[Senate Hearing 113-]
[From the U.S. Government Publishing Office]



 
   MILITARY CONSTRUCTION AND VETERANS AFFAIRS, AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2015

                              ----------                              


                        TUESDAY, MARCH 25, 2014

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:05 a.m., in room SD-124, Dirksen 
Senate Office Building, Hon. Tim Johnson (chairman) presiding.
    Present: Senators Johnson, Reed, Pryor, Udall, Begich, 
Kirk, Collins, Hoeven, Johanns, and Mikulski.

                     DEPARTMENT OF VETERANS AFFAIRS

STATEMENT OF HON. ERIC K. SHINSEKI, SECRETARY
ACCOMPANIED BY:
        HON. DR. ROBERT A. PETZEL, M.D., UNDER SECRETARY FOR HEALTH
        HON. ALLISON A. HICKEY, UNDER SECRETARY FOR BENEFITS
        HON. STEVEN L. MURO, UNDER SECRETARY FOR MEMORIAL AFFAIRS
        MR. STEPHEN WARREN, EXECUTIVE IN CHARGE FOR INFORMATION AND 
            TECHNOLOGY
        MS. HELEN TIERNEY, EXECUTIVE IN CHARGE FOR THE OFFICE OF 
            MANAGEMENT AND CHIEF FINANCIAL OFFICER


                opening statement of senator tim johnson


    Senator Johnson. Good morning. This hearing will come to 
order.
    We meet today to review the President's fiscal year 2015 
budget request for the Department of Veterans Affairs (VA). 
Secretary Shinseki, I welcome you and your colleagues, and 
thank you for your appearance before this subcommittee.
    I am also pleased to welcome Chairwoman Mikulski to this 
hearing. She is a strong and tireless advocate of America's 
vets, and we welcome her support of the work of this 
subcommittee. Before I turn to my opening statement, I want to 
recognize the Chairwoman for any opening remarks she may have.
    Chairman Mikulski.


                statement of senator barbara a. mikulski


    Senator Mikulski. Mr. Chairman, in the interest of time, I 
waive my opening statement, and ask that it be included in the 
record.
    I just want to make two quick points.
    First of all, hats off to you, Mr. Chairman. I know this is 
your last official hearing on this committee with the head of 
the VA. And on behalf of the committee and the Senate, I just 
wanted to thank you for your tireless, unrelenting passion for 
helping veterans.
    And as we move ahead with our allocations and implementing 
the President's request and working with our partners, we want 
to make sure that our veterans have the best healthcare that 
they can get, and that their claims are handled as 
expeditiously as possible. And when you leave the Senate, you 
go out with a big drum roll with the gratitude and the thanks 
of the veterans. But I think we all just want to thank you and 
look forward to the testimony.
    I will reserve my questions for my appropriate time.
    [The prepared statement follows:]

           Prepared Statement of Senator Barbara A. Mikulski
    Thank you to Senators Johnson and Kirk for convening this hearing, 
and for your leadership on this subcommittee. I also want to thank all 
Members of the Committee who worked so hard to enact the omnibus. We 
left no bills behind, and showed we can govern. We have a budget deal 
for 2015, and the President's budget. We are beginning our hearings and 
will mark up our bills quickly. My goal is to get our work done by 
October 1 to avoid shutdowns and showdowns, and show the American 
people that we can continue to govern.
    Secretary Shinseki, I am happy to have you here. It's been an 
incredibly busy year, tackling the VA backlog, expanding healthcare, 
and increasing job opportunities among veterans. Your leadership and 
the work of your dedicated VA employees across the country is needed 
now more than ever.
    Thank you to the men and women who work at the VA, from healthcare 
providers to those on the front lines trying to reduce the backlog. 
Your mission is critical and we value and appreciate you. I am 
committed to a budget that supports our veterans and your mission.
    I am happy to see that your budget funds programs to improve mental 
health initiatives, programs for women veterans, prosthetics, veterans 
jobs, and veterans homelessness.
    I am also pleased to see that there is an increase in funds to 
address the VA backlog, specifically to fund the Veterans Benefits 
Management System and Veterans Claims Intake Program. One of my biggest 
priorities is reducing the backlog of pending veterans' disability 
claims.
    Last year I used my power as Full Committee Chair to convene a 
meeting on the backlog. Our goal was to cut across all the agency 
smoke-stacks. We identified the challenges that are preventing better 
inter-agency collaboration and got moving on solutions to solve the 
problem.
    I was happy to work with Senators Johnson and Kirk to include a 10-
Point Checklist for Reform in the 2014 Omnibus. You've made progress 
over the last 12 months, there are 248,000 fewer backlogged cases 
pending than this time last year. That's a reduction of 41 percent. But 
the average veteran is still waiting over 5 months to have his or her 
claim answered.
    Unfortunately there has not been as much progress in the Baltimore 
Regional Office. This office continues to be the worst performing 
office in the entire country. More than 62 percent of cases in 
Baltimore have been pending for more than 125 days, and the average 
time veterans are waiting is 6 months. This is inexcusable.
    I have a number of questions I will ask later in this hearing, but 
I will ask you to be personally involved in the selection of the next 
Director at the Baltimore Regional Office, and for an inventory of 
remaining issues in Baltimore so we can take another aggressive step 
forward together in fixing this problem.

    Senator Johnson. Thank you, Madam Chairwoman.
    Mr. Secretary, as you know, this is my last year of 
chairing this subcommittee, as I relinquish my chairmanship 
when I retire from the Senate. I have enjoyed my time as 
chairman and will miss working on these important issues.
    The VA is our first and last line of defense in meeting the 
changing needs of our Nation's vets from current and past 
conflicts, and I appreciate the leadership you have shown in 
moving the VA forward to find 21st century solutions to address 
the most critical needs facing our vets.
    I note that your priorities have not wavered from the first 
time you appeared before this subcommittee: to end homelessness 
among vets, to increase access to care, and to speed claims 
processing.
    I think you have made great progress in the first two 
categories over the past 6 years, and I believe you are 
beginning to make progress in recovering from significant 
setbacks in claims processing. But I am sure you will agree 
with me that there is much more to be done. The progress you 
have made in addressing homelessness, access to care, and 
claims processing will need to be sustained for the long term. 
That will require a sustainable funding commitment and an agile 
management model that is proactive, not reactive.
    And so I ask you today to reflect on the long view of the 
future of the VA. Medical care costs are going to continue to 
rise. Compensation and pension costs are going to continue to 
rise. Homelessness among vets will continue to be a chronic 
problem. Access to care will pose new challenges as the current 
generation of vets, many of them from the Guard and Reserve, 
disperses throughout the country, often in rural areas that 
pose unique challenges to accessing medical care. And timely 
claims processing will be a continuing challenge as new and 
more complex claims flood a system that can sustain a surge 
capacity for only so long.
    There are also looming problems that are not reflected in 
your priority initiatives, headlined by VA facility 
sustainment. Quality VA medical care cannot be provided in 
substandard facilities, and yet the VA's investment in major 
and minor construction and non-recurring maintenance is 
woefully inadequate and falling further behind every year. If 
these shortfalls are not addressed soon, patient care will 
suffer.
    It was not that long ago that VA healthcare was decried as 
being substandard. That has changed dramatically to the point 
that VA healthcare is now viewed as a model of excellence. That 
must not be allowed to deteriorate. Facility replacement, 
repair, and maintenance are key to maintaining the quality of 
VA medical care, but the VA budget request for these essential 
investments is nowhere near adequate to maintaining these 
facilities.
    I look forward to discussing these and other long-term 
challenges facing the VA.
    I now ask my ranking member for any opening remarks he 
cares to make.
    Senator Kirk.

                     STATEMENT OF SENATOR MARK KIRK

    Senator Kirk. Thank you, Mr. Chairman.
    Let me just show a graphic to the committee. I think 
members already have this.
    This shows a shortening of the disability claims recently, 
due to the Johnson-Kirk Ten Point Plan. I would say Mikulski 
Plan on that. I randomly just picked Chicago and Baltimore for 
the wait times on disability.
    For Baltimore, it is now 295 days; for Chicago, it is 322 
days just for the VA to determine if you are disabled. We have 
now shortened that Mr. Secretary, with your diligent work, by 
200 days, given the Johnson Ten Point Plan. I would say 
Johnson-Tina Ten Point Plan because Tina helped really put it 
together. We have to give credit where credit is due here.
    [The prepared statement follows:]
                Prepared Statement of Senator Mark Kirk
    Thank you, Mr. Chairman. I'm pleased to be here today with you as 
ranking member of this subcommittee. As you have announced your 
retirement, I am sad to say this is the last VA budget rollout hearing 
we will handle together. I appreciate your service to our Nation's 
veterans on this subcommittee, and I will truly miss working with you 
on these important issues. I would like to join you in welcoming 
Secretary Shinseki and our other witnesses and guests to discuss the 
President's 2015 budget request for the Department of Veterans Affairs.
    Mr. Chairman, the VA under the leadership of Secretary Shinseki is 
doing a great job taking care of our Nation's veterans and I would like 
to thank him for his hard work and dedication. There are many topics we 
need to discuss today, but I want to focus on a few important to all 
veterans and specifically those in my home State of Illinois: the 
electronic health record, the disability claims backlog, and the Lovell 
Federal Health Care Center in Chicago.
                        electronic health record
    Last year, the Department of Veterans Affairs and Defense decided 
not to pursue a single, common, joint, integrated Electronic Health 
Record. Instead, the VA is now working to evolve VistA while the 
Department of Defense is planning to select a commercial product. My 
concern is both Departments are moving along separate paths, upgrading 
their own Electronic Health Records, and hoping at the end of each 
journey these two distinct record systems will talk to one another. Mr. 
Secretary, I want to hear assurances from you today that 
interoperability with the Department of Defense is your main goal, and 
I want to know how you are guaranteeing that. Our men and women in 
uniform need to trust their health record will follow them seamlessly 
from the day they raise their right hand through their time as a proud 
veteran of this Nation, and we will work with you and your Department 
to make this a reality.
                   lovell federal health care center
    Mr. Secretary, as you know, the long-serving director of Lovell 
Federal Health Care Center in Chicago has retired. My friend Pat 
Sullivan has done an outstanding job leading this joint VA/DOD facility 
since it was stood up in 2010. His work has been remarkable, as he has 
dealt with some great challenges fostering this new model of joint care 
between your Department and the Department of Defense. In my view, this 
model has been a tremendous success in Chicago and has enjoyed strong, 
effective leadership. I would like to hear your views on the success of 
this facility and also hear where you are in the process of bringing on 
board another director to lead continued success.
                           claims processing
    Like everyone here today, I remain frustrated by the backlog of 
disability claims waiting to be adjudicated by your Department. I am 
happy to hear of the advances your folks have made in cutting down the 
backlog, however, I am as concerned as ever about the number of 
veterans who have yet to receive closure on their disability claim. The 
number of days a veteran waits for his or her claim decision in the 
Chicago Regional Office is still unbelievably high. Assure me today 
that you are putting into place the people and the processes that will 
end this backlog and insure we aren't here 1 year or 5 years from now 
discussing the same problems.
    Mr. Chairman, this subcommittee has always worked hard together to 
provide the Department with the all the resources it needs. I look 
forward to working with you to make sure we give our veterans all they 
have earned.
    Thank you, Mr. Chairman.

    Senator Johnson. Thank you, Senator Kirk.
    Again, Mr. Secretary, welcome and thank you for appearing 
before this subcommittee. I understand that yours will be the 
only opening statement. Your full statement will be included in 
the record, so please feel free to summarize your remarks.

