[Senate Hearing 114-]
[From the U.S. Government Publishing Office]




 
     MILITARY CONSTRUCTION, VETERANS AFFAIRS, AND RELATED AGENCIES 
                  APPROPRIATIONS FOR FISCAL YEAR 2017

                              ----------                              


                        THURSDAY, MARCH 3, 2016

                                       U.S. Senate,
           Subcommittee of the Committee on Appropriations,
                                                    Washington, DC.
    The subcommittee met at 10:55 a.m., in room SD-124, Dirksen 
Senate Office Building, Hon. Mark Kirk (chairman) presiding.
    Present: Senators Kirk, Murkowski, Boozman, Capito, 
Cassidy, Tester, Murray, Udall, Schatz, Baldwin, and Murphy.

                     DEPARTMENT OF VETERANS AFFAIRS

                     Veterans Health Administration

STATEMENT OF HON. DAVID J. SHULKIN, MD, UNDER SECRETARY 
            FOR HEALTH
ACCOMPANIED BY MARK YOW, CHIEF FINANCIAL OFFICER

                 OPENING STATEMENT OF SENATOR MARK KIRK

    Senator Kirk. The subcommittee is holding a hearing today 
to review the 2017 budget request. The President's request is 
for $78 billion for funding the Department of Veterans Affairs 
(VA), an increase of 4.9 percent. About $68 billion of that, 87 
percent, is for veterans' medical care.
    This subcommittee and this Congress have given all of the 
funding that you have requested and more. The answer to every 
VA problem is not just more money and not just give us 
flexibility. We need to talk about the VA's culture of 
corruption with results and talk about performance. We need to 
talk about accountability and putting veterans first, not 
bureaucrats.
    First, a few housekeeping items. We will follow the early 
bird rule, alternating sides, majority and minority, to defer 
opening statements, and do 5-minute rounds of questions. And we 
will do a second round if needed.
    Let me now recognize my friend, the man representing the 
entire Big Sandy metroplex in Montana.

                    STATEMENT OF SENATOR JON TESTER

    Senator Tester. Thank you, Mr. Chairman, and a metroplex it 
is. I want to thank all of you for being here today in front of 
the appropriations subcommittee, VA military construction 
(MILCON), and I want to thank you for your service to this 
country's veterans. You have difficult jobs, and I appreciate 
the work that you do. In many ways, both the Veterans Health 
Administration (VHA) and the Veterans Benefit Administration 
(VBA) have made some significant progress over the past year, 
but I am sure that you would agree that we have much more work 
to do.
    The intent of the Choice Act was to give veterans more 
opportunity to seek timely care in their communities, but as we 
all know, in practice it simply has not happened. Some of the 
fault lies with the VA. Some of the fault lies with us in 
Congress. And at least in my opinion, much of that fault, which 
we have to bear the responsibility for, bears with a third-
party administrator, at least it does in the State of Montana.
    Veterans in places like Butte continue to be frustrated by 
the time and hassle it takes to schedule appointments through 
Choice, and that is directly related to the third-party 
administrator. Community providers in places like Billings 
continue to be frustrated by the time it takes to get 
authorization and reimbursement for care. As a result, the 
largest healthcare provider in my State of Montana will not 
participate in Choice, and that is because of that third-party 
administrator.
    VA employees continue to be frustrated because they have to 
go through a middleman, the third-party administrator, to 
connect veterans with the care that they need. And I have heard 
these frustrations directly from Montanans, and their 
frustration, along with mine, is not getting less. It is 
getting greater each day.
    Dr. Shulkin, we have had conversations about this. They are 
the same conversations that I have had with Secretary McDonald 
multiple times over the past weeks. Yes, fixing the VA, making 
sure that we provide the benefits to our veterans does require 
some resources, and that is what we are here today to discuss, 
your budget.
    But it also requires using all the tools that are available 
to you in a more effective way. If you do not have the tools 
that you need, we need to know about it because if you are not 
effectively using the tools you have because of a problem we 
have created, we need to fix it. Today I want to hear more 
about the budgetary needs of the VA, but I also want to hear 
about how the VA is going to make more effective use of the 
tools that you already have at your disposal.
    Again, I want to thank all of you for being here today. I 
look forward to this discussion. And, Mr. Chairman, I 
appreciate your work on this subcommittee. Thank you.
    Senator Kirk. I would like to welcome our witnesses. David 
Shulkin is the Under Secretary for Health. Mr. Shulkin--Dr. 
Shulkin--I will give you a chance for first testimony, and we 
welcome you now.

             SUMMARY STATEMENT OF HON. DR. DAVID J. SHULKIN

    Dr. Shulkin. Thank you. Good morning, Chairman Kirk, 
Ranking Member Tester. Thank you for this opportunity to appear 
before you to discuss the Veterans Health Administration's 
fiscal year 2017 and 2018 medical care appropriations budget 
request. I am accompanied today to my right by Mark Yow, who is 
our Chief Financial Officer.
    Last year in 2015 it was a very big year for addressing 
some of the critical issues that we have before us in VHA. The 
Department is working hard to rebuild trust with veterans and 
the American people, improving service delivery, setting the 
long-term course for VA excellence and reform, while delivering 
better access to care and benefits. This includes the 
Department's MyVA initiative, which reorients VA around the 
veterans' needs and empowers employees to assist them in 
developing excellent customer service to improve the veteran 
experience.
    As we enter into 2016, all of us in the VA healthcare 
system will be focused on the MyVA initiative, as well as VHA's 
Blueprint for Excellence. The Blueprint is aligned with the 
Department's strategic plan and supports the MyVA initiative. 
The Blueprint for Excellence will serve as a guide in all of 
the programs I mentioned in my written testimony. I am 
confident that the deep sense of mission we carry through the 
next year and any challenges that we may face will be addressed 
by this.
    VHA's 2017 budget request will support VA's goals to expand 
access to timely, high-quality healthcare, and to continue to 
transform the Department through its MyVA initiatives. Through 
the fiscal year 2017 budget, we will continue to develop and 
expand our mental healthcare system with the goal to reduce 
veteran suicides. We are committed to increasing access to care 
for veterans and focus our efforts on addressing veterans who 
have the most significant health needs first.
    We have placed a special emphasis on telehealth services 
for those in rural and remote locations, and for areas that 
have a shortage of specific healthcare professionals, such as 
psychiatrists. This past weekend, in fact, VHA held its second 
system-wide access stand down where every medical center across 
the country this past Saturday was working hard to reduce the 
wait times for veterans who were waiting for care.
    To address the growing number of women veterans, VA is 
strategically enhancing the services and access for female 
veterans. Another high priority is ensuring that all enrolled 
veterans who require treatment for hepatitis C have access to 
the necessary therapies. VA is also dedicated to promoting the 
health and well-being of Caregivers. It is important to know 
that this budget allows us to continue our commitment to 
innovative and cutting-edge medical research that is focused on 
improving veteran health outcomes.
    I want to highlight our Million Veteran Program and 
research in precision medicine that will allow VA to remain a 
leader in advancing discoveries to improve healthcare for all 
Americans.
    The cost of fulfilling this care and other obligations to 
our veterans grows, and we expect it will continue to grow for 
the foreseeable future. We know that services and benefits for 
veterans do not peak until roughly 4 decades after a conflict 
ends. Therefore, more resources will be required to ensure that 
VA can provide timely, high-quality healthcare into the future.
    We know that we have much work to do in fixing access 
issues for veterans, and filling our critical leadership and 
healthcare professional openings, and ensuring our new Veterans 
Choice Plan works better for veterans than it has over the past 
year. I came to VA approximately 8 months ago from the private 
sector to fix these problems, and I am building a leadership 
team that is now committed to doing this and implementing 
sustainable change. The fiscal year 2017 budget requests 
additional resources which are critical to providing veterans 
the care they have earned through their service and sacrifice.
    In conclusion, I appreciate the hard work and dedication of 
VA employees, our partners from veteran service organizations 
who are important advocates for veterans, our community 
stakeholders, and our dedicated VA volunteers. I respect the 
important role that Congress has in ensuring veterans receive 
quality healthcare and benefits that they rightly deserve. I 
look forward to continuing our strong collaboration and 
partnership with the subcommittee, and other committees of 
jurisdiction, and the entire Congress as we work together to 
continue to enhance the delivery of healthcare to our Nation's 
veterans.
    Mr. Chairman, members of the subcommittee, this concludes 
my remarks. Thank you again for this opportunity to testify. My 
colleagues and I will be happy to respond to any questions from 
you and members of the subcommittee. Thank you.
    [The statement follows:]
           Prepared Statement of Hon. David J. Shulkin, M.D.
    Good morning Chairman Kirk, Ranking Member Tester, and members of 
the subcommittee. Thank you for the opportunity to appear before you to 
discuss the Department of Veterans Affairs (VA) Veterans Health 
Administration (VHA) fiscal year 2017 and fiscal year 2018 Medical Care 
Advance Appropriations budget request. I am accompanied today by Mark 
Yow, VHA's Chief Financial Officer.
    The year 2015 was a big year in addressing some of the critical 
issues that we have before us in VHA. VA, as a whole, is working to 
rebuild trust with veterans and the American people, improve service 
delivery, and set the course for long-term VA excellence and reform. 
This initiative is called ``MyVA.'' As we enter 2016, all of us in the 
VA healthcare system are focused on the ``MyVA'' initiative as well as 
VHA's Blueprint for Excellence. The Blueprint is aligned with the 
Department's Strategic Plan and supports the ``MyVA'' initiative. The 
Blueprint lays out themes and supporting strategies for transformation 
to improve the performance of VA healthcare now--making it not only 
more veteran-centric, but also veteran-driven by putting our customers 
in control of their VA experience. The Blueprint for Excellence will 
serve as a guide in all of the programs I mention throughout my 
testimony.
    To ensure that we remain aligned with ``MyVA'' and the Blueprint 
for Excellence, I have five priorities that are the focus of VHA. 
First, we must fix the access issues and continue to work on reducing 
the wait time for veterans who need our services. Second, VHA must be a 
model for high-performance care and develop a high-performance network. 
Third, we must improve staff and employee morale and make VA a place 
where all of our employees feel comfortable and supported in an 
environment that allows them to do the best job to serve our veterans. 
Fourth, to ensure consistency of best practices and resource 
prioritization, we must share promising practices among facilities and 
focus on the things that we know are working best within VA. Finally, 
and most important, VHA must restore the trust and confidence that the 
American public and veterans have in the services that we provide.
    The President's fiscal year 2017 budget request will support VA's 
goals to expand access to timely, high-quality healthcare; sustain 
funding to support programs dedicated to ending homelessness among 
veterans; and continue to transform the Department through its ``MyVA'' 
initiative, which reorients VA around veteran needs and empowers 
employees to assist them by delivering excellent customer service to 
improve the veteran experience.
    The cost of fulfilling this care and other obligations to our 
veterans grows, and we expect it will continue to grow for the 
foreseeable future. We know that services and benefits for veterans do 
not peak until roughly four decades after a conflict ends. Therefore, 
more resources will be required to ensure that VA can provide timely, 
high-quality healthcare into the future. The fiscal year 2017 budget 
requests additional resources, which are critical in providing veterans 
the care that they have earned through their service and sacrifice.
                        improved access to care
    VA is taking multiple steps to expand capacity at our facilities by 
focusing on staffing, space, productivity, and VA Community Care. The 
fiscal year 2017 budget request provides $65 billion for VA medical 
care, a 6.3-percent increase above the 2016 enacted level. The increase 
in 2017 is driven by veterans' demand for VA healthcare as a result of 
demographic factors, economic assumptions, investments in access, high-
priority investments for Caregivers, and new hepatitis C treatments.
    Building on momentum generated by the November 14, 2016, Stand 
Down, VA is continuing efforts to improve access to care, improve the 
veteran experience, and improve the VA employee experience by 
maximizing accessibility to outpatient services and initiating a second 
Stand Down held on February 27, 2016. We are re-focusing people, tools, 
and systems as we embark on a continuous improvement journey towards 
same day access for primary care and urgent specialty care.
    We are empowering each VA facility to focus on the needs of its 
specific population under the aforementioned guiding principles. 
Clinical operations will meet customer demand through resource-neutral, 
continuous improvements at the facility level and scaling-up excellence 
across the enterprise.
    VA has placed special emphasis on increasing access for veterans in 
rural and remote locations. Telehealth services are mission-critical to 
the future of VA care to veterans. Telehealth utilizes information and 
telecommunication technologies to provide healthcare services when the 
patient and practitioner are separated by geographical distance. The 
fiscal year 2017 budget requests $1.2 billion, an increase of $56 
million (5.1 percent) above the 2016 enacted level for telemedicine. 
The number of veterans receiving care via VHA's telehealth services 
grew approximately 5 percent in fiscal year 2015, and is anticipated to 
grow by approximately 6 percent in fiscal year 2016. In fiscal year 
2015, during more than 2.1 million telehealth episodes of care, VHA 
provided care to more than 677,000 veterans via the three telehealth 
modalities (i.e., Clinical Video Telehealth, Home Telehealth and Store 
and Forward Telehealth). Forty-five percent of these veterans lived in 
rural areas, and otherwise may have had limited access to VA 
healthcare.
    We are appreciative of Congress' support to improve access as we 
build capacity within the VA system to better serve veterans who rely 
on us for healthcare. My testimony will now discuss key initiatives 
highlighted in the President's 2017 budget request.
       mental health care (suicide prevention--a call to action)
    Long deployments and intense combat conditions require 
comprehensive support for the emotional and mental health needs of 
veterans and their families. Accordingly, VA continues to develop and 
expand its mental health system. VA has integrated mental health 
services into primary care in the Patient Aligned Care Team model. 
Providing mental healthcare within the primary care clinic minimizes 
barriers that may discourage veterans from seeking mental healthcare. 
This integrated healthcare is not seen in other healthcare systems 
nationally.
    VA has many entry points for mental healthcare, including 167 
medical centers, 1,035 Community-Based Outpatient Clinics and 
Outpatient Services sites, 300 Vet Centers providing readjustment 
counseling, 80 Mobile Vet Centers, a national Veterans Crisis Line, VA 
staff on college and university campuses, and a variety of other 
outreach efforts.
    VA's Primary Care-Mental Health Integration (PC-MHI) program, which 
provides mental healthcare as a routine component of primary care, is 
now established in 98.8 percent of VHA divisions, 98.5 percent of the 
very large and 81.2 percent of large community based outpatient 
clinics. VHA provided over 1 million PC-MHI encounters in 2015, an 
increase of 8 percent from 2014 and an increase of 28 percent from 
2013.
    The fiscal year 2017 budget requests $7.8 billion, an increase of 
$347 million (4.6 percent), to ensure the availability of a range of 
mental health services, from treatment of common mental health 
conditions in primary care to more intensive interventions in specialty 
mental health programs for more severe and persisting mental health 
conditions. We will continue to focus on expanding and transforming 
mental health services for veterans to ensure that accessible and 
patient-centered care, including treatment for posttraumatic stress 
disorder (PTSD), ensuring timely access to mental healthcare, and 
treatment for military sexual trauma.
    On February 2, 2016, Secretary Robert McDonald and I held a 
groundbreaking event ``Preventing Veteran Suicide: A Call to Action.'' 
This day-long summit was attended by over 230 participants, including 
members of Congress, the Department of Defense, other Federal partners, 
veterans, their family members, Veterans Service Organizations, 
academics, and other stakeholders. The primary goal of the event was to 
develop a concrete plan of action to engage more veterans at risk for 
suicide by bringing them into VA's system. Independent studies have 
shown that veterans who engage in VA care are at lower risk of suicide 
than those who do not engage in VA care. VA continues to develop a 
proactive action plan with steps to move forward with suicide-
prevention efforts based on the feedback and presentations of the 
summit.
    VA is committed to ensuring the safety of our veterans, especially 
when they are in crisis. Our suicide prevention program is based on 
enhancing veterans' access to high-quality mental healthcare and 
programs specifically designed to help prevent veteran suicide. Losing 
one veteran to suicide shatters an entire world. Veterans who reach out 
for help must receive that help when and where they need it and in 
terms that they value.
                           hepatitis c virus
    VA places a high priority on ensuring that all enrolled veterans 
who require treatment for the hepatitis C virus (HCV) have access to 
the necessary therapies. Chronic infection with HCV is the most common 
blood-borne infection in the world and is a major public health problem 
facing not only veterans, but the United States in general. The fiscal 
year 2017 budget requests $1.5 billion to capitalize on the 
availability of new therapies to improve access to and quality of HCV 
care. These new drugs will save veterans' lives. During fiscal year 
2015, VA medical facilities treated over 30,000 veterans for HCV with 
these new drugs with remarkable success, achieving cure rates of 90 
percent.
                         care in the community
    VA is committed to providing veterans access to timely, high-
quality healthcare. The 2017 budget includes $12.3 billion for Care in 
the Community and includes a new Medical Care in the Community budget 
account, as mandated in the VA Budget and Choice Improvement Act 
(Public Law 114-41). Of the total, $7.2 billion will be provided 
through a transfer of the 2017 advance appropriations for Medical 
Services to the new budget account, $250 million will be provided 
through anticipated collections in the new account, and $4.8 billion 
will be provided through the Veterans Choice Program. The 2017 budget 
will support over 15.6 million visits/procedures for veterans by non-VA 
providers.
    On October 30, 2015, VA provided Congress with its plan for the 
consolidation and improvement of all purchased care programs into one 
New Veterans Choice Program (New VCP).
    In today's complex and rapidly changing healthcare environment 
where VA is experiencing a steep increase in demand for care, it is 
essential for VA to work with providers in communities across the 
country to meet veterans' needs. To be effective, these relationships 
must be principle-based, streamlined, and easy to navigate for 
veterans, community providers, and VA employees.
                       caregiver support program
    VHA recognizes the crucial role that family caregivers play. These 
individuals are central to our mission in caring for those who have 
``borne the battle.'' They are partners in helping veterans as they 
recover from injury and illness, in supporting veterans in their daily 
lives in their communities, and in helping veterans remain at home. VHA 
is dedicated to providing caregivers with the support and services they 
need.
    The fiscal year 2017 budget requests $725 million for the National 
Caregivers Support Program to support nearly 36,600 Caregivers, an 
increase of $102 million (16.4 percent) from fiscal year 2016, of which 
$629 million in 2017 will be for the monthly stipends paid to 
designated primary family caregivers under VA's Program of 
Comprehensive Assistance for Family Caregivers, an increase of $140 
million (29 percent) from fiscal year 2016. The increases to the 
stipend obligations are due to an increase in the number of caregivers 
approved to participate in the Program of Comprehensive Assistance as 
well as the increases in the underlying hourly wages used to calculate 
the monthly stipend rates.
    In addition to the Program of Comprehensive Assistance for Family 
Caregivers, VA offers a variety of services and resources through the 
General Caregiver Support Program, including: local Caregiver Support 
Coordinators, the National Caregiver Support Line staffed by licensed 
social workers, the VA Web site dedicated to family caregivers, as well 
as the Peer Support Mentoring Program. Additionally, VA offers a 
variety of training and provides many educational opportunities for 
caregivers of veterans. VA is dedicated to promoting the health and 
well-being of caregivers who care for our Nation's veterans, through 
education, resources, support, and services.
                      ending veterans homelessness
    Ending and preventing veteran homelessness is now becoming a 
reality in many communities. Between 2010 and 2015, overall veteran 
homelessness dropped by 36 percent, as measured by the yearly Point-in-
Time count, and we have achieved a nearly 50-percent decrease in 
unsheltered veteran homelessness. Through unprecedented partnerships 
with Federal and local partners, we have greatly increased access to 
permanent housing, a full range of healthcare including primary care, 
specialty care, and mental healthcare; employment; and benefits for 
homeless and at risk for homeless veterans and their families. As a 
result of these investments, in fiscal year 2015 alone, VA provided 
services to more than 365,000 homeless or at-risk veterans in VHA's 
homeless programs. Nearly 65,000 veterans obtained permanent housing 
through VHA Homeless Programs interventions, and more than 36,000 
veterans and their family members, including 6,555 children, were 
prevented from becoming homeless.
    In fiscal year 2017, VA will continue to focus on prevention and 
treatment services. The fiscal year 2017 budget request of $1.6 billion 
will support programs such as Grant and Per Diem, Veterans Justice 
Outreach, Supportive Services for Veteran Families and case management 
services for the Department of Housing and Urban Development-VA 
Supportive Housing program. All of these programs will continue to work 
towards achieving a systematic end to homelessness, meaning that there 
are no veterans sleeping on our streets and every veteran has access to 
permanent housing.
              advances in medical and prosthetic research
    For over 75 years, VA Research has produced innovative and cutting-
edge medical and prosthetic advances that are broad and significant. VA 
research is focused on the U.S. veteran population, and allows VA 
research to uniquely address scientific questions to improve veterans 
healthcare. Most VA researchers are also clinicians and healthcare 
providers who treat patients. Thus, VA research arises from the desire 
to heal rather than pure scientific curiosity, and yields remarkable 
returns.
    In 2017, Medical Research will be supported through a $663 million 
direct appropriation, and an additional $1.2 billion from VA's medical 
care program and other Federal and non-Federal grants. Total funding 
for Medical and Prosthetic Research will be over $1.9 billion in 2017.
    The 2017 budget submission emphasizes transformational elements 
emanating from VA research and incorporating the evolving science of 
Genomic Medicine--how genes affect health--to support Precision 
Medicine innovations. This budget directly supports the President's 
initiative to invest in Precision Medicine to drive personalized 
medical treatment.

