[House Hearing, 113 Congress]
[From the U.S. Government Publishing Office]





  RESTORING TRUST: THE VIEW OF THE ACTING SECRETARY AND THE VETERANS 
                               COMMUNITY

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



                                HEARING

                               before the


                     COMMITTEE ON VETERANS' AFFAIRS
                     
                     U.S. HOUSE OF REPRESENTATIVES

                    ONE HUNDRED THIRTEENTH CONGRESS

                             SECOND SESSION

                               __________

                        THURSDAY, JULY 24, 2014

                               __________

                           Serial No. 113-82

                               __________

       Printed for the use of the Committee on Veterans' Affairs


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                     COMMITTEE ON VETERANS' AFFAIRS

                     JEFF MILLER, Florida, Chairman

DOUG LAMBORN, Colorado               MICHAEL H. MICHAUD, Maine, Ranking 
GUS M. BILIRAKIS, Florida, Vice-         Minority Member
    Chairman                         CORRINE BROWN, Florida
DAVID P. ROE, Tennessee              MARK TAKANO, California
BILL FLORES, Texas                   JULIA BROWNLEY, California
JEFF DENHAM, California              DINA TITUS, Nevada
JON RUNYAN, New Jersey               ANN KIRKPATRICK, Arizona
DAN BENISHEK, Michigan               RAUL RUIZ, California
TIM HUELSKAMP, Kansas                GLORIA NEGRETE McLEOD, California
MIKE COFFMAN, Colorado               ANN M. KUSTER, New Hampshire
BRAD R. WENSTRUP, Ohio               BETO O'ROURKE, Texas
PAUL COOK, California                TIMOTHY J. WALZ, Minnesota
JACKIE WALORSKI, Indiana
DAVID JOLLY, Florida
                       Jon Towers, Staff Director
                 Nancy Dolan, Democratic Staff Director

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

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                                                                   Page

                        Thursday, July 24, 2014

Restoring Trust: The View of the Acting Secretary and the 
  Veterans Community.............................................     1

                           OPENING STATEMENTS

Hon. Jeff Miller, Chairman.......................................     1
    Prepared Statement...........................................    87

Hon. Michael Michaud, Ranking Minority Member....................     4
    Prepared Statement...........................................    88
Hon. Corrine Brown
    Prepared Statement...........................................    89

                               WITNESSES

Hon. Sloan Gibson, Acting Secretary U.S. Department of Veterans 
  Affairs........................................................     5
    Prepared Statement...........................................    90

    Accompanied by:

        Mr. Danny Pummill, Principal Deputy Under Secretary for 
            Benefits, Veterans Benefit Administration, U.S. 
            Department of Veterans Affairs

        Mr. Philip Matkovsky, Assistant Deputy Under Secretary 
            for Health for Administrative Operations, Veterans 
            Health Administration, U.S. Department of Veterans 
            Affairs

Ms. Verna Jones, Veteran Affairs Director, The American Legion...    49
    Prepared Statement...........................................    95

 Mr. Ryan Gallucci, Deputy Director, National Legislative 
  Service, Veterans of Foreign Wars of the United States.........    51
    Prepared Statement...........................................   106

Mr. Carl Blake, Acting Associate Executive Director for 
  Government Relations, Paralyzed Veterans of America............    53
    Prepared Statement...........................................   109

Mr. Joseph Violante, National Legislative Director, Disabled 
  American Veterans..............................................    55
    Prepared Statement...........................................   117

Mr. Richard Weidman, Executive Director of Government Affairs, 
  Vietnam Veterans of America....................................    56
    Prepared Statement...........................................   128

Mr. Alex Nicholson, Legislative Director, Iraq and Afghanistan 
  Veterans of America............................................    58
    Prepared Statement...........................................   138

 
  RESTORING TRUST: THE VIEW OF THE ACTING SECRETARY AND THE VETERANS 
                               COMMUNITY

                        Thursday, July 24, 2014

             U.S. House of Representatives,
                    Committee on Veterans' Affairs,
                                                   Washington, D.C.
    The committee met, pursuant to notice, at 9:32 a.m., in 
Room 334, Cannon House Office Building, Hon. Jeff Miller 
[chairman of the committee] presiding.
    Present:  Representatives Miller, Lamborn, Bilirakis, Roe, 
Flores, Denham, Runyan, Benishek, Huelskamp, Coffman, Wenstrup, 
Cook, Walorski, Jolly, Michaud, Brown, Takano, Brownley, Titus, 
Kirkpatrick, Ruiz, Negrete McLeod, Kuster, O'Rourke, and Walz.
    Also present:  Representative Fitzpatrick.

           OPENING STATEMENT OF CHAIRMAN, JEFF MILLER

    The Chairman. Good morning. I want to welcome everybody to 
today's oversight hearing entitled Restoring Trust.
    I want to ask unanimous consent also that Representative 
Michael Fitzpatrick from the State of Pennsylvania be allowed 
to join us at the dais today and participate in this morning's 
hearing. Without objection, so ordered.
    The committee is going to examine this morning what steps 
we need to take to help the Department of Veterans Affairs to 
get back on track to meet its core mission, a mission to 
provide quality health care to our veterans.
    Since the beginning of June, this committee has held almost 
a dozen full committee oversight hearings. Some of them, as you 
well know, have gone way into the night and some into the early 
morning hours.
    We want to do a top-to-bottom review of VA and to delve 
into how we are now situated in a crisis at the Department of 
Veterans Affairs. And while I hope to focus on the major themes 
we have covered and to receive updates from VA this morning on 
the topics that we have talked about over the last few weeks, I 
can promise the department and the committee Members here that, 
as we move forward to help mend the broken VA system, the 
oversight done by this committee is going to continue.
    Mr. Secretary, in your written statement, you state that 
the status quo and our working relationship must change and 
that the department will continue to work openly with Congress 
and provide information in a timely manner.
    First I agree that the relationship between VA and this 
committee must change. We must go back to the way business used 
to be handled for decades when Members and staff could 
communicate directly with VA senior leaders about routine 
business we conduct with the department.
    But using the phrase continue to work openly is in my 
opinion not a reflection of the current reality that we find 
ourselves in. Members of this committee, other Members of 
Congress and our staffs are still being stonewalled to this day 
and you will hear several questions that relate to that 
information.
    For example, the day after our July 14th VBA hearing, our 
colleague, Mr. Jolly, personally spoke to Kerrie Witty, the 
director of the St. Petersburg Regional Office and asked for 
information regarding the firing of Mr. Javier Soto, a 
whistleblower who testified at that hearing.
    Mr. Soto had raised very serious concerns about both 
retaliatory action and mismanagement at the St. Pete RO. And it 
is incumbent upon this committee to investigate those 
allegations.
    But instead of being open and honest about the process, 
about Mr. Soto's removal, VA has equivocated, stonewalled, 
changed its story, and obstructed Members of this committee in 
what appears to be an attempt to cover up, VA's retaliation 
against Mr. Soto.
    We are prepared to subpoena the documents if that is what 
it takes. We have got to get compliance with the multiple 
requests that we have made to the department.
    I could not agree with you more that the department needs 
to earn back the trust of veterans, their families, the veteran 
service organizations, Members of Congress, and the American 
people through deliberate, decisive, and truthful action.
    The recent scandals that have tarnished trust in the VA are 
a reflection of a broken system that didn't just happen 
overnight, nor can it be fixed overnight.
    Upon stepping up as the acting secretary, you have stated 
that there has to be change and there has to be accountability, 
but I have yet to see where the department has drawn the line 
and brought those people who have caused this crisis to 
justice.
    We have shown through many of our hearings that one 
contributing factor to the current crisis is that VA has 
clearly lost sight of its core mission and that extra funding 
didn't go to improvements in patient care but towards ancillary 
pet projects and an ever-growing bureaucracy.
    According to an article by former under secretary of 
Health, Dr. Ken Kizer, in the New England Journal of Medicine, 
VHA's central office staff has grown from about 800 in the late 
1990s to nearly 11,000 in 2012. This further illustrates VA's 
shift of focus to building a bureaucracy as opposed to 
fulfilling its duty to providing quality patient care.
    And as I said before, the problems that exist today will 
not be fixed overnight and it cannot be fixed by simply 
throwing money at those problems. To date, the VA has been 
given every resource requested by the Administration. Every 
year during our budget oversight hearings, Members of this 
committee and Dr. Roe in particular has asked if the secretary 
had enough to do his job and every time we as a committee were 
told unequivocally yes.
    This is why last week the acting secretary said that an 
additional $17.6 billion was needed to ensure that VA is 
available to deliver high-quality and timely health care to our 
veterans and when he did that, it raised some very obvious 
questions. Where did the number come from? What assumptions 
underlie this request and how were they made? What effort was 
made to look within existing resources at the department to 
meet these new sources or resource needs?
    I know many of my colleagues would agree that after 
multiple oversight hearings, outside investigations, countless 
accounts being made by whistleblowers, VA's numbers simply 
cannot be trusted.
    VA's determination that 10,000 additional medical staff is 
needed is also surprising when the secretary's own written 
statement states, and I quote, ``VA doesn't have the refined 
capacity to accurately quantify its staffing requirements,'' 
end quote.
    If they don't have the ability to accurately predict 
staffing needs, then how do we know that 10,000 more bodies is 
what is needed to solve the problem?
    I would also remind Members that we don't have any type of 
grasp on how the department is going to spend the new funding 
that they have requested. The President's 2015 budget request, 
1,300 pages. You have all seen it. It is in your office, 1,300 
pages.
    The request from the department, the first request from the 
department I had been saying was a three-page request and that 
request actually is a single page. This is all we got. I hope 
all of you got a copy of this because this is how they, in 
fact, justified their request.
    And I asked the secretary on the telephone early this week 
if he would delve into and give us a more complete review of 
what they requested and I was told that we would get a much 
more detailed request. We got two pages. That is all we got, 
two pages entitled Working Estimate as of July 22nd of 2014 for 
$17.6 billion.
    Now, yes, the number has been refined to about $13 and a 
half billion now, but, still, two pages for $13 and a half 
billion? Our veterans deserve the best, but throwing money at 
the department into a system that has never been denied a dime 
will not automatically fix the perverse culture that has 
encompassed the department.
    VA can no longer consider itself the sacred cow that is not 
subject to rules of good government and ethical behavior. 
Veterans are sacred. VA is not. Ultimately we are talking about 
a system that has a long road ahead of it before it can get 
back to an organization deserving of our veterans and the 
sacrifices that they have made.
    I hope that today we receive the needed insight from our 
veteran service organizations. They and their members are on 
the ground. They need to be partners as VA tries to rebuild the 
trust that is lost. I hope that together we can bring about 
true change to this broken system and a change that will fix 
the corrosive culture that has encompassed the Department of 
Veterans Affairs for far too long.

    [The prepared statement of Chairman Jeff Miller appears in 
the Appendix]

    With that, I yield to the ranking member for his opening 
statement.

 OPENING STATEMENT OF MICHAEL MICHAUD, RANKING MINORITY MEMBER

    Mr. Michaud. Thank you very much, Mr. Chairman, and good 
morning.
    I want to thank you, Mr. Chairman, for holding today's 
hearing and for leading our rigorous oversight over these past 
few months. It has been a long road getting here. The hearings 
that we have held over the past few months have yielded 
difficult, disturbing, but ultimately important information.
    With each hearing, we have heard of a different aspect of 
the Department of Veterans Affairs that just isn't working. We 
heard about some challenges like the claims backlog and 
technology issues which we have been confronting for quite some 
time now. We learned of others like how the VA treats 
whistleblowers and the reality of the data VA reports and new 
ones.
    The VA has a good product. When veterans get to see a VA 
doctor, they like the care that they get. When veterans get the 
eligibility rating and starts receiving VA benefits, they find 
those benefits to be useful and helpful.
    But the business model for producing and delivering and 
supporting the VA product is fundamentally broken. We have 
heard this time again over the course of these hearings. There 
is a clear cultural problem at the Department of Veterans 
Administration. There are scheduling failures and technology 
problems. Inconsistent office practices lead to backlogs that 
appear to be tackled at the expense of other services.
    The Department of Veterans Administration is a sprawling 
agency that offers critical services to millions of our 
veterans. It is clear to me that we need a business-minded 
approach to reform the agency. More of the same isn't going to 
solve the underlying problems. Tweaks and band-aids around the 
margins aren't going to sustain the system.
    We need a new model, a new approach, and a new way of 
thinking about and looking at the department. We need immediate 
short-term fixes, but we also need a long-term vision and a new 
approach to the business of the Department of Veterans 
Administration.
    And I would like to thank you, Secretary Gibson, for 
joining us today and for your efforts over the last few months. 
You have stepped up to the plate at the most challenging 
moments in the Department of Veterans Affairs' history and you 
owned the problem of the organization that has been experienced 
over the last several years.
    And I thank you for your increased effort to communicate 
with us on The Hill, for your dedication to our Nation's 
veterans, and for exhibiting the courage to be the face of the 
Department of Veterans Administration during these very 
difficult times.
    I would also like to similarly thank Bob McDonald who I 
hope will soon be confirmed as the next VA secretary. I am 
looking forward to talking with Mr. McDonald about his vision 
for reforming the Department of Veterans Administration both in 
the short term as well as in the long term.
    Like Mr. Gibson, Mr. McDonald is exhibiting extraordinary 
courage and commitment for taking on this role at this very 
important time.
    I would also like to thank the veteran service 
organizations for joining us today. You have been strong and 
relentless advocates for the well-being of our veterans. You 
have done an excellent job in holding all of us in Congress and 
the department accountable. You are a key stakeholder in this 
whole debate over the Department of Veterans Affairs. You need 
to be active, engaged in the process of long-term reforms for 
the Department of Veterans Administration.
    So I want to thank all the VSOs as well for your continued 
effort that you have been doing and keeping an eye on what is 
happening with the department and for joining us today.
    So, once again, Mr. Chairman, I want to thank you for 
having this very important hearing. With that, I yield back the 
balance of my time.

    [The prepared statement of Hon. Michael Michaud appears in 
the Appendix]

    The Chairman. Thank you very much to my good friend, Mr. 
Michaud.
    Before we begin this morning, I want to recognize some 
participants that are in the audience with us from The American 
Legion Boys Nation who joined us here today. Welcome to all of 
you and thanks for being here. We are glad to have you with us.
    This morning, we are going to hear from the Honorable Sloan 
Gibson, acting secretary for the Department of Veterans 
Affairs. And to you, sir, we owe a great debt of gratitude for 
stepping in as number two and then stepping up, as my ranking 
member has said, during a very trying time for the department. 
And we appreciate you being here.
    He is accompanied by Mr. Danny Pummill, deputy under 
secretary for Benefits at the Department of Veterans Affairs, 
and Philip Matkovsky, assistant director under secretary for 
Health and Administrative Operations at the Department of 
Veterans Affairs.
    And as always, your complete written statement, Mr. 
Secretary, will be made a part of the hearing record. And with 
that, you are recognized for your opening statement.

STATEMENT OF SLOAN D. GIBSON, ACTING SECRETARY, U.S. DEPARTMENT 
 OF VETERANS AFFAIRS, ACCOMPANIED BY DANNY PUMMILL, PRINCIPAL 
     DEPUTY UNDER SECRETARY FOR BENEFITS, VETERANS BENEFIT 
  ADMINISTRATION, U.S. DEPARTMENT OF VETERANS AFFAIRS; PHILIP 
  MATKOVSKY, ASSISTANT DEPUTY UNDER SECRETARY FOR HEALTH FOR 
ADMINISTRATIVE OPERATIONS, VETERANS HEALTH ADMINISTRATION, U.S. 
                 DEPARTMENT OF VETERANS AFFAIRS

                  STATEMENT OF SLOAN D. GIBSON

    Mr. Gibson. Thank you, Mr. Chairman.
    I will get straight to business. Concerning VA health care, 
we have serious issues. Here is how I see the problems.
    First, veterans are waiting too long for care. Second, 
scheduling improprieties were widespread including deliberate 
acts to falsify scheduling data. Third, an environment exists 
where many staff members are afraid to raise concerns for fear 
of retaliation. Fourth, metrics became the focal point for some 
staff instead of focusing on the veterans we are here to serve. 
Fifth, VA has failed to hold people accountable for wrongdoing 
and negligence. And, last, we lack sufficient resources to meet 
the current demand for timely, high-quality health care.
    As a consequence of these failures, the trust of the 
veterans we serve, the American people, and their elected 
representatives has eroded. We have to earn that trust back 
through decisive action and by greater transparency in dealing 
with all of our stakeholders.
    To begin restoring trust, we have focused on six key 
priorities. Get veterans off wait lists and into clinics; fix 
systemic scheduling problems; ensure that veterans are the 
focus of all we do. In a culture where leaders ensure 
accountability, where transparency is the norm, and where 
employees live, our VA values every day.
    Hold people accountable where willful misconduct or 
management negligence are documented; establish regular and 
ongoing disclosures of information; and, finally, quantify the 
resources needed to consistently deliver timely, high-quality 
health care.
    Here is what we are doing now. VHA has reached out to over 
173,000 veterans to get them off wait lists and into clinics. 
We are adding more clinic hours, recruiting to fill clinical 
staff vacancies, deploying mobile medical units using temporary 
staffing resources, and expanding the use of private sector 
care.
    In the last two months between mid May to mid July, we have 
made over 570,000 referrals for veterans to receive care in the 
private sector. That is up more than 107,000 over the 
comparable period a year ago. Each of those referrals will on 
average result in seven actual appointments and visits. So that 
produces an increase of more than 700,000 appointments and 
visits for care in the community above last year just 
associated with the increase in referrals over a two-month 
period.
    VHA is posting regular twice monthly data updates to keep 
veterans informed about progress we are making in access. As 
part of the effort to improve transparency, I recognize, Mr. 
Chairman, that we have more work to do in providing complete 
and timely responses to congressional inquiries and requests. 
You all are keeping us very busy in that regard right now.
    We are moving to improve our existing scheduling system and 
simultaneously pursuing the purchase of a modern commercial 
off-the-shelf system. I have directed medical center and VISN 
directors to conduct monthly in-person inspections of their 
clinics to assess scheduling practices and identify any related 
obstacles to timely care for veterans. To date, over 1,500 of 
these visits have been completed.
    We are putting in place a comprehensive external audit of 
scheduling practices across VHA and we are building a more 
robust system for measuring patient satisfaction. I have 
personally visited 13 VA medical centers in the last six weeks 
to hear directly from the field how we are getting veterans off 
wait lists and into clinics.
    The 14-day access measure has been removed from over 13,000 
individual performance plans. For willful misconduct, 
management negligence, or whistleblower retaliation is 
documented, appropriate personnel actions will be taken.
    I have frozen VHA's central office and VISN headquarters 
hiring. VHA has dispatched teams to provide direct assistance 
to facilities requiring the most improvement including a large 
team on the ground in Phoenix right now. In addition, we have 
taken action on all of the recommendations made in the IG's May 
interim report on Phoenix.
    All VHA senior executive performance awards for fiscal year 
2014 have been suspended. Additionally, I have directed a 
fundamental revision of all medical center and VISN directors' 
performance objectives to ensure they are aligned with patient 
outcomes.
    I have repeatedly taken a firm stand on the subject of 
whistleblower retaliation. In messages to the entire workforce 
and in numerous face-to-face meetings with employees and 
leaders, I have made it clear that we will not tolerate 
retaliation against whistleblowers.
    Furthermore, I committed to Carolyn Lerner when I met with 
her several weeks ago that we will achieve compliance with the 
Office of Special Counsel certification program, and she and I 
have agreed to streamline the process by which we work together 
to ensure appropriate whistleblower protection.
    We have also established internal processes to ensure 
appropriate personnel actions are taken where retaliation has 
been documented. I have made a number of leadership changes 
including naming Dr. Carolyn Clancy interim under secretary for 
Health. New to VA, she is spearheading our immediate efforts to 
accelerate veterans' access to care.
    Dr. Jonathan Perlin has begun his short-term assignment as 
senior advisor to the secretary. Dr. Perlin comes to us on loan 
from the Hospital Corporation of America where he is the chief 
medical officer and the president of clinical services. He is 
also chairman elect of the American Hospital Association. Dr. 
Perlin brings a wealth of knowledge and experience to help us 
bridge the period until we have a confirmed new under secretary 
for Health, a position Dr. Perlin himself once held.
    As part of the restructure of VHA's Office of the Medical 
Inspector, we call that OMI internally, Dr. Jerry Cox has been 
appointed to serve as interim director. A career naval medical 
officer and a former assistant inspector general of the navy 
for medical matters, Dr. Cox will help ensure OMI provides a 
strong internal audit function, helping to ensure the highest 
standards of care quality and patient safety.
    As we complete reviews and investigations, we are beginning 
to initiate personnel actions to hold those accountable who 
committed wrongdoing or were negligent. To support this 
critical work, Ms. Lee Bradley has begun a four-month 
assignment as special counsel to the secretary. Ms. Bradley is 
former general counsel at VA and most recently a senior member 
of the general counsel team at the Department of Defense where 
she has direct responsibility for their ethics portfolio.
    Shifting gears, in the area of resources, I believe that 
the greatest risk to veterans over the intermediate to long 
term is that additional resources are provided only to support 
increased purchases of care in the community and not to 
materially remedy the shortfall in internal VA capacity. Such 
an outcome would leave VA even more poorly positioned to meet 
future demand.
    Today VA's clinical staff and space capacity are strained. 
Between 2009 and 2013, the number of unique veterans we treat 
annually has increased by over a half a million. And the 
typical veteran we treat today has on average nine major 
diagnoses.
    In just the last three years, 40 veterans' health care 
facilities have experienced double digit growth in the number 
of patients who come through their doors. As an example, at the 
Fayetteville, North Carolina VA Medical Center which I visited 
several weeks ago, the number of patients being treated has 
grown 22 percent in the last three years.
    Resources required to meet current demand covering the 
remainder of fiscal year 2014 through fiscal year 2017 total 
over $17 billion. While the amount is large, it represents a 
moderate percentage increase in annual expenditures. These 
funds would address clinical staff, space, information 
technology, and information technology necessary to provide 
timely, high-quality care.
    Let me briefly address benefits. Since arriving at VA, I 
have been very impressed with VBA's ongoing transformation. I 
doubt that any major part of the Federal Government has 
transformed so much in the past two to three years. And I 
believe that because of this transformation, we are on track to 
eliminate the disability claims backlog in 2015.
    Having said that, veterans still wait too long to have 
their claims decided and our quality is still not up to our own 
standard. A portion of our request for additional resources 
will be invested to accelerate accurate and timely claims 
decisions for veterans.
    In closing, we understand the seriousness of the problems 
we face. We own them. We are taking decisive action to begin to 
resolve them. The President, Congress, veterans, VSOs, the 
American people, and VA staff all understand the need for 
change. We must, all of us, seize this opportunity. We can turn 
these challenges into the greatest opportunity for improvement, 
I believe in the history of the department.
    Furthermore, I think that in as little as two years, the 
conversation can change, that VA can be the trusted provider 
for veterans' health care and for benefits. Our ability to do 
that depends on our willingness to seize the opportunity, 
challenge the status quo, and drive positive change.
    I deeply respect the important role that Congress and the 
Members of this committee play in serving veterans. I am 
grateful for your long-term support and will work hard to earn 
your trust.
    We cannot succeed without the collaboration and support of 
veteran service organizations. I conducted some 20 meetings and 
calls in the last two months with VSO leaders and other 
stakeholders to solicit their ideas for improving access and 
rebuilding trust. And I look forward to hearing the VSO 
testimony on the panel that follows.
    And, last, I appreciate the hard work and dedication of VA 
employees, the vast majority of whom I continue to believe care 
deeply about our mission, want to do the right thing, and work 
hard every day to care for veterans. Because of their work 
today, Thursday, today, hundreds of thousands of veterans will 
receive great care in facilities all the way from Maine to 
Manila.
    And in the midst of this crisis, it is all too easy for us 
to forget that simple fact. Mr. Chairman, I am prepared to take 
your questions.

    [The prepared statement of Sloan D. Gibson appears in the 
Appendix]