               SUMMARY STATEMENT OF HON. ERIC K. SHINSEKI

    Mr. Shinseki. Chairman Johnson, Ranking Member Kirk, 
Chairwoman Mikulski, other distinguished members of the 
subcommittee.
    Let me begin by extending to Chairman Johnson, much as the 
Chairwoman did, and I do it on behalf of all of us at VA, my 
deep appreciation for his many years of service to the veterans 
of South Dakota, but indeed, veterans all across this country.
    Mr. Chairman, your advocacy for serving our rural and 
highly rural veterans has been a hallmark, as well as serving 
them as well as VA serves veterans in the urban areas, and that 
has been a particular focus of yours.
    Your push to invest in tele-health initiatives, to 
modernize our electronic medical records, to automate our 
claims processing, and your abiding commitment to Native 
American issues, have been strong and consistent. Thank you for 
all you have accomplished on behalf of our Nation's veterans. 
We are honored to have worked these priorities, among many 
others, with you.
    To the members of the subcommittee, thank you for this 
opportunity to present the President's fiscal year 2015 budget, 
and 2016 advance appropriations requests for the Department of 
Veterans Affairs. I am now working my sixth budget cycle with 
all of you, and we at VA deeply appreciate your unwavering 
support for our Nation's veterans.
    I also want to acknowledge the representatives of our 
veterans service organizations who are here today. Their 
insights always make us better at our mission and their support 
is most important. I acknowledge their presence and thank them 
for their help in caring for our veterans, their families, and 
our survivors.
    Mr. Chairman, let me introduce the VA leaders who are here 
with me on panel today. To my left, and your far right, is 
Stephen Warren, our Executive in Charge of Information and 
Technology. Next to me is Helen Tierney, VA's Executive in 
Charge of the Office of Management, and more importantly, our 
Acting Chief Financial Officer. To my right, is Dr. Robert 
Petzel, Under Secretary for Health; then Allison Hickey, Under 
Secretary for Benefits; and finally, Steve Muro, Under 
Secretary for Memorial Affairs.
    Mr. Chairman, thank you for accepting my written statement 
for the record.
    Let me begin by saying that the 2015 budget and 2016 
advance appropriations requests demonstrate, once again, 
President Obama's steadfast commitment to our Nation's 
veterans. His leadership, the Congress, especially members of 
this subcommittee, and that of our veteran service 
organizations, has allowed us for 5 years now to answer 
President Lincoln's charge from 149 years ago to care for those 
who shall have borne the battle, and their families, and our 
survivors. Thanks to the members, all of you, for your 
commitment to veterans, and I seek, once again, your support of 
these budget requests.
    The President's vision, reflected in these budget requests, 
is about empowering veterans to help rebuild the middle class 
in this country, much as they did after World War II with the 
original GI Bill, through quality healthcare, benefits, 
education, and training, and employment; all that enable 
achieving the American dream.
    The VA's 2015 budget request seeks $163.9 billion; $68.4 
billion of that amount in discretionary funding. This includes 
medical care collections, and represents an increase of 3 
percent above our fiscal year 2014 enacted funding level.
    The other piece of that is $95.6 billion in mandatory 
funding. This budget also requests $58.7 billion for the fiscal 
year 2016 advance medical care appropriations, an increase of 
$2.7 billion, or 4.7 percent above the 2015 budget request we 
submitted.
    It is another strong budget and your support of it is 
critical to providing veterans the care and benefits they have 
earned through their service and sacrifice, and our ability to 
deliver on that.
    It enables VA to further the significant progress made on 
our department's three priorities, which we established 5 years 
ago now, and we have put out well into the future so we could 
continue to work at it. And Mr. Chairman, you mentioned 
expanding access, through veterans' access to the benefits and 
services we provide; by eliminating this thing called the 
disability claims backlog in 2015, next year, and ending the 
rescue of homeless veterans in 2015, as well.
    Since 2009, we focused the resources you provided to 
address these three key priorities. Other requirements as well, 
but clearly focused on these three to best serve veterans.
    In terms of access, more than 2 million additional veterans 
have enrolled in VA healthcare. We opened our 151st VA medical 
center, the first in 17 years, in Las Vegas. We have increased 
our community-based outpatient clinics by a net gain of 55, 
bringing our total community-based outpatient clinics to 820.
    More than 1 million veteran and family member students have 
received VA assistance with educational assistance and 
vocational training. Nearly 90 percent of all veterans now have 
a burial option within 75 miles of home, and we expect to be 
able to increase that to 96 percent in 2017.
    In terms of the disability claims, the backlog has declined 
over 40 percent since March of last year, in the last 12 
months, and many thanks to the committee for the Ten Point Plan 
you suggested.
    We are transitioning claims from paper to digital 
processing. This is a huge turnover year, a transition year for 
us. We are still doing paper and learning to do digits but 
every day, more digits, less paper. We will work through this 
transition this year. As I indicated, we are on track to end 
the backlog in 2015.
    In terms of veterans' homelessness, the estimated number of 
homeless veterans fell by 24 percent between 2010 and 2013, and 
we expect another reduction when this year's point-in-time 
count is finalized, which was just conducted in January. When 
that count is tallied by the Department of Housing and Urban 
Development (HUD), we expect another drop in the numbers.
    These are some of our key accomplishments, and for these, I 
would tell you momentum is up for these three priorities, as 
well as others. We are making good progress across the board, 
and we will continue to leverage every resource in the budget 
requests to do what is right for veterans.
    As I have promised for 5 years now, the resources that this 
committee and the Congress provide are important and we focus 
on them. We put resources to effective use, we are efficient 
about resources, and we are accountable for how those 
expenditures are made.
    Again, thank you for the opportunity to appear here today, 
and I look forward to your questions.
    [The statement follows:]
            Prepared Statement of the Hon. Eric K. Shinseki
    Chairman Johnson, Ranking Member Kirk, distinguished members of the 
Senate Appropriations Committee, Subcommittee on Military Construction, 
Veterans Affairs and Related Agencies: Thank you for the opportunity to 
present the President's 2015 budget and 2016 advance appropriations 
requests for the Department of Veterans Affairs (VA). This budget 
continues the President's historic initiatives and strong budgetary 
support for veterans, their families, and survivors. We value the 
sustained support that Congress has demonstrated in providing the 
resources and legislative authorities needed to honor our Nation's 
promises to these unique and special citizens. Let me acknowledge our 
partners here today--the veterans service organizations--whose insight 
and support make us better at fulfilling our mission.
    After more than a decade of war, many servicemembers are returning 
home and making the transition to veteran status. As the war in 
Afghanistan enters its final chapter, our work is more urgent than 
ever. The current generation of veterans will help to grow our middle 
class and provide a significant return on the Nation's investments in 
them. The President fully supports veterans and their families, and by 
providing them the care and benefits they have earned, we pay tribute 
to the sacrifices that veterans have made for this Nation.
    The 2015 budget for VA requests $163.9 billion--$68.4 billion in 
discretionary funds, including medical care collections, and $95.6 
billion in mandatory funds for veterans benefits programs. The 
discretionary request reflects an increase of $2.0 billion (3.0 
percent) above the 2014 budget level. The budget also requests a 2016 
advance appropriation for medical care of $58.7 billion, an increase of 
$2.7 billion (4.7 percent) above the 2015 budget. The President's 2015 
budget will allow VA to operate the largest integrated healthcare 
system in the country, including nearly 1,750 VA points of healthcare 
and approximately 9.3 million veterans enrolled to receive healthcare; 
the ninth largest life insurance provider, covering both Active Duty 
servicemembers and enrolled veterans; an education assistance program 
serving nearly 1.1 million students; a home mortgage program with a 
portfolio of over 2 million active loans, guaranteed by the agency; and 
the largest national cemetery system that leads the Nation as a high-
performing organization, with projections to inter 128,100 veterans and 
family members in 2015.
              growing demand for va services and benefits
    Long after conflicts end, VA requirements continue to grow, due to 
the substantial needs of veterans. VA's budgetary requirements arise 
from our Nation's national security engagements, which are not within 
our control. As the President said on Veterans' Day last November, 
``when we talk about fulfilling our promises to our veterans, we don't 
just mean for a few years; we mean now, tomorrow, and forever.'' Over 
the next decade, the Department of Defense (DOD) predicts that military 
separations will approach three million. This growing population is 
demanding more services from VA than ever before. Currently, 11 million 
of the approximately 22 million veterans in this country are 
registered, enrolled, or use at least one VA benefit or service, and 
this number will undoubtedly continue to grow.
                      meeting va's top three goals
    In 2015, our challenges are clear and significant. VA must deliver 
on the ambitious goals we established 5 years ago, which are to:
  --Increase veterans' access to VA benefits and services;
  --Eliminate the disability claims backlog in 2015; and
  --End veterans' homelessness in 2015.
    The 2015 budget is critical to VA meeting these goals. Without the 
proper level of funding to meet the growing demand for benefits and 
services, investing in our physical and Information Technology (IT) 
infrastructure to assure reliable access, eliminating the disability 
claims backlog, and ending veterans' homelessness become even more 
difficult. VA remains committed to meeting these challenges and 
appreciates the continued support of the Congress.
                        stewardship of resources
    At VA, we are committed to responsible stewardship, using resources 
effectively and efficiently and aggressively identifying budget 
savings. Over the past 3 years, we have averaged $1.6 billion annually 
in efficiencies and budget savings, and in 2015, that commitment to 
budget efficiencies and savings is more than $2 billion. We are 
attentive to areas in which we need to improve our operations, and are 
committed to taking swift corrective action to eliminate any practices 
that do not deliver value for veterans. For 15 consecutive years, VA 
delivered clean financial audits, during which time material weaknesses 
were reduced from 4-to-1, and in 2013, for the first time, we had no 
significant deficiencies, having eliminated 16 prior significant 
financial deficiencies. This is an area of major accomplishment in our 
internal controls and fiscal integrity.
                         information technology
    To serve veterans as well as they have served us, we are working to 
deliver a 21st century VA that provides medical care, benefits, and 
services through a secure digital infrastructure. IT affects every 
aspect of what we do at VA. It has a direct impact on the quality of 
healthcare we provide veterans; our ability to process claims 
efficiently; and our ability to provide veterans' benefits and 
services. In 2013, VA IT systems supported nearly 1,750 VA points of 
healthcare: 151 medical centers, 135 community living centers, 103 
domiciliary rehabilitation treatment programs, 820 community-based 
outpatient clinics, 300 vet centers, and 70 mobile vet centers. The 
corresponding increase we have seen in the medical care spending for 
these facilities directly translates to new and increased services 
provided to veterans. To provide veterans access and benefits, we must 
make the necessary investments in IT innovations and deployments.
    Our 2015 budget requests $3.9 billion for IT, consisting of $531 
million for development; $2.3 billion for sustainment; and $1 billion 
for more than 7,400 staff, most of whom serve in VA hospitals and 
regional offices. The request will sustain our infrastructure while 
making necessary investments in critical business processes, such as 
modernizing healthcare scheduling, streamlining benefits processing, 
enhancing and modernizing VA's electronic health record, enhancing data 
security, and achieving health data interoperability with DOD.
    Information security is a top priority at VA. The 2015 budget 
requests $156 million for information protection and cybersecurity, an 
increase of $33 million (27 percent) over 2014. VA is constantly 
strengthening information security and improving technology and 
processes to ensure veteran data and VA's network are secure. Like any 
organization, public or private, we must continue to adapt. Our 
security posture is based on a ``defense-in-depth'' approach, which 
includes our partners at the Department of Homeland Security who 
maintain an over watch on our exterior perimeter. Working inward from 
our firewalls, VA has additional layers and protections that are 
constantly monitoring potential threats.
    Technology is also a critical component for achieving our goal to 
eliminate the disability claims backlog in 2015. The 2015 budget 
requests $137 million in IT funding for the Veterans Benefits 
Management System (VBMS), including $44.5 million for development and 
$92.5 million for sustainment. The 2015 development funds will allow VA 
to electronically process disability compensation claims in VBMS, from 
establishment to award. Planned enhancements and increased automation 
will allow end-users to focus on more difficult disability compensation 
claims by reducing the time required to process less complex claims. 
Sustainment funds will support the infrastructure behind VBMS as well 
as the deployment of additional new functionality features.
    The 2015 budget continues our progress toward evolving VA's VistA 
electronic health record (EHR) and achieving seamless integration of 
health data with the DOD by 2017. The budget requests $269 million to 
help achieve our shared goal of providing the best possible support for 
servicemembers and veterans. In the near term, we are working to create 
seamless integration of DOD, VA, and private provider health data. In 
the mid-term, we are working to modernize the software supporting DOD 
and VA clinicians. Together, these two goals will help to create an 
environment in which clinicians and patients from both Departments are 
able to share current and future healthcare information for continuity 
of care and improved treatment. As we strive to build on our successful 
history of health data sharing and collaboration, we understand our EHR 
modernization efforts are complicated, dynamic, and multi-faceted.
        improving and expanding access to benefits and services
    The number of veterans receiving VA benefits and services has grown 
steadily and will continue to rise as overseas conflicts end and more 
servicemembers transition to veteran status. In 2015, the number of 
patients treated within VA's healthcare system is projected to reach 
6.7 million, an increase of nearly 1 million patients (17.4 percent) 
since 2009. Within VBA, the number of veterans and survivors receiving 
compensation and pension benefits will approach 5 million in 2015, 
while the number of education and vocational rehabilitation 
beneficiaries will exceed 1.1 million.
    We continue to improve access to VA services by opening new, and 
improving current, facilities closer to where veterans live. Since 
January 2009, we have added approximately 55 community-based outpatient 
clinics (CBOCs), for a total of 820 CBOCs, and the number of mobile 
outpatient clinics and Mobile Vet Centers, serving rural veterans, has 
increased by 21, to the current level of 78. In addition, while opening 
new and improved facilities is essential for VA to provide world-class 
healthcare to veterans, so too is enhancing the use of ground breaking 
new technologies to reach countless other veterans. We continue to 
invest in ``taking the facility to the Veteran''--through expanded 
access to telehealth, sending mobile vet centers to reach veterans in 
rural areas where certain services are limited or difficult to reach, 
and by deploying social media to connect with veterans to share 
information on the VA benefits they have earned.
    The Affordable Care Act (ACA) expands access to coverage, provides 
new ways to bring down healthcare costs, improves the Nation's 
healthcare delivery system, and has important implications for VA. VA 
is ensuring a coordinated and collaborative approach to ACA 
implementation. We estimate that there are approximately 1.3 million 
uninsured veterans, of which 1 million may be eligible for, but not 
enrolled in VA healthcare. We will continue our education and outreach 
efforts so veterans know the healthcare law does not affect their VA 
health benefits or out-of-pocket costs, and that
    Veterans enrolled in VA healthcare do not need to take additional 
steps to meet ACA's new coverage standards. We will also encourage 
veterans' family members not enrolled in a VA healthcare program to 
obtain coverage through the health insurance marketplaces.
    A large part of our veteran population hails from the small towns 
of rural America. Some 3.1 million veterans enrolled in VA's healthcare 
system live in rural or highly rural areas, about 36 percent of all 
enrolled veterans. In total, more than $17.36 billion were obligated in 
2013 for the healthcare needs of rural veterans. As technology advances 
and broadband access expands across rural America, we have been able to 
extend the availability of VA healthcare through telemedicine, Web-
based networking tools, and the use of mobile devices--all of which 
help improve access to care and support economic development for people 
in rural areas. Telehealth is a transformative breakthrough in 
healthcare delivery in 21st century medicine, allowing care to reach 
veterans who otherwise may not have access, especially those who live 
in rural and extremely remote areas. VA has made a significant 
investment in telehealth, which translates to a nearly seven-fold 
increase in funding since 2009. The 2015 budget requests $567 million 
for telehealth, including $72 million for Rural telehealth.
    Changing demographics are driving transformation at VA. Women now 
comprise nearly 15 and 18 percent of today's Active Duty military 
forces and Reserve component, respectively. Women are the fastest 
growing segment of our veteran population. Since 2009, the number of 
women veterans enrolled in VA healthcare increased by almost 29 
percent, to 629,683. The 2015 budget includes $403 million for gender-
specific healthcare services for women veterans. Today, nearly 49 
percent of our facilities have comprehensive women's clinics, and every 
VA healthcare system has designated women's health primary care 
providers and a women veterans' program manager on staff.
    The Caregivers and Veterans Omnibus Health Services Act (Caregivers 
Act) marked a major step forward in America's commitment to those who 
provide daily care for wounded warriors, who have borne the battle for 
us all. The sustainment phase of the Caregivers program began in 2013, 
and includes application processing; stipends; travel and healthcare 
coverage; education, training, and competency; and IT support. The 2015 
budget includes $306 million for the Caregivers program, including $235 
million for caregiver stipends.
    Since VA began implementation of the Honoring America's Veterans 
and Caring for Camp Lejeune Families Act in August 2012, more than 
10,100 veterans have contacted VA concerning Camp Lejeune-related 
treatment, as of February 27, 2014. Of these, roughly 8,300 were 
already enrolled in VA healthcare. Veterans who are eligible for care 
under the Camp Lejeune authority, regardless of current enrollment 
status with VA, will not be charged a co-payment for healthcare related 
to the 15 illnesses or conditions recognized, nor will a third-party 
insurance company be billed for these services. VA continues a robust 
outreach campaign to these veterans and family members while we press 
forward with implementing this law. The 2015 budget includes $51 
million to provide healthcare for veterans and family members who were 
potentially exposed to contaminated drinking water at Camp Lejeune.
    The Grants for Construction of State Extended Care Facilities 
program provides grants to States to acquire or construct State home 
facilities; furnish domiciliary or nursing home care to veterans; and 
expand, remodel, or alter existing buildings for furnishing domiciliary 
or nursing home care to veterans in State homes. VA's funds are 
leveraged by State-matching funds, which provide 35 percent of project 
costs. The 2015 budget is requesting $80.0 million for this program. 
The 2015 budget request will support life-safety projects, new 
construction, and renovation projects.
    The 2015 budget requests $99.6 million in IT funding for the 
Veterans Relationship Management (VRM) initiative, which is 
transforming veterans' access to VA benefits and services by empowering 
veterans with new self-service tools. In addition, VRM is essential to 
achieving our access goals. We are transforming VA's national call 
centers into service centers by delivering enhanced, integrated, 
system-wide telephone capabilities. VBA is also implementing the Client 
Relationship Management Unified Desktop that provides veterans or 
beneficiary contact history and a consolidated view of benefit programs 
for our employees to enhance the customer's experience and provide 
responsive and complete information.
    As part of this experience, VBA aggressively promoted eBenefits and 
improved veterans ability to enroll in and access VA benefits and 
services. The joint VA-DOD eBenefits Web portal is a personalized 
central location for veterans, servicemembers, and their families to 
research, access, and manage their benefits and personal information. 
More than 3.2 million servicemembers and veterans are enrolled in 
eBenefits, and our goal is to expand enrollment to 5 million users in 
2015. Over 50 self-service features, including online filing of claims, 
online uploading of evidence, and claim status tracking are now 
available in eBenefits; VA and DOD continue to expand functionality 
with each quarterly release.
    VA also continues to increase access to burial services for 
veterans and their families through the largest expansion of its 
national cemetery system since the civil war. At present, approximately 
90 percent of the Veteran population--about 20 million Veterans--has 
access to a burial option in a national, State, or tribal Veterans 
cemetery within 75 miles of their homes. In 2004, only 75 percent of 
Veterans had such access. This dramatic increase is the result of a 
comprehensive strategic planning process that efficiently uses 
resources to serve the greatest number of Veterans.
               improving access to mental health services
    We have been a Nation at war for more than a decade, and the state 
of servicemembers' and Veterans' mental health is a national priority. 
At VA, meeting the individual mental health needs of Veterans is more 
than a system of comprehensive treatments and services; it is a 
philosophy of ensuring that Veterans receive the best mental healthcare 
possible, while focusing on the overall mental well-being of each 
Veteran. VA remains committed to doing all we can to meet this 
challenge.
    Through the strong leadership of the President and the support of 
Congress, Veterans' access to mental healthcare has significantly 
improved. Some of the stigma associated with seeking help has 
diminished. We proactively screen all Veterans for PTSD, depression, 
TBI, problem drinking, substance abuse, and military sexual trauma 
(MST) to identify issues early and provide treatments and intervention 
opportunities. We know that when we diagnose and treat people, they get 
better. Rates of suicide among those who use VHA services have not 
shown increases similar to those observed in all Veterans and the 
general U.S. population. Since 2006, the number of Veterans receiving 
specialized mental health treatment has risen each year from 927,000 to 
more than 1.3 million in 2013. In addition, Outpatient visits and 
encounters will increase to 12.8 million in 2015, from 12.1 million in 
2013. Vet centers are another avenue for mental healthcare access, 
providing services to 195,913 Veterans and their families in 2013.
    While we made significant progress in serving the growing number of 
Veterans seeking mental healthcare, our work is not done. The 2015 
budget includes $7.2 billion for mental healthcare, an increase of $309 
million (4.5 percent). VA efforts are crucial to dispel the lingering 
stigma surrounding treatment, and help Veterans regain their dignity 
and the ability to hold meaningful employment and maintain a home, 
which helps, in turn, strengthen our Nation's economy.
    In response to the growing demand for mental health services, VA 
enhanced capacity and improved the system of care so that services are 
more readily accessible. In 2012, VA completed a comprehensive 
assessment of the mental health program at every VA medical center and 
is using the results of that assessment to improve programs and share 
best practices across VISNs and facilities. VA also held mental health 
summits at each of our 151 medical centers, broadening the community 
dialogue between clinicians and stakeholders.
    We are developing new measures to gauge mental healthcare 
performance, including timeliness, patient satisfaction, capacity, and 
availability of evidence-based therapies. Evidence-based staffing 
guidelines are being written for specialty and general mental health. 
In addition, VA is working with the National Academy of Sciences to 
develop and implement measures and corresponding guidelines to improve 
the quality of mental healthcare. To help VA clinicians better manage 
Veteran patients' mental health needs, VA is developing innovative 
electronic tools. For example, clinical reminders give clinicians 
timely information about patient health maintenance schedules, and the 
high-risk mental health national reminder and flag system allows VA 
clinicians to flag patients who are at-risk for suicide. When an at-
risk patient does not keep an appointment, clinical reminders prompt 
the clinician to follow up with the Veteran.
    Since its inception in 2007, the VA's Veterans' Crisis Line in 
Canandaigua, New York, answered nearly 1,000,000 and responded to more 
than 143,000 texts and chat sessions from Veterans in need. The 
Veterans' Crisis line provides 24/7 crisis intervention services and 
personalized contact between VA staff, peers, and at-risk Veterans, 
which may be the difference between life and death. In the most serious 
calls, approximately 35,000 men and women have been rescued from a 
suicide in progress because of our intervention--the rough equivalent 
of two Army divisions.
                     eliminating the claims backlog
    VA has no greater responsibility than ensuring Veterans and their 
survivors receive timely, accurate decisions on their disability 
compensation and pension claims. Too many Veterans have waited too long 
to receive their benefits--and this has never been acceptable to VA, 
including the employees of VBA, over half of whom are Veterans. To 
attack this longstanding problem, we launched a historic plan to 
transform our people, processes, and technology. Our strategy advances 
VBA's tools, streamlines claims processes, trains its workforce, 
improves workload management, and meaningfully enhances interaction 
with Veterans and stakeholders to deliver more timely and accurate 
benefit decisions and services to Veterans and their families. Despite 
an escalating workload brought about by the correct decisions for 
Veterans on agent orange, gulf war, and combat PTSD presumptions--and 
successful outreach to Veterans informing them of their benefits--we 
are making steady progress toward our goal of eliminating the 
disability claims backlog in 2015.
    The 2015 budget requests $2.5 billion for VBA, an increase of $28.8 
million from 2014. VBA projects a beneficiary caseload of 5.1 million 
in 2015, with more than $78.7 billion in disability compensation and 
pension benefits obligations. We expect to process 1.5 million 
compensation and pension claims in 2015, up from 1.25 million claims in 
2014, an increase of nearly 17 percent over 2014.
    Through our claims transformation initiatives, the use of mandatory 
overtime, and other innovative strategies, we are making real progress 
in reducing the disability claims backlog. As of March 8, 2014, the 
backlog stood at 368,829 claims, down 242,244 (40 percent) from its 
highest point on March 25, 2013. Additionally, under its Oldest Claims 
Initiative that began in April 2013, VA provided decisions to over 
500,000 Veterans whose claims had been pending the longest. VA 
continues to work closely with DOD, the Internal Revenue Service, the 
Social Security Administration, and our other Federal partners to 
identify electronic data-sharing opportunities and process reforms to 
streamline workflows and limit paper claims filing.
    VBMS is key to VBA's transformation and success in meeting our 2015 
goal. In June 2013, VBA completed national deployment of VBMS--6 months 
ahead of schedule--providing access to over 25,000 end-users. 
Approximately 80 percent of VA's pending disability claims are in a 
digital format for electronic processing in VBMS. Moving to a digital 
environment is critical. VA anticipates there will be approximately 
250,000 new servicemembers transitioning to Veteran status each of the 
next 4 years, for a total of 1 million new Veterans added during the 
next 4 years. As a result of our increased efforts to enable more 
Veterans to access the benefits they have earned and deserved, many of 
these Veterans are likely to file a claim with VBA within the first 
year of separation.
    The 2015 budget includes $138.7 million for continued investment in 
the Veterans Claims Intake Program (VCIP), which converts paper claims 
into an electronic format and enables electronic transfer of medical 
and personnel records. This electronic transfer is critical to creating 
the necessary digital environment for populating the eFolders and 
supporting end-to-end electronic claims processing for each stage of 
the claims lifecycle. Although VA continues to accept paper claims from 
Veterans who are not familiar with or cannot access computer 
technology, VBA is working with stakeholders to increase the number of 
claims submitted electronically. VBA now converts paper claims to 
electronic format as we receive them, saving time and effort and 
improving accuracy. As of December 2013, over 25,000 VBMS users could 
access 424 million electronic images converted from paper.
    The 2015 budget includes $94.3 million for the Board of Veterans' 
Appeals (the Board), which we are requesting as a new appropriation 
separate from the General Administration appropriation. The Board 
provides direct service to Veterans and their families by conducting 
hearings and issuing final appeals decisions. VA is actively pursuing 
initiatives to improve the appeals process and reduce wait times for 
Veterans, including a Board-led initiative that pre-screens appeals to 
ensure that the record is fully developed and ready for adjudication. 
The Board is also streamlining decision writing to increase output and 
efficiency. Expanded use of VBMS and the eventual incorporation of 
appeals functionality in VBMS will save resources currently spent 
handling, accessing, storing, and transporting paper claims files 
between the Board and VBA regional offices. The Board completed major 
technological upgrades to its video teleconference (VTC) equipment and 
the Board now conducts slightly over half of their hearings by video 
teleconference, a significant increase from 29 percent in 2009. We 
project appeals will increase to 72,786 cases in 2015, an increase of 
12 percent from 2014's 64,941 cases.
                      ending veteran homelessness
    Every Veteran who has served America ought to have a home in 
America. We made great progress toward achieving our goal to end 
Veteran homelessness in 2015. VA will use knowledge gained over the 
past 4 years to ensure robust prevention programs are in place for 
future years. The 2015 budget request is essential for VA to 
successfully achieve an end-to-the-rescue phase, and prevent future 
homelessness among Veterans at-risk in the years to come.
    Since 2009, VA, together with our Federal, State, and local 
partners, has reduced the estimated number of homeless Veterans by 24 
percent. We have conducted over six million clinical visits with over 
600,000 Veterans who were homeless, at-risk of homelessness (including 
formerly homeless). In 2013 alone, VA served more than 240,000 Veterans 
who were homeless or at-risk of becoming homeless--21 percent more than 
the year before. Over the past 4 years, the point-in-time (PIT) count 
of homeless Veterans declined steadily, despite challenging economic 
times. The PIT count estimate of the number of homeless Veterans 
dropped from 75,609 in January 2009, to 57,849 in January 2013, a 24-
percent decrease.
    VA's programs constitute the largest integrated network of programs 
with components of homeless assistance in the Nation. They provide 
homeless Veterans with nearly 80,000 beds or units, including permanent 
supportive housing through the Department of Housing and Urban 
Development-VA Supportive Housing (HUD-VASH) program; link Veterans 
with needed mental health and other medical care; and provide 
supportive services and opportunities to reintegrate Veterans back into 
the community and workforce. VA's cost-effective, evidence-based 
homeless programs produce large savings and cost avoidance in 
budgetary, social, and economic terms. Using a Housing First strategy, 
VA relies on research that shows that placing homeless Veterans into 
Housing First reduces emergency room visits, other forms of intensive 
hospitalization, and substance overdose. Medical care costs are roughly 
three times as expensive for homeless compared to Veterans who are not 
homeless.
    Despite significant progress and important accomplishments, much 
work remains. We estimate that between 2013 and 2015, approximately 
200,000 Veterans will experience homelessness at some point in time. To 
reach our goal of ending Veteran homelessness in 2015, the budget 
requests $1.6 billion for VA homeless-related programs, including case 
management support for the HUD-VASH voucher program, the Grant and Per 
Diem Program, the Supportive Services for Veteran Families (SSVF) 
program, and VA justice programs. This represents an increase of $248 
million (17.8 percent) over the 2014 budget level. This budget supports 
VA's long-range plan to end Veteran homelessness by emphasizing rescue 
for those who are homeless today, and prevention for those at risk of 
homelessness.
    HUD-VASH provides permanent supportive housing to the most 
vulnerable of our homeless Veterans. The 2015 budget requests $374 
million for HUD-VASH, an increase of $47 million (14 percent) over the 
2014 budget level. This funding will support nearly 3,500 case managers 
to provide intensive wraparound services to nearly 80,000 Veterans. 
These case managers provide an average number of 12 clinical visits per 
year to these Veterans to ensure that they remain in housing and do not 
become homelessness again. Veterans in HUD-VASH are vulnerable; the 
majority meets criteria for chronic homelessness, and suffers from 
serious mental illness, substance use disorders, and chronic medical 
conditions. This partnership remains the most responsive housing option 
available to VA and is a critical component of our strategy to move 
homeless Veterans from the streets to a safe and stable home.
    The Grant and Per Diem Program helps fund community agencies 
providing services to homeless Veterans with the goal of helping them 
achieve residential stability, increase their skill levels and/or 
income, obtain greater self-determination, independent living, and 
employment as soon as possible. The 2015 budget requests $253 million 
for the Grant and Per Diem Program, an increase of $3 million (1.1 
percent) over the 2014 budget level. In 2015, the program will provide 
over 15,500 transitional housing beds to Veterans through partnerships 
with more than 650 projects.
    VA's SSVF is a critical aspect of our strategy to prevent and end 
Veteran homelessness. This program provides both prevention and rapid 
rehousing services to Veterans and family members. In 2013, SSVF 
successfully prevented over 60,000 at-risk Veterans and family members 
from falling into homelessness, and successfully placed over 84 percent 
of homeless Veterans and family members into permanent housing. In the 
last 3 years, VA awarded grants totaling $459.6 million to 324 
community agencies in all 50 States, the District of Columbia, Puerto 
Rico, and the Virgin Islands. SSVF grants to private non-profit 
organizations and consumer cooperatives provide a range of supportive 
services to include outreach, case management, assistance in obtaining 
VA benefits, and assistance in obtaining and coordinating other public 
benefits. In 2015, VA will deploy SSVF grants strategically to target 
resources to communities with concentrations of homeless Veterans.
    In addition, VA's justice programs, which facilitate access to 
needed VA treatment for Veterans in criminal justice settings such as 
Veterans treatment courts, are an important prevention effort for 
homeless and at-risk Veterans. The goal of these Courts is to divert 
those with mental health issues and homelessness risk from the 
traditional justice system and give them treatment and tools for 
rehabilitation and readjustment. The first Veterans court was 
established in 2008 in Buffalo, NY. By the end of 2013, there were 257 
courts nationwide, positively affecting the lives of 7,724 Veterans; VA 
serves Veterans in each of these courts. Many of the participating 
Veterans have avoided incarceration and the cycle of homelessness, that 
often follows incarceration. The 2015 budget requests $35 million for 
Veterans justice programs, an increase of $1.5 million (4 percent) over 
the 2014 budget level.
    To increase homeless Veterans' access to benefits, care, and 
services, VA established the National Call Center for Homeless Veterans 
(NCCHV). The NCCHV provides homeless Veterans and Veterans at-risk for 
homelessness free, 24/7 access to trained counselors. The call center 
is intended to assist homeless Veterans and their families; VA medical 
centers; Federal, State, and local partners; community agencies; 
service providers; and others in the community. In 2013, the National 
Call Center for Homeless Veterans received 111,096 calls (38 percent 
increase over 2012) and made 78,622 referrals to VA Medical Centers (55 
percent increase over 2012). The 2015 budget requests $5.6 million for 
NCCHV, an increase of $1.7 million (45 percent) over the 2014 budget 
level. VA has established 28 Community Resource and Referral Centers 
(CRRC) to provide rapid assistance to homeless Veterans.
                   multi-year budget for medical care
    Due to Congress's foresight, under the Veterans Health Care Budget 
Reform and Transparency Act of 2009, VA includes a request for an 
advance appropriation for its medical care budget. The legislation 
requires VA to plan its medical care budget using a multi-year 
approach, which ensures that VA requirements are reviewed and updated 
based on the most recent data available and actual program experience. 
The 2015 medical care budget of $59.1 billion, including collections, 
will fund treatment to over 6.7 million unique patients, an increase of 
4 percent over the 2013 estimate. Of those unique patients, 4.7 million 
Veterans are in priority groups 1-6, an increase of more than 204,836 
(4.5 percent). Additionally, VA anticipates treating over 757,600 
Veterans from the conflicts in Iraq and Afghanistan, an increase of 
over 141,100 patients (23 percent) over the 2013 level. VA also 
provides medical care to non-Veterans through programs such as the 
Civilian Health and Medical Program of the Department of Veterans 
Affairs (CHAMPVA) and the Spina Bifida Health Care Program; we expect 
this population to increase by over 42,600 patients (6.3 percent), 
during the same period.
    Based on updated 2015 estimates largely derived from the Enrollee 
Health Care Projection Model, the 2015 budget will allow VA to increase 
funding for programs to end Veteran homelessness; continue 
implementation of the Caregivers and Veterans Omnibus Health Services 
Act; fulfill multiple responsibilities under the ACA; provide for 
activation requirements for new or replacement medical facilities; and 
invest in strategic initiatives to improve the quality and 
accessibility of VA healthcare programs. The 2015 appropriations 
request includes an additional $368 million above the enacted 2015 
advance appropriations level. Our multi-year budget plan assumes that 
VHA will carry over a small percentage of unobligated balances from 
2014 into 2015 to ensure that funds are available at the beginning of 
the fiscal year to cover any unforeseen costs.
    The 2016 medical care budget of $61.9 billion, including 
collections, provides for healthcare services to treat over 6.8 million 
unique patients, an increase of 1.5 percent over the 2015 estimate. The 
2016 request for medical care advance appropriations is an increase of 
$2.9 billion, or 4.9 percent, over the 2015 budget request. Medical 
care funding levels for 2016, including funding for activations, non-
recurring maintenance, and initiatives, will be revisited during the 
2016 budget process, and could be revised to reflect updated 
information on known funding requirements and unobligated balances.
                    medical and prosthetic research
    VA supports the President's national action plan to guide mental 
health research across government, industry and academia, and develop 
more effective ways to prevent, diagnose, and treat mental health 
conditions like TBI and PTSD. VA's medical research programs 
demonstrate the creativity and ingenuity of our Nation's greatest minds 
to help save Veterans' lives, limit their incapacitation, and build a 
better world for their families. Projects funded in 2015 will focus on 
identifying or developing new treatments for gulf war Veterans, 
improving social reintegration following traumatic brain injury, 
reducing suicide, evaluating the effectiveness of complementary and 
alternative medicine, developing blood tests to assist in the diagnosis 
of PTSD and mild traumatic brain injury, and advancing genomic 
medicine.
    In 2015, Medical Research will be supported through a $589 million 
direct appropriation, and an additional $1.3 billion from VA's medical 
care program, Federal grants, and non-Federal grants. Including Medical 
Care support, other Federal resources, and private resources, total 
funding for Medical and Prosthetic Research will be nearly $1.9 billion 
in 2015. VA's research program benefits Veterans, their families, and 
the Nation.
            increasing employment opportunities for veterans
    Under the President's leadership, VA, the Department of Labor, DOD, 
and the entire Federal Government made Veterans' employment one of 
their highest priorities. At VA, we led by example. We made great 
strides during the last 5 years and remain committed to meeting our 
goal of 40 percent of VA employees being Veterans, compared to 32.4 
percent currently. During 2013, 33.8 percent of all new hires at VA 
were Veterans, including an impressive 78.5 percent of all new 
employees in our National Cemetery Administration (NCA).
    We continue to work to ensure that all of America's Veterans have 
the support they need and deserve when they leave the military, look 
for a job, and enter the civilian workforce. The interagency Employment 
Initiative Task Force, co-led by VA and DOD, developed a new training 
and services delivery model to help strengthen the transition of our 
Veteran servicemembers from military to civilian life. Accordingly, the 
2015 budget includes $106 million to meet VA's responsibilities under 
the President's Veterans Employment Initiative and the VOW to Hire 
Heroes Act. In addition, the 2015 budget includes $1 billion in 
mandatory funding over 5 years to develop a Veterans Job Corps 
conservation program that will put up to 20,000 Veterans back to work 
over the next 5 years protecting and rebuilding America. Jobs will 
include park maintenance projects, patrolling public lands, 
rehabilitating natural and recreational areas, and law enforcement-
related activities. Additionally, Veterans will help make a significant 
dent in the deferred maintenance of our Federal, State, local, and 
tribal lands, including jobs that will repair and rehabilitate trails, 
roads, levees, recreation facilities, and other assets. The program 
will serve all Veterans, but have a particular focus on post-9/11 
Veterans.
    Since 2009, VA provided over $31.8 billion in Post-9/11 GI Bill 
benefits in the form of tuition and other education-related payments to 
cover the education and training of more than 1 million servicemembers, 
Veterans, family members, and survivors. As part of this effort VBA 
launched an online GI Bill Comparison Tool to make it easier for 
Veterans, servicemembers, and dependents to calculate their Post-9/11 
GI Bill benefits and learn more about VA's approved colleges, 
universities, and other education and training programs across the 
country. The GI Bill Comparison Tool provides key information about 
college affordability and brings together information from more than 17 
online sources and three Federal agencies, including the number of 
students receiving VA education benefits at each school.
    VA is also now working with Student Veterans of America to track 
graduation and training completion rates, and we expect a draft report 
by the end of 2014 to quantify program outcomes. The Post-9/11 GI Bill 
continues to be a focus of VBA transformation, as it implements the 
automated Long-Term Solution (LTS), VA's end-to-end claims processing 
solution that utilizes rules-based, industry-standard technologies for 
the delivery of education benefits. At the end of January 2014, we had 
68,215 education claims pending, 21 percent lower than the total claims 
pending the same time last year. The average days to process Post-9/11 
GI Bill supplemental claims decreased by 9.1 days, from 16.1 days in 
September 2012 to 7 days in January 2014. The average time to process 
initial Post-9/11 GI Bill original education benefit decreased by 15.3 
days in the same period, from 32.5 days to 17.2 days.
                         capital infrastructure
    The 2015 budget requests $1.06 billion for VA's major and minor 
construction programs, the same as the 2014 budget level. The capital 
asset budget demonstrates VA's commitment to address critical major 
construction projects that directly impact patient safety and seismic 
issues and reflects VA's ongoing promise to provide safe, secure, 
sustainable, and accessible facilities for Veterans. The request also 
reflects the current fiscal climate and the great challenges VA faces 
in order to close the gaps identified in our Strategic Capital 
Investment Planning (SCIP) process.
Major Construction
    The major construction request in 2015 is $561.8 million. The 
request provides funding for four on-going major medical facility 
projects. They include: (1) seismic corrections to renovate building 
205 for homeless programs at the West Los Angeles, CA VA Medical 
Center; (2) seismic corrections and construction of a new mental health 
facility and parking structure at the Long Beach Healthcare System; (3) 
construction of a new community living center (CLC), domiciliary and 
outpatient facility in Canandaigua, NY; and (4) construction of a new 
spinal cord injury/CLC facility, hospice nursing unit, and upgrades to 
a high-risk seismic building in San Diego, CA. These projects represent 
VA's most critical major construction projects and correct critical 
safety and seismic deficiencies that are currently putting Veterans, VA 
staff, and the public at risk. Once the projects are completed, 
Veterans seeking care will be served in more modern and safer 
facilities.
    The 2015 budget also includes $2.5 million for NCA for advance 
planning activities and $7.5 million for land acquisition to support 
the establishment of five additional national cemeteries in Cape 
Canaveral and Tallahassee, Florida; Omaha, Nebraska; southern Colorado; 
and western New York to meet the burial access policies included in the 
2011 budget.
Minor Construction
    The 2015 budget includes a minor construction request of $495.2 
million. The requested amount would provide funding for ongoing and 
newly identified projects that renovate, expand, and improve VA 
facilities. This year's focus is a balance between continuing to fund 
minor construction projects that we can implement quickly to maintain 
and repair our aging infrastructure, while using major construction 
funding to address life-threatening safety and seismic issues that 
currently exist at multiple VA medical facilities.
Opportunity, Growth and Security Initiative
    The budget also includes a separate $56 billion Opportunity, 
Growth, and Security Initiative to spur economic progress, promote 
opportunity, and strengthen national security. This Initiative would 
increase employment, while achieving important economic outcomes in 
areas from education to research to manufacturing and public health and 
safety. Moreover, the Opportunity, Growth, and Security Initiative is 
fully paid for with a balanced package of spending cuts and tax 
loophole closers.
    At the Department of Veterans Affairs (VA), the Opportunity, 
Growth, and Security Initiative will support capital investments 
essential to expanding and protecting Veterans' access to quality care 
and benefits. By providing an additional $400 million for the VA 
capital program, enactment of the Initiative will allow additional 
progress in addressing the Department's highest priority capital needs, 
including a major construction project to replace a seismically 
deficient research facility in San Francisco, California.
                    national cemetery administration
    The NCA has the solemn duty to honor Veterans and their families 
with final resting places in national shrines and with lasting tributes 
that commemorate their service and sacrifice to our Nation. We honor 
those individuals' service through our 133 national cemeteries, which 
includes two national cemeteries scheduled to open in 2015, 33 
Soldiers' lots and monuments, the Presidential Memorial Certificate 
program, and through the markers and medallions that we place on the 
graves of Veterans around the world. The 2015 budget includes $256.8 
million for operations and maintenance to uphold NCA's responsibility 
for this mission, including funds to open two new national cemeteries 
and to begin preparations for opening two National Veterans Burial 
Grounds.
    NCA projects its workload will continue to increase. For 2015, we 
anticipate conducting approximately 128,100 interments of Veterans or 
their family members, and maintaining and providing perpetual care for 
approximately 3.5 million gravesites. NCA will also maintain 8,882 
developed acres and process approximately 362,900 headstone and marker 
applications.
    NCA maintains a strong commitment to hiring Veterans. Currently, 
Veterans comprise over 74 percent of its workforce. Since 2009, NCA 
hired over 450 returning Iraq and Afghanistan Veterans. In addition, 
NCA awarded 66.5 percent of contract awards in 2013 to Veteran-owned 
and service-disabled, Veteran-owned small businesses. NCA's committed, 
Veteran-centric workforce is the main reason it is able to provide a 
world-class level of customer service. NCA participated for the 5th 
time in the American Customer Satisfaction Index (ACSI), sponsored by 
the Federal Consulting Group and Claes Fornell International (CFI) 
Group. In the 2013 review, NCA received a score of 96 out of a possible 
100, the highest score to date for any organization in the public or 
private sector.
    NCA continues to leverage its partnerships to increase service for 
Veterans and their families. As a complement to the national cemetery 
system, NCA administers the Veterans Cemetery Grant Service (VCGS), 
which provides grants to establish, expand, or improve State and tribal 
Veterans' cemeteries. There are currently 90 operational State and 
tribal cemeteries in 45 States, Guam, and Saipan, with five more under 
construction. Since 1980, VCGS awarded grants totaling more than $566 
million to establish, expand, or improve these Veterans' cemeteries. In 
2013, these cemeteries conducted over 32,000 burials for Veterans and 
family members.
                              legislation
    In addition to presenting VA's resource requirements, the 2015 
President's budget also proposes legislative action that will benefit 
Veterans. These proposals build on VA's legislative agenda transmitted 
in the first session of the 113th Congress, as part of the 2014 
President's budget. Let me highlight a few provisions: VA proposes a 
measure that will allow better coordination of care when a Veteran also 
receives other care at a non-VA hospital, by streamlining the exchange 
of patient information. Additionally, we propose allowing the CHAMPVA 
to cover children up to age 26, to make that program consistent with 
benefits conferred under the ACA. We also are submitting a proposal 
that would modernize our domiciliary care program by removing income-
based eligibility restrictions.
    To continue our priority to end Veteran homelessness, VA proposes 
increased flexibility in the Grant and Per Diem program to focus on the 
transition to permanent housing. Also among our proposals is a measure 
that would allow VA to speed payment of dependency and indemnity 
compensation and other benefits to surviving spouses by eliminating the 
need for a formal claim when there already is sufficient evidence for 
VA to act. We greatly appreciate consideration of these and other 
legislative proposals included in the 2015 budget and look forward to 
working with Congress to enact them.
                                summary
    Since the founding of our great Nation, Veterans helped our country 
meet all challenges; this remains true today as Veterans help rebuild 
the American middle class. At VA, we continue to implement the 
President's vision and transform VA into a 21st century leader of 
efficiency, effectiveness, and innovation within the Federal 
Government. Our 2015 budget supports Presidential priorities to always 
add value to the Nation, boost economic growth, strengthen the middle 
class, and work side-by-side with Federal partners to eliminate 
unnecessary overlaps or redundancies.
    Given today's challenging fiscal environment, this budget focuses 
VA resources, policies, and strategies on the most urgent issues facing 
Veterans and provides the resources critical to expand access, 
eliminate the disability claims backlog in 2015, and end Veteran 
homelessness in 2015. There is no greater mission than serving 
Veterans. Again, thank you for the opportunity to appear before you 
today and for your unwavering support of Veterans.