[GRAPHIC(S) NOT AVAILABLE IN TIFF FORMAT]


    Beyond VA's support of over 2,200 ongoing research projects, VA 
will leverage our Million Veteran Program (MVP)--already one of the 
world's largest databases of genetic information--to support several 
Precision Medicine Initiatives. The first initiative will evaluate 
whether using a patient's genetic makeup to inform medication selection 
is effective in reducing complications and getting patients the most 
effective medication. This initiative will focus on up to 21,500 
veterans with PTSD, depression, pain, and/or substance abuse.
    The second initiative will focus on additional analysis of 
Deoxyribonucleic acid (DNA) specimens already collected in the Million 
Veteran Program. More than 438,000 veteran volunteers have contributed 
DNA samples so far. Genomic analysis on these DNA specimens allows 
researchers to extract critical genetic information from these 
specimens. There are several possible ``levels'' of genomic analyses, 
with increasing cost. Built into the design of MVP and currently funded 
within VA's research program is a process known as ``exome chip'' 
genotyping--the tip of the iceberg in genomic analysis. Exome chip 
genotyping provides useful information, but newer technologies promise 
significantly greater information for improving treatments.
    VA proposes conducting the next level of analysis, known as ``exome 
sequencing'' on up to 100,000 veterans who are enrolled in MVP. This 
exome sequencing analyzes the part of the genome that codes for 
proteins--the large, complex molecules that perform most critical 
functions in the body. Sequencing efforts will begin with a focus on 
veterans with PTSD and frequently co-occurring conditions, such as 
depression, pain, and substance abuse, and expand to other chronic 
illnesses such as diabetes and heart disease, among others. This more 
detailed genetic analysis will provide greater information on the 
biological factors that may cause or increase the risk for these 
illnesses.
                               conclusion
    In conclusion, VA is committed to providing the highest quality 
care, which our veterans have earned and deserve. I appreciate the hard 
work and dedication of VA employees, our partners from Veterans Service 
Organizations--that are our important advocates for veterans--our 
community stakeholders, and our dedicated VA volunteers. I respect the 
important role that Congress has in ensuring that veterans receive the 
quality healthcare and benefits that they rightfully deserve. I look 
forward to continuing our strong collaboration and partnership with 
this subcommittee, our other committees of jurisdiction, and the entire 
Congress, as we work together to continue to enhance the delivery of 
healthcare services to our Nation's veterans.
    Mr. Chairman, members of the subcommittee, this concludes my 
remarks. Thank you again for the opportunity to testify. My colleague 
and I will be happy to respond to any questions from you or other 
members of the subcommittee.

    Senator Kirk. Thank you. And, Mr. Pummill, after 30 years 
of service in the Army infantry, I will say--I want to say that 
you now should be addressed as Colonel Pummill.

                    Veterans Benefits Administration

STATEMENT OF DANNY G.I. PUMMILL (RET.), ACTING UNDER 
            SECRETARY FOR BENEFITS
ACCOMPANIED BY JAMIE MANKER, CHIEF FINANCIAL OFFICER

    Mr. Pummill. Thank you, Chairman Kirk. Chairman Kirk, 
Ranking Member Tester, and members of the subcommittee, thank 
you for the opportunity to present VBA's 2017 budget request. I 
am accompanied today by Jamie Manker, our Chief Financial 
Officer. I am going to pose all the real tough questions to 
him.
    Our 2017 budget request includes $2.8 billion in 
discretionary funds and $103.6 billion in mandatory funds, 
reflecting the ever-growing demand for VA benefits and 
services. The budget also requests a 2018 advanced 
appropriation of $103.9 billion for VBA's three mandatory 
appropriations, including compensation and pensions, 
readjustment benefits, and insurance indemnities.
    The demand for benefits and services for veterans of all 
eras continues to increase and will continue to increase 
decades after conflicts end. For the past 15 years, the 
percentage of the veteran population receiving disability 
compensation has increased to 20 percent from 8.5 percent where 
it had remained steady for the past 40 years.
    The average disability rating has also increased. For 45 
years, the average disability rating degree of disability held 
steady at 30 percent, but since 2000 that has risen to 49 
percent. Despite these challenges, VBA has made major strides 
in increasing productivity and reducing the claims backlog.
    As a direct result of our transformation initiatives, we 
have reduced the pending disability claims inventory by 60 
percent and the claims backlog by 87 percent. In making this 
progress, we also ensured that quality was not compromised. We 
have increased claim-based accuracy from 83 percent to 90 
percent, and issue-based accuracy has improved to 96 percent. 
Veterans are waiting less time for decisions and benefits. The 
average time to decide a claim has improved by 90 days from 
fiscal year 2014, and the average age of a pending claim has 
improved by 188 days.
    VBA is also working to further improve services to veterans 
in alignment with the Secretary's MyVA vision to become the 
number one customer service agency in the Federal Government. 
We are focused on improving veterans' experiences in the 
compensation and examination process as one of the Secretary's 
MyVA breakthrough priorities to help veterans better the exam 
process as it relates to their claims and enhanced procedures 
for exam scheduling. We are working on another MyVA 
breakthrough initiative to simplify and streamline the appeals 
process so veterans can receive their final decision on an 
appeal within 365 days from filing.
    This budget supports this simplified appeals process which 
also requires Congress's continued support through legislative 
action. Our budget request includes funding for technology 
investments and other initiatives necessary to provide 
veterans, their families, and survivors with the benefits and 
services they earned and deserve. By moving to a paperless 
electronic claims processing system, VBA increased claim and 
medical issue productivity, which helped mitigate the effects 
of a 131-percent increase in workload between 2009 and 2015. 
The transformation from a paper intensive process to a full 
electronic processing system resulted in VA completing a record 
breaking 1.4 million disability compensation pension claims for 
veterans and their survivors.
    Our technological advancements will expand and enhance 
existing services, and will also focus on delivering key 
functionality that enables quicker, more accurate and 
integrated claims processing. As VBA continues to receive and 
complete more rating claims, the volume of appeals, non-rated 
claims, and fiduciary exams correspondingly increase. To 
address this, we are requesting an additional $29.1 million for 
300 personnel to process non-rating compensation and pension 
claims, as well as an additional $25 million to help meet 
veterans' expectations for more timely claim decisions.
    We appreciate the opportunity to discuss our budget request 
and look forward to working with you to identify and prioritize 
spending in the best interest of our veterans, their families, 
and survivors, and our Nation. I welcome any questions you and 
the subcommittee may have.
    [The statement follows:]
               Prepared Statement of Danny G. I. Pummill
    Chairman Kirk, Ranking Member Tester, and 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 2017 budget and 2018 advance 
appropriations requests for the Veterans Benefits Administration (VBA). 
I am accompanied today by Mr. Jamie Manker, VBA's Chief Financial 
Officer.
                     summary of 2017 budget request
    The President's 2017 budget for the Department of Veterans Affairs 
(VA) will allow VA to manage the comprehensive array of integrated 
benefits and services provided for our Nation's veterans, their 
families, and survivors, administered through our nationwide network of 
56 regional offices (ROs). The 2017 budget request includes $2.8 
billion in discretionary funds and $103.6 billion in mandatory funds 
for VBA. The budget also requests 2018 advance appropriations of $103.9 
billion for VBA's three mandatory appropriations: compensation and 
pensions, readjustment benefits, and insurance and indemnities. With 
the resources requested in the 2017 budget, VA will provide:

  --Disability compensation for 4.4 million veterans with service-
        connected disabilities;
  --Dependency and indemnity compensation for 405,000 veterans' 
        survivors;
  --Pension for 297,000 wartime veterans and almost 210,000 of their 
        survivors;
  --Vocational rehabilitation and employment benefits paid for nearly 
        141,000 disabled veterans;
  --Education and training assistance for nearly 1.1 million veterans 
        and family members;
  --Home loan assistance for over 2 million veterans and family members 
        with active VA loans;
  --Fiduciary activities providing estate protection services for 
        224,000 VA beneficiaries unable to manage their own funds; and
  --Life insurance programs for over 6 million veterans, 
        servicemembers, and their families.

    The President's 2017 budget request also includes funding for 
technology investments and other initiatives necessary to timely 
provide veterans, their families, and survivors with the benefits and 
services they earned and deserve.
                 rising demand for disability benefits
    As VBA becomes more productive through our implemented people, 
process, and technology initiatives, the demand for benefits and 
services from veterans of all eras continues to increase, exceeding our 
capacity to meet it. This increased demand is fueled by more than a 
decade of war, agent orange-related disability claims, a disjointed and 
redundant claim appeal process, demographic shifts, increased medical 
issues claimed, and other factors. In addition, VBA is providing 
services to an older veteran population with more chronic conditions.
    Veterans' benefit requirements continue to increase decades after 
conflicts end, which is a fundamental, long-term challenge for VA. Even 
though the Vietnam war ended 40 years ago, the number of Vietnam-era 
veterans receiving disability compensation has not yet peaked. We 
anticipate a similar trend for Gulf war-era veterans, of whom only 26 
percent have been awarded disability compensation. For the past 15 
years, the percentage of the veteran population receiving disability 
compensation increased to 20 percent from 8.5 percent where it had 
remained steady for over 40 years. Moreover, the total number of 
service-connected disabilities for veterans receiving disability 
compensation grew from 11.8 million in 2009 to 19.7 million in 2015, an 
increase of more than 67 percent in just 6 years. This dramatic growth, 
along with estimates based on historic trends, predicts an even greater 
increase in claims for more benefits as veterans' age and disabilities 
become more acute.

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    Along with the increase in the number of veterans receiving 
disability compensation, there has been a significant rise in the 
average degree of disability compensation granted to veterans. For 45 
years, from 1950 to 1995, the average degree of disability held steady 
at 30 percent. But, since 2000, the average degree of disability has 
risen to 49 percent. VBA's mandatory request for 2017 is $103.6 
billion, twice the amount spent in fiscal year 2009.