    The Chairman. Thank you very much, Mr. Secretary, and it is 
an honor to have an opportunity to work with you, call you a 
friend.
    We have got some questions that we are going to ask today 
and both sides will have some pretty probing questions. And I 
think we appreciate the actions that have been taken at the 
department to move the veterans off of wait lists.
    And I think probably one of the significant questions that 
needs to be asked right now is how many veterans currently are 
on waiting lists over 30 days for appointments?
    Mr. Gibson. Do you want to take the wait list question and 
I will address the broader issue?
    Mr. Matkovsky. Veterans on the EWL or electronic wait list 
number about 40,000 nationwide today, down from 57,000 May 
15th.
    Mr. Gibson. The new enrollee appointment request list which 
was another focal point for this overall effort started at 
roughly 64,000. It is currently sitting on what is really going 
to be a permanent level of about 2,000 because there is flow in 
and out just about every single day.
    When you look at the number of veterans that are waiting, 
that are scheduled, but waiting longer than 30 days for their 
appointments, it is about 640,000 total. We see the number of 
veterans waiting longer than 90 days as we release information 
each two weeks. We see that coming down steadily, but not 
precipitously, not fast enough.
    The Chairman. If we can talk a little bit about the funding 
request that you alluded to in your----
    Mr. Gibson. Yes, sir.
    The Chairman [continuing]. Opening statement. Is this a 
formal request being made by the President? Is it an emergency 
request, a supplemental request?
    Mr. Gibson. What I am trying to do here is to articulate 
the requirement as best as I can possibly articulate it. From 
my perspective, it is a formal request for funding.
    The Chairman. From the Administration?
    Mr. Gibson. That is my understanding, yes, sir.
    The Chairman. Is anybody aware of how the supplemental 
request was made by the White House in regards to the process 
crisis that exists on the border right now, $3.4 billion?
    Mr. Gibson. I am not aware of the method by which it was 
conveyed.
    The Chairman. It was a supplemental request from the White 
House. And so I am trying to figure out, because everybody 
keeps dancing around the word request, even yesterday, an under 
secretary did here on The Hill, and I am trying to find out 
what do we--you know, it is a desire, but ordinarily it would 
come through the White House. And so walk me through. How did 
this come up right now? What was the impetus that began you 
looking at the need? We already got $35 billion on the table 
and so now during negotiations on a conference committee 
report, you have injected $17.6.
    Mr. Gibson. I think as we launched into, now over two 
months ago, we launched into an effort to accelerate care for 
those veterans that are waiting the longest, we undertook 
simultaneously a process of evaluating the adequate resources 
in the field in order to be able to meet that standard of 
consistent high-quality health care, timely, high-quality 
health care.
    As we work through that process using the information 
systems that we have available to us, we developed an initial 
set of requirements and began working with the Office of 
Management and Budget.
    As my testimony last week to the Senate became closer and 
closer, nearer and nearer, there was an increased effort there 
to try to get that process to closure so that during that 
testimony as well as this testimony that I would be able to 
present that statement of requirement.
    The Chairman. So the memo that you gave to Senator Sanders 
on the 16th of July says per your request, attached for your 
information is a summary for additional resource needs through 
2017.
    So was it Senator Sanders' request, a combination, or 
yours?
    Mr. Gibson. Senator Sanders requested the information, the 
information, the requirement that is being communicated here, 
and, if you will, the request is our request.
    The Chairman. You come from a banking background. If 
somebody came into your bank with three pieces of paper and 
asked for a million dollars, would you give them a million 
dollars?
    Mr. Gibson. The honest answer there is it probably would 
depend on who the borrower was. But I understand your point. 
The committee needs additional information.
    The Chairman. And we have set a goal of trying to wrap up 
the conference committee by the end of next week before we 
leave so that we can get something to the President for his 
signature. And we got three pieces of paper to justify a 
request that Senator Sanders clearly wants put into the scope 
of the conference, making it very, very difficult for us to be 
able to do our job if all we get are sheets of paper that 
basically says they are working documents. At some point, they 
have to say this is the document.
    With that, Mr. Michaud, you are recognized.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    Once again, I want to thank you, Mr. Secretary, for being 
here.
    You stated in your statement that VA doesn't have the 
resources that it needs. In your view, what led to this lack of 
resources, number one, and when was this under-resourcing 
identified? And my third question is, what did the department 
actually request in their budget?
    The reason why I ask that question is when I first became a 
Member of this committee, when I was first elected, we had 
Secretary Principi sitting where you are sitting and we asked 
him as he was defending the President's budget and the question 
was can you deliver the services for our veterans with Iraq and 
Afghanistan and the current. His response was, he requested an 
additional $1.2 billion, did not receive it, but he will make 
due with this budget.
    So I would be interested in knowing what your actual 
request was when you originally submitted your budget.
    Mr. Gibson. First of all, as I have come into the 
department five months and six days ago, I formed opinions 
about what I see and what I hear. My general sense is that what 
we have done historically is we have managed to a budget number 
as opposed to managing to requirements which is what you do in 
the private sector.
    And I think as a result of that, what has happened is we 
have sort of muddled our way along and not been able to meet 
the standard of care that veterans deserve because we did not 
manage to requirements.
    The exercise that we have gone through and, frankly, 
continue to go through as we work to ensure that we are ringing 
all the productivity that we can out of the existing resources 
is really about managing to requirements.
    I would tell you that process, as I mentioned in response 
to the chairman's question, has really been underway for about 
the last two months. I have been in place as the acting now for 
seven weeks. And so we are working through that process.
    In the private sector, this would be a routine part of the 
business. You would be managing to requirements. You would be 
continuously exercising productivity tools and over a period of 
years, you would be building the organizational capacity to 
ensure that you have got the responsive resources to be able to 
meet existing demand. That is simply not the way the department 
has historically been run. We have managed to a budget number 
instead.
    I can't answer your question about what the specific budget 
request was in relation to what was actually finally approved, 
but we will take that one for the record and get you an answer.
    Mr. Michaud. I appreciate that and I appreciate your 
comments because that was my same response to Secretary 
Principi at the time was I don't care how big of a budget 
increase you received. I want to know are you taking care of 
the veterans. The outcome is so critical.
    And over the years through several secretaries I have sat 
here and listened to, I believe that they have always operated 
the department based upon the budget they had, not what they 
need to take care of our veterans. And hopefully that will 
change.
    Mr. Gibson. Well, if I may interrupt, sir. I committed to 
the President, I committed to employees at VA, and, most 
importantly, I have committed to veterans, I will not hold 
back. If I think resources are required, I am going to ask for 
them. And I have told the internal staff don't you ask for one 
penny more than you can justify.
    You know, I am not looking here for some kind of a blank 
check, but I am not going to sit here--in my meetings with 
individual employees as they raise issues about the needs that 
they have and the resources that they lack, you know, I have 
come to understand what my job is.
    My title may be acting secretary, but my job is to create 
the conditions for them to successfully meet the needs of the 
veterans that they serve. And that is what I am obligated to do 
when I come here and sit in this seat.
    Mr. Michaud. I appreciate that.
    Do you think the business operating model that the VA 
currently operates is sustainable in the long term?
    And getting to what Chairman Miller had mentioned, when you 
look at the fact that at the VISN level, they have exploded 
with management. And I think the VA definitely has to be 
reorganized and, you know, in a better format.
    Do you think the current business model is sustainable in 
the long term?
    Mr. Gibson. My sense is that there are opportunities for us 
to structure differently. I don't like bureaucracy, but I 
understand in an organization as large as this one, you have 
got to have some of it. The challenge is making it work for the 
people that are serving veterans day in and day out. And I 
don't think we are doing that very well.
    So I think there are opportunities. There has been 
concentration at the VISN level and at the VA central office 
level. Part of that I would tell you I think was positively 
done as part of taking and consolidating support activities 
either at the VISN level or at the VHA central office level 
where they can be performed more efficiently and effectively 
than they can scattered in 150 different locations. But that 
doesn't mean that we got it exactly right. There is still work 
to do there.
    Mr. Michaud. Thank you.
    Thank you, Mr. Chairman.
    The Chairman. Mr. Lamborn, you are recognized for five 
minutes.
    Mr. Lamborn. Thank you, Mr. Chairman.
    Thank you, Secretary Gibson, for being here today.
    And I want to follow-up on something that was brought up 
earlier by Chairman Miller, a very important issue that I would 
like to get more information on, and it has to do with where 
you said in your statement we don't have the refined capacity 
to accurately quantify our staffing requirements.
    And, yet, in your $17.6 billion resource requirement, you 
are requesting $8.2 billion for about 10,000 primary and 
specialty care physicians and other clinical staff.
    Given that you said that the department is unable to 
quantify its staffing needs, how can a number like that even be 
arrived at?
    Mr. Gibson. I am going to let Philip Matkovsky, who is 
intimately involved in helping to develop the estimates, 
address the fundamental question.
    I would tell you generally speaking what we have got, as I 
said earlier, we have not been working to solve to 
requirements. I think earlier today some of the staff 
participated and I think Congressman Wenstrup may have 
participated in a briefing that we delivered about the 
operation of our ophthalmology specialty.
    And inside that model when you look at some of the 
productivity tools that we are now rolling out into the 
organization, you get a good microcosm of what ultimately is 
going to give us the kind of granularity. We are going to find 
as we exercise that model there are some locations that have 
enough staff.
    There are some other locations that may need some 
additional support resources, either some additional support 
staff or additional space, and then there are going to be other 
locations where we look and we say we have enough providers 
here. And it is going through that kind of bottom-up, highly 
granular process that is going to give us the precise answer.
    And we are working and doing that right now. But in the 
meantime, as we go out in the field, as I go out in the field 
and as we look at top-down requirements, it is clear to us that 
we do not have the resources we need.
    Philip, the process that we have used.
    Mr. Matkovsky. The one thing I would indicate is we tried 
to use a bottom-up approach which was looking at veterans who 
are waiting greater than 30 days for care and forecasting that 
into fiscal year 2015, 2016, and 2017.
    We made certain assumptions about improving efficiency over 
the years and that for us gave us the definition of the count 
of appointments that we needed to accelerate and cost in the 
model.
    Then we worked with the assumption that in year one, we are 
going to do mostly purchasing of care in the private sector 
because of staffing issues that would take time. And then we 
would blend it over time and sustain it using internal staff.
    But the way that we came about that was estimating the 
number of veterans and their appointments that wouldn't be 
delivered in a timely manner, then costing that and turning 
that into the $8.2 billion.
    Mr. Lamborn. Okay. Well, it sounds like it is a work in 
progress as you both are saying. So I question how specific you 
can actually be.
    But a follow-up question is, are there a lot of slots that 
are sitting empty right now that you haven't been able to find 
someone to fill, either a doctor or other health care 
professional?
    Mr. Gibson. I would say yes, there are thousands of vacant 
positions. All across VHA, roughly 28,000 vacant positions. And 
in some instances, those aren't all being actively recruited to 
fill. I would tell you as part of accelerating care we have 
been pushing particularly on clinical staff and direct support 
staff to accelerate some of that hiring.
    Mr. Lamborn. Well, then my follow-up question there is if 
you have 28,000 minus X open slots and you add 10,000 or so 
more open slots, are you ever going to even be able to fill 
those slots under current requirements?
    The current productivity requirements you have which I 
understand from testimony is different than in the private 
sector.
    Mr. Matkovsky. I think organizations will always have some 
measure of organic vacancy rates. You will have turnover in 
your staff. But what it allows us to do is to raise the floor 
so that the floor of the fully encumbered positions grows with 
additional staff brought in.
    So I think there will be staff that leave the organization. 
People leave. They retire. They move on to other jobs. There 
will be a vacancy rate. Our vacancy right now is about 10 
percent and that sort of reflects the turnover rate. So as 
turnovers occur, you have a certain vacancy rate.
    The other thing we are looking at, though, at the same time 
that we are doing this is looking at our position management 
practices. Rather than hiring to vacancy, hiring to the 
requirement which may require in certain cases that we have 
fully encumbered staff as opposed to where we are today.
    But to your point, I think the additional staff allows us 
to raise the floor of the on-board FTE.
    Mr. Lamborn. Okay. Thank you, Mr. Chairman. I yield back.
    The Chairman. Thank you very much.
    Was Ms. Brown here at the gavel?
    Ms. Brown, you are recognized for five minutes.
    Ms. Brown. Thank you, Mr. Chairman.
    And I want you to know I was here before the chairman.
    I have been on this committee for 22 years. In fact, when I 
came, Jesse Brown was the secretary and his motto was putting 
veterans first. And I have been through all of the secretaries 
and, you know, some of them left a lot to be desired and some 
was--but the point of the matter is that I understand that VA 
has changed over the period of time.
    And at one time, we were serving a certain kind of veteran. 
Now we have expanded to the veteran. I don't want to say they 
are sicker. Their conditions are different because of the war. 
They come back with different ailments.
    How can you plan for that, because they want their services 
at the VA? I want to make sure that the VA is there for them. 
And it is a lot more complicated than what we are seeing 
because, like you said, they have 10 additional things as 
opposed to at one time. It was maybe a lot more simple than it 
is now.
    Mr. Matkovsky. We have an actuarial model that we use to 
forecast. Part of that looks at the past practice and then 
forecasts into the future. That is part of it. The other part, 
I think, though, is to start introducing more bottom-up 
planning and having our field give us, if you will, the 
statement of requirements, so if this is the number of veterans 
that you think you can serve.
    I also think that, and I neglected to mention this for 
Congressman Lamborn's question, if we improve performance, that 
is if we are better at providing high-quality and timely care, 
that is going to affect veterans coming to the VA. They will 
come to us more if they can get care more timely.
    So having a bottom-up planning approach and working with 
our medical center leadership and our network leadership to 
give us a bottom-up operating plan of what their financial 
requirement is in the out years, I think will also help us be 
better prepared to adjust for where we are succeeding and when 
we succeed.
    Ms. Brown. And someone said that we have given the VA 
everything they requested. Now, I guess institutional memory 
should be important because I remember in 2007 and 2008, it was 
the first time that the veterans was able to get the budget 
that they requested, forward budgeting. You know, that was 
under President Barack Obama. I know I am the only one that 
remembers that.
    But, you know, it is important to remember how you got 
where you are. As we move forward, you need to remember that 
many of us talk the talk, but we didn't walk the walk or roll 
the roll. So I think that is important for us to remember how 
we got where we are.
    And VA, yes, we are having problems, but we are not to the 
point that we need to destroy the system. And I feel very 
strongly about that and I don't want to be the only one saying 
that the VA shouldn't--I mean, I think we should work with 
community partners and community stakeholders.
    And how do you feel about that? We have teaching hospitals 
that we should partner with. We could share equipment. But I 
still want VA to be in charge.
    Mr. Gibson. Yes, ma'am. You know, as I travel around and 
visit VA medical centers, one of the----
    Ms. Brown. You just returned from Gainesville.
    Mr. Gibson. Yes, ma'am. And at medical center after medical 
center, I am impressed with the academic affiliations that we 
have with local partners in the community and the benefits, all 
the many benefits, the extraordinary care that that has allowed 
to be made available for veterans, the expert staff, clinical 
staff that we are able to recruit in part because of those 
strong affiliations. It is one of our opportunities to continue 
to pursue.
    Ms. Brown. Thank you very much. And thank you very much for 
your service.
    Mr. Gibson. Yes, ma'am.
    Ms. Brown. I yield back the balance of my time, sir.
    The Chairman. You got 42 seconds.
    Dr. Roe, you are recognized.
    Dr. Roe. Thanks very much, Mr. Chairman.
    And thank you, Mr. Secretary, for being here today and 
thank you for your service in this tough time.
    I agree with your opening statement. I have said this from 
the very beginning. One of the problems that VA has, that it 
did have was loss of trust. And I think Ms. Brown brought up 
the point a minute ago that a previous secretary, and I have 
said this from the very beginning, what the motto should be of 
the VA is we work for the veterans. I don't work for the VA, 
but I work for the veterans. So I think those things, that 
cultural change will help.
    One of the things that I am just not sure about having more 
people is going to solve the problem because when I came on 
this committee five and a half years ago, a quarter of a 
million people worked for the VA, 250,000 people. And the 
number I saw in your testimony was 341,000. That is more people 
that work for the VA than any city in my district. It is huge.
    And I am just not convinced getting bigger is going to 
solve the problem. I think getting better will solve the 
problem and getting more efficient will solve the problem, but 
I don't think--getting larger may make the problem worse. I 
honestly believe that.
    And when you see an office go from 800 people at a VISN 
level to 11,000, that is mind boggling to me that that many 
more people could be needed when you don't have that many more 
employees. And I think you are looking internally. I truly 
believe that.
    A question I have is, you mentioned accountability, has 
anyone been held accountable yet and terminated?
    Mr. Gibson. There were three actions that were announced 
dealing with Phoenix back about two months ago. There is an 
additional individual, senior executive manager that has been 
placed on a leave of absence. I would tell you----
    Dr. Roe. But is there anybody that doesn't have a job that 
had a job?
    Mr. Gibson. There is nobody----
    Dr. Roe. Nobody at all being fired? Has anybody----
    Mr. Gibson. Well, I understand what being fired means. And 
I am also learning the hard way how you do that in the Federal 
Government. And so, you know, it starts when you create this 
massive base of information that is documented.
    The end of June, I got the first results from the IG 
finally released on one location, a thousand pages of 
transcripts of sworn testimony. And in the midst of all of 
that, there still wasn't all the information needed, so we had 
to dispatch additional investigators to go take additional 
testimony.
    We reviewed all of that. We pulled email traffic and then 
we go through the process of I have to delegate authority for a 
proposing official and a deciding official. And they have to 
review all the information.
    There are two things going on right now in the 
accountability space.
    Dr. Roe. Mr. Secretary, let me interrupt you because my 
time is short. You have just made my point. When you were in 
the private sector, did you have to go through a thousand 
pages----
    Mr. Gibson. No.
    Dr. Roe [continuing]. And do all this to fire somebody?
    Mr. Gibson. No. No.
    Dr. Roe. The answer is, no, you didn't. And so creating 
more inefficiencies in there, I think more people making this 
bigger before we trim it down and make it better is not the 
right direction.
    And I want to very briefly, I don't have a lot of time 
left, but we are going to try to have to make some decisions, 
big decisions in the next week or so that involve a lot of 
money, the taxpayers' money. And it is $17 billion or that is 
the request.
    And as the chairman pointed out, I have asked every time we 
have had a budget hearing, I have asked do you have enough 
money to carry out your mission. And the answer each time has 
been, yes, we have enough money to carry out our mission.
    So how will I know this is enough money when I have been 
told before you had enough money because I voted for every 
single budget? That is one of the things I will never apologize 
for up here is to spend money on our veterans. I absolutely 
will never do that because I think they have served this 
country. We would not have this country the way it is that I 
enjoy and have grown up in if it were not for the veterans of 
this Nation.
    So that is not an issue, but I don't want to take the money 
that hard-working people including veterans go out and pay 
taxes and not spend it wisely. So can you tell me how this $17 
billion, and that is $17,000 million--where I am from, that is 
a lot of money.
    Mr. Gibson. A lot of money where I am from too.
    Dr. Roe. How is it going to be spent and can I know that it 
will be spent wisely? And would it be better to take some of 
that money and not look at building this bigger bureaucracy but 
to veterans who want to--if a veteran says I would like to go 
to see my doctor outside, just let that veteran do that. Would 
that not be cheaper?
    The infrastructure is already out there. The hospitals are 
already out there. We had those folks in here a week and a half 
ago, I guess a week ago it was today, who expressed the desire 
to do that and they had the capacity to do that. Wouldn't it 
just be easier and more efficient to do just that?
    Mr. Gibson. You know, one of the points that was made 
earlier in one of the opening statements was the fact that 
veterans are pleased with the care they get. It is just once 
you get it. It is hard to get it.
    Dr. Roe. I agree, but they are pleased with the care they 
get in the private sector, too, for the most part.
    Mr. Gibson. The other thing that has been interesting to me 
is we have been working down these lists and we call veterans 
that are waiting too long for care and we ask them do you want 
us to refer you out into the community. Sometimes the answer is 
yes, but more often than not, the answer is no, I want to wait 
for my appointment inside VA.
    Dr. Roe. Mr. Chairman, just one thing I want to tell you. I 
had a sergeant in my office this week. I am not going to say 
who. But he called the VA to cancel his appointment. He was on 
hold for two hours, two hours. He just walked around his office 
doing his job.
    And then later when he had an appointment, he--you all have 
done something, I will tell you that, because he said he got 
eight different phone calls from eight different people about 
his appointment. Now, is that efficient or is that inefficient?
    Mr. Gibson. It doesn't sound very efficient to me, sir.
    Dr. Roe. I yield back.
    The Chairman. Thank you very much.
    Mr. Takano, you are recognized for five minutes.
    Mr. Takano. Thank you, Mr. Chairman.
    Mr. Secretary, point blank, is there a shortage of doctors 
at the VA and, if so, what areas are the shortages in?
    Mr. Gibson. I would say the short direct answer is yes, 
there are shortages and there are shortages in primary care and 
specialty care and in mental health, all three.
    Mr. Takano. Mental health is a big portion of the shortage. 
I have heard that there is problems referring people to 
specialists, so certain areas of specialty care is in deficit.
    What are the VA's most successful physician recruitment 
tools and does the VA need stronger tools for recruitment?
    Mr. Matkovsky. I think we have a number of very strong 
improvement tools. One of the areas where we have done a lot of 
work is in surgery. The surgery program has actually made 
significant use of informatics to actually look at practice, 
process, and then to identify deficiencies. That program runs 
nationally and is able to actually support both at the regional 
level, national level, and local level tracking and trend----
    Mr. Takano. Recruitment tool.
    Mr. Matkovsky. Recruitment.
    Mr. Takano. Recruitment.
    Mr. Matkovsky. I said improvement tools. Geez. I am very 
sorry, Congressman.
    One of the areas that had come up before, would we look to 
have tuition reimbursement and other kinds of authorities like 
that provided. And I think looking at costs, those are 
valuable. And I think we need to look at extending those.
    Mr. Takano. But recruitment is going to, that kind of 
recruitment, tuition reimbursement presupposes that there is a 
supply that is adequate to recruit from.
    We know that doctors are more likely to stay in practice in 
the place where they completed graduate and medical school 
education. GMEs seem like one of the best recruitment tools 
that hospitals have.
    Is the VA GME effectively?
    Mr. Matkovsky. I think we are. I think where we find that 
we don't have a really good strong academic affiliate, 
sometimes we have challenges. And where we have developed a 
strong academic affiliate, we have a good pipeline of quality 
providers who want to work for the VA. They have done work in 
the VA. They were introduced. They understand our mission. They 
love our mission and they come to work for us.
    Mr. Takano. Would you welcome funding to expand the VA's 
GME program?
    I know that nationally the VA has normally been 10 to 12 
percent of graduate and medical school education with Medicaid 
and Medicare taking the other 90 or so percent. We have been 
frozen at a number since 1996. I have to think that that is 
contributing to a shortage of doctors generally.
    Mr. Matkovsky. I would have to look at that. I mean, I 
would say that conceptually we would support it, but I just 
need to look at the details.
    Mr. Takano. Well, I mean, do you think this would help 
address the physician shortage at the VA if we were to be able 
to get and to get more timely care to our veterans if we were 
to increase the number of graduate and medical school education 
slots at the VA?
    Mr. Matkovsky. I think so.
    Mr. Takano. Is my time up, Mr. Chairman?
    Ms. Chairman. No.
    Mr. Takano. Okay. With the current fee-basis system, has 
the lack of interoperability between the electronic health 
records at the VA and non-VA providers been a barrier to 
providing high-quality continuity of care to our veterans?
    Mr. Matkovsky. I think one of the things that separates us 
when we talk about private sector and other sort of fee-for-
service systems, for instance, Medicare, is the requirement 
that we have. We have the responsibility to maintain continuity 
and coordination of care. It has, Congressman Takano.
    I think in some of our contract options, we have the 
ability to exchange electronic data and that is written into 
the contract. So we actually get clinical documentation back.
    Mr. Takano. Here is the thing. You know, I think many of us 
support the idea of non-VA access given our emergency 
situation, cooperation with county, both public and private. We 
support that, a lot of us on the democratic side.
    But our concern about the solution that is the focal point 
of the funding is this potential lack of continuity. And is 
that part of your plan going forward?
    Mr. Matkovsky. It is a part of it. We are looking at one of 
our major contracts that we have in place today to look at 
further making the data that we share back and forth 
computable. Today it is not computable. When we have individual 
authorizations for fee care, it will come in sometimes as paper 
and we scan it, image it, put it into the clinical record. In 
contracts, we get a PDF, but we need to make it data.
    Mr. Takano. So we need more interoperability between the VA 
and non-VA care to really make outsource with the non-VA 
providers more feasible.
    The IG, the interim IG or the acting IG said in the long 
run, the best efficiencies for the VA are going to be to own 
its own doctors and to keep care within its system. I mean, no 
system really, whether you are private or public, wants to 
outsource to out-of-network care. There is usually a huge 
charge to go out of network.
    And I think the VA has the same sort of challenge, right? 
But in this emergency situation, we do want to make sure that 
when we do outsource that there is continuity of care.
    Mr. Gibson. As we look at purchase care in the community, 
we think in terms of extraordinary geography, extraordinary 
technology, and extraordinary demand. Clearly we are in a 
period right now of extraordinary demand that we are dealing 
with as we accelerate care to veterans waiting too long.
    Extraordinary geography, there are always going to be 
communities where we can't justify building a CBOC. And so we 
are going to have to provide timely and appropriate access to 
care for those veterans.
    And then there are going to be occasions where very highly 
specialized procedures, not going to make sense for us to do 
those in-house and want to refer them out.
    Mr. Takano. I think many of us want to support more non-VA 
care, but we want to maybe set the parameters so it really is 
possible and really does work.
    Mr. Gibson. Correct.
    Mr. Takano. Mr. Chairman, I yield back.
    The Chairman. Thank you very much.
    Mr. Flores, you are recognized for five minutes.
    Mr. Flores. Thank you, Mr. Chairman.
    Thank you, Secretary Gibson, for joining us today.
    In your testimony, you said, quote, ``We will work hard to 
earn your trust,'' unquote, we being the VA and your trust 
being the trust of Congress.
    Your background and my background are fairly similar. We 
were both sea level officers in private organizations, you as a 
chief financial officer and me as chief financial officer and 
chief executive officer.
    Now, in those positions, each of us had to report to boards 
who were responsible in a fiduciary manner for the oversight of 
the resources of those organizations. And so I am going to lay 
out the following sort of environment.
    Let's say that you are the CFO of an organization that 
looks like this. It is a corrosive culture. It has performance 
measures that aren't trustworthy. It has senior executives who 
manipulated information in order to receive bonuses. Its past 
financial projects included requests for funding that caused 
funding levels to be higher than were not actually used, in 
this case by billions of dollars, and then those funds were 
reprogrammed to other purposes without letting the board know. 
And then you have a resource management system that according 
to your own testimony is not accurate.
    So in light of that, what do you think the board's reaction 
would be if you go to it and say I need a whole bunch more 
money and I am only going to give you three pages to explain 
it?
    So that is sort of the first part of the question. The 
second part of the question is, wouldn't it have been much more 
wise to come and say we need a small amount and we are going to 
come back to you in a few months and show you what a great job 
we did with this small amount and then say in light of that, we 
would like to make a larger request because we are on the right 
track? So that's my first question.
    Mr. Gibson. Well, I think the sense is that we needed to 
provide, as the conference committee was considering other 
appropriations, we needed to provide our best estimate of the 
requirements to meet the current demand.
    Mr. Flores. But you turned those requirements into a 
request and I don't think that was wise. I think it would have 
been a lot smarter to come back to us and say this is the down 
payment that we need and if we are successful at turning this 
around and putting veterans' health care first, then we're 
going to come back to you and ask for X, Y, and Z. But you 
asked for the whole enchilada at one time.
    And that has caused a lot of us to struggle. And now we 
have got other folks that are trying to latch on to that and 
say that has got to be an integral part of the deal to reform 
the VA. I just don't think that is a good idea.
    Let's go into a little bit more granular information. In 
the health care model that the VA uses, it is called the 
enrollee health care projection model or EHCPM, that takes into 
consideration a number of components, projected number of 
enrollees, projected workload, projected unit cost for 
providing the services.
    In fiscal 2011 and 2012, the VA used the EHCPM to estimate 
the resources for about 83 percent of its health care budget 
estimates. In 2014, it expanded the use of EHCPM to develop 
cost estimates beyond that.
    Over the years, the GAO has identified many problems with 
the EHCPM. In essence, it is not a very trustworthy product. 
And so that is an issue.
    And now the Administration is requesting $17.6 billion 
which I think was an unwise request to ask without proving that 
things are going to get better.
    So here are my questions and I am going to run out of time, 
but you can answer these supplementally, hopefully before the 
end of today.
    Number one is, was the EHCPM used to estimate the 
additional $17.6 billion needed to clear out the current 
backlog at the VHA? Number two, why did the EHCPM fail to 
predict the demand on the VHA system and is there a way the 
model can be adjusted to incorporate reasonable wait times? 
And, number three, and this is the most important one, should 
we continue to advance appropriate VA health care funding if 
clearly the method used to predict the funding needs so far in 
advance is not working?
    As I said earlier in my testimony, the VA overestimated and 
then used the funds for other purposes again without talking to 
Congress or its board, if you will. And so the model just goes 
all over the place. Now you are saying that it needs $17.6 
billion.
    So let's ask the first question. Did you use EHCPM for the 
$17.6 billion budget estimate?
    Mr. Matkovsky. Indirectly. We used costs, unit costs that 
were derived from the model, but looked at appointment wait 
time and used the data that we had for veterans waiting for 
care greater than 30 days. That is different than the model, 
though.
    Mr. Flores. Okay. So the only thing from the model is the 
unit costs; is that correct?
    Mr. Matkovsky. Yes, sir.
    Mr. Flores. Everything else was starting----
    Mr. Matkovsky. Looking at the data that we had at the time.
    Mr. Flores. Okay. Do you know why the EHCPM failed to 
predict these estimates in the past?
    Mr. Matkovsky. I don't know that it did fail to predict it. 
I would have to go look at the details.
    Mr. Flores. The facts say it did fail.
    Mr. Matkovsky. Okay.
    Mr. Flores. But, anyway, get back to us on that----
    Mr. Matkovsky. I will.
    Mr. Flores [continuing]. As well as my third question. 
Thank you. I yield back.
    The Chairman. Thank you very much.
    Ms. Titus, you are recognized for five minutes. Ms. Titus, 
you are recognized.
    Ms. Titus. Excuse me, Mr. Chairman.
    Well, I think we all agree that the purpose of these 
hearings and of your proposed reforms is to increase service to 
our veterans and to their families. These are services that 
they have deserved.
    And I thank you, Mr. Secretary, for being here and all that 
you propose to make that happen.
    We have heard of all the many problems and if these 
problems exist generally for veterans, I think that the 
problems are perhaps even worse for our LGBT and women 
veterans. And that is where I would like to address my 
concerns.
    I would ask you, Mr. Secretary, do you believe that 
veterans and their spouses should have equal access to federal 
benefits through the VA regardless of their current state of 
residency?
    Mr. Gibson. Yes, ma'am, I do.
    Ms. Titus. Well, I thank you for that answer. And I ask you 
this because last month, the VA announced that your agency has 
exhausted all avenues in the wake of the decision by the 
Supreme Court in Windsor versus the U.S. that struck down DAMA 
for giving benefits to our LGBT veterans.
    And unless Congress acts, those veterans and their families 
who live in states that don't recognize their marriages will be 
denied access to earned benefits; is that correct?
    Mr. Gibson. That is correct, yes, ma'am.
    Ms. Titus. Well, and that is most unfortunate. But because 
of that, I recognize that need. And after the Supreme Court 
decision, I introduced H.R. 2529. That is a very simple bill 
that would correct that language problem in the statute.
    We had a hearing on that last March. Nobody came forward to 
oppose it. We had VSOs speaking in favor of it. Nobody is 
working against it.
    And I would ask you would you support our efforts here in 
Congress to make that change so all our veterans who have all 
worn the uniform, who have all served equally, who served the 
United States, not a particular state, could have access to 
those benefits?
    Mr. Gibson. Ma'am, I am not familiar with the legislation 
specifically, but my own policy decisions at the department 
have been to provide equal benefits to all veterans to the 
maximum extent permitted by the law.
    Ms. Titus. And I thank you for that, and our veterans do, 
too, I am sure.
    As for women, I would like to ask you about that. Some of 
the recent reports have highlighted some very disturbing 
statistics about the low quality of care that our women 
veterans face. And they are less likely to seek out care. They 
are often called our silent veterans.
    But when they do, we found that the VA served 390,000 vets 
last year, yet nearly one in four of the VA hospitals does not 
have a permanent gynecologist on staff. And one out of every 
two female veterans received medication that was determined 
could have caused birth defects even though they are at an age 
where they might want to have children.
    These are unacceptable statistics and they really address 
the question of quality of care. I sent a letter along with 50 
of my colleagues here in the House asking that this be 
addressed. I know you have been busy. I haven't heard back from 
you.
    But I wonder if you could speak to that this morning.
    Mr. Gibson. Well, I owe you an answer, first of all, 
apologies, and we will get you one. We are, quite frankly, 
playing catch up. The growth rate in women veterans that are 
coming to VA for care radically outstrips the overall growth 
rate in the number of veterans that are coming to VA for care.
    We have not historically been well positioned to provide 
that care. We are doing things. We are training for existing 
providers, hiring additional providers as well as I know what a 
big deal it is every time we are able to cut the ribbon on a 
new women's clinic in a medical center because I always get 
invited and I attend as many of those as I can.
    So it is a really big deal, but we are playing catch up and 
we have got work to do.
    Ms. Titus. Well, I appreciate that, and I thank you for 
your answers because sometimes we look at this in the big 
picture and we forget that there are certain veterans who are 
perhaps being overlooked. And I want our improvement of 
services to go for all our veterans because they have all 
served and sacrificed as have their families.
    So thank you very much.
    I yield back, Mr. Chairman.
    The Chairman. Thank you very much, Ms. Titus.
    Looks like, Dr. Benishek, you are recognized for five 
minutes.
    Dr. Benishek. Thank you, Mr. Chairman.
    And thank you, Mr. Secretary.
    Frankly, your story of coming in, you know, in the interim 
like this and trying to pick up the pieces of a system that has 
obviously been under, you know, a lot of stress is admirable 
and I appreciate what you are doing.
    I have a couple of quick questions----
    Mr. Gibson. Yes, sir.
    Dr. Benishek [contining]. That I hope you will be able to 
help me with. First of all, I just want to address a personal 
issue. You know, the CBOC in Traverse City, Michigan has been 
scheduled to be increased in size for years. And, actually, the 
money is apparently in your department and all it needs is a 
signature from you to get that to happen.
    So I would like to get your signature on that to make that. 
My district has been waiting for this for years. And the money 
has been appropriated and it is in the budget, but, you know, 
we have been trying to get this to happen for a long time. So I 
hope you can fix that.
    Mr. Gibson. We will dig into that one, sir.
    Dr. Benishek. Well, I have been trying to get this to 
happen for a long time.
    Mr. Gibson. I've got to tell you when I am out in the 
field, I run into all kinds of instances where----
    Dr. Benishek. Well, you know, I appreciate the fact that 
you are out there.
    Mr. Gibson [continuing]. Before I leave the room.
    Dr. Benishek. I appreciate that you are out there yourself 
seeing what is happening on the ground because, you know, my 
problem with management is that when somebody is sitting back 
behind their desk and listening to their subordinates tell them 
how things are, that is when trouble happens.
    Mr. Gibson. Yes.
    Dr. Benishek. And I think that is what has happened in the 
past, frankly, here.
    Now, the question that we brought up and some of the 
Members brought it up earlier is what does the secretary need 
to do his job? You mentioned how difficult it is to remove 
people, so what would your recommendations be to--what powers 
should the secretary have that he doesn't have now to make sure 
that change happens?
    Mr. Gibson. That is not an easy question to answer. I have 
said repeatedly I will use whatever authority I have got and 
use it to the maximum extent that I can to hold people 
accountable.
    There are different proposals out there about granting 
additional authority to the secretary and if those are 
provided, then we will use them. We recognize that to the 
extent that those are targeted solely at the Department of 
Veterans Affairs, that has an impact over time on our ability, 
I believe----
    Dr. Benishek. No. You are explaining a lot, but you are not 
giving me an answer. What do you need to make this happen 
better?
    Mr. Gibson. Well, you know, somebody asked a question 
earlier about is that how it worked in the private sector. I 
would tell you, you know, let's work like we do in the private 
sector. But that ignores a century of authority and----
    Dr. Benishek. Well, what is a century of mismanagement? 
Let's make a step forward. What would the number one thing that 
you would recommend to make it easier for the secretary to do 
his job and promote accountability and action?
    Mr. Gibson. Well, I think the flexibility to expedite 
personnel actions.
    Dr. Benishek. All right. Thank you.
    Mr. Gibson. That would be a big deal.
    Dr. Benishek. Let me ask another question and that is, we 
are trying to get the patients off of waiting lists and into 
the private sector, so, you know, my experience with the VA is 
it is very difficult to make that happen because there is like 
so much paperwork that the veterans have to go through.
    What have you done in this emergency situation to make it 
easier for that veteran actually to get out into the private 
sector and make it happen and the guys get paid and it all is 
happening quickly? Now, what have you actually done to make 
this happen?
    Mr. Matkovsky. That is a good question. Congressman 
Benishek, one of the things that we have done is we have 
created these new tools. I know we have talked about them 
before, non-VA care coordination. It helps us to automate the 
documentation of the referral so that it occurs a little bit 
faster.
    But what it also allows us to do is it for the first time, 
we get to look at that referral through all of its stages and 
we get to manage to it. So we get to look at when was the 
referral created, when was it authorized.
    Did we sit on it too long before we authorized it? After it 
was authorized, when was the appointment scheduled, how much 
time passed, and then, finally, when was the care delivered and 
the documentation returned?
    That is helping us. It is not perfect yet. We still have 
work to do. I think----
    Dr. Benishek. Well, what exactly are you doing to get these 
people off the waiting lists and into the doctor's office in 
the private sector? Tell me how that process works.
    Mr. Matkovsky. So specifically it is phone calls to 
veterans asking them if they would like to be seen in the 
private sector if they would. And we can coordinate with PC3. 
We are using our PC3 partners----
    Dr. Benishek. PC3 is not in place for the most part?
    Mr. Matkovsky. Not fully, but where it is, PC3 will 
coordinate that appointment for us and where it is not, we are 
working with veterans. If they know a provider they want to 
work with, they will work with their own provider. If they 
don't, we will work to set up that appointment with providers 
we have relationships with.
    And there is a scripted process. We did script it this 
time. I think it is a little bit better. We still have a lot of 
work to do to get that done right. Actually, we have even 
talked with some VSOs to help us look at that process from a 
veteran's perspective. Is it easy to understand? Is it easy to 
follow through? I think we have work to do there.
    Dr. Benishek. I am glad you admit to that. Thank you.
    The Chairman. Dr. Ruiz, you are recognized. Excuse me. Mrs. 
Kirkpatrick, you are recognized for five minutes.
    Mrs. Kirkpatrick. Thank you, Mr. Chairman.
    Secretary, thank you for being here today.
    On Monday, I was out on the Navajo Nation in my district 
and talking with lots of folks. And we have a lot of veterans 
and many of them live in areas with no cell phone coverage or 
broadband coverage. And I know one of your goals is to expand 
tele-medicine and that is a great opportunity for my district.
    But my first question is is, in your budget, do you have 
money for expanding broadband infrastructure in those areas 
where we have veterans who have no access?
    Mr. Matkovsky. I think it is one of the things we will have 
to look at. In the supplemental request, we did have additional 
support for IT to include hardware and bandwidth for expanded 
care. But I think we need to look at that specifically. I don't 
want to give you a false answer.
    Mrs. Kirkpatrick. And I would love to be part of that 
conversation as we continue on because it is going to be so 
critical to getting them the care they need.
    My other question is for the secretary. I mean, you know, 
the inspector general's reports have been very valuable to this 
committee in trying to unravel the problems at the VA and come 
up with real solutions, and just would like to know what you 
have done, what you have put in place since the interim report 
from the inspector general in May.
    Mr. Gibson. There were a series of findings and 
recommendations that were included in the IG's May report, most 
of them having to do with first working the list of 1,700 
veterans that they had turned up in their process which we have 
reached out to every single one of those. I think roughly a 
thousand appointments have been or appointments for a thousand 
veterans had been scheduled as a result of that particular 
process.
    There were recommendations in the report about producing 
the NEAR report, the new enrollee appointment request report, 
producing that at the medical center level and distributing 
that out so that it can be worked. That has happened. And as I 
mentioned earlier, the NEAR list has gone from 64,000 to--it 
was 2,100 the last time I looked which is going to be about the 
bottom of that.
    There were items that I am not remembering. Seems like 
there were one or two others.
    Mr. Matkovsky. Yeah. Each one of them became a specific 
action plan. We have worked on them. We have, I think, closed 
them. We have implemented their recommendations in the interim. 
Whatever the IG--sorry, sir.
    Mr. Gibson. I got it. There was also a recommendation 
regarding reviewing wait lists nationwide which obviously we 
do. We are producing them and publishing them every two weeks. 
And those are really the four or five recommendations and we 
have vigorously pursued every single one of them.
    Mrs. Kirkpatrick. Well, I thank you for that effort.
    And I just want you to know I visited recently with a 
doctor at Flagstaff Medical Center and they had just entered 
into a contract with the VA to treat local veterans. And they 
were very happy and pleased to do that.
    So with that, I yield back. Thank you, Mr. Chairman.
    The Chairman. Thank you very much.
    Dr. Wenstrup, you are recognized.
    Dr. Wenstrup. Thank you, Mr. Chairman.
    And thank you, Mr. Secretary, for being here today and for 
your many years of service to our country in many, many ways.
    You know, let me just start by let's take the assumption 
that the goal of the VA is to see all those that are eligible 
for care as soon as possible and provide quality care. And that 
I think should be the assumption there.
    But what I find is that the motivational factors that are 
really needed to accomplish that and to achieve that on a 
regular basis and to comply with human nature don't really 
exist. In other words, the incentives aren't necessarily there 
that would exist in the private sector, et cetera.
    And I am curious how you would propose in this mass 
bureaucracy that we are dealing with from administrators to 
physicians and nurses to those that are support staff, how do 
we create an environment where truly seeing the veteran patient 
is an asset rather than a liability to the system?
    Mr. Gibson. Interesting way to frame the issue. As I 
mentioned in my opening statement, I continue to believe when I 
go out to the field--I was in Phoenix several weeks ago and 
visited with a roomful of employees and, you know, that is 
clearly our most troubled location faced with what I have 
characterized as leadership failure, mismanagement, chronic 
under-investment and, yet, person after person raised their 
hand and talked about the things they were doing, the things 
they had to overcome in order to be able to take care of their 
veterans.
    I still find everywhere I go the vast majority of people 
care deeply about the veterans that we are serving. And I would 
tell you if we didn't have that, I wouldn't have anything to 
reach in and grab a hold of. As I try to take this organization 
in the direction that we need to go in, being able to reach in 
there and grab a hold of the fact that they care, they want to 
do the right thing is a critical, critical element of what we 
are doing.
    I would tell you other structural things. And, again, I 
alluded to it in my opening statement. I have got situations 
where quality of care at a medical center is declining and 
medical center directors are getting top-box scores on their 
evaluations.
    And that was what prompted my direction to say we are going 
to overhaul the standard performance contract for medical 
center directors and VISN directors because we are not going to 
have a contract where their result isn't aligned with the 
patient outcomes that we are delivering.
    And I think it is going to take some of those kinds of 
structural changes as well to ensure that we got people focused 
on veterans.
    The last thing I would say to this point, you know, we are 
so focused on wait times. And as we think about how we gauge 
timeliness of access in the future, I think the centerpiece of 
that is going to be a much more robust focus on patient 
satisfaction. I think that helps us recenter back on the 
veteran that we are serving and not looking at wait times and 
the 700 other metrics that we have got people trying to----
    Dr. Wenstrup. And those types of responses should be the 
driving force to whether someone gets a bonus or how they are 
compensated.
    Mr. Gibson. Yes.
    Dr. Wenstrup. And, you know, inspector general implied to 
us that as money over the last decade has increased, it led to 
more layers of administrative aspects rather than actual care. 
And that really is a concern.
    As you know, I had a meeting this morning with several 
Members on measuring productivity and efficiency which we have 
done a couple times with some of the doctors here. And I think 
they are going in the right direction, but I still think that 
there is some things missing. When you evaluate just based on 
RVUs, what you are able to look at is how much we are paying 
the doctor per RVU. But there is a lot more that goes into that 
for us to be efficient.
    And this comes into when we are asking for $17 billion, 
right? And so, for example, if you have an old physical plant, 
you know, you have got to take a look at how much you are 
spending for productivity and RVUs in a plant that is costing 
you out of this world. You may be better closing that entire 
facility and putting everything in the community in that 
particular spot.
    But we are not measuring that. Those are the types of 
things we have to measure as well because when you talk about 
outsourcing and saying it costs, maybe it doesn't cost more if 
your physical plant is costing you so much more. Those are 
business decisions and that has got to be the approach. We 
can't assume that where we are is the best place to be always.
    So I am going to continue to work with that group and with 
you. And hopefully we can see these types of changes. And I 
appreciate it.
    And with that, I am out of time and I yield back. Thank 
you.
    The Chairman. Thank you very much.
    Ms. Brownley, you are recognized for five minutes.
    Ms. Brownley. Thank you, Mr. Chairman. I appreciate it very 
much.
    And thank you, Mr. Secretary.
    Mr. Secretary, the way I understand your proposal of the 
$17.6 billion is predominantly for additional space, additional 
personnel, professionals, and some money for IT. And I 
certainly agree that in terms of facilities and personnel, 
there is a need.
    My CBOC in Oxnard, California has, as you stated in your 
testimony, is one that has had double digit increases each year 
over the last couple of years and not much has been done over 
those last couple of years, I will add.
    I think what I have learned through all of the hearings 
that we have had that the care for veterans once they get in 
the system is pretty good. It is accessing the system is where 
we have seen is truly broken.
    And when I see the IT proposal there, it concerns me. It is 
a red flag for me because you did mention off-the-shelf 
products that you are looking at, off-the-shelf technology that 
you are looking at.
    But I really want to know. We have got to fix the access 
part of this and I don't want to invest more money into a 
broken system. I want to invest money into new technologies and 
innovation and getting the VA into the 21st century much like 
the private sector is and the tools that they have to access a 
health care system.
    So if you could just comment on that, please.
    Mr. Gibson. First of all, I would say the majority of the 
IT resources, as I understand the proposal here, are associated 
with the activation of the facilities, so it is the IT 
infrastructure that we need as we activate facilities and bring 
on additional clinical staff.
    There are a number of things underway to really take us 
into the 21st century here. Part of it is the purchase of the 
commercial off-the-shelf scheduling system which is not 
included here. It is already provided within the core funding.
    But there are other things. We were talking about 
interoperability for purchase care and there are technology 
investments that are included here associated with that.
    Philip, anything else to add?
    Mr. Matkovsky. I would just add a couple of items relative 
to the IT. I mean, part of it is we have a capital request in 
there and we are requesting a certain amount. I think it is 
about 12 to 13 million square feet for leased space, but we 
have to outfit that leased space with IT actually to make it 
useful to connect PCs, cables, networks, wireless, telecoms, et 
cetera. Sorry.
    Mrs. Kirkpatrick. Yeah, I can't see. I'm sorry.
    Mr. Matkovsky. So that is a part of it. So that is built 
into it. It is not all just raw development work. It is what 
you need actually to make use of the space you get and then to 
actually connect the staff you are hiring. You need IT to make 
that happen. So that is part of the request.
    Mrs. Kirkpatrick. So, Mr. Secretary, then in terms of off-
the-shelf solutions that you are speaking of, what is the time 
frame in that? What are we looking at?
    Mr. Gibson. Sure. There are actually three or four 
different initiatives, kind of parallel initiatives on the 
scheduling front. We have already let a contract to deal with 
some of the most challenging aspects of the current system and 
we are expecting those to begin to be fielded within the next 
six to 12 months.
    The time line for the purchase of the commercial off-the-
shelf system is still a bit up in the air based upon the 
contracting approach that we are going to have to pursue there, 
but I think 2016 is probably the best case scenario for the 
introduction of that particular system.
    Does that sound right, Philip?
    And so that is one of the reasons we are going ahead to 
make the investments in the fixes to the existing system so 
that we don't wait two years to have that improved 
functionality.
    Mrs. Kirkpatrick. Thank you.
    And very quickly, in your opening comments as well, you 
talked about the VBA and the improvements there. We also 
learned in our hearings that we have had a 2,000 percent 
increase in the appeals with regards to benefits. So when you 
add that together, to me it gives me pause in terms of 
believing that we have made the improvement.
    And if you could just briefly comment on that.
    Mr. Gibson. Sure. Glad to. There has been this laser sharp 
focus on the disability claims backlog. I perceived that 
walking in the door the morning of my third day at VA. I was 
over at the White House talking about the backlog and VBMS. And 
so, you know, this laser sharp focus on the disability claims 
backlog, we have not been as focused as we needed to be on non-
rating claims and on appeals and on our fiduciary claims.
    And that is what we are really talking about doing here, 
particularly with appeals where the majority, 90 percent of the 
number of appeals that are in process sit in VBA. We have 
allocated additional resources, thank you very much to 
Congress's support, to the Board of Veterans Appeals which is 
helping us and we are using some technology there to make them 
more efficient.
    But we have work to do in the VBA side to be able to 
provide----
    Mrs. Kirkpatrick. Thank you. I yield back.