    Senator Johnson. Thank you.
    For the information of our colleagues, we will limit 
questions to 6-minute rounds to ensure that everyone has a 
chance to be heard. If needed, we will have a second round.
    I will now defer to the Chairwoman for any questions she 
may have.
    Senator Mikulski. Thank you very much, Mr. Chairman.
    And to Senator Kirk, thank you for that courtesy.
    General, and to your team, first of all that this committee 
is really committed to the VA appropriations, and it is our 
goal to make the VA subcommittee, the VA MILCON, one of our 
earliest markups.
    We now have a committee goal of completing our work by 
October 1. It would be the first time since 1996 that it did 
it. We are in the process of holding 60 hearings in 6 weeks. We 
are on a brisk pace, but our goal will be on May 22 to have our 
first full committee markup. If I am advised by the 
subcommittee chair and his vice chair that they are ready to 
go, the committee will be ready to go. And I pledge to all here 
that they will be, if not the first bill, the first three bills 
that we will mark up. We want to be on the floor as soon after 
Memorial Day as we can to show that it is not just words, but 
it is deeds, and that we will do the discretionary part that we 
are supposed to do and to do it.
    So I just say that in an open forum, and I hope it 
encourages you. That you will actually have floor time, the way 
we have it structured.
    As you know, General, my deep concern is about veterans' 
healthcare; others will be asking those questions.
    On the backlog, last year we held a robust, multiple 
subcommittee hearing on the coordination of agencies working 
with you. You needed the help of the Internal Revenue Service 
(IRS), Social Security, and the Department of Defense (DOD). I 
note that you comment on that on page 8 of your testimony.
    Did that really make a difference? Are you really getting 
the help you need from other agencies? Or is that one of the 
impediments or pitfalls to further reduction of the backlog?

                             CLAIMS BACKLOG

    Mr. Shinseki. Madam Chairwoman, that meeting was very 
helpful for us. It brought together all the players as you 
indicated.
    We have with DOD, for example, years of being astride a 
river of paper coming to us. We now, effective in January, have 
begun receiving service treatment records, as complete as they 
are. Personnel records now electronically transferred to us 
from the DOD to VA with the capability that they will fill our 
information bins for processing of claims. We are also 
connected with the Social Security Administration and with IRS.
    Senator Mikulski. But are they really sending you what you 
need----
    Mr. Shinseki. They are.
    Senator Mikulski [continuing]. In a timely way and 
essentially up their game in working with you?
    Mr. Shinseki. They are.
    Senator Mikulski. Administrator Colvin at Social Security 
tells me she has really increased the time when she 
communicates with you, rather than twice a year or quarterly. 
Is that correct, or perhaps Ms. Hickey could comment?
    Mr. Shinseki. That is correct. Administrator Colvin has 
been very, very supportive and we are now connected in this 
way. We get that information as soon as we need it.
    Senator Mikulski. Well, we want to continue the momentum of 
the Ten Point Plan. I think we have got momentum which, of 
course, takes me to the Baltimore office, which you know, is 
rated as poor performance.
    We have not had a leader for several months, and we have 
had five directors in 2 years. Could you tell me--in order to 
improve Baltimore, you need a clear, consistent leader with 
real management capability--could you or your team share with 
me the status of getting us a new director who is going to be 
primetime and stay with us for a while to continue the momentum 
that we have embarked upon?

                       BALTIMORE REGIONAL OFFICE

    Mr. Shinseki. Certainly, Chairwoman. I am going to call on 
Secretary Hickey here to provide some details. We just had 
conversations about this yesterday. I know she is down to a 
select number of candidates and is about to make a decision. So 
we are going to have a decision here for you shortly.
    I regret the track record you just described. I do agree 
that if you want to make change in a large organization, 
stability and leadership is important. So that is our 
commitment to you here.
    Secretary Hickey.
    Ms. Hickey. Chairwoman Mikulski, the position actually 
closes this week. I have put it on a fast track to make sure 
that we are aggressively moving through the required processes 
that we have to do by Federal regulation to make that candidate 
available, and we will make that candidate available quickly.
    I will also tell you that we have established a long-term 
service center manager position there and that person has 
already been onboard for the last couple of months. There now 
is a stability factor in the service center manager, who is the 
one that manages the day-to-day claims operation.
    We will have a full-time team there very shortly, and we 
will notify you as soon as we have made the candidate 
selection.
    Senator Mikulski. Well, my time is near an end. We want to 
continue the momentum, so we need not only a leader, we need a 
real leader.
    The second thing is that we are concerned that though the 
numbers look like they are coming down, are we just 
rearranging? In other words, one of the reasons numbers have 
come down is that cases have been sent to other offices. Also, 
numbers have come down because there has been a partial 
decision.
    I am not going to take the time in the committee to go into 
it, but I think Baltimore is a cameo of some of these other 
issues. So when we send them to other offices, are we tracking 
them? When they do the partial payment for current benefits, 
the retro-benefit continues to lag. So let us continue to work 
together on that.
    And then I would also like for Mr. Warren to submit, for 
the record, the question of interoperability particularly 
between the VA and DOD's electronic systems. Because there have 
been several reports that give one pause and I want it to be 
the pause that refreshes, not the pause that gives us 
heartburn. And we really do not want a techno-Katrina. We have 
had too many boondoggles in the area of IT, whether it has been 
the health exchanges, the FBI case files. It is just not unique 
to you.
    [The information follows:]

    Answer. Ensuring that our servicemembers, veterans, and their 
families receive world class healthcare is of the utmost importance for 
both Departments. A key to the success of this mission is to make sure 
the DOD and VA electronic health records (EHR) achieve and maintain 
full interoperability.
    To further coordinate the Departments' interoperability efforts, on 
December 5, 2013, the Departments signed a new charter for the 
Interagency Program Office (IPO) identifying the IPO as the entity 
responsible for establishing, monitoring, and approving the clinical 
and technical standards profile and processes to create the seamless 
integration of health data between the two departments and healthcare 
providers.
    The IPO recently inaugurated an Integrated Master Schedule to 
document our collective efforts for approximately the next 2 years to 
expedite our enhanced EHR interoperability.
    At the end of March 2014 the Department of Veterans Affairs 
delivered several documents to the Subcommittee on Military 
Construction, Veterans Affairs, and Related Agencies that provide more 
detailed information on interoperability and the way forward.
  --1. IPO Q2 Fiscal Year 2014 Data Sharing Status Report
  --2. VistA Evolution Testing and Standards Conformance Plan for 
        lnteroperability
  --3. VistA 4 Product Roadmap (Section 6)

    Senator Mikulski. Thank you, Mr. Chairman, for your 
graciousness today. I appreciate it.

                             INFRASTRUCTURE

    Senator Johnson. Thank you, Chairwoman.
    Mr. Secretary, despite robust funding for healthcare in 
this budget, I am very concerned about the corresponding lack 
of investment in VA's aging hospital infrastructure. The VA's 
Facility Assistance Report highlights $9.8 billion in code 
violations and safety deficiencies at existing hospitals and 
clinics. Moreover, the VA's strategic capital investment plan 
lays out a $55 billion need over 10 years for new construction 
or renovation across the system.
    Despite this, this request for a nonrecurring maintenance 
in fiscal year 2015 is $461 million. This is down $839 million 
or 65 percent in just 2 years. Couple this with a major 
construction budget of $562 million, and you are barely 
scratching the surface of the needs in the system, let alone 
keeping up with the problem. I know budgets are tight, but it 
seems to me that if this trend continues, in a few years, the 
VA is going to be faced with some hard decisions on how 
healthcare is going to be delivered to our vets. The longer we 
wait, the more expensive these problems become.
    How does the VA plan to address the growing need to 
modernize its infrastructure? And will the lack of investment 
today mean more cuts in care in the outyears?
    Mr. Shinseki. Well, Mr. Chairman, this is an important 
area, and as I have indicated, this is one of the areas that I 
watch very closely. We have had to make some tough choices in 
allocating funding between infrastructure and our operating 
requirements; our funds for operating and our capital 
requirements.
    As you have pointed out, we generally talk about this in 
those three buckets: major construction, minor construction, 
and nonrecurring maintenance. We have taken a hard look at our 
infrastructure. We have made commitments over time in relooking 
at our priorities, and making sure that the most important 
priorities are addressed first. Safety, security, taking care 
of what we have, and then looking for where we must provide 
facilities that do not exist today.
    That is the descending order of our look. It is not 
absolute, but that is generally how we approach this. Safety, 
security, taking care of what we have so that we maintain 
whatever access veterans have today, which is quality, and then 
where do we need new access.
    When we look at our existing facilities and we want to 
modernize and keep them safe, secure, and energy-efficient, we 
look at our minor construction opportunities and our 
nonrecurring maintenance needs. In these two accounts, minor, 
as you indicated, is $494 million; nonrecurring maintenance is 
about $460 million.
    When we look at new facilities for providing additional 
access to veterans for healthcare and services, then we are 
into the major construction pieces of that; about $561 million.
    We also have leases as part of new facilities, and that 
comes out of our medical care account. Today, we have about 32 
leases that are waiting approval.
    Then we have a third category which we call ``New 
Thinking,'' because overall, construction is about access, 
providing access to veterans for the healthcare they need, 
where it is more convenient, when they need it. So the third 
category we have looks beyond brick and mortar. I would say 
that in addition to construction, we have put funding in this 
area as well to ensure that veterans can get the access they 
need.
    First is non-VA fee care, which is about $6.7 billion to 
take care of paying for that care. We also have beneficiary 
travel to ensure that veterans can get to care if it is not 
closely adjacent to where they live. This way they can get to 
the facilities that provide them care, and that is funding of 
about $969 million.
    We provide a per diem for State homes for veterans at about 
$1 billion; $950 million. We have invested in tele-health, as 
we have discussed with you, at about $567 million, and finally, 
State home grants, at about $80 million. In order to provide 
access, we have this category that goes beyond brick and 
mortar. But still, the construction account is important.
    Over the last 5 years, we have executed 75 major 
construction projects valued at over $3 billion. We have seven 
major construction projects scheduled for delivery in the 2014 
budget, and we have restructured the way we manage projects to 
be more efficient and ensure a higher opportunity for delivery.
    I would say there is another account here that I would 
respectfully address with the committee, and that is the 
Opportunity, Growth, and Security Initiative. In that fund, an 
investment fund, $400 million has been placed by the 
Administration for VA projects. These are line projects with 
detailed project-level detail in them, at 35 percent design, 
and if there is a way to leverage those dollars and combine the 
funds with the $1.5 billion in our base budget, we have an 
opportunity for about $2 billion of construction resourcing.
    Senator Johnson. Senator Kirk.
    Senator Kirk. Thank you.
    Mr. Secretary, I want to go with one of my top priorities, 
with the fully electronic medical record project which you have 
had. I hope the transcript of our hearing here will lay out 
some groundwork for some key principles which we are going to 
follow. That will be, the key principles would be that we would 
go with a commercial off-the-shelf (COTS) solution, an open-
source code.
    The vision that I have for you is, since you control about 
25 million records, you will be able to be the market 
superheavyweight if you establish a COTS, open-source code 
system. It will lead the whole industry and I think the 
American electronic medical records industry can dominate the 
planet on the medical administration. Based on the decisions 
you are about to make, several billion dollars in the industry 
may hang on the decisions that you make to deploy this in a 
COTS open-source. To make sure that we are successful like the 
Motorola Android system in coming up with private sector 
applications, out the yin-yang, to help everybody to administer 
medical records electronically.
    But I would say in the key meeting that the full committee 
chair had with you, Secretary Hagel identified the Under 
Secretary for Acquisition, Frank Kendall. And I think we can 
safely say that this subcommittee is coming at him, to misquote 
Katy Perry, like a dark horse at him, to make sure that we get 
the complete--the vision is a completely seamless transition 
from DOD to VA with all your electronic records passing over; 
to make sure that your VA healthcare is seamless from the DOD.
    That is it, Mr. Chairman.
    Senator Johnson. Senator Reed.
    Senator Reed. Well, thank you very much, Mr. Chairman, and 
thank you, Mr. Secretary.
    One of the initiatives that you have undertaken, along with 
Secretary Donovan, has been trying to end veterans' 
homelessness. And with the HUD-Veterans Affairs Supportive 
Housing (VASH) vouchers and also with the Supportive Services 
for Veteran Families program, the goal is in sight. In fact, in 
my home State of Rhode Island, we are getting close and we 
would like to go across the line, the finish line.
    As you approach the target date, which is 2015, of 
essentially ending homelessness, what is the most critical 
funding that we should be doing? Should we consider shifting to 
the supportive services or should we put more resources into 
VASH?

                                HUD-VASH

    Mr. Shinseki. Well, Senator, I would say both are 
important. HUD-VASH is probably the most versatile housing tool 
we have today, and it allows us to take care of not just 
veterans, but veterans with families and children. A large 
percentage of our being able to rescue folks has involved 
children; a significant number of children.
    In terms of Supportive Services to Veteran Families (SSVF), 
for the last 2 years we put about $300 million into this rescue 
effort. This is working with probably 4,000 to 5,000 partners 
down at the municipal level. Folks who are nonprofits--Catholic 
Charities, Salvation Army, Volunteers of America, and Swords to 
Plowshares--all the folks who know their neighborhoods, and 
know the homeless veterans, and what their issues are.
    This is to provide them the opportunity to reach out and 
make sure that we have them moving off the street. That is why 
I call it rescue: moving into stable housing, and then giving 
us the opportunity to provide them care, and treatment for 
onward movement.
    A 25-percent decrease from 10 to 13 may not sound like 
much, but in a time during a sluggish economy, usually these 
things go up and they go up in other ways, so the longer you 
wrestle with this, the steeper the climb. Instead, we 
remarkably had turned this 24 percent downward. I think we have 
good tools and the economy is strengthening. I think we are 
going to see much more momentum in this.
    Of the vouchers--I think both vouchers and services are 
important in getting the balance right. Secretary Donovan has 
been just a magnificent partner in the HUD-VASH program.
    Senator Reed. One of the things we did in the 2014 
appropriations bill is provide HUD and the VA the discretion to 
consider other factors in the allocation of HUD-VASH vouchers.
    Can you give us an idea of what some of those other factors 
are?
    Mr. Shinseki. Let me call on Dr. Petzel.
    Senator Reed. Thank you, Dr. Petzel.
    Dr. Petzel. Thank you.
    Senator Reed, the major effort with the HUD-VASH vouchers 
is to, first, deal with the chronic homeless. I am very proud. 
The VA has moved from maybe spending 50 percent of their 
vouchers on the chronically homeless to well over 75 percent. 
It is surpassing the goal that HUD had provided.
    Now, I want to put a point on something that the Secretary 
said. HUD-VASH is our most important permanent housing effort. 
We rely very heavily on HUD-VASH vouchers to provide for 
permanent housing and that, of course, is our goal. First, we 
are going to rescue everybody off the street, but eventually we 
want every veteran into a permanent, stable housing situation. 
And HUD-VASH is, again, the most important program that we have 
to accomplish that.
    Senator Reed. Thank you very much, Doctor.
    You have asked for advanced appropriations for medical 
care, an increase of $2.7 billion in 2015. Is that just a 
projection of the anticipated demand you are seeing as people 
return from active service?
    Mr. Shinseki. It is based on our Milliman model looking 
forward. I would say that we have been working with DOD for 
several years now, trying to understand that when they have to 
make decisions about downsizing, what might we expect in terms 
of place, date, and rate; all three of those are important. I 
think with the DOD decisions on budget, they have a better 
opportunity to provide us some sense of what that plan is. We 
work with DOD and that will also impact our planning in the 
next budget cycle.
    Senator Reed. Thank you.
    Thank you, Mr. Chairman.
    Senator Johnson. Senator Collins.
    Senator Collins. Thank you, Mr. Chairman.
    Mr. Secretary, welcome. It is good to see you here again.
    On previous occasions, we have discussed the overwhelming 
success of the access received close to home, or ARCH pilot 
program in northern Maine, located in Caribou, Maine, in 
increasing access to healthcare for veterans who are living in 
that part of my State.
    Recently, a veteran from northern Maine used this program 
for emergency surgery. It was on a broken hip. Had the ARCH 
program not been in place, he would have had to endure a 250-
mile, hours-long ambulance ride to the Togus Hospital in 
Augusta over bumpy, winter roads in extreme pain.
    In December of last year, the VA held a town hall meeting 
in which two separate veterans came forward and said that they 
had received cardiac care. And they indicated that they believe 
they would not be alive today but for the care that they 
received through the Access Received Closer to Home (ARCH) 
program, because it was so accessible. So thanks to the ARCH 
program, veterans like these have been able to receive the care 
that they need right at home, or close to home, and close to 
their families.
    What concerns me is that this highly effective, indeed 
life-saving program is scheduled to end at the end of this 
fiscal year, which is coming up very rapidly, and the VA has 
yet to recommend whether or not the ARCH program should 
continue. I personally believe that the success of the ARCH 
program in northern Maine could serve as a model for the entire 
country.
    I wrote to you back in December about this issue, the 
letter was signed by my colleague from Maine, but we have yet 
to get an answer; and I know you have been tied up with budgets 
and backlogs. But I am hoping today that you can answer the 
question of whether the VA intends to recommend an extension of 
the ARCH pilot program.

                                  ARCH

    Mr. Shinseki. Senator, I regret that you have not had a 
response yet to your question.
    We are in the stages of, as you indicate, the pilot ending 
this fiscal year, and we are in the process of analyzing all of 
the good stories that have come out, as well as where could we 
have been effective.
    As you know, ARCH only went into five States, I believe. As 
we look at our national healthcare responsibilities, let us try 
to understand how we take what we learned from ARCH and make 
sure we are addressing needs for rural veterans and highly 
rural veterans elsewhere.
    I am going to call on Dr. Petzel. I do not know that he is 
prepared to recommend on ARCH at this point. I know they are 
still in final deliberations about what the results mean. Let 
me call on Dr. Petzel.
    Dr. Petzel. Thank you, Mr. Secretary.
    Senator Collins, as the Secretary mentioned, we are still 
in the final stages of evaluating the project. We have learned 
a lot of lessons from that pilot. Specifically in Maine, the 
ARCH was worked through the Kerry Medical Center in Caribou, 
and that has been very successful from our perspective, 
particularly in terms of providing specialty care.
    We have developed a program called Patient-Centered 
Community Care (PC3) across the country where we have two 
entities that we have contracted with who, in turn, have set up 
networks across the country to provide that same sort of 
service nationally that you have seen with ARCH. Because we do 
believe that access to specialty care, particularly in rural 
America, is an important issue for the veteran community. We 
want to provide the same level of service in rural America that 
we do in urban America, and we think that PC3, built on the 
lessons that we learned from ARCH, are going to accomplish 
that.
    Specifically in Caribou, we are going to continue our 
relationship with Kerry. We are going to continue to have the 
services available that you have seen available under Project 
ARCH. I think that during the transition that we are going to 
be making to the PC3 contract, it is going to be seamless as 
far as the veterans that live in Maine or the other areas where 
we had the pilot program.
    Senator Collins. Let me just tell you that the concern I am 
hearing about the PC3 program is that it is not likely to be 
fully implemented until this summer. And there is lots of 
concern about whether it will be as broad in scope of its 
coverage as the ARCH program has been, and I just want to pass 
that feedback onto you.
    I am told that the ARCH program in Caribou has been the 
most successful of the five sites which, of course, does not 
surprise me because it is my hometown. But in all seriousness, 
I think the link of the local hospital with the VA--there is a 
veterans home also located right next to the hospital, and the 
work that they have done with the veterans services 
organizations--has made it extremely successful and a great 
model for you to replicate.
    Dr. Petzel. I would, if I could, just comment. You are 
absolutely right. The Caribou, Maine Kerry relationship has 
been one of the most successful aspects of Project ARCH, and 
our intention is to continue the relationship with Kerry, and 
to continue the relationship that we have with the veterans in 
that community and their use of that wonderful community asset.
    Senator Collins. Thank you. I know my time has expired, so 
I will submit the rest of my questions for the record with 
permission of the chairman.
    But I do hope we can get a drug take-back program 
established at the VA. I am convinced, from the inspector 
general's report that the misuse of unneeded prescription drugs 
is a major contributor to veteran suicide. And I hope the Drug 
Enforcement Administration (DEA) has finally come around to 
recognize that we need, at VA facilities, a means of veterans 
to turn in their unneeded and unused medication.
    Senator Johnson. Senator Begich.
    Senator Begich. Thank you, Mr. Chairman, and I want to 
follow up on Senator Collins' comment.
    In Maine, the description she gave of the rural capacity; 
in Alaska, it is more severe. And I first want to ask some 
comments or question to you about the tribal agreements that we 
have done in a program that I have worked aggressively with you 
all, and I think it is creating some success, and I want to 
just get a sense from you.
    I know in Alaska when we worked with the VA and Indian 
Health Services to try to utilize and maximize these great 
resources we have, Secretary Shinseki, you were in Alaska and 
you saw firsthand some of our veterans who just needed care, 
and they did not want to travel, literally at some cost of 
$2,000 in airfare or a day and a half to get just basic care.
    So the agreement you have all worked out regarding Indian 
Health Services in Alaska, which I think has been successful. I 
think we have already capped out, or done, over $2 million in 
reimbursements. So now veterans, Native and non-Native, can go 
and access these facilities, and get healthcare right next to 
their home, but still have choice; that they can still go to 
the clinic and the hospital, which is very important to VA.
    So I want to first, commend you for this work, and I am 
hearing good news on it. There are always bugs to work out and 
where I know you guys are working on that with our Indian 
Health Service folks, but we are seeing great impact because it 
is all Federal money anyway, and these veterans deserve the 
care, no matter how remote it is.
    But I want to ask you, do you see this, and are you now 
looking at a longer term expansion in other areas, such as 
other Indian Reservations or other places within the Lower 48. 
I can tell you, the response has been very good.
    I was up in the arctic about a week and a half ago, and met 
with some veterans, and there is no question in their mind that 
the access to healthcare has greatly increased, and they get 
better choice now, and the VA basically reimburses Indian 
Health Services for those costs that they qualify for. So, can 
you give me some thought?
    And again, I want to thank you for working with me on this 
project.

                                 ACCESS

    Mr. Shinseki. Senator, I am going to call on Dr. Petzel, 
who has the details here.
    But our approach to this has been to provide our veterans, 
whether they are rural, highly rural, or remote Native 
Americans, the same access that we try to provide to veterans 
in urban areas where veterans have more choices. A lot of good 
work has been done by the Health Administration.
    We want, ideally, for veterans to be able to walk-in and 
have that access to healthcare, and let VA figure out the 
payment streams are. You know, we can sort that out.
    Senator Begich. Right.
    Mr. Shinseki. That is what Dr. Petzel does for us.
    Senator Begich. Great. Dr. Petzel.
    Dr. Petzel. Just to give a few of the details, Senator 
Begich.
    The Secretary is absolutely right. We are committed to 
providing a high level of access to both primary and specialty 
care in remote areas. Maine, as we discussed earlier, and 
Alaska are two of the many excellent examples of how we are 
having some success in doing that.
    In the Care Closer to Home program in Alaska, last year, 
about 900 people who normally would have traveled down to 
Seattle or to Portland for care, were delivered care in the 
community.
    We spent about $10 million on oncology care in Alaska and 
over $23 million in specialty care services with the private 
community as well as the Indian Health Service (IHS). I want to 
highlight what has happened between the VA and the tribal 
organizations in Alaska.
    There are 26 tribes that we have agreements with. VA has a 
memorandum of understanding (MOU) with all 26 of these tribes 
where we share services. They have specialty services 
available, as an example, in Anchorage that we do not have and 
we now buy those services for veterans in the Native community. 
In addition to that----
    Senator Begich. And it is high quality care.
    Dr. Petzel. It is excellent care; the South-Central----
    Senator Begich. Foundation.
    Dr. Petzel. Foundation, which is the organization that runs 
the healthcare system there and is, by Don Berwick's estimate, 
the best healthcare system in the United States.
    Senator Begich. Fantastic.
    Dr. Petzel. It is excellent care.
    In addition to that, though, with the other MOUs that we 
have with the IHS and tribes, we are able to pay for veteran 
care, in Native installations, by the IHS or by the tribes. We 
are able to reimburse them for the care. And this year, we are 
expecting, in 2014, to spend about $36 million around the 
country doing that, and even more, in fiscal year 2015.
    We have arrangements with basically all of the IHS 
facilities in the United States and about 81 tribal entities 
right now, and we are expecting another 75 tribal entities to 
be signed up with us before the end of 2014; very successful 
from our point of view.
    Senator Begich. Fantastic. Well, I am glad you were able to 
do that. I am glad Alaska could be a model and really just 
cannot say enough about your team reaching out and doing that. 
Let me give you bad new-good news.
    Bad news was I got a letter, and you guys did very quick 
work to solve this, and it was an issue of a non-college degree 
program, Maritime and Multi-Skilled Workforce Credential, 
really critical; we have shipbuilding going on.
    We wrote you on this because the VA responded that this did 
not qualify for educational reimbursement because they 
qualified it as ``bartending and personality development,'' and 
``avocational and recreational,'' for some odd reason. This is 
actually in the letter, and that is why I want to read it 
because you guys corrected it very quickly, and I want to make 
sure it is permanent.
    ``The Maritime and Multi-Skilled Worker Program is 
avocational and a personality development course in that it 
does not lead to a specific education objective. Instead, it 
prepares individuals to be more attractive to future 
employers,'' which is exactly what education is supposed to do. 
And you guys, I want to say, thank you for reaching very 
quickly to fix this problem because this made no sense at all, 
especially that letter, that line I just read you. That, yes, 
education is to help people be prepared for education and get 
the education they need for future jobs.
    So thank you for doing this and fixing this problem because 
we have a lot of people who want to enter this field in Alaska, 
and these are veterans who have great skills to be 
transferrable. So thank you for this very quick, I think it was 
less than 24 hours, and that is amazing, especially this young 
person who was just trying to get into an educational system. 
So thank you.
    I will submit some questions for the record, Mr. Chairman, 
in regards to advanced appropriations. As an appropriator, I 
know it sounds odd, but I support advanced appropriations. I 
think it has worked on the health side and I want to see it 
work on the VA. So I want to get in the record your comments, 
as well as some issues around suicide and military sexual 
trauma.
    And again, thank you all very much for working with Alaska 
regarding the healthcare delivery system, and this educational 
piece, which is huge.
    Thank you, Mr. Chairman.
    Senator Johnson. Senator Johanns.
    Senator Johanns. Thank you, Mr. Chairman.
    Mr. Secretary, it is good to see you and your team again. I 
sit on both the Veterans Committee and this committee, I get 
two bites at the apple, I guess you could say.
    Since we last visited, I had an opportunity when I was back 
home, to visit a development. It is called the Victory 
Apartments in Omaha. It is a HUD-VASH program, Victory 
Apartments. And I have to tell you, after spending an afternoon 
there a couple of weekends ago, I came away a true believer in 
that program and what it is doing for homelessness.
    And yet, I am mindful of the fact because I asked even with 
this doing so well there, how many homeless veterans would we 
estimate are on the streets each night in Omaha? And they said 
probably in the vicinity of 500. As you know, Mr. Secretary, 
that is a drop in a very large bucket of people who are 
homeless who have served our country, and one would be too 
many.
    My question is, as you think about the HUD-VASH program, 
are there any changes that we could make to take a program that 
really is doing good things and maybe take it to the next 
level? Is it money? Is it restrictions in the language of the 
program? Anything that comes to your mind that might be helpful 
in expanding what we are doing here?