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                    claims processing transformation
    VBA underwent the largest transformation in its history by 
modernizing the delivery of VA benefits and services. To achieve VA's 
goal of processing all claims within 125 days with improved accuracy, 
VBA aggressively implemented its transformation plan--a set of actions 
targeted to reorganize and retain its people, streamlined its 
processes, and deployed technology--and, as of January 31, 2016, VBA 
has achieved the following results:

  --VBA is reducing the pending disability claims inventory.
    --Peak: 884,000 claims in July 2012.
    --Now: 352,554 claims--Improvement: 60 percent.
  --Rating accuracy has improved.
    --12-month claim-based accuracy increased from 83 percent in 2011 
            to 90 percent--Improvement: 6 percentage points.
    --12-month issue-based accuracy increased from 95 percent in fiscal 
            year 2013 to 96 percent--Improvement: 1 percentage point.
  --Veterans are waiting less time for decisions and benefits.
    --The average time to decide a veteran's disability claim was 
            reduced from 218 days in fiscal year 2014 to 128 days--
            Improvement: 90 days.
    --The average age of pending disability claims:
      -- Peak: 282 days in March 2013.
      -- Now: 94 days--Improvement: 188 days.
  --Despite the challenges of an increase in disability claims workload 
        as well as increased complexity of workload, VBA has made major 
        strides in increasing its productivity.
  --The number of claims pending over 125 days and considered part of 
        the claims backlog has decreased.
    --Peak: over 611,000 claims in March 2013.
    --As of January 31, 2016: 79,106 claims--Improvement: 87 percent.
              myva transformation--meeting veterans' needs
    In addition to improving the quality and timeliness of disability 
claim decisions through our transformative people, processes, and 
technology initiatives, VBA is working to further improve services to 
veterans in alignment with the Secretary's MyVA vision: to become the 
Number 1 customer-service agency in the Federal Government. We are 
putting the needs and interests of veterans and their families foremost 
in all that we do.
    VBA has realigned its ROs into 5 districts under the MyVA framework 
that simplifies internal coordination, facilitates partnering, enhances 
customer service, and allows veterans to more easily navigate VA. As 
the districts continue to mature, there is increased coordination and 
collaboration among VA entities, veterans, community partners, and 
stakeholders to transform our agency into a more customer-centric 
organization. VA has enabled 36 Community Veterans Engagement Boards, a 
national network designed to leverage all community assets, not just VA 
assets, to meet local veteran needs. VBA ROs actively participate and 
engage with communities and Veterans Service Organizations (VSO) to 
focus on identifying solutions for veterans in the local communities 
and to establish the foundation for a strong MyVA community.
    VA launched the Veterans Economic Communities Initiative (VECI) in 
May 2015 to complement the goals of MyVA and VA's Transition Assistance 
Program, promoting local collaboration, dialogue, and partnerships 
among organizations that serve transitioning servicemembers, veterans, 
and their families. Economic liaisons in each VECI community 
collaborate and partner with government leaders, businesses, policy 
experts, educational institutions, and nonprofit organizations to build 
an integrated network of support and resources and to maximize impact 
to improve outcomes for veterans and their families. We are expanding 
to 25 new VECI communities in early 2016, bringing the total to 50 U.S. 
metropolitan statistical areas.
    One of VA's MyVA 12 breakthrough priorities is focused on improving 
veterans' experiences in the compensation and pension examination 
process. We are working to help veterans better understand the exam 
process as it relates to their claims. We are enhancing procedures for 
examination scheduling to facilitate veterans' direct involvement and 
providing training to ensure VA employees understand how their role 
directly impacts veterans' experiences and perceptions of VA.
    We are also working collaboratively with our partners on the MyVA 
breakthrough priority to simplify the appeals process. Our goal is to 
provide veterans with a simple, fair, and streamlined appeals procedure 
in which they would receive a final appeals decision within 365 days 
from the filing of an appeal by fiscal year 2021. This goal would 
require Congress' continued support through legislative action and 
additional funding. The 2017 budget supports this simplified appeals 
process, which is explained in more detail later.
   transformation initiatives in the president's 2017 budget request
    The MyVA transformation will ensure that VA is a sound steward of 
taxpayers' dollars as a result of instituting operational efficiencies, 
cost savings, and service innovations to support this and future budget 
requests. Few realize that when it comes to the general operating 
expense of delivering over $100 billion in benefits to over 5.3 million 
veterans and survivors, VBA spends only 3 cents on the dollar. To boost 
efficiency and employee productivity, VBA moved to paperless claims 
processing from its historically manual, paper-intensive process. 
Modernizing to an electronic claims processing system helped VBA 
increase claim productivity per claims processor by 25 percent since 
2011 and medical issue productivity by 82 percent per claims processor 
since 2009. This significant productivity increase helped mitigate the 
effects of the 131-percent increase in workload between 2009 and 2015, 
when the number of medical issues rose from 2.7 million to 6.4 million. 
The President's 2017 budget will allow VBA to continue building on the 
success of these initiatives.
    Veterans Claims Intake Program (VCIP).--VBA shifted to electronic 
claims processing by converting paper files to eFolders through VCIP, 
which streamlined processes for receiving digital records and data into 
the Veterans Benefits Management System (VBMS) and other VBA systems. 
VCIP scans paper claims, converts them into digital format, and 
extracts important data for input into electronic folders. VBMS has 
also expanded document conversion services to include centralized mail 
processing. More than 1.9 billion images have been converted from 
paper, and over 99.8 percent of compensation claims are now being 
electronically processed in VBMS. In addition to supporting scanning 
operations and centralized mail processing, VBA's 2017 request of 
$142.9 million will sustain current operations, support future 
conversion efforts, and enable the disposition of paper materials.
    Centralized Mail Initiative (CMI).--CMI consolidates inbound paper 
mail from VA's ROs to a centralized intake site, expands VBA's 
capabilities for scanning and conversion of claims evidence, increases 
electronic claims processing capabilities; and assists in converting 
100 percent of received source materials to an electronic format. VBA 
has already deployed centralized inbound mail for all ROs. When coupled 
with VBA's contract examination vehicle, this will enable VBA to 
improve and enhance the speed and consistency for requesting VA 
examinations. The 2017 budget request of $26.7 million provides 
resources to sustain operations and expand this initiative to include 
in-bound and out-bound mail for all benefits through fiscal year 2020.
    Veterans Benefits Management System (VBMS).--VBMS is a Web-based, 
paperless claims process solution complemented by improved business 
processes. As the cornerstone of VBA's claims transformation strategy, 
VBMS serves as enabling technology to provide veterans and their 
dependents with timely, high-quality decisions. VBA's shift to 
electronic folders in VBMS addressed the inefficiencies of the paper 
folders and the problems of misplaced files and records. Through a Web-
based application, multiple, geographically separated users can view 
the electronic folders simultaneously, thereby minimizing the need for 
sequential processing and eliminating the delays of receipt of paper 
folders at ROs. VBMS also provides automation of processes, such as the 
receipt of evidence, movement of claims to the next stage, and updates 
to the claims status, which means more veterans are receiving faster 
decisions. As of January 31, 2016, VBA completed over 4.2 million 
rating decisions and processed over 2.4 million claims end-to-end in 
VBMS.
    Under the VBMS initiative, we will continue to reduce our reliance 
on legacy systems with planned improvements to the electronic folder, 
such as adding a unique identifier on VA correspondence. When veterans 
return information with the identifier, it will automatically upload 
the information in the veteran's electronic folder. Both this fiscal 
year and in fiscal year 2017, VBMS enhancements will focus on 
delivering key functionality that enables quicker, more accurate, and 
integrated claims processing while laying the foundation for future, 
veteran-centric enterprise business capabilities. These include the 
delivery of electronic service treatment records, establishing one 
authoritative source for veteran contact information, and collaborating 
with the Board of Veterans' Appeals (Board) to define the appeals 
functionality needed both at the ROs and as part of the broader appeals 
modernization efforts. The 2017 budget request for $37.4 million for 
VBA and $143 million for the Office of Information &Technology (OI&T) 
provides resources to sustain operations and expand future enhancements 
and initiatives.
    National Work Queue (NWQ).--In conjunction with VBMS, VBA is 
implementing a national workload strategy through NWQ, which will 
provide greater flexibility in management of workload and performance 
by enabling automated distribution of claims across VBA. NWQ 
prioritizes and distributes our claims inventory at a national level 
and further standardizes claims processing. NWQ will distribute claims 
electronically from a centralized queue based on RO capacity, so that 
veterans' claims will be automatically directed across all ROs to 
efficiently match claim demand with available expertise and processing 
capacity regardless of RO jurisdiction. Generally, the veteran's State 
of residence will continue to be the first filter for assigning claims, 
thereby increasing the likelihood that the RO in the veteran's State of 
residence will process the claim. Veterans are still able to receive 
assistance with their claims by visiting their RO for personal 
assistance at the public contact sites, going online through eBenefits, 
and utilizing VBA's National Call Centers. Veterans, congressional 
staff, and VSO representatives will continue to have access to claim 
status and information through current venues. The electronic inventory 
provides real-time updates, no matter where the claim is assigned for 
processing. The 2017 budget request of $3.3 million provides resources 
to fully implement the NWQ to all ROs and will expand this initiative 
to include electronically routing non-rating claims (claims that in 
most cases do not require a rating decision but directly impact 
benefits, such as survivors pension, burial claims, dependency claims, 
income adjustments, and drill pay adjustments).
    new agency priority goal to improve dependency claim processing
    As VA continues to improve timeliness of disability claim 
decisions, VA is now also focusing on the dependency claims that are 
the direct result of the dramatic increase in completed disability 
rating decisions and the growth in the number of veterans receiving 
compensation at the higher disability evaluation levels (30 percent and 
above). VA has established as one of its Agency Priority Goals (APGs) 
to reduce the overall inventory of dependency claims to 100,000 and 
improve the average days to complete (ADC) dependency claims to 125 
days by the end of fiscal year 2017. Our improvement efforts include 
expansion of rules-based processing, promotion of online dependency 
claim submission, and streamlining of policies and procedures. The new 
dependency claims APG represents a 56-percent improvement from the 
fiscal year 2015 baseline of 227,000 pending dependency claims, and a 
43-percent improvement from the fiscal year 2015 ADC baseline of 221 
days.
                        all vba benefit programs
    The transition from a paper-intensive process to a fully electronic 
processing system resulted in VA deciding a record-breaking 1.4 million 
disability compensation and pension claims for veterans and their 
survivors in fiscal year 2015. VBA's success in processing an 
unprecedented number of rating claims in recent fiscal years has also 
resulted in other unmet workload demands. With increases in rating 
claims receipts and completions, the volume of non-rating claims, 
fiduciary field examinations, and appeals increases correspondingly. To 
address this, VBA requests $2.8 billion for general operating expenses, 
an increase of $118.4 million (4.4 percent) over the 2016 enacted 
level. These resources will support 22,171 full-time equivalent (FTE) 
employees and includes an additional $29.1 million for 300 FTE to 
process non-rating compensation and pension claims. In 2015, VA 
completed nearly 37-percent more non-rating work than in 2013 and 15-
percent more than in 2014. These additional FTE are needed to reduce 
the non-rating claims inventory and provide veterans with more timely 
decisions on non-rating claims. To ensure that all aspects of the 
claims process are improved for veterans, VBA is also requesting an 
additional $25 million to help meet veterans' expectations for more 
timely claim decisions, for a total increase of $118.4 million over the 
2016 enacted level.
    This budget will allow VBA to administer compensation and pension 
benefits totaling $86 billion to over 5.3 million veterans and 
survivors. It will also enable VA to administer education benefits and 
vocational rehabilitation and employment benefits and services to over 
1.2 million participants; guarantee more than 429,000 new home loans; 
and provide life insurance coverage to 1 million veterans, 2.2 million 
servicemembers, and 2.8 million family members.
    Insurance.--VBA's insurance program maintains life insurance 
programs, giving financial security and peace of mind to 
servicemembers, veterans, and their families. In 2017, we anticipate 
that our insurance programs will provide $1.2 trillion of insurance 
coverage to 2.2 million servicemembers, 1 million veterans, and 2.8 
million spouses and children. The 2017 budget request for $35.4 
million, of which $879,000 is in the general operating expenses 
appropriation and $34.5 million is reimbursable by the Insurance funds, 
will support 345 FTE and provide servicemembers and their families with 
universally available life insurance, as well as traumatic injury 
protection insurance for servicemembers.
    Education.--VA's education programs provide education and training 
benefits to eligible servicemembers, veterans, and dependents. 
Education programs assist them in their readjustment to civilian life 
and also help the armed forces with recruitment and retention of 
members. In addition, these programs enhance our Nation's economic 
competitiveness by developing a more highly educated and productive 
workforce. Through the Post-9/11 GI Bill program, as of February 8, 
2016, we have issued approximately $60.4 billion in benefits payments 
to 1,546,035 individuals and their educational institutions since the 
program's inception in August 2009. With the successful automation of 
Post-9/11 GI Bill claims, we are currently issuing benefits to the 
majority of beneficiaries in an average of 7 days at 99-percent 
accuracy. The 2017 budget request is $212.4 million and 1,904 FTE to 
continue providing veterans, servicemembers, Reservists, and qualified 
family members with such educational resources.
    Vocational Rehabilitation and Employment (VR&E).--The VR&E program 
provides the services and assistance necessary to enable veterans with 
service-connected disabilities to become employable and obtain and 
maintain suitable employment, or, to the maximum extent feasible, 
achieve independence in daily living. VR&E services include career 
vocational counseling, job search assistance, and post-secondary 
training for service-disabled veterans. VBA seeks to enhance outreach 
and service delivery of education and vocational counseling services. 
Counselors from VR&E and Integrated Disability Evaluation System, as 
well as contract rehabilitation counselors will provide these 
counseling services through the VetSuccess on Campus programs at more 
than 94 schools.
    Our alignment with the MyVA initiatives and objectives include 
investments in the Veterans Employment Center (VEC), which provides 
transitioning servicemembers, veterans, and their families with a 
single authoritative Internet source that connects them with job 
opportunities, and provides tools to translate their military skills 
into plain language and build a profile that can be shared--in real 
time--with employers. Employers have made commitments to hire over a 
million individuals and over 2.2 million private- and public-sector 
jobs are listed on the VEC. In addition, our Transition GPS program 
helps separating servicemembers prepare for civilian life by providing 
benefits briefings and other transition activities. So far, VBA has 
provided over 45,000 benefits briefings, career technical training 
courses, and support for capstone events to over 550,000 attendees. 
(Because servicemembers and their family members can attend more than 
one briefing, this count does not represent unique servicemembers). As 
previously mentioned, VBA is involved in the MyVA Economic Opportunity 
Campaign, which involves the collaboration with public and private 
partners in communities across the country to help connect and amplify 
available resources and support for veterans and their families.
    The VR&E program request is $331.3 million and 1,594 FTE. This 
funding will help ensure that VA continues to build pathways to 
meaningful career opportunities for veterans by bringing them together 
with educators and employers across U.S. cities and communities and 
leveraging unique VA and interagency programs and resources to improve 
economic outcomes for veterans.
    Home Loan Guaranty.--Our request of $170 million and 907 FTE for 
the housing program is funded through appropriations to credit accounts 
and helps eligible veterans, active duty personnel, surviving spouses, 
and members of the Reserve components and National Guard to purchase, 
retain, and adapt homes in recognition of their service to the nation. 
The 2017 budget includes $34 million for the VA Loan Electronic 
Reporting Interface (VALERI) to manage over 2 million VA-guaranteed 
loans for veterans and their families. VA uses the VALERI tool to 
manage and monitor efforts taken by private-sector loan servicers and 
VA staff in providing timely and appropriate loss mitigation assistance 
to defaulted borrowers. In addition to supporting the payment of 
guaranty and acquisition claims, it connects VA with more than 320,000 
veteran borrowers and more than 225,000 mortgage servicer contacts. 
Without these resources, approximately 90,000 veterans and their 
families would be in jeopardy of losing their homes each year, 
potentially costing the Government an additional $2.8 billion per year.
                              legislation
    The 2017 President's budget also proposes legislative actions that 
are necessary to ensure that veterans receive timely and quality 
delivery of benefits. Designated as one of our MyVA breakthrough 
priorities, VA proposes to streamline and modernize the appeals 
process.
    The current VA appeals process is broken. The more than 80-year-old 
process was conceived in a time when medical treatment was far less 
frequent than it is today, so it is encumbered by antiquated laws that 
have evolved since World War I and steadily accumulated in layers.
    Under current law, the VA appeals framework is complex, 
ineffective, confusing, and understandably frustrating for veterans who 
wait much too long for final resolution of their appeal. The system has 
no defined endpoint, and multiple steps are set in statute. The system 
requires continuous evidence gathering and multiple re-adjudications of 
the very same or similar matter. A veteran, survivor, or other 
appellant can submit new evidence or make new arguments at any time, 
while VA's duty to assist requires continuous development and re-
adjudication. The VA appeals process is unlike other standard appeals 
processes across Federal and judicial systems.
    Fundamental legislative reform is essential to ensure that veterans 
receive timely and quality appeal decisions, and we must begin an open, 
honest dialogue about what it will take for us to provide veterans with 
the timely, fair, and streamlined appeals decisions they deserve. To 
put the needs, and interests of veterans and beneficiaries first--a 
goal on which we can all agree--the appeals process must be modernized.
    The 2017 budget proposes a Simplified Appeals process--legislation 
and resources (i.e., people, process, and technology) --that would 
provide veterans with a simple, fair, and streamlined appeals process 
in which they would receive a final decision on their appeal within 1 
year from filing the appeal by fiscal year 2021.
    Over the last 20 years, appeal rates have continued to hold steady 
at between 11 and 12 percent of completed claims. As VBA received and 
completed record-breaking numbers of disability rating claims, the 
number of appeals correspondingly increased. Between December 2012 and 
November 2015, the number of pending appeals rose by 34 percent. Under 
current law with no radical change in resources, the number of pending 
appeals is projected to soar by 397 percent--from 437,000 to 2.17 
million--between November 2015 and fiscal year 2027.
    Without legislative change or significant increases in staffing, VA 
will face a soaring appeals inventory, and veterans will wait even 
longer for a decision on their appeal. If Congress fails to enact VA's 
proposed legislation to simplify the appeals process, Congress would 
need to provide resources for VA to sustain more than double its 
appeals FTE, with approximately 5,100 appeals FTE onboard. The prospect 
of such a dramatic increase, while ignoring the need for structural 
reform, is not a good result for veterans or taxpayers.
    While the Simplified Appeals proposal would require FTE increases 
for the first several years to resolve the more than 440,000 currently 
pending appeals, by fiscal year 2022, VA would be able to reduce 
appeals FTE to a sustainment level of roughly 1,030 FTE (including 980 
FTE at the Board and 50 at VBA), a level sufficient to process all 
simplified appeals in 1 year. Notably, such a sustainment level is 
1,135 FTE less than the current 2016 budget requires, and is 4,070 FTE 
less Department-wide than would be required to address this workload 
with FTE resources alone.
    In 2015, the Board was still adjudicating an appeal that originated 
25 years ago, even though the appeal had previously been decided by VA 
more than 27 times. Under the Simplified Appeals process, most veterans 
would receive a final appeals decision within 1 year of filing an 
appeal. Additionally, rather than trying to navigate a multi-step 
process that is too complex and too difficult to understand, veterans 
would be afforded a transparent, single-step appeals process with only 
one entity responsible for processing the appeal. Essentially, under a 
Simplified Appeals process, as soon as a veteran files an appeal, the 
case would go straight to the Board where a Judge would review the same 
record considered by the initial decision-maker and issue a final 
decision within 1 year; the veteran would be informed quickly whether 
that initial decision was substantially correct, contained an error 
that must be corrected, or was simply wrong. There would be a limited 
exception allowing the Board to remand appeals to correct duty to 
notify and assist errors made on the part of the agency of original 
jurisdiction (AOJ) prior to issuance of the initial AOJ decision. If a 
veteran disagrees with any or all of the final appeals decision, the 
veteran always has the option of pursuing an appeal to the Court of 
Appeals for Veterans Claims or reopening the claim with new and 
material evidence.
    VA firmly believes that justice delayed is justice denied. The VA 
team is passionate about fixing the broken, antiquated appeals process; 
this is a MyVA breakthrough priority. We look forward to working with 
Congress, veterans, and other stakeholders to implement improvements to 
provide veterans with the timely and fair appeals decisions they 
deserve and we appreciate the collaboration and feedback received from 
our ongoing discussions with Veterans Service Organizations on 
modernizing the appeals process.
                                closing
    Thank you for the opportunity to appear before you today to provide 
additional information on VBA's 2017 budget request. We are committed 
to administering benefits effectively and efficiently as responsible 
stewards of the taxpayers' dollars, while continuing to strive to 
improve the delivery of benefits and comprehensive information and 
assistance to our veterans, their families, and survivors. We are 
grateful for your continuing support and appreciate your efforts to 
pass legislation enabling VA to provide veterans with the benefits they 
have earned and deserve.
    This concludes my remarks. I am happy to respond to any questions 
from you or other members of the subcommittee.

