Center. [From Psychiatric Services, Dec. 2014] Timing of Mental Health Treatment and PTSD Symptom Improvement Among Iraq and Afghanistan Veterans (By Shira Maguen, Ph.D.; Erin Madden, M.P.H.; Thomas C. Neylan, M.D.; Beth E. Cohen, M.D., M.A.S.; Daniel Bertenthal, M.P.H.; Karen H. Seal, M.D., M.P.H.) Objective
This study examined demographic, military, temporal, and logistic variables associated with improvement of posttraumatic stress disorder (PTSD) among Iraq and Afghanistan veterans who received mental health outpatient treatment from the U.S. Department of Veterans Affairs (VA) health care system. The authors sought to determine whether time between last deployment and initiating mental health treatment was associated with a lack of improvement in PTSD symptoms. Methods
The authors conducted a retrospective analysis of existing medical records of Iraq and Afghanistan veterans who enrolled in VA health care, received a postdeployment PTSD diagnosis, and initiated treatment for one or more mental health problems between October 1, 2007, and December 31, 2011, and whose records contained results of PTSD screening at the start of treatment and approximately one year later (N=39,690). Results
At the start of treatment, 75% of veterans diagnosed as having PTSD had a positive PTSD screen. At follow-up, 27% of those with a positive screen at baseline had improved, and 43% of those with a negative screen at baseline remained negative. A negative PTSD screen at follow-up was associated with female gender, older age, white race, having never married, officer rank, non-Army service, closer proximity to the nearest VA facility, and earlier initiation of treatment after the end of the last deployment. Conclusions
Interventions to reduce delays in initiating mental health treatment may improve veterans' treatment response. Further studies are needed to test interventions for particular veteran subgroups who were less likely than others to improve with treatment. (Psychiatric Services 65:1414-1419, 2014; doi: 10.1176/appi.ps.201300453)
Posttraumatic stress disorder (PTSD) is one of the most common mental disorders among veterans returning from recent deployments. Yet, despite the availability of evidence-based treatments, there are multiple barriers to initiating mental health treatment. Many military personnel and veterans who report barriers to mental health care do not seek treatment or postpone seeking it.
Among veterans who do seek mental health care, the time lag is quite significant. In a previous study, we found that recently returning veterans with psychiatric diagnoses had delayed initiating mental health care at the U.S. Department of Veterans Affairs (VA) by a median of over two years after their last deployment ended. Delays in care can translate into delays in symptom and functional improvement, hindering readjustment to civilian life, family, and community.
Some studies have examined predictors of PTSD symptom worsening, but outside of randomized treatment trials, only a few studies have examined variables that are associated with PTSD symptom improvement. In other words, few studies have examined variables that are associated with PTSD symptom improvement in a naturalistic fashion, by allowing treatment initiation or engagement to vary among participants. Furthermore, even fewer studies have examined these questions among military personnel or veterans, particularly among those who have served in Iraq and Afghanistan. Existing studies have found a few variables that were associated with PTSD symptom improvement. For example, service members serving in multiple deployments demonstrated greater symptom improvement than those serving in a single deployment. For other demographic variables, the association with improvement is unclear. For example, although we know that female gender may be associated with the development of PTSD, it is not clear how gender is related to PTSD symptom improvement.
If we can better understand why some individuals improve, we can better understand the course and trajectories of PTSD and how to best contribute to individuals' recovery. This study evaluated demographic, military, temporal, and logistic variables that may be associated with PTSD symptom improvement. We were particularly interested in whether seeking mental health treatment sooner was associated with improvement in PTSD symptoms. Methods Data source and extraction
We conducted a retrospective analysis of existing medical records from the VA's Operation Enduring Freedom (OEF)/ Operation Iraqi Freedom (OIF)/Operation New Dawn (OND) roster, a national database of veterans who have separated from OEF/OIF/OND military service and who have enrolled in VA health care. Veterans of OEF served predominantly in Afghanistan, and veterans of OIF and OND served predominantly in Iraq. We linked the OEF/OIF/OND roster database, which contains veterans' demographic and military service information, to the Decision Support System's National Data Extract of pharmacy data and the VA National Patient Care Database, which provides VA visit dates and associated diagnostic codes from the International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM). These data are derived from electronic medical records generated during clinical visits. Visits to mental health outpatient and primary care services are categorized by clinic stop codes. Mental health outpatient services include visits to integrated care clinics providing primary care and mental health care. Fee basis codes designate care that is rendered at non-VA facilities and reimbursed by the VA but do not capture all non-VA care, such as care reimbursed by private insurance. The results of PTSD screening were extracted from the VA Corporate Data Warehouse.