    Mr. Gibson []. Timely decisions.
    The Chairman. Thank you.
    Dr. Huelskamp, you are recognized for five minutes.
    Dr. Huelskamp. Thank you, Mr. Chairman. Appreciate your 
continued leadership on so many issues and appreciate the 
opportunity to question the acting secretary.
    And I want to bring attention first to a very famous 
publication, Life Magazine, May 22nd, 1970. I presume you are 
somewhat familiar with this publication and also the photo that 
gained much attention across the country of, again, May 1970 in 
which the VA was found to have abused the trust and neglected 
our veterans.
    And, Mr. Gibson, I think we sit here today and that is the 
same topic, how are we going to restore the trust to our 
American veterans and to the American people. And what I have 
heard from you today so far has been that if we will spend, 
give you another $17.6 billion, somehow that will restore that 
trust. And I don't think that does that for my constituents, 
certainly not for my veterans.
    And I have some very specific questions I would like to ask 
of you. First of all, have all secret waiting lists been 
eliminated and identified?
    Mr. Gibson. To the best of my knowledge, yes, they have.
    Dr. Huelskamp. You have identified, at least Mr. Matkovsky 
identified those on the electronic waiting list, but it is my 
understanding there are 18 different schemes identified 
internally. So you are absolutely certain that every one of 
those waiting lists have been identified?
    Mr. Gibson. I don't know where the number 18 comes from.
    Dr. Huelskamp. That comes from the OIG report and, 
actually, from a memo in 2010 that came from your department. I 
just say if we are going to restore trust----
    Mr. Gibson. Well, the IG is in over 80 locations right now 
and I am not privy to what they are finding. So that is why I 
say to the best of my knowledge, they have been uncovered. But 
until the IG completes their reviews in all those locations and 
comes back and issues their reports, I can't tell you that 
definitively.
    Dr. Huelskamp. Well, how do we restore that trust if we 
don't know the extent of the problem?
    Mr. Gibson. Well, I think you start where you are.
    Dr. Huelskamp. You start by spending money?
    Mr. Gibson. No. You start where you are. You start by 
articulating expectations about how we are going to operate. 
You start by getting veterans off of wait lists and into 
clinics. You start by fixing the chronic scheduling problems 
that exist within the organization.
    Dr. Huelskamp. Well, how do we know we are achieving 
progress? What we have heard and I am sure you are aware of 
numerous employees from the VA have come before this 
committee----
    Mr. Gibson. Yes, they have.
    Dr. Huelskamp [continuing]. And identified falsified data, 
fake data presented to this committee. And you come in here 
today and present data and say, hey, we are making progress.
    How do we restore the trust that we can actually believe 
the data you are presenting to the committee?
    Mr. Gibson. I would tell you when I directed all the 
medical center directors and VISN directors to go out and spend 
time in each of their clinics and engage with their schedulers, 
you know, people have asked me, well, gee, that doesn't sound 
like much of a check and balance because they are on the 
inside.
    The real motivation behind that direction was for them to 
be out there on the ground and to take ownership for the 
quality of health care that is being delivered including the 
timeliness of the health care that is being----
    Dr. Huelskamp. Well, the whistleblowers that I hear from, 
Mr. Secretary--I am short on time--they are saying that has not 
changed.
    Mr. Gibson. We are coming behind that. We are coming behind 
that with an independent audit, comprehensive audit of 
scheduling practices all across the organization because we 
need to restore that trust.
    Dr. Huelskamp. Has anyone lost their job for retaliating 
against----
    Mr. Gibson. No, there has not. There are two whistleblower 
retaliation referrals that have just come from the Office of 
Special Counsel. And Tuesday morning, I will have investigators 
on the ground pursuing those specific----
    Dr. Huelskamp. How many ongoing investigations are 
currently underway for investigating these retaliation 
complaints?
    Mr. Gibson. Oh, it is 70 or something.
    Dr. Huelskamp. Seventy.
    Mr. Gibson. The number is----
    Dr. Huelskamp. And so we are going to hear about two and 
the other 68 are still ongoing?
    Mr. Gibson. These are ongoing at the Office of Special 
Counsel. I am waiting for the Office of Special Counsel to 
provide me the results of their investigation. I can't----
    Dr. Huelskamp. What are you doing about it?
    Mr. Gibson. What I can do----
    Dr. Huelskamp. What we heard from whistleblowers is----
    Mr. Gibson. What I can do----
    Dr. Huelskamp. Let me describe what we heard from 
whistleblowers. Maybe you didn't hear that. But they said we 
get an email once a year that says we have a right to 
whistleblow.
    Mr. Gibson. What I can do is----
    Dr. Huelskamp. And then we are faced with retaliation. I am 
hearing this still going on today.
    Mr. Gibson. I have no doubt that it is. I can articulate 
over and over again the expectation that we are not going to 
tolerate that behavior. But until I have got a set of facts 
that I can act on, I can't take the action. I can't take the 
personnel action. And so nobody is more anxious than I am to 
have that opportunity.
    That is why, in fact, this morning, I checked again have we 
gotten anything from the Office of Special Counsel. The answer 
was yes, we just got two. Tuesday morning, we will have 
investigators on the ground at that level.
    Dr. Huelskamp. I requested in the last meeting, following 
the last meeting information of contacts between a 
whistleblower here that had contacted the chief of staff to the 
President. I don't believe we received that information.
    Your department can look into that. You have access to the 
information. You just need to call Mr. Nabors. That hasn't been 
looked into. That hasn't been responded to. These are very 
serious allegations, Mr. Secretary.
    And I presume we are going to have a new secretary in a 
couple weeks. But to come in and say we are going to restore 
the trust, but we haven't addressed the whistleblower problem 
because that is somebody else's job, that if you give us $17 
billion----
    Mr. Gibson. No, it is not somebody else's job. It is my 
job.
    Dr. Huelskamp. No. It is the OIG's job.
    Mr. Gibson. I just can't take action until I have got the 
results of the investigation.
    Dr. Huelskamp. From the OIG. So we are waiting on----
    Mr. Gibson. Either from the OIG or from the Office of 
Special Counsel, one or the other.
    Dr. Huelskamp. Have you issued any new statements to the VA 
system about whistleblowers?
    Mr. Gibson. Yes.
    Dr. Huelskamp. Okay. Could you provide that to the 
committee?
    I yield back, Mr. Chairman.
    Mr. Gibson. Yes, sir.
    The Chairman. Thank you very much.
    Dr. Ruiz, you are recognized for five minutes.
    Dr. Ruiz. Thank you so much, Mr. Chairman.
    Thank you, Secretary, for your hard work.
    Before I begin, I want to recognize a friend of all of 
ours, Nancy Brown Park. She is the national president of The 
American Legion Women's Auxiliary who is here in our room 
today. She is visiting us from my district, California's 36. 
And as you know, it is in southern California, so it is a long 
trek.
    Thank you for being here and thank you for all your hard 
work.
    You know, recently my office has really done an incredibly 
detailed, thorough investigation of the different issues that 
face our veterans not only when I started office last summer 
when we held community forums, stakeholder analysis, research 
but also key stakeholder interviews.
    We underwent that again in light of this crisis. We have a 
veterans' advisory board that is just top notch. We conducted 
surveys. We did more interviews and had multiple meetings with 
the Loma Linda VA and the VA Administration.
    And we recently conducted this informal survey of veterans 
in my district to assess their satisfaction with access to the 
VA health care.
    But, you know, our approach means the world of difference 
to veterans and we approach this with a spirit of problem 
solving. We approach this with the spirit of partnerships for 
solutions. We approach this with the spirit of honoring our 
veterans with our relentless determination to serve and put 
them above anything else.
    And we found, and I am going to give you some information, 
though, and we understand there is some selection bias here, so 
I take these numbers with a grain of salt, but, nevertheless, 
they tell a story, we found that the vast majority of my 
district veterans who responded said that they waited more than 
60 days. Of course, these are individuals who are upset and who 
are willing to conduct this survey.
    When asked what issues were preventing them from obtaining 
timely care, about a third said that they cited a shortage of 
staff which is echoing the concerns raised by Secretary Gibson 
and the VSOs represented here today.
    Even more troubling, when asked what could be improved to 
better provide timely care, the vast majority again said, 
quote, ``people who care.'' And we have heard that on multiple 
occasions.
    So we also heard that there is this culture where the VA 
system believes that perhaps it is about them. And we need to 
change that culture to make it a more high-performance, 
veteran-centered culture. The VA exists to honor, respect, and 
give dignity and care for our veterans who have put their lives 
at risk. The veterans do not exist to serve the VA health care 
system. That is very important for that sentiment to penetrate 
every level of the VA health care system.
    Now, my question to you is, what is the plan for a system-
wide cultural change that will create a culture of high-
performance, veteran-centered system?
    Mr. Gibson. I think as you look at organizational change, 
cultural change in an organization, the critical ingredient in 
all of my experience is leadership. Part of that has to do with 
articulating expectations and then holding people accountable 
for behavior that is aligned with those expectations.
    You know, we are working hard to do the first part. We are 
working hard to get ready to do the second part. And we are 
anxious to do the second part as well because, quite frankly, I 
think that is where we begin to get real traction.
    I would also tell you on the leadership part I agree with 
you completely. I think there is a fundamental shift in culture 
that has to happen. One of the things that I talk about an 
awful lot internally is ownership really at all levels, and we 
are talking about leaders not at the top of the organization, 
but leaders at all levels, taking ownership for issues that are 
getting in the way of delivering care to veterans.
    In some instances, it could be a leader that is taking 
ownership for a greeter's less than cordial welcome of a 
veteran. It could be more fundamental in terms of a leader 
taking ownership for the steps that need to be taken to get X-
ray machines repaired in an operating room as I ran into in 
Phoenix.
    But it is really about taking ownership and understanding 
that, you know, my job, as I said earlier, my job is to create 
the conditions for them to successfully take care of veterans.
    Dr. Ruiz. I believe that that is very important. That leads 
to a culture of accountability which we absolutely need.
    Mr. Gibson. Yes.
    Dr. Ruiz. However, we need a veteran-centered culture. So 
what are you being held accountable for? What are the 
institutionalized tools that you are going to use to make sure 
that our eyes aren't necessarily on the spreadsheet but are 
always on the veterans themselves?
    And that can be done with veterans' advisory boards. That 
can be done with veteran surveys. That can be done with tying 
promotions----
    Mr. Gibson. Yes.
    Dr. Ruiz [continuing]. To veteran satisfaction. That can be 
done in a lot of different ways that focuses on all of our 
eyes, all of our accountability, everything we do, everything 
that we strive for and exists even in our high performance 
always answers the question through the lens of the veterans.
    Mr. Gibson. Agree.
    Dr. Ruiz. Thank you. I yield back my time.
    The Chairman. Thank you very much, Dr. Ruiz.
    Colonel Cook, you are recognized, sir, for five minutes.
    Mr. Cook. Thank you, Mr. Secretary. Appreciate you being 
here.
    We are talking about trust and confidence. And I will be 
very honest with you. I lost a lot of trust and confidence in 
the VA. You know, when I was in a platoon, felt very, very 
confident with the troops that I had, the company commander, 
trust and confidence in the battalion all the way up there. And 
I am trying to, you know, not let the events of the past, you 
know, influence my judgment.
    About three months ago, I called one of the VAs. I am not 
going to call as Congressman Cook. I am not going to call as 
Colonel Cook. I just said, hey, this is Paul Cook. You know, I 
am on file in there. I just want to get an appointment. I 
couldn't even get past the switchboard. Okay?
    Called the VA, the regional office and told them about 
that, but there is part of me that wanted to go to war, if you 
will, but there is part of me that my office, they do a great 
job handling the veterans and I didn't want to endanger other 
cases that are on file.
    So, anyway, I said to myself, okay, Cook, what are you 
going to do. You are a dumb marine. So I said, all right, here 
is what is going to happen. I am going to walk into a VA and I 
am going to try and get an appointment. I am going to bring my 
ID card. I probably will not show them first. I just want to 
give them my driver's license. They are going to look at it. 
Right away they are going to see I am older than dirt. But it 
will have my Social Security number on there.
    And what I want to know from you guys, if you can, what 
five questions should I have answered right then and there so I 
can go forward with the process because if I think those 
questions are working, I am going to spread that through every 
veteran that, hey, you going to VA, make sure you have blah, 
blah, blah, blah, blah, and you ask these questions because I 
am going to say if they didn't answer those questions, then we 
have a problem and we have to address it. And I will come back 
to you and here we go again.
    Sorry. It is a long question, I guess.
    Mr. Matkovsky. I think to get care in any VA, you should 
ask only one question, am I enrolled. If you are enrolled, you 
should be getting care. The second questions after that would 
be what kind of care would you want. If you are not enrolled, 
the second question after that would be I would like to enroll, 
how do I do that.
    Mr. Cook. I am enrolled. Let's go with that.
    Mr. Matkovsky. That should be just the one question, I am 
enrolled and I would like to get an appointment.
    Mr. Cook. Then the next one? Just ask----
    Mr. Matkovsky. I would like to see my primary care 
provider. I would like to see this provider. That is it. You 
shouldn't be asking any other questions.
    Mr. Cook. Okay. So two questions----
    Mr. Matkovsky. Yes, sir.
    Mr. Cook [continuing]. Or three questions. Okay. Got a 
couple of questions of the IG. The IG, you might not be able to 
answer. How many of the IG visits are unannounced?
    Mr. Gibson. I am sorry. How many IG visits----
    Mr. Cook. Are unannounced.
    Mr. Gibson. I would say the large majority.
    Mr. Cook. Okay. So they don't know in advance that they 
are--okay.
    Mr. Gibson. Oftentimes they are responding to a hotline 
call or something like that. I don't even know where the IG 
is----
    Mr. Cook. Yeah. But, you know, I mentioned this before 
about the principle, and I was an IG, so this thing about 
managing by walking around where sometimes you walk into a 
battalion or what have you, you know, you don't like to do that 
when you have evidence that there is something going on with 
the unit.
    I walked in one time. I found a live mortar in a place with 
the bore riding safety pin off. Unbelievable. And, yet, when 
you come in like that, particularly if you are worried about an 
organization based upon the statistics that have gone out 
there.
    So I don't know. I am kind of excited about you being here. 
You answered your question. I still don't understand 
granularity and it is the third time I have heard it in two 
committees in the last two days. It took me a long while to 
understand pseudomonas aeruginosa, escherichia coli, and 
tricuspid valvelectomies, and now you throw that at me. I am 
just a dumb marine, but I am glad we are going to start over 
again and we are focused on it.
    And Dr. Ruiz is right. It is about the culture of the 
military and we can never forget that. Thank you.
    I yield back.
    The Chairman. Thank you very much.
    Mr. O'Rourke, you are recognized for five minutes.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    Mr. Secretary, let me begin by thanking you not only for 
being here but for the amazing job that you have done in under 
two months as the acting secretary. You have been incredibly 
responsive. You have been transparent. You focused on issues of 
accountability and I believe you have defined a vision for 
excellence even in the first two minutes of your opening 
statement.
    And my hope is that as we have a new secretary for the VA 
that you will still be part of this organization at the very 
highest level continuing that very aggressive, ambitious push 
towards excellence and accountability and changing this culture 
that all of us have been working on and talking about for so 
many months and in some cases years now.
    Let me quickly switch to El Paso, and I realize it is 
parochial, but I hope that it has some implications for others 
who have similar situations in their districts and for the 
system as a whole.
    You visited 13 facilities, I believe. El Paso was one of 
them. The amazing Verna Jones from The American Legion also set 
up a command center there within the last month. That shows us 
that you are taking this issue seriously, but it also shows us 
that we have a problem in El Paso.
    The access rankings that we saw from the VHA reported in 
June showed that out of 151 facilities, we were dead last, 
absolute worst for established veterans' access to mental 
health care appointments. We were fourth worst for new 
veterans' access to mental health and second worst for 
specialty care.
    You in some of your comments that you made while you were 
in El Paso talked about problems with the capacity of the 
facility that we have, the quality of the facility that we 
have. I would love for you right now to say, Beto, I am going 
to help you with a full-service veterans' hospital. I am not 
going to ask you to make a commitment that you can't follow 
through on and don't have the power to implement.
    But I will ask you this. Will you work with me to ensure 
that we can increase capacity, that we can improve the level 
and quality and access to care in El Paso and similarly under-
served, poor-performing facilities in this country?
    Mr. Gibson. I absolutely will. El Paso is one of those 
locations that has grown almost 20 percent over the last three 
years. It is located, as we both know, in a medically under-
served market.
    And so we have got challenges there as it relates to space, 
as it relates to the scope of services that we are providing 
organically in that particular location, and challenges in some 
instances, which you have personally helped us with, in terms 
of trying to attract clinicians to come to work there.
    Mr. O'Rourke. Let me, if you don't mind, Mr. Secretary, I 
told you Friday that I was going to call a psychologist who we 
were trying to recruit to El Paso. When I was sworn in in 
January of 2013, we had 19 and a half vacancies in mental 
health care in El Paso. As of last month, we had 19 and a half 
vacancies in mental health care in El Paso.
    I have been making recruitment calls. I spoke to a 
wonderful psychologist yesterday, a leader in PTSD care. I 
learned that because we are a clinic, she will be a GS-13 most 
likely. That will be the pay scale. If she were coming to a 
hospital, she would be a GS-14.
    I cannot blame her or anyone who would make a decision 
based on what they will be able to earn in a position given the 
fact that they are coming into a historically under-served 
area. It is another piece of the case that I am making that we 
need a full-service VHA hospital in El Paso.
    Quickly switching gears, the chairman and ranking member 
convened an amazing panel week before last of survivors of 
servicemembers who have taken their lives as they transition 
into civilian life. And we talked about PTSD and the need to do 
a better job of taking care of these servicemembers when they 
come back.
    And the parents of Daniel Somers, Dr. and Mrs. Somers, also 
provided a potential solution or at least a suggestion for us 
to explore and that was, and kind of picking up on something 
that Dr. Roe said about how we coordinate with community care 
and private care, could the VHA become a center of excellence 
for war-related injuries for survivors of PTSD, of TBI, of 
musculoskeletal injuries, of exposure to toxins like Agent 
Orange and those that our servicemembers were exposed to in the 
Gulf War, and have community care for all other services.
    I am not endorsing the idea, but I would love to get your 
thoughts and perhaps Mr. Matkovsky's thoughts with the 
chairman's permission since I am close to running out of time.
    Mr. Gibson. Well, I think the first part of the question 
should we become a center of excellence around a lot of those 
practice areas, I would tell you we either are or should be. 
And so those are instances where we need to have deep knowledge 
and expertise but also exceptional capacity to be able to meet 
the needs of servicemembers there.
    How that fits into a revised model of VA care delivery, you 
know, I don't know that I am ready to give you a view on that, 
but clearly in those particular areas, and as I learned from 
our friends at PVA, oftentimes the things that VA has over the 
decades developed deep specialties in are absolutely vital to 
our veterans. And these are great examples of today's areas.
    Mr. O'Rourke. As I yield back, I would just ask that we 
continue to work together to at least explore this concept. 
Perhaps the VA cannot be everything to all veterans and maybe 
we should focus on centers of excellence.
    With that, I yield back to the chair.
    The Chairman. Thank you, Mr. O'Rourke.
    Mrs. Walorski, you are recognized for five minutes.
    Mrs. Walorski. Thank you, Mr. Chairman.
    And, Secretary Gibson, it is an honor to meet you. I 
appreciate you being here.
    I just want to take a second and just let you know why I am 
stymied by this request for $17 billion because I just want to 
take you back how this started on the committee.
    I am from the State of Indiana. We have 6.2 million 
Hoosiers that live in the State of Indiana. We have a half a 
million veterans out of 6.2 million people. Our State is 
passionate and they are freedom fighters. We love the military. 
We embrace the VA in the State of Indiana. We have the fourth 
largest national guard in the Nation, a little tiny State in 
the Midwest behind California and Texas. We love and we are 
patriots in our State.
    So I am passionate about this issue because I believe that 
when our little State, a half a million people answer the call 
and they heard a promise from this government, and I have sat 
here for 18 months with a lot of my fellow freshmen on this 
committee, and I still have for you today the original 
questions I asked when these hearings began because we have 
never got an answer from the VA.
    And all we wanted to know, all I wanted to know was, what 
is the status of my State? What is happening with the clinics 
in my State?
    I have gone to several hospitals in my State. I have a 
hospital that is not even a fully functioning hospital. They 
don't even have an ICU. So if you are a veteran that comes in, 
you are going to be looked at in the ER and shipped across the 
street to a private facility and, yet, taxpayers are paying for 
both.
    I have got a large institution in Indiana I went through 
two weeks ago that had probably two-thirds beds empty and they 
have never been called by the VA on the supposed nationwide 
check. They showed up on the list of 122 original audits that 
the VA had additional questions from and the CEO personally 
told me he has never heard a word. Nobody has ever checked with 
him. There have been no checks.
    Nobody has been fired. They are still harassing 
whistleblowers. There have been no checks. We don't know the 
status of our states. We can't get the answers to the questions 
that we started with.
    And I guess the question I want to ask you, but I am almost 
mortified to hear your answer is, when will we know the status 
of our states? Mr. Matkovsky has been here before. I am sure I 
have asked those questions from day one, but when are we going 
to hear the status of our states? And please don't tell me it 
is up to counsel general, it is up to the IG and everybody is 
cryptic and mysterious and anonymous.
    Mr. Matkovsky. Monday and Wednesday of next week, 
Congresswoman Walorski, myself and maybe one or two of my peers 
will be conducting eight-hour briefings here to the committees 
both in the Senate, the House, and all the State delegations. 
We will also be sending that data out to the field as well so 
that what we provide to you, we provide to the facilities and 
the networks themselves.
    Mrs. Walorski. Perfect.
    Mr. Matkovsky. So Monday and Wednesday.
    Mrs. Walorski. Yea, because that has been a huge concern.
    My second question goes back to Representative Brownley's, 
which is we have sat in here on many, many hearings on IT. And, 
in fact, I will never forget the gentleman in charge of IT was 
sitting where that blank microphone is right now. And your IT, 
according to the hearings that we have had, has been a 
disaster. There have been many breaches. Our veterans have had 
their information coopted and breached.
    And the gentleman that was in charge of IT sat there and I 
said to him, do you have enough money to do what you need to do 
to protect our VA and to protect our veterans and to upgrade 
the systems that you need. Yes, ma'am.
    We find out during a subsequent hearing that, and the $17 
billion request, that we have allocated long before I got here, 
this committee has consistently, faithfully allocated all the 
money the VA IT department has asked for, and then we find out 
a revelation in one of these hearings, that they are using 1985 
scheduling software. And I think that is one of the most 
shocking revelations I heard.
    So in one of the hearings just a few months ago, I said 
where are the billions of dollars, where did they go in this 
giant VA? They obviously weren't addressing IT.
    And when you come to us and ask for $17 billion and nobody 
can answer the question of why we are using antiquated 
equipment, when every request has been funded, the IT at the VA 
is a disaster.
    What is the answer to the question of how can we possibly 
trust you now even for another billion just for IT when all 
that money has been unaccounted for and the revelation under 
oath was we are using 1985 software?
    I think that is shocking and I think the American taxpayers 
deserve an answer as to where did their money go and how can 
they trust you with another $17 billion or just $1 billion in 
IT upgrade, either of you.
    Mr. Gibson. I was listening for a question there.
    Mrs. Walorski. My question is, how can the American people 
trust you for more money, even a billion?
    Mr. Gibson. Be glad to come give you a lay down of the work 
that IT does on an annual basis, the projects that are 
undertaken, the systems that are both maintained and developed, 
and the functionality that is delivered.
    Mrs. Walorski. So I guess, Mr. Chairman, if I could indulge 
just one final question, so I guess the information we heard 
that day from your IT, the guy in charge of IT was incorrect 
and it could not have possibly been correct information then 
for us to find out under a hearing where people are taking an 
oath that we are using 1985 outdated scheduling software when 
he simply sat there to me and said we need no more money, we 
are compliant, we are fine, thank you very much.
    So the information he gave us then wasn't true, correct?
    Mr. Gibson. I think he gave you an honest answer. I think 
what you heard was the result of an organization that is 
managing to a budget as opposed to an organization that is 
managing to requirements.
    I would tell you one of the things we need is a scheduling 
system. We have got it built into our budget for 2015 and 2016 
and we are----
    Mrs. Walorski. In all due respect----
    Mr. Gibson [continuing]. And we are going to----
    Mrs. Walorski [continuing]. According to your professional, 
it was built into the budgets for years and we were funding it. 
And we were trusting that it was used for the allocation that 
was requested.
    Mr. Gibson. There was a highly reported failed development 
effort that occurred back years ago where VA invested a 
substantial amount of money in a scheduling system and it 
wasn't able to deliver.
    And I would tell you in the years since that time starting 
in 2010 when VA developed the project management accountability 
system, and I would refer to you and I will make sure that we 
get you a copy of the recent GAO report where GAO looked at 
seven different major departments and the progress that their 
IT functions have done, particularly in agile development which 
is the way we go about delivering software these days, VA was 
the only one of the seven departments that passed the grade 
with the GAO.
    Mrs. Walorski. I appreciate it.
    Mr. Gibson. So lots----
    Mrs. Walorski. And the other question I would love 
answered----
    Mr. Gibson [continuing]. Lots of change and improvement.
    Mrs. Walorski [continuing]. Is if that guy who is in charge 
of your IT got a bonus, I am curious, for the information he 
has provided for the lack of adequate resources that you have. 
I want to know if the guy got a bonus. I would just appreciate 
it for the record.
    Thank you, Mr. Chairman. I yield back.
    The Chairman. For Mrs. Walorski 's knowledge and the rest 
of the Members, we actually were going to have an oversight 
hearing this week in regards to IT. We were not able to do it 
because the person who is responsible for IT is out of the 
country on a long-planned family vacation and so we cancelled 
in hopes that he would be able to attend on another date in the 
future.
    Mr. Walz, you are recognized.
    Mr. Walz. Thank you, Mr. Chairman.
    Mr. Secretary, thank you. I, for one, am thankful and 
grateful that this nation still producing citizens like 
yourself. I have had the privilege of working with you in other 
capacities on the USO and your commitment is unquestioned.
    And I think when you started out, Mr. Secretary, when you 
talked about--I agree with you on this. This is one of our 
greatest opportunities to make lasting improvement. What we do 
possibly within the next weeks and months will have decades 
long implications. That is why it is important that we get it 
right, not just get it done; they are hand in hand.
    I have been advocating that what has been missing is a 
national veterans strategy very similar to the Quadrennial 
Defense Review that sets that priorities, that gets that 
transition. Because I am interested--in a minute I am going to 
ask you about your commander's intent and the transition, if 
you will, as it goes to the next commander as we all know and 
how that will work.
    But what I am hearing and I think what you are hearing the 
concern on this is, this nation is committed to getting this 
right. This nation is committed to providing the resources. But 
we also have a commitment, and they are not mutually exclusive, 
to ask that every dollar be spent in a wise manner. In trying 
to strike that out--I am going back to best practices. Because 
I want to clarify when we talk about the private sector, let's 
be clear, eight out of ten businesses fail in the private 
sector. Don't pick the eight where you are getting your 
information. So this oversimplification, or if the Government 
is going to do it right and get into these idealogical 
differences, that clouds it and I think it takes us away from 
the mission is there is best practices. There is things that 
are out there.
    So I would ask you this, and this is what I would like to 
get your take on, Mr. Secretary: I have the privilege of 
representing the number one hospital in the nation, the Mayo 
Clinic, and I have watched and I have looked at and I 
understand how Mayo has done this and one of the things that 
Mayo has always, of course, been focused on is the patient 
first, just like we are talking about the veteran first, but 
systems analysis, from the very beginning over a hundred years 
ago has been at the mantra of what they are done. And these 
things, as far as Baldrige criteria and performance excellence 
drives what they do. And interestingly enough, it starts on the 
flowchart with leadership and it ends with results.
    And so my question is in Mayo, they have a quality 
academy--the levels correspond to Six Sigma and all of those 
things--they are asking, basically, and been there because--
many people don't know this, but Mayo was basically founded on 
battlefield medicine--so they are deeply engrained into 
battlefield medicine, the VA, and they have partnerships with 
you. They are asking now what they can do. I guess my question 
is when Under Secretary Hickey said here, she talked about ISO 
9001 certification, so if they can come back and answer where 
this is from. What are you suggesting or what can be done in 
VHA to ensure a Baldrige-type, Mayo-Six Sigma-type of 
performance so that then we know if we give you the money, how 
it is going to be implemented?
    Mr. Gibson. Interestingly enough, when we did a review of 
scheduling practices and access practices, we invited folks 
from Mayo to come brief us. When we looked at water safety 
practices and the VA, we invited engineers from the Mayo Clinic 
to come. So I would completely agree with you that they are a 
model organization.
    I think one of the things we need to look at--I agree with 
your characterization that we should look at it as a system and 
look at our entire health care system as a system, not just 
focusing on a metric here, a metric there, but looking at 
concepts like throughput, looking at concepts like being 
veteran-centric and how do we measure, how do we manage, how do 
we assess that? I think over the next couple of months we are 
going to go take a look at some of our productivity work that 
we have done. We have briefed Dr. Wenstrup on it. Maybe bring 
some folks from the outside, and help us look at doing 
purposeful system changes. Not spot initiatives here and there, 
by looking at what the practice would look like if we changed 
it, maximized throughput, assess it with real clinicians, to 
Dr. Benishek's point, on the ground. Real physicians, does this 
work? Can we deploy it? Test it and measure it? Use the 
principals of measurement?
    And then I think for the long-term sustainability, VHA and 
VA, but especially VHA, used to have these academies that were 
really great and we sort of let that erode and we have to bring 
them back and we have to build leaders by focusing the training 
on them, building them over time, and investing in them to 
succeed.
    Mr. Walz. And I think that is what we want here. This 
corresponds to the quality of care. I think all stems from 
there, and I think this is an opportunity to build that hybrid, 
not this either/or, the private sector does it best, you do it 
here.
    The core mission of the VA needs to remain intact. We need 
to strengthen it. There are certainly positive lessons out 
there in the private sector, Mayo and others, and we heard last 
week from a panel that offered up great suggestions. I thought 
there was a great one coming from Indiana. Mrs. Walorski was 
talking about Indiana University says he looks out the window 
and he sees five hospitals. He knows on any given day, they are 
only using 79 percent of their capacity. Let's tap that other 
21.
    So, Mr. Secretary.
    Secretary Gibson. Well, I was just going to say I was in 
St. Louis on Tuesday and had the opportunity to visit our 
training academy on the cemetery side of the business, and 
cited that as an internal best practice----
    Mr. Walz. Absolutely.
    Secretary Gibson. [continuing]. That we need to import into 
the VHA because we don't have the kind of talent development 
and succession planning inside VHA that you would find in a 
private sector.
    Mr. Walz. And I think it is important that you bring that 
back up again. The older members here will remember this, the 
crisis out at our cemeteries, out at Arlington and others, and 
the focus that was put on that and the turnaround that has been 
there and the verifiable turnaround and the quality that has 
been made. We can do this, but if we miss this opportunity or 
don't cease to rise to the occasion, then shame on all of us.
    So, I yield back.
    The Chairman. Thank you very much.
    Mr. Runyan, you are recognized for five minutes.
    Mr. Runyan. Thank you, Mr. Chairman.
    And I am going to probably throw out a couple rhetorical 
questions and maybe some analogies to kind of set the table, 
and one you probably won't answer, but I just want to throw it 
out there and see if you can respond to why someone would seen 
ask it: Is VA took too big to fail? I mean that is something 
that we have dealt with in other sectors in the last decade. I 
think it is a legitimate question.
    And when we talk about trust and processes, how are we 
going to get there? As Representative Flores said earlier, and 
you followed up answering Mr. Huelskamp's question about 
process, and your quote was, ``On the personal factor, you need 
a set of facts to act on.'' That can be done in a budgetary 
process.
    I will use the analogy. I will go back to your high school/
college days. You know, your girlfriend broke up with you. You 
made up the next day, but you didn't ask her to marry her that 
day. A legitimate process of gaining trust over time. And to go 
to that, and I love the fact that you brought up manage to 
requirements. There is what, seven, eight members on this 
committee that serve on Armed Services? And Mr. Walz brought up 
Quadrennial Defense Review. I think most of us that sit on that 
committee believes the DoD does the same thing; they tweak the 
requirements to meet the budget. They don't lay the whole thing 
out to Congress and allow us to say, at some point we are going 
to have to prioritize what we are going to do because there is 
only so much to go around, but we have to know what is out 
there. And when we are dealing with a crisis like this--and I 
asked the question to Under Secretary Hickey last week--I said, 
when we are attacking something and me and maybe the chairman--
and we are attacking something like the claims backlog, that is 
a category of claims. Now, when you do your analysis to say we 
need this much money to solve this problem, are we going all 
the way back into everything from--and I know it changes on a 
daily basis--could you do it by a quarterly basis, a biannual 
basis to say to eliminate all of the claims in whether it is 
death benefits, whether it is burials, whether it is education, 
pension, all that kind of stuff, is that even possible to move 
the overlay of what we are making definitions of putting claims 
in piles, to say, do you have an idea of even what that number 
is, VA, why?
    Because you are alluded to it on several patient aspects, 
but in an overall claims--because we continue to say well, we 
are only going to ask for this much because I put this overlay 
on it, what is the overall big picture? What is that 
requirement to eliminate this once and for all?
    I don't think these questions really get asked and/or 
answered on a regular basis.
    Secretary Gibson. And you are talking about on the claims' 
side, on the benefits' side? I am not clear.
    Mr. Runyan. Just to boil the whole thing down. Let's just 
say claims. Every single one of them that is sitting on a desk 
in an RO somewhere, what is that number and what is that fiscal 
number that goes to eliminate that? I mean because you are--a 
lot of times I know you talk a lot about modeling and all of 
that. Well, your models, you are using filters and layers to 
actually actuate those numbers that come out of those models. 
What is the big picture? Is the crisis bigger than we--I think 
we are realizing it is bigger than we thought it was a year 
ago, but can we, at some point, push all of this back and say 
we really got to step back and take a look at this and realize 
this is a bigger problem and we really need to dive into this 
deep.
    Secretary Gibson. You know, I think as it relates to both 
the claims side of the business, the benefits side of the 
business, if you will, and the health care side of the 
business, part of what you are seeing, and VBA has done this 
for some period of time, this regular, weekly publication of 
detailed information, not just about the disability claims, but 
also now detailed information about all the nonrating claims 
buckets, so that people have that complete picture.
    The same thing on wait times. You know, up until six weeks 
ago, we weren't pushing detailed wait time information out on 
every single location--care quality and patient safety 
information out on every single location so that we are 
creating that kind of openness and transparency so that people 
can understand the magnitude of the problem. So that as I sit 
here and say it is 641,000 veterans that have appointments that 
are more than 30 days from when they wanted to see.
    Mr. Runyan. And I know my time is running out, and I just 
want to tell you that I have experienced this in my four years 
in Congress, as you build trust and we say we are going to do 
it one step at a time, I don't think that there is anybody on 
this committee that would have a problem coming in here and you 
tackling this $10 million at a time. I don't think they would. 
As we do that and make sure we get it right and have that set 
of facts that we can act on, as you said.
    So with that, I will yield back, Chairman.
    The Chairman. Thank you, Mr. Runyan.
    Ms. Kuster, you are recognized for five minutes.
    Ms. Kuster. Thank you, Mr. Chair, and thank you so much, 
Secretary Gibson for being with us today and taking on this 
extraordinary task. We appreciate it. I want to echo the 
comments of my colleagues. I think that you will find that this 
is one of the very rare bipartisan committees on Capitol Hill 
right now when we strive to work together.
    I want to focus in on the issue you mentioned, Ms. Bradley 
and the work on ethics and accountability, because what my 
concern is, is while I wholeheartedly believe that we need to 
do every possible thing to ensure that our veterans get the 
care that they deserve, I have a hard time addressing the 
funding request before we get into how the VA is going to fix 
this underlying systemic issue of integrity. In particular, the 
testimony that we have heard here about this scandal, of people 
receiving bonuses upon manipulated data, frankly, a lack of 
truthfulness--truthiness, if you call it, honesty, and 
integrity, that not only the veterans deserve, but, frankly, 
the American taxpayer deserves.
    And so if you could address--before we get into the 
additional funding--how do you intend to restore that level of 
integrity throughout this system and what will be the actions 
taken for deceit and failure to abide by basic, basic issues of 
integrity?
    Secretary Gibson. Yes, ma'am.
    When the President told me that he was going to have me to 
be the acting secretary, I said, ``Don't expect me to behave 
like 'acting' is in front of the job title,'' and I have tried 
not to do that consistently. We have moved out on every front 
that we can conceivably move out on.
    So it has been a process of working, not sequentially on 
tackling different issues, but working across a much broader 
front at the same time. So working to get veterans off of wait 
lists; working to fix scheduling issues; and simultaneously 
working to build the processes so we can hold people 
accountable for willful misconduct and management negligence 
when it arises.
    As we went through this process I perceived the need for 
additional expertise in that area which is why I went and 
recruited Leigh Bradley and with Secretary Hagel's strong 
support, to come over to the Department, to return to the 
Department of Veterans Affairs. We have built underneath her a 
cross-functional team of senior leaders from across the 
organization. Part of the process--part of the challenge that 
we are going through the right now, part of it is just what it 
takes in the Federal Government to pursue personnel actions and 
to have them done in a way that you at least hope it is going 
to stand up to an appeal.
    The other challenge that we are working through right now 
is really the re-calibration of the Department's yardstick, if 
you will.
    Ms. Kuster. Uh-huh.
    Secretary Gibson. That behavior that looks like this, which 
in the past might not have had any accountability action 
associated with it at all, may, in the future be appropriate--
deemed appropriate for removal from federal service or for very 
extended period of suspension.
    So what we have done and as we have now, I mentioned 
earlier, got the first of these cases in from the IG, are now 
exercising that process; following due process, but also 
managing through this reset that has to happen, this re-
calibration that has to happen to ensure that appropriate 
accountability actions are taken for the wrongdoing that has 
been identified.
    Ms. Kuster. And if there is anything that we can do in our 
capacity in congress and I know that, you know, including 
passing a bill to give you the authority to literally fire 
employees, because I think that is the only thing that is going 
to bring this integrity back.
    And I just want to say, for the record, I had a tremendous 
honor this week. My constituent, Sergeant Ryan Pitts, received 
the Presidential Medal of Honor, and I was there for the 
ceremony with he and his wife, Amy, and son, Luke, at the White 
House and as he was inducted into the Hall of Fame at the 
Pentagon. I was very interested in his comments this morning on 
national television when asked about his own care at the VA, 
that the care he has received in New Hampshire has been a very 
high quality. But I want to say for the record that every 
veteran deserves that care.
    And my time is coming up, but I do want to say is that I 
hope you will pursue best practices, because I think we have 
some exemplary care in New Hampshire and I'd like to see that 
throughout the country.
    Secretary Gibson. Yes, ma'am.
    Ms. Kuster. So thank you, and on that, I yield back.
    The Chairman. Thank you very much, Ms. Kuster.
    Mr. Secretary, I apologize. Some Members are going to have 
to depart to go to a conference committee meeting over in the 
visitors' center which is at twelve noon. We tried every way we 
could to find a time that was agreeable for everybody, but I am 
going to turn the chair over to Mr. Bilirakis at this time and 
recognize him for his statements. But thank you, sir, for your 
service, your candor, and I look forward to continuing to work 
with you.
    Secretary Gibson. Yes, sir.
    Mr. Bilirakis. [Presiding] Thank you, Mr. Chairman. I 
appreciate that and I will recognize myself for five minutes.
    Mr. Secretary, again, thank you for your service to our 
country. Mr. Secretary, are you aware of this incident that 
occurred I believe on Monday in an Orange County, Florida, 
facility, a CBOC, where a marine, a veteran was actually 
waiting three hours for care, did not receive that care, and 
then he was subsequently locked into a facility during closing 
time, so it was inadvertent, obviously. I mean what are we 
going to do about this? This is accountability. Are you 
investigating this? Will the people responsible, the 
administrators, be held responsible?
    Secretary Gibson. All I know about it is what I read in the 
clippings this morning. It will be an object of intensive 
review to determine what happened and ensure that nothing like 
that happens again at that CBOC.
    Mr. Bilirakis. Okay. Can you report back to me, Mr. 
Secretary, with regard to that?
    Secretary Gibson. Yes, sir. Will do.
    Mr. Bilirakis. I mean it is outrageous, as far as I am 
concerned.
    Next question: You have directed that an independent 
external audit of VA's scheduling practices be performed. What 
do you expect the external audit to reveal that VA's own audit 
has not--has a contract been awarded, and how long do you 
anticipate this to go on, and then I have a couple other 
questions to follow.
    Secretary Gibson. The contract has not been awarded yet 
which is why I am not in a position to be able to reveal the 
entity that we are working with. I believe once it is 
announced, the reaction will be that they must be pretty 
serious about making sure this gets done right.
    Quite frankly, I hope it doesn't tell us anything that we 
don't already know. I hope it confirms that what we now have in 
place are scheduling practices that are aligned with our 
policies. But I think to some of the earlier questions that 
were asked about the need for some verification, you know, how 
do you believe--we are publishing wait-time data every two 
weeks--is it valid data? And one of the issues for us there is 
to look at the scheduling practices and have a rigorous 
independent review. Determine that they are sound practices 
aligned with our policy and, therefore, we have credible data 
for external consumption, as well as for our own internal 
actions.
    Mr. Bilirakis. Okay. What is the expected costs of the 
audit?
    Secretary Gibson. I don't have a number for you. I will 
take that for the record.
    Mr. Bilirakis. Okay. Very good. Thank you.
    Again, with regard to the bonuses, have any bonuses been 
rescinded so far due to, you know, willful misconduct or 
negligence management? Can you answer that question?
    Secretary Gibson. I will give you the best answer as I know 
it. There were some bonuses that were rescinded recently that 
were associated with administrative error. The law allows us to 
do that.
    Where there is a--something is learned after the 
performance period and after the performance contract has been 
officially--the performance review has been officially 
approved, we don't legally have the ability to go back and 
change that performance evaluation, and therefore, claw back 
that particular bone us. We do have the ability to go and 
reduce salary and take other actions which would be the typical 
actions upon some subsequent, learning of some subsequent 
information that affected performance during a performance 
period.
    Mr. Bilirakis. Okay. Last question: I understand that you 
implemented a hiring freeze for the VHA central office and the 
VISN offices with the exception of so-called critical 
positions, to be approved by you in a case-by-case manner. What 
would you consider a critical position for a VHA central office 
and the VISN offices?
    Secretary Gibson. Well, I would say, for example, we 
currently have, if my memory serves me right, four vacant VISN 
director positions. And if we were in a--if we were where we 
had the right person identified to step into one of those key 
leadership roles, then I would be prepared to grant an 
exception for that personnel action.
    Mr. Bilirakis. Have you granted an exception so far?
    Secretary Gibson. I have not for that purpose. There is one 
employee that I granted an exception for where he has already 
been made an offer and accepted an offer, and had already begun 
to relocate, and for that instance, I did grant an exception.
    This is really focused on the roughly 3,000 people that 
comprise the VISN headquarters leadership, as well as the VHA 
central office leadership. There are other staff that are 
associated with those particular areas, such as call centers. 
We have thousands of people who work in our call centers in VHA 
and those would not be positions because they are providing--
that would be subject to the hiring freeze--because they are 
providing direct service to veterans.
    Mr. Bilirakis. How long will the hiring freeze be in 
effect?
    Secretary Gibson. Don't know.
    Mr. Bilirakis. Okay. You can't anticipate how long, huh?
    Secretary Gibson. You know, the real purpose of that hiring 
freeze, very directly here, was to basically send a shot across 
the bow of the bureaucracy to say we have got to get ourselves 
refocused here on delivering the support that the frontline 
needs, the people that are taking care of veterans day in and 
day out. So that is really the purpose behind that particular 
freeze.
    Mr. Bilirakis. Okay. Thank you very much. I appreciate 
that.
    And I have Ms. McLeod, you are recognized for five minutes, 
ma'am.
    Ms. Negrete-McLeod. Thank you, Mr. Chairman, and thank you 
Mr. Acting Secretary for being here. However being near the 
end, all of the questions have been asked, so rather than being 
redundant, I yield my time.
    Mr. Bilirakis. You are finished? Okay. Thank you very much. 
I apologize. Thank you.
    I will recognize Mr. Fitzpatrick for five minutes.
    Mr. Fitzpatrick. I also thank the chairman and I would 
thank the acting secretary for your time here today. I know 
that we all honor and appreciate your service. It hasn't been 
said here today about your time at the USO, which was a real 
turnaround, a great success, a great American story----
    Secretary Gibson. Yes, sir.
    Mr. Fitzpatrick [continuing]. And I want to thank you for 
that. We saw that in Philadelphia with the USO organization 
there and, of course, we all hope that you can bring that 
enthusiasm and that success and bring it back to the 
organization at the VA--desperately needs it and needs your 
leadership there. And I echo the comments of some of my 
previous colleagues who said that we hope that you stick around 
the VA and continue----
    Secretary Gibson. I plan to.
    Mr. Fitzpatrick. The VA is really a stool with really three 
legs and they are--we have the health administration here. We 
have the benefits administration here. Of course, the third is 
the cemetery administration.
    As Mr. Walz said, in the past, you know, has not been 
without its issues, but I have to say coming from Bucks County, 
Pennsylvania, we have a new national cemetery, the Washington 
Crossing National Cemetery, beautifully being developed, 
serving very well the constituents of southeastern 
Pennsylvania, the greater region, and so the, you know, the 
veteran community, the families of military and the bigger 
communities is left with a very positive view of the Veterans 
Administration because of the cemetery administration there and 
the community; not so much with the benefits administration.
    Mr. Secretary, I am sure that you are familiar with the 
hearing that we had here last week when we went well into the 
early hours of the morning. There was a whistleblower from 
Philadelphia, an outstanding employee, very dedicated employee 
who parenthetically, is a whistleblower for her work providing 
direct outstanding service to veterans and indirect service by 
going to her middle managers, pointing out flaws in the system. 
She's pointed out backlog and delays. She's pointed out double 
and duplicate payments that she thinks should be recalled and 
having been recalled. She pointed out shredding of documents, 
and for that she's been sort of vilified and set aside and made 
a victim herself, when really the administration and the 
management there at the Philadelphia VARO should be embracing 
her.
    And I know that you were in Philadelphia a couple of weeks 
ago. My staff really appreciated your time and commitment in 
going through, but based on what you saw in Philadelphia and 
based on what you heard and what you now know, I would ask: 
What is the plan? What are the action steps to turn around the 
Philadelphia office, which would apply to many of the other ROs 
across the country?
    Secretary Gibson. That is a great question, Congressman. I 
think we are back to the earlier point of leadership. We have 
one of our most capable and experienced senior leaders that is 
in the process of relocating to take over that troubled 
location and I would expect in the wake of her arrival, to see 
steady improvement.
    I have, as I go out to visit medical centers, I make a 
point to visit regional offices in the communities, and there 
are a number of those that I visited fairly recently, that not 
that long ago were not necessarily distinguishing themselves 
for a variety of reasons in terms of the timeliness or the 
accuracy of the work that they were doing or some other 
challenges and problems. And yet find that has we get new 
leadership in there on the ground, the right kind of 
leadership, that we see a very strong recovery and improvement 
and that is what I am looking for in Philadelphia and am 
expecting. It is a vital location for us.
    Mr. Fitzpatrick. It is a change in leadership, but there 
needs to be a complete change in culture and there has been a 
lot of discussion of the number $17.8 billion. I mean how many 
billion dollars does it take to fix a broken culture within the 
VA?
    Secretary Gibson. You know, I would say, as I was alluding 
to earlier, this is not a one-stage effort. This is not 
something, either, that we feel like veterans expect us to 
tackle some of these problems in sequence, because if we did, 
we would be three years before we got veterans out of a wait 
list the way they need to be gotten off of wait lists. So there 
are things that we are doing to get veterans off of wait lists; 
to fix scheduling practices; to address cultural issues; to 
enforce accountability; and along with that, part of that is 
identifying and quantifying the resources that we believe that 
we need over the next several years to be able to meet the time 
we can deliver care.
    Mr. Fitzpatrick. And in my remaining little time here, I 
just want to get into this issue of the goal to eliminate the 
backlog. I don't see it in your written testimony, but I think 
you testified here today that you have an intent to see that 
backlog eliminated by--I think you said----
    Secretary Gibson. 2015.
    Mr. Fitzpatrick. 2015.
    Secretary Gibson. Absolutely.
    Mr. Fitzpatrick. And, you know, that is an audacious goal. 
It is one that I hope--I find it hard to believe, based on what 
I heard about Philadelphia recently, and based upon our own 
investigations where you have middle managers essentially 
cooking the books to the point where they with produce reports 
and send them up the chain of command to say, based upon these 
metrics, we have met the goal, but it is a hollow victory, 
which is no victory at all. Because we may look like we have 
met the goal and we may celebrate meeting the goal, but there 
still would be hundreds of thousands of veterans waiting to be 
served. So how do you address that?
    We heard General Shinseki a couple of years ago say that we 
will eliminate veteran homelessness by 2015. How are we doing 
on that goal?
    Secretary Gibson. We make steady progress. That is one 
particular goal that doesn't necessarily lend itself to the 
most frequent and accurate measurement, but there is progress, 
steady progress being made in reducing the number of veterans 
who are living on the streets. And I would tell you, and I will 
say it again right now, I believe that we will eliminate the 
disability claims backlog in 2015. I think we are on track to 
do that; notwithstanding the challenges that we have got in a 
number of our regional offices. We have work to do.
    Mr. Fitzpatrick. Thank you, Mr. Secretary.
    Secretary Gibson. Yes, sir.
    Mr. Bilirakis. Thank you, Mr. Fitzpatrick. You yield back.
    Well, if there are no further questions, you are now all 
excused and I will invite the second panel, the final panel for 
witnesses, all the witnesses to the table, please.
    On our second panel we have Ms. Verna Jones, Veterans 
Affairs Director, for The American Legion. Welcome.
    Mr. Ryan Gallucci, deputy director of the National Veterans 
Service for Veterans of Foreign Wars of the United States. 
Welcome, sir.
    Mr. Carl Blake, Acting Associate Executive Director For 
Government Relations, Paralyzed Veterans of America. Welcome, 
sir.
    Mr. Joe Violante who is the National Legislative Director 
for Disabled American Veterans. Welcome, sir.
    Mr. Rick Weidman, Executive Director of Government Affairs 
for the Vietnam Veterans of America. Welcome, sir.
    And Mr. Alex Nicholson who is the Legislative Director for 
the Iraq and Afghanistan Veterans of America. Welcome, sir.
    Thank you all for joinings here this morning. Thank you so 
much for your patience. Your complete written statements will 
be made part of the hearing record.
    Ms. Jones, if you are ready, you are now recognized for 
five minutes.