                          VETERAN CRISIS LINE

    Senator Kirk. Let me ask the first question here. Over the 
weekend I met with the family of Illinois Army Specialist, Tom 
Young, who has served two tours in Iraq with the 10th Mountain 
Division. This 30-year-old father of Vivian and Maggie called 
your suicide hotline looking for help, but was sent to 
voicemail. Afterwards, he laid down on the metro tracks near 
the Prospect Heights train station and was killed by an 
oncoming train. The next morning, Tom's family answered the 
call from the Veterans Crisis Line calling him back telling him 
that there were beds available.
    Three weeks ago, the VA inspector general released a report 
on the suicide hotline calls being sent to voicemail or 
answered by staff who are not properly trained. Just last week, 
Deputy Secretary Sloan Gibson said that the report was based on 
old data and that VA had taken steps months ago. Question for 
you. If the changes occurred months ago, how could Tom Young 
have been sent to voicemail just 7 months ago?
    Dr. Shulkin. First of all, this is a terrible tragedy that 
happened to Tom Young, and should never happen, and is totally 
unacceptable. The inspector general report that was mentioned 
found that there was an episode of approximately a two-week 
period of time in 2014 where calls went to voicemail was also 
unacceptable. This actually happened with a contractor. This 
was not the VA staff at the service line when----
    Senator Kirk. David, let me follow up.
    Dr. Shulkin. Yes.
    Senator Kirk. Who is responsible for the Veterans Crisis 
Line under you? I would just like a name.
    Dr. Shulkin. Yes. His name is Matt Eitutis.
    Senator Kirk. Matt Eitutis.
    Dr. Shulkin. E-I-T-U-T-I-S. That is a recent change that we 
put in place. After the inspector general report came out, we 
made a management change. We put this under professional 
business practices, and we are doing everything that we can. 
And steps have been taking place over the last year to update 
the technology, the staffing, the physical location. And our 
goal, it is one of our priorities in the Secretary's MyVA 
initiative, is to make sure that these calls are answered by VA 
staff, and that they do not roll over to secondary contractors.
    Senator Kirk. When you say there was a contractor involved, 
who was the contractor involved?
    Dr. Shulkin. It is--Senator Kirk, I will get you the 
specific name. It is--we use an acronym, something--I do not 
want to say the wrong name. I would probably get another 
company in trouble that have nothing to do with this, but----
    Senator Kirk. But, David----
    Dr. Shulkin. Yes.
    Senator Kirk [continuing]. My staff has been trying for 
weeks to find out who was the person responsible for the 
Veterans Crisis Line. It is almost impossible to find out.
    Dr. Shulkin. Oh, yes. You know, I know that your office had 
a name, that that person has now subsequently left. If you tell 
the time period you are looking for, Senator, we can get you a 
specific name.
    Senator Kirk. The time period that I am most interested 
in----
    Dr. Shulkin. Yes.
    Senator Kirk [continuing]. Is when my constituent called 
the crisis line. You know, for a veteran to admit that there is 
a big enough problem that he is contemplating a suicide, that 
is a huge decision to get on the phone with the Veterans Crisis 
Line.
    Dr. Shulkin. Absolutely.
    Senator Kirk. And we are dealing with a very fragile 
person. In the case of Tom Young, he just walked in front of 
the train and got killed.
    Dr. Shulkin. This is--as I said, there is no excuse for 
this. The Veterans Crisis Line saves lives every day. They 
actually have referred 11,000 veterans to emergency services, 
dispatched ambulances, saved lives every day. These are some of 
the hardest working staff in the VA. This is a tough, tough 
job. They do miraculous things.
    But the phone calls have to be answered. That is why we 
have put new management in place. We are not going to accept 
even a call--there is no voicemail today, I can assure you 
that. That is unacceptable. That was done by a contractor.
    Senator Kirk. Great.
    Dr. Shulkin. But absolutely, we will get you that name, but 
we are working extremely hard. This will not happen again, but 
these people are being supported the way that they need to 
answer those calls.

    [The information follows: the requested information was not 
available at the time this publication went to print.]

    Senator Kirk. One of the acting directors of mental health 
operations in 2014, at the time of the Office of Inspector 
General investigation, was Ira Katz. Was he the same Ira Katz 
who, according to CBS News, in 2008 covered up the veterans 
suicide rates leading both Senators Akaka and Murray to call 
for his resignation?
    Dr. Shulkin. Senator, Dr. Katz is a psychiatrist who works 
out of our Philadelphia area.
    Senator Kirk. So you had two United States Senators at the 
time of the congressional majority calling for his resignation, 
and he is still on the job.
    Dr. Shulkin. Dr. Katz is actively on the job. I am actually 
not aware of what the specific issues were with the Senators. 
So, again, since I am not aware of exactly what those 
allegations are----
    Senator Kirk. If the Choice Act gave you the authority 
using the Secretary's authority to fire employees, could you 
consider getting rid of Ira Katz when Senators Akaka and Murray 
have already called for him to resign?
    Dr. Shulkin. Well, I will commit to you today that I will 
go back and look into those issues. But any time there is an 
allegation, it is our responsibility to make sure that we look 
into it, that we have an objective evaluation, but we do make 
our disciplinary decisions based upon that.
    I happen to have known Dr. Katz for about 25 years. He is a 
well-respected psychiatrist. But I absolutely will go back and 
make sure that we look into that and provide follow up.

    [The information follows: the requested information was not 
available at the time this publication went to print.]

    Senator Kirk. Thank you.
    Mr. Tester.
    Senator Tester. Go with Tom.
    Senator Kirk. Mr. Udall.

                             ACCESS TO CARE

    Senator Udall. Thank you. Thank you very much, Mr. 
Chairman. And, Dr. Shulkin and Mr. Pummill, thank you for 
taking the time to speak here and be with us today. Almost more 
than any other issue that we work on here in Congress, helping 
veterans access benefits and healthcare is one of the most 
important services my office offers to veterans.
    But it is also one of the most frustrating. As I have said 
here before, the majority of veterans are satisfied with the 
care they receive from the VA when and if they can get it. And 
I would just underline that ``when and if they can get it.'' 
Most veterans I have spoken to believe that the care you 
provide is second to none, and this budget helps support that. 
This budget, however, also helps to ensure that the VA's care 
remains in place for the future and that improvements are made 
where care is lacking.

                      OPEN AIR BURN PITS REGISTRY

    Dr. Shulkin, I am glad to see that the VA's budget 
justification specifically supports research into exposure to 
airborne particulate matter from burn pits. The Open Air Burn 
Pit Registry is the result of a bill I authored. National 
Guardsman Master Sergeant Jessey Baca, and his wife, Maria, of 
Albuquerque were the driving force behind this effort. Jessey 
has battled cancer, bronchiolitis, PTSD, and numerous other 
ailments believed to be connected to his contact with toxic 
burn pit fumes while deployed in Iraq.
    In last year's omnibus, I secured a provision requiring the 
VA and the Department of Defense (DOD) to share information 
about when and how servicemembers may have been exposed to 
airborne hazards and open burn pits. Does the new research 
called for in the fiscal year 2017 request include data from 
DOD and the Open Air Burn Pits Registry?
    Dr. Shulkin. Well, first of all, thank you. Thank you for 
that bill. I think that that is very, very important for us to 
fulfill our mission to the veterans who served in Iraq and 
Afghanistan. As you know, we have 45,000 veterans who have 
registered into your registry. And we are working with DOD to 
do interagency cooperation exactly as you have suggested to be 
able to study this.
    Our research will be active this year. As you know, we 
worked with the Institute on Medicine, the National Academy of 
Sciences in the past to look at this issue. Some of those 
questions actually that were asked about the exposure and the 
risk hazard, there was not enough evidence. So we do need to 
continue that research, and that is something that we are 
committed to making progress on in our current fiscal year.
    The registry helps us considerably in being able to track 
these long-term outcomes of the veterans. So thank you, and, 
yes, we are committed to following up on that.

                            APPEALS BACKLOG

    Senator Udall. Great. Thank you very much. And, Mr. 
Pummill, I am happy to see that the Albuquerque VA has made 
significant progress, the percentage of backlog claims from 
around 60 percent in 2013 to 20 percent just last month. 
However, more veterans are unhappy with the decisions on their 
claims, which has led to more appeals. What can be done to make 
sure the appeals process does not fall victim to the same 
backlog that we saw in initial claims while also guaranteeing 
appeals receive the due process they deserve?
    Mr. Pummill. Senator, that is an excellent question. 
Appeals is the number one concern for VBA right now. The 
Secretary has directed us to get with our constituents and 
figure out how to resolve the current appeals process. We are 
meeting next with the VSOs, the veterans service organizations, 
the State and county veterans service organizations. We are 
basically locking everybody in a room for 3 days, and the 
Secretary told us you do not leave the room until you come up 
with something that you can present to the Congress to change 
the way that we are doing appeals right now.
    The appeals process is tied up in laws. It is one of the 
most complicated processes that exist in the Federal 
Government. We are going to need some kind of legislative 
change. What we need to present to you is something that we, 
the VSOs, and the veterans all agree that is the right thing to 
do so that we can offer that legislative change.
    Senator Udall. Thank you for that answer. And I have a 
couple of other questions--I am near the end of my time here--
on reform of the Comp and Pen exam, and also rural telehealth, 
which I think is very, very important to our vets. And I see 
that you are trying to increase investments in that area and 
get additional telehealth out into rural areas. So I will 
submit those for the record and yield back, Mr. Chairman. Thank 
you.
    Senator Kirk. Mr. Tester.

                MONTANA'S CHOICE PROGRAM WITH HEALTH NET

    Senator Tester. Thank you, Mr. Chairman. Dr. Shulkin, in my 
opening remarks, I talked about the problems veterans are 
having in Montana. Could I get your personal assurance that you 
will directly engage in the efforts to address the frustrations 
with veterans in my State with the Choice Program, specifically 
with Health Net?
    Dr. Shulkin. Yes, Senator. In fact, we have committed to 
having a team out to Montana. That is going to be the week of 
March 28th where Dr. Yehia and his team will personally be 
there to meet with Health Net and with your staff, as well as 
the staff at VA to work this out.