All analyses were restricted to OEF/OIF/OND veterans who had received a diagnosis of PTSD (ICD-9-CM code 309.81) during two or more clinical encounters that occurred after the end of their last deployment and before December 31, 2012; had utilized mental health outpatient care between October 1, 2007 (beginning of nationwide primary care screenings), and December 31, 2012, and had not made any prior use of VA care; and had received PTSD screenings at both the start of treatment (up to three months before and one month after the first mental health visit) and on at least one other occasion occurring at least one year later (N=39,690). Of veterans who newly entered mental health treatment, 83% had a baseline screen for PTSD, and of those with a baseline screen, 50% had a follow-up screen during the period beginning one year later. The follow-up screen that was closest in proximity to the one-year follow-up date was utilized. Measures
PTSD symptoms were assessed by using the Primary Care PTSD Screen (PC-PTSD), the PTSD Checklist (PCL), or both. Both measures were included in order to capture the most representative sample, given that the PC-PTSD screen is mainly used in VA primary care settings and other non-mental health settings and the PCL is used primarily in VA mental health settings. The PC-PTSD, a brief four-item screen given annually and after each deployment, is designed to detect possible PTSD symptoms. The screen yields binary responses (yes or no) for each of four PTSD symptom clusters: reexperiencing, avoidance, emotional numbing, and hyperarousal; a score of 3 designates a positive PTSD screen for veterans.
The PCL is a 17-item measure, with each item rating the presence of a different symptom over the past month on a 5- point Likert scale, from not at all to a little bit, moderately, quite a bit, and extremely. The PCL has been shown to have very good internal consistency, and it correlates strongly with other measures of PTSD symptoms. The PCL also demonstrates high diagnostic efficiency (.90). Within the VA, the PCL is mainly administered at the discretion of treating clinicians, typically to track patient progress during the course of mental health treatment. For the purposes of this study, symptoms rated as moderately or above on the PCL were considered present. PTSD symptoms from the PCL were combined in order to create indicators that paralleled each of the four symptom cluster proxies from the PC-PTSD. The validity of the mapping of PCL questions onto PC-PTSD items was tested by examining concordance between the two screens given at the VA on the same date. For the purposes of validation, all OEF/OIF/OND veterans who were administered the PCL and the PC-PTSD on the same date (not restricted to our study sample) were included (N=53,756), with a total of 57,889 instances in which a given veteran had both a PC-PTSD and PCL administered on the same day. [A table describing the mapping of the PCL to the PC-PTSD and agreement between the two instruments is available online as a data supplement to this article.]
We created a composite variable, referred to as the PTSD screen result; endorsing three or more symptoms on either measure constituted a positive screen for PTSD. Dependent variable
The binary dependent variable, a negative (versus positive) PTSD screen result, was defined as a score of <3 at follow-up on the PTSD screen. This outcome comprised PTSD screen results that had improved or had remained negative compared with baseline results (versus having worsened or remained positive). Independent variables
The main independent variable was time until initiation of mental health outpatient treatment, which was defined for each person as the time (in years) from the end of the last deployment until the first mental health outpatient visit. Other independent variables included date of birth, gender, race-ethnicity, marital status, and military characteristics. Details about each person's military characteristics (armed forces branch [Army, Marines, Navy or Coast Guard, or Air Force], rank, component type [National Guard and reserves or active duty], and number of deployments [one or multiple deployments]) were extracted from the OEF/OIF/OND roster. Information about the type of VA facility nearest to the individual and the distance to the closest facility was derived from the OEF/OIF/OND roster by the VA planning and system support group.