    STATEMENTS OF VERNA JONES, VETERANS AFFAIRS DIRECTOR, THE 
AMERICAN LEGION; RYAN M. GALLUCCI, DEPUTY DIRECTOR, NATIONAL 
LEGISLATIVE SERVICE, VETERANS OF FOREIGN WARS OF THE UNITED 
STATES; CARL BLAKE, ACTING ASSOCIATE EXECUTIVE DIRECTOR FOR 
GOVERNMENT RELATIONS, PARALYZED VETERANS OF AMERICA; JOSEPH A. 
VIOLANTE, NATIONAL LEGISLATIVE DIRECTOR, DISABLED AMERICAN 
VETERANS; RICK WEIDMAN, EXECUTIVE DIRECTOR OF GOVERNMENT 
AFFAIRS, VIETNAM VETERANS OF AMERICA; ALEX NICHOLSON, 
LEGISLATIVE DIRECTOR, IRAQ AND AFGHANISTAN VETERANS OF AMERICA.

                    STATEMENT OF VERNA JONES

    Ms. Jones. I wonder how many people in this room would bet 
their last $40 in a long-shot chance to make some sense of the 
VA.
    Mr. Vice Chairman, Ranking Member Michaud, on behalf of the 
National Commander Dan Dellinger, and the 2.4 million members 
of The American Legion, thank you for your diligence and 
oversight during this crisis.
    The American Legion has spent the least six weeks in five 
cities setting up crisis centers. We have seen over 2,000 
veterans. I have been at each one of those crisis centers and I 
can tell you that it is bad and I am deeply saddened. The 
American Legion is saddened. We is listened to veterans and 
widows and children who, one by one, told their stories of 
broken promises, pain, mistreatment, delays, and, yes, even 
death. Many of them full of hurt, anger, confusion, and 
uncertainty just want to be heard, yet they have told their 
stories many times, but their pleas have fallen on deaf ears. 
During this town hall meetings, The American Legion listened, 
because what those veterans and family members have to say is 
important and we want to help. It is woven into the very fabric 
of who we are as an organization.
    I am going to tell you about a man in Fort Collins, 
Colorado, who spent his last $40 on a cab ride to get to an 
American Legion crisis center because he literally had nothing 
left. I met a widow in Phoenix, Arizona, 70 years old reduced 
to sometimes sleeping in public bathrooms because the VA 
couldn't get her DIC claim correct. They came to us in tears. 
We were able to put her in front of the VA and get those errors 
fixed on the spot in our crisis center. In El Paso, Texas, 
within the first three days, with 74 veterans, we recovered 
$462,000 on the spot for those veterans who were entitled to 
those monies.
    I read a letter from the Office of Special Counsel about 
the VA and the harmless errors that included a veteran waiting 
more than eight years for a psychiatric appointment: eight 
years. We have veterans taking their own lives. Twenty-two 
veterans a day, here in America, and it is a harmless error 
that a veteran has to wait eight years for an appointment?
    We saw in North Carolina a veteran who had been working on 
his claim for 14 years. As he left the crisis center he said, 
``I can't believe it took me 90 minutes to fix what I have been 
working on for 14 years.''
    That is what we have been doing. Five cities and we have a 
half a dozen more scheduled. We are making the extra effort; 
that is what it takes. We all heard whistleblower talk about--
talk to this committee about the boxes of mail languishing in 
Pennsylvania. ``You can identify that mail,'' she said, ``it 
just takes a little extra effort, but they don't allow you to 
make the effort.''
    If an employee wants to make extra effort to help veterans 
at the VA, that employee shouldn't have her car vandalized and 
be subject to harassment. You need to promote that kind of 
employee. I hope the VA is listening. I how about you take the 
whistleblowers, you know, the people with the guts to stand up 
and say, ``That is not the right way to treat veterans,'' and 
put them in leadership positions so they can be the example for 
the people who work for them? You can make some room for them 
by getting rid of the ones who covered up veterans waiting for 
care so they could earn a little extra money every year or 
overstate accuracy to look good.
    I want to be perfectly clear, though. This is not about 
tearing down the VA; it is about saving the VA. The American 
Legion wants a good VA for all veterans. Abraham Lincoln said, 
``To care for him who shall have borne the battle, for his 
widow and his orphan.'' I didn't read the part that said that 
is null and void if that affects your bonus.
    Who talked to veterans in every city who wanted VA, a place 
that belongs to them. They want doctors and medical 
professionals who understand that what--their service and 
understand their needs. When The American Legion says the VA 
has a problem with access and accuracy and leadership, we don't 
want to throw out the VA; we want to help restore it and make 
it what it should be for veterans, make it what veterans 
deserve.
    The man I told you about in Colorado, he had been let down 
by the system. The system was supposed to care for him. He was 
broke. He felt broken and he spent his last $40 on a cab ride 
to get The American Legion crisis center. All of his worldly 
positions on his back in a knapsack, he arrived at the crisis 
center after it closed that day, so he had to sleep at a gas 
station waiting for us to open. The next morning we were able 
to get him in front of the VA and that gentleman was placed in 
a housing program and received the services that he really 
needed.
    Our chairman of veterans affairs and rehabilitation for The 
American Legion was so affected that he gave that gentleman 
back his $40 because The American Legion truly believes that no 
veteran should have to pay for services they have already paid 
for by virtue of their own service. We have served over 2,000 
veterans through these crisis centers and life-changing 
decisions have been made, and we appreciate the support and 
collaboration of the VA. Those VA employees came into the 
crisis centers and worked with veterans and they did a great 
job. This is what happens when we all come together and do what 
we know is right.
    And while we as an organization have been honored to help, 
the question still remains: Why did it have to come to this 
point in the first place? Thank you for listening.

    [The prepared statement of Verna Jones appears in the 
Appendix]

    Mr. Bilirakis. Thank you, Ms. Jones. Thank you so much for 
that testimony.
    Now, I will recognize Mr. Gallucci for five minutes, sir.

                 STATEMENT OF RYAN M. GALLUCCI

    Mr. Gallucci. Thank you, Mr. Vice Chairman, and Ranking 
Member Michaud and Members of the Committee, on behalf of the 
Veterans of Foreign Wars, thank you for the opportunity to 
testify on the state of VA care and restoring trust in the VA 
system.
    The allegations made against VA are outrageous and our 
members are rightfully outraged, plus the VFW worries that the 
loss of trust among veterans has the potential to be more 
harmful than some of the impropriety that we have seen. When 
the scandal broke, the VFW worked quickly to intervene directly 
on behalf of veterans. We advertised our help line, 1-800-VFW-
1899, where veterans could turn for assistance or share their 
experiences. We also conducted a series of town halls and 
directed surveys around the country.
    And over the first two months of our outreach, we received 
more than 1,500 comments, most of which were negative. The VFW 
then worked with VA leadership to help resolve more than 200 
critical issues. Next, we sorted through this data to identify 
trends and make specific recommendations to fix the system.
    As we seek to resolve these issues, we must be careful not 
to dismantle VA or abdicate VA of its responsibility to care 
for veterans. VA care is far too important since many of its 
services cannot be duplicated civilian-side. My full comments 
are submitted for the record.
    Today I will share specific concerns on scheduling, non-VA 
care, and accountability. The major issue facing the VA Health 
Care System is timely access. Even veterans who relayed 
positive experiences to VFW still shared concerns over 
unreasonable wait times. To date, to the VFW outdated 
appointment scheduling technology is central to the access 
issue. VA knows that its antiquated patchwork system allows 
patients to slip through the cracks and makes it nearly 
impossible to manage clinician workload. This is why the 
scheduling system is rife with fraud and manipulation and why 
veteran care suffers.
    One veteran who contacted the VFW shared his problems 
transferring into the Salt Lake City VA system. At first, VA 
said it would take six months to see primary care. After six 
months, VA told the veteran it would be another six months. Six 
months later, when the veteran called VA, he was informed that 
he was disenrolled since he had not been seen in more than a 
year. We have to do better than this. This is why Congress must 
provide VA with the resources to--necessary to acquire a modern 
and sustainable appointment scheduling system.
    Next, the VFW acknowledges that VA must fully leverage its 
non-care authority; however, VA must have the responsibility 
and resources to properly coordinate and deliver non-VA care, 
otherwise, veterans will suffer. Earlier this week I spoke with 
a veteran caregiver in Missouri who recounted a recent 
nightmare receiving non-VA care. The veteran needed a seemingly 
routine knee surgery, but VA was backlogged and had to send him 
on the economy for the procedure. What followed was a 
bureaucratic mess. After the outside provider performed the 
operation, the veteran was quickly discharged and told that the 
hospital had no further responsibility, meaning the veteran and 
his caregiver had to drive directly to VA to receive proper 
medication and prosthetics needed for recovery.
    Now, the VFW understands that the VA may have been best 
suited to provide both, but this was not communicated to the 
veteran prior to the procedure. Moreover, the caregiver 
reported that the non-VA facility was inflexible in providing 
basic assistance to a veteran who was clearly in pain while 
still in their care. This is a prime example of why outsourcing 
VA care is not a catchall solution.
    Must VA outsource care when they cannot deliver it in a 
timely manner? Absolutely; however, VA must continue to serve 
as the guarantor of such care and Congress must ensure that VA 
referral teams and private networks can make responsible, 
timely health care decisions.
    Finally, we all know accountability is a major problem for 
VA and a problem that goes beyond executive employees. Secrecy 
and a low morale seem to be symptoms of a VA culture that 
focuses on internal processes rather than patients. Veterans 
tell the VFW that resources are stretched too thin but 
employees are afraid to speak up and worse, as we have heard 
today, penalized when they do.
    VA has to focus on patients first by changing this mindset. 
This demands strong executive leadership and strong 
whistleblower protections. The VFW also worries that the 
current bureaucracy incentivizes retention of poor-performing 
employees over termination and replacement, since VA 
acknowledges it can take up to a year to fill vacancies. If VA 
cannot quickly hire top talent, we cannot expect VA to fire bad 
employees. If VA cannot fire bad employees, we cannot expect VA 
to deliver timely quality care to the veterans who need it.
    Thankfully, not everything the VFW hears about VA care has 
been bad. Nearly 40 percent of the veterans who contacted us 
praised VA. Just this week, several veterans sought out our 
professional staff at our national convention to share how VA 
doctors had saved their lives. Others offered perspective on 
how the system has improved over the years. We believe the 
system can work, but it cannot work without Congress taking 
action.
    This week at our national convention VFW members also 
passed a stern resolution calling to pass the VA Access and 
Accountability Act. Both chambers have already agreed that 
these reforms will help veterans receive timely care which is 
why our members insist that Congress absolutely cannot go into 
the August recess without passing this bill. When the current 
scandal broke, every legislator in Washington agreed that this 
was a national imperative; however, some have recently backed 
off, it is post caring more about costs than the veterans who 
are waiting for care.
    We have an opportunity here. We have an opportunity to show 
our veterans and those still serving in harm's way that our 
nation will live up to its promise to care for those who defend 
it. We have to get this right. We have to restore trust and 
confidence in the VA system and the VFW will do whatever it 
takes to make that happen.
    Mr. Chairman, Ranking Member, Members of the Committee, 
this concludes my testimony, and I am happy to answer any 
questions that you may have.

    [The prepared statement of Ryan M. Gallucci appears in the 
Appendix]

    Mr. Bilirakis. Thank you, Mr. Gallucci.
    And now I will recognize Mr. Blake for five minutes.

                    STATEMENT OF CARL BLAKE

    Mr. Blake. Thank you Vice Chairman Bilirakis, Ranking 
Member Michaud, Members of the Committee. On behalf of 
Paralyzed Veterans of America, I would like to thank you for 
the opportunity to testify today.
    You know, it is truly frustrating and disappointing to see 
the things that have been reported about the VA Health Care 
System in the last several months, and yet not a thing we have 
heard is surprising. PVA members, veterans with spinal cord 
injury and dysfunction, are the highest percentage users of the 
VA health care system in the veteran population. I can promise 
you that our members are experienced the long delays and the 
appointment scheduling gimmicks have that been disclosed.
    I am a regular user of the VA. It has happened to me as a 
regular user of the VA; however, we have fortunate because VPA, 
30 years ago, developed an agreement with the VA to allow us to 
do annual site visits to fully understand what goes on in the 
SCI system of care and to ensure that adequate staffing and 
adequate resources are devoted to that system. The sad reality 
is that veterans who try to access the larger VA health care 
system do not have that luxury.
    The fact is that we are all responsible for these problems. 
Veterans service organizations should have provoked greater 
examination of our concerns by encouraging Congress and senior 
VA leadership to examine the face of these problems has we saw 
it. Meanwhile, the administration should have been fully honest 
about the resources and staffing needed to meet actual demand 
on the system; not manipulating demand data and statistics to 
make things look better than they obviously were. Finally, 
Congress should have actually listened to what we had to say as 
advocates, and as we have been saying for years.
    These access problems can be traced all the way back to 
2003 when the VA had to actually begin denying enrollment to 
eligible veterans who were seeking care because it did not have 
the capacity or the resources then. Unfortunately, instead of 
taking meaningful steps then, we allowed the VA to just close 
its doors to some people and now it has simply got worse, and 
so here we are today talking about this problem.
    In a meeting recently, a member of congress told several of 
us in the VSO community, ``We thought we were giving the VA 
enough resources.'' That is a ridiculous statement. This just 
affirms that no one is listening to what we, the VSOs, and 
particularly the co-authors of the Independent Budget, have to 
say because we have been pointing to these problems in both our 
budget and policy recommendations for 28 years. In fact for 
years now, we have not once had the opportunity to formally 
present in front of the MilCon/VA Appropriations Subcommittee 
to outline our concerns--for years now.
    I will not dispute the fact that the VA health care system 
has been given large sums of money in recent years and that the 
VA has done a poor job of managing and spending those 
resources; those are facts. But that does not automatically 
mean that additional resources are not needed now. We believe 
they absolutely are, whether to address the recommendations 
made by the VA or the Administration or the White House or 
whoever made the $17 billion recommendation, or to address 
legislation that the conference committee is currently 
wrangling over right now.
    Unfortunately, the discussion was turned more towards using 
private health care to resolve these problems instead of 
restrengthening the VA from within. Sending veterans out into 
the private marketplace may alleviate the serious pressures on 
access right now, but that is not the answer to the long-term 
problem. The VA has provided its appraisal, and yet some 
Members of Congress have laughed that off as being unacceptable 
or not part of this debate.
    When will it be part of this debate? Because I am convinced 
that it will never be a part of this debate. Is Congress not 
really interested in fixing the VA from within?
    I hear all the discussions about culture and I couldn't 
agree with anyone more. The culture needs to be fixed. I use 
the VA, so I know what the culture of the VA is like, but I can 
tell you that I prefer to go to my VA doctor.
    The question was asked at this committee hearing last week 
about the possibility of VA contracting out for most services, 
nonspecialized care or care that is unique to the VA. But that 
question ignores the fact that primary care is not a generic 
function, particularly when it comes to veterans. Even the 
representative from the American Hospital Association sat right 
there and admitted that they would need time to understand the 
nature of the veteran patient population before they could 
actually begin to truly meet demand.
    Meanwhile, one of the other representatives who sat right 
here in this seat said, ``We have longstanding concerns about 
the rates of reimbursement.'' Are we not concerned when the 
people that it seems that we are going to turn to, to help us 
address these access problems, will readily admit that they 
fully do not understand veterans as patients and that they are 
worried about how much they are going to get paid? Their 
motivations are not our motivations. Their mission is not the 
mission of the VA.
    To be clear, PVA finds it wholly unacceptable that tens of 
thousands of veterans have waited for far too long for care and 
in many cases are still waiting to be seen or have never been 
seen. Not a single veteran should have to wait for care when it 
is needed and it is incumbent upon this committee, all of us at 
this table, and the folks sitting behind me to get this right 
because it will matter in the long run to millions of veterans. 
So it is time for the rhetoric to stop.
    Thank you, again, Mr. Chairman. I would be happy to answer 
any questions that you may have.

    [The prepared statement of Carl Blake appears in the 
Appendix]

    Mr. Bilirakis. Thank you, Mr. Blake. I appreciate it.
    I will now call on Mr. Violante. You are recognized, sir, 
for five minutes.

                STATEMENT OF JOSEPH A. VIOLANTE

    Mr. Violante. Thank you, Vice Chair Bilirakis and Members 
of the Committee. Thank you for inviting DAV to testify today.
    When the allegations of secret waiting lists came to light 
we were outraged, but like you, we wanted to wait for all of 
the facts before reaching final conclusions. Today there is no 
longer any doubt that the serious problems uncovered by this 
Committee and validated by VA's OIG are real and must be 
corrected.
    Over a decade ago, VA faced similar crisis. In May, 2003, a 
Presidential Task Force, or PTF, appointed by President Bush 
reported the following, and I will quote from this book, ``As 
of July, 2003, at least 236,000 veterans were waiting six 
months or more for first appointments or initial follow-up, a 
clear indication of lack of sufficient capacity or, at a 
minimum, a lack of adequate resources to provide required 
care,'' end quote. The PTF concluded there was a mismatch in VA 
between demand for access and available funding.
    As Mr. Michaud pointed out earlier, at a hearing here in 
February, 2004, Secretary Principi sat at this table and 
stated, ``I asked OMB for $1.2 billion more than I received.'' 
One year later, after stating unequivocally that VA's budget 
for fiscal year 2005 and 2006 were sufficient, Secretary 
Nicholson admitted VA needed an additional $975 million for 
2005 and $2 billion for 2006.
    Even when VA accurately indicates its needs, OMB passbacks, 
a lower number in the final budget. That is why DAV and our IB 
partners have testified over the past decade that VA's medical 
care and construction budgets were inadequate. In the prior ten 
years, the funding provided for medical care was more than $7.8 
billion less than what the IB recommended. For next year, we 
project it will be $2 billion less than needed.
    Here is what the Congressional Budget Office said in a 
recent report, and I quote, ``Under current law, for 2015, and 
CBO's baseline projections for 2016, VA's appropriations for 
health care are not projected to keep pace with growth in the 
patient population or growth in per capita spending for health 
care, meaning that waiting times will tend to increase,'' end 
quote. In addition, over the ten years the funding appropriated 
for construction has been about $9 billion less than what was 
needed and that is based on VA's only internal analysis.
    Mr. Chairman, in 1905 American philosopher, George 
Santayana, famously wrote that, quote, ``Those who cannot 
remember the past are condemned to repeat it,'' end quote. The 
question is: Will we learn from the mistakes of the past?
    In our view, the debate over whether there is a mismatch 
between demand to VA health care and the resources provided is 
a settled issue. Why else would the House vote 426 to 0 and the 
Senate vote 93 to 3 for legislation to expand veterans access 
to health care that CBO estimated could cost $30 billion for 
two years of coverage and up to $54 billion annually after that 
if there was already enough money.
    Acting Secretary Gibson testified about the progress made 
over the past two months, adding more clinic hours, filling 
physician vacancies and using temporary staffing resources. 
Secretary Gibson also testified that in order to continue this 
expanded access initiative for this year and the next three 
years, VA will need supplemental resources totalling $17.6 
billion. Unlike the proposals in the conference committee, VA's 
proposal would have an immediate impact by continuing VA's 
expanded access initiative and its purchase care while building 
up internal capacity for the future. For these reasons, we 
support the supplemental request approach.
    Mr. Chairman, DAV, has for decades said the funding 
provided to VA was inadequate to meet current and future health 
care needs for veterans. Sadly, history has proven us correct. 
It is up to Congress and the Administration to take steps 
necessary to end the mismatch, provide VA the resources it 
needs and work with VSOs to strengthen the VA Health Care 
System so enrolled veterans receive high-quality, timely, and 
convenient medical care.
    That concludes my testimony. I would be happy to answer 
questions. Thank you.

    [The prepared statement of Joseph A. Violante appears in 
the Appendix]

    Mr. Bilirakis. Thank you, sir.
    Mr. Weidman, you are recognized for five minutes.