         IMPROVING VETERANS ACCESS TO CARE IN THE COMMUNITY ACT

    Senator Tester. Good. I want to follow up with you, but we 
can do that offline as we move forward.
    So, while pushing to make changes, I also fully recognize 
that Congress needs to do what we need to do to allow you to do 
your job. Today with a number of my colleagues, including 
Senator Udall and Blumenthal, I am introducing legislation 
called the Improving Veterans Access to Care in the Community 
Act. This bill includes a number of provisions, many drafted in 
consultation with the VA and other stakeholders, that will 
greatly empower your efforts to deliver more timely and quality 
care for our veterans.
    By including provider agreement language sought by the VA, 
this legislation would ensure that you are able to provide care 
in the community for veterans in a timely manner. Would you 
agree with that?
    Dr. Shulkin. Absolutely would agree with that.
    Senator Tester. Okay. The VA has previously said that a 
failure to address this issue would have enormous negative 
impacts on veterans' access to healthcare. A huge issue.
    Dr. Shulkin. We are seeing this every day, Senator.
    Senator Tester. So you would agree with that statement, 
too.
    Dr. Shulkin. I would.
    Senator Tester. Okay. By providing funding--spending--I am 
sorry. By providing spending flexibility across community care 
programs, this legislation would provide the VA with the 
ability it needs in places like Montana and other areas, by the 
way, to steer veterans to care in the manner that makes the 
most sense for that veteran. Would you agree it would do that?
    Dr. Shulkin. It absolutely will. It will help simplify the 
program for veterans, no question about it.
    Senator Tester. Okay. And by consolidating the VA's 
multiple community care programs, and there are many, into one 
single program with consistent and streamlined eligibility 
criteria and administrative rules, that that would reduce the 
confusion for veterans and VA employees alike. Is that correct?
    Dr. Shulkin. Yes, seven programs at least into one would be 
very helpful.
    Senator Tester. Okay, and streamlined.
    Dr. Shulkin. Streamlined.
    Senator Tester. Smooth.
    Dr. Shulkin. Exactly.
    Senator Tester. No red tape, or minimal. Let us put it that 
way.
    Dr. Shulkin. Yeah.
    Senator Tester. And it would greatly reduce administrative 
burdens for the community providers, too, then.
    Dr. Shulkin. Provider agreements and the streamlined 
funding would make it easier for community providers by a huge 
amount, Senator.
    Senator Tester. So you would anticipate that it would make 
it--this Choice Program better for the providers and, thus, 
entice them to come on board.
    Dr. Shulkin. And I would hope your largest provider in 
Montana would consider coming back.
    Senator Tester. Well, so do I. Together all of these things 
would assure that the VA is better able to utilize the tools at 
its disposal to better meet the healthcare needs of veterans. 
You would agree on that also.
    Dr. Shulkin. I would.
    Senator Tester. Okay. So we are going to be working with 
Chairman Isakson and others hopefully in this room so that we 
could get this to the President as quickly as possible.

                           VBA BUDGET REQUEST

    I got about a minute and a half in this round. Mr. Pummill, 
how does this budget ensure that the VBA is able to fulfill its 
mission 1 year down the road, 5 years down the road, even 10 
years down the road?
    Mr. Pummill. We are going to have to take the budget that 
you have provided to us, which I believe is an appropriate 
budget, and with the proper training of the people that we have 
on board, and with automation, take care of the needs of the 
veterans into the future. We know just from past history that 
20, 30, 40 years after a conflict, as veterans age we get a 
large number of veterans coming in for increased benefits and 
services.
    We have to be prepared for the Iraq and Afghanistan 
veterans that come in requesting those services in the future. 
We just need to capitalize on our automation systems and our 
training to make sure we are ready for them when they come.

                  MILITARY SEXUAL TRAUMA ADJUDICATION

    Senator Tester. Could you speak specifically to the 
progress that is being made, if any, and I hope there is being 
progress made on this, by the way, to more properly adjudicate 
claims involving military sexual trauma?
    Mr. Pummill. Yes, we have made massive and substantial 
changes in how we do military sexual trauma (MST). We have 
actually trained people--there is at least one person in each 
RO that specializes in that now so that they understand that it 
is something that is not always right out front in somebody's 
military records, that you have to dig and you have to find the 
markers that support that.
    Senator Tester. Okay. To test this a little more, do you 
believe that the standards for adjudicating PTSD claims from 
combat trauma should be the same standards used to adjudicate 
PTSD from claims from MST?
    Mr. Pummill. I believe that PTSD is PTSD. It should be the 
same.

                FULLY DEVELOPED CLAIMS EXPEDITED PROCESS

    Senator Tester. Okay, thank you. Earlier this year I 
introduced legislation with Senator Sullivan and some others 
that would provide veterans with the option of filing a fully 
developed appeal that would be adjudicated through an expedited 
process. Do you support that? Do you think it is a step in the 
right direction?
    Mr. Pummill. I think it is a step in the right direction. 
That is one of the things that we are going to be pushing at 
our meeting next week.
    Senator Tester. Do you think other changes need to be made?
    Mr. Pummill. Yes, I do.
    Senator Tester. What are they?

                        SIMPLIFY APPEALS PROCESS

    Mr. Pummill. We have to simplify the appeal process so that 
there are not so many bites at the apple. The best example is a 
veteran who has been appealing for 25 years and has added 27 
different variances to his claim as he goes through. That ties 
up the whole system. It is just a waste of everybody's time.
    Senator Tester. Do you have any statistics on claims that 
are put forth that are bogus?
    Mr. Pummill. Not off the top of my head. I do not know. We 
would have to get back to you on that. Frankly it is my 
experience, it is not very high. The vast majority of veterans 
are honest and forthright. They are just frustrated about how 
long things take. I do not see very much fraud, to be honest 
with you.
    Senator Tester. Okay. I will wait for the second round. 
Thank you, Mr. Chairman.
    Senator Kirk. Mr. Schatz.

                      TELEHEALTH AND TELEMEDICINE

    Senator Schatz. Thank you, Mr. Chairman. Dr. Shulkin, I 
wanted to talk to you about telemedicine and telehealth. I know 
VA has done leading-edge work in this space. I want to--I want 
to ask you two questions. First of all, generally speaking, 
where do you see the future opportunities in telehealth and 
telemedicine in terms of serving veterans?
    Dr. Shulkin. Very briefly, Senator, VA is actually the 
largest provider of telehealth services, 2.1 million visits 
last year, but we need to be doing much more. We need to be 
going to mobile devices because that is where people are 
carrying their information. And we need to be using telehealth 
as a way to keep veterans at home and out of institutions, and 
having to have them travel several hundred miles to reach 
facilities. They should be able to get the care where they are.
    Senator Schatz. So we have a different problem on the 
Department of Health and Human Services (HHS) side. They lack 
some of the statutory authorities that you have. But I have a 
concern in terms of funding requests because it seems to me 
that you--and this is great. You expect the number of veterans 
receiving telehealth services to increase by 12.6 percent 
through 2017, but you have asked for a roughly 5 percent 
increase in funding. Now, that may be because this is a highly 
leveraged thing, but I want to--I want to understand that 
discrepancy.
    Dr. Shulkin. Yeah. VA, because of its early adoption of 
telehealth because, frankly, we have needed to do this, has 
invested hundreds of millions of dollars in infrastructure that 
can be leveraged, and we can add to its capabilities without 
dollar-for-dollar investments.
    Senator Schatz. How did you get to the 12.6-percent target?
    Dr. Shulkin. The 12.6-percent target was done out of our--
out of our projections, out of our enrollment projects, and 
targeting specific areas that we believe that we can expand. 
Quite frankly, I think that is conservative when you see what 
is happening in the healthcare industry. We are seeing much, 
much larger increases year to year. And so, I think that that 
will be a conservative estimate.
    Senator Schatz. How much of the challenge is introducing 
patients to telemedicine, you know, at the front end? It seems 
to me that on the one hand for psychology, psychiatry, case 
management in terms of mental health services, there might be 
less--eventually less of a barrier to accessing services. But 
on the front end, it may just seem odd for people to utilize a 
device to get the services they need. So how are you dealing 
with that sort of getting the veteran through the threshold?
    Dr. Shulkin. Well, you know, as you know, I have spent my 
career in the private sector, so coming into VA months ago this 
was one of the surprises, how many different specialties VA is 
using telehealth in. It is doing teledermatology, 
telepathology, teleradiology, telehepatology. I mean, all sorts 
of things.
    And we have studied the acceptance use of veterans, and it 
is sky high. It is in the 90s, and we are publishing on this 
now. So the acceptance really has been extraordinary because it 
saves a veteran from sometimes having to travel hundreds of 
miles, and they are getting the care that they need.
    Senator Schatz. Absolutely, and thank you for your good 
work in this area. You can count on me to try to support this 
as much possible. And if you can keep talking to HHS, we would 
really appreciate it as well.
    Dr. Shulkin. Sure, absolutely.

            ELECTRONIC HEALTH RECORD AND GAO HIGH RISK LIST

    Senator Schatz. I want to talk to you about the electronic 
health records. I was told that the initial read-only version 
of the system would be available by the end--would be available 
on some sites in 2015 with full deployment by 2018. But last 
fall, GAO testified that you are not on track. DOD is not on 
track. And so, my question is, what is the new timeframe, and 
when do you anticipate being taken off the GAO's high-risk 
list?
    Dr. Shulkin. Okay. I think there are a couple of questions 
there. I think your question about the electronic medical 
record is about interoperability with the Department of 
Defense?
    Senator Schatz. Yes.
    Dr. Shulkin. We currently have a joint viewer up and 
operational. In fact, 35,000 VA providers are actively using 
this today. So if you come into a VA, we are able to access 
through what we call the joint viewer DOD records. So we are 
currently operational, and would be glad to demonstrate that 
for you if you are open to that, how that is working.
    The GAO high-risk list, we were put on that list by GAO not 
specifically because of the electronic medical record, but many 
other issues. We, again, are meeting with GAO on a regular 
basis and actively working that list down to close all the 
recommendations. And you do not come off the GAO list very 
quickly. You really have to demonstrate that you have addressed 
these commitments. And so, we are working towards that. We hope 
that we are making good enough progress to be able to give an 
indication of where are towards the end of the year.
    Senator Schatz. Thank you.
    Senator Kirk. Mr. Boozman.
    Senator Boozman. Thank you, Mr. Chairman, Ranking Member. 
Thank you all very much for being here. We appreciate your hard 
work.

                     STANDARD PRODUCTIVITY MEASURES

    Dr. Shulkin, I know that one of the things I have been 
pleased with that you all really are trying to do a good job 
regarding metrics, measuring things. In regard to being able to 
determine the cost associated with providing care versus buying 
care in the community, I know your IT infrastructure is maybe 
not quite as good as you would like for it to be. Can you talk 
a little bit about that and how you are trying to determine 
that, again, in a difficult environment?
    Dr. Shulkin. Right. Thank you, Senator. We are very data 
rich at the VA. It is one of our strengths, why we have been 
able to drive improvements particularly on the clinical side. 
And wherever we can, we are trying now to use metrics that we 
can compare to the private sector because I think that is 
appropriate. In fact, we have too many metrics, so we are 
trying to pare it down to what is most important.
    The area that we struggle the most with are financial 
comparisons because what we do in the VA does not directly 
compare always--sometimes it does, but does not always directly 
compare to the private sector. So we have begun to measure 
relative value units (RVUs), so we know--which is standard 
productivity measure both in the private sector and the VA, so 
we can tell you VA actually increased its RVU, its productivity 
measures, 10 percent last year.
    The direct financial comparisons are a challenge, so what 
we are beginning to do is to ask specific questions. What would 
it do for an eye exam in the VA healthcare system versus 
outside? And so, we are going to be making specific choices 
about what is better for veterans, what is better for taxpayers 
as part of the new Veterans Choice Plan to bring those 
financial considerations in place.
    And let me just ask whether our Chief Financial Officer has 
a better or more specific answer about these comparisons.
    Mr. Yow. One of the challenges we have had is we do a lot 
of things in the VA that are not comparably done in the private 
sector, things like homeless programs, things like the fact 
that we have a richer mental health benefit, things like if we 
have a richer long-term care benefit program than in the 
private sector insurance would have.
    So when we get asked questions like cost per RVU, it really 
becomes an apples and oranges comparison unless we try and 
drill down and get that further. And our systems are so old 
right now, it is very difficult for us to go through to get 
that granularity to do that. It is not for lack of wanting that 
we have not been able to do it thus far.

                  HEALTHCARE FACILITIES BUDGET REQUEST

    Senator Boozman. Very good. Not in follow up, but another 
question to our chief financial officer, the VA budget requests 
$836 million for the activation of new and enhanced healthcare 
facilities. What are the VA's priorities for the upgrades? How 
much of this funding will be used for new facilities versus 
enhancements? And has the VA determined where the projects will 
be located?
    Mr. Yow. Yes, sir, we have a list that we provided the 
staff, and we can provide that to you again, the specific 
projects locations. They are all from what we call major 
construction or major lease projects, so they are essentially 
new facilities more so than renovations or replacement leases. 
That is where we fund activations from.
    It primarily does two things. It does what we call non-
recurring cost, initial outfitting, if you will, of a new 
facility, things like equipment, supplies, and so forth, to get 
it ready to open its doors. And then recurring costs for about 
a 2- to 3-year period as they prepare to open their doors and 
make their way into the healthcare projection model and get 
funding for them into the future.
    So, for example, if it is a recurring lease and there is no 
new staff, they would not need as much recurring funding. But 
if it is expanding or a brand new facility, we would have to 
hire new staff as well. So it varies a great deal by project.
    Senator Boozman. And the average age of our infrastructure 
is what, 50?
    Dr. Shulkin. We have about 60 percent of our facilities are 
50 years old or older.
    Senator Boozman. Very much. Thank you, Mr. Chairman. Thank 
you. Thank you, guys.
    Senator Kirk. Mr. Murphy.
    Senator Murphy. Thank you very much, Mr. Chairman. Thank 
you all for your fantastic work.

                   OTHER THAN DISHONORABLE DISCHARGE

    You are probably aware of reports that the U.S. Army has 
forcibly separated over 22,000 soldiers for misconduct after 
they return from deployment in Iraq and Afghanistan that were 
also diagnosed with mental health problems or traumatic brain 
injury (TBI). As a result of this disclosure, the Army 
inspector general and the surgeon general are going back and 
doing a review of those 22,000 cases and apparently are going 
to make recommendations as to some of them and some 
recommendations going forward.
    But as I understand it, the VA looks at the character of 
discharge to determine whether a person meets the basic 
eligibility requirements, and you determine whether the 
incidents that led to the discharge are found to be under 
conditions other than dishonorable. So you have essentially a 
chance to look at those conditions of discharge and make a 
determination as to whether they would be able to be able for 
benefits.
    So I do not know whether this is a question for you, Dr. 
Shulkin, or for you, Mr. Pummill, but to ask a question about 
what has the VA done in the wake of this disclosure, and 
pending this review that is happening in the Army, what can you 
do to perhaps remedy some of those 22,000 who should have not 
been given a discharge under non-medical terms?
    Mr. Pummill. Yes, Senator. First of all, it is a serious 
concern for the VA. We know that most of these men and women 
are going to end up homeless, that they already have one foot 
in a bad place, and this does not help. Some of the things that 
we--first of all, we cannot change the character of discharge. 
Only the military service can do that. We do contact the 
veterans. We advise them how to get to the Army Board for 
Correction of Military Records or the equivalent in the other 
services so they can request a change in their discharge and 
upgrading their discharge.
    We have worked with the services. The services have sent 
out letters to veterans saying, hey, if you feel that your 
discharge may have been improper because of something that 
happened to you in combat or deployment, please come back, file 
your paperwork. They are not getting a very high response rate, 
so we sent letters out underneath the Under Secretary of 
Benefits' signature to those same veterans to see if maybe a 
letter from the VA saying, hey, go back to your military 
department, if we could help it out.
    Senator Murphy. But let me just clarify.
    Mr. Pummill. Certainly.
    Senator Murphy. My understanding is that you have the 
ability to review the circumstances of the discharge. If there 
is a discharge for misconduct, you are saying their only 
recourse is to go back to have the conditions of discharge 
changed.
    Dr. Shulkin. Senator, that is our understanding that this 
is a Department of Defense decision. This is not a VA decision. 
And we are prohibited by law from treating somebody in what we 
call bad paper, a dishonorable discharge.
    Senator Murphy. And that is your understanding as well?
    Mr. Pummill. It is my understanding that we cannot change 
the character of the discharge, Senator, yes.
    Senator Murphy. Okay.
    Dr. Shulkin. One of the things that VA is doing because 
they take this very seriously, and I know this is where you are 
coming from, too. It is one of the reasons why we have worked 
so hard to develop strategic partnerships with community groups 
because when we find these veterans and they show up at VA, we 
are working with community groups to actually help in the 
treatment of these patients.
    Senator Murphy. Mr. Chairman, I just want to underscore 
this, and Senator Tester has been a great leader on this. There 
are 22,000 veterans out there today just since 2009----
    Senator Kirk. Yes.
    Senator Murphy [continuing]. Who have been discharged for 
misconduct, who prior to that discharge had a diagnosis of TBI 
or PTSD. There is an ongoing investigation as to the 
circumstances of those discharges. We as a subcommittee have to 
grapple with the fact that you have--it is not just what we 
know about it, right? Twenty-thousand brave men and women who 
were potentially wrongfully discharged for misconduct who 
cannot access VA services who are going to be out on the 
streets. So I would love to follow up with you----
    Mr. Pummill. Yes.
    Senator Murphy [continuing]. On this topic to think about 
ways in which--while this review is happening. I have asked for 
a moratorium on discharges for misconduct with respect to 
individuals who have been diagnosed with PTSD or TBI during 
this period of review. The Army has not looked favorably upon 
that request, so the numbers are just going to continue to 
mount.
    I have another question, but I will put it in for the 
record.