The following independent variables were treated as potential confounders because each could account for change in PTSD symptoms: mental health outpatient treatment utilization, defined as the number of mental health clinic visits between the start of mental health treatment and the follow-up screen; regular use of primary care services, defined as a mean interval between visits of six months or fewer; and use of a selective serotonin reuptake inhibitor (SSRI) for 12 consecutive weeks or more, as encoded in VA outpatient pharmacy data. Analysis
We used logistic regression analysis to examine the association of independent predictor variables with a negative PTSD screen result. In separate logistic regression models, we examined predictors of PTSD screen results for each of the four PTSD symptom clusters (reexperiencing, avoidance, emotional numbing, and hyperarousal). The main predictors of interest included time from the end of the last deployment to initiation of mental health outpatient treatment, gender, age, race-ethnicity, marital status, military component, rank, branch, number of deployments, and distance to and type of nearest VA facility. The multi- variable analysis adjusted for potential confounders of the association between changes in PTSD symptoms and predictors. Potential confounders included baseline PTSD screen result, timing of follow-up screen, regular utilization of primary care services, total mental health outpatient treatment utilization, and SSRI use. Primary care and mental health service utilization and antidepressant use were included only for adjustment purposes because of potential biases due to confounding by indication. More specifically, persons who are more symptomatic are more likely to utilize health services and antidepressant medications.
We tested interactions of demographic and military predictors with each other and, separately, with time to initiation of mental health outpatient treatment. As mentioned above, the study combined results for veterans whose PTSD screen result had improved from baseline with those for veterans whose screen result had remained negative. To determine whether it was valid to combine these scores, we tested interactions of baseline screen results with demographic and military factors and, separately, with time from the end of the last deployment to initiation of mental health outpatient treatment. All tests were two-tailed. Analyses were performed by using SAS, version 9.3. The study was approved by the Committee on Human Research, University of California, San Francisco, and the San Francisco VA Medical Center. RESULTS
The sample was 90% male, with a mean
Multivariable logistic regression analysis showed that the following characteristics were associated with a negative PTSD screen result: women compared with men, older versus younger age at first mental health outpatient visit, officer rank compared with enlisted rank, service in branches of the military other than the Army, and negative PTSD screen at baseline (Table 2).
Blacks were less likely than whites to have a negative screen result (Table 2), and this difference persisted after adjustment for time from the end of the last deployment to mental health outpatient treatment. Similar to findings of previous studies, the median interval between the end of the last deployment and the use of services was about three months longer for blacks than for whites (p<.001; data not shown). The reduced likelihood among blacks versus whites of a negative PTSD screen result was partly driven by the 7% greater probability that blacks would screen positive for PTSD at follow-up after having screened negative at baseline (p<.001; results not shown).
Veterans who were married were slightly less likely than those who were never married to have a negative PTSD screen result. Veterans who lived more than ten miles away from the nearest VA facility were less likely than veterans who lived closer to have a negative screen result. Veterans who lived closer to a community-based outpatient clinic than to a VA medical center were also less likely to have a negative screen result.
Notably, veterans who waited longer to initiate mental health outpatient treatment were less likely to have a negative screen result. Figure 1 illustrates the decreasing probability of a negative screen result with each year that passed after the end of the last deployment.
Logistic regression analyses found similar patterns of association between predictor variables and PTSD screen results for each of the four PTSD symptom clusters (results not shown). DISCUSSION
A number of demographic, military, temporal, and logistic variables were associated with symptom improvement or with continuing to score below the threshold for a positive PTSD screen. Although temporal variables are rarely examined, we found that greater time to mental health outpatient treatment engagement was negatively associated with PTSD symptom improvement. More specifically, veterans who waited longer to get mental health treatment were less likely than veterans who sought treatment sooner to experience PTSD symptom improvement during the study period. This finding sheds light on the importance of continuing to better understand barriers to mental health treatment, particularly given that less than half of veterans with mental health problems seek care and those who seek care do so after significant delays.
Outreach efforts to help veterans engage in treatment in a timely manner are critical and may, in turn, help with PTSD symptom improvement over time. Intervening early when mental health problems are first detected should be a priority. Given that integrated primary and mental health care is now becoming available at many VA health care facilities, this ``one-stop shop'' model provides an optimal way to decrease time to seeking mental health care. Veterans in primary care who screen positive for any mental health problems can receive immediate mental health assistance within an integrated care model, which may assist with the stigma of receiving care in a mental health setting. Indeed, veterans who received integrated primary care were more likely to receive a mental health evaluation or care within a month.