                   STATEMENT OF RICK WEIDMAN

    Mr. Weidman. Thank you very much, Congressman, Mr. Vice 
Chairman.
    We are a simple bunch and our legislative agenda for the 
112th Congress and for the 113th Congress consisted only of 
four things. Number one, fix the VA. And what we meant by that 
was gobbledygook that meant nothing in terms of adding to 
accomplishing the mission.
    Secondly is that there be true accountability. When people 
lie they get fired. If I lie to our National President John 
Rowan, I am toast, and I absolutely agree with that decision. 
You cannot run an outfit where people systematically and 
unblushingly do not tell the truth.
    The third thing is that they have adequate resources, and I 
have to agree with my colleagues here, is we have being saying 
for a long time that they don't have adequate resources.
    And lastly on our agenda is addressing toxic wounds which 
hasn't really been adequately done for any generation. It 
wasn't done for those exposed to ionizing radiation at the end 
of World War II or during the 1950s. It wasn't true of Vietnam 
vets with Agent Orange and other toxic exposures. Not true of 
Gulf War vets who were exposed to sarin, low levels of sarin 
gas and others which, in fact, do have long-term health care 
consequences and they haven't addressed that of the young folks 
today.
    It is something that needs to change in the system and not 
an add-on, but change in the way that VA approaches their 
mission of veterans health care. It is not a general Health 
Care System that happens to be for vets. It has to be based on 
military exposures, whether that be all the things that people 
talked about here earlier today in terms of spinal cord injury, 
visual impaired and blind services, prosthetics, and on and on 
and on, and certainly toxic exposures, and that is why we have 
such high cancer rates.
    I noticed that somebody, and it wasn't us, put it out on 
the table, a little card from the American Academy of Nursing. 
And where they get this from, the information in this, they are 
disseminating it to their members. Why? Because VA is not 
talking to private sector medicine about the wounds, maladies, 
injuries, illnesses and conditions that stem from military 
service based on branch of service, when did you serve, where 
did you serve, and when and what was your military occupational 
specialty, and, in fact, it should be because 70 percent or 60 
to 70 percent of veterans don't go anywhere near a VA hospital 
and more would and more do today than did 20 years ago because 
the care is better, frankly, once you get in.
    But we still don't have the adequate resources and most 
importantly, we don't have the right kind of attitude. The 
plantation mentality of ``we are going to tell these poor vets 
what they need''--no. How about asking the vets, What do you 
need? What do you all think? Here is the problem, can we solve 
this together? Not just at the national level, but at the VISN 
level, that work level, and at most importantly, we believe, at 
the VA medical center level.
    All too often people have it all backwards. I will use one 
example. The White House mandated that everybody do a summit on 
mental health last August and September, so they did it. And 
they were supposed to meet with stakeholders in the community, 
including all the VSOs and set the agenda and work together to 
hold the summit.
    Well, that is not what happened. They had a pre-determined 
message. They invited a couple of people from each VSO and told 
us what we ought to think. That is not a summit. That is not a 
partnership. And once we change this at the local level, then 
we will start to turn it around.
    I will say that under the acting secretary, there is a--
winds of fresh thought are wafting through 810 Vermont. It 
hasn't gotten out to the field yet, but it is wafting through. 
And so people are doing what they should have been doing all 
along. Not that we call the shots from VSOs and other 
stakeholders, but that they ask our opinion.
    As an example, on the scheduling system, some people 
weren't going to ask our opinion and the acting secretary made 
them listen because we know what it is like because it is our 
folks who go through the nonsense. And if you want to change a 
VA, you change that particular part of it. Forcing VA to listen 
to the stakeholders and to really do patient-centered care or 
veteran-centric care. And to do that, you have to respect the 
individual veteran and the veterans organizations that--and 
other stakeholders.
    I want to just touch on resources here for a second. We 
have said from the outset that the Millman formula imposed in 
2003 was no daggone good. Why? Because it is a civilian formula 
that is designed by Millman for PPOs and HMOs and middle-class 
people that can afford those. That is not who uses VA.
    The average number of presentations at that time was five 
to seven presentations of things wrong with veterans coming in 
the VA hospitals, and today, among the youngest vets, OIF/OEF, 
it is 14 presentations. But the Millman formula figures on one 
to three presentations. Now, it doesn't take a rocket 
scientist--even I can figure out that you are going to fall 
further and further and further behind if you use that to 
estimate what the need is going to be. We need to junk that and 
go to a more realistic funding based on the needs of the people 
in the catchment area.
    The last thing I want to comment on, and as an appendix to 
today, people have been saying, where are we going to find the 
medical professionals? And a number of people inside, 
particularly those within the AFGE, have been working on a 
program called ``Grow Our Own'' and it is based off the old 
medics program, and not just for former medics and corpsman to 
become physician assistants, but why not send them to school, 
even if they are smart enough to go to medical school and they 
give back two years for every year that they are in school. 
Then you are growing your own. It is veterans who have served 
and who are committed to the system from the heart outward and 
we will have enough people for the future.
    And so I recommend that to the Committee. I thank you for 
the opportunity to appear here today and thank you for your 
indulgence because I see I am over.

    [The prepared statement of Rick Weidman appears in the 
Appendix]

    Mr. Bilirakis. My pleasure. Thank you for your testimony, 
sir.
    Now we will recognize Mr. Nicholson for five minutes.

                  STATEMENT OF ALEX NICHOLSON

    Mr. Nicholson. Vice Chair Bilirakis, Ranking Member 
Michaud, and distinguished Members of the Committee, on behalf 
of the Iraq and Afghanistan Veterans of America, we appreciate 
the opportunity to share with you our views and recommendations 
on what changes and reforms should be made to the Department of 
Veterans Affairs and on VA communication and collaboration with 
veterans service and advocacy organizations.
    In recent months, revelations about extensive patient wait 
times, a manipulation of data, a systematic lack of 
accountability, and even preventable veteran deaths within the 
VA system have undermined the trust of the American public and 
our VA and it has had a particular impact on the trust and 
confidence of IAVA's members in the system. While it is true 
that many of our members have expressed general satisfaction 
with the quality and delivery of health care they receive from 
VA, many have also expressed serious frustration with general 
access to and direct communication with the VA system.
    IAVA is pleased to see some recent changes within the VHA, 
but we are eager to see more structural reforms pursued in the 
areas of accountability, the adoption of best technologies, and 
increased capacity to deal with future needs. Congress has 
acted swiftly in the area of accountability and response to the 
systemwide VA scheduling scandal by passing the VA Management 
Accountability Act. We are pleased to see this legislation move 
forward, but our members want to ensure that the secretary 
actually uses it once it is signed into law.
    We would even welcome an extension and application of 
similar authority to Title 38 and GS employees, as well, within 
the VA with appropriate due process protections, of course, as 
a part of that. IAVA would also like to see VA adopt not only 
new, more user friendly technological platforms, especially 
those that are veteran-facing, but we believe the organization 
needs to begin a shift in the way it looks at its technology 
needs and how it goes about acquiring and/or designing those 
systems. Compared to the private sector user interfaces that 
our members use, the VA's web-based platforms and portals are 
frankly a joke to many Iraq and Afghanistan-era veterans.
    Finally, our members want to see an increase in VA's 
capacity to deliver critical services to veterans, especially 
in the realm of mental health care. The shortage of 
psychologists, psychiatrists, counselors, case and social 
workers, and other mental health professionals and service and 
support staff must be quickly remedied. Some of these, and more 
other reforms and actions are actions the VA could have pursued 
at least partially all along. Unfortunately, the VA's level of 
communication, cooperation, and collaboration with new 
generation organizations like IAVA over the past five years has 
been severely lacking. In fact, prior to the outbreak of the VA 
scandal, the current VA access scandal, the former secretary of 
veterans affairs had only met with IAVA directly on one 
occasion during his entire tenure as secretary.
    Much like the VA's attitude towards this committee, if the 
prior regime within the VA did not like what they were hearing 
from its non-profit partners or those partners refused to toe 
the party line, they were shut out from top-level access 
entirely.
    VA's interim leadership, however, has been much more 
communicative with IAVA and other VSOs and veterans advocacy 
groups, and the new VSO liaison brought on by VA immediately 
prior to the access crisis, has done phenomenal job in working 
to repair the relationship between VA and the nation's largest 
organization of Iraq and Afghanistan veterans and their 
families.
    In addition to the above, we also want to take the 
opportunity to let members of the committee know that today, 
right now, the National Press Club, IAVA is releasing the 
results of its 2014 member survey. IAVA's policies, position, 
and priorities are driven every year by our annual member 
survey and the data this year overwhelmingly revealed that 
suicide and mental health care access at the VA are the top 
challenges facing this generation of veterans.
    More information about the results of our member survey are 
available today at IAVA.org and our staff and search team, led 
by Dr. Jackie Maffucci in our DC office would be happy to brief 
you and your staff on our detailed 2014 findings in the very 
near future.
    Mr. Vice Chair, we appreciate the opportunity to share our 
views on these topics and look forward to working with you and 
your staff to improve the lives of veterans and their families 
moving forward. Thank you.

    [The prepared statement of Alex Nicholson appears in the 
Appendix]