        CONNECTICUT CAMPAIGN TO END CHRONIC VETERAN HOMELESSNESS

    Senator Murphy. I just want to thank you for your work with 
Connecticut on our campaign to end chronic veteran 
homelessness.
    Dr. Shulkin. Congratulations.
    Senator Murphy. We are the first big State in the Nation to 
do that.
    Dr. Shulkin. Yes.
    Senator Murphy. And that is a consequence of a dramatic 
increase in HUD vouchers, which we desperately need to keep or 
we will slide back on that commitment. But it is also a 
consequence of your very successful integration of mental 
health services with physical help services that has allowed us 
to make those great gains. And I congratulate you on doing 
something in the VA that the private sector should be doing at 
a much greater rate.
    Dr. Shulkin. What we have learned, Senator, is this is all 
about working with the community, and the Connecticut 
leadership coming out of the Governor and your community groups 
have really--they deserve the credit for this. And we thank you 
for your support.
    Senator Murphy. Thank you very much, Mr. Chairman.
    Senator Kirk. Senator Cassidy.
    Senator Cassidy. Dr. Shulkin, you have got an impressive 
resume, man. I wish my resume looked like yours.
    Dr. Shulkin. I think you are doing all right.
    Senator Cassidy. My son does not think so, but that is a 
son, huh? We are both physicians, so as you know there is a 
collegiality. I will go around the country and visit with 
different--Murphy and I have this connection with mental 
health, so the mental health folks in the VA will come and 
approach me. I have learned, at least this is a little bit 
dated, but your administration is new, so I will ask you again 
to see if it has changed.

                MENTAL HEALTH NO-SHOW RATE APPOINTMENTS

    There is great variability in the systems used for mental 
health. I gather there might be a place in Kansas which is 
really working well, but you go elsewhere and the doc will, 
say, oh, yes, if they miss their appointment, they are 
scheduled 3 weeks later. The better system is to leave some 
slack at the end of the day, and to know that there are going 
to be a certain percent late, but that some of the folks will, 
you know, frankly be pleased that they are less busy.
    To what degree do you have the ability to look at no show 
rates, average time to rescheduling, average time for new 
appointment, et cetera, and compare them against one another? 
If you are able to do that, what is the current variability 
between different clinics?
    Dr. Shulkin. Excellent questions. We have a 20-percent-plus 
no-show rate in mental health appointments.
    Senator Cassidy. Now, is that standard or, no, here it is 
three, and there it is 60?
    Dr. Shulkin. There is a wide spectrum. And so, what you are 
describing is the situation that I found when I came in, which 
is that VA has tremendous variability in many of these clinical 
measures. And what healthcare systems that are accepting the 
challenge of being healthcare systems are doing now are 
decreasing that variability. They are identifying best 
practices and standard----
    Senator Cassidy. Totally get that. So that is what your 
expertise is.
    Dr. Shulkin. Absolutely.

                         BEST PRACTICES SYSTEM

    Senator Cassidy. To what degree can I go to a clinic now 
that formerly told me, oh, man, we got all kinds of no shows, 
and I cannot get anybody to change it, to, no, we actually have 
the system such as best practices?
    Dr. Shulkin. The first thing that we have done already is 
we have identified these best practices. We had a call for best 
practices in the last month where we identified 250 of the best 
practices in VA, many related to access. Today we have brought 
in those best practice leaders to share and map out their best 
practices. Tomorrow we are bringing in the industry leaders in 
how to do best practice implementation to advise VA.
    We are committing towards the end of the year to have these 
best practices in place. It is exactly what we need to do, and 
it relates to what the GAO found that put us on the high-risk 
list.
    Senator Cassidy. So I know that--again, you and I both know 
this--in healthcare systems, it is data, data, data. To what 
degree can you share with each of us as regards what the 
institutions in our State are doing at this moment in time, and 
then the trajectory of how they are improving over time.
    Dr. Shulkin. Be glad to do that. VA is actually very good 
at producing those metrics. We have clinical metrics, outcomes 
called the sail measurement system, which we can share with you 
and show improvement, or actually those that are not improving, 
and on access measures, lots of data that we can share and 
other process measures. And, in fact, we are targeting this. 
This is one of my five priorities to implement these best 
practices.

                     FRONT LINE DISCIPLINARY ACTION

    Senator Cassidy. Now, also related to all this, again, the 
kind of conversation someone will tell me, but will not do it 
under oath, that there is at the front desk perhaps someone who 
is abusive to that patient who comes in, the veteran who 
perhaps is different because he has a mental health issue, and 
very rude. We have focused a lot on high-ranking officials 
within the VA and the difficulty of replacing them. What this 
doc tells me, I cannot get rid of that clerk, that that 
actually has to go here and then there.
    I toured a VA and asked the director, and he goes, well, 
there is a report, and we counsel, and it comes back. What I 
really got a sense of is that it would take months, maybe even 
a year or two, in order to get rid of someone who is at the 
front desk. Again, not talking about the person padding their 
check by everything we have read about in the paper, but that 
person right there speaking to that vet who is having a hard 
time keeping it together, and, therefore, acts a little 
strangely.
    To what degree is that true, and to what degree do the 
union contracts kind of limit the ability to discipline, 
replace, make it better for the veteran? I will stop there.
    Dr. Shulkin. Well, one of the things when the Secretary 
came in, as you know he had us all sign and agree to the I Care 
Principles, of which respect and customer service is right 
there. When we find that people are not sharing our values, my 
expectation is, the Secretary's expectation, is that we are 
going to take actions to remove people who are not following 
the VA values.
    Then you get into due process, and we have due process, and 
we need to adhere to it, and it is longer than some of us want 
and more complex. But we are not going to let somebody be 
disrespectful to veterans and stay in those positions.
    Senator Cassidy. Now, let me say I have worked in a public 
hospital, and there are 95 percent great people struggling to 
make it work, and there is 5 percent that really--but that 5 
percent becomes the face of the organization, and at times that 
one person destroys it for that patient, if you will. Believe 
me, I have worked in a hospital in Louisiana. I know that.
    You spoke of due process. Let us assume that there is 
someone, as we have described, as I have been told of. I have 
learned to say what I have been told, not what I know, but that 
what I have been told of. How long would it take for that 
person to be dismissed?
    Dr. Shulkin. Our expectation is that if there is a behavior 
that is not consistent with our values, they would be removed 
from that position, the veteran patient position. And then we 
have to assign them to other work, hopefully not involving 
direct contact with veterans, and let the due process, you 
know, work its way through. But it would not be acceptable 
because of bureaucracy and red tape to allow a person who we 
know is not sharing our values to continue with a direct 
veteran-facing position.
    Senator Cassidy. So that person could be reassigned fairly 
quickly----
    Dr. Shulkin. Absolutely.
    Senator Cassidy [continuing]. As in a month or a week?
    Dr. Shulkin. Oh, no. I am talking about immediate. When 
somebody comes to us with a concern or allegation, it is 
investigated because, as you know, as you said, in a lot of 
these situations in my experience, you know, it is not always 
what you first hear the story.
    Senator Cassidy. I get that.
    Dr. Shulkin. So you have to get the facts. But if the facts 
confirm that this is a person who is not treating veterans the 
way that we believe they should be treated, then they should be 
removed from that position immediately, reassigned to something 
else while there is due process. There are certain violations 
that would be immediate termination, and we certainly do that 
as well.
    Senator Cassidy. There is an inspector general report about 
a fellow who actually killed a patient who is still on the job, 
so that is kind of what--just to say that is high profile. But 
just to say it seems as in in theory sometimes it takes a long 
time.
    Dr. Shulkin. I would like to get that specific situation 
from you and then follow up with you on that. That certainly is 
a circumstance that I would want to know about.
    Senator Cassidy. Okay. I yield back. Thank you.
    Senator Kirk. Mrs. Capito.
    Senator Capito. Thank you, Mr. Chairman, and thank all of 
you. I apologize for not being able to hear the entire hearing, 
but we have got several going on at the same time, as Senator 
Murray and I have seen each other a couple of times today. So I 
appreciate your--and so if I repeat a little bit, please excuse 
me.

               CHOICE PROGRAM THIRD PARTY ADMINISTRATORS

    I wanted to talk about the Choice Program. We just had some 
veterans in our office the other day. In one instance, the 
veteran had an appointment with a specialist, only to find when 
he called that office, the entire facility did not have that 
type of specialist. And it was the second call that that 
facility had had for that type of specialist. The same veteran 
had another instance where he had called Health Net Choice four 
times to have an appointment made and did not get satisfaction. 
We are hearing these stories all over the place.
    And I guess, what is being done from your perspective, and 
I am going to say are these the third-party administrators that 
are not filling the gaps? What are you all doing to hold the 
third-party administrators' feet to the fire here?
    Dr. Shulkin. Okay. I should start off by saying that the 
Choice Program is not working the way that any of us want it. 
So I am aware that you are probably not the only Senator who is 
getting a lot of these issues.
    We are continually meeting with the third-party 
administrators, and not only letting them know it is our 
expectation that they adhere to the contract. The contract says 
that a routine consult needs to be scheduled in 5 days. An 
urgent consult needs to be scheduled in 2 days. And when they 
are not able to do that, we need those authorizations returned 
to the VA so we can use our community relationships to help the 
veteran.
    We are not only working with them, but we are throughout 
the country now trying new models of delivering care, like 
embedding their staff alongside our staff to be able to try 
this. So we are doing this in Alaska and several other sites.
    But the program is just simply not working the way that we 
intended it to work, and we are going to stick at this until we 
can get this working better for veterans. So we would ask if 
you are hearing specific veterans having issues, please let us 
know with their names so we can help them.
    Senator Capito. Okay. That I will do, and I know that it 
just seems like there is a lot of confusion.
    Dr. Shulkin. Yes.
    Senator Capito. Best intentions aside, it is still, as you 
said. And I appreciate your candor there really.
    Dr. Shulkin. One of the things that you missed, Senator, is 
Senator Tester had mentioned that part of this we need your 
help on. And Senator Tester and Senator Blumenthal and Udall 
just submitted a bill that helps us consolidate community care, 
simplify this for the veterans, simplify it for the VA. And so, 
this is where we could use your help because have identified 
where the program needs to change and what we have learned over 
the past year. That would help us a great deal.

                    VETERANS TO AGRICULTURE PROJECT

    Senator Capito. Thank you. Thank you. One of the programs 
that I have been sort of interested, it is a small program, and 
it is growing--it is in West Virginia and growing in some other 
States. And it is the West Virginia Warriors and then Veterans 
to Agriculture Project. It seems to have met with quite some 
success with some of our younger veterans.
    So I do know, Mr. Pummill, I do not know who would take 
this question. What are you doing with--in terms of encouraging 
veterans to transition to agriculture? Is that part of an 
emphasis within the VA, and how is that going?
    Mr. Pummill. We have expanded what we encourage veterans to 
do when they leave military service greatly under the new 
transition program. It used to be, you know, pretty much your 
only option was use the GI bill and go to college. Now we are 
offering a GI bill, agriculture, entrepreneurship where they 
can learn how to start their own business, or technical 
training, technical schools, truck driving, things like that, 
realizing that one size does not fit all. And we are trying to 
find the thing that best suits that individual and lead them in 
the transition to that
    The best success we have had, like you just said, in West 
Virginia is working with the State and local agencies so that 
when we know where the individual, which State he or she is 
going back to, they have somebody to link up back there with 
what they need to do.

                   OPIOID DEPENDENCE AND ALTERNATIVES

    Senator Capito. Right. Good. And then lastly, Senator 
Baldwin and I have under her leadership worked on the Opioid 
Safety Act, which as a result for me was from a young man, 
Andrew White, who I believe died in his sleep, I think, as a 
result of a shoebox of prescriptions that had been filled--
prescribed to him by the VA.
    What are you doing in this area now that you have more of a 
directive and I think more of an area of emphasis because of 
what we have done here?
    Dr. Shulkin. I think as you know, and we appreciate your 
leadership in this, the opioid dependence crisis is really a 
national crisis. I was at a dinner last night with the director 
of the Centers for Disease Control and Prevention (CDC) who 
said this is the area he is most concerned about nationally. 
Fortunately I think VA, and thanks again to several of you who 
have taken the lead on this, has really understood this for 
several years. And we are doing really what the rest of the 
country should be doing. Our numbers are going down while the 
rest of the country is going up.
    Senator Capito. In terms of prescribing?
    Dr. Shulkin. In terms of number of veterans on opioids and 
finding alternatives for them. So we have instituted mandatory 
training. We have instituted mandatory reporting into all the 
States that require the drug monitoring programs. We use a 
stepped management approach. We are encouraging providers with 
what we call academic detailing where we train them to use 
other non-medication approaches to pain management, like 
integrative therapies. We have adopted not only the CDC 
guidelines, but work with DOD on DOD-VA guidelines for opioid 
management.
    So we are making progress. We need to do much, much more, 
but our numbers are coming down, and I think we are headed in 
the right direction. And we are going to stick at this until we 
can actually get to this to the very minimum number of patients 
who need to be on opioids.
    Senator Capito. Thank you.
    Senator Kirk. Mrs. Murray.
    Senator Murray. Thank you, Mr. Chairman.