We also found that female gender was associated with greater PTSD symptom improvement compared with male gender. Although civilian studies found that females are at greater risk of PTSD, findings in military samples have been mixed, with some studies finding no gender differences. In addition, we recently found that although both genders experienced a delay in engaging in minimally adequate mental health care (eight mental health outpatient visits within a year), female veterans received minimally adequate mental health care about two years sooner than male veterans, which may explain why they achieved greater symptom improvement.
Black veterans were less likely, but only modestly so, to demonstrate PTSD symptom improvement, compared with their white counterparts, and this difference was not explained by longer time from the end of the last deployment to mental health outpatient treatment initiation. That is not surprising, given that studies have consistently found that unmet treatment needs are greatest in underserved groups, including racial-ethnic minority groups). It may be that veterans from racial-ethnic minority groups face particular barriers to treatment that are important to acknowledge, and more research is needed in this area in order to optimize outcomes. Furthermore, other variables, such as differential rates of traumatic stressors and preexisting conditions, are important to further explore and may explain some of these differences.
Officers were more likely than enlisted personnel to experience PTSD symptom improvement. One possible explanation is that officer status may be a proxy for higher education; research has shown that lower levels of education are associated with chronic trajectories of PTSD. However, other variables that we were not able to measure, such as social support in the aftermath of trauma, may also explain some of these findings.
A number of limitations should be considered when interpreting these findings. First, this study was conducted with a population of treatment-seeking veterans who had at least one visit to a VA health care facility. Therefore, our results should not be generalized to all OEF/OIF/OND military personnel or veterans. Second, we selected a population of veterans who served in support of OEF/OIF/OND, and, therefore, these results should not be generalized to veterans of other eras or to veterans from other countries. Third, ICD-9-CM diagnoses were acquired from administrative health records and were not verified with standardized diagnostic measures. A related concern is the combined use of two separate validated tools, the PCL and the PC-PTSD. We used both the PCL and the PC-PTSD in order to obtain the most representative sample and because they are the measures used by the VA system. Furthermore, we found that the method we used was statistically reliable. Nonetheless, combining two separate validated tools may have resulted in variations in these data. Future studies should continue to examine the validity and reliability of this method.
Fourth, because of the ways in which data appear in the VA administrative database, we were not able to distinguish between the types of mental health treatments that veterans were receiving, such as evidence-based treatment for PTSD or other mental health problems versus supportive therapy; rather, we could account only for number of visits. We hope to have better indicators of evidence-based treatment for PTSD in the future so that the particular types of care that veterans receive can be examined more closely in relation to symptom improvement. Fifth, because we used administrative data, we were not able to examine third variables that may be associated with our outcome, including severe avoidance symptoms, interpersonal difficulties, and poor attachment, among others. Finally, we were able to include only veterans whose PTSD symptoms were measured during at least two occasions; those who dropped out after one visit are not as well represented. Conclusions
Veterans who waited longer to get mental health treatment were less likely to experience PTSD symptom improvement during the study period. Furthermore, improving barriers for black, male, younger, rural, lower-ranking, and possibly less well educated veterans is an important priority, given our findings. Models that integrate primary care and mental health care may be an optimal way to help expedite veteran treatment engagement. Acknowledgments and disclosures
This research was supported by VA Health Services Research and Development Service (HSR&D) Career Development Award (RCD 06-042) to Dr. Maguen, an HSR&D Service Directed Research Award (SDR-08-408) to Dr. Seal, and a Department of Defense Mental Health Research Infrastructure Award (W81XWH-11-2- 0189) to Dr. Neylan. The authors thank Julie Dinh, B.A., for assistance.
Dr. Neylan has received study medication for a study funded by the Department of Defense and study medication for a study funded by the VA. The other authors report no competing interests.
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Mr. TAKANO. A smooth care transition from DOD to VA can help support veterans as they adjust to the next phase of their lives and provide easy access to healthcare should any challenges arise.
Everyday Americans find it difficult and frustrating to sign up for healthcare. Now, imagine that you have just come off Active-Duty military service where, for years you were told when and where to show up for your healthcare. You probably heard something about VA services during your transition assistance program but, frankly, you were focused on everything you had to do to finalize your separation from the military and possibly looking for new employment and relocating your family.