    Mr. Bilirakis. Thank you, Mr. Nicholson.
    Thank you all for your testimony, and I will recognize 
myself for questions for five minutes.
    First question for the entire panel, Mr. Robert McDonald, 
as you know, has been nominated by President Obama to be the 
next secretary, permanent secretary. I am sure that we all 
agree that of course he will face--he has his hands full to 
restore the trust in the VA. What is your opinion of the 
president's choice to have Mr. McDonald run the Agency, the 
Department as the permanent secretary at the VA? Does his lack 
of experience of running a Health Care System concern you?
    And we will start with the gentleman--actually, ma'am, we 
will start with you, Ms. Jones.
    Ms. Jones. The American Legion stands ready to assist 
anyone that is appointed as the secretary. Whoever the choice 
is, The American Legion has a history of advocating for 
veterans and as we stood by the previous secretaries, The 
American Legion will continue to stand by and to let Mr. 
McDonald know that we are here to assist him with whatever he 
needs. The lack of experience--The American Legion has been 
around since 1919 and we are going to be here to help, as we 
have always done, whatever veterans need.
    Mr. Bilirakis. Have you had any contact with Mr. McDonald?
    Ms. Jones. I have not, sir.
    Mr. Bilirakis. Okay. What is one piece of advice that you 
have for him or an area that you would like him to focus on the 
most?
    Ms. Jones. Transparency. We would like to see more 
transparency so things like the scandal doesn't happen again; 
so we know what the VA needs; so we can advocate for those 
needs, we would like for the secretary, whoever that may be, to 
let us know what is needed and to be transparent. So as long as 
we know what we are working with, it can always be fixed. We 
can work towards making sure that veterans are taken care of 
timely and that they receive quality service.
    Mr. Bilirakis. Mr. Gallucci, same question.
    Mr. Gallucci. Thank you, Mr. Bilirakis.
    The VFW has been supportive of the selection of Mr. 
McDonald, the nomination of Mr. McDonald for the position of VA 
secretary. We think it is time to do something a little 
different. We think the expertise that he brings has the 
opportunity to change the mindset of the VA system.
    This goes beyond just VA health care. The secretary is 
responsible for coordinating the myriad of veterans programs 
that millions of veterans rely on, whether it is Post 9/11--GI 
Bill, disability compensation, home loan program, and really 
think that the corporate mindset might be beneficial for the VA 
system.
    And to one of your other questions about what do we think 
that the VA should focus on, I think from the VFW's 
perspective, it would be improved business processes. From what 
we have seen and from what we have heard from our veterans, we 
know that the system hasn't been patient-centric when it should 
be, and that is the VA Health Care System specifically. But we 
think by improving business processes and streamlining the way 
decisions are made within the VA system, we can improve the 
delivery of services to veterans.
    Mr. Bilirakis. Thank you.
    Mr. Blake, please.
    Mr. Blake. Mr. Bilirakis, we don't typically take official 
positions on nominees for secretary, but what I will say, 
having said in the confirmation hearing on Tuesday, I was very 
encouraged by the things that the nominee, Mr. McDonald, had to 
say. He certainly addressed the concerns raised by Ms. Jones 
about transparency a number of times. And I am sure--while he 
may not have said it to you yet--I am sure that one of the 
first things he will tell you is he will give all of you his 
cell phone number and expect you to call him and he will call 
you at all hours of the night. So he certainly seems to be 
willing to be actively engaged with the committee, so hopefully 
that will fix transparency.
    I think his first priority ought to be culture. I think the 
bad actors, the bad attitude, and the bad processes ultimately 
stem from the culture that is set. I think Acting Secretary 
Gibson has done a good job of trying to change that, but you 
can't change that overnight. I think the committees are 
debating right now--tools. The question was asked about the 
challenges and certainly Secretary Gibson made it clear that 
the challenge of firing people is a tough one.
    I won't argue with you. If somebody did something illegal, 
wrong or immoral or whatever, if it somehow in some way harmed 
the health care delivery for veterans, they should be fired. 
But that question ignores the fact that Congress put in place 
federal rules that make that a difficult process. So if 
Congress thinks that that should be changed, then so be it. I 
know that the Committee is looking at legislation that will 
address that issue, but it is going to take a--and Mr. McDonald 
seemed to be committed to changing the culture and I think that 
is going to be first in his mind.
    Mr. Bilirakis. Mr. Violante, again, give me your opinion of 
the secretary and what piece of advice would you give him?
    Mr. Violante. I was also at the confirmation hearing and I 
was impressed with his responses to the committee's questions, 
as well as his oral remarks. I just hope he can accomplish most 
of what he said. In my mind, the one important thing that he 
said was transparency, and that, I think more than anything 
else, we need to see at VA. I don't know that we will ever see 
it accomplished, but I think it is a goal that the new 
secretary should try to achieve so that we know what is going 
on and what needs to be done.
    Mr. Bilirakis. Mr. Weidman, what should the secretary focus 
on?
    Mr. Weidman. I think the most important goal is what people 
have already said, and as a means to that, I forget how many 
hundred communications folks they have over at the central 
office of VA. They are not in the business of communication. 
They are in the business of obstructing and obfuscation, and 
most of those folks need to be assisted in finding another way 
to contribute to the good of the world and you need two or 
three really smart press people. Curt--does a better job than 
all of them put together, who is the PIO for the committee.
    And what it does is that things that ought to be on the web 
suddenly become FOIAs, or Freedom of Information Act, and drag 
out for months. Example is just asking for job descriptions of 
major positions within the VA, which happened to me last year. 
It took me five months to get the darned thing. I had already 
gotten it another way, but--and one of them, they said they 
didn't have because it wasn't available in 810 Vermont Avenue 
and that was the job description for the director of the 
national center for PTSD.
    You don't have a job description? How could that be? And, 
of course, it wasn't, but you had some attorney who could be 
put to use enabling veterans to get their claims approved, as 
opposed to messing around with bureaucratic junk. And that 
should be the litmus test, certainly for everybody in VHA, is 
how much do they and how much do they contribute to 
accomplishing the mission. And at VHA, all of those middle 
people, almost all of them, need to go away because they just 
get in the way of the mission.
    Mr. Bilirakis. Mr. Nicholson, last question: Again, does it 
trouble you that Mr. McDonald lacks the health care management 
experience?
    Mr. Nicholson. It does not necessarily. I mean he has a 
phenomenal business background, and like I think Ryan 
mentioned, business processes is something that I think, you 
know, the VA certainly needs some focus on. IAVA is supportive 
of Mr. McDonald. We were not consulted by the White House on 
the selection process or the nomination, but he was sort of an 
out-of-the-blue pick for us so we had to do a lot of catching 
up in learning about him and still are in the process of that, 
as is everyone else, I believe.
    But we are generally supportive of him. I mean we would 
agree, I think, that accountability and transparency are top 
priorities, but also tech upgrades, as well.
    Mr. Bilirakis. Thank you very much. I yield back----
    Mr. Weidman. Mr. Bilirakis, can I add just one thing?
    Mr. Bilirakis. Yeah.
    Mr. Weidman. Earlier I noticed in the audience the 
Honorable Harry Walters, and when he took--came in in 1982, the 
veterans organizations were so mad that everybody was chewing 
on nails. And he came in as a businessman, no experience, and 
took over the VA, restored confidence in what they were doing, 
and straightened out a whole lot of problems, including 
assisting Vietnam veterans truly for the first time. So it is 
possible, with a background, to be one heck of an administrator 
at that time, and today we call it the secretary.
    Mr. Bilirakis. I yield back, Mr. Chairman. Thanks so much.
    The Chairman [Presiding]. Thank you, Mr. Bilirakis.
    I apologize to the panel. We were having a conference 
committee meeting and I would say, Rick, that I will be meeting 
with Mr. Walters this afternoon at 3:30 to gain some insight 
from his time as the administrator.
    Mr. Michaud, you are recognized.
    Mr. Michaud. Thank you very much, Mr. Chairman.
    And before I ask my questions, I do want to commend 
Secretary Gibson for still being here. It shows that your 
commitment to listen to the VSOs--I think this is the first 
time that I have ever seen a secretary sit through another 
whole panel--so I really want to commend you for doing that. It 
shows that you are taking your job very seriously as well, and 
hopefully we will see action as well.
    For each of the panelists, as you know, Congress 
continuously asked the VA about what they need for services. 
You heard my comments earlier about Secretary Principi was 
actually the first secretary that really showed that disconnect 
between what the needs were and what the Administration asked 
for.
    My question is, to each of you--if you could keep it short, 
it would be great--do we need to do an independent audit to 
properly plan the VA's budget? My biggest concern has always 
been--I have made it very clear over the years--is I don't care 
how big the increase it is within the VA budget, is are we 
taking care of our veterans? And as you heard the secretary 
mention earlier it has always been budget-driven and not 
outcome-driven.
    So I guess we will start with Mr. Nicholson first. Should 
we have an independent audit to properly plan the VA's budget?
    Mr. Nicholson. Sure. You know, the first thing that comes 
to mind is in a way we already do. I mean we have the 
Independent Budget, which many of the VSOs sitting here play a 
very prominent role in putting together. I know that Carl is 
sort of our community's budgetary expert and we defer to him on 
a lot of these issues. But I think it is certainly helpful.
    But please keep in mind that we don't have to reinvent the 
wheel. Please use resources that already exist and give 
credible weight to those as well.
    Mr. Weidman. The VA has reached out to some places like the 
Mayo Clinic, but, in fact, nobody has really reached out in a 
systematic way to all sectors of our society. The one thing we 
do know, when the issue is veterans, people will step up from 
industry, from the not-for-profit sector, from the medical 
sector, et cetera, and we need to tap into that in an organized 
way--and including organized labor, by the way--in a way that 
makes sense in order to get what we need to get in terms of 
designing a system that actually can estimate the needs and 
then put it together in a way where people are held accountable 
as it moves back down the chain.
    Mr. Violante. I disagree with my colleague, what he--with 
Rick, what he said earlier about the actuarial model. I mean 
when we were still pushing for mandatory funding for VA health 
care, we went in a number of times to talk to the VA budget 
people and at that time they told us that the model, which was 
based on a civilian model was revised to, you know, be specific 
for veterans use.
    And I believe if there was transparency in the process and 
we could see what VA was putting into that model and what comes 
out without OMB having a shot at it, that we would be better 
off and know exactly what the needs are. Because that is all we 
want to know, is what VA needs. I don't care about building an 
empire for anyone. I want veterans to be taken care of and the 
only thing that is important is to make sure that their needs 
are met.
    Mr. Blake. First, Mr. Michaud, let me say I'm not sure that 
I want the distinction of being recognized as the community 
budget expert.
    From the perspective of the Independent Budget, what I will 
say the difference between what we do and what the 
Administration does is--and Secretary Gibson hit this on the 
head--managing the budget versus managing the need. We take 
whatever information we have available to us, look at what the 
actual need is and figure out what we believe the cost is. We 
don't take a budget number and try to fix--smash the services 
down into the available budget that is given. That is what the 
VA is required to do.
    You asked about an independent audit and when we advocated 
for advanced appropriations, this is one of the ideas that we 
had wrestled with, was having a type of independent audit of 
the VA budget. The best we came up with in that legislation I 
think was the GAO responsibility within that. I am not sure if 
that is going to get us to where we want, but that is the idea. 
So I think we agree with what your notion is there and we would 
like to see it enhanced, perhaps.
    Mr. Gallucci. I think the VFW generally agrees with that 
concept and we testified to this effect when the Senate hosted 
a hearing right when the scandal broke, back in May. And the 
real problem is we have assessed what VA's workload could be or 
what their problems are, but as we have learned with the 
scheduling system, it is software that is decades old and VA, 
by their own admission, says they have no accurate measure of 
wait times, no accurate measure of wait lists. Thousands of 
veterans waiting for initial appointments, based on their 
independent review that was recently conducted.
    So I think right now being able to even evaluate the need 
is very difficult. I have seen it myself, as my colleague Carl 
said, he is a patient at the VA. Many of us at this table also 
use VA for our health care and I have seen it, waiting for a 
specialty appointment and you call in and they say the next 
thing that we have is 60 days from now.
    Well, what are my options at that point? And that 
demonstrates to me, as a veteran, as an end user, that there is 
obviously something missing from here. Either capacity isn't 
where it needs to be or they haven't fully evaluated what the 
need is in their community.
    Ms. Jones. The American Legion wants all available 
resources used to make sure that veterans are okay. If that 
means an independent audit of the budget--absolutely. We want 
to make sure that there is enough resources, enough of 
everything so that veterans are taken care of and they don't 
have to suffer like they are suffering right now.
    The Chairman. Dr. Huelskamp.
    Dr. Huelskamp. Thank you, Mr. Chairman.
    I appreciate the ladies and gentlemen that are here today. 
I first want to thank Mr. Nicholson for the whistleblower 
hotline. I believe that is our association that set that up, 
and what is stunning to me--I have served on this committee for 
three years--and we have heard from the VA again and again and 
usually it was always that things are fine, and then we have 
whistleblowers step forward.
    I am just curious. Were you all hearing that from your 
associations, from your membership about these secret waiting 
lists? I never heard that coming from your groups, and so I am 
just curious on background of how this can happen. You know, I 
was just looking through the Life magazine article for May of 
1970 of how that suddenly burst on the scene. Folks were 
suggesting that there were problems then and suddenly it 
happened, but that is--you know, just a few months ago, all of 
a sudden, boom, here it is.
    And in this committee we have heard warning signs from 
folks inside, but we will talk a little bit about the budget 
question. But first question, what you were hearing from your 
members and did that match up with what the whistleblowers had 
reported to us?
    Mr. Blake. Dr. Huelskamp, I will say, as I mentioned in my 
oral statement, the one luxury that we have from PVA's 
perspective is our site visits that we conduct. So we don't 
necessarily have to just rely on what we hear from our members. 
We have trained medical staff who go into the SCI centers and 
see what is going on there and they see firsthand where the 
shortages are; where there is a need for doctors; where there 
is a need for social workers, nurses or what have you.
    The difference between what has happened with this and what 
we do is we have an agreement with VA and we worked those 
differences out to come to a resolution that will benefit the 
veteran. This is all sort of played out more in the public eye, 
which is fine in as much as maybe by drawing attention to the 
larger problem, we get real reform and real fixes. But these, 
again, are not shocking.
    We have seen these. We have identified them in our site 
visits----
    Dr. Huelskamp. But the secret waiting list, I mean here is 
what I saw at one facility. We had the director of the VA at 
the VA facility in Wichita on a Friday said everything was 
fine, and then within five days they admit that they had secret 
waiting lists they knew about. And so my question is--and I 
can't go look through the data.
    Are you going through looking through the data and actually 
talking to the schedulers? Because this is the thing: They went 
in and falsified the data and then presented it to us.
    I am trying to see how we can have you continue to help 
with these visits and how far you can dig into that to help, 
enjoy, provide some more transparency.
    Mr. Weidman. We have been complaining that they were 
underresourced all along, and certainly to the former under 
secretary, that you are spending way too much money on people 
who aren't direct service providers. Congress--we are not 
speculating that that is why Congress gave you more money; that 
is exactly what the appropriators told us they were giving us 
money for, was more people who were hands-on delivery of 
service and you guys are spending on people who never lay a 
hand on a patient.
    Dr. Huelskamp. Sure. Sure.
    And, again, I appreciate that because we get reports, and, 
again, if you heard on the other panel, in the last month, 
every single bureaucrat from the VA, every under secretary, 
every bureaucrat came here and said we have plenty of 
resources; it is a cultural problem. It is how we are spending 
them. And so either they are totally wrong or you are totally 
wrong and we are trying to figure out what we can do about it.
    But what Mr. Gallucci said at the end was very interesting 
because, you know, how, as policymakers, when the data is 
unclear, there is a lack of integrity, how are we supposed to 
make a decision to give more money? In the past decade, 
roughly, it has been a 250 percent--256 percent increase, 
meanwhile the number of veterans are 30 to 40 percent. And 
trying to say, well, why didn't I get an MA? That is what is 
happening. It went to overhead, rather than direct care.
    But what is frustrating to me is when they lie about the 
data. They make it up or they refuse to be transparent so we 
can't make good decisions and then we hear from the top-level 
folks that say the way the Union rules work, we can't get rid 
of somebody until we get all of the facts, and right now we 
don't have all of the facts when the claims are that we need 
more money. We want to make sure that that happens.
    One of the other things we heard, which is interesting: Why 
can't they stay open until five o'clock? Why can't they do 
that? You mean to tell me that they all go home at 4:30? Why 
not five o'clock? We just had that report would fix and add 
additional resources without making significant changes. Those 
are the kind of things that make sense. Appreciate your input, 
but I appreciate particularly the whistleblowers who are 
bravely shown up and said, Hey, we are going to tell you what 
is happening here so we can improve the system.
    So with that, Mr. Chairman, I yield back.
    Mr. Violante. I would just like to make a comment about the 
fact that secretaries come in here and they say they have 
sufficient funds or under secretaries. You know, I have been 
doing this for a long time, and with the exception of Secretary 
Principi who said that he got less, I mean most of the time 
that is what we hear. And, you know, other than three years 
during the Clinton Administration when they were flatlining the 
budget, Congress agreed with those numbers.
    Up until recently, I mean Congress has always provided more 
than what the Administration has asked for. You know, they are 
part of a team and while it is frustrating to hear them say 
they have the resources, I mean I don't think they would be in 
their position very long if they told you, as Secretary 
Principi did, and at that time we were asking for over $3 
billion more when he said that he needed 1.2.
    So I would be a little bit leery of asking them that 
question and expecting an accurate response unless you put them 
under oath, but I mean it is just a concern.
    The Chairman. Mr. Violante, are you saying that Secretary 
Principi, in fact, did tell the truth?
    Mr. Violante. I am saying that he admitted that he asked 
for more. What I am saying is at that time we were asking for 
almost twice that amount for VA's needs.
    The Chairman. So would you say the other secretaries were 
not being truthful? This is just Mr. Violante.
    Mr. Violante. I mean they are not under oath, so----
    The Chairman. They can tell the truth whether they are 
under oath or not.
    Mr. Violante. Yeah, but when have you heard anyone admit to 
you as part of another team that they didn't get what they 
asked for, other than Secretary Principi.
    The Chairman. Okay. So Mr. Violante said the other 
secretaries lied. Thank you, sir.
    (Laughter)
    The Chairman. Mr. Takano, you are recognized.
    Mr. Takano. Thank you, Mr. Chairman.
    Mr. Violante, I think I understand what you are saying. I 
mean I used to be on a board of trustees and, you know, all of 
the administrators all come to me and they all kind of toe the 
administration line. It is not a matter of lying or not lying; 
it is a matter of that is just the way it is in the 
administration. And that would be true of a Republican or 
Democratic Administration, you would want loyal people 
underneath you.
    So, you know, real quickly, you can almost answer yes or 
no, would you say that your organizations and your members 
basically want to mend, not end the VA, Ms. Jones?
    Ms. Jones. Yes, we want to restore the VA and restore the 
veterans' trust in VA.
    Mr. Takano. Thank you.
    Mr. Gallucci. We absolutely want to restore trust in VA and 
build a system that has the capacity to care for the needs of 
veterans.
    Mr. Takano. Mr. Blake.
    Mr. Blake. Yes. Our members want the VA.
    Mr. Violante. We want to save the VA, but fix it.
    Mr. Nicholson. Absolutely. We are all in favor of mending 
and not ending the VA.
    Mr. Takano. Let me just turn the other way starting with 
you Mr. Nicholson. Mr. Nicholson, does your organization 
support the 17 billion supplemental requested by the VA on top 
of, you know, recently with Secretary Gibson?
    Mr. Nicholson. Sure. IAVA certainly supports giving the VA 
more resources and believes that it does need more. Whether or 
not 17.6 or 8 billion is the exact number, I don't know, and I 
don't believe we know. Our concern with the number is just 
making sure that it is well-justified, but making sure that the 
VA is well-resourced is a primary concern.
    Mr. Takano. I have a short amount of time. I just want to 
know in general, I mean, if that is something that is on the 
table, if you are supportive or not, Mr. Weidman?
    Mr. Weidman. The 17.6 number we are not going to defend 
because we have no idea how it became that. The point is that 
really--from our point of view--how much is asked for and how 
much additional is appropriated; it is tracking how it is used.
    You remember when it was in 1999, $319 million appropriated 
specifically for Hepatitis C and a year later, they couldn't 
tell you what the heck happened to the money.
    Mr. Takano. Great. Thank you.
    Mr. Violante.
    Mr. Violante. We support the approach of supplemental 
versus what is going through conference.
    Mr. Takano. Great. Thank you.
    Mr. Blake. I can't say for sure whether $17 billion is the 
appropriate number. I can tell you what the IB has done over 
the same period of time. I think the idea of strengthening the 
VA through more doctors and more nurses and that type of thing 
is part of the approach that needs to be taken.
    Mr. Takano. Thank you.
    Mr. Gallucci. I would agree with a lot of what my 
colleagues have said. It is not necessarily about a dollar 
amount, but what we do support is providing VA the resources 
that it needs if they can demonstrate that they need it.
    And like I mentioned before, just as end users of the VA, 
it seems clear to us and from what we have heard from our 
members, that something is needed.
    Mr. Takano. Sure.
    Ms. Jones. The American Legion supports veterans having 
what they need, but we don't have enough information right now 
to support or not support.
    Mr. Takano. Okay. I take that information very, very--I 
appreciate it. I see the conference as fluid and, you know, we 
need to really get down to the business of finding out what 
that appropriate number is.
    Now, the shortage of doctors is something that I have been 
very much concerned about. I am most skeptical about an 
approach which only funds non-VA--access to more non-VA care is 
the solution. I think it is part of the solution. I am 
skeptical of us being able to find that there are shortages in 
many communities that even this access to non-VA care is not 
going to work unless we increase down the line, a supply of 
doctors.
    Mr. Weidman, I appreciated your sense of let's grow our 
own, but even if we send these medics to medical school, we are 
still frozen at 1996 levels of graduate medical school 
education; the education that is basically what we would call 
residencies.
    Would you all consider supporting the expansion of, you 
know, we have--Dina Titus has a bill that would expand 
residencies by 2,000 and let the secretary designate where our 
greatest need is, especially in, say, mental health care?
    Mr. Nicholson. You know, IAVA would absolutely support 
anything that increased capacity at VA, but I think the 
important thing to keep in mind is those are going to be 
intermediate to long-term solutions. It takes awhile for 
someone to go through residency. It takes awhile for 
recruitment to happen and for those folks to actually become 
practicing physicians or providers within VA.
    The support for private sector care is intended to be a 
short-term solution to address the crisis going on right now 
and that is why we strongly support that. I don't think that it 
has to be either/or. One is a short-term solution and one is--
--
    Mr. Takano. I agree with you. I think we need to support 
non-VA access. I understand that we have 2,000 medical students 
presently that aren't matched with residencies. We actually 
have people in the pipeline here who could begin their 
residencies right now.
    Mr. Chairman, I am sorry. I ran out of time.
    The Chairman. Thank you, Mr. Takano.
    If I could just ask a question, you know, because every one 
of you answered, and this is an issue that has been thrust into 
the middle of the conference committee and that is the $17.6 
billion request. It is not even a request, okay. It is not. It 
is an unfunded list.
    With all of your resources and all of your people and all 
of your expertise, you sit here today and you tell me exactly 
what we are saying, is there is not enough clarity to know 
whether or not this is a good request or a bad request, too 
much money, not enough money. And I don't think that you have 
heard a single member of this committee say that they are not 
willing to fund what is necessary.
    So I just, you know, I want to make sure that folks know 
that nobody up here is trying to tear the VA down. We are 
trying to get the VA to serve the veterans that each of you 
represent and I hope you understand that. But there was a 
letter that was signed yesterday and while you may not have 
intended for it to say that you supported the entire 17.6 
billion, you put the full weight of support of your folks 
behind that in the middle of very tenuous negotiations between 
the House and the Senate. We just went over and made a very 
prudent offer. Unfortunately, the Senate Democrats were not 
there. You guys, thank you for holding the fort back here and 
covering. Mrs. Kirkpatrick was there.
    And I think the reason that we did it the way we did it was 
we have not had a public meeting for four weeks and our intent 
was to publicly say that the House's offer--I say the House--my 
offer, was not cheap on the money in regards to what CBO had 
scored. Just so you all know, the offer was, to take up the 
Senate Bill, pay for it by putting $10 billion in emergency 
funding mandatory up front, a good solid down payment. And also 
we said extend that 10 billion out as long as it will go 
because I don't believe they will spend it in a year. I just 
don't think they will do it. I think it will actually go into 
the second year.
    And for the second 25 billion, we go through regular order, 
which is, Rick, exactly what you were saying just a second ago. 
You know, oversight, what is it for?
    Each of you, probably not on purpose, has said, we need 
more docs; we need more this; we need more that. But I haven't 
heard--and you may have said it before, maybe in your 
testimony--look for efficiencies within the system. There are 
inefficiencies in the system, whereby doctors are only seeing 
six, eight, ten patients a day. That is not enough. Mental 
health providers that are only seeing patients two hours out of 
a day, as my colleague has said, expand the office hours so the 
infrastructure that is already in place can be used to 
supplement the doctors that are there.
    So we are all in this trying to work together and we said 
let's do the $25 billion through the normal appropriations 
process and look, we are right now negotiating--well, I don't 
know--has the Senate passed their vote on the VA appropriations 
bill?
    The Chairman. The Senate hadn't even passed a VA bill; the 
House has. But we want to begin negotiations, and if we need to 
interject additional dollars, that is where we should do it. It 
is not that we don't necessarily think that the money may not 
be needed, it is we don't know and you don't either. So we are 
asking for clarity from the VA--the secretary and I have talked 
about it--two pages of documentation for a $17-and-a-half-
billion request.
    And then we have an under secretary come here yesterday and 
when asked particularly about the request, she didn't know how 
to answer it. She says, ``Whatever they are calling it.'' We 
can't work that way. You wouldn't want us working that way. You 
couldn't do your jobs working that way. We have to know what 
the money is going to go for. What it is being benchmarked 
against so that we get this right.
    This is not a partisan issue. It is not partisan. Mike 
Michaud, the other members on the democrat side and all of the 
Republicans have done everything that we can to make this a 
bipartisan issue. I have tried not to walk too far out in front 
of my ranking member when it comes to subpoenas or letters or 
anything that I do, as the chairman of this committee. And if 
he is comfortable signing something, I ask for his signature, 
and if he is not comfortable, that is just fine, not a problem. 
Because we do come from different districts, we serve in 
different caucuses, and I get where that comes from.
    But all of a sudden this morning, it is being said in the 
press that this has evolved into a partisan negotiation--no, it 
has not. No, it is not. It is an American negotiation. It is 
for the men and women that you serve. It is for the men and 
women that we serve. We cannot fail them and we cannot get it 
wrong. We have to get it right, and sometimes it takes a little 
longer to get it right, but we are going to get it right. I 
promise you that we are going to get it right and we can do it 
with your help, every one of you. Because you have all been 
great help us to as we have gone through this process.
    Mr. Blake. Can we comment, Mr. Chairman?
    The Chairman. If I can, let me go to Ms. Brownley. And, 
again, I appreciate it. That was my five minutes. Ms. Brownley?
    Ms. Brownley. Thank you, Mr. Chairman.
    And based on what the chairman just said, I think that is a 
good segway to hear what you have to say in response to some of 
his comments. It will be my questioning, so I can start from 
either end.
    Mr. Blake. Mr. Chairman, I was just going to say I don't 
think I disagree with anything that you had to say. If we have 
concern, it is that I am not sure there has been enough focus, 
other than on the culture of VA. There has been a lot of 
discussion about fixing the culture of the VA, and as I said in 
my statement, I think that is probably the first thing that 
needs to be fixed.
    But I am not sure I am convinced that there has been much 
of a discussion about what to do about the capacity problems in 
the VA.
    The Chairman. Will the gentleman yield if you allow him to 
yield?
    Ms. Brownley. Absolutely, Mr. Chairperson.
    The Chairman. Dr. Wenstrup sat right up there a few nights 
ago and asked, ``How much does it cost the VA to serve a 
patient?'' They couldn't answer the question. We asked the 
question, ``What is the typical panel of docs--how much does a 
doc see on a daily basis?'' And some people couldn't answer the 
question.
    So, yes, the focus is on doing whatever we need to do and 
that is efficiencies inside and capabilities outside, and that 
is why the choice piece may be and you guys--I am going to be 
real honest with you--some of you thankfully have not gotten 
really spun up about the choice piece when you could have 
because a lot of people in the past have said that is a way to 
tear the VA down. That is not what we are trying to do and I 
don't think that there is going to be this fleeing out of the 
system. I think many, many people are going to stay in the 
system.
    And so we have focused, from an oversight perspective, we 
haven't been able to get the answers that we have been asking 
for, and I would be glad to share with you the list of 
information that we have asked for and have not received. The 
secretary gets it every week.
    But I agree, and, yes, there has been a lot of focus on the 
outside, but there has been focus on the inside, and I yield 
back.
    Mr. Blake. And, Mr. Chairman, my one point that I would 
make about the point that you made with Dr. Wenstrup was about 
how much does it cost per patient, what the hell is the 
information that they publish in their budget books? There is a 
particular line item that says ``priority group one'' and a 
cost associated with that patient. Maybe I don't understand 
what that means, but I interpret that to mean exactly what the 
question was you asked.
    The Chairman. Then why can't they answer the question?
    Mr. Blake. I don't know. I could have pulled that number 
out in a second right out of the budget book.
    The Chairman. You need to go work for VA.
    Mr. Blake. I would have.
    The Chairman. You need to go work for VA.
    Mr. Gallucci. From a VFW perspective, we certainly 
understand everything that you are talking about Chairman 
Miller, but our members are frustrated. I just returned from 
our national convention in St. Louis where the membership 
passed a resolution insisting that Congress pass that bill and 
send it to the president before the August recess.
    And the frustration comes from the fact that this was a 
major priority two months ago for each chamber to get together, 
outline its priorities, get them down on paper and start moving 
on it. And what our members have told us is that they don't see 
progress. In fact, what they have seen is a narrative changing 
where it used to be about caring for veterans and now it is 
about costs.
    The Chairman. Will the gentleman yield?
    Mr. Gallucci. I am sorry?
    The Chairman. Will the gentleman yield?
    Mr. Gallucci. Yes, Mr. Chairman.
    The Chairman. We had a meeting today for the first time in 
four weeks and the Senate boycotted. We were trying to tell the 
American people exactly what we were doing; quit trying to 
negotiate behind closed doors. Do this in public so people know 
what is going on.
    I will tell you this: There has been a tremendous amount of 
work that has gone on behind the scenes in an attempt to 
negotiate this, and I think everybody has said the intent is 
not to leave unless this is finished, and we appreciate the 
urgency with which the VFW expressed in their resolution, but, 
again, there has been a lot going on and today we hold a public 
meeting and the Senate boycotts. I yield back.
    Mr. Gallucci. Mr. Chairman----
    Ms. Brownley. I yield my time to Mr. Walz.
    The Chairman. And I didn't mean to take Ms. Brownley's----
    Mr. Walz. Thank you, Ms. Brownley. We are using your time 
on this.
    Mr. Walz. This is a bipartisan effort, but--and the 
chairman and I are friends and he knows me well enough, he 
knows that nobody does passive-aggressiveness like 
Minnesotans--so to characterize that the meeting was--as a good 
Minnesotan, I was actually in bed before notice of that meeting 
was even put out. And then when I asked this morning about what 
was going to be put out at that, we weren't given that.
    That is not a conference report, Mr. Chairman, and you are 
a friend of mine, whom I trust.
    The Chairman. Will the gentleman yield?
    Mr. Walz. I will yield to you from Ms. Brownley. This is 
our time to be honest and----
    The Chairman. I will be very honest with you. All right. 
Let's go all the way back to the very beginning of how this 
conference started, all right?
    The last conference committee that was held, many of you 
were probably here in 1999, the Senate chaired that conference, 
so it comes to the House to chair this conference, all right? 
And at the beginning of the conference, there was some 
discussion between myself and Mr. Sanders as to who was going 
to chair and I said, ``Let's be co-chairs, all right, let's be 
co-chairs.''
    I asked the senator earlier this week could we do this 
yesterday and he said nope, didn't want to do it yesterday. All 
right. We were trying to negotiate all day yesterday, trying to 
figure out when we could do this and I was told time and time 
and time again that I better not unilaterally call a meeting.
    Now, as the House position that should be the chair of the 
committee and for Senator Sanders to make a good effort to stop 
us from having a public meeting, after a good effort from my 
part to make him co-chair, and sitting down at this hearing, I 
did share what the offer was with the chair and I asked him to 
share it with everybody here. It is not a conference report; it 
is an offer.
    It is on one page. Our offer is on the same amount of paper 
that VA's justification to $17.5 billion is on. So it wasn't 
done as a partisan move.
    Mr. Walz. Was any of that conveyed to us? I mean----
    The Chairman. We met at 9:30----
    Mr. Walz. And I had with the secretary sitting in front of 
us----
    The Chairman. We met at 9:30. Look, it was an offer. It 
wasn't intended to be a House offer. It really wasn't, because 
I know that you can't do that, but it was just to say the House 
is prepared to put money--$10 billion has been in the 
negotiations from probably the second day, hard money.
    Have you seen it in the press one time? Probably not. What 
you see is the House is trying to do it on the cheap. And so it 
was an attempt to bring it forward and say, look, here is where 
we are, the House position is that it is difficult to fund any 
of the $17.6 billion without more justification. In the offer I 
think we put 102 million in to finish out through the end of 
2014. I will go ahead and notice I wrote a letter to the 
senator and I asked him, you know, be prepared to meet on 
Monday. Don't know when and don't know where, but just so 
everybody knows, we will be back in time, it will be in time 
for everybody to be back here.
    But, you know, what has happened is by negotiating behind 
closed doors, and we have gotten pretty darned close, you know, 
this whole thing, I just saw them report it in the meeting a 
little while ago that this thing is doomed. No, it is not. It 
is not doomed. As long as we work together in trying to resolve 
it.
    But I didn't want to put you in a position to say you are 
making us decide whether we want it or we don't. This was an 
offer from me, from me, and I get it. Yeah, I could have told 
you I didn't know until probably eight o'clock last night what 
the offer was actually going to be. I just knew that it needed 
to be done in public and that is why we did it the way we did 
it and it only lasted 15 minutes.
    Mr. Walz. Well, my commitment to you, Chairman, is to do 
this together because I think what these folks know and the 
public knows, they don't care if it is the Senate's fault or 
our fault; it is our responsibility. They have seen this song 
and dance. We have got to get it done and I stand with you to 
get it done.
    Mr. Michaud. Thank you.
    And as the Chairman mentioned----
    Mr. Walz. Who has yielded to you?
    Mr. Michaud. No one.
    Ms. Brownley has.
    The Chairman. You are out of time. (Laughter)
    Mr. Michaud. You know, I did lean over to the chair earlier 
and asked him what his proposal was. I am an optimist. The 
bottom line is now we know what the chairman's proposal is. We 
also know what the chairman's proposal is on the Senate side, 
which we have never seen in black and white either, so I think 
now we know where you both are coming from and hopefully we 
will be able to work in a bipartisan manner to get this thing 
done.
    And I am not interested in blaming anyone. My concern has 
always been how do we take care of the veterans that we have to 
take care of and I hope that both sides, that everyone on the 
conference committee will focus on that particular issue, as 
well.
    With that, Mr. Chairman, I just say we probably ought to 
give Ms. Brownley her five minutes back.
    The Chairman. Without objection. Thank you.
    Ms. Brownley. Thank you, Mr. Chair.
    Just to chime in on this conversation, I agree that we--
this must not--should not be--must be a bipartisan approach to 
this and we must collectively solve this problem.
    And I will say that when the House passed the bill almost 
unanimously and when the Senate passed the bill almost 
unanimously, I think the expectation is we would go to 
conference and resolve the smaller differences and move 
forward, and I just don't want to take a large step backwards. 
But I think we are making progress. There is movement here, so 
we are making progress. We have got to continue to work to make 
sure that we do, indeed, have the resources to make sure that 
we can serve our veterans well once and for all.
    And we all know that this has been a problem that has not--
this crisis has been specific in terms of wait times, but we 
know that we have had issues with capacity and our ability to 
serve our veterans in the proper way for a very, very long time 
and this is our opportunity, I believe very, very strongly, for 
us to move forward, and to once and for all, to be able to 
really try to make a difference in how we serve our veterans 
throughout our country.
    I wanted to ask specific question. I think Mr. Weidman, I 
think it was in your testimony where you talk about the fact 
that you believe that the current leadership and the change in 
culture and the change in leadership is beginning to permeate 
at the upper levels, but it is not necessarily permeating 
throughout the VISNs and the VA hospitals across the country so 
forth and so on. And I think, obviously, that has to happen--
for culture to change, that has to happen. I am wondering if 
there is anything that you believe we should be doing to assist 
the VA to making sure that that communication does get to the 
VISN level, to the hospital level, to the CBOC level, at every 
corner throughout our country where we are serving our 
veterans. Is there anything that you think that we should be 
doing?
    Mr. Weidman. I suggest that you get your district staff 
together with your veterans advisory committee and I know that 
most of you have them, and give them a copy of Acting Secretary 
Gibson's memo that you will meet with the VSOs every month and 
you will jointly put together the agenda for those meetings. 
Because we are getting back--I know the memo got out there, but 
people aren't responding and our folks ain't hearing much, and 
it is--the--best persons you have at the VA are the veterans in 
your district, ma'am. And if you give them the right 
information, they will pick up the ball and start to run with 
it, and if it is real wrong, they will go to the press.
    Ms. Brownley. Thank you for that.
    And, Mr. Blake, you are the budget guy, the annoyed budget 
guy here, and the VSOs, I mean you have done--you must have 
done a needs assessment of what the VA needs and what it costs. 
I mean do you have that information?
    Mr. Blake. I do. If you prefer, I have it. It is a lot of 
numbers and gobbledygook. I think Mr. Weidman said that. I 
would be glad to share it with your staff.
    You know, we are fortunate that we--every year we meet with 
John Towers and Nancy Dolan and the staff of the committees and 
we put out the same invitation to the legislative assistants 
for all of the offices to discuss this very issue, to discuss 
what we recommend.
    Ms. Brownley. Well, can you, based on your needs 
assessment, can you give me a ballpark figure of what you think 
the needs are budgetarily, to meet those needs?
    Mr. Blake. For this year or overall? I can't project them 
in the way that the VA just said they need $17 billion out 
through 2017.
    What I can tell you is the IB recommendation is 
approximately for all medical care about $2 billion more than 
what the VA recommended for fiscal year 2015, which will be 
starting soon and something less than a billion dollars or 
approximately--don't quote me on that--approximately a billion 
dollars more for fiscal year 2016 as an advance.
    What I will also say is over the last ten years, the 
difference between what the IB has recommended overall for 
medical care is $8 billion more than what has been 
appropriated, and I can tell you that for the most part, what 
has been appropriated is virtually equal to what has been asked 
for by the Administration. There has not been a whole lot of 
difference between those two.
    So basically over that period of time, what I would suggest 
to you is if that kind of commitment had been made over that 
period of time, maybe it would have incrementally built 
capacity in. I think part of what is hard to stomach about $17 
billion right now is--and this gets to the chairman's concerns 
about spending resources appropriately and all that--can they 
really spend $17 billion in such a short period of time 
appropriately to get the right staff in the right place doing 
the right thing, and that is the concern.
    Whereas, if it had been done incrementally over a greater 
period of time, in a perfect world it would have been done 
correctly, at least.
    Ms. Brownley. I yield back, Mr. Chairman.
    The Chairman. Mr. Cook.
    Mr. Cook. Thank you, Mr. Chairman.
    Appreciate everyone here. I try to keep up with many of the 
organizations. The four of you, I pay my dues and I get my 
magazine. I always make my joke about the calendars, but I 
won't. I am going to ask you the same question that I have 
asked other veterans organizations and I will probably ask it 
if I am still around in six months or what have you.
    You know in a military environment whether a unit is combat 
ready or not combat read. It is very, very simple. As of today, 
is the VA combat or mission ready or not mission ready? Mr. 
Nicholson, do you want to start?
    Mr. Nicholson. I'd say it is not fully mission ready, 
absolutely not.
    Mr. Cook. Sir.
    Mr. Weidman. At least half of the hospitals aren't mission 
ready.
    Mr. Violante. I would say they are not mission ready, but 
they are moving in that direction.
    Mr. Blake. When I was in the army we had X and circle X for 
maintenance concerns and I would say that a lot of places are 
circled X.
    Mr. Gallucci. I would agree, not mission ready, and I think 
that the veterans who have contacted us share that concern.
    Ms. Jones. Not mission ready, and we have seen evidence of 
that throughout the crisis across the country, not mission 
ready.
    Mr. Cook. Thank you.
    Your organizations, you have a lot of credibility. You have 
a lot of credibility throughout the United States with this 
panel. Do you rate different hospitals by region, one, two, 
three, four, five, and do you give a reason why one is, you 
know, great care, fully staffed, what have you?
    And before you answer, the reason is coming from a military 
environment, whether you like it or not, you are always rated--
fitness reports--everyone here, we get--somebody scores us on 
this bill. It is just a way of life, but it almost is, you 
know, you call attention to that.
    Back when I got out of the Marine Corps and became a 
professor and they had this--I tell everybody, 
rateyourprofessor.com and it was like, oh, boy, who is 
disgruntled this week or who loves me this week? I probably 
gave everybody eights, but--no, I won't go into that.
    But do you think or do you right now rate hospitals? Do you 
rate other aspects of VA and publish them in your magazine, 
sir?
    Mr. Nicholson. IAVA does not. We don't have the capacity. 
We are a smaller--we might be--but we are a small organization 
and don't have the staff and resources the others do.
    Mr. Cook. Okay.
    Mr. Weidman. We do not, sir.
    Mr. Cook. Okay.
    Mr. Violante. DAV does not.
    Mr. Blake. We don't rate, but we certainly evaluate the SCI 
centers specifically, and while we don't publish a list, I am 
sure I can put that question to senior executives that oversee 
that and they can list every SCI center in the VA system in 
rank order from best to worst.
    Mr. Gallucci. We do not rank hospital systems.
    Ms. Jones. The American Legion doesn't necessarily rank the 
systems, but our system saving team and task force go out to 
different facilities across the country and we provide--do site 
visits. We look at each individual hospital to see what is 
going on and we hold a town hall meeting, as well, to talk to 
the veterans in that local community to understand their 
concerns as well and then we meet with leadership.
    Mr. Cook. Okay. The reason I brought that up is obviously 
in the previous panel and I had to meet with some folks' trust 
and confidence, and you know, I was very honest, I have 
problems with trust and confidence in the VA. I got a lot of 
trust and confidence in you guys, and maybe because we go back 
a long ways and what have you, and you have helped me. So I am 
not trying to get you involved in a situation like this, but 
you do have credibility and you got--at least with me, and so 
it is something to consider.
    Now, Mr. Weidman, I want to ask you about Vietnam veterans. 
You know one of the issues I have, and maybe because I am a 
Vietnam veteran, I always felt that, you know, after the 
paralyzed veterans, people that needed care right then and 
there, that I always felt like the VA was, ah, Vietnam 
veterans--and this is something that the Vietnam veterans told 
me--that, ah, you guys are at that stage, you are probably 
going to be dead before you get seen for an appointment let 
alone treated.
    And I am wondering and I actually do think because of the 
age factor and they probably have more debilitating illnesses 
and what have you, and--but I am very, very concerned whether 
that is a perception with your organization that--and this is 
based on the history of what happened years ago where the 
country turned its back because, oh, you served in Vietnam, you 
are a baby killer, et cetera, et cetera, et cetera.
    So I am specifying exactly if you could address that issue.
    Mr. Weidman. Well let me just say that because of that our 
founding principal is really very straightforward and very 
simple. Never again will one generation of American veterans 
abandon another, and we don't, and so we have put a lot of 
resources, even though where by choice, a bunch of old guys and 
gals----
    Mr. Cook. Easy now, I am one of those.
    Mr. Weidman [continuing]. But we do a lot of things for the 
younger vets and we do things for our fathers' generation, even 
though they basically told us to go pound salt.
    Now having said that much of the care at the VA is--most of 
it is good, some of it is very good, and sometimes excellent. 
The problem in the perception that we are getting back from our 
members is, particularly when it comes to PTSD and 
neuropsychiatric wounds, that they are being pushed out.
    And, you know, on a triage I was a medic with the 196 
Americal, and the hardest thing I have ever done in my life is 
have to triage for real under fast changing circumstances. And 
maybe they are triaging, but that is--the way in which we 
regard that is, if you don't have the resources you need in 
order to do all the job ask for it, and if they don't give it 
to you, and this begins at the clinic level, then hospital, 
then VISNs, then national, and they don't give it to you shame 
on them, but if you don't ask shame on you.
    Mr. Cook. Thank you.
    I yield back, and thank you for what you do here. 
Appreciate it.
    The Chairman. Thank you, Colonel.
    Ms. Titus, you are recognized for five minutes.
    Ms. Titus. Thank you, Mr. Chairman.
    I think we all agree there are serious problems at the VA, 
but I was very glad to hear you answer Mr. Takano's question, 
mend it not end it, and I appreciate the chairman saying that 
we are not out to do away with the VA, but I especially 
appreciated a very articulate statement that you made, Mr. 
Blake, okay, expressing some concerns that I share with you 
about this push to privatize.
    Now, I can't help but believe that this is part of an 
agenda, by some, not by all, but just to kind of dismantle the 
federal government and leave citizens, in this case veterans, 
out there to fend on their own in the so-called private sector.
    Now if you look at what is happening here with the private 
care and the push to private care maybe this is a short-term 
fix as one of you mentioned, but specifically some of the 
concerns I have about that are things that we need to address 
before we go pell-mell down this direction.
    One of them is just as you raise, there are concerns that 
doctors and hospitals as they admitted themselves don't have 
the culture of the VA, they don't have the expertise of the VA, 
they aren't used to dealing with the kind of problems that 
veterans have, whether it is PTSD or Agent Orange. So if we 
push them out there into the private sector we don't know that 
the quality of care is going to be any better.
    Second, this committee asked over and over, give me the 
hard facts, give me the numbers, give me this, and yet there is 
no evidence out there to show that if you put patients in the 
private practice that it will be cheaper, faster, or better. In 
fact we just don't have that information. In fact if you looked 
at kind of a roughly parallel situation like Medicare Advantage 
you would find that the evidence is actually to the contrary.
    The third thing, and Mr. Takano mentioned this too, is the 
lack of doctors in many parts of the country. I am in Las 
Vegas, there is rural Nevada, we just don't have physicians, we 
are at the bottom of every list for different specialities, and 
also just general practitioners, and so if we send them out to 
the private sector that doesn't mean they are going to get it 
faster or even they are going to be able to find the care. Yet 
if we pass this conference bill that is going to be the 
national news, veterans sent to private care, veterans can now 
use private care. Well that is just not going to be true.
    And I wonder, how are you going to tell your members what 
to do now under this new scenario? Anybody?
    Mr. Gallucci. Well, I think first and foremost one of the 
important things to look at in the access and accountability 
bill is that we have far too many veterans waiting far too long 
for care.
    I am a strong defender of the VA system. To be perfectly 
honest I probably wouldn't be in this position if it weren't 
for the help that I received from the VA system when I returned 
from Iraq. That being said as a patient in the VA system I have 
also had appointments cancelled on me. I have had--I have shown 
up to clinics where they have said, well, we can't see you 
today. I have had months long waiting periods for appointments. 
And I am just one example.
    I guess the problem is we need to balance it correctly. 
Outside care can be appropriate at times, but we can't use it 
as a catch-all, as I outlined in my testimony, or a supplement 
for the competencies that the VA has, especially on issues like 
combat-related mental health care, prosthetics, or any other 
speciality services as my colleague, Rick Weidman, said related 
to toxic exposures in the war zone.
    Mr. Violante. You know, and you are exactly right about 
private care. I have a secretary in my office who went into a 
doctor almost four weeks ago now, she needs surgery, the doctor 
recommended she have two appointments that she needed to make 
before she can have the surgery. One was scheduled at that time 
for this past Tuesday, the other one for in August. And so she 
needs to have both of those appointments met before she can go 
in for her surgery. So she is waiting over probably eight weeks 
in order to do that. So private sector isn't much better.
    You know, it is frustrating because we have the acting 
secretary putting forth a plan that would insure that we had 
the capacity at VA and build up, you know, the number of 
doctors that need to be there, plus take care of veterans on 
the outside when necessary for an amount that is a fraction of 
what CBO has a cost estimate on for the bills pending in 
conference. I mean they claim 30 billion for the first two 
years and another additional 54 billion after that. And I mean 
that is what I don't understand is why we are, you know, 
condemning VA and their numbers when CBO is saying it is even 
going to be more than that. It is just frustrating.
    Ms. Titus. Mr. Miller.
    Mr. Blake. Ms. Titus, I would say this. You know, from the 
perspective of a PVA member it doesn't matter what bill you 
pass, because at the end of the day the only and best option 
for our members is the VA. There really isn't another option 
out there. Yes, there are places out there that can meet some 
need they have, but there is no real option.
    It is almost unfair to answer that question a little bit, 
but what I would say is, we have never said they shouldn't be 
contracting out for any--or purchasing care at all, in fact I 
think we have many times that the VA had done a terrible job of 
using that authority in the past. They are now seemingly moving 
more in a judicious manner to do that under their accelerated 
access to care initiative, you know, they have got NVCC now, 
they have PCCC, all these different things, so there is 
certainly an avenue to go there.
    One of the concerns, and you mentioned this about the 
doctors that are out there in the private sector, one of the 
hearings--one of the oversight hearings, I am not sure if it 
was one of the midnight hearings or one of the daytime hearings 
this committee had, but Mr. Ruiz made a point at one of the 
hearings that when they did an analysis of his district, 
granted his district is pretty rural, but it is not unlike a 
lot of districts in this country, when they did an analysis of 
his district they discovered that there was approximately 1 
physician for every 9,000 people in that district.
    Ms. Titus. Uh-huh.
    Mr. Blake. I would suggest that is probably an underserved 
district by in large, and there is probably a lot of other 
places in this country. There are a lot of underserved veterans 
in many of those same areas, so what happens when you put them 
into that situation?
    Ms. Titus. Exactly.
    Mr. Blake. So there is certainly a concern there.
    Ms. Titus. Thank you, Mr. Chairman.
    The Chairman. Thank you very much. And also it is 17.6 
billion over and above the CBO score, so the fact that it is a 
lower number I understand that, but it is 35 billion plus 17.6.
    Mr. Walz.
    Mr. Walz. Thank you, Mr. Chairman.
    And I think and that is a valid point. I think all of us 
where you get it, we are trying to separate adequate resources 
from effective use of those resources and we are calling for 
both, and if we conflate the two together we end up going in 
the wrong direction.
    But I would like to point out though, and I don't know if 
this has happened since I have been here, it may have, but it 
is certainly for me gratifying. Oftentimes we see people up 
here testifying and you guys standing behind them, both 
figuratively and literally standing behind them as veterans, 
the acting secretary stayed throughout this whole thing, and I 
don't know if any of us have seen that before, but I want to 
make note that actions speak loudly to all of us. As we know 
words are cheap, especially sometimes around here.
    This is a pivotal moment that we are at, pivotal. The 
decisions that are going to be made as I said over the next 
weeks and months are going to I think could have decades long 
impact. I think you are absolutely right to flex your--the 
ability of pressure points to get situations done, but keep in 
mind, and they are right to have those when you can turn up the 
heat or whatever, but now there is going to be a race to get 
something done by next Friday. And getting it done and getting 
it right are not necessarily synonymous.
    And so my concern is as we work together and as we bear 
down on this, because there is no question that we all want to 
get it right, the spats you are seeing here are actually fairly 
healthy in this committee, they are aired openly, they are 
there. I need all of you to think deeply, and as you are doing 
is how do we get to that point? Because here is my biggest 
fear. We pass something, everybody goes home in August and 
pounds their chest, there is more money in the system or 
something, and now the VA is taken care of.
    I would go back to what Mr. Nicholson said, we have got to 
multitask here. His point on suicides is, the chairman and I 
just introduced the Clay Hunt Safe Act, which I would say is 
critically important going forward, and if now, oh, the VA work 
is done and we will move on to the next crisis of the day or 
whatever it would be and forget that.
    We need to make sure that we are looking at the long game. 
We need to make sure we are looking at that national veteran 
strategy, and we need to figure out a way--and you guys have 
said this too--Alex, when you said you weren't consulted on who 
the next secretary was going to be, don't feel left out, I was 
not either, so--and that--and I bring to that not necessarily 
facetiously, I bring it to the point is you said it and I think 
Carl it might it have been you who said it, we are all 
responsible for this, and you took responsibility as an 
organization and I take responsibility.
    The question I have is, I am okay taking responsibility 
until I have no teeth to effect what is being done. And I would 
suggest to you and try and figure this out, this committee is 
your entry point into this system in many cases. You are right, 
MILCON VA Appropriations, heck, I don't even know who is on it. 
I mean that is what happens on that. Good luck getting in over 
there or having Armed Services come over here.
    So I am making the suggestion, been making the suggestion, 
I will take responsibility, but why does the second largest 
agency in the federal government have one of the smallest 
committees? How come we don't have the resources to do more on 
that? How come we don't have the ability to get out there? And 
how come we are not adding you in as partners with the VA?
    So I think as you look at this major reform, as you look at 
what the long-term implication is, don't forget that if the 
peoples' influence is going to be felt it is going to be felt 
through this committee, and we have to have the resources, we 
have to have the ability, and we have to have your backing as 
partners to getting this done.
    So with that being said I am just going to leave it all to 
you. What do all of you hope to see come out of the conference, 
and it will get done. Chairman Miller's leadership, Mr. 
Michaud's leadership, they will work with Senator Sanders, we 
will get this thing done, but has to, what is the redline that 
has to come out of that? What has to be done before we go home? 
Because as Mr. Gallucci as your organization said, don't worry 
about coming back if you don't do it. If we are going to come 
back what do we have to get done next week?
    Mr. Gallucci. Well thank you, Mr. Walz for the question. 
Yes, what we put out was very strongly worded and our members 
are very frustrated by what we have seen. And we certainly echo 
the frustrations of Chairman Miller and the rest of the 
committee in how we get to a quality product.
    I think from the membership--from the perspective of the 
VFW what we want to see come out of this is an adequately 
funded--or adequately resourced--I don't want to say funding, 
that is--adequately resourced VA health care system capable of 
delivering health care in a timely manner to veterans, and when 
it is incapable of delivering that timely care to veterans that 
they have the resource and protocols in place to delivery it 
through either contract care or just through non-VA care 
coordination.
    And in addition to that the accountability side would be 
that VA has the ability to properly sanction and fire poor 
performing employees and replace them in a timely manner.
    There has been a lot of talk about that front end, about 
how many people have you fired, how many people have you fired? 
Well, I outlined it in my testimony and I have been talking 
about this for the last two months, I think VA makes tradeoffs 
many times in the way that they evaluate their employees. If 
you can't hire a quality replacement in a timely manner why--
are you really going to give a poor performance review to 
somebody or try to fire somebody when you can't replace them or 
when there is the threat of them leaving? If you have a 
clinician seeing two patients when they should be seeing five 
are you going to fire them when you know it takes another year 
to replace them? And then those two patients go without care.
    Mr. Walz. My time is up. Maybe if we come back around on a 
second round I will get the answers to this to each of you, 
because it is important for us. I have got to know what--at the 
end of the day we are going to vote yes or no, and we have got 
to know what we are going to do.
    The Chairman. Mr. O'Rourke, five minutes.
    Mr. O'Rourke. Thank you, Mr. Chairman.
    I first want to thank each of you for being here and I want 
to thank you and your organizations for helping me as a new 
member get up to speed and better represent the veterans that I 
serve in El Paso. Your feedback on bills that we will be voting 
on, on bills that we are offering has been instrumental, they 
have improved the legislation that we have been working on, I 
have been making better decisions for your feedback. So I want 
to thank you.
    And I especially want to thank Ms. Jones and the American 
Legion. As we were discovering how awful the crisis in El Paso 
was about the gap in coverage, about the wait time for 
disability claims, and then the wait time on appeals for 
disability claims, and we are hoping to get some kind of 
response from the VA, which since then has come. You and your 
organization stepped in to fill the gap, literally set up a 
command center and saw hundreds and thousands of veterans 
there, connected them with benefits, connected them with care, 
and I cannot thank you enough for doing that. So really 
appreciate what you are doing.
    Let me follow up on one of the achievements that the 
secretary cited and that I am very grateful for, which is 
removing that 14-day deadline and moving it back to 30, 
accelerating access to care, putting money into the local VAs 
to make sure that we could access that. And by that same model 
and thinking about El Paso where I mentioned earlier if you 
were here that we had nearly 20 full-time vacancies in mental 
health, we have 20 full-time vacancies today. We had a 
commitment from our VA director and Dr. Jesse and Dr. Petzel 
before him that we would have those filled by the end of this 
month. We just checked in this morning, they will not be 
filled.
    PTSD, mental health care, being able to help somebody who 
is in need and who may be a danger to him or herself or to a 
spouse or loved one or the community and at best may just be 
suffering without help is a critical unmet need within the VA, 
certainly in El Paso, but I understand throughout the country.
    Guide me through this idea proposed by a panel week before 
last that the VA focuses and prioritizes and becomes excellent 
in care for PTSD, TBI, prosthetics, the kinds of combat and 
war-related injuries that we are seeing from all of our 
engagements, especially post 9/11, and refer other care that is 
not combat or war-related out into the community. In other 
words give me the ability to say to the veteran in El Paso, if 
you have PTSD you are going to come to the El Paso VA, you will 
be seen quickly, you will get the best care, you will have 
consistency in care, you will see a psychiatrist, you will have 
access to medication. I can say none of those things right now.
    And part of my suspicion is that we are trying to do too 
much, and whether it is 17 billion or 30 billion we cannot 
spend enough to sustain a system that is today serving 9 
million veterans it will be many more years from now.
    Walk me through my thinking and how I could approach this 
idea and problem of balancing, creating excellence within the 
VA with accessing resources in the community. And I will start 
with Ms. Jones and work down the line for anyone who would like 
to respond.
    Ms. Jones. You know, I think if we can answer that question 
and walk you through it we wouldn't absolutely have to be here 
today. That is an excellent question. There is so much that 
needs to be done. As a matter of fact the American Legion, we 
have a TBI, PTSD committee full time to research PTSD and TBI 
and what needs to be done next. There is so much the veterans 
needs, especially as evidenced while we have been out, you 
know, across the country talking to veterans who have been in 
crisis.
    I think that there are times when veterans need to be--when 
purchased care is necessary, depending on the veterans, how far 
they live away, what their conditions are, whether it is 
advantageous to the veteran to be seen outside the VA that 
particular time. It may be harmful for them to drive in. All of 
those things taken into consideration.
    I think what has to happen is the VA has to become experts 
in every area that veterans--where veterans need things. TBI, 
PTSD, women veterans' issues, all kinds of speciality clinics. 
Veterans have conditions that need to be taken care of and they 
need to be able to come to the VA and expect excellent care in 
all areas from the VA.
    We cannot use purchased care as a substitute for what the 
VA needs to do. That is a cope out. The VA needs to be able to 
do excellently what they have been created to do.
    Mr. O'Rourke. Anyone else want to comment on essentially 
offering fewer services but doing them better and referring the 
remainder out into the community? I have about ten seconds 
left, so with the chairman's indulgence maybe we can go over a 
little bit, but----
    Mr. Blake. I would say this, Mr. O'Rourke----
    The Chairman. Five seconds.
    Mr. Blake. Thank you, Mr. O'Rourke, I rest.
    I would say this, you know, let us not forget that the VA 
is a fully integrated health care system and all of the 
components of it support one another, so if one of our members 
who has a spinal cord injury needs primary care he gets primary 
care in the VA and he needs that to be good care, and you can't 
just send that SCI veteran out. If they need audiology, which 
is kind of a basic service, which seemingly could be purchased 
in the community, that should be provided in the VA. If they 
need orthopedics, which is very common, the expertise should 
reside within the VA, because those things all prop one another 
up and that veteran depends on all of those things over the 
course of their life.
    The concern becomes if we send them out for primary care, 
audiology or what have you, is that care really being 
coordinated, is the VA managing it, are we keeping track of 
what is going on so that all of the aspects of that veteran as 
he is being treated are being properly managed? And if you 
start sending out pieces you loose a lot of that I think, and 
then you ultimately put the overall and long-term health of a 
veteran, particularly veterans with the most complex needs, in 
jeopardy.
    Mr. O'Rourke. Great. Great feedback. Thank you. Thanks 
again. Mr. Chairman, thank you.
    The Chairman. Mr. Walz, you had an additional question you 
wanted to ask?
    Mr. Walz. Just if anyone wanted to follow up on. We are 
going to make a decision next week, what do we have to come out 
with?
    Mr. Blake. Mr. Walz, I would say this, you know, I had kind 
of resigned myself to something was going to pass, and truth is 
paralyzed veterans of America in particular has some concerns 
with the Choice Act and those provisions.
    The great irony of this is, both of the committees went 
into a conference with the most--probably the most difficult 
part of legislation virtually mirroring each other, the rest is 
some other provisions in the Senate bill, but the heavy lifting 
has been done because you went into a conference with bills 
that are very close to one another, and somehow you are going 
farther and farther apart on your own. I don't even know how 
that happens. It is just amazing.
    So I kind of assumed that the Choice Act or whatever the 
final name is going to be was going to pass. My concern is not 
that bill because we just assumed it, my concern is what 
happens next? I don't want this to become the end of the 
debate, and Mr. Chairman, that is why I made the point, we need 
to--we don't want to thump our chest you said. If we go home in 
August and everybody is going to say look at the great things 
we have done for veterans and lead into the election and 
whatever and we forget that there are still serious problems 
that have to be addressed in the VA.
    So it is not just about what comes out of legislation, 
because I just assume you are going to pass legislation pretty 
much like it looks. It is going to be what are we going to do 
after the fact?
    Mr. Weidman. As long as something gets done. And I think 
that we are under tremendous pressure just like all of you are 
under tremendous pressure to enact something, and to start to 
really truly address it, but really truly addressing the crisis 
is in terms of it not being repeated anytime soon is going to 
be several years of effort. Not just of funding, but of effort, 
to rebuild a management structure that you can have faith in. 
And every time I talk to VA employees they say, well what do 
you think about it? I said, I think this is before all this 
blew up, that we need VA management as good as most of the 
clinicians and workers within VA and we don't have it, and we 
haven't had it for a long time. Didn't begin with this 
administration. And so that really needs to get really the 
primary focus.
    One last thing, and Ms. Brownley has left, there is no 
fixing it once and for all. It is not a widget. It is an 
institution of people that will change as the needs of the 
people change and as the Nation itself changes. And so we 
regard it much more as a garden that you need to continue to 
plant and fertilize and weed, and the weeding hasn't been done 
in management in a long time and that is what needs to be done 
now.
    Mr. Violante. Mr. Walz, my concern is again as my 
colleagues have said, this is a temporary fix. I think we are 
heightening the expectations of veterans and not going to be 
able to meet those expectations, and I think in the end I think 
we could even be weakening VA instead of making it strong, and 
we need to make sure that in the end VA is stronger and that 
they are able to fulfill their mission to the veterans.
    Mr. Nicholson. And can I say just briefly that my biggest 
concern with the conference right now is the House and the 
Senate passed several really good bills, and you went into the 
conference with our understanding being that the jurisdiction 
of it was going to merge those two bills, to make some tweaks, 
and pass it out. Now everything--it seems like everybody and 
their brother is wanting to throw in extra things because they 
see this as one of the only if not the only moving trains on 
vets issues perhaps before the end of the Congress.
    Now if you all could focus on, and you certainly have our 
support in doing so, merging and tweaking and finalizing what 
you passed and getting that done and not throwing in all these 
other provisions that people, you know, want to put on the 
moving train, the 17 billion extra. I mean I think if you guys 
could pass what you have in front of you now within the 
jurisdiction of the conference committee and then--in my 
opinion--and then tackle the supplemental that we would come 
out with something for sure, whereas, if we are adding in 
everything else and considering everything else and then having 
to fight over and discuss whether or not to pay for it and how 
to pay for it, et cetera, we may end up with nothing. And if we 
go into August and this doesn't get done and a new secretary is 
confirmed and then he comes in and he wants to make adjustments 
to the 17 billion or maybe add another 17 billion who knows 
what we are not going to get anything done.
    So I would rather see you all finish what you started with, 
get that done, and then move on to step two and three.
    Mr. Walz. Well, I appreciate that, and I think that has 
been my position that we triage this, we deal with the access 
to crisis care, we work with you as you are getting there, we 
start to deal with some of those, and then we breath a little 
bit, we have a long-range vision, we put that in place, and we 
continue to follow through. Because I too have as you have all 
expressed have this great fear, and you know how this is going 
to go, it is going to be well you are already done with this, 
this is your one bite off the apple, it is done, don't come 
back asking for anything, don't do this.
    And, Rick, I always say with the VA and health care it is a 
journey, not a destination, we need to keep moving forward. But 
there is a danger because I hear from people if we don't do 
this and we don't do it now the window will close and wouldn't 
get done. I think they are missing the passion of the American 
people to get this right and sticking with us. This is our 
time.
    So a little bit of patience, an awful lot of collaboration 
continuing this on, and the help from you would be is, help us 
keep the realistic expectations on that, don't have the all or 
nothing by next Friday but have danged sure better do something 
you better do and you better get some results out of, and then 
keep the momentum to keep moving forward.
    I yield back.
    The Chairman. Thank you, Mr. Walz.
    I appreciate the panel for being here today and precisely 
what occurred last week when the $17.6 billion was injected 
into this conversation is when things started going sideways. 
We were very, very close to resolving our differences, and 
Senator Sanders feels that the only time that he will ever be 
able to get this money done is in this bill, and I have assured 
him that that is not the case, that if VA can make the case for 
the dollars in certain areas that they are asking for that we 
will go to work to see that they get those dollars. 
Unfortunately he has convinced other people that this is the 
only way to get this $17.6 billion put into this emergency 
bill. That is not the case.
    The House had actually narrowed the scope down in our bill 
to access and to accountability. Ours was more narrowly crafted 
than what the Senate had, but we were giving and taking, adding 
things in, taking things out, the House was receding to 
positions that the Senate had.
    So again, as I understand Senator Sanders has just held a 
press conference, I can't believe he unilaterally held a press 
conference without letting me know he was holding a press 
conference or asking for my permission, but he did, and I think 
that the thing is we are not done. We did not give a take it or 
leave it offer. We just want to make sure that those that are 
on the conference committee understand that the House is not 
trying to say everything has to be paid for. We are going for 
the same number. The House has actually gone to the Senate 
number. We did that when the CBO came out with the second score 
instead of holding to our number, which was higher because we 
had a 14-day trigger, we went to the 30-day trigger.
    And so understand, just as Mr. Walz has already said, 
getting this done right is important. It is critical. And that 
is what we are committed to doing, and I have assured everybody 
on the conference committee that if it takes staying through 
the weekend this weekend I am prepared to do that. I was 
supposed to be at Normandy for the 70th anniversary as the 
chairman of the committee that has oversight over the American 
battle monuments, and I did not go because I stayed here to 
help negotiate this bill. I stayed in Washington an entire 
week. And so I am committed as are all the members of this 
House committee to making sure that we get it right, and with 
your help we will, and we will get it done in a timely fashion 
that serves the veterans.
    Remember, the veteran is the most important thing, not VA.
    And with that we are adjourned.
    [Whereupon, at 2:03 p.m., the committee was adjourned.]
                                APPENDIX
              Prepared Statement of Jeff Miller, Chairman
    Good morning.
    I would like to welcome everyone to this morning's oversight 
hearing entitled, ``Restoring Trust: The View of the Acting Secretary 
and the Veterans Community''
    Today, the Committee will examine what steps we need to take to 
help the Department of Veterans Affairs back on track to meeting its 
core mission--to provide quality health care to our veterans. Since the 
beginning of June we have held almost a dozen Full Committee oversight 
hearings, some going into the early hours of the morning, to do a top 
to bottom review of VA and to delve into how we arrived at the current 
crisis.
    It is time for this Committee, the Department, Veteran Service 
Organizations, and other stakeholders to come together to get it right 
for those who selflessly served this country. While I hope to focus on 
the major themes we've covered and receive updates from VA on the 
topics we have covered in the last few weeks, I can promise the 
Department and Committee Members that as we move forward to mend VA's 
broken system, the oversight done by this Committee will continue.
    Mr. Secretary, in your written statement, you state that ``the 
status quo in our working relationship must change,'' and that ``the 
Department will continue to work openly with Congress and provide 
information in a timely manner.'' First, I agree that the relationship 
between VA and this Committee must change. We must go back to the way 
business used to be handled for decades when Members and staff could 
communicate directly with VA senior leaders about the routine business 
we conduct with VA. But using the phrase ``continue to work openly'' 
is, in my opinion, not a reflection of the current reality we are in. 
Members of this Committee, other Members of Congress, and our staffs 
are still being stonewalled to this day.
    For example, the day after our July 14th VBA hearing, our 
colleague, Mr. Jolly personally spoke to Kerrie Witty, the Director of 
the St. Petersburg Regional Office, and asked for information regarding 
the firing of Mr. Javier Soto, a whistleblower who testified at that 
hearing. Mr. Soto had raised very serious concerns on both retaliatory 
action and mismanagement at the St. Petersburg Regional Office, and it 
is incumbent upon this Committee to investigate those allegations.
    Instead of being open and honest about the process about Mr. Soto's 
removal, VA has equivocated, stonewalled, changed its story, and 
obstructed Members of this Committee in what appears to be an attempt 
to cover up VA's retaliation against Mr. Soto. And this is not the 
first time this Committee has received a back and forth response from 
VA. I am prepared to subpoena the relevant documents related to the 
Soto firing as well as employees of the St. Pete RO and Central Office 
if we do not get a prompt compliance with our multiple requests.
    Secretary Gibson, I could not agree with you more that the 
Department needs to earn back the trust of veterans, their families, 
Members of this Congress, VSOs, and the American people through 
deliberate, and decisive, and truthful action. The recent scandals that 
have tarnished our trust in the VA, are a reflection of a broken system 
that didn't just develop overnight, nor can it just be fixed overnight. 
The Department cannot continue to reward failure, or turn a blind eye 
to illegal and unethical practices, or ignore incriminating IG and GAO 
reports. Upon stepping up as Acting Secretary, you have stated that 
there must be change and accountability, but I still have yet to see 
where the Department has drawn the line and brought bad actors to 
justice.
    We have shown through many of our hearings that one contributing 
factor to the current crisis is that VA has clearly lost sight of its 
mission and that extra funding didn't go to improvements in patient 
care but toward ancillary pet projects and an ever growing bureaucracy. 
According, to an article by former Under Secretary of Health, Dr. Ken 
Kizer, in the New England Journal of Medicine, ``VHA's central-office 
staff has grown from about 800 in the late 1990s to nearly 11,000 in 
2012'' further illustrating VA's shift of focus to building bureaucracy 
as opposed to fulfilling its duty of providing quality patient care. VA 
needs to return to what it was intended to be, a patient-centered-care 
agency for our veterans.
    As I said before, the problems at VA cannot be fixed overnight, and 
it cannot be fixed by simply throwing more money at those problems. To 
date, VA has been given every resource requested by the Administration. 
Every year during our budget oversight hearings we have asked the 
Secretary if he had enough to do the job, and every time we were told 
unequivocally ``yes''.
    This is why when Acting Secretary Gibson said last week that an 
additional $17.6 billion was needed to ensure that VA is able to 
deliver high quality and timely health care to veterans, it came as a 
shock to many and raised obvious questions. Where exactly did this 
number come from? What assumptions underlie this request and are they 
valid? What effort was made to look within existing resources to meet 
this new resource need? I know many of my colleagues would agree that 
after multiple oversight hearings done by this Committee, our internal 
investigations, outside investigations, and countless accounts made by 
whistleblowers-VA's numbers cannot be trusted. VA's determination that 
10,000 additional medical staff is needed is also surprising when in 
the Secretary's written statement it states that VA doesn't ``have the 
refined capacity to accurately quantify its staffing requirements.'' If 
they don't have the ability to accurately predict staffing needs then 
how do we know that 10,000 more bodies is what is needed? Again, VA's 
numbers are something I believe many of us call into question, and I 
believe a better understanding of where these numbers were pulled from 
is needed.
    I would also remind members that we also don't have any type of a 
grasp on how the Department is going to spend the new funding they have 
requested. The President's FY 2015 budget request for the department is 
over 1300 pages long. [SHOW BUDGET BOOKS HERE] The request we received 
from VA is five pages . . . just five. Clearly not the type of 
justification anyone would expect for $17.6 billion dollars.
    Our veterans certainly deserve the best, but just throwing billions 
upon billions of dollars into a system that has never been denied a 
dime will not automatically fix the perverse culture that has 
encompassed the Department. Real change needs to be made in the 
management at the Department to refocus on the core mission and in the 
priorities of the VA. VA can no longer consider itself a sacred cow 
that is not subject to the rules of good government and ethical 
behavior. Veterans are sacred. VA is not.
    Ultimately, we are talking about a system that has a long road 
ahead of it before it can get back to an organization deserving of our 
veterans and the sacrifices they've made. I hope that today we receive 
the needed insight from our Veteran Service Organizations. They and 
their members are on the ground and need to be partners as VA tries to 
rebuild the trust it has lost. I hope that together we can bring about 
true change to this broken system, and change the corrosive culture 
that has encompassed the Department of Veterans Affairs for far too 
long.
    With that, I recognize the Ranking Member, Mr. Michaud, for his 
opening remarks.
                                 