                            HOMELESS PROGRAM

    Mr. Shinseki. I am going to call on Dr. Petzel to talk 
about the homeless program, and then address this question. 
Because of his network of healthcare all across the country in 
various communities, he had the best reach to be able to 
address these homeless issues.
    When we talk about the homeless, we looked at this as a 
flow. So when I say ``homeless,'' the image that comes to mind 
is someone in the middle of winter, sleeping on a steam grate--
--
    Senator Johanns. Yes.
    Mr. Shinseki [continuing]. Swaddled in blankets. It is 
rescuing that individual off the street, as the first effort to 
get them into a safe shelter. It may not be HUD-VASH. It will 
probably be a grant per diem arrangement that gives temporary 
shelter, stabilization, and lets us figure out what is going on 
here. Then we set up a plan for onward movement; all of which 
is designed for success.
    At the time the individual is ready to live independently, 
we will have done significant work. Then the HUD-VASH voucher 
plays a part. It is a continuum. It is independent living and 
the veterans are essentially on their own. We want to do that 
at the right time in the right way.
    We can always use more HUD-VASH vouchers. It is something 
that we work very closely on with Secretary Donovan. We get 
those vouchers from HUD and it is versatile for us and for 
other programs as well. We get about 10,000 vouchers a year 
from him, which is helpful.
    Let me just call on Dr. Petzel.
    Dr. Petzel. Well, I have very little to add, Mr. Secretary, 
to what you said. It was an excellent job. I want to emphasize 
the importance of the HUD-VASH vouchers, and its relationship 
to the Supportive Services for Veteran Families (SSVF).
    We get the voucher, which is a Section 8 voucher from HUD, 
and then we case manage those individuals, which is something 
that, in the homeless business, is unique. We provide a wrap-
around set of services through a case manager to the individual 
that has that voucher. We ensure they are getting educational 
benefits if they need them, to ensure that they are employed. 
To ensure that all of their needs are being met in terms of 
once they are in permanent housing with HUD-VASH, thus 
preventing them from relapsing into homelessness. I would echo 
what the Secretary said. We could always use more HUD-VASH 
vouchers.
    Last year, we put 42,000 people into permanent housing with 
HUD-VASH; a big impact. It is our most important housing 
project. HUD-VASH and the Supportive Services for Veterans, 
which is the wraparound support, are our two most important 
arrows in the quiver to end homelessness.
    Mr. Shinseki. I would just add, Senator, we have 
prioritized the chronically homeless, which is usually among 
your toughest issues. We prioritize them upfront for HUD-VASH. 
The fact that we have a 24-percent decrease is also an 
indication that this is hard work, but we have our priorities 
right.
    Senator Johanns. You know what occurred to me, because we 
met with, we even went into the apartment of a woman who had 
served, and there was just nothing but positive comments about 
their home, about the safe atmosphere.
    And everybody we talked to, when we would say, ``What do 
you like most?'' They would say, ``You know, I am safe here.'' 
And I guess if you have spent time out on the street that, for 
them, was a huge priority.
    So as we start thinking about how do we accomplish this 
goal, and I know you have said 2015, which seems ambitious to 
end homelessness for veterans, but maybe it is not so much new 
programs and another program, but it is stepping up the level 
of a program that, I think, is really doing the job. Like I 
said, I was there. I walked away. I was just a true believer. 
You talk to the people, and they are thrilled about what they 
have finally in their life. Their life is stable and safe. It 
is very positive.
    Mr. Shinseki. Mr. Chairman, may I just proffer one 
concluding comment here?
    Senator Johnson. Yes.

                                HOMELESS

    Mr. Shinseki. The rescue mission of people off the streets 
is important. The immediate sheltering, stabilization, and 
onward movement is important.
    2015 is ambitious. We are pushing hard. Rescue is only one 
piece of this. The other piece is prevention, and for every 
youngster who is in college and training, we are working hard 
to make sure that they complete their education and training 
programs, so that they have the opportunity for employment. If 
you do not do this, there is a chance that they may end up in 
this other homeless statistic.
    All the mental health work that is done by the Veterans 
Health Administration in treating depression and dealing with 
insomnia and substance use disorders are all huge in the 
prevention aspects as well.
    Last year, 80,000 veteran home mortgage holders defaulted 
on their home loans; 70,000 were kept in their homes through 
good work by the Veterans Benefits Administration. That still 
leaves us a question mark about the other 10,000. Some of them 
lost employment, relationships come apart, and so we have more 
work to do in that area.
    I just want to assure you that we are doing as much work on 
prevention as we are on the rescue. If we get prevention right, 
the rescue will be less of a challenge in the years ahead.
    Senator Johnson. Senator Udall.
    Senator Udall. Thank you, Mr. Chairman.
    And Secretary Shinseki, thank you very much for being here 
today to visit with us about these important issues facing our 
Nation's veterans. And I really want to thank you for your many 
years of service to our country.
    Listening to you respond to many of the questions sitting 
here, I am always impressed with the Veterans Administration 
under your leadership, and how you are really trying to tackle 
those problems and solve them. So thank you for that also.
    I just wanted to say a couple of things about the claims 
backlog and then get to questions. As you know, and I think you 
said this in your prepared statement, the claims backlog 
remains a challenge to the VA. I continue to hear from New 
Mexico veterans about this problem. There is no doubt the VA 
must accelerate progress on this front. And I am committed as a 
member of this committee to provide the necessary resources so 
that you can get the job done.
    I realize the backlog is down 40 percent from its high 
point a year ago, which means we still have a lot more work to 
do addressing the claims backlog. It is just one step, I think, 
in better serving our veterans. And now, to my questions.
    I recently introduced a bill with Senator Heller of Nevada 
to improve care and access to care for rural veterans. One of 
the provisions in the Rural Veterans Improvement Act was to 
enhance mental healthcare for our rural veterans.
    After talking with veterans in places like Taos, New 
Mexico, and Roswell, New Mexico, it became clear to me that 
rural veterans who suffer from post-traumatic stress disorder 
(PTSD) and other service-connected mental health issues are not 
always getting access to the care they deserve. This is 
concerning because veterans who do not access mental healthcare 
can be at high risk of hurting themselves and others.
    Mr. Secretary, would you support initiatives, such as the 
Rural Veterans Improvement Act, to make fee-for-service 
available to veterans suffering from PTSD, traumatic brain 
injury, or other service-connected mental health issues under 
certain conditions? Where treatment at a clinic serving rural 
veterans is not available, or where treatment options, such as 
complementary or alternative medicine including traditional 
Native American healing methods are not available?

                            RURAL HEALTHCARE

    Mr. Shinseki. Senator, I am going to call on Dr. Petzel to 
provide some detail because some of what you have described in 
some measure, we are currently doing in some locations. I just 
need to make sure that we understand and are responsive to your 
initiative here.
    I would say, we have had young people carrying the mission 
now for 10 years. These are great youngsters who have done so 
well. We are all proud of them. Mental health is something that 
we continue to focus on. As I have said, we have increased the 
budget by 61 percent over the last six budget cycles. It is 
something we work hard at.
    Rural issues are challenging and we have tried some 
initiatives, some of them seem to be bearing out. Let me call 
on Dr. Petzel here to respond to your question.
    Senator Udall. Thank you.
    Dr. Petzel. Senator Udall, you are absolutely right, there 
is a challenge in rural America to providing the services that 
these veterans have earned and deserve.
    What we do now is, number one in all of our community-based 
outpatient clinics, we provide mental health services. Either 
there is somebody providing services there, we pay for that 
service in the community, or we provide tele-health or tele-
mental health connections.
    We do buy a substantial amount of mental health in our fee 
basis program with referrals. We do tele-mental health, 
actually, in the home where patients sit with their Webcam and 
have a therapeutic episode with a psychiatrist at a remote 
area. Last year, 80,000 veterans participated in our tele-
mental health efforts, and we expect that to increase 
substantially in 2014 and 2015.
    We would like to work with you to see what the details are 
of the legislation, to see how it fits with what we are already 
doing. We are committed, as I know you are, to getting mental 
health services into these rural areas, because there is very 
good evidence that when people come to us, and we are able to 
treat them, they do get better.
    Senator Udall. Great. Thank you, very much.
    And I think you all are realizing, like the medical 
profession overall is realizing, that tele-health and tele-
medicine is really a great opportunity for us to move out into 
these rural areas.
    Let me ask you in terms of this budget, what do you do? 
Because one of the problems that I hear about visiting these 
clinics is the high turnover rate in rural VA clinics. What 
will this budget do in order to make that turnover not nearly 
as likely?

                           EMPLOYEE TURNOVER

    Dr. Petzel. That is an excellent question, because you are 
quite correct. We have difficulty, Senator, in rural areas, as 
does everybody. This is not something that is unique to the VA.
    Our turnover rate generally across the system is much lower 
than you would see in the private sector. In rural parts of the 
country, when we are looking at physicians, physician 
assistants, advanced practice nurses, et cetera, the things 
that we have or the tools we have available are, number one, a 
lot of flexibility with salaries. We do pay competitive 
salaries.
    Number two, VA is an excellent place to have a career. 
There are all kinds of opportunities for advancement. We have 
recruitment and retention bonuses or awards, and we are also 
able to forgive the educational debts that a number of these 
people have.
    I think there is, within the budget, the money and the 
tools available that we need in order to make practicing in 
rural America an attractive proposition.
    Senator Udall. Thank you very much, and thank you for your 
good work, and I will submit several questions for the record.
    Dr. Petzel, I had a call with you about Dr. Barnell and us 
moving into a different status.
    Dr. Petzel. Right.
    Senator Udall. I have a question on that and a couple more.
    Thank you. Sorry for running over.
    Senator Johnson. Senator Hoeven.
    Senator Hoeven. Thank you, Mr. Chairman.
    Secretary Shinseki, thank you for the work that you do and 
for your service. I appreciate it very much. I also want to 
thank you for the VA clinic facility that is being constructed 
in Devils Lake. We worked hard and worked for a long time to 
get that, and I want to thank you for moving forward with it. 
It should be open sometime this spring. So it is very much 
needed, very important, and I thank you for your willingness to 
help us make it happen.
    Also, the Fargo VA Health Center continues to do 
outstanding work. You have been out there before. I want to 
invite you again. They are doing an outstanding job, constantly 
updating the facility, but they serve North Dakota and a big 
swath of Minnesota as well, and they are doing tremendous work.
    But one of the challenges we have is western North Dakota. 
North Dakota is now the fastest growing State in the Nation, 
and particularly in the west with energy development, we have 
incredible growth. Williston is the fastest growing community 
in the country under 50,000. Dickinson is the fourth fastest. 
Minot is the eighth fastest, although Minot may be over 50,000 
now. So we have a real need for services out there, and we have 
the walk-in clinics.
    But for services beyond what they can provide, from 
Williston, North Dakota to Fargo, to access the VA Health 
Center there, it is 800 miles roundtrip; so a 400-mile trip, so 
800 miles roundtrip. Grant Carns, the Veterans Service Officer 
in Williston, has talked to us about how we have had veterans 
who have actually passed away going or coming because it is 
such a long trip.
    So our challenge is how do we get the VA to offer more 
services in the local communities? We have hospitals there. And 
I understand you are doing some things with tele-health, but we 
really need the ability to be able to get more services from 
the hospitals in those communities so that our veterans are not 
looking at an 800-mile roundtrip to get services.
    What can we do there?
    [The information follows:]

    Answer. The Fargo VA Health Care System (HCS) has adequate 
financial resources to provide services to veterans in western North 
Dakota. When authorizing non-VA, community care for veterans, the 
facility takes into consideration the medical services that can and 
should be performed by the VA, the availability of services in the 
local community, the distance from the Fargo VA HCS, the convenience 
for veterans, and the cost of care as well as potential travel pay.
    Community resources are increasing throughout the Bakken region. 
Therefore, Fargo VA will have opportunities to expand referrals to 
local healthcare facilities. Further, if services are not available in 
Dickinson and Williston, Fargo VA will refer veterans to non-VA 
facilities in Minot or Bismarck whenever feasible.
    The facility is actively engaged with VHA's new Patient-Centered 
Community Care Contract (PC3), which is a broad healthcare contract for 
specialty care, mental health and limited emergency care. This region's 
contract was awarded to Health Net and they are currently establishing 
a network of providers. Health Net will work closely with the VA and 
Veterans to arrange appointments in community facilities and ensure 
medical documentation is returned to the VA.
    In some instances, it is in the best interest of veterans to 
receive their care from the VA. When this appears to be the case, a 
specially assigned physician reviews the medical record and makes an 
assessment.

                       RURAL HEALTHCARE IN FARGO

    Mr. Shinseki. Senator, let me call on Dr. Petzel. When we 
have a rapid growth in a community like this, it is one that we 
focus on and are a little bit reactive to, but let me call on 
Dr. Petzel.
    Dr. Petzel. Thank you, Mr. Secretary.
    Senator Hoeven, I have visited Williston when I was the 
Network Director in that area and what I was told when I was 
there is that it is further to the VA hospital in Fargo from 
Williston than it is from Washington, DC, to Atlanta, just to 
put a point on how incredible that journey is. The Bakken 
oilfield development has put a lot of population pressure on 
everything that we do for veterans out there. There is just a 
tremendous number of people pouring into that region.
    Fortunately, we have established clinics in Dickinson and 
in Williston, which are right in the middle, actually, of the 
Bakken field. We have built those clinics up so that we can do 
a better job of serving veterans, particularly those with 
mental health issues. I happen to agree with you that we need 
to be buying more services in the community by using fee basis 
to provide care in that community. We have discussed this with 
Devon Liversage, who is the Director at Fargo, and I think you 
will see an increased use of the community in the months going 
forward.
    Senator Hoeven. Again, I would like to invite the 
Secretary, you or Doctor, to come to Williston and Dickinson. 
We need to find ways to provide more of those services locally. 
And so, if you would help us do that and give us some kind of 
plan or program as to how we can get more of those services 
locally, particularly out in the western part of the State, it 
is a critical need that has to be addressed.
    Also Mr. Secretary, I would ask for an update, both in 
terms of how you are doing on suicide prevention and PTSD, and 
whether your resources are adequate to address those needs or 
if you have additional need for resources in those areas.
    [The information follows:]

    Answer. The Fargo VA Health Care System has adequate financial 
resources to provide services to veterans in western North Dakota. 
Facility staff worked diligently to address the mental health needs of 
veterans in the Bakken Oil Region. These efforts have included hiring 
one full-time mental health social worker, one full-time psychiatrist 
and one full-time mental health registered nurse in Bismarck, and one 
full-time mental health social worker in Minot. A full-time outreach 
social worker is now on staff in Williston as well.
    Mental Health services are currently being offered via telemedicine 
at contracted CBOCs in Dickinson and Williston. Telehealth services 
include:
  --Medication management;
  --Evidence based psychotherapies;
  --Supportive therapy;
  --Brief focused therapies;
  --Group PTSD;
  --Health behavior coordinator--individual and group (education, 
        disease management);
  --Substance abuse evaluation and ongoing therapy; and
  --PC-MHI-team services.

                             MENTAL HEALTH

    Mr. Shinseki. Senator, I said earlier, the young people 
are, and it is not just this current generation but every 
generation, carrying this mission load for 10 years now. We 
expect that mental health is going to be an ongoing area of 
importance. Along with that, VA is being attentive to, and 
alert for, coming up with better responses to the potential for 
suicide.
    We have done considerable work here. I am going to ask Dr. 
Petzel to provide some detail. By committing to ending 
homelessness in 2015 and focusing on suicide prevention, we see 
a nexus, in fact, that shows up as we deal in both discussions, 
and it gives us an opportunity to begin to focus resources on 
things that we can do to prevent suicides.
    Dr. Petzel.
    Dr. Petzel. Thank you, Mr. Secretary.
    Senator Hoeven, there is good evidence that veterans who 
seek care and are treated by the VA do better. I mean, these 
mental health issues are a consequence of many factors, but 
including their participation in the conflicts both past and 
present are very, very difficult to treat and very, very 
important.
    We have in the VA, a network of suicide prevention 
activities. One, is prevention coordinators in each one of our 
medical centers. Two, is education of all of our providers 
about recognizing potentially suicidal individuals and 
providing them with the training as to where they need to go 
and how they can deal with those issues directly.
    We case manage everybody that we identify as being at high 
risk for suicide. We screen every veteran that comes to us for 
medical care, for suicidal ideation, for PTSD, for depression, 
and for substance misuse or abuse, are often antecedents to 
suicide. The suicide crisis hotline, has been very effective; 
900,000 calls since its inception in 2007 and better than 
30,000 rescues, who are people prevented from harming 
themselves or somebody else.
    We have two campaigns going on nationally to raise 
awareness amongst veterans and the community as to the issues 
of deployment and returning from deployment, particularly 
around the mental health issues and where they can seek care. 
It is as important to educate families, friends and the 
community, as it is to educate the veteran about what the 
potential issues are. There is good evidence, as I said in the 
beginning, that if we identify a veteran who has mental health 
issues and are able to treat them, then we are able to decrease 
the risk of self-harm.
    Mr. Shinseki. I would just close, Senator, by saying we 
work this issue hard. I mean, our philosophy is one suicide is 
one too many and every suicide is a tragedy, and so, this is 
not just some discussion about it. It is how to get in there 
and figure out how to be more effective.
    In our efforts, we have come up with factors that seem to 
show up in the population that we focus on, things like 
depression, sleep disorders, substance misuse, and PTSD to some 
extent. VA is still trying to understand what the direct ties 
are; the relationship issues. And for all of this and dealing 
with depression, we have a mental health program that has great 
capabilities. Insomnia, we can deal and treat by working with 
people; also on substance use, misuse, and disorder.
    In the work of the Veterans Health Administration, they 
have focused on reducing the amount of opioid prescriptions 
specifically reducing the amount of Oxycontin prescriptions 
that are distributed. In an earlier response, we would have 
provided to Senator Collins' question that not only are we 
interested in the take-back program, we are also interested in 
reducing the amount of these very potent drugs being 
prescribed.
    In one of our VA Medical Centers, already about 3 years' 
worth of work, they have reduced the high potency opioid 
prescription writing by 50 percent; Oxycontin, had a 99-percent 
reduction. We are taking this and then sharing it with the rest 
of the country throughout VA so we can begin to influence, in 
major ways, the impact that substance misuse has on potential 
suicides.
    Senator Hoeven. Thank you.
    Senator Johnson. Mr. Secretary, I have spoken to you 
personally about an issue that I am very concerned about and I 
am going to ask you to elaborate on what is the status of the 
hospital, the VA hospital in the Black Hills and Hot Springs, 
South Dakota?

                      BLACK HILLS AND HOT SPRINGS

    Mr. Shinseki. Certainly. Mr. Chairman, I would tell you 
that we have decided to step forward with a decision to conduct 
an environmental impact study. This is an open consultation 
where the community has an opportunity to provide insights. It 
is probably a 10- to 18-month process in arriving at a decision 
here.
    As you know, over several years now, we have restructured 
the delivery of healthcare in the Black Hills area; everything 
from providing community-based outpatient clinics to some rural 
settings, and also looking at how to structure healthcare 
delivery in Hot Springs. All of this will be discussed with 
stakeholders and hopefully in 10 to 18 months, we will have a 
decision that all of us can see goodness in.
    Senator Johnson. Thank you for your testimony, Mr. 
Secretary. And thank you, and your colleagues, for your work on 
behalf of the VA and the Nation's vets.