Now, after having separated from the military, you are a veteran, and maybe for the first time you have to figure out how to check your eligibility for VA healthcare and navigate the system while potentially also facing some new stress in your personal and family life. This is completely avoidable with EVEST, which simply enrolls you in the VA healthcare for which you are already eligible, ensuring that when you need VA, there aren't any unnecessary roadblocks to seeing a doctor.
Now, let me say that again. This legislation has nothing to do with a veteran's eligibility, nor does it change VA standards or who is eligible. It only connects eligible veterans to VA care faster and easier.
We know that veterans are much more likely to use VA services and care when the process to enroll is simple, and we know that VA care is world class. EVEST is a straightforward tool that will allow us to simplify the transition process and take steps toward preventing veteran suicide.
Automatic enrollment is something policymakers and veterans service organizations and stakeholders have been trying to advance for years, and with EVEST it will finally become a reality.
Paralyzed Veterans of America and Disabled American Veterans have formally endorsed this legislation. The Nurses Organization of Veterans Affairs, the American Federation of Government Employees, the Veterans Healthcare Policy Institute, and the American Psychological Association also support EVEST.
Again, Mr. Speaker, I include in the Record letters of support from the Nurses Organization of Veterans Affairs and the Veterans Healthcare Policy Institute. Nurses Organization of Veterans Affairs, January 14, 2021. Chairman Mark Takano, Committee on Veterans' Affairs, Washington, DC.
Dear Chairman Takano: On behalf of the nearly 3,000 members of the Nurses Organization of Veterans Affairs (NOVA) we would like to offer our strong support for your bill, H.R. 4673, Ensuring Veterans' Smooth Transition Act (EVEST).
As nurses, caring for Veterans is our number one priority. Your bill will provide Veterans with the option of enrolling in VA healthcare during the critical months following their transition to civilian life and ensure servicemembers separating from active duty receive the critical health care to which they are eligible.
Your bill will also help eliminate barriers to care-- including those who may not know they are even eligible to receive care at VA. It will also help to assure the Veteran that they are not alone in seeking care for any physical or mental health condition acquired during their military service.
Offering automatic enrollment with an opt out will help to lessen the burden of navigating the VA healthcare system at a time when they are dealing with many challenges as they transition to civilian life.
NOVA believes that most Veterans will find care provided them within the VA is suited to their individual and complex needs and cannot be matched in the private sector. Many providers at the VA are Veterans themselves so they understand what it means to serve and are trained to provide a Whole Health approach to the Veteran patients' health and well-being.
Thank you for your leadership on this issue and your continued support for Veterans and the healthcare professionals who care for them. Sincerely, Taryn-Janae Wilcox-Olson, MHS, RN,
President, Nurses Organization of Veterans Affairs (NOVA). ____ Veterans Healthcare Policy Institute (VHPI), January 19, 2022. Endorsement of the ``Ensuring Veterans' Smooth Transition Act''
The Veterans Healthcare Policy Institute (VHPI) is pleased to formally endorse House bill H.R. 4673, the ``Ensuring Veterans' Smooth Transition Act'' or ``EVEST Act.'' The EVEST Act creates a process to automatically enroll Veterans who are eligible, upon their discharge from the military, into the VA for medical care, with an opportunity to opt out. Many Veterans do not receive the health care they have earned through their service because they are unaware of their eligibility or are too overwhelmed during the complex period of transitioning from active duty. By automatically enrolling Veterans into the VA system, many more eligible veterans will be able to utilize valuable VA health care benefits. Many lives will be saved.
This is one of the most important bills in many years, and we are pleased to support its passage.
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Mr. TAKANO. Mr. Speaker, I wish to thank Speaker Pelosi and Leader Hoyer for considering this legislation today, and I urge the rest of my colleagues to support this vital legislation to increase access to care and ensure a smooth transition to civilian life for veterans.
I reiterate that we should not be hiding the care that our veterans have earned. Let me quickly say that this bill has been in the public domain for 2 years. It was reintroduced last summer, and the minority had over 6 months to talk with us and the VA about it.
Furthermore, the committee has held six hearings on suicide prevention and transition since 2019. The common sense of this bill shines through.