                           CAREGIVERS PROGRAM

    Mr. Secretary, Dr. Shulkin, I am really pleased to see that 
you are requesting a significant increase for the Caregivers 
Program, which, as you know, gives veterans more control over 
their own healthcare and supports the loved ones who sacrifice 
their life, their own time, their health, their energy to 
provide that care. This is really a personal issue for me. My 
mother cared for my father, who was a World War II veteran, 
after he developed MS, and I know the impacts to these 
families.
    So now as demands on the VA continues to rise, I strongly 
believe that the Caregivers Program is really a key to helping 
VA carry out its duty to provide accessible high-quality care. 
And to make this program work, the VA is continuing to increase 
the number of Caregiver support coordinators. Considering the 
expected increase in Caregivers, and if we can finally pass the 
legislation to expand the Caregivers Program to all veterans, I 
am concerned we will need more.
    And my question for you today is, is the workload for 
individual Caregiver support coordinators going down, or do you 
need more staff to keep up with the demand?
    Dr. Shulkin. Yeah, it is a great question. This is--Senator 
Murray, I know you are passionate on this, and I thank you for 
that. This is an area that VA is so different than the private 
sector in recognizing this and supporting Caregivers. 
Interestingly, the data is coming out now to say this is a 
cost-effective way to manage healthcare costs.
    Senator Murray. I am not surprised, but I am glad there is 
data.
    Dr. Shulkin. Without Caregivers, these patients end up back 
in the institutions, and they do not want to be there, and it 
is very expensive to keep them there. So we are expanding this. 
And you are correct, we do need to keep up with the caseload 
because Caregivers need support. Elizabeth Dole, Secretary 
Dole, is very articulate about this, and has actually been 
working with us to help us support our Caregivers.
    So the workload is going up, but we are so pleased to be 
able to expand this program with this budget request.
    Senator Murray. Okay, great. Secondly, I have heard from 
veterans in my home State of Washington who are frustrated 
always about waiting months or even longer to get answers to 
questions about benefits and care. So I am really pleased to 
see that you are requesting significantly more funding for both 
the Health and Benefits Administration. That is really 
essential to providing good customer service.
    But I am concerned again whether that will be enough and 
whether the Department is managing its money appropriately. The 
crisis that we faced last year when the VA threatened to shut 
down the healthcare system and nearly ran out of money cannot 
be repeated. So the funding that we provide in 2017 and 2018 
has to account for major increasing demands on the VA, 
including providing, as you know, treatment for hepatitis C, 
increasing demand for care both in the VA and in the community, 
and the costs associated with the VA's new proposal to 
consolidate care in the community.

                      FORECAST FOR BENEFITS DEMAND

    So in light of all of those pressures, how do you 
anticipate demand for care benefits growing over the next 2 
years?
    Mr. Manker. So we--as look at the caseload, what we see 
is--in 2017 and 2018 we see an increase in the request for 
claims. And the second and third order of effective claims is 
as folks file claims that we--they go over to the Health 
Administration for care there.
    Senator Murray. So you see increasing demand.
    Mr. Manker. We do.
    Senator Murray. And does this budget accommodate that?
    Mr. Manker. I know from the VBA perspective it does, yes.
    Senator Murray. Okay, because that is what we hear 
constantly from our constituents when we do not have enough 
people out there to process. So we are going to be looking at 
this closely.

                       CAREGIVER TRACKING SYSTEM

    Let me go back again, Secretary Shulkin, to you. The budget 
request actually attributes most of the increase in the 
Caregivers Program to more Caregivers receiving stipends. But 
as you know, one of the GAO recommendations for the Caregiver 
Program is to create a new IT system to administer the program 
and to make it more efficient. This system will be really 
essential as we come closer to expanding the Caregiver Program. 
I wanted to ask you, is there enough funding in your request 
for the new Caregiver Tracking System, and will it be ready on 
time?
    Dr. Shulkin. Senator, that is something that I going to ask 
if I can back to you on because that is--I am going to need to 
work with counsel and the OI&T on that, and make sure that 
there is the appropriate resources to do that. And if I could, 
I would get back to you.
    Senator Murray. Okay. If you could answer me for the 
record.
    Dr. Shulkin. Yes.

    [The information follows: the requested information was not 
available at the time this publication went to print.]

    Senator Murray. And that is a really important part of 
making this work effectively.
    Dr. Shulkin. Yes.
    Senator Murray. So we need to have that ready, on time, and 
at capacity.
    Dr. Shulkin. Absolutely.
    Senator Murray. Thank you very much, and I will submit the 
rest for my record--questions for the record.
    Senator Kirk. Now, the Senator from King Cove, Alaska.

                     VA HEALTHCARE SYSTEM IN ALASKA

    Senator Murkowski. Thank you, Mr. Chairman. Dr. Shulkin, it 
is has been about a year since you last visited my office. I do 
appreciate you coming to the State last summer, but I regret to 
tell you that we have seen very little follow up on the state 
of the VA health system in Alaska. So let me tell you where I 
think we are right now in Alaska, and this is not necessarily 
through my eyes. This is through the members of the Veterans 
Service Organizations that have been flooding my office in the 
past several weeks.
    Before you and Secretary McDonald came to your jobs, we had 
a VA system--a healthcare system that worked up in the State. 
Our vets were seen in a timely fashion. Those that had 
conditions that could not be handled by the VA were seen in the 
community at fee-based care providers. We had good partnerships 
with our community health centers and with the native 
healthcare system to back up.
    But the vets who have been coming in, again, over these 
past weeks and when I have been up home, they are telling me 
that the current leadership team at the VA took a system that 
was working well in our State and went about dismantling it. 
And a couple of illustrations here with regards to the Choice 
Act that did not require the VA abandon its legacy fee-based 
programs. VA reads it otherwise, and canceled fee-based 
appointments. These vets were forced to deal with the 
dysfunctional TriWest referral system. They still are. Veterans 
who have been forced to use the Choice Act then discovered that 
VA did not pay for their care as they had done previously. And 
now what we are getting--the letters that I am getting from 
vets are saying my bills are being sent to collection agencies 
when the VA does not pay.
    We do not have very deep representation with medical 
specialists, but specialists who were willing to take the 
Choice card are now telling me they do not want to have 
anything to do with the hassle, nothing at all. So we have got 
a loss there.
    We had a great and innovative director at Anchorage VA 
Healthcare System. Not there anymore. That position has still 
not been filled. There is still no full-time physician at the 
Wasilla CBOC (Community-based Outpatient Clinic). The VA is 
able to find some providers who may consider relocation, but 
then they pull out after the relocation promises that have been 
made by the VA recruiters are withdrawn because they never 
should have been made. And, again, we are not seeing VA senior 
leadership coming and saying we have got--we are willing to 
work with you. We are going to solve these problems.
    So the question to you, Dr. Shulkin, is how would you 
assess--I have given you my assessment and the assessment of so 
many of the veterans who are coming to my office. But how would 
you assess the state of the Alaska healthcare system for the VA 
in my State right now? What needs to be done to restore the 
access and the quality of care that our veterans had, but they 
no longer are experiencing?
    Dr. Shulkin. Okay. Well, you have mentioned a lot, Senator, 
and so let me try to briefly just tell how I look at this. I 
think that you have identified several things. So pre-Choice I 
think Alaska had a very innovative system that was working 
well.
    Senator Murkowski. It took a long time, but we got there.
    Dr. Shulkin. No question about that. Choice was implemented 
and system was changed. And I think that some of the situation 
you are talking about was dated a while ago where essentially 
we were not using fee-based programs. We were not using 
community care programs, and we were only using Choice. That 
situation has now changed in Alaska where after our visits up 
there, we are working very closely with the Indian Health 
Service, we are working with the South Central Foundation, we 
are working with the DOD facilities there where I think that 
you are not seeing some of the problems that had existed 
before.
    The Choice Program still continues to be a challenge, and 
that is why we have worked closely with TriWest to actually 
embed TriWest employees in with our VA people, and there are 
three embedded TriWest employees today in the Anchorage 
facility. It still is somewhat problematic, and that is why we 
are continuing to ask for a contract modification so that VA 
can take over the scheduling of those patients, very similar to 
what you had before. And we are waiting for that contract 
modification to be approved.
    So Alaska is--was a system that, frankly, was a great model 
for the country. It went through some tough times. We are 
trying to get that back. I think that part of what we are 
trying to do with this new legislation that Senator Tester has 
taken the lead on is to bring back the customer service pieces, 
what you had in Alaska back to the VA. And we know that we have 
a lot of work to do.
    Senator Murkowski. Well, and I am sure you can appreciate 
the frustration of the many veterans who for years had 
struggled with a system that did not work, and then through the 
good work of cooperation and collaboration between IHS, 
community health centers, we kind of built this system.
    Dr. Shulkin. Yes.
    Senator Murkowski. And we were providing the care that our 
veterans deserved and expected, and we wanted to be able to 
provide, and it worked throughout agencies. And then we come in 
and we have got this top down approach, and we are starting all 
over. And your term ``somewhat problematic''--``somewhat 
problematic''--is not what I am hearing from our veterans. They 
are saying it is fouled up! It is screwed up. It is a mess. And 
it is unacceptable. It is unacceptable because we know how to 
correct it because we corrected it. And then you come in and 
you create chaos.
    So we had asked in the fiscal year 2016 approps bill that a 
report be submitted on the current status of VA healthcare in 
Alaska. We are waiting for a status of that report. You know, 
you suggest that some of the information that I have here is 
dated. It is not--it is not dated, not based on the experience 
of veterans who are trying to access their healthcare now, who 
are getting these bills from collection agencies now. This is 
not based on some things that were happening a year ago, 6 
months ago.
    So I am--we will have Secretary McDonald here before the 
subcommittee, and I certainly intend to ask him what corrective 
actions plans you have regarding all of these issues that I 
have outlined. In the interim, it might be helpful certainly 
for you all and my staff to meet to have a more comprehensive 
conversation about the quality and the access because what is 
happening now is the--is the quality of care, the access to 
care has been compromised for these Alaskan veterans. And there 
will be no compromise. There cannot be no compromise for these 
healthcare benefits.
    And, again, I think part of the frustration that we have is 
we have come so far only to see it turned over literally within 
the course of a couple months. And you cannot pull the rug out 
from underneath those who have earned these healthcare 
benefits, and that is exactly what your system has done.
    And we thought that the visits to Alaska were going to 
materialize in some changes that our veterans could see, but I 
am pressing each and every one of them. I am saying you got to 
be honest with me because the information that we get from you 
is the most telling. And what they are telling me is it has not 
been fixed, it has not been corrected, and they are not doing 
enough.
    There is no compromise on what our veterans have earned, so 
know that we are going to keep working at it. And it would be 
great if we could set up some time to sit down on that.
    Dr. Shulkin. Senator, I just want to mention a few things. 
First of all, I appreciate where you are coming from. I heard 
it personally----
    Senator Murkowski. I know you did.
    Dr. Shulkin [continuing]. In Fairbanks, and Anchorage, and 
the Kenai Peninsula. And these were packed houses of people 
saying exactly what you are saying.
    But I just do want to say a couple of things that I hope 
will be helpful. First of all, this was the Choice Program. 
This was Congress' program that we are trying to make work, and 
we understand that it is not working well, and that is why we 
are working with you, and we look for your support to make the 
changes that we need to make.
    But currently, 96 percent of all appointments are scheduled 
within 30 days in Alaska. We have 120 outstanding consults more 
than 30 days that are urgent consults. They are all out in the 
Choice Program. They are all scheduled, but that is too long, 
and that is what we are working with TriWest to fix to make 
sure that we can improve that.
    In terms of putting veterans in line with their own credit, 
unacceptable. We do not want that happening. We have 
established a toll free hotline now that is 1 (877) 881-7618 
that veterans should call if they are being hounded by 
creditors so we can intervene on their behalf because we do not 
want them put in that position. And I know that is happening 
for people in Alaska and across the country, and we are going 
to--we are going to help them with that. Thank you.
    Senator Murkowski. Well, I look forward to our sit down. 
Thank you, Mr. Chairman.
    Senator Kirk. Senator Baldwin.
    Senator Baldwin. Thank you, Mr. Chairman.

      ADMINISTRATIVE INVESTIGATION BOARD ON MILWAUKEE DOMICILIARY

    Dr. Shulkin, as a result of concerns that I reported and 
shared with the VA, the VA convened an Administrative 
Investigation Board in October of last year to review many 
allegations regarding improprieties at the Milwaukee 
domiciliary. One conclusion reached by the Administrative 
Investigation Board, otherwise known as AIB, was that the 
domiciliary environment was not safe and secure.
    An issue raised to corroborate this assertion was that the 
non-inspection of veterans' belongings. Veterans were found to 
have alcohol, box cutters, and straight razors. More alarming, 
during the time of that review, while the AIB members were 
there, a veteran tried to commit suicide.
    Mr. Chairman, I would like to insert in the record a news 
article that appeared last night on CBS 58 in Milwaukee that 
has to do with the story that I am about to tell.
    Senator Kirk. So ordered.
    Senator Baldwin. Thank you.

    [The information follows: the requested information was not 
available at the time this publication went to print.]

    Senator Baldwin. In my view, this puts a finer point on the 
need to inspect what veterans and visitors are bringing into 
the domiciliary. Last year, a young veteran, a resident of the 
VA domiciliary in Milwaukee, he was recently out of a rehab 
program, overdosed on heroin, and was found dead in his room at 
the facility. My understanding is that he was able to bring in 
needles into the facility and potentially the drugs that caused 
that overdose. This is someone who came to the VA for help.
    Dr. Shulkin, I am very concerned about the whole 
domiciliary program. At my request, the inspector general's 
office is reviewing the issues surrounding the death of this 
young veteran. But I think we need to go a step further and 
reassess the program to determine whether security measures 
nationwide are appropriate, and whether domiciliaries are the 
right place for veterans such as ones who have attempted 
suicide or who have overdosed. It seems to me that a facility 
like this has lax oversight of its resident population, and may 
not be the best place for these veterans.
    So can you speak today to the security of VA domiciliaries, 
and whether you are willing to take a hard look at the 
appropriateness of the program for veterans who may need 
greater supervision?
    Dr. Shulkin. Yeah. Senator, what we are talking about is 
the best approach towards this issue that, frankly, is a 
national epidemic we are seeing all over the country on 
substance abuse. And veterans are a particular risk for 
substance abuse.
    And so, the domiciliary programs are part of our approach, 
and I do think, and I am open to taking a look at better ways 
of doing this and better ways of trying to address both 
treatment and prevention of substance abuse. And I wish I could 
tell you that we have found the magic bullet for this, but we 
need to be trying harder.
    On the issue of security, I will tell you this is a problem 
for hospitals everywhere. I have struggled with this throughout 
my career. It is simply is not possible to search every patient 
and every visitor and ensuring what they are bringing in does 
not contain drugs or paraphernalia like syringes. It just 
simply would not be effective. You would have to have 
essentially what amounts to what they do in prisons, which we 
do not want our facilities to be like that.
    So what we do is we need to set up rules about behaviors 
that we expect and what happens and consequences if you break 
those rules, being discharged from the programs. Do we need to 
look at new ways to be able to make sure these are safer 
places? Absolutely we need to. But I do not want to give the 
expectation that by searching people we are going to be able to 
prevent this completely.
    Senator Baldwin. Okay. Just in follow up and based on your 
answer, there is absolutely a range of activities and 
procedures that could be put into place to increase safety and 
security beyond the search issue. I will note that I have heard 
that the AIB members who were present on site to conduct their 
investigation were able to gain access the facility with no one 
checking them at the door or even, you know, they were already 
wandering about. And so, that obviously suggests a lax set of 
protocols.
    I would appreciate it if you can commit to reporting back 
to this subcommittee on at least an initial review of the use 
of these domiciliaries, and the security, and supervision 
levels, and safety. This is a big concern.