                     ADDITIONAL COMMITTEE QUESTIONS

    For the information of members, questions for the record 
should be submitted by the close of business on April 1.
    [The following questions were not asked at the hearing, but 
were submitted to the Department for response subsequent to the 
hearing:]
         Questions Submitted to Secretary Hon. Eric K. Shinseki
               Questions Submitted by Senator Tim Johnson
                        black hills realignment
    Question. Mr. Secretary, from the beginning I have been concerned 
about how the VA's proposed Black Hills restructuring relies heavily on 
contracting out care to private facilities. There are very real 
concerns about whether these local hospitals have the resources to 
handle an increase in patients and the expertise in vets healthcare. I 
also fear relying so much on outside care can lead to problems with 
vets not understanding what benefits are covered and providers not 
knowing what the VA will reimburse. In March, the Government 
Accountability Office (GAO) published a report on compliance with the 
Millennium Act emergency care benefit at four VA facilities, including 
the Black Hills Health Care System. The report highlighted instances of 
VA staff not complying with requirements, weak oversight, and lack of 
knowledge among veterans about their Millennium Act eligibility.
    Secretary, when there are already problems with vets 
misunderstanding these benefits and the VA incorrectly denying claims, 
why should my constituents and I believe that these problems won't be 
exacerbated under the proposed restructuring?
    Answer. The improvements planned in the proposed reconfiguration of 
the Department of Veterans Affairs (VA) Black Hills Health Care System 
would be achieved by expanding existing, and well-working, partnerships 
with community healthcare agencies including, but not limited to, the 
Department of Defense's Ellsworth Air Force Base, the Indian Health 
Service and the South Dakota National Guard, to purchase more 
healthcare services in or near veterans' hometowns. The most 
significant part of this purchased care for Hot Springs VA is it 
provides the medical inpatient and long-term care (or nursing home) 
that our veterans need. This volume and type of healthcare services, 
spread across local healthcare facilities in South Dakota, and parts of 
Nebraska and Wyoming, should not present a challenge.
    Some of the key goals are to reduce the distance veterans travel to 
obtain services, especially services not now provided by VA Black Hills 
Health Care System, and reduce veterans' personal out-of-pocket 
expenses for travel, whether or not they are eligible for VA-funded 
beneficiary travel. VA Black Hills intends to expand the use of VA 
nurses as case management and care coordination resources. Veterans who 
do not receive day-to-day care at one of our VA-staffed sites will have 
a VA nurse to help with referrals for VA and non-VA care; the 
coordination of that care between VA and non-VA facilities, including 
helping our veterans and their families understand their earned 
benefits; and questions and concerns. Veterans who continue to receive 
care at VA clinics at Hot Springs, Rapid City, or Fort Meade, are being 
cared for by patient aligned care teams, which include a primary care 
provider (a physician, nurse practitioner, or physician assistant) and 
his or her support staff.
    An indication of success is the expenditure by VA Black Hills of 
almost $30 million each year in local non-VA healthcare. VA has 
received feedback that veterans appreciate getting this care closer to 
home and frequently request this approach rather than traveling long 
distances to our tertiary VA facilities in Minneapolis, Omaha, or 
Denver.
                           claims processing
    Question. Department of Veterans Affairs (VA) is making progress in 
lowering the number of backlogged claims in the system. A lot of this 
success is from several temporary initiatives such as mandatory 
overtime and processing the oldest claims first. What systemic changes 
have you made or are you making to change the way claims are 
adjudicated so that we don't see another backlog 5 years from now?
    Answer. Implementation of VA's transformation initiatives, 
including temporary initiatives like mandatory overtime, has produced 
very positive results. The Veterans Benefits Administration's (VBA) 
transformation is the largest in its history and the major initiatives 
are designed to fundamentally change the way claims are processed. VBA 
is aggressively pursuing initiatives to retrain and reorganize its 
people, streamline its business processes, and build and implement new 
secure technology solutions that enable paperless claims processing. 
These initiatives are long-term solutions that will permanently 
eliminate the backlog of disability compensation claims and 
substantially improve the way veterans, their families, and Survivors 
receive their benefits and services.
    VBA has reduced the claims backlog (i.e., claims pending over 125 
days) from its peak of 611,000 in March 2013 to 306,000 as of May 8, 
2014--a 50-percent reduction. Veterans are now waiting less time for 
their decisions and benefits. Claims currently in the inventory have 
been pending an average of 160 days, a 43-percent reduction from the 
peak of 282 days in February 2013. At the same time, the accuracy of 
our rating decisions continues to improve. VBA's national ``claim-
level'' accuracy rate, determined by dividing the total number of cases 
that are error-free by the total number of cases reviewed, is currently 
91 percent--an 8-percentage-point improvement since 2011. When 
measuring the accuracy of rating individual medical conditions inside 
each claim, the 3-month accuracy level is 96 percent.
    Question. Last year we included additional funding for the VA to 
provide additional training for processors at poorly performing 
regional offices. Have you developed a plan for this funding and do you 
have plans for routine follow-up and testing?
    Answer. VA's fiscal year 2014 appropriation included an additional 
$10 million to train claims processors. VA's plan to utilize this 
funding includes conducting a Specialized Adjudication Review Course 
(SPARC) to retrain approximately 1,250 veterans service representatives 
and 900 rating veterans service representatives. SPARC will provide 
refresher training for employees who are having difficulty meeting 
performance standards to help them become fully successful. VA will 
also use this funding to provide Supervisory Technical Analysis of Data 
(STAND) training for 750 coaches and assistant coaches. Training will 
focus on data analysis and personnel management tools. SPARC and STAND 
training are scheduled for May through July 2014. Although VBA may 
experience a short-term decrease in claims production during training, 
these important investments will lead to long-term improvements in 
production and decision accuracy.
    VA conducts routine training by requiring claims processors to 
complete a minimum of 85 hours of training each fiscal year. These 
employees are required to complete 5 hours of annual VA training on 
topics such as Privacy, Health Insurance Accountability and Portability 
Act, and ethics. They are required to complete another 10 hours of 
mandated national training regarding changes in regulations and 
procedures at a national level as well as trends identified during 
monthly quality reviews by Systematic Technical Accuracy Review (STAR) 
staff, fast letters, training letters, and court decisions. For the 
remaining 70 hours of training, regional offices have autonomy to 
select courses based on training needs identified during reviews 
conducted by local quality review teams and national quality review 
staff, as well as national quality trends and requirements for a 
particular position.
    VBA has an ongoing program of skills certification testing for 
coaches, decision review officers, rating veterans service 
representatives, and veterans service representatives. Each test is 
offered approximately every 6 months. In fiscal year 2013, 10 skill 
certification tests were administered to claims processors and 
supervisors.
    Question. As the backlog has come down, it seems the number of 
appeals is on the rise and the number of days it takes to process an 
appeal is growing. What is the Department's strategy to speed the 
appellate process?
    Answer. VA's strategy to improve the appellate process is available 
in the attached Strategic Plan to Transform the Appeal Process, which 
was shared with the Senate Committee on Veterans' Affairs in February 
2014. The current process provides appellants with multiple reviews in 
VBA and one or more reviews at the Board of Veterans' Appeals (the 
Board), depending upon the submission of new evidence or whether the 
Board determines that it is necessary to remand the matter to VBA. The 
multi-step, open-record appeal process set out in current law precludes 
the efficient delivery of benefits to all veterans. The longer an 
appeal takes, the more likely it is that a claimed disability will 
change, resulting in the need for additional medical and other evidence 
and further processing delays. As a result, the length of the process 
is driven by how many cycles and readjudications are triggered. VA is 
implementing a series of initiatives to improve the appeal process and 
continues to work with Congress and other stakeholders to explore long-
term solutions that would provide veterans the timely appeals process 
they deserve.
    [An appeals report follows:] 
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    
    Question. How did VA determine that the number of days it takes to 
resolve an appeal is going to fall in fiscal year 2014 to 625 days from 
912 days in fiscal year 2013? This seems optimistic given recent 
increases in appeals.
    Answer. The Appeals Resolution Time (ART) of 625 days is a 
strategic VA target. ART is a joint measure between VBA and the Board 
of Veterans Appeals that tracks the average time to process an appeal 
from the date an appellant files a Notice of Disagreement until the 
appeal is resolved, whether VBA or the Board finally resolves it. VA is 
exploring a series of [efficiency] initiatives related to people, 
processes, and technology within existing authorities to improve the 
appeal process (see VA's Strategic Plan to Transform the Appeal 
Process). VA continues to work with Congress, veterans, and other 
stakeholders to identify and implement improvements so all veterans can 
receive more timely and accurate decisions on their appeals.
                              rural health
    Question. Mr. Secretary, I know you are aware of my interest in 
rural health, which is why I created the Rural Health Initiative in 
2009 and provided $250 million in seed money. I appreciate the support 
of the VA in providing $250 million annually in its base budget since 
then to continue this important initiative.
    Given the current budget constraints, do you believe this funding 
level can be sustained or increased in future years to meet the growing 
needs of rural vets?
    Answer. From fiscal year 2009 through fiscal year 2013, Veterans 
Health Administration's (VHA) Office of Rural Health (ORH) funded over 
$1.23 billion in programs, projects, and pilots to meet its legislative 
mandate to increase access and improve care and services for veterans 
who reside in rural areas of the United States. Since inception, ORH 
has allocated its funds to a wide variety of innovative programs and 
projects in the following areas:
  --Patient care (rural home-based primary care and innovative models 
        of care, such as tele-audiology, tele-mental health);
  --Rural workforce development (training and education of new 
        physicians, nurse practitioners, and nurses in rural clinical 
        settings; and training for existing VA rural providers and 
        clinical staff);
  --Service infrastructure (rural community-based outpatient clinic 
        (CBOC) construction, telehealth outreach clinic construction, 
        rural personnel staffing costs, equipment, and mobile clinics);
  --Outreach (special populations and care coordination);
  --Transportation (purchase/use of vehicles, driver wages, and other 
        costs of patient transportation);
  --Caregiver support; and
  --Ancillary services, such as health promotion and rural clergy 
        training.
    In 2014, ORH is allocating its $250 million budget to sustain and 
expand many of the programs most effective at delivering care and 
services to veterans living in rural and highly rural areas and is 
investing in partnerships with Veterans Integrated Service Networks 
(VISN) and VHA program offices to provide rural veterans even greater 
access to transportation, veteran-initiated electronic care 
coordination using Electronic Health Records (EHR), and Health 
Information Exchange (HIE), to ensure the best possible care for 
veterans who use both VA and community healthcare providers.
    ORH is preparing new funding initiatives for fiscal year 2015 that 
will sustain successful programs and invite even greater innovation in 
increased access for rural veterans. These initiatives are targeted on 
disseminating the most promising practices developed over the last 5 
years, inviting innovative proposals for new projects designed to 
increase rural veterans' access to care, and providing opportunities 
for training providers who care for our rural veterans and their 
families. ORH anticipates that, for fiscal year 2015, the $250 million 
budget will be divided as follows: sustainment of current successful 
projects in the VISNs; development of new, innovative programs to 
increase rural access; rural healthcare workforce development; 
transportation for rural veterans; and the strengthening of rural 
veteran programs in HIE and electronic care coordination.
    Question. Telehealth is a very important tool in reaching rural 
vets, but it is no substitute for access to VA medical facilities. 
Distance and travel costs are major obstacles for rural vets wishing to 
see a VA doctor or go to a VA medical facility. Looking ahead, how can 
the VA improve not only outreach but also access to VA facilities for 
rural vets?
    Answer. In addition to telehealth technology, VA seeks to increase 
outreach and access to care for rural veterans by deploying a 
comprehensive and strategic network of VA and contracted CBOCs, and 
purchased care from non-VA community providers in an effort to make 
care available closer to home for rural veterans. In addition, VA 
supports multiple transportation options to support veterans traveling 
a distance to access primary, specialty, or ancillary services that may 
be located beyond the local VA clinic. ORH has a formal partnership 
agreement with the Veterans Transportation Service (VTS) to address a 
broad range of rural veterans transportation needs. VTS has established 
collaborative initiatives with multiple organizations such as veterans 
service organizations, Federal, State and local government 
transportation agencies. VA participates in United We Ride and the 
Veteran Community Living Initiative, and also has a Highly Rural 
Transportation Grants Program; all aimed at coordinating and enhancing 
transportation resources to assist veterans in accessing the care they 
have earned and deserve. It should be noted that other rural health 
initiatives include targeted interagency collaborations with the Indian 
Health Service and the Department of Health and Human Services to 
promote increased use of technology to support care delivery and care 
coordination among veterans' providers in rural and tribal communities.
                                 ______
                                 
                Questions Submitted by Senator Mark Kirk
                              lovell fhcc
    Question. In 2010, the Department of Veterans Affairs and the 
Department of Defense stood up the Captain James A. Lovell Federal 
Health Care Center (FHCC). This first-of-its-kind partnership delivers 
state-of-the-art care to approximately 67,000 servicemembers, veterans, 
and their families in Illinois and Wisconsin.
    What is your assessment of this partnership and does the Department 
envision future joint facilities similar to the Lovell FHCC?
    Answer. Section 1701 of the National Defense Authorization Act for 
fiscal year 2010 (NDAA) authorized a five-year demonstration of the 
joint use by Department of Defense (DOD) and Department of Veterans 
Affairs (VA) of a new Navy ambulatory care center in North Chicago, 
Illinois, (now known as the James A. Lovell Federal Health Care Center 
(FHCC)). The legislation includes a requirement for a joint final 
report of the demonstration, not later than 180 days after the fifth 
anniversary of the date of execution of the required executive 
agreement, including:
  --(a) a comprehensive description and assessment of the exercise of 
        the authorities in this title, and
  --(b) the recommendation of the Secretaries as to whether the 
        exercise of the authorities in this title should continue.
    A contract was awarded in November 2013 to conduct the required 
comprehensive assessment. This report is due to Congress in October 
2015.
    Also required by the above legislation, on April 4, 2010, DOD and 
VA jointly submitted a report to the appropriate committees of Congress 
on additional locations where Executive Agreements, similar to the one 
being developed for the DOD/VA Medical Facility Demonstration Project, 
Federal Health Care Center (FHCC) at North Chicago, may be developed. 
The report stated that, ``The Departments do not currently plan another 
location replicating the FHCC Demonstration Project and development of 
similar executive agreements. The Executive Agreement for the FHCC at 
North Chicago will be unique, in that this facility will be operating 
under a management concept that entails full vertical integration of 
all functions. While the FHCC at North Chicago continues to move 
towards its expected operational status, it has not yet reached optimal 
full integration and will be in a demonstration test status for 
approximately 5 years. We expect that there will be unanticipated 
issues to address and resolve as it progresses. The lessons that we are 
able to harvest from the North Chicago Demonstration Project will 
better prepare us to determine the true benefit and effectiveness of 
this type of full integration at some future location(s).''
    To date, there is no change to the above response. Reassessment 
will be considered after the comprehensive evaluation of the FHCC. 
Collaboration at the FHCC continues to evolve. An important step 
forward in the relationship between VA and the Navy occurred with the 
execution of the reorganization that began in April 2014, which added 
additional directorates and established additional leadership positions 
for Navy personnel. Also, with the departure of the long-time Director 
of the facility, the Network Director asked the Navy Captain Deputy 
Director to accept the role of Acting Director until a new Director can 
be put in place. The Network Director also detailed an experienced VA 
Associate Director from a complex level 1 facility to act in the role 
of Deputy Director to ensure strong leadership during this interim 
period. That juxtaposition of VA and Navy roles in the command suite 
will enhance the partnership between the Departments and the employees 
at the center.
    Question. What is the Department's timeline to identify a new 
Director for the Lovell FHCC?
    Answer. The best qualified candidates have been interviewed, and 
the nomination package is being completed. VA anticipates a new 
Director to be in place prior to the outgoing Commander leaving.
    Question. How has the relationship with the Department of Navy 
improved over the past year?
    Answer. An important step forward in the relationship between VA 
and Navy occurred with the execution of the reorganization that began 
in April 2014 which added additional directorates and established 
additional leadership positions for Navy personnel. Also, with the 
departure of the long-time Director of the facility, the Network 
Director (ND) asked the Navy Captain Deputy Director to accept the role 
of Acting Director until a new Director can be put in place. The ND 
also detailed-in an experienced VA Associate Director from a complex 
level 1 facility to act in the role of Deputy Director, to ensure 
strong leadership during this interim period. That juxtaposition of the 
VA and Navy roles in the command suite will enhance the partnership 
between the Departments and the employees at the center.
                        duplicative jobs portals
    Question. Today the Departments of Veterans Affairs, Defense, and 
Labor all run duplicative job portals for veterans seeking private and 
public sector employment. At the same time, the level of unemployment 
among Gulf War II-era veterans remains higher than their nonveteran 
peers.
    Do you believe that veterans would benefit from a single one-stop 
Federal portal for employment resources/searches and are there any 
initiatives underway across the interagency to consolidate them?
    Answer. On April 23, 2014, Department of Veterans Affairs (VA) 
announced the new Veterans Employment Center on eBenefits as the one-
stop shop connecting veterans, transitioning servicemembers, and their 
spouses to employers. The Veterans Employment Center was created by VA 
based on requirements from an interagency team including the Department 
of Defense, the Department of Labor, and the Office of Personnel 
Management.
    The Employment Center includes a skills translator, resume builder, 
job-search tools, and other resources for job seekers. It also includes 
a searchable resume bank and other resources for employers. The 
Veterans Employment Center is available at: https://
www.ebenefits.va.gov/ebenefits/jobs. For a step-by-step introduction to 
the site, a video is available at: https://www.youtube.com/
watch?v=VWfhI-eSoWk.
    Question. If there are such initiatives, when does VA expect this 
process to be complete?
    Answer. The initial launch of the Veterans Employment Center Web 
site was completed in April 2014. Moving forward, VA will continually 
collect feedback and work to better meet the needs of all customers 
including veterans, transitioning servicemembers, family members, and 
employers.
                        electronic health record
    Question. The Department's modernization of VistA at the same time 
as the Department of Defense's acquisition of a commercial off the 
shelf product raises concerns that veterans' health records will remain 
complicated by two distinct systems that do not talk to each other. 
This strategy could defy Congress' intention of an interoperable 
record.
    How is the Department ensuring an evolved VistA will be compatible 
with the new core system Department of Defense (DOD) will select so we 
actually achieve an interoperable health record?
    Answer. VA plans to implement open national clinical data standards 
(that are agreed upon by VA and DOD) at the core of future evolved 
VistA. DOD's new core system adoption of these same open national 
clinical standards will ensure optimal interoperability. On December 5, 
2013, the VA/DOD Interagency Program Office (IPO) was re-chartered to 
address terminology and technical standards and processes supporting 
health data interoperability. The IPO is responsible for establishing, 
monitoring, and approving the clinical and technical standards profile 
and processes to create seamless integration of health data between DOD 
and VA electronic health record (EHR) systems.
    Where the Office of the National Coordinator (ONC) has established 
terminology and technical standards, the Departments will use those 
standards for interoperability. The VA/DOD Target Health Standards 
Profile (HSP) contains the agreed-upon, cross-agency standards that 
both VA and DOD will adhere to, at the direction of the IPO. The VistA 
Evolution Program data standards will conform to the HSP; as new 
standards are added, the VistA Evolution Program will proactively 
respond to and adopt the new standards.
    Additionally, joint testing between VA and DOD, as defined by the 
designated joint working group--consisting of Defense Medical 
Information Exchange Integrated Quality Assurance and VA Enterprise 
Testing Services personnel--will ensure that the systems are 
compatible.
    Question. What steps is VA taking to ensure that VistA is as 
competitive as other commercial off-the-shelf products for DOD's 
solicitation?
    Answer. VA is committed to an evolved VistA that is based upon an 
open architecture, data standards-compliant, and non-proprietary in 
design, which will provide additional capabilities, through a set of 
milestones, in 2014. The functionality to be delivered in September 
2014 will provide the foundational elements of interoperability and 
clinician-facing enhancements.
    VistA will be in a position to compete in DOD's acquisition process 
through open source vendors. VA has already put in place tools to help 
ensure VistA's viability in this process, including the Joint Legacy 
Viewer tool for jointly viewing VA/DOD patient records. There are 
Office of the National Coordinator fiscal year 2014-certified VistA 
options available at the current time. VA expects that an industry 
partner will use the open source VistA baseline to respond to DOD's 
request for proposal scheduled to be issued by the end of this fiscal 
year. We believe that native use of open national clinical data 
standards will promote innovation in future VA systems.
    Question. Have you discussed your thoughts on VistA with Secretary 
Hagel?
    Answer. Yes. Secretary Hagel is aware that VA is committed to an 
evolved VistA that is based upon an open architecture, data standards-
compliant, and non-proprietary in design, which will provide additional 
capabilities, through a set of milestones, in 2014. Further, we remain 
fully committed to achieving the enhanced interoperability required by 
the fiscal year 2014 National Defense Authorization Act between the 
health record systems of the two Departments as well as the private 
healthcare sector, and are on track to continue to deliver capabilities 
as health standards mature and are incorporated into our information 
technology systems. Enabling health information exchange from EHR 
systems in the DOD, VA, and the private sector will serve as the 
foundation for a patient-centric healthcare experience, seamless care 
transitions, and improved care delivery for servicemembers, veterans, 
and their families.
                        drug take-back programs
    Question. On September 27, 2013, I joined 18 Senators in writing to 
Attorney General Eric Holder Jr. regarding a proposed rule to establish 
drug take-back programs at Department of Defense and VA facilities. It 
is my understanding that the Office of Management and Budget (OMB) is 
currently analyzing changes to this rule that would enable these two 
entities to carry out this important mission.
    What is the status of OMB's review and when do you expect it to be 
finalized?
    Answer. In 2012, the Office of Management and Budget sent the Drug 
Enforcement Administration/Department of Justice's (DEA/DOJ) draft 
proposed rule, ``Disposal of Controlled Substances,'' to VA for our 
review. VA provided comments, and the proposed rule (RIN: 1117-AB18) 
was published on December 21, 2012 (77 Fed. Reg. 75,784). DEA/DOJ 
received 194 public comments. On February 25, 2014, DEA/DOJ submitted 
the final rule to OMB for review.
                                 ______
                                 
           Questions Submitted by Senator Barbara A. Mikulski
                            interoperability
    Question. Secretary Shinseki, I am pleased with the Department of 
Veterans Affairs initiative to transition to a fully digitized system. 
I am also glad to see funding requests for the Veterans Benefit 
Management System and Veterans Claims Intake Program in the fiscal year 
2015 budget request. I understand these will go a long way in helping 
the VA reach their goal of fully implementing a paperless claims 
system.
    Although these programs appear to make great strides I am concerned 
with any paper processing still occurring and the progress of 
interoperating digitally between all the agencies.
    Secretary Shinseki, is there any part of the Department of Veterans 
Affairs' (VA) claims process, besides the initial paper claims 
submission, that is still on paper? If so, why?
    Answer. The only part of the disability claims process that will 
continue to be in paper is the receipt of claims and supporting 
evidence. This fiscal year through March, 4.5 percent of disability 
compensation claims were filed electronically through our eBenefits Web 
portal. Although the majority of VA's claimants still file in paper, 
all paper applications and records are now converted to electronic 
images for paperless processing in Veterans Benefit Management System 
(VBMS). With scanning support, nearly 90 percent of Veterans Benefits 
Administration's (VBA) current disability claims inventory is 
electronic. As VA continues to focus on completing the remaining paper 
claims in our inventory, the number of claims processed in VBMS is 
rapidly growing. In March 2014, 63 percent of the rating claims 
completed were processed electronically in VBMS.
    VA recognizes that some veterans prefer to submit information in 
paper, and VA will continue to accept claims and supporting evidence in 
paper. However, VA has initiated an aggressive outreach campaign to 
encourage more veterans and their families to enroll in eBenefits and 
to make them aware of the advantages of filing fully developed claims 
online.
    Question. What else is the VA doing to fix this?
    Answer. VA continues to develop and implement initiatives to 
improve the electronic claims process for veterans as well as claims 
processors. Veterans primarily see these improvements through 
eBenefits, a joint VA-Department of Defense (DOD) client-services 
portal with over 50 self-service options that allow users to file 
benefit claims online; upload supporting claims information; check the 
status of claims or appeals; review their VA payment history; and 
obtain military documents, among other actions.
    Claims processors are seeing improvements in electronic claims 
processing through numerous initiatives. Examples include:
  --VA continues to expand and enhance automated processing 
        capabilities in VBMS. VA's Web-based electronic claims 
        processing system. This technology helps VA gain processing 
        speed within a digital claims processing environment, improves 
        access, and drives automation.
  --The rules-based processing system (RBPS) automates processing and 
        payment of dependency claims for veterans who file online. Over 
        50 percent of dependency claims that are filed online are now 
        being completed without human intervention. The remaining 50 
        percent are immediately triaged to make it easier for the 
        claims processor to target the needed evidence for resolution.
  --VBA is starting to centralize mail for inbound compensation claims, 
        which will be redirected from regional offices to scanning 
        vendors. These scanning vendors convert mail into electronic 
        images that are accessible by VA claims processors. By July 
        2014, these scanning vendors will receive and process all 
        compensation-related mail, reducing the time required to 
        process incoming mail at regional offices.
  --On January 1, 2014, an interface was implemented to transmit 
        Service Treatment Records (STR) between DOD's Health Artifact 
        and Image Management Solution (HAIMS) and VA's VBMS. With the 
        exception of records requested as part of the Integrated 
        Disability Evaluation System process, DOD no longer sends paper 
        STRs to VA. All certified and complete STRs requested by VA 
        come to VA electronically.
    Question. How is the VA interoperating digitally between the VA, 
DOD, and private medical facilities? Is it effective?
    Answer. Beginning January 1, 2014, systems interfaces were 
implemented to electronically transmit DOD STRs from DOD's HAIMS to 
VA's VBMS. This electronic STR process pertains to servicemembers who 
separated from military service after January 1, 2014. With the 
exception of records requested as part of the Integrated Disability 
Evaluation System process, DOD no longer sends paper STRs to VA.
    To assist in obtaining veterans' records from private medical 
facilities, nine regional offices are currently piloting the Private 
Medical Records (PMR) Program, which utilizes contract support that 
enables VA to electronically request, receive, and view PMRs. In this 
pilot, the wait time to receive PMRs has been reduced by half. VA plans 
to implement the PMR Program nationally in fiscal year 2015.
    Question. How long are veterans waiting for their medical records 
to transfer between agencies?
    Answer. As of May 1, 2014, VBA requested 4,800 STRs from DOD 
through the electronic process. DOD has provided 852 certified and 
complete STRs, or 18 percent of the total requested. Of the 3,948 
requests outstanding, approximately 31 percent are within the 45-
calendar-day timeframe from separation/retirement agreed upon by VA and 
DOD, and 69 percent are past due. DOD is committed to timely providing 
VA certified and complete STRs in a searchable electronic format. VBA 
and DOD are developing metrics and a reporting method for certification 
of STRs. Responsibility and oversight for certification belongs to 
DOD's new Medical Records Management Office.
    Question. What improvements can be made to ensure seamless 
interaction between these agencies?
    Answer. VA and DOD have already made great strides in transitioning 
from paper to electronic exchange of information. VA and DOD agree that 
continued enhancements to VBMS and HAIMS are needed to improve 
timeliness of transmission and tracking of STRs. VA and DOD's Medical 
Records Working Group meets weekly and continues to work on resolving 
issues regarding the transfer of STRs.
                              collections
    Question. I understand that the Department of Veteran Affairs is 
currently owed over $2 billion in outstanding copays from private 
insurance companies. Now more than ever, effectively collecting what is 
owed to the government is not only responsible but necessary. We cannot 
afford to only collect 38 percent of what is owed. These funds can be 
used to build state-of-the-art facilities and ensure veterans receive 
the superior care they deserve.
    Secretary Shinseki, in your testimony you claimed commitment to 
responsible stewardship yet the VA is owed $2 billion in copays from 
private insurance companies.
    What is the VA's plan to collect what is owed to them?
    Answer. Department of Veterans Affairs (VA) is not owed $2 billion 
dollars in copays from private insurance companies. As of May 2014, our 
aged third-party receivables, which are defined as payments from 
insurers that haven't been received by 90 days after billing, amounted 
to $114 million. VA is prohibited by statute from balance-billing 
veterans for their private insurance copay amounts. Private insurance 
companies are required to pay VA the lesser of the amount billed or the 
amount they would pay other providers in the same geographic area for 
the same services minus any deductible or copay. The majority of 
private insurance companies elect to pay the amount they pay other 
providers, which results in reimbursement at less than billed charges.
    VA continues to pursue multiple efforts to improve the efficiency 
of revenue cycle operations. Toward that end, in fiscal year 2012, VA 
deployed seven industry best practice Consolidated Patient Account 
Centers (CPAC) with standardized processes, enhanced employee training 
and greater accountability. Specific accomplishments from this new 
organizational model include:
  --State of the Art Accounts Receivable Management Program.--CPAC has 
        implemented an Accounts Management follow-up process that 
        includes an automated work-flow engine to ensure greater 
        oversight of work performed. This tool also includes denials 
        management and appeals management components to challenge bills 
        not paid by insurance companies. VA currently has 16 percent of 
        its accounts aged more than 90 days versus the commercial 
        industry average of 24 percent.
  --Payer Relations Analytical Tools.--CPAC collection efforts have 
        focused on analytics, including the development of a payer 
        compliance tool that allows for an automated review of actual 
        payments versus expected amounts. This tool allows CPAC to 
        detect missed revenue due to payer noncompliance and identify 
        opportunities to improve agreement rates.
  --Stringent Internal Controls.--CPAC implemented an Internal Controls 
        Program that provides oversight of entity-level risk management 
        and enforcement of key controls through the formalization of 
        managerial oversight and monitoring high-risk areas inherent to 
        all business processes. The Internal Controls Program consists 
        of an annual monitoring plan that ensures remediation of 
        identified control deficiencies. This proactive identification 
        and correction of control deficiencies has increased efficiency 
        and improved third-party collections.
    Question. What are our veterans losing in the form of better 
treatment, support, and facilities due to these astronomical 
outstanding dues from insurance companies?
    Answer. VA has collected significant revenues through our Medical 
Care Collection Fund program that go directly to providing care and 
treatment to veterans. In fiscal year 2013 alone, VA collected $1.9 
billion in insurance collections. This represents an increase of $483 
million compared to fiscal year 2008. Our collections-to-billing (CtB) 
ratio, which is defined as our total collections over total billings, 
was 41.2 percent for fiscal year 2013. This is a significant 
improvement over the CtB in fiscal year 2011 when our CtB was 33.9 
percent. VA continues to work diligently to ensure all monies owed to 
VA are collected in an accurate and timely manner. In absence of the 
payments, veterans still receive the quality care they deserve.
                                 ______
                                 