And let me also add that regarding the capacity of VA--and I am glad that the ranking member has entered the statement of administrative support into the Record; that statement clearly says and declares the administration's support and its willingness to work with the administration.
Data shows that VA enrollment has been going down in recent years, and while new enrollment hovers around 400,000 per year, it used to be double that, around one million per year, and using current assumptions, VA projects veteran enrollment in VHA to remain relatively steady from 2019 to 2029.
I am very confident about VA's ability to absorb the additional veterans that will take advantage of VA's world-class healthcare.
I want to add that, in response to the esteemed ranking member, VA formally supports this legislation and has been discussing auto enrollment for years.
VA has already been working to make transition into VA healthcare smoother with Solid Start and will soon have data showing that warm handoffs have a positive impact on veteran outcomes without overwhelming the VA system.
In response to the criticism that VSOs have not had input, I want to point out that VSOs, including Paralyzed Veterans of America and Disabled American Veterans, have already formally endorsed EVEST. Why? Because the common sense of this legislation shines through.
All VSOs have had a chance to weigh in, and many did. The Nurses Organization of Veterans Affairs, the American Federation of Government Employees, the Veterans Health Policy Institute, and the American Psychological Association also support this legislation.
Let me say that the amendments that we are considering to this bill today, which I consider friendly, will address many of the ranking member's concerns about the reaching out.
I yield 3 minutes to the gentleman from Connecticut (Mr. Himes), my good friend who serves on the Financial Services Committee and the Permanent Select Committee on Intelligence.
Mr. Speaker, let me just say, in response to my friend, the esteemed ranking member, that his MTR, which would delay implementation in order to avoid harm to our veterans, dare I say that the harm is in the delay.
I am reminded of a quote from the VFW's Pat Murray that we had at yesterday's roundtable on toxic exposure: Our pay-for for this bill and our pay-for, frankly, for all that we do for veterans was the ticket that we sent servicemembers overseas to serve. I repeat: Our pay-for was the ticket we sent servicemembers overseas to serve.
And a little further discussion on the pay-for issue: The Congressional Budget Office does not estimate that this bill will increase mandatory spending and does not require an offset. These are the rules we play by.
Again, we are not creating new eligibility here. The only cost of this bill is veterans seeking care that they are already eligible for. We are all better off when veterans are seeking the care that they need, and we should not be hiding that care for which they are eligible.
Automatic enrollment in VA healthcare for eligible veterans is a long-needed suicide prevention tool. We cannot put a price tag on protecting the health and safety of our veterans. Many of these veterans would go on to use VA healthcare even if they are not automatically enrolled, and the minority does not give a compelling reason why we should hinder or make that process more difficult for our veterans.
Again, I repeat, we should not be hiding the care for which our veterans are already eligible.
Mr. Speaker, I ask that all my colleagues join me in passing H.R. 4673, as amended, and I anticipate we will see a big bipartisan vote today.
Mrs. JACKSON LEE. Mr. Speaker, I stand here in strong support of H.R. 1836, the Ensuring Veterans' Smooth Transition Act (EVEST), which provides automatic enrollment in the VA for all transitioning service members, and veterans who don't want to obtain its services have the easy choice of opting out.
Specifically, this bill would:
Automatically enroll new veterans into VA Health Care;
Provide VA with information about transitioning service members;
Require the VA to reach out to veterans about the scope of, and access to, benefits.
Assuring future cohorts of veterans--including those struggling with the Taliban triumph in Afghanistan--don't go without health care during their transition from military to civilian life is the worthy goal of this bill.
After attempting suicide while serving on active duty in Iraq, Kristofer Goldsmith was given a general discharge by the Army and little else.
The overwhelmed 21-year-old returned to his hometown on Long Island, N.Y., totally unaware that he was eligible for care from the Veterans Health Administration (VA).
``I had just lost my income, my support network, my identity, and almost my life. I was in a total mental health crisis,'' Goldsmith said.
During the critical months following his transition to civilian life, he went without desperately needed services.
If his mother hadn't forced him to go to the VA, Goldsmith, who credits the VA with helping him rebuild his life, doesn't know what would have happened to him.
Of this, however, he is certain, ``If I had heard from my local VA informing me of what benefits I had and that I'd been enrolled in the system, it would have changed my life drastically.''