    [The information follows:]

    Context of Inquiry: Will VA commit to reviewing the domiciliary 
program, including the security and safety protocols and the 
appropriateness of participation of veterans who may require greater 
supervision? When can we expect the results of that review? [reference 
Dr. Shulkin's testimony that he is ``open to taking a look at better 
ways of doing this.'' And ``Do we need to look at new ways to be able 
to make sure these were safer places? Absolutely, we need to.'']
    Response: VHA Domiciliary Care programs are safe, effective and an 
appropriate level of care for Veterans with mental health and substance 
use disorders when appropriately operated in conformance with national 
policy. VHA will continue to closely monitor domiciliary safety and 
security and look for opportunities to improve Veteran care. One 
Veteran death is too many and every effort will continue to support the 
medical centers in providing a safe and secure environment focused on 
recovery. Veterans admitted to the residential treatment programs are 
assessed as needing increased supervision and support for symptom 
reduction and engagement in recovery and for whom outpatient care has 
not been effective. VHA's residential treatment programs provide vital 
services in the mental health continuum of care which includes general 
outpatient, intensive outpatient, residential and acute inpatient. VHA 
fully recognizes the increased risk in serving Veterans with mental 
health and substance use disorders in a residential level of care.
    At the end of fiscal year 2015, VHA operated 244 Mental Health 
Residential Rehabilitation Treatment Programs (MHRRTP) with 8,148 beds 
at 113 VA Medical Centers. During fiscal year 2015, there were over 
37,500 admissions to domiciliary care with 87 percent of the Veterans 
admitted having a Substance Use Disorder (SUD) diagnosis. Over 15,000 
Veterans were provided residential specialty care specifically to treat 
their SUD. In fiscal year 2015, there were over 2 million patient bed 
days of care provided in VHA Domiciliary programs. During this period, 
there were 13 reported Veteran overdoses resulting in four overdose 
deaths. The mortality rate for Veterans during their residential stay 
during fiscal year 2014 was 0.06 percent and has decreased by 56.8 
percent since 2004.
    VHA is currently revising and updating the VHA MHRRTP Handbook, 
1162.02. The revisions will include updates to safety and security 
policy and procedures based on lessons learned since the Handbook was 
published in 2010. VHA recently updated guidance clarifying 
expectations for contraband detection and prevention in Domiciliary 
programs. This guidance has been shared with key stakeholders and was 
recently shared with the field. Concepts discussed in the guidance 
document have been routine topics of conversation with the field 
through regular monthly calls and at the National MHRRTP Managers 
conference on May 3-5, 2016. A significant step forward in the safety 
and supervision of VHA's residential care is the current development of 
a Nursing Model that will guide the provision of 24/7 nursing services 
in Domiciliary programs based on the Veteran's needs. This 
collaborative effort between the Office of Nursing Service and Mental 
Health Services is currently being piloted at ten Domiciliary locations 
and when completed will be implemented at all locations. This 
initiative is expected to result in improved patient care and the 
supervision of the residential units.

                    NALOXONE KITS AS A HIGH PRIORITY

    Senator Baldwin. I want to just briefly pivot to the 
related issue of over reliance on opioids, and I appreciated 
Senator Moore Capito talking about the bill we have worked 
jointly together named in honor of a marine veteran in 
Wisconsin, Jason Simcakoski, who died at a VA hospital in 
Tomah.
    You may recall that the inspector general report released 
last August detailing his death from mixed drug toxicity 
revealed that antidotes to overdose, like naloxone and 
flumazenil, were not available on the emergency crash carts 
that were brought to Jason's room, and that a facility staff 
member was tasked with securing an antidote from the urgent 
care clinic, and then it arrived in his room some 33 minutes 
later after he was found unresponsive.
    So I understand that the availability of naloxone and 
related antidotes are tremendously important. They can and do 
save lives. That leads me to the VA's legislative proposal to 
eliminate co-pay requirements for naloxone kits it distributes 
to high-risk veterans. Since its implementation more than 2 
years ago, they have been extensively distributed, and lives 
have been saved.
    But I also know, and you know, that the recently signed 
Omnibus Appropriations Bill and the Jason Simcakoski Memorial 
Act that I referred to would expand the VA's overdose education 
and naloxone distribution program to ensure that every VA 
medical facility and pharmacy is equipped with opioid receptor 
antagonists such as naloxone.
    I want you to please to speak to why providing these kits 
free of charge is such a high priority.
    Dr. Shulkin. Yes. Well, I think you have said it very well, 
Senator, which is that in the case of overdose, these are 
lifesaving drugs. I have personally used them, and people go 
from being essentially unconscious to waking up and talking to 
you in a matter of seconds. And so, if you do not take the 
right actions, they stop breathing, and obviously they can die.
    So I could not agree with you more. Having these available, 
much like years ago we did with the automatic implantable 
defibrillators that you see now in waiting rooms, and airports, 
and restaurants. VA has been distributing these kits out to 
community partners in various areas. We have been doing it by 
the thousands and successfully. I think that getting more of 
them out will be helpful.
    Last year we prescribed 18,000 prescriptions for naloxone. 
I think you mentioned the issue of co-pays. Fifty percent of 
them required a co-pay. Eight dollars is our average co-pay. So 
anything that we can do to help eliminate barriers to the use 
of these drugs I think would be important, and education is a 
primary target of ours as well.
    Senator Baldwin. Thank you. And, Mr. Chairman and Ranking 
Member, I will submit some additional questions for the record. 
I thank you for the time.

                       HEPATITIS C DRUG TREATMENT

    Senator Kirk. With your indulgence, I will go with a second 
round here. Let me get you on the record about hepatitis C. 
Last year the subcommittee appropriated $1.5 billion for 
treatment of hepatitis C. We have also appropriated another 
$1.5 billion for advance appropriations in 2017 for the 
treatment of hepatitis C, which should be a good news story. 
There are dramatically different figures put out by you and the 
Department about how many new patients starts will be achieved 
in this fiscal year on hepatitis C.
    I would like to see how many do you project will be started 
in fiscal year 2016.
    Dr. Shulkin. Yes. Well, first of all, I could not agree 
more. We thank you for your leadership in providing this to 
veterans. This is one of those miracle drugs that have come 
through----
    Senator Kirk. I would say this is a chance for us to have a 
hepatitis C free veteran population.
    Dr. Shulkin. Yes, absolutely.
    Senator Kirk. Probably the best legacy for the President on 
his way out of office.
    Dr. Shulkin. Well, with a 95 percent cure rate, I am not 
sure that you can do that many things this well, so thank you 
again for that support.
    Let me go over the numbers. There should not be any 
confusion about this. VA estimates, using its databases, that 
we have 120,000 veterans who have hepatitis C. You can measure 
hepatitis C in the blood. We were originally given the $1.5 
billion and, given our pricing for hepatitis C drugs, able to 
treat this year 35,000 veterans. However, the price of the drug 
has dropped.
    Senator Kirk. They have to go through a course as I 
remember, and for those 35,000 new starts----
    Dr. Shulkin. It's a series of treatments, yes.
    Senator Kirk [continuing]. We would then expect a 97-
percent success rate with the new starts.
    Dr. Shulkin. I think--I think that is pretty good. But the 
reason why there may be some confusion, we have had additional 
good news, and that is the pricing on this drug has dropped. 
That means we are going to be able to treat more veterans this 
year. So instead of 35,000, we potentially--potentially--could 
treat 70,000. That means that if you were able to treat 70,000 
veterans and you only have 120,000, we could actually eliminate 
or cure those that have hepatitis C today because new veterans 
will enter the system----
    Senator Kirk. Right.
    Dr. Shulkin [continuing]. In approximately 2 years. What 
a--what a great story. This would be a miracle and, frankly, a 
great thing to do for veterans.
    The reason why my staff may be using a different number 
than the 70,000 is that this is the potential. To get 70,000 
veterans through the VA to screen them, to make sure they are 
appropriate to put them through all these treatments, that 
would require us right now given where we are in fiscal year 
2016 already, we have treated 9,100 patients this year in 
fiscal year 2016, to do 2,000 starts per week.
    We have once done that in a week in September of 2015 when 
we went through extraordinary efforts right before the budget 
year ended to get as many veterans in to spend last year's $1.5 
billion. But maintaining 2,000 veterans a week for the rest of 
the year, frankly is not going to be practical given our 
current resources.
    So what we are looking to do is to ask for some flexibility 
in the $1.5 billion, 5 percent of it, to actually increase our 
staffing in these clinics so we can bring through 2,000 
veterans a week. So if we can actually staff up a tiny bit in 
these hepatology clinics, these hepatitis C clinics, that would 
be our goal in 2 years to essentially eliminate this from the 
VA system.
    It is going to take an effort operationally to catch up. 
Right now we are very comfortable that our staffing levels are 
doing about 1,300 starts a week, okay? That is really our 
capacity given our current staffing that we could sustain. That 
would get us part way towards that number. It would get us, you 
know, in the 40- to 50,000 a year, and, frankly, we are going 
to do everything we can to treat every veteran with hepatitis 
C.

                      OVER PRESCRIPTION OF OPIOIDS

    Senator Kirk. Good. Could I divert from you to what I have 
noticed is what I would call a VA way of practicing medicine. 
This has happened in my own family where it seems like--you 
already described the over prescription and ways to deal with 
opioids. Last night the Senate passed the Kirk amendment that 
would bring the VA into the reporting system that we created 
under the legislation to make sure that we are going downward 
on over prescription.
    In my experience, the over prescription has been Xanax and 
Ambien, too much of that where you develop a real dependency. 
Is there a way that we can make sure that with psychotropic 
drugs that we are doing less and less and less of that just to 
get the patient out of the door?
    Dr. Shulkin. Yeah, actually VA does have measures on this. 
I do not have the statistics off the top of my head, but we not 
only know how many patients are on benzodiazepines, but 
actually the combination between benzodiazepines and opioids. 
And we have targeted that as a high-risk sort of high-alert 
area.
    Senator Kirk. Just see if it is part of socialized medicine 
to get the patient quickly out the door to give them Xanax and 
Ambien in nearly unlimited quantities. I would note that 
Senator Baldwin has talked about the Tomah facility----
    Dr. Shulkin. Yes.
    Senator Kirk [continuing]. Which was called the candy 
factory because so much was over prescribed there.
    Dr. Shulkin. Yes. Yes. So I think we recognize this is a 
challenge. That is why we are doing so much provider and 
mandatory training on this, something that I think that we are 
looking to make significant progress on. Thank you.
    Senator Kirk. Mr. Tester, any final words?

                        VHA 2018 ADVANCE REQUEST

    Senator Tester. I do. Thank you, Mr. Chairman. I want to 
drill down a little bit on the numbers, particularly with the 
2018 advance request. I do not see any of the annualized costs 
for the new doctors and nurses that are going to be hired with 
the Choice Act funding. Now, you are going to get another bite 
at the apple next year as far as fiscal year 2018 goes. But 
does this not leave a huge hole in your future budget?
    Dr. Shulkin. It does. I think you are correct. There is no 
continued funding in fiscal year 2018 for these new hires. And 
I would also add there are some other components, such as our 
graduate medical education residents. The 5,000 residents that 
were granted, they also did not continue. And so, and there are 
actually some other components. But I am going to ask the 
expert on this to just clarify exactly what you are asking 
about, Senator.
    Senator Tester. Yes.
    Mr. Yow. Yes, sir. We would need about $1.3 billion to 
continue the hires in fiscal year 2018.
    Senator Tester. Yeah.
    Mr. Yow. We would need about $280 million to continue 
leases that were funded with VACCA section 801 funding, and we 
need about $90 million to continue the residents that were 
hired under section 301 of VACCA.
    Senator Tester. Okay. I got it, and I appreciate your 
frankness. $1.3 billion, $280 million, $90 million for the 
residency. This is going to leave a hell of a hole, guys. I 
mean, why are we putting an emphasis on getting healthcare 
providers across the system, urban and rural areas. We are 
going to be laying these folks off.
    Dr. Shulkin. Well, the advance appropriation is to be able 
to supply us with a stable amount of money going forward, but 
there has to be a second step, as you mentioned, Senator, for 
us to identify what our actual needs are. Now, with the new 
Veterans Choice Program, what we are trying to understand is 
what those exact numbers are so we can come back and talk about 
that.

               VA AND DOD JOINT ELECTRONIC HEALTH RECORD

    Senator Tester. Okay. I gotcha, and I just want to tell you 
that from my perspective, if you need $1.3 billion for the new 
hires that we are hiring and it is not in the budget for 2018, 
we are not doing our job, I will just tell you that. I mean, it 
becomes a problem. And the worst thing that could happen, and 
by the way, it would hurt for recruitment, is hire these folks 
and then not keep them around. I want to talk about IT for a 
second, but we really do need to get that fixed if we could.
    The IT, I mean, we have included language in the omnibus 
requiring the VA to develop and submit to this subcommittee a 
detailed plan on how to replace or fix the IT. I know you do 
not lead the IT team over at VA, by the way.
    Dr. Shulkin. No, I do not.
    Senator Tester. But I do know that you have probably been 
involved in these discussions.
    Dr. Shulkin. Yes.
    Senator Tester. Why is it taking so long to fix this 
system?
    Dr. Shulkin. That is one that I would be glad to defer to 
Laverne Council, who ably leads our IT Department. I have a 
great deal of confidence in her. She has gone in like you would 
want with her private sector background, and really challenged 
all of the assumptions that frankly have led to an 
underperforming part of the organization. And so, Laverne, I am 
sure when we come back to talk to you March 10th or 11th--I 
forget the specific day--would be glad to address that in a 
very clear way.
    Senator Tester. That would be good because, I mean, I think 
it has been 10 years ago----
    Senator Kirk. Remind him we are going to do a hearing on 
the joint records April 14th----
    Dr. Shulkin. Okay.
    Senator Kirk [continuing]. And would want your best 
possible details on that for the subcommittee.
    Dr. Shulkin. Absolutely. We will be prepared.
    Senator Kirk. I have been holding back as prerogative as 
chairman to tell you what my IT program would be to make sure 
that we would require all narratives in the Microsoft world and 
all documents in .jpg to make sure there was complete usability 
for everybody in the industry.
    Dr. Shulkin. Okay.
    Senator Kirk. And make sure that we do not have a separate 
beltway bandit code. And when I talked about this with 
Secretary Shinseki, wanting to make sure that everything was 
open code based on the success that Motorola has had with the 
Android system when they made Android all open code, and got 
70,000 apps to that system. My hope is eventually if we take 
25, 27 million patients in DOD and VA with an open code system 
will establish the medical records technologies, undeniably 
American. And an entire industry will always--worldwide will be 
here. And that is my hope that we do not let an individual 
beltway bandit create their own code.
    Dr. Shulkin. Okay. Well, thank you. Thank you for giving us 
a little insight as to what your approach is on that. Thank 
you.
    Senator Tester. So when the hearing comes around, you said 
on April 14th? Is that correct?
    Senator Kirk. April 14th, right.
    Senator Tester. April 14th, it would be great to know where 
we are as far as the status for replacing or modernizing that 
system. It would be great to know what the cost estimates are 
for that replacement.
    Dr. Shulkin. Absolutely.
    Senator Tester. So that it is. I just want to thank you all 
for being here. It is a bit of mental gymnastics for you guys, 
and I appreciate your professionalism, and I appreciate your 
honesty. And I look forward to working with you as I know 
others on this subcommittee do to making sure that we meet the 
needs of our veterans. Thank you.
    Dr. Shulkin. Thank you.
    Senator Kirk. Let us--we have beat you up enough here--
close. I want to thank our witnesses, especially my partner, 
Senator Tester.
    And the record will be open until the close of business 
next week, Thursday, so that members can submit questions for 
the record.

                          SUBCOMMITTEE RECESS

    Senator Kirk. The next hearing of the subcommittee will be 
on Thursday, March 10.
    Dr. Shulkin. That is better than 1:00 a.m.
    Senator Kirk. Better than 1:00 a.m.
    Dr. Shulkin. Yeah. Yeah.
    Senator Tester. Thank you, Mr. Chairman.
    Dr. Shulkin. Thank you.
    Senator Kirk. And we will stand adjourned.
    Senator Tester. Thanks, Kirk.
    [Whereupon, at 12:34 p.m., Thursday, March 3, the 
subcommittee was recessed, to reconvene Thursday, March 10, at 
a time subject to the call of the Chair.]