              Questions Submitted by Senator Patty Murray
                         spokane medical center
    Question. A recent Veterans' Affairs Committee hearing afforded the 
opportunity to discuss underfunding at the Mann-Grandstaff VA Medical 
Center. Taken into consideration with similar situations observed at 
other medical centers in previous years, such as the Indianapolis 
medical center, this raises concerns that other facilities in VISN 20 
and around the country may be facing similar budget situations.
    What is VA doing to ensure other VISNs and facilities are receiving 
the resources they need?
    Answer. The Department of Veterans Affairs (VA) uses the Veterans 
Equitable Resource Allocation (VERA) methodology to allocate funds to 
each of the 21 Veterans Integrated Service Networks (VISN) nationwide. 
The VERA methodology ensures that:
  --Discretionary appropriations for medical care are distributed 
        equitably to the VISNs based on the number of veterans who use 
        the system.
  --Funds are allocated to provide medical care access for veterans who 
        have the highest priority for healthcare and special healthcare 
        needs.
                           allocation process
    In allocating resources among the 21 VISNs, VERA makes adjustments 
for variances in the complexity of care provided; labor and contract 
costs; research support; education support; equipment; non-recurring 
maintenance (NRM); and high-cost patients.
  --Research support is based on the amount of research activity.
  --Education support is based on the number of residents.
  --Equipment funding is based on the number of patients.
  --NRM is allocated based on factors including Strategic Capital 
        Investment Plan prioritized project design costs, Facility 
        Condition Assessment high-priority projects, and facility 
        sustainment requirements.
  --The allocation for high-cost patients is determined by the costs of 
        patients that exceed the high-cost threshold.
    In fiscal year 2011, VA implemented a new resource allocation 
process that includes a standardized model for VISNs to use in 
allocating funds to their subordinate VA Medical Centers (VAMC). The 
model is designed to provide consistency in the allocation process 
across VISNs, while ensuring that VISN Directors retain the flexibility 
to make appropriate adjustments to modeled VAMC allocations.
                             visn reserves
    VISNs initially retain some resources for initiatives, centrally 
managed activities, and to address changing mission requirements. This 
includes, but is not limited to, start-up costs for new VISN 
initiatives to enhance veteran healthcare; funding for consolidated 
services that are shared across the VISN; and up to 1.5 percent of the 
total allocation for a contingency reserve used for unanticipated VAMC 
costs, such as natural disasters or high-cost non-VA care patients.
    VA compares each VISN's actual budget execution against their 
budget operating plans monthly to ensure that all VISNs have sufficient 
resources to meet their planned mission requirements. In addition, a 
VISN Director may identify urgent resource requirements that exceed the 
VISN's ability to fund within their available resources. These 
requirements are reviewed by the Under Secretary for Health, and if 
approved, are funded by reallocating unexecuted funds from the National 
Reserve or from other programs that are considered to be a lower 
priority than the newly identified requirement.
    Question. What additional resources can VA make available to 
facilities projecting budget shortfalls?
    Answer. VISN Directors may move funding within their network to 
ensure each facility has sufficient funding to meet their requirements. 
If there is a budget shortfall that the VISN cannot manage internally 
with available resources, the VISN Director may request additional 
funds from the Under Secretary for Health. If approved, the requirement 
is funded by reallocating unexecuted funds from the National Reserve or 
from other programs that are considered to be a lower priority than the 
newly identified requirement.
                    state veterans home construction
    Question. The Independent Budget recommends $250 million for State 
veteran's home construction grants to address an overwhelming need for 
such grants, yet the President's budget request proposes cutting 
funding to $80 million. Veterans, such as the more than 1,000 affected 
veterans in Walla Walla, are waiting for this care.
    Why is VA not requesting a stronger investment in this program?
    Answer. As with every Federal agency, VA prioritizes it budgetary 
request based upon the most important demands for veteran services. For 
fiscal year 2015, this request included a focus on eliminating 
homelessness, reducing the claims backlog, investing in information 
technology infrastructure to support these priorities and supporting 
VA's direct capital program.
                       vocational rehabilitation
    Question. VA has taken commendable steps in recent years to improve 
its Vocational Rehabilitation and Education program (VR&E), however, 
the program may not be meeting the needs of some veterans with mental 
health injuries as well as possible. GAO recently found that veterans 
participating in VR&E were l2 percent less likely to achieve suitable 
employment than veterans without such conditions. This gap represented 
the largest difference for any type of disability.
    Is VA considering modifications to make VR&E more effective for 
veterans with mental health injuries?
    Answer. VA continues to explore ways to improve service delivery 
and eliminate the stigma employers may have regarding veterans with 
service-connected mental health disabilities in the Vocational 
Rehabilitation and Education (VR&E) program. VR&E's Vocational 
Rehabilitation Counselors (VRC) are fully trained to address the 
challenges and barriers facing veterans who have mental health 
conditions. VRCs have a master's degree in Rehabilitation Counseling 
and similar fields, and many of them have nationally and State-
recognized licenses and certifications in counseling. VA provides VRCs 
with training on mental health disabilities and the vocational 
implications associated with these conditions. Additionally, VRCs work 
to ensure all employment barriers are overcome through a comprehensive 
approach to service delivery, which includes an individualized 
rehabilitation plan and coordination with VA medical centers and vet 
centers for mental health services needed by VR&E participants.
                  integrated electronic health record
    Question. It has been over a year since VA and DOD announced that 
the Departments would be abandoning the goal of a jointly developed and 
common electronic health record, and would instead be pursuing separate 
interoperable systems. A GAO report released last month found that VA 
and DOD have not been transparent about the cost and timeline of the 
Departments' current approach, nor have they detailed the clinical 
domains to be addressed by the interoperable electronic health records, 
among other concerns. After being repeatedly assured that abandoning a 
joint, common, and open approach would yield better results sooner and 
at lower cost, these findings are very troubling.
    What steps is VA taking towards addressing the issues identified by 
GAO?
    Answer. The GAO final report, titled ``ELECTRONIC HEALTH RECORDS: 
VA and DOD Need to Support Cost and Schedule Claims, Develop 
Interoperability Plans, and Improve Collaboration (GAO-14-302)'' was 
delivered to both VA and Department of Defense (DOD) on February 27, 
2014, which concluded the year-long audit.
    In an effort to foster transparency with GAO, VA is embarking on a 
series of meetings to update GAO on our interoperability work with DOD, 
with the first meeting to occur in May 2014. Through these meetings, VA 
will be able to describe the work being done to address the issues 
identified by GAO--specifically, the progress made on the VistA 
Evolution Program and toward the interoperability of the Departments' 
health record systems.
    As an example, the first GAO recommendation was to ``develop a cost 
and schedule estimate for their current approach . . . that includes 
the estimated cost and schedule of VA's VistA Evolution program.''
    The VistA 4 Product Cost Estimate, which is a top-down initial 
development, deployment, and operations cost estimate for the VistA 4 
product, was transmitted to GAO and Congress on March 24, 2014. The 
Department is currently working to refine the VistA 4 Product Cost 
Estimate, using a bottom-up cost estimate methodology, which is 
expected to be complete in June 2014.
    A bottom-up estimate is typically considered more accurate than a 
top-down cost estimate because it is based on a granular work breakdown 
structure considering the details and dependencies associated with an 
information technology development. In contrast, a top-down estimate 
relies more on the judgment of subject matter experts, market 
comparisons, and model-based overhead approaches in the absence of the 
detailed information contained in a work breakdown structure.
    Secretary Shinseki testified that VA will submit a bid for DOD's 
procurement of an EHR.
    Question. In the event that VistA Evolution is not selected, how 
will the Departments ensure interoperability between the systems?
    Answer. Conformance to open standards will ensure interoperability 
with VistA. VistA Evolution will incorporate terminology standards such 
as Systematized Nomenclature of Medicine--Clinical Terms, Logical 
Observations, Identifiers, Names, and Codes and RxNorm. By ensuring 
that VistA Evolution uses these recognized terminology standards of the 
Department of Health and Human Services (HHS), Office of the National 
Coordinator (ONC), we are establishing the foundation for semantic 
interoperability between systems that also leverage these standards.
    On December 5, 2013, the VA/DOD Interagency Program Office (IPO) 
was re-chartered to address terminology and technical standards and 
processes supporting health data interoperability. The IPO is 
responsible for establishing, monitoring, and approving the clinical 
and technical standards profile and processes to create seamless 
integration of health data between DOD and VA EHR systems. Where the 
ONC has established terminology and technical standards, the 
Departments will use those standards for interoperability. The VA/DOD 
Target Health Standards Profile (HSP) contains the agreed-upon, cross-
agency standards that both VA and DOD will adhere to, at the direction 
of the IPO. The VistA Evolution Program data standards will conform to 
the HSP and as new standards are added, the VistA Evolution Program 
will proactively respond to and adopt the new standards.
    Further, investments in infrastructure, such as Medical Community 
of Interest, are being made to ensure interoperability. Additionally, 
joint testing between VA and DOD will ensure that the systems are 
compatible, as defined by the designated joint working group--
consisting of Defense Medical Information Exchange Integrated Quality 
Assurance and VA Enterprise Testing Services personnel.
    Question. How will that plan be impacted by the selection of a 
closed, proprietary electronic healthcare record?
    Answer. Any commercial off-the-shelf (COTS) EHR selected by DOD as 
its solution will have to be interoperable with both VA's system and 
with the private healthcare sector; it is one of the core elements of 
their request for proposal.
    DOD requires ONC Health Information Technology Certification. The 
standards and certification criteria established by ONC set the 
required capabilities and related standards and implementation 
specifications. ONC addresses terminology standards and 
interoperability in their certification criteria. The use of 
proprietary software code, versus open source software code, has no 
relationship to certification or interoperability. DOD will evaluate 
ONC-certified product offerings that use supported open source as well 
as proprietary software in the competitive acquisition.
    As a significant portion of the healthcare provided to 
servicemembers, veterans, and eligible beneficiaries occurs in the 
private sector, it is essential to ensure interoperability between DOD, 
VA, and the private sector. As such, DOD shares our commitment to 
interoperability, and whatever EHR system it selects must conform to 
open standards and be interoperable not only with VA, but with private 
sector clinicians as well.
    To further coordinate the Department's interoperability efforts, on 
December 5, 2013, the Departments signed a new charter for the 
Interagency Program Office (IPO) identifying the IPO as the entity 
responsible for establishing, monitoring, and approving the clinical 
and technical standards profile and processes to create the seamless 
integration of health data. The IPO will support the ONC's efforts to 
adopt and further national health data and exchange standards, 
specifications, and certification criteria to improve health 
information technology and its applications. The IPO's partnership with 
ONC to pursue adoption and maturing of national standards provides a 
vital link in making DOD and VA data interoperable with the private 
sector, and also provides the Departments' EHR systems the flexibility 
to respond to the evolving healthcare marketplace. Standards-based 
exchange will enable all EHRs in VA, DOD, and the private sector to 
exchange health data so that any clinician treating our patients has 
the most complete information available.
                       iehr funding restrictions
    Question. For the past 2 years, this subcommittee has made 75 
percent of appropriations for iEHR contingent on the Departments' 
submission of a GAO-reviewed plan to Congress. However, the 
subcommittee has yet to receive that plan.
    What steps is VA taking towards completing this plan and when will 
it be submitted?
    Answer. The 2014 plan was delivered to the subcommittee on March 
24, 2014. At the same time VA delivered a copy to GAO to meet Public 
Law 113-76, which required VA to submit the plan to the Government 
Accountability Office for review.
                     epilepsy center of excellence
    Question. The Department recently rescinded $2 million from the 
Epilepsy Center of Excellence's budget with little notice. As the 
ECoE's budget was only $8 million, it is difficult to see how this 
action will not have serious detrimental effects on operations and the 
provision of care.
    Why did the Department rescind these funds and what actions are 
being taken to ensure full services are available to veterans in need 
of this care?
    Answer. The Epilepsy Centers of Excellence (ECoE) were established 
by Public Law 110-387 enacted on October 10, 2008. VA began 
implementation with the establishment of four regional Epilepsy Centers 
using the congressionally authorized appropriation funding of $6 
million annually for fiscal year 2009 through fiscal year 2013. 
National ECoE Networks of Care were developed using a hub and spoke 
network model with 52 spoke sites distributed among the four networks 
to successfully cover all VHA facilities in the continental United 
States, Alaska, and Hawaii, and are involved in the care of 
approximately 56 percent of veterans with epilepsy, including veterans 
with complex epilepsy. VA supports sustainment funding of $6.1 million 
annually for ECoE.
    Upon review, an executive decision memorandum about the fiscal year 
2014 budget being $8 million instead of $6 million was not properly 
executed. Pending clarification of the issue, a proposed plan for 
spending the additional $2 million, if it were to be subsequently 
authorized, was submitted, but not approved by Specialty Care Services. 
Extra funds that were initially sent in error were subsequently 
withdrawn without any adverse impact on the operations of the centers 
or its mission. Ongoing support remains intact for the ECoE at the 
level of funding of $6.1 million annually, which is slightly higher 
than it has been during the past 5 years.
    There was an initial error and miscommunication about the level of 
fiscal year 2014 funding. The level of funding should have been $6 
million, but due to the error, an additional $2 million was released in 
November 2013. We have worked closely with the ECoC Director throughout 
this issue to identify and return funds over the $6 million that have 
not already been obligated. Fortunately, the vast bulk of the 
additional funds was not expended and was returned without any adverse 
impact on the operations of the ECoE or its mission. Ongoing support 
remains intact for the ECoE at the level of funding that has been in 
place during the past 5 years. When it appeared that EcoEs had an 
unanticipated additional $2 million in their national fiscal year 2014 
budget, a spend plan was drafted for the current fiscal year that 
included $620,000 for networked epilepsy diagnostic and other equipment 
purchases. Following withdrawal of the funding distributed in error, 
the Centers were asked to identify equipment needs to provide epilepsy 
telemedicine services. Telehealth funding in the amount of $544,032 has 
been made available to the Epilepsy centers, which will meet nearly all 
of their remaining equipment requests for fiscal year 2014 (some 
equipment had already been acquired using Medical Center funds).
    Additionally, VA is working with the medical centers to use 
equipment dollars to fund the electroencephalography replacement 
equipment that is not telehealth related.
                                 ______
                                 
               Questions Submitted by Senator Mark Begich
                         advance appropriation
    Question. Secretary Shinseki, last year's government shutdown 
almost cut off earned benefit payments to millions of veterans, 
including students, disabled and survivors. If the Shutdown extended 
past November 1, these veterans would have been extremely impacted. 
Veterans healthcare was protected because of advanced appropriations. I 
have a bill with Senator Bozeman and others to extend full advance 
appropriations to all VA accounts.
    I think I know the Administration's views, but I want to know if 
full advance appropriations would help the Department of Veterans 
Affairs (VA) and specifically the veterans you serve as it has done 
with Veterans Health Administration?
    Answer. President Obama's budget reflects cooperation and 
synchronized effort across the Federal Government and balances 
priorities and risks. The best way to care for veterans is for Congress 
to provide funding for VA and the entire government each year.
    Question. And if VA does not support, what is the opposition to 
ensuring our vets receive their earned benefits?
    Answer. VA serves veterans in partnership with many Federal 
agencies that have a role in the benefits they receive. These agencies 
receive an annual budget and it is essential that these synchronized 
efforts across the Federal Government be maintained.
                         military sexual trauma
    Question. Military sexual trauma (MST) continues to be prevalent 
especially in the past several years; survivors deserve the best 
treatment and help in developing their claims. Glad to see VA is 
screening all patients enrolled in and referred to care.
    Does the VA have the resources necessary to assist all the 
survivors both now and future?
    Answer. Under the reporting requirements of title 38 U.S.C. section 
1720D(e), Department of Veterans Affairs' (VA) national Military Sexual 
Trauma (MST) Support Team completes an annual report to determine 
whether each VA healthcare system (HCS) has adequate capacity to 
provide MST-related care. Adequate capacity is assessed by comparing 
each facility to a benchmark staffing-to-population size ratio. The 
benchmark ratio was established by examining VHA facilities that 
provide a high volume of MST-related mental healthcare. Facilities that 
fall within two standard deviations of the staffing-to-population size 
ratios of these ``high volume'' VA healthcare systems are considered to 
have adequate capacity to provide MST-related care.
    The most recent report concerning fiscal year 2012 mental 
healthcare, found 99 percent of VA HCSs were at or above the 
established benchmark for MST-related mental health staffing capacity. 
During the year, over 64,000 veterans received MST-related mental 
healthcare resourced from a VA healthcare facility. These veterans 
received a total of over 693,000 MST-related mental healthcare visits 
from over 17,950 individual providers. Only one VA healthcare system 
was found to be below the target level for MST-related mental health 
staffing capacity. To address this finding, the MST Support Team and 
the VA Office of Mental Health Operations (OMHO) partnered with mental 
health stakeholders at the HCS and healthcare network levels to develop 
and implement an action plan to increase documented staffing levels. 
This facility reports consistent progress on the action plan in 
quarterly reports to the MST Support Team and OMHO. The MST Support 
Team, in collaboration with OMHO, regularly provides technical 
assistance and consultation to all VA HCSs to ensure the highest 
capacity for and quality of mental healthcare for veterans who have 
experienced MST.
    Question. That includes including training for women veterans 
coordinators, therapists, the dedicated MST-PTSD related claims staff, 
etc.?
    Answer. The Veterans Health Administration (VHA) provides a range 
of education and training programs to ensure that VA healthcare 
facility staff members receive training on MST, appropriate to their 
role with veterans. All mental health and primary care providers must 
complete a one-time mandatory training requirement on MST. Mental 
health providers complete a Web-based training on MST that provides a 
comprehensive review of issues relevant to provision of mental 
healthcare to MST survivors. Primary care providers must complete a 
Web-based training that reviews a range of issues including health 
conditions associated with MST; screening sensitively for MST; how MST 
can affect a veteran's experience of healthcare; how to appropriately 
adapt care to address the needs of MST survivors; and VA documentation 
requirements.
    Complementing the mandatory training, VA's national MST Support 
Team engages in a range of national education and training initiatives 
related to MST. The team oversees a monthly teleconference training 
call series on topics related to MST that is open to all VA staff. 
These calls are well-attended, typically with over 200 teleconference 
lines used. The team also hosts an annual training conference on MST 
program development, aimed primarily at increasing the knowledge and 
skills of the MST coordinators in each VA healthcare facility who 
serves as local point persons for MST-related issues, programming, and 
policy implementation. The team also maintains a VA Intranet community 
of practice Web site where all VA staff can access MST-related 
resources and materials, review data on MST screening and treatment in 
healthcare facilities, and participate in MST-related discussion 
forums.
    The MST Support Team has partnered with VA rollouts of empirically 
supported treatments for post-traumatic stress disorder (PTSD), 
depression, and anxiety to include MST-specific information. These 
national initiatives train therapists in evidence-based practices such 
as Cognitive Processing Therapy, Prolonged Exposure, Acceptance and 
Commitment Therapy, and Cognitive Behavioral Therapy. Conditions 
targeted by these treatments are strongly associated with MST, meaning 
these national initiatives have been an important means of expanding 
MST survivors' access to cutting-edge treatments.
    VBA has responded to the sensitive and complex task of adjudicating 
MST/PTSD disability compensation claims by providing relevant training 
to all VA regional office claims processing personnel and additional 
training to those directly involved with MST/PTSD claims and claimants. 
Specially trained woman veteran coordinators are available in each 
regional office to assist and respond to veteran claimants with MST-
related issues. In addition, VBA's recent initiatives to improve 
disability compensation claims processing have placed MST/PTSD claims 
in a ``special operations'' lane which signifies they are a priority. 
This ensures that these claims are processed by dedicated regional 
office personnel specifically trained to understand the gathering and 
evaluation of supporting evidence, which is critical to properly 
adjudicating these claims.
    Question. Is the funding sufficient for the vet centers?
    Answer. Yes. In fiscal year 2013, the Vet Center program obligated 
$206 million for the provision of readjustment counseling, including 
services for military sexual trauma. In fiscal year 2014, the program 
has been allocated $221 million, and the published fiscal year 2015 
President's budget provides $238 million. These funding increases 
demonstrate VHA's commitment to providing veterans quality readjustment 
counseling. Military sexual trauma services are an integral segment of 
the overall spectrum of readjustment counseling. In 2012, each vet 
center was required to have one counselor qualified to provide military 
sexual trauma services. Currently, over 250 of the 300 vet centers meet 
this requirement. Each remaining site is required to have a training 
plan in place for an existing counselor or to actively recruit a 
counselor with these skills for any vacant counseling positions.
    Question. Have you a dollar amount on how much beneficiary travel 
for veterans seeking MST-related mental health treatment outside of 
their enrollment area would cost? I would like you to get back to me on 
what you need from us to make this happen.
    Answer. We are basing this reply on an assumption it relates to MST 
patients who are ineligible for beneficiary travel (BT) and who require 
transport to a distant specialized MST treatment center. Currently 
approximately 82 percent of VA MST users are already eligible for BT. 
For those not already covered, our cost estimate to add this benefit 
would be $55 million over 5 years and $107 million over 10 years for a 
total of $163 million as noted in the table below.

                          [Dollars in millions]
------------------------------------------------------------------------
                  Fiscal year                      Total cost estimate
------------------------------------------------------------------------
2014...........................................                     $8.3
2015...........................................                      9.5
2016...........................................                     10.8
2017...........................................                     12.4
2018...........................................                     14.1
                                                ------------------------
5-year.........................................                     55.1
                                                ------------------------
2019...........................................                     16.2
2020...........................................                     18.5
2021...........................................                     21.1
2022...........................................                     24.1
2023...........................................                     27.6
                                                ------------------------
10-year........................................                    163.0
------------------------------------------------------------------------


Assumptions:

  --VA is unsure how the provision of expanded BT benefits would impact 
        MST workload, as well as travel needs of veterans who were 
        previously ineligible for BT benefits. However, based upon 
        historical MST user increases and BT use, estimated travel 
        costs for MST program users who become BT eligible are 
        provided. It is assumed the same percentage of MST users would 
        request or require travel benefits and the workload increases 
        at the projected 10 percent. For each year, the number of 
        estimated veterans receiving care was multiplied times the 
        estimated travel cost per user. Each year's totals were added 
        to get 5- and 10-year costs.
  --Historical data indicate for the period of fiscal year 2010 through 
        fiscal year 2012 between 54.4 percent and 56.7 percent of 
        females and 37.6 percent and 41.5 percent of males with a 
        positive MST screen received MST-related mental healthcare each 
        year. In fiscal year 2010 the total was 50,538 veterans 
        increasing to 64,161 veterans seen in fiscal year 2012. Growth 
        was 14 percent from fiscal year 2010 to fiscal year 2011 and 12 
        percent for fiscal year 2011 to fiscal year 2012. The number of 
        positive MST screens is increasing about 10 percent per year.
  --Approximately 82 percent of VA MST care users are already eligible 
        for beneficiary travel.
  --About 85 percent of those requiring MST residential inpatient care 
        must travel to a distant facility generally resulting in higher 
        travel costs. However, an expanded benefit will also require 
        reimbursement for mileage and common carrier transport (bus, 
        plane, taxi, etc.), as well as when medically indicated, 
        special mode (ambulance, wheelchair van) travel. As such, it is 
        unclear as to the extent of travel that will be required by 
        each MST patient. Therefore, the historical national average 
        for BT benefits per other VA healthcare users was applied to 
        this group. BT user cost was increased by VA Consumer Price 
        Index for each outlying year.
  --Historically, VHA BT has seen increased number of claimants and 
        claims (visits) resulting in increased costs of between 15 
        percent and 25 percent whenever there has been an expansion in 
        travel eligibility or mileage reimbursement rate. However, VA 
        has recently begun to experience a slower rate of BT as well as 
        MST user growth. Therefore, because of the MST workload changes 
        previously noted a 10 percent workload increase was applied to 
        outlying years.
  --Mileage rate will remain unchanged from current $0.415 per mile.
  --Deductible rates of $3 per one-way trip, $6 round trip, and 
        calendar month cap of $18 or six one-way trips, whichever 
        occurs first, will remain unchanged.
                                suicide
    Question. I don't have to tell you that one suicide is one too 
many. VA is working on many fronts to reach veterans in crisis, through 
the crisis line, apps, texts veterans have more access to getting help 
quicker, however there is more to be done. The VSO's Independent Budget 
suggests an increase in research dollars, at a time when more veterans 
will be entering the VA, this is a priority for me and hope for the VA.
    I have a bill to increase funding for Suicide Prevention through 
brain research at the National Institute of Mental Health. What are the 
plans for VA to expand research, specifically in the area of suicide 
prevention, PTSD and TBI? Are more resources needed?
    Answer. The VA Office of Research and Development currently 
supports a research portfolio of studies on the topics of suicide 
prevention, PTSD, and traumatic brain injury ($88 million in fiscal 
year 2015). Together with other Federal research funding agencies, VA 
developed a National Research Action Plan (NRAP) specifically 
addressing these topics. Details of the plan can be found at the 
following link: http://www.whitehouse.gov/sites/default/files/uploads/
nrap_for_eo_on_mental_
health_august_2013.pdf.
    This NRAP agenda is directing a program of research intended to 
improve agency coordination and reduce the number of affected men and 
women through, for example, planned support of ongoing and future 
research that identifies modifiable risk factors and advanced 
interventions for suicide through rigorous clinical trials. The fiscal 
year 2015 President's budget provides adequate resources for the VA 
mental health research portfolio.
    In accordance with section 1705 of Public Law 110-181, VA's 
Assisted Living Pilot Program for Veterans with Traumatic Brain Injury 
(AL-TBI) will conclude on October 6, 2014, 5 years from the date the 
pilot program commenced.
    VA will provide a report to Congress after the completion of the 
pilot program, as required by section 1705(e) that includes VA's 
``assessment of the utility of the activities under the pilot program 
in enhancing the rehabilitation, quality of life, and community 
reintegration of veterans with traumatic brain injury'' as well as any 
recommendations ``regarding the extension or expansion of the pilot 
program.''
          hud-vash case management and grant per diem programs
    Question. HUD-VASH and grant per diem are both important to your 
goal of ending homelessness. I still have some concerns about the case 
management piece.
    What are the efforts to expand the case management to the 
community?
    Answer. Department of Housing and Urban Development--VA Supportive 
Housing (HUD-VASH) Program is a collaborative program between HUD and 
VA for eligible homeless veterans to receive a HUD-provided Housing 
Choice voucher and VHA-provided clinical case management and supportive 
services to support stability and recovery from physical and mental 
health, substance use, and functional concerns contributing to or 
resulting from homelessness. The intent of HUD-VASH case management is 
to help the veteran maintain his or her housing and integrate 
successfully back into the community. HUD-VASH programs work closely 
with the Health Care for Homeless Veterans (HCHV) outreach staff to 
identify veterans who are on the streets or in shelters who would best 
be served through permanent supportive housing. These two programs work 
together to build the trust of veterans and move them into housing. 
Case management also relies on collaboration with community partners to 
assist veterans with integrating into the community, and successfully 
becoming productive members of their community. Case management is 
driven by the veterans' individual goals and wants.
    Due to the emphasis on Housing First principles, many HUD-VASH 
veterans receive their case management from a multi-disciplinary team. 
The team may include a substance use disorder specialist, a psychiatric 
nurse practitioner, a peer support specialist, a social worker, a 
housing specialist, and an employment specialist. The team is able to 
provide specialized services to meet the needs of the veteran.
                    grant and per diem (gpd) program
    Question. The Grant and Per Diem (GPD) Program is VA's largest 
transitional housing program, with over 650 projects providing over 
15,500 operational beds nationwide. The GPD Program allows VA to award 
grants to community-based agencies to create transitional housing 
programs, and provides per diem payments to the programs to support 
operational costs. The purpose is to promote the development and 
provision of supportive housing and/or supportive services with the 
goal of helping homeless veterans achieve residential stability, 
increase their skill levels and/or income, and obtain greater self-
determination. GPD-funded projects offer communities a way to help 
homeless veterans with housing and services while assisting VAMCs by 
augmenting or supplementing medical and mental healthcare.
    Case management is a crucial part of providing transitional housing 
services to homeless veterans in the GPD Program. The GPD Program uses 
per diem payments to help support GPD grantees' operational costs, 
including case management services. Although the GPD Program is not 
authorized to provide grants exclusively for case management services, 
case management is one of the services that may be provided as part of 
a GPD-funded transitional housing or service center grant. 
Additionally, the GPD Program supports close to 300 GPD liaison 
positions at local VAMCs that provide case management services and 
connect veterans with local VA and community mental health services.
    I would also like to know what your plans are for outreach to 
provide more contracts to community groups with expertise to support 
homeless veterans and their families. Is the amount requested 
sufficient to cover the increase in families?
    Answer. One of the key pillars of VA's Plan to End Homelessness 
Among Veterans is to provide effective outreach to homeless veterans 
and veterans at risk of homelessness. Successful outreach includes VA 
and local partners actively working in the community to successfully 
intervene in episodes of veteran homelessness. Without effective 
outreach efforts locating homeless and at-risk veterans, VA has little 
chance of ending veteran homelessness. Although many VA homeless 
programs conduct outreach, the Health Care for Homeless Veterans (HCHV) 
Program is VA's premier homeless outreach program. The foundation of 
the program is to provide targeted outreach in the community to 
veterans who are homeless or at risk of homelessness and not currently 
receiving VA services. These outreach efforts are an essential 
component of VA's plan to eliminate homelessness among veterans and 
provide opportunities for critical medical and psychiatric care and 
referrals. Once identified and effectively engaged within their own 
communities, homeless veterans can then be provided with both immediate 
and permanent stable housing solutions and supportive services.
    In fiscal year 2013, HCHV staff conducted outreach and provided 
outpatient services to over 146,000 veterans, and the HCHV Program's 
Contract Residential Services offered more than 13,200 episodes of 
contract residential community-based treatment. Outreach has proven to 
be a successful link, as overall data findings suggest that more than 
90 percent of the veterans engaged with HCHV received VA mental health 
services (including direct services provided by the HCHV Contract 
Residential Services Program) in the 6 months following outreach.
    The HCHV Program works in collaboration with community 
organizations and other VA programs through a combination of outreach, 
case management, housing, and supportive services. The program 
collaborates with a multitude of VA homeless programs, including the 
HUD-VASH Program, GPD Program, Veterans Justice Outreach Program, 
Health Care for Reentry Veterans Program, Homeless Veteran Supported 
Employment Program, Homeless Patient Aligned Care Teams, as well as 
community outreach providers (e.g., 100,000 Homes Campaign, Projects 
for Assistance in Transition from Homelessness Program, and local 
homeless continuums of care).
    Generally, VA does not contract for homeless outreach services, but 
the GPD Program and Supportive Services for Veteran Families (SSVF) 
Program provide grants to community organizations that include outreach 
components in the overall homeless services grants. For example, GPD 
grantees are expected to have a working community outreach plan. The 
GPD Program provides grant funding and per diem payments to community-
based organizations to provide transitional housing and supportive 
services to homeless veterans. The GPD Program does not have authority 
to offer grants to provide outreach services only. Per diem payments 
help offset operational costs, but can only be paid for the homeless 
veteran. Community-based organizations can seek out other funding 
sources for costs associated with providing services to non-veteran 
family members.
    Similarly, extensive community outreach is a crucial part of SSVF 
services. The SSVF Program provides supportive services grants to 
private nonprofit organizations and consumer cooperatives to coordinate 
or provide supportive services for very low-income veteran families. 
The SSVF Program is designed to rapidly re-house homeless veteran 
families and prevent homelessness for those at imminent risk of 
homelessness due to a housing crisis. Grant applications for the SSVF 
Program are evaluated on, among other things, the feasibility and 
effectiveness of an applicant's outreach plan. SSVF grantees are 
expected to collaborate with VA and community partners in providing 
outreach and referrals. The SSVF Program's focus on outreach and case 
management has yielded tremendous results; in fiscal year 2013, SSVF 
served over 60,000 participants (veterans and family members), of whom, 
close to 40,000 were veterans. As part of VA's ongoing effort to 
integrate VA services into the community and reach veterans and their 
families, VA recently published an fiscal year 2014 Notice of Funding 
Availability announcing the availability of approximately $600 million 
in SSVF grant funding. VA is offering $300 million in fiscal year 2014 
funds and $300 million in fiscal year 2015 funds, subject to available 
appropriations. Of the $600 million announced, VA is focusing up to 
$300 million in surge funding on 76 high priority continuums of care, 
in an unprecedented effort to end veteran homelessness in these 
communities.
                                 ______
                                 
               Question Submitted by Senator John Hoeven
                             data security
    Question. Data security is an essential component of any future 
electronic records system at the VA. I am aware of research being done 
at the U.S. Air Force Academy's Center of Innovation on a project 
funded through the Department of Homeland Security that is making 
excellent strides in protecting sensitive electronic information. In 
fact, I wrote the Department a few weeks ago to highlight the project. 
Because this research is already being done within the U.S. Government, 
I believe it would make sense for the VA to evaluate the technology for 
possible integration into future electronic records at the VA.
    Is the VA aware of this project and has the Department considered 
whether it could enhance the security of a future electronic record 
system?
    Answer. Yes, May 1, 2014, Department of Veterans Affairs (VA) 
provided a response to your letter regarding electronic health records. 
Security of veterans' data is a top priority for VA. VA's current 
Electronic Health Record, the Veterans Health Information Systems and 
Technology Architecture (VistA), already has appropriate access and 
audit capabilities for users of VistA logging into and using VistA. 
Through VA's VistA Evolution program, VistA's clinical and technical 
capabilities will be enhanced as will interoperability with the 
Department of Defense (DOD). VA is developing a VistA Evolution data 
strategy to ensure secure transfer of data from DOD and commercial 
sources, through interoperability gateways, to VA's VistA Exchange. The 
improvements to VistA will meet or exceed all Federal information 
assurance requirements including the Federal Information Security 
Management Act, the Health Insurance Portability and Accountability Act 
of 1996 Security Rule, applicable National Institute of Standards and 
Technology standards and special publications, Federal Identity, 
Access, and Credential Management policies. In addition, these actions 
fulfill VA-specific security requirements outlined in various VA 
Directives and Handbooks.
    VA will use the processes and procedures approved by VA's Office of 
Information Technology to ensure that the security controls and 
security posture remain effective throughout the lifecycle development 
process. These actions will ensure that access to electronic health 
records is based on the established permissions for each user of the 
electronic health record system.
    To further refine the security posture of the VistA system, we are 
continuing to work with DHS's Center of Innovation to implement 
emerging technologies to meet healthcare line of business security 
needs, while ensuring the veteran experience is secure.
                                 ______
                                 
             Questions Submitted by Senator Mitch McConnell
    Question. Kentucky veterans are exasperated by the Department of 
Veterans Affairs' (VA) significant backlog of pending claims. What 
steps is the VA taking to address this ongoing problem? Does the VA 
require additional legislative authority from Congress to resolve the 
issue?
    Answer. VA is working within its existing legislative authority to 
resolve this issue. Veterans Benefits Administration (VBA) is currently 
undergoing the largest transformation in its history to eliminate the 
backlog of disability compensation claims, and substantially improve 
the way veterans, their families, and Survivors receive their benefits 
and services. VA is aggressively implementing its plan to eliminate the 
backlog using a series of actions targeted at reorganizing and 
retraining its people, streamlining its processes, and deploying 
technology designed to achieve VA's goal of processing all claims 
within 125 days with 98-percent accuracy in 2015.
    Since April 2013, VA has focused on completing its oldest claims, 
resulting in benefit determinations for those who have been waiting the 
longest, many of whom are awarded VA compensation benefits for the 
first time or who have medical conditions that have worsened. VA has 
made significant progress, reducing the claims backlog (i.e., claims 
pending over 125 days) from its peak of 611,000 in March 2013 to 
297,000 as of May 15, 2014--a 51.4-percent reduction. Veterans are now 
waiting less time for their decisions and benefits. Claims currently in 
the inventory have been pending an average of 158 days, a 44-percent 
reduction from the peak of 282 days in February 2013.
    At the same time, the accuracy of our rating decisions continues to 
improve. VA's national ``claim-level'' accuracy rate, determined by 
dividing the total number of cases that are error-free by the total 
number of cases reviewed, is currently 91 percent--an 8-percentage-
point improvement since 2011. When measuring the accuracy of rating 
individual medical conditions inside each claim, the 3-month accuracy 
level is 96 percent.
    The Louisville regional office has reduced its claims backlog by 17 
percent, from 7,974 in January 2013, to 6,628 as of the end of April 
2014. Accuracy of rating decisions at the Louisville regional office 
has improved as well. Three-month claim-based accuracy has increased by 
13.7 percentage points, from 75.4 percent in June 2012 to 89.1 percent 
in April 2014. Three-month issue-level accuracy is currently 95.4 
percent.
    Question 2a. Many veterans suffer from mental health issues such as 
post-traumatic stress disorder (PTSD) and traumatic brain injury (TBI) 
and continue to experience disturbing rates of suicide. What is the VA 
doing to address these issues?
    Answer. VA uses a variety of strategies to address risk of suicide 
among veterans with PTSD and other mental disorders, with and without 
TBI. One strategy is the development and implementation of a VA-
Department of Defense PTSD Clinical Practice Guideline to promote the 
delivery of evidence-based treatments for PTSD 
(www.healthquality.va.gov/Post_Traumatic_Stress_Disorder_PTSD.asp). The 
first line treatments for PTSD are evidence-based, trauma-focused 
psychotherapies such as Cognitive Processing Therapy (CPT) or Prolonged 
Exposure (PE) therapy, which have the highest level of evidence. 
Enhancing care for PTSD is important because research suggests that 
effectively treating PTSD can reduce suicidal ideation. Veterans who 
learn skills in these treatments to manage their PTSD can also apply 
these skills to address co-occurring depression. VA requires that all 
veterans with PTSD have access to CPT or PE. VA has developed national 
training programs to enhance the ability of VA providers to deliver 
these therapies. In terms of medications, the PTSD Clinical Practice 
Guideline strongly recommends selective serotonin reuptake inhibitors 
(SSRI) or serotonin norepinephrine reuptake inhibitors (SNRI). The 
SSRI/SNRI classes of medications were initially developed as effective 
antidepressants. A 2009 VA consensus conference on management of co-
occurring PTSD, Pain, and TBI determined that veterans with co-
occurring PTSD and TBI can be effectively treated for these disorders 
concurrently using the relevant Clinical Practice Guidelines.
    VA has a robust Suicide Prevention program. August 2013, marked 6 
years since the establishment of VA's Veterans Crisis Line (1-800-273-
TALK (8255), press 1), which has expanded to include a chat service and 
texting option for contacting the Crisis Line. The program continues to 
save lives and link veterans with effective ongoing mental health 
services on a daily basis. As of March 2014, the Crisis Line program 
had:
  --Over 1,150,000 calls, over 160,000 chat connections, and over 
        21,000 texts;
  --Over 37,000 rescues of those in immediate suicidal crisis;
  --Over 200,000 callers provided referral to a VA suicide prevention 
        coordinator.
    VA's basic strategy for suicide prevention requires ready access to 
high-quality mental health (and other healthcare) services supplemented 
by programs designed to help individuals and families engage in care 
and to address suicide prevention in high-risk patients. Some of the 
initiatives that have proven to be very effective include:
  --Each VA medical center has a suicide prevention coordinator or 
        team;
  --Screening and assessment processes have been set up throughout the 
        system to assist in the identification of patients at risk for 
        suicide;
  --A chart ``flagging'' system has been developed to assure continuity 
        of care and provide awareness among caregivers;
  --Patients who have been identified as being at high risk receive an 
        enhanced level of care, including missed appointment follow-
        ups, safety planning, weekly follow-up visits and care plans 
        that directly address their suicidality;
  --Reporting and tracking systems have been established in order to 
        learn more about veterans who may be at risk and help determine 
        areas for intervention.
    VA has two centers devoted to research, education, and clinical 
practice in the area of suicide prevention. VA's Veterans Integrated 
Service Network (VISN) 2 Center of Excellence in Canandaigua, New York, 
develops and tests clinical and public health intervention strategies 
for suicide prevention. This site is the home of the Veterans Crisis 
Line operation. VA's VISN 19 Mental Illness Research Education and 
Clinical Center (MIRECC) in Denver, Colorado, focuses on: (1) clinical 
conditions and neurobiological underpinnings that can lead to increased 
suicide risk; (2) the implementation of interventions aimed at 
decreasing negative outcomes; and (3) training future leaders in the 
area of VA suicide prevention.
    The National Center for PTSD's Consultation Program was established 
in 2011 to assist any VA provider who treats veterans with PTSD, 
including those in VA PTSD specialty care, those in other areas of 
mental health, primary care providers, and case managers. The 
Consultation Program helps with questions about assessment and 
treatment services for veterans with PTSD. By the close of fiscal year 
2013, there were 668 consultations completed, 589 for PTSD and 79 for 
suicide risk management, a feature added this year to the consultation 
service.
    Question 2b. Does the VA require additional legislative authority 
to provide mental health services to veterans in need of support?
    Answer. The President's fiscal year 2015 budget package included a 
proposal to amend title 38 U.S.C. section 1720D to authorize VA to 
provide military sexual trauma (MST) related healthcare to veterans who 
experienced sexual assault or harassment during inActive Duty training 
(i.e., drill weekends for Reserve and National Guard servicemembers). 
This provision is now part of the Veterans' Access to Care through 
Choice, Accountability, and Transparency Act of 2014 bill currently 
under consideration in Congress. VA supports this provision and 
welcomes its inclusion in the omnibus bill.
    There is no other need at this time for additional legislative 
authority to carry out our mission of treatment for veterans with 
mental disorders, including suicide prevention activities and care for 
veterans with comorbid PTSD and TBI.
    VA provides a full continuum of forward-looking outpatient, 
residential, and inpatient mental health services across the country. 
We have many entry points for care that include our 150 medical 
centers, 820 community-based outpatient clinics, 300 vet centers that 
provide readjustment counseling, the Veterans Crisis Line, VA staff on 
college and university campuses, and other outreach efforts. In fiscal 
year 2013, more than 1.4 million veterans received specialized mental 
health treatment from VA. This number has risen each year from 927,052 
in fiscal year 2006. VA believes this increase is partly attributable 
to proactive screening to identify veterans who may have symptoms of 
depression, PTSD, problem use of alcohol or who have experienced 
military sexual trauma.
    Question. Many veterans suffer from insomnia which is a known risk 
factor for suicide, PTSD and depression. I am told the VA has an app 
for tracking insomnia. Has the VA explored the potential benefits of 
using electronic-based programs to provide access to cognitive behavior 
therapy (CBT) to help treat insomnia? As I understand it, such programs 
may provide a positive benefit to servicemembers suffering from 
insomnia.
    Answer. Cognitive Behavioral Therapy for Insomnia (CBT-I) is a 
psychotherapy for treatment of primary and secondary insomnia in 
veterans and civilian populations. A nationwide training is currently 
underway to expand the ranks of VA clinicians who can administer this 
highly effective protocol to veterans. Leaders in the science and 
administration of CBT-I, and the VA's nationwide training, have also 
participated in the development of a partner mobile application, CBT-I 
Coach. CBT-I Coach is designed to facilitate and enhance ongoing face-
to-face care by optimizing required sleep diary data entry, reminding 
patients to engage in behavioral prescriptions, and providing 24/7 
access to treatment-appropriate resources. This mobile solution is 
intended to increase flexibility, accuracy, and privacy, for patients 
engaged in CBT-I. The National Center for Posttraumatic Stress Disorder 
is also embarking on research studies to learn more about how CBT-I 
Coach improves the delivery of this important treatment to veterans.
    Question. What is the VA doing to address the significant emotional 
and financial burdens often experienced by the caregivers of disabled 
veterans?
    Answer. VA recognizes the crucial role that caregivers play in 
helping veterans recover from injury and illness and in the daily care 
of veterans in the community. VA values the sacrifices caregivers make 
to help veterans remain at home. Caregivers are partners in the care of 
veterans and VA is dedicated to providing them with the support and 
services they need.
    The Caregivers and Veterans Omnibus Health Services Act of 2010, 
signed into law by President Obama on May 5, 2010, allows VA to provide 
unprecedented benefits to family caregivers of veterans. The Caregiver 
Law (Public Law 111-163, title I) directly benefits family caregivers 
by establishing a comprehensive National Caregiver Support Program with 
a prevention and wellness focus that includes the use of evidence-based 
training and support services for family caregivers.
    Public Law 111-163 establishes additional support and services for 
family caregivers of eligible post-9/11 veterans seriously injured in 
the line of duty under the Program of Comprehensive Assistance for 
Family Caregivers. Additional support and services include a stipend 
paid directly to the Family caregiver, enrollment in VA's Civilian 
Health and Medical Program if the family caregiver is not already 
eligible under a healthcare plan, an expanded respite benefit, and 
mental health treatment.
    The VA's Caregiver Support Program has been accepting applications 
for The Program of Comprehensive Assistance for Family Caregivers since 
May 9, 2011, and as of April 2014, has more than 15,000 family 
caregivers participating. The monthly average stipend payment across 
the country ranges from $630-$2,370, based on the level of the tier and 
geographic location of new applicants.
    VA has partnered with Easter Seals to provide comprehensive family 
caregiver training for eligible family caregivers. Training is 
available for family caregivers in traditional classroom settings, in a 
workbook format, and in an online format. More than 18,000 family 
caregivers have completed training.
    Beginning in November 2013, all caregivers of veterans receiving 
healthcare through VA and all veterans who are caregivers have access 
to a series of four courses focused on supporting and meeting their 
needs as Caregivers, Managing Stress, Problem Solving and Effective 
Communication, Taking Care of Yourself, and Utilizing Technology. Each 
course is 3 hours in length and taught by a 2-person team of healthcare 
professionals through a contract with Easter Seals. More than 360 
caregivers have participated at more than 17 sites across the country.
    Caregiver support coordinators at each VA medical center serve as 
the clinical experts on caregiver issues and are knowledgeable of both 
VA and non-VA support services and benefits available for veterans of 
all eras and their family caregivers. Caregiver support coordinators 
can also assist eligible post-9/11 veterans and their caregivers in 
applying for additional services.
    VA's National Caregiver Support Line (855-260-3274) continues to be 
available to respond to inquiries about the caregiver services, as well 
as serve as a resource and referral center for caregivers, veterans, 
and others seeking caregiver information; provide referrals to local VA 
Medical Center caregiver support coordinators and VA/community 
resources; and provide emotional support. More than 125,000 calls have 
been received from caregivers of veterans of all eras.
    VA's Web site dedicated to family caregivers, www.caregiver.va.gov, 
provides caregiver stories, resources, and a zip code look-up feature 
that allows caregivers to identify their local caregiver support 
coordinator. The site averages more than 1,300 visits per day with 
close to 3 pages viewed per visit, for a total of more than 3,500 pages 
viewed daily.
    The Caregiver Support Program's Peer Support Mentoring Program 
matches more experienced caregivers with less experienced caregivers to 
receive guidance, and to share their experiences, wisdom, and skills 
with one another. Caregivers of veterans of all eras are eligible to 
participate in the Program, both as mentors and as mentees. Mentors 
receive training before being assigned a mentee and as well as receive 
ongoing support in this new role. More than 150 caregivers have 
participated in the program.
    In February 2013, VA launched its first Building Better 
CaregiversTM (BBC) workshop in partnership with the National 
Council on Aging, available to caregivers of veterans of all eras. BBC 
is an online, interactive 6-week workshop designed to help caregivers 
to better problem solve and to better manage their own emotions.
    Question. What is the VA doing to help servicemembers transition to 
civilian life and find employment after their military service? What 
employment programs seem to be the most successful, and in which areas 
can the VA improve veterans' employment services?
    Answer. VA offers a number of important resources to help veterans 
connect with and succeed in high-demand civilian careers. These 
resources include:
  --Higher Education and Training: The Post-9/11 GI Bill provides 
        funding for secondary education and training as well as on-the-
        job training and apprenticeships to eligible veterans. The 
        Post-9/11 GI Bill Web site (www.benefits.va.gov/gibill) has a 
        number of resources including career interest and aptitude 
        tests, resources to help choose a school, and benefit 
        comparison tools.
  --VR&E: The VR&E Program helps disabled servicemembers and veterans 
        with job training, employment accommodations, resume 
        development, and job-seeking skills coaching. Other services 
        may be provided to assist veterans in starting their own 
        businesses or with independent living if they are severely 
        disabled and unable to work in traditional employment.
  --Education and Career Counseling: VA provides a wide range of 
        education and career counseling to veterans, servicemembers, 
        and family members who are entitled to or participating in a VA 
        education benefit program. These services help the individual 
        identify a career goal and choose an educational program to 
        reach that goal. Counseling may also be provided to assist the 
        student in overcoming barriers to academic success.
  --The Veterans Hiring Guide: VA's Guide to Hiring Veterans provides 
        employers with valuable information to establish a veterans 
        recruitment program and inform them of existing recruitment 
        programs. The guide helps ensure employers are aware of the 
        various programs and services available to find, hire, train, 
        and employ veterans. The guide is available here: https://
        www.vetsuccess.va.gov/public/assets/2013-11-
        13_Veterans_Hiring_Guide_
        FINAL_2.pdf
  --Veterans Employment Center: The Veterans Employment Center on 
        eBenefits is a one-stop shop connecting veterans, transitioning 
        servicemembers, and their spouses to employers. The Veterans 
        Employment Center was created by VA based on requirements from 
        an interagency team including the Department of Defense, the 
        Department of Labor, and the Office of Personnel Management. 
        The Veterans Employment Center is available at: https://
        www.ebenefits.va.gov/ebenefits/jobs.
    VA also works closely with Federal and private-sector partners to 
support veteran employment. For example:
  --VA has partnered with the U.S. Chamber of Commerce to promote job 
        fairs and support its initiatives to match employers with 
        capable veteran employees. VA has supported the Chamber of 
        Commerce at over 600 Hiring Our Heroes job fairs throughout the 
        country. Since its launch in March 2011, Hiring Our Heroes has 
        helped more than 100,000 veterans and military spouses find 
        meaningful employment.
  --VA and the Department of Labor collaborate to connect employers 
        with servicemembers and veterans throughout the process of 
        separating from the military. Both Departments are deeply 
        committed to helping veterans find employment and are 
        significantly increasing interagency collaboration.
    VA continually strives to improve how we connect veterans to 
employment and is working to increase awareness of our education and 
career counseling benefits while growing our partnerships with 
potential veteran employers.
    Question. What steps is the VA taking to ensure female veterans in 
particular are receiving the quality medical care they deserve in a 
comfortable setting? Please include any relevant supporting data.
    Answer. VA recognizes the increase in the numbers of women veterans 
enrolling in Veterans Health Administration (VHA) for healthcare 
services and how these shifting demographics have placed new demands on 
VHA's healthcare system, which had previously treated mostly men. 
Currently, there are over 2.2 million women veterans in the United 
States and over 390,000 utilized VHA healthcare services in fiscal year 
2013. VA is continuing to enhance services and access to ensure that 
women veterans receive, and are satisfied with, the high-quality care 
they have earned.
    VA successfully invested in comprehensive primary care for women 
veterans in all of VA healthcare systems. Comprehensive care for women 
veterans is defined as care by a designated women's health provider who 
is interested and proficient in women's health and can provide primary 
care and gender-specific care in the context of a continuous patient-
clinician relationship. Designated Women's Health Providers are now 
available at all VA Health Care Systems, 95 percent of VA Medical 
Centers (VAMC) and 84 percent of Community Based Outpatient Clinics. VA 
is continuing to train primary care and emergency providers in the care 
of women. To date, VA has provided intensive training to over 1,850 
physicians, physician assistants, and nurses. An additional 300 
clinicians will be trained by the end of this fiscal year. Ongoing 
clinical updates are also an essential component of maintaining this 
proficient women's health workforce.
    With regard to quality, VA has continued to provide the highest 
quality preventive care for our veterans, and in many cases exceeding 
the private sector, Medicare and Medicaid programs as previously stated 
in testimony and based on Healthcare Effectiveness Data and Information 
Set, American Customer Satisfaction Index, and The Joint Commission 
data/reports. However, both in VA and in private sector, the care of 
women did lag behind that delivered to men. Since 2008, VA has 
addressed this gender disparity through a focus on improved care for 
women in such areas as hypertension, flu prevention, diabetes, and 
screening for depression and post-traumatic stress disorder. In 
contrast to private sector, VA has succeeded in significant narrowing 
of the gender gap in clinical performance. Now VA provides equally 
high-quality care to women and men in our health system. This 
information is provided in a monograph available at http://
www.womenshealth.va.gov/WOMENSHEALTH/docs/
WVHC_GenderDisparities_Rpt_061212_FINAL.pdf.
    VA Women's Health Services conducts ongoing evaluation of our 
women's veteran health program through several mechanisms. Every VAMC 
completes an annual assessment of the implementation of women veterans 
services through an internal survey Women's Assessment Tool for 
Comprehensive Health. This survey includes an assessment of current and 
future enrollment and utilization projections, a strategic plan for 
women veterans services, and reports on the providers and capacity for 
clinical services such as primary care, gynecology, and emergency 
services.
    In addition, VA has established an independent contract to conduct 
detailed site visits in order to objectively assess the implementation 
of services for women veterans nationwide. To date, site visits have 
been conducted at 50 percent of the Medical centers and annual reports 
have been provided to VA Central Office and VISN leadership. This has 
allowed VA leadership to examine trends in implementation and to 
identify potential gaps in services available for women veterans.
    Every VAMC is assigned a full time Women Veterans Program Manager 
(WVPM). One of the responsibilities of the WVPM is to participate in a 
regular review of the physical environment in order to identify 
potential privacy and safety deficiencies. The WVPM is also regularly 
involved with plans for renovation and construction of new patient care 
areas, thereby ensuring that the needs of women veterans are addressed. 
During fiscal year 2014, VHA developed an innovative, Web-based tool 
that will transform the way Environment of Care (EOC) rounds are 
managed throughout the entire healthcare system. The EOC Assessment and 
Compliance Tool will simplify, streamline and standardize the EOC 
rounding process. VHA will be able to identify and track common 
deficiencies and improve the overall environment that our women 
veterans encounter to ensure a welcoming environment.
    Question. Many Kentucky veterans have expressed concerns regarding 
access to various specialty healthcare services. What criteria does the 
VA use in determining which clinics provide specialty care, such as 
access to podiatry, orthopedics, dentistry and ophthalmology?
    Answer. VHA Directive 2009-001, Restructuring of VHA Clinical 
Programs, provides policy implementing the restructuring of, addition 
to, or decrease in major clinical programs that may change or impact 
the delivery of care provided to veterans. Some examples include: 
initiation of a new clinical program or service that has not been 
previously provided at the facility or a clinic that involves a 
significant increase in complexity or volume of clinical workload, 
expansion of an existing surgery program, or an expansion of medical 
services beyond primary care, such as specialty care services 
(podiatry, dialysis, etc.).
    When a facility or VISN plans a restructuring of a service or 
program, the facility and VISN are responsible for completing and 
submitting to VA Central Office a comprehensive, multi-part business 
plan that is reviewed by subject matter experts and approved by the 
Under Secretary for Health through the Deputy Under Secretary for 
Health for Operations and Management and the Deputy Under Secretary for 
Health for Policy and Services. The intent of the business plan is to 
provide a description and justification for the proposed clinical 
restructuring, expected outcomes and process of care, and an 
affirmation that the facility has sufficient workload and 
infrastructure to support the program.
    One component of the business plan is the justification for the 
request. This includes a general description of the proposed program or 
service expansion, rationale for this expansion of the program or 
service, resources currently available for provision of the program or 
service, and the impact of the proposal on current patient care 
programs or services. Similarly, the business plan includes information 
describing how the addition of a clinical program or service will 
improve the quality of care provided to the veterans served by the 
facility or within the VISN, and a discussion and analysis of 
alternative approaches to providing needed services. A demographic 
analysis/projected workload is also incorporated. These data become 
part of the comprehensive business plan to support the justification 
when the request is submitted to VA Central Office for consideration in 
the approval process.
    Question. What criteria does the VA use to determine eligibility 
for contracting mobile X-ray units to provide services to clinics in 
rural areas that do not have X-ray capabilities?
    Answer. Facilities have the option of implementing mobile x-ray if 
the patient's drive time is excessive. But few do because it is usually 
more convenient for the patient and less expensive for VA to go to a 
local private sector imaging facility on fee basis or contract.
    Question. Homelessness is a persistent problem within the veterans' 
community. What VA programs are in place to address this issue? Are 
these programs having the desired effect?
    Answer. Between 2010 and 2013, there was a 24-percent reduction in 
veteran homelessness. To build on our progress to reduce homelessness, 
VA has increased programs and funding to help veterans who are homeless 
or at risk of becoming homeless. As a result of these investments, in 
fiscal year 2013 alone, VA provided services to more than 240,000 
homeless or at-risk veterans in VHA's homeless programs. Indeed, our 
goal is a systematic end to veteran homelessness, which means there are 
no veterans sleeping on our streets and every veteran has access to 
permanent housing. Should veterans become homeless, or be at-risk of 
becoming homeless, VA will have the capacity to quickly connect them to 
the help they need to achieve housing stability. The ultimate goal is 
that all veterans have permanent, sustainable housing with access to 
high-quality healthcare and other supportive services that improve 
their quality of life.
    VA has developed a comprehensive continuum of services dedicated to 
assist homeless veterans and veterans who are at-risk for homelessness. 
These services include: outreach services to engage homeless veterans 
through the Health Care for Homeless Veterans (HCHV) Program; 
contracted residential services for short-term placement of veterans 
for assessment and stabilization; transitional housing and supportive 
services provided through Grant and Per Diem funded community 
organizations; permanent supportive housing through the Department of 
Housing and Urban Development--VA Supportive Housing program; and 
rapid-rehousing and homeless prevention services through the Supportive 
Services for Veteran Families (SSVF) program. Additionally, VA has two 
justice-oriented programs to help prevent homelessness or a return to 
homelessness. The Veterans Justice Outreach Program was developed to 
avoid the unnecessary criminalization of mental illness and extended 
incarceration among veterans by ensuring that eligible justice-involved 
veterans have timely access to clinically appropriate VHA services. The 
Health Care for Reentry Veterans Program provides outreach and pre-
release assessment services for veterans in prison; referrals and 
linkages to medical, psychiatric, and social services; and short-term 
case management assistance upon release.
    Additionally, VA has developed specialized medical care programs 
for the needs of homeless veterans. For example, the Homeless Patient 
Aligned Care Teams (H-PACT) are an innovative treatment model being 
implemented at VA medical centers across the country. H-PACT clinics 
co-locate medical staff, social workers, mental health and substance 
use counselors, nurses, and homeless program staff. These professionals 
form a team that provides veterans with comprehensive, individualized 
care, including services that lead to permanent housing. VA's Homeless 
Veterans Dental Program also provides dental treatment for eligible 
veterans in a number of VA homeless programs.
    Question. Veterans in Kentucky have expressed concerns that wait 
times for prostheses have increased significantly due to changes in the 
VA's procurement process for these devices. What was the VA's reasoning 
for altering this process? What is the VA doing to ensure that veterans 
are receiving the prosthetic devices they require in a timely manner?
    Answer. The procurement of all prosthetic devices above the micro-
purchase level ($3,000) was transitioned to warranted procurement 
employees on October 1, 2013. This transition was necessary in order to 
ensure fiscal accountability and integrity in compliance with Federal 
Acquisition Regulation requirements and Federal requirements for 
contracting officer certification. To facilitate this transition, VHA 
released a directive that establishes policy and significantly reduces 
variability across the healthcare system. VHA Directive 1081 
``Procurement Process for Individual Prosthetic Appliances and Sensory 
Aids Devices Above the Micro-Purchase Threshold'' was signed by the 
Under Secretary for Health and released to the field on March 26, 2014.
    For procurement of devices above the micro-purchase level, VHA 
monitors the critical time elements that are required to provide these 
highly specialized and often complex prosthetic devices from the time 
of clinical prescription to the final award of a contract. The 
Procurement Acquisition Lead Time (PALT) tool is an interactive tool 
that has been deployed and is used by leadership to measure the 
timeliness of most prosthetic procurements above the micro-purchase 
threshold. The PALT tool is used extensively by VHA leadership during 
weekly calls with network contracting and prosthetic managers to 
facilitate conversations and analysis regarding procurement timelines 
at the network and facility level. With this improved communication 
established, purchases for veterans with the greatest medical need are 
readily prioritized and acted on appropriately. The PALT tool has been 
briefed to several veterans service organizations, as well as to 
several congressional staff members since its deployment at the 
beginning of fiscal year 2014. This tool is maintained on a VA intranet 
site and is fully accessible by VHA leadership and staff.
    For procurement of prosthetic devices below the micro-purchase 
threshold, timeliness is monitored for the number of days from when the 
clinician submits a prescription until the purchase of the device or 
service (fulfilled). The current standard is at least 75 percent of the 
orders are to be fulfilled in 5 days or less. This threshold was set to 
accommodate the longer length of time that can be required for more 
complex device prescriptions. Timeliness is extracted from automated 
data points generated from the ordering system to reduce the potential 
alteration of data by individuals to make timeliness look better.
    VA national program office meets with VISN Prosthetic 
Representatives on a quarterly basis to review data, provide feedback, 
discuss best practices and assist in developing corrective action plans 
related to purchasing timeliness of prosthetic devices below the micro-
purchase threshold.
    Question. Please provide an updated timeline for the design and 
construction phases for the new Robley Rex VA Medical Center in 
Louisville, Kentucky. When does the VA intend to break ground on the 
project? What capabilities specifically for female veterans are planned 
for this new medical center?
    Answer. Design for the new Robley Rex Medical Center is currently 
underway in the schematic design phase. However, continuing the design 
effort and beginning construction on the facility will be tied to 
funding available in a future major construction budget that has not 
yet been determined. As it pertains to female veterans, the new 
Louisville VA medical center facility will likely have:
  --Women veterans center with a separate facility entrance and waiting 
        area;
  --Inpatient units will have private rooms on both medical and 
        psychiatric units to provide women's privacy, including a 
        separate bathing and toileting area;
  --Women's Health will be integrated into the primary care patient 
        aligned care teams to provide comprehensive women's care;
  --Patient exam rooms will be designed for women's privacy and 
        accommodate related women's health exams for gynecological 
        needs, including private connected restrooms;
  --Medical center will provide onsite state-of-the-art mammography 
        services; and
  --Provision of complete primary care and care coordination by one 
        primary care provider.
    Question. Many veterans face difficulty beginning families when 
they return from service, particularly those who have sustained 
injuries such as spinal cord injury or disorder (SCI/D). Is 
reproductive assistance a standard VA medical service provided to 
veterans with service-connected injuries? What is the VA doing to 
address the needs of veterans seeking reproductive assistance? Does the 
VA need additional legislative authority to provide such service?
    Answer. A major goal of VA is to restore to the greatest extent 
possible the physical and mental functions of veterans with 
disabilities and improve the quality of their lives and that of their 
families. For many, having children is an important and essential 
aspect of life. Those who desire but are unable to have children of 
their own, can experience feelings of depression, grief, inadequacy, 
poor adjustment, and poor quality of life.
    Under 38 CFR 17.38, VA may provide to enrolled veterans care that 
is determined by appropriate healthcare professionals to be needed to 
promote, preserve, or restore the health of the individual and to be in 
accord with generally accepted standards of medical practice. 
Consistent with VA's goal of improving veterans' health and the quality 
of their lives, such care may include certain infertility treatments. 
Limited infertility services for both male and female veterans are 
already available at VA facilities. Diagnostic options readily 
available include such tests as laboratory blood testing, diagnostic 
imaging, semen analysis, post-coital test, diagnostic laparoscopy, and 
endometrial biopsy. Treatment options include evaluation and treatment 
of erectile dysfunction, surgical correction of structural pathology, 
hormonal therapies, and controlled ovarian hyper-stimulation. Sperm 
retrieval and cryopreservation, oocyte cryopreservation, and 
intrauterine insemination are available.
    However, 38 CFR 17.38 specifically excludes in vitro fertilization 
(IVF) from the medical benefits package. Treatments that are currently 
available to veterans under 38 CFR 17.38--in particular, intrauterine 
insemination (IUI)--have limited effectiveness, especially for certain 
male veterans with spinal cord injury (SCI). In these veterans, the 
motility of sperm is often abnormal, and sometimes severely reduced, 
resulting in low rates of IUI. Following IUI, the pregnancy rates for 
spinal cord injured men with very low motility rates have been reported 
to be as low as 1.1 percent whereas higher motility rates resulted in 
pregnancy rates of 32.2 percent--40 percent. In contrast, success of in 
vitro fertilization is not affected by decreased sperm motility. 
Similar pregnancy and live birth rates have been achieved with in vitro 
fertilization in couples with SCI male partners compared with couples 
with other etiologies of male factor infertility. For IVF, pregnancy 
rates for couples when the male partner had an SCI have been reported 
consistently over 50 percent (51 percent-70 percent).
    Moreover, only the veteran is eligible for the VA-covered 
infertility treatment services. Non-veteran partners (spouses or 
significant others) are not eligible to receive infertility tests or 
treatments from VA.
    The provision of Assisted Reproductive Services, (including IVF and 
other assisted reproductive technologies when indicated) would assist 
in reducing the disabling effects of the veteran's service-related 
injury by restoring the veteran's ability to procreate with his or her 
spouse/partner and become a biological parent. Additional legislative 
authority would be required to provide these services, and additional 
resources would be required were such authority to be provided.
    Question. What specific steps has the VA taken to successfully plan 
for the large influx of currently active-duty military personnel that 
will enter the VA system over the coming years?
    Answer. VA uses results from the Veteran Population Projection 
Model (VetPop) as input into the VA Enrollee Health Care Projection 
Model (EHCPM) to project future enrollments in the VA healthcare 
system. The VetPop model uses historical and active military records 
from DOD's personnel system (DEERS) as one of its key data sources.
    Question. Does VA currently have a formal way of honoring the 
spouses of veterans or servicemembers at the time of the spouse's 
death? How can the VA better honor these deceased spouses who have also 
helped serve our nation by supporting their servicemembers and 
veterans?
    Answer. Yes. Eligible spouses receive a committal service of the 
family's choosing; opening and closing of the gravesite; a government-
furnished headstone or marker; and perpetual care of the gravesite. 
Committal services are conducted in accordance with the wishes of each 
family, and often include a personalized tribute to the spouse, 
veteran, or servicemember. VA recognizes the support of veteran's 
spouses and family members by ensuring they are honored in an 
appropriate manner similar to veterans. Eligible spouses and family 
members receive the same burial and memorial services at VA national 
cemeteries as do veterans and servicemembers, except for elements that 
specifically commemorate uniformed service, such as military funeral 
honors and the Presidential Memorial Certificate.
    Question. What is the status of the CBOC at Fort Knox? Is the 
project's design linked with plans to replace the Ireland Army Hospital 
with a new medical facility?
    Answer. Yes, VHA's Minor project for the construction of a new 
clinic at Fort Knox was contingent upon the Army's plans to replace the 
Ireland Army Hospital. The Army's recent decision to cancel 
construction of the replacement hospital has required the VA to place 
the current minor construction project on hold while options to expand 
VA's current space within the existing Ireland Army Hospital are 
reviewed.
    Question. How would the VA plan to accommodate any potential 
expansion of the Servicemembers Civil Relief Act for new populations, 
including for fully disabled veterans?
    Answer. The Servicemembers Civil Relief Act (SCRA) ultimately falls 
under the jurisdiction of the Department of Defense; however, potential 
expansion may impact VA in some ways. VA's Loan Guaranty Service would 
plan to accommodate any expansion of SCRA by including the additional 
populations in our SCRA policies of monitoring VA loan files for 
possible SCRA violations, intervening with the affected borrower and 
servicer, and referring violations to the Department of Justice. VA 
notes that expanding SCRA for new populations could increase VA's claim 
payments, as SCRA protections may delay foreclosure proceedings 
resulting in the potential for higher amounts of accrued debt. VA 
welcomes the opportunity to provide technical assistance to the 
Committee on legislation extending SCRA to disabled veterans.
                                 ______
                                 