This bill would help thousands of veterans who need services for the multitude of conditions acquired or exacerbated by military service but are confused about how to access them.
These ailments include everything from respiratory problems caused by burn-pit toxic exposure to signature combat conditions such as Traumatic Brain Injury (TBI) and Post-Traumatic Stress Disorder (PTSD).
For all these problems, prompt attention means everything.
For example, according to research conducted by the VA, veterans who received care soon after the end of their service ``had lower levels of PTSD upon follow-up a year after they initiated care.
According to the study, for each year that a veteran waited to initiate treatment, there was about a 5 percent increase in the odds of their PTSD either not improving or worsening.
In 2018, the National Academies of Sciences, Engineering and Medicine found that post-9/11 veterans who had not sought VA mental health care didn't know how to apply for benefits--or were unsure whether they were even eligible.
Some didn't know what services the VA offered or felt that they didn't deserve care even if they could get it.
Some women veterans are similarly unsure whether VA services are even available to their gender.
This legislation will not only be key to eliminating these barriers but also to reducing the veteran suicide crisis.
A disproportionate number of veterans die by suicide during the initial months and years following separation from military service.
Veterans ages 18 to 34 have the highest rate of suicide.
Automatic pre-enrollment could be lifesaving during a crisis when speed is of the essence.
Smoother access to VA health care has never been more important than it is today.
The tumultuous end of the war in Afghanistan is intensifying mental health symptoms within the veteran population.
I am proud to support this legislation in order to better serve veterans and reduce veteran suicide.
This bill, in which we further the benefits and recognition that our servicemen and women deserve, also reminds us that we have an overriding duty to protect the health and dignity of those serving today.
For this reason, I would like to discuss the crisis that our National Guardsmen and Guardswomen have been thrust into at the Texas Governor's direction on our Southern Border.
In March 2021, the Texas Governor launched the ill-fated and ineffective Operation Lone Star which he claimed was necessary to stem a so-called invasion of migrants at Texas' southern border.
As of November 2021, more than 10,000 Texas National Guardsmen have been deployed to the southern border in pursuit of this folly.
According to published media accounts, National Guard members who have been activated for Operation Lone Star are experiencing habitual pay delays and poor working conditions during the border mission, including being exposed to COVID-19, and many are missing the equipment necessary for safety and mission success.
In addition, the National Guard has faced austere conditions and limited resources, leading to unsanitary conditions such as the lack of portable restrooms.
Rather than addressing these conditions, just last week the Texas Governor filed a frivolous lawsuit in federal court challenging the authority of President Biden, the Commander-in-Chief of the Armed Forces to require that members of the National Guard be vaccinated against COVID-19.
There is no merit to this nuisance law suit as demonstrated by the summary rejection of similar arguments raised by neighboring Oklahoma Governor Stitt.
The Texas Governor's failure to comply with the policies intended to reduce the spread of COVID-19 among the Armed Forces will mean that there will be less military personnel available national disasters that have struck Texas in recent years, such as the winter freeze of last year.
This will also mean that there are fewer personnel to respond to any attacks on the homeland.
Encouraged by the Texas Governor's obstinacy, about 40% of the members of the Texas Army National Guard are refusing to get vaccinated, which puts at risk their colleagues and the persons they are sworn to defend and protect.
National Guardsmen and Guardswomen deployed in this disastrous mission at the Texas Governor's insistence face the deadly spread of COVID-19, unsanitary conditions, lack of pay, and a lack of a certain future.
These uniformed men and women deserve better, and some of them, seeing no alternative to their present reality, have decided to end it all.
Five National guard soldiers have shot and killed themselves in the past three months, and one more survived a suicide attempt.
One of these men, private first class Joshua R. Cortez, was preparing to accept a ``lifetime job'' with one of the nation's biggest health insurance companies in late October last year, but the Texas National Guard had other ideas.
Operation Lone Star required involuntary activations to meet the Texas Governor's troop quotas, and Cortez was one of the soldiers tapped to go on state active duty orders--with no idea how long the mission would last.
In November, the 21-year-old mechanic requested a hardship release from the mission: ``I've been waiting for this job and I'm on my way to getting hired . . . I missed my first opportunity in September when I had to go on the flood mission in Louisiana. . . . I can not miss this opportunity because it is my last opportunity for this lifetime job.''