           Prepared Statement of Mike Michaud, Ranking Member
    Good Morning, and thank you Mr. Chairman for holding today's 
hearing--and for leading our rigorous oversight these past few months.
    It's been a long road getting here. The hearings we have held over 
the past few months have yielded difficult, disturbing, but 
ultimately--important--information.
    With each hearing, we heard of a different aspect of the Department 
of Veterans Affairs that just isn't working. We heard about some 
challenges--like the claims backlog and technology issues--which we 
have been confronting for quite some time now. We learned of others--
like how the VA treats whistleblowers, and the reliability of the data 
VA reports--that were new.
    The VA has a good product. When veterans get in to see a VA doctor, 
they like the care they get. When veterans get an eligibility rating 
and start receiving VA benefits, they find those benefits useful and 
helpful.
    But, the business model for producing, delivering and supporting 
the VA product is fundamentally broken. We have heard this time and 
again over the course of these hearings. There is a clear cultural 
problem at the VA. There are scheduling failures and technology 
problems. Inconsistent office practices lead to backlogs that appear to 
be tackled at the expense of other services.
    VA is a sprawling agency that offers critical services to millions 
of veterans. It's clear to me that we need a business-minded approach 
to reform the agency. More of the same isn't going to solve the 
underlying problems. Tweaks and band-aids around the margins aren't 
going to sustain the system. We need a new model, a new approach, a new 
way of thinking about and looking at the Department. We need immediate, 
short-term fixes. But we also need a long-term vision and a new 
approach to the business of VA.
    I'd like to thank Acting Secretary Sloan Gibson for joining us 
today, and for his efforts over the last few months. Mr. Gibson, you 
stepped up to the plate at the most challenging moment in the VA's 
history, and you owned the problems the organization was experiencing. 
I thank you for your increased efforts to communicate with us here on 
the Hill, for your dedication to our nation's veterans, and for 
exhibiting the courage to be the face of the VA during this difficult 
time.
    I'd like to similarly thank Bob McDonald, who I hope will soon be 
confirmed as the next VA Secretary. I'm meeting with Mr. McDonald 
tomorrow and I'm looking forward to discussing with him his vision for 
reforming the VA, both in the short-term and the long-term. Like Mr. 
Gibson, Mr. McDonald is exhibiting extraordinary courage and commitment 
for taking on this role at this moment in time.
    I'd also like to thank our Veterans Service Organizations for 
joining us today. You have been strong and relentless advocates for the 
well-being of veterans. You have done an excellent job holding all of 
us--in Congress and at the VA--accountable. You are key stakeholders. 
You need to be actively engaged in the process of long-term reform at 
VA. Thank you for joining us today, and I look forward to continuing to 
work with all of you.
    And with that, I thank you Mr. Chairman and yield back my time.

                                 

                Prepared Statement of Hon. Corrine Brown
    Thank you, Mr. Chairman and Ranking Member, for inviting the Acting 
Secretary here today.
    Mr. Secretary, it seems so long ago since you first testified in 
front of this Committee. It was only 3 and a half months.
    At the time you were the Deputy Secretary and I feel that you have 
acquitted yourself very well in your time at the VA.
    I do hope you will stay on at the VA and help guide the Department 
through the rough times to come.
    The VA operates 1,700 sites of care, and conducts approximately 85 
million appointments each year, which comes to 236,000 health care 
appointments each day.
    The latest American Customer Satisfaction Index, an independent 
customer service survey, ranks VA customer satisfaction among Veteran 
patients among the best in the nation and equal to or better than 
ratings for private sector hospitals.
    I am confident in the health care our veterans in Florida are 
receiving. With eight VA Medical Centers in Florida, Georgia and Puerto 
Rico and over 55 clinics serving over 1.6 million veterans, veterans 
are getting is the best in the world.
    Over 2,312 physicians and 5,310 nurses are serving the 546,874 
veterans who made nearly 8 million visits to the facilities in our 
region. Of the total 25,133 VA employees, one-third are veterans.
    In 2013, 37,221 women received health care services at VA hospitals 
and clinics in Florida, South Georgia and the Caribbean--more than any 
other VA health care network nationwide. This means that more than 75% 
of women Veterans enrolled for VA health care in VISN 8 were seen by 
providers in 2013.
    I am especially pleased at the new Jacksonville Replacement 
Outpatient Clinic that was recently opened. The two-story, 133,500 
square foot clinic provides state of the art technology and increased 
specialty services including diagnostics, improved laboratory 
facilities, expansion of women's services, minor ambulatory surgical 
procedures, expanded mental health tele-health services and additional 
audiology.
    When opened, the Orlando VA Medical Center will include 134 
inpatient beds, an outpatient clinic, parking garages, chapel and 
central energy plant. Currently, the 120-bed community living center 
and 60-bed domiciliary are open and accepting veterans.
    While this committee and many others concerned with the well-being 
of our veterans have been quick to point out what they think are some 
of the most horrible crimes in the history of man that have supposedly 
occurred at your department.
    However, once this House passes the Conference report updating the 
policies of the VA and hopefully addressing the wait times our veterans 
have had to deal with, the real work begins. Your agency will have to 
work twice as hard to address not only the health care of the veterans 
but the culture that permeated the department.
    How do you fix that? That is something you will need to work out. 
This committee will stand ready to offer suggestions as to how to work 
better for our veterans.
    It is important that you keep the channels of communication open 
between not only your office and this committee, but your office and 
the Medical Centers.
    You have visited many Medical Centers during your short tenure as 
the head of the VA. I am pleased you came to Gainesville. I look 
forward to many more visits over the coming years.
    The VA provides quality timely health care to our veterans. We have 
a duty to make sure that all those who have defended this country when 
called upon and receive the care they have earned through their 
service.

    Questions:

    Mr. Secretary:
    How do you feel about putting VA into wings of private or community 
hospitals, where all involved can share resources?
    In my time on this committee, the mission of the VA has expanded 
from just providing service connected care for the veteran to holistic 
care for the veteran and his or her family.
    This is a good change, but it comes at a price. How do you propose 
to continue this mission knowing the issues the VA faces at this time?

                                 

                Prepared Statement Hon. Sloan D. Gibson

    Chairman Miller, Ranking Member Michaud, and Distinguished Members 
of the House Committee on Veterans' Affairs, thank you for the 
opportunity to discuss with you changes within the Department of 
Veterans Affairs (VA). We at VA are committed to consistently providing 
the high quality care and benefits our Veterans have earned and deserve 
in order to improve their health and well-being. We owe that to each 
and every Veteran that is under our care.
    The Veterans Health Administration (VHA) operates the largest 
integrated health care delivery system in the United States. VHA has 
over 1,700 sites of care, including 150 medical centers, 820 community-
based outpatient clinics, 300 Vet Centers, 135 community living 
centers, 104 domiciliary rehabilitation treatment programs, and 70 
mobile Vet Centers. VHA conducts approximately 236,000 health care 
appointments every day and approximately 85 million appointments each 
year. Over 300,000 VHA leaders and health care employees--many who also 
are Veterans--strive to provide exceptional care to nearly 6.5 million 
Veterans and other beneficiaries annually. While there are things that 
VA does very well, there are also areas that need improvement.

Issues VA is Facing

    We have serious problems. First and foremost, Veterans are waiting 
too long for care. Second, scheduling improprieties were widespread, 
including deliberate acts to falsify scheduling data. Third, an 
environment exists where many staff members are afraid to raise 
concerns or offer suggestions for fear of retaliation. Fourth, in an 
attempt to manage performance, a vast number of metrics have become the 
focal point for staff instead of focusing on the Veterans we are here 
to serve. Fifth, VA has failed to hold people accountable for 
wrongdoing and negligence. And last, we lack sufficient clinicians, 
direct patient support staff, space, information technology resources, 
and purchased care funding to meet the current demand for timely, high-
quality healthcare.
    Furthermore, we don't have the refined capacity to accurately 
quantify our staffing requirements but are actively working to assess 
these needs. As a consequence of all these failures, the trust that is 
the foundation of all we do--the trust of the Veterans we serve and the 
trust of the American people and their elected representatives--has 
eroded.
    I apologize to our Veterans, their families and loved ones, Members 
of Congress, Veterans Service Organizations (VSO), and to the American 
people. We can and must solve these problems as we work to earn back 
the trust of Veterans.
    We have to earn that trust back through deliberate and decisive 
action--and by creating an open and transparent approach for dealing 
with our stakeholders to better serve Veterans.

VA Key Priorities Going Forward

    To begin restoring trust, we have focused on six key priorities:

        1.  Get Veterans off wait lists and into clinics;
        2.  Fix systemic scheduling problems;
        3.  Address cultural issues;
        4.  Hold people accountable where willful misconduct or 
        management negligence are documented;
        5.  Establish regular and ongoing disclosures of information;
        6.  Quantify the resources needed to consistently deliver 
        timely, high-quality health care.

Current VA Actions

    VA has taken a number of actions already to address its key 
priorities related to scheduling and wait times:

         Between May 15 and July 15, 2014, we have made 571,163 
        referrals for Veterans to receive their care in the private 
        sector. VA made roughly 463,567 referrals during this same time 
        period in 2013. Therefore, in comparison to last year, we had a 
        107,596 referral increase over this same time period. On 
        average, each referral to private sector care produces seven 
        visits or appointments for care. So here, we would expect the 
        107,596 additional referrals to result in approximately 753,172 
        visits or appointments for care in the community over and above 
        the level of a year ago during this same time period.
         VHA facilities are adding more clinic hours, 
        aggressively recruiting to fill physician vacancies, deploying 
        mobile medical units, and using temporary staffing resources, 
        to provide care to more Veterans as quickly as possible in our 
        healthcare facilities. VA is addressing VHA's antiquated 
        medical appointment scheduling system with VSOs actively 
        engaged in the process. We have developed a three-part plan to 
        improve VHA's scheduling system:
         First, VA has just awarded a contract to both fix and 
        enhance the Veterans Health Information Systems and Technology 
        Architecture (VistA) Scheduling Legacy Software. This work will 
        proceed over the next 12 months, providing much needed support 
        for schedulers.
         Second, VA is actively working on scheduling ``apps'' 
        that are expected to roll out over the next 6 to 12 months. For 
        example, one will replace the blue- screen roll-and-scroll with 
        a point and click user interface.
         Finally, VA aims to acquire a comprehensive ``commercial 
        off-the-shelf'' state-of-the-art scheduling system to markedly 
        enhance capability. VA is making steady progress toward the 
        comprehensive solution called Medical Appointment Scheduling 
        System (MASS). On June 18, 2014, VA hosted pre- solicitation 
        ``Industry Day'' meetings with technology vendors to discuss 
        the Department's upcoming scheduling system acquisition. This 
        Industry Day presented an important opportunity for VA to 
        communicate directly with potential vendors on all aspects of 
        the upcoming scheduling system acquisition.

    In addition, VA conducted a live scheduling system architecture 
question and answer session to ensure potential solutions seamlessly 
interface with VA's VistA electronic health record. Written responses 
to VA's request for information are being evaluated now in advance of 
publication of VA's final Request for Proposal. After selection, VA 
anticipates working with one VA site in 2015 to create software 
interfaces with MASS and a repeatable implementation pattern before 
beginning a system-wide implementation in 2015. Briefings and 
discussions have also been held with VSO leaders to solicit their 
input.

         We are putting in place a comprehensive external audit 
        of scheduling practices across the entire VHA system and 
        working on using an outside private entity to do the audit. We 
        will begin those audits early next fiscal year.
         I have directed every Medical Center Director to 
        conduct in-person visits to all of their assigned facilities. 
        In-person site inspections include observing daily scheduling 
        processes and interacting with scheduling staff to ensure all 
        scheduling practices are appropriate. VISN Directors will also 
        conduct similar visits to at least one medical center within 
        their area of responsibility every 30 days, completing visits 
        to all medical centers in their network every 90 days. To date, 
        over 1,100 of these visits have been conducted.
         We are building a more robust, continuous system for 
        measuring patient satisfaction by establishing a new program to 
        provide real-time, site-specific information on patient 
        satisfaction, including satisfaction measurements of those 
        Veterans attempting to access VA health care for the first 
        time. VA has now begun using its longstanding Survey of Health 
        Experiences of Patients (SHEP) program to provide facility-
        specific monthly updates about access as experienced by 
        Veterans--including how easy or difficult it is to obtain 
        routine appointments, urgent appointments, and same-day answers 
        to their medical questions. We plan to expand our capabilities 
        in the coming year to capture further Veteran experience data 
        using telephone, social media, and on-line means. Our efforts 
        will include close collaboration with VSOs, with whom we have 
        already met to begin planning our efforts. We also will learn 
        what other leading health care systems are doing to track 
        patient access experiences.
         I have personally visited 13 VA Medical Centers in the 
        last seven weeks to hear directly from the field on the actions 
        being taken to get Veterans off wait lists and into clinics. 
        Those visits to Phoenix, Arizona; San Antonio, Texas; 
        Fayetteville, North Carolina; Gainesville, Florida; Baltimore, 
        Maryland; Washington, DC; Columbia, South Carolina; 
        Philadelphia, Pennsylvania; Augusta, Georgia; Jackson, 
        Mississippi; Albuquerque, New Mexico; El Paso, Texas, and St. 
        Louis, Missouri have been invaluable to me, both from the 
        perspective of speaking to Veterans, local VSOs and VA 
        employees, and seeing firsthand what the scope and nature of 
        the issues we face are, as well as the perceptions of those who 
        receive our care and those who deliver it to Veterans.
         The 14-day access measure has been removed from all 
        individual employee performance plans to eliminate any motive 
        for inappropriate scheduling practices or behaviors. In the 
        course of completing this task, over 13,000 performance plans 
        were amended.
         VA is posting regular data updates showing progress on 
        its efforts to accelerate access to quality health care for 
        Veterans who have been waiting for appointments. The first data 
        release was on June 9, 2014. These access data updates will 
        continue to be posted at the middle and end of each month at 
        www.VA.gov to enhance transparency and provide the immediate 
        information to Veterans and the public on improvements to 
        Veterans' access to care. We know that we must not only restore 
        the public's trust in VA, but more importantly, we also must 
        restore the trust of our Veterans who depend on us for care.
         Where willful misconduct or management negligence is 
        documented, appropriate personnel actions will be taken--this 
        also applies to whistleblower retaliation. At VA, we depend on 
        the service of VA employees and leaders who place the interests 
        of Veterans above and beyond self-interest, and who live by 
        VA's core values of Integrity, Commitment, Advocacy, Respect, 
        and Excellence. Accountability, delivering results, and honesty 
        are also key to serving our Veterans. Those who have not 
        performed and have not delivered results honestly, will be held 
        accountable.
         I have frozen VHA Central Office and VISN Office 
        headquarters hiring--as a first step to ensure we are all 
        working to support those delivering care directly to Veterans.
         VHA has dispatched teams to provide direct assistance 
        to facilities requiring the most improvement, including a large 
        multi-disciplinary team on the ground, right now, in Phoenix.
         All VHA senior executive performance awards for fiscal 
        year (FY) 2014 have been suspended.
         VHA is expanding our use of private sector care to 
        improve access to health care for Veterans who are experiencing 
        or who may experience excessive wait times for Primary, 
        Specialty, and Mental Health Care. VHA is now operationally 
        monitoring the effectiveness of our sites' use of non-VA care 
        to ensure Veterans are receiving their timely care by looking 
        at (1) the time stamps for consultation, (2) the authorization 
        of referral, (3) the appointment completion, (4) the return of 
        clinical documentation, and (5) the referral closeout.
         I sent a message to all 341,000 VA employees, and have 
        reiterated during every visit to VA facilities, that 
        whistleblowers will be protected. As I have stated in the past, 
        we depend on the service of VA employees and leaders who place 
        the interests of Veterans above and beyond self-interest. We 
        are committed to ensuring that our employees have a voice 
        without fear of repercussion. We are deeply concerned and 
        distressed about the allegations that employees, who sought to 
        report deficiencies, were either ignored, or worse, intimidated 
        into silence. We will not tolerate an environment where 
        intimidation or suppression of reports occurs. We will not 
        tolerate retaliation against whistleblowers.

VA Personnel Updates

    In the area of leadership, we have taken immediate action in areas 
where we are allowed without the confirmation process, to bring in 
professionals to help us in the immediate future:
         First, I named Dr. Carolyn Clancy interim Under 
        Secretary for Health (USH). She will spearhead our immediate 
        efforts to accelerate Veterans' access to care and restore the 
        trust of Veterans.
         Second, Dr. Jonathan Perlin, a former USH at VA, 
        currently on leave of absence from his duties as Chief Medical 
        Officer and President, Clinical Services for Hospital 
        Corporation of America, has begun his short term assignment at 
        VA as Senior Advisor to the Secretary. Dr. Perlin's expertise, 
        judgment, and professional advice will help bridge the gap 
        until VA has a confirmed USH.
         Third, Dr. Gerard Cox has agreed to serve as Interim 
        Director of the Office of Medical Inspector (OMI); a Navy 
        medical officer for more than 30 years, and a former Assistant 
        Inspector General of the Navy for Medical Matters, Dr. Cox will 
        provide new leadership and a fresh perspective to help 
        restructure OMI and ensure a strong internal audit function.
         And last, as we complete reviews, fact-finding, and 
        other investigations, we are beginning to initiate personnel 
        actions to hold those accountable who committed wrongdoing or 
        were negligent in discharging their management 
        responsibilities.

    To support this critical work, Ms. Leigh Bradley has begun a four-
month assignment as Special Counsel to the Secretary. Ms. Bradley is a 
former General Counsel at VA and, most recently, a senior member of the 
general counsel team at the Department of Defense with direct 
responsibility for the ethics portfolio.

Veterans Benefits Administration (VBA)

    Thus far, I have focused largely on problems and corrective actions 
related to VA's delivery of health care. However, that is only one 
aspect of our sacred obligation to care for Veterans. I also take 
seriously our commitment to providing timely, accurate benefits, in the 
programs VBA administers and maintaining the integrity of our data 
systems and claims processes. We understand that recent investigations 
by the independent VA Office of the Inspector General (OIG), media 
coverage related to those investigations, and issues raised at 
Congressional hearings have called into question whether the 
compensation and pension data and systems within VBA can be trusted.
    VBA has a comprehensive program of quality assurance at both the 
local and national levels and extensive data quality controls built 
into its processing systems. VBA data is held at the national level--
not on local data systems--and it is updated and protected every night 
with controlled access. We also have a dedicated analytics team that 
constantly reviews the workload data, looking for anomalies within the 
system so management can respond quickly. However, based on the 
improprieties recently identified, we are taking action to add more 
checks and balances as we work to improve delivery of earned benefits. 
I have directed that an expert team be assembled to determine possible 
scenarios where an individual might find a way ``around the system'' 
and decide if further controls are needed. Under Secretary Hickey has 
directed a 100-percent facility and desk audit of mail and 
documentation at all 56 regional offices. The purpose of the review is 
to ensure records management compliance and proper control, storage, 
and maintenance of claim mail and other benefit-related documents. VBA 
is applying for ISO 9001 certification--considered the ultimate global 
benchmark for quality management. This will provide external validation 
and additional quality assurance of VBA's data. If an individual 
employee is found to have ``worked around'' the standard claims 
process, VA will immediately take necessary actions, including 
proactive referral to the OIG. In addition, VA will continue to provide 
publicly-available performance data on benefits through VBA's Monday 
Morning Workload Reports each week at www.vba.va.gov/reports.

Resource Requirements

    I believe that the greatest risk to Veterans over the intermediate 
to long-term is that additional resources are provided only to support 
increased purchased care in the community and not to materially remedy 
the historic shortfall in internal VA capacity.
    Such an outcome would leave VA even more poorly positioned to meet 
future demand.
    We have been working closely with the Office of Management and 
Budget for several weeks to develop the request for funding. While the 
amounts under consideration are large, in the context of VA's size, 
scope, and existing budget, they represent a moderate percentage 
increase in annual expenditures. Furthermore, a substantial portion of 
the funds required are non-recurring investments in space and 
information technology that would not be reflected in long-term run 
rates.
    Resources required to meet current demand covering the remainder of 
FY 2014 through FY 2017 total $17.6 billion. This funding would address 
challenges such as clinical staff, space, information technology, and 
benefits processing necessary to provide timely, high-quality care and 
benefits.

Working With VSOs

    I appreciate the hard work and dedication of our VSO partners--
important advocates for Veterans and their families--our community 
stakeholders, and our dedicated VA volunteers. I have conducted more 
than 15 meetings and calls with senior representatives of VSOs and 
other stakeholder groups to solicit their ideas for improving access 
and restoring trust. Just 2 weeks ago, I met with the leadership of 26 
Military Service Organizations (MSO) and VSOs to reaffirm VA's 
commitment to work together to address the unacceptable, systemic 
problems in accessing VA health care. During this meeting, I updated 
the organizations' representatives on VA's work to restore Veterans' 
trust in the system and on VA's progress in reaching out to get 
Veterans off of waiting lists and into clinics.
    MSOs and VSOs are VA's valuable partners in serving Veterans and 
continuing to improve the Department. I am grateful for their ideas on 
how VA can improve Veterans' access to care and services. VA 
particularly appreciates a longstanding and ongoing partnership with 
the excellent Veterans organizations that focus on specialized services 
and rehabilitation programs to ensure that VA continues to give 
priority to providing these services and programs for disabled Veterans 
(e.g., spinal cord injury, blind, amputees, polytrauma). In addition, 
we embrace partnerships with all of the service organizations that help 
us to keep our compass pointed in the right direction. I meet regularly 
with MSOs and VSOs to share information and solicit their input.
    Similarly, I have directed medical center Directors to meet with 
their local MSOs and VSOs on a monthly basis to ensure we have the 
benefit of their perspectives from the local as well as the national 
level.

Working With Congress and the House Committee on Veterans' Affairs

    I also respect the important role Congress and the dedicated 
Members of this Committee play in serving our Veterans. I look forward 
to continuing our work with Congress to ensure Veterans have timely 
access to the quality health care they have earned.
    As I stated to you when I appeared before the Committee in April, 
for the benefit of our Veterans, the status quo in our working 
relationship must change. My perspective then was that we as a 
Department must and can do better--and my assessment has not changed. I 
remain convinced that our Veterans are best served when the Veterans' 
Affairs Committees and the VA work together in a collaborative and 
constructive manner.
    The Department will continue to work openly with Congress and to 
provide information in a timely manner. VA's participation in 18 
congressional hearings in June and July demonstrates our commitment in 
support of Congress' oversight role. I specifically acknowledge the 
need to improve the timeliness of our responses to congressional 
inquiry. We will continue our efforts to improve and to build our 
relationship with Congress in order to restore trust.

Conclusion

    We understand the seriousness of the problems we face. We own them. 
We are taking decisive action to begin to resolve them.
    The President, Congress, Veterans, VSOs, the American people, and 
VA's staff all understand the need for change. We must--all of us--
seize this opportunity.
    We can turn these challenges into the greatest opportunity for 
improvement in the history of the Department.
    I believe that in as little as 2 years, the conversation can 
change--that VA can be the trusted provider of choice for healthcare 
and benefits.
    If we are successful, who wins? Veterans will be the clear winners 
if we can meet, overcome, and prevail in the challenges and issues VA 
is facing. That includes the growing number of Veterans that turn to VA 
for healthcare each year; the 700,000 Veterans who are currently 
diagnosed with PTSD; the million Iraq and Afghanistan Veterans that 
have turned to VA for healthcare since 2002; and, the average Veteran 
who turns to VA for healthcare who is older (50 percent over age 65), 
sicker (many have multiple and serious chronic conditions), and poorer 
(60 percent have less than $20,000 income), than average patients in 
the private sector.
    Those are the Veterans who will win when VA becomes the trusted 
provider of care and benefits. That is what, and where, we want to be--
in the shortest time possible. Our ability to get there depends on our 
will to seize the opportunity, challenge the status quo, and drive 
positive change.
    I appreciate the hard work and dedication of VA employees, the vast 
majority of whom care deeply about our mission, want to do the right 
thing, and work hard every day to care for Veterans. As well, I 
appreciate our partners from Veterans Service Organizations, our 
community stakeholders, and dedicated VA volunteers.
    Last, I deeply respect the important role that Congress and the 
members of this committee play in serving Veterans, and I am grateful 
for your long-term support.
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                 Prepared Statement of Ryan M. Gallucci