              Question Submitted by Senator Mark L. Pryor
    Question. Secretary, I had a great breakfast meeting with you 2 
weeks ago. In that meeting I asked your staff to help on two issues. 
One was the North Little Rock, Arkansas veterans home land transfer and 
the second was about a constituent who needs help on his claim. I 
personally asked your Congressional Affairs staff for help and my staff 
has reached out twice to seek answers and guidance.
    Could your staff please respond to my staff on these two issues 
this week?
    Answer. Office of Congressional and Legislative Affairs (OCLA) 
staff received the requests from your staff and subsequently provided 
the requested information. On April 4, 2014, OCLA staff provided 
responsive information concerning your constituent's disability 
benefits claim. On April 29, 2014, various Department of Veterans 
Affairs subject matter experts provided a briefing to your staff and 
State of Arkansas officials concerning the status of the North Little 
Rock State Veteran Home Construction Grant process.
                                 ______
                                 
                Questions Submitted by Senator Tom Udall
    Question. Recently Senator Corker and I wrote to you regarding the 
delay in implementing the bipartisan Burn Pits Registry Act. The 
registry was originally supposed to come online in January. First, when 
do we expect the registry to go online?
    Answer. On June 19, 2014, VA announced the availability of the 
Airborne Hazards and Open Burn Pit Registry, after successfully pilot 
testing the Registry at three facilities in Detroit, Indianapolis, and 
New Jersey. The registry is now available online at https://
veteran.mobilehealth.va.gov/AHBurnPitRegistry/#page/home.
    Question. Second, what specifically are VA's plans to utilize the 
information from the registry, such as funding research into the 
impacts and enlisting other agencies and organizations to analyze the 
registry data?
    Answer. VA is nearing award of a contract to an independent 
scientific organization, as required by Public Law 112-260, to provide 
recommendations to VA and Congress. In addition, VA is collaborating 
with the Department of Defense (DOD) on an ongoing longitudinal cohort 
study, the Millennium Cohort Study, of the potential adverse health 
effects related to military deployment to Iraq and Afghanistan, which 
will include potential exposure to airborne hazards and burn pits. 
Also, VA is developing a pilot study through its Cooperative Studies 
Program (CSP) to examine pulmonary effects of exposures of interest, 
such as particulate matter (PM) after deployment; planning for this 
study is currently underway, and the study is expected to begin in 
fiscal year 2015. These studies will be informed by data gathered in 
the registry. By capturing information from these studies and the 
registry, VA will increase its ability to understand important 
information about the potential long-term health consequences of 
airborne hazards and burn pit exposures.
    Question. And finally, would it be helpful to create a network of 
research centers to better understand the impact of burn pits on our 
veterans and Active Duty servicemembers?
    Answer. VA and DOD are actively conducting research on the long-
term health impacts of burn pits and airborne hazards. VA's War Related 
Illness and Injury Study Center (WRIISC) sites at Palo Alto, 
California; Washington, DC; and East Orange, New Jersey, provide 
clinical consultations to veterans, train VA healthcare providers on 
complex environmental exposures and difficult to diagnose illnesses, 
and conduct research to better understand these issues. The WRIISC 
sites continue to expand their capabilities to evaluate airborne hazard 
exposure and outcomes. Case series from the WRIISC and other VA 
researchers, are available in peer-reviewed scientific publications and 
have been presented at national scientific gatherings. VA continues to 
collaborate with DOD to develop educational products for staff who 
evaluate veterans and servicemembers, to monitor relevant research, and 
to exchange information with civilian providers who may evaluate 
veterans. Thus we do not believe that additional research centers are 
needed.
    Question. As you know, the Director of the New Mexico VA, Mr. 
George Marnell is retiring. First, I want to thank him for his service 
to the VA. As I stated to Dr. Petzel in a call earlier this year, I 
want to express my support during the hiring process for a replacement 
Director, and encourage the VA to find a Director who can provide new 
and creative leadership to help find solutions to the challenges facing 
our vets in New Mexico, especially our rural vets who do not have 
access to the facilities in Albuquerque.
    With regards to finding a new director, and ensuring he or she is 
prepared to get off to a fast start, does the VA plan on reviewing the 
needs of the New Mexico VA system in order to determine where the new 
Director should focus their efforts when they come onboard?
    Answer. The Veterans Integrated Service Network (VISN) 18 Director 
and her executive leadership team is partnering with the New Mexico VA 
Health Care System (NMVAHCS) executive leadership team and VA's 
National Center for Organizational Development to develop a transition 
briefing for the permanent NMVAHCS Director replacement.
    Question. It has been sometime since the VA OIG has focused on the 
New Mexico VA. Would you support a review of the New Mexico VA by the 
OIG in light of this change in leadership?
    Answer. Most recently a report was completed on May 23, 2014, by 
the VA Office of Inspector General Office of Healthcare Inspections who 
conducted an inspection in the Gastroenterology Department at the New 
Mexico VA Health Care System (facility), Albuquerque, New Mexico. 
Additionally, during the week of June 2, 2014, they conducted an onsite 
Combined Assessment Program review at the New Mexico VA Health Care 
System.
    Question. Current law, members of the Guard or Reserve who served 
in Iraq or Afghanistan, but did not accumulate 24 months of non-entry 
level training are not eligible for 100 percent educational benefits, 
or even to have their initial entry level training time counted towards 
this benefit. This is a disservice to those who have served on the 
front lines in the War on Terror and is a contradiction to the spirit 
of the Post-9/11 GI Bill. I have previously introduced amendments to 
change this disservice.
    Would the Department of Veterans Affairs (VA) support such efforts 
to ensure that our guardsmen and reservists who served in Operation 
Enduring Freedom, Operation Iraqi Freedom, and New Dawn have the same 
educational opportunities as our Active Duty servicemembers?
    Answer. Post-9/11 GI Bill eligibility rules apply equally to 
members of the regular Active Duty service components, National Guard, 
and Selected Reserve. Individuals qualify for the same eligibility 
percentage based on the amount of qualifying Active Duty service 
accrued, including the incorporation of entry-level and skill training 
once an individual has accrued 24 months of service. Individuals 
honorably discharged from the regular Active Duty service components 
with less than 24 months of service (for any reason other than a 
service-connected disability) do not receive credit for entry-level or 
skill training. This significantly reduces their eligibility benefit 
level or makes them ineligible altogether. While VA supports 
legislation to provide benefits to our Nation's veterans, including 
members of the National Guard and Reserve components, removing the 
requirement for members of the National Guard and Reserve components 
would create an inequity for Active Duty members. In this instance, 
those who are serving full-time would be required to serve more time to 
qualify for the same educational benefit. VA believes that any change 
made to the eligibility criteria should be applicable to all eligible 
individuals, regardless of service affiliation.
    Question. I would like to reiterate my support for the State of New 
Mexico's VA State home construction grant application. The New Mexico 
State Veterans Home is the only nursing facility for veterans in the 
State. Three levels of care are offered at the State Veterans Home: 
skilled nursing care, routine nursing care and adult residential care--
including independent living assistance. The project has been on the 
VA's priority list 1 for multiple years now, and funding would allow 
the State to add an Alzheimer's and Wellness building with 59 total 
beds, a new rehabilitation section for inpatient and outpatient 
services, and a new pool.
    Does the VA currently have enough budgeted to fund all of the 
projects on the VA's priority list 1, and if not, how much more would 
the VA need to adequately fund these projects?
    Answer. All VA State home construction grant program safety and 
security projects with State-matching funds are funded by VA annually. 
Once the safety and security projects are funded, VA then allocates 
funds to certain new construction and renovation projects in the 
priority group 1 category, based on availability of resources. In 
fiscal year 2014, VA will award 23 grants in priority group 1.
    Question. Many veterans have to travel hundreds of miles and 
sometimes across States to gain access to a polytrauma center. For 
example, one of the areas of the country with the largest military 
population, southern New Mexico and El Paso, Texas . . .  which is home 
to Ft. Bliss, White Sands Missile Range, and Holloman Air Force Base is 
over 300 miles in every direction to the nearest polytrauma 
rehabilitation center or network site. I asked about this problem last 
year and unfortunately no progress has been made to solve this problem 
of access to quality care.
    What is VA doing to address the lack of a polytrauma centers in 
this and similarly isolated regions and will the VA consider locating a 
center in the area in the future and providing sufficient funding for a 
polytrauma center in its budget?
    Answer. Veterans Health Administration VHA national program office 
for polytrauma and traumatic brain injury (TBI) continually monitors 
and assesses TBI associated service utilization and access to these 
services, and takes action to implement changes as appropriate. 
Consideration for appropriate polytrauma programming includes review of 
veterans with TBI in the area and access to TBI services.
    In fiscal year 2013, VISN 18 provided care to over 4,300 veterans 
with TBI. More specifically, the El Paso VA Health Care System (VAHCS) 
provided care to 807 veterans with TBI. VA continues to enhance 
services for polytrauma and TBI in southern New Mexico and El Paso, 
Texas.
    For example, with support from the El Paso VA Leadership, VISN 18, 
and the Polytrauma Network Site in Tucson, VA has augmented services 
for veterans with TBI and polytrauma by hiring and training new staff 
at El Paso VAHCS. In the last year, El Paso VA added three new 
providers with dedicated time in polytrauma/TBI care including a 
neurologist, a psychologist, and an occupational therapist. These 
providers have augmented the existing polytrauma providers that include 
a nurse practitioner, audiologist, and optometrist. The team also has 
in-house access to medical specialists in urology, cardiology, 
gastroenterology, hematology, orthopedics, amputee clinic, social work, 
behavioral health, caregiver program, and home programs. Increased 
utilization of telehealth has been leveraged, as has reaching out to 
other providers in the community to supplement needed care.
    Telehealth technologies are used to complement face-to-face 
clinical encounters and to facilitate access to polytrauma care. Since 
2010, VISN 18 has experienced a 70-percent increase in TBI and 
polytrauma visits completed via telehealth. The El Paso team consults 
with providers in Tucson and Albuquerque for the assessment and 
treatment of veterans with specialized needs, and to coordinate 
clinical services across VA facilities. When polytrauma services are 
not readily available in VA, care is delivered in collaboration with 
non-VA providers. These include the Beaumont Army Medical Center used 
for inpatient care, and two community rehabilitation providers used for 
episodic services under non-VA medical care.
    El Paso's core polytrauma/TBI staff have also visited and 
participated in training with the Polytrauma Network Site in Tucson. 
The training targeted specific evidence-based clinical processes and 
requirements for TBI and polytrauma care in the VA. These two 
healthcare teams continue to communicate regularly and focus on meeting 
veterans' rehabilitation needs.
    VA is currently pursuing establishment of a Polytrauma Support 
Clinic Team at the El Paso VA Health Care System to further enhance 
existing TBI and polytrauma services. This will add capacity for 
cognitive rehabilitation, psychosocial interventions, active 
telehealth, and other virtual care components to accommodate the demand 
for specialized rehabilitation services in this region. This strategic 
approach is similarly applied across other isolated regions across the 
country, as VHA continually monitors and assesses the need, utilization 
and provision of such services.
    VA continues to actively ensure that El Paso and other VA regions 
around the country have the core assets and services available on-site, 
and/or through telehealth and consultation in order to sufficiently 
meet the wide range of medical and rehabilitation needs of veterans 
with TBI and polytrauma.
                                 ______
                                 
         Questions Submitted to Under Secretary Allison Hickey
              Questions Submitted by Senator Mark L. Pryor
    Question. Under Secretary Hickey, as the number of veterans 
continues to grow as a result of over a decade of war, it is important 
that we make the right decisions regarding their care. Our commitment 
to our Nation's veterans does not end once the war in Afghanistan is 
over. We must continue to support our Nation's sons and daughters that 
have sacrificed so much for this country. We must ensure that proposed 
VA spending levels are focused on providing the right care and services 
to our veterans while demonstrating an unwavering commitment to our 
veterans. This is especially true as thousands of veterans begin their 
transition from military service into the civilian workforce.
    How does the VA intend to implement the Veterans Job Corp program 
and how does the VA intend to provide oversight to ensure that the 
program is meeting its purpose in providing our veterans with high-
quality employment opportunities?
    Answer. The goal of the Veterans Job Corps is to enable veterans to 
leverage the skills developed in the military in jobs on the country's 
public lands and in its communities, ranging from conservation and 
infrastructure projects to law enforcement and first responder jobs, 
such as park rangers, police officers, and firefighters. The 
Administration would like to work with the Congress to pass legislation 
to authorize the Veterans Job Corps and address details such as 
credentialing and the program's linkages to Department of Veterans 
Affairs' certificate, licensing, and degree-granting programs, such as 
the Post 9/11 G.I. Bill.
    Question. How will local and State agencies, such as the Little 
Rock Police Department, be able to partner with the Veterans Job Corps 
program to provide these employment services to our local veterans?
    Answer. The Administration would like to work with the Congress to 
pass legislation to authorize the Veterans Job Corps and address 
details such as post-program employment opportunities for veterans who 
participate in the program.
                                 ______
                                 
        Questions Submitted to Under Secretary Dr. Robert Petzel
              Questions Submitted by Senator Mark L. Pryor
    Question. Under Secretary Petzel, providing quality mental 
healthcare for our veterans requires an innovative approach that 
addresses both the physical and mental health of a veteran. We must 
continue to expand efforts to connect more veterans to mental health 
resources, and must ensure that servicemembers are thoroughly evaluated 
for injuries and properly diagnosed so that, as veterans, they are 
eligible to receive the care they need for the injuries that they have 
sustained during their service.
    A growing number of veterans demand mental health services and 
treatment to address mental health disorders that are attributed to the 
strains of multiple combat tours. How do you intend to transform and 
increase the capacity of the VA to meet these veterans' demand for 
mental healthcare?
    Answer. VA is addressing the current and growing demand for mental 
health services through a summarized strategy covering several major 
themes including:
    1.  The leveraging of tele-health and other technologies that 
extend the reach of brick and mortar facilities into rural communities 
and digital phone technologies that provide ``on demand'' veteran 
access to behavioral health support;
    2.  Staffing recruitment; and
    3.  Leveraging community partnerships.
    In order to reach veterans in rural communities, tele-mental health 
efforts have resulted in tele-health psychotherapy mental health 
encounters tripling between fiscal year 2011 and fiscal year 2013. In 
addition, a digital phone application that supports the treatment of 
post-traumatic stress disorder (PTSD coach) has been developed and 
downloaded 126,000 times for iPhones and Android smartphones. To date, 
over 530,000 veterans (over 140,000 Operation Enduring Freedom/
Operation Iraqi Freedom/Operation New Dawn (OEF/OIF/OND)) received 
treatment for PTSD in VA medical centers and clinics, up from just over 
500,000 veterans (over 100,000 OEF/OIF/OND) in fiscal year 2011.
    To meet this growing demand, VA has hired more than 1,600 
additional mental health clinicians and expanded its mental health 
workforce to include more than 800 peer specialists (peer specialists 
are veterans). VA also recognizes that coordinated, collaborative care 
is effective care, and in fiscal year 2013, VA hosted 151 local mental 
health summits at each of our medical centers, broadening the community 
dialogue. Preliminary data from these summits suggest an improved 
understanding and relationship was fostered between VA facilities and 
the communities in which they are embedded.
    Question. In Arkansas, we have many veterans that live in rural 
areas which limits their access to mental health professionals. How 
will the VA's proposed plan to work with community partners increase 
the access to mental health services for our veterans that live in 
rural areas?
    Answer. VHA acknowledges the vital need for mental health support 
and services for all veterans, regardless of their geographic locale. 
Rural veterans have historically had less access to physical or mental 
health services than urban veterans. VHA, recognizing the disparity of 
care offered to urban versus rural veterans, has established multiple 
ways to ensure appropriate care and service accessibility.
    In 2007, VA created the Office of Rural Health (ORH). ORH 
collaborates with other program offices, Federal partners (e.g. Indian 
Health Services, Department of Defense, etc.), State partners, and 
rural communities to establish access points to care, and increase 
healthcare options for rural veterans. The mission of ORH is to 
``Improve access and quality of care for enrolled rural and highly 
rural veterans by developing evidence-based policies and innovative 
practices to support the unique needs of enrolled veterans residing in 
geographically remote areas.''
    VA uses several means to accomplish this mission:
  --Expansion of community-based outpatient clinics (CBOC) and 
        enhancement of the delivery of mental health services in CBOCs 
        by tele-mental health;
  --Increased partnerships with non-VA rural providers (through VA's 
        Non-VA Care Program);
  --Telemedicine pilots; and
  --Concentrated efforts to recruit and retain providers to rural 
        areas.
    For additional information on ORH and their programs, an ORH fact 
sheet follows: 


                          SUBCOMMITTEE RECESS

    Senator Johnson. This hearing is adjourned.
    [Whereupon, at 11:23 a.m., Tuesday, March 25, the 
subcommittee was recessed, to reconvene subject to the call of 
the Chair.]