Cortez's company commander recommended approval. But his battalion commander and brigade commander disapproved.
Within 36 hours of his request being denied, Cortez drove to a parking lot in northwest San Antonio and shot himself in the head.
Three other soldiers tied to Operation lone Star have died by suicide, including:
Sgt. Jose L. De Hoyos was found dead in Laredo, Texas, on Oct. 26. He was a member of the 949th Brigade Support Battalion's headquarters company.
1st Sgt. John ``Kenny'' Crutcher died Nov. 12, as time ran out on his temporary hardship waiver. He was the top NCO for B Company, 3rd Battalion, 144th Infantry.
1st Lt. Charles Williams, a platoon leader in Crutcher's company, died at home overnight Dec. 17 while on pass.
The string of suicides raises urgent questions about the mission's conditions and purpose, as well as the way it's organized and manned through indefinite involuntary call-ups.
This is an excellent and common-sense bill that will enhance the benefits of our servicemen and women.
We must also act to ensure that our servicemen and women are protected from COVID-19, both for their own safety and the safety of our nation.
Although we cannot bring back the lives lost due to the Texas Governor's misguided actions, we can remember the names of those we have lost and work to ensure that we treat all members of our military equally and with dignity and respect.
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Mr. TAKANO. Mr. Speaker, pursuant to section 5 of House Resolution 860, I rise to offer the four amendments en bloc to H.R. 4673.
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Mr. TAKANO. Mr. Speaker, I rise today in support of these en bloc amendments. Seamlessly connecting veterans with the benefits and care they earned through their service is paramount to the transition process.
The Delgado amendment No. 1 makes sure that VA can easily notify veterans regarding care and services through mass texting. As technology and communication methods improve, so should how VA uses those capabilities to easily inform veterans of their benefits. Texting eligible veterans to tell them they have been auto-enrolled in VA healthcare is an effective, simple way to increase awareness of the care available to them.
The Delgado amendment No. 2 requires GAO to submit a report to determine the best methods to notify veterans regarding their automatic enrollment in VA healthcare. This amendment will strengthen the underlying bill and inform best practices for how VA can ensure veterans have the information they need regarding their access to care and services.
Getting information to veterans in an effective manner is crucial to their transition into civilian life, and the Delgado amendment No. 2 will help improve how VA communicates an eligible veteran's enrollment in VA healthcare so they can easily access the care they need.
The Hayes amendment requires that VA notify veterans who opt out of automatic enrollment that they may elect to enroll at a later date. We understand there will be some veterans who opt out for auto-enrollment for a variety of reasons, but it is our duty that they know that the VA will be waiting for them if their future needs change.
Ensuring VA adopts and scales best practices related to auto- enrollment while also learning from any issues that arise during its rollout is important to the long-term effectiveness of the aims of H.R. 4673.
The Tlaib amendment requires the VA to submit a report a year after the first veteran is auto-enrolled in VA healthcare to preserve lessons learned from the rollout. This report will help improve auto-enrollment for both the VA administrators implementing the program and veteran users alike.
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Mr. TAKANO.
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Mr. TAKANO. Tlaib), my good friend and author of this amendment. She serves on the Financial Services Committee, the Natural Resources Committee and the Oversight and Reform Committee.
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Mr. TAKANO. Mr. Speaker, I have no further speakers. I am prepared to close. I ask all my colleagues to support me in supporting these four amendments.
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Mr. TAKANO. Mr. Speaker, I rise in support of the Escobar amendment to H.R. 4673.
Mr. Speaker, seamlessly connecting veterans with the benefits and care they have earned through their service is paramount to the transition process. The Escobar amendment extends the automatic enrollment in VA healthcare to eligible veterans discharged within 90 days before enactment of the underlying bill.
Mr. Speaker, many of the 175,000 veterans who served in Operation Enduring Freedom, Operation Iraqi Freedom, and Operation New Dawn are unaware of their eligibility for 5 years of VA healthcare upon separation. Automatically enrolling recently separated eligible veterans into VA healthcare will support our aim to prevent veteran suicides and improve their access to care during their transition to civilian life.
Mr. Speaker, I urge my colleagues to support the Escobar amendment.
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