    Mr. Chairman and Members of the Committee:
    On behalf of the men and women of the Veterans of Foreign Wars of 
the United States (VFW) and our Auxiliaries, I would like to thank you 
for the opportunity to testify today on the current state of Department 
of Veterans Affairs (VA) health care and steps the VFW believes we need 
to take to restore trust and confidence in the VA health care system.
    The recent events at the Phoenix VA Medical Center, the subsequent 
national audit of all VA facilities, and repeated whistleblower 
accusations of impropriety within VA have all shed light on major 
issues facing the VA health care system as it seeks to deliver timely, 
quality health care to our nation's veterans. Over the past three 
months, we have seen a VA Secretary and numerous deputies resign. We 
have also seen a newly-minted Acting Secretary working diligently to 
understand the situation on the ground at VA health care facilities 
across the country, seeking to expose systemic problems and prescribe 
corrective action.
    The allegations made against VA over the past three months are 
outrageous, and the 1.9 million members of the VFW and our auxiliaries 
are rightfully outraged. However, the VFW also worries that the loss of 
trust among the veterans' community has the potential to be more 
harmful to our nation's veterans than much of the impropriety about 
which we have recently learned.
    At the center of the recent scandal is the inability of veterans to 
receive timely care from VA. For more than a decade, the VFW has warned 
both VA and Congress about the potential dangers of long wait times and 
improper scheduling procedures. After Phoenix, we now know that these 
potential dangers were all too real.
    When news of the scandal broke, the VFW knew that it had to 
intervene directly on behalf of veterans. We had no time to wait for VA 
to sort out its affairs through traditional channels, which is why we 
readvertised our health care help line, 1-800-VFW-1899, where veterans 
could turn for direct intervention on the VA health care concerns, or 
simply share their experiences to benefit their fellow veterans. Over 
the first two months of the outreach campaign for the VFW help line, we 
received more than 1,500 comments and complaints from our members, most 
of whom reported negative VA care experiences. The VFW worked directly 
with VA leadership to help resolve more than 200 critical health care 
issues most often related to oncology, gastroenterology, cardiovascular 
health or mental health.
    In addition, the VFW sorted through all 1,500 comments to evaluate 
the current state of VA care and make specific recommendations to 
ensure VA never faces these problems in the future. For our testimony 
today, we will focus specifically on scheduling inefficiencies, non-VA 
care coordination, and the culture of accountability.
    According to many of the veterans who contacted the VFW over the 
past two months, the major issue facing the VA health care system is 
timely access. Even veterans who relayed positive health care 
experiences still shared significant concerns over appointment wait 
times.
    While some have sought to focus solely on the issues of access, 
appointment scheduling and care referral processes, the VFW has 
recognized that access to care is clearly linked to quality health care 
outcomes and customer service. Veterans who contacted the VFW often 
pointed to delayed diagnoses, worsening health conditions and hurried 
screenings for potentially serious health conditions when they could 
not receive appointments in a timely manner.
    As the strain on the VA health care system continues to grow, the 
VFW's evidence also demonstrates that staff attitudes are rapidly 
deteriorating as veterans report doctors who shrug off serious symptoms 
during routine screenings and phone operators or clerks who treat 
veterans with contempt. It would be easy to single out these employees 
and blame them individually for their poor attitudes, low morale, and 
inadequate customer service. However, given the systemic scope of 
similar allegations across multiple VA health care facilities, the VFW 
believes that such poor staff attitudes indicate that the system is too 
strained to properly handle all of the veterans who require care.
    After all of the recent scrutiny of the VA health care system, the 
VFW believes that we understand the problems now facing VA. However, we 
also recognize that there is no silver bullet solution to the current 
crisis. To the VFW, improper resourcing, archaic accountability 
standards, outdated technology, and inconsistent business practices 
have all contributed to the current crisis.
    As we seek to resolve these issues, we must be careful not to 
dismantle the VA health care system or abdicate VA of its 
responsibilities to care for veterans. The VFW believes that the VA 
health care system is far too important, and many of its veteran-
specific services cannot be easily duplicated in the civilian health 
care sector.
    To the VFW, outdated appointment scheduling and tracking technology 
is central to the current crisis. Built and implemented in the 1980s, 
VA's appointment-scheduling software has not changed much over the 
years--except for the occasional patches and work-arounds designed to 
gather new information. Moreover, VA's systems that track incoming 
patients and specialty consults are only loosely linked to the 
scheduling system, meaning VA scheduling is rife with inaccuracies, 
allowing patients to easily slip through the cracks. VA has asked 
repeatedly for a new scheduling system, but IT funding shortfalls have 
made it nearly impossible to take the major steps of replacing a 
system-wide software platform.
    VA also acknowledges that this antiquated, patch-work system makes 
it impossible to properly monitor the supply of available appointments. 
This means that VA cannot adhere to private industry wait time 
standards and also exposes the scheduling system to rampant fraud and 
manipulation, as evidenced by repeated VA memos to health care 
facilities chastising those who seek to game appointment scheduling. 
This also makes it nearly impossible for VA to manage the workload for 
its clinicians, meaning that some clinicians may be overworked, while 
others may be under performing. In either case, veteran care quality 
suffers.
    One veteran who recently contacted the VFW shared his experience 
trying to transfer into the Salt Lake City VA Medical System. He told 
the VFW that when he tried to enroll, VA said it would take at least 
six months to see a primary care doctor. After six months, VA contacted 
the veteran again to inform him that it would take another six months 
to get an appointment. When the veteran followed up with VA, he was 
informed that he was disenrolled since he had not seen his primary care 
physician in more than a year. This is a clear failure of VA scheduling 
protocols and business practices. We have to do better. This is why the 
VFW calls on Congress to immediately provide VA with the resources 
necessary to acquire a modern and sustainable appointment-scheduling 
system that will allow patients to easily access appointments and allow 
VA to finally measure its workload and adapt accordingly.
    Since the scandal broke, some in Congress have presented non-VA 
care as the best solution to ensure veterans can receive timely care. 
The VFW acknowledges that VA must fully leverage its authority to 
provide non-VA care to veterans when VA cannot provide direct care. 
However, VA still must have the responsibility and the resources to 
properly coordinate non-VA care and ensure that such care is delivered 
properly. The VFW also worries that the civilian health care system 
lacks sufficient capacity to deliver comparable care in a timely 
manner.
    Earlier this week at the VFW National Convention, I had the 
opportunity to speak with a veteran's caregiver who recounted a recent 
nightmare in receiving non-VA care. The veteran who needed a seemingly-
routine knee surgery was sent to a major outside health care provider 
for the procedure, since VA was backlogged for nearly two years to 
conduct the procedure in-house. While VA coordinated the care on behalf 
of the veteran, what followed was a bureaucratic nightmare for the both 
the veteran and his caregiver once the surgery was performed.
    After the non-VA provider performed the operation, the veteran was 
quickly discharged and told that the civilian provider had no further 
responsibility for his convalescence. The facility discharged the 
veteran without providing a simple prescription for pain management 
associated directly with the procedure. In fact, the veteran and his 
caregiver had to immediately go from the non-VA facility to VA to 
receive proper convalescent medication and the requisite prosthetic 
devices that the veteran would need for recovery.
    While the VFW understands that VA may have been best suited to 
provide both the medication and the necessary prosthetics, this was not 
properly communicated to the veteran prior to the procedure. Moreover, 
the veteran caregiver reported that the non-VA facility was inflexible 
in providing basic recovery services to the veteran while still in 
their care.
    To the VFW, this is a prime example of why outsourcing VA care is 
not a catch-all solution to the current crisis. Must VA outsource care 
when they cannot deliver it in a timely manner? Absolutely. However, VA 
must continue to serve as the guarantor of such care, and it must be 
responsibly coordinated to ensure veterans have positive health 
outcomes.
    The VFW has been fully supportive of VA's efforts to revamp its 
delivery of non-VA care through the creation of Non-VA Care 
Coordination (NVCC) teams and the implementation of the Patient-Centric 
Coordinated Care (PC3) program. NVCC teams are charged with 
coordinating non-VA care on behalf of veterans who cannot receive 
adequate care from VA. While the VFW supports the concept of NVCC, 
Congress must ensure that NVCC teams are properly staffed with 
professionals capable of making responsible, timely health care 
decisions. PC3 is VA's new program designed to deliver coordinated non-
VA specialty care through established civilian health care networks. 
PC3 is a program that the VFW believes can make a difference, but we 
caution that Congress must have proper oversight of how PC3 works and 
whether referrals through PC3 can deliver timely care.
    While VA must properly leverage non-VA care, the VFW also 
recognizes that the challenges VA faces in tracking and scheduling 
appointments immediately affects VA's ability to refer veterans to non-
VA providers in a timely manner.
    The VFW also worries that accountability issues within VA present 
major, multifaceted problems. While the VFW has supported legislation 
to ensure the VA Secretary can easily sanction executive-level 
employees, we also acknowledge that accountability is a major issue at 
all levels in VA's chain of command. To the VFW, allegations of under 
performing and apathetic employees is likely the result of a 
bureaucratic culture in which VA cannot efficiently reprimand or 
terminate poor-performing employees; or hire quality new employees in a 
timely manner.
    When then-VA Secretary Eric Shinseki was pressed by the Senate over 
how many employees he had fired under his watch, Shinseki acknowledged 
that very few of the 3,000 employees reprimanded had a significant 
adverse personnel action taken against them, such as demotion or 
termination. Moreover, VA has repeatedly acknowledged that the hiring 
process for new employees takes between six months to a year.
    This prompted the VFW to ask whether or not VA managers make trade-
offs in evaluating employee performance. The VFW believes that if VA 
has a poor-performing employee, the current system incentivizes 
retaining that poor-performing employee in lieu of initiating the 
laborious process of terminating the employee, then finding a quality 
replacement.
    The hiring process makes it even more difficult for VA to properly 
staff its facilities. Veterans have consistently reported to the VFW 
that staffing shortages and high turnover, even among clinicians, has 
contributed to current access issues. To make this situation worse, VA 
simply cannot compete with the private health care sector when it seeks 
to hire new clinicians. Private health systems can hire new clinicians 
in a matter of days and weeks. So even if a doctor wants to work for 
VA, the VFW recognizes that many doctors cannot wait six months to a 
year for VA to follow through. If VA cannot quickly fill its vacancies 
with top talent, we cannot expect VA to properly reprimand poor 
performers. If VA cannot reprimand poor performers, we cannot 
reasonably expect VA to deliver timely, quality care to the veterans 
who need it. This will take significant changes to federal employee 
protections and federal hiring practices, but the VFW believes that 
this can be done equitably to provide reasonable protections for 
employees, but decisive accountability for under performers.
    The VFW is also concerned that for far too long VA has focused on 
its internal business models rather than the needs of its end-users, 
the veterans. In other words, in accomplishing its mission, VA does 
what is best for VA, instead of what is best for the customer. The VFW 
believes that this culture must change.
    To the VFW, the culture of secrecy and low morale among VA 
employees are symptoms of a VA culture that does not focus on the well-
being of patients. The VFW has heard concerns from veterans that 
resources are stretched too thin, but employees are afraid to speak up. 
In this environment, if doctors are forced to rush treatment, they will 
naturally misdiagnose their patients or botch a critical procedure. 
Doctors will also burn out and leave VA--especially when hospital 
administrators downplay or neglect the legitimacy of their concerns.
    To make this situation worse, inspectors have found clear examples 
where whistleblowers who exposed inadequate care standards or 
disingenuous business practices were quickly penalized for speaking up. 
Instead of incentivizing proper care or patient safety, the business 
mind-set of VA seemed to encourage employees to cut corners in order to 
make the system work.
    VA has to change this business mind-set. Administrators and 
clinicians must recognize that their primary mission is serving 
veterans--not VA. Congress must also ensure that VA employees at all 
levels feel comfortable asking for help or voicing their concerns to 
leadership when the situation demands it.
    Finally, the VFW has repeatedly heard from veterans that VA Patient 
Advocates are incapable of directly intervening on behalf of veterans 
at many VA health care facilities. Some veterans even quipped that 
Patient Advocates do not advocate for the patients; they advocate for 
VA. The Patient Advocate is designed as the primary method of recourse 
for a veteran to resolve health care issues locally. They are supposed 
to be able to intervene directly with either hospital directors or care 
providers. However, veterans have told the VFW that Patient Advocates 
often lack the authority to perform their most basic functions. VA 
Patient Advocates must be appropriately staffed with professionals 
capable of intervening on behalf of veterans. They must also have the 
institutional support of VA leadership to intervene in difficult 
circumstances.
    As you can see, the current problems in VA are multifaceted and 
demand decisive reforms. Thankfully, not everything the VFW hears about 
VA health care has been bad. Nearly 40 percent of the veterans who 
contacted us to share their health care experiences praised the care 
they received at VA. At the recent VFW National Convention, several 
veterans sought out our national staff to share their stories on how VA 
doctors had saved their lives. Others offered their perspective on how 
much the VA health care system has improved over the last three 
decades. We believe the system can work, but it cannot work unless 
Congress takes action.
    This week at the VFW National Convention, the membership of our 
organization passed a stern resolution calling on Congress to quickly 
pass the VA Access and Accountability Act that currently sits in 
conference. Though this bill will not solve all of VA's current woes, 
both the House and Senate have already agreed that these necessary 
reforms will help veterans receive the care that they need. Congress 
absolutely cannot go into the August recess without passing this bill. 
When the current VA scandal broke, every legislator agreed that this 
was a national imperative. However, in recent weeks, some legislators 
have backed off, caring more about the cost of the legislation than the 
veterans who are waiting for care. This week, the members of the VFW 
said this is unacceptable. If Congress fails to pass this legislation 
before the recess, our members will hold their representatives 
accountable during the August recess.
    We have an opportunity here. We have an opportunity to show our 
veterans and the men and women still serving in harm's way that our 
nation will live up to its promise to care for those who defend our way 
of life. We have to get this right. We have to restore trust and 
confidence in the VA system, and the VFW will do whatever it takes to 
make that happen.
    Mr. Chairman, this concludes my testimony and I am prepared to take 
any questions you or the committee members may have.

Information Required by Rule XI2(g)(4) of the House of Representatives

    Pursuant to Rule XI2(g)(4) of the House of Representatives, VFW has 
not received any federal grants in Fiscal Year 2013, nor has it 
received any federal grants in the two previous Fiscal Years.

                                 

                    Prepared Statement of Carl Blake

    Chairman Miller, Ranking Member Michaud, and members of the 
Committee, Paralyzed Veterans of America (PVA) would like to thank you 
for the opportunity to testify today on the current state of health 
care provided by the Department of Veterans Affairs (VA), the changes 
that have been made by the VA in the wake of serious access problems 
that have been reported in recent months, and additional changes that 
we believe are warranted moving forward. PVA members--veterans with 
spinal cord injury or dysfunction (SCI/D)--have the unique perspective 
of dealing with a system of care within the VA that is wholly dedicated 
to their health care needs. No group of veterans understands the full 
scope of care provided by the VA better than our members. PVA members 
are the highest percentage of users among the veteran population. They 
are also the most vulnerable when access to health care and other 
challenges impact quality of care.
    Yet, as the VA has made significant changes to address the 
nationwide access problems facing the system, and as Congress continues 
to debate legislation to address these problems, the specialized health 
care needs of our members, and other veterans with catastrophic 
disabilities--loss of limbs, blindness, polytrauma and traumatic brain 
injury, etc.--have been all but ignored. The simple truth is the VA is 
the best health care provider for veterans.

VA Accelerated Access to Care Initiative

    As you are aware, immediately following the media reports about the 
serious access problems at the Phoenix VA Medical Center (and other 
facilities around the country), the VA instituted the Accelerated 
Access to Care Initiative. Through this program, VA will reach out to 
all veterans it has identified who have waited longer than currently 
established access standards to provide them the first available 
appointment within the VA health care system or immediately seek care 
in the community. This program essentially reflects an expansion of 
fee-basis care authority. PVA has long argued that VA does not do a 
good job of managing its fee-basis authority or ensuring that the care 
provided is properly coordinated with VA 
providers. Hospital directors and Veterans Integrated Service Network 
(VISN) directors were incentivized to use fee-basis care as little as 
possible as a part of their performance evaluations. As a result, 
veterans were often denied access to fee-basis care even when it was 
appropriate, leaving veterans waiting longer than necessary for care or 
traveling great distances to receive care.
    We believe that the steps being taken to expand access to care 
through this initiative are appropriate. However, we believe that VA 
should focus on many of the concepts outlined by its Patient-Centered 
Coordinated Care (PCCC) program as it expands contract care options. 
The PCCC program places the responsibility for management and 
coordination on the VA, but it also places specific requirements on its 
contract partners regarding veterans' medical records and follow-up 
prior to guaranteeing payment.
    As the VA has rolled out this initiative, many of us in the 
veterans service organization (VSO) community have heard that many of 
the solicitations to veterans to provide service through this program 
continue to be haphazard and not well managed. We are certain that this 
is not the intent of the Veterans Health Administration (VHA), but the 
only way to ensure success is to overcome these types of concerns. We 
would encourage the Committee to conduct serious oversight of the 
Accelerated Access to Care Initiative to ensure that high quality 
health care is provided in a timely manner and that it is managed in a 
well-coordinated and reasonable manner.

Providing Veterans a Choice for Health Care

    As a result of the serious scrutiny that the VA Health Care System 
has been under in recent months, Congress is moving on a bipartisan 
basis to expand contract care activities within the VA to address the 
problems that have been identified. We continue to reiterate the fact 
that the VA's specialized services--spinal cord injury care, amputee 
care, blinded care, polytrauma care, etc.--are incomparable resources 
that cannot be duplicated in the private sector. Moreover, establishing 
a scenario whereby veterans can choose to leave the VA Health Care 
System places the entire system at risk. Former VA Secretary Anthony 
Principi recently wrote in the Wall Street Journal why the concept of a 
veterans' card (as provided for in the ``Veterans Choice Act'') is not 
a viable long-term solution to the problems facing the VA Health Care 
System:
    ``Vouchers (similar to cards) are not necessary to ensure high-
quality health care .1A.1A. While this may have value in areas with 
long waiting lists, it raises serious questions. The VA system is 
valuable because it is able to provide specialized health care for the 
unique medical issues that veterans face, such as prosthetic care, 
spinal-cord injury and mental-health care. If there is too great a 
clamor for vouchers to be used in outside hospitals and clinics, the VA 
system will fail for lack of patients and funds, and the nation would 
lose a unique health-care asset.''
    These services do not operate in a vacuum. The viability of the VA 
Health Care System depends upon a fully integrated system where all of 
the services support each other. Sending veterans into the private 
health care marketplace serves only to undermine this principle. 
However, as Congress and the Administration move forward with broader 
contract care, it is important that VA remain responsible for 
coordinating and managing that care.
    To be clear, PVA finds it wholly unacceptable that tens of 
thousands of veterans have waited for far too long to be seen for an 
appointment, and in many cases were never seen. We fully understand the 
intent of H.R. 4810, the ``Veterans Access to Care Act,'' and similar 
legislation that is being considered by the conference with the Senate 
Committee on Veterans' Affairs. However, we have raised many questions 
as it relates to these bills in the past that we believe continue to be 
unanswered:

         How will continuity of care, seamless medical record 
        exchange, and accountability be ensured when non-contracted, 
        non-VA providers are added to a veteran's circle of care?
          What actions will Congress take when doctors choose 
        not to accept veterans as patients because they choose not to 
        accept the Medicare rate (a common and growing problem in the 
        medical provider community)?
         How will Congress respond when reimbursements to 
        private providers are not provided in a timely manner?
         What actions will Congress take when it becomes 
        apparent that the private sector cannot provide timely access 
        to high-quality care as well?
         What actions will Congress take when it becomes 
        evident that the care being provided in the private sector is 
        substandard to the VA?
         Will Congress provide the additional funds that will 
        be absolutely necessary to support such a program when it 
        becomes apparent that the cost of care provided in the private 
        sector is significantly more expensive than care currently 
        provided in the VA system?

    Unfortunately, for those clamoring for it, contract health care is 
not the answer to this problem. Studies have shown that contract health 
care providers cannot provide the same quality of care as the VA at any 
less cost, despite claims by some that it can. Similarly, contract care 
simply is not a viable option for veterans with the most complex and 
specialized health care needs. A veteran with a cervical spine injury 
whose autonomic dysreflexia was mistakenly treated as a stroke is not 
better served at a local outpatient clinic or the local doctor's office 
closer to his or her home. Sending those individuals outside of the VA 
actually places their health at significant risk while abrogating VA of 
the responsibility to ensure timely delivery of high quality health 
care for our nation's veterans. This is not to suggest that leveraging 
coordinated, purchased care is not part of the solution to access 
problems in the VA. However, granting easier access to the private 
sector should not come at the expense of the existing health care 
system and the men and women who rely almost solely on the VA for their 
health care.
    Specialized services, such as spinal cord injury care, are part of 
the core mission and responsibility of the VA. These services were 
initially developed to care for the complex and unique health care 
needs of the most severely disabled veterans. The provision of 
specialized services is vital to maintaining a viable VA Health Care 
System. The fragmentation of these services would lead to the 
degradation of the larger VA health care mission. With growing pressure 
to allow veterans to seek care outside of the VA, the VA faces the real 
possibility that the critical mass of patients needed to keep all 
services viable could significantly decline. All of the primary care 
support services are critical to the broader specialized care programs 
provided to veterans. If primary care services decline, specialized 
care is then also diminished.

Understanding VA Capacity: Utilization vs. Demand

    PVA has a unique perspective on the issue of capacity. In order to 
better track these issues and ensure they are addressed by the VA, PVA 
developed a memorandum of understanding with the VA more than 30 years 
ago that authorizes site visit teams managed by our Medical Services 
Department to conduct annual site visits of all VA SCI/D centers (hubs) 
as well as medical centers (spokes) that support the hubs. We are able 
to clearly identify where inadequate capacity exists in the SCI/D 
system. This opportunity has allowed us to work with the Veterans 
Health Administration (VHA) over the years to identify concerns, 
particularly with regard to staffing, and offer recommendations to 
address these concerns. What's more important, PVA is the only VSO that 
employs a staff of licensed physicians, registered nurses, and 
architects to conduct these visits and report on the conditions. 
Unfortunately, this concept is not easily transferable to the larger VA 
Health Care System.
    The fact is that the most common complaint from veterans who are 
seeking care, or who have already received care in the VA, is that 
access to care is not timely. PVA believes that VA's access issues 
result from the broad array of staff shortages within the VHA, which 
brings into question the VA's capability to provide care to veterans 
when it is needed--VA's capacity. Evaluating the capacity of the VA to 
care for veterans will require comprehensive analysis of veterans' 
health care demand and utilization measured against staffing, funding, 
and VHA infrastructure.
    We believe that VHA capacity is currently based on skewed 
utilization versus true demand for services as ultimately revealed by 
systemic hidden waiting lists. For instance, a shortage of nurses 
within the SCI/D system of care has resulted in VA facilities 
restricting admissions to SCI/D centers (an issue that we believe 
mirrors the larger access issues that are being reported around the 
country). Reports of bed consolidations or closures have been received 
and attributed to nursing shortages. When veterans are denied admission 
to SCI/D centers and beds are consolidated, leadership is not able to 
capture or report accurate data for the average daily census--demand. 
The average daily census is not only important to ensure adequate 
staffing to meet the medical needs of veterans; it is also a vital 
component to ensure that SCI/D centers receive adequate funding. Since 
SCI/D centers are funded based on utilization, refusing care to 
veterans does not accurately depict the growing needs of SCI/D veterans 
and stymies VA's ability to address the needs of new incoming and 
returning veterans. Lack of transparency made it impossible to prove to 
the (disingenuously) skeptical senior VHA leadership that veterans were 
languishing on waiting lists despite growing empirical evidence to the 
contrary (as evidenced by PVA's site visits), field staff engagement 
with facility and VISN directors, frequent meetings between PVA 
national leadership and the Under Secretary of Health, and the co-
authors of The Independent Budget.
    Meanwhile, the VA has manipulated scheduling practices and uses 
inadequate staffing ratios to misrepresent the demand for VA health 
care services. Staffing models are flawed by an underestimation of SCI/
D patient acuities and loose interpretations of SCI/D bed/staffing 
policy. This has had a downstream impact on adequacy of funding for new 
major and minor construction, which has been lacking over the past 
decade. Limited care alternatives for groups requiring specialized 
services, particularly veterans with SCI/D, amputations, blindness, and 
polytrauma/TBI, become even more limited as demand increases thus 
stretching existing VA capacity at the seams and impacting access and 
quality of care in many cases.
    This is simply unacceptable. The statistics reflect the fact that 
many veterans who might be seeking care in the VA are unable to attain 
that care. We believe that these staffing shortages exist not only in 
the SCI/D system of care, but across the entire VHA. Therefore, we 
recommend that an evaluation of VA's capacity include a comprehensive 
analysis of VHA staffing needs to include the recently identified 
veterans who were denied care, or are on wait lists for primary care. 
We also recommend the VA conduct outreach in its specialized systems of 
care to identify eligible veterans in need of care and ensure that they 
have access to the VA.
    Evaluating VA's capacity to provide care will require the VA's 
commitment to transparency and the implementation of policies, 
procedures, and systems that will allow for the collection of data that 
accurately reflect the demand for VA health care in primary care and 
specialty care, and specialized services. We appreciate the fact that 
Acting Secretary Gibson outlined a plan to expand clinical staff across 
the VHA last week. However, it is important that the mistakes of the 
past are not repeated if Congress chooses to provide additional funding 
to address the concerns outlined by the VA. It is imperative that the 
VA commit to hiring actual providers who are delivering services. 
Otherwise, capacity will continue to be insufficient to meet actual 
demand.
    Last, as a result of P.L. 104-262, the ``Veterans Health Care 
Eligibility Reform Act of 1996,'' the VA developed policy that required 
the baseline of capacity for the spinal cord injury/disorder system of 
care to be measured by the number of staffed beds and the number of 
full-time equivalent employees assigned to provide care (the basis for 
PVA's site visits today). This law also required the VA to provide 
Congress with an annual capacity report to ensure that the VA is 
operating at the mandated levels of capacity for health care delivery 
for all specialized services. Unfortunately, the requirement for the 
capacity report expired in 2008.
    PVA has made reinstatement of this annual capacity report as a 
legislative priority for 2014. We would like to thank Rep. Jeff Denham 
for introducing H.R. 4198, the ``Appropriate Care for Disabled Veterans 
Act.'' This legislation would reinstate this critically important 
capacity reporting requirement. The report affords the House and Senate 
Committees on Veterans' Affairs, and the veteran stakeholders, the 
ability to analyze the accessibility of VA specialized care for 
veterans in such areas as SCI/D, mental health, women's health, and 
polytrauma. We urge the Committee to consider this legislation as soon 
as possible. Additionally, while this legislation focuses on VA 
specialized services, such a reporting requirement for all of VHA every 
few years would allow VA and Congress to have a more accurate 
reflection of what is needed to maintain VA's Health Care System.

Structure of the Veterans Health Administration

    The overall structure of the VHA has obscured accountability. By 
design (and perhaps intent), the current structure places too much 
unchecked power in the hands of the 21 loosely aligned VISN directors 
with little evidence of operational control and accountability at the 
VA Central Office level. The original vision for the VISN structure was 
an efficient management system with limited staffing that would allow 
the top leadership of the VHA to delegate responsibility for delivering 
services. Unfortunately, the VISN system has evolved into a costly 
model that has too many administrators and too much bureaucracy with 
not enough nurses, clinicians, and therapists to deliver actual 
services.
    Legislation has been considered in recent years that would reduce 
the number of VISNs significantly. We believe that the concepts of 
those bills have serious merit. In fact, we believe the time has come 
for the VHA to streamline itself and realign to a sharper focused group 
of networks with greater control retained at the VA Central Office 
level. Meanwhile, we maintain the position that Congress should not 
dictate specifically how many VISNs should be established to operate 
the VA Health Care System. Congress is not the appropriate entity to 
determine the optimal organizational structure of the VA Health Care 
System. That decision should be left to health care administrators at 
the top of the VA who have experience with these matters. However, that 
does not mean that significant pressure should not be brought to bear 
on VA management to make changes to the VISN structure, including 
reducing their numbers.
    Paralyzed Veterans also has serious concerns with the 
organizational realignment of the Chief Consultants of the specialized 
services at the VA Central Office. Under previous leadership, the VHA 
separated the Under Secretary of Health and VA Secretary by management 
filters added within the hierarchy. In other words, the Chief 
Consultant for SCI/D previously reported directly to the Under 
Secretary of Health, but now he or she reports to the Chief of Patient 
Services who reports to the Deputy Chief Under Secretary who then 
reports to the Under Secretary for Health. This reporting structure 
distances senior leaders from subject-matter advisers and filters 
concerns, essentially making the chief consultant of SCI/D an adviser 
to an adviser to an adviser who has direct access to the Under 
Secretary. It has rendered consultants, who report under Policy (10P), 
ineffective as they have no practical impact on the Operations (10N) 
side of VHA.
    This chasm between the operations and policy components of VHA 
creates variability and inconsistent interpretation of VHA policies, 
particularly in the SCI/D system of care. This has made it difficult to 
monitor compliance with directives on critical concerns, such as timely 
SCI/D patient transfer to hubs and administration of fee-basis care. It 
also muddles top-down, bottom-up communication and discourages lateral 
communication.
    Last, the current organizational structure has allowed for 
plausible deniability when serious systemic problems are identified. 
Senior VHA leadership was shielded from accountability in the wake of 
Legionella-related deaths in Pittsburgh, and colonoscopy-related deaths 
in Columbia and Augusta. As it is, while the VA touts itself as ``One 
VA,'' it really is 21 VAs (the VISNs) that function autonomously. It is 
time for this to change.

    Ongoing Problems With Prosthetics Procurement

    The VA Prosthetic and Sensory Aids Service (PSAS) has created a 
prosthetics and surgical products contracting center within the VA 
Office of Acquisition and Logistics that is responsible for ordering 
prosthetic devices that cost $3,000 or more. Additionally, the 
``warrant transition'' process added layers of bureaucracy by inserting 
a corps of administrators and acquisitions staff member into the 
clinical process supposedly driven by patient needs. Similarly, VHA 
downgraded the Chief Consultant for Prosthetics to a National Director 
and reversed course on a procurement process that was flawed by its 
former underpinning to the Federal Acquisition Regulations.
    The ``warrant transition'' process placed Title 38 U.S.C. Sec. 8123 
authority for purchases above the micro purchase threshold of $3,000 
(customized wheelchairs, limbs, surgical implants, etc.) in the hands 
of contracting specialists instead of on-site purchasing agents, thus 
creating physical and temporal distance between veterans with special 
needs and those who authorize purchases to meet those needs. Senior VA 
and VHA leaders who have oversight of acquisitions and procurement have 
made marginal progress in attempting to refine this process that is 
merely adequate for many instead of the best possible process available 
for all.
    Unfortunately, these changes have resulted in delayed delivery of 
prosthetic devices, the diminution of quality service delivery for 
disabled veterans, and prolonged hospital stays for veterans waiting 
for the prosthetic equipment that they need to safely move forward in 
the rehabilitation process. The implementation of the new warrant 
transition process has not unfolded as planned, and an increasing 
number of veterans are suffering the consequences, languishing in 
hospitals as in-patients, or at home without their much needed 
prosthetic equipment. The VA is not communicating effectively with 
veterans and stakeholders in the veterans community to learn of the 
various ways that this change is impacting veterans and the delivery of 
their care. PVA believes that VA's ``warrant transition'' process 
deserves more attention than it is currently receiving, and we 
recommend increased Congressional oversight to bring attention to the 
negative outcomes that have resulted from this change and to identify 
ways to address the issues.
    Although the ``warrant transition'' involves a small percentage of 
the total workload for the VHA, this change includes critical 
prosthetic devices such as artificial limbs, wheeled mobility chairs, 
and surgical implants. Delays in these procurements prove costly to 
both the government, in terms of unnecessarily extended hospital stays 
while awaiting equipment, and veterans, in terms of lost independence 
and quality of life.

VHA Rulemaking Without Stakeholder Input

    PVA has serious concerns that the VHA continues to develop new 
regulations with little to no input from external stakeholders. Some 
VHA workgroups are 
reportedly allowing one or two veterans to participate but limited 
information is offered on the details. Prosthetics directives are 
currently being drafted and posted with virtually no notification 
despite PVA's insistence that the rules that impact catastrophically 
disabled veterans include our expertly derived and experience-based 
input as they are being developed (most recently, the HISA VHA 1173 
directive), not as an afterthought when collegiality must necessarily 
give way to more adversarial means of engagement.

Focus on Underserved Veterans With MS and ALS

    The need for multiple sclerosis (MS) and amyotrophic lateral 
sclerosis (ALS) systems of care are well documented. Unfortunately, 
this critical need has largely ignored by senior VHA leadership. The MS 
system of care directive was published but not fully implemented, 
particularly with regard to staffing and funding, across all of the 
VHA. It is inconsistently administered leaving some veterans with 
substandard care while others enjoy the full realm of rehabilitative 
therapies.
    Meanwhile, the ALS directive was just approved after sitting on a 
senior VA official's desk for the past five years. It was approved 
without any substantive changes over that period of time. The fact that 
the VHA cannot get this done in a timely manner suggests a complete 
disregard for one of the most vulnerable populations of veterans. It is 
simply unacceptable that the VHA's lack of action on this issue leaves 
veterans with ALS with an inconsistent system.

Accredited Representative Status for VSOs

    PVA believes that serious steps should be taken to strengthen 
accredited representative status of Congressionally chartered veterans 
service organizations in the VHA. While the Veterans Benefits 
Administration (VBA) acknowledges the role of accredited 
representatives pursuant to applications for VA benefits on behalf of 
claimants, the accredited representative power of attorney is 
misunderstood by senior leaders in the VHA. In cases where a veteran 
desires to pursue a health benefit or appeal a clinical decision, some 
VHA leaders will arbitrarily limit statutorily authorized access to 
health information by invoking Privacy Act and HIPAA shields that have 
no application, particularly when the veteran has explicitly authorized 
access to records for the purpose of pursuing benefits. This creates a 
system where duly appointed veterans advocates are hindered in their 
ability to timely address health care issues and obtain benefits on 
behalf of clients. It also stifles a process that would otherwise 
reveal systemic problems. Denying access to accredited representatives 
denies veteran patients an important advocate who can assist with 
obtaining health care services and benefits.

VA Health Care

    Ultimately, PVA believes that the quality of VA health care is 
excellent, when it is accessible. In fact, as mentioned previously, VA 
patient satisfaction surveys reflect that more than 85 percent of 
veterans receiving care directly from the VA rate that care as 
excellent (a number that surpasses satisfaction in the private sector). 
The fact is that the most common complaint from veterans who are 
seeking care or who have already received care in the VA is timely 
access. PVA cannot deny that there are serious access problems around 
the country. The broad array of staff shortages that we previously 
mentioned in our statement naturally lead to the access problems that 
VA is facing across the nation. Many of the problems that the media 
continues to report are really access problems, not quality of care 
problems. While there are many detractors of the VA who would like to 
convince veterans and the public at large that the VA is providing poor 
quality care, that is simply not true. In fact, the complaints of 
veterans about access often ring true about health care delivery in 
private hospitals and clinics as well. It is no secret that wait times 
for appointments for specialty care in the private sector tend to be 
extremely long.
    We believe many of the access problems facing the VA Health Care 
System are the responsibility of Congress and the Administration 
together. The Administration (and previous Administrations) has 
requested wholly insufficient resources to meet the ever-growing demand 
for health care services, while at the same time attempting to fragment 
the VHA health system framework. Meanwhile, it has committed to 
operation improvements and management efficiencies that are not 
adequate enough to fill the gaps in funding. Similarly, Congress has 
been equally responsible for this problem as it continues to provide 
insufficient funding through the appropriations process to meet the 
needs of veterans seeking care.
    For many years, the co-authors of The Independent Budget--AMVETS, 
Disabled American Veterans, Paralyzed Veterans of America, and Veterans 
of Foreign Wars--have advocated for sufficient funding for the VA 
Health Care System, and the larger VA. In recent years, our 
recommendations have been largely ignored by Congress. Our 
recommendations reflect a thorough analysis of health care utilization 
in the VA and full and sufficient budget recommendations to address 
current and future utilization. Moreover, our recommendations are not 
clouded by the politics of fiscal policy. Despite the recommendations 
of The Independent Budget for FY 2015 (released in February of this 
year), the House approved earlier this year an appropriations bill for 
the VA that we believe is nearly $2.0 billion short for VA health care 
in FY 2015 and approximately $500 million short for FY 2016.
    While we understand that significant pressure continues to be 
placed on federal agencies to hold down spending and Congress has moved 
more toward fiscal restraint in recent years, the health care of 
veterans outweighs those priorities. If Congress refuses to acknowledge 
that it has not provided sufficient resources for the VA, and that many 
of these access problems that are being reported around the country are 
a result of those decisions, then we will. Until Congress and the 
Administration make a serious commitment to providing sufficient 
resources so that adequate staffing and capacity can be established in 
the VA Health Care System, access will continue to be a problem.
    Additionally, inadequate funding for VA infrastructure has weakened 
the capacity of the VA to provide care to veterans. This year the 
Administration requested $561 million for Major Construction. This 
included funding for only four primary projects and secondary 
construction costs--despite a backlog of construction projects that 
requires a minimum of $23 billion over the next 10 years in order to 
maintain adequate and serviceable infrastructure.
    If the Administration refuses to properly address this construction 
funding problem, then we ask Congress to fill this void. There is no 
doubt that the new funding (approximately $6.0 billion) requested by 
Secretary Gibson last week is critically needed. The Independent Budget 
has repeatedly expressed concerns with the woefully inadequate funding 
requests submitted by the Administration (and previous Administrations) 
and the amounts provided by Congress. Ultimately, if VA is not provided 
sufficient resources to address the critical infrastructure needs 
throughout the system, it will have no choice but to seek care options 
in other settings, particularly the private sector. Maintaining the 
capacity of the VA as a comprehensive health care provider and 
increasing the number of veterans seeking care within the private 
community is fiscally impossible. Therefore, funding VA's 
infrastructure needs is critical to its ability to provide safe, 
quality health care.
    Mr. Chairman and members of the Committee, we appreciate your 
commitment to ensuring that veterans receive the best health care 
available. We also appreciate the fact that this Committee has 
functioned in a generally bipartisan manner over the years. 
Unfortunately, even veterans issues are now held hostage to political 
gridlock and partisan wrangling. It is time for this to stop! Political 
interests do not come before the needs of the men and women who have 
served and sacrificed for this country. We call on this Committee, 
Congress as a whole, and the Administration to redouble your efforts to 
ensure that veterans get the absolute best health care provided when 
they need it, not when it is convenient. PVA's members and all veterans 
will not stand for anything less.
    This concludes my statement. I would be happy to answer any 
questions that you may have.

        Information Required by Rule XI 2(g)(4) of the House of 
        Representatives
        Pursuant to Rule XI 2(g)(4) of the House of Representatives, 
        the following information is provided regarding federal grants 
        and contracts.
        Fiscal Year 2013
        National Council on Disability--Contract for Services--$35,000.
        Fiscal Year 2012
        No federal grants or contracts received.
        Fiscal Year 2011

    Court of Appeals for Veterans Claims, administered by the Legal 
Services Corporation--National Veterans Legal Services Program--
$262,787.
    William Carl Blake, Acting Associate Executive Director for 
Government Relations, Paralyzed Veterans of America, 801 18th Street 
NW., Washington, D.C. 20006, (202) 416-7708.
    Carl Blake is the Acting Associate Executive Director for 
Government Relations for Paralyzed Veterans of America (PVA) at its 
National Office in Washington, D.C. He is responsible for the planning, 
coordination, and implementation of PVA's National Legislative and 
Advocacy Program agendas with the United States Congress and federal 
departments and agencies. He develops and executes PVA's Washington 
agenda in areas of budget, appropriations, health care, and veterans 
benefits issues, as well as disability civil rights. He also represents 
PVA to federal agencies including the Department of Defense, Department 
of Labor, Small Business Administration, the Department of 
Transportation, Department of Justice, and the Office of Personnel 
Management. He coordinates all activities with PVA's Association of 
Chapter Government Relations Directors as well with PVA's Executive 
Committee, Board of Directors, and senior leadership.
    Carl was raised in Woodford, Virginia. He attended the United 
States Military Academy at West Point, New York. He received a Bachelor 
of Science degree from the Military Academy in May 1998.
    Upon graduation from the Military Academy, he was commissioned as a 
Second Lieutenant in the Infantry in the United States Army. He was 
assigned to the 2nd Battalion, 504th Parachute Infantry Regiment (1st 
Brigade) of the 82nd Airborne Division at Fort Bragg, North Carolina. 
He graduated from Infantry Officer Basic Course, U.S. Army Ranger 
School, U.S. Army Airborne School, and Air Assault School. His awards 
include the Army Commendation Medal, Expert Infantryman's Badge, and 
German Parachutist Badge. Carl retired from the military in October 
2000 due to injuries suffered during a parachute training exercise.
    Carl is a member of the Virginia Mid-Atlantic chapter of the 
Paralyzed Veterans of America.
    Carl lives in Fredericksburg, Virginia, with his wife, Venus; son, 
    
Jonathan; and daughter, Brooke